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Kaiser Permanente Bernard J. Tyson School of Medicine, Inc. Exclusive Provider Organization (EPO) Student Blanket Health Plan Formulary

Effective September 1, 2021

Health Plan Products: Kaiser Permanente Bernard J. Tyson School of Medicine, EPO Student Blanket Health Plan offered by Kaiser Permanente Insurance Company

For the most current list of covered or for help understanding your KPIC insurance plan benefits, including cost sharing for under the benefit and under the medical benefit:

Call 1-800-533-1833, TTY 711, Monday through Friday, 7 a.m. to 9 p.m. ET

Visit kaiserpermanente.org to: • Find a participating retail pharmacy by ZIP code. • Look up possible lower-cost alternatives. • Compare medication pricing and options. • Find an electronic copy of the formulary here. • Get plan coverage information.

For cost sharing information for the outpatient prescription drug benefits in your specific plan, please visit kp.org/kpic-websiteTBD

The formulary is subject to change and all previous versions of the formulary are no longer in effect. Kaiser Permanente Last updated: September 1, 2021 Table of Contents

Informational Section...... 3 DRUGS - Drugs for Allergy...... 9 ANTI-INFECTIVE AGENTS - Drugs for ...... 11 ANTINEOPLASTIC AGENTS - Drugs for Cancer...... 30 ANTITOXINS,IMMUNE GLOB,TOXOIDS, - DRUGS FOR THE ...... 45 AUTONOMIC DRUGS - Drugs for the ...... 52 FORMATION, , THROMBOSIS - Drugs for the Blood...... 65 CARDIOVASCULAR DRUGS - Drugs for the Heart...... 78 CELLULAR AND GENE THERAPY - Drugs for Cancer...... 117 CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System...... 117 DEVICES - Medical Supplies and Durable Medical Equipment...... 160 DIAGNOSTIC AGENTS...... 167 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants...... 173 ELECTROLYTIC, CALORIC, AND WATER BALANCE...... 173 ...... 183 EYE, EAR, NOSE AND THROAT (EENT) PREPS...... 184 GASTROINTESTINAL DRUGS...... 197 GASTROINTESTINAL DRUGS - Drugs for the Stomach...... 197 GOLD COMPOUNDS...... 206 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron...... 206 AND SYNTHETIC SUBSTITUTES - Hormones...... 207 LOCAL (PARENTERAL) - Drugs for Numbing...... 247 MISCELLANEOUS THERAPEUTIC AGENTS...... 248 NONHORMONAL CONTRACEPTIVES - Drugs for Women...... 273 OXYTOCICS - Drugs for Women...... 274 PHARMACEUTICAL AIDS...... 274 RADIOACTIVE AGENTS...... 275 RESPIRATORY TRACT AGENTS - Drugs for the Lungs...... 275 AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin...... 288 SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles...... 327 ...... 328

TOC-2 Understanding your formulary

What is a formulary? This formulary provides a list of the approved prescription About this formulary medications covered under your Health Insurance Plan including Where differences between both generic and brand-name drugs. This list applies only to this formulary and your benefit prescribed outpatient prescription drugs obtained through a plan exist, the benefit plan Kaiser Permanente pharmacy or a retail pharmacy within the documents rule. This may OptumRx network. not be a complete list of This list does not apply to medications administered in the medications that are covered doctor’s office or in the hospital which are covered under your by your plan, and it doesn’t medical benefit. For information on drugs covered under your mean that you are guaranteed medical benefit, please see the General Benefits section of your to receive a medication on this Certificate of Insurance. list. Please review your benefit plan for full details. Review the formulary using either the categorical list of drugs or the alphabetical index. The categorical list of drugs groups medications into drug categories and classes that are organized by the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification system. A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the brand or generic name of the drug in the alphabetical index. A drug is listed alphabetically by the brand and generic name in the therapeutic category and class to which it belongs. The generic name for a brand-name drug is included after the brand-name in parentheses in all lowercase italicized letters. If a generic equivalent for a brand-name drug is both available and covered, the generic drug will be listed separately from the brand medication in all lowercase italicized letters. If a generic drug is marketed under a proprietary, trademark protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. If a generic equivalent for a brand-name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name.

How do I use my formulary? You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. A non-formulary drug must be covered when your doctor says it is medically necessary. If your medication is not listed here, please visit your plan’s member website or call the number on your member ID card to submit a non-formulary exception request. Some medications on your formulary have extra requirements before they can be covered. A few of the most common coverage programs are prior authorization (PA), step therapy (ST), Non-formulary (NF), quantity limits (QL) or max day supply limit per prescription (DSL). Please note, this formulary is not subject to PA or ST programs.

3 Understanding your formulary

You may request exception to certain non-formulary programs when your doctor feels it is necessary. If OptumRx doesn’t respond to your non-urgent NF exception request within 72 hours or your urgent NF exception request within 24 hours, then your request will be automatically granted. You may appeal the denial of an exception request. Please review your coverage documents for more information on appeal rights and procedures. We use programs like these to help make sure the medication you take is safe and effective. When you request coverage of a non-formulary drug, we will notify you or your designee and your provider of the coverage determination within these time frames. If the decision is to provide coverage for a non-urgent request, coverage will be for the duration of the prescription, including refills. If the coverage decision is based on exigent circumstances, coverage will be for the duration of the exigency. Check your plan documents for more information. Some Affordable Care Act (ACA) or Health Care Reform (HCR) preventive medications may have coverage restrictions.

What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. This is how much you will pay when you fill a prescription.

Mail order How can I receive medications by mail? Most prescription refills can be mailed to you at no extra charge.You can sign up for mail-order services at your Kaiser Permanente pharmacy by calling the number on the back of your ID card or by visiting kp.org.

When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic equal becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication. OptumRx and Kaiser Permanente Insurance Company may not limit or exclude coverage for a drug if the health insurer previously approved coverage of the drug for an insured’s medical condition and the prescribing provider continues to prescribe the drug for the condition. This is provided that the drug is appropriately prescribed and safe and effective for treating the insured’s medical condition.

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

4 Understanding your formulary

What is the maximum cost-share for oral anti-cancer drugs? The cost-share for orally administered anti-cancer drugs shall not exceed $250 for a 30-day supply.

What categories of medications are covered through my plan? Your prescription drug benefit will generally cover prescribed generic and brand-name medications listed on the formulary as long as the drug is medically necessary; the prescription is filled by an OptumRx network pharmacy provider; and other coverage rules are followed. Over-the-counter (OTC) medications are not generally covered; however, certain preventive OTC medications are covered when prescribed by a doctor, such as and smoking cessation drugs. Durable medical equipment, prescribed by a doctor to treat or to assist with inhalation devices is also covered. The formulary lists the pharmacy benefits covered under your outpatient prescription drug benefit and obtained from a Kaiser Permanente pharmacy or an OptumRx network participating retail pharmacy. This formulary does not apply to medications and devices that are obtained through the medical benefit portion of your coverage. For example, medications provided or administered in the doctor’s office or in the hospital or, unless specifically stated otherwise, devices covered under the durable medical equipment benefit that are obtained at the doctor’s office or through a durable medical equipment vendor.

Diabetes medication and equipment. Your outpatient prescription medication coverage includes the following prescription items for the management and treatment of diabetes: • • Needles and syringes for injecting insulin • Prescriptive medications for the treatment of diabetes •

Other medical benefit items.Some durable medical equipment that is covered through your medical benefit is also available at the pharmacy, such as disposable blood strips; blood glucose monitors; and lancets and lancet puncture devices.

Contraceptives. Your outpatient prescription drug coverage includes all prescribed FDA-approved contraceptive drugs, including over the counter FDA-approved female contraceptive methods at no cost-share when prescribed by a licensed health care professional authorized to prescribe drugs. All such medications require a prescription from your doctor.

ACA Preventive drugs at no cost. All medications, even OTC drugs included under the federal Patient Affordable Care Act (ACA) as preventive medications, are eligible for coverage with no cost-share if the insured has a prescription from his or her doctor. Please note: some medications are only covered at no cost for patients who meet the criteria listed in the formulary.

5 Medication tips

What is the difference between brand-name and generic medications? Over-the-counter Generic medications contain the same active ingredients (what medications makes the medication work) as brand-name medications, but they An over-the-counter (OTC) often cost less. Once the patent for a brand-name medication medication may be the right ends, the FDA can approve a generic version with the same active treatment for some conditions. ingredients. Talk to your doctor about available OTC options. Even What if my doctor writes a brand-name prescription? though OTC medications If your doctor gives you a prescription for a brand-name may not be covered by your medication, ask if a generic or lower-cost option could be right for pharmacy benefit, they may you. Generic medications are usually your lowest-cost option. cost less than a prescription medication.

6 Definitions

Brand name drug A drug that is marketed under a its symptoms and that meet accepted standards of proprietary, trademark-protected name. A brand name medicine. Health insurance usually does not cover drug is listed in this formulary in all CAPITAL letters. health care benefits that are not medically necessary. The fact that a doctor may prescribe, authorize, or Coinsurance Percentage of the cost of a covered direct a service does not by itself make it medically health care benefit that you pay after you have paid necessary or confirm coverage by the policy. the deductible, if a deductible applies to the health care benefit. Nonformulary drug A prescription drug that is not listed on this formulary. Copayment Fixed dollar amount that you pay for a covered health care benefit after you have paid Out-of-pocket cost Your expenses for health the deductible, if a deductible applies to the health care benefits that aren’t reimbursed by your health care benefit. insurance. Out-of-pocket costs include deductibles, copayments, and coinsurance for covered health care Deductible Amount you pay for covered health care benefits, plus all costs for health care benefits that benefits that are subject to the deductible before are not covered. your health insurer begins to pay. If your health insurance policy has a deductible, it may have either Prescribing provider A health care provider who one deductible or separate deductibles for medical can write a prescription for a drug to diagnose, treat, benefits and prescription drug benefits. After you pay or prevent a medical condition. Prescription An oral, your deductible, you usually pay only a copayment written, or electronic order from a prescribing provider or coinsurance for covered health care benefits. Your authorizing a prescription drug to be provided to a insurance company pays the rest. specific individual.

Drug Tier A group of prescription drugs that correspond Prescription drug A drug that by law requires to a specified cost sharing tier in your health insurance a prescription. policy. The drug tier in which a prescription drug is A decision by your health insurer placed determines your portion of the cost for the drug. Prior Authorization that a health care benefit is medically necessary Exception request A request for coverage of a for you. If a prescription drug is subject to prior non-formulary drug. If you, your designee, or your authorization in this formulary, your prescribing prescribing health care provider submits a request for provider must request approval from your health coverage of a non-formulary drug, your insurer must insurer to cover the drug before you fill your cover the nonformulary drug when it is medically prescription. Your health insurer must grant a prior necessary for you to take the drug. authorization request when it is medically necessary for you to take the drug. Exigent circumstances When you are suffering from a medical condition that may seriously jeopardize Step therapy A specific sequence in which your life, health, or ability to regain maximum prescription drugs for a particular medical condition function, or when you are undergoing a current must be tried. If a drug is subject to step therapy course of treatment using a nonformulary drug. in this formulary, you may have to try one or more other drugs before your health insurance policy Formulary or prescription drug list The list of drugs will cover that drug for your medical condition. If that is covered by your health insurance policy under your prescribing provider submits a request for an the prescription drug benefit of the policy. exception to the step therapy requirement, your Generic drug A drug that is the same as its brand health insurer must grant the request when it is name drug equivalent in dosage, strength, effect, medically necessary for you to take the drug. how it is taken, quality, safety, and intended use. A Over-the-counter (OTC) drugs are medications generic drug is listed in this formulary in italicized sold directly to a consumer without requiring a lowercase letters. prescription. For this formulary, OTC drugs that are Medically Necessary Health care benefits needed covered under your outpatient prescription drug to diagnose, treat, or prevent a medical condition or benefit require a prescription from your doctor.

7 Reading your formulary

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

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible. The copayment or coinsurance for a covered outpatient prescription drug for an individual prescription should not exceed $250 for a 30-day supply after meeting the deductible, if any. Please refer to the tier definition table below to see how to identify which medications are preferred or non-preferred drugs.

Drug Tier Includes Helpful Tips PV $0 Preventative drugs Preventative drugs required under the Affordable Care Act (ACA) at $0 cost share. Tier 1 $ Lower-cost generics Use Tier 1 drugs for the lowest out-of-pocket costs. and some brand name Tier 2 $$ Mid-range cost Use Tier 2 drugs if Tier 1 drugs are not available or you preferred brand name prefer a brand. Tier 3 $$ Exception-based Tier 3 drugs in this plan require an exception for non-preferred brand coverage. Drug list information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

OC Oral anti-cancer – Cost share not to exceed $250 per month for a 30-day supply. QL Quantity Limit – Medication may be limited to a certain quantity. DSL Day Supply Limit – Medication may be restricted to a maximum day supply limit per prescription. Please refer to your COI (Certificate of Insurance) for more information about: • Your medical coverage • Filing an appeal related to a denial of a coverage request. Your COI • Existing conditions will provide more information on appeal rights and procedures. • Non-formulary drugs • Outpatient prescription drug benefit

OptumRx updates the formulary on a monthly basis. The notice includes a description of the types of changes made during the plan or policy year, and the dates on which such changes are effective. Changes may include: • Removal of a drug or dosage form of a medication from the formulary. • Any change in tier placement of a medication that results in an increase in cost sharing. • Adding or changing medication coverage requirements such as PA, ST and QL programs. 8 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIHISTAMINE DRUGS - Drugs for Allergy ETHANOLAMINE DERIVATIVES - Drugs for Allergy carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg, 6 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cvs motion sickness oral tablet 50 mg PV DICOPANOL FUSEPAQ ORAL SUSPENSION 3 RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 DI-PHEN ORAL LIQUID 12.5 MG/5ML 3 diphenhydramine hcl solution 50 mg/ml 1 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) motion sickness relief oral tablet 50 mg PV ryvent oral tablet 6 mg 1 FIRST GEN. ANTIHIST. DERIVATIVES, MISC. - Drugs for Allergy hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 FIRST GENERATION - Drugs for Allergy carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg, 6 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cvs motion sickness oral tablet 50 mg PV cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 dexchlorpheniramine maleate oral solution 2 mg/5ml 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 DI-PHEN ORAL LIQUID 12.5 MG/5ML 3 diphenhydramine hcl injection solution 50 mg/ml 1 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) motion sickness relief oral tablet 50 mg PV ryvent oral tablet 6 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 9 Coverage Requirements & Prescription Drug Name Drug Tier Limits PHENOTHIAZINE DERIVATIVES - Drugs for Allergy PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML PV (promethazine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml PV promethazine hcl oral solution 6.25 mg/5ml PV promethazine hcl oral syrup 6.25 mg/5ml PV promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg PV promethazine hcl rectal suppository 12.5 mg, 25 mg PV promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 promethazine hcl (Promethegan Rectal Suppository 12.5 Mg, PV 25 Mg) promethegan rectal suppository 50 mg PV PIPERAZINE DERIVATIVES - Drugs for Allergy hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 meclizine hcl oral tablet 12.5 mg, 25 mg PV meclizine hcl oral tablet chewable 25 mg PV motion sickness relief oral tablet chewable 25 mg PV PROPYLAMINE DERIVATIVES - Drugs for Allergy dexchlorpheniramine maleate oral solution 2 mg/5ml 1 hydrocodone polst-chlorphen polst er susp oral suspension 1 extended release 10-8 mg/5ml NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML 3 (phenylephrine-chlorphen-dm) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 3 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) SECOND GENERATION ANTIHISTAMINES - Drugs for Allergy cetirizine hcl oral solution 1 mg/ml, 5 mg/5ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 10 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) desloratadine oral tablet 5 mg 1 desloratadine oral tablet dispersible 5 mg 1 levocetirizine dihydrochloride oral solution 2.5 mg/5ml 1 levocetirizine dihydrochloride oral tablet 5 mg 1 ANTI-INFECTIVE AGENTS - Drugs for Infections 1ST GENERATION CEPHALOSPORIN - Antibiotics cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension reconstituted 250 mg/5ml, 500 1 mg/5ml cefadroxil oral tablet 1 gm 1 cefazolin sodium injection solution reconstituted 1 gm, 10 gm 1 cefazolin sodium-dextrose intravenous solution 2-4 gm/100ml-% 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 cephalexin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml cephalexin oral tablet 250 mg, 500 mg 1 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefaclor er oral tablet extended release 12 hour 500 mg 1 cefaclor oral capsule 250 mg, 500 mg 1 cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 1 375 mg/5ml cefotetan disodium injection solution reconstituted 1 gm, 2 gm 1 cefoxitin sodium injection solution reconstituted 10 gm 1 cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefprozil oral tablet 250 mg, 500 mg 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefdinir oral capsule 300 mg 1 cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefixime oral capsule 400 mg 1 cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml 1 cefotaxime sodium injection solution reconstituted 1 gm, 2 gm 1 cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 1 50 mg/5ml Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 11 Coverage Requirements & Prescription Drug Name Drug Tier Limits cefpodoxime proxetil oral tablet 100 mg, 200 mg 1 ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm 1 ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 1 250 mg, 500 mg SUPRAX ORAL SUSPENSION RECONSTITUTED 100 2 MG/5ML (cefixime) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 3 MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 3 (cefixime) ceftazidime (Tazicef Injection Solution Reconstituted 1 Gm, 2 1 Gm, 6 Gm) tazicef intravenous solution reconstituted 1 gm 1 4TH GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefepime hcl injection solution reconstituted 2 gm 1 5TH GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 600 3 MG (ceftaroline fosamil) ADAMANTANE ANTIVIRALS - Drugs for Viral Infections amantadine hcl oral capsule 100 mg PV amantadine hcl oral syrup 50 mg/5ml PV amantadine hcl oral tablet 100 mg PV GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR PV DSL = 30 days 137 MG, 68.5 MG (amantadine hcl) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK PV 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 PV HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) rimantadine hcl oral tablet 100 mg PV ALLYLAMINE - Drugs for Fungus terbinafine hcl oral tablet 250 mg 1 AMEBICIDES - Drugs for the Mouth and Throat HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 paromomycin sulfate oral capsule 250 mg 1 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 12 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIBIOTICS - Antibiotics sulfate injection solution 500 mg/2ml 1 ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML 3 DSL = 30 days (amikacin sulfate liposome) KITABIS PAK INHALATION NEBULIZATION SOLUTION 300 3 MG/5ML (tobramycin) sulfate oral tablet 500 mg 1 paromomycin sulfate oral capsule 250 mg 1 streptomycin sulfate intramuscular solution reconstituted 1 gm 1 TOBI PODHALER INHALATION CAPSULE 28 MG 2 (tobramycin) tobramycin inhalation nebulization solution 300 mg/4ml 1 tobramycin nebulization solution 300 mg/5ml inhalation 300 1 mg/5ml TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML 3 INHALATION 300 MG/5ML ZEMDRI INTRAVENOUS SOLUTION 500 MG/10ML 3 (plazomicin sulfate) AMINOMETHYLCYCLINES - Antibiotics NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) 3 SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG 3 DSL = 30 days (sarecycline hcl) AMINOPENICILLIN ANTIBIOTICS - Antibiotics amoxicill-clarithro-lansopraz oral 1 amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 1 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 amoxicillin-potassium clavulanate er oral tablet extended 1 release 12 hour 1000-62.5 mg amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 1 mg/5ml amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500- 1 125 mg, 875-125 mg amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 1 mg, 400-57 mg ampicillin oral capsule 500 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 13 Coverage Requirements & Prescription Drug Name Drug Tier Limits ampicillin-sulbactam sodium injection solution reconstituted 3 1 (2-1) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125- 2 31.25 MG/5ML (amoxicillin-pot clavulanate) OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill-clarithro- 3 omeprazole) TALICIA ORAL CAPSULE DELAYED RELEASE 250-12.5-10 3 MG (amoxicill-rifabutin-omeprazole) - Drugs for Parasites albendazole oral tablet 200 mg 1 DSL = 30 days ALBENZA ORAL TABLET 200 MG (albendazole) 3 DSL = 30 days BILTRICIDE ORAL TABLET 600 MG (praziquantel) 2 EGATEN ORAL TABLET 250 MG (triclabendazole) 3 EMVERM ORAL TABLET CHEWABLE 100 MG (mebendazole) 3 ivermectin oral tablet 3 mg 1 praziquantel oral tablet 600 mg 1 ANTIFUNGALS, MISCELLANEOUS - Drugs for Fungus griseofulvin microsize oral suspension 125 mg/5ml 1 griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 STRONG ORAL SOLUTION 5 % 3 SSKI ORAL SOLUTION 1 GM/ML (potassium iodide 3 (expectorant)) ANTIMALARIALS - Drugs for the Mouth and Throat ARAKODA ORAL TABLET 100 MG (tafenoquine succinate) PV atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg PV chloroquine oral tablet 250 mg, 500 mg PV COARTEM ORAL TABLET 20-120 MG (artemether- PV lumefantrine) DARAPRIM ORAL TABLET 25 MG (pyrimethamine) PV DSL = 30 days HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 sulfate oral tablet 200 mg PV KRINTAFEL ORAL TABLET 150 MG (tafenoquine succinate) PV MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG PV (atovaquone-proguanil hcl) mefloquine hcl oral tablet 250 mg PV PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine PV sulfate) primaquine phosphate oral tablet 26.3 mg PV Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 14 Coverage Requirements & Prescription Drug Name Drug Tier Limits PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) pyrimethamine oral tablet 25 mg PV DSL = 30 days QUALAQUIN ORAL CAPSULE 324 MG (quinine sulfate) PV quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 quinine sulfate oral capsule 324 mg PV , MISCELLANEOUS - Antibiotics oral tablet 100 mg, 25 mg 1 , MISCELLANEOUS - Drugs for the Mouth and Throat ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 2 (nitazoxanide) ALINIA ORAL TABLET 500 MG (nitazoxanide) 2 atovaquone oral suspension 750 mg/5ml PV BENZNIDAZOLE ORAL TABLET 100 MG, 12.5 MG 3 dapsone oral tablet 100 mg, 25 mg 1 HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) 3 DSL = 30 days LAMPIT ORAL TABLET 120 MG, 30 MG (nifurtimox) 3 MEPRON ORAL SUSPENSION 750 MG/5ML (atovaquone) PV metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 PV MG (pentamidine isethionate) nitazoxanide oral tablet 500 mg 1 PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG PV (pentamidine isethionate) pentamidine isethionate inhalation solution reconstituted 300 PV mg pentamidine isethionate injection solution reconstituted 300 mg PV PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) SOLOSEC ORAL PACKET 2 GM (secnidazole) 3 tinidazole oral tablet 250 mg, 500 mg 1 ANTITUBERCULOSIS AGENTS - Antibiotics amikacin sulfate injection solution 500 mg/2ml 1 CAPASTAT SULFATE INJECTION SOLUTION 2 RECONSTITUTED 1 GM (capreomycin sulfate) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 15 Coverage Requirements & Prescription Drug Name Drug Tier Limits CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 2 (5%), 500 MG/5ML (10%) (ciprofloxacin) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 cycloserine oral capsule 250 mg 1 ethambutol hcl oral tablet 100 mg, 400 mg 1 isoniazid oral syrup 50 mg/5ml 1 isoniazid oral tablet 100 mg, 300 mg 1 levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl in nacl intravenous solution 400 mg/250ml 1 moxifloxacin hcl oral tablet 400 mg 1 PASER ORAL PACKET 4 GM (aminosalicylic acid) 3 PRETOMANID ORAL TABLET 200 MG 3 PRIFTIN ORAL TABLET 150 MG (rifapentine) 2 pyrazinamide oral tablet 500 mg 1 rifabutin oral capsule 150 mg 1 rifampin oral capsule 150 mg, 300 mg 1 SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline 3 DSL = 30 days fumarate) streptomycin sulfate intramuscular solution reconstituted 1 gm 1 TRECATOR ORAL TABLET 250 MG (ethionamide) 2 ANTIVIRALS, MISCELLANEOUS - Drugs for Viral Infections foscarnet sodium intravenous solution 6000 mg/250ml PV FOSCAVIR INTRAVENOUS SOLUTION 6000 MG/250ML PV (foscarnet sodium) PREVYMIS INTRAVENOUS SOLUTION 240 MG/12ML, 480 PV DSL = 30 days MG/24ML (letermovir) PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) PV DSL = 30 days XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 3 X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 3 X 40 MG (baloxavir marboxil) AZOLE ANTIFUNGALS - Drugs for Fungus CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium 3 sulfate) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 16 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml 1 fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 itraconazole oral capsule 100 mg 1 itraconazole oral solution 10 mg/ml 1 oral tablet 200 mg 1 NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) 3 posaconazole oral tablet delayed release 100 mg 1 SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) 2 TOLSURA ORAL CAPSULE 65 MG 3 VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML PV (voriconazole) VFEND ORAL TABLET 200 MG, 50 MG (voriconazole) PV voriconazole oral suspension reconstituted 40 mg/ml PV voriconazole oral tablet 200 mg, 50 mg PV CARBAPENEM ANTIBIOTICS - Antibiotics ertapenem sodium injection solution reconstituted 1 gm 1 imipenem-cilastatin intravenous solution reconstituted 250 mg 1 INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM 2 (ertapenem sodium) meropenem intravenous solution reconstituted 500 mg 1 MEROPENEM-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION RECONSTITUTED 1 GM/50ML, 500 MG/50ML RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 1.25 GM (imipenem-cilastatin-relebactam) CEPHAMYCIN ANTIBIOTICS - Antibiotics cefotetan disodium injection solution reconstituted 1 gm, 2 gm 1 cefoxitin sodium injection solution reconstituted 10 gm 1 ANTIBIOTICS - Antibiotics chloramphenicol sod succinate intravenous solution 1 reconstituted 1 gm CYCLIC LIPOPEPTIDE ANTIBIOTICS - Antibiotics CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 2 MG (daptomycin) CUBICIN RF INTRAVENOUS SOLUTION RECONSTITUTED 2 500 MG (daptomycin) daptomycin intravenous solution reconstituted 350 mg, 500 mg 1 ECHINOCANDIN ANTIFUNGALS - Drugs for Fungus CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 70 2 MG (caspofungin acetate) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 17 Coverage Requirements & Prescription Drug Name Drug Tier Limits caspofungin acetate intravenous solution reconstituted 70 mg 1 ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 3 MG (anidulafungin) micafungin sodium intravenous solution reconstituted 100 mg 1 ANTIBIOTICS - Antibiotics E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 3 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 3 MG/5ML (erythromycin ethylsuccinate) ERYTHROCIN STEARATE ORAL TABLET 250 MG 3 (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 1 mg erythromycin base oral tablet 250 mg, 500 mg 1 erythromycin base oral tablet delayed release 250 mg, 333 mg, 1 500 mg erythromycin ethylsuccinate oral suspension reconstituted 200 1 mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg 1 erythromycin oral tablet delayed release 250 mg, 333 mg, 500 1 mg EXTENDED-SPECTRUM PENICILLINS - Antibiotics piperacillin sod-tazobactam so intravenous solution 1 reconstituted 4.5 (4-0.5) gm GLYCOPEPTIDE ANTIBIOTICS - Antibiotics FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 2 MG/ML (vancomycin hcl) vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-% 1 vancomycin hcl intravenous solution 1000 mg/200ml, 1250 mg/250ml, 1500 mg/300ml, 1750 mg/350ml, 2000 mg/400ml, 1 500 mg/100ml, 750 mg/150ml vancomycin hcl oral capsule 125 mg, 250 mg 1 vancomycin hcl oral solution reconstituted 250 mg/5ml 1 GLYCYLCYCLINE ANTIBIOTICS - Antibiotics tigecycline intravenous solution reconstituted 50 mg 1 HCV POLYMERASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir-velpatasvir) 3 DSL = 30 days EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir-velpatasvir) 2 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 18 Coverage Requirements & Prescription Drug Name Drug Tier Limits HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG 3 DSL = 30 days (ledipasvir-sofosbuvir) HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 3 DSL = 30 days HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 2 DSL = 30 days LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 DSL = 30 days SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 DSL = 30 days SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) 3 DSL = 30 days SOVALDI ORAL TABLET 200 MG (sofosbuvir) 3 DSL = 30 days SOVALDI ORAL TABLET 400 MG (sofosbuvir) 2 DSL = 30 days VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 3 DSL = 30 days &250 MG (ombitas-paritapre-ritona-dasab) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv-velpatasv- 2 DSL = 30 days voxilaprev) HCV PROTEASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections MAVYRET ORAL TABLET 100-40 MG (glecaprevir- 3 DSL = 30 days pibrentasvir) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 3 DSL = 30 days &250 MG (ombitas-paritapre-ritona-dasab) ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 3 DSL = 30 days HCV REPLICATION COMPLEX INHIBITORS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir-velpatasvir) 3 DSL = 30 days EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir-velpatasvir) 2 DSL = 30 days HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG 3 DSL = 30 days (ledipasvir-sofosbuvir) HARVONI ORAL TABLET 45-200 MG (ledipasvir-sofosbuvir) 3 DSL = 30 days HARVONI ORAL TABLET 90-400 MG (ledipasvir-sofosbuvir) 2 DSL = 30 days LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 DSL = 30 days MAVYRET ORAL TABLET 100-40 MG (glecaprevir- 3 DSL = 30 days pibrentasvir) SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 DSL = 30 days VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 3 DSL = 30 days &250 MG (ombitas-paritapre-ritona-dasab) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv-velpatasv- 2 DSL = 30 days voxilaprev) ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 3 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 19 Coverage Requirements & Prescription Drug Name Drug Tier Limits HIV ENTRY AND FUSION INHIBITORS - Drugs for Viral Infections FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 2 DSL = 30 days MG (enfuvirtide) RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR 3 600 MG (fostemsavir tromethamine) SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) 3 SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG 2 (maraviroc) TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33ML 3 (ibalizumab-uiyk) HIV INTEGRASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) CABENUVA INTRAMUSCULAR SUSPENSION EXTENDED 3 RELEASE 400 & 600 MG/2ML, 600 & 900 MG/3ML DOVATO ORAL TABLET 50-300 MG (dolutegravir-lamivudine) 2 GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 emtricit-tenofaf) ISENTRESS HD ORAL TABLET 600 MG (raltegravir 2 potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir potassium) 3 ISENTRESS ORAL TABLET 400 MG (raltegravir potassium) 2 ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG 2 (raltegravir potassium) JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 2 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg-cobic- 2 emtricit-tenofdf) TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG (dolutegravir 2 sodium) TIVICAY PD ORAL TABLET SOLUBLE 5 MG (dolutegravir 2 sodium) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 dolutegravir-lamivud) VOCABRIA ORAL TABLET 30 MG 3 HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. - Drugs for Viral Infections ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- 3 DSL = 30 days emtricitab-tenofovir)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 20 Coverage Requirements & Prescription Drug Name Drug Tier Limits COMPLERA ORAL TABLET 200-25-300 MG (emtricitab-rilpivir- 2 tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 3 lamivudin-tenofov df) EDURANT ORAL TABLET 25 MG (rilpivirine hcl) 2 efavirenz oral capsule 200 mg, 50 mg 1 efavirenz oral tablet 600 mg 1 efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600- 1 300-300 mg INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG 2 (etravirine) JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 2 nevirapine er oral tablet extended release 24 hour 100 mg, 400 1 mg nevirapine oral suspension 50 mg/5ml 1 nevirapine oral tablet 200 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 tenofov af) PIFELTRO ORAL TABLET 100 MG (doravirine) 3 VIRAMUNE ORAL SUSPENSION 50 MG/5ML (nevirapine) 2 HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS - Drugs for Viral Infections abacavir sulfate oral solution 20 mg/ml 1 abacavir sulfate oral tablet 300 mg 1 abacavir sulfate-lamivudine oral tablet 600-300 mg 1 abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg 1 ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- 3 DSL = 30 days emtricitab-tenofovir) BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 COMPLERA ORAL TABLET 200-25-300 MG (emtricitab-rilpivir- 2 tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 3 lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine-tenofovir PV af) DOVATO ORAL TABLET 50-300 MG (dolutegravir-lamivudine) 2 efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 21 Coverage Requirements & Prescription Drug Name Drug Tier Limits efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600- 1 300-300 mg emtricitabine oral capsule 200 mg 1 emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 1 167-250 mg, 200-300 mg EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) 3 EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) 2 EPIVIR HBV ORAL SOLUTION 5 MG/ML (lamivudine) 2 EPIVIR HBV ORAL TABLET 100 MG (lamivudine) 2 GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 emtricit-tenofaf) lamivudine oral solution 10 mg/ml 1 lamivudine oral tablet 100 mg, 150 mg, 300 mg 1 lamivudine-zidovudine oral tablet 150-300 mg 1 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 tenofov af) RETROVIR INTRAVENOUS SOLUTION 10 MG/ML 2 (zidovudine) stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg-cobic- 2 emtricit-tenofdf) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 tenofovir disoproxil fumarate oral tablet 300 mg 1 TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 dolutegravir-lamivud) TRUVADA ORAL TABLET 200-300 MG (emtricitabine-tenofovir PV df) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil 3 fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG (tenofovir 3 disoproxil fumarate) ZIAGEN ORAL SOLUTION 20 MG/ML (abacavir sulfate) 2 zidovudine oral capsule 100 mg 1 zidovudine oral syrup 50 mg/5ml 1 zidovudine oral tablet 300 mg 1 HIV PROTEASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections APTIVUS ORAL CAPSULE 250 MG (tipranavir) 2 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 22 Coverage Requirements & Prescription Drug Name Drug Tier Limits APTIVUS ORAL SOLUTION 100 MG/ML (tipranavir) 3 atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg 1 CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) 2 EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 2 fosamprenavir oral tablet 700 mg 1 INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) 2 KALETRA ORAL SOLUTION 400-100 MG/5ML (lopinavir- 2 ritonavir) KALETRA ORAL TABLET 100-25 MG, 200-50 MG (lopinavir- 2 ritonavir) LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir 3 calcium) LEXIVA ORAL TABLET 700 MG (fosamprenavir calcium) 2 lopinavir-ritonavir oral solution 400-100 mg/5ml 1 NORVIR ORAL PACKET 100 MG (ritonavir) 3 NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) 2 PREZCOBIX ORAL TABLET 800-150 MG (darunavir-cobicistat) 2 PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir 3 ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 (darunavir ethanolate) REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 3 (atazanavir sulfate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) 3 ritonavir oral tablet 100 mg 1 SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 emtricit-tenofaf) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 3 DSL = 30 days &250 MG (ombitas-paritapre-ritona-dasab) VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir 2 mesylate) INTERFERON ANTIVIRALS - Drugs for Viral Infections ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 3 (interferon alfa-n3) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 2 DSL = 30 days 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 2 DSL = 30 days alfa-2b)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 23 Coverage Requirements & Prescription Drug Name Drug Tier Limits PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 2 DSL = 30 days 180 MCG/ML (peginterferon alfa-2a) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML 2 DSL = 30 days (peginterferon alfa-2b) LINCOMYCIN ANTIBIOTICS - Antibiotics CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML 2 ( palmitate hcl) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml 1 lincomycin hcl injection solution 300 mg/ml 1 MACROLIDE ANTIBIOTICS - Antibiotics E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 3 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 3 MG/5ML (erythromycin ethylsuccinate) ERYTHROCIN STEARATE ORAL TABLET 250 MG 3 (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 1 mg erythromycin base oral tablet 250 mg, 500 mg 1 erythromycin base oral tablet delayed release 250 mg, 333 mg, 1 500 mg erythromycin ethylsuccinate oral suspension reconstituted 200 1 mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg 1 erythromycin oral tablet delayed release 250 mg, 333 mg, 500 1 mg MONOBACTAM ANTIBIOTICS - Antibiotics CAYSTON INHALATION SOLUTION RECONSTITUTED 75 3 DSL = 30 days MG (aztreonam ) MONOCLONAL ANTIBODY ANTIVIRALS - Drugs for Viral Infections BAMLANIVIMAB INTRAVENOUS SOLUTION 700 MG/20ML 3 CASIRIVIMAB INTRAVENOUS SOLUTION 1332 MG/11.1ML, 3 300 MG/2.5ML ETESEVIMAB INTRAVENOUS SOLUTION 700 MG/20ML 3 IMDEVIMAB INTRAVENOUS SOLUTION 1332 MG/11.1ML, 3 300 MG/2.5ML SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 2 MG/0.5ML (palivizumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 24 Coverage Requirements & Prescription Drug Name Drug Tier Limits NATURAL PENICILLIN ANTIBIOTICS - Antibiotics BICILLIN L-A INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML (penicillin g 2 benzathine) penicillin g potassium injection solution reconstituted 5000000 1 unit penicillin g procaine intramuscular suspension 600000 unit/ml 1 penicillin g sodium injection solution reconstituted 5000000 unit 1 penicillin v potassium oral solution reconstituted 125 mg/5ml, 1 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg 1 INHIBITOR ANTIVIRALS - Drugs for Viral Infections oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg PV oseltamivir phosphate oral suspension reconstituted 6 mg/ml PV RAPIVAB INTRAVENOUS SOLUTION 200 MG/20ML PV (peramivir) RELENZA DISKHALER INHALATION AEROSOL POWDER PV BREATH ACTIVATED 5 MG/BLISTER (zanamivir) TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG (oseltamivir PV phosphate) TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML PV (oseltamivir phosphate) NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS - Drugs for Viral Infections acyclovir oral capsule 200 mg PV acyclovir oral suspension 200 mg/5ml PV acyclovir oral tablet 400 mg, 800 mg PV ACYCLOVIX COMBINATION THERAPY PACK 200-10 MG-% 3 adefovir dipivoxil oral tablet 10 mg 1 BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) 2 BARACLUDE ORAL TABLET 0.5 MG, 1 MG (entecavir) 3 cidofovir intravenous solution 75 mg/ml PV entecavir oral tablet 0.5 mg, 1 mg 1 famciclovir oral tablet 125 mg, 250 mg, 500 mg PV PREVYMIS INTRAVENOUS SOLUTION 240 MG/12ML, 480 PV DSL = 30 days MG/24ML (letermovir) PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) PV DSL = 30 days ribavirin inhalation solution reconstituted 6 gm 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 25 Coverage Requirements & Prescription Drug Name Drug Tier Limits ribavirin oral capsule 200 mg 1 ribavirin oral tablet 200 mg 1 SITAVIG BUCCAL TABLET 50 MG (acyclovir) PV SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 emtricit-tenofaf) valacyclovir hcl oral tablet 1 gm, 500 mg PV VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML PV DSL = 30 days (valganciclovir hcl) VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) PV DSL = 30 days valganciclovir hcl oral solution reconstituted 50 mg/ml PV DSL = 30 days valganciclovir hcl oral tablet 450 mg PV DSL = 30 days VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir hcl) PV VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide 3 DSL = 30 days fumarate) VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM 2 (ribavirin) ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) PV OTHER MACROLIDE ANTIBIOTICS - Antibiotics amoxicill-clarithro-lansopraz oral 1 azithromycin oral packet 1 gm 1 azithromycin oral suspension reconstituted 100 mg/5ml, 200 1 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 1 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 DIFICID ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 DSL = 30 days (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) 3 DSL = 30 days OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill-clarithro- 3 omeprazole) ZITHROMAX ORAL PACKET 1 GM (azithromycin) 2 OTHER MISC. ANTIBACTERIAL AGENTS - Antibiotics HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 26 Coverage Requirements & Prescription Drug Name Drug Tier Limits OXAZOLIDINONE ANTIBIOTICS - Antibiotics linezolid in sodium chloride intravenous solution 600-0.9 1 mg/300ml-% linezolid intravenous solution 600 mg/300ml 1 linezolid oral suspension reconstituted 100 mg/5ml 1 linezolid oral tablet 600 mg 1 SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 3 200 MG (tedizolid phosphate) SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) 3 ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML, 600 3 MG/300ML (linezolid) ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 2 (linezolid) ZYVOX ORAL TABLET 600 MG (linezolid) 2 PENICILLINASE-RESISTANT PENICILLINS - Antibiotics dicloxacillin sodium oral capsule 250 mg, 500 mg 1 nafcillin sodium injection solution reconstituted 1 gm 1 nafcillin sodium intravenous solution reconstituted 10 gm 1 oxacillin sodium injection solution reconstituted 1 gm 1 oxacillin sodium intravenous solution reconstituted 10 gm 1 PLEUROMUTILINS - Antibiotics XENLETA INTRAVENOUS SOLUTION 150 MG/15ML 3 DSL = 30 days (lefamulin acetate) XENLETA ORAL TABLET 600 MG (lefamulin acetate) 3 DSL = 30 days POLYENE ANTIFUNGALS - Drugs for Fungus nystatin mouth/throat suspension 100000 unit/ml 1 nystatin oral tablet 500000 unit 1 POLYMYXIN ANTIBIOTICS - Antibiotics colistimethate sodium (cba) injection solution reconstituted 150 1 mg polymyxin b sulfate injection solution reconstituted 500000 unit 1 PYRIMIDINE ANTIFUNGALS - Drugs for Fungus flucytosine oral capsule 250 mg, 500 mg 1 QUINOLONE ANTIBIOTICS - Antibiotics BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 3 MG (delafloxacin meglumine) BAXDELA ORAL TABLET 450 MG (delafloxacin meglumine) 3 CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 2 (5%), 500 MG/5ML (10%) (ciprofloxacin) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 27 Coverage Requirements & Prescription Drug Name Drug Tier Limits ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl in nacl intravenous solution 400 mg/250ml 1 moxifloxacin hcl oral tablet 400 mg 1 ofloxacin oral tablet 300 mg, 400 mg 1 ANTIBIOTICS - Antibiotics AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG 3 (rifamycin sodium) PRIFTIN ORAL TABLET 150 MG (rifapentine) 2 rifabutin oral capsule 150 mg 1 rifampin oral capsule 150 mg, 300 mg 1 TALICIA ORAL CAPSULE DELAYED RELEASE 250-12.5-10 3 MG (amoxicill-rifabutin-omeprazole) XIFAXAN ORAL TABLET 200 MG () 3 DSL = 30 days XIFAXAN ORAL TABLET 550 MG (rifaximin) 2 DSL = 30 days SIDEROPHORE CEPHALOSPORINS - Antibiotics FETROJA INTRAVENOUS SOLUTION RECONSTITUTED 1 3 DSL = 30 days GM (cefiderocol sulfate tosylate) ANTIBIOTICS (SYSTEMIC) - Antibiotics sulfadiazine oral tablet 500 mg 1 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 1 mg sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 sulfamethoxazole-trimethoprim (Sulfatrim Pediatric Oral 1 Suspension 200-40 Mg/5Ml) ANTIBIOTICS - Antibiotics AVIDOXY DK COMBINATION KIT 100 MG (- 3 suncreen-sal acid) avidoxy oral tablet 100 mg 1 BENZODOX COMBINATION THERAPY PACK 30 X 100 MG & 3 4.4%, 60 X 100 MG & 4.4% (doxycycline-) hcl (Coremino Oral Tablet Extended Release 24 1 Hour 135 Mg, 45 Mg, 90 Mg) hcl oral tablet 150 mg, 300 mg 1 DORYX MPC ORAL TABLET DELAYED RELEASE 120 MG 3 (doxycycline hyclate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 28 Coverage Requirements & Prescription Drug Name Drug Tier Limits DORYX ORAL TABLET DELAYED RELEASE 80 MG 3 (doxycycline hyclate) doxycycline hyclate (Doxy 100 Intravenous Solution 1 Reconstituted 100 Mg) doxycycline hyclate intravenous solution reconstituted 100 mg 1 doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 1 doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 1 200 mg, 50 mg, 75 mg DOXYCYCLINE HYCLATE ORAL TABLET DELAYED 3 RELEASE 80 MG doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 1 75 mg doxycycline monohydrate oral suspension reconstituted 25 1 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 1 75 mg doxycycline oral capsule delayed release 40 mg 1 HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED 3 RELEASE 24 HOUR 135 MG, 45 MG, 90 MG minocycline hcl er oral tablet extended release 24 hour 105 mg, 1 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1 minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1 MINOLIRA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 105 MG, 135 MG (minocycline hcl) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 Mg, 1 75 Mg) MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG 3 (doxycycline hyclate-cleanser) doxycycline hyclate (Morgidox Oral Capsule 100 Mg) 1 NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3- 3 e) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG 3 DSL = 30 days (sarecycline hcl) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 105 MG, 115 MG, 55 MG, 65 MG, 80 MG (minocycline hcl) tetracycline hcl oral capsule 250 mg, 500 mg 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 29 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline calcium) 3 XIMINO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 135 MG, 45 MG, 90 MG (minocycline hcl) URINARY ANTI-INFECTIVES - Drugs for the Urinary System fosfomycin tromethamine oral packet 3 gm 1 HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz acd- 3 ph sal) MACRODANTIN ORAL CAPSULE 25 MG (nitrofurantoin 2 macrocrystal) me/naphos/mb/hyo1 oral tablet 81.6 mg 1 methenamine hippurate oral tablet 1 gm 1 methenamine mandelate oral tablet 0.5 gm, 1 gm 1 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg 1 nitrofurantoin monohydrate macrocrystals oral capsule 100 mg 1 nitrofurantoin oral suspension 25 mg/5ml 1 meth-hyo-m bl-na phos-ph sal (Phosphasal Oral Tablet 81.6 3 Mg) PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim hcl) 2 trimethoprim oral tablet 100 mg 1 meth-hyo-m bl-na phos-ph sal (Urelle Oral Tablet 81 Mg) 3 meth-hyo-m bl-na phos-ph sal (Uretron D/S Oral Tablet 81.6 1 Mg) meth-hyo-m bl-na phos-ph sal (Uribel Oral Capsule 118 Mg) 3 URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos-ph 3 sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 3 meth blue-na phos) uro-mp oral capsule 118 mg 1 meth-hyo-m bl-na phos-ph sal (Ustell Oral Capsule 120 Mg) 3 meth-hyo-m bl-na phos-ph sal (Utira-C Oral Tablet 81.6 Mg) 3 meth-hyo-m bl-na phos-ph sal (Vilamit Mb Oral Capsule 118 3 Mg) meth-hyo-m bl-na phos-ph sal (Vilevev Mb Oral Tablet 81 Mg) 3 ANTINEOPLASTIC AGENTS - Drugs for Cancer ANTINEOPLASTIC AGENTS - Drugs for Cancer oral tablet 250 mg, 500 mg 1 OC

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 30 Coverage Requirements & Prescription Drug Name Drug Tier Limits ABRAXANE INTRAVENOUS SUSPENSION 2 RECONSTITUTED 100 MG (paclitaxel protein-bound part) ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 2 MG (brentuximab vedotin) doxorubicin hcl (Adriamycin Intravenous Solution 2 Mg/Ml) 1 adriamycin intravenous solution reconstituted 10 mg 1 adriamycin intravenous solution reconstituted 50 mg 1 AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 3 DSL = 30 days; OC MG (everolimus) AFINITOR ORAL TABLET 10 MG (everolimus) 2 DSL = 30 days; OC AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG (everolimus) 3 DSL = 30 days; OC ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) 2 DSL = 30 days; OC ALFERON N INJECTION SOLUTION 5000000 UNIT/ML 3 (interferon alfa-n3) ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 3 MG (pemetrexed disodium) ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 2 MG (pemetrexed disodium) ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 3 DSL = 30 days MG (copanlisib hcl) ALKERAN ORAL TABLET 2 MG (melphalan) 2 OC ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG (brigatinib) 2 DSL = 30 days; OC ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG 2 DSL = 30 days; OC (brigatinib) anastrozole oral tablet 1 mg PV OC ARIMIDEX ORAL TABLET 1 MG (anastrozole) PV OC AROMASIN ORAL TABLET 25 MG () PV OC ARRANON INTRAVENOUS SOLUTION 5 MG/ML (nelarabine) 2 arsenic trioxide intravenous solution 10 mg/10ml 1 arsenic trioxide intravenous solution 12 mg/6ml 1 DSL = 30 days ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML, 3 DSL = 30 days 1000 MG/50ML (ofatumumab) ASPARLAS INTRAVENOUS SOLUTION 3750 UNIT/5ML 3 DSL = 30 days (calaspargase pegol-mknl) AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 2 MG/16ML (bevacizumab) AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG 3 DSL = 30 days (avapritinib) azacitidine injection suspension reconstituted 100 mg 1 BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG (erdafitinib) 3 DSL = 30 days Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 31 Coverage Requirements & Prescription Drug Name Drug Tier Limits BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML 3 DSL = 30 days (avelumab) BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 500 MG (belinostat) BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML 2 DSL = 30 days (bendamustine hcl) BENDEKA INTRAVENOUS SOLUTION 100 MG/4ML 2 DSL = 30 days (bendamustine hcl) BESPONSA INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 0.9 MG (inotuzumab ozogamicin) bexarotene oral capsule 75 mg 1 OC oral tablet 50 mg 1 OC BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 2 MG (carmustine) BLENREP INTRAVENOUS SOLUTION RECONSTITUTED 100 3 DSL = 30 days MG (belantamab mafodotin-blmf) bleomycin sulfate injection solution reconstituted 15 unit, 30 unit 1 BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 2 DSL = 30 days MCG (blinatumomab) BORTEZOMIB INTRAVENOUS SOLUTION RECONSTITUTED 3 3.5 MG BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG (bosutinib) 3 DSL = 30 days; OC BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) 3 DSL = 30 days BREYANZI INTRAVENOUS SUSPENSION (lisocabtagene 3 maraleucel) BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) 3 DSL = 30 days busulfan intravenous solution 6 mg/ml 1 CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG 2 DSL = 30 days; OC (cabozantinib s-malate) CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) 3 DSL = 30 days; OC CAMPATH INTRAVENOUS SOLUTION 30 MG/ML 3 (alemtuzumab) capecitabine oral tablet 150 mg, 500 mg 1 DSL = 30 days; OC CAPRELSA ORAL TABLET 100 MG, 300 MG (vandetanib) 3 OC CARAC EXTERNAL 0.5 % (fluorouracil) 3 carboplatin intravenous solution 150 mg/15ml, 450 mg/45ml, 50 1 mg/5ml, 600 mg/60ml carmustine intravenous solution reconstituted 100 mg 1 CASODEX ORAL TABLET 50 MG (bicalutamide) 3 OC

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 32 Coverage Requirements & Prescription Drug Name Drug Tier Limits cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 1 mg/50ml CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED 50 3 MG cladribine intravenous solution 10 mg/10ml 1 clofarabine intravenous solution 1 mg/ml 1 COMETRIQ ORAL KIT 20 MG, 3 X 20 MG & 80 MG, 80 & 20 2 DSL = 30 days; OC MG (cabozantinib s-malate) COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) 2 DSL = 30 days COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 2 0.5 MG (dactinomycin) COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) 2 DSL = 30 days; OC cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 1 500 mg CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION 1 3 GM/5ML, 500 MG/2.5ML cyclophosphamide oral capsule 25 mg, 50 mg 1 OC CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 3 OC CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 2 DSL = 30 days MG/50ML (ramucirumab) cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml 1 cytarabine injection solution 20 mg/ml 1 dacarbazine intravenous solution reconstituted 100 mg, 200 mg 1 DACOGEN INTRAVENOUS SOLUTION RECONSTITUTED 50 2 MG (decitabine) dactinomycin intravenous solution reconstituted 0.5 mg 1 DANYELZA INTRAVENOUS SOLUTION 40 MG/10ML 3 DSL = 30 days (naxitamab-gqgk) DARZALEX FASPRO SUBCUTANEOUS SOLUTION 1800- 3 DSL = 30 days 30000 MG-UT/15ML (daratumumab--fihj) DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML, 400 2 DSL = 30 days MG/20ML (daratumumab) daunorubicin hcl intravenous solution 20 mg/4ml, 50 mg/10ml 1 DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib 3 maleate) decitabine intravenous solution reconstituted 50 mg 1 diclofenac sodium external gel 3 % 1 docetaxel intravenous concentrate 160 mg/8ml, 20 mg/ml, 80 1 mg/4ml

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 33 Coverage Requirements & Prescription Drug Name Drug Tier Limits docetaxel intravenous solution 160 mg/16ml, 20 mg/2ml, 80 1 mg/8ml DOXIL INTRAVENOUS INJECTABLE 2 MG/ML (doxorubicin 2 hcl liposomal) doxorubicin hcl intravenous solution 2 mg/ml 1 doxorubicin hcl liposomal intravenous injectable 2 mg/ml 1 DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 3 (hydroxyurea) ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate 3 (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 3 month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 3 month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 ELZONRIS INTRAVENOUS SOLUTION 1000 MCG/ML 3 DSL = 30 days (tagraxofusp-erzs) EMCYT ORAL CAPSULE 140 MG ( phosphate 2 DSL = 30 days; OC sodium) EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 300 MG, 400 MG (elotuzumab) ENHERTU INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 100 MG (fam-trastuzumab deruxtec-nxki) epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml 1 ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML, 200 2 MG/100ML (cetuximab) ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) 2 DSL = 30 days; OC ERLEADA ORAL TABLET 60 MG () 3 DSL = 30 days; OC erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg 1 DSL = 30 days; OC ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 2 UNIT (asparaginase erwinia chrysanth) ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 100 MG (etoposide phosphate) etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 1 mg/25ml etoposide oral capsule 50 mg 1 OC everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 DSL = 30 days; OC EVOMELA INTRAVENOUS SOLUTION RECONSTITUTED 50 3 DSL = 30 days MG (melphalan hcl) exemestane oral tablet 25 mg PV OC

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 34 Coverage Requirements & Prescription Drug Name Drug Tier Limits FARESTON ORAL TABLET 60 MG (toremifene citrate) PV OC FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG 3 DSL = 30 days; OC (panobinostat lactate) FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML 3 DSL = 30 days (fulvestrant) FEMARA ORAL TABLET 2.5 MG (letrozole) PV OC FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG (PED) 3 (leuprolide acetate (6 month)) floxuridine injection solution reconstituted 0.5 gm 1 fludarabine phosphate intravenous solution 50 mg/2ml 1 fludarabine phosphate intravenous solution reconstituted 50 mg 1 FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) 2 FLUOROURACIL EXTERNAL CREAM 0.5 % 3 fluorouracil external cream 5 % 1 fluorouracil external solution 2 %, 5 % 1 fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 5 1 gm/100ml, 500 mg/10ml oral capsule 125 mg 1 OC FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML, 40 MG/2ML 3 (pralatrexate) FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG (tivozanib hcl) 3 fulvestrant intramuscular solution 250 mg/5ml 1 DSL = 30 days GAVRETO ORAL CAPSULE 100 MG (pralsetinib) 3 DSL = 30 days GAZYVA INTRAVENOUS SOLUTION 1000 MG/40ML 2 DSL = 30 days (obinutuzumab) gemcitabine hcl intravenous solution 1 gm/10ml, 1 gm/26.3ml, 1.5 gm/15ml, 2 gm/20ml, 2 gm/52.6ml, 200 mg/2ml, 200 1 mg/5.26ml gemcitabine hcl intravenous solution reconstituted 1 gm, 2 gm, 1 200 mg GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG (afatinib 3 DSL = 30 days; OC dimaleate) GLEEVEC ORAL TABLET 100 MG, 400 MG (imatinib mesylate) 3 DSL = 30 days; OC GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG 2 OC (lomustine) HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML (eribulin 2 mesylate) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600- 3 10000 MG-UNT/5ML (trastuzumab-hyaluronidase-oysk)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 35 Coverage Requirements & Prescription Drug Name Drug Tier Limits HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 150 MG (trastuzumab) HERZUMA INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 150 MG, 420 MG (trastuzumab-pkrb) HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan hcl) 2 DSL = 30 days; OC HYDREA ORAL CAPSULE 500 MG (hydroxyurea) 3 OC hydroxyurea oral capsule 500 mg 1 OC IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 2 DSL = 30 days; OC (palbociclib) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG 3 DSL = 30 days (palbociclib) ICLUSIG ORAL TABLET 10 MG, 30 MG (ponatinib hcl) 3 ICLUSIG ORAL TABLET 15 MG, 45 MG (ponatinib hcl) 3 DSL = 30 days; OC IDAMYCIN PFS INTRAVENOUS SOLUTION 10 MG/10ML, 20 2 MG/20ML, 5 MG/5ML (idarubicin hcl) idarubicin hcl intravenous solution 10 mg/10ml, 20 mg/20ml, 5 1 mg/5ml IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib mesylate) 3 DSL = 30 days; OC ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml 1 ifosfamide intravenous solution reconstituted 1 gm, 3 gm 1 imatinib mesylate oral tablet 100 mg, 400 mg 1 OC IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) 2 DSL = 30 days; OC IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 2 DSL = 30 days; OC MG (ibrutinib) IMFINZI INTRAVENOUS SOLUTION 120 MG/2.4ML, 500 3 DSL = 30 days MG/10ML (durvalumab) IMLYGIC INTRALESIONAL SUSPENSION 1000000 UNIT/ML, 3 100000000 UNIT/ML (talimogene laherparepvec) INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML- %, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, 1700-0.9 MG/170ML-%, 3 DSL = 30 days 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% (gemcitabine hcl-nacl) INLYTA ORAL TABLET 1 MG, 5 MG (axitinib) 3 DSL = 30 days; OC INQOVI ORAL TABLET 35-100 MG (decitabine-cedazuridine) 3 DSL = 30 days INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) 3 DSL = 30 days INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 2 DSL = 30 days 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 2 DSL = 30 days alfa-2b) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 36 Coverage Requirements & Prescription Drug Name Drug Tier Limits IRESSA ORAL TABLET 250 MG (gefitinib) 2 DSL = 30 days; OC irinotecan hcl intravenous solution 100 mg/5ml, 300 mg/15ml, 1 40 mg/2ml, 500 mg/25ml ISTODAX (OVERFILL) INTRAVENOUS SOLUTION 2 RECONSTITUTED 10 MG (romidepsin) IXEMPRA KIT INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 15 MG, 45 MG (ixabepilone) JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 2 DSL = 30 days; OC (ruxolitinib phosphate) JELMYTO SOLUTION RECONSTITUTED 80 (2 X 40) MG 3 DSL = 30 days (mitomycin) JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML 2 (cabazitaxel) KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 2 DSL = 30 days MG, 160 MG (ado-trastuzumab emtansine) KANJINTI INTRAVENOUS SOLUTION RECONSTITUTED 150 3 DSL = 30 days MG, 420 MG (trastuzumab-anns) KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML 2 DSL = 30 days (pembrolizumab) KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 3 DSL = 30 days; OC MG (ribociclib-letrozole) KISQALI ORAL TABLET THERAPY PACK 200 MG (ribociclib 3 DSL = 30 days; OC succinate) KOSELUGO ORAL CAPSULE 10 MG, 25 MG (selumetinib 3 DSL = 30 days sulfate) KYMRIAH INTRAVENOUS SUSPENSION (tisagenlecleucel) 3 KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 2 DSL = 30 days MG, 30 MG, 60 MG (carfilzomib) lapatinib ditosylate oral tablet 250 mg 1 DSL = 30 days; OC LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 10 2 DSL = 30 days; OC MG, 2 X 10 MG, 2 X 10 MG & 4 MG (lenvatinib mesylate) LENVIMA ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 3 DSL = 30 days; OC MG, 2 X 4 MG (lenvatinib mesylate) LENVIMA ORAL CAPSULE THERAPY PACK 3 X 4 MG, 4 MG 3 DSL = 30 days (lenvatinib mesylate) letrozole oral tablet 2.5 mg PV OC LEUKERAN ORAL TABLET 2 MG (chlorambucil) 2 OC leuprolide acetate injection kit 1 mg/0.2ml 2 LIBTAYO INTRAVENOUS SOLUTION 350 MG/7ML 3 DSL = 30 days (cemiplimab-rwlc)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 37 Coverage Requirements & Prescription Drug Name Drug Tier Limits LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG 2 DSL = 30 days; OC (trifluridine-tipiracil) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) 2 DSL = 30 days LUMOXITI INTRAVENOUS SOLUTION RECONSTITUTED 1 3 DSL = 30 days MG (moxetumomab pasudotox-tdfk) LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 3 MG (leuprolide & norethindrone) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 2 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 2 MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG 2 INTRAMUSCULAR KIT 30 MG (leuprolide acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG 2 INTRAMUSCULAR KIT 45 MG (leuprolide acetate (6 month)) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 2 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 2 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 month)) LUTATHERA INTRAVENOUS SOLUTION 370 MBQ/ML 3 (lutetium lu 177 dotatate) LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) 2 DSL = 30 days; OC LYSODREN ORAL TABLET 500 MG (mitotane) 2 DSL = 30 days; OC MARGENZA INTRAVENOUS SOLUTION 250 MG/10ML 3 (margetuximab-cmkb) MARQIBO INTRAVENOUS SUSPENSION 5 MG/31ML 2 DSL = 30 days (vincristine sulfate liposome) MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) 2 DSL = 30 days; OC oral suspension 40 mg/ml 1 megestrol acetate oral suspension 625 mg/5ml PV megestrol acetate oral tablet 20 mg, 40 mg 1 OC MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib dimethyl 2 DSL = 30 days; OC sulfoxide) MEKTOVI ORAL TABLET 15 MG (binimetinib) 3 DSL = 30 days melphalan hcl intravenous solution reconstituted 50 mg 1 melphalan oral tablet 2 mg 1 OC mercaptopurine oral tablet 50 mg 1 OC methotrexate oral tablet 2.5 mg 1 OC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 38 Coverage Requirements & Prescription Drug Name Drug Tier Limits methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 OC mitomycin intravenous solution reconstituted 20 mg, 40 mg, 5 1 mg MITOMYCIN INTRAVESICAL SOLUTION PREFILLED 3 SYRINGE 20 MG/40ML mitoxantrone hcl intravenous concentrate 20 mg/10ml, 25 1 mg/12.5ml, 30 mg/15ml MONJUVI INTRAVENOUS SOLUTION RECONSTITUTED 200 3 DSL = 30 days MG (tafasitamab-cxix) mitomycin (Mutamycin Intravenous Solution Reconstituted 20 1 Mg, 40 Mg, 5 Mg) MVASI INTRAVENOUS SOLUTION 100 MG/4ML, 400 3 DSL = 30 days MG/16ML (bevacizumab-awwb) MYLERAN ORAL TABLET 2 MG (busulfan) 2 OC MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 4.5 MG (gemtuzumab ozogamicin) NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML, 50 3 MG/5ML (vinorelbine tartrate) NERLYNX ORAL TABLET 40 MG (neratinib maleate) 3 DSL = 30 days; OC NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) 2 DSL = 30 days; OC NILANDRON ORAL TABLET 150 MG () 3 OC nilutamide oral tablet 150 mg 1 OC NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG (ixazomib 2 DSL = 30 days; OC citrate) NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 3 MG (pentostatin) NUBEQA ORAL TABLET 300 MG () 3 DSL = 30 days ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) 2 DSL = 30 days; OC OGIVRI INTRAVENOUS SOLUTION RECONSTITUTED 150 3 DSL = 30 days MG, 420 MG (trastuzumab-dkst) ONCASPAR INJECTION SOLUTION 750 UNIT/ML 2 (pegaspargase) ONIVYDE INTRAVENOUS INJECTABLE 43 MG/10ML 3 DSL = 30 days (irinotecan hcl liposome) ONTRUZANT INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 150 MG, 420 MG (trastuzumab-dttb) ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) 3 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 39 Coverage Requirements & Prescription Drug Name Drug Tier Limits OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 40 2 DSL = 30 days MG/4ML (nivolumab) OPDIVO INTRAVENOUS SOLUTION 240 MG/24ML 3 DSL = 30 days (nivolumab) ORGOVYX ORAL TABLET 120 MG (relugolix) 3 DSL = 30 days OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 3 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate (anti-rheumatic)) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 20 MG/0.4ML (methotrexate (anti-rheumatic)) oxaliplatin intravenous solution 100 mg/20ml, 200 mg/40ml, 50 1 mg/10ml oxaliplatin intravenous solution reconstituted 100 mg, 50 mg 1 paclitaxel intravenous concentrate 100 mg/16.67ml, 100 1 mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml PADCEV INTRAVENOUS SOLUTION RECONSTITUTED 20 3 DSL = 30 days MG, 30 MG (enfortumab vedotin-ejfv) PANRETIN EXTERNAL GEL 0.1 % () 3 DSL = 30 days paraplatin intravenous solution 1000 mg/100ml 1 carboplatin (Paraplatin Intravenous Solution 150 Mg/15Ml, 450 1 Mg/45Ml, 50 Mg/5Ml, 600 Mg/60Ml) PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG 3 DSL = 30 days (pemigatinib) PEPAXTO INTRAVENOUS SOLUTION RECONSTITUTED 20 3 MG (melphalan flufenamide hcl) PERJETA INTRAVENOUS SOLUTION 420 MG/14ML 2 DSL = 30 days (pertuzumab) PHESGO SUBCUTANEOUS SOLUTION 60-60-2000 MG-MG- 3 DSL = 30 days U/ML, 80-40-2000 MG-MG-U/ML (pertuz-trastuz-hyaluron-zzxf) PHOTOFRIN INTRAVENOUS SOLUTION RECONSTITUTED 3 75 MG (porfimer sodium) PIQRAY ORAL TABLET THERAPY PACK 2 X 150 MG, 200 & 3 50 MG, 200 MG (alpelisib) POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 3 MG (polatuzumab vedotin-piiq) POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 30 3 DSL = 30 days MG (polatuzumab vedotin-piiq) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 2 DSL = 30 days; OC (pomalidomide) PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50ML 3 DSL = 30 days (necitumumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 40 Coverage Requirements & Prescription Drug Name Drug Tier Limits POTELIGEO INTRAVENOUS SOLUTION 20 MG/5ML 3 DSL = 30 days (mogamulizumab-kpkc) PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 22000000 UNIT (aldesleukin) PURIXAN ORAL SUSPENSION 2000 MG/100ML 2 DSL = 30 days; OC (mercaptopurine) QINLOCK ORAL TABLET 50 MG (ripretinib) 3 DSL = 30 days RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 2 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) RETEVMO ORAL CAPSULE 40 MG, 80 MG (selpercatinib) 3 DSL = 30 days REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 2 DSL = 30 days; OC 25 MG, 5 MG (lenalidomide) RIABNI INTRAVENOUS SOLUTION 100 MG/10ML, 500 3 DSL = 30 days MG/50ML (rituximab-arrx) RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400-23400 MG -UT/11.7ML, 1600-26800 MG -UT/13.4ML (rituximab- 3 DSL = 30 days hyaluronidase human) RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 2 MG/50ML (rituximab) ROMIDEPSIN INTRAVENOUS SOLUTION 27.5 MG/5.5ML 3 ROZLYTREK ORAL CAPSULE 100 MG, 200 MG (entrectinib) 3 DSL = 30 days RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG 3 DSL = 30 days; OC (rucaparib camsylate) RUXIENCE INTRAVENOUS SOLUTION 100 MG/10ML 3 DSL = 30 days (rituximab-pvvr) RUXIENCE INTRAVENOUS SOLUTION 500 MG/50ML 3 (rituximab-pvvr) RYDAPT ORAL CAPSULE 25 MG (midostaurin) 2 DSL = 30 days; OC SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, 500 3 DSL = 30 days MG/25ML (isatuximab-irfc) SIKLOS ORAL TABLET 100 MG (hydroxyurea) 3 SIKLOS ORAL TABLET 1000 MG (hydroxyurea) 3 DSL = 30 days SOLARAVIX EXTERNAL THERAPY PACK 3 % 3 SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) PV OC SPRYCEL ORAL TABLET 100 MG, 20 MG, 50 MG, 70 MG, 80 2 DSL = 30 days; OC MG (dasatinib) SPRYCEL ORAL TABLET 140 MG (dasatinib) 3 DSL = 30 days; OC STIVARGA ORAL TABLET 40 MG (regorafenib) 2 DSL = 30 days; OC

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 41 Coverage Requirements & Prescription Drug Name Drug Tier Limits SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin 3 acetate (cpp)) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG 2 DSL = 30 days; OC (sunitinib malate) SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 2 DSL = 30 days MG, 400 MG (siltuximab) SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 3.5 MG (omacetaxine mepesuccinate) TABLOID ORAL TABLET 40 MG (thioguanine) 2 OC TABRECTA ORAL TABLET 150 MG, 200 MG (capmatinib hcl) 3 DSL = 30 days TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib 2 DSL = 30 days; OC mesylate) TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib 2 DSL = 30 days; OC mesylate) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib 3 tosylate) tamoxifen citrate oral tablet 10 mg, 20 mg PV OC TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG (erlotinib 3 DSL = 30 days; OC hcl) TARGRETIN EXTERNAL GEL 1 % (bexarotene) 2 TARGRETIN ORAL CAPSULE 75 MG (bexarotene) 2 OC TASIGNA ORAL CAPSULE 150 MG, 200 MG (nilotinib hcl) 2 DSL = 30 days; OC TASIGNA ORAL CAPSULE 50 MG (nilotinib hcl) 3 DSL = 30 days TAZVERIK ORAL TABLET 200 MG (tazemetostat hbr) 3 DSL = 30 days TECARTUS INTRAVENOUS SUSPENSION (brexucabtagene 3 autoleucel) TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML 2 DSL = 30 days (atezolizumab) TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14ML 3 (atezolizumab) TEMODAR INTRAVENOUS SOLUTION RECONSTITUTED 3 100 MG (temozolomide) TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 250 3 OC MG (temozolomide) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 1 OC 250 mg, 5 mg temsirolimus intravenous solution 25 mg/ml 1 teniposide intravenous solution 10 mg/ml 1 TEPADINA INJECTION SOLUTION RECONSTITUTED 100 3 DSL = 30 days MG, 15 MG (thiotepa)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 42 Coverage Requirements & Prescription Drug Name Drug Tier Limits TEPMETKO ORAL TABLET 225 MG (tepotinib hcl) 3 DSL = 30 days thiotepa injection solution reconstituted 100 mg, 15 mg 1 DSL = 30 days TIBSOVO ORAL TABLET 250 MG (ivosidenib) 3 DSL = 30 days TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 2 50 MG (bcg live) etoposide (Toposar Intravenous Solution 1 Gm/50Ml, 100 1 Mg/5Ml, 500 Mg/25Ml) topotecan hcl intravenous solution 4 mg/4ml 1 topotecan hcl intravenous solution reconstituted 4 mg 1 toremifene citrate oral tablet 60 mg PV OC TORISEL INTRAVENOUS SOLUTION 25 MG/ML 2 (temsirolimus) TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 3 150 MG (trastuzumab-qyyp) TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 420 MG (trastuzumab-qyyp) TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 2 MG (bendamustine hcl) TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 25 3 MG (bendamustine hcl) TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG (triptorelin 3 pamoate) oral capsule 10 mg 1 DSL = 30 days; OC TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 OC (methotrexate sodium) TRIPTODUR INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED ER 22.5 MG (triptorelin pamoate) TRISENOX INTRAVENOUS SOLUTION 12 MG/6ML (arsenic 2 DSL = 30 days trioxide) TRODELVY INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 180 MG (sacituzumab govitecan-hziy) TRUXIMA INTRAVENOUS SOLUTION 100 MG/10ML, 500 3 DSL = 30 days MG/50ML (rituximab-abbs) TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) 3 DSL = 30 days TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) 3 DSL = 30 days TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) 2 DSL = 30 days; OC UKONIQ ORAL TABLET 200 MG (umbralisib tosylate) 3 DSL = 30 days UNITUXIN INTRAVENOUS SOLUTION 17.5 MG/5ML 2 DSL = 30 days (dinutuximab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 43 Coverage Requirements & Prescription Drug Name Drug Tier Limits VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine hcl 3 DSL = 30 days (topical)) valrubicin intravesical solution 40 mg/ml 1 VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) 3 VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 3 MG/20ML (panitumumab) VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG 2 (bortezomib) VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG 2 DSL = 30 days; OC (venetoclax) VENCLEXTA STARTING PACK ORAL TABLET THERAPY 2 DSL = 30 days; OC PACK 10 & 50 & 100 MG (venetoclax) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 DSL = 30 days; OC (abemaciclib) vinblastine sulfate intravenous solution 1 mg/ml 1 vincristine sulfate intravenous solution 1 mg/ml 1 vinorelbine tartrate intravenous solution 10 mg/ml, 50 mg/5ml 1 VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib 3 DSL = 30 days sulfate) VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib sulfate) 3 DSL = 30 days VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG (dacomitinib) 3 DSL = 30 days VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) 2 DSL = 30 days; OC VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 2 DSL = 30 days 44-100 MG (daunorubicin-cytarabine lipo) XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) 2 DSL = 30 days; OC XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 DSL = 30 days; OC XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) 3 DSL = 30 days; OC XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) 3 XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 DSL = 30 days PACK 20 MG (selinexor) XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 DSL = 30 days PACK 20 MG (selinexor) XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY 3 DSL = 30 days PACK 20 MG (selinexor) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 DSL = 30 days PACK 20 MG (selinexor) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY 3 DSL = 30 days PACK 20 MG (selinexor) XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 DSL = 30 days PACK 20 MG (selinexor)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 44 Coverage Requirements & Prescription Drug Name Drug Tier Limits XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY 3 DSL = 30 days PACK 20 MG (selinexor) XTANDI ORAL CAPSULE 40 MG () 2 DSL = 30 days; OC XTANDI ORAL TABLET 40 MG, 80 MG (enzalutamide) 2 YERVOY INTRAVENOUS SOLUTION 200 MG/40ML, 50 2 MG/10ML (ipilimumab) YESCARTA INTRAVENOUS SUSPENSION (axicabtagene 3 ciloleucel) YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 2 DSL = 30 days MG (trabectedin) YONSA ORAL TABLET 125 MG (abiraterone acetate) 3 DSL = 30 days ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML, 200 3 DSL = 30 days MG/8ML (ziv-aflibercept) ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 2 GM (streptozocin) ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) 2 DSL = 30 days; OC ZELBORAF ORAL TABLET 240 MG (vemurafenib) 2 DSL = 30 days; OC ZEPZELCA INTRAVENOUS SOLUTION RECONSTITUTED 4 3 DSL = 30 days MG (lurbinectedin) ZEVALIN Y-90 INTRAVENOUS KIT 3.2 MG/2ML (ibritumomab 3 tiuxetan for y-90) ZIRABEV INTRAVENOUS SOLUTION 100 MG/4ML 3 DSL = 30 days (bevacizumab-bvzr) ZIRABEV INTRAVENOUS SOLUTION 400 MG/16ML 3 (bevacizumab-bvzr) ZOLINZA ORAL CAPSULE 100 MG (vorinostat) 3 OC ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) 2 DSL = 30 days; OC ZYKADIA ORAL TABLET 150 MG (ceritinib) 2 DSL = 30 days ZYTIGA ORAL TABLET 250 MG (abiraterone acetate) 3 DSL = 30 days; OC ZYTIGA ORAL TABLET 500 MG (abiraterone acetate) 2 DSL = 30 days; OC ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM ALLERGENIC EXTRACTS (THERAPEUTIC) - DRUGS FOR THE IMMUNE SYSTEM ACACIA SUBCUTANEOUS SOLUTION 1:20 3 ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 ALDER SUBCUTANEOUS SOLUTION 1:20 3 ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20 3 AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 45 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20 3 ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20 3 AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 3 PNU/ML, 20000 PNU/ML AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20 3 BAHIA SUBCUTANEOUS SOLUTION 1:20 3 BALD CYPRESS SUBCUTANEOUS SOLUTION 1:20 3 BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 3 1:20 BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 3 BAU/ML BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20 3 BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 BROME SUBCUTANEOUS SOLUTION 1:20 3 CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 3 1:20 CANDIDA ALBICANS EXTRACT SUBCUTANEOUS 3 SOLUTION 10000 PNU/ML CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 3 BAU/ML CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 3 CEDAR ELM SUBCUTANEOUS SOLUTION 1:20 3 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS 3 SOLUTION 10000 PNU/ML, 20000 PNU/ML CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS 3 SOLUTION 20000 PNU/ML COCKLEBUR SUBCUTANEOUS SOLUTION 1:20 3 CORN POLLEN SUBCUTANEOUS SOLUTION 1:20 3 CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20 3 DOG FENNEL SUBCUTANEOUS SOLUTION 1:20 3 DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS 3 SOLUTION 10000 AU/ML EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 3 1:20 EPICOCCUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 46 Coverage Requirements & Prescription Drug Name Drug Tier Limits FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML GERMAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 3 GOLDENROD SUBCUTANEOUS SOLUTION 1:20 3 GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU 2 (timothy grass pollen allergen) HACKBERRY SUBCUTANEOUS SOLUTION 1:20 3 HONEY BEE VENOM SUBCUTANEOUS SOLUTION 3 RECONSTITUTED 1100 MCG HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 3 1:20 JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20 3 JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML KAPOK SUBCUTANEOUS SOLUTION 1:20 3 KOCHIA SUBCUTANEOUS SOLUTION 1:20 3 MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML MELALEUCA SUBCUTANEOUS SOLUTION 1:20 3 MESQUITE SUBCUTANEOUS SOLUTION 1:20 3 MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 3 AU/ML MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 3 10000 AU/ML MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 3 PNU/ML MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20 3 MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20 3 MIXED VESPID VENOM PROTEIN SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 1100-1100-1100 MCG MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20 3 MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 3 MUCOR SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 3 PNU/ML MUGWORT SUBCUTANEOUS SOLUTION 1:20 3 ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM 2 (dust mite mixed allergen ext) OLIVE TREE SUBCUTANEOUS SOLUTION 1:20 3 ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET 3 SUBLINGUAL 300 IR (grass mix pollens allergen ext)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 47 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORALAIR CHILDRENS STARTER PACK SUBLINGUAL 3 TABLET SUBLINGUAL 100 IR (grass mix pollens allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR (grass 3 mix pollens allergen ext) ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 3 100000 BAU/ML PALFORZIA ORAL 0.5 & 1 & 1.5 & 3 & 6 MG, 2 X 1 MG & 10 MG, 2 X 100 MG, 2 X 20 MG, 2 X 20 MG & 2 X 100 MG, 20 3 DSL = 30 days MG, 20 MG & 100 MG, 3 X 1 MG, 3 X 20 MG & 100 MG, 4 X 20 MG, 6 X 1 MG (peanut powder-dnfp) PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 DSL = 30 days PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 3 10000 PNU/ML, 20000 PNU/ML PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 3 PNU/ML PRIVET SUBCUTANEOUS SOLUTION 1:20 3 QUEEN PALM SUBCUTANEOUS SOLUTION 1:20 3 RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 3 1:20 RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 3 1-U (short ragweed pollen ext) RED MAPLE SUBCUTANEOUS SOLUTION 1:20 3 RED MULBERRY SUBCUTANEOUS SOLUTION 1:20 3 RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 3 100000 BAU/ML RHIZOPUS SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20 3 RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20 3 SACCHAROMYCES CEREVISIAE SUBCUTANEOUS 3 SOLUTION 20000 PNU/ML SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20 3 SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20 3 SHORT RAGWEED POLLEN EXT SUBCUTANEOUS 3 SOLUTION 1:20 SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20 3 SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20 3 SWEET GUM SUBCUTANEOUS SOLUTION 1:20 3 SWEET VERNAL GRASS POLLEN SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 48 Coverage Requirements & Prescription Drug Name Drug Tier Limits TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20 3 TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS 3 SOLUTION 10000 BAU/ML, 100000 BAU/ML TRICHOPHYTON MENTAGROPHYTES SUBCUTANEOUS 3 SOLUTION 1:20 TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 3 PNU/ML WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED 1100 MCG WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20 3 WHITE BIRCH SUBCUTANEOUS SOLUTION 1:20 3 WHITE FACED HORNET VENOM SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 1100 MCG WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20 3 WHITE OAK SUBCUTANEOUS SOLUTION 1:20 3 WHITE PINE SUBCUTANEOUS SOLUTION 1:20 3 YELLOW DOCK SUBCUTANEOUS SOLUTION 1:20 3 YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 1100 MCG YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 120 MCG ANTITOXINS AND IMMUNE GLOBULINS - Organ Transplant ANTIVENIN LATRODECTUS MACTANS INJECTION KIT 2 ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION 3 RECONSTITUTED ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML (immune 3 DSL = 30 days globulin (human)-slra) BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML (immune 2 globulin (human)) CARIMUNE NF INTRAVENOUS SOLUTION 2 RECONSTITUTED 12 GM, 6 GM (immune globulin (human)) CROFAB INTRAVENOUS SOLUTION RECONSTITUTED 2 (crotalidae polyval immune fab) CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 GM/48ML 3 (immune globulin (human)-hipp) CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 2 DSL = 30 days GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin (human)) CUVITRU SUBCUTANEOUS SOLUTION 8 GM/40ML (immune 3 DSL = 30 days globulin (human))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 49 Coverage Requirements & Prescription Drug Name Drug Tier Limits CYTOGAM INTRAVENOUS INJECTABLE 50 MG/ML 2 (cytomegalovirus immune glob) DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 2 MG (digoxin immune fab) FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 2 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMASTAN INTRAMUSCULAR INJECTABLE (immune 2 globulin (human)) GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 2 GM/50ML (immune globulin (human)) GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION 2 RECONSTITUTED 10 GM, 5 GM (immune globulin (human)) GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML (immune globulin 2 (human)) GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 2 GM/50ML (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML (immune 2 globulin (human)) GAMUNEX-C INJECTION SOLUTION 40 GM/400ML (immune 3 globulin (human)) HEPAGAM B INJECTION SOLUTION ( b immune 3 globulin) HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 2 DSL = 30 days GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune 3 globulin (human)) HYPERHEP B INTRAMUSCULAR SOLUTION (hepatitis b 2 immune globulin) HYPERRAB INJECTION SOLUTION 1500 UNIT/5ML, 900 3 UNIT/3ML (rabies immune globulin) HYPERRAB INJECTION SOLUTION 300 UNIT/ML (rabies 2 immune globulin) HYPERRAB S/D INJECTION SOLUTION 1500 UNIT/10ML, 3 300 UNIT/2ML (rabies immune globulin) HYPERRHO S/D INTRAMUSCULAR SOLUTION PREFILLED 2 SYRINGE 1500 UNIT, 250 UNIT (rho d immune globulin)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 50 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYPERTET S/D INTRAMUSCULAR INJECTABLE 250 2 UNIT/ML (tetanus immune globulin) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML (immune globulin- 2 DSL = 30 days hyaluronidase) IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML 3 (rabies immune globulin) KEDRAB INJECTION SOLUTION 1500 UNIT/10ML, 300 3 UNIT/2ML MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 250 UNIT (rho d immune 2 globulin) NABI-HB INTRAMUSCULAR SOLUTION (hepatitis b immune 2 globulin) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 25 2 GM/500ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) OCTAGAM INTRAVENOUS SOLUTION 2 GM/20ML, 30 3 GM/300ML (immune globulin (human)) PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 3 GM/50ML (immune globulin (human)-ifas) PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 2 GM/200ML, 5 GM/50ML (immune globulin (human)) PRIVIGEN INTRAVENOUS SOLUTION 40 GM/400ML 3 (immune globulin (human)) RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 1500 UNIT (rho d immune 2 globulin) RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE 2 1500 UNIT/2ML (rho d immune globulin) VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML 3 (varicella-zoster immune glob) WINRHO SDF INJECTION SOLUTION 1500 UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000 UNIT/4.4ML (rho d 3 immune globulin) XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin (human)- 3 DSL = 30 days klhw) ZINPLAVA INTRAVENOUS SOLUTION 1000 MG/40ML 3 (bezlotoxumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 51 Coverage Requirements & Prescription Drug Name Drug Tier Limits VACCINES - Vaccines AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PV (influenza vac split quad) AFLURIA QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.25 ML, 0.5 ML (influenza vac split PV quad) FLUAD INTRAMUSCULAR SUSPENSION PREFILLED PV SYRINGE 0.5 ML (influenza vac a&b surf ant adj) FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED PV SYRINGE 0.5 ML (influenza vac a&b sa adj quad) FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PV PREFILLED SYRINGE 0.5 ML (influenza vac split quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR PV SUSPENSION (influenza vac subunit quad) FLUCELVAX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac PV subunit quad) FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac PV split quad) FLUMIST QUADRIVALENT NASAL SUSPENSION (influenza PV virus vac live quad) FLUZONE HIGH-DOSE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.7 ML (influenza vac PV high-dose quad) FLUZONE QUADRIVALENT INTRAMUSCULAR PV SUSPENSION , 0.5 ML (influenza vac split quad) FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML (influenza vac PV split quad) TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 2 50 MG (bcg live) AUTONOMIC DRUGS - Drugs for the Nervous System ALPHA- AND BETA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADRENALIN INJECTION SOLUTION 1 MG/ML (epinephrine) 3 ADYPHREN AMP II INJECTION KIT 1 MG/ML (epinephrine) 3 ADYPHREN AMP INJECTION KIT 1 MG/ML (epinephrine) 3 ADYPHREN II INJECTION KIT 1 MG/ML (epinephrine) 3 ADYPHREN INJECTION KIT 1 MG/ML (epinephrine) 3 AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 3 DSL = 30 days MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 52 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) droxidopa oral capsule 100 mg, 200 mg, 300 mg 1 DSL = 30 days ephedrine sulfate intravenous solution 50 mg/ml 1 EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 50-0.9 MG/10ML-%, 50-0.9 MG/5ML-% epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 1 DSL = 30 days mg/0.3ml epinephrine injection solution auto-injector 0.15 mg/0.3ml 1 EPINEPHRINE PROFESSIONAL INJECTION KIT 1 MG/ML 3 EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML 3 (epinephrine) EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML 3 (epinephrine) EPISNAP INJECTION KIT 1 MG/ML (epinephrine) 3 NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG 3 DSL = 30 days (droxidopa) pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 3 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ALPHA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 3 MG/24HR (clonidine) CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY 0.2 3 MG/24HR (clonidine) CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY 0.3 3 MG/24HR (clonidine) clonidine hcl er oral tablet extended release 12 hour 0.1 mg 1 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 1 0.3 mg/24hr GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) 3 DSL = 30 days methyldopa oral tablet 250 mg, 500 mg 1 methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 1 mg midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 53 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML 3 (phenylephrine-chlorphen-dm) PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 1-0.9 MG/10ML-%, 20-0.9 MG/50ML-% promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 ANTIMUSCARINICS/ANTISPASMODICS - Drugs for Parkinson ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 (hyoscyamine sulfate) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 vilanterol) ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML (atropine sulfate) atropine sulfate injection solution 0.4 mg/ml, 1 mg/ml, 8 1 mg/20ml atropine sulfate injection solution prefilled syringe 0.25 mg/5ml, 1 0.5 mg/5ml, 1 mg/10ml atropine sulfate intravenous solution 0.4 mg/ml, 1 mg/ml 1 ATROPINE SULFATE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 0.8 MG/2ML, 1 MG/2.5ML, 1.2 MG/3ML ATROVENT HFA INHALATION AEROSOL SOLUTION 17 PV MCG/ACT (ipratropium bromide hfa) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 3 MCG/ACT (glycopyrrolate-formoterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 MCG/ACT (budeson-glycopyrrol-formoterol) chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION PV 20-100 MCG/ACT (ipratropium-albuterol) CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) 2 dicyclomine hcl oral capsule 10 mg 1 dicyclomine hcl oral solution 10 mg/5ml 1 dicyclomine hcl oral tablet 20 mg 1 diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 54 Coverage Requirements & Prescription Drug Name Drug Tier Limits DONNATAL ORAL ELIXIR 16.2 MG/5ML (pb-hyoscy-atropine- 2 scopolamine) DONNATAL ORAL TABLET 16.2 MG (pb-hyoscy-atropine- 3 scopolamine) DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 DSL = 30 days formoterol fum) ED-SPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 GLYCATE ORAL TABLET 1.5 MG (glycopyrrolate) 3 GLYCOPYRROLATE INJECTION SOLUTION PREFILLED 3 SYRINGE 0.6 MG/3ML, 1 MG/5ML GLYCOPYRROLATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 0.6 MG/3ML, 1 MG/5ML glycopyrrolate oral tablet 1 mg, 2 mg 1 GLYCOPYRROLATE ORAL TABLET 1.5 MG 3 glycopyrrolate pf injection solution prefilled syringe 0.2 mg/ml, 1 0.4 mg/2ml GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE 0.6 3 MG/3ML, 1 MG/5ML (glycopyrrolate) hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 hydrocodone-homatropine oral tablet 5-1.5 mg 1 hydromet oral syrup 5-1.5 mg/5ml 1 hyoscyamine sulfate er oral tablet extended release 12 hour 1 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml 1 hyoscyamine sulfate oral solution 0.125 mg/ml 1 hyoscyamine sulfate oral tablet 0.125 mg 1 hyoscyamine sulfate oral tablet dispersible 0.125 mg 1 hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg 1 hyoscyamine sulfate sublingual tablet sublingual 0.125 mg 1 hyosyne oral elixir 0.125 mg/5ml 1 hyosyne oral solution 0.125 mg/ml 1 INCRUSE ELLIPTA INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 62.5 MCG/INH (umeclidinium bromide) ipratropium bromide inhalation solution 0.02 % PV ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 3 0.375 MG (hyoscyamine sulfate) LEVSIN ORAL TABLET 0.125 MG (hyoscyamine sulfate) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 55 Coverage Requirements & Prescription Drug Name Drug Tier Limits LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 3 (hyoscyamine sulfate) LONHALA MAGNAIR REFILL KIT INHALATION SOLUTION 25 3 DSL = 30 days MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION SOLUTION 3 DSL = 30 days 25 MCG/ML (glycopyrrolate) methscopolamine bromide oral tablet 2.5 mg, 5 mg 1 hyoscyamine sulfate (Nulev Oral Tablet Dispersible 0.125 Mg) 3 oscimin oral tablet 0.125 mg 1 oscimin sr oral tablet extended release 12 hour 0.375 mg 1 oscimin sublingual tablet sublingual 0.125 mg 1 pb-hyoscy-atropine-scopolamine oral elixir 16.2 mg/5ml 1 pb-hyoscy-atropine-scopolamine oral tablet 16.2 mg 1 phenobarbital-belladonna alk oral elixir 16.2 mg/5ml 1 phenobarbital-belladonna alk oral tablet 16.2 mg 1 pb-hyoscy-atropine-scopolamine (Phenohytro Oral Elixir 16.2 2 Mg/5Ml) pb-hyoscy-atropine-scopolamine (Phenohytro Oral Tablet 16.2 3 Mg) QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium tosylate) 3 SEEBRI NEOHALER INHALATION CAPSULE 15.6 MCG 3 (glycopyrrolate) SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 3 (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 3 MCG/ACT (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 2 MCG/ACT (tiotropium bromide monohydrate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5-2.5 MCG/ACT (tiotropium bromide-olodaterol) SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 3 MG (hyoscyamine sulfate) hyoscyamine sulfate (Symax-Sl Sublingual Tablet Sublingual 3 0.125 Mg) hyoscyamine sulfate (Symax-Sr Oral Tablet Extended Release 3 12 Hour 0.375 Mg) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 3 umeclidin-vilant) TUDORZA PRESSAIR INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 400 MCG/ACT (aclidinium bromide) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 56 Coverage Requirements & Prescription Drug Name Drug Tier Limits UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 3 MCG (indacaterol-glycopyrrolate) YUPELRI INHALATION SOLUTION 175 MCG/3ML 3 (revefenacin) ANTIPARKINSONIAN AGENTS - Drugs for Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 trihexyphenidyl hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 AUTONOMIC DRUGS, MISCELLANEOUS - Drugs for the Nervous System CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG PV (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline tartrate) PV CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X PV 11 & 1 MG X 42 (varenicline tartrate) goodsense nicotine mouth/throat lozenge 4 mg PV NICORETTE MOUTH/THROAT GUM 2 MG (nicotine polacrilex) PV nicotine polacrilex mouth/throat gum 2 mg, 4 mg PV nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg PV nicotine step 1 transdermal patch 24 hour 21 mg/24hr PV nicotine step 2 transdermal patch 24 hour 14 mg/24hr PV nicotine step 3 transdermal patch 24 hour 7 mg/24hr PV NICOTROL INHALATION INHALER 10 MG (nicotine) PV NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) PV CENTRALLY ACTING RELAXNT - Drugs for Relaxing Muscles carisoprodol oral tablet 250 mg, 350 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 chlorzoxazone oral tablet 250 mg 1 DSL = 30 days chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg 1 cyclobenzaprine hcl er oral capsule extended release 24 hour 1 15 mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg 1 CYCLOPAK COMBINATION THERAPY PACK 5 & 2.5-2.5 MG 3 & % (cyclobenz-lido-prilo-swall spr) chlorzoxazone (Lorzone Oral Tablet 375 Mg, 750 Mg) 3 metaxalone oral tablet 400 mg, 800 mg 1 methocarbamol oral tablet 500 mg, 750 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 57 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOPIOID-LMC KIT COMBINATION THERAPY PACK 7.5 & 4-4 3 MG & % (cyclobenzaprine-lidocaine-ment) tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg 1 tizanidine hcl oral tablet 2 mg, 4 mg 1 DIRECT-ACTING SKELETAL MUSCLE RELAXANTS - Drugs for Relaxing Muscles dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1 GABA-DERIVATIVE SKELETAL - Drugs for Relaxing Muscles baclofen intrathecal solution 10 mg/20ml, 20000 mcg/20ml, 40 1 mg/20ml baclofen oral tablet 10 mg, 20 mg, 5 mg 1 GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 10000 MCG/20ML, 20000 MCG/20ML, 40000 2 MCG/20ML, 50 MCG/ML (baclofen) LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 3 MG/5ML (baclofen) OZOBAX ORAL SOLUTION 5 MG/5ML (baclofen) 3 NEUROMUSCULAR BLOCKING AGENTS - Drugs for Relaxing Muscles SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 140 MG/7ML VECURONIUM BROMIDE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 10 MG/10ML NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 hour 1 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol hcl) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 58 Coverage Requirements & Prescription Drug Name Drug Tier Limits INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS - Drugs for the Heart CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 2 DIBENZYLINE ORAL CAPSULE 10 MG (phenoxybenzamine 3 hcl) dihydroergotamine mesylate injection solution 1 mg/ml 1 DSL = 30 days dihydroergotamine mesylate nasal solution 4 mg/ml 1 DSL = 30 days ergoloid mesylates oral tablet 1 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 2 (ergotamine tartrate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 59 Coverage Requirements & Prescription Drug Name Drug Tier Limits ergotamine-caffeine oral tablet 1-100 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 2 caffeine) MIGRANAL NASAL SOLUTION 4 MG/ML (dihydroergotamine 2 DSL = 30 days mesylate) phenoxybenzamine hcl oral capsule 10 mg 1 phentolamine mesylate injection solution reconstituted 5 mg 1 TRI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 2 150-5-50 MG-MG-MCG PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) - Drugs for Bladder Incontinence bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1 cevimeline hcl oral capsule 30 mg 1 donepezil hcl oral tablet 10 mg, 23 mg, 5 mg 1 donepezil hcl oral tablet dispersible 10 mg, 5 mg 1 galantamine hydrobromide er oral capsule extended release 24 1 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml 1 galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg 1 GUANIDINE HCL ORAL TABLET 125 MG 2 MESTINON ORAL SOLUTION 60 MG/5ML (pyridostigmine 2 bromide) MESTINON ORAL TABLET EXTENDED RELEASE 180 MG 2 (pyridostigmine bromide) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 3 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 DSL = 30 days 14-10 MG, 28-10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 21-10 MG, 7-10 MG (memantine hcl-donepezil hcl) NEOSTIGMINE METHYLSULFATE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE 5 MG/5ML pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 pyridostigmine bromide er oral tablet extended release 180 mg 1 pyridostigmine bromide oral solution 60 mg/5ml 1 pyridostigmine bromide oral tablet 30 mg, 60 mg 1 rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 1 rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 1 mg/24hr, 9.5 mg/24hr

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 60 Coverage Requirements & Prescription Drug Name Drug Tier Limits SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT - Drugs for the Heart alfuzosin hcl er oral tablet extended release 24 hour 10 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 hour 1 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) -tamsulosin hcl oral capsule 0.5-0.4 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 silodosin oral capsule 4 mg, 8 mg 1 tamsulosin hcl oral capsule 0.4 mg 1 SELECTIVE BETA-2-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 2 MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 3 55-14 MCG/ACT (fluticasone-salmeterol) AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT 3 (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT 3 (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT (fluticasone- 3 salmeterol) albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 PV mg albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act PV inhalation 108 (90 base) mcg/act ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) PV 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 61 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 PV MG/ML) 0.5% INHALATION (5 MG/ML) 0.5% albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation PV (5 mg/ml) 0.5% albuterol sulfate oral syrup 2 mg/5ml PV albuterol sulfate oral tablet 2 mg, 4 mg PV ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 vilanterol) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 3 MCG/ACT (glycopyrrolate-formoterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH (fluticasone 3 furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 MCG/ACT (budeson-glycopyrrol-formoterol) BROVANA INHALATION NEBULIZATION SOLUTION 15 3 MCG/2ML (arformoterol tartrate) BUDESONIDE-FORMOTEROL FUMARATE INHALATION 3 AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION PV 20-100 MCG/ACT (ipratropium-albuterol) DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 DSL = 30 days formoterol fum) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 3 MCG/ACT, 50-5 MCG/ACT (mometasone furo-formoterol fum) fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 1 mcg/dose FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 3 MCG/ACT, 55-14 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 3 MCG/2ML (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER PV BREATH ACTIVATED 108 MCG/ACT (albuterol sulfate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 62 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT (albuterol PV sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT (albuterol sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5-2.5 MCG/ACT (tiotropium bromide-olodaterol) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5 MCG/ACT (olodaterol hcl) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 4.5 MCG/ACT (budesonide-formoterol fumarate) terbutaline sulfate injection solution 1 mg/ml PV terbutaline sulfate oral tablet 2.5 mg, 5 mg PV TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 3 umeclidin-vilant) UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 3 MCG (indacaterol-glycopyrrolate) VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT (albuterol sulfate) fluticasone-salmeterol (Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 Mcg/Dose, 250-50 Mcg/Dose, 500-50 1 Mcg/Dose) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT 3 (levalbuterol tartrate) SELECTIVE BETA-ADRENERGIC BLOCKING AGENT - Drugs for the Heart acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 63 Coverage Requirements & Prescription Drug Name Drug Tier Limits ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 1 75 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS - Drugs for Relaxing Muscles BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 2 200 UNIT (onabotulinumtoxina) DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 3 300 UNIT, 500 UNIT (abobotulinumtoxina) MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, 2 2500 UNIT/0.5ML, 5000 UNIT/ML (rimabotulinumtoxinb) NORGESIC FORTE ORAL TABLET 50-770-60 MG 3 orphenadrine citrate er oral tablet extended release 12 hour 100 1 mg orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet 3 50-770-60 Mg) XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 3 100 UNIT, 200 UNIT, 50 UNIT (incobotulinumtoxina)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 64 Coverage Requirements & Prescription Drug Name Drug Tier Limits BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood ANTIANEMIA DRUGS - Vitamins and Minerals REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 25 MG, 75 MG (luspatercept-aamt) - Drugs to Prevent Blood Clots TRICITRASOL IN VITRO CONCENTRATE 46.7 % 3 ( sodium citrate) ANTICOAGULANTS, MISCELLANEOUS - Drugs to Prevent Blood Clots ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 2 GM/100ML (anticoagulant cit dext soln a) ANTICOAGULANT SODIUM CITRATE IN VITRO SOLUTION 4 3 GM/100ML ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 3 DSL = 30 days MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML (fondaparinux sodium) fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 1 DSL = 30 days mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml REGIOCIT IN VITRO SOLUTION 0.529 % (anticoagulant na cit 3 (crrt)) THROMBATE III INTRAVENOUS SOLUTION 3 RECONSTITUTED 1000 UNIT (antithrombin iii (human)) THROMBATE III INTRAVENOUS SOLUTION 2 RECONSTITUTED 500 UNIT (antithrombin iii (human)) AGENTS, MISCELLANEOUS - Drugs to Prevent Bleeding ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 200 3 MG (coag fact xa inactivated-zhzo) PRAXBIND INTRAVENOUS SOLUTION 2.5 GM/50ML 2 (idarucizumab) AGENTS, MISCELLANEOUS - Drugs to Prevent Blood Clots CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) 3 DSL = 30 days BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC. - Drugs to Prevent Bleeding ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML 3 DSL = 30 days (crizanlizumab-tmca) OXBRYTA ORAL TABLET 500 MG (voxelotor) 3 DSL = 30 days TAVALISSE ORAL TABLET 100 MG, 150 MG (fostamatinib 3 DSL = 30 days disodium)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 65 Coverage Requirements & Prescription Drug Name Drug Tier Limits COUMARIN DERIVATIVES - Drugs to Prevent Blood Clots warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, 2.5 1 Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 1 mg, 5 mg, 6 mg, 7.5 mg DIRECT FACTOR XA INHIBITORS - Drugs to Prevent Blood Clots ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 2.5 3 DSL = 30 days MG/0.5ML, 5 MG/0.4ML, 7.5 MG/0.6ML (fondaparinux sodium) ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY 3 PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) 3 fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 1 DSL = 30 days mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG (edoxaban 3 tosylate) XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG 3 (rivaroxaban) XARELTO STARTER PACK ORAL TABLET THERAPY PACK 3 15 & 20 MG (rivaroxaban) DIRECT THROMBIN INHIBITORS - Drugs to Prevent Blood Clots PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 2 (dabigatran etexilate mesylate) HEMATOPOIETIC AGENTS - Drugs for Anemia ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 PV DSL = 30 days MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 PV DSL = 30 days MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) DOPTELET ORAL TABLET 20 MG (avatrombopag maleate) 3 DSL = 30 days EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PV DSL = 30 days (epoetin alfa) FULPHILA SUBCUTANEOUS SOLUTION PREFILLED PV DSL = 30 days SYRINGE 6 MG/0.6ML (pegfilgrastim-jmdb) GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 PV DSL = 30 days MCG/1.6ML (tbo-filgrastim)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 66 Coverage Requirements & Prescription Drug Name Drug Tier Limits GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE PV DSL = 30 days 300 MCG/0.5ML, 480 MCG/0.8ML (tbo-filgrastim) LEUKINE INJECTION SOLUTION RECONSTITUTED 250 PV DSL = 30 days MCG (sargramostim) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 PV MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML (methoxy peg- epoetin beta) MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML 3 (plerixafor) MULPLETA ORAL TABLET 3 MG (lusutrombopag) 3 DSL = 30 days NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE PV KIT 6 MG/0.6ML (pegfilgrastim) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED PV SYRINGE 6 MG/0.6ML (pegfilgrastim) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 PV DSL = 30 days MCG/1.6ML (filgrastim) NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE PV DSL = 30 days 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 PV DSL = 30 days MCG/1.6ML (filgrastim-aafi) NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE PV DSL = 30 days 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim-aafi) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 125 MCG, 250 MCG, 500 MCG (romiplostim) NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED PV DSL = 30 days SYRINGE 6 MG/0.6ML (pegfilgrastim-apgf) PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, PV DSL = 30 days 40000 UNIT/ML (epoetin alfa) PROMACTA ORAL PACKET 12.5 MG, 25 MG (eltrombopag 3 DSL = 30 days olamine) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG 2 DSL = 30 days (eltrombopag olamine) REBLOZYL SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 25 MG, 75 MG (luspatercept-aamt) RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, PV DSL = 30 days 40000 UNIT/ML (epoetin alfa-epbx) UDENYCA SUBCUTANEOUS SOLUTION PREFILLED PV DSL = 30 days SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 67 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 PV DSL = 30 days MCG/0.5ML, 480 MCG/0.8ML (filgrastim-sndz) ZIEXTENZO SUBCUTANEOUS SOLUTION PREFILLED PV DSL = 30 days SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) HEMORRHEOLOGIC AGENTS - Drugs for Blood Flow pentoxifylline er oral tablet extended release 400 mg 1 HEMOSTATICS - Drugs to Prevent Bleeding ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 (antihemophil factor (rahf-pfm)) ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 4000 2 DSL = 30 days UNIT (antihemophil factor (rahf-pfm)) ADYNOVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 2 UNIT, 750 UNIT AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT 2 DSL = 30 days (antihemophil fact single chain) ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT 2 (antihemophilic factor-vwf) ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT 2 (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 4000 UNIT, 500 2 UNIT (coagulation factor ix (rfixfc)) aminocaproic acid oral solution 0.25 gm/ml 1 aminocaproic acid oral tablet 1000 mg, 500 mg 1 ASTRINGYN EXTERNAL SOLUTION 259 MG/GM (ferric 3 subsulfate) AVITENE EXTERNAL PAD (microfibrillar coll hemostat) 3 AVITENE FLOUR EXTERNAL POWDER (microfibrillar coll 3 hemostat) BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 2 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 2 250 UNIT, 500 UNIT (coagulation factor x (human)) CORIFACT INTRAVENOUS KIT 1000-1600 UNIT (factor xiii 2 concentrate human) DDAVP RHINAL TUBE NASAL SOLUTION 0.01 % 2 (desmopressin ace refrigerated)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 68 Coverage Requirements & Prescription Drug Name Drug Tier Limits desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml 1 ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 2 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc)) ENDO AVITENE EXTERNAL (absorbable collagen hemostat) 3 ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT 3 (antihemoph fact rcmb gpeg-exei) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant cmplx) FIBRYGA INTRAVENOUS SOLUTION RECONSTITUTED 2 (fibrinogen concentrate (human)) GELFOAM MOUTH/THROAT POWDER (gelatin absorbable) 3 HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 2 DSL = 30 days MG/ML, 30 MG/ML, 60 MG/0.4ML (emicizumab-kxwh) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 UNIT (antihemophilic 2 factor) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-1200 UNIT 2 (antihemophilic factor-vwf) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT (coagulation factor 2 ix (rix-fp)) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 3 3500 UNIT (coagulation factor ix (rix-fp)) IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 (coagulation factor ix (recomb)) JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd-rfviii peg- 3 DSL = 30 days aucl)) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT, 250 UNIT, 500 UNIT (antihemophilic factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 250 UNIT, 2 DSL = 30 days 500 UNIT (antihem factor recomb (rfviii))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 69 Coverage Requirements & Prescription Drug Name Drug Tier Limits KOGENATE FS INTRAVENOUS KIT 2000 UNIT, 3000 UNIT 2 (antihem factor recomb (rfviii)) KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT 2 (antihemophil factor (rahf-pfm)) MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 2 1000 UNIT (coagulation factor ix) monsels ferric subsulfate external solution 1 NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 55.3 MCG (desmopressin acetate) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 2 UNIT (antihemophil fact bd truncated) NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation 2 DSL = 30 days factor viia recomb) NUWIQ INTRAVENOUS KIT 1000 UNIT, 250 UNIT, 500 UNIT 3 DSL = 30 days (antihem fact (bdd-rfviii,sim)) NUWIQ INTRAVENOUS KIT 2000 UNIT, 2500 UNIT, 3000 3 UNIT, 4000 UNIT (antihem fact (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT (antihem fact (bdd- 2 rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 2500 3 UNIT, 3000 UNIT, 4000 UNIT (antihem fact (bdd-rfviii,sim)) OBIZUR INTRAVENOUS SOLUTION RECONSTITUTED 500 2 UNIT PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 1000 UNIT, 1500 UNIT, 500 UNIT (factor ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT (coagulation factor ix 3 glycopeg) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, 801- 2 DSL = 30 days 1240 UNIT (antihem factor recomb (rfviii)) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 220-400 UNIT, 401-800 UNIT (antihem 2 factor recomb (rfviii)) RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 2 20000 UNIT, 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION 2 RECONSTITUTED 20000 UNIT (thrombin (recombinant))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 70 Coverage Requirements & Prescription Drug Name Drug Tier Limits RIASTAP INTRAVENOUS SOLUTION RECONSTITUTED 2 (fibrinogen concentrate (human)) RIXUBIS INTRAVENOUS SOLUTION RECONSTITUTED 1000 2 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT SEVENFACT INTRAVENOUS SOLUTION RECONSTITUTED 3 1 MG, 5 MG (coagulation factor viia-jncw) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 2 acetate) SYRINGE AVITENE EXTERNAL (absorbable collagen 3 hemostat) TACHOSIL EXTERNAL PATCH 4.8 X 4.8 CM, 9.5 X 4.8 CM 3 (absorbable fibrin sealant) THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT 3 (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT (thrombin) 2 THROMBIN-JMI EXTERNAL KIT 5000 UNIT (thrombin) 3 tranexamic acid intravenous solution 1000 mg/10ml 1 tranexamic acid oral tablet 650 mg 1 TRANEXAMIC ACID-NACL INTRAVENOUS SOLUTION 1000- 3 0.7 MG/100ML-% TRETTEN INTRAVENOUS SOLUTION RECONSTITUTED 2 2000-3125 UNIT (coagulation factor xiii a-sub) VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 1300 UNIT, 650 UNIT (von willebrand factor (recomb)) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 UNIT 2 (antihemophilic factor-vwf) XYNTHA INTRAVENOUS KIT 1000 UNIT, 250 UNIT, 500 UNIT 2 DSL = 30 days (antihem fact (bdd-rfviii,mor)) XYNTHA INTRAVENOUS KIT 2000 UNIT (antihem fact (bdd- 2 rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 250 2 DSL = 30 days UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 2000 UNIT, 3000 2 UNIT (antihem fact (bdd-rfviii,mor)) HEPARINS - Drugs to Prevent Blood Clots enoxaparin sodium injection solution 300 mg/3ml 1 DSL = 30 days enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 1 DSL = 30 days 80 mg/0.8ml

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 71 Coverage Requirements & Prescription Drug Name Drug Tier Limits FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 3 DSL = 30 days 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin (porcine) in nacl intravenous solution 1000-0.9 1 ut/500ml-%, 2000-0.9 unit/l-% heparin lock flush intravenous solution 10 unit/ml 1 heparin sodium (porcine) injection solution 1000 unit/ml, 10000 1 unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) injection solution prefilled syringe 1 5000 unit/0.5ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml, 1 5000 unit/ml heparin sodium lock flush intravenous solution 100 unit/ml 1 LOVENOX INJECTION SOLUTION 300 MG/3ML (enoxaparin 2 DSL = 30 days sodium) LOVENOX SUBCUTANEOUS SOLUTION 100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 2 DSL = 30 days MG/0.6ML, 80 MG/0.8ML (enoxaparin sodium) IRON PREPARATIONS - Vitamins and Minerals ACTIVE FE ORAL TABLET 75-1.25 MG 3 AZESCHEW PRENATAL/POSTNATAL ORAL TABLET 3 CHEWABLE 13-1 MG AZESCO ORAL TABLET 13-1 MG 3 BACMIN ORAL TABLET (multiple vitamins-minerals) 3 b-plex plus oral tablet 1 CENTRATEX ORAL CAPSULE 106-1 MG (fe fum-fa-b cmp-c- 3 zn-mg-mn-cu) iron combinations (Chromagen Oral Capsule) 3 CITRANATAL BLOOM ORAL TABLET 90-1 MG (prenatal-dss- 3 fecb-fegl-fa) CORVITE 150 ORAL TABLET (iron combinations) 3 CORVITE 150 ORAL TABLET 150-1.25 MG (iron-folic acid-c- 3 b6-b12-) corvite fe oral tablet 1 ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) ENLYTE ORAL CAPSULE (dietary management product) 3 FERAHEME INTRAVENOUS SOLUTION 510 MG/17ML PV (ferumoxytol)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 72 Coverage Requirements & Prescription Drug Name Drug Tier Limits FERIVA 21/7 ORAL TABLET 75-1 MG (feasp-b12-fa-c-dss- 3 succac-zn) FERIVAFA ORAL CAPSULE 110-1 MG (iron-vit c-fa-b12-biot- 3 cu-dss) ferocon oral capsule PV ferotrinsic oral capsule PV FERRALET 90 ORAL TABLET 90-1 MG (fe cbn-fe gluc-fa-b12- 3 c-dss) ferraplus 90 oral tablet 90-1 mg 1 fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet 106- 1 1 Mg) ferrous sulfate oral solution 75 (15 fe) mg/ml PV FOLITIN-Z ORAL TABLET (multiple vitamins-minerals) 3 foltrin oral capsule PV FUSION PLUS ORAL CAPSULE (iron-fa-b cmp-c-biot-probiotic) 3 hematinic plus vit/minerals oral tablet 106-1 mg 1 hematinic/folic acid oral tablet 324-1 mg 1 HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG (fe 3 fum-vit c-vit b12-fa) HEMATRON-AF ORAL TABLET 150-1 MG (iron-dss-b12-fa-c- 3 e-cu-biotin) HEMETAB ORAL TABLET 22-6-1-0.025 MG 3 HEMOCYTE PLUS ORAL CAPSULE 106-1 MG (fe fum-fa-b 3 cmp-c-zn-mg-mn-cu) ferrous fumarate-folic acid (Hemocyte-F Oral Tablet 324-1 Mg) 1 ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG (iron-vit c- 3 vit b12-folic acid) iron polysacch cmplx-b12-fa (Iferex 150 Forte Oral Capsule 1 150-25-1 Mg-Mcg-Mg) INFED INJECTION SOLUTION 50 MG/ML (iron dextran) 2 INTEGRA F ORAL CAPSULE 125-1 MG (fe fum-fepoly-fa-vit c- 3 vit b3) INTEGRA PLUS ORAL CAPSULE (fefum-fepoly-fa-b cmp-c- 3 biot) IROSPAN 24/6 ORAL (fe-succ ac-b cmplx-c-ca-fa) 3 M-NATAL PLUS ORAL TABLET 27-1 MG 3 MONOFERRIC INTRAVENOUS SOLUTION 1000 MG/10ML 3 (ferric derisomaltose) MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- PV succ-c-thre-b12-fa)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 73 Coverage Requirements & Prescription Drug Name Drug Tier Limits MULTIGEN ORAL TABLET 70 MG (fe-succ-c-thre-b12-des PV stomach) MULTIGEN PLUS ORAL TABLET 50-101-1 MG (feasp-fefum - 3 suc-c-thre-b12-fa) MULTIPRO ORAL CAPSULE 3 multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multi-/fluoride/iron oral solution 0.25-10 mg/ml 1 myferon 150 forte oral capsule 150-25-1 mg-mcg-mg 1 na ferric gluc cplx in sucrose intravenous solution 12.5 mg/ml 1 NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- 3 methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o vit 3 a) NIFEREX ORAL TABLET (iron combinations) 3 NUFERA ORAL TABLET (iron combinations) 3 NUTRICAP ORAL TABLET (multiple vitamins-minerals) 3 NUTRIVIT ORAL LIQUID (b complex-lysine-min-fe-fa) 3 PNV TABS 20-1 ORAL TABLET 20-1 MG 3 poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg 1 polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg 1 POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PREGEN DHA ORAL CAPSULE 28-1-35 MG 3 PREGENNA ORAL TABLET 20-1 MG 3 PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 3 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 74 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATRIX ORAL TABLET 27-1 MG (prenatal vit-fe fumarate- 3 fa) PRENATRYL ORAL TABLET 27-1 MG (prenatal vit-fe 3 fumarate-fa) preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) purevit dualfe plus oral capsule 162-115.2-1 mg 1 QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa) QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 MG/ML (ped 3 multivitamins-fl-iron) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- 3 minerals-fa) SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 3 vit-fe psac cmplx-fa) se-tan plus oral capsule 162-115.2-1 mg 1 SIDEROL ORAL TABLET (multiple vitamins-minerals) 3 STROVITE FORTE ORAL SYRUP (multiple vitamins-minerals- 3 fa) STROVITE FORTE ORAL TABLET (multiple vitamins-minerals) 3 tl-hem 150 oral tablet 150-1 mg 1 TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) fe fumarate-b12-vit c-fa-ifc (Tricon Oral Capsule) PV TRIFERIC HEMODIALYSIS PACKET 272 MG (ferric 3 pyrophosphate citrate) TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) 3 TRINAZ ORAL TABLET 12-1 MG 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 VENOFER INTRAVENOUS SOLUTION 20 MG/ML (iron 2 sucrose)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 75 Coverage Requirements & Prescription Drug Name Drug Tier Limits VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VIRT-FEFA PLUS ORAL CAPSULE 3 multiple vitamins-minerals (Vita S Forte Oral Tablet) 1 VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) VITRANOL FE ORAL TABLET (multiple vitamins-minerals) 3 VITREXATE FE ORAL TABLET (multiple vitamins-minerals) 3 VITREXYL + IRON ORAL TABLET (multiple vitamins-minerals) 3 vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTAB PLUS ORAL TABLET 27-1 MG 3 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 ZALVIT ORAL TABLET 13-1 MG 3 -AGGREGATION INHIBITORS - Drugs to Prevent Blood Clots adult aspirin regimen oral tablet delayed release 81 mg PV aspirin adult low strength oral tablet delayed release 81 mg PV aspirin childrens oral tablet chewable 81 mg PV aspirin ec low dose oral tablet delayed release 81 mg PV aspirin ec low strength oral tablet delayed release 81 mg PV aspirin ec oral tablet delayed release 325 mg PV aspirin low dose oral tablet chewable 81 mg PV aspirin low dose oral tablet delayed release 81 mg PV aspirin oral tablet 325 mg PV aspirin oral tablet delayed release 325 mg, 81 mg PV aspirin-dipyridamole er oral capsule extended release 12 hour 1 25-200 mg ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 325-40 MG, 81-40 MG BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED PV RELEASE 81 MG (aspirin) BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) PV BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG PV (aspirin) BRILINTA ORAL TABLET 60 MG (ticagrelor) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 76 Coverage Requirements & Prescription Drug Name Drug Tier Limits BRILINTA ORAL TABLET 90 MG (ticagrelor) 2 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 cilostazol oral tablet 100 mg, 50 mg 1 clopidogrel bisulfate oral tablet 300 mg, 75 mg 1 dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 162.5 MG (aspirin) EFFIENT ORAL TABLET 10 MG, 5 MG (prasugrel hcl) 2 goodsense aspirin low dose oral tablet delayed release 81 mg PV PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) 3 prasugrel hcl oral tablet 10 mg, 5 mg 1 ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE PV 81 MG (aspirin) tri-buffered aspirin oral tablet 325 mg PV YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 3 81-40 MG (aspirin-omeprazole) ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) 3 PLATELET-REDUCING AGENTS - Drugs to Prevent Blood Clots anagrelide hcl oral capsule 0.5 mg, 1 mg 1 THROMBOLYTIC AGENTS - Drugs to Prevent Blood Clots ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG, 50 MG (alteplase) adult aspirin regimen oral tablet delayed release 81 mg PV aspirin adult low strength oral tablet delayed release 81 mg PV aspirin childrens oral tablet chewable 81 mg PV aspirin ec low dose oral tablet delayed release 81 mg PV aspirin ec low strength oral tablet delayed release 81 mg PV aspirin ec oral tablet delayed release 325 mg PV aspirin low dose oral tablet chewable 81 mg PV aspirin low dose oral tablet delayed release 81 mg PV aspirin oral tablet 325 mg PV aspirin oral tablet delayed release 325 mg, 81 mg PV ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 325-40 MG, 81-40 MG BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED PV RELEASE 81 MG (aspirin)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 77 Coverage Requirements & Prescription Drug Name Drug Tier Limits BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) PV BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG PV (aspirin) butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 CATHFLO ACTIVASE INJECTION SOLUTION 2 RECONSTITUTED 2 MG (alteplase) DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 162.5 MG (aspirin) goodsense aspirin low dose oral tablet delayed release 81 mg PV ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE PV 81 MG (aspirin) tri-buffered aspirin oral tablet 325 mg PV YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 3 81-40 MG (aspirin-omeprazole) CARDIOVASCULAR DRUGS - Drugs for the Heart ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for High CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 hour 1 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ALPHA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 78 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN) - Drugs for High Blood Pressure & Angina amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 mg, 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160- 1 25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32- 3 25 MG (candesartan cilexetil-hctz) ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (candesartan cilexetil) AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG 3 (irbesartan-hydrochlorothiazide) AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG (irbesartan) 3 AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 MG (amlodipine-olmesartan) BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 3 MG (olmesartan medoxomil-hctz) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG (olmesartan 3 medoxomil) candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 1 32-25 mg COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG (losartan 3 potassium) DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320- 12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- 3 hydrochlorothiazide) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG 3 (valsartan) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan medoxomil) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 79 Coverage Requirements & Prescription Drug Name Drug Tier Limits EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 (azilsartan-chlorthalidone) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG (amlodipine- 3 valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 5-320 MG (amlodipine besylate-valsartan) HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 MG (losartan potassium-hctz) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 50-12.5 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80- 3 25 MG (telmisartan-hctz) MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG (telmisartan) 3 olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 1 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 5 MG (telmisartan-amlodipine) valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 1 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS - Drugs for the Heart amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 mg, 5-40 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 80 Coverage Requirements & Prescription Drug Name Drug Tier Limits amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160- 1 25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32- 3 25 MG (candesartan cilexetil-hctz) ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (candesartan cilexetil) AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG 3 (irbesartan-hydrochlorothiazide) AVAPRO ORAL TABLET 150 MG, 300 MG, 75 MG (irbesartan) 3 AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 MG (amlodipine-olmesartan) BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 3 MG (olmesartan medoxomil-hctz) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG (olmesartan 3 medoxomil) candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 1 32-25 mg COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG (losartan 3 potassium) DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320- 12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- 3 hydrochlorothiazide) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 MG 3 (valsartan) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan medoxomil) 3 EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 (azilsartan-chlorthalidone) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 2 (sacubitril-valsartan) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG (amlodipine- 3 valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 5-320 MG (amlodipine besylate-valsartan) HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 MG (losartan potassium-hctz) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 81 Coverage Requirements & Prescription Drug Name Drug Tier Limits losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 50-12.5 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80- 3 25 MG (telmisartan-hctz) MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG (telmisartan) 3 olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 1 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 5 MG (telmisartan-amlodipine) valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 1 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN-CONVERT. INHIB(HYPOTN) - Drugs for High Blood Pressure & Angina ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (quinapril hcl) ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG 3 (ramipril) amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg, 5-6.25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 1 50-15 mg, 50-25 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 82 Coverage Requirements & Prescription Drug Name Drug Tier Limits fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG (benazepril 3 hcl) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 (perindopril arg-amlodipine) PRINIVIL ORAL TABLET 20 MG (lisinopril) 3 QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) 3 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl) trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg VASERETIC ORAL TABLET 10-25 MG (enalapril- 3 hydrochlorothiazide) VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (enalapril maleate) ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (lisinopril-hydrochlorothiazide) ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 3 MG, 5 MG (lisinopril) ANGIOTENSIN-CONVERTING ENZYME INHIBITORS - Drugs for the Heart ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (quinapril hcl) ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 83 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALTACE ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG 3 (ramipril) amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg, 5-6.25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 1 50-15 mg, 50-25 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG (benazepril 3 hcl) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 (perindopril arg-amlodipine) PRINIVIL ORAL TABLET 20 MG (lisinopril) 3 QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) 3 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl) trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 84 Coverage Requirements & Prescription Drug Name Drug Tier Limits VASERETIC ORAL TABLET 10-25 MG (enalapril- 3 hydrochlorothiazide) VASOTEC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (enalapril maleate) ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (lisinopril-hydrochlorothiazide) ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 3 MG, 5 MG (lisinopril) ANTIARRHYTHMICS, MISCELLANEOUS - Drugs for Angina digoxin (Digitek Oral Tablet 125 Mcg, 250 Mcg) PV digoxin (Digox Oral Tablet 125 Mcg, 250 Mcg) PV digoxin oral solution 0.05 mg/ml PV digoxin oral tablet 125 mcg, 250 mcg PV LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG PV (digoxin) sulfate intravenous solution 2 gm/50ml, 20 PV gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml SOLUTION 50 % INJECTION 50 % PV magnesium sulfate solution 50 % injection 50 % PV ANTILIPEMIC AGENTS, MISCELLANEOUS - Drugs for Cholesterol ANIMI-3 ORAL CAPSULE 1 MG (fa-b6-b12-d-omega 3- 3 phytoster) ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG (fa-b6-b12-d- 3 omega 3-phytoster) bp vit 3 oral capsule 1 mg 1 EVKEEZA INTRAVENOUS SOLUTION 1200 MG/8ML, 345 3 MG/2.3ML (evinacumab-dgnb) icosapent ethyl oral capsule 1 gm 1 JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG 3 DSL = 30 days (lomitapide mesylate) NEXLETOL ORAL TABLET 180 MG (bempedoic acid) 3 NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 3 ezetimibe) niacin (antihyperlipidemic) oral tablet 500 mg 1 niacin er (antihyperlipidemic) oral tablet extended release 1000 1 mg, 500 mg, 750 mg niacor oral tablet 500 mg 1 NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 3 500 MG, 750 MG (niacin (antihyperlipidemic))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 85 Coverage Requirements & Prescription Drug Name Drug Tier Limits omega-3-acid ethyl esters oral capsule 1 gm 1 VASCEPA ORAL CAPSULE 0.5 GM, 1 GM (icosapent ethyl) 3 BETA-ADRENERGIC BLOCKING AGENTS - Drugs for Abnormal Heart Rhythms acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG 3 (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 hour 1 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide) ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol hcl) 3 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 86 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 1 75 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) BETA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 87 Coverage Requirements & Prescription Drug Name Drug Tier Limits bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide) ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol hcl) 3 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 1 75 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 88 Coverage Requirements & Prescription Drug Name Drug Tier Limits TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) BILE ACID SEQUESTRANTS - Drugs for Cholesterol cholestyramine light oral packet 4 gm 1 cholestyramine light oral powder 4 gm/dose 1 cholestyramine oral packet 4 gm 1 cholestyramine oral powder 4 gm/dose 1 hcl oral packet 3.75 gm 1 colesevelam hcl oral tablet 625 mg 1 COLESTID FLAVORED ORAL GRANULES 5 GM (colestipol 3 hcl) COLESTID FLAVORED ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL GRANULES 5 GM (colestipol hcl) 3 COLESTID ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL TABLET 1 GM (colestipol hcl) 3 colestipol hcl oral granules 5 gm 1 colestipol hcl oral packet 5 gm 1 colestipol hcl oral tablet 1 gm 1 cholestyramine light (Prevalite Oral Packet 4 Gm) 1 cholestyramine light (Prevalite Oral Powder 4 Gm/Dose) 1 QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE 3 (cholestyramine light) QUESTRAN ORAL PACKET 4 GM (cholestyramine) 3 QUESTRAN ORAL POWDER 4 GM/DOSE (cholestyramine) 3 WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 3 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 3 CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN) - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 89 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 125-5 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg diltiazem hcl coated beads (Matzim La Oral Tablet Extended 1 Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl) diltiazem hcl er beads (Taztia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 1 420 Mg) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 90 Coverage Requirements & Prescription Drug Name Drug Tier Limits VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CALCIUM-CHANNEL BLOCKING AGENTS - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 1 mg, 5-40 mg, 5-80 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 mg, 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160- 1 25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 MG (amlodipine-olmesartan) CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG (amlodipine- 3 atorvastatin) CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 maleate) diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 91 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 125-5 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG (amlodipine- 3 valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 5-320 MG (amlodipine besylate-valsartan) felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) diltiazem hcl coated beads (Matzim La Oral Tablet Extended 1 Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 DSL = 30 days olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 (perindopril arg-amlodipine)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 92 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROCARDIA ORAL CAPSULE 10 MG (nifedipine) 3 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl) diltiazem hcl er beads (Taztia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 mg, 80-5 mg diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 1 420 Mg) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 5 MG (telmisartan-amlodipine) verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN) - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 93 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 125-5 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg diltiazem hcl coated beads (Matzim La Oral Tablet Extended 1 Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 (perindopril arg-amlodipine) diltiazem hcl er beads (Taztia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 1 420 Mg) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 94 Coverage Requirements & Prescription Drug Name Drug Tier Limits VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CALCIUM-CHANNEL BLOCKING AGENTS, MISC. - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 125-5 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg diltiazem hcl coated beads (Matzim La Oral Tablet Extended 1 Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl) diltiazem hcl er beads (Taztia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 1 420 Mg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 95 Coverage Requirements & Prescription Drug Name Drug Tier Limits TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CARBONIC ANHYDRASE INHIBITORS(HYPOTEN) - Drugs for High Blood Pressure & Angina acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 CARDIAC DRUGS, MISCELLANEOUS - Drugs for Angina CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 3 DSL = 30 days ranolazine er oral tablet extended release 12 hour 1000 mg, 1 500 mg VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 3 DSL = 30 days VYNDAQEL ORAL CAPSULE 20 MG (tafamidis meglumine 3 (cardiac)) CARDIOTONIC AGENTS - Drugs for Angina digoxin (Digitek Oral Tablet 125 Mcg, 250 Mcg) PV digoxin (Digox Oral Tablet 125 Mcg, 250 Mcg) PV digoxin oral solution 0.05 mg/ml PV digoxin oral tablet 125 mcg, 250 mcg PV LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG PV (digoxin) milrinone lactate in dextrose intravenous solution 20-5 1 mg/100ml-%, 40-5 mg/200ml-% milrinone lactate intravenous solution 10 mg/10ml, 20 mg/20ml, 1 50 mg/50ml

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 96 Coverage Requirements & Prescription Drug Name Drug Tier Limits CENTRAL ALPHA-AGONISTS - Drugs for High Blood Pressure & Angina CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 3 MG/24HR (clonidine) CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY 0.2 3 MG/24HR (clonidine) CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY 0.3 3 MG/24HR (clonidine) clonidine hcl er oral tablet extended release 12 hour 0.1 mg 1 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 1 0.3 mg/24hr guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 1 mg, 3 mg, 4 mg guanfacine hcl oral tablet 1 mg, 2 mg 1 methyldopa oral tablet 250 mg, 500 mg 1 methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 1 mg CHOLESTEROL ABSORPTION INHIBITORS - Drugs for Cholesterol ezetimibe oral tablet 10 mg 1 ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 1 mg, 10-80 mg NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 3 ezetimibe) ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-5 3 MG (ezetimibe-rosuvastatin) VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 3 80 MG (ezetimibe-simvastatin) ZETIA ORAL TABLET 10 MG (ezetimibe) 3 CLASS IA ANTIARRHYTHMICS - Drugs for Angina disopyramide phosphate oral capsule 100 mg, 150 mg 1 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 2 HOUR 100 MG, 150 MG (disopyramide phosphate) procainamide hcl injection solution 100 mg/ml, 500 mg/ml 1 quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 CLASS IB ANTIARRHYTHMICS - Drugs for Angina DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium 2 extended)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 97 Coverage Requirements & Prescription Drug Name Drug Tier Limits LIDOCAINE HCL INJECTION SOLUTION PREFILLED 3 SYRINGE 10 MG/ML mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1 phenytoin (Phenytoin Infatabs Oral Tablet Chewable 50 Mg) 1 phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 1 mg CLASS IC ANTIARRHYTHMICS - Drugs for Angina flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1 propafenone hcl er oral capsule extended release 12 hour 225 1 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1 CLASS II ANTIARRHYTHMICS - Drugs for Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 hour 1 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide) ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/10ML HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol hcl) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 98 Coverage Requirements & Prescription Drug Name Drug Tier Limits INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 hour 1 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 1 75 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) TENORMIN ORAL TABLET 100 MG, 25 MG, 50 MG (atenolol) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) CLASS III ANTIARRHYTHMICS - Drugs for Angina amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 99 Coverage Requirements & Prescription Drug Name Drug Tier Limits BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 MULTAQ ORAL TABLET 400 MG (dronedarone hcl) 3 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 CLASS IV ANTIARRHYTHMICS - Drugs for Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 125-5 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg diltiazem hcl coated beads (Matzim La Oral Tablet Extended 1 Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) diltiazem hcl er beads (Taztia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 100 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 1 420 Mg) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) DIHYDROPYRIDINES - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 1 mg, 5-40 mg, 5-80 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 mg, 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160- 1 25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 MG (amlodipine-olmesartan) CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG (amlodipine- 3 atorvastatin) CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 maleate) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 MG 3 (amlodipine besylate-celecoxib) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG (amlodipine- 3 valsartan-hctz)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 101 Coverage Requirements & Prescription Drug Name Drug Tier Limits EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 5-320 MG (amlodipine besylate-valsartan) felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 DSL = 30 days olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 (perindopril arg-amlodipine) PROCARDIA ORAL CAPSULE 10 MG (nifedipine) 3 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 mg, 80-5 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 5 MG (telmisartan-amlodipine) DIHYDROPYRIDINES (ANTIHYPERTENSIVE) - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 102 Coverage Requirements & Prescription Drug Name Drug Tier Limits amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 1 mg, 5-40 mg, 5-80 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 mg, 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160- 1 25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 MG (amlodipine-olmesartan) CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG (amlodipine- 3 atorvastatin) CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 maleate) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG (amlodipine- 3 valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 5-320 MG (amlodipine besylate-valsartan) felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 DSL = 30 days Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 103 Coverage Requirements & Prescription Drug Name Drug Tier Limits olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 (perindopril arg-amlodipine) PROCARDIA ORAL CAPSULE 10 MG (nifedipine) 3 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 mg, 80-5 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 5 MG (telmisartan-amlodipine) DIRECT VASODILATORS - Drugs for High Blood Pressure & Angina BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 3 hydralazine) hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 oral tablet 10 mg, 2.5 mg 1 , MISCELLANEOUS (HYPOTENSIVE) - Drugs for High Blood Pressure & Angina ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, PV 450 mg theophylline er oral tablet extended release 24 hour 400 mg, PV 600 mg theophylline oral solution 80 mg/15ml 1 FIBRIC ACID DERIVATIVES - Drugs for Cholesterol ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate 3 micronized) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 1 43 mg, 67 mg fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 1 mg fenofibrate oral tablet 120 mg, 145 mg, 160 mg, 40 mg, 48 mg, 1 54 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 104 Coverage Requirements & Prescription Drug Name Drug Tier Limits fenofibric acid oral capsule delayed release 135 mg, 45 mg 1 fenofibric acid oral tablet 105 mg, 35 mg 1 FENOGLIDE ORAL TABLET 120 MG, 40 MG (fenofibrate) 3 FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric acid) 3 gemfibrozil oral tablet 600 mg 1 LIPOFEN ORAL CAPSULE 150 MG, 50 MG (fenofibrate) 3 LOPID ORAL TABLET 600 MG (gemfibrozil) 3 TRICOR ORAL TABLET 145 MG, 48 MG (fenofibrate) 3 TRILIPIX ORAL CAPSULE DELAYED RELEASE 135 MG, 45 3 MG (choline fenofibrate) HMG-COA REDUCTASE INHIBITORS - Drugs for Cholesterol ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HOUR PV 20 MG, 40 MG, 60 MG (lovastatin) amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 1 mg, 5-40 mg, 5-80 mg atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg PV CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG (amlodipine- 3 atorvastatin) CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG PV (rosuvastatin calcium) EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 3 MG, 40 MG, 5 MG (rosuvastatin calcium) ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 1 mg, 10-80 mg FLOLIPID ORAL SUSPENSION 20 MG/5ML, 40 MG/5ML 3 fluvastatin sodium er oral tablet extended release 24 hour 80 PV mg fluvastatin sodium oral capsule 20 mg, 40 mg PV LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HOUR PV 80 MG (fluvastatin sodium) LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG PV (atorvastatin calcium) LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin PV calcium) lovastatin oral tablet 10 mg, 20 mg, 40 mg PV pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg PV rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 105 Coverage Requirements & Prescription Drug Name Drug Tier Limits ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-5 3 MG (ezetimibe-rosuvastatin) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg PV VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 3 80 MG (ezetimibe-simvastatin) ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG PV (simvastatin) ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin 3 magnesium) HYPOTENSIVE AGENTS, MISCELLANEOUS - Drugs for High Blood Pressure & Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 mg, 5-40 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 MG (amlodipine-olmesartan) BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG (sotalol 3 hcl) betaxolol hcl oral tablet 10 mg, 20 mg 1 CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 carvedilol phosphate er oral capsule extended release 24 hour 1 10 mg, 20 mg, 40 mg, 80 mg CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 maleate) COREG CR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) COREG ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG 3 (carvedilol) DIBENZYLINE ORAL CAPSULE 10 MG (phenoxybenzamine 3 hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 106 Coverage Requirements & Prescription Drug Name Drug Tier Limits doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 5-320 MG (amlodipine besylate-valsartan) felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol hcl) 3 INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 DSL = 30 days phenoxybenzamine hcl oral capsule 10 mg 1 phentolamine mesylate injection solution reconstituted 5 mg 1 pindolol oral tablet 10 mg, 5 mg 1 PROCARDIA ORAL CAPSULE 10 MG (nifedipine) 3 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 107 Coverage Requirements & Prescription Drug Name Drug Tier Limits sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) 3 DSL = 30 days LOOP DIURETICS (HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 2 ethacrynic acid oral tablet 25 mg 1 furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 (ALDOSTERONE) ANTAGNTS - Drugs for the Heart ALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG 3 (-hctz) ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 eplerenone oral tablet 25 mg, 50 mg 1 INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 MINERALOCORTICOID(ALDOSTER.)ANTAG(HYPOT) - Drugs for High Blood Pressure & Angina ALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG 3 (spironolactone-hctz) ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 eplerenone oral tablet 25 mg, 50 mg 1 INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 108 Coverage Requirements & Prescription Drug Name Drug Tier Limits NITRATES AND NITRITES - Drugs for the Heart BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 3 hydralazine) DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 3 MG (isosorbide dinitrate) GONITRO SUBLINGUAL PACKET 400 MCG (nitroglycerin) 3 isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 1 mg isosorbide mononitrate er oral tablet extended release 24 hour 1 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 1 nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 Mg/Hr, 1 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-BID TRANSDERMAL OINTMENT 2 % (nitroglycerin) 2 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 3 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 2 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 1 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray 1 NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 3 MCG/SPRAY (nitroglycerin) NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 2 0.4 MG, 0.6 MG (nitroglycerin) NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 3 6.5 MG, 9 MG (nitroglycerin) PCSK9 INHIBITORS - Drugs for Cholesterol PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 150 MG/ML, 75 MG/ML (alirocumab) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS 3 DSL = 30 days SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 140 MG/ML (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO- 3 DSL = 30 days INJECTOR 140 MG/ML (evolocumab) PHOSPHODIESTERASE TYPE 5 INHIBITORS - Drugs for the Heart tadalafil (pah) (Alyq Oral Tablet 20 Mg) 1 DSL = 30 days cilostazol oral tablet 100 mg, 50 mg 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 109 Coverage Requirements & Prescription Drug Name Drug Tier Limits LEVITRA ORAL TABLET 20 MG (vardenafil hcl) 2 REVATIO ORAL TABLET 20 MG (sildenafil citrate) 3 sildenafil citrate intravenous solution 10 mg/12.5ml 1 sildenafil citrate oral suspension reconstituted 10 mg/ml 1 DSL = 30 days sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 2 sildenafil citrate oral tablet 20 mg 1 STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG (avanafil) 2 tadalafil (pah) oral tablet 20 mg 1 DSL = 30 days tadalafil oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 2 vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 2 vardenafil hcl oral tablet dispersible 10 mg 2 POTASSIUM-SPARING DIURETICS (HYPOTEN) - Drugs for High Blood Pressure & Angina ALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG 3 (spironolactone-hctz) ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) amiloride hcl oral tablet 5 mg 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 2 eplerenone oral tablet 25 mg, 50 mg 1 INSPRA ORAL TABLET 25 MG, 50 MG (eplerenone) 3 MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 triamterene oral capsule 100 mg, 50 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 RENIN INHIBITORS - Drugs for the Heart aliskiren fumarate oral tablet 150 mg, 300 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG (aliskiren 3 fumarate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 110 Coverage Requirements & Prescription Drug Name Drug Tier Limits RENIN-ANGIOTEN.-ALDOST. SYS. INHIB, MISC - Drugs for the Heart ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 2 (sacubitril-valsartan) SCLEROSING AGENTS - Drugs for Varicose Veins STERITALC INTRAPLEURAL POWDER 2 GM, 3 GM, 4 GM 3 (talc) THIAZIDE DIURETICS(HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) ALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG 3 (spironolactone-hctz) amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160- 1 25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32- 3 25 MG (candesartan cilexetil-hctz) AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG 3 (irbesartan-hydrochlorothiazide) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg, 5-6.25 mg BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 3 MG (olmesartan medoxomil-hctz) bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 1 32-25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 1 50-15 mg, 50-25 mg DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320- 12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- 3 hydrochlorothiazide) DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 3 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide) enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG (amlodipine- 3 valsartan-hctz) fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 111 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 MG (losartan potassium-hctz) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 50-12.5 mg LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 1 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80- 3 25 MG (telmisartan-hctz) olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 1 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg spironolactone-hctz oral tablet 25-25 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 1 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg VASERETIC ORAL TABLET 10-25 MG (enalapril- 3 hydrochlorothiazide)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 112 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (lisinopril-hydrochlorothiazide) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT) - Drugs for High Blood Pressure & Angina atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 (azilsartan-chlorthalidone) indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) VASODILATING AGENTS, MISCELLANEOUS - Drugs for the Heart ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 3 DSL = 30 days MG (riociguat) ambrisentan oral tablet 10 mg, 5 mg 1 DSL = 30 days amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10- 1 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 1 mg, 5-160 mg, 5-320 mg amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 1 mg, 5-40 mg, 5-80 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 1 mg, 5-40 mg aspirin-dipyridamole er oral capsule extended release 12 hour 1 25-200 mg AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-40 3 MG (amlodipine-olmesartan) bosentan oral tablet 125 mg, 62.5 mg 1 DSL = 30 days CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10- 80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG (amlodipine- 3 atorvastatin) CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 113 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem 3 hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG (diltiazem 3 hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 2 MCG (alprostadil (vasodilator)) CAVERJECT INTRACAVERNOSAL SOLUTION 2 RECONSTITUTED 40 MCG (alprostadil (vasodilator)) CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine 3 maleate) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 MG 3 (amlodipine besylate-celecoxib) diltiazem hcl er beads oral capsule extended release 24 hour 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 1 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 1 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 DILTIAZEM HCL-DEXTROSE INTRAVENOUS SOLUTION 3 125-5 MG/125ML-% dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 1 240 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40 MCG 2 (alprostadil (vasodilator)) epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1 1.5 mg EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 MG, 3 5-320 MG (amlodipine besylate-valsartan) felodipine er oral tablet extended release 24 hour 10 mg, 2.5 1 mg, 5 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 114 Coverage Requirements & Prescription Drug Name Drug Tier Limits isoxsuprine hcl oral tablet 10 mg, 20 mg 1 isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 benzoate) LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) 2 DSL = 30 days LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5- 3 20 MG (amlodipine besy-benazepril hcl) diltiazem hcl coated beads (Matzim La Oral Tablet Extended 1 Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) MUSE URETHRAL PELLET 1000 MCG, 125 MCG, 250 MCG, 2 500 MCG (alprostadil (vasodilator)) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 1 90 mg nifedipine er osmotic release oral tablet extended release 24 1 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 1 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG (amlodipine 3 besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) 3 DSL = 30 days olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg OPSUMIT ORAL TABLET 10 MG (macitentan) 3 DSL = 30 days ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 3 DSL = 30 days MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil diolamine) papaverine hcl injection solution 30 mg/ml 2 PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 (perindopril arg-amlodipine) PROCARDIA ORAL CAPSULE 10 MG (nifedipine) 3 PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 30 MG, 60 MG, 90 MG (nifedipine) REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 2 MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 115 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er beads (Taztia Xt Oral Capsule Extended 1 Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 1 mg, 80-5 mg diltiazem hcl er beads (Tiadylt Er Oral Capsule Extended Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg, 1 420 Mg) TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) 2 DSL = 30 days TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) 2 DSL = 30 days trandolapril-verapamil hcl er oral tablet extended release 1-240 1 mg, 2-180 mg, 2-240 mg, 4-240 mg treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 1 mg/20ml, 50 mg/20ml TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) TRI-MIX INTRACAVERNOSAL SOLUTION RECONSTITUTED 2 150-5-50 MG-MG-MCG TWYNSTA ORAL TABLET 40-10 MG, 40-5 MG, 80-10 MG, 80- 3 5 MG (telmisartan-amlodipine) TYVASO INHALATION SOLUTION 0.6 MG/ML (treprostinil) 2 DSL = 30 days TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML 2 DSL = 30 days (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML 2 DSL = 30 days (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 3 DSL = 30 days (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG 3 DSL = 30 days (selexipag) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML 2 DSL = 30 days (iloprost) verapamil hcl er oral capsule extended release 24 hour 100 mg, 1 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 1 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 116 Coverage Requirements & Prescription Drug Name Drug Tier Limits VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) VERQUVO ORAL TABLET 10 MG, 2.5 MG, 5 MG (vericiguat) 3 CELLULAR AND GENE THERAPY - Drugs for Cancer CELLULAR AND GENE THERAPY - Drugs for Cancer PROVENGE INTRAVENOUS SUSPENSION (sipuleucel-t) 3 CELLULAR THERAPY - Drugs for Cancer PROVENGE INTRAVENOUS SUSPENSION (sipuleucel-t) 3 GENE THERAPY - Drugs for Cancer BREYANZI INTRAVENOUS SUSPENSION (lisocabtagene 3 maraleucel) KYMRIAH INTRAVENOUS SUSPENSION (tisagenlecleucel) 3 LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 3 VG/ML (voretigene neparvovec-rzyl) TECARTUS INTRAVENOUS SUSPENSION (brexucabtagene 3 autoleucel) YESCARTA INTRAVENOUS SUSPENSION (axicabtagene 3 ciloleucel) ZOLGENSMA INTRAVENOUS KIT 1X5.5ML & 2X8.3ML, 1X5.5ML & 3X8.3ML, 1X5.5ML & 4X8.3ML, 1X5.5ML & 5X8.3ML, 1X5.5ML & 6X8.3ML, 1X5.5ML & 7X8.3ML, 1X5.5ML & 8X8.3ML, 2X5.5ML & 1X8.3ML, 2X5.5ML & 2X8.3ML, 3 2X5.5ML & 3X8.3ML, 2X5.5ML & 4X8.3ML, 2X5.5ML & 5X8.3ML, 2X5.5ML & 6X8.3ML, 2X5.5ML & 7X8.3ML, 2X8.3 ML, 3X8.3 ML, 4X8.3 ML, 5X8.3 ML, 6X8.3 ML, 7X8.3 ML, 8X8.3 ML, 9X8.3 ML (onasemnogene abeparvovec-xioi) CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ADAMANTANES (CNS) - Drugs for Parkinson amantadine hcl oral capsule 100 mg PV amantadine hcl oral syrup 50 mg/5ml PV amantadine hcl oral tablet 100 mg PV GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR PV DSL = 30 days 137 MG, 68.5 MG (amantadine hcl) OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK PV 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 PV HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) AMPHETAMINE DERIVATIVES - Drugs for the Nervous System diethylpropion hcl er oral tablet extended release 24 hour 75 mg 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 117 Coverage Requirements & Prescription Drug Name Drug Tier Limits diethylpropion hcl oral tablet 25 mg 2 LOMAIRA ORAL TABLET 8 MG (phentermine hcl) 2 phendimetrazine tartrate er oral capsule extended release 24 2 hour 105 mg phendimetrazine tartrate oral tablet 35 mg 2 phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg 2 phentermine hcl oral tablet 37.5 mg 2 QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG 2 (phentermine-topiramate) AMPHETAMINES - Drugs for the Nervous System ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG 3 (amphetamine-dextroamphetamine) ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 3 DSL = 30 days 1.25 MG/ML (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 3 9.4 MG (amphetamine) AMPHETAMINE ER ORAL SUSPENSION EXTENDED 3 DSL = 30 days RELEASE 1.25 MG/ML amphetamine sulfate oral tablet 10 mg, 5 mg 1 amphetamine-dextroamphetamine er oral capsule extended 1 release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 1 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg benzphetamine hcl oral tablet 25 mg, 50 mg 2 dextroamphetamine sulfate er oral capsule extended release 24 1 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml 1 dextroamphetamine sulfate oral tablet 10 mg, 5 mg 1 DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE 3 2.5 MG/ML (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 3 20 MG, 5 MG (amphetamine sulfate) methamphetamine hcl oral tablet 5 mg 1 MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- 3 DSL = 30 days dextroamphetamine) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 2 MG, 60 MG, 70 MG (lisdexamfetamine dimesylate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 118 Coverage Requirements & Prescription Drug Name Drug Tier Limits VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 3 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 3 MG (dextroamphetamine sulfate) AND ANTIPYRETICS, MISC. - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300- 1 60 mg ALLZITAL ORAL TABLET 25-325 MG (butalbital- 3 acetaminophen) APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 3 DSL = 30 days MG (benzhydrocodone-acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) 1 BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 DSL = 30 days 4.08-325 MG, 6.12-325 MG, 8.16-325 MG butalbital-acetaminophen capsule 50-300 mg oral 50-300 mg 1 BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL 3 50-300 MG butalbital-acetaminophen oral tablet 25-325 mg, 50-300 mg, 50- 1 325 mg butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- 1 40-30 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 1 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg, 1 DSL = 30 days 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GRALISE ORAL TABLET 300 MG, 600 MG (gabapentin (once- 3 daily)) HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 3 600 MG (gabapentin enacarbil)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 119 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5- 1 325 mg/15ml hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 1 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 2 acetaminophen) LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 165 MG, 330 MG, 82.5 MG (pregabalin) NALOCET ORAL TABLET 2.5-300 MG 3 DSL = 30 days oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 1 DSL = 30 days 5-325 mg, 7.5-325 mg OXYCODONE-ACETAMINOPHEN ORAL TABLET 2.5-300 MG 3 DSL = 30 days pregabalin er oral tablet extended release 24 hour 165 mg, 330 1 mg, 82.5 mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 1 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml 1 PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 500 3 MCG/20ML, 500 MCG/5ML (ziconotide acetate) PROLATE ORAL SOLUTION 10-300 MG/5ML (oxycodone- 3 DSL = 30 days acetaminophen) PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG 3 DSL = 30 days (oxycodone-acetaminophen) TENCON ORAL TABLET 50-325 MG (butalbital- 3 acetaminophen) tramadol-acetaminophen oral tablet 37.5-325 mg 1 VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 3 apap-caffeine) ANOREXIGENIC AGENTS, MISCELLANEOUS - Drugs for the Nervous System CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR 2 8-90 MG (naltrexone-bupropion hcl) IMCIVREE SUBCUTANEOUS SOLUTION 10 MG/ML 2 DSL = 30 days ( acetate) QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG 2 (phentermine-topiramate) ANTICHOLINERGIC AGENTS (CNS) - Drugs for Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 trihexyphenidyl hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 120 Coverage Requirements & Prescription Drug Name Drug Tier Limits , MISCELLANEOUS - Drugs for Seizures APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG 3 (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) 2 BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) 2 BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML 3 DSL = 30 days (brivaracetam) BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) 2 DSL = 30 days BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 2 DSL = 30 days MG (brivaracetam) carbamazepine er oral capsule extended release 12 hour 100 1 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 mg, 1 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 PV HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 PV MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED PV RELEASE SPRINKLE 125 MG (divalproex sodium) DIACOMIT ORAL CAPSULE 250 MG, 500 MG (stiripentol) 3 DSL = 30 days DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) 3 DSL = 30 days divalproex sodium er oral tablet extended release 24 hour 250 PV mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg PV divalproex sodium oral tablet delayed release 125 mg, 250 mg, PV 500 mg ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 1000 MG, 1500 MG (levetiracetam) EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) 3 DSL = 30 days carbamazepine (Epitol Oral Tablet 200 Mg) 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 300 MG (carbamazepine ()) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 200 MG (carbamazepine (antipsychotic)) felbamate oral suspension 600 mg/5ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 121 Coverage Requirements & Prescription Drug Name Drug Tier Limits felbamate oral tablet 400 mg, 600 mg 1 FELBATOL ORAL SUSPENSION 600 MG/5ML (felbamate) 3 FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine hcl) 3 DSL = 30 days FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) 3 FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 3 DSL = 30 days 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG 3 (tiagabine hcl) GRALISE ORAL TABLET 300 MG, 600 MG (gabapentin (once- 3 daily)) HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 3 600 MG (gabapentin enacarbil) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 PV & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 PV MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG PV (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG PV (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 PV X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & PV 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG PV (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 PV mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral kit 25 & 50 & 100 mg PV lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg PV lamotrigine oral tablet chewable 25 mg, 5 mg PV lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 PV mg lamotrigine starter kit-blue oral kit 35 x 25 mg PV lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg PV lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 122 Coverage Requirements & Prescription Drug Name Drug Tier Limits levetiracetam er oral tablet extended release 24 hour 500 mg, 1 750 mg levetiracetam intravenous solution 500 mg/5ml 1 levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 1 LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 165 MG, 330 MG, 82.5 MG (pregabalin) magnesium sulfate intravenous solution 2 gm/50ml, 20 PV gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml MAGNESIUM SULFATE SOLUTION 50 % INJECTION 50 % PV magnesium sulfate solution 50 % injection 50 % PV oxcarbazepine oral suspension 300 mg/5ml 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 3 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine) pregabalin er oral tablet extended release 24 hour 165 mg, 330 1 mg, 82.5 mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 1 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml 1 QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG 2 (phentermine-topiramate) levetiracetam (Roweepra Oral Tablet 500 Mg) 1 rufinamide oral suspension 40 mg/ml 1 SABRIL ORAL PACKET 500 MG (vigabatrin) 2 SABRIL ORAL TABLET 500 MG (vigabatrin) 3 DSL = 30 days SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 3 MG, 250 MG, 500 MG, 750 MG (levetiracetam) lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Mg, 25 PV Mg) lamotrigine (Subvenite Starter Kit-Blue Oral Kit 35 X 25 Mg) PV lamotrigine (Subvenite Starter Kit-Green Oral Kit 84 X 25 Mg & PV 14X100 Mg) lamotrigine (Subvenite Starter Kit-Orange Oral Kit 42 X 25 Mg & PV 7 X 100 Mg) TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 123 Coverage Requirements & Prescription Drug Name Drug Tier Limits topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 1 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 25 MG, 50 MG (topiramate) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 vigabatrin oral packet 500 mg 1 vigabatrin oral tablet 500 mg 1 DSL = 30 days vigabatrin (Vigadrone Oral Packet 500 Mg) 1 VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML 3 (lacosamide) VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) 3 VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 (lacosamide) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 DSL = 30 days (cenobamate) XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG & 14 X100 3 DSL = 30 days MG, 150 & 200 MG, 50 & 200 MG (cenobamate) zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 , MISCELLANEOUS - Drugs for Depression & Psychosis APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR PV 174 MG, 348 MG, 522 MG (bupropion hbr) bupropion hcl er (smoking det) oral tablet extended release 12 PV hour 150 mg bupropion hcl er (sr) oral tablet extended release 12 hour 100 PV mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 PV mg, 300 mg BUPROPION HCL ER (XL) ORAL TABLET EXTENDED PV RELEASE 24 HOUR 450 MG bupropion hcl oral tablet 100 mg, 75 mg PV FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR PV 450 MG (bupropion hcl) mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg PV mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg PV REMERON ORAL TABLET 15 MG, 30 MG (mirtazapine) PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 124 Coverage Requirements & Prescription Drug Name Drug Tier Limits REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 PV MG, 45 MG (mirtazapine) SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY 3 PACK 28 MG/DEVICE (esketamine hcl) SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY 3 PACK 28 MG/DEVICE (esketamine hcl) WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 PV HOUR 100 MG, 150 MG, 200 MG (bupropion hcl) WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 PV HOUR 150 MG, 300 MG (bupropion hcl) ZULRESSO INTRAVENOUS SOLUTION 100 MG/20ML 3 (brexanolone) ANTIMANIC AGENTS - Drugs for Personality Disorder ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PV SYRINGE 300 MG, 400 MG (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION PV RECONSTITUTED ER 300 MG, 400 MG (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, PV 15 MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 20 PV MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 PV MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, PV 5 MG (aripiprazole) aripiprazole oral solution 1 mg/ml PV aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 PV mg aripiprazole oral tablet dispersible 10 mg, 15 mg PV ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE PV 675 MG/2.4ML (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML PV (aripiprazole lauroxil) asenapine maleate sublingual tablet sublingual 10 mg, 2.5 mg, PV 5 mg carbamazepine er oral capsule extended release 12 hour 100 1 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 mg, 1 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 125 Coverage Requirements & Prescription Drug Name Drug Tier Limits carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1 DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 PV HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 PV MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED PV RELEASE SPRINKLE 125 MG (divalproex sodium) divalproex sodium er oral tablet extended release 24 hour 250 PV mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg PV divalproex sodium oral tablet delayed release 125 mg, 250 mg, PV 500 mg carbamazepine (Epitol Oral Tablet 200 Mg) 1 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 300 MG (carbamazepine (antipsychotic)) EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 2 200 MG (carbamazepine (antipsychotic)) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED PV 20 MG (ziprasidone mesylate) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG PV (ziprasidone hcl) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 PV & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 PV MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG PV (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG PV (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 PV X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) lamotrigine oral kit 25 & 50 & 100 mg PV lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg PV lamotrigine oral tablet chewable 25 mg, 5 mg PV lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 PV mg lamotrigine starter kit-blue oral kit 35 x 25 mg PV lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg PV lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 126 Coverage Requirements & Prescription Drug Name Drug Tier Limits carbonate er oral tablet extended release 300 mg, 450 PV mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg PV lithium carbonate oral tablet 300 mg PV lithium oral solution 8 meq/5ml PV LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG PV (lithium carbonate) olanzapine intramuscular solution reconstituted 10 mg PV olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 PV mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg PV PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, 3 90 MG (risperidone) quetiapine fumarate er oral tablet extended release 24 hour 150 PV mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 PV mg, 400 mg, 50 mg RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG PV (risperidone microspheres) RISPERDAL ORAL SOLUTION 1 MG/ML (risperidone) PV RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG PV (risperidone) risperidone oral solution 1 mg/ml PV risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg PV risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, PV 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 PV MG, 5 MG (asenapine maleate) SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR, 3 5.7 MG/24HR, 7.6 MG/24HR (asenapine) SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 PV MG, 400 MG, 50 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG (quetiapine PV fumarate) lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Mg, 25 PV Mg) lamotrigine (Subvenite Starter Kit-Blue Oral Kit 35 X 25 Mg) PV lamotrigine (Subvenite Starter Kit-Green Oral Kit 84 X 25 Mg & PV 14X100 Mg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 127 Coverage Requirements & Prescription Drug Name Drug Tier Limits lamotrigine (Subvenite Starter Kit-Orange Oral Kit 42 X 25 Mg & PV 7 X 100 Mg) TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg PV ziprasidone mesylate intramuscular solution reconstituted 20 PV mg ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED PV 10 MG (olanzapine) ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 PV MG, 7.5 MG (olanzapine) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG (olanzapine PV pamoate) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 PV MG, 20 MG, 5 MG (olanzapine) ANTIMIGRAINE AGENTS, MISCELLANEOUS - Migraine Treatment adult aspirin regimen oral tablet delayed release 81 mg PV AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 140 MG/ML (erenumab-aooe) AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 3 DSL = 30 days MG/ML (erenumab-aooe) AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 DSL = 30 days 225 MG/1.5ML (fremanezumab-vfrm) butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- 1 325-40-30 Mg) aspirin adult low strength oral tablet delayed release 81 mg PV aspirin childrens oral tablet chewable 81 mg PV aspirin ec low dose oral tablet delayed release 81 mg PV aspirin ec low strength oral tablet delayed release 81 mg PV aspirin ec oral tablet delayed release 325 mg PV aspirin low dose oral tablet chewable 81 mg PV aspirin low dose oral tablet delayed release 81 mg PV aspirin oral tablet 325 mg PV aspirin oral tablet delayed release 325 mg, 81 mg PV butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 128 Coverage Requirements & Prescription Drug Name Drug Tier Limits BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED PV RELEASE 81 MG (aspirin) BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) PV BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG PV (aspirin) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- 1 40-30 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 1 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 2 CAMBIA ORAL PACKET 50 MG (diclofenac 3 potassium(migraine)) DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 PV HOUR 250 MG, 500 MG (divalproex sodium) DEPAKOTE ORAL TABLET DELAYED RELEASE 125 MG, 250 PV MG, 500 MG (divalproex sodium) DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED PV RELEASE SPRINKLE 125 MG (divalproex sodium) dihydroergotamine mesylate injection solution 1 mg/ml 1 DSL = 30 days dihydroergotamine mesylate nasal solution 4 mg/ml 1 DSL = 30 days divalproex sodium er oral tablet extended release 24 hour 250 PV mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg PV divalproex sodium oral tablet delayed release 125 mg, 250 mg, PV 500 mg DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 162.5 MG (aspirin) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 120 MG/ML (galcanezumab-gnlm) ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 2 (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg 1 goodsense aspirin low dose oral tablet delayed release 81 mg PV HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol hcl) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 129 Coverage Requirements & Prescription Drug Name Drug Tier Limits INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 120 MG, 80 MG (propranolol hcl sr beads) MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 2 caffeine) MIGRANAL NASAL SOLUTION 4 MG/ML (dihydroergotamine 2 DSL = 30 days mesylate) propranolol hcl er oral capsule extended release 24 hour 120 1 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE PV 81 MG (aspirin) timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 tramadol-acetaminophen oral tablet 37.5-325 mg 1 tri-buffered aspirin oral tablet 325 mg PV valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 3 apap-caffeine) , MISCELLANEOUS - Drugs for Depression & Psychosis ADASUVE INHALATION AEROSOL POWDER BREATH PV ACTIVATED 10 MG (loxapine) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg PV molindone hcl oral tablet 10 mg, 25 mg, 5 mg PV pimozide oral tablet 1 mg, 2 mg PV ,,AND ,MISC - Drugs for Anxiety & Sleep Disorder BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 3 (suvorexant) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg PV DAYVIGO ORAL TABLET 10 MG, 5 MG (lemborexant) 3 dexmedetomidine hcl in nacl intravenous solution 200 1 mcg/50ml, 200-0.9 mcg/50ml-%, 400 mcg/100ml, 80 mcg/20ml dexmedetomidine hcl intravenous solution 200 mcg/2ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 130 Coverage Requirements & Prescription Drug Name Drug Tier Limits EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG 3 DSL = 30 days (zolpidem tartrate) eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 DSL = 30 days HETLIOZ LQ ORAL SUSPENSION 4 MG/ML (tasimelteon) 3 HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) 3 DSL = 30 days hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 meprobamate oral tablet 200 mg, 400 mg PV PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML PV (promethazine hcl) PRECEDEX INTRAVENOUS SOLUTION 1000 MCG/250ML 3 (dexmedetomidine hcl in nacl) PRECEDEX INTRAVENOUS SOLUTION 200 MCG/2ML 2 (dexmedetomidine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml PV promethazine hcl oral solution 6.25 mg/5ml PV promethazine hcl oral syrup 6.25 mg/5ml PV promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg PV promethazine hcl rectal suppository 12.5 mg, 25 mg PV promethazine hcl (Promethegan Rectal Suppository 12.5 Mg, PV 25 Mg) promethegan rectal suppository 50 mg PV ramelteon oral tablet 8 mg 1 zaleplon oral capsule 10 mg, 5 mg 1 DSL = 30 days zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 1 DSL = 30 days mg zolpidem tartrate oral tablet 10 mg, 5 mg 1 DSL = 30 days zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg 1 DSL = 30 days ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem tartrate) 3 DSL = 30 days ATYPICAL ANTIPSYCHOTICS - Drugs for Depression & Psychosis ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PV SYRINGE 300 MG, 400 MG (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION PV RECONSTITUTED ER 300 MG, 400 MG (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, PV 15 MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 131 Coverage Requirements & Prescription Drug Name Drug Tier Limits ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, 20 PV MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 MG, 15 PV MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, PV 5 MG (aripiprazole) aripiprazole oral solution 1 mg/ml PV aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 PV mg aripiprazole oral tablet dispersible 10 mg, 15 mg PV ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE PV 675 MG/2.4ML (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML PV (aripiprazole lauroxil) asenapine maleate sublingual tablet sublingual 10 mg, 2.5 mg, PV 5 mg CAPLYTA ORAL CAPSULE 42 MG (lumateperone tosylate) 3 DSL = 30 days clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg PV clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200 PV mg, 25 mg CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG PV (clozapine) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 PV MG, 8 MG (iloperidone) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG PV (iloperidone) GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED PV 20 MG (ziprasidone mesylate) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG PV (ziprasidone hcl) INVEGA ORAL TABLET EXTENDED RELEASE 24 HOUR 1.5 PV MG, 3 MG, 6 MG, 9 MG (paliperidone) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, 156 MG/ML, 234 PV MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 MG/1.315ML, PV 546 MG/1.75ML, 819 MG/2.625ML (paliperidone palmitate) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 PV MG (lurasidone hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 132 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUPLAZID ORAL CAPSULE 34 MG (pimavanserin tartrate) 3 DSL = 30 days NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) 3 DSL = 30 days olanzapine intramuscular solution reconstituted 10 mg PV olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 PV mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg PV olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3- PV 25 mg, 6-25 mg, 6-50 mg paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 PV mg, 6 mg, 9 mg PERSERIS SUBCUTANEOUS PREFILLED SYRINGE 120 MG, 3 90 MG (risperidone) quetiapine fumarate er oral tablet extended release 24 hour 150 PV mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 PV mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 PV MG, 4 MG (brexpiprazole) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, 37.5 MG, 50 MG PV (risperidone microspheres) RISPERDAL ORAL SOLUTION 1 MG/ML (risperidone) PV RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG PV (risperidone) risperidone oral solution 1 mg/ml PV risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg PV risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, PV 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 PV MG, 5 MG (asenapine maleate) SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24HR, 3 5.7 MG/24HR, 7.6 MG/24HR (asenapine) SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 PV MG, 400 MG, 50 MG (quetiapine fumarate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG (quetiapine PV fumarate) SYMBYAX ORAL CAPSULE 12-50 MG, 3-25 MG, 6-25 MG, 6- PV 50 MG (olanzapine-fluoxetine hcl) VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 133 Coverage Requirements & Prescription Drug Name Drug Tier Limits VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG PV DSL = 30 days (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG PV DSL = 30 days (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg PV ziprasidone mesylate intramuscular solution reconstituted 20 PV mg ZYPREXA INTRAMUSCULAR SOLUTION RECONSTITUTED PV 10 MG (olanzapine) ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 PV MG, 7.5 MG (olanzapine) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 MG (olanzapine PV pamoate) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 PV MG, 20 MG, 5 MG (olanzapine) BARBITURATES (ANTICONVULSANTS) - Drugs for Seizures DONNATAL ORAL ELIXIR 16.2 MG/5ML (pb-hyoscy-atropine- 2 scopolamine) DONNATAL ORAL TABLET 16.2 MG (pb-hyoscy-atropine- 3 scopolamine) METHOHEXITAL SODIUM INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 100 MG/10ML pb-hyoscy-atropine-scopolamine oral elixir 16.2 mg/5ml 1 pb-hyoscy-atropine-scopolamine oral tablet 16.2 mg 1 phenobarbital oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 1 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital-belladonna alk oral elixir 16.2 mg/5ml 1 phenobarbital-belladonna alk oral tablet 16.2 mg 1 pb-hyoscy-atropine-scopolamine (Phenohytro Oral Elixir 16.2 2 Mg/5Ml) pb-hyoscy-atropine-scopolamine (Phenohytro Oral Tablet 16.2 3 Mg) primidone oral tablet 250 mg, 50 mg 1 BARBITURATES (, /HYP) - Drugs for Anxiety & Sleep Disorder ALLZITAL ORAL TABLET 25-325 MG (butalbital- 3 acetaminophen)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 134 Coverage Requirements & Prescription Drug Name Drug Tier Limits butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- 1 325-40-30 Mg) butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) 1 butalbital-acetaminophen capsule 50-300 mg oral 50-300 mg 1 BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL 3 50-300 MG butalbital-acetaminophen oral tablet 25-325 mg, 50-300 mg, 50- 1 325 mg butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- 1 40-30 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 1 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 DONNATAL ORAL ELIXIR 16.2 MG/5ML (pb-hyoscy-atropine- 2 scopolamine) DONNATAL ORAL TABLET 16.2 MG (pb-hyoscy-atropine- 3 scopolamine) pb-hyoscy-atropine-scopolamine oral elixir 16.2 mg/5ml 1 pb-hyoscy-atropine-scopolamine oral tablet 16.2 mg 1 phenobarbital oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 1 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital-belladonna alk oral elixir 16.2 mg/5ml 1 phenobarbital-belladonna alk oral tablet 16.2 mg 1 pb-hyoscy-atropine-scopolamine (Phenohytro Oral Elixir 16.2 2 Mg/5Ml) pb-hyoscy-atropine-scopolamine (Phenohytro Oral Tablet 16.2 3 Mg) TENCON ORAL TABLET 50-325 MG (butalbital- 3 acetaminophen) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 3 apap-caffeine) BARBITURATES (GENERAL ANESTHETICS) - Anesthetics METHOHEXITAL SODIUM INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 100 MG/10ML

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 135 Coverage Requirements & Prescription Drug Name Drug Tier Limits BENZODIAZEPINES (ANTICONVULSANTS) - Drugs for Seizures ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG (lorazepam) PV DSL = 30 days clobazam oral suspension 2.5 mg/ml 1 clobazam oral tablet 10 mg, 20 mg 1 clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg PV DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 2 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 2 diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) PV diazepam oral concentrate 5 mg/ml PV diazepam oral solution 5 mg/5ml PV diazepam oral tablet 10 mg, 2 mg, 5 mg PV diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 lorazepam injection solution 2 mg/ml, 4 mg/ml 1 lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) PV DSL = 30 days lorazepam oral concentrate 2 mg/ml PV DSL = 30 days lorazepam oral tablet 0.5 mg, 1 mg, 2 mg PV DSL = 30 days NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam 3 DSL = 30 days ()) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG (clobazam) 3 TRANXENE-T ORAL TABLET 7.5 MG (clorazepate PV dipotassium) VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) PV VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML 3 (diazepam) VALTOCO NASAL LIQUID THERAPY PACK 10 MG/0.1ML, 7.5 3 MG/0.1ML (diazepam) BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) - Drugs for Anxiety & Sleep Disorder alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 PV DSL = 30 days mg, 2 mg, 3 mg alprazolam intensol oral concentrate 1 mg/ml PV DSL = 30 days alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg PV DSL = 30 days alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg PV DSL = 30 days alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 PV DSL = 30 days mg, 2 mg, 3 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 136 Coverage Requirements & Prescription Drug Name Drug Tier Limits ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG (lorazepam) PV DSL = 30 days chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg PV chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg PV chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 clobazam oral suspension 2.5 mg/ml 1 clobazam oral tablet 10 mg, 20 mg 1 clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg PV DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 2 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 2 diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) PV diazepam oral concentrate 5 mg/ml PV diazepam oral solution 5 mg/5ml PV diazepam oral tablet 10 mg, 2 mg, 5 mg PV diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 estazolam oral tablet 1 mg, 2 mg 1 flurazepam hcl oral capsule 15 mg, 30 mg 1 DSL = 30 days lorazepam injection solution 2 mg/ml, 4 mg/ml 1 lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) PV DSL = 30 days lorazepam oral concentrate 2 mg/ml PV DSL = 30 days lorazepam oral tablet 0.5 mg, 1 mg, 2 mg PV DSL = 30 days midazolam hcl oral syrup 2 mg/ml 1 MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-0.8 MG/100ML-%, 100-0.9 MG/100ML-%, 50- 3 0.9 MG/50ML-% MKO MELT DOSE PACK MOUTH/THROAT TROCHE 3-25-2 3 MG NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam 3 DSL = 30 days (anticonvulsant)) oxazepam oral capsule 10 mg, 15 mg, 30 mg PV DSL = 30 days quazepam oral tablet 15 mg 1 SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG (clobazam) 3 temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 1 DSL = 30 days TRANXENE-T ORAL TABLET 7.5 MG (clorazepate PV dipotassium) triazolam oral tablet 0.125 mg, 0.25 mg 1 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 137 Coverage Requirements & Prescription Drug Name Drug Tier Limits VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) PV VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML 3 (diazepam) VALTOCO NASAL LIQUID THERAPY PACK 10 MG/0.1ML, 7.5 3 MG/0.1ML (diazepam) XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG PV DSL = 30 days (alprazolam) XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR PV DSL = 30 days 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam) BUTYROPHENONES - Drugs for Depression & Psychosis HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 PV MG/ML, 50 MG/ML (haloperidol decanoate) haloperidol decanoate intramuscular solution 100 mg/ml, 50 PV mg/ml haloperidol lactate oral concentrate 2 mg/ml PV haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg PV CALCITONIN GENE-RELATED ANTAG. - Migraine Treatment AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 140 MG/ML (erenumab-aooe) AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 3 DSL = 30 days MG/ML (erenumab-aooe) AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 225 3 MG/1.5ML (fremanezumab-vfrm) AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 DSL = 30 days 225 MG/1.5ML (fremanezumab-vfrm) EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION 3 PREFILLED SYRINGE 100 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 120 MG/ML (galcanezumab-gnlm) NURTEC ORAL TABLET DISPERSIBLE 75 MG (rimegepant 3 DSL = 30 days sulfate) UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) 3 DSL = 30 days VYEPTI INTRAVENOUS SOLUTION 100 MG/ML 3 (eptinezumab-jjmr)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 138 Coverage Requirements & Prescription Drug Name Drug Tier Limits CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. - Drugs for Parkinson carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg entacapone oral tablet 200 mg 1 ONGENTYS ORAL CAPSULE 25 MG, 50 MG (opicapone) 3 TASMAR ORAL TABLET 100 MG (tolcapone) 3 tolcapone oral tablet 100 mg 1 CENTRAL NERVOUS SYSTEM AGENTS, MISC. - Drugs for Attention Deficit Disorder acamprosate calcium oral tablet delayed release 333 mg 1 ADDYI ORAL TABLET 100 MG (flibanserin) 3 DSL = 30 days atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 1 mg, 60 mg, 80 mg AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG 3 DSL = 30 days (deutetrabenazine) carbidopa oral tablet 25 mg 1 guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 1 mg, 3 mg, 4 mg guanfacine hcl oral tablet 1 mg, 2 mg 1 INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine 3 DSL = 30 days tosylate) LODOSYN ORAL TABLET 25 MG (carbidopa) 2 memantine hcl er oral capsule extended release 24 hour 14 mg, 1 21 mg, 28 mg, 7 mg memantine hcl oral solution 2 mg/ml 1 memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg 1 NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 2 10 MG (memantine hcl) NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG 3 (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 3 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 DSL = 30 days 14-10 MG, 28-10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 21-10 MG, 7-10 MG (memantine hcl-donepezil hcl) NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) 3 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 139 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUEDEXTA ORAL CAPSULE 20-10 MG (dextromethorphan- 3 DSL = 30 days quinidine) QELBREE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 150 MG, 200 MG (viloxazine hcl) RADICAVA INTRAVENOUS SOLUTION 30 MG/100ML 3 DSL = 30 days (edaravone) riluzole oral tablet 50 mg 1 STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 3 MG, 40 MG, 60 MG, 80 MG (atomoxetine hcl) tetrabenazine oral tablet 12.5 mg, 25 mg 1 TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) 3 VYLEESI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 1.75 MG/0.3ML ( acetate) XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) 3 DSL = 30 days XYWAV ORAL SOLUTION 500 MG/ML (ca, mg, k, and na 3 DSL = 30 days oxybates) CYCLOOXYGENASE-2 (COX-2) INHIBITORS - Drugs for Pain celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg 1 CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 MG 3 (amlodipine besylate-celecoxib) NUDROXIPAK COMBINATION THERAPY PACK 200 MG 3 (celecoxib-capsaic-men-methsal) DOPAMINE PRECURSORS - Drugs for Parkinson carbidopa-levodopa er oral tablet extended release 25-100 mg, 1 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 1 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 1 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 1 150-200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML (carbidopa- 2 levodopa) INBRIJA INHALATION CAPSULE 42 MG (levodopa) 3 DSL = 30 days RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG (carbidopa- 3 levodopa)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 140 Coverage Requirements & Prescription Drug Name Drug Tier Limits ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS - Drugs for Parkinson mesylate oral capsule 5 mg 1 bromocriptine mesylate oral tablet 2.5 mg 1 cabergoline oral tablet 0.5 mg 1 CYCLOSET ORAL TABLET 0.8 MG (bromocriptine mesylate) 2 FIBROMYALGIA AGENTS - Drugs for Nerve Pain CYMBALTA ORAL CAPSULE DELAYED RELEASE PV PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 3 SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 30 PV mg, 40 mg, 60 mg LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 165 MG, 330 MG, 82.5 MG (pregabalin) pregabalin er oral tablet extended release 24 hour 165 mg, 330 1 mg, 82.5 mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 1 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml 1 SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 (milnacipran hcl) GENERAL ANESTHETICS, MISCELLANEOUS - Anesthetics KETAMINE HCL SUBLINGUAL TROCHE 100 MG 3 KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE 50-0.9 MG/5ML-% MKO MELT DOSE PACK MOUTH/THROAT TROCHE 3-25-2 3 MG HYDANTOINS - Drugs for Seizures DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium 2 extended) fosphenytoin sodium injection solution 500 mg pe/10ml 1 phenytoin (Phenytoin Infatabs Oral Tablet Chewable 50 Mg) 1 phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 1 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 141 Coverage Requirements & Prescription Drug Name Drug Tier Limits INHALATION ANESTHETICS - Anesthetics desflurane inhalation solution 1 FORANE INHALATION SOLUTION (isoflurane) 2 isoflurane inhalation solution 1 sevoflurane inhalation solution 1 isoflurane (Terrell Inhalation Solution) 1 MONOAMINE OXIDASE B INHIBITORS - Drugs for Parkinson EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR (selegiline) rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 XADAGO ORAL TABLET 100 MG, 50 MG (safinamide 3 mesylate) ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 3 hcl) MONOAMINE OXIDASE INHIBITORS - Drugs for Depression & Psychosis EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 MG/24HR, 9 MG/24HR (selegiline) MARPLAN ORAL TABLET 10 MG (isocarboxazid) PV NARDIL ORAL TABLET 15 MG (phenelzine sulfate) PV PARNATE ORAL TABLET 10 MG (tranylcypromine sulfate) PV phenelzine sulfate oral tablet 15 mg PV rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 tranylcypromine sulfate oral tablet 10 mg PV ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline 3 hcl) NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST - Drugs for Parkinson APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 2 DSL = 30 days MG/3ML (apomorphine hcl) KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 3 DSL = 30 days 30 MG (apomorphine hcl) KYNMOBI TITRATION KIT SUBLINGUAL KIT 10/15/20/25/30 3 DSL = 30 days MG (apomorphine hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 142 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR 3 (rotigotine) pramipexole dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 1 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 1 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 1 mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 1 mg, 5 mg OPIATE AGONISTS - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300- 1 60 mg APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 3 DSL = 30 days MG (benzhydrocodone-acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- 1 325-40-30 Mg) belladonna -opium rectal suppository 16.2-30 mg, 16.2- 1 60 mg BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 DSL = 30 days 4.08-325 MG, 6.12-325 MG, 8.16-325 MG butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- 1 40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 DSL = 30 days CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG (tramadol hcl) DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 MCG 3 (sufentanil citrate) duramorph injection solution 0.5 mg/ml, 1 mg/ml 1 oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg, 1 DSL = 30 days 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 143 Coverage Requirements & Prescription Drug Name Drug Tier Limits fentanyl citrate (pf) injection solution 100 mcg/2ml, 1000 mcg/20ml, 250 mcg/5ml, 2500 mcg/50ml, 50 mcg/ml, 500 1 DSL = 30 days mcg/10ml fentanyl citrate (pf) injection solution cartridge 100 mcg/2ml 1 DSL = 30 days fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 1 DSL = 30 days mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg FENTANYL CITRATE BUCCAL TABLET 100 MCG, 200 MCG, 3 DSL = 30 days 400 MCG, 600 MCG, 800 MCG FENTANYL CITRATE INTRAVENOUS SOLUTION PREFILLED 3 SYRINGE 100 MCG/2ML FENTANYL CITRATE-NACL INJECTION SOLUTION 10-0.9 3 DSL = 30 days MCG/ML-% FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 1-0.9 MG/100ML-%, 1.25-0.9 MG/250ML-%, 2-0.9 MG/100ML-%, 2.5- 3 0.9 MG/250ML-% FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 500-0.9 MCG/50ML-% fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 1 DSL = 30 days mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 1 87.5 mcg/hr FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2- 0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.5-0.0625- 3 0.9 MG/250ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-% FENTANYL-BUPIVACAINE-NACL INJECTION SOLUTION 2- 3 DSL = 30 days 0.125-0.9 MCG/ML-%-% FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 3 DSL = 30 days 600 MCG, 800 MCG (fentanyl citrate) guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 hydrocodone bitartrate er oral capsule extended release 12 1 DSL = 30 days hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent 1 DSL = 30 days 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg hydrocodone polst-chlorphen polst er susp oral suspension 1 extended release 10-8 mg/5ml hydrocodone-acetaminophen oral solution 10-325 mg/15ml, 7.5- 1 325 mg/15ml hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 1 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 144 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocodone-homatropine oral tablet 5-1.5 mg 1 hydrocodone- oral tablet 10-200 mg, 5-200 mg, 7.5- 1 200 mg hydromet oral syrup 5-1.5 mg/5ml 1 hydromorphone hcl er oral tablet extended release 24 hour 12 1 DSL = 30 days mg, 16 mg, 32 mg, 8 mg hydromorphone hcl injection solution 2 mg/ml 1 DSL = 30 days hydromorphone hcl oral liquid 1 mg/ml 1 DSL = 30 days hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg 1 DSL = 30 days hydromorphone hcl rectal suppository 3 mg 1 DSL = 30 days HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 3 25-0.9 MG/50ML-%, 50-0.9 MG/50ML-% HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-0.9 MG/50ML-%, 15-0.9 MG/30ML- 3 % HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 3 DSL = 30 days MG, 80 MG (hydrocodone bitartrate) INFUMORPH 200 INJECTION SOLUTION 200 MG/20ML (10 2 DSL = 30 days MG/ML) (morphine sulfate microinfusion) INFUMORPH 500 INJECTION SOLUTION 500 MG/20ML (25 2 DSL = 30 days MG/ML) (morphine sulfate microinfusion) LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT 3 DSL = 30 days (fentanyl citrate) levorphanol tartrate oral tablet 2 mg 1 DSL = 30 days levorphanol tartrate oral tablet 3 mg 1 LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 2 acetaminophen) maxi-tuss ac oral solution 100-10 mg/5ml 1 meperidine hcl injection solution 50 mg/ml 1 DSL = 30 days meperidine hcl oral solution 50 mg/5ml 1 DSL = 30 days meperidine hcl oral tablet 50 mg 1 DSL = 30 days methadone hcl injection solution 10 mg/ml 1 DSL = 30 days methadone hcl (Methadone Hcl Intensol Oral Concentrate 10 1 DSL = 30 days Mg/Ml) methadone hcl oral concentrate 10 mg/ml 1 DSL = 30 days methadone hcl oral solution 10 mg/5ml, 5 mg/5ml 1 DSL = 30 days methadone hcl oral tablet 10 mg, 5 mg 1 DSL = 30 days methadone hcl oral tablet soluble 40 mg 1 DSL = 30 days methadose oral concentrate 10 mg/ml 1 DSL = 30 days Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 145 Coverage Requirements & Prescription Drug Name Drug Tier Limits methadone hcl (Methadose Oral Tablet Soluble 40 Mg) 1 DSL = 30 days methadose sugar-free oral concentrate 10 mg/ml 1 DSL = 30 days morphine sulfate microinfusion (Mitigo Injection Solution 200 1 DSL = 30 days Mg/20Ml (10 Mg/Ml), 500 Mg/20Ml (25 Mg/Ml)) morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 1 mg/ml morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml, 10 1 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml morphine sulfate (pf) intravenous solution 10 mg/ml, 2 mg/ml, 4 1 mg/ml, 8 mg/ml morphine sulfate er beads oral capsule extended release 24 1 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 10 1 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, 1 200 mg, 30 mg, 60 mg MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML 3 DSL = 30 days morphine sulfate injection solution 2 mg/ml, 4 mg/ml 1 MORPHINE SULFATE INTRAVENOUS SOLUTION 0.5 MG/ML 3 morphine sulfate intravenous solution 50 mg/ml 1 morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml 1 morphine sulfate oral tablet 15 mg, 30 mg 1 morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg 1 MORPHINE SULFATE SOLUTION 1 MG/ML INTRAVENOUS 1 3 MG/ML morphine sulfate solution 1 mg/ml intravenous 1 mg/ml 1 MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 50-0.9 MG/50ML-% NALOCET ORAL TABLET 2.5-300 MG 3 DSL = 30 days NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG (tapentadol 3 DSL = 30 days hcl) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG (tapentadol 3 DSL = 30 days hcl) opium oral tincture 10 mg/ml (1%) 1 OXAYDO ORAL TABLET 5 MG, 7.5 MG (oxycodone hcl) 3 DSL = 30 days OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 3 DSL = 30 days 80 MG oxycodone hcl oral capsule 5 mg 1 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 146 Coverage Requirements & Prescription Drug Name Drug Tier Limits oxycodone hcl oral concentrate 100 mg/5ml 1 DSL = 30 days oxycodone hcl oral solution 5 mg/5ml 1 DSL = 30 days oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg 1 DSL = 30 days oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 1 DSL = 30 days 5-325 mg, 7.5-325 mg OXYCODONE-ACETAMINOPHEN ORAL TABLET 2.5-300 MG 3 DSL = 30 days oxycodone-aspirin oral tablet 4.8355-325 mg 1 DSL = 30 days OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 3 DSL = 30 days 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 1 DSL = 30 days 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg oxymorphone hcl oral tablet 10 mg, 5 mg 1 DSL = 30 days PROLATE ORAL SOLUTION 10-300 MG/5ML (oxycodone- 3 DSL = 30 days acetaminophen) PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 MG 3 DSL = 30 days (oxycodone-acetaminophen) promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-codeine oral solution 6.25-10 mg/5ml 1 promethazine-codeine oral syrup 6.25-10 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 QDOLO ORAL SOLUTION 5 MG/ML (tramadol hcl) 3 SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 MCG, 3 DSL = 30 days 800 MCG (fentanyl) SYNAPRYN FUSEPAQ ORAL SUSPENSION 3 RECONSTITUTED 10 MG/ML (tramadol hcl) tramadol hcl er (biphasic) oral tablet extended release 24 hour 1 100 mg, 200 mg, 300 mg TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 3 24 HOUR 100 MG, 200 MG, 300 MG tramadol hcl er oral tablet extended release 24 hour 100 mg, 1 200 mg, 300 mg tramadol hcl oral tablet 100 mg, 50 mg 1 tramadol-acetaminophen oral tablet 37.5-325 mg 1 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 147 Coverage Requirements & Prescription Drug Name Drug Tier Limits TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 3 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG 3 (oxycodone) OPIATE ANTAGONISTS - Drugs for Overdose or Poisoning LIFEMS NALOXONE INJECTION PREFILLED SYRINGE KIT 2 3 MG/2ML naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 naloxone hcl injection solution cartridge 0.4 mg/ml 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml 1 naltrexone hcl oral tablet 50 mg 1 NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) 3 VIVITROL INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED 380 MG (naltrexone) OPIATE PARTIAL AGONISTS - Drugs for Pain BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 3 MCG, 75 MCG, 750 MCG, 900 MCG (buprenorphine hcl) BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG 3 (buprenorphine hcl-naloxone hcl) buprenorphine hcl injection solution 0.3 mg/ml 1 buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg 1 buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 4-1 mg 1 buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 8-2 1 DSL = 30 days mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- 1 0.5 mg, 8-2 mg buprenorphine transdermal patch weekly 10 mcg/hr, 20 mcg/hr, 1 DSL = 30 days 5 mcg/hr buprenorphine transdermal patch weekly 15 mcg/hr, 7.5 mcg/hr 1 butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml 1 butorphanol tartrate nasal solution 10 mg/ml 1 nalbuphine hcl injection solution 20 mg/ml 1 pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 PROBUPHINE IMPLANT KIT SUBCUTANEOUS IMPLANT 3 74.2 MG (buprenorphine hcl) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 100 MG/0.5ML, 300 MG/1.5ML (buprenorphine)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 148 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 3 DSL = 30 days MG (buprenorphine hcl-naloxone hcl) OTHER ANTI-INFLAM. AGENTS - Drugs for Pain ADVIL JUNIOR STRENGTH ORAL TABLET 100 MG PV (ibuprofen) ADVIL JUNIOR STRENGTH ORAL TABLET CHEWABLE 100 PV MG (ibuprofen) ADVIL MIGRAINE ORAL CAPSULE 200 MG (ibuprofen) PV ADVIL ORAL CAPSULE 200 MG (ibuprofen) PV ADVIL ORAL TABLET 200 MG (ibuprofen) PV ALEVE ORAL TABLET 220 MG (naproxen sodium) PV CALDOLOR INTRAVENOUS SOLUTION 800 MG/200ML, 800 PV MG/8ML (ibuprofen) CAMBIA ORAL PACKET 50 MG (diclofenac 3 potassium(migraine)) CAPSFENAC PAK COMBINATION THERAPY PACK 1.5 & 3 0.025 % CAPSINAC COMBINATION THERAPY PACK 0.025-1.5 % 3 diclofenac potassium (Cataflam Oral Tablet 50 Mg) PV DAYPRO ORAL TABLET 600 MG (oxaprozin) PV DERMACINRX LEXITRAL PHARMAPAK COMBINATION 3 THERAPY PACK 1.5 & 0.025 % (diclofenac sodium-capsaicin) DICLOFENAC CAP ORAL CAPSULE 35 MG PV DICLOFENAC PATCH EXTERNAL PATCH 1.3 % PV diclofenac potassium oral tablet 50 mg PV diclofenac sodium er oral tablet extended release 24 hour 100 PV mg diclofenac sodium external gel 1 % PV diclofenac sodium external solution 1.5 % PV diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 PV mg diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 1 75-0.2 mg DICLOFENAC-NA HYALURON-NIACIN EXTERNAL GEL 3-2-4 3 % DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) PV DICLOPR EXTERNAL KIT 1 & 10-30 % 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 149 Coverage Requirements & Prescription Drug Name Drug Tier Limits DICLOTREX EXTERNAL THERAPY PACK 1.5 & 4-10 % 3 (diclofenac sod-camphor-menthol) DICLOVIX COMBINATION KIT 1.5 & 2-2.5-4 % 3 DICLOVIX M EXTERNAL THERAPY PACK 1.5-8 % 3 DICLOZOR EXTERNAL THERAPY PACK 1 % 3 diflunisal oral tablet 500 mg 1 DIMENTHO EXTERNAL THERAPY PACK 1.5 & 10 % 3 DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-famotidine) 3 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, PV 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg PV etodolac er oral tablet extended release 24 hour 400 mg, 500 PV mg, 600 mg etodolac oral capsule 200 mg, 300 mg PV etodolac oral tablet 400 mg, 500 mg PV FELDENE ORAL CAPSULE 10 MG, 20 MG (piroxicam) PV fenoprofen calcium oral capsule 200 mg, 400 mg PV fenoprofen calcium oral tablet 600 mg PV fenortho oral capsule 200 mg PV FLECTOR EXTERNAL PATCH 1.3 % (diclofenac epolamine) PV FLEXIPAK COMBINATION THERAPY PACK 75 & 0.025 MG-% 3 flurbiprofen oral tablet 100 mg, 50 mg PV goodsense ibuprofen oral capsule 200 mg PV hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5- 1 200 mg IBUPAK ORAL KIT 600 MG (ibuprofen) PV ibuprofen infants oral suspension 50 mg/1.25ml PV ibuprofen oral capsule 200 mg PV ibuprofen oral suspension 100 mg/5ml PV ibuprofen oral tablet 200 mg PV ibuprofen (Ibuprofen Oral Tablet 400 Mg, 600 Mg, 800 Mg) PV inavix combination therapy pack 75 & 0.025 mg-% 1 INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) PV INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) PV indomethacin er oral capsule extended release 75 mg PV INDOMETHACIN ORAL CAPSULE 20 MG PV indomethacin oral capsule 25 mg, 50 mg PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 150 Coverage Requirements & Prescription Drug Name Drug Tier Limits diclofenac sodium-capsaicin (Inflammacin Combination Therapy 3 Pack 75 & 0.025 Mg-%) INFLATHERM COMBINATION THERAPY PACK 75 & 3-3 MG 3 & % (diclofenac-menthol-camphor) kapzin dc combination therapy pack 0.025-1.5 % 1 ketoprofen er oral capsule extended release 24 hour 200 mg PV ketoprofen oral capsule 25 mg, 50 mg, 75 mg PV ketorolac tromethamine injection solution 15 mg/ml PV ketorolac tromethamine intramuscular solution 60 mg/2ml PV KETOROLAC TROMETHAMINE NASAL SOLUTION 15.75 PV MG/SPRAY ketorolac tromethamine oral tablet 10 mg PV ketorolac tromethamine solution 30 mg/ml injection 30 mg/ml PV KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML PV INJECTION 30 MG/ML LICART EXTERNAL PATCH 24 HOUR 1.3 % (diclofenac PV epolamine) LODINE ORAL TABLET 400 MG (etodolac) PV meclofenamate sodium oral capsule 100 mg, 50 mg PV mefenamic acid oral capsule 250 mg PV meloxicam oral capsule 10 mg, 5 mg PV meloxicam oral tablet 15 mg, 7.5 mg PV MOBIC ORAL TABLET 15 MG, 7.5 MG (meloxicam) PV MOTRIN IB ORAL CAPSULE 200 MG (ibuprofen) PV MOTRIN INFANTS DROPS ORAL SUSPENSION 50 PV MG/1.25ML (ibuprofen) nabumetone oral tablet 500 mg, 750 mg PV NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) PV NALFON ORAL TABLET 600 MG (fenoprofen calcium) PV NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR PV 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML (naproxen) PV NAPROSYN ORAL TABLET 500 MG (naproxen) PV naproxen oral suspension 125 mg/5ml PV naproxen oral tablet 250 mg, 375 mg, 500 mg PV naproxen oral tablet delayed release 375 mg, 500 mg PV naproxen sodium er oral tablet extended release 24 hour 375 PV mg, 500 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 151 Coverage Requirements & Prescription Drug Name Drug Tier Limits NAPROXEN SODIUM ER ORAL TABLET EXTENDED PV RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 220 mg, 275 mg, 550 mg PV naproxen-esomeprazole oral tablet delayed release 375-20 mg, 1 500-20 mg diclofenac sodium-capsaicin (Nudiclo Solupak Combination 3 Therapy Pack 1.5 & 0.025 %) diclofenac sodium-capsaicin (Nudiclo Tabpak Combination 3 Therapy Pack 75 & 0.025 Mg-%) NUDROXIPAK DSDR-50 COMBINATION KIT 50 MG PV (diclofenac sodium-liniment) NUDROXIPAK DSDR-75 COMBINATION KIT 75 MG PV (diclofenac sodium-liniment) NUDROXIPAK E-400 COMBINATION KIT 400 MG (etodolac- PV liniment) NUDROXIPAK I-800 COMBINATION KIT 800 MG (ibuprofen- PV liniment) NUDROXIPAK N-500 COMBINATION KIT 500 MG PV (nabumetone-liniment) oxaprozin oral tablet 600 mg PV PENNSAID EXTERNAL SOLUTION 2 % (diclofenac sodium) PV piroxicam oral capsule 10 mg, 20 mg PV previdolrx plus combination therapy pack 75 & 0.025 1 mg-% QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 MG PV (meloxicam) RELAFEN DS ORAL TABLET 1000 MG (nabumetone) PV DSL = 30 days nabumetone (Relafen Oral Tablet 500 Mg, 750 Mg) PV ROAOXIA EXTERNAL GEL 3-4 % 3 SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac PV tromethamine) sulindac oral tablet 150 mg, 200 mg PV sumatriptan-naproxen sodium oral tablet 85-500 mg 1 sure result dss premium pack combination therapy pack 1.5 & 1 0.025 % TIVORBEX ORAL CAPSULE 20 MG (indomethacin) PV tolmetin sodium oral capsule 400 mg PV tolmetin sodium oral tablet 600 mg PV TORONOVA II SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & )

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 152 Coverage Requirements & Prescription Drug Name Drug Tier Limits TORONOVA SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & anesthetic) VAROPHEN EXTERNAL KIT 1.5-10-15 % (diclofenac& 3 menthol-methyl sal) VENNGEL ONE EXTERNAL KIT 1 % (diclofenac sodium) PV VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) PV VOLTAREN EXTERNAL GEL 1 % (diclofenac sodium) PV XRYLIX EXTERNAL THERAPY PACK 1.5 % (diclofenac sod- 3 adhesive sheet) ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) PV ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) PV PHENOTHIAZINES - Drugs for Depression & Psychosis hcl injection solution 25 mg/ml, 50 mg/2ml PV chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, PV 50 mg prochlorperazine (Compro Rectal Suppository 25 Mg) PV fluphenazine decanoate injection solution 25 mg/ml PV fluphenazine hcl injection solution 2.5 mg/ml PV fluphenazine hcl oral concentrate 5 mg/ml PV fluphenazine hcl oral elixir 2.5 mg/5ml PV fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg PV perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg PV perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 PV mg, 4-25 mg, 4-50 mg prochlorperazine maleate oral tablet 10 mg, 5 mg PV prochlorperazine rectal suppository 25 mg PV thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg PV trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg PV RESPIRATORY AND CNS - Drugs for the Nervous System ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG 3 (methylphenidate hcl) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg 1 apap-caff-dihydrocodeine oral tablet 325-30-16 mg 1 butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- 1 325-40-30 Mg) butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 153 Coverage Requirements & Prescription Drug Name Drug Tier Limits butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- 1 40-30 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 1 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 1 CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 3 MG, 36 MG, 54 MG (methylphenidate hcl) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE 3 DSL = 30 days DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 3 MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 1 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG 3 (methylphenidate hcl) methylphenidate hcl er (cd) oral capsule extended release 10 1 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 1 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er (xr) oral capsule extended release 24 1 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 18 1 mg, 20 mg, 27 mg, 36 mg, 54 mg, 72 mg methylphenidate hcl er oral tablet extended release 24 hour 18 1 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml 1 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg 1 QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED 3 RELEASE 20 MG, 30 MG, 40 MG (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 3 25 MG/5ML (methylphenidate hcl) relexxii oral tablet extended release 72 mg 1 VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 3 apap-caffeine) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 154 Coverage Requirements & Prescription Drug Name Drug Tier Limits SALICYLATES - Drugs for Pain adult aspirin regimen oral tablet delayed release 81 mg PV butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- 1 325-40-30 Mg) aspirin adult low strength oral tablet delayed release 81 mg PV aspirin childrens oral tablet chewable 81 mg PV aspirin ec low dose oral tablet delayed release 81 mg PV aspirin ec low strength oral tablet delayed release 81 mg PV aspirin ec oral tablet delayed release 325 mg PV aspirin low dose oral tablet chewable 81 mg PV aspirin low dose oral tablet delayed release 81 mg PV aspirin oral tablet 325 mg PV aspirin oral tablet delayed release 325 mg, 81 mg PV aspirin-dipyridamole er oral capsule extended release 12 hour 1 25-200 mg ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 325-40 MG, 81-40 MG BAYER ASPIRIN EC LOW DOSE ORAL TABLET DELAYED PV RELEASE 81 MG (aspirin) BAYER ASPIRIN ORAL TABLET 325 MG (aspirin) PV BAYER ASPIRIN ORAL TABLET DELAYED RELEASE 325 MG PV (aspirin) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 1 DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 162.5 MG (aspirin) goodsense aspirin low dose oral tablet delayed release 81 mg PV methyl salicylate external liquid 1 NORGESIC FORTE ORAL TABLET 50-770-60 MG 3 orphenadrine-asa-caffeine oral tablet 50-770-60 mg 1 orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet 3 50-770-60 Mg) oxycodone-aspirin oral tablet 4.8355-325 mg 1 DSL = 30 days salsalate oral tablet 500 mg, 750 mg 1 ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE PV 81 MG (aspirin) tri-buffered aspirin oral tablet 325 mg PV Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 155 Coverage Requirements & Prescription Drug Name Drug Tier Limits WPR PLUS WOUND HEALING SYSTEM EXTERNAL 3 THERAPY PACK 4 & 10-30 % YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 3 81-40 MG (aspirin-omeprazole) SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR - Drugs for Depression & Psychosis CYMBALTA ORAL CAPSULE DELAYED RELEASE PV PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE PV 24 HOUR 100 MG, 50 MG desvenlafaxine succinate er oral tablet extended release 24 PV hour 100 mg, 25 mg, 50 mg DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 3 SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 30 PV mg, 40 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE 24 PV HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR PV 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR PV THERAPY PACK 20 & 40 MG (levomilnacipran hcl) PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 100 PV MG, 25 MG, 50 MG (desvenlafaxine succinate) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 (milnacipran hcl) venlafaxine hcl er oral capsule extended release 24 hour 150 PV mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, PV 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 PV mg SELECTIVE SEROTONIN AGONISTS - Migraine Treatment almotriptan malate oral tablet 12.5 mg, 6.25 mg 1 eletriptan hydrobromide oral tablet 20 mg, 40 mg 1 frovatriptan succinate oral tablet 2.5 mg 1 IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT 3 (sumatriptan)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 156 Coverage Requirements & Prescription Drug Name Drug Tier Limits IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG (sumatriptan 3 succinate) MIGRANOW COMBINATION THERAPY PACK 50 & 4-10 MG 3 & % (sumatriptan & camphor-menthol) naratriptan hcl oral tablet 1 mg, 2.5 mg 1 ONZETRA XSAIL NASAL EXHALER POWDER 11 3 MG/NOSEPC (sumatriptan succinate) REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan 3 DSL = 30 days succinate) rizatriptan benzoate oral tablet 10 mg, 5 mg 1 rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 1 sumatriptan nasal solution 20 mg/act, 5 mg/act 1 sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 sumatriptan succinate refill subcutaneous solution cartridge 4 1 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml 1 sumatriptan succinate subcutaneous solution auto-injector 4 1 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 1 mg/0.5ml sumatriptan-naproxen sodium oral tablet 85-500 mg 1 TOSYMRA NASAL SOLUTION 10 MG/ACT (sumatriptan) 3 DSL = 30 days ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION 3 AUTO-INJECTOR 3 MG/0.5ML (sumatriptan succinate) ZOLMITRIPTAN NASAL SOLUTION 2.5 MG, 5 MG 3 zolmitriptan oral tablet 2.5 mg, 5 mg 1 zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 1 ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) 3 SELECTIVE-SEROTONIN REUPTAKE INHIBITORS - Drugs for Depression & Psychosis CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG (citalopram PV hydrobromide) citalopram hydrobromide oral solution 10 mg/5ml PV citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg PV escitalopram oxalate oral solution 5 mg/5ml PV escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg PV fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg PV fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg PV fluoxetine hcl oral capsule delayed release 90 mg PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 157 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluoxetine hcl oral solution 20 mg/5ml PV fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg PV fluvoxamine maleate er oral capsule extended release 24 hour PV 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg PV LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG (escitalopram PV oxalate) olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3- PV 25 mg, 6-25 mg, 6-50 mg paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, PV 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg PV paroxetine mesylate oral capsule 7.5 mg 1 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HOUR PV 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) PV PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PV (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PV (paroxetine mesylate) PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG (fluoxetine PV hcl) sertraline hcl oral concentrate 20 mg/ml PV sertraline hcl oral tablet 100 mg, 25 mg, 50 mg PV SYMBYAX ORAL CAPSULE 12-50 MG, 3-25 MG, 6-25 MG, 6- PV 50 MG (olanzapine-fluoxetine hcl) ZOLOFT ORAL CONCENTRATE 20 MG/ML (sertraline hcl) PV ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG (sertraline PV hcl) SEROTONIN MODULATORS - Drugs for Depression & Psychosis nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 PV mg trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg PV TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG (vortioxetine PV hbr) VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG (vilazodone PV hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG (vilazodone PV hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 158 Coverage Requirements & Prescription Drug Name Drug Tier Limits SUCCINIMIDES - Drugs for Seizures CELONTIN ORAL CAPSULE 300 MG (methsuximide) 2 ethosuximide oral capsule 250 mg 1 ethosuximide oral solution 250 mg/5ml 1 THIOXANTHENES - Drugs for Depression & Psychosis thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg PV TRICYCLICS, OTHER NOREPI-RU INHIBITORS - Drugs for Depression & Psychosis amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 PV mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg PV ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG PV (clomipramine hcl) chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg PV clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg PV desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 PV mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 PV mg, 75 mg doxepin hcl oral concentrate 10 mg/ml PV doxepin hcl oral tablet 3 mg, 6 mg 1 enovarx-amitriptyline external kit 2 % PV imipramine hcl oral tablet 10 mg, 25 mg, 50 mg PV imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 PV mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg PV NORPRAMIN ORAL TABLET 10 MG, 25 MG (desipramine hcl) PV nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg PV nortriptyline hcl oral solution 10 mg/5ml PV PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG PV (nortriptyline hcl) perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 PV mg, 4-25 mg, 4-50 mg protriptyline hcl oral tablet 10 mg, 5 mg PV trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg PV VESICULAR MONOAMINE TRANSPORT2 INHIBITOR - Drugs for the Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG 3 DSL = 30 days (deutetrabenazine)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 159 Coverage Requirements & Prescription Drug Name Drug Tier Limits INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine 3 DSL = 30 days tosylate) INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 MG 3 DSL = 30 days (valbenazine tosylate) tetrabenazine oral tablet 12.5 mg, 25 mg 1 WAKEFULNESS-PROMOTING AGENTS - Drugs for the Nervous System armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg 1 modafinil oral tablet 100 mg, 200 mg 1 SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) 3 WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant hcl) 3 DSL = 30 days DEVICES - Medical Supplies and Durable Medical Equipment DEVICES - Medical Supplies and Durable Medical Equipment ACCUCAINE COMBINATION KIT 1 % (lido-pentaf-tetrafl- 3 ultrasound) ACCU-CHEK AVIVA IN VITRO SOLUTION (blood glucose 2 calibration) ACCU-CHEK COMPACT PLUS CONTROL IN VITRO 2 SOLUTION (blood glucose calibration) ACCU-CHEK FASTCLIX LANCET KIT KIT (lancets misc.) 2 ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID (blood 2 glucose calibration) ACCU-CHEK GUIDE KIT W/DEVICE ( 2 suppl) ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID 2 (blood glucose calibration) ACCU-CHEK SOFTCLIX LANCET DEVICE KIT KIT (lancets 2 misc.) ACCU-CHEK TENDER 1 INFUSION KIT (iv sets-tubing) 3 ACCU-CHEK ULTRAFLEX INF SET (insulin infusion pump 3 supplies) ASTERO EXTERNAL GEL 4 % (lidocaine hcl) 3 ATOPADERM EXTERNAL CREAM 3 ATOPICLAIR EXTERNAL CREAM (dermatological products, 3 misc.) AUTOLET LANCING DEVICE (lancet devices) PV AUTOSOFT 30 INFUSION SET (insulin infusion pump supplies) 3 AUTOSOFT 90 INFUSION SET (insulin infusion pump supplies) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 160 Coverage Requirements & Prescription Drug Name Drug Tier Limits AUTOSOFT XC INFUSION SET (insulin infusion pump 3 supplies) BEAU RX EXTERNAL GEL 3 BETALOAN SUIK COMBINATION KIT 30 MG/5ML (betameth 3 sod phos-ace & anesth) CADIRAMD EXTERNAL KIT 2.5-2.5 % (lido-prilocaine-blood 3 collect) CARETOUCH LANCING/EJECTOR (lancet devices) PV CEQUR SIMPLICITY 2U DEVICE (injection device for insulin) PV CONTOUR CONTROL IN VITRO LIQUID HIGH , LOW , 2 NORMAL (blood glucose calibration) CONTOUR MONITOR DEVICE DEVICE (blood glucose 2 monitoring suppl) CONTOUR MONITOR KIT W/DEVICE KIT W/DEVICE (blood 2 glucose monitoring suppl) CONTOUR NEXT CONTROL IN VITRO SOLUTION LOW , 2 NORMAL (blood glucose calibration) CONTOUR NEXT EZ KIT W/DEVICE (blood glucose monitoring 2 suppl) CONTOUR NEXT LINK KIT W/DEVICE (blood glucose 2 monitoring suppl) CONTOUR NEXT MONITOR KIT W/DEVICE (blood glucose 2 monitoring suppl) DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) (continuous 3 blood gluc transmit) DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE 3 (continuous blood gluc receiver) DMT SUIK COMBINATION KIT 10 MG/ML (dexameth sod phos 3 & anesthetic) DUROLANE INTRA-ARTICULAR PREFILLED SYRINGE 60 3 MG/3ML (sodium hyaluronate (viscosup)) EASIVENT (spacer/aero-holding chambers) 2 EASYMAX CONTROL IN VITRO SOLUTION NORMAL (blood 2 glucose calibration) ELETONE EXTERNAL CREAM (dermatological products, 3 misc.) EMULSION SB EXTERNAL EMULSION (dermatological 3 products, misc.) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 161 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENTTY SPRAY EXTERNAL EMULSION (dermatological 3 products, misc.) EPICERAM EXTERNAL EMULSION (dermatological products, 3 misc.) EPISIL MOUTH/THROAT LIQUID (oral wound care products) 3 EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 20 MG/2ML (sodium hyaluronate (viscosup)) FLEXICHAMBER ADULT MASK/SMALL (spacer/aero-hold 3 chamber mask) FLEXICHAMBER CHILD MASK/LARGE (spacer/aero-hold 3 chamber mask) FLEXICHAMBER CHILD MASK/SMALL (spacer/aero-hold 3 chamber mask) FORTISCARE CONTROL IN VITRO SOLUTION HIGH , LOW , 2 NORMAL (blood glucose calibration) FREESTYLE LIBRE 14 DAY READER DEVICE (continuous 3 blood gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood gluc 3 sensor) FREESTYLE LIBRE 2 READER DEVICE (continuous blood 3 gluc receiver) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc sensor) 3 FREESTYLE LIBRE READER DEVICE (continuous blood gluc 3 receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood gluc 3 sensor) GEBAUERS PAIN EASE EXTERNAL AEROSOL 3 (pentafluoroprop-tetrafluoroeth) GEBAUERS SPRAY AND STRETCH EXTERNAL AEROSOL 3 (pentafluoroprop-tetrafluoroeth) GELCLAIR MOUTH/THROAT GEL (povidone-nahyaluron- 3 glycyrrhet) GEL-FLOW EXTERNAL KIT (gelatin absorb-thrombin) 3 GEL-FLOW NT EXTERNAL PREFILLED SYRINGE (gelatin 3 absorbable) GELFOAM COMPRESSED SIZE 100 EXTERNAL (gelatin 3 absorbable) GELFOAM DENTAL PACK SIZE 4 EXTERNAL (gelatin 3 absorbable) GELFOAM MOUTH/THROAT POWDER (gelatin absorbable) 3 GELFOAM SPONGE EXTERNAL 12-7 MM (gelatin absorbable) 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 162 Coverage Requirements & Prescription Drug Name Drug Tier Limits GELFOAM SPONGE SIZE 100 EXTERNAL (gelatin 2 absorbable) GELFOAM SPONGE SIZE 200 EXTERNAL (gelatin 3 absorbable) GELFOAM SPONGE SIZE 50 EXTERNAL (gelatin absorbable) 2 GELFOAM-JMI POWDER EXTERNAL KIT (gelatin absorb- 3 thrombin) GELFOAM-JMI SPONGE EXTERNAL KIT (gelatin absorb- 3 thrombin) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 16.8 MG/2ML (sodium hyaluronate (viscosup)) GELX MOUTH/THROAT GEL (oral wound care products) 3 GENADUR COMBINATION KIT (dermatological products, 3 misc.) GENADUR EXTERNAL LIQUID (dermatological products, 3 misc.) GUARDIAN SENSOR (3) (continuous blood gluc sensor) 3 heparin (porcine) in nacl intravenous solution 1000-0.9 1 ut/500ml-%, 2000-0.9 unit/l-% heparin lock flush intravenous solution 10 unit/ml 1 heparin sodium lock flush intravenous solution 100 unit/ml 1 HPR PLUS EXTERNAL CREAM (dermatological products, 3 misc.) hpr plus external foam 1 HPR PLUS HYDROGEL EXTERNAL KIT (dermatological 3 products, misc.) HUMATROPEN FOR 12MG DEVICE (injection device) PV HUMATROPEN FOR 24MG DEVICE (injection device) PV HUMATROPEN FOR 6MG DEVICE (injection device) PV HYALGAN INTRA-ARTICULAR SOLUTION 20 MG/2ML 3 (sodium hyaluronate (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 20 MG/2ML (sodium hyaluronate (viscosup)) HYLATOPIC PLUS EXTERNAL CREAM (dermatological 3 products, misc.) HYLATOPIC PLUS EXTERNAL LOTION (dermatological 3 products, misc.) HYMOVIS INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 24 MG/3ML (hyaluronan) HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 3 7 % (sodium chloride) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 163 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) 3 INSPIREASE RESERVOIR BAGS (spacer/aero-hold chamber 2 bags) INSULIN PEN NEEDLES 29G X 12.7MM , 29G X 5MM , 29G X 8MM , 31G X 5 MM , 32G X 4 MM , 33G X 4 MM (insulin pen PV needle) INSULIN PEN NEEDLES 29G X 12MM , 31G X 6 MM , 31G X 8 PV MM INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 PV ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) KAMDOY EXTERNAL EMULSION (dermatological products, 3 misc.) KELARX EXTERNAL GEL (scar treatment products) 3 KIVIK EXTERNAL EMULSION (dermatological products, misc.) 3 LDO PLUS EXTERNAL GEL 4 % (lidocaine hcl) 3 lidocaine-prilocaine (Lido Bdk External Kit 2.5-2.5 %) 3 MARVONA SUIK COMBINATION KIT 0.5 % (bupivacaine hcl & 3 anesthetic) MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G X PV 1/2" 1 ML (insulin syringe-needle u-100) MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) MEDROLOAN SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) MICROLET NEXT LANCING DEVICE (lancet devices) PV MIMYX EXTERNAL CREAM (dermatological products, misc.) 3 MINIMED PUMP RESERVOIR 3ML (insulin infusion pump 3 supplies) MONOVISC INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 88 MG/4ML (hyaluronan) MUCOSITISRX MOUTH/THROAT PACKET (artificial saliva) 3 MUGARD MOUTH/THROAT LIQUID (oral wound care 3 products) NEOSALUS EXTERNAL CREAM (dermatological products, 3 misc.) NEOSALUS EXTERNAL FOAM (dermatological products, 3 misc.)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 164 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEOSALUS EXTERNAL LOTION (dermatological products, 3 misc.) NORDIPEN 5 INJECTION DEVICE (injection device) PV NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM (insulin PV pen needle) NOVOFINE PEN NEEDLE 32G X 6 MM (insulin pen needle) PV NOVOFINE PLUS PEN NEEDLE 32G X 4 MM (insulin pen PV needle) NOVOPEN ECHO DEVICE (injection device for insulin) PV NOVOTWIST PEN NEEDLE 32G X 5 MM (insulin pen needle) PV NUVAIL EXTERNAL SOLUTION (dermatological products, 3 misc.) ONETOUCH DELICA LANCING DEV (lancet devices) PV ONETOUCH DELICA PLUS LANCING (lancet devices) PV ONETOUCH ULTRA 2 KIT W/DEVICE (blood glucose 2 monitoring suppl) ONETOUCH ULTRA MINI KIT W/DEVICE (blood glucose 2 monitoring suppl) ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE KIT 2 W/DEVICE (blood glucose monitoring suppl) ONETOUCH VERIO IN VITRO SOLUTION HIGH (blood 2 glucose calibration) ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE (blood 2 glucose monitoring suppl) ONETOUCH VERIO KIT W/DEVICE (blood glucose monitoring 2 suppl) ONETOUCH VERIO REFLECT KIT W/DEVICE (blood glucose 2 monitoring suppl) ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE KIT 2 W/DEVICE (blood glucose monitoring suppl) ORAMAGICRX MOUTH/THROAT SUSPENSION 3 RECONSTITUTED (oral wound care products) ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 30 MG/2ML (hyaluronan) PARI ALTERA NEBULIZER HANDSET (respiratory therapy 2 supplies) PARI TREK S COMBO PACK DEVICE (respiratory therapy 3 supplies) P-CARE K40G COMBINATION KIT 40 MG/ML 3 P-CARE K80G COMBINATION KIT 40 MG/ML 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 165 Coverage Requirements & Prescription Drug Name Drug Tier Limits PENLEN EXTERNAL EMULSION (dermatological products, 3 misc.) PHLAG SPRAY EXTERNAL EMULSION (dermatological 3 products, misc.) PR CREAM EXTERNAL KIT (dermatological products, misc.) 3 PRECISION XTRA DEVICE (blood glucose monitoring suppl) 2 PRESERA EXTERNAL FOAM (dermatological products, misc.) 3 PROMISEB EXTERNAL CREAM (antiseborrheic products, 3 misc.) PROSILK EXTERNAL GEL (silicone) 3 PRUCLAIR EXTERNAL CREAM (dermatological products, 3 misc.) PRUMYX EXTERNAL CREAM (dermatological products, misc.) 3 RECEDO EXTERNAL GEL (scar treatment products) 3 SALICEPT MOUTH/THROAT SUSPENSION 3 RECONSTITUTED (oral wound care products) SALIVAMAX MOUTH/THROAT PACKET (artificial saliva) 3 SCARCIN EXTERNAL GEL 3 SCARCIN EXTERNAL LIQUID 3 SCARSILK EXTERNAL GEL 3 SHARPS CONTAINER 3 SILIPAC EXTERNAL KIT 3 sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 1 %, 7 % SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED 2 SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID (blood 2 glucose calibration) SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID (blood 2 glucose calibration) SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID 2 (blood glucose calibration) SUVICORT EXTERNAL EMULSION 3 SYNERDERM EXTERNAL EMULSION (dermatological 3 products, misc.) SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 16 MG/2ML (hylan) SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 48 MG/6ML (hylan)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 166 Coverage Requirements & Prescription Drug Name Drug Tier Limits THROMBI-GEL 10 EXTERNAL PAD (thrombin-cmc-cacl- 3 gelatin) THROMBI-GEL 100 EXTERNAL PAD (thrombin-cmc-cacl- 3 gelatin) THROMBI-GEL 40 EXTERNAL PAD (thrombin-cmc-cacl- 3 gelatin) THROMBI-PAD EXTERNAL PAD 3"X3" (thrombin-cmc-cacl) 3 TORONOVA II SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & anesthetic) TORONOVA SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & anesthetic) TRILOAN II SUIK COMBINATION KIT 40 MG/ML 3 ( acet & anesth) TRILOAN SUIK COMBINATION KIT 40 MG/ML (triamcinolone 3 acet & anesth) TRILURON INTRA-ARTICULAR SOLUTION PREFILLED 3 SYRINGE 20 MG/2ML (sodium hyaluronate (viscosup)) TRUE METRIX LEVEL 1 IN VITRO SOLUTION LOW (blood 2 glucose calibration) TRUE METRIX LEVEL 2 IN VITRO SOLUTION NORMAL 2 (blood glucose calibration) TRUE METRIX LEVEL 3 IN VITRO SOLUTION HIGH (blood 2 glucose calibration) TRUSTEEL INFUSION SET (insulin infusion pump supplies) 3 UNISTRIP CONTROL IN VITRO SOLUTION LOW (blood 2 glucose calibration) VARISOFT INFUSION SET (insulin infusion pump supplies) 3 XEROSTOMIA RELIEF SPRAY MOUTH/THROAT SOLUTION 3 (artificial saliva) DIAGNOSTIC AGENTS ADRENOCORTICAL INSUFFICIENCY ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) 2 DSL = 30 days CORTROSYN INJECTION SOLUTION RECONSTITUTED 0.25 2 MG (cosyntropin) cosyntropin injection solution reconstituted 0.25 mg 1 ALLERGENIC EXTRACTS (DIAGNOSTIC) ACACIA SUBCUTANEOUS SOLUTION 1:20 3 ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 ALDER SUBCUTANEOUS SOLUTION 1:20 3 ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 167 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20 3 AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 3 AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20 3 ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20 3 AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 3 PNU/ML, 20000 PNU/ML AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20 3 BAHIA SUBCUTANEOUS SOLUTION 1:20 3 BALD CYPRESS SUBCUTANEOUS SOLUTION 1:20 3 BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 3 1:20 BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 3 BAU/ML BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20 3 BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 BROME SUBCUTANEOUS SOLUTION 1:20 3 CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 3 1:20 CANDIDA ALBICANS EXTRACT SUBCUTANEOUS 3 SOLUTION 10000 PNU/ML CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 3 BAU/ML CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 3 CEDAR ELM SUBCUTANEOUS SOLUTION 1:20 3 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS 3 SOLUTION 10000 PNU/ML, 20000 PNU/ML CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS 3 SOLUTION 20000 PNU/ML COCKLEBUR SUBCUTANEOUS SOLUTION 1:20 3 CORN POLLEN SUBCUTANEOUS SOLUTION 1:20 3 CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20 3 DOG FENNEL SUBCUTANEOUS SOLUTION 1:20 3 DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS 3 SOLUTION 10000 AU/ML EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 3 1:20

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 168 Coverage Requirements & Prescription Drug Name Drug Tier Limits EPICOCCUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20 3 FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML GERMAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 3 GOLDENROD SUBCUTANEOUS SOLUTION 1:20 3 HACKBERRY SUBCUTANEOUS SOLUTION 1:20 3 HONEY BEE VENOM SUBCUTANEOUS SOLUTION 3 RECONSTITUTED 1100 MCG HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 3 1:20 JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20 3 JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML KAPOK SUBCUTANEOUS SOLUTION 1:20 3 KOCHIA SUBCUTANEOUS SOLUTION 1:20 3 MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML MELALEUCA SUBCUTANEOUS SOLUTION 1:20 3 MESQUITE SUBCUTANEOUS SOLUTION 1:20 3 MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 3 AU/ML MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 3 10000 AU/ML MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 3 PNU/ML MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20 3 MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20 3 MIXED VESPID VENOM PROTEIN SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 1100-1100-1100 MCG MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20 3 MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 3 MUCOR SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 3 PNU/ML MUGWORT SUBCUTANEOUS SOLUTION 1:20 3 OLIVE TREE SUBCUTANEOUS SOLUTION 1:20 3 ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 3 100000 BAU/ML

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 169 Coverage Requirements & Prescription Drug Name Drug Tier Limits PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 3 10000 PNU/ML, 20000 PNU/ML PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 3 PNU/ML PRIVET SUBCUTANEOUS SOLUTION 1:20 3 QUEEN PALM SUBCUTANEOUS SOLUTION 1:20 3 RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 3 1:20 RED MAPLE SUBCUTANEOUS SOLUTION 1:20 3 RED MULBERRY SUBCUTANEOUS SOLUTION 1:20 3 RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 3 100000 BAU/ML RHIZOPUS SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20 3 RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20 3 SACCHAROMYCES CEREVISIAE SUBCUTANEOUS 3 SOLUTION 20000 PNU/ML SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20 3 SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20 3 SHORT RAGWEED POLLEN EXT SUBCUTANEOUS 3 SOLUTION 1:20 SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20 3 SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20 3 SWEET GUM SUBCUTANEOUS SOLUTION 1:20 3 SWEET VERNAL GRASS POLLEN SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20 3 TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS 3 SOLUTION 10000 BAU/ML, 100000 BAU/ML TRICHOPHYTON MENTAGROPHYTES SUBCUTANEOUS 3 SOLUTION 1:20 TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 3 PNU/ML WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION 3 RECONSTITUTED 1100 MCG WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20 3 WHITE BIRCH SUBCUTANEOUS SOLUTION 1:20 3 WHITE FACED HORNET VENOM SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 1100 MCG WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 170 Coverage Requirements & Prescription Drug Name Drug Tier Limits WHITE OAK SUBCUTANEOUS SOLUTION 1:20 3 WHITE PINE SUBCUTANEOUS SOLUTION 1:20 3 YELLOW DOCK SUBCUTANEOUS SOLUTION 1:20 3 YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 1100 MCG YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS 3 SOLUTION RECONSTITUTED 120 MCG DIABETES MELLITUS ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose blood) PV ACCU-CHEK COMPACT PLUS TEST STRIPS IN VITRO PV STRIP (glucose blood) ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) PV ACCU-CHEK SMARTVIEW TEST STRIPS IN VITRO STRIP PV (glucose blood) CARETOUCH TEST IN VITRO STRIP (glucose blood) PV CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) PV CONTOUR TEST IN VITRO STRIP (glucose blood) PV FREESTYLE PRECISION NEO TEST IN VITRO STRIP PV (glucose blood) MICRODOT TEST IN VITRO STRIP (glucose blood) PV ONETOUCH ULTRA IN VITRO STRIP (glucose blood) PV ONETOUCH VERIO IN VITRO STRIP (glucose blood) PV PRECISION PCX PLUS TEST IN VITRO STRIP (glucose PV blood) PRECISION QID TEST IN VITRO STRIP (glucose blood) PV PRECISION SOF-TACT TEST IN VITRO STRIP (glucose PV blood) PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP PV (glucose blood) RELION BLOOD GLUCOSE TEST IN VITRO STRIP (glucose PV blood) TRUE METRIX BLOOD GLUCOSE TEST IN VITRO STRIP PV (glucose blood) TRUE METRIX PRO BLOOD GLUCOSE IN VITRO STRIP PV (glucose blood) TRUETRACK TEST IN VITRO STRIP (glucose blood) PV DIAGNOSTIC AGENTS GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 GM 3 (aminolevulinic acid hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 171 Coverage Requirements & Prescription Drug Name Drug Tier Limits KETONES KETONE TEST IN VITRO STRIP 2 KETOSTIX IN VITRO STRIP (acetone (urine) test) 2 MYASTHENIA GRAVIS NEOSTIGMINE METHYLSULFATE INTRAVENOUS 3 SOLUTION PREFILLED SYRINGE 5 MG/5ML OCULAR DISORDERS ALTAFLUOR BENOX OPHTHALMIC SOLUTION 0.25-0.4 % 3 fluorescein sodium (Bio Glo Ophthalmic Strip 1 Mg) 3 fluorescein-proparacaine (Flucaine Ophthalmic Solution 0.25- 3 0.5 %) FLUORESCEIN SODIUM/BENOXINATE OPHTHALMIC 3 SOLUTION 0.3-0.4 % fluorescein-benoxinate ophthalmic solution 0.25-0.4 % 1 fluorescein sodium (Fluor-I-Strips A.T. Ophthalmic Strip 1 Mg) 1 FLURA-SAFE OPHTHALMIC SOLUTION 0.35-0.4 % 3 (fluorexon-benoxinate) FUL-GLO OPHTHALMIC STRIP 0.6 MG (fluorescein sodium) 3 fluorescein sodium (Ful-Glo Ophthalmic Strip 1 Mg) 3 fluorescein sodium (Glostrips Ophthalmic Strip 1 Mg) 3 GREEN GLO LISSAMINE GREEN OPHTHALMIC STRIP 1.5 3 MG (lissamine green) proparacaine-fluorescein ophthalmic solution 0.5-0.25 % 1 VISIONBLUE OPHTHALMIC SOLUTION 0.06 % (trypan blue) 3 PITUITARY FUNCTION MACRILEN ORAL PACKET 60 MG (macimorelin acetate) 3 METOPIRONE ORAL CAPSULE 250 MG (metyrapone) 2 RESPIRATORY FUNCTION ARIDOL INHALATION KIT 0 & 5 & 10 & 20 & 40 MG (mannitol) 3 METHACHOLINE CHLORIDE INHALATION KIT 3 ROENTGENOGRAPHY AND OTHER IMAGING AGENTS GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 GM 3 (aminolevulinic acid hcl) THYROID FUNCTION THYROGEN INTRAMUSCULAR SOLUTION 2 RECONSTITUTED 1.1 MG (thyrotropin alfa)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 172 Coverage Requirements & Prescription Drug Name Drug Tier Limits DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants GLUTARALDEHYDE EXTERNAL SOLUTION 25 % 3 ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AGENTS K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac PV ) K-PHOS ORAL TABLET 500 MG (potassium phosphate PV monobasic) K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG (k phos PV mono-sod phos di & mono) k phos mono-sod phos di & mono (Phospha 250 Neutral Oral PV Tablet 155-852-130 Mg) phosphorous oral tablet 155-852-130 mg PV k phos mono-sod phos di & mono (Phospho-Trin 250 Neutral PV Oral Tablet 155-852-130 Mg) virt-phos 250 neutral oral tablet 155-852-130 mg PV ALKALINIZING AGENTS ANTICOAGULANT SODIUM CITRATE IN VITRO SOLUTION 4 3 GM/100ML cytra k crystals oral packet 3300-1002 mg 1 ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate-citric 3 acid) potassium citrate er oral tablet extended release 10 meq (1080 1 mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml 1 REGIOCIT IN VITRO SOLUTION 0.529 % (anticoagulant na cit 3 (crrt)) sod citrate-citric acid oral solution 500-334 mg/5ml 1 sodium bicarbonate intravenous solution 4.2 %, 7.5 % 1 SODIUM BICARBONATE ORAL POWDER 3 sodium bicarbonate solution 8.4 % intravenous 8.4 % 1 SODIUM BICARBONATE SOLUTION 8.4 % INTRAVENOUS 3 8.4 % TRICITRASOL IN VITRO CONCENTRATE 46.7 % 3 (anticoagulant sodium citrate) tricitrates oral solution 550-500-334 mg/5ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 173 Coverage Requirements & Prescription Drug Name Drug Tier Limits AMMONIA DETOXICANTS BUPHENYL ORAL POWDER 3 GM/TSP (sodium 3 DSL = 30 days phenylbutyrate) BUPHENYL ORAL TABLET 500 MG () 2 DSL = 30 days CARBAGLU ORAL TABLET 200 MG () 3 constulose oral solution 10 gm/15ml 1 enulose oral solution 10 gm/15ml 1 generlac oral solution 10 gm/15ml 1 KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) 3 lactulose encephalopathy oral solution 10 gm/15ml 1 lactulose oral packet 10 gm 1 lactulose oral solution 10 gm/15ml, 20 gm/30ml 1 LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic acid) 2 RAVICTI ORAL LIQUID 1.1 GM/ML () 3 DSL = 30 days sodium phenylbutyrate oral powder 3 gm/tsp 1 DSL = 30 days sodium phenylbutyrate oral tablet 500 mg 1 DSL = 30 days CALORIC AGENTS - Drugs for Nutrition 3232a infant formula oral powder 2 AXONA ORAL PACKET (dietary management product) 3 CAMINO PRO COMPLETE/GLYTACTIN ORAL BAR (nutritional 2 supplements) DOJOLVI ORAL LIQUID 100 % () 3 DSL = 30 days EQUACARE JR ORAL POWDER 2 ESSENTIAL CARE JR ORAL POWDER (nutritional 2 supplements) GLYTACTIN BETTERMILK 15 ORAL PACKET (nutritional 2 supplements) GLYTACTIN BETTERMILK DE-LITE ORAL PACKET 2 (nutritional supplements) GLYTACTIN BUILD 10PE ORAL PACKET (nutritional 2 supplements) GLYTACTIN BUILD 20/20 ORAL PACKET (nutritional 2 supplements) GLYTACTIN BUILD 20/20 PKU ORAL PACKET (nutritional 2 supplements) GLYTACTIN BURST ORAL PACKET (nutritional supplements) 2 GLYTACTIN COMPLETE 10PE ORAL BAR (nutritional 2 supplements)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 174 Coverage Requirements & Prescription Drug Name Drug Tier Limits GLYTACTIN RESTORE 10 ORAL LIQUID (nutritional 2 supplements) GLYTACTIN RESTORE 5 ORAL PACKET (nutritional 2 supplements) GLYTACTIN RESTORE LITE 10 ORAL LIQUID (nutritional 2 supplements) GLYTACTIN RESTORE LITE 10PE ORAL PACKET (nutritional 2 supplements) GLYTACTIN RTD 10 ORAL LIQUID (nutritional supplements) 2 GLYTACTIN RTD 15 ORAL LIQUID (nutritional supplements) 2 GLYTACTIN RTD LITE 15 ORAL LIQUID (nutritional 2 supplements) GLYTACTIN SWIRL 15PE ORAL PACKET (nutritional 2 supplements) HCU EASY ORAL TABLET (nutritional supplements) 3 HOMACTIN AA PLUS ORAL LIQUID (nutritional supplements) 2 KETOVIE ORAL LIQUID (nutritional supplements) 2 KETOVIE PEPTIDE ORAL LIQUID (nutritional supplements) 2 L-CYSTINE POWDER 3 multiple vitamins-minerals (Lysiplex Plus Oral Tablet) 1 MSUD EASY ORAL TABLET (nutritional supplements) 3 PKU EASY MICROTABS ORAL TABLET DELAYED RELEASE 3 (nutritional supplements) PKU EASY ORAL TABLET (nutritional supplements) 3 PKU GO ORAL PACKET (nutritional supplements) 2 TYLACTIN BUILD 20PE TYR ORAL PACKET (nutritional 2 supplements) TYLACTIN COMPLETE 15 PE ORAL BAR (nutritional 2 supplements) TYLACTIN RESTORE 10 ORAL LIQUID (nutritional 2 supplements) TYLACTIN RESTORE 5PE ORAL PACKET (nutritional 2 supplements) TYLACTIN RTD 15 ORAL LIQUID (nutritional supplements) 2 TYR EASY ORAL TABLET (nutritional supplements) 3 TYROS 2 ORAL POWDER (nutritional supplements) 2 VILACTIN AA PLUS ORAL LIQUID (nutritional supplements) 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 175 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARBONIC ANHYDRASE INHIBITORS - Drugs for Water Balance acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 DIURETICS, MISCELLANEOUS - Drugs for Water Balance ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, PV 450 mg theophylline er oral tablet extended release 24 hour 400 mg, PV 600 mg theophylline oral solution 80 mg/15ml 1 ELECTROLYTIC,CALORIC,WATER BALANCE MISC, CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML, 20 3 DSL = 30 days MG/ML, 30 MG/ML (burosumab-twza) IRRIGATING SOLUTIONS aminoacetic acid irrigation solution 1.5 % 1 glycine irrigation solution 1.5 % 1 glycine urologic irrigation solution 1.5 % 1 irrigation solns physiological (Physiolyte Irrigation Solution) 3 irrigation solns physiological (Physiosol Irrigation Irrigation 3 Solution) RENACIDIN IRRIGATION SOLUTION (citric ac-gluconolact-mg 3 carb) RESECTISOL IRRIGATION SOLUTION 5 % (mannitol (gu 3 irrigant)) RIMSO-50 INTRAVESICAL SOLUTION 50 % (dimethyl 2 sulfoxide) ringers irrigation irrigation solution 1 SORBITOL IRRIGATION SOLUTION 3 %, 3.3 % 3 sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml 1 ringers irrigation (Tis-U-Sol Irrigation Solution) 1 LOOP DIURETICS - Drugs for Water Balance bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 2 ethacrynic acid oral tablet 25 mg 1 furosemide oral solution 10 mg/ml, 8 mg/ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 176 Coverage Requirements & Prescription Drug Name Drug Tier Limits furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 OSMOTIC DIURETICS - Drugs for Water Balance sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml 1 OTHER -REMOVING AGENTS RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 insoluble) PHOSPHATE-REMOVING AGENTS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric citrate) 3 DSL = 30 days calcium acetate (phos binder) oral capsule 667 mg PV calcium acetate (phos binder) oral tablet 667 mg PV calcium acetate oral tablet 667 mg PV FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum PV carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, PV 750 MG (lanthanum carbonate) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, PV 750 mg MAGNEBIND 400 ORAL TABLET 400-200-1 MG (magnesium- 3 calcium-folic acid) PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate PV (phos binder)) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) PV RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer PV carbonate) RENVELA ORAL TABLET 800 MG (sevelamer carbonate) PV sevelamer carbonate oral packet 0.8 gm, 2.4 gm PV sevelamer carbonate oral tablet 800 mg PV sevelamer hcl oral tablet 400 mg, 800 mg PV VELPHORO ORAL TABLET CHEWABLE 500 MG (sucroferric 3 oxyhydroxide) POTASSIUM-REMOVING AGENTS LOKELMA ORAL PACKET 10 GM, 5 GM (sodium zirconium 3 cyclosilicate) sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM 3 DSL = 30 days (patiromer sorbitex calcium)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 177 Coverage Requirements & Prescription Drug Name Drug Tier Limits POTASSIUM-SPARING DIURETICS - Drugs for Water Balance ALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG 3 (spironolactone-hctz) ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) amiloride hcl oral tablet 5 mg 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML (spironolactone) 3 DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 2 MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 triamterene oral capsule 100 mg, 50 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 REPLACEMENT PREPARATIONS calcium acetate (phos binder) oral tablet 667 mg PV calcium-folic acid plus d oral wafer 1342-1 mg 1 CARDIOPLEGIA DEL NIDO FORMULA PERFUSION 3 SOLUTION CARDIOPLEGIA IND PLASMA HIGH K PERFUSION 3 SOLUTION CARDIOPLEGIA IND PLASMA-TROMET PERFUSION 3 SOLUTION CARDIOPLEGIA INDUCTION HIGH K PERFUSION 3 SOLUTION CARDIOPLEGIA INDUCTION LOW DEX PERFUSION 3 SOLUTION CARDIOPLEGIA INDUCTION NON-ENR PERFUSION 3 SOLUTION CARDIOPLEGIA MAIN LOW DEXTROSE PERFUSION 3 SOLUTION CARDIOPLEGIA MAIN LOW TROMETHA PERFUSION 3 SOLUTION CARDIOPLEGIA MAIN PLASMA-TROME PERFUSION 3 SOLUTION CARDIOPLEGIA MAINTENANCE PERFUSION SOLUTION 3 CARDIOPLEGIA REPERFUSATE 4:1 PERFUSION SOLUTION 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 178 Coverage Requirements & Prescription Drug Name Drug Tier Limits EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ PV (potassium bicarb-citric acid) potassium bicarbonate (Effer-K Oral Tablet Effervescent 25 1 Meq) FOLGARD OS ORAL TABLET 500-1.1 MG (multiple vit-min- 3 calcium-fa) FOLITE ORAL TABLET 3 FOSTEUM PLUS ORAL CAPSULE (dietary management 3 product) HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 3 7 % (sodium chloride) ISOLYTE-S INTRAVENOUS SOLUTION (electrolyte-s) 3 KCL-LIDOCAINE-NACL INTRAVENOUS SOLUTION 10-10 3 MEQ-MG /100ML potassium chloride (Klor-Con 10 Oral Tablet Extended Release PV 10 Meq) potassium chloride crys er (Klor-Con M10 Oral Tablet Extended PV Release 10 Meq) KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 PV MEQ (potassium chloride crys er) potassium chloride crys er (Klor-Con M20 Oral Tablet Extended PV Release 20 Meq) potassium chloride (Klor-Con Oral Packet 20 Meq) PV potassium chloride (Klor-Con Oral Tablet Extended Release 8 PV Meq) potassium bicarbonate (Klor-Con/Ef Oral Tablet Effervescent 25 1 Meq) potassium bicarbonate (K-Prime Oral Tablet Effervescent 25 1 Meq) K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 PV MEQ, 8 MEQ (potassium chloride) MICROPLEGIA MSA-MSG PERFUSION SOLUTION 3 M-NATAL PLUS ORAL TABLET 27-1 MG 3 NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o vit 3 a) phosphorus supplement oral packet 280-160-250 mg PV phosphorus w/sod & potassium oral packet 280-160-250 mg PV PHOXILLUM B22K4/0 INTRAVENOUS SOLUTION 22-4-1 3 MEQ-MMOL/L PHOXILLUM BK4/2.5 INTRAVENOUS SOLUTION 32-4-2.5-1 3 MEQ-MMOL/L

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 179 Coverage Requirements & Prescription Drug Name Drug Tier Limits PLASMA-LYTE 148 INTRAVENOUS SOLUTION (electrolyte- 3 148) PLASMA-LYTE A INTRAVENOUS SOLUTION (electrolyte-a) 2 potassium chloride crys er oral tablet extended release 10 meq, PV 20 meq potassium chloride er oral capsule extended release 10 meq, 8 PV meq potassium chloride er oral tablet extended release 10 meq, 20 PV meq, 8 meq potassium chloride in nacl intravenous solution 20-0.45 meq/l- 1 %, 20-0.9 meq/l-%, 40-0.9 meq/l-% potassium chloride oral packet 20 meq PV potassium chloride oral solution 20 meq/15ml (10%), 40 PV meq/15ml (20%) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 3 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat mv- 3 min-methylfolate-fa) preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 REGIOCIT IN VITRO SOLUTION 0.529 % (anticoagulant na cit 3 (crrt)) sodium chloride (pf) injection solution 0.9 % 1 sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 1 %, 7 % sodium chloride injection solution 2.5 meq/ml 1 sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 4 1 meq/ml, 5 % TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) 3 VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) WESTAB PLUS ORAL TABLET 27-1 MG 3 zinc sulfate oral tablet 220 (50 zn) mg PV THIAZIDE DIURETICS - Drugs for Water Balance ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 180 Coverage Requirements & Prescription Drug Name Drug Tier Limits ALDACTAZIDE ORAL TABLET 25-25 MG, 50-50 MG 3 (spironolactone-hctz) amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160- 1 25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 MG, 32- 3 25 MG (candesartan cilexetil-hctz) AVALIDE ORAL TABLET 150-12.5 MG, 300-12.5 MG 3 (irbesartan-hydrochlorothiazide) benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg, 5-6.25 mg BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 3 MG (olmesartan medoxomil-hctz) bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 1 mg, 5-6.25 mg candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 1 32-25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 1 50-15 mg, 50-25 mg DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320- 12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- 3 hydrochlorothiazide) DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 3 DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- 3 hydrochlorothiazide) enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG (amlodipine- 3 valsartan-hctz) fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 MG (losartan potassium-hctz) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 1 12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 1 50-12.5 mg

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 181 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 1 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 1 mg, 50-25 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 MG, 80- 3 25 MG (telmisartan-hctz) olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 1 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- 1 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg propranolol-hctz oral tablet 40-25 mg, 80-25 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 1 mg, 20-25 mg spironolactone-hctz oral tablet 25-25 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG, 40-5-25 MG (olmesartan- 3 amlodipine-hctz) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 1 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg VASERETIC ORAL TABLET 10-25 MG (enalapril- 3 hydrochlorothiazide) ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (lisinopril-hydrochlorothiazide) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) THIAZIDE-LIKE DIURETICS - Drugs for Water Balance atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 (azilsartan-chlorthalidone) indapamide oral tablet 1.25 mg, 2.5 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 182 Coverage Requirements & Prescription Drug Name Drug Tier Limits metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 TENORETIC 100 ORAL TABLET 100-25 MG (atenolol- 3 chlorthalidone) TENORETIC 50 ORAL TABLET 50-25 MG (atenolol- 3 chlorthalidone) URICOSURIC AGENTS colchicine-probenecid oral tablet 0.5-500 mg 1 probenecid oral tablet 500 mg 1 VASOPRESSIN ANTAGONISTS - Drugs for Water Balance JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) 3 DSL = 30 days JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 45 & 15 3 DSL = 30 days MG, 60 & 30 MG, 90 & 30 MG (tolvaptan) JYNARQUE ORAL TABLET THERAPY PACK 30 & 15 MG 3 (tolvaptan) SAMSCA ORAL TABLET 15 MG, 30 MG (tolvaptan) 3 DSL = 30 days TOLVAPTAN ORAL TABLET 15 MG 3 DSL = 30 days tolvaptan oral tablet 30 mg 1 DSL = 30 days ENZYMES ENZYMES ACTIVASE INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG, 50 MG (alteplase) ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML 2 (laronidase) BRINEURA KIT 2 X 150 MG/5ML (cerliponase alfa) 3 CATHFLO ACTIVASE INJECTION SOLUTION 2 RECONSTITUTED 2 MG (alteplase) CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 2 400 UNIT () ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML 2 DSL = 30 days () ELELYSO INTRAVENOUS SOLUTION RECONSTITUTED 200 3 DSL = 30 days UNIT () ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 2 MG, 7.5 MG (rasburicase) FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 35 MG, 5 MG (agalsidase beta) KANUMA INTRAVENOUS SOLUTION 20 MG/10ML 3 DSL = 30 days () LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 2 DSL = 30 days MG ()

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 183 Coverage Requirements & Prescription Drug Name Drug Tier Limits MEPSEVII INTRAVENOUS SOLUTION 10 MG/5ML 3 (vestronidase alfa-vjbk) NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML 2 DSL = 30 days (galsulfase) PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML 3 DSL = 30 days (-pqpz) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase 2 alfa) REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5ML 3 (elapegademase-lvlr) STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 2 DSL = 30 days MG/0.7ML, 40 MG/ML, 80 MG/0.8ML () SUCRAID ORAL SOLUTION 8500 UNIT/ML () 3 VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML (elosulfase 2 DSL = 30 days alfa) VITRASE INJECTION SOLUTION 200 UNIT/ML (hyaluronidase 3 ovine) VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED PV DSL = 30 days 1000 UNIT (glucarpidase) VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 2 UNIT () XIAFLEX INJECTION SOLUTION RECONSTITUTED 0.9 MG 3 (collagenase clostrid histolyt) EYE, EAR, NOSE AND THROAT (EENT) PREPS. ALPHA-ADRENERGIC AGONISTS (EENT) - Drugs for the Eye ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % ( 3 tartrate) brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % 1 BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 3 0.15-2 % COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % (brimonidine 3 tartrate-timolol) SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 3 (brinzolamide-brimonidine) TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC 3 SOLUTION 0.5-0.15-2 -0.005% TIMOLOL-BRIMONIDINE-DORZOLAMID OPHTHALMIC 3 SOLUTION 0.5-0.15-2 %

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 184 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIALLERGIC AGENTS - Drugs for Allergy ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil sodium) 2 ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 3 tromethamine) azelastine hcl nasal solution 0.1 %, 0.15 %, 137 mcg/spray 1 azelastine hcl ophthalmic solution 0.05 % 1 azelastine-fluticasone nasal suspension 137-50 mcg/act 1 BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine 3 besilate) cromolyn sodium ophthalmic solution 4 % 1 epinastine hcl ophthalmic solution 0.05 % 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 olopatadine hcl nasal solution 0.6 % 1 olopatadine hcl ophthalmic solution 0.1 %, 0.2 % 1 ZERVIATE OPHTHALMIC SOLUTION 0.24 % (cetirizine hcl) 3 ANTIBACTERIALS (EENT) - Drugs for Infections ak-poly-bac ophthalmic ointment 500-10000 unit/gm 1 ARESTIN DENTAL 1 MG (minocycline hcl) 3 AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) 3 ophthalmic ointment 500 unit/gm 1 bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BESIVANCE OPHTHALMIC SUSPENSION 0.6 % (besifloxacin 3 hcl) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 2 (-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 2 (sulfacetamide-prednisolone) CILOXAN OPHTHALMIC OINTMENT 0.3 % (ciprofloxacin hcl) 3 CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 ) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 3 dexamethasone) ciprofloxacin hcl ophthalmic solution 0.3 % 1 ciprofloxacin hcl otic solution 0.2 % 1 ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % 1 CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3- 3 0.025 %

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 185 Coverage Requirements & Prescription Drug Name Drug Tier Limits CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 2 (neomycin-colist-hc-thonzonium) doxycycline hyclate oral tablet 20 mg 1 erythromycin ophthalmic ointment 5 mg/gm 1 gatifloxacin ophthalmic solution 0.5 % 1 gentak ophthalmic ointment 0.3 % 1 sulfate ophthalmic solution 0.3 % 1 KLARITY-A OPHTHALMIC SOLUTION 1 % (azithromycin) 3 levofloxacin ophthalmic solution 0.5 % 1 moxifloxacin hcl (2x day) ophthalmic solution 0.5 % 1 moxifloxacin hcl ophthalmic solution 0.5 % 1 neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400- 1 10000 , 5-400-10000 neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- 1 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 1 10000-0.1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- 1 10000-.025 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 1 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 bacitracin-polymyx-neo-hc (Neo-Polycin Hc Ophthalmic 1 Ointment 1 %) neomycin-bacitracin zn-polymyx (Neo-Polycin Ophthalmic 1 Ointment 3.5-400-10000) ofloxacin ophthalmic solution 0.3 % 1 ofloxacin otic solution 0.3 % 1 OTIPRIO INTRATYMPANIC SUSPENSION 6 % (ciprofloxacin) 3 OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- 3 fluocinolone) bacitracin-polymyxin b (Polycin Ophthalmic Ointment 500- 1 10000 Unit/Gm) polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml- 1 % PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 186 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLONE ACET-MOXIFLOXACIN OPHTHALMIC 3 SUSPENSION 1-0.5 % PREDNISOLONE-GATIFLOXACIN OPHTHALMIC 3 SUSPENSION 1-0.5 % PREDNISOLONE-MOXIFLOXACIN OPHTHALMIC SOLUTION 3 1-0.5 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.1 % sulfacetamide sodium ophthalmic ointment 10 % 1 sulfacetamide sodium ophthalmic solution 10 % 1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % (tobramycin- 2 dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 3 (tobramycin-dexamethasone) tobramycin ophthalmic solution 0.3 % 1 tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 TOBREX OPHTHALMIC OINTMENT 0.3 % (tobramycin) 2 ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) ZYMAXID OPHTHALMIC SOLUTION 0.5 % (gatifloxacin) 2 ANTIFUNGALS (EENT) - Drugs for Infections NATACYN OPHTHALMIC SUSPENSION 5 % (natamycin) 2 ANTIGLAUCOMA AGENTS, MISCELLANEOUS - Drugs for the Eye MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) 2 RHOPRESSA OPHTHALMIC SOLUTION 0.02 % (netarsudil 3 dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 (netarsudil-latanoprost) ANTIVIRALS (EENT) - Drugs for Infections trifluridine ophthalmic solution 1 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 187 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) 3 BETA-ADRENERGIC BLOCKING AGENTS (EENT) - Drugs for the Eye betaxolol hcl ophthalmic solution 0.5 % 1 BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 3 hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % (betaxolol 3 hcl) carteolol hcl ophthalmic solution 1 % 1 COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % (brimonidine 3 tartrate-timolol) dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 LATANOPROST-TIMOLOL MALEATE OPHTHALMIC 3 SOLUTION 0.005-0.5 % hcl ophthalmic solution 0.5 % 1 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % 1 timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily) 1 timolol maleate pf ophthalmic solution 0.5 % 1 TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC 3 SOLUTION 0.5-0.15-2 -0.005% TIMOLOL-BRIMONIDINE-DORZOLAMID OPHTHALMIC 3 SOLUTION 0.5-0.15-2 % TIMOLOL-DORZOLAMID-LATANOPROST OPHTHALMIC 3 SOLUTION 0.5-0.15-0.005 % TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % 3 (timolol maleate) CARBONIC ANHYDRASE INHIBITORS (EENT) - Drugs for the Eye acetazolamide er oral capsule extended release 12 hour 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 3 0.15-2 % brinzolamide ophthalmic suspension 1 % 1 DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC 2 % 3 dorzolamide hcl solution 2 % ophthalmic 2 % 1 dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 1 KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) 3 DSL = 30 days Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 188 Coverage Requirements & Prescription Drug Name Drug Tier Limits methazolamide oral tablet 25 mg, 50 mg 1 SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 3 (brinzolamide-brimonidine) TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC 3 SOLUTION 0.5-0.15-2 -0.005% TIMOLOL-BRIMONIDINE-DORZOLAMID OPHTHALMIC 3 SOLUTION 0.5-0.15-2 % TIMOLOL-DORZOLAMID-LATANOPROST OPHTHALMIC 3 SOLUTION 0.5-0.15-0.005 % (EENT) - Drugs for Inflammation ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol 3 etabonate) azelastine-fluticasone nasal suspension 137-50 mcg/act 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 3 (beclomethasone diprop monohyd) CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 3 dexamethasone) ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % 1 CIPROFLOXACIN-FLUOCINOLONE PF OTIC SOLUTION 0.3- 3 0.025 % CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML (hc- 3 pramoxine-chloroxylenol) dexamethasone sodium phosphate ophthalmic solution 0.1 % 1 DEXTENZA OPHTHALMIC INSERT 0.4 MG (dexamethasone) 3 DEXYCU INTRAOCULAR SUSPENSION 9 % 3 (dexamethasone) DUREZOL OPHTHALMIC EMULSION 0.05 % (difluprednate) 3 exotic-hc otic solution 10-10-1 mg/ml 1 EYSUVIS OPHTHALMIC SUSPENSION 0.25 % (loteprednol 3 etabonate) fluocinolone acetonide (Flac Otic Oil 0.01 %) 1 FLAREX OPHTHALMIC SUSPENSION 0.1 % (fluorometholone 3 acetate) flunisolide nasal solution 25 mcg/act (0.025%) 1 fluocinolone acetonide otic oil 0.01 % 1 fluorometholone ophthalmic suspension 0.1 % 1 fluticasone propionate nasal suspension 50 mcg/act 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 189 Coverage Requirements & Prescription Drug Name Drug Tier Limits FML FORTE OPHTHALMIC SUSPENSION 0.25 % 2 (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % (fluorometholone) 2 hydrocortisone-acetic acid otic solution 1-2 % 1 ILUVIEN INTRAVITREAL IMPLANT 0.19 MG (fluocinolone 3 acetonide) INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol 3 etabonate) KLARITY-L OPHTHALMIC EMULSION 0.2 %, 0.5 % 3 (loteprednol etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol 3 etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol 3 etabonate) loteprednol etabonate ophthalmic gel 0.5 % 1 loteprednol etabonate ophthalmic suspension 0.5 % 1 MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 3 (dexamethasone) mometasone furoate nasal suspension 50 mcg/act 1 neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- 1 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 1 10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 1 bacitracin-polymyx-neo-hc (Neo-Polycin Hc Ophthalmic 1 Ointment 1 %) OMNARIS NASAL SUSPENSION 50 MCG/ACT (ciclesonide) 3 OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- 3 fluocinolone) OZURDEX INTRAVITREAL IMPLANT 0.7 MG 2 (dexamethasone) PRED FORTE OPHTHALMIC SUSPENSION 1 % PV () PRED MILD OPHTHALMIC SUSPENSION 0.12 % 2 (prednisolone acetate) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 %

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 190 Coverage Requirements & Prescription Drug Name Drug Tier Limits prednisolone acetate ophthalmic suspension 1 % PV prednisolone acetate p-f ophthalmic suspension 1 % PV PREDNISOLONE ACETATE-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.1 % PREDNISOLONE ACET-MOXIFLOXACIN OPHTHALMIC 3 SUSPENSION 1-0.5 % prednisolone sodium phosphate ophthalmic solution 1 % 1 PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1- 3 0.075 % PREDNISOLONE-BROMFENAC OPHTHALMIC SUSPENSION 3 1-0.075 % PREDNISOLONE-GATIFLOXACIN OPHTHALMIC 3 SUSPENSION 1-0.5 % PREDNISOLONE-MOXIFLOXACIN OPHTHALMIC SOLUTION 3 1-0.5 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.1 % QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 3 MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT 3 (beclomethasone diprop (nasal)) QUINIXIL EXTERNAL THERAPY PACK 0.1 & 5 % 3 (mometasone furo-dimethicone) RETISERT INTRAVITREAL IMPLANT 0.59 MG (fluocinolone 2 acetonide) SINUVA NASAL IMPLANT 1350 MCG (mometasone furoate) 3 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % (tobramycin- 2 dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 3 (tobramycin-dexamethasone) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT 3 (fluticasone propionate) YUTIQ INTRAVITREAL IMPLANT 0.18 MG (fluocinolone 3 acetonide)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 191 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT 3 (ciclesonide) ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) EENT ANTI-INFECTIVES, MISCELLANEOUS - Drugs for Infections acetic acid otic solution 2 % 1 BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 3 % (povidone-iodine) chlorhexidine gluconate mouth/throat solution 0.12 % 1 hydrocortisone-acetic acid otic solution 1-2 % 1 chlorhexidine gluconate (Periogard Mouth/Throat Solution 0.12 1 %) PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 EENT ANTI-INFLAMMATORY AGENTS, MISC. - Drugs for Inflammation CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) 2 CYCLOSPORINE IN KLARITY OPHTHALMIC EMULSION 0.1 3 % (cyclosporine) RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 % 3 (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % (cyclosporine) 3 XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) 3 EENT DRUGS, MISCELLANEOUS apraclonidine hcl ophthalmic solution 0.5 % 1 BEOVU INTRAVITREAL SOLUTION 6 MG/0.05ML 3 DSL = 30 days (brolucizumab-dbll) BEVACIZUMAB INTRAOCULAR SOLUTION PREFILLED 3 SYRINGE 2.75 MG/0.11ML, 3.75 MG/0.15ML BEVACIZUMAB INTRAVITREAL SOLUTION PREFILLED 3 SYRINGE 2.5 MG/0.1ML, 3.25 MG/0.13ML, 3.75 MG/0.15ML CHONDROITIN SULFATE OPHTHALMIC SOLUTION 0.25 % 3 CYSTADROPS OPHTHALMIC SOLUTION 0.37 % ( 3 DSL = 30 days hcl) CYSTARAN OPHTHALMIC SOLUTION 0.44 % (cysteamine 3 hcl) DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % (sulfuric 3 acid-sulf phenolics) DICLOFENAC-NA HYALURON-NIACIN EXTERNAL GEL 3-2-4 3 %

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 192 Coverage Requirements & Prescription Drug Name Drug Tier Limits EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML (aflibercept) 2 EYLEA INTRAVITREAL SOLUTION PREFILLED SYRINGE 2 2 MG/0.05ML (aflibercept) GELFILM OPHTHALMIC FILM (gelatin adsorbable) 2 IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine hcl) 2 ipratropium bromide nasal solution 0.03 %, 0.06 % PV LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear insert) 2 LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05ML, 0.5 2 DSL = 30 days MG/0.05ML (ranibizumab) LUCENTIS INTRAVITREAL SOLUTION PREFILLED SYRINGE 2 DSL = 30 days 0.3 MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) OXERVATE OPHTHALMIC SOLUTION 0.002 % (cenegermin- 3 DSL = 30 days bkbj) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146 &0.146-20 % 2 (riboflav5 & riboflav5-dextran) ROAOXIA EXTERNAL GEL 3-4 % 3 TEPEZZA INTRAVENOUS SOLUTION RECONSTITUTED 500 3 DSL = 30 days MG (teprotumumab-trbw) VISUDYNE INTRAVENOUS SOLUTION RECONSTITUTED 15 2 MG (verteporfin) EENT NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Inflammation ACULAR LS OPHTHALMIC SOLUTION 0.4 % (ketorolac PV tromethamine) ACULAR OPHTHALMIC SOLUTION 0.5 % (ketorolac PV tromethamine) ACUVAIL OPHTHALMIC SOLUTION 0.45 % (ketorolac PV tromethamine) bromfenac sodium (once-daily) ophthalmic solution 0.09 % PV BROMSITE OPHTHALMIC SOLUTION 0.075 % (bromfenac PV sodium) diclofenac sodium ophthalmic solution 0.1 % PV flurbiprofen sodium ophthalmic solution 0.03 % PV ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) PV ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % PV NEVANAC OPHTHALMIC SUSPENSION 0.1 % (nepafenac) PV PREDNISOL ACE-MOXIFLOX-BROMFEN OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 %

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 193 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREDNISOLONE ACETATE-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.1 % PREDNISOLONE-BROMFENAC OPHTHALMIC SOLUTION 1- 3 0.075 % PREDNISOLONE-BROMFENAC OPHTHALMIC SUSPENSION 3 1-0.075 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % PREDNISOLON-MOXIFLOX-NEPAFENAC OPHTHALMIC 3 SUSPENSION 1-0.5-0.1 % PROLENSA OPHTHALMIC SOLUTION 0.07 % (bromfenac PV sodium) TROPIC-CYCLOPENT-PE-KETOROLAC OPHTHALMIC 3 SOLUTION PREFILLED SYRINGE 1-1-10-0.5 %, 1-1-2.5-0.5 % TROPIC-CYCLOP-PE-KETO-PROPAR OPHTHALMIC 3 SOLUTION PREFILLED SYRINGE TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 SOLUTION 1-0.5-2.5-0.5 % LOCAL ANESTHETICS (EENT) - Drugs for Numbing AKTEN OPHTHALMIC GEL 3.5 % (lidocaine hcl) 2 ALCAINE OPHTHALMIC SOLUTION 0.5 % (proparacaine hcl) 2 tetracaine hcl (Altacaine Ophthalmic Solution 0.5 %) 3 ALTAFLUOR BENOX OPHTHALMIC SOLUTION 0.25-0.4 % 3 COCAINE HCL NASAL SOLUTION 40 MG/ML 3 fluorescein-proparacaine (Flucaine Ophthalmic Solution 0.25- 3 0.5 %) FLUORESCEIN SODIUM/BENOXINATE OPHTHALMIC 3 SOLUTION 0.3-0.4 % fluorescein-benoxinate ophthalmic solution 0.25-0.4 % 1 lidocaine hcl (Glydo External Prefilled Syringe 2 %) 1 GOPRELTO NASAL SOLUTION 40 MG/ML 3 lidocaine hcl external solution 4 % 1 lidocaine hcl urethral/mucosal external gel 2 % 1 lidocaine hcl urethral/mucosal external prefilled syringe 2 % 1 lidocaine viscous hcl mouth/throat solution 2 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 194 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUMBRINO NASAL SOLUTION 40 MG/ML (cocaine hcl (nasal 3 anesthetic)) PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 3 PROFESSIONAL DNA COLLECTION COMBINATION KIT 3 proparacaine hcl ophthalmic solution 0.5 % 1 proparacaine-fluorescein ophthalmic solution 0.5-0.25 % 1 tetracaine hcl ophthalmic solution 0.5 % 1 TROPIC-CYCLOP-PE-KETO-PROPAR OPHTHALMIC 3 SOLUTION PREFILLED SYRINGE TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 SOLUTION 1-0.5-2.5-0.5 % MIOTICS - Drugs for the Eye PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION 2 RECONSTITUTED 0.125 % (echothiophate iodide) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 MYDRIATICS - Drugs for the Eye atropine sulfate ophthalmic ointment 1 % 1 ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 % 3 atropine sulfate ophthalmic solution 1 % 1 CYCLOGYL OPHTHALMIC SOLUTION 0.5 % (cyclopentolate 2 hcl) CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 2 (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % 1 homatropaire ophthalmic solution 5 % 1 ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % (atropine 2 sulfate) PAREMYD OPHTHALMIC SOLUTION 1-0.25 % 3 (hydroxyamphetamine-tropicamide) tropicamide ophthalmic solution 0.5 %, 1 % 1 TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC 3 SOLUTION 1-1-2.5 % TROPICAMIDE-PHENYLEPHRINE OPHTHALMIC SOLUTION 3 1-2.5 % TROPIC-CYCLOPENT-PE-KETOROLAC OPHTHALMIC 3 SOLUTION PREFILLED SYRINGE 1-1-10-0.5 %, 1-1-2.5-0.5 % TROPIC-CYCLOP-PE-KETO-PROPAR OPHTHALMIC 3 SOLUTION PREFILLED SYRINGE TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 SOLUTION 1-0.5-2.5-0.5 %

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 195 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROSTAGLANDIN ANALOGS - Drugs for the Eye bimatoprost ophthalmic solution 0.03 % 1 DURYSTA INTRAOCULAR IMPLANT 10 MCG (bimatoprost) 3 DSL = 30 days latanoprost ophthalmic solution 0.005 % 1 LATANOPROST-TIMOLOL MALEATE OPHTHALMIC 3 SOLUTION 0.005-0.5 % LUMIGAN OPHTHALMIC SOLUTION 0.01 % (bimatoprost) 3 ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 (netarsudil-latanoprost) TIMOLOL-BRIMON-DORZOL-LATANOPR OPHTHALMIC 3 SOLUTION 0.5-0.15-2 -0.005% TIMOLOL-DORZOLAMID-LATANOPROST OPHTHALMIC 3 SOLUTION 0.5-0.15-0.005 % travoprost (bak free) ophthalmic solution 0.004 % 1 VYZULTA OPHTHALMIC SOLUTION 0.024 % (latanoprostene 3 bunod) XELPROS OPHTHALMIC EMULSION 0.005 % (latanoprost) 3 ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % (tafluprost) 3 RHO KINASE INHIBITORS - Drugs for the Eye RHOPRESSA OPHTHALMIC SOLUTION 0.02 % (netarsudil 3 dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % 3 (netarsudil-latanoprost) VASOCONSTRICTORS ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 3 (nasal)) phenylephrine hcl (Altafrin Ophthalmic Solution 10 %, 2.5 %) 1 phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 TROPICAMIDE-CYCLOPENTOLATE-PE OPHTHALMIC 3 SOLUTION 1-1-2.5 % TROPIC-CYCLOPENT-PE-KETOROLAC OPHTHALMIC 3 SOLUTION PREFILLED SYRINGE 1-1-10-0.5 %, 1-1-2.5-0.5 % TROPIC-CYCLOP-PE-KETO-PROPAR OPHTHALMIC 3 SOLUTION PREFILLED SYRINGE TROPIC-PROPARACA-PE-KETOROLAC OPHTHALMIC 3 SOLUTION 1-0.5-2.5-0.5 % UPNEEQ OPHTHALMIC SOLUTION 0.1 % (oxymetazoline hcl) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 196 Coverage Requirements & Prescription Drug Name Drug Tier Limits GASTROINTESTINAL DRUGS AND ADSORBENTS magnesium oxide oral tablet 400 (241.3 mg) mg, 400 mg, 420 PV mg magnesium-oxide oral tablet 400 (241.3 mg) mg PV mag-oxide oral tablet 200 mg PV SODIUM BICARBONATE ORAL POWDER 3 stomach relief oral tablet chewable 262 mg 1 GASTROINTESTINAL DRUGS - Drugs for the Stomach 5-HT3 RECEPTOR ANTAGONISTS - Drugs for Vomiting and AKYNZEO INTRAVENOUS SOLUTION 235-0.25 MG/20ML 3 (fosnetupitant-palonosetron) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 3 235-0.25 MG (fosnetupitant-palonosetron) AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 2 DSL = 30 days palonosetron) ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML PV (palonosetron hcl) ANZEMET ORAL TABLET 100 MG, 50 MG (dolasetron PV DSL = 30 days mesylate) granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml PV granisetron hcl oral tablet 1 mg PV MKO MELT DOSE PACK MOUTH/THROAT TROCHE 3-25-2 3 MG ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml PV ondansetron hcl oral solution 4 mg/5ml PV ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg PV ondansetron odt oral tablet dispersible 4 mg, 8 mg PV palonosetron hcl intravenous solution 0.25 mg/2ml, 0.25 mg/5ml PV palonosetron hcl intravenous solution prefilled syringe 0.25 PV mg/5ml SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR PV (granisetron) SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 PV MG/0.4ML (granisetron) ZOFRAN ORAL TABLET 4 MG (ondansetron hcl) PV ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 197 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIDIARRHEA AGENTS - Drugs for Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 loperamide hcl oral capsule 2 mg 1 MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin-atropine) 3 MYTESI ORAL TABLET DELAYED RELEASE 125 MG 3 (crofelemer) opium oral tincture 10 mg/ml (1%) 1 stomach relief oral tablet chewable 262 mg 1 XERMELO ORAL TABLET 250 MG (telotristat etiprate) 3 DSL = 30 days , MISCELLANEOUS - Drugs for Vomiting and Nausea BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG 3 (doxylamine-pyridoxine) doxylamine-pyridoxine oral tablet delayed release 10-10 mg 1 DSL = 30 days dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 scopolamine transdermal patch 72 hour 1 mg/3days PV SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) 3 DSL = 30 days TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 PV HOUR 1 MG/3DAYS (scopolamine base) TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 PV HOUR 1 MG/3DAYS (scopolamine base) ANTIHISTAMINES (GI DRUGS) - Drugs for Vomiting and Nausea BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG 3 (doxylamine-pyridoxine) prochlorperazine (Compro Rectal Suppository 25 Mg) PV cvs motion sickness oral tablet 50 mg PV doxylamine-pyridoxine oral tablet delayed release 10-10 mg 1 DSL = 30 days meclizine hcl oral tablet 12.5 mg, 25 mg PV meclizine hcl oral tablet chewable 25 mg PV motion sickness relief oral tablet 50 mg PV motion sickness relief oral tablet chewable 25 mg PV prochlorperazine maleate oral tablet 10 mg, 5 mg PV prochlorperazine rectal suppository 25 mg PV TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML PV (trimethobenzamide hcl) TIGAN ORAL CAPSULE 300 MG (trimethobenzamide hcl) PV trimethobenzamide hcl oral capsule 300 mg PV Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 198 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTI-INFLAMMATORY AGENTS (GI DRUGS) - Drugs for Inflammation alosetron hcl oral tablet 0.5 mg, 1 mg 1 DSL = 30 days balsalazide disodium oral capsule 750 mg 1 CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) 3 DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) 3 DSL = 30 days LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 2 (mesalamine) LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) 3 DSL = 30 days mesalamine er oral capsule extended release 24 hour 0.375 gm 1 mesalamine oral capsule delayed release 400 mg 1 mesalamine oral tablet delayed release 1.2 gm, 800 mg 1 mesalamine rectal enema 4 gm 1 mesalamine rectal suppository 1000 mg 1 mesalamine-cleanser rectal kit 4 gm 1 PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 2 500 MG (mesalamine) SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) 3 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 ANTIULCER AGENTS AND ACID SUPPRESS.,MISC - Drugs for Ulcers and Stomach Acid HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- 3 metronid-tetracyc) TALICIA ORAL CAPSULE DELAYED RELEASE 250-12.5-10 3 MG (amoxicill-rifabutin-omeprazole) CATHARTICS AND - Drugs for Constipation AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) 2 bisacodyl ec oral tablet delayed release 5 mg PV bisacodyl rectal suppository 10 mg PV cascara sagrada oral fluid extract 1 gm/ml 1 citroma oral solution 1.745 gm/30ml PV clearlax oral powder 17 gm/scoop PV CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML PV (sod picosulfate-mag ox-cit acd) cvs gentle rectal suppository 10 mg PV docusate sodium oral capsule 100 mg PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 199 Coverage Requirements & Prescription Drug Name Drug Tier Limits EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG PV (bisacodyl) gavilax oral powder 17 gm/scoop PV gavilyte-c oral solution reconstituted 240 gm PV peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G Oral Solution PV Reconstituted 236 Gm) bisacodyl-peg-kcl-nabicar-nacl (Gavilyte-H Oral Kit 5-210 Mg- PV Gm) peg 3350-kcl-na bicarb-nacl (Gavilyte-N With Flavor Pack Oral PV Solution Reconstituted 420 Gm) gentle laxative oral tablet delayed release 5 mg PV gentle laxative rectal suppository 10 mg PV GIALAX ORAL KIT (polyethylene glycol 3350) 3 glycolax oral powder 17 gm/scoop PV GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM PV (peg 3350-kcl-nabcb-nacl-nasulf) hm stool softener oral capsule 100 mg PV LUBIPROSTONE ORAL CAPSULE 24 MCG, 8 MCG 2 magnesium citrate oral solution 1.745 gm/30ml PV oil heavy oral oil 1 MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM PV (peg-kcl-nacl-nasulf-na asc-c) NULYTELY LEMON-LIME ORAL SOLUTION PV RECONSTITUTED 420 GM (peg 3350-kcl-na bicarb-nacl) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos mono- PV sod phos dibasic) peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm PV peg-3350/electrolytes oral solution reconstituted 236 gm PV peg-3350/electrolytes/ascorbat oral solution reconstituted 100 PV gm peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm PV bisacodyl-peg-kcl-nabicar-nacl (Peg-Prep Oral Kit 5-210 Mg- PV Gm) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- PV kcl-nacl-nasulf-na asc-c) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 3 qc magnesium citrate oral solution 1.745 gm/30ml PV stool softener laxative oral capsule 100 mg PV stool softener oral capsule 100 mg PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 200 Coverage Requirements & Prescription Drug Name Drug Tier Limits SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 PV GM/177ML (na sulfate-k sulfate-mg sulf) SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate-mag PV sulfate-kcl) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) CHOLELITHOLYTIC AGENTS - Drugs for the Stomach CHENODAL ORAL TABLET 250 MG (chenodiol) 3 DSL = 30 days RELTONE ORAL CAPSULE 200 MG, 400 MG (ursodiol) 3 DSL = 30 days URSO FORTE ORAL TABLET 500 MG (ursodiol) 2 ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 DIGESTANTS - Drugs for the Stomach CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 2 UNIT, 6000 UNIT (pancrelipase (lip-prot-amyl)) ENZADYNE ORAL CAPSULE 3 PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 3 UNIT, 4200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 24000-86250 UNIT, 4000 UNIT, 8000 UNIT 3 (pancrelipase (lip-prot-amyl)) VIOKACE ORAL TABLET 10440 UNIT, 20880 UNIT 3 (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 3 3000-14000 UNIT (pancrelipase (lip-prot-amyl)) GI DRUGS, MISCELLANEOUS - Drugs for the Stomach alvimopan oral capsule 12 mg 1 AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 3 DSL = 30 days MG (infliximab-axxq) CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) 3 DSL = 30 days CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 3 DSL = 30 days MG/ML (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML 3 (certolizumab pegol)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 201 Coverage Requirements & Prescription Drug Name Drug Tier Limits CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab 3 DSL = 30 days pegol) ENDARI ORAL PACKET 5 GM ( (sickle )) 3 DSL = 30 days ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 3 MG (vedolizumab) GATTEX SUBCUTANEOUS KIT 5 MG ( (rdna)) 3 DSL = 30 days HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 3 DSL = 30 days 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 3 DSL = 30 days MG/0.4ML, 80 MG/0.8ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 2 DSL = 30 days INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 3 DSL = 30 days INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS 3 DSL = 30 days PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS 2 DSL = 30 days PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 3 DSL = 30 days (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 3 DSL = 30 days MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab) INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab-dyyb) LACTEROL ORAL CAPSULE (probiotic product) 3 LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG 3 (linaclotide) MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol 3 oxalate) OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) 3 DSL = 30 days PROBICHEW ORAL TABLET CHEWABLE 3 PRODIGEN ORAL CAPSULE 3 PROMELLA IN PREBIOTIC ORAL CAPSULE 3 RELISTOR ORAL TABLET 150 MG (methylnaltrexone bromide) 3 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 202 Coverage Requirements & Prescription Drug Name Drug Tier Limits RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 3 DSL = 30 days MG/0.4ML (methylnaltrexone bromide) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 3 100 MG (infliximab-abda) RESTORA RX ORAL CAPSULE 60-1.25 MG (lactobacillus 3 casei-folic acid) SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML 3 (golimumab) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) 3 TRULANCE ORAL TABLET 3 MG (plecanatide) 3 VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) 3 DSL = 30 days VISBIOME ORAL PACKET (probiotic product) 3 XENICAL ORAL CAPSULE 120 MG (orlistat) 2 ZELAC ORAL CAPSULE 3 ZELNORM ORAL TABLET 6 MG (tegaserod maleate) 3 DSL = 30 days HISTAMINE H2-ANTAGONISTS - Drugs for Ulcers and Stomach Acid acid reducer oral tablet 10 mg PV hcl oral solution 300 mg/5ml PV cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg PV DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-famotidine) 3 famotidine oral suspension reconstituted 40 mg/5ml PV famotidine oral tablet 20 mg, 40 mg PV famotidine orig st oral tablet 10 mg PV nizatidine oral capsule 150 mg, 300 mg PV nizatidine oral solution 15 mg/ml PV PEPCID ORAL TABLET 20 MG, 40 MG (famotidine) PV NEUROKININ-1 RECEPTOR ANTAGONISTS - Drugs for Vomiting and Nausea AKYNZEO INTRAVENOUS SOLUTION 235-0.25 MG/20ML 3 (fosnetupitant-palonosetron) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 3 235-0.25 MG (fosnetupitant-palonosetron)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 203 Coverage Requirements & Prescription Drug Name Drug Tier Limits AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 2 DSL = 30 days palonosetron) aprepitant oral 80 & 125 mg PV DSL = 30 days aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg PV DSL = 30 days EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 PV MG (fosaprepitant dimeglumine) EMEND ORAL CAPSULE 80 MG (aprepitant) PV DSL = 30 days EMEND ORAL SUSPENSION RECONSTITUTED 125 MG/5ML PV DSL = 30 days (aprepitant) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG (aprepitant) PV DSL = 30 days fosaprepitant dimeglumine intravenous solution reconstituted PV 150 mg VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK 2 X PV 90 MG (rolapitant hcl) PROKINETIC AGENTS - Drugs for the Stomach GIMOTI NASAL SOLUTION 15 MG/ACT (metoclopramide hcl) PV DSL = 30 days metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml PV metoclopramide hcl oral tablet 10 mg, 5 mg PV metoclopramide hcl oral tablet dispersible 10 mg, 5 mg PV MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride 3 succinate) REGLAN ORAL TABLET 10 MG, 5 MG (metoclopramide hcl) PV ZELNORM ORAL TABLET 6 MG (tegaserod maleate) 3 DSL = 30 days PROSTAGLANDINS - Drugs for Ulcers and Stomach Acid CYTOTEC ORAL TABLET 100 MCG, 200 MCG (misoprostol) PV diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 1 75-0.2 mg misoprostol oral tablet 100 mcg, 200 mcg PV PROTECTANTS - Drugs for Ulcers and Stomach Acid CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) PV CARAFATE ORAL TABLET 1 GM (sucralfate) PV sucralfate oral suspension 1 gm/10ml PV sucralfate oral tablet 1 gm PV PROTON-PUMP INHIBITORS - Drugs for Ulcers and Stomach Acid ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 5 3 MG (rabeprazole sodium) amoxicill-clarithro-lansopraz oral 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 204 Coverage Requirements & Prescription Drug Name Drug Tier Limits ASPIRIN-OMEPRAZOLE ORAL TABLET DELAYED RELEASE 3 325-40 MG, 81-40 MG DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 3 MG (dexlansoprazole) ESOMEP-EZS ORAL KIT 20 MG (esomeprazole magnesium) PV esomeprazole magnesium oral capsule delayed release 20 mg, PV 40 mg esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg PV ESOMEPRAZOLE ORAL CAPSULE DELAYED PV RELEASE 49.3 MG FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML PV (lansoprazole) FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML PV (omeprazole) lansoprazole oral capsule delayed release 15 mg, 30 mg PV lansoprazole oral tablet delayed release dispersible 15 mg, 30 PV mg naproxen-esomeprazole oral tablet delayed release 375-20 mg, 1 500-20 mg NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 PV MG (esomeprazole magnesium) NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG PV (esomeprazole magnesium) OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill-clarithro- 3 omeprazole) omeprazole magnesium oral tablet delayed release 20 mg PV omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg PV omeprazole oral tablet delayed release 20 mg PV OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 PV MG/ML (omeprazole) omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40- 1 1100 mg omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40- 1 1680 mg pantoprazole sodium oral packet 40 mg PV pantoprazole sodium oral tablet delayed release 20 mg, 40 mg PV PREVACID 24HR ORAL CAPSULE DELAYED RELEASE 15 PV MG (lansoprazole) PREVACID ORAL CAPSULE DELAYED RELEASE 15 MG, 30 PV MG (lansoprazole)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 205 Coverage Requirements & Prescription Drug Name Drug Tier Limits PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE PV DISPERSIBLE 15 MG, 30 MG (lansoprazole) PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole PV magnesium) PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) PV PROTONIX ORAL TABLET DELAYED RELEASE 20 MG, 40 PV MG (pantoprazole sodium) RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE 10 MG 3 rabeprazole sodium oral tablet delayed release 20 mg 1 TALICIA ORAL CAPSULE DELAYED RELEASE 250-12.5-10 3 MG (amoxicill-rifabutin-omeprazole) YOSPRALA ORAL TABLET DELAYED RELEASE 325-40 MG, 3 81-40 MG (aspirin-omeprazole) GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA ORAL CAPSULE 3 MG (auranofin) 2 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron CHEMET ORAL CAPSULE 100 MG (succimer) 2 trientine hcl (Clovique Oral Capsule 250 Mg) 1 DSL = 30 days CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) 3 deferasirox granules oral packet 180 mg, 360 mg, 90 mg 1 deferasirox oral packet 180 mg, 360 mg, 90 mg 1 deferasirox oral tablet 180 mg, 360 mg, 90 mg 1 deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg 1 deferiprone oral tablet 500 mg 1 DSL = 30 days deferoxamine mesylate injection solution reconstituted 2 gm, 1 500 mg DEPEN TITRATABS ORAL TABLET 250 MG (penicillamine) 2 EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG 2 DSL = 30 days (deferasirox) FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) 3 DSL = 30 days FERRIPROX ORAL TABLET 1000 MG (deferiprone) 3 FERRIPROX ORAL TABLET 500 MG (deferiprone) 3 DSL = 30 days FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG 3 DSL = 30 days (deferiprone) GALZIN ORAL CAPSULE 25 MG, 50 MG ( (oral)) 3 JADENU ORAL TABLET 180 MG, 360 MG, 90 MG 2 DSL = 30 days (deferasirox)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 206 Coverage Requirements & Prescription Drug Name Drug Tier Limits JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG 2 DSL = 30 days (deferasirox) penicillamine oral capsule 250 mg 1 penicillamine oral tablet 250 mg 1 trientine hcl oral capsule 250 mg 1 DSL = 30 days WILZIN ORAL CAPSULE 25 MG (zinc acetate (oral)) 3 HORMONES AND SYNTHETIC SUBSTITUTES - Hormones ADRENALS - Hormones ACTIVE INJECTION D INJECTION KIT 10 MG/ML 3 ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 2 MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 3 55-14 MCG/ACT (fluticasone-salmeterol) AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT 3 (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT 3 (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT (fluticasone- 3 salmeterol) ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE 0.5 MG, 1 3 DSL = 30 days MG, 2 MG, 5 MG (hydrocortisone) ALVESCO INHALATION AEROSOL SOLUTION 160 2 MCG/ACT, 80 MCG/ACT (ciclesonide) ARMONAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT, 232 MCG/ACT, 55 3 MCG/ACT (fluticasone propionate (inhal)) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 3 MCG/ACT (fluticasone furoate) ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 furoate) ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 furoate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 207 Coverage Requirements & Prescription Drug Name Drug Tier Limits ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH 2 (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 furoate) ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH (mometasone 2 furoate) ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 2 DSL = 30 days MCG/ACT (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 50 MCG/ACT PV DSL = 30 days (mometasone furoate) BETA 1 KIT INJECTION KIT 30 MG/5ML 3 BETALOAN SUIK COMBINATION KIT 30 MG/5ML (betameth 3 sod phos-ace & anesth) BETAMETHASONE SOD PHOS & ACET INJECTION 3 SUSPENSION 7 (4-3) MG/ML BETAMETHASONE SOD PHOS & ACET SUSPENSION 6 (3- 3 3) MG/ML INJECTION 6 (3-3) MG/ML betamethasone sod phos & acet suspension 6 (3-3) mg/ml 1 injection 6 (3-3) mg/ml BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH (fluticasone 3 furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 MCG/ACT (budeson-glycopyrrol-formoterol) BSP 0820 INJECTION KIT 30 MG/5ML 3 budesonide er oral tablet extended release 24 hour 9 mg 1 DSL = 30 days budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 1 mg/2ml budesonide oral capsule delayed release particles 3 mg 1 DSL = 30 days BUDESONIDE-FORMOTEROL FUMARATE INHALATION 3 AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 Mg, 3 6 Mg) DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML, 40 PV MG/ML, 80 MG/ML (methylprednisolone acetate) DEXABLISS ORAL TABLET THERAPY PACK 1.5 MG (39) 3 dexamethasone intensol oral concentrate 1 mg/ml 1 dexamethasone oral elixir 0.5 mg/5ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 208 Coverage Requirements & Prescription Drug Name Drug Tier Limits dexamethasone oral solution 0.5 mg/5ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 1 mg, 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg 1 (35), 1.5 mg (51) dexamethasone sod phosphate pf injection solution 10 mg/ml 1 dexamethasone sod phosphate pf injection solution prefilled 1 syringe 10 mg/ml dexamethasone sodium phosphate injection solution 100 1 mg/10ml, 120 mg/30ml, 20 mg/5ml DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 3 MG/ML INJECTION 10 MG/ML dexamethasone sodium phosphate solution 10 mg/ml injection 1 10 mg/ml DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 3 MG/ML INJECTION 4 MG/ML dexamethasone sodium phosphate solution 4 mg/ml injection 4 1 mg/ml DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 MG/5ML 3 (dexamethasone sodium phosphate) DMT SUIK COMBINATION KIT 10 MG/ML (dexameth sod phos 3 & anesthetic) DOUBLEDEX INJECTION KIT 10 MG/ML (dexamethasone 3 sodium phosphate) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 3 MCG/ACT, 50-5 MCG/ACT (mometasone furo-formoterol fum) DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (dexamethasone) EMFLAZA ORAL SUSPENSION 22.75 MG/ML (deflazacort) 3 DSL = 30 days EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG 3 DSL = 30 days (deflazacort) ENTOCORT EC ORAL CAPSULE DELAYED RELEASE 3 DSL = 30 days PARTICLES 3 MG (budesonide) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 3 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 3 MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT 2 (fluticasone propionate hfa) fludrocortisone acetate oral tablet 0.1 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 209 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 1 mcg/dose FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 3 MCG/ACT, 55-14 MCG/ACT HEMADY ORAL TABLET 20 MG (dexamethasone) 3 dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5 Mg 3 (21)) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 INTRAROSA VAGINAL INSERT 6.5 MG () 3 KENALOG INJECTION SUSPENSION 10 MG/ML, 40 MG/ML 2 (triamcinolone acetonide) KENALOG-80 INJECTION SUSPENSION 80 MG/ML 3 (triamcinolone acetonide) MAS CARE-PAK INJECTION KIT 10 MG/ML (dexamethasone 3 sodium phosphate) MEDROL ORAL TABLET 16 MG, 2 MG, 32 MG, 4 MG, 8 MG PV (methylprednisolone) MEDROL ORAL TABLET THERAPY PACK 4 MG PV (methylprednisolone) MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) MEDROLOAN SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) METHYLPREDNISOLONE ACETATE INJECTION PV SUSPENSION 50 MG/ML METHYLPREDNISOLONE ACETATE SUSPENSION 40 PV MG/ML INJECTION 40 MG/ML methylprednisolone acetate suspension 40 mg/ml injection 40 PV mg/ml METHYLPREDNISOLONE ACETATE SUSPENSION 80 PV MG/ML INJECTION 80 MG/ML methylprednisolone acetate suspension 80 mg/ml injection 80 PV mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg PV methylprednisolone oral tablet therapy pack 4 mg PV MILLIPRED ORAL TABLET 5 MG (prednisolone) 2 ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 DSL = 30 days 6 MG, 9 MG (budesonide) P-CARE K40 INJECTION KIT 40 MG/ML 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 210 Coverage Requirements & Prescription Drug Name Drug Tier Limits P-CARE K40G COMBINATION KIT 40 MG/ML 3 P-CARE K80 INJECTION KIT 2 X 40 MG/ML 3 P-CARE K80G COMBINATION KIT 40 MG/ML 3 physicians ez use /tunnel combination kit 40-1 mg/ml-% 1 PHYSICIANS EZ USE M-PRED INJECTION KIT 40-0.5 3 MG/ML-% POD-CARE 100K INJECTION KIT 40 MG/ML 3 prednisolone oral solution 15 mg/5ml 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 15 1 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 1 15 mg, 30 mg prednisone intensol oral concentrate 5 mg/ml PV prednisone oral solution 5 mg/5ml PV prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 PV mg prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 PV mg (21), 5 mg (48) PRO-C-DURE 5 INJECTION KIT 2 X 40 MG/ML (triamcinolone 3 acetonide) PRO-C-DURE 6 INJECTION KIT 3 X 40 MG/ML (triamcinolone 3 acetonide) PULMICORT FLEXHALER INHALATION AEROSOL POWDER 2 BREATH ACTIVATED 180 MCG/ACT (budesonide) PULMICORT FLEXHALER INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 90 MCG/ACT (budesonide) PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 3 MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone 3 diprop hfa) RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 MG, 5 PV MG (prednisone) READYSHARP BETAMETHASONE INJECTION KIT 30 3 MG/5ML (betamethasone sod phos & acet) READYSHARP DEXAMETHASONE INJECTION KIT 10 3 MG/ML (dexamethasone sodium phosphate) SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 2 100 MG (hydrocortisone sod succinate) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 4.5 MCG/ACT (budesonide-formoterol fumarate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 211 Coverage Requirements & Prescription Drug Name Drug Tier Limits TAPERDEX 12-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (49) (dexamethasone) dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack 1.5 3 Mg, 1.5 Mg (21)) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (27) (dexamethasone) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 3 umeclidin-vilant) TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 3 MG/ML triamcinolone acetonide suspension 40 mg/ml injection 40 1 mg/ml TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML 2 INJECTION 40 MG/ML TRILOAN II SUIK COMBINATION KIT 40 MG/ML 3 (triamcinolone acet & anesth) TRILOAN SUIK COMBINATION KIT 40 MG/ML (triamcinolone 3 acet & anesth) UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 3 DSL = 30 days MG (budesonide) UCERIS RECTAL FOAM 2 MG/ACT (budesonide) 3 fluticasone-salmeterol (Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 Mcg/Dose, 250-50 Mcg/Dose, 500-50 1 Mcg/Dose) ZCORT 7-DAY ORAL TABLET THERAPY PACK 1.5 MG (25) 3 ZILRETTA INTRA-ARTICULAR SUSPENSION 3 RECONSTITUTED ER 32 MG (triamcinolone acetonide) ALPHA-GLUCOSIDASE INHIBITORS - Drugs for Diabetes oral tablet 100 mg, 25 mg, 50 mg 2 oral tablet 100 mg, 25 mg, 50 mg 2 PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG (acarbose) 2 AMYLINOMIMETICS - Drugs for Diabetes SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 2700 MCG/2.7ML ( acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 1500 MCG/1.5ML (pramlintide acetate) - Hormones ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 2 MG/24HR, 4 MG/24HR ()

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 212 Coverage Requirements & Prescription Drug Name Drug Tier Limits AVEED INTRAMUSCULAR SOLUTION 750 MG/3ML 3 () est -methyltest (Covaryx Hs Oral Tablet 0.625-1.25 3 Mg) est estrogens-methyltest (Covaryx Oral Tablet 1.25-2.5 Mg) 3 oral capsule 100 mg, 200 mg, 50 mg 1 DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 2 MG/ML, 200 MG/ML () est estrogens-methyltest (Eemt Hs Oral Tablet 0.625-1.25 Mg) 3 est estrogens-methyltest (Eemt Oral Tablet 1.25-2.5 Mg) 3 est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG 3 DSL = 30 days (testosterone undecanoate) METHITEST ORAL TABLET 10 MG 2 oral capsule 10 mg 1 NATESTO NASAL GEL 5.5 MG/ACT (testosterone) 3 oral tablet 10 mg, 2.5 mg 1 TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML 3 (testosterone cypionate) TESTOPEL IMPLANT PELLET 75 MG (testosterone) 3 TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 2 MG/ML testosterone cypionate intramuscular solution 100 mg/ml, 200 1 mg/ml intramuscular solution 200 mg/ml 1 TESTOSTERONE IMPLANT PELLET 100 MG, 200 MG, 50 MG 3 testosterone transdermal gel 1.62 %, 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 1 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) testosterone transdermal solution 30 mg/act 1 VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%) 2 (testosterone) XYOSTED SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML (testosterone 3 enanthate) ANTIDIABETIC AGENTS, MISCELLANEOUS - Drugs for Diabetes colesevelam hcl oral packet 3.75 gm 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 213 Coverage Requirements & Prescription Drug Name Drug Tier Limits colesevelam hcl oral tablet 625 mg 1 KORLYM ORAL TABLET 300 MG () 2 DSL = 30 days WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 3 WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 3 ANTIESTROGENS - Drugs for Women anastrozole oral tablet 1 mg PV OC ARIMIDEX ORAL TABLET 1 MG (anastrozole) PV OC AROMASIN ORAL TABLET 25 MG (exemestane) PV OC exemestane oral tablet 25 mg PV OC FEMARA ORAL TABLET 2.5 MG (letrozole) PV OC KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 3 DSL = 30 days; OC MG (ribociclib-letrozole) letrozole oral tablet 2.5 mg PV OC ANTIGONADTROPINS - Hormones CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix 2 acetate) ganirelix acetate subcutaneous solution prefilled syringe 250 2 mcg/0.5ml ORGOVYX ORAL TABLET 120 MG (relugolix) 3 DSL = 30 days ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 DSL = 30 days MG (elagolix--norethind) ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix sodium) 3 DSL = 30 days ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS - Hormones diazoxide oral suspension 50 mg/ml 2 PROGLYCEM ORAL SUSPENSION 50 MG/ML (diazoxide) 2 ANTIPARATHYROID AGENTS - Drugs for calcitonin (salmon) nasal solution 200 unit/act 1 cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 1 MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin 3 DSL = 30 days (salmon)) PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 3 MG/0.5ML, 5 MG/ML (etelcalcetide hcl) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG (cinacalcet 3 hcl) ANTITHYROID AGENTS - Drugs for the Thyroid IODINE STRONG ORAL SOLUTION 5 % 3 methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 214 Coverage Requirements & Prescription Drug Name Drug Tier Limits SSKI ORAL SOLUTION 1 GM/ML (potassium iodide 3 (expectorant)) - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 2 ( hcl- hcl) -METFORMIN HCL ORAL TABLET 12.5-1000 2 MG, 12.5-500 MG FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 2 1000 MG, 500 MG (metformin hcl) -metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- 2 500 mg GLUMETZA ORAL TABLET EXTENDED RELEASE 24 HOUR 2 1000 MG, 500 MG (metformin hcl) glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 2 mg INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50- 2 1000 MG, 50-500 MG (-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG 2 (canagliflozin-metformin hcl) JANUMET ORAL TABLET 50-1000 MG, 50-500 MG (- 2 metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG (sitagliptin- 2 metformin hcl) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 850 MG (-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG (- 2 metformin) metformin hcl er (mod) oral tablet extended release 24 hour 2 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour 2 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg, 2 750 mg metformin hcl oral solution 500 mg/5ml 2 metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 215 Coverage Requirements & Prescription Drug Name Drug Tier Limits pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 2 RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) 2 SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5- 2 1000 MG, 7.5-500 MG (-metformin hcl) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 1000 MG, 5-500 MG (-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG 2 (empagliflozin-metformin hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5- 2 2.5-1000 MG (empagliflozin-linaglip-metform) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG 2 (-metformin hcl) CONTRACEPTIVES - Drugs for Women -ethinyl estrad (Afirmelle Oral Tablet 0.1-20 Mg- PV Mcg) levonorgestrel-ethinyl estrad (Altavera Oral Tablet 0.15-30 Mg- PV Mcg) alyacen 1/35 oral tablet 1-35 mg-mcg PV alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg PV levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03 PV &0.01 Mg) levonorgestrel-ethinyl estrad (Amethyst Oral Tablet 90-20 Mcg) PV ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR PV (segesterone-ethinyl estradiol) -ethinyl estradiol (Apri Oral Tablet 0.15-30 Mg-Mcg) PV norethin-eth estrad triphasic (Aranelle Oral Tablet 0.5/1/0.5-35 PV Mg-Mcg) levonorgest-eth estrad 91-day (Ashlyna Oral Tablet 0.15-0.03 PV &0.01 Mg) levonorgestrel-ethinyl estrad (Aubra Eq Oral Tablet 0.1-20 Mg- PV Mcg) levonorgestrel-ethinyl estrad (Aubra Oral Tablet 0.1-20 Mg-Mcg) PV norethindrone acet-ethinyl est (Aurovela 1.5/30 Oral Tablet 1.5- PV 30 Mg-Mcg) norethindrone acet-ethinyl est (Aurovela 1/20 Oral Tablet 1-20 PV Mg-Mcg) norethin ace-eth estrad-fe (Aurovela 24 Fe Oral Tablet 1-20 Mg- PV Mcg(24))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 216 Coverage Requirements & Prescription Drug Name Drug Tier Limits norethin ace-eth estrad-fe (Aurovela Fe 1.5/30 Oral Tablet 1.5- PV 30 Mg-Mcg) norethin ace-eth estrad-fe (Aurovela Fe 1/20 Oral Tablet 1-20 PV Mg-Mcg) levonorgestrel-ethinyl estrad (Aviane Oral Tablet 0.1-20 Mg- PV Mcg) levonorgestrel-ethinyl estrad (Ayuna Oral Tablet 0.15-30 Mg- PV Mcg) desogestrel-ethinyl estradiol (Azurette Oral Tablet 0.15- PV 0.02/0.01 Mg (21/5)) BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) PV (levonorgest-eth estrad-fe bisg) norethindrone-eth estradiol (Balziva Oral Tablet 0.4-35 Mg-Mcg) PV desogestrel-ethinyl estradiol (Bekyree Oral Tablet 0.15- PV 0.02/0.01 Mg (21/5)) BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth estrad- PV levomefol) norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg- PV Mcg(24)) norethin ace-eth estrad-fe (Blisovi Fe 1.5/30 Oral Tablet 1.5-30 PV Mg-Mcg) norethin ace-eth estrad-fe (Blisovi Fe 1/20 Oral Tablet 1-20 Mg- PV Mcg) briellyn oral tablet 0.4-35 mg-mcg PV norethindrone (Camila Oral Tablet 0.35 Mg) PV levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1- PV 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Camrese Oral Tablet 0.15-0.03 PV &0.01 Mg) desogestrel-ethinyl estradiol (Caziant Oral Tablet 0.1/0.125/0.15 PV -0.025 Mg) norethin ace-eth estrad-fe (Charlotte 24 Fe Oral Tablet PV Chewable 1-20 Mg-Mcg(24)) levonorgestrel-ethinyl estrad (Chateal Eq Oral Tablet 0.15-30 PV Mg-Mcg) levonorgestrel-ethinyl estrad (Chateal Oral Tablet 0.15-30 Mg- PV Mcg) -ethinyl estradiol (Cryselle-28 Oral Tablet 0.3-30 Mg- PV Mcg) norethindrone-eth estradiol (Cyclafem 1/35 Oral Tablet 1-35 PV Mg-Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 217 Coverage Requirements & Prescription Drug Name Drug Tier Limits norethin-eth estrad triphasic (Cyclafem 7/7/7 Oral Tablet PV 0.5/0.75/1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Eq Oral Tablet 0.15-30 Mg- PV Mcg) desogestrel-ethinyl estradiol (Cyred Oral Tablet 0.15-30 Mg- PV Mcg) norethindrone-eth estradiol (Dasetta 1/35 Oral Tablet 1-35 Mg- PV Mcg) norethin-eth estrad triphasic (Dasetta 7/7/7 Oral Tablet PV 0.5/0.75/1-35 Mg-Mcg) levonorgest-eth estrad 91-day (Daysee Oral Tablet 0.15-0.03 PV &0.01 Mg) norethindrone (Deblitane Oral Tablet 0.35 Mg) PV levonorgestrel-ethinyl estrad (Delyla Oral Tablet 0.1-20 Mg- PV Mcg) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg PV (21/5), 0.15-30 mg-mcg drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- PV 0.03-0.451 mg -ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg PV norgestrel-ethinyl estradiol (Elinest Oral Tablet 0.3-30 Mg-Mcg) PV ELLA ORAL TABLET 30 MG (ulipristal acetate) PV -ethinyl estradiol (Eluryng Vaginal Ring 0.12-0.015 PV Mg/24Hr) desogestrel-ethinyl estradiol (Emoquette Oral Tablet 0.15-30 PV Mg-Mcg) levonorg-eth estrad triphasic (Enpresse-28 Oral Tablet 50- PV 30/75-40/ 125-30 Mcg) desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15-30 Mg- PV Mcg) norethindrone (Errin Oral Tablet 0.35 Mg) PV -eth estradiol (Estarylla Oral Tablet 0.25-35 Mg- PV Mcg) ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG PV (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- PV mcg etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr PV levonorgestrel-ethinyl estrad (Falmina Oral Tablet 0.1-20 Mg- PV Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 218 Coverage Requirements & Prescription Drug Name Drug Tier Limits levonorgest-eth estrad 91-day (Fayosim Oral Tablet 42-21-21-7 PV Days) norgestimate-eth estradiol (Femynor Oral Tablet 0.25-35 Mg- PV Mcg) norethin ace-eth estrad-fe (Gemmily Oral Capsule 1-20 Mg- PV Mcg(24)) GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG PV (norethin-eth estradiol-fe) norethindrone acet-ethinyl est (Hailey 1.5/30 Oral Tablet 1.5-30 PV Mg-Mcg) norethin ace-eth estrad-fe (Hailey 24 Fe Oral Tablet 1-20 Mg- PV Mcg(24)) norethin ace-eth estrad-fe (Hailey Fe 1.5/30 Oral Tablet 1.5-30 PV Mg-Mcg) norethin ace-eth estrad-fe (Hailey Fe 1/20 Oral Tablet 1-20 Mg- PV Mcg) norethindrone (Heather Oral Tablet 0.35 Mg) PV levonorgest-eth estrad 91-day (Iclevia Oral Tablet 0.15-0.03 PV Mg) norethindrone (Incassia Oral Tablet 0.35 Mg) PV levonorgest-eth estrad 91-day (Introvale Oral Tablet 0.15-0.03 PV Mg) desogestrel-ethinyl estradiol (Isibloom Oral Tablet 0.15-30 Mg- PV Mcg) levonorgest-eth estrad 91-day (Jaimiess Oral Tablet 0.15-0.03 PV &0.01 Mg) drospirenone-ethinyl estradiol (Jasmiel Oral Tablet 3-0.02 Mg) PV norethindrone (Jencycla Oral Tablet 0.35 Mg) PV levonorgest-eth estrad 91-day (Jolessa Oral Tablet 0.15-0.03 PV Mg) desogestrel-ethinyl estradiol (Juleber Oral Tablet 0.15-30 Mg- PV Mcg) norethindrone acet-ethinyl est (Junel 1.5/30 Oral Tablet 1.5-30 PV Mg-Mcg) norethindrone acet-ethinyl est (Junel 1/20 Oral Tablet 1-20 Mg- PV Mcg) norethin ace-eth estrad-fe (Junel Fe 1.5/30 Oral Tablet 1.5-30 PV Mg-Mcg) norethin ace-eth estrad-fe (Junel Fe 1/20 Oral Tablet 1-20 Mg- PV Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 219 Coverage Requirements & Prescription Drug Name Drug Tier Limits norethin ace-eth estrad-fe (Junel Fe 24 Oral Tablet 1-20 Mg- PV Mcg(24)) norethin-eth estradiol-fe (Kaitlib Fe Oral Tablet Chewable 0.8-25 PV Mg-Mcg) desogestrel-ethinyl estradiol (Kalliga Oral Tablet 0.15-30 Mg- PV Mcg) desogestrel-ethinyl estradiol (Kariva Oral Tablet 0.15-0.02/0.01 PV Mg (21/5)) ethynodiol diac-eth estradiol (Kelnor 1/35 Oral Tablet 1-35 Mg- PV Mcg) ethynodiol diac-eth estradiol (Kelnor 1/50 Oral Tablet 1-50 Mg- PV Mcg) levonorgestrel-ethinyl estrad (Kurvelo Oral Tablet 0.15-30 Mg- PV Mcg) KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MG PV (levonorgestrel) norethindrone acet-ethinyl est (Larin 1.5/30 Oral Tablet 1.5-30 PV Mg-Mcg) norethindrone acet-ethinyl est (Larin 1/20 Oral Tablet 1-20 Mg- PV Mcg) norethin ace-eth estrad-fe (Larin 24 Fe Oral Tablet 1-20 Mg- PV Mcg(24)) norethin ace-eth estrad-fe (Larin Fe 1.5/30 Oral Tablet 1.5-30 PV Mg-Mcg) norethin ace-eth estrad-fe (Larin Fe 1/20 Oral Tablet 1-20 Mg- PV Mcg) levonorgestrel-ethinyl estrad (Larissia Oral Tablet 0.1-20 Mg- PV Mcg) norethin-eth estradiol-fe (Layolis Fe Oral Tablet Chewable 0.8- PV 25 Mg-Mcg) norethin-eth estrad triphasic (Leena Oral Tablet 0.5/1/0.5-35 PV Mg-Mcg) levonorgestrel-ethinyl estrad (Lessina Oral Tablet 0.1-20 Mg- PV Mcg) levonorg-eth estrad triphasic (Levonest Oral Tablet 50-30/75- PV 40/ 125-30 Mcg) levonorgest-eth est & eth est oral tablet 42-21-21-7 days PV levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, PV 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg PV levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 PV mg-mcg, 90-20 mcg Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 220 Coverage Requirements & Prescription Drug Name Drug Tier Limits levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 PV mcg levonorgestrel-ethinyl estrad (Levora 0.15/30 (28) Oral Tablet PV 0.15-30 Mg-Mcg) LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE PV 19.5 MCG/DAY (levonorgestrel) levonorgestrel-ethinyl estrad (Lillow Oral Tablet 0.15-30 Mg- PV Mcg) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG PV (norethin-eth estrad-fe biphas) norethindrone acet-ethinyl est (Loestrin 1.5/30 (21) Oral Tablet PV 1.5-30 Mg-Mcg) norethindrone acet-ethinyl est (Loestrin 1/20 (21) Oral Tablet 1- PV 20 Mg-Mcg) norethin ace-eth estrad-fe (Loestrin Fe 1.5/30 Oral Tablet 1.5- PV 30 Mg-Mcg) norethin ace-eth estrad-fe (Loestrin Fe 1/20 Oral Tablet 1-20 PV Mg-Mcg) levonorgest-eth estrad 91-day (Lojaimiess Oral Tablet 0.1-0.02 PV & 0.01 Mg) drospirenone-ethinyl estradiol (Loryna Oral Tablet 3-0.02 Mg) PV LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG PV (levonorgest-eth estrad 91-day) norgestrel-ethinyl estradiol (Low-Ogestrel Oral Tablet 0.3-30 PV Mg-Mcg) drospirenone-ethinyl estradiol (Lo-Zumandimine Oral Tablet 3- PV 0.02 Mg) levonorgestrel-ethinyl estrad (Lutera Oral Tablet 0.1-20 Mg- PV Mcg) norethindrone (Lyleq Oral Tablet 0.35 Mg) PV norethindrone (Lyza Oral Tablet 0.35 Mg) PV marlissa oral tablet 0.15-30 mg-mcg PV norethin ace-eth estrad-fe (Merzee Oral Capsule 1-20 Mg- PV Mcg(24)) norethin ace-eth estrad-fe (Mibelas 24 Fe Oral Tablet Chewable PV 1-20 Mg-Mcg(24)) norethindrone acet-ethinyl est (Microgestin 1.5/30 Oral Tablet PV 1.5-30 Mg-Mcg) norethindrone acet-ethinyl est (Microgestin 1/20 Oral Tablet 1- PV 20 Mg-Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 221 Coverage Requirements & Prescription Drug Name Drug Tier Limits norethin ace-eth estrad-fe (Microgestin 24 Fe Oral Tablet 1-20 PV Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1.5/30 Oral Tablet PV 1.5-30 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1/20 Oral Tablet 1-20 PV Mg-Mcg) norgestimate-eth estradiol (Mili Oral Tablet 0.25-35 Mg-Mcg) PV MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG- PV MCG(24) (norethin ace-eth estrad-fe) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) PV (desogestrel-ethinyl estradiol) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE PV 20 MCG/24HR (levonorgestrel) norgestimate-eth estradiol (Mono-Linyah Oral Tablet 0.25-35 PV Mg-Mcg) NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (- PV ) norethindrone-eth estradiol (Necon 0.5/35 (28) Oral Tablet 0.5- PV 35 Mg-Mcg) NEXPLANON SUBCUTANEOUS IMPLANT 68 MG PV (etonogestrel) drospirenone-ethinyl estradiol (Nikki Oral Tablet 3-0.02 Mg) PV norethindrone (Nora-Be Oral Tablet 0.35 Mg) PV norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) PV norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg- PV mcg norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- PV mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5-30 PV mg-mcg norethindrone oral tablet 0.35 mg PV norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, PV 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg PV norgestimate-ethinyl estradiol triphasic oral tablet PV 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg norethindrone (Norlyda Oral Tablet 0.35 Mg) PV norethindrone (Norlyroc Oral Tablet 0.35 Mg) PV norethindrone-eth estradiol (Nortrel 0.5/35 (28) Oral Tablet 0.5- PV 35 Mg-Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 222 Coverage Requirements & Prescription Drug Name Drug Tier Limits norethindrone-eth estradiol (Nortrel 1/35 (21) Oral Tablet 1-35 PV Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (28) Oral Tablet 1-35 PV Mg-Mcg) norethin-eth estrad triphasic (Nortrel 7/7/7 Oral Tablet PV 0.5/0.75/1-35 Mg-Mcg) NUVARING VAGINAL RING 0.12-0.015 MG/24HR PV (etonogestrel-ethinyl estradiol) norethin-eth estrad triphasic (Nylia 7/7/7 Oral Tablet 0.5/0.75/1- PV 35 Mg-Mcg) norgestimate-eth estradiol (Nymyo Oral Tablet 0.25-35 Mg-Mcg) PV drospirenone-ethinyl estradiol (Ocella Oral Tablet 3-0.03 Mg) PV levonorgestrel-ethinyl estrad (Orsythia Oral Tablet 0.1-20 Mg- PV Mcg) ORTHO MICRONOR ORAL TABLET 0.35 MG (norethindrone) PV norethindrone-eth estradiol (Philith Oral Tablet 0.4-35 Mg-Mcg) PV desogestrel-ethinyl estradiol (Pimtrea Oral Tablet 0.15- PV 0.02/0.01 Mg (21/5)) norethindrone-eth estradiol (Pirmella 1/35 Oral Tablet 1-35 Mg- PV Mcg) norethin-eth estrad triphasic (Pirmella 7/7/7 Oral Tablet PV 0.5/0.75/1-35 Mg-Mcg) PLAN B ONE-STEP ORAL TABLET 1.5 MG (levonorgestrel) PV levonorgestrel-ethinyl estrad (Portia-28 Oral Tablet 0.15-30 Mg- PV Mcg) norgestimate-eth estradiol (Previfem Oral Tablet 0.25-35 Mg- PV Mcg) QUARTETTE ORAL TABLET 42-21-21-7 DAYS (levonorgest- PV eth estrad 91-day) desogestrel-ethinyl estradiol (Reclipsen Oral Tablet 0.15-30 Mg- PV Mcg) levonorgest-eth estrad 91-day (Rivelsa Oral Tablet 42-21-21-7 PV Days) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth PV estrad-levomefol) SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG PV (levonorgest-eth estrad 91-day) levonorgest-eth estrad 91-day (Setlakin Oral Tablet 0.15-0.03 PV Mg) norethindrone (Sharobel Oral Tablet 0.35 Mg) PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 223 Coverage Requirements & Prescription Drug Name Drug Tier Limits desogestrel-ethinyl estradiol (Simliya Oral Tablet 0.15-0.02/0.01 PV Mg (21/5)) levonorgest-eth estrad 91-day (Simpesse Oral Tablet 0.15-0.03 PV &0.01 Mg) SKYLA INTRAUTERINE INTRAUTERINE DEVICE 13.5 MG PV (levonorgestrel) SLYND ORAL TABLET 4 MG (drospirenone) PV norgestimate-eth estradiol (Sprintec 28 Oral Tablet 0.25-35 Mg- PV Mcg) levonorgestrel-ethinyl estrad (Sronyx Oral Tablet 0.1-20 Mg- PV Mcg) drospirenone-ethinyl estradiol (Syeda Oral Tablet 3-0.03 Mg) PV norethin ace-eth estrad-fe (Tarina 24 Fe Oral Tablet 1-20 Mg- PV Mcg(24)) norethin ace-eth estrad-fe (Tarina Fe 1/20 Eq Oral Tablet 1-20 PV Mg-Mcg) norethin ace-eth estrad-fe (Tarina Fe 1/20 Oral Tablet 1-20 Mg- PV Mcg) TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) (norethin ace- PV eth estrad-fe) norethindron-ethinyl estrad-fe (Tilia Fe Oral Tablet 1-20/1-30/1- PV 35 Mg-Mcg) norgestim-eth estrad triphasic (Tri Femynor Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Estarylla Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) norethindron-ethinyl estrad-fe (Tri-Legest Fe Oral Tablet 1-20/1- PV 30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri-Linyah Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Estarylla Oral Tablet PV 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Marzia Oral Tablet PV 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Mili Oral Tablet PV 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Sprintec Oral Tablet PV 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Mili Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Nymyo Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 224 Coverage Requirements & Prescription Drug Name Drug Tier Limits norgestim-eth estrad triphasic (Tri-Previfem Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Sprintec Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) levonorg-eth estrad triphasic (Trivora (28) Oral Tablet 50-30/75- PV 40/ 125-30 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Lo Oral Tablet PV 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Oral Tablet PV 0.18/0.215/0.25 Mg-35 Mcg) norethindrone (Tulana Oral Tablet 0.35 Mg) PV TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 2 MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg PV drospiren-eth estrad-levomefol (Tydemy Oral Tablet 3-0.03- PV 0.451 Mg) desogestrel-ethinyl estradiol (Velivet Oral Tablet 0.1/0.125/0.15 PV -0.025 Mg) drospirenone-ethinyl estradiol (Vestura Oral Tablet 3-0.02 Mg) PV levonorgestrel-ethinyl estrad (Vienva Oral Tablet 0.1-20 Mg- PV Mcg) viorele oral tablet 0.15-0.02/0.01 mg (21/5) PV desogestrel-ethinyl estradiol (Volnea Oral Tablet 0.15-0.02/0.01 PV Mg (21/5)) norethindrone-eth estradiol (Vyfemla Oral Tablet 0.4-35 Mg- PV Mcg) norgestimate-eth estradiol (Vylibra Oral Tablet 0.25-35 Mg-Mcg) PV norethindrone-eth estradiol (Wera Oral Tablet 0.5-35 Mg-Mcg) PV norethin-eth estradiol-fe (Wymzya Fe Oral Tablet Chewable 0.4- PV 35 Mg-Mcg) -eth estradiol (Xulane Transdermal Patch Weekly PV 150-35 Mcg/24Hr) YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-ethinyl PV estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl estradiol) PV norelgestromin-eth estradiol (Zafemy Transdermal Patch PV Weekly 150-35 Mcg/24Hr) drospirenone-ethinyl estradiol (Zarah Oral Tablet 3-0.03 Mg) PV ethynodiol diac-eth estradiol (Zovia 1/35 (28) Oral Tablet 1-35 PV Mg-Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 225 Coverage Requirements & Prescription Drug Name Drug Tier Limits ethynodiol diac-eth estradiol (Zovia 1/35E (28) Oral Tablet 1-35 PV Mg-Mcg) drospirenone-ethinyl estradiol (Zumandimine Oral Tablet 3-0.03 PV Mg) DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS - Drugs for Diabetes ALOGLIPTIN BENZOATE ORAL TABLET 12.5 MG, 25 MG, 2 6.25 MG ALOGLIPTIN-METFORMIN HCL ORAL TABLET 12.5-1000 2 MG, 12.5-500 MG ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 2 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 linagliptin) JANUMET ORAL TABLET 50-1000 MG, 50-500 MG (sitagliptin- 2 metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG (sitagliptin- 2 metformin hcl) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG (sitagliptin 2 phosphate) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG (saxagliptin- 2 metformin) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG (alogliptin 2 benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) 2 OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- 2 saxagliptin) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG 2 (ertugliflozin-sitagliptin) TRADJENTA ORAL TABLET 5 MG (linagliptin) 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 226 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5- 2 2.5-1000 MG (empagliflozin-linaglip-metform) AGONIST-ANTAGONISTS - Drugs for Women clomiphene citrate oral tablet 50 mg 2 DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 bazedoxifene) EVISTA ORAL TABLET 60 MG (raloxifene hcl) 3 FARESTON ORAL TABLET 60 MG (toremifene citrate) PV OC OSPHENA ORAL TABLET 60 MG (ospemifene) PV raloxifene hcl oral tablet 60 mg 1 SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) PV OC tamoxifen citrate oral tablet 10 mg, 20 mg PV OC toremifene citrate oral tablet 60 mg PV OC ESTROGENS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol-norethindrone PV acet) ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR PV (estradiol) estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg, PV 1-0.5 Mg) ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) BIJUVA ORAL CAPSULE 1-100 MG (estradiol-) 3 CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- 3 0.015 MG/DAY (estradiol-levonorgestrel) CLIMARA TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 PV MG/24HR, 0.1 MG/24HR (estradiol) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol-norethindrone PV acet) est estrogens-methyltest (Covaryx Hs Oral Tablet 0.625-1.25 3 Mg) est estrogens-methyltest (Covaryx Oral Tablet 1.25-2.5 Mg) 3 DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML (estradiol 3 valerate) DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 2 MG/ML (estradiol valerate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 227 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML (estradiol 2 cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM PV (estradiol) estradiol (Dotti Transdermal Patch Twice Weekly 0.025 Mg/24Hr, 0.0375 Mg/24Hr, 0.05 Mg/24Hr, 0.075 Mg/24Hr, 0.1 PV Mg/24Hr) DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 3 bazedoxifene) est estrogens-methyltest (Eemt Hs Oral Tablet 0.625-1.25 Mg) 3 est estrogens-methyltest (Eemt Oral Tablet 1.25-2.5 Mg) 3 ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) PV (estradiol) est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG (estradiol) PV ESTRACE VAGINAL CREAM 0.1 MG/GM (estradiol) 2 estradiol oral tablet 0.5 mg, 1 mg, 2 mg PV estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 PV mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 PV mg/24hr estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg PV ESTRING VAGINAL RING 2 MG (estradiol) 2 ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) PV (estradiol) EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY PV (estradiol) FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG PV (norethindrone-eth estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 (estradiol acetate) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- PV Mcg, 1-5 Mg-Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 228 Coverage Requirements & Prescription Drug Name Drug Tier Limits IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG, 3 4 MCG (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG, 4 3 MCG (estradiol) norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) PV estradiol (Lyllana Transdermal Patch Twice Weekly 0.025 Mg/24Hr, 0.0375 Mg/24Hr, 0.05 Mg/24Hr, 0.075 Mg/24Hr, 0.1 PV Mg/24Hr) MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG PV (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 PV MCG/24HR (estradiol) estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) PV MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, PV 0.1 MG/24HR (estradiol) norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- PV mcg ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 DSL = 30 days MG (elagolix-estradiol-norethind) PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 3 norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 PV MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 3 conjugated) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- PV medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 PV MG, 0.625-5 MG (conj estrog-medroxyprogest ace) VAGIFEM VAGINAL TABLET 10 MCG (estradiol) 2 VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 PV MG/24HR, 0.1 MG/24HR (estradiol) estradiol (Yuvafem Vaginal Tablet 10 Mcg) 1 GLYCOGENOLYTIC AGENTS - Hormones BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) GLUCAGEN HYPOKIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 229 Coverage Requirements & Prescription Drug Name Drug Tier Limits glucagon emergency kit 1 mg injection 1 mg PV GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG PV GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO- 2 INJECTOR 0.6 MG/0.6ML ( hcl) ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 0.6 MG/0.6ML (dasiglucagon hcl) GONADOTROPINS - Hormones chorionic gonadotropin intramuscular solution reconstituted 2 10000 unit ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate 3 (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 3 month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 3 month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG (PED) 3 (leuprolide acetate (6 month)) FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML (follitropin 2 beta) GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 2 UNIT, 450 UNIT (follitropin alfa) GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 2 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML (follitropin alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION 2 RECONSTITUTED 75 UNIT (follitropin alfa) leuprolide acetate injection kit 1 mg/0.2ml 2 LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 3 MG (leuprolide & norethindrone) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 2 MG, 7.5 MG (leuprolide acetate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 230 Coverage Requirements & Prescription Drug Name Drug Tier Limits LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 2 MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG 2 INTRAMUSCULAR KIT 30 MG (leuprolide acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG 2 INTRAMUSCULAR KIT 45 MG (leuprolide acetate (6 month)) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 2 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 2 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 month)) MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 2 75 UNIT (menotropins) novarel intramuscular solution reconstituted 10000 unit 2 NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 2 5000 UNIT (chorionic gonadotropin) OVIDREL SUBCUTANEOUS INJECTABLE 250 MCG/0.5ML 2 (choriogonadotropin alfa) pregnyl intramuscular solution reconstituted 10000 unit 2 SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin 3 acetate (cpp)) SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin acetate) 2 TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, 3.75 MG (triptorelin 3 pamoate) TRIPTODUR INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED ER 22.5 MG (triptorelin pamoate) VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) 3 GONADOTROPINS AND ANTIGONADOTROPINS - Hormones chorionic gonadotropin intramuscular solution reconstituted 2 10000 unit ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide acetate 3 (3 month)) ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide acetate (4 3 month)) ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide acetate (6 3 month)) ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide acetate) 3 FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300 UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML (follitropin 2 beta)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 231 Coverage Requirements & Prescription Drug Name Drug Tier Limits GONAL-F INJECTION SOLUTION RECONSTITUTED 1050 2 UNIT, 450 UNIT (follitropin alfa) GONAL-F RFF REDIJECT SUBCUTANEOUS SOLUTION 300 2 UNIT/0.5ML, 450 UNT/0.75ML, 900 UNIT/1.5ML (follitropin alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION 2 RECONSTITUTED 75 UNIT (follitropin alfa) leuprolide acetate injection kit 1 mg/0.2ml 2 LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 3 MG (leuprolide & norethindrone) LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 2 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 2 MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG 2 INTRAMUSCULAR KIT 30 MG (leuprolide acetate (4 month)) LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG 2 INTRAMUSCULAR KIT 45 MG (leuprolide acetate (6 month)) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 2 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 2 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 month)) MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED 2 75 UNIT (menotropins) novarel intramuscular solution reconstituted 10000 unit 2 NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 2 5000 UNIT (chorionic gonadotropin) OVIDREL SUBCUTANEOUS INJECTABLE 250 MCG/0.5ML 2 (choriogonadotropin alfa) pregnyl intramuscular solution reconstituted 10000 unit 2 SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin 3 acetate (cpp)) SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin acetate) 2 TRIPTODUR INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED ER 22.5 MG (triptorelin pamoate) VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) 3 MIMETICS - Drugs for Diabetes ADLYXIN STARTER PACK SUBCUTANEOUS PEN- 2 INJECTOR KIT 10 & 20 MCG/0.2ML () ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 2 MCG/0.2ML (lixisenatide)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 232 Coverage Requirements & Prescription Drug Name Drug Tier Limits BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS 2 AUTO-INJECTOR 2 MG/0.85ML () BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 10 MCG/0.04ML (exenatide) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 5 MCG/0.02ML (exenatide) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 2 MG/1.5ML, 4 MG/3ML () RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG (semaglutide) 2 DSL = 30 days SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 2 MG/3ML ( -weight management) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- 2 DSL = 30 days 33 UNT-MCG/ML (-lixisenatide) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML 2 DSL = 30 days () VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 2 MG/3ML (liraglutide) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 DSL = 30 days 100-3.6 UNIT-MG/ML (-liraglutide) - Drugs for Diabetes ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML () ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 (insulin lispro) AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT (insulin regular 2 human) AFREZZA INHALATION POWDER 90 X 8 UNIT & 90X12 UNIT 2 DSL = 30 days (insulin regular human) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML () APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 2 glulisine) BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin glargine) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML ( (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 2 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin 2 aspart (w/niacinamide))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 233 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION 2 (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION 2 (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro) HUMALOG VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 (insulin lispro) HUMALOG VIAL SUBCUTANEOUS SOLUTION CARTRIDGE 2 100 UNIT/ML (insulin lispro) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION 2 PEN-INJECTOR 100 UNIT/ML (insulin nph human (isophane)) HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PV PEN-INJECTOR 500 UNIT/ML (insulin regular human) HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION 500 2 UNIT/ML (insulin regular human) HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) INSULIN ASP PROT & ASP FLEXPEN SUBCUTANEOUS 2 SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML INSULIN ASPART FLEXPEN SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 100 UNIT/ML INSULIN ASPART PENFILL SUBCUTANEOUS SOLUTION 2 CARTRIDGE 100 UNIT/ML INSULIN ASPART PROT & ASPART SUBCUTANEOUS 2 SUSPENSION (70-30) 100 UNIT/ML

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 234 Coverage Requirements & Prescription Drug Name Drug Tier Limits INSULIN ASPART SUBCUTANEOUS SOLUTION 100 2 UNIT/ML INSULIN LISPRO (1 UNIT DIAL) SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML INSULIN LISPRO JUNIOR KWIKPEN SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML INSULIN LISPRO PROT & LISPRO SUBCUTANEOUS 2 SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin glargine) LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin glargine) LEVEMIR U-100 FLEXTOUCH SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 100 UNIT/ML () LEVEMIR U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin detemir) LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro-aabc) LYUMJEV VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 2 lispro-aabc) MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML- 2 % (insulin regular(human) in nacl) NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph 2 human (isophane)) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION 2 PEN-INJECTOR 100 UNIT/ML (insulin nph human (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) NOVOLIN N VIAL SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 235 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) NOVOLIN R VIAL INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 aspart prot & aspart) NOVOLOG MIX 70/30 VIAL SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION 2 CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin aspart) SEMGLEE SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 DSL = 30 days (insulin glargine) SEMGLEE SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 DSL = 30 days 100 UNIT/ML (insulin glargine) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- 2 DSL = 30 days 33 UNT-MCG/ML (insulin glargine-lixisenatide) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION 2 DSL = 30 days PEN-INJECTOR 300 UNIT/ML (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 DSL = 30 days INJECTOR 300 UNIT/ML (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 DSL = 30 days INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin 2 degludec) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 DSL = 30 days 100-3.6 UNIT-MG/ML (insulin degludec-liraglutide) INTERMEDIATE-ACTING INSULINS - Drugs for Diabetes HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION 2 (50-50) 100 UNIT/ML (insulin lispro prot & lispro)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 236 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION 2 (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION 2 PEN-INJECTOR 100 UNIT/ML (insulin nph human (isophane)) HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) INSULIN ASP PROT & ASP FLEXPEN SUBCUTANEOUS 2 SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML INSULIN ASPART PROT & ASPART SUBCUTANEOUS 2 SUSPENSION (70-30) 100 UNIT/ML INSULIN LISPRO PROT & LISPRO SUBCUTANEOUS 2 SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN N FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph 2 human (isophane)) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION 2 PEN-INJECTOR 100 UNIT/ML (insulin nph human (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) NOVOLIN N VIAL SUBCUTANEOUS SUSPENSION 100 2 UNIT/ML (insulin nph human (isophane)) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 aspart prot & aspart)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 237 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOLOG MIX 70/30 VIAL SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin aspart prot & aspart) LEPTINS - Hormones MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 11.3 MG () LONG-ACTING INSULINS - Drugs for Diabetes BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin glargine) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin glargine) LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin glargine) LEVEMIR U-100 FLEXTOUCH SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 100 UNIT/ML (insulin detemir) LEVEMIR U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin detemir) SEMGLEE SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 DSL = 30 days (insulin glargine) SEMGLEE SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 DSL = 30 days 100 UNIT/ML (insulin glargine) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- 2 DSL = 30 days 33 UNT-MCG/ML (insulin glargine-lixisenatide) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION 2 DSL = 30 days PEN-INJECTOR 300 UNIT/ML (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 DSL = 30 days INJECTOR 300 UNIT/ML (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 DSL = 30 days INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin 2 degludec) XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 DSL = 30 days 100-3.6 UNIT-MG/ML (insulin degludec-liraglutide) - Drugs for Diabetes oral tablet 120 mg, 60 mg 2 oral tablet 0.5 mg, 1 mg, 2 mg 2 STARLIX ORAL TABLET 120 MG (nateglinide) 2 PARATHYROID AGENTS - Drugs for Bones FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 2 DSL = 30 days MCG/2.48ML (teriparatide (recombinant)) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 3 DSL = 30 days MCG, 50 MCG, 75 MCG (parathyroid (recomb))

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 238 Coverage Requirements & Prescription Drug Name Drug Tier Limits TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS 2 DSL = 30 days SOLUTION PEN-INJECTOR 620 MCG/2.48ML TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 3 DSL = 30 days MCG/1.56ML (abaloparatide) PARATHYROID AND ANTIPARATHYROID AGENTS - Drugs for Bones calcitonin (salmon) nasal solution 200 unit/act 1 FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 2 DSL = 30 days MCG/2.48ML (teriparatide (recombinant)) MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin 3 DSL = 30 days (salmon)) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 3 DSL = 30 days MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 3 DSL = 30 days MCG/1.56ML (abaloparatide) PITUITARY - Hormones ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) 2 DSL = 30 days DDAVP RHINAL TUBE NASAL SOLUTION 0.01 % 2 (desmopressin ace refrigerated) desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate injection solution 4 mcg/ml 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate pf injection solution 4 mcg/ml 1 desmopressin acetate spray nasal solution 0.01 % 1 GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 2 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG (somatropin) GENOTROPIN SUBCUTANEOUS SOLUTION 2 RECONSTITUTED 12 MG, 5 MG (somatropin) HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 2 MG, 24 MG, 5 MG, 6 MG (somatropin) NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 55.3 MCG (desmopressin acetate) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 2 MG/1.5ML (somatropin) NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 10 MG/2ML (somatropin) NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 20 MG/2ML (somatropin)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 239 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 5 MG/2ML (somatropin) OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE 10 2 MG/1.5ML, 5 MG/1.5ML (somatropin) OMNITROPE SUBCUTANEOUS SOLUTION 2 RECONSTITUTED 5.8 MG (somatropin) SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 2 MG (somatropin (non-refrigerated)) SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 2 MG (somatropin (non-refrigerated)) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 2 4 MG, 5 MG, 6 MG (somatropin (non-refrigerated)) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 2 acetate) ZOMACTON (FOR ZOMA-JET 10) SUBCUTANEOUS 2 SOLUTION RECONSTITUTED 10 MG (somatropin) ZOMACTON SUBCUTANEOUS SOLUTION 2 RECONSTITUTED 10 MG, 5 MG (somatropin) ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 2 8.8 MG (somatropin (non-refrigerated)) PROGESTINS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol-norethindrone PV acet) estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg, PV 1-0.5 Mg) ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) AYGESTIN ORAL TABLET 5 MG (norethindrone acetate) PV BIJUVA ORAL CAPSULE 1-100 MG (estradiol-progesterone) 3 COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol-norethindrone PV acet) CRINONE VAGINAL GEL 4 %, 8 % (progesterone) PV DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 PV MG/ML (medroxyprogesterone acetate) DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 150 MG/ML (medroxyprogesterone PV acetate) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML PV (medroxyprogesterone acetate) ENDOMETRIN VAGINAL INSERT 100 MG (progesterone) PV Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 240 Coverage Requirements & Prescription Drug Name Drug Tier Limits estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg PV FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG PV (norethindrone-eth estradiol) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- PV Mcg, 1-5 Mg-Mcg) hydroxyprogesterone caproate intramuscular oil 250 mg/ml PV DSL = 30 days hydroxyprogesterone caproate intramuscular solution 1.25 1 DSL = 30 days gm/5ml norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) PV LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, 3.75 & 5 3 MG (leuprolide & norethindrone) MAKENA INTRAMUSCULAR OIL 250 MG/ML PV DSL = 30 days (hydroxyprogesterone caproate) MAKENA SUBCUTANEOUS SOLUTION AUTO-INJECTOR PV DSL = 30 days 275 MG/1.1ML (hydroxyprogesterone caproate) medroxyprogesterone acetate intramuscular suspension 150 PV mg/ml medroxyprogesterone acetate intramuscular suspension PV prefilled syringe 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg PV megestrol acetate oral suspension 40 mg/ml 1 megestrol acetate oral suspension 625 mg/5ml PV megestrol acetate oral tablet 20 mg, 40 mg 1 OC estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) PV norethindrone acetate oral tablet 5 mg PV norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- PV mcg ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 DSL = 30 days MG (elagolix-estradiol-norethind) progesterone intramuscular oil 50 mg/ml PV progesterone oral capsule 100 mg, 200 mg PV PROMETRIUM ORAL CAPSULE 100 MG, 200 MG PV (progesterone) PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG PV (medroxyprogesterone acetate) SLYND ORAL TABLET 4 MG (drospirenone) PV RAPID-ACTING INSULINS - Drugs for Diabetes ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin lispro)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 241 Coverage Requirements & Prescription Drug Name Drug Tier Limits ADMELOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 (insulin lispro) AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT (insulin regular 2 human) AFREZZA INHALATION POWDER 90 X 8 UNIT & 90X12 UNIT 2 DSL = 30 days (insulin regular human) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin glulisine) APIDRA VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 2 glulisine) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 2 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML (insulin 2 aspart (w/niacinamide)) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION 2 (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION 2 (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro) HUMALOG VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 (insulin lispro) HUMALOG VIAL SUBCUTANEOUS SOLUTION CARTRIDGE 2 100 UNIT/ML (insulin lispro) INSULIN ASP PROT & ASP FLEXPEN SUBCUTANEOUS 2 SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML INSULIN ASPART FLEXPEN SUBCUTANEOUS SOLUTION 2 PEN-INJECTOR 100 UNIT/ML INSULIN ASPART PENFILL SUBCUTANEOUS SOLUTION 2 CARTRIDGE 100 UNIT/ML

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 242 Coverage Requirements & Prescription Drug Name Drug Tier Limits INSULIN ASPART PROT & ASPART SUBCUTANEOUS 2 SUSPENSION (70-30) 100 UNIT/ML INSULIN ASPART SUBCUTANEOUS SOLUTION 100 2 UNIT/ML INSULIN LISPRO (1 UNIT DIAL) SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML INSULIN LISPRO JUNIOR KWIKPEN SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML INSULIN LISPRO PROT & LISPRO SUBCUTANEOUS 2 SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML INSULIN LISPRO SUBCUTANEOUS SOLUTION 100 UNIT/ML 2 LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro-aabc) LYUMJEV VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 2 lispro-aabc) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 aspart prot & aspart) NOVOLOG MIX 70/30 VIAL SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION 2 CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG U-100 VIAL SUBCUTANEOUS SOLUTION 100 2 UNIT/ML (insulin aspart) SHORT-ACTING INSULINS - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PV PEN-INJECTOR 500 UNIT/ML (insulin regular human) HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION 500 2 UNIT/ML (insulin regular human) HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML- 2 % (insulin regular(human) in nacl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 243 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin 2 nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane & 2 regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION 2 (70-30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 2 30) 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN- 2 INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) NOVOLIN R VIAL INJECTION SOLUTION 100 UNIT/ML 2 (insulin regular human) SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB - Drugs for Diabetes FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin 2 propanediol) GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 linagliptin) INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50- 2 1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG 2 (canagliflozin-metformin hcl) INVOKANA ORAL TABLET 100 MG, 300 MG (canagliflozin) 2 JARDIANCE ORAL TABLET 10 MG, 25 MG (empagliflozin) 2 QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- 2 saxagliptin) SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 7.5- 2 1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin l- 2 pyroglutamicac) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG 2 (ertugliflozin-sitagliptin) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 1000 MG, 5-500 MG (empagliflozin-metformin hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 244 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 MG 2 (empagliflozin-metformin hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5- 2 2.5-1000 MG (empagliflozin-linaglip-metform) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 5-500 MG 2 (dapagliflozin-metformin hcl) SOMATOSTATIN AGONISTS - Hormones BYNFEZIA PEN SUBCUTANEOUS SOLUTION PEN- 3 DSL = 30 days INJECTOR 2500 MCG/ML (2.8 ML) ( acetate) MYCAPSSA ORAL CAPSULE DELAYED RELEASE 20 MG 3 DSL = 30 days (octreotide acetate) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 1 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 2 DSL = 30 days 20 MG, 30 MG (octreotide acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60 MG 3 DSL = 30 days (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 3 DSL = 30 days MG/ML, 0.9 MG/ML (pasireotide diaspartate) SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 3 DSL = 30 days MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide acetate) SOMATOTROPIN AGONISTS - Hormones EGRIFTA SV SUBCUTANEOUS SOLUTION 2 DSL = 30 days RECONSTITUTED 2 MG (tesamorelin acetate) INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML 3 (mecasermin) SOMATOTROPIN ANTAGONISTS - Hormones SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 10 MG, 15 MG, 20 MG, 25 MG, 30 MG (pegvisomant) - Drugs for Diabetes AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG () 2 DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone hcl- 2 glimepiride) glimepiride oral tablet 1 mg, 2 mg, 4 mg 2 glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 2 5 mg glipizide oral tablet 10 mg, 5 mg 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 245 Coverage Requirements & Prescription Drug Name Drug Tier Limits glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 2 5 mg glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- 2 500 mg GLUCOTROL ORAL TABLET 10 MG (glipizide) 2 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 2 HOUR 10 MG, 2.5 MG, 5 MG (glipizide) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 2 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 2 glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 2 mg GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG (glyburide 2 micronized) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 2 oral tablet 500 mg 2 - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 2 (pioglitazone hcl-metformin hcl) ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG (pioglitazone 2 hcl) ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 2 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone hcl- 2 glimepiride) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 2 pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 2 pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 2 THYROID AGENTS - Drugs for the Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 3 240 MG, 30 MG, 300 MG, 60 MG, 90 MG (thyroid) CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG 3 (liothyronine sodium) levothyroxine sodium (Euthyrox Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 50 1 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium (Levo-T Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 300 1 Mcg, 50 Mcg, 75 Mcg, 88 Mcg)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 246 Coverage Requirements & Prescription Drug Name Drug Tier Limits LEVOTHYROXINE SODIUM ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 3 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 1 mcg, 75 mcg, 88 mcg levothyroxine sodium (Levoxyl Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 50 1 Mcg, 75 Mcg, 88 Mcg) liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1 NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 3 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg 1 THYQUIDITY ORAL SOLUTION 100 MCG/5ML (levothyroxine 3 sodium) TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 3 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 3 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) levothyroxine sodium (Unithroid Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 300 1 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 3 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 3 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing ACCUCAINE COMBINATION KIT 1 % (lido-pentaf-tetrafl- 3 ultrasound) bupivacaine fisiopharma injection solution 2.5 mg/ml, 5 mg/ml 1 bupivacaine hcl (pf) injection solution 0.25 %, 0.5 %, 0.75 % 1 bupivacaine hcl injection solution 0.25 %, 0.5 % 1 EXPAREL INJECTION SUSPENSION 1.3 % (bupivacaine 3 liposome)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 247 Coverage Requirements & Prescription Drug Name Drug Tier Limits FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 0.2- 0.1-0.9 MG/100ML-%, 0.2-0.125-0.9 MG/100ML-%, 0.5-0.0625- 3 0.9 MG/250ML-%, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125-0.9 MG/250ML-% FENTANYL-BUPIVACAINE-NACL INJECTION SOLUTION 2- 3 DSL = 30 days 0.125-0.9 MCG/ML-%-% lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %, 4 % 1 lidocaine hcl injection solution 0.5 % 1 LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MG/ML, 100 MG/10ML, 100 MG/5ML, 200 3 MG/10ML, 60 MG/3ML LIDOCAINE HCL INTRADERMAL JET-INJECTOR 0.5 MG 3 LIDOCAINE HCL SOLUTION 1 % INJECTION 1 % 3 lidocaine hcl solution 1 % injection 1 % 1 LIDOCAINE HCL SOLUTION 2 % INJECTION 2 % 3 lidocaine hcl solution 2 % injection 2 % 1 LIDOMARK 2/5 INJECTION KIT 2 % 3 MARVONA SUIK COMBINATION KIT 0.5 % (bupivacaine hcl & 3 anesthetic) physicians ez use joint/tunnel combination kit 40-1 mg/ml-% 1 bupivacaine hcl (Sensorcaine Injection Solution 0.25 %, 0.5 %) 3 bupivacaine hcl (Sensorcaine-Mpf Injection Solution 0.75 %) 3 bupivacaine hcl (Sensorcaine-Mpf Solution 0.25 % Injection 1 0.25 %) bupivacaine hcl (Sensorcaine-Mpf Solution 0.25 % Injection 2 0.25 %) bupivacaine hcl (Sensorcaine-Mpf Solution 0.5 % Injection 0.5 1 %) bupivacaine hcl (Sensorcaine-Mpf Solution 0.5 % Injection 0.5 3 %) XARACOLL IMPLANT IMPLANT 3 X 100 MG (bupivacaine hcl) 3 ZINGO INTRADERMAL JET-INJECTOR 0.5 MG (lidocaine hcl) 3 MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA-REDUCTASE INHIBITORS dutasteride oral capsule 0.5 mg 1 dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 1 oral tablet 5 mg 1 ALCOHOL DETERRENTS - Drugs for Alcohol Dependence disulfiram oral tablet 250 mg, 500 mg 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 248 Coverage Requirements & Prescription Drug Name Drug Tier Limits naltrexone hcl oral tablet 50 mg 1 VIVITROL INTRAMUSCULAR SUSPENSION 3 RECONSTITUTED 380 MG (naltrexone) - Drugs for Overdose or Poisoning ANTIVENIN LATRODECTUS MACTANS INJECTION KIT 2 ANTIVENIN MICRURUS FULVIUS INTRAVENOUS SOLUTION 3 RECONSTITUTED ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML (atropine sulfate) BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE 2 (glucagon) BRIDION INTRAVENOUS SOLUTION 200 MG/2ML 2 (sugammadex sodium) BRIDION INTRAVENOUS SOLUTION 500 MG/5ML 3 (sugammadex sodium) CHEMET ORAL CAPSULE 100 MG (succimer) 2 CROFAB INTRAVENOUS SOLUTION RECONSTITUTED 2 (crotalidae polyval immune fab) deferoxamine mesylate injection solution reconstituted 2 gm, 1 500 mg DIGIFAB INTRAVENOUS SOLUTION RECONSTITUTED 40 2 MG (digoxin immune fab) FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum PV carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, PV 750 MG (lanthanum carbonate) GLUCAGEN HYPOKIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency kit 1 mg injection 1 mg PV GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG PV GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 AUTO-INJECTOR 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) IODINE STRONG ORAL SOLUTION 5 % 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 249 Coverage Requirements & Prescription Drug Name Drug Tier Limits KHAPZORY INTRAVENOUS SOLUTION RECONSTITUTED PV DSL = 30 days 175 MG, 300 MG (levoleucovorin) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, PV 750 mg leucovorin calcium injection solution 100 mg/10ml, 500 mg/50ml PV leucovorin calcium injection solution reconstituted 100 mg, 200 PV mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg PV levoleucovorin calcium intravenous solution reconstituted 50 mg PV levoleucovorin calcium pf intravenous solution 175 mg/17.5ml, PV 250 mg/25ml LIFEMS NALOXONE INJECTION PREFILLED SYRINGE KIT 2 3 MG/2ML magnesium sulfate intravenous solution 2 gm/50ml, 20 PV gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml MAGNESIUM SULFATE SOLUTION 50 % INJECTION 50 % PV magnesium sulfate solution 50 % injection 50 % PV MEPHYTON ORAL TABLET 5 MG (phytonadione) PV naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml 1 naloxone hcl injection solution cartridge 0.4 mg/ml 1 naloxone hcl injection solution prefilled syringe 2 mg/2ml 1 NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) 3 phytonadione injection solution 1 mg/0.5ml, 10 mg/ml 1 phytonadione oral tablet 5 mg PV RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 insoluble) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) PV RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer PV carbonate) RENVELA ORAL TABLET 800 MG (sevelamer carbonate) PV sevelamer carbonate oral packet 0.8 gm, 2.4 gm PV sevelamer carbonate oral tablet 800 mg PV sevelamer hcl oral tablet 400 mg, 800 mg PV sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 SSKI ORAL SOLUTION 1 GM/ML (potassium iodide 3 (expectorant)) VISTOGARD ORAL PACKET 10 GM () 3 DSL = 30 days vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 250 Coverage Requirements & Prescription Drug Name Drug Tier Limits VORAXAZE INTRAVENOUS SOLUTION RECONSTITUTED PV DSL = 30 days 1000 UNIT (glucarpidase) ANTIGOUT AGENTS - Drugs for Gout ALEVE ORAL TABLET 220 MG (naproxen sodium) PV allopurinol oral tablet 100 mg, 300 mg PV COLCHICINE ORAL CAPSULE 0.6 MG PV colchicine oral tablet 0.6 mg PV colchicine-probenecid oral tablet 0.5-500 mg 1 COLCRYS ORAL TABLET 0.6 MG (colchicine) PV EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, PV 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg PV febuxostat oral tablet 40 mg, 80 mg PV GLOPERBA ORAL SOLUTION 0.6 MG/5ML (colchicine) PV DSL = 30 days INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) PV INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) PV indomethacin er oral capsule extended release 75 mg PV INDOMETHACIN ORAL CAPSULE 20 MG PV indomethacin oral capsule 25 mg, 50 mg PV KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML PV (pegloticase) MITIGARE ORAL CAPSULE 0.6 MG (colchicine) PV NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR PV 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML (naproxen) PV NAPROSYN ORAL TABLET 500 MG (naproxen) PV naproxen oral suspension 125 mg/5ml PV naproxen oral tablet 250 mg, 375 mg, 500 mg PV naproxen oral tablet delayed release 375 mg, 500 mg PV naproxen sodium er oral tablet extended release 24 hour 375 PV mg, 500 mg NAPROXEN SODIUM ER ORAL TABLET EXTENDED PV RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 220 mg, 275 mg, 550 mg PV probenecid oral tablet 500 mg 1 TIVORBEX ORAL CAPSULE 20 MG (indomethacin) PV ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) PV ZYLOPRIM ORAL TABLET 100 MG, 300 MG (allopurinol) PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 251 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTISENSE OLIGONUCLEOTIDES AMONDYS 45 INTRAVENOUS SOLUTION 100 MG/2ML 3 EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 MG/ML 3 DSL = 30 days (risdiplam) EXONDYS 51 INTRAVENOUS SOLUTION 100 MG/2ML, 500 3 DSL = 30 days MG/10ML (eteplirsen) SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML 3 DSL = 30 days (nusinersen) TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 284 MG/1.5ML (inotersen sodium) VILTEPSO INTRAVENOUS SOLUTION 250 MG/5ML 3 DSL = 30 days (viltolarsen) VYONDYS 53 INTRAVENOUS SOLUTION 100 MG/2ML 3 DSL = 30 days (golodirsen) ANABOLIC AGENTS EVENITY SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 105 MG/1.17ML (romosozumab-aqqg) FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 2 DSL = 30 days MCG/2.48ML (teriparatide (recombinant)) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 3 DSL = 30 days MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS 2 DSL = 30 days SOLUTION PEN-INJECTOR 620 MCG/2.48ML TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 3 DSL = 30 days MCG/1.56ML (abaloparatide) BONE RESORPTION INHIBITORS - Drugs for Bone Loss ACTONEL ORAL TABLET 150 MG, 35 MG (risedronate 3 sodium) alendronate sodium oral solution 70 mg/75ml 1 alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 ATELVIA ORAL TABLET DELAYED RELEASE 35 MG 3 (risedronate sodium) BINOSTO ORAL TABLET EFFERVESCENT 70 MG 3 (alendronate sodium) BONIVA ORAL TABLET 150 MG (ibandronate sodium) 3 calcitonin (salmon) nasal solution 200 unit/act 1 EVISTA ORAL TABLET 60 MG (raloxifene hcl) 3 FOSAMAX ORAL TABLET 70 MG (alendronate sodium) 3 FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 5600 MG-UNIT (alendronate-cholecalciferol)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 252 Coverage Requirements & Prescription Drug Name Drug Tier Limits ibandronate sodium intravenous solution 3 mg/3ml 1 ibandronate sodium oral tablet 150 mg 1 MIACALCIN INJECTION SOLUTION 200 UNIT/ML (calcitonin 3 DSL = 30 days (salmon)) pamidronate disodium intravenous solution 30 mg/10ml, 6 1 mg/ml, 90 mg/10ml pamidronate disodium intravenous solution reconstituted 30 mg, 1 90 mg PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 60 MG/ML (denosumab) raloxifene hcl oral tablet 60 mg 1 risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg 1 risedronate sodium oral tablet delayed release 35 mg 1 XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML 2 DSL = 30 days (denosumab) zoledronic acid intravenous concentrate 4 mg/5ml 1 zoledronic acid intravenous solution 4 mg/100ml, 5 mg/100ml 1 CARIOSTATIC AGENTS - Vitamins and Fluoride adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 sodium fluoride (Cavarest Dental Gel 1.1 %) PV sodium fluoride (Clinpro 5000 Dental Paste 1.1 %) PV sodium fluoride (Denta 5000 Plus Dental Cream 1.1 %) PV sodium fluoride (Dentagel Dental Gel 1.1 %) PV FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium 3 fluoride-vitamin d) FLORIVA ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG 3 (ped multiple vit-minerals-fl) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML (pediatric 3 multivitamins-fl) sodium fluoride (Fluoridex Dental Paste 1.1 %) PV sod fluoride-potassium nitrate (Fluoridex Sensitivity Relief 3 Dental Paste 1.1-5 %) fluoritab oral solution 0.275 (0.125 f) mg/drop PV multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25- 3 0.3 MG

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 253 Coverage Requirements & Prescription Drug Name Drug Tier Limits multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NAFRINSE DAILY/NEUTRAL MOUTH/THROAT SOLUTION PV RECONSTITUTED 0.05 % (sodium fluoride) POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (pediatric 3 multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 3 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 % PV (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % (sodium PV fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE 1.1-5 3 % (sod fluoride-potassium nitrate) PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE 1.1 % PV (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium PV fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % (sod 3 fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) PV PREVIDENT MOUTH/THROAT SOLUTION 0.2 % (sodium PV fluoride) QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa) QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 MG/ML (ped 3 multivitamins-fl-iron) QUFLORA GUMMIES ORAL TABLET CHEWABLE 0.125 MG 3 (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 3 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 3 0.5 MG, 1 MG (pediatric multivitamins-fl) sf 5000 plus dental cream 1.1 % PV sf dental gel 1.1 % PV sodium fluoride 5000 enamel dental paste 1.1-5 % 1 sodium fluoride 5000 plus dental cream 1.1 % PV sodium fluoride 5000 ppm dental cream 1.1 % PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 254 Coverage Requirements & Prescription Drug Name Drug Tier Limits sodium fluoride 5000 ppm dental paste 1.1 % PV sodium fluoride 5000 sensitive dental paste 1.1-5 % 1 sodium fluoride dental cream 1.1 % PV sodium fluoride dental gel 1.1 % PV sodium fluoride oral solution 1.1 (0.5 f) mg/ml PV sodium fluoride oral tablet 1.1 (0.5 f) mg, 2.2 (1 f) mg PV sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) PV mg, 2.2 (1 f) mg TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 COMPLEMENT INHIBITORS BERINERT INTRAVENOUS KIT 500 UNIT (c1 esterase 3 DSL = 30 days inhibitor (human)) CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 2 DSL = 30 days UNIT (c1 esterase inhibitor (human)) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML (icatibant 2 DSL = 30 days acetate) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 2000 UNIT, 3000 UNIT (c1 esterase inhibitor (human)) icatibant acetate subcutaneous solution 30 mg/3ml 1 DSL = 30 days ORLADEYO ORAL CAPSULE 110 MG, 150 MG (berotralstat 3 DSL = 30 days hcl) RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 2100 UNIT (c1 esterase inhibitor (recomb)) SOLIRIS INTRAVENOUS SOLUTION 300 MG/30ML 2 (eculizumab) TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2ML 2 DSL = 30 days (lanadelumab-flyo) ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG/11ML, 300 3 MG/3ML (ravulizumab-cwvz) ULTOMIRIS INTRAVENOUS SOLUTION 300 MG/30ML 3 DSL = 30 days (ravulizumab-cwvz) DISEASE-MODIFYING ANTIRHEUMATIC AGENTS - Drugs for Arthritis ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- 3 INJECTOR 162 MG/0.9ML (tocilizumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 255 Coverage Requirements & Prescription Drug Name Drug Tier Limits ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 3 MG/20ML, 80 MG/4ML (tocilizumab) ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 162 MG/0.9ML (tocilizumab) AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 3 DSL = 30 days MG (infliximab-axxq) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 azathioprine sodium injection solution reconstituted 100 mg 1 CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 3 DSL = 30 days MG/ML (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML 3 (certolizumab pegol) CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab 3 DSL = 30 days pegol) CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) 3 cyclosporine intravenous solution 50 mg/ml 1 cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 DEPEN TITRATABS ORAL TABLET 250 MG (penicillamine) 2 ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 3 DSL = 30 days MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML 3 DSL = 30 days (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED 2 DSL = 30 days SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 2 DSL = 30 days MG (etanercept) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- 2 DSL = 30 days INJECTOR 50 MG/ML (etanercept) cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) 1 cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) 1 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS 3 DSL = 30 days PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 3 DSL = 30 days MG/0.4ML, 80 MG/0.8ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 256 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 2 DSL = 30 days INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 3 DSL = 30 days INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS 3 DSL = 30 days PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS 2 DSL = 30 days PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 3 DSL = 30 days (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 3 DSL = 30 days MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab) hydroxychloroquine sulfate oral tablet 200 mg PV INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab-dyyb) KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) KINERET SUBCUTANEOUS SOLUTION PREFILLED 2 DSL = 30 days SYRINGE 100 MG/0.67ML (anakinra) leflunomide oral tablet 10 mg, 20 mg 1 LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) 3 DSL = 30 days methotrexate oral tablet 2.5 mg 1 OC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 OC NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine 2 modified) OLUMIANT ORAL TABLET 1 MG, 2 MG (baricitinib) 3 DSL = 30 days ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- 2 DSL = 30 days INJECTOR 125 MG/ML (abatacept) ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 2 DSL = 30 days MG (abatacept)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 257 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML 2 DSL = 30 days (abatacept) OTEZLA ORAL TABLET 30 MG (apremilast) 2 DSL = 30 days OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG 2 DSL = 30 days (apremilast) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 3 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate (anti-rheumatic)) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 20 MG/0.4ML (methotrexate (anti-rheumatic)) penicillamine oral capsule 250 mg 1 penicillamine oral tablet 250 mg 1 PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine PV sulfate) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 2 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.4ML, 12.5 MG/0.5ML, 15 MG/0.6ML, 17.5 3 MG/0.7ML, 20 MG/0.8ML, 22.5 MG/0.9ML, 25 MG/ML, 7.5 MG/0.3ML (methotrexate (anti-rheumatic)) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 3 100 MG (infliximab-abda) RIDAURA ORAL CAPSULE 3 MG (auranofin) 2 RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 3 DSL = 30 days MG (upadacitinib) SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML 2 (cyclosporine) SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 2 (cyclosporine) SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2 SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML 3 (golimumab) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 258 Coverage Requirements & Prescription Drug Name Drug Tier Limits STELARA INTRAVENOUS SOLUTION 130 MG/26ML 3 (ustekinumab) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML 2 (ustekinumab) STELARA SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 OC (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 DSL = 30 days; OC XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) 3 DSL = 30 days XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib citrate) 2 DSL = 30 days XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 DSL = 30 days 11 MG (tofacitinib citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 22 MG (tofacitinib citrate) GONADOTROPIN-RELEASING HORMONE ANTAGNTS - Hormones CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix 2 acetate) ganirelix acetate subcutaneous solution prefilled syringe 250 2 mcg/0.5ml IMMUNOMODULATORY AGENTS - DRUGS FOR THE IMMUNE SYSTEM ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- 3 INJECTOR 162 MG/0.9ML (tocilizumab) ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML, 400 3 MG/20ML, 80 MG/4ML (tocilizumab) ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 162 MG/0.9ML (tocilizumab) ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 2 DSL = 30 days UNIT/0.5ML (interferon gamma-1b) AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) 3 DSL = 30 days AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 2 DSL = 30 days MCG/0.5ML (interferon beta-1a) AVONEX PREFILLED INTRAMUSCULAR PREFILLED 2 DSL = 30 days SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 3 DSL = 30 days MG (infliximab-axxq) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 259 Coverage Requirements & Prescription Drug Name Drug Tier Limits azathioprine oral tablet 50 mg 1 azathioprine sodium injection solution reconstituted 100 mg 1 BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 MG 3 DSL = 30 days (monomethyl fumarate) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon beta- 3 DSL = 30 days 1b) CIMZIA PREFILLED KIT SUBCUTANEOUS KIT 2 X 200 3 DSL = 30 days MG/ML (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS KIT 6 X 200 MG/ML 3 (certolizumab pegol) CIMZIA SUBCUTANEOUS KIT 2 X 200 MG (certolizumab 3 DSL = 30 days pegol) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 20 MG/ML, 40 MG/ML (glatiramer acetate) cyclosporine intravenous solution 50 mg/ml 1 cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 dimethyl fumarate oral capsule delayed release 120 mg, 240 1 DSL = 30 days mg dimethyl fumarate starter pack oral 120 & 240 mg 1 DSL = 30 days ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 3 DSL = 30 days MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML 3 DSL = 30 days (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED 2 DSL = 30 days SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 2 DSL = 30 days MG (etanercept) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- 2 DSL = 30 days INJECTOR 50 MG/ML (etanercept) ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 120 MG/ML (satralizumab-mwge) ENTYVIO INTRAVENOUS SOLUTION RECONSTITUTED 300 3 MG (vedolizumab) EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta-1b) 3 DSL = 30 days cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) 1 cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) 1 GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG (fingolimod hcl) 3 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 260 Coverage Requirements & Prescription Drug Name Drug Tier Limits glatiramer acetate subcutaneous solution prefilled syringe 20 1 DSL = 30 days mg/ml, 40 mg/ml glatiramer acetate (Glatopa Subcutaneous Solution Prefilled 1 DSL = 30 days Syringe 20 Mg/Ml, 40 Mg/Ml) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 3 DSL = 30 days 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 3 DSL = 30 days MG/0.4ML, 80 MG/0.8ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 2 DSL = 30 days INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 3 DSL = 30 days INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS 3 DSL = 30 days PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS 2 DSL = 30 days PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 3 DSL = 30 days (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 3 DSL = 30 days MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab) hydroxychloroquine sulfate oral tablet 200 mg PV INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab-dyyb) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 2 DSL = 30 days 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon 2 DSL = 30 days alfa-2b) KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 20 MG/0.4ML (ofatumumab) KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) KINERET SUBCUTANEOUS SOLUTION PREFILLED 2 DSL = 30 days SYRINGE 100 MG/0.67ML (anakinra)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 261 Coverage Requirements & Prescription Drug Name Drug Tier Limits leflunomide oral tablet 10 mg, 20 mg 1 LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2ML 3 DSL = 30 days (alemtuzumab) MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod 3 fumarate) methotrexate oral tablet 2.5 mg 1 OC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 OC NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine 2 modified) OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML 3 DSL = 30 days (ocrelizumab) OLUMIANT ORAL TABLET 1 MG, 2 MG (baricitinib) 3 DSL = 30 days ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO- 2 DSL = 30 days INJECTOR 125 MG/ML (abatacept) ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 2 DSL = 30 days MG (abatacept) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML 2 DSL = 30 days (abatacept) OTEZLA ORAL TABLET 30 MG (apremilast) 2 DSL = 30 days OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG 2 DSL = 30 days (apremilast) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 3 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate (anti-rheumatic)) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 20 MG/0.4ML (methotrexate (anti-rheumatic)) PLAQUENIL ORAL TABLET 200 MG (hydroxychloroquine PV sulfate) PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION 3 DSL = 30 days PEN-INJECTOR 63 & 94 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML (peginterferon 3 DSL = 30 days beta-1a)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 262 Coverage Requirements & Prescription Drug Name Drug Tier Limits PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 DSL = 30 days 125 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 2 DSL = 30 days; OC (pomalidomide) PONVORY ORAL TABLET 20 MG (ponesimod) 3 PONVORY STARTER PACK ORAL TABLET THERAPY PACK 3 2-3-4-5-6-7-8-9 & 10 MG (ponesimod) PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 22000000 UNIT (aldesleukin) RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 2 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO- 3 INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG (interferon 3 beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta-1a) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION 3 PREFILLED SYRINGE 6X8.8 & 6X22 MCG (interferon beta-1a) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.4ML, 12.5 MG/0.5ML, 15 MG/0.6ML, 17.5 3 MG/0.7ML, 20 MG/0.8ML, 22.5 MG/0.9ML, 25 MG/ML, 7.5 MG/0.3ML (methotrexate (anti-rheumatic)) REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 3 100 MG (infliximab-abda) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 2 DSL = 30 days; OC 25 MG, 5 MG (lenalidomide) RIDAURA ORAL CAPSULE 3 MG (auranofin) 2 RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 3 DSL = 30 days MG (upadacitinib) SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML 2 (cyclosporine) SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 2 (cyclosporine) SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 263 Coverage Requirements & Prescription Drug Name Drug Tier Limits SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML 3 (golimumab) SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab) STELARA INTRAVENOUS SOLUTION 130 MG/26ML 3 (ustekinumab) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML 2 (ustekinumab) STELARA SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) 3 DSL = 30 days TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 3 DSL = 30 days 240 MG (dimethyl fumarate) THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 2 DSL = 30 days; OC MG () TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 OC (methotrexate sodium) TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML 2 DSL = 30 days (natalizumab) UPLIZNA INTRAVENOUS SOLUTION 100 MG/10ML 3 DSL = 30 days (inebilizumab-cdon) VUMERITY ORAL CAPSULE DELAYED RELEASE 231 MG 3 DSL = 30 days (diroximel fumarate) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 DSL = 30 days; OC XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) 3 DSL = 30 days XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib citrate) 2 DSL = 30 days XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 DSL = 30 days 11 MG (tofacitinib citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 22 MG (tofacitinib citrate) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE 3 DSL = 30 days THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod hcl) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) 3 DSL = 30 days ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK 3 DSL = 30 days 0.23MG & 0.46MG & 0.92MG (ozanimod hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 264 Coverage Requirements & Prescription Drug Name Drug Tier Limits IMMUNOSUPPRESSIVE AGENTS - Drugs for Transplant ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 0.5 MG, 1 MG, 5 MG () ATGAM INTRAVENOUS INJECTABLE 50 MG/ML 2 (lymphocyte,anti-thymo imm glob) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 azathioprine sodium injection solution reconstituted 100 mg 1 BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 120 MG, 400 MG (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 DSL = 30 days 200 MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 200 MG/ML (belimumab) cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 1 500 mg CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION 1 3 GM/5ML, 500 MG/2.5ML cyclophosphamide oral capsule 25 mg, 50 mg 1 OC CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 3 OC cyclosporine intravenous solution 50 mg/ml 1 cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 1 cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 ELIDEL EXTERNAL CREAM 1 % () 3 ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 3 HOUR 0.75 MG, 1 MG, 4 MG (tacrolimus) everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML, 100 3 DSL = 30 days MG/20ML, 50 MG/10ML (emapalumab-lzsg) cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) 1 cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) 1 LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) 3 DSL = 30 days MAVENCLAD ORAL TABLET THERAPY PACK 10 MG 3 (cladribine) mercaptopurine oral tablet 50 mg 1 OC methotrexate oral tablet 2.5 mg 1 OC methotrexate sodium (pf) injection solution 1 gm/40ml, 250 1 mg/10ml, 50 mg/2ml

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 265 Coverage Requirements & Prescription Drug Name Drug Tier Limits methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml 1 methotrexate sodium injection solution reconstituted 1 gm 1 methotrexate sodium oral tablet 2.5 mg 1 OC mycophenolate mofetil hcl intravenous solution reconstituted 1 500 mg mycophenolate mofetil intravenous solution reconstituted 500 1 mg mycophenolate mofetil oral capsule 250 mg 1 mycophenolate mofetil oral suspension reconstituted 200 mg/ml 1 mycophenolate mofetil oral tablet 500 mg 1 mycophenolate sodium oral tablet delayed release 180 mg, 360 1 mg NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine 2 modified) NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 3 MG (belatacept) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 3 22.5 MG/0.4ML, 25 MG/0.4ML (methotrexate (anti-rheumatic)) OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 2 20 MG/0.4ML (methotrexate (anti-rheumatic)) pimecrolimus external cream 1 % 1 PROGRAF INTRAVENOUS SOLUTION 5 MG/ML (tacrolimus) 2 PROGRAF ORAL PACKET 0.2 MG, 1 MG (tacrolimus) 3 PURIXAN ORAL SUSPENSION 2000 MG/100ML 2 DSL = 30 days; OC (mercaptopurine) RAPAMUNE ORAL SOLUTION 1 MG/ML (sirolimus) 2 RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 2 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/0.4ML, 12.5 MG/0.5ML, 15 MG/0.6ML, 17.5 3 MG/0.7ML, 20 MG/0.8ML, 22.5 MG/0.9ML, 25 MG/ML, 7.5 MG/0.3ML (methotrexate (anti-rheumatic)) SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML 2 (cyclosporine) SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG 2 (cyclosporine) SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 266 Coverage Requirements & Prescription Drug Name Drug Tier Limits SIMULECT INTRAVENOUS SOLUTION RECONSTITUTED 10 3 MG, 20 MG (basiliximab) sirolimus oral solution 1 mg/ml 1 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 THYMOGLOBULIN INTRAVENOUS SOLUTION 3 RECONSTITUTED 25 MG (anti-thymocyte glob (rabbit)) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 OC (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) 3 DSL = 30 days; OC ZORTRESS ORAL TABLET 1 MG (everolimus) 3 OTHER MISCELLANEOUS THERAPEUTIC AGENTS ACACIA SUBCUTANEOUS SOLUTION 1:20 3 acetylcysteine inhalation solution 10 %, 20 % 1 ACREMONIUM SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 ALDER SUBCUTANEOUS SOLUTION 1:20 3 ALTERNARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 AMERICAN BEECH SUBCUTANEOUS SOLUTION 1:20 3 AMERICAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 3 AMERICAN ELM SUBCUTANEOUS SOLUTION 1:20 3 amino acids (Aminoreliefrms Oral Capsule) 2 AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 3 DSL = 30 days MG (dalfampridine) ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 3 220 MG (rilonacept) ARIZONA CYPRESS SUBCUTANEOUS SOLUTION 1:20 3 AUREOBASIDIUM SUBCUTANEOUS SOLUTION 10000 3 PNU/ML, 20000 PNU/ML AUSTRALIAN PINE SUBCUTANEOUS SOLUTION 1:20 3 AVAILNEX ORAL TABLET CHEWABLE 750 MG 3 (carbocysteine) AZALGIA ORAL CAPSULE 3 BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 MG 3 DSL = 30 days (monomethyl fumarate) BAHIA SUBCUTANEOUS SOLUTION 1:20 3 BALD CYPRESS SUBCUTANEOUS SOLUTION 1:20 3 BAYBERRY (WAX MYRTLE) SUBCUTANEOUS SOLUTION 3 1:20

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 267 Coverage Requirements & Prescription Drug Name Drug Tier Limits BERMUDA GRASS SUBCUTANEOUS SOLUTION 10000 3 BAU/ML BLACK WILLOW SUBCUTANEOUS SOLUTION 1:20 3 BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 2 200 UNIT (onabotulinumtoxina) BOTRYTIS SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 BROME SUBCUTANEOUS SOLUTION 1:20 3 CALIFORNIA PEPPER TREE SUBCUTANEOUS SOLUTION 3 1:20 CANDIDA ALBICANS EXTRACT SUBCUTANEOUS 3 SOLUTION 10000 PNU/ML CARDIOVID PLUS ORAL CAPSULE (dha-epa-vit b6-b12-folic 3 acid) CARNITOR INTRAVENOUS SOLUTION 200 MG/ML 2 (levocarnitine) CARTICEL INTRA-ARTICULAR IMPLANT (autologous culture 3 chondrocyte) CAT HAIR EXTRACT SUBCUTANEOUS SOLUTION 10000 3 BAU/ML CATTLE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 3 CEDAR ELM SUBCUTANEOUS SOLUTION 1:20 3 CERDELGA ORAL CAPSULE 84 MG ( tartrate) 2 DSL = 30 days cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 1 CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS 3 SOLUTION 10000 PNU/ML, 20000 PNU/ML CLADOSPORIUM SPHAEROSPERMUM SUBCUTANEOUS 3 SOLUTION 20000 PNU/ML COCKLEBUR SUBCUTANEOUS SOLUTION 1:20 3 CORN POLLEN SUBCUTANEOUS SOLUTION 1:20 3 CURVULARIA SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 CYSTADANE ORAL POWDER (betaine) 2 DSL = 30 days CYSTAGON ORAL CAPSULE 150 MG, 50 MG (cysteamine 2 DSL = 30 days bitartrate) dalfampridine er oral tablet extended release 12 hour 10 mg 1 DSL = 30 days DEMSER ORAL CAPSULE 250 MG (metyrosine) 3 DOG EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 1:20 3 DOG FENNEL SUBCUTANEOUS SOLUTION 1:20 3 DRECHSLERA SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 268 Coverage Requirements & Prescription Drug Name Drug Tier Limits DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS 3 SOLUTION 10000 AU/ML DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 3 300 UNIT, 500 UNIT (abobotulinumtoxina) EASTERN COTTONWOOD SUBCUTANEOUS SOLUTION 3 1:20 ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) 3 DSL = 30 days ENTERAGAM ORAL PACKET 5 GM (sbi/protein isolate) 3 EPICOCCUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 2 EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 MG/ML 3 DSL = 30 days (risdiplam) EXONDYS 51 INTRAVENOUS SOLUTION 100 MG/2ML, 500 3 DSL = 30 days MG/10ML (eteplirsen) FIRDAPSE ORAL TABLET 10 MG (amifampridine phosphate) 3 FIRE ANT SUBCUTANEOUS SOLUTION 1:10 , 1:20 3 FOSTEUM ORAL CAPSULE 27-20-200 MG-MG-UNIT 3 (genistein-zn chelate-vit d) FOSTEUM PLUS ORAL CAPSULE (dietary management 3 product) FUSARIUM SUBCUTANEOUS SOLUTION 10000 PNU/ML, 3 20000 PNU/ML GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) 3 DSL = 30 days GERMAN COCKROACH SUBCUTANEOUS SOLUTION 1:20 3 GIVLAARI SUBCUTANEOUS SOLUTION 189 MG/ML 3 DSL = 30 days ( sodium) GOLDENROD SUBCUTANEOUS SOLUTION 1:20 3 GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU 2 (timothy grass pollen allergen) HACKBERRY SUBCUTANEOUS SOLUTION 1:20 3 HORSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 3 1:20 ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML 3 DSL = 30 days (canakinumab) ISTURISA ORAL TABLET 1 MG, 10 MG, 5 MG (osilodrostat 3 DSL = 30 days phosphate) JOHNSON GRASS SUBCUTANEOUS SOLUTION 1:20 3 JUNE GRASS POLLEN STANDARDIZED SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 269 Coverage Requirements & Prescription Drug Name Drug Tier Limits KAPOK SUBCUTANEOUS SOLUTION 1:20 3 KOCHIA SUBCUTANEOUS SOLUTION 1:20 3 KUVAN ORAL PACKET 100 MG (sapropterin dihydrochloride) 3 DSL = 30 days KUVAN ORAL TABLET 100 MG (sapropterin dihydrochloride) 3 DSL = 30 days levocarnitine oral solution 1 gm/10ml 2 levocarnitine oral tablet 330 mg 2 levocarnitine sf oral solution 1 gm/10ml 2 LIMBREL ORAL CAPSULE 250 MG, 500 MG (flavocoxid) 3 LIMBREL250 ORAL CAPSULE 250-50 MG (flavocoxid-cit zn 3 bisglcinate) LIMBREL500 ORAL CAPSULE 500-50 MG (flavocoxid-cit zn 3 bisglcinate) MEADOW FESCUE GRASS POLLEN SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML MELALEUCA SUBCUTANEOUS SOLUTION 1:20 3 MESQUITE SUBCUTANEOUS SOLUTION 1:20 3 metyrosine oral capsule 250 mg 1 oral capsule 100 mg 1 DSL = 30 days MITE (D. FARINAE) SUBCUTANEOUS SOLUTION 10000 3 AU/ML MITE (D. PTERONYSSINUS) SUBCUTANEOUS SOLUTION 3 10000 AU/ML MIXED ASPERGILLUS SUBCUTANEOUS SOLUTION 20000 3 PNU/ML MIXED FEATHERS SUBCUTANEOUS SOLUTION 1:20 3 MIXED RAGWEED SUBCUTANEOUS SOLUTION 1:20 3 MOUNTAIN CEDAR SUBCUTANEOUS SOLUTION 1:20 3 MOUSE EPITHELIUM SUBCUTANEOUS SOLUTION 1:20 3 MUCOR SUBCUTANEOUS SOLUTION 10000 PNU/ML, 20000 3 PNU/ML MUGWORT SUBCUTANEOUS SOLUTION 1:20 3 MYOBLOC INTRAMUSCULAR SOLUTION 10000 UNIT/2ML, 2 2500 UNIT/0.5ML, 5000 UNIT/ML (rimabotulinumtoxinb) n-acetyl-l-cysteine oral capsule 600 mg 1 NICADAN ORAL TABLET (multiple vitamins-minerals) 3 NICAPRIN ORAL TABLET (dietary management product) 3 NICAZEL FORTE ORAL TABLET (multiple vitamins-minerals) 3 NICAZEL ORAL TABLET (multiple vitamins-minerals) 3 NICAZYME ORAL TABLET 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 270 Coverage Requirements & Prescription Drug Name Drug Tier Limits oral capsule 10 mg, 2 mg, 5 mg 1 DSL = 30 days NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) 3 DSL = 30 days NULIBRY INTRAVENOUS SOLUTION RECONSTITUTED 9.5 3 MG (fosdenopterin hydrobromide) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 1 200 mcg/ml, 50 mcg/ml, 500 mcg/ml OLIVE TREE SUBCUTANEOUS SOLUTION 1:20 3 ONPATTRO INTRAVENOUS SOLUTION 10 MG/5ML (patisiran 3 DSL = 30 days sodium) ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET 3 SUBLINGUAL 300 IR (grass mix pollens allergen ext) ORALAIR CHILDRENS STARTER PACK SUBLINGUAL 3 TABLET SUBLINGUAL 100 IR (grass mix pollens allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR (grass 3 mix pollens allergen ext) ORCHARD GRASS POLLEN SUBCUTANEOUS SOLUTION 3 100000 BAU/ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG 3 DSL = 30 days (nitisinone) ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) 3 DSL = 30 days OVEEZA ORAL CAPSULE 0.5 MG (fa-b12-ala-co q10-omega 3 3) OXLUMO SUBCUTANEOUS SOLUTION 94.5 MG/0.5ML 3 ( sodium) PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 3 350 MG (hemin) PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5 3 MG/0.5ML, 5 MG/ML (etelcalcetide hcl) PENICILLIUM NOTATUM SUBCUTANEOUS SOLUTION 3 10000 PNU/ML, 20000 PNU/ML PHOMA EXIGUA SUBCUTANEOUS SOLUTION 20000 3 PNU/ML POTABA ORAL CAPSULE 500 MG (potassium 2 aminobenzoate) PREZCOBIX ORAL TABLET 800-150 MG (darunavir-cobicistat) 2 PRIVET SUBCUTANEOUS SOLUTION 1:20 3 PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 3 DSL = 30 days MG (cysteamine bitartrate) PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine 3 DSL = 30 days bitartrate) QUEEN PALM SUBCUTANEOUS SOLUTION 1:20 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 271 Coverage Requirements & Prescription Drug Name Drug Tier Limits RABBIT EPITHELIUM SUBCUTANEOUS SOLUTION 1:10 , 3 1:20 RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 3 1-U (short ragweed pollen ext) RED MAPLE SUBCUTANEOUS SOLUTION 1:20 3 RED MULBERRY SUBCUTANEOUS SOLUTION 1:20 3 RED TOP GRASS POLLEN SUBCUTANEOUS SOLUTION 3 100000 BAU/ML REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab) RHEUMATE ORAL CAPSULE (dietary management product) 3 RHIZOPUS SUBCUTANEOUS SOLUTION 20000 PNU/ML 3 ROUGH MARSH ELDER SUBCUTANEOUS SOLUTION 1:20 3 RUSSIAN THISTLE SUBCUTANEOUS SOLUTION 1:20 3 RUZURGI ORAL TABLET 10 MG (amifampridine) 3 SACCHAROMYCES CEREVISIAE SUBCUTANEOUS 3 SOLUTION 20000 PNU/ML SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 2 DSL = 30 days 20 MG, 30 MG (octreotide acetate) sapropterin dihydrochloride oral packet 100 mg 1 DSL = 30 days sapropterin dihydrochloride oral packet 500 mg 1 sapropterin dihydrochloride oral tablet 100 mg 1 DSL = 30 days SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG (cinacalcet 3 hcl) SHAGBARK HICKORY SUBCUTANEOUS SOLUTION 1:20 3 SHEEP SORREL SUBCUTANEOUS SOLUTION 1:20 3 SHORT RAGWEED POLLEN EXT SUBCUTANEOUS 3 SOLUTION 1:20 SORREL/DOCK MIX SUBCUTANEOUS SOLUTION 1:20 3 SPINRAZA INTRATHECAL SOLUTION 12 MG/5ML 3 DSL = 30 days (nusinersen) SPINY PIGWEED SUBCUTANEOUS SOLUTION 1:20 3 SWEET GUM SUBCUTANEOUS SOLUTION 1:20 3 SWEET VERNAL GRASS POLLEN SUBCUTANEOUS 3 SOLUTION 100000 BAU/ML SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 emtricit-tenofaf) TALIVA ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- 3 phytosterols) TALL RAGWEED SUBCUTANEOUS SOLUTION 1:20 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 272 Coverage Requirements & Prescription Drug Name Drug Tier Limits THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 3 MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) 2 TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS 3 SOLUTION 10000 BAU/ML, 100000 BAU/ML TRICHOPHYTON SUBCUTANEOUS SOLUTION 20000 3 PNU/ML TYBOST ORAL TABLET 150 MG (cobicistat) 3 ULTRA HIS ORAL CAPSULE 3 VASCULERA ORAL TABLET (dietary management product) 3 WESTERN JUNIPER SUBCUTANEOUS SOLUTION 1:20 3 WHITE BIRCH SUBCUTANEOUS SOLUTION 1:20 3 WHITE MULBERRY SUBCUTANEOUS SOLUTION 1:20 3 WHITE OAK SUBCUTANEOUS SOLUTION 1:20 3 WHITE PINE SUBCUTANEOUS SOLUTION 1:20 3 XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 3 100 UNIT, 200 UNIT, 50 UNIT (incobotulinumtoxina) XURIDEN ORAL PACKET 2 GM (uridine triacetate) 3 DSL = 30 days XYZMUNE ORAL CAPSULE 3 YELLOW DOCK SUBCUTANEOUS SOLUTION 1:20 3 ZOKINVY ORAL CAPSULE 50 MG, 75 MG (lonafarnib) 3 DSL = 30 days PROTECTIVE AGENTS COSELA INTRAVENOUS SOLUTION RECONSTITUTED 300 PV DSL = 30 days MG (trilaciclib dihydrochloride) dexrazoxane hcl intravenous solution reconstituted 250 mg, 500 PV mg ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate 2 sodium) ETHYOL INTRAVENOUS SOLUTION RECONSTITUTED 500 PV MG (amifostine) mesna intravenous solution 100 mg/ml PV MESNEX INTRAVENOUS SOLUTION 100 MG/ML (mesna) PV MESNEX ORAL TABLET 400 MG (mesna) PV DSL = 30 days; OC TOTECT INTRAVENOUS SOLUTION RECONSTITUTED 500 PV MG (dexrazoxane hcl) NONHORMONAL CONTRACEPTIVES - Drugs for Women NONHORMONAL CONTRACEPTIVES - Drugs for Women CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) PV

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 273 Coverage Requirements & Prescription Drug Name Drug Tier Limits PARAGARD INTRAUTERINE COPPER INTRAUTERINE PV INTRAUTERINE DEVICE (copper) PHEXXI VAGINAL GEL 1.8-1-0.4 % (lactic ac-citric ac-pot 3 bitart) VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 % PV (nonoxynol-9) vcf vaginal contraceptive vaginal gel 4 % PV WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 % PV (diaphragm wide seal) OXYTOCICS - Drugs for Women OXYTOCICS - Drugs for Women CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) 2 methylergonovine maleate (Methergine Oral Tablet 0.2 Mg) 1 methylergonovine maleate oral tablet 0.2 mg 1 MIFEPREX ORAL TABLET 200 MG (mifepristone) PV mifepristone oral tablet 200 mg PV OXYTOCIN-LACTATED RINGERS INTRAVENOUS 3 SOLUTION 30 UNIT/500ML OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 3 20-0.9 UNIT/L-%, 20-0.9 UNT/L-% PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) 2 PROSTIN E2 VAGINAL SUPPOSITORY 20 MG (dinoprostone) 2 PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS ASPARTAME (NUTRASWEET) POWDER (aspartame) 3 ASPARTAME POWDER 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 274 Coverage Requirements & Prescription Drug Name Drug Tier Limits benzoin compound external tincture 1 BENZOIN EXTERNAL TINCTURE 2 COPASIL EXTERNAL GEL (scar treatment products) 3 formaldehyde external solution 10 % 1 FORMALDEHYDE EXTERNAL SOLUTION 37 % 3 GELFILM EXTERNAL FILM (gelatin absorbable) 3 L-ISOLEUCINE POWDER 2 monsels ferric subsulfate external solution 1 RECURA EXTERNAL CREAM (misc combo 3 products) STRATA CTX EXTERNAL GEL (dermatological products, 3 misc.) STRATA XRT EXTERNAL GEL (dermatological products, 3 misc.) TURPENTINE EXTERNAL SPIRIT 3 RADIOACTIVE AGENTS RADIOACTIVE AGENTS LUTATHERA INTRAVENOUS SOLUTION 370 MBQ/ML 3 (lutetium lu 177 dotatate) XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML (radium ra 3 223 dichloride) RESPIRATORY TRACT AGENTS - Drugs for the Lungs ALPHA AND BETA ADRENERGIC AGONIST(RESPR) - Drugs for Asthma/COPD ADRENALIN INJECTION SOLUTION 1 MG/ML (epinephrine) 3 ADYPHREN AMP II INJECTION KIT 1 MG/ML (epinephrine) 3 ADYPHREN AMP INJECTION KIT 1 MG/ML (epinephrine) 3 ADYPHREN II INJECTION KIT 1 MG/ML (epinephrine) 3 ADYPHREN INJECTION KIT 1 MG/ML (epinephrine) 3 AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 3 DSL = 30 days MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) ephedrine sulfate intravenous solution 50 mg/ml 1 EPHEDRINE SULFATE-NACL INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 50-0.9 MG/10ML-%, 50-0.9 MG/5ML-% epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.3 1 DSL = 30 days mg/0.3ml epinephrine injection solution auto-injector 0.15 mg/0.3ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 275 Coverage Requirements & Prescription Drug Name Drug Tier Limits EPINEPHRINE PROFESSIONAL INJECTION KIT 1 MG/ML 3 EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML 3 (epinephrine) EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML 3 (epinephrine) EPISNAP INJECTION KIT 1 MG/ML (epinephrine) 3 pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 3 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ANTICHOLINERGIC AGENTS (RESPIR.TRACT) - Drugs for Asthma/COPD ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 vilanterol) ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR 3 0.5 MG/0.7ML, 1 MG/0.7ML, 2 MG/0.7ML (atropine sulfate) atropine sulfate injection solution 0.4 mg/ml, 1 mg/ml, 8 1 mg/20ml atropine sulfate injection solution prefilled syringe 0.25 mg/5ml, 1 0.5 mg/5ml, 1 mg/10ml ATROPINE SULFATE INTRAVENOUS SOLUTION 3 PREFILLED SYRINGE 0.8 MG/2ML ATROVENT HFA INHALATION AEROSOL SOLUTION 17 PV MCG/ACT (ipratropium bromide hfa) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 3 MCG/ACT (glycopyrrolate-formoterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 MCG/ACT (budeson-glycopyrrol-formoterol) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION PV 20-100 MCG/ACT (ipratropium-albuterol) diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 DSL = 30 days formoterol fum) INCRUSE ELLIPTA INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 62.5 MCG/INH (umeclidinium bromide) ipratropium bromide inhalation solution 0.02 % PV ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 3 (tiotropium bromide monohydrate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 276 Coverage Requirements & Prescription Drug Name Drug Tier Limits SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 3 MCG/ACT (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 2 MCG/ACT (tiotropium bromide monohydrate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5-2.5 MCG/ACT (tiotropium bromide-olodaterol) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 3 MCG/INH (fluticasone-umeclidin-vilant) TUDORZA PRESSAIR INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 400 MCG/ACT (aclidinium bromide) UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 3 MCG (indacaterol-glycopyrrolate) ANTIFIBROTIC AGENTS - Drugs for the Lungs ESBRIET ORAL CAPSULE 267 MG (pirfenidone) 3 DSL = 30 days ESBRIET ORAL TABLET 267 MG (pirfenidone) 3 ESBRIET ORAL TABLET 801 MG (pirfenidone) 3 DSL = 30 days OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib esylate) 3 DSL = 30 days ANTI-INFLAMMATORY AGENTS (RESPIRATORY) - Drugs for Inflammation NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 100 MG (mepolizumab) ANTITUSSIVES - Drugs for Cough and Cold benzonatate oral capsule 100 mg, 150 mg, 200 mg 1 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 DSL = 30 days guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 hydrocodone polst-chlorphen polst er susp oral suspension 1 extended release 10-8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 hydrocodone-homatropine oral tablet 5-1.5 mg 1 hydromet oral syrup 5-1.5 mg/5ml 1 maxi-tuss ac oral solution 100-10 mg/5ml 1 NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML 3 (phenylephrine-chlorphen-dm) NUEDEXTA ORAL CAPSULE 20-10 MG (dextromethorphan- 3 DSL = 30 days quinidine) promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-codeine oral solution 6.25-10 mg/5ml 1 promethazine-codeine oral syrup 6.25-10 mg/5ml 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 277 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 3 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 (CFTR) CORRECTORS - Drugs for the Lungs ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG 2 DSL = 30 days (lumacaftor-ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG 2 DSL = 30 days (lumacaftor-ivacaftor) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 2 DSL = 30 days MG (tezacaftor-ivacaftor) SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG 3 DSL = 30 days (tezacaftor-ivacaftor) CYSTIC FIBROSIS (CFTR) POTENTIATORS - Drugs for the Lungs KALYDECO ORAL PACKET 25 MG (ivacaftor) 3 DSL = 30 days KALYDECO ORAL PACKET 50 MG, 75 MG (ivacaftor) 2 DSL = 30 days KALYDECO ORAL TABLET 150 MG (ivacaftor) 2 DSL = 30 days ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG 2 DSL = 30 days (lumacaftor-ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG 2 DSL = 30 days (lumacaftor-ivacaftor) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 2 DSL = 30 days MG (tezacaftor-ivacaftor) SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG 3 DSL = 30 days (tezacaftor-ivacaftor) EXPECTORANTS - Drugs for the Lungs GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 IODINE STRONG ORAL SOLUTION 5 % 3 maxi-tuss ac oral solution 100-10 mg/5ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 278 Coverage Requirements & Prescription Drug Name Drug Tier Limits SSKI ORAL SOLUTION 1 GM/ML (potassium iodide 3 (expectorant)) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 FIRST GENERATION ANTIHIST.(RESPIR TRACT) - Drugs for Allergy BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG 3 (doxylamine-pyridoxine) carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg, 6 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cvs motion sickness oral tablet 50 mg PV cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 dexchlorpheniramine maleate oral solution 2 mg/5ml 1 DICOPANOL FUSEPAQ ORAL SUSPENSION 3 RECONSTITUTED 5 MG/ML (diphenhydramine hcl) diphen oral elixir 12.5 mg/5ml 1 DI-PHEN ORAL LIQUID 12.5 MG/5ML 3 diphenhydramine hcl injection solution 50 mg/ml 1 diphenhydramine hcl oral elixir 12.5 mg/5ml 1 doxylamine-pyridoxine oral tablet delayed release 10-10 mg 1 DSL = 30 days hydrocodone polst-chlorphen polst er susp oral suspension 1 extended release 10-8 mg/5ml KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) motion sickness relief oral tablet 50 mg PV NEOTUSS PLUS ORAL LIQUID 7.5-4-30 MG/5ML 3 (phenylephrine-chlorphen-dm) PHENERGAN INJECTION SOLUTION 25 MG/ML, 50 MG/ML PV (promethazine hcl) promethazine hcl injection solution 25 mg/ml, 50 mg/ml PV promethazine hcl oral solution 6.25 mg/5ml PV promethazine hcl oral syrup 6.25 mg/5ml PV promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg PV promethazine vc oral syrup 6.25-5 mg/5ml 1 promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-codeine oral solution 6.25-10 mg/5ml 1 promethazine-codeine oral syrup 6.25-10 mg/5ml 1 promethazine-dm oral syrup 6.25-15 mg/5ml 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 279 Coverage Requirements & Prescription Drug Name Drug Tier Limits promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml 1 promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 1 ryvent oral tablet 6 mg 1 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR 3 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE 3 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) INTERLEUKIN ANTAGONISTS - Drugs for Inflammation CINQAIR INTRAVENOUS SOLUTION 100 MG/10ML 3 DSL = 30 days (reslizumab) DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 DSL = 30 days 300 MG/2ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 200 MG/1.14ML, 300 MG/2ML (dupilumab) FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- 3 DSL = 30 days INJECTOR 30 MG/ML (benralizumab) FASENRA SUBCUTANEOUS SOLUTION PREFILLED 3 SYRINGE 30 MG/ML (benralizumab) NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 3 DSL = 30 days MG/ML (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION PREFILLED 3 SYRINGE 100 MG/ML (mepolizumab) NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 3 DSL = 30 days 100 MG (mepolizumab) LEUKOTRIENE MODIFIERS - Drugs for Inflammation ACCOLATE ORAL TABLET 10 MG, 20 MG (zafirlukast) PV montelukast sodium oral packet 4 mg PV montelukast sodium oral tablet 10 mg PV montelukast sodium oral tablet chewable 4 mg, 5 mg PV SINGULAIR ORAL PACKET 4 MG (montelukast sodium) PV SINGULAIR ORAL TABLET 10 MG (montelukast sodium) PV SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG PV (montelukast sodium) zafirlukast oral tablet 10 mg, 20 mg PV zileuton er oral tablet extended release 12 hour 600 mg 1 DSL = 30 days ZYFLO ORAL TABLET 600 MG (zileuton) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 280 Coverage Requirements & Prescription Drug Name Drug Tier Limits MAST-CELL STABILIZERS - Drugs for Inflammation ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil sodium) 2 cromolyn sodium inhalation nebulization solution 20 mg/2ml PV cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 MUCOLYTIC AGENTS - Drugs for the Lungs acetylcysteine inhalation solution 10 %, 20 % 1 PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase 2 alfa) NASAL PREPARATIONS () - Drugs for Inflammation azelastine-fluticasone nasal suspension 137-50 mcg/act 1 BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY 3 (beclomethasone diprop monohyd) flunisolide nasal solution 25 mcg/act (0.025%) 1 fluticasone propionate nasal suspension 50 mcg/act 1 mometasone furoate nasal suspension 50 mcg/act 1 OMNARIS NASAL SUSPENSION 50 MCG/ACT (ciclesonide) 3 QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 3 MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT 3 (beclomethasone diprop (nasal)) SINUVA NASAL IMPLANT 1350 MCG (mometasone furoate) 3 XHANCE NASAL EXHALER SUSPENSION 93 MCG/ACT 3 (fluticasone propionate) ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT 3 (ciclesonide) ORALLY INHALED PREPARATIONS (STEROIDS) - Drugs for Inflammation ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 2 MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 3 55-14 MCG/ACT (fluticasone-salmeterol) AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT 3 (fluticasone-salmeterol)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 281 Coverage Requirements & Prescription Drug Name Drug Tier Limits AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT 3 (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT (fluticasone- 3 salmeterol) ALVESCO INHALATION AEROSOL SOLUTION 160 2 MCG/ACT, 80 MCG/ACT (ciclesonide) ARMONAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113 MCG/ACT, 232 MCG/ACT, 55 3 MCG/ACT (fluticasone propionate (inhal)) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 3 MCG/ACT (fluticasone furoate) ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 furoate) ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 furoate) ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH 2 (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH (mometasone 2 furoate) ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH (mometasone 2 furoate) ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 2 DSL = 30 days MCG/ACT (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 50 MCG/ACT PV DSL = 30 days (mometasone furoate) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH (fluticasone 3 furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 MCG/ACT (budeson-glycopyrrol-formoterol) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 1 mg/2ml BUDESONIDE-FORMOTEROL FUMARATE INHALATION 3 AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 282 Coverage Requirements & Prescription Drug Name Drug Tier Limits DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 3 MCG/ACT, 50-5 MCG/ACT (mometasone furo-formoterol fum) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 3 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 3 MCG/ACT (fluticasone propionate hfa) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT 2 (fluticasone propionate hfa) fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 1 mcg/dose FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 3 MCG/ACT, 55-14 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER 2 BREATH ACTIVATED 180 MCG/ACT (budesonide) PULMICORT FLEXHALER INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 90 MCG/ACT (budesonide) PULMICORT SUSPENSION INHALATION SUSPENSION 0.25 3 MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone 3 diprop hfa) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 4.5 MCG/ACT (budesonide-formoterol fumarate) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 3 MCG/INH (fluticasone-umeclidin-vilant) fluticasone-salmeterol (Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 Mcg/Dose, 250-50 Mcg/Dose, 500-50 1 Mcg/Dose) PHOSPHODIESTERASE TYPE 4 INHIBITORS - Drugs for the Lungs DALIRESP ORAL TABLET 250 MCG (roflumilast) 3 DALIRESP ORAL TABLET 500 MCG (roflumilast) 2 PULMONARY SURFACTANTS - Drugs for the Lungs CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML 2 (poractant alfa) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-% 3 (calfactant in nacl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 283 Coverage Requirements & Prescription Drug Name Drug Tier Limits SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML- 2 % (beractant in nacl) RESPIRATORY TRACT AGENTS, MISCELLANEOUS - Drugs for the Lungs ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 1000 MG, 500 MG (alpha1-proteinase inhibitor) BRONCHITOL INHALATION CAPSULE 40 MG (mannitol 3 DSL = 30 days (cystic fibrosis)) BRONCHITOL TOLERANCE TEST INHALATION CAPSULE 40 3 DSL = 30 days MG (mannitol (cystic fibrosis)) GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML (alpha1- 3 DSL = 30 days proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION 1000 MG/20ML 3 (alpha1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 1000 MG (alpha1-proteinase inhibitor) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 2 150 MG/ML, 75 MG/0.5ML (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 2 DSL = 30 days MG (omalizumab) ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 1000 MG (alpha1-proteinase inhibitor) SECOND GENERATION ANTIHIST(RESPIR TRACT) - Drugs for Allergy azelastine-fluticasone nasal suspension 137-50 mcg/act 1 cetirizine hcl oral solution 1 mg/ml, 5 mg/5ml 1 CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) desloratadine oral tablet 5 mg 1 desloratadine oral tablet dispersible 5 mg 1 levocetirizine dihydrochloride oral solution 2.5 mg/5ml 1 levocetirizine dihydrochloride oral tablet 5 mg 1 SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR) - Drugs for Asthma/COPD ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 2 MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- 2 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 284 Coverage Requirements & Prescription Drug Name Drug Tier Limits AIRDUO DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 3 55-14 MCG/ACT (fluticasone-salmeterol) AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT 3 (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT 3 (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT (fluticasone- 3 salmeterol) albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 PV mg albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act PV inhalation 108 (90 base) mcg/act ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) PV 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 PV MG/ML) 0.5% INHALATION (5 MG/ML) 0.5% albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation PV (5 mg/ml) 0.5% albuterol sulfate oral syrup 2 mg/5ml PV albuterol sulfate oral tablet 2 mg, 4 mg PV ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 vilanterol) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 3 MCG/ACT (glycopyrrolate-formoterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH (fluticasone 3 furoate-vilanterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 3 MCG/ACT (budeson-glycopyrrol-formoterol) BROVANA INHALATION NEBULIZATION SOLUTION 15 3 MCG/2ML (arformoterol tartrate) BUDESONIDE-FORMOTEROL FUMARATE INHALATION 3 AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION PV 20-100 MCG/ACT (ipratropium-albuterol)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 285 Coverage Requirements & Prescription Drug Name Drug Tier Limits DUAKLIR PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400-12 MCG/ACT (aclidinium br- 3 DSL = 30 days formoterol fum) DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 3 MCG/ACT, 50-5 MCG/ACT (mometasone furo-formoterol fum) fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 1 mcg/dose FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 3 MCG/ACT, 55-14 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 3 MCG/2ML (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER PV BREATH ACTIVATED 108 MCG/ACT (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT (albuterol PV sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT (albuterol sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5-2.5 MCG/ACT (tiotropium bromide-olodaterol) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 2.5 MCG/ACT (olodaterol hcl) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 4.5 MCG/ACT (budesonide-formoterol fumarate) terbutaline sulfate injection solution 1 mg/ml PV terbutaline sulfate oral tablet 2.5 mg, 5 mg PV TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, 200-62.5-25 3 MCG/INH (fluticasone-umeclidin-vilant) UTIBRON NEOHALER INHALATION CAPSULE 27.5-15.6 3 MCG (indacaterol-glycopyrrolate)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 286 Coverage Requirements & Prescription Drug Name Drug Tier Limits VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 PV BASE) MCG/ACT (albuterol sulfate) fluticasone-salmeterol (Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 Mcg/Dose, 250-50 Mcg/Dose, 500-50 1 Mcg/Dose) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT 3 (levalbuterol tartrate) VASODILATING AGENTS (RESPIRATORY TRACT) - Drugs for the Lungs ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 3 DSL = 30 days MG (riociguat) tadalafil (pah) (Alyq Oral Tablet 20 Mg) 1 DSL = 30 days ambrisentan oral tablet 10 mg, 5 mg 1 DSL = 30 days bosentan oral tablet 125 mg, 62.5 mg 1 DSL = 30 days epoprostenol sodium intravenous solution reconstituted 0.5 mg, 1 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) 2 DSL = 30 days OPSUMIT ORAL TABLET 10 MG (macitentan) 3 DSL = 30 days ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 3 DSL = 30 days MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil diolamine) REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 2 MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) REVATIO ORAL TABLET 20 MG (sildenafil citrate) 3 sildenafil citrate intravenous solution 10 mg/12.5ml 1 sildenafil citrate oral suspension reconstituted 10 mg/ml 1 DSL = 30 days sildenafil citrate oral tablet 20 mg 1 tadalafil (pah) oral tablet 20 mg 1 DSL = 30 days TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) 2 DSL = 30 days TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) 2 DSL = 30 days treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 1 mg/20ml, 50 mg/20ml TYVASO INHALATION SOLUTION 0.6 MG/ML (treprostinil) 2 DSL = 30 days TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML 2 DSL = 30 days (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML 2 DSL = 30 days (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 3 DSL = 30 days (selexipag)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 287 Coverage Requirements & Prescription Drug Name Drug Tier Limits UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG 3 DSL = 30 days (selexipag) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML 2 DSL = 30 days (iloprost) XANTHINE DERIVATIVES - Drugs for Asthma/COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, PV 450 mg theophylline er oral tablet extended release 24 hour 400 mg, PV 600 mg theophylline oral solution 80 mg/15ml 1 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin naftifine hcl external cream 1 %, 2 % 1 naftifine hcl external gel 1 % 1 NAFTIN EXTERNAL GEL 2 % (naftifine hcl) 3 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 3 -BENZOYL PER-CLINDAMY EXTERNAL GEL 3 0.3-2.5-1 % ALTABAX EXTERNAL OINTMENT 1 % (retapamulin) 3 AMZEEQ EXTERNAL FOAM 4 % (minocycline hcl micronized) 3 AVEIDAOXIA EXTERNAL GEL 1-1-4 % 3 BENZ PER-CLIND-NIACIN-TRETIN EXTERNAL GEL 2.5-1-2- 3 0.025 %, 5-1-2-0.025 %, 5-1-2-0.05 % benzoyl peroxide-erythromycin external gel 5-3 % 1 CENTANY AT EXTERNAL KIT 2 % () 3 CLEOCIN VAGINAL SUPPOSITORY 100 MG (clindamycin 3 phosphate) CLINDACIN ETZ EXTERNAL KIT 1 % (clindamycin phos & 3 cleanser) clindamycin phosphate (Clindacin Etz External Swab 1 %) 1 CLINDACIN PAC EXTERNAL KIT 1 % (clindamycin phos & 3 cleanser) clindamycin phosphate (Clindacin-P External Swab 1 %) 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 288 Coverage Requirements & Prescription Drug Name Drug Tier Limits CLINDAGEL EXTERNAL GEL 1 % (clindamycin phosphate) 3 CLINDAMY-BENZOYL PER-NIACINAM EXTERNAL GEL 1-5-4 3 %, 2.5-1-4 % clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1 1.2-5 % CLINDAMYCIN PHOS-NIACINAMIDE EXTERNAL GEL 1-4 % 3 CLINDAMYCIN PHOS-NIACINAMIDE EXTERNAL LOTION 1-4 3 % clindamycin phosphate external foam 1 % 1 clindamycin phosphate external lotion 1 % 1 clindamycin phosphate external solution 1 % 1 clindamycin phosphate external swab 1 % 1 CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL 1 % 3 clindamycin phosphate gel 1 % external 1 % 1 clindamycin phosphate vaginal cream 2 % 1 CLINDAMYCIN-NIACIN-TRETINOIN EXTERNAL CREAM 1-4- 3 0.025 % clindamycin-tretinoin external gel 1.2-0.025 % 1 CLINDESSE VAGINAL CREAM 2 % (clindamycin phosphate (1 3 dose)) CLIND-NIACIN-SPIRONOLAC-TRETIN EXTERNAL GEL 1-4-2- 3 0.025 % dapsone external gel 5 % 1 dapsone gel 7.5 % external 7.5 % 1 DAPSONE GEL 7.5 % EXTERNAL 7.5 % 3 DAPSONE-NIACINAMIDE EXTERNAL GEL 6-4 %, 8.5-4 % 3 DAPSONE-NIACINAMIDE-SPIRONOLAC EXTERNAL GEL 6- 3 2-5 %, 8.5-2-5 % DEOXIA EXTERNAL GEL 1-4 % 3 DEOXIA EXTERNAL LOTION 1-4 % 3 DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 & 5 % 3 (OINT) (chlorhex-mupir-dimeth-silicone) DIADIMAXIA EXTERNAL GEL 6-2-5 % 3 DIAOXIA EXTERNAL GEL 6-4 % 3 DIASDIMAXIA EXTERNAL GEL 8.5-2-5 % 3 DIASOXIA EXTERNAL GEL 8.5-4 % 3 ery external pad 2 % 1 erythromycin external gel 2 % 1 erythromycin external solution 2 % 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 289 Coverage Requirements & Prescription Drug Name Drug Tier Limits gentamicin sulfate external cream 0.1 % 1 gentamicin sulfate external ointment 0.1 % 1 IVERMECTIN-METRONIDAZOL-NIACIN EXTERNAL GEL 1-1- 3 4 % metronidazole external cream 0.75 % 1 metronidazole external gel 0.75 %, 1 % 1 metronidazole external lotion 0.75 % 1 metronidazole vaginal gel 0.75 % 1 mupirocin calcium external cream 2 % 1 mupirocin external ointment 2 % 1 neomycin-polymyxin b gu irrigation solution 40-200000 1 NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % (neomycin- 3 fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo-fluocinolone 3 & emollient) clindamycin-benzoyl per (refr) (Neuac External Gel 1.2-5 %) 1 NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 3 moist) NORITATE EXTERNAL CREAM 1 % (metronidazole) 3 NUCARACLINPAK EXTERNAL KIT 1 % (clindamycin phos- 3 moisturizer) NUCARARXPAK EXTERNAL KIT 1-2.5 % (clindamycin-benzoyl 3 per-moist) NUSURGEPAK SURGICAL PREP/CARE EXTERNAL KIT 4 & 3 2 & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) NUVESSA VAGINAL GEL 1.3 % (metronidazole) 3 ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- 3 benzoyl perox) ONZDEOXIA EXTERNAL GEL 1-5-4 % 3 metronidazole (Rosadan External Cream 0.75 %) 1 metronidazole (Rosadan External Gel 0.75 %) 1 ROSADAN EXTERNAL KIT 0.75 % (CREAM), 0.75 % (GEL) 3 (metronidazole-cleanser) TARDEOXIA EXTERNAL CREAM 1-4-0.025 % 3 metronidazole (Vandazole Vaginal Gel 0.75 %) 1 VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 XEPI EXTERNAL CREAM 1 % (ozenoxacin) 3 ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl micronized) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 290 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC - Drugs for the Skin ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) 3 EXODERM EXTERNAL LOTION 25-1 % (sod thiosulfate- 3 salicylic acd) ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS) - Drugs for the Skin ADVANCED ALLERGY COLLECTION EXTERNAL KIT 2.5 % 3 (hydrocortisone) ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) 3 ala-cort external cream 1 %, 2.5 % 1 ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) 3 alclometasone dipropionate external cream 0.05 % 1 alclometasone dipropionate external ointment 0.05 % 1 ALCORTIN A EXTERNAL GEL 1-2-1 % (iodoquinol-hc-aloe 3 polysacch) amcinonide external cream 0.1 % 1 amcinonide external lotion 0.1 % 1 amcinonide external ointment 0.1 % 1 lidocaine-hydrocortisone ace (Ana-Lex Rectal Kit 2-2 %) 1 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 3 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 2 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % (hydrocortisone 2 ace-pramoxine) anucort-hc rectal suppository 25 mg 1 hydrocortisone acetate (Anusol-Hc Rectal Suppository 25 Mg) 3 APEXICON E EXTERNAL CREAM 0.05 % (diflorasone diacet 3 emoll base) fluticasone propionate (Beser External Lotion 0.05 %) 1 betamethasone dipropionate aug external cream 0.05 % 1 betamethasone dipropionate aug external gel 0.05 % 1 betamethasone dipropionate aug external lotion 0.05 % 1 betamethasone dipropionate aug external ointment 0.05 % 1 betamethasone dipropionate external cream 0.05 % 1 betamethasone dipropionate external lotion 0.05 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 291 Coverage Requirements & Prescription Drug Name Drug Tier Limits betamethasone dipropionate external ointment 0.05 % 1 betamethasone valerate external cream 0.1 % 1 betamethasone valerate external foam 0.12 % 1 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 calcipotriene-betameth diprop external ointment 0.005-0.064 % 1 DSL = 30 days calcipotriene-betameth diprop external suspension 0.005-0.064 1 % CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone 3 acetonide) clobetasol prop emollient base external cream 0.05 % 1 clobetasol propionate e external cream 0.05 % 1 clobetasol propionate emulsion external foam 0.05 % 1 clobetasol propionate external cream 0.05 % 1 clobetasol propionate external foam 0.05 % 1 clobetasol propionate external gel 0.05 % 1 clobetasol propionate external liquid 0.05 % 1 clobetasol propionate external lotion 0.05 % 1 clobetasol propionate external ointment 0.05 % 1 clobetasol propionate external shampoo 0.05 % 1 clobetasol propionate external solution 0.05 % 1 CLOBEX EXTERNAL LOTION 0.05 % (clobetasol propionate) 2 CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol 2 propionate) clocortolone pivalate external cream 0.1 % 1 CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & cleanser) 3 clobetasol propionate (Clodan External Shampoo 0.05 %) 1 -betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) 3 CORDRAN EXTERNAL TAPE 4 MCG/SQCM (flurandrenolide) 2 CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone acetate) 3 DERMACINRX THERAZOLE PAK EXTERNAL THERAPY 3 PACK 1-0.05 & 20 % (clotrimazole-betameth & zn ox) desonide external cream 0.05 % 1 desonide external gel 0.05 % 1 desonide external lotion 0.05 % 1 desonide external ointment 0.05 % 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 292 Coverage Requirements & Prescription Drug Name Drug Tier Limits desoximetasone external cream 0.05 %, 0.25 % 1 desoximetasone external gel 0.05 % 1 desoximetasone external liquid 0.25 % 1 desoximetasone external ointment 0.05 %, 0.25 % 1 diflorasone diacetate external cream 0.05 % 1 diflorasone diacetate external ointment 0.05 % 1 enovarx-ibuprofen external cream 10 % PV enovarx-naproxen external cream 10 % PV ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- 3 betameth diprop) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 3 EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) 3 FLUOCINOLONE ACET-NIACINAMIDE EXTERNAL CREAM 3 0.01-4 %, 0.025-4 % fluocinolone acetonide body external oil 0.01 % 1 fluocinolone acetonide external cream 0.01 %, 0.025 % 1 fluocinolone acetonide external ointment 0.025 % 1 fluocinolone acetonide external solution 0.01 % 1 fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 %, 0.1 % 1 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1 flurandrenolide external cream 0.05 % 1 flurandrenolide external lotion 0.05 % 1 flurandrenolide external ointment 0.05 % 1 fluticasone propionate external cream 0.05 % 1 fluticasone propionate external lotion 0.05 % 1 fluticasone propionate external ointment 0.005 % 1 FROTEK EXTERNAL CREAM 10 % (ketoprofen) PV halcinonide external cream 0.1 % 1 halobetasol propionate external cream 0.05 % 1 halobetasol propionate external ointment 0.05 % 1 HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) 3 HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) 3 DSL = 30 days

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 293 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocortisone acetate (Hemmorex-Hc Rectal Suppository 25 3 Mg) hydrocortisone (perianal) external cream 1 %, 2.5 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocortisone acetate rectal suppository 25 mg, 30 mg 1 hydrocortisone butyr lipo base external cream 0.1 % 1 hydrocortisone butyrate external cream 0.1 % 1 hydrocortisone butyrate external lotion 0.1 % 1 hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1 hydrocortisone external cream 1 %, 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 %, 2.5 % 1 hydrocortisone rectal enema 100 mg/60ml 1 hydrocortisone valerate external cream 0.2 % 1 hydrocortisone valerate external ointment 0.2 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol propionate) 3 iodoquinol-hc-aloe polysacch external gel 1-2-1 % 1 iodoquinol-hydrocortisone-aloe external cream 1-1.9 % 1 lidocaine-hydrocort (perianal) external cream 3-0.5 % 1 LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 3 % lidocaine-hydrocortisone ace rectal kit 2-2 %, 3-0.5 %, 3-1 %, 3- 1 2.5 % lidocaine-hydrocortisone ace (Lidocort External Cream 3-0.5 %) 3 mometasone furoate external cream 0.1 % 1 mometasone furoate external ointment 0.1 % 1 mometasone furoate external solution 0.1 % 1 NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % (neomycin- 3 fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo-fluocinolone 3 & emollient) flurandrenolide (Nolix External Cream 0.05 %) 1 flurandrenolide (Nolix External Lotion 0.05 %) 1 NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) 3 NUCORT EXTERNAL LOTION 2 % (hydrocortisone acetate) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 294 Coverage Requirements & Prescription Drug Name Drug Tier Limits triamcinolone-dimeth-silicone (Nutriarx Creampak External Kit 3 0.1 & 5 %) triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) 1 PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone probutate) 3 pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 3 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % 2 (pramoxine-hc) prednicarbate external cream 0.1 % 1 prednicarbate external ointment 0.1 % 1 PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 3 ace-pramoxine) PROCTOCORT RECTAL SUPPOSITORY 30 MG 3 (hydrocortisone acetate) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 3 ace-pramoxine) hydrocortisone (Procto-Med Hc External Cream 2.5 %) 1 hydrocortisone (Procto-Pak External Cream 1 %) 1 hydrocortisone (Proctozone-Hc External Cream 2.5 %) 1 PSORCON EXTERNAL CREAM 0.05 % 3 RIMSO-50 INTRAVESICAL SOLUTION 50 % (dimethyl 2 sulfoxide) SANADERMRX SKIN REPAIR EXTERNAL KIT 0.1 & 5 % 3 SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 & shampoo) SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone 3 dipropionate) SYNALAR (CREAM) EXTERNAL KIT 0.025 % (fluocinolone- 3 emollient) SYNALAR (OINTMENT) EXTERNAL KIT 0.025 % 3 (fluocinolone-emollient) SYNALAR TS EXTERNAL KIT 0.01 % (fluocinolone & cleanser) 3 TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) TEXACORT EXTERNAL SOLUTION 2.5 % (hydrocortisone) 3 TOPICORT SPRAY EXTERNAL LIQUID 0.25 % 3 (desoximetasone) clobetasol propionate emulsion (Tovet External Foam 0.05 %) 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 295 Coverage Requirements & Prescription Drug Name Drug Tier Limits triamcinolone acetonide external aerosol solution 0.147 mg/gm 1 triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % 1 triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 triamcinolone acetonide external ointment 0.025 %, 0.05 %, 0.1 1 %, 0.5 % triamcinolone acetonide mouth/throat paste 0.1 % 1 triamcinolone acetonide (Trianex External Ointment 0.05 %) 3 triamcinolone acetonide (Triderm External Cream 0.1 %, 0.5 %) 1 triamcinolone-dimeth-silicone (Trivix External Kit 0.1 & 5 %) 3 ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol 3 DSL = 30 days propionate) benzoyl perox-hydrocortisone (Vanoxide-Hc External Lotion 5- 3 0.5 %) VERDESO EXTERNAL FOAM 0.05 % (desonide) 3 VYTONE EXTERNAL CREAM 1-1.9 % (iodoquinol- 3 hydrocortisone-aloe) XERESE EXTERNAL CREAM 5-1 % (acyclovir-hydrocortisone) 3 ANTI-INFLAMMATORY AGENTS, MISC (SKIN) - Drugs for the Skin EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) 3 AND LOCAL ANESTHETICS - Drugs for the Skin ACCUCAINE COMBINATION KIT 1 % (lido-pentaf-tetrafl- 3 ultrasound) AGONEAZE EXTERNAL KIT 2.5-2.5 % 3 ANACAINE EXTERNAL OINTMENT 10 % (benzocaine) 3 lidocaine-hydrocortisone ace (Ana-Lex Rectal Kit 2-2 %) 1 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 3 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 2 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % (hydrocortisone 2 ace-pramoxine) ANODYNE LPT EXTERNAL KIT 2.5-2.5 % 3 APRIZIO PAK EXTERNAL KIT 2.5-2.5 % (lidocaine-prilocaine- 3 ) APRIZIO PAK II EXTERNAL KIT 2.5-2.5 % (lidocaine- 3 prilocaine-dressing)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 296 Coverage Requirements & Prescription Drug Name Drug Tier Limits ASTERO EXTERNAL GEL 4 % (lidocaine hcl) 3 BETALOAN SUIK COMBINATION KIT 30 MG/5ML (betameth 3 sod phos-ace & anesth) CADIRAMD EXTERNAL KIT 2.5-2.5 % (lido-prilocaine-blood 3 collect) CETACAINE EXTERNAL AEROSOL 2-2-14 % (butamben- 3 tetracaine-benzocaine) CYCLOPAK COMBINATION THERAPY PACK 5 & 2.5-2.5 MG 3 & % (cyclobenz-lido-prilo-swall spr) lidocaine-prilocaine (Dermacinrx Empricaine External Kit 2.5-2.5 3 %) DERMACINRX PHN EXTERNAL THERAPY PACK 5 & 5 % 3 (lidocaine-dimethicone) lidocaine-prilocaine (Dermacinrx Prizopak External Kit 2.5-2.5 3 %) DERMACINRX ZRM EXTERNAL THERAPY PACK 5 % 3 (lidocaine-emollient) DERMALID EXTERNAL THERAPY PACK 5 % 3 DICLOVIX COMBINATION KIT 1.5 & 2-2.5-4 % 3 doxepin hcl external cream 5 % 1 EHA EXTERNAL LOTION 4 % 3 EMPRICAINE-II EXTERNAL KIT 2.5-2.5 % (lidocaine- 3 prilocaine-dressing) enovarx-lidocaine hcl external cream 10 %, 5 % 1 EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 3 ethyl chloride external aerosol 1 GEBAUERS PAIN EASE EXTERNAL AEROSOL 3 (pentafluoroprop-tetrafluoroeth) GEBAUERS SPRAY AND STRETCH EXTERNAL AEROSOL 3 (pentafluoroprop-tetrafluoroeth) GEN7T EXTERNAL LOTION 3.5 % 3 GEN7T EXTERNAL PATCH 3.5 % 3 GEN7T PLUS EXTERNAL LOTION 3.5-7 % 3 GEN7T PLUS EXTERNAL PATCH 3.5-7 % 3 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 LDO PLUS EXTERNAL GEL 4 % (lidocaine hcl) 3 lets kit 1 lidocaine-prilocaine (Lido Bdk External Kit 2.5-2.5 %) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 297 Coverage Requirements & Prescription Drug Name Drug Tier Limits lidocaine external ointment 5 % 1 lidocaine external patch 5 % 1 lidocaine hcl external cream 3 % 1 lidocaine hcl external lotion 3 % 1 lidocaine hcl external solution 4 % 1 lidocaine hcl mouth/throat solution 4 % 1 lidocaine-hydrocort (perianal) external cream 3-0.5 % 1 LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 3 % lidocaine-hydrocortisone ace rectal kit 2-2 %, 3-0.5 %, 3-1 %, 3- 1 2.5 % lidocaine-prilocaine external cream 2.5-2.5 % 1 lidocaine-prilocaine external kit 2.5-2.5 % 1 LIDOCAINE-TETRACAINE EXTERNAL CREAM 7-7 % 3 lidocaine-hydrocortisone ace (Lidocort External Cream 3-0.5 %) 3 LIDO-EPINEPHRINE-TETRACAINE EXTERNAL SOLUTION 4- 3 0.05-0.5 % LIDOPAC EXTERNAL KIT 5 % 3 lidopin external cream 3 % 1 LIDOPIN EXTERNAL CREAM 3.25 % 3 LIDOPRIL EXTERNAL KIT 2.5-2.5 % 3 LIDOPRIL XR EXTERNAL KIT 2.5-2.5 % 3 lidocaine-prilocaine (Lido-Prilo Caine Pack External Kit 2.5-2.5 3 %) LIDOPURE PATCH EXTERNAL KIT 5 % (lidocaine-adhesive 3 sheets) LIDORX EXTERNAL GEL 3 % 3 lidocaine hcl (Lido-Sorb External Lotion 3 %) 3 LIDOTRAL EXTERNAL CREAM 3.88 % (lidocaine hcl) 3 LIDTOPIC MAX EXTERNAL CREAM 10 % (lidocaine hcl) 3 lidocaine-prilocaine (Livixil Pak External Kit 2.5-2.5 %) 3 LMR PLUS EXTERNAL KIT 5 & 0.5-0.5 % (lidocaine-camphor- 3 menthol) MARVONA SUIK COMBINATION KIT 0.5 % (bupivacaine hcl & 3 anesthetic) MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) MEDROLOAN SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 298 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOPIOID-LMC KIT COMBINATION THERAPY PACK 7.5 & 4-4 3 MG & % (cyclobenzaprine-lidocaine-ment) NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) 3 lidocaine-prilocaine (Nuvakaan External Kit 2.5-2.5 %) 3 NUVAKAAN-II EXTERNAL KIT 2.5-2.5 % (lido-prilo & silicone 3 dressing) PAINGO KFT EXTERNAL KIT 2.5-2.5-10-30 % 3 phenazopyridine hcl (Phenazo Oral Tablet 200 Mg) 1 phenazopyridine hcl oral tablet 100 mg, 200 mg 1 PLIAGLIS EXTERNAL CREAM 7-7 % (lidocaine-tetracaine) 3 pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 3 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % 2 (pramoxine-hc) pramox external gel 1 % 1 PRILO PATCH EXTERNAL KIT 2.5 % (lidocaine-prilocaine) 3 PRILO PATCH II EXTERNAL KIT 2.5-2.5 & 5 % (lidocaine- 3 prilocaine) PRILOLID EXTERNAL KIT 2.5-2.5 % 3 PRILOVIX EXTERNAL KIT 2.5-2.5 % 3 PRILOVIX LITE EXTERNAL KIT 2.5-2.5 % 3 PRILOVIX LITE PLUS EXTERNAL KIT 2.5-2.5 % 3 PRILOVIX PLUS EXTERNAL KIT 2.5-2.5 % 3 PRILOVIX ULTRALITE EXTERNAL KIT 2.5-2.5 % 3 PRILOVIX ULTRALITE PLUS EXTERNAL KIT 2.5-2.5 % 3 PRILOVIXIL EXTERNAL KIT 2.5-2.5 % 3 PRIZOPAK II EXTERNAL KIT 2.5-2.5 % (lidocaine-prilocaine- 3 dressing) PRIZOTRAL-II EXTERNAL KIT 2.5-2.5 & 3.88 % (lidocaine- 3 prilocaine) PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 3 ace-pramoxine) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 3 ace-pramoxine) PYRIDIUM ORAL TABLET 100 MG, 200 MG (phenazopyridine 3 hcl) lidocaine-prilocaine (Relador Pak External Kit 2.5-2.5 %) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 299 Coverage Requirements & Prescription Drug Name Drug Tier Limits lidocaine-prilocaine (Relador Pak Plus External Kit 2.5-2.5 %) 3 SKYADERM-LP EXTERNAL KIT 2.5-2.5 % (lidocaine- 3 prilocaine-dressing) STERILE TOPICAL L.E.T. GEL EXTERNAL GEL 0.18-4-0.5 % 3 (lido-epinephrine-tetracaine) SYNERA EXTERNAL PATCH 70-70 MG (lidocaine-tetracaine) 3 WPR PLUS WOUND HEALING SYSTEM EXTERNAL 3 THERAPY PACK 4 & 10-30 % ZERUVIA EXTERNAL PATCH 4-1 % 3 ZILACAINE PATCH EXTERNAL THERAPY PACK 5 % 3 (lidocaine-silicone) ZIONODIL 100 EXTERNAL LOTION 3 % 3 ZIONODIL EXTERNAL LOTION 3 % 3 ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) 3 ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin acyclovir external cream 5 % 1 acyclovir external ointment 5 % 1 DENAVIR EXTERNAL CREAM 1 % () 3 XERESE EXTERNAL CREAM 5-1 % (acyclovir-hydrocortisone) 3 ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) 3 ASTRINGENTS - Drugs for the Skin DRYSOL EXTERNAL SOLUTION 20 % (aluminum chloride) 2 XERAC AC EXTERNAL SOLUTION 6.25 % (aluminum chloride 2 in alcohol) AZOLES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin clotrimazole external cream 1 % 1 clotrimazole external solution 1 % 1 clotrimazole mouth/throat troche 10 mg 1 clotrimazole-betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 DERMACINRX THERAZOLE PAK EXTERNAL THERAPY 3 PACK 1-0.05 & 20 % (clotrimazole-betameth & zn ox) DIFMETIOXRIME EXTERNAL SOLUTION 4-2-1-4 % 3 ECONASIL EXTERNAL KIT 1 % (econaz & gauze & silicone 3 tape) econazole nitrate external cream 1 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 300 Coverage Requirements & Prescription Drug Name Drug Tier Limits ECONAZOLE NITRATE-NIACINAMIDE EXTERNAL CREAM 1- 3 4 % ECOZA EXTERNAL FOAM 1 % (econazole nitrate) 3 ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) 3 EXELDERM EXTERNAL CREAM 1 % (sulconazole nitrate) 3 EXELDERM EXTERNAL SOLUTION 1 % (sulconazole nitrate) 3 FLUCON-IBUPROF-ITRACON-TERBINA EXTERNAL 3 SOLUTION 4-2-1-4 % GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole nitrate (1 3 dose)) IMIOXIA EXTERNAL CREAM 1-4 % 3 IODOQUINOL-HC-KETOCONAZOLE EXTERNAL CREAM 1- 3 2.5-2 % JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) 3 ketoconazole external cream 2 % 1 ketoconazole external foam 2 % 1 ketoconazole external shampoo 2 % 1 KETOCONAZOLE-HYDROCORTISONE EXTERNAL CREAM 3 2-2.5 % ketoconazole (Ketodan External Foam 2 %) 1 KETODAN EXTERNAL KIT 2 % (ketoconazole-cleanser) 3 LULICONAZOLE EXTERNAL CREAM 1 % 3 LUZU EXTERNAL CREAM 1 % (luliconazole) 3 3 vaginal suppository 200 mg 1 MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 3 OINTMENT 0.25-15-81.35 % ORAVIG BUCCAL TABLET 50 MG (miconazole) 3 oxiconazole nitrate external cream 1 % 1 OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) 3 PEDIZOLPAK EXTERNAL THERAPY PACK 2 & 2 % 3 PHEODOYO EXTERNAL CREAM 1-2.5-2 % 3 PHEYO EXTERNAL CREAM 2.5-2 % 3 SULCONAZOLE NITRATE EXTERNAL CREAM 1 % 3 SULCONAZOLE NITRATE EXTERNAL SOLUTION 1 % 3 terconazole vaginal cream 0.4 %, 0.8 % 1 terconazole vaginal suppository 80 mg 1 VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 3 (miconazole-zinc oxide-petrolat)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 301 Coverage Requirements & Prescription Drug Name Drug Tier Limits XOLEGEL EXTERNAL GEL 2 % (ketoconazole) 3 ZOLPAK EXTERNAL KIT 1 % (econazole nitrate & dressing) 3 BASIC LOTIONS AND LINIMENTS - Drugs for the Skin ammonium lactate external lotion 12 % 1 ATOPICLAIR EXTERNAL CREAM (dermatological products, 3 misc.) lactic acid external lotion 10 % 1 PRUCLAIR EXTERNAL CREAM (dermatological products, 3 misc.) BASIC OILS AND OTHER SOLVENTS - Drugs for the Skin CERACADE EXTERNAL EMULSION (dermatological products, 3 misc.) PHLAG SPRAY EXTERNAL EMULSION (dermatological 3 products, misc.) SYNERDERM EXTERNAL EMULSION (dermatological 3 products, misc.) BASIC OINTMENTS AND PROTECTANTS - Drugs for the Skin ammonium lactate external cream 12 % 1 benzoin compound external tincture 1 DERMACINRX PHN EXTERNAL THERAPY PACK 5 & 5 % 3 (lidocaine-dimethicone) DERMACINRX THERAZOLE PAK EXTERNAL THERAPY 3 PACK 1-0.05 & 20 % (clotrimazole-betameth & zn ox) DERMACINRX ZRM EXTERNAL THERAPY PACK 5 % 3 (lidocaine-emollient) DERMELLE EXTERNAL GEL (scar treatment products) 3 DEXERYL EXTERNAL CREAM (dermatological products, 3 misc.) ELETONE EXTERNAL CREAM (dermatological products, 3 misc.) HALUCORT EXTERNAL GEL (dermatological products, misc.) 3 lactic acid e external cream 10-3500 %-unt/30gm 1 NUDERMRXPAK 120 EXTERNAL THERAPY PACK 0.005-5 % 3 (calcipotriene-dimethicone) NUDERMRXPAK 60 EXTERNAL THERAPY PACK 0.005-5 % 3 (calcipotriene-dimethicone) NUTRASEB EXTERNAL CREAM (antiseborrheic products, 3 misc.)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 302 Coverage Requirements & Prescription Drug Name Drug Tier Limits STRATA MARK EXTERNAL GEL (dermatological products, 3 misc.) scar treatment products (Strata Triz External Gel) 3 TETRIX EXTERNAL CREAM (dermatological products, misc.) 3 BENZYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin MENTAX EXTERNAL CREAM 1 % (butenafine hcl) 3 CELL STIMULANTS AND PROLIFERANTS - Drugs for the Skin ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) 3 tretinoin (Avita External Cream 0.025 %) 2 tretinoin (Avita External Gel 0.025 %) 2 BENZ PER-CLIND-NIACIN-TRETIN EXTERNAL GEL 2.5-1-2- 3 0.025 %, 5-1-2-0.025 %, 5-1-2-0.05 % CLINDAMYCIN-NIACIN-TRETINOIN EXTERNAL CREAM 1-4- 3 0.025 % clindamycin-tretinoin external gel 1.2-0.025 % 1 CLIND-NIACIN-SPIRONOLAC-TRETIN EXTERNAL GEL 1-4-2- 3 0.025 % HYALURONATE-NIACINAM-TRETINOIN EXTERNAL CREAM 3 0.5-4-0.025 %, 0.5-4-0.05 %, 0.5-4-0.1 % -LEVOCET-TRETINOIN EXTERNAL GEL 5-1-0.05 3 % KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 2 DSL = 30 days 6.25 MG (palifermin) NIACINAMIDE-TRETINOIN EXTERNAL CREAM 4-0.025 %, 4- 3 0.05 % NIACINAMIDE-TRETINOIN EXTERNAL GEL 4-0.025 %, 4-0.05 3 % NIACIN-SPIRONOLACTON-TRETINOIN EXTERNAL GEL 2-5- 3 0.025 %, 2-5-0.05 % OXIATAR EXTERNAL CREAM 4-0.025 % 3 OXIAVARRY EXTERNAL CREAM 4-0.05 % 3 RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % 2 (tretinoin) RETIN-A EXTERNAL GEL 0.01 %, 0.025 % (tretinoin) 2 RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % (tretinoin 2 microsphere) RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 % 2 (tretinoin microsphere)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 303 Coverage Requirements & Prescription Drug Name Drug Tier Limits RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % (tretinoin 3 DSL = 30 days microsphere) RETIN-A MICRO PUMP EXTERNAL GEL 0.08 % (tretinoin 3 microsphere) TARDEOXIA EXTERNAL CREAM 1-4-0.025 % 3 TARDIMAXIA EXTERNAL GEL 2-5-0.025 % 3 TAROXIA EXTERNAL CREAM 4-0.025 % 3 TAROXIA EXTERNAL GEL 4-0.025 % 3 tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1 tretinoin external gel 0.01 %, 0.025 %, 0.05 % 1 tretinoin microsphere external gel 0.04 %, 0.1 % 1 tretinoin microsphere pump external gel 0.04 %, 0.1 % 1 VARDIMAXIA EXTERNAL GEL 2-5-0.05 % 3 VAROXIA EXTERNAL CREAM 4-0.05 % 3 VAROXIA EXTERNAL GEL 4-0.05 % 3 VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-tretinoin) 3 CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ADVANCED ALLERGY COLLECTION EXTERNAL KIT 2.5 % 3 (hydrocortisone) ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) 3 ala-cort external cream 1 %, 2.5 % 1 ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) 3 alclometasone dipropionate external cream 0.05 % 1 alclometasone dipropionate external ointment 0.05 % 1 ALCORTIN A EXTERNAL GEL 1-2-1 % (iodoquinol-hc-aloe 3 polysacch) amcinonide external cream 0.1 % 1 amcinonide external lotion 0.1 % 1 amcinonide external ointment 0.1 % 1 lidocaine-hydrocortisone ace (Ana-Lex Rectal Kit 2-2 %) 1 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 3 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 3 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 2 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % (hydrocortisone 2 ace-pramoxine)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 304 Coverage Requirements & Prescription Drug Name Drug Tier Limits anucort-hc rectal suppository 25 mg 1 hydrocortisone acetate (Anusol-Hc Rectal Suppository 25 Mg) 3 APEXICON E EXTERNAL CREAM 0.05 % (diflorasone diacet 3 emoll base) BESER EXTERNAL KIT 0.05 % (fluticasone-emollient) 3 fluticasone propionate (Beser External Lotion 0.05 %) 1 betamethasone dipropionate aug external cream 0.05 % 1 betamethasone dipropionate aug external gel 0.05 % 1 betamethasone dipropionate aug external lotion 0.05 % 1 betamethasone dipropionate aug external ointment 0.05 % 1 betamethasone dipropionate external cream 0.05 % 1 betamethasone dipropionate external lotion 0.05 % 1 betamethasone dipropionate external ointment 0.05 % 1 betamethasone valerate external cream 0.1 % 1 betamethasone valerate external foam 0.12 % 1 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 BRYHALI EXTERNAL LOTION 0.01 % (halobetasol propionate) 3 calcipotriene-betameth diprop external ointment 0.005-0.064 % 1 DSL = 30 days calcipotriene-betameth diprop external suspension 0.005-0.064 1 % CALCIPOTRIENE-CLOBETASOL PROP EXTERNAL 3 SOLUTION 0.005-0.05 % CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone 3 acetonide) CHLOOXIA EXTERNAL CREAM 0.05-4 % 3 CHLOOXIA EXTERNAL OINTMENT 0.05-4 % 3 CHLOOXIA EXTERNAL SOLUTION 0.05-4 % 3 -CLOBETASOL EXTERNAL SHAMPOO 0.77- 3 0.05 % CICLOPIROX-CLOBETASOL-SAL ACID EXTERNAL 3 SHAMPOO 0.77-0.05-3 % clobetasol prop emollient base external cream 0.05 % 1 clobetasol propionate e external cream 0.05 % 1 clobetasol propionate emulsion external foam 0.05 % 1 clobetasol propionate external cream 0.05 % 1 clobetasol propionate external foam 0.05 % 1 clobetasol propionate external gel 0.05 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 305 Coverage Requirements & Prescription Drug Name Drug Tier Limits clobetasol propionate external liquid 0.05 % 1 clobetasol propionate external lotion 0.05 % 1 clobetasol propionate external ointment 0.05 % 1 clobetasol propionate external shampoo 0.05 % 1 clobetasol propionate external solution 0.05 % 1 CLOBETASOL PROP-LEVOCETIRIZINE EXTERNAL 3 SHAMPOO 0.05-2 % CLOBETASOL PROP-NIACINAMIDE EXTERNAL CREAM 3 0.05-4 % CLOBETASOL PROP-NIACINAMIDE EXTERNAL OINTMENT 3 0.05-4 % CLOBETASOL PROP-NIACINAMIDE EXTERNAL SOLUTION 3 0.05-4 % CLOBETAVIX EXTERNAL KIT 0.05 % 3 CLOBEX EXTERNAL LOTION 0.05 % (clobetasol propionate) 2 CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol 2 propionate) clocortolone pivalate external cream 0.1 % 1 CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & cleanser) 3 clobetasol propionate (Clodan External Shampoo 0.05 %) 1 clotrimazole-betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) 3 CORDRAN EXTERNAL TAPE 4 MCG/SQCM (flurandrenolide) 2 CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone acetate) 3 DERMACINRX THERAZOLE PAK EXTERNAL THERAPY 3 PACK 1-0.05 & 20 % (clotrimazole-betameth & zn ox) desonide external cream 0.05 % 1 desonide external gel 0.05 % 1 desonide external lotion 0.05 % 1 desonide external ointment 0.05 % 1 desoximetasone external cream 0.05 %, 0.25 % 1 desoximetasone external gel 0.05 % 1 desoximetasone external liquid 0.25 % 1 desoximetasone external ointment 0.05 %, 0.25 % 1 diflorasone diacetate external cream 0.05 % 1 diflorasone diacetate external ointment 0.05 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 306 Coverage Requirements & Prescription Drug Name Drug Tier Limits DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol prop- 3 ) ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- 3 betameth diprop) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 3 fluocinolone acetonide body external oil 0.01 % 1 fluocinolone acetonide external cream 0.01 %, 0.025 % 1 fluocinolone acetonide external ointment 0.025 % 1 fluocinolone acetonide external solution 0.01 % 1 fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 %, 0.1 % 1 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1 FLUOPAR EXTERNAL KIT 0.1 & 5 % (fluocinonide & 3 dimethicone) FLUOVIX EXTERNAL THERAPY PACK 0.1 % 3 FLUOVIX PLUS EXTERNAL THERAPY PACK 0.1 % 3 flurandrenolide external cream 0.05 % 1 flurandrenolide external lotion 0.05 % 1 flurandrenolide external ointment 0.05 % 1 fluticasone propionate external cream 0.05 % 1 fluticasone propionate external lotion 0.05 % 1 fluticasone propionate external ointment 0.005 % 1 halcinonide external cream 0.1 % 1 halobetasol propionate external cream 0.05 % 1 HALOBETASOL PROPIONATE EXTERNAL FOAM 0.05 % 3 DSL = 30 days halobetasol propionate external ointment 0.05 % 1 HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) 3 HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) 3 DSL = 30 days hydrocortisone acetate (Hemmorex-Hc Rectal Suppository 25 3 Mg) hydrocortisone (perianal) external cream 1 %, 2.5 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocortisone acetate rectal suppository 25 mg, 30 mg 1 hydrocortisone butyr lipo base external cream 0.1 % 1 hydrocortisone butyrate external cream 0.1 % 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 307 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocortisone butyrate external lotion 0.1 % 1 hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1 hydrocortisone external cream 1 %, 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 %, 2.5 % 1 hydrocortisone rectal enema 100 mg/60ml 1 hydrocortisone valerate external cream 0.2 % 1 hydrocortisone valerate external ointment 0.2 % 1 hydrocortisone-iodoquinol external cream 1-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 IMPEKLO EXTERNAL LOTION 0.15 MG/ACT (0.05%) 3 (clobetasol propionate) IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol propionate) 3 iodoquinol-hc-aloe polysacch external gel 1-2-1 % 1 IODOQUINOL-HC-KETOCONAZOLE EXTERNAL CREAM 1- 3 2.5-2 % iodoquinol-hydrocortisone-aloe external cream 1-1.9 % 1 KETOCONAZOLE-HYDROCORTISONE EXTERNAL CREAM 3 2-2.5 % LEXETTE EXTERNAL FOAM 0.05 % (halobetasol propionate) 3 DSL = 30 days lidocaine-hydrocort (perianal) external cream 3-0.5 % 1 LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL 2.8-0.55 3 % lidocaine-hydrocortisone ace rectal kit 2-2 %, 3-0.5 %, 3-1 %, 3- 1 2.5 % lidocaine-hydrocortisone ace (Lidocort External Cream 3-0.5 %) 3 mometasone furoate external cream 0.1 % 1 mometasone furoate external ointment 0.1 % 1 mometasone furoate external solution 0.1 % 1 NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % (neomycin- 3 fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo-fluocinolone 3 & emollient) NIACINAMIDE-TRIAMCINOLONE ACET EXTERNAL CREAM 3 4-0.1 % flurandrenolide (Nolix External Cream 0.05 %) 1 flurandrenolide (Nolix External Lotion 0.05 %) 1 NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 308 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUCORT EXTERNAL LOTION 2 % (hydrocortisone acetate) 3 triamcinolone-dimeth-silicone (Nutriarx Creampak External Kit 3 0.1 & 5 %) triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) 1 PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone probutate) 3 PHEODOYO EXTERNAL CREAM 1-2.5-2 % 3 PHEYO EXTERNAL CREAM 2.5-2 % 3 pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 3 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % 2 (pramoxine-hc) prednicarbate external cream 0.1 % 1 prednicarbate external ointment 0.1 % 1 PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 3 ace-pramoxine) PROCTOCORT RECTAL SUPPOSITORY 30 MG 3 (hydrocortisone acetate) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 3 ace-pramoxine) hydrocortisone (Procto-Med Hc External Cream 2.5 %) 1 hydrocortisone (Procto-Pak External Cream 1 %) 1 hydrocortisone (Proctozone-Hc External Cream 2.5 %) 1 PSORCON EXTERNAL CREAM 0.05 % 3 QUINIXIL EXTERNAL THERAPY PACK 0.1 & 5 % 3 (mometasone furo-dimethicone) SANADERMRX SKIN REPAIR EXTERNAL KIT 0.1 & 5 % 3 SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 sulfur & shampoo) SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone 3 dipropionate) SILA III EXTERNAL THERAPY PACK 0.1 % (triamcinolone 3 acet-silicone) SYNALAR (CREAM) EXTERNAL KIT 0.025 % (fluocinolone- 3 emollient) SYNALAR (OINTMENT) EXTERNAL KIT 0.025 % 3 (fluocinolone-emollient) SYNALAR TS EXTERNAL KIT 0.01 % (fluocinolone & cleanser) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 309 Coverage Requirements & Prescription Drug Name Drug Tier Limits TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) TASOPROL EXTERNAL KIT 0.05 % (clobetasol propionate) 3 TEXACORT EXTERNAL SOLUTION 2.5 % (hydrocortisone) 3 TOPICORT SPRAY EXTERNAL LIQUID 0.25 % 3 (desoximetasone) clobetasol propionate emulsion (Tovet External Foam 0.05 %) 1 TOVET EXTERNAL KIT 0.05 % (clobetasol emul foam 3 w/moistcr) triamcinolone acetonide external aerosol solution 0.147 mg/gm 1 triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % 1 triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 triamcinolone acetonide external ointment 0.025 %, 0.05 %, 0.1 1 %, 0.5 % triamcinolone acetonide mouth/throat paste 0.1 % 1 triamcinolone acetonide (Trianex External Ointment 0.05 %) 3 triamcinolone acetonide (Triderm External Cream 0.1 %, 0.5 %) 1 TRILOCICLO EXTERNAL KIT 0.1 & 8 % (triamcinolone acet- 3 ciclopirox) triamcinolone-dimeth-silicone (Trivix External Kit 0.1 & 5 %) 3 ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol 3 DSL = 30 days propionate) benzoyl perox-hydrocortisone (Vanoxide-Hc External Lotion 5- 3 0.5 %) VERDESO EXTERNAL FOAM 0.05 % (desonide) 3 VYTONE EXTERNAL CREAM 1-1.9 % (iodoquinol- 3 hydrocortisone-aloe) WYNZORA EXTERNAL CREAM 0.005-0.064 % (calcipotriene- 3 DSL = 30 days betameth diprop) XERESE EXTERNAL CREAM 5-1 % (acyclovir-hydrocortisone) 3 HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ciclopirox (Ciclodan External Solution 8 %) 1 ciclopirox external gel 0.77 % 1 ciclopirox external shampoo 1 % 1 ciclopirox external solution 8 % 1 ciclopirox olamine external cream 0.77 % 1 ciclopirox olamine external suspension 0.77 % 1 ciclopirox treatment external kit 8 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 310 Coverage Requirements & Prescription Drug Name Drug Tier Limits CICLOPIROX-CLOBETASOL EXTERNAL SHAMPOO 0.77- 3 0.05 % CICLOPIROX-CLOBETASOL-SAL ACID EXTERNAL 3 SHAMPOO 0.77-0.05-3 % CICLOPIROX- EXTERNAL SHAMPOO 0.77-2 3 % LOPROX EXTERNAL KIT 0.77 %, 0.77 % (SUSP) (ciclopirox 3 olamine-cleanser) TRILOCICLO EXTERNAL KIT 0.1 & 8 % (triamcinolone acet- 3 ciclopirox) AGENTS - Drugs for the Skin ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 % 3 (silver nitrate-pot nitrate) sulfacetamide sodium-sulfur (Avar Cleanser External Emulsion 3 10-5 %) AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % 3 (sulfacetamide sodium-sulfur) sulfacetamide sodium-sulfur (Avar-E Emollient External Cream 3 10-5 %) sulfacetamide sodium-sulfur (Avar-E Green External Cream 10- 3 5 %) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) BENSAL HP EXTERNAL OINTMENT 3 % 3 BENZAC AC WASH EXTERNAL LIQUID 5 % (benzoyl 3 peroxide) benzoyl peroxide (Benzepro Creamy Wash External Liquid 7 %) 3 BENZEPRO EXTERNAL 5.8 % (benzoyl peroxide) 3 BENZEPRO EXTERNAL FOAM 5.2 % (benzoyl peroxide) 3 benzoyl peroxide (Benzepro External Foam 5.3 %) 1 benzoyl peroxide (Benzepro Foaming Cloths External 6 %) 3 benzoyl peroxide (Benzepro Short Contact External Foam 9.8 3 %) BENZODOX COMBINATION THERAPY PACK 30 X 100 MG & 3 4.4%, 60 X 100 MG & 4.4% (doxycycline-benzoyl peroxide) benzoyl peroxide external foam 9.8 % 1 BENZOYL PEROXIDE EXTERNAL GEL 8 % 3 bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 bp wash external liquid 2.5 %, 7 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 311 Coverage Requirements & Prescription Drug Name Drug Tier Limits CEM- EXTERNAL SOLUTION 45 % (urea) 3 urea (Cerovel External Lotion 40 %) 1 ciclopirox treatment external kit 8 % 1 CICLOPIROX-CLOBETASOL-SAL ACID EXTERNAL 3 SHAMPOO 0.77-0.05-3 % CICLOPIROX-SALICYLIC ACID EXTERNAL SHAMPOO 0.77-2 3 % CIMETIDINE-LIDO-SALICYLIC ACID EXTERNAL CREAM 10- 3 5-40 % CLINDAMY-BENZOYL PER-NIACINAM EXTERNAL GEL 1-5-4 3 %, 2.5-1-4 % clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, 1 1.2-5 % DRAXACE EXTERNAL SUSPENSION 2-8 % 3 DRAXACE LOTION CLEANSER EXTERNAL SUSPENSION 2- 3 8 % DRIXECE EXTERNAL SUSPENSION 5-10 % 3 benzoyl peroxide (Enzoclear External Foam 9.8 %) 3 ESKATA EXTERNAL SOLUTION 40 % (hydrogen peroxide) 3 GEAMETDRAY EXTERNAL GEL 5-2-17 % 3 GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 3 acid-lactic acid) GUANENDRUX EXTERNAL CREAM 10-5-40 % 3 HYDRO 40 EXTERNAL FOAM 40 % (urea) 3 INOVA 4/1 CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % (benzoyl peroxide- 3 vitamin e) KERALAC EXTERNAL CREAM 47 % (urea) 3 KERALYT EXTERNAL GEL 6 % (salicylic acid) 2 salicylic acid (Keralyt External Shampoo 6 %) 3 KERALYT SCALP EXTERNAL KIT 6 % (salicylic acid) 3 clindamycin-benzoyl per (refr) (Neuac External Gel 1.2-5 %) 1 NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 3 moist) NUCARARXPAK EXTERNAL KIT 1-2.5 % (clindamycin-benzoyl 3 per-moist)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 312 Coverage Requirements & Prescription Drug Name Drug Tier Limits ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- 3 benzoyl perox) ONZDEOXIA EXTERNAL GEL 1-5-4 % 3 PLEXION CLEANSER EXTERNAL LIQUID 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) benzoyl peroxide (Pr Benzoyl Peroxide Wash External Liquid 7 3 %) RIAX EXTERNAL FOAM 5.5 %, 9.5 % (benzoyl peroxide) 3 SALEX EXTERNAL SHAMPOO 6 % (salicylic acid) 3 salicylic acid er external solution 28.5 % 1 salicylic acid external foam 6 % 1 salicylic acid external gel 6 % 1 salicylic acid external shampoo 6 % 1 salicylic acid external solution 26 % 1 salicylic acid wart remover external liquid 27.5 % 1 salicylic acid-cleanser external kit 6 % (cream) 1 SALICYLIC ACID-SULFACETAMIDE EXTERNAL 3 SUSPENSION 2-8 %, 5-10 % salimez external cream 6 % 1 SALIMEZ FORTE EXTERNAL CREAM 10 % 3 SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % (salicylic acid- 3 urea in lactac) SALVAX EXTERNAL FOAM 6 % (salicylic acid) 3 silver nitrate external solution 10 % 1 sss 10-5 external cream 10-5 % 1 sss 10-5 external foam 10-5 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 1 9.8-4.8 % sulfacetamide sodium-sulfur external emulsion 10-5 % 1 sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 1 %, 9.8-4.8 % sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external pad 10-4 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 313 Coverage Requirements & Prescription Drug Name Drug Tier Limits sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 % 1 sulfacetamide sod-sulfur wash external kit 9-4.5 % 1 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 1 sulfacetamide-sulfur in urea external emulsion 10-5 % 1 sulfacetamide sodium-sulfur (Sulfacleanse 8/4 External 3 Suspension 8-4 %) SUMADAN EXTERNAL KIT 9-4.5 % (sulfacetamide-sulfur- 3 cleanser) SUMADAN WASH EXTERNAL LIQUID 9-4.5 % (sulfacetamide 3 sodium-sulfur) SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide-sulfur- 3 sunscreen) SUMAXIN CP EXTERNAL KIT 10-4 % (sulfacetamide-sulfur- 3 cleanser) SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) SUMAXIN WASH EXTERNAL LIQUID 9-4 % (sulfacetamide 3 sodium-sulfur) ULTRASAL-ER EXTERNAL SOLUTION 28.5 % (salicylic acid) 3 urea (Umecta Mousse External Foam 40 %) 3 URAMAXIN EXTERNAL GEL 45 % (urea) 3 urea external cream 39 %, 40 %, 41 %, 45 %, 47 % 1 urea external lotion 40 % 1 urea hydrating external foam 35 % 1 urea nail external gel 45 % 1 UTOPIC EXTERNAL CREAM 41 % (urea) 3 VIRASAL EXTERNAL LIQUID 27.5 % (salicylic acid) 3 XALIX EXTERNAL SOLUTION 28 % (salicylic acid) 3 xurea external cream 39 % 1 ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % (benzoyl 3 peroxide-hyaluronate) zaclir cleansing external lotion 8 % 1 KERATOPLASTIC AGENTS - Drugs for the Skin EXTERNAL SOLUTION 20 % 3 DRITHO-CREME HP EXTERNAL CREAM 1 % (anthralin) 2 NUDERMRXPAK 120 EXTERNAL THERAPY PACK 0.005-5 % 3 (calcipotriene-dimethicone) NUDERMRXPAK 60 EXTERNAL THERAPY PACK 0.005-5 % 3 (calcipotriene-dimethicone)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 314 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZITHRANOL EXTERNAL SHAMPOO 1 % (anthralin) 3 LOCAL ANTI-INFECTIVES, MISCELLANEOUS - Drugs for the Skin ALCOHOL PREP PADS PAD 3 ALCOHOL PREP PADS PAD 70 % 3 ALCORTIN A EXTERNAL GEL 1-2-1 % (iodoquinol-hc-aloe 3 polysacch) sulfacetamide sodium-sulfur (Avar Cleanser External Emulsion 3 10-5 %) AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % 3 (sulfacetamide sodium-sulfur) sulfacetamide sodium-sulfur (Avar-E Emollient External Cream 3 10-5 %) sulfacetamide sodium-sulfur (Avar-E Green External Cream 10- 3 5 %) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 3 benzalkonium chloride external solution 50 % 1 bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 & 5 % 3 (OINT) (chlorhex-mupir-dimeth-silicone) DRAXACE EXTERNAL SUSPENSION 2-8 % 3 DRAXACE LOTION CLEANSER EXTERNAL SUSPENSION 2- 3 8 % DRIXECE EXTERNAL SUSPENSION 5-10 % 3 ECEOXIA EXTERNAL CREAM 4-10 % 3 FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid-oxyquinoline) 3 HIBICLENS EXTERNAL LIQUID 4 % (chlorhexidine gluconate) 3 hydrocortisone-iodoquinol external cream 1-1 % 1 iodine tincture external tincture 2 % 1 iodoquinol-hc-aloe polysacch external gel 1-2-1 % 1 IODOQUINOL-HC-KETOCONAZOLE EXTERNAL CREAM 1- 3 2.5-2 % iodoquinol-hydrocortisone-aloe external cream 1-1.9 % 1 LUGOLS STRONG IODINE EXTERNAL SOLUTION 5-10 % 3 acetate external packet 5 % 1 NIACINAMIDE-SULFACETAMIDE EXTERNAL CREAM 4-10 % 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 315 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUSURGEPAK SURGICAL PREP/CARE EXTERNAL KIT 4 & 3 2 & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) OVACE PLUS EXTERNAL CREAM 10 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL FOAM 9.8 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL LOTION 9.8 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL SHAMPOO 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL GEL 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL LIQUID 10 % (sulfacetamide 3 sodium) OVACE WASH EXTERNAL LIQUID 10 % (sulfacetamide 3 sodium) PHEODOYO EXTERNAL CREAM 1-2.5-2 % 3 PLEXION CLEANSER EXTERNAL LIQUID 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) QUINJA EXTERNAL GEL 1.25-1 % (iodoquinol-aloe 3 polysaccharide) SALICYLIC ACID-SULFACETAMIDE EXTERNAL 3 SUSPENSION 2-8 %, 5-10 % selenium sulfide external lotion 2.5 % 1 selenium sulfide external shampoo 2.25 %, 2.3 % 1 SELRX EXTERNAL SHAMPOO 2.3 % (selenium sulfide) 3 silver nitrate external solution 0.5 %, 25 %, 50 % 1 external cream 1 % 1 sodium sulfacetamide external shampoo 10 % 1 sodium sulfacetamide wash external liquid 10 % 1 SODIUM SULFACETAMIDE- EXTERNAL LIQUID 3 10 % silver sulfadiazine (Ssd External Cream 1 %) 1 sss 10-5 external cream 10-5 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 316 Coverage Requirements & Prescription Drug Name Drug Tier Limits sss 10-5 external foam 10-5 % 1 sulfacetamide sodium (acne) external lotion 10 % 1 sulfacetamide sodium external gel 10 % (cleans) 1 sulfacetamide sodium external liquid 10 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 1 9.8-4.8 % sulfacetamide sodium-sulfur external emulsion 10-5 % 1 sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 1 %, 9.8-4.8 % sulfacetamide sodium-sulfur external lotion 10-5 %, 9.8-4.8 % 1 sulfacetamide sodium-sulfur external pad 10-4 % 1 sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 % 1 sulfacetamide sod-sulfur wash external kit 9-4.5 % 1 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 1 sulfacetamide-sulfur in urea external emulsion 10-5 % 1 sulfacetamide sodium-sulfur (Sulfacleanse 8/4 External 3 Suspension 8-4 %) SULFAMYLON EXTERNAL CREAM 85 MG/GM (mafenide 2 acetate) SUMADAN EXTERNAL KIT 9-4.5 % (sulfacetamide-sulfur- 3 cleanser) SUMADAN WASH EXTERNAL LIQUID 9-4.5 % (sulfacetamide 3 sodium-sulfur) SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide-sulfur- 3 sunscreen) SUMAXIN CP EXTERNAL KIT 10-4 % (sulfacetamide-sulfur- 3 cleanser) SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) SUMAXIN WASH EXTERNAL LIQUID 9-4 % (sulfacetamide 3 sodium-sulfur) VYTONE EXTERNAL CREAM 1-1.9 % (iodoquinol- 3 hydrocortisone-aloe) NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) - Drugs for the Skin CAPSFENAC PAK COMBINATION THERAPY PACK 1.5 & 3 0.025 % CAPSINAC COMBINATION THERAPY PACK 0.025-1.5 % 3 DERMACINRX LEXITRAL PHARMAPAK COMBINATION 3 THERAPY PACK 1.5 & 0.025 % (diclofenac sodium-capsaicin)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 317 Coverage Requirements & Prescription Drug Name Drug Tier Limits DICLOFENAC PATCH EXTERNAL PATCH 1.3 % PV diclofenac sodium external gel 1 % PV diclofenac sodium external gel 3 % 1 diclofenac sodium external solution 1.5 % PV DICLOFENAC-NA HYALURON-NIACIN EXTERNAL GEL 3-2-4 3 % DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) PV DICLOPR EXTERNAL KIT 1 & 10-30 % 3 DICLOTREX EXTERNAL THERAPY PACK 1.5 & 4-10 % 3 (diclofenac sod-camphor-menthol) DICLOVIX COMBINATION KIT 1.5 & 2-2.5-4 % 3 DICLOVIX M EXTERNAL THERAPY PACK 1.5-8 % 3 DICLOZOR EXTERNAL THERAPY PACK 1 % 3 DIMENTHO EXTERNAL THERAPY PACK 1.5 & 10 % 3 enovarx-ibuprofen external cream 10 % PV enovarx-naproxen external cream 10 % PV FLECTOR EXTERNAL PATCH 1.3 % (diclofenac epolamine) PV FROTEK EXTERNAL CREAM 10 % (ketoprofen) PV GEAMETDRAY EXTERNAL GEL 5-2-17 % 3 kapzin dc combination therapy pack 0.025-1.5 % 1 LICART EXTERNAL PATCH 24 HOUR 1.3 % (diclofenac PV epolamine) diclofenac sodium-capsaicin (Nudiclo Solupak Combination 3 Therapy Pack 1.5 & 0.025 %) PENNSAID EXTERNAL SOLUTION 2 % (diclofenac sodium) PV ROAOXIA EXTERNAL GEL 3-4 % 3 SOLARAVIX EXTERNAL THERAPY PACK 3 % 3 sure result dss premium pack combination therapy pack 1.5 & 1 0.025 % VAROPHEN EXTERNAL KIT 1.5-10-15 % (diclofenac& 3 menthol-methyl sal) VENNGEL ONE EXTERNAL KIT 1 % (diclofenac sodium) PV VOLTAREN EXTERNAL GEL 1 % (diclofenac sodium) PV XRYLIX EXTERNAL THERAPY PACK 1.5 % (diclofenac sod- 3 adhesive sheet) OXABOROLES - Drugs for the Skin tavaborole external solution 5 % 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 318 Coverage Requirements & Prescription Drug Name Drug Tier Limits PIGMENTING AGENTS - Drugs for the Skin rapid oral capsule 10 mg 1 POLYENES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin nystatin (Nyamyc External Powder 100000 Unit/Gm) 1 nystatin external cream 100000 unit/gm 1 nystatin external ointment 100000 unit/gm 1 nystatin external powder 100000 unit/gm 1 nystatin-triamcinolone external cream 100000-0.1 unit/gm-% 1 nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% 1 nystatin (Nystop External Powder 100000 Unit/Gm) 1 SCABICIDES AND PEDICULICIDES - Drugs for the Skin ACYCLOVIX COMBINATION THERAPY PACK 200-10 MG-% 3 AVEIDAOXIA EXTERNAL GEL 1-1-4 % 3 crotan external lotion 10 % 1 ELIMITE EXTERNAL CREAM 5 % (permethrin) 3 ivermectin external lotion 0.5 % 1 IVERMECTIN-METRONIDAZOL-NIACIN EXTERNAL GEL 1-1- 3 4 % lindane external shampoo 1 % 1 malathion external lotion 0.5 % 1 permethrin external cream 5 % 1 spinosad external suspension 0.9 % 1 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. - Drugs for the Skin ABSORICA LD ORAL CAPSULE 16 MG, 24 MG, 32 MG, 8 MG 3 DSL = 30 days ( micronized) ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG 3 (isotretinoin) ABSORICA ORAL CAPSULE 25 MG, 35 MG (isotretinoin) 3 DSL = 30 days isotretinoin (Accutane Oral Capsule 20 Mg, 30 Mg, 40 Mg) 1 ACIOXIAY EXTERNAL CREAM 15-4 % 3 acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 DSL = 30 days ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 3 adapalene external cream 0.1 % 1 adapalene external gel 0.1 %, 0.3 % 1 ADAPALENE EXTERNAL PAD 0.1 % 3 ADAPALENE EXTERNAL SOLUTION 0.1 % 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 319 Coverage Requirements & Prescription Drug Name Drug Tier Limits ADAPALENE-BENZOYL PER-CLINDAMY EXTERNAL GEL 3 0.3-2.5-1 % ADAPALENE-BENZOYL PER-NIACINAM EXTERNAL GEL 0.3- 3 2.5-4 % adapalene-benzoyl peroxide external gel 0.1-2.5 % 1 AKLIEF EXTERNAL CREAM 0.005 % (trifarotene) 3 AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) 3 isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Mg) 1 ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) 3 ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 AVSOLA INTRAVENOUS SOLUTION RECONSTITUTED 100 3 DSL = 30 days MG (infliximab-axxq) external gel 15 % 1 AZELAIC ACID-NIACINAMIDE EXTERNAL CREAM 15-4 % 3 AZELEX EXTERNAL CREAM 20 % (azelaic acid) 3 BENZOIN EXTERNAL TINCTURE 2 calcipotriene external cream 0.005 % 1 CALCIPOTRIENE EXTERNAL FOAM 0.005 % 3 calcipotriene external ointment 0.005 % 1 calcipotriene external solution 0.005 % 1 calcipotriene-betameth diprop external ointment 0.005-0.064 % 1 DSL = 30 days calcipotriene-betameth diprop external suspension 0.005-0.064 1 % CALCIPOTRIENE-CLOBETASOL PROP EXTERNAL 3 SOLUTION 0.005-0.05 % calcitriol external ointment 3 mcg/gm 1 CANTHARIDIN EXTERNAL SOLUTION 0.7 % 3 capsaicin external cream 0.025 % 1 CAPSFENAC PAK COMBINATION THERAPY PACK 1.5 & 3 0.025 % CAPSINAC COMBINATION THERAPY PACK 0.025-1.5 % 3 CARAC EXTERNAL CREAM 0.5 % (fluorouracil) 3 isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 1 Mg) CONDYLOX EXTERNAL GEL 0.5 % (podofilox) 2 minocycline hcl (Coremino Oral Tablet Extended Release 24 1 Hour 135 Mg, 45 Mg, 90 Mg) COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION 2 DSL = 30 days PREFILLED SYRINGE 150 MG/ML (secukinumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 320 Coverage Requirements & Prescription Drug Name Drug Tier Limits COSENTYX 150 MG/ML SUBCUTANEOUS SOLUTION 2 DSL = 30 days PREFILLED SYRINGE 150 MG/ML (secukinumab) COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS 2 DSL = 30 days SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) COSENTYX SENSOREADY PEN SUBCUTANEOUS 2 DSL = 30 days SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) dapsone external gel 5 % 1 dapsone gel 7.5 % external 7.5 % 1 DAPSONE GEL 7.5 % EXTERNAL 7.5 % 3 DAPSONE-NIACINAMIDE EXTERNAL GEL 6-4 %, 8.5-4 % 3 DAPSONE-NIACINAMIDE-SPIRONOLAC EXTERNAL GEL 6- 3 2-5 %, 8.5-2-5 % DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % (sulfuric 3 acid-sulf phenolics) DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 & 5 % 3 (OINT) (chlorhex-mupir-dimeth-silicone) DERMACINRX LEXITRAL PHARMAPAK COMBINATION 3 THERAPY PACK 1.5 & 0.025 % (diclofenac sodium-capsaicin) DERMACINRX PENETRAL EXTERNAL CREAM 0.025 % 2 (capsaicin) DIADIMAXIA EXTERNAL GEL 6-2-5 % 3 DIAOXIA EXTERNAL GEL 6-4 % 3 DIASDIMAXIA EXTERNAL GEL 8.5-2-5 % 3 DIASOXIA EXTERNAL GEL 8.5-4 % 3 DICLOFENAC PATCH EXTERNAL PATCH 1.3 % PV diclofenac sodium external gel 1 % PV diclofenac sodium external gel 3 % 1 diclofenac sodium external solution 1.5 % PV DICLOFENAC-NA HYALURON-NIACIN EXTERNAL GEL 3-2-4 3 % DICLOPR EXTERNAL KIT 1 & 10-30 % 3 DICLOZOR EXTERNAL THERAPY PACK 1 % 3 DIFFERIN EXTERNAL CREAM 0.1 % (adapalene) 2 DIFFERIN EXTERNAL GEL 0.3 % (adapalene) 3 DIFFERIN EXTERNAL LOTION 0.1 % (adapalene) 3 DIMOXIA EXTERNAL GEL 4-5 % 3 doxycycline oral capsule delayed release 40 mg 1 DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol prop- 3 tazarotene)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 321 Coverage Requirements & Prescription Drug Name Drug Tier Limits DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 DSL = 30 days 300 MG/2ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED 3 DSL = 30 days SYRINGE 200 MG/1.14ML, 300 MG/2ML (dupilumab) ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) 3 ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 3 DSL = 30 days MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML 3 DSL = 30 days (etanercept) ENBREL SUBCUTANEOUS SOLUTION PREFILLED 2 DSL = 30 days SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 2 DSL = 30 days MG (etanercept) ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- 2 DSL = 30 days INJECTOR 50 MG/ML (etanercept) enovarx-baclofen external cream 1 % 1 enovarx-cyclobenzaprine hcl transdermal cream 20 mg/gm 1 ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- 3 betameth diprop) EPIDUO EXTERNAL GEL 0.1-2.5 % (adapalene-benzoyl 3 peroxide) EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- 2 benzoyl peroxide) ESKATA EXTERNAL SOLUTION 40 % (hydrogen peroxide) 3 ETHOXIA EXTERNAL CREAM 4-0.05 % 3 FABIOR EXTERNAL FOAM 0.1 % (tazarotene) 3 FINACEA EXTERNAL FOAM 15 % (azelaic acid) 3 FIRST-MOUTHWASH BLM MOUTH/THROAT SUSPENSION 3 (dph-lido-alhydr-mghydr-simeth) FLECTOR EXTERNAL PATCH 1.3 % (diclofenac epolamine) PV FLEXIPAK COMBINATION THERAPY PACK 75 & 0.025 MG-% 3 FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) 2 FLUOROURACIL EXTERNAL CREAM 0.5 % 3 fluorouracil external cream 5 % 1 fluorouracil external solution 2 %, 5 % 1 formaldehyde external solution 10 % 1 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS 3 DSL = 30 days PREFILLED SYRINGE KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 3 DSL = 30 days MG/0.4ML, 80 MG/0.8ML (adalimumab)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 322 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 2 DSL = 30 days INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- 3 DSL = 30 days INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PEDIATRIC UC START SUBCUTANEOUS 3 DSL = 30 days PEN-INJECTOR KIT 80 MG/0.8ML (adalimumab) HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS 2 DSL = 30 days PEN-INJECTOR KIT 40 MG/0.8ML (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML 3 DSL = 30 days (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 3 DSL = 30 days MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 2 DSL = 30 days MG/0.8ML (adalimumab) HYALURONATE-NIACIN-TACROLIMUS EXTERNAL CREAM 3 1-4-0.1 % ILUMYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 100 MG/ML (tildrakizumab-asmn) imiquimod external cream 3.75 %, 5 % 1 IMIQUIMOD PUMP EXTERNAL CREAM 3.75 % 3 IMIQUIMOD-LEVOCETIRIZIN-NIACIN EXTERNAL GEL 5-1-2 3 % IMIQUIMOD-LEVOCET-TRETINOIN EXTERNAL GEL 5-1-0.05 3 % inavix combination therapy pack 75 & 0.025 mg-% 1 diclofenac sodium-capsaicin (Inflammacin Combination Therapy 3 Pack 75 & 0.025 Mg-%) INFLATHERM COMBINATION THERAPY PACK 75 & 3-3 MG 3 & % (diclofenac-menthol-camphor) INFLECTRA INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab-dyyb) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 ITHOXIA EXTERNAL CREAM 4-0.1 % 3 kapzin dc combination therapy pack 0.025-1.5 % 1 KLISYRI EXTERNAL OINTMENT 1 % (tirbanibulin) 3 DSL = 30 days LEVULAN KERASTICK EXTERNAL SOLUTION 2 RECONSTITUTED 20 % (aminolevulinic acid hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 323 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOPROX EXTERNAL KIT 0.77 %, 0.77 % (SUSP) (ciclopirox 3 olamine-cleanser) MIGRANOW COMBINATION THERAPY PACK 50 & 4-10 MG 3 & % (sumatriptan & camphor-menthol) MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED 3 RELEASE 24 HOUR 135 MG, 45 MG, 90 MG minocycline hcl er oral tablet extended release 24 hour 105 mg, 1 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg MINOLIRA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 105 MG, 135 MG (minocycline hcl) MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) 3 MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG 3 (doxycycline hyclate-cleanser) MUCOTROL MOUTH/THROAT WAFER (oral wound care 3 products) isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 1 Mg) NEURAPTINE EXTERNAL CREAM 10 % (gabapentin) 3 NIACINAMIDE-SPIRONOLACTONE EXTERNAL GEL 4-5 % 3 NIACINAMIDE-TACROLIMUS EXTERNAL OINTMENT 4-0.1 % 3 NIACINAMIDE-TAZAROTENE EXTERNAL CREAM 4-0.05 %, 3 4-0.1 % NUDERMRXPAK 120 EXTERNAL THERAPY PACK 0.005-5 % 3 (calcipotriene-dimethicone) NUDERMRXPAK 60 EXTERNAL THERAPY PACK 0.005-5 % 3 (calcipotriene-dimethicone) diclofenac sodium-capsaicin (Nudiclo Solupak Combination 3 Therapy Pack 1.5 & 0.025 %) diclofenac sodium-capsaicin (Nudiclo Tabpak Combination 3 Therapy Pack 75 & 0.025 Mg-%) NUDROXIPAK COMBINATION THERAPY PACK 200 MG 3 (celecoxib-capsaic-men-methsal) NUDROXIPAK DSDR-50 COMBINATION KIT 50 MG PV (diclofenac sodium-liniment) NUDROXIPAK DSDR-75 COMBINATION KIT 75 MG PV (diclofenac sodium-liniment) NUDROXIPAK E-400 COMBINATION KIT 400 MG (etodolac- PV liniment) NUDROXIPAK I-800 COMBINATION KIT 800 MG (ibuprofen- PV liniment)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 324 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUDROXIPAK N-500 COMBINATION KIT 500 MG PV (nabumetone-liniment) NUSURGEPAK SURGICAL PREP/CARE EXTERNAL KIT 4 & 3 2 & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) OTEZLA ORAL TABLET 30 MG (apremilast) 2 DSL = 30 days OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG 2 DSL = 30 days (apremilast) OXIANUJO EXTERNAL CREAM 4-0.1 % 3 OXIANUJO EXTERNAL OINTMENT 4-0.1 % 3 PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) 3 DSL = 30 days PENNSAID EXTERNAL SOLUTION 2 % (diclofenac sodium) PV pimecrolimus external cream 1 % 1 podocon external solution 25 % 1 podofilox external solution 0.5 % 1 previdolrx plus analgesic combination therapy pack 75 & 0.025 1 mg-% PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 3 QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium tosylate) 3 QUTENZA (2 PATCH) EXTERNAL KIT 8 % (capsaicin- 3 cleansing gel) QUTENZA (4 PATCH) EXTERNAL KIT 8 % (capsaicin- 3 cleansing gel) QUTENZA EXTERNAL KIT 8 % (capsaicin-cleansing gel) 3 RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) 3 REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 2 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION RECONSTITUTED 3 100 MG (infliximab-abda) RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) 3 ROAOXIA EXTERNAL GEL 3-4 % 3 SANTYL EXTERNAL OINTMENT 250 UNIT/GM (collagenase) 2 SCENESSE SUBCUTANEOUS IMPLANT 16 MG 3 DSL = 30 days (afamelanotide acetate) SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 DSL = 30 days 210 MG/1.5ML (brodalumab) SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED 2 DSL = 30 days SYRINGE KIT 75 MG/0.83ML (risankizumab-rzaa) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 105 MG, 115 MG, 55 MG, 65 MG, 80 MG (minocycline hcl) SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 325 Coverage Requirements & Prescription Drug Name Drug Tier Limits SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) 3 STELARA INTRAVENOUS SOLUTION 130 MG/26ML 3 (ustekinumab) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML 2 (ustekinumab) STELARA SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) sure result dss premium pack combination therapy pack 1.5 & 1 0.025 % TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 (calcipotriene-betameth diprop) TACROLIMUS EXTERNAL CREAM 0.1 % 3 tacrolimus external ointment 0.03 %, 0.1 % 1 TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80 3 DSL = 30 days MG/ML (ixekizumab) TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 3 DSL = 30 days 80 MG/ML (ixekizumab) TARGRETIN EXTERNAL GEL 1 % (bexarotene) 2 tazarotene external cream 0.1 % 1 TAZAROTENE EXTERNAL FOAM 0.1 % 3 TAZORAC EXTERNAL CREAM 0.05 % (tazarotene) 2 TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) 2 TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML (fibrin sealant 3 component) TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 2 MG/ML (guselkumab) TREMFYA SUBCUTANEOUS SOLUTION PREFILLED 2 SYRINGE 100 MG/ML (guselkumab) TRI-CHLOR EXTERNAL LIQUID 80 % (trichloroacetic acid) 2 VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine hcl 3 DSL = 30 days (topical)) VECTICAL EXTERNAL OINTMENT 3 MCG/GM (calcitriol) 2 VENNGEL ONE EXTERNAL KIT 1 % (diclofenac sodium) PV VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) 3 VOLTAREN EXTERNAL GEL 1 % (diclofenac sodium) PV WINLEVI EXTERNAL CREAM 1 % (clascoterone) 3 WYNZORA EXTERNAL CREAM 0.005-0.064 % (calcipotriene- 3 DSL = 30 days betameth diprop) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 135 MG, 45 MG, 90 MG (minocycline hcl)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 326 Coverage Requirements & Prescription Drug Name Drug Tier Limits XRYLIX EXTERNAL THERAPY PACK 1.5 % (diclofenac sod- 3 adhesive sheet) isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 1 Mg) ZYCLARA PUMP EXTERNAL CREAM 2.5 %, 3.75 % 3 (imiquimod) SUNSCREEN AGENTS - Drugs for the Skin NUCARACLINPAK EXTERNAL KIT 1 % (clindamycin phos- 3 moisturizer) NUCARARXPAK EXTERNAL KIT 1-2.5 % (clindamycin-benzoyl 3 per-moist) SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide-sulfur- 3 sunscreen) SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ANTIMUSCARINICS - Drugs for the Urinary System darifenacin hydrobromide er oral tablet extended release 24 1 hour 15 mg, 7.5 mg flavoxate hcl oral tablet 100 mg 1 GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin chloride) 3 oxybutynin chloride er oral tablet extended release 24 hour 10 1 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 1 oxybutynin chloride oral tablet 5 mg 1 OXYTROL TRANSDERMAL PATCH TWICE WEEKLY 3.9 2 MG/24HR (oxybutynin) solifenacin succinate oral tablet 10 mg, 5 mg 1 tolterodine tartrate er oral capsule extended release 24 hour 2 1 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 3 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 60 1 mg trospium chloride oral tablet 20 mg 1 VESICARE LS ORAL SUSPENSION 5 MG/5ML (solifenacin 3 succinate) RESPIRATORY SMOOTH MUSCLE RELAXANTS - Drugs for Lungs ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 327 Coverage Requirements & Prescription Drug Name Drug Tier Limits THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, PV 450 mg theophylline er oral tablet extended release 24 hour 400 mg, PV 600 mg theophylline oral solution 80 mg/15ml 1 SELECTIVE BETA-3-ADRENERGIC AGONISTS - Drugs for the Urinary System GEMTESA ORAL TABLET 75 MG (vibegron) 3 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 3 25 MG, 50 MG (mirabegron) VITAMINS MULTIVITAMIN PREPARATIONS ACTIVE FE ORAL TABLET 75-1.25 MG 3 adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 ANIMI-3 ORAL CAPSULE 1 MG (fa-b6-b12-d-omega 3- 3 phytoster) ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG (fa-b6-b12-d- 3 omega 3-phytoster) AXONA ORAL PACKET (dietary management product) 3 AZESCHEW PRENATAL/POSTNATAL ORAL TABLET 3 CHEWABLE 13-1 MG AZESCO ORAL TABLET 13-1 MG 3 BACMIN ORAL TABLET (multiple vitamins-minerals) 3 biocel oral tablet 1 b-plex plus oral tablet 1 CENTRATEX ORAL CAPSULE 106-1 MG (fe fum-fa-b cmp-c- 3 zn-mg-mn-cu) CORVITE 150 ORAL TABLET (iron combinations) 3 corvite fe oral tablet 1 ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) ENLYTE ORAL CAPSULE (dietary management product) 3 FLORIVA ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG 3 (ped multiple vit-minerals-fl) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML (pediatric 3 multivitamins-fl) FOLIC-K ORAL CAPSULE 1 MG 3 FOLITIN-Z ORAL TABLET (multiple vitamins-minerals) 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 328 Coverage Requirements & Prescription Drug Name Drug Tier Limits HEMOCYTE PLUS ORAL CAPSULE 106-1 MG (fe fum-fa-b 3 cmp-c-zn-mg-mn-cu) INFUVITE ADULT INTRAVENOUS INJECTABLE (multiple 2 vitamin) INFUVITE PEDIATRIC INTRAVENOUS SOLUTION (pediatric 2 multiple vitamins) M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple vitamin) 2 M.V.I. PEDIATRIC INTRAVENOUS SOLUTION 3 RECONSTITUTED (pediatric multiple vitamins) M-NATAL PLUS ORAL TABLET 27-1 MG 3 MULTIPRO ORAL CAPSULE 3 multi-vit/iron/fluoride oral solution 0.25-10 mg/ml 1 multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multi-vitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg 1 MULTIVITAMIN/FLUORIDE ORAL TABLET CHEWABLE 0.25- 3 0.3 MG multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml 1 NEOVITE ORAL TABLET 3 NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- 3 methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o vit 3 a) NUTRICAP ORAL TABLET (multiple vitamins-minerals) 3 NUTRIVIT ORAL LIQUID (b complex-lysine-min-fe-fa) 3 OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins-minerals- 3 fa) OMNIVEX ORAL TABLET 3 ONEVITE ORAL TABLET 1 MG 3 PNV TABS 20-1 ORAL TABLET 20-1 MG 3 POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (pediatric 3 multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 3 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 MG/ML 3 (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-10 MG 3 (ped multivitamins-fl-iron) PREGEN DHA ORAL CAPSULE 28-1-35 MG 3 PREGENNA ORAL TABLET 20-1 MG 3 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 329 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 3 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat mv- 3 min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATRIX ORAL TABLET 27-1 MG (prenatal vit-fe fumarate- 3 fa) PRENATRYL ORAL TABLET 27-1 MG (prenatal vit-fe 3 fumarate-fa) preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG (multi vit- 3 min-fluoride-fe-fa) QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 MG/ML (ped 3 multivitamins-fl-iron) QUFLORA GUMMIES ORAL TABLET CHEWABLE 0.125 MG 3 (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, 0.5 3 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE 0.25 MG, 3 0.5 MG, 1 MG (pediatric multivitamins-fl) RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- 3 minerals-fa)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 330 Coverage Requirements & Prescription Drug Name Drug Tier Limits REQ 49+ ORAL TABLET (multiple vitamins-minerals) 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 3 vit-fe psac cmplx-fa) STROVITE FORTE ORAL SYRUP (multiple vitamins-minerals- 3 fa) STROVITE FORTE ORAL TABLET (multiple vitamins-minerals) 3 STROVITE ONE ORAL TABLET (multiple vitamins-minerals) 3 support oral liquid 1 TOBAKIENT ORAL CAPSULE (dietary management product) 3 TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) 3 TRINAZ ORAL TABLET 12-1 MG 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 (ped vit a-c-d-methylfolate-fl) TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML, 0.5 MG/ML 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 UDAMIN SP ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) urosex oral tablet 1 v-c forte oral capsule 1 VENEXA ORAL TABLET (multiple vitamins-minerals) 3 multiple vitamins-minerals (Vic-Forte Oral Capsule) 1 VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) multiple vitamins-minerals (Vita S Forte Oral Tablet) 1 multiple vitamins-minerals (Vitacel Oral Tablet) 1 VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITA-RX DIABETIC VITAMIN ORAL CAPSULE 3 VITRANOL FE ORAL TABLET (multiple vitamins-minerals) 3 VITREXATE FE ORAL TABLET (multiple vitamins-minerals) 3 VITREXATE ORAL TABLET (multiple vitamins-minerals) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 331 Coverage Requirements & Prescription Drug Name Drug Tier Limits VITREXYL + IRON ORAL TABLET (multiple vitamins-minerals) 3 VITREXYL ORAL TABLET (multiple vitamins-minerals) 3 vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTAB PLUS ORAL TABLET 27-1 MG 3 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 XYZBAC ORAL TABLET 3 ZALVIT ORAL TABLET 13-1 MG 3 ZYVANA ORAL CAPSULE 3 ZYVIT ORAL TABLET 3 VITAMIN A adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 AQUASOL A INTRAMUSCULAR SOLUTION 15 MG/ML, 50000 2 UNIT/ML (vitamin a) COD OIL ORAL OIL 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITAMIN B COMPLEX cyanocobalamin-methylcobalamin (Abaneu-Sl Sublingual Tablet 3 Sublingual 600-600 Mcg) ACTIVE FE ORAL TABLET 75-1.25 MG 3 ACTIVITE ORAL TABLET 1 MG 3 folic acid-vit b6-vit b12 (Airavite Oral Tablet 2.5-25-1 Mg) 1 ANIMI-3 ORAL CAPSULE 1 MG (fa-b6-b12-d-omega 3- 3 phytoster) ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG (fa-b6-b12-d- 3 omega 3-phytoster) AZESCHEW PRENATAL/POSTNATAL ORAL TABLET 3 CHEWABLE 13-1 MG AZESCO ORAL TABLET 13-1 MG 3 B-12 COMPLIANCE INJECTION INJECTION KIT 1000 3 MCG/ML BACMIN ORAL TABLET (multiple vitamins-minerals) 3 biocel oral tablet 1 BONJESTA ORAL TABLET EXTENDED RELEASE 20-20 MG 3 (doxylamine-pyridoxine) bp vit 3 oral capsule 1 mg 1 b-plex oral tablet 1 CENFOL ORAL TABLET 2.3-24.5-2 MG (folic acid-vit b6-vit 3 b12) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 332 Coverage Requirements & Prescription Drug Name Drug Tier Limits cerefolin nac oral tablet 6-90.314-2-600 mg 1 CHOLECAL DF ORAL TABLET 1-3800 MG-UNIT 3 iron combinations (Chromagen Oral Capsule) 3 CIFEREX ORAL CAPSULE 1-3775 MG-UNIT (folic acid- 3 cholecalciferol) CITRANATAL BLOOM ORAL TABLET 90-1 MG (prenatal-dss- 3 fecb-fegl-fa) CORVITE 150 ORAL TABLET (iron combinations) 3 CORVITE 150 ORAL TABLET 150-1.25 MG (iron-folic acid-c- 3 b6-b12-zinc) corvite fe oral tablet 1 cyanocobalamin injection solution 1000 mcg/ml 1 DEPLIN 15 ORAL CAPSULE 15-90.314 MG (l-methylfolate- 3 algae) DEPLIN 7.5 ORAL CAPSULE 7.5-90.314 MG (l-methylfolate- 3 algae) DERMACINRX PUREFOLIX ORAL TABLET 1-5000 MG-UNIT 3 (folic acid-cholecalciferol) b complex-c-folic acid (Dexifol Oral Tablet 5 Mg) 3 DIALYVITE 3000 ORAL TABLET 3 MG (b complex-c-biotin-e- 3 min-fa) DIALYVITE 5000 ORAL TABLET 5 MG (b complex-c-biotin-e- 3 min-fa) b complex-c-folic acid (Dialyvite Oral Tablet) 3 DIALYVITE SUPREME D ORAL TABLET 3 MG (multiple 3 vitamins-minerals-fa) DIALYVITE/ZINC ORAL TABLET (b complex-c-zn-folic acid) 3 doxylamine-pyridoxine oral tablet delayed release 10-10 mg 1 DSL = 30 days ELFOLATE ORAL TABLET 15 MG, 7.5 MG (l-methylfolate) 3 ELFOLATE PLUS ORAL TABLET 3-35-2 MG (l-methylfolate- 3 b6-b12) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 3 omega) ENLYTE ORAL CAPSULE (dietary management product) 3 fabb oral tablet 2.2-25-1 mg 1 FALESSA ORAL KIT 20-1-0.1 MCG-MG (levonorgestrel-eth PV estrad & fa) fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg 1 FERIVA 21/7 ORAL TABLET 75-1 MG (feasp-b12-fa-c-dss- 3 succac-zn)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 333 Coverage Requirements & Prescription Drug Name Drug Tier Limits FERIVAFA ORAL CAPSULE 110-1 MG (iron-vit c-fa-b12-biot- 3 cu-dss) FERRALET 90 ORAL TABLET 90-1 MG (fe cbn-fe gluc-fa-b12- 3 c-dss) ferraplus 90 oral tablet 90-1 mg 1 fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet 106- 1 1 Mg) folbee oral tablet 2.5-25-1 mg 1 FOLBEE PLUS CZ ORAL TABLET 5 MG (b-complex-c-biotin- 3 minerals-fa) folbee plus oral tablet 1 FOLBIC RF ORAL TABLET 1.13-25-2 MG (l-methylfolate-b6- 3 b12) FOLGARD RX ORAL TABLET 2.2-25-1 MG (folic acid-vit b6-vit 3 b12) folic acid injection solution 5 mg/ml 1 folic acid oral tablet 1 mg 1 FOLIC D3 ORAL CAPSULE 1-3775 MG-UNIT 3 FOLIC-K ORAL CAPSULE 1 MG 3 FOLITE ORAL TABLET 3 FOLITIN-Z ORAL TABLET (multiple vitamins-minerals) 3 FOLIXAPURE ORAL TABLET 1-5000 MG-UNIT (folic acid- 3 cholecalciferol) folplex 2.2 oral tablet 2.2-25-0.5 mg 1 foltanx oral tablet 3-35-2 mg 1 FOLTANX RF ORAL CAPSULE 3-90.314-2-35 MG (l- 3 methylfolate-algae-b12-b6) FOLTRATE ORAL TABLET 500-1 MCG-MG (cobalamin 3 combinations) FOLTREXYL ORAL TABLET 1-5000 MG-UNIT (folic acid- 3 cholecalciferol) FOLTX ORAL TABLET 1.13-25-2 MG (l-methylfolate-b6-b12) 3 folic acid-cholecalciferol (Folvite-D Oral Tablet 1-3775 Mg-Unit) 3 FUSION PLUS ORAL CAPSULE (iron-fa-b cmp-c-biot-probiotic) 3 GENADUR COMBINATION KIT (dermatological products, 3 misc.) GENICIN VITA-D ORAL TABLET 1-3775 MG-UNIT (folic acid- 3 cholecalciferol) GENICIN VITA-Q ORAL TABLET 1 MG (multiple vitamins with 3 fa)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 334 Coverage Requirements & Prescription Drug Name Drug Tier Limits b complex-c-folic acid (Genicin Vita-S Oral Tablet 1 Mg) 3 hematinic plus vit/minerals oral tablet 106-1 mg 1 hematinic/folic acid oral tablet 324-1 mg 1 HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG (fe 3 fum-vit c-vit b12-fa) HEMETAB ORAL TABLET 22-6-1-0.025 MG 3 ferrous fumarate-folic acid (Hemocyte-F Oral Tablet 324-1 Mg) 1 HYLAVITE ORAL TABLET 3 HYLAZINC ORAL TABLET 3 ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG (iron-vit c- 3 vit b12-folic acid) iron polysacch cmplx-b12-fa (Iferex 150 Forte Oral Capsule 1 150-25-1 Mg-Mcg-Mg) INTEGRA F ORAL CAPSULE 125-1 MG (fe fum-fepoly-fa-vit c- 3 vit b3) INTEGRA PLUS ORAL CAPSULE (fefum-fepoly-fa-b cmp-c- 3 biot) IROSPAN 24/6 ORAL (fe-succ ac-b cmplx-c-ca-fa) 3 l-methylfolate ca me-cbl nac oral tablet 6-90.314-2-600 mg 1 l-methylfolate calcium oral tablet 15 mg, 7.5 mg 1 l-methylfolate forte oral capsule 15-90.314 mg, 7.5-90.314 mg 1 l-methylfolate oral tablet 15 mg, 7.5 mg 1 l-methylfolate-algae oral capsule 15-90.314 mg 1 l-methylfolate-algae-b12-b6 oral capsule 3-90.314-2-35 mg 1 l-methylfolate-b6-b12 oral tablet 3-35-2 mg 1 l-methyl-mc nac oral tablet 6-2-600 mg 1 l-methyl-mc oral tablet 6-1-50-5 mg 1 LORID ORAL TABLET 1 MG 3 LORMATE ORAL CAPSULE 3 metafolbic oral tablet 6-1-50-5 mg 1 metafolbic plus oral tablet 6-2-600 mg 1 METAFOLBIC PLUS RF ORAL TABLET 6-90.314-2-600 MG 3 (methylfol-algae-b12-acetylcyst) METANX ORAL CAPSULE 3-90.314-2-35 MG (l-methylfolate- 3 algae-b12-b6) METHAVER ORAL CAPSULE 3 methylfol-algae-b12-acetylcyst oral tablet 6-90.314-2-600 mg 1 M-NATAL PLUS ORAL TABLET 27-1 MG 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 335 Coverage Requirements & Prescription Drug Name Drug Tier Limits MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- PV succ-c-thre-b12-fa) MULTIGEN PLUS ORAL TABLET 50-101-1 MG (feasp-fefum - 3 suc-c-thre-b12-fa) MULTIPRO ORAL CAPSULE 3 myferon 150 forte oral capsule 150-25-1 mg-mcg-mg 1 mynephrocaps oral capsule 1 mg 1 b complex-c-folic acid (Mynephron Oral Capsule 1 Mg) 3 NASCOBAL NASAL SOLUTION 500 MCG/0.1ML 3 (cyanocobalamin) NEOVITE ORAL TABLET 3 NEPHPLEX RX ORAL TABLET (b complex-c-zn-folic acid) 3 b complex-c-folic acid (Nephronex Oral Tablet) 1 NEPHRO-VITE RX ORAL TABLET 1 MG (b complex-c-folic 3 acid) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- 3 methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o vit 3 a) NEURIN-SL SUBLINGUAL TABLET SUBLINGUAL 600-600 3 MCG NICADAN ORAL TABLET (multiple vitamins-minerals) 3 NICAPRIN ORAL TABLET (dietary management product) 3 NICAZEL FORTE ORAL TABLET (multiple vitamins-minerals) 3 NICAZEL ORAL TABLET (multiple vitamins-minerals) 3 NICAZYME ORAL TABLET 3 NICOMIDE ORAL TABLET 750-27-2-0.5 MG (niacinamide-zn- 3 cu-methfo-se-cr) NIFEREX ORAL TABLET (iron combinations) 3 NUFERA ORAL TABLET (iron combinations) 3 NUTRICAP ORAL TABLET (multiple vitamins-minerals) 3 NUTRIVIT ORAL LIQUID (b complex-lysine-min-fe-fa) 3 OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins-minerals- 3 fa) OMNIVEX ORAL TABLET 3 ONEVITE ORAL TABLET 1 MG 3 ORTHO DF ORAL CAPSULE 1-3775 MG-UNIT 3 PHYSICIANS EZ USE B-12 INJECTION KIT 1000 MCG/ML 3 PNV TABS 20-1 ORAL TABLET 20-1 MG 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 336 Coverage Requirements & Prescription Drug Name Drug Tier Limits PODIAPN ORAL CAPSULE (l-methylfolate-b6-b12) 3 poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg 1 polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg 1 PREGEN DHA ORAL CAPSULE 28-1-35 MG 3 PREGENNA ORAL TABLET 20-1 MG 3 PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 3 prenatal oral tablet 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 3 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 3 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 3 fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG (prenat mv- 3 min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 3 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 3 (prenat w/o a-fe-methfol-fa-dha) PRENATRIX ORAL TABLET 27-1 MG (prenatal vit-fe fumarate- 3 fa) PRENATRYL ORAL TABLET 27-1 MG (prenatal vit-fe 3 fumarate-fa) preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 3 PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-meth-fa- 3 omeg w/o a) pyridoxine hcl injection solution 100 mg/ml 1 RELNATE DHA ORAL CAPSULE 28-1-200 MG 3 REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- 3 minerals-fa) b complex-c-folic acid (Renal Oral Capsule 1 Mg) 3 RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c- 3 biotin-e-fa-fe cbn)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 337 Coverage Requirements & Prescription Drug Name Drug Tier Limits RESTORA RX ORAL CAPSULE 60-1.25 MG (lactobacillus 3 casei-folic acid) REVESTA ORAL CAPSULE 1-5750 MG-UNIT 3 RIBOZEL ORAL CAPSULE 3 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 3 vit-fe psac cmplx-fa) SIDEROL ORAL TABLET (multiple vitamins-minerals) 3 STROVITE FORTE ORAL SYRUP (multiple vitamins-minerals- 3 fa) STROVITE FORTE ORAL TABLET (multiple vitamins-minerals) 3 STROVITE ONE ORAL TABLET (multiple vitamins-minerals) 3 SUPERVITE ORAL LIQUID (b complex-lysine-zn-fa) 3 SUPPORT-500 ORAL CAPSULE (specialty vitamins products) 3 thiamine hcl injection solution 100 mg/ml 1 tl-hem 150 oral tablet 150-1 mg 1 TOBAKIENT ORAL CAPSULE (dietary management product) 3 TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 3 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) 3 TRINAZ ORAL TABLET 12-1 MG 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 TRONVITE ORAL TABLET 1 MG 3 UDAMIN SP ORAL TABLET 1 MG (multiple vitamins-minerals- 3 fa) urosex oral tablet 1 v-c forte oral capsule 1 VENEXA ORAL TABLET (multiple vitamins-minerals) 3 multiple vitamins-minerals (Vic-Forte Oral Capsule) 1 VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 3 fumarate-fa) virt-caps oral capsule 1 mg 1 VIRT-FEFA PLUS ORAL CAPSULE 3 folic acid-vit b6-vit b12 (Virt-Gard Oral Tablet 2.2-25-1 Mg) 1 multiple vitamins-minerals (Vita S Forte Oral Tablet) 1 multiple vitamins-minerals (Vitacel Oral Tablet) 1 VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 3 fum-methf-fa w/o a) Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 338 Coverage Requirements & Prescription Drug Name Drug Tier Limits VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 3 fum-fa-dha) VITAL-D RX ORAL TABLET 1 MG (b complex-c-biotin-d-zinc- 3 fa) vitamin b complex 100 injection injectable 1 vitamin b-complex 100 injection injectable 1 VITA-RX DIABETIC VITAMIN ORAL CAPSULE 3 VITASURE ORAL TABLET 1 MG 3 VITRANOL FE ORAL TABLET (multiple vitamins-minerals) 3 VITREXATE FE ORAL TABLET (multiple vitamins-minerals) 3 VITREXATE ORAL TABLET (multiple vitamins-minerals) 3 VITREXYL + IRON ORAL TABLET (multiple vitamins-minerals) 3 VITREXYL ORAL TABLET (multiple vitamins-minerals) 3 vp-pnv-dha oral capsule 28-1-215.8 mg 1 vp-vite rx oral tablet 1 mg 1 westab max oral tablet 2.5-25-2 mg 1 westab mini oral tablet 2.2-25-1 mg 1 westab one oral tablet 2.5-25-1 mg 1 WESTAB PLUS ORAL TABLET 27-1 MG 3 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 3 XAQUIL XR ORAL TABLET EXTENDED RELEASE 30 MG 3 (levomefolate glucosamine) XVITE ORAL TABLET 1 MG 3 XYZBAC ORAL TABLET 3 ZALVIT ORAL TABLET 13-1 MG 3 ZYVANA ORAL CAPSULE 3 ZYVIT ORAL TABLET 3 VITAMIN C ACTIVITE ORAL TABLET 1 MG 3 adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML 3 (ascorbic acid) ASCORBIC ACID SOLUTION 500 MG/ML INJECTION 500 3 MG/ML ascorbic acid solution 500 mg/ml injection 500 mg/ml 1 b-plex oral tablet 1 iron combinations (Chromagen Oral Capsule) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 339 Coverage Requirements & Prescription Drug Name Drug Tier Limits CITRANATAL BLOOM ORAL TABLET 90-1 MG (prenatal-dss- 3 fecb-fegl-fa) CORVITE 150 ORAL TABLET 150-1.25 MG (iron-folic acid-c- 3 b6-b12-zinc) b complex-c-folic acid (Dexifol Oral Tablet 5 Mg) 3 b complex-c-folic acid (Dialyvite Oral Tablet) 3 DIALYVITE/ZINC ORAL TABLET (b complex-c-zn-folic acid) 3 ENLYTE ORAL CAPSULE (dietary management product) 3 FERIVA 21/7 ORAL TABLET 75-1 MG (feasp-b12-fa-c-dss- 3 succac-zn) FERIVAFA ORAL CAPSULE 110-1 MG (iron-vit c-fa-b12-biot- 3 cu-dss) FERRALET 90 ORAL TABLET 90-1 MG (fe cbn-fe gluc-fa-b12- 3 c-dss) ferraplus 90 oral tablet 90-1 mg 1 fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet 106- 1 1 Mg) folbee plus oral tablet 1 FUSION PLUS ORAL CAPSULE (iron-fa-b cmp-c-biot-probiotic) 3 b complex-c-folic acid (Genicin Vita-S Oral Tablet 1 Mg) 3 hematinic plus vit/minerals oral tablet 106-1 mg 1 HEMATOGEN FA ORAL CAPSULE 200-250-0.01-1 MG (fe 3 fum-vit c-vit b12-fa) HYLAVITE ORAL TABLET 3 ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG (iron-vit c- 3 vit b12-folic acid) INTEGRA F ORAL CAPSULE 125-1 MG (fe fum-fepoly-fa-vit c- 3 vit b3) INTEGRA PLUS ORAL CAPSULE (fefum-fepoly-fa-b cmp-c- 3 biot) IROSPAN 24/6 ORAL (fe-succ ac-b cmplx-c-ca-fa) 3 LORID ORAL TABLET 1 MG 3 MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- PV succ-c-thre-b12-fa) MULTIGEN PLUS ORAL TABLET 50-101-1 MG (feasp-fefum - 3 suc-c-thre-b12-fa) mynephrocaps oral capsule 1 mg 1 b complex-c-folic acid (Mynephron Oral Capsule 1 Mg) 3 NEPHPLEX RX ORAL TABLET (b complex-c-zn-folic acid) 3 b complex-c-folic acid (Nephronex Oral Tablet) 1 Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 340 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEPHRO-VITE RX ORAL TABLET 1 MG (b complex-c-folic 3 acid) NIFEREX ORAL TABLET (iron combinations) 3 NUFERA ORAL TABLET (iron combinations) 3 OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins-minerals- 3 fa) b complex-c-folic acid (Renal Oral Capsule 1 Mg) 3 RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c- 3 biotin-e-fa-fe cbn) RIBOZEL ORAL CAPSULE 3 SIDEROL ORAL TABLET (multiple vitamins-minerals) 3 SUPPORT-500 ORAL CAPSULE (specialty vitamins products) 3 tl-hem 150 oral tablet 150-1 mg 1 TOBAKIENT ORAL CAPSULE (dietary management product) 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 TRONVITE ORAL TABLET 1 MG 3 virt-caps oral capsule 1 mg 1 VIRT-FEFA PLUS ORAL CAPSULE 3 VITAL-D RX ORAL TABLET 1 MG (b complex-c-biotin-d-zinc- 3 fa) vitamins acd-fluoride oral solution 0.25 mg/ml 1 VITASURE ORAL TABLET 1 MG 3 vp-vite rx oral tablet 1 mg 1 XVITE ORAL TABLET 1 MG 3 ZYVANA ORAL CAPSULE 3 VITAMIN D adc/f (0.5mg/ml) oral solution 0.5 mg/ml 1 ANIMI-3 ORAL CAPSULE 1 MG (fa-b6-b12-d-omega 3- 3 phytoster) ANIMI-3/VITAMIN D ORAL CAPSULE 1 MG (fa-b6-b12-d- 3 omega 3-phytoster) calcidol oral solution 200 mcg/ml PV calcitriol intravenous solution 1 mcg/ml PV calcitriol oral capsule 0.25 mcg, 0.5 mcg PV calcitriol oral solution 1 mcg/ml PV CHOLECAL DF ORAL TABLET 1-3800 MG-UNIT 3 CIFEREX ORAL CAPSULE 1-3775 MG-UNIT (folic acid- 3 cholecalciferol)

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 341 Coverage Requirements & Prescription Drug Name Drug Tier Limits COD LIVER OIL ORAL OIL 3 d3 high potency oral capsule 25 mcg (1000 ut) 1 d3 super strength oral capsule 50 mcg (2000 ut) 1 DECARA ORAL CAPSULE 1.25 MG (50000 UT), 250 MCG 3 (10000 UT) (cholecalciferol) DERMACINRX PUREFOLIX ORAL TABLET 1-5000 MG-UNIT 3 (folic acid-cholecalciferol) DIALYVITE SUPREME D ORAL TABLET 3 MG (multiple 3 vitamins-minerals-fa) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1 DRISDOL ORAL CAPSULE 1.25 MG (50000 UT) PV (ergocalciferol) ERGOCAL ORAL CAPSULE 62.5 MCG (2500 UT) PV ergocalciferol oral capsule 1.25 mg (50000 ut) PV ergocalciferol oral solution 200 mcg/ml PV FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium 3 fluoride-vitamin d) FOLIC D3 ORAL CAPSULE 1-3775 MG-UNIT 3 FOLITE ORAL TABLET 3 FOLIXAPURE ORAL TABLET 1-5000 MG-UNIT (folic acid- 3 cholecalciferol) FOLTREXYL ORAL TABLET 1-5000 MG-UNIT (folic acid- 3 cholecalciferol) folic acid-cholecalciferol (Folvite-D Oral Tablet 1-3775 Mg-Unit) 3 FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 5600 MG-UNIT (alendronate-cholecalciferol) GENICIN VITA-D ORAL TABLET 1-3775 MG-UNIT (folic acid- 3 cholecalciferol) b complex-c-folic acid (Nephronex Oral Tablet) 1 NUFERA ORAL TABLET (iron combinations) 3 ORTHO DF ORAL CAPSULE 1-3775 MG-UNIT 3 paricalcitol intravenous solution 2 mcg/ml, 5 mcg/ml 1 paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG PV DSL = 30 days (calcifediol) REVESTA ORAL CAPSULE 1-5750 MG-UNIT 3 ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG (calcitriol) PV ROCALTROL ORAL SOLUTION 1 MCG/ML (calcitriol) PV STROVITE ONE ORAL TABLET (multiple vitamins-minerals) 3

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 342 Coverage Requirements & Prescription Drug Name Drug Tier Limits TOBAKIENT ORAL CAPSULE (dietary management product) 3 tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml 1 VITAL-D RX ORAL TABLET 1 MG (b complex-c-biotin-d-zinc- 3 fa) vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) PV vitamins acd-fluoride oral solution 0.25 mg/ml 1 weekly-d oral capsule 1.25 mg (50000 ut) 1 ZYVANA ORAL CAPSULE 3 VITAMIN E FOLIC-K ORAL CAPSULE 1 MG 3 OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins-minerals- 3 fa) WHEAT GERM OIL ORAL OIL 3 VITAMIN K ACTIVITY INFUVITE ADULT INTRAVENOUS INJECTABLE (multiple 2 vitamin) MEPHYTON ORAL TABLET 5 MG (phytonadione) PV phytonadione injection solution 1 mg/0.5ml, 10 mg/ml 1 phytonadione oral tablet 5 mg PV vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml 1

Drug Tier 1: Formulary Generic; Drug Tier 2: Formulary Brand; Drug Tier 3: Non-Formulary, Non-Preferred Brand; OC: Oral anti-cancer; PV: Preventative; QL: Quantity Limit; DSL: Max day supply limit per prescription 343 Index of Drugs 3232a infant formula...... 174 acetaminophen-codeine #3 ADRENALIN...... 52, 196, 275 abacavir sulfate...... 21 ...... 119, 143 Adriamycin...... 31 abacavir sulfate-lamivudine...... 21 acetaminophen-codeine #4 adriamycin...... 31 abacavir-lamivudine- ...... 119, 143 adult aspirin regimen zidovudine...... 21 acetazolamide...... 96, 176, 188 ...... 76, 77, 128, 155 Abaneu-Sl...... 332 acetazolamide er...... 96, 176, 188 ADVAIR DISKUS ABILIFY...... 125, 132 acetic acid...... 192 ...... 61, 207, 281, 284 ABILIFY MAINTENA...... 125, 131 acetylcysteine...... 267, 281 ADVAIR HFA.... 61, 207, 281, 284 ABILIFY MYCITE...... 125, 132 acid reducer...... 203 ADVANCED ALLERGY ABILIFY MYCITE ACIOXIAY...... 319 COLLECTION...... 291, 304 MAINTENANCE KIT...... 125, 131 ACIPHEX SPRINKLE...... 204 ADVATE...... 68 ABILIFY MYCITE STARTER acitretin...... 319 ADVIL...... 149 KIT...... 125, 132 ACREMONIUM...... 45, 167, 267 ADVIL JUNIOR STRENGTH.. 149 abiraterone acetate...... 30 ACTEMRA...... 256, 259 ADVIL MIGRAINE...... 149 ABRAXANE...... 31 ACTEMRA ACTPEN...... 255, 259 ADYNOVATE...... 68 ABSORICA...... 319 ACTHAR...... 167, 239 ADYPHREN...... 52, 275 ABSORICA LD...... 319 ACTIMMUNE...... 259 ADYPHREN AMP...... 52, 275 ACACIA...... 45, 167, 267 ACTIVASE...... 77, 183 ADYPHREN AMP II...... 52, 275 acamprosate calcium...... 139 ACTIVE FE...... 72, 328, 332 ADYPHREN II...... 52, 275 acarbose...... 212 ACTIVE INJECTION D...... 207 ADZENYS ER...... 118 ACCOLATE...... 280 ACTIVELLA...... 227, 240 ADZENYS XR-ODT...... 118 ACCUCAINE...... 160, 247, 296 ACTIVITE...... 332, 339 AEMCOLO...... 28 ACCU-CHEK AVIVA...... 160 ACTONEL...... 252 AFINITOR...... 31 ACCU-CHEK AVIVA PLUS.....171 ACTOPLUS MET...... 215, 246 AFINITOR DISPERZ...... 31 ACCU-CHEK COMPACT ACTOS...... 246 Afirmelle...... 216 PLUS CONTROL...... 160 ACULAR...... 193 AFLURIA QUADRIVALENT...... 52 ACCU-CHEK COMPACT ACULAR LS...... 193 AFREZZA...... 233, 242 PLUS TEST STRIPS...... 171 ACUVAIL...... 193 AFSTYLA...... 68 ACCU-CHEK FASTCLIX acyclovir...... 25, 300 AGONEAZE...... 296 LANCET KIT...... 160 ACYCLOVIX...... 25, 319 AIMOVIG...... 128, 138 ACCU-CHEK GUIDE...... 160, 171 ACZONE...... 288, 319 Airavite...... 332 ACCU-CHEK GUIDE ADAKVEO...... 65 AIRDUO DIGIHALER CONTROL...... 160 adapalene...... 319 ...... 61, 207, 281, 285 ACCU-CHEK SMARTVIEW ADAPALENE...... 319 AIRDUO RESPICLICK 113/14 CONTROL...... 160 ADAPALENE-BENZOYL PER- ...... 61, 207, 281, 285 ACCU-CHEK SMARTVIEW CLINDAMY...... 288, 320 AIRDUO RESPICLICK 232/14 TEST STRIPS...... 171 ADAPALENE-BENZOYL PER- ...... 61, 207, 282, 285 ACCU-CHEK SOFTCLIX NIACINAM...... 320 AIRDUO RESPICLICK 55/14 LANCET DEVICE KIT...... 160 adapalene-benzoyl peroxide...320 ...... 61, 207, 282, 285 ACCU-CHEK TENDER 1 ADASUVE...... 130 AJOVY...... 128, 138 INFUSION...... 160 adc/f (0.5mg/ml) AKLIEF...... 320 ACCU-CHEK ULTRAFLEX ...... 253, 328, 332, 339, 341 ak-poly-bac...... 185 INF SET...... 160 ADCETRIS...... 31 AKTEN...... 194 ACCUPRIL...... 82, 83 ADDERALL XR...... 118 AKYNZEO...... 197, 203, 204 ACCURETIC...... 82, 83, 111, 180 ADDYI...... 139 ALA SCALP...... 291, 304 Accutane...... 319 adefovir dipivoxil...... 25 ala-cort...... 291, 304 ACD-A NOCLOT-50...... 65 ADEMPAS...... 113, 287 ALA-QUIN...... 291, 304 acebutolol hcl.. 63, 86, 87, 98, 106 ADHANSIA XR...... 153 albendazole...... 14 acetaminophen-codeine..119, 143 ADLYXIN...... 232 ALBENZA...... 14 acetaminophen-codeine #2 ADLYXIN STARTER PACK.... 232 albuterol sulfate...... 61, 62, 285 ...... 119, 143 ADMELOG...... 233, 242 ALBUTEROL SULFATE... 62, 285 ADMELOG SOLOSTAR. 233, 241 albuterol sulfate er...... 61, 285

344 albuterol sulfate hfa...... 61, 285 ALTOPREV...... 105 AMPHETAMINE ER...... 118 ALBUTEROL SULFATE HFA ALTRENO...... 303 amphetamine sulfate...... 118 ...... 61, 285 ALUNBRIG...... 31 amphetamine- ALCAINE...... 194 ALVESCO...... 207, 282 dextroamphetamine...... 118 alclometasone dipropionate alvimopan...... 201 amphetamine- ...... 291, 304 alyacen 1/35...... 216 dextroamphetamine er...... 118 ALCOHOL PREP PADS...... 315 alyacen 7/7/7...... 216 ampicillin...... 13 ALCORTIN A...... 291, 304, 315 Alyq...... 109, 287 ampicillin-sulbactam sodium..... 14 ALDACTAZIDE Amabelz...... 227, 240 AMPYRA...... 267 ...... 108, 110, 111, 178, 181 amantadine hcl...... 12, 117 AMZEEQ...... 288 ALDACTONE...... 108, 110, 178 AMARYL...... 245 ANACAINE...... 296 ALDER...... 45, 167, 267 ambrisentan...... 113, 287 ANAFRANIL...... 159 ALDURAZYME...... 183 amcinonide...... 291, 304 anagrelide hcl...... 77 ALECENSA...... 31 AMELUZ...... 320 Ana-Lex...... 291, 296, 304 alendronate sodium...... 252 AMERICAN BEECH..45, 168, 267 ANALPRAM HC...... 291, 296, 304 ALEVE...... 149, 251 AMERICAN COCKROACH ANALPRAM HC SINGLES ALFERON N...... 23, 31 ...... 45, 168, 267 ...... 291, 296, 304 alfuzosin hcl er...... 61 AMERICAN ELM...... 46, 168, 267 ANALPRAM-HC...... 291, 296, 304 ALIMTA...... 31 Amethia...... 216 ANASPAZ...... 54 ALINIA...... 15 Amethyst...... 216 anastrozole...... 31, 214 ALIQOPA...... 31 amikacin sulfate...... 13, 15 ANDEXXA...... 65 aliskiren fumarate...... 110 amiloride hcl...... 110, 178 ANDRODERM...... 212 ALKERAN...... 31 amiloride-hydrochlorothiazide ANGELIQ...... 227, 240 ALKINDI SPRINKLE...... 207 ...... 110, 111, 178, 181 ANIMI-3...... 85, 328, 332, 341 allopurinol...... 251 aminoacetic acid...... 176 ANIMI-3/VITAMIN D ALLZITAL...... 119, 134 aminocaproic acid...... 68 ...... 85, 328, 332, 341 almotriptan malate...... 156 Aminoreliefrms...... 267 ANNOVERA...... 216 ALOCRIL...... 185, 281 amiodarone hcl...... 99 ANODYNE LPT...... 296 ALOGLIPTIN BENZOATE...... 226 AMITIZA...... 199 ANORO ELLIPTA54, 62, 276, 285 ALOGLIPTIN-METFORMIN amitriptyline hcl...... 159 ANTARA...... 104 HCL...... 215, 226 amlodipine besylate ANTICOAGULANT SODIUM ALOGLIPTIN-PIOGLITAZONE ...... 91, 101, 102, 106, 113 CITRATE...... 65, 173 ...... 226, 246 amlodipine besylate-benazepril ANTIVENIN LATRODECTUS ALOMIDE...... 185 hcl. 82, 84, 91, 101, 103, 106, 113 MACTANS...... 49, 249 ALORA...... 227 amlodipine besylate-valsartan ANTIVENIN MICRURUS alosetron hcl...... 199 ...... 79, 80, 91, 101, 103, 106, 113 FULVIUS...... 49, 249 ALOXI...... 197 amlodipine-atorvastatin anucort-hc...... 291, 305 ALPHAGAN P...... 184 ...... 91, 101, 103, 105, 113 Anusol-Hc...... 291, 305 ALPHANATE...... 68 amlodipine-olmesartan ANZEMET...... 197 ALPHANINE SD...... 68 ...... 79, 80, 91, 101, 103, 106, 113 APADAZ...... 119, 143 alprazolam...... 136 amlodipine-valsartan-hctz apap-caff-dihydrocodeine alprazolam er...... 136 ...... 79, 81, 91, 101, 103, 111, 181 ...... 119, 143, 153 alprazolam intensol...... 136 ammonium lactate...... 302 APEXICON E...... 291, 305 alprazolam xr...... 136 Amnesteem...... 320 APIDRA SOLOSTAR...... 233, 242 ALPROLIX...... 68 AMONDYS 45...... 252 APIDRA VIAL...... 233, 242 ALREX...... 189 amoxapine...... 159 APLENZIN...... 124 ALTABAX...... 288 amoxicill-clarithro-lansopraz APOKYN...... 142 Altacaine...... 194 ...... 13, 26, 204 apraclonidine hcl...... 192 ALTACE...... 82, 84 amoxicillin...... 13 aprepitant...... 204 ALTAFLUOR BENOX..... 172, 194 amoxicillin-potassium Apri...... 216 Altafrin...... 196 clavulanate...... 13 APRIZIO PAK...... 296 Altavera...... 216 amoxicillin-potassium APRIZIO PAK II...... 296 ALTERNARIA...... 45, 167, 267 clavulanate er...... 13 APTIOM...... 121

345 APTIVUS...... 22, 23 aspirin adult low strength AUTOSOFT 90 INFUSION AQUASOL A...... 332 ...... 76, 77, 128, 155 SET...... 160 ARAKODA...... 14 aspirin childrens.. 76, 77, 128, 155 AUTOSOFT XC INFUSION ARALAST NP...... 284 aspirin ec...... 76, 77, 128, 155 SET...... 161 Aranelle...... 216 aspirin ec low dose AUVI-Q...... 52, 275 ARANESP (ALBUMIN FREE)...66 ...... 76, 77, 128, 155 AVAILNEX...... 267 ARAZLO...... 320 aspirin ec low strength AVALIDE...... 79, 81, 111, 181 ARCALYST...... 267 ...... 76, 77, 128, 155 AVAPRO...... 79, 81 ARESTIN...... 185 aspirin low dose.. 76, 77, 128, 155 Avar Cleanser...... 311, 315 ARIDOL...... 172 aspirin-dipyridamole er AVAR LS CLEANSER.... 311, 315 ARIKAYCE...... 13 ...... 76, 113, 155 Avar-E Emollient...... 311, 315 ARIMIDEX...... 31, 214 ASPIRIN-OMEPRAZOLE Avar-E Green...... 311, 315 aripiprazole...... 125, 132 ...... 76, 77, 155, 205 AVAR-E LS...... 311, 315 ARISTADA...... 125, 132 ASTAGRAF XL...... 265 AVASTIN...... 31 ARISTADA INITIO...... 125, 132 ASTERO...... 160, 297 AVEED...... 213 ARIXTRA...... 65, 66 ASTRINGYN...... 68 AVEIDAOXIA...... 288, 319 ARIZONA CYPRESS 46, 168, 267 ATACAND...... 79, 81 Aviane...... 217 armodafinil...... 160 ATACAND HCT.. 79, 81, 111, 181 avidoxy...... 28 ARMONAIR DIGIHALER 207, 282 atazanavir sulfate...... 23 AVIDOXY DK...... 28 ARMOUR THYROID...... 246 ATELVIA...... 252 Avita...... 303 ARNUITY ELLIPTA...... 207, 282 atenolol...... 63, 86, 87, 98 AVITENE...... 68 AROMASIN...... 31, 214 atenolol-chlorthalidone AVITENE FLOUR...... 68 ARRANON...... 31 ...... 63, 86, 87, 98, 113, 182 AVONEX PEN...... 259 arsenic trioxide...... 31 ATGAM...... 265 AVONEX PREFILLED...... 259 ARTISS...... 320 ATIVAN...... 136, 137 AVSOLA...... 201, 256, 259, 320 ARZERRA...... 31 atomoxetine hcl...... 139 AXONA...... 174, 328 ARZOL SILVER NIT ATOPADERM...... 160 AYGESTIN...... 240 APPLICATORS...... 311 ATOPICLAIR...... 160, 302 Ayuna...... 217 ASCENIV...... 49 atorvastatin calcium...... 105 AYVAKIT...... 31 Ascomp-Codeine atovaquone...... 15 azacitidine...... 31 ...... 128, 135, 143, 153, 155 atovaquone-proguanil hcl...... 14 AZALGIA...... 267 ASCOR...... 339 ATRIPLA...... 20, 21 AZASAN...... 256, 259, 265 ASCORBIC ACID...... 339 ATROPEN...... 54, 249, 276 AZASITE...... 185 ascorbic acid...... 339 atropine sulfate...... 54, 195, 276 azathioprine...... 256, 260, 265 asenapine maleate...... 125, 132 ATROPINE SULFATE azathioprine sodium 256, 260, 265 Ashlyna...... 216 ...... 54, 195, 276 azelaic acid...... 320 ASMANEX (120 METERED ATROVENT HFA...... 54, 276 AZELAIC ACID-NIACINAMIDE DOSES)...... 207, 282 AUBAGIO...... 259 ...... 320 ASMANEX (14 METERED Aubra...... 216 azelastine hcl...... 185 DOSES)...... 207, 282 Aubra Eq...... 216 azelastine-fluticasone ASMANEX (30 METERED AUGMENTIN...... 14 ...... 185, 189, 281, 284 DOSES)...... 208, 282 AUREOBASIDIUM....46, 168, 267 AZELEX...... 320 ASMANEX (60 METERED Aurovela 1.5/30...... 216 AZESCHEW DOSES)...... 208, 282 Aurovela 1/20...... 216 PRENATAL/POSTNATAL ASMANEX (7 METERED Aurovela 24 Fe...... 216 ...... 72, 328, 332 DOSES)...... 208, 282 Aurovela Fe 1.5/30...... 217 AZESCO...... 72, 328, 332 ASMANEX HFA...... 208, 282 Aurovela Fe 1/20...... 217 azithromycin...... 26 ASPARLAS...... 31 AURYXIA...... 177 AZOR ASPARTAME...... 274 AUSTEDO...... 139, 159 ...... 79, 81, 91, 101, 103, 106, 113 ASPARTAME AUSTRALIAN PINE.. 46, 168, 267 Azurette...... 217 (NUTRASWEET)...... 274 AUTOLET LANCING DEVICE 160 B-12 COMPLIANCE aspirin...... 76, 77, 128, 155 AUTOSOFT 30 INFUSION INJECTION...... 332 SET...... 160 Bac...... 119, 128, 135, 153

346 bacitracin...... 185 BENZHYDROCODONE- BIJUVA...... 227, 240 bacitracin-polymyxin b...... 185 ACETAMINOPHEN...... 119, 143 BIKTARVY...... 20, 21 bacitra-neomycin-polymyxin-hc BENZNIDAZOLE...... 15 BILTRICIDE...... 14 ...... 185, 189 BENZODOX...... 28, 311 bimatoprost...... 196 baclofen...... 58 BENZOIN...... 275, 320 BINOSTO...... 252 BACMIN...... 72, 328, 332 benzoin compound...... 275, 302 Bio Glo...... 172 BAFIERTAM...... 260, 267 benzonatate...... 277 biocel...... 328, 332 BAHIA...... 46, 168, 267 benzoyl peroxide...... 311 bisacodyl...... 199 BALCOLTRA...... 217 BENZOYL PEROXIDE...... 311 bisacodyl ec...... 199 BALD CYPRESS...... 46, 168, 267 benzoyl peroxide-erythromycin bisoprolol fumarate. 63, 86, 87, 98 balsalazide disodium...... 199 ...... 288 bisoprolol-hydrochlorothiazide BALVERSA...... 31 benzphetamine hcl...... 118 ...... 63, 86, 88, 98, 111, 181 Balziva...... 217 benztropine mesylate...... 57, 120 BIVIGAM...... 49 BAMLANIVIMAB...... 24 BEOVU...... 192 BLACK WILLOW...... 46, 168, 268 BANZEL...... 121 BEPREVE...... 185 BLENREP...... 32 BAQSIMI ONE PACK..... 229, 249 BERINERT...... 255 bleomycin sulfate...... 32 BAQSIMI TWO PACK.....229, 249 BERMUDA GRASS.. 46, 168, 268 BLEPHAMIDE...... 185 BARACLUDE...... 25 Beser...... 291, 305 BLEPHAMIDE S.O.P...... 185 BASAGLAR KWIKPEN... 233, 238 BESER...... 305 BLINCYTO...... 32 BAVENCIO...... 32 BESIVANCE...... 185 Blisovi 24 Fe...... 217 BAXDELA...... 27 BESPONSA...... 32 Blisovi Fe 1.5/30...... 217 BAYBERRY (WAX MYRTLE) BETA 1 KIT...... 208 Blisovi Fe 1/20...... 217 ...... 46, 168, 267 BETADINE OPHTHALMIC BONIVA...... 252 BAYER ASPIRIN 76, 78, 129, 155 PREP...... 192 BONJESTA...... 198, 279, 332 BAYER ASPIRIN EC LOW BETALOAN SUIK... 161, 208, 297 BORTEZOMIB...... 32 DOSE...... 76, 77, 129, 155 betamethasone dipropionate bosentan...... 113, 287 BEAU RX...... 161 ...... 291, 292, 305 BOSULIF...... 32 BECONASE AQ...... 189, 281 betamethasone dipropionate BOTOX...... 64, 268 Bekyree...... 217 aug...... 291, 305 BOTRYTIS...... 46, 168, 268 BELBUCA...... 148 BETAMETHASONE SOD bp 10-1...... 311, 315 BELEODAQ...... 32 PHOS & ACET...... 208 bp cleansing wash...... 311, 315 belladonna alkaloids-opium.... 143 betamethasone sod phos & bp vit 3...... 85, 332 BELRAPZO...... 32 acet...... 208 bp wash...... 311 BELSOMRA...... 130 betamethasone valerate. 292, 305 b-plex...... 332, 339 benazepril hcl...... 82, 84 BETAPACE b-plex plus...... 72, 328 benazepril-hydrochlorothiazide ...... 58, 86, 87, 98, 100, 106 BRAFTOVI...... 32 ...... 82, 84, 111, 181 BETAPACE AF BREO ELLIPTA 62, 208, 282, 285 BENDEKA...... 32 ...... 58, 86, 87, 98, 100, 106 BREYANZI...... 32, 117 BENEFIX...... 68 BETASERON...... 260 BREZTRI AEROSPHERE BENICAR...... 79, 81 betaxolol hcl ...... 54, 62, 208, 276, 282, 285 BENICAR HCT....79, 81, 111, 181 ...... 63, 86, 87, 98, 106, 188 BRIDION...... 249 BENLYSTA...... 265 bethanechol chloride...... 60 briellyn...... 217 BENSAL HP...... 311 BETIMOL...... 188 BRILINTA...... 76, 77 BENZ PER-CLIND-NIACIN- BETOPTIC-S...... 188 brimonidine tartrate...... 184 TRETIN...... 288, 303 BEVACIZUMAB...... 192 BRIMONIDINE- BENZAC AC WASH...... 311 BEVESPI AEROSPHERE DORZOLAMIDE...... 184, 188 BENZALKONIUM CHLORIDE 315 ...... 54, 62, 276, 285 BRINEURA...... 183 benzalkonium chloride...... 315 bexarotene...... 32 brinzolamide...... 188 BENZEPRO...... 311 BEYAZ...... 217 BRIVIACT...... 121 Benzepro...... 311 bicalutamide...... 32 BROME...... 46, 168, 268 Benzepro Creamy Wash...... 311 BICILLIN L-A...... 25 bromfenac sodium (once-daily) Benzepro Foaming Cloths...... 311 BICNU...... 32 ...... 193 Benzepro Short Contact...... 311 BIDIL...... 104, 109 bromocriptine mesylate...... 141

347 BROMSITE...... 193 CADUET... 91, 101, 103, 105, 113 carbidopa...... 139 BRONCHITOL...... 284 CAFERGOT...... 59, 129 carbidopa-levodopa...... 140 BRONCHITOL TOLERANCE caffeine citrate...... 154 carbidopa-levodopa er...... 140 TEST...... 284 CALAN SR carbidopa-levodopa- BROVANA...... 62, 285 ...... 89, 91, 93, 95, 100, 113 entacapone...... 139, 140 BRUKINSA...... 32 calcidol...... 341 carbinoxamine maleate...... 9, 279 BRYHALI...... 305 calcipotriene...... 320 carboplatin...... 32 BSP 0820...... 208 CALCIPOTRIENE...... 320 CARDIOPLEGIA DEL NIDO budesonide...... 208, 282 calcipotriene-betameth diprop FORMULA...... 178 budesonide er...... 208 ...... 292, 305, 320 CARDIOPLEGIA IND PLASMA BUDESONIDE- CALCIPOTRIENE- HIGH K...... 178 FORMOTEROL FUMARATE CLOBETASOL PROP.....305, 320 CARDIOPLEGIA IND ...... 62, 208, 282, 285 calcitonin (salmon).. 214, 239, 252 PLASMA-TROMET...... 178 bumetanide...... 108, 176 calcitriol...... 320, 341 CARDIOPLEGIA INDUCTION BUNAVAIL...... 148 calcium acetate...... 177 HIGH K...... 178 BUPHENYL...... 174 calcium acetate (phos binder) CARDIOPLEGIA INDUCTION bupivacaine fisiopharma...... 247 ...... 177, 178 LOW DEX...... 178 bupivacaine hcl...... 247 calcium-folic acid plus d...... 178 CARDIOPLEGIA INDUCTION bupivacaine hcl (pf)...... 247 CALDOLOR...... 149 NON-ENR...... 178 buprenorphine...... 148 CALIFORNIA PEPPER TREE CARDIOPLEGIA MAIN LOW buprenorphine hcl...... 148 ...... 46, 168, 268 DEXTROSE...... 178 buprenorphine hcl-naloxone CALQUENCE...... 32 CARDIOPLEGIA MAIN LOW hcl...... 148 CAMBIA...... 129, 149 TROMETHA...... 178 bupropion hcl...... 124 Camila...... 217 CARDIOPLEGIA MAIN bupropion hcl er (smoking det)124 CAMINO PRO PLASMA-TROME...... 178 bupropion hcl er (sr)...... 124 COMPLETE/GLYTACTIN...... 174 CARDIOPLEGIA bupropion hcl er (xl)...... 124 CAMPATH...... 32 MAINTENANCE...... 178 BUPROPION HCL ER (XL).... 124 Camrese...... 217 CARDIOPLEGIA buspirone hcl...... 130 Camrese Lo...... 217 REPERFUSATE 4:1...... 178 busulfan...... 32 CANASA...... 199 CARDIOVID PLUS...... 268 butalbital-acetaminophen 119, 135 CANCIDAS...... 17 CARDIZEM BUTALBITAL- candesartan cilexetil...... 79, 81 ...... 90, 91, 94, 95, 100, 114 ACETAMINOPHEN...... 119, 135 candesartan cilexetil-hctz CARDIZEM CD butalbital-apap-caff-cod ...... 79, 81, 111, 181 ...... 89, 91, 93, 95, 100, 114 ...... 119, 129, 135, 143, 154 CANDIDA ALBICANS CARDIZEM LA butalbital-apap-caffeine EXTRACT...... 46, 168, 268 ...... 90, 91, 94, 95, 100, 114 ...... 119, 129, 135, 154 CANTHARIDIN...... 320 CARDURA...... 59, 78, 106 butalbital-asa-caff-codeine CAPASTAT SULFATE...... 15 CARDURA XL...... 59, 78, 79, 106 ...... 129, 135, 143, 154, 155 capecitabine...... 32 CARETOUCH butalbital-aspirin-caffeine CAPEX...... 292, 305 LANCING/EJECTOR...... 161 ...... 77, 78, 129, 135, 154, 155 CAPLYTA...... 132 CARETOUCH TEST...... 171 butorphanol tartrate...... 148 CAPRELSA...... 32 CARIMUNE NF...... 49 BYDUREON BCISE capsaicin...... 320 carisoprodol...... 57 AUTOINJECTOR...... 233 CAPSFENAC PAK..149, 317, 320 carisoprodol-aspirin-codeine BYETTA 10 MCG PEN...... 233 CAPSINAC...... 149, 317, 320 ...... 57, 143, 155 BYETTA 5 MCG PEN...... 233 captopril...... 82, 84 carmustine...... 32 BYNFEZIA PEN...... 245 captopril-hydrochlorothiazide CARNITOR...... 268 BYSTOLIC...... 58, 86 ...... 82, 84, 111, 181 CAROSPIR...... 108, 110, 178 CABENUVA...... 20 CARAC...... 32, 320 carteolol hcl...... 188 cabergoline...... 141 CARAFATE...... 204 Cartia Xt.. 90, 91, 94, 95, 100, 114 CABLIVI...... 65 CARBAGLU...... 174 CARTICEL...... 268 CABOMETYX...... 32 carbamazepine...... 121, 125, 126 carvedilol...58, 61, 78, 86, 98, 106 CADIRAMD...... 161, 297 carbamazepine er...... 121, 125

348 carvedilol phosphate er CETACAINE...... 297 CIMZIA PREFILLED KIT ...... 58, 61, 78, 86, 98, 106 cetirizine hcl...... 10, 284 ...... 201, 256, 260 cascara sagrada...... 199 CETROTIDE...... 214, 259 CIMZIA STARTER KIT CASIRIVIMAB...... 24 cevimeline hcl...... 60 ...... 201, 256, 260 CASODEX...... 32 CHANTIX...... 57 cinacalcet hcl...... 214, 268 caspofungin acetate...... 18 CHANTIX CONTINUING CINQAIR...... 280 CAT HAIR EXTRACT46, 168, 268 MONTH PAK...... 57 CINRYZE...... 255 Cataflam...... 149 CHANTIX STARTING MONTH CIPRO...... 16, 27 CATAPRES-TTS-1...... 53, 97 PAK...... 57 CIPRO HC...... 185, 189 CATAPRES-TTS-2...... 53, 97 Charlotte 24 Fe...... 217 CIPRODEX...... 185, 189 CATAPRES-TTS-3...... 53, 97 Chateal...... 217 ciprofloxacin hcl...... 16, 28, 185 CATHFLO ACTIVASE...... 78, 183 Chateal Eq...... 217 ciprofloxacin-dexamethasone CATTLE EPITHELIUM CHEMET...... 206, 249 ...... 185, 189 ...... 46, 168, 268 CHENODAL...... 201 CIPROFLOXACIN- Cavarest...... 253 CHLOOXIA...... 305 FLUOCINOLONE PF...... 185, 189 CAVERJECT...... 114 chloramphenicol sod succinate.17 cisplatin...... 33 CAVERJECT IMPULSE...... 114 chlordiazepoxide hcl...... 137 CISPLATIN...... 33 CAYA...... 273 chlordiazepoxide-amitriptyline citalopram hydrobromide...... 157 CAYSTON...... 24 ...... 137, 159 CITRANATAL BLOOM Caziant...... 217 chlordiazepoxide-clidinium 54, 137 ...... 72, 333, 340 CEDAR ELM...... 46, 168, 268 chlorhexidine gluconate...... 192 citroma...... 199 cefaclor...... 11 chloroquine phosphate...... 14 CLADOSPORIUM cefaclor er...... 11 chlorpromazine hcl...... 153 CLADOSPORIOIDES46, 168, 268 cefadroxil...... 11 chlorthalidone...... 113, 182 CLADOSPORIUM cefazolin sodium...... 11 chlorzoxazone...... 57 SPHAEROSPERMUM cefazolin sodium-dextrose...... 11 CHOLBAM...... 201 ...... 46, 168, 268 cefdinir...... 11 CHOLECAL DF...... 333, 341 cladribine...... 33 cefepime hcl...... 12 cholestyramine...... 89 Claravis...... 320 cefixime...... 11 cholestyramine light...... 89 CLARINEX-D 12 HOUR cefotaxime sodium...... 11 CHONDROITIN SULFATE..... 192 ...... 11, 53, 275, 284 cefotetan disodium...... 11, 17 chorionic gonadotropin....230, 231 clarithromycin...... 16, 26 cefoxitin sodium...... 11, 17 Chromagen...... 72, 333, 339 clarithromycin er...... 16, 26 cefpodoxime proxetil...... 11, 12 Ciclodan...... 310 clearlax...... 199 cefprozil...... 11 ciclopirox...... 310 clemastine fumarate...... 9, 279 ceftazidime...... 12 ciclopirox olamine...... 310 CLENPIQ...... 199 ceftriaxone sodium...... 12 ciclopirox treatment...... 310, 312 CLEOCIN...... 24, 288 cefuroxime axetil...... 11 CICLOPIROX-CLOBETASOL CLIMARA...... 227 celecoxib...... 140 ...... 305, 311 CLIMARA PRO...... 227 CELEXA...... 157 CICLOPIROX-CLOBETASOL- CLINDACIN ETZ...... 288 CELONTIN...... 159 SAL ACID...... 305, 311, 312 Clindacin Etz...... 288 CEM-UREA...... 312 CICLOPIROX-SALICYLIC CLINDACIN PAC...... 288 CENFOL...... 332 ACID...... 311, 312 Clindacin-P...... 288 CENTANY AT...... 288 cidofovir...... 25 CLINDAGEL...... 289 CENTRATEX...... 72, 328 CIFEREX...... 333, 341 CLINDAMY-BENZOYL PER- cephalexin...... 11 cilostazol...... 77, 109 NIACINAM...... 289, 312 CEQUA...... 192 CILOXAN...... 185 clindamycin hcl...... 24 CEQUR SIMPLICITY 2U...... 161 CIMDUO...... 21 clindamycin palmitate hcl...... 24 CERACADE...... 302 cimetidine...... 203 clindamycin phos-benzoyl CERDELGA...... 268 cimetidine hcl...... 203 perox...... 289, 312 cerefolin nac...... 333 CIMETIDINE-LIDO- CLINDAMYCIN PHOS- CEREZYME...... 183 SALICYLIC ACID...... 312 NIACINAMIDE...... 289 Cerovel...... 312 CIMZIA...... 202, 256, 260 clindamycin phosphate...... 289 CERVIDIL...... 274 CLINDAMYCIN PHOSPHATE 289

349 CLINDAMYCIN-NIACIN- COLESTID FLAVORED...... 89 COSMEGEN...... 33 TRETINOIN...... 289, 303 colestipol hcl...... 89 cosyntropin...... 167 clindamycin-tretinoin...... 289, 303 colistimethate sodium (cba)...... 27 COTELLIC...... 33 CLINDESSE...... 289 COMBIGAN...... 184, 188 COTEMPLA XR-ODT...... 154 CLIND-NIACIN- COMBIPATCH...... 227, 240 Covaryx...... 213, 227 SPIRONOLAC-TRETIN.. 289, 303 COMBIVENT RESPIMAT Covaryx Hs...... 213, 227 Clinpro 5000...... 253 ...... 54, 62, 276, 285 COZAAR...... 79, 81 clobazam...... 136, 137 COMETRIQ...... 33 CREON...... 201 clobetasol prop emollient base COMPLERA...... 21 CRESEMBA...... 16 ...... 292, 305 Compro...... 153, 198 CRESTOR...... 105 clobetasol propionate CONCERTA...... 154 CRINONE...... 240 ...... 292, 305, 306 CONDYLOX...... 320 CRIXIVAN...... 23 clobetasol propionate e...292, 305 CONJUPRI91, 101, 103, 106, 114 CROFAB...... 49, 249 clobetasol propionate emulsion CONSENSI...... 101, 114, 140 cromolyn sodium...... 185, 281 ...... 292, 305 constulose...... 174 crotan...... 319 CLOBETASOL PROP- CONTOUR CONTROL...... 161 Cryselle-28...... 217 LEVOCETIRIZINE...... 306 CONTOUR MONITOR CRYSVITA...... 176 CLOBETASOL PROP- DEVICE...... 161 CUBICIN...... 17 NIACINAMIDE...... 306 CONTOUR MONITOR KIT CUBICIN RF...... 17 CLOBETAVIX...... 306 W/DEVICE...... 161 CUPRIMINE...... 206, 256 CLOBEX...... 292, 306 CONTOUR NEXT CONTROL.161 CUROSURF...... 283 CLOBEX SPRAY...... 292, 306 CONTOUR NEXT EZ...... 161 CURVULARIA...... 46, 168, 268 clocortolone pivalate...... 292, 306 CONTOUR NEXT LINK...... 161 CUTAQUIG...... 49 CLODAN...... 292, 306 CONTOUR NEXT MONITOR. 161 CUVITRU...... 49 Clodan...... 292, 306 CONTOUR NEXT TEST...... 171 CUVPOSA...... 54 clofarabine...... 33 CONTOUR TEST...... 171 cvs gentle laxative...... 199 clomiphene citrate...... 227 CONTRAVE...... 120 cvs motion sickness.... 9, 198, 279 clomipramine hcl...... 159 CONZIP...... 143 cyanocobalamin...... 333 clonazepam...... 136, 137 COPASIL...... 275 Cyclafem 1/35...... 217 clonidine...... 53, 97 COPAXONE...... 260 Cyclafem 7/7/7...... 218 clonidine hcl...... 53, 97 COPIKTRA...... 33 cyclobenzaprine hcl...... 57 clonidine hcl er...... 53, 97 CORDRAN...... 292, 306 cyclobenzaprine hcl er...... 57 clopidogrel bisulfate...... 77 COREG.....58, 61, 78, 86, 98, 106 CYCLOGYL...... 195 clorazepate dipotassium. 136, 137 COREG CR CYCLOMYDRIL...... 195 clotrimazole...... 300 ...... 58, 61, 78, 86, 98, 106 CYCLOPAK...... 57, 297 clotrimazole-betamethasone Coremino...... 28, 320 cyclopentolate hcl...... 195 ...... 292, 300, 306 CORGARD...... 58, 86, 88, 98 cyclophosphamide...... 33, 265 Clovique...... 206 CORIFACT...... 68 CYCLOPHOSPHAMIDE... 33, 265 clozapine...... 132 CORLANOR...... 96 cycloserine...... 16 CLOZARIL...... 132 CORN POLLEN...... 46, 168, 268 CYCLOSET...... 141 COAGADEX...... 68 CORTANE-B...... 189 cyclosporine...... 256, 260, 265 COAL TAR...... 314 CORTIFOAM...... 292, 306 CYCLOSPORINE IN KLARITY COARTEM...... 14 CORTISPORIN-TC...... 186 ...... 192 COCAINE HCL...... 194 CORTROSYN...... 167 cyclosporine modified COCKLEBUR...... 46, 168, 268 CORVITE 150... 72, 328, 333, 340 ...... 256, 260, 265 COD LIVER OIL...... 332, 342 corvite fe...... 72, 328, 333 CYMBALTA...... 141, 156 codeine sulfate...... 143, 277 COSELA...... 273 cyproheptadine hcl...... 9, 279 COLCHICINE...... 251 COSENTYX (300 MG DOSE).320 CYRAMZA...... 33 colchicine...... 251 COSENTYX 150 MG/ML...... 321 Cyred...... 218 colchicine-probenecid..... 183, 251 COSENTYX SENSOREADY Cyred Eq...... 218 COLCRYS...... 251 (300 MG)...... 321 CYSTADANE...... 268 colesevelam hcl...... 89, 213, 214 COSENTYX SENSOREADY CYSTADROPS...... 192 COLESTID...... 89 PEN...... 321 CYSTAGON...... 268

350 CYSTARAN...... 192 Dentagel...... 253 dexchlorpheniramine maleate cytarabine...... 33 DEOXIA...... 289 ...... 9, 10, 279 cytarabine (pf)...... 33 DEPAKOTE...... 121, 126, 129 DEXCOM G4 / G5 / G6 CYTOGAM...... 50 DEPAKOTE ER...... 121, 126, 129 RECEIVER, TRANSMITTER, CYTOMEL...... 246 DEPAKOTE SPRINKLES SENSOR (INCLUDING CYTOTEC...... 204 ...... 121, 126, 129 PLATINUM, PLATINUM cytra k crystals...... 173 DEPEN TITRATABS...... 206, 256 PEDIATRIC)...... 161 d3 high potency...... 342 DEPLIN 15...... 333 DEXERYL...... 302 d3 super strength...... 342 DEPLIN 7.5...... 333 Dexifol...... 333, 340 dacarbazine...... 33 DEPO-ESTRADIOL...... 228 DEXILANT...... 205 DACOGEN...... 33 DEPO-MEDROL...... 208 dexmedetomidine hcl...... 130 dactinomycin...... 33 DEPO-PROVERA...... 240 dexmedetomidine hcl in nacl...130 dalfampridine er...... 268 DEPO-SUBQ PROVERA 104.240 dexmethylphenidate hcl...... 154 DALIRESP...... 283 DEPO-TESTOSTERONE...... 213 dexmethylphenidate hcl er...... 154 danazol...... 213 DERMACINRX DEXONTO 0.4%...... 209 dantrolene sodium...... 58 CLORHEXACIN...... 289, 315, 321 dexrazoxane hcl...... 273 DANYELZA...... 33 Dermacinrx Empricaine...... 297 DEXTENZA...... 189 dapsone...... 15, 289, 321 DERMACINRX LEXITRAL dextroamphetamine sulfate.....118 DAPSONE...... 289, 321 PHARMAPAK...... 149, 317, 321 dextroamphetamine sulfate er 118 DAPSONE-NIACINAMIDE DERMACINRX PENETRAL....321 DEXYCU...... 189 ...... 289, 321 DERMACINRX PHN...... 297, 302 DIACOMIT...... 121 DAPSONE-NIACINAMIDE- Dermacinrx Prizopak...... 297 DIADIMAXIA...... 289, 321 SPIRONOLAC...... 289, 321 DERMACINRX PUREFOLIX Dialyvite...... 333, 340 daptomycin...... 17 ...... 333, 342 DIALYVITE 3000...... 333 DARAPRIM...... 14 DERMACINRX THERAZOLE DIALYVITE 5000...... 333 darifenacin hydrobromide er... 327 PAK...... 292, 300, 302, 306 DIALYVITE SUPREME D333, 342 DARZALEX...... 33 DERMACINRX ZRM...... 297, 302 DIALYVITE/ZINC...... 333, 340 DARZALEX FASPRO...... 33 DERMALID...... 297 DIAOXIA...... 289, 321 Dasetta 1/35...... 218 DERMELLE...... 302 DIASDIMAXIA...... 289, 321 Dasetta 7/7/7...... 218 DESCOVY...... 21 DIASOXIA...... 289, 321 daunorubicin hcl...... 33 desflurane...... 142 DIASTAT ACUDIAL...... 136, 137 DAURISMO...... 33 desipramine hcl...... 159 DIASTAT PEDIATRIC.....136, 137 DAYPRO...... 149 desloratadine...... 11, 284 diazepam...... 136, 137 Daysee...... 218 desmopressin ace spray refrig Diazepam Intensol...... 136, 137 DAYTRANA...... 154 ...... 69, 239 diazoxide...... 214 DAYVIGO...... 130 desmopressin acetate...... 69, 239 DIBENZYLINE...... 59, 106 DDAVP RHINAL TUBE.....68, 239 desmopressin acetate pf...69, 239 DICLOFENAC CAP...... 149 DEBACTEROL...... 192, 321 desmopressin acetate spray... 239 DICLOFENAC PATCH Deblitane...... 218 desogestrel-ethinyl estradiol... 218 ...... 149, 318, 321 Decadron...... 208 desonide...... 292, 306 diclofenac potassium...... 149 DECARA...... 342 desoximetasone...... 293, 306 diclofenac sodium decitabine...... 33 DESVENLAFAXINE ER...... 156 ...... 33, 149, 193, 318, 321 deferasirox...... 206 desvenlafaxine succinate er....156 diclofenac sodium er...... 149 deferasirox granules...... 206 DEXABLISS...... 208 diclofenac-misoprostol.... 149, 204 deferiprone...... 206 dexamethasone...... 208, 209 DICLOFENAC-NA deferoxamine mesylate...206, 249 dexamethasone intensol...... 208 HYALURON-NIACIN DELESTROGEN...... 227 dexamethasone sod ...... 149, 192, 318, 321 DELSTRIGO...... 21 phosphate pf...... 209 DICLOFONO...... 149, 318 Delyla...... 218 dexamethasone sodium DICLOPR...... 149, 318, 321 demeclocycline hcl...... 28 phosphate...... 189, 209 DICLOTREX...... 150, 318 DEMSER...... 268 DEXAMETHASONE SODIUM DICLOVIX...... 150, 297, 318 DENAVIR...... 300 PHOSPHATE...... 209 DICLOVIX M...... 150, 318 Denta 5000 Plus...... 253 dicloxacillin sodium...... 27

351 DICLOZOR...... 150, 318, 321 DOG EPITHELIUM... 46, 168, 268 DUPIXENT...... 280, 322 DICOPANOL FUSEPAQ.....9, 279 DOG FENNEL...... 46, 168, 268 duramorph...... 143 dicyclomine hcl...... 54 DOJOLVI...... 174 DUREZOL...... 189 diethylpropion hcl...... 118 donepezil hcl...... 60 DURLAZA...... 77, 78, 129, 155 diethylpropion hcl er...... 117 DONNATAL...... 55, 134, 135 DUROLANE...... 161 DIFFERIN...... 321 DOPTELET...... 66 DURYSTA...... 196 DIFICID...... 26 DORYX...... 29 DUST MITE MIXED diflorasone diacetate...... 293, 306 DORYX MPC...... 28 ALLERGEN EXT...... 46, 168, 269 diflunisal...... 150 DORZOLAMIDE HCL...... 188 dutasteride...... 248 DIFMETIOXRIME...... 300 dorzolamide hcl...... 188 dutasteride-tamsulosin hcl 61, 248 DIGIFAB...... 50, 249 dorzolamide hcl-timolol mal.... 188 DUTOPROL Digitek...... 85, 96 dorzolamide hcl-timolol mal pf 188 ...... 63, 86, 88, 98, 111, 181 Digox...... 85, 96 Dotti...... 228 DXEVO 11-DAY...... 209 digoxin...... 85, 96 DOUBLEDEX...... 209 DYANAVEL XR...... 118 dihydroergotamine mesylate DOVATO...... 20, 21 DYRENIUM...... 110, 178 ...... 59, 129 doxazosin mesylate DYSPORT...... 64, 269 DILANTIN...... 97, 141 ...... 59, 78, 79, 107 E.E.S. GRANULES...... 18, 24 DILATRATE-SR...... 109 doxepin hcl...... 159, 297 EASIVENT...... 161 diltiazem hcl doxercalciferol...... 342 EASTERN COTTONWOOD ...... 90, 92, 94, 95, 100, 114 DOXIL...... 34 ...... 46, 168, 269 diltiazem hcl er doxorubicin hcl...... 34 EASYMAX CONTROL...... 161 ...... 90, 92, 94, 95, 100, 114 doxorubicin hcl liposomal...... 34 ECEOXIA...... 315 diltiazem hcl er beads Doxy 100...... 29 EC-NAPROSYN...... 150, 251 ...... 90, 91, 94, 95, 100, 114 doxycycline...... 29, 321 ec-naproxen...... 150, 251 diltiazem hcl er coated beads doxycycline hyclate...... 29, 186 ECONASIL...... 300 ...... 90, 91, 92, 94, 95, 100, 114 DOXYCYCLINE HYCLATE...... 29 econazole nitrate...... 300 DILTIAZEM HCL-DEXTROSE doxycycline monohydrate...... 29 ECONAZOLE NITRATE- ...... 90, 92, 94, 95, 100, 114 doxylamine-pyridoxine NIACINAMIDE...... 301 dilt-xr...... 90, 92, 94, 95, 100, 114 ...... 198, 279, 333 ECOZA...... 301 DIMENTHO...... 150, 318 DRAXACE...... 312, 315 EDARBI...... 79, 81 dimethyl fumarate...... 260 DRAXACE LOTION EDARBYCLOR... 80, 81, 113, 182 dimethyl fumarate starter pack 260 CLEANSER...... 312, 315 EDECRIN...... 108, 176 DIMOXIA...... 321 DRECHSLERA...... 46, 168, 268 EDEX...... 114 DIOVAN...... 79, 81 DRISDOL...... 342 EDLUAR...... 131 DIOVAN HCT...... 79, 81, 111, 181 DRITHO-CREME HP...... 314 ED-SPAZ...... 55 DIPENTUM...... 199 DRIXECE...... 312, 315 EDURANT...... 21 diphen...... 9, 279 DRIZALMA SPRINKLE... 141, 156 Eemt...... 213, 228 DI-PHEN...... 9, 279 dronabinol...... 198 Eemt Hs...... 213, 228 diphenhydramine hcl...... 9, 279 drospiren-eth estrad-levomefol218 efavirenz...... 21 diphenoxylate-atropine drospirenone-ethinyl estradiol.218 efavirenz-emtricitab-tenofovir....21 ...... 54, 198, 276 DROXIA...... 34 efavirenz-lamivudine-tenofovir dipyridamole...... 77, 114 droxidopa...... 53 ...... 21, 22 disopyramide phosphate...... 97 DRYSOL...... 300 EFFER-K...... 179 disulfiram...... 248 DSUVIA...... 143 Effer-K...... 179 DIURIL...... 111, 181 DUAKLIR PRESSAIR EFFEXOR XR...... 156 divalproex sodium... 121, 126, 129 ...... 55, 62, 276, 286 EFFIENT...... 77 divalproex sodium er DUAVEE...... 227, 228 EGATEN...... 14 ...... 121, 126, 129 DUETACT...... 245, 246 EGRIFTA SV...... 245 DIVIGEL...... 228 DUEXIS...... 150, 203 EHA...... 297 DMT SUIK...... 161, 209 DULERA...... 62, 209, 283, 286 ELAPRASE...... 183 docetaxel...... 33, 34 duloxetine hcl...... 141, 156 ELELYSO...... 183 docusate sodium...... 199 DUOBRII...... 307, 321 ELEPSIA XR...... 121 dofetilide...... 100 DUOPA...... 140 ELESTRIN...... 228

352 ELETONE...... 161, 302 enovarx-lidocaine hcl...... 297 ERIVEDGE...... 34 eletriptan hydrobromide...... 156 enovarx-naproxen...... 293, 318 ERLEADA...... 34 ELFOLATE...... 333 enoxaparin sodium...... 71 erlotinib hcl...... 34 ELFOLATE PLUS...... 333 Enpresse-28...... 218 Errin...... 218 ELIDEL...... 265, 322 Enskyce...... 218 ERTACZO...... 301 ELIGARD...... 34, 230, 231 ENSPRYNG...... 260 ertapenem sodium...... 17 ELIMITE...... 319 ENSTILAR...... 293, 307, 322 ERWINAZE...... 34 Elinest...... 218 entacapone...... 139 ery...... 289 ELIQUIS...... 66 entecavir...... 25 ERYPED 200...... 18, 24 ELIQUIS DVT/PE STARTER ENTERAGAM...... 269 ERYTHROCIN STEARATE 18, 24 PACK...... 66 ENTOCORT EC...... 209 erythromycin...... 18, 24, 186, 289 ELITEK...... 183 ENTRESTO...... 81, 111 erythromycin base...... 18, 24 ELIXOPHYLLIN ENTTY SPRAY...... 162 erythromycin ethylsuccinate 18, 24 ...... 104, 176, 288, 327 ENTYVIO...... 202, 260 ESBRIET...... 277 ELLA...... 218 enulose...... 174 escitalopram oxalate...... 157 ELMIRON...... 273 ENVARSUS XR...... 265 ESKATA...... 312, 322 ELOCTATE...... 69 ENZADYNE...... 201 ESMOLOL HCL...... 64, 86, 88, 98 Eluryng...... 218 Enzoclear...... 312 ESOMEP-EZS...... 205 ELZONRIS...... 34 EPANED...... 82, 84 esomeprazole magnesium...... 205 EMCYT...... 34 EPCLUSA...... 18, 19 ESOMEPRAZOLE EMEND...... 204 ephedrine sulfate...... 53, 275 STRONTIUM...... 205 EMEND TRI-PACK...... 204 EPHEDRINE SULFATE-NACL ESPEROCT...... 69 EMFLAZA...... 209 ...... 53, 275 ESSENTIAL CARE JR...... 174 EMGALITY...... 129, 138 EPICERAM...... 162 est estrogens-methyltest.213, 228 EMGALITY (300 MG DOSE).. 138 EPICOCCUM...... 46, 169, 269 est estrogens-methyltest ds Emoquette...... 218 EPIDIOLEX...... 121 ...... 213, 228 EMPLICITI...... 34 EPIDUO...... 322 est estrogens-methyltest hs EMPRICAINE-II...... 297 EPIDUO FORTE...... 322 ...... 213, 228 EMSAM...... 142 EPIFOAM...... 293, 297, 307 Estarylla...... 218 emtricitabine...... 22 epinastine hcl...... 185 estazolam...... 137 emtricitabine-tenofovir df...... 22 epinephrine...... 53, 275 ESTRACE...... 228 EMTRIVA...... 22 EPINEPHRINE estradiol...... 228 EMULSION SB...... 161 PROFESSIONAL...... 53, 276 estradiol valerate...... 228 EMVERM...... 14 EPINEPHRINESNAP-EMS estradiol-norethindrone acet enalapril maleate...... 82, 84 ...... 53, 276 ...... 228, 241 enalapril-hydrochlorothiazide EPINEPHRINESNAP-V.... 53, 276 ESTRING...... 228 ...... 82, 84, 111, 181 epirubicin hcl...... 34 ESTROGEL...... 228 ENBRACE HR...... 72, 328, 333 EPISIL...... 162 ESTROSTEP FE...... 218 ENBREL...... 256, 260, 322 EPISNAP...... 53, 276 eszopiclone...... 131 ENBREL MINI...... 256, 260, 322 Epitol...... 121, 126 ETESEVIMAB...... 24 ENBREL SURECLICK EPIVIR HBV...... 22 ethacrynic acid...... 108, 176 ...... 256, 260, 322 eplerenone...... 108, 110 ethambutol hcl...... 16 ENDARI...... 202, 269 EPOGEN...... 66 ethosuximide...... 159 ENDO AVITENE...... 69 epoprostenol sodium...... 114, 287 ETHOXIA...... 322 Endocet...... 119, 143 EQUACARE JR...... 174 ethyl chloride...... 297 ENDOMETRIN...... 240 EQUETRO...... 121, 126 ethynodiol diac-eth estradiol... 218 ENHERTU...... 34 ERAXIS...... 18 ETHYOL...... 273 ENLITE GLUCOSE SENSOR.161 ERBITUX...... 34 etodolac...... 150 ENLYTE...... 72, 328, 333, 340 ERGOCAL...... 342 etodolac er...... 150 enovarx-amitriptyline...... 159 ergocalciferol...... 342 etonogestrel-ethinyl estradiol.. 218 enovarx-baclofen...... 322 ergoloid mesylates...... 59 ETOPOPHOS...... 34 enovarx-cyclobenzaprine hcl.. 322 ERGOMAR...... 59, 129 etoposide...... 34 enovarx-ibuprofen...... 293, 318 ergotamine-caffeine...... 60, 129 EUCRISA...... 293, 296

353 EUFLEXXA...... 162 felodipine er flavoxate hcl...... 327 Euthyrox...... 246 ...... 92, 102, 103, 107, 114 FLEBOGAMMA DIF...... 50 EVAMIST...... 228 FEM PH...... 315 flecainide acetate...... 98 EVEKEO ODT...... 118 FEMARA...... 35, 214 FLECTOR...... 150, 318, 322 EVENITY...... 252 FEMHRT LOW DOSE.....228, 241 FLEXICHAMBER ADULT everolimus...... 34, 265 FEMRING...... 228 MASK/SMALL...... 162 EVISTA...... 227, 252 Femynor...... 219 FLEXICHAMBER CHILD EVKEEZA...... 85 fenofibrate...... 104 MASK/LARGE...... 162 EVOMELA...... 34 fenofibrate micronized...... 104 FLEXICHAMBER CHILD EVOTAZ...... 23, 269 fenofibric acid...... 105 MASK/SMALL...... 162 EVRYSDI...... 252, 269 FENOGLIDE...... 105 FLEXIPAK...... 150, 322 EXELDERM...... 301 fenoprofen calcium...... 150 FLOLIPID...... 105 exemestane...... 34, 214 fenortho...... 150 FLORIVA...... 253, 328, 342 EXFORGE FENSOLVI (6 MONTH).....35, 230 FLORIVA PLUS...... 253, 328 ...... 80, 81, 92, 102, 103, 107, 114 fentanyl...... 144 FLOVENT DISKUS...... 209, 283 EXFORGE HCT fentanyl citrate...... 144 FLOVENT HFA...... 209, 283 ...... 80, 81, 92, 101, 103, 111, 181 FENTANYL CITRATE...... 144 floxuridine...... 35 EXJADE...... 206 fentanyl citrate (pf)...... 144 FLUAD...... 52 EX-LAX ULTRA...... 200 FENTANYL CITRATE-NACL.. 144 FLUAD QUADRIVALENT...... 52 EXODERM...... 291 FENTANYL-BUPIVACAINE- FLUARIX QUADRIVALENT...... 52 EXONDYS 51...... 252, 269 NACL...... 144, 248 Flucaine...... 172, 194 exotic-hc...... 189 FENTORA...... 144 FLUCELVAX EXPAREL...... 247 FERAHEME...... 72 QUADRIVALENT...... 52 EXTAVIA...... 260 FERIVA 21/7...... 73, 333, 340 fluconazole...... 17 EYLEA...... 193 FERIVAFA...... 73, 334, 340 FLUCON-IBUPROF- EYSUVIS...... 189 ferocon...... 73 ITRACON-TERBINA...... 301 EZALLOR SPRINKLE...... 105 ferotrinsic...... 73 flucytosine...... 27 ezetimibe...... 97 FERRALET 90...... 73, 334, 340 fludarabine phosphate...... 35 ezetimibe-simvastatin...... 97, 105 ferraplus 90...... 73, 334, 340 fludrocortisone acetate...... 209 fabb...... 333 FERRIPROX...... 206 FLULAVAL QUADRIVALENT... 52 FABIOR...... 322 FERRIPROX TWICE-A-DAY.. 206 FLUMIST QUADRIVALENT...... 52 FABRAZYME...... 183 Ferrocite Plus...... 73, 334, 340 flunisolide...... 189, 281 FALESSA...... 333 ferrous sulfate...... 73 FLUOCINOLONE ACET- Falmina...... 218 FETROJA...... 28 NIACINAMIDE...... 293 famciclovir...... 25 FETZIMA...... 156 fluocinolone acetonide famotidine...... 203 FETZIMA TITRATION...... 156 ...... 189, 293, 307 famotidine orig st...... 203 FIASP...... 233, 242 fluocinolone acetonide body FANAPT...... 132 FIASP FLEXTOUCH...... 233, 242 ...... 293, 307 FANAPT TITRATION PACK... 132 FIASP PENFILL...... 233, 242 fluocinolone acetonide scalp FARESTON...... 35, 227 FIBRICOR...... 105 ...... 293, 307 FARXIGA...... 244 FIBRYGA...... 69 fluocinonide...... 293, 307 FARYDAK...... 35 FINACEA...... 322 fluocinonide emulsified base FASENRA...... 280 finasteride...... 248 ...... 293, 307 FASENRA PEN...... 280 FINTEPLA...... 122 FLUOPAR...... 307 FASLODEX...... 35 FIRAZYR...... 255 FLUORESCEIN fa-vitamin b-6-vitamin b-12..... 333 FIRDAPSE...... 269 SODIUM/BENOXINATE. 172, 194 Fayosim...... 219 FIRE ANT...... 46, 169, 269 fluorescein-benoxinate....172, 194 febuxostat...... 251 FIRST-LANSOPRAZOLE...... 205 Fluoridex...... 253 FEIBA...... 69 FIRST-MOUTHWASH BLM.... 322 Fluoridex Sensitivity Relief...... 253 felbamate...... 121, 122 FIRST-OMEPRAZOLE...... 205 Fluor-I-Strips A.T...... 172 FELBATOL...... 122 FIRVANQ...... 18 fluoritab...... 253 FELDENE...... 150 Flac...... 189 fluorometholone...... 189 FLAREX...... 189 FLUOROPLEX...... 35, 322

354 FLUOROURACIL...... 35, 322 FORFIVO XL...... 124 GALZIN...... 206 fluorouracil...... 35, 322 formaldehyde...... 275, 322 GAMASTAN...... 50 FLUOVIX...... 307 FORMALDEHYDE...... 275 GAMIFANT...... 265 FLUOVIX PLUS...... 307 FORTAMET...... 215 GAMMAGARD...... 50 fluoxetine hcl...... 157, 158 FORTEO...... 238, 239, 252 GAMMAGARD S/D LESS IGA..50 fluoxetine hcl (pmdd)...... 157 FORTISCARE CONTROL...... 162 GAMMAKED...... 50 fluphenazine decanoate...... 153 FOSAMAX...... 252 GAMMAPLEX...... 50 fluphenazine hcl...... 153 FOSAMAX PLUS D...... 252, 342 GAMUNEX-C...... 50 flurandrenolide...... 293, 307 fosamprenavir calcium...... 23 ganirelix acetate...... 214, 259 FLURA-SAFE...... 172 fosaprepitant dimeglumine...... 204 gatifloxacin...... 186 flurazepam hcl...... 137 foscarnet sodium...... 16 GATTEX...... 202 flurbiprofen...... 150 FOSCAVIR...... 16 gavilax...... 200 flurbiprofen sodium...... 193 fosfomycin tromethamine...... 30 gavilyte-c...... 200 flutamide...... 35 fosinopril sodium...... 83, 84 Gavilyte-G...... 200 fluticasone propionate fosinopril sodium-hctz Gavilyte-H...... 200 ...... 189, 281, 293, 307 ...... 83, 84, 111, 181 Gavilyte-N With Flavor Pack... 200 fluticasone-salmeterol fosphenytoin sodium...... 141 GAVRETO...... 35 ...... 62, 210, 283, 286 FOSRENOL...... 177, 249 GAZYVA...... 35 FLUTICASONE- FOSTEUM...... 269 GEAMETDRAY...... 312, 318 SALMETEROL..62, 210, 283, 286 FOSTEUM PLUS...... 179, 269 GEBAUERS PAIN EASE 162, 297 fluvastatin sodium...... 105 FOTIVDA...... 35 GEBAUERS SPRAY AND fluvastatin sodium er...... 105 FRAGMIN...... 72 STRETCH...... 162, 297 fluvoxamine maleate...... 158 FREESTYLE LIBRE 14 DAY GELCLAIR...... 162 fluvoxamine maleate er...... 158 READER...... 162 GELFILM...... 193, 275 FLUZONE HIGH-DOSE FREESTYLE LIBRE 14 DAY GEL-FLOW...... 162 QUADRIVALENT...... 52 SENSOR...... 162 GEL-FLOW NT...... 162 FLUZONE QUADRIVALENT.... 52 FREESTYLE LIBRE 2 GELFOAM...... 69, 162 FML...... 190 READER...... 162 GELFOAM COMPRESSED FML FORTE...... 190 FREESTYLE LIBRE 2 SIZE 100...... 162 folbee...... 334 SENSOR...... 162 GELFOAM DENTAL PACK folbee plus...... 334, 340 FREESTYLE LIBRE READER 162 SIZE 4...... 162 FOLBEE PLUS CZ...... 334 FREESTYLE LIBRE SENSOR GELFOAM SPONGE...... 162 FOLBIC RF...... 334 SYSTEM...... 162 GELFOAM SPONGE SIZE FOLGARD OS...... 179 FREESTYLE PRECISION 100...... 163 FOLGARD RX...... 334 NEO TEST...... 171 GELFOAM SPONGE SIZE folic acid...... 334 FROTEK...... 293, 318 200...... 163 FOLIC D3...... 334, 342 frovatriptan succinate...... 156 GELFOAM SPONGE SIZE 50 163 FOLIC-K...... 328, 334, 343 FUL-GLO...... 172 GELFOAM-JMI POWDER...... 163 FOLITE...... 179, 334, 342 Ful-Glo...... 172 GELFOAM-JMI SPONGE...... 163 FOLITIN-Z...... 73, 328, 334 FULPHILA...... 66 GELNIQUE...... 327 FOLIXAPURE...... 334, 342 fulvestrant...... 35 GELSYN-3...... 163 FOLLISTIM AQ...... 230, 231 furosemide...... 108, 176, 177 GELX...... 163 FOLOTYN...... 35 FUSARIUM...... 47, 169, 269 gemcitabine hcl...... 35 folplex 2.2...... 334 FUSION PLUS...... 73, 334, 340 gemfibrozil...... 105 foltanx...... 334 FUZEON...... 20 Gemmily...... 219 FOLTANX RF...... 334 Fyavolv...... 228, 241 GEMTESA...... 328 FOLTRATE...... 334 FYCOMPA...... 122 GEN7T...... 297 FOLTREXYL...... 334, 342 gabapentin...... 119, 122 GEN7T PLUS...... 297 foltrin...... 73 GABITRIL...... 122 GENADUR...... 163, 334 FOLTX...... 334 GABLOFEN...... 58 GENERESS FE...... 219 Folvite-D...... 334, 342 GALAFOLD...... 269 generlac...... 174 fondaparinux sodium...... 65, 66 galantamine hydrobromide...... 60 Gengraf...... 256, 260, 265 FORANE...... 142 galantamine hydrobromide er... 60 GENICIN VITA-D...... 334, 342

355 GENICIN VITA-Q...... 334 GLYTACTIN BETTERMILK GVOKE HYPOPEN 2-PACK Genicin Vita-S...... 335, 340 DE-LITE...... 174 ...... 230, 249 GENOTROPIN...... 239 GLYTACTIN BUILD 10PE...... 174 GVOKE PFS...... 230, 249 GENOTROPIN MINIQUICK....239 GLYTACTIN BUILD 20/20...... 174 GYNAZOLE-1...... 301 gentak...... 186 GLYTACTIN BUILD 20/20 HACKBERRY...... 47, 169, 269 gentamicin sulfate...... 186, 290 PKU...... 174 HAEGARDA...... 255 gentle laxative...... 200 GLYTACTIN BURST...... 174 Hailey 1.5/30...... 219 GENVOYA...... 20, 22 GLYTACTIN COMPLETE Hailey 24 Fe...... 219 GEODON...... 126, 132 10PE...... 174 Hailey Fe 1.5/30...... 219 GERMAN COCKROACH GLYTACTIN RESTORE 10.... 175 Hailey Fe 1/20...... 219 ...... 47, 169, 269 GLYTACTIN RESTORE 5...... 175 HALAVEN...... 35 GIALAX...... 200 GLYTACTIN RESTORE LITE halcinonide...... 293, 307 GILENYA...... 260 10...... 175 HALDOL DECANOATE...... 138 GILOTRIF...... 35 GLYTACTIN RESTORE LITE halobetasol propionate....293, 307 GILPHEX TR...... 53, 278 10PE...... 175 HALOBETASOL GIMOTI...... 204 GLYTACTIN RTD 10...... 175 PROPIONATE...... 307 GIVLAARI...... 269 GLYTACTIN RTD 15...... 175 HALOG...... 293, 307 GLASSIA...... 284 GLYTACTIN RTD LITE 15...... 175 haloperidol...... 138 glatiramer acetate...... 261 GLYTACTIN SWIRL 15PE...... 175 haloperidol decanoate...... 138 Glatopa...... 261 GLYXAMBI...... 226, 244 haloperidol lactate...... 138 GLEEVEC...... 35 GOCOVRI...... 12, 117 HALUCORT...... 302 GLEOLAN...... 171, 172 GOLDENROD...... 47, 169, 269 HARVONI...... 19 GLEOSTINE...... 35 GOLYTELY...... 200 HCU EASY...... 175 glimepiride...... 245 GONAL-F...... 230, 232 Heather...... 219 glipizide...... 245 GONAL-F RFF...... 230, 232 HELIDAC THERAPY glipizide er...... 245 GONAL-F RFF REDIJECT ...... 12, 14, 15, 26, 29, 199 glipizide xl...... 246 ...... 230, 232 HEMADY...... 210 glipizide-metformin hcl.... 215, 246 GONITRO...... 109 HEMANGEOL GLOPERBA...... 251 goodsense aspirin low dose ...... 58, 86, 88, 98, 107, 129 Glostrips...... 172 ...... 77, 78, 129, 155 hematinic plus vit/minerals GLUCAGEN HYPOKIT... 229, 249 goodsense ibuprofen...... 150 ...... 73, 335, 340 glucagon emergency kit.. 230, 249 goodsense nicotine...... 57 hematinic/folic acid...... 73, 335 GLUCAGON EMERGENCY GOPRELTO...... 194 HEMATOGEN FA..... 73, 335, 340 KIT...... 230, 249 GORDOFILM...... 312 HEMATRON-AF...... 73 GLUCOTROL...... 246 GRALISE...... 119, 122 HEMETAB...... 73, 335 GLUCOTROL XL...... 246 granisetron hcl...... 197 HEMLIBRA...... 69 GLUMETZA...... 215 GRANIX...... 66, 67 Hemmorex-Hc...... 294, 307 GLUTARALDEHYDE...... 173 GRASTEK...... 47, 269 HEMOCYTE PLUS...... 73, 329 glyburide...... 246 GREEN GLO LISSAMINE Hemocyte-F...... 73, 335 glyburide micronized...... 246 GREEN...... 172 HEMOFIL M...... 69 glyburide-metformin...... 215, 246 griseofulvin microsize...... 14 HEPAGAM B...... 50 GLYCATE...... 55 griseofulvin ultramicrosize...... 14 heparin (porcine) in nacl... 72, 163 glycine...... 176 guaiatussin ac...... 144, 277, 278 heparin lock flush...... 72, 163 glycine urologic...... 176 guaifenesin ac...... 144, 277, 278 heparin sodium (porcine)...... 72 glycolax...... 200 GUANENDRUX...... 312 heparin sodium (porcine) pf...... 72 GLYCOPYRROLATE...... 55 guanfacine hcl...... 97, 139 heparin sodium lock flush. 72, 163 glycopyrrolate...... 55 guanfacine hcl er...... 97, 139 HERCEPTIN...... 36 glycopyrrolate pf...... 55 GUANIDINE HCL...... 60 HERCEPTIN HYLECTA...... 35 Glydo...... 194 GUARDIAN SENSOR (3)...... 163 HERZUMA...... 36 GLYNASE...... 246 GVOKE HYPOPEN 1-PACK HETLIOZ...... 131 GLYRX-PF...... 55 ...... 230, 249 HETLIOZ LQ...... 131 GLYTACTIN BETTERMILK 15174 HIBICLENS...... 315 Hidex 6-Day...... 210

356 HIZENTRA...... 50 HYALURONATE-NIACINAM- HYPERHEP B...... 50 hm stool softener...... 200 TRETINOIN...... 303 HYPERRAB...... 50 HOMACTIN AA PLUS...... 175 HYALURONATE-NIACIN- HYPERRAB S/D...... 50 homatropaire...... 195 TACROLIMUS...... 323 HYPERRHO S/D...... 50 HONEY BEE VENOM...... 47, 169 HYCAMTIN...... 36 HYPERSAL...... 163, 179 HORIZANT...... 119, 122 hydralazine hcl...... 104 HYPERTET S/D...... 51 HORSE EPITHELIUM HYDREA...... 36 HYPOCYN...... 164 ...... 47, 169, 269 HYDRO 40...... 312 HYQVIA...... 51 HPR PLUS...... 163 hydrochlorothiazide...... 112, 181 HYSINGLA ER...... 145 hpr plus...... 163 hydrocodone bitartrate er...... 144 HYZAAR...... 80, 81, 112, 181 HPR PLUS HYDROGEL...... 163 hydrocodone polst-chlorphen ibandronate sodium...... 253 HUMALOG KWIKPEN.... 234, 242 polst er susp...... 10, 144, 277, 279 IBRANCE...... 36 HUMALOG MIX 50/50 hydrocodone-acetaminophen IBUPAK...... 150 KWIKPEN...... 234, 236, 242 ...... 120, 144 ibuprofen...... 150 HUMALOG MIX 50/50 VIAL hydrocodone-homatropine Ibuprofen...... 150 ...... 234, 236, 242 ...... 55, 144, 145, 277 ibuprofen infants...... 150 HUMALOG MIX 75/25 hydrocodone-ibuprofen... 145, 150 ICAR-C PLUS...... 73, 335, 340 KWIKPEN...... 234, 237, 242 hydrocortisone...... 210, 294, 308 icatibant acetate...... 255 HUMALOG MIX 75/25 VIAL hydrocortisone (perianal) 294, 307 Iclevia...... 219 ...... 234, 237, 242 hydrocortisone ace-pramoxine ICLUSIG...... 36 HUMALOG U-100 JUNIOR ...... 294, 297, 307 icosapent ethyl...... 85 KWIKPEN...... 234, 242 hydrocortisone acetate....294, 307 IDAMYCIN PFS...... 36 HUMALOG VIAL...... 234, 242 hydrocortisone butyr lipo base idarubicin hcl...... 36 HUMATE-P...... 69 ...... 294, 307 IDELVION...... 69 HUMATROPE...... 239 hydrocortisone butyrate IDHIFA...... 36 HUMATROPEN FOR 12MG... 163 ...... 294, 307, 308 Iferex 150 Forte...... 73, 335 HUMATROPEN FOR 24MG... 163 hydrocortisone valerate...294, 308 ifosfamide...... 36 HUMATROPEN FOR 6MG..... 163 hydrocortisone-acetic acid ILARIS...... 269 HUMIRA...... 202, 257, 261, 323 ...... 190, 192 ILEVRO...... 193 HUMIRA PEDIATRIC hydrocortisone-iodoquinol ILUMYA...... 323 CROHNS START ...... 308, 315 ILUVIEN...... 190 ...... 202, 256, 261, 322 hydrocort-pramoxine (perianal) imatinib mesylate...... 36 HUMIRA PEN ...... 294, 297, 308 IMBRUVICA...... 36 ...... 202, 256, 261, 322, 323 hydromet...... 55, 145, 277 IMCIVREE...... 120 HUMIRA PEN-CD/UC/HS hydromorphone hcl...... 145 IMDEVIMAB...... 24 STARTER...... 202, 257, 261, 323 hydromorphone hcl er...... 145 IMFINZI...... 36 HUMIRA PEN-PEDIATRIC UC HYDROMORPHONE HCL- IMIOXIA...... 301 START...... 202, 257, 261, 323 NACL...... 145 imipenem-cilastatin...... 17 HUMIRA PEN-PS/UV/ADOL hydroxychloroquine sulfate imipramine hcl...... 159 HS START...... 202, 257, 261, 323 ...... 14, 257, 261 imipramine pamoate...... 159 HUMIRA PEN-PSOR/UVEIT hydroxyprogesterone caproate241 imiquimod...... 323 STARTER...... 202, 257, 261, 323 hydroxyurea...... 36 IMIQUIMOD PUMP...... 323 HUMULIN 70/30 KWIKPEN hydroxyzine hcl...... 10, 131 IMIQUIMOD-LEVOCETIRIZIN- ...... 234, 237, 243 hydroxyzine pamoate...... 10, 131 NIACIN...... 323 HUMULIN 70/30 VIAL HYLATOPIC PLUS...... 163 IMIQUIMOD-LEVOCET- ...... 234, 237, 243 HYLAVITE...... 335, 340 TRETINOIN...... 303, 323 HUMULIN N KWIKPEN.. 234, 237 HYLAZINC...... 335 IMITREX...... 156, 157 HUMULIN N VIAL...... 234, 237 HYMOVIS...... 163 IMLYGIC...... 36 HUMULIN R U-500 KWIKPEN HYOPHEN...... 30 IMOGAM RABIES-HT...... 51 ...... 234, 243 hyoscyamine sulfate...... 55 IMPAVIDO...... 15 HUMULIN R U-500 VIAL 234, 243 hyoscyamine sulfate er...... 55 IMPEKLO...... 308 HUMULIN R VIAL...... 234, 243 hyoscyamine sulfate sl...... 55 IMPOYZ...... 294, 308 HYALGAN...... 163 hyosyne...... 55

357 IMVEXXY MAINTENANCE INSULIN LISPRO JUNIOR ISTODAX (OVERFILL)...... 37 PACK...... 229 KWIKPEN...... 235, 243 ISTURISA...... 269 IMVEXXY STARTER PACK... 229 INSULIN LISPRO PROT & ITHOXIA...... 323 inavix...... 150, 323 LISPRO...... 235, 237, 243 itraconazole...... 17 INBRIJA...... 140 INSULIN PEN NEEDLES...... 164 ivermectin...... 14, 319 Incassia...... 219 INSULIN SYRINGES...... 164 IVERMECTIN- INCRELEX...... 245 INTEGRA F...... 73, 335, 340 METRONIDAZOL-NIACIN INCRUSE ELLIPTA...... 55, 276 INTEGRA PLUS...... 73, 335, 340 ...... 290, 319 indapamide...... 113, 182 INTELENCE...... 21 IXEMPRA KIT...... 37 INDERAL LA INTRAROSA...... 210 IXINITY...... 69 ...... 59, 86, 88, 99, 107, 130 INTRON A...... 23, 36, 261 JADENU...... 206 INDERAL XL Introvale...... 219 JADENU SPRINKLE...... 207 ...... 59, 86, 88, 99, 107, 130 INVANZ...... 17 Jaimiess...... 219 INDOCIN...... 150, 251 INVEGA...... 132 JAKAFI...... 37 INDOMETHACIN...... 150, 251 INVEGA SUSTENNA...... 132 Jantoven...... 66 indomethacin...... 150, 251 INVEGA TRINZA...... 132 JANUMET...... 215, 226 indomethacin er...... 150, 251 INVELTYS...... 190 JANUMET XR...... 215, 226 INFASURF...... 283 INVIRASE...... 23 JANUVIA...... 226 INFED...... 73 INVOKAMET...... 215, 244 JARDIANCE...... 244 Inflammacin...... 151, 323 INVOKAMET XR...... 215, 244 Jasmiel...... 219 INFLATHERM...... 151, 323 INVOKANA...... 244 JATENZO...... 213 INFLECTRA.... 202, 257, 261, 323 IODINE STRONG JELMYTO...... 37 INFUGEM...... 36 ...... 14, 214, 249, 278 Jencycla...... 219 INFUMORPH 200...... 145 iodine tincture...... 315 JENTADUETO...... 215, 226 INFUMORPH 500...... 145 iodoquinol-hc-aloe polysacch JENTADUETO XR...... 215, 226 INFUVITE ADULT...... 329, 343 ...... 294, 308, 315 JEVTANA...... 37 INFUVITE PEDIATRIC...... 329 IODOQUINOL-HC- Jinteli...... 229, 241 INGREZZA...... 139, 160 KETOCONAZOLE.. 301, 308, 315 JIVI...... 69 INLYTA...... 36 iodoquinol-hydrocortisone-aloe JOHNSON GRASS...47, 169, 269 INNOPRAN XL ...... 294, 308, 315 Jolessa...... 219 ...... 59, 86, 88, 99, 107, 130 IOPIDINE...... 193 JORNAY PM...... 154 INOVA...... 312 ipratropium bromide.. 55, 193, 276 JUBLIA...... 301 INOVA 4/1 ACNE CONTROL ipratropium-albuterol Juleber...... 219 THERAPY...... 312 ...... 55, 62, 276, 286 JULUCA...... 20, 21 INOVA 8/2 ACNE CONTROL irbesartan...... 80, 81 JUNE GRASS POLLEN THERAPY...... 312 irbesartan-hydrochlorothiazide STANDARDIZED...... 47, 169, 269 INQOVI...... 36 ...... 80, 81, 112, 181 Junel 1.5/30...... 219 INREBIC...... 36 IRESSA...... 37 Junel 1/20...... 219 INSPIREASE RESERVOIR irinotecan hcl...... 37 Junel Fe 1.5/30...... 219 BAGS...... 164 IROSPAN 24/6...... 73, 335, 340 Junel Fe 1/20...... 219 INSPRA...... 108, 110 ISENTRESS...... 20 Junel Fe 24...... 220 INSULIN ASP PROT & ASP ISENTRESS HD...... 20 JUXTAPID...... 85 FLEXPEN...... 234, 237, 242 Isibloom...... 219 JYNARQUE...... 183 INSULIN ASPART...... 235, 243 isoflurane...... 142 KADCYLA...... 37 INSULIN ASPART FLEXPEN ISOLYTE-S...... 179 Kaitlib Fe...... 220 ...... 234, 242 isoniazid...... 16 KALETRA...... 23 INSULIN ASPART PENFILL ISOPTO ATROPINE...... 195 Kalliga...... 220 ...... 234, 242 isosorbide dinitrate...... 109 KALYDECO...... 278 INSULIN ASPART PROT & isosorbide mononitrate...... 109 KAMDOY...... 164 ASPART...... 234, 237, 243 isosorbide mononitrate er...... 109 KANJINTI...... 37 INSULIN LISPRO...... 235, 243 isotretinoin...... 323 KANUMA...... 183 INSULIN LISPRO (1 UNIT isoxsuprine hcl...... 115 KAPOK...... 47, 169, 270 DIAL)...... 235, 243 isradipine...92, 102, 103, 107, 115

358 KAPSPARGO SPRINKLE Klor-Con M20...... 179 lapatinib ditosylate...... 37 ...... 64, 86, 88, 99 Klor-Con/Ef...... 179 Larin 1.5/30...... 220 kapzin dc...... 151, 318, 323 KOATE...... 69 Larin 1/20...... 220 KARBINAL ER...... 9, 279 KOATE-DVI...... 69 Larin 24 Fe...... 220 Kariva...... 220 KOCHIA...... 47, 169, 270 Larin Fe 1.5/30...... 220 KATERZIA 92, 102, 103, 107, 115 KOGENATE FS...... 69, 70 Larin Fe 1/20...... 220 KAZANO...... 215, 226 KOMBIGLYZE XR...... 215, 226 Larissia...... 220 KCL-LIDOCAINE-NACL...... 179 KORLYM...... 214 LASIX...... 108, 177 KEDRAB...... 51 KOSELUGO...... 37 LASTACAFT...... 185 KELARX...... 164 KOVALTRY...... 70 latanoprost...... 196 Kelnor 1/35...... 220 K-PHOS...... 173 LATANOPROST-TIMOLOL Kelnor 1/50...... 220 K-PHOS NO 2...... 173 MALEATE...... 188, 196 KENALOG...... 210 K-PHOS-NEUTRAL...... 173 LATUDA...... 132 KENALOG-80...... 210 K-Prime...... 179 Layolis Fe...... 220 KEPIVANCE...... 303 KRINTAFEL...... 14 LAZANDA...... 145 KERALAC...... 312 KRISTALOSE...... 174 L-CYSTINE...... 175 KERALYT...... 312 KRYSTEXXA...... 251 LDO PLUS...... 164, 297 Keralyt...... 312 K-TAB...... 179 LEDIPASVIR-SOFOSBUVIR.... 19 KERALYT SCALP...... 312 Kurvelo...... 220 Leena...... 220 KESIMPTA...... 261 KUVAN...... 270 leflunomide...... 257, 262 KETAMINE HCL...... 141 KYLEENA...... 220 LEMTRADA...... 262 KETAMINE HCL-SODIUM KYMRIAH...... 37, 117 LENVIMA...... 37 CHLORIDE...... 141 KYNMOBI...... 142 LESCOL XL...... 105 ketoconazole...... 17, 301 KYNMOBI TITRATION KIT.....142 Lessina...... 220 KETOCONAZOLE- KYPROLIS...... 37 LETAIRIS...... 115, 287 HYDROCORTISONE...... 301, 308 labetalol hcl letrozole...... 37, 214 Ketodan...... 301 ...... 59, 61, 78, 79, 86, 88, 99 lets...... 297 KETODAN...... 301 LACRISERT...... 193 leucovorin calcium...... 250 KETONE TEST...... 172 LACTEROL...... 202 LEUKERAN...... 37 ketoprofen...... 151 lactic acid...... 302 LEUKINE...... 67 ketoprofen er...... 151 lactic acid e...... 302 leuprolide acetate...... 37, 230, 232 ketorolac tromethamine.. 151, 193 lactulose...... 174 levalbuterol hcl...... 62, 286 KETOROLAC lactulose encephalopathy...... 174 LEVALBUTEROL HFA...... 62, 286 TROMETHAMINE...... 151 LAMICTAL...... 122, 126 LEVBID...... 55 KETOSTIX...... 172 LAMICTAL ODT...... 122, 126 LEVEMIR U-100 FLEXTOUCH KETOVIE...... 175 LAMICTAL STARTER.....122, 126 ...... 235, 238 KETOVIE PEPTIDE...... 175 LAMICTAL XR...... 122 LEVEMIR U-100 VIAL.....235, 238 KEVEYIS...... 188 lamivudine...... 22 levetiracetam...... 123 KEVZARA...... 257, 261 lamivudine-zidovudine...... 22 levetiracetam er...... 123 KEYTRUDA...... 37 lamotrigine...... 122, 126 LEVITRA...... 110 KHAPZORY...... 250 lamotrigine er...... 122 levobunolol hcl...... 188 KINERET...... 257, 261 lamotrigine starter kit-blue levocarnitine...... 270 KISQALI...... 37 ...... 122, 126 levocarnitine sf...... 270 KISQALI FEMARA...... 37, 214 lamotrigine starter kit-green levocetirizine dihydrochloride KITABIS PAK...... 13 ...... 122, 126 ...... 11, 284 KIVIK...... 164 lamotrigine starter kit-orange levofloxacin...... 16, 28, 186 KLARITY-A...... 186 ...... 122, 126 levoleucovorin calcium...... 250 KLARITY-L...... 190 LAMPIT...... 15 levoleucovorin calcium pf...... 250 KLISYRI...... 323 LANOXIN...... 85, 96 Levonest...... 220 Klor-Con...... 179 lansoprazole...... 205 levonorgest-eth est & eth est.. 220 Klor-Con 10...... 179 lanthanum carbonate...... 177, 250 levonorgest-eth estrad 91-day 220 Klor-Con M10...... 179 LANTUS SOLOSTAR..... 235, 238 levonorgestrel...... 220 KLOR-CON M15...... 179 LANTUS U-100 VIAL...... 235, 238 levonorgestrel-ethinyl estrad...220

359 levonorg-eth estrad triphasic...221 lincomycin hcl...... 24 LORID...... 335, 340 Levora 0.15/30 (28)...... 221 lindane...... 319 LORMATE...... 335 levorphanol tartrate...... 145 linezolid...... 27 LORTAB...... 120, 145 Levo-T...... 246 linezolid in sodium chloride...... 27 Loryna...... 221 LEVOTHYROXINE SODIUM.. 247 LINZESS...... 202 Lorzone...... 57 levothyroxine sodium...... 247 LIORESAL...... 58 losartan potassium...... 80, 81 Levoxyl...... 247 liothyronine sodium...... 247 losartan potassium-hctz LEVSIN...... 55 LIPITOR...... 105 ...... 80, 82, 112, 181 LEVSIN/SL...... 56 LIPOFEN...... 105 LOSEASONIQUE...... 221 LEVULAN KERASTICK...... 323 lisinopril...... 83, 84 LOTEMAX...... 190 LEXAPRO...... 158 lisinopril-hydrochlorothiazide LOTEMAX SM...... 190 LEXETTE...... 308 ...... 83, 84, 112, 181 LOTENSIN...... 83, 84 LEXIVA...... 23 L-ISOLEUCINE...... 275 LOTENSIN HCT..83, 84, 112, 182 LIALDA...... 199 lithium...... 127 loteprednol etabonate...... 190 LIBTAYO...... 37 lithium carbonate...... 127 LOTREL LICART...... 151, 318 lithium carbonate er...... 127 ...... 83, 84, 92, 102, 103, 107, 115 Lido Bdk...... 164, 297 LITHOBID...... 127 LOTRONEX...... 199 lidocaine...... 298 LITHOSTAT...... 174 lovastatin...... 105 LIDOCAINE HCL...... 98, 248 LIVALO...... 105 LOVENOX...... 72 lidocaine hcl...... 194, 248, 298 Livixil Pak...... 298 Low-Ogestrel...... 221 lidocaine hcl (pf)...... 248 l-methylfolate...... 335 loxapine succinate...... 130 lidocaine hcl urethral/mucosal.194 l-methylfolate ca me-cbl nac... 335 Lo-Zumandimine...... 221 lidocaine viscous hcl...... 194 l-methylfolate calcium...... 335 LUBIPROSTONE...... 200 lidocaine-hydrocort (perianal) l-methylfolate forte...... 335 LUCEMYRA...... 53 ...... 294, 298, 308 l-methylfolate-algae...... 335 LUCENTIS...... 193 LIDOCAINE- l-methylfolate-algae-b12-b6.... 335 LUGOLS STRONG IODINE....315 HYDROCORTISONE ACE l-methylfolate-b6-b12...... 335 LULICONAZOLE...... 301 ...... 294, 298, 308 l-methyl-mc...... 335 LUMIGAN...... 196 lidocaine-hydrocortisone ace l-methyl-mc nac...... 335 LUMIZYME...... 183 ...... 294, 298, 308 LMR PLUS...... 298 LUMOXITI...... 38 lidocaine-prilocaine...... 298 LO LOESTRIN FE...... 221 LUPANETA PACK LIDOCAINE-TETRACAINE.....298 LODINE...... 151 ...... 38, 230, 232, 241 Lidocort...... 294, 298, 308 LODOSYN...... 139 LUPKYNIS...... 257, 265 LIDO-EPINEPHRINE- Loestrin 1.5/30 (21)...... 221 LUPRON DEPOT (1-MONTH) TETRACAINE...... 298 Loestrin 1/20 (21)...... 221 ...... 38, 230, 232 LIDOMARK 2/5...... 248 Loestrin Fe 1.5/30...... 221 LUPRON DEPOT (3-MONTH) LIDOPAC...... 298 Loestrin Fe 1/20...... 221 ...... 38, 231, 232 lidopin...... 298 Lojaimiess...... 221 LUPRON DEPOT (4-MONTH) LIDOPIN...... 298 LOKELMA...... 177 INTRAMUSCULAR KIT 30MG LIDOPRIL...... 298 LOMAIRA...... 118 ...... 38, 231, 232 LIDOPRIL XR...... 298 LONHALA MAGNAIR REFILL LUPRON DEPOT (6-MONTH) Lido-Prilo Caine Pack...... 298 KIT...... 56 INTRAMUSCULAR KIT 45MG LIDOPURE PATCH...... 298 LONHALA MAGNAIR ...... 38, 231, 232 LIDORX...... 298 STARTER KIT...... 56 LUPRON DEPOT-PED (1- Lido-Sorb...... 298 LONSURF...... 38 MONTH)...... 38, 231, 232 LIDOTRAL...... 298 loperamide hcl...... 198 LUPRON DEPOT-PED (3- LIDTOPIC MAX...... 298 LOPID...... 105 MONTH)...... 38, 231, 232 LIFEMS NALOXONE...... 148, 250 lopinavir-ritonavir...... 23 LUTATHERA...... 38, 275 LILETTA (52 MG)...... 221 LOPRESSOR...... 64, 87, 88, 99 Lutera...... 221 Lillow...... 221 LOPROX...... 311, 324 LUXTURNA...... 117 LIMBREL...... 270 lorazepam...... 136, 137 LUZU...... 301 LIMBREL250...... 270 Lorazepam Intensol...... 136, 137 Lyleq...... 221 LIMBREL500...... 270 LORBRENA...... 38 Lyllana...... 229

360 LYNPARZA...... 38 megestrol acetate...... 38, 241 methocarbamol...... 57 LYRICA CR...... 120, 123, 141 MEKINIST...... 38 METHOHEXITAL SODIUM Lysiplex Plus...... 175 MEKTOVI...... 38 ...... 134, 135 LYSODREN...... 38 MELALEUCA...... 47, 169, 270 methotrexate..... 38, 257, 262, 265 LYUMJEV KWIKPEN...... 235, 243 meloxicam...... 151 methotrexate sodium LYUMJEV VIAL...... 235, 243 melphalan...... 38 ...... 39, 257, 262, 266 Lyza...... 221 melphalan hcl...... 38 methotrexate sodium (pf) M.V.I. ADULT...... 329 memantine hcl...... 139 ...... 38, 257, 262, 265 M.V.I. PEDIATRIC...... 329 memantine hcl er...... 139 methoxsalen rapid...... 319 MACRILEN...... 172 MENEST...... 229 methscopolamine bromide...... 56 MACRODANTIN...... 30 MENOPUR...... 231, 232 methyl salicylate...... 155 mafenide acetate...... 315 MENOSTAR...... 229 methyldopa...... 53, 97 MAGNEBIND 400...... 177 MENTAX...... 303 methyldopa- magnesium citrate...... 200 meperidine hcl...... 145 hydrochlorothiazide magnesium oxide...... 197 MEPHYTON...... 250, 343 ...... 53, 97, 112, 182 magnesium sulfate....85, 123, 250 meprobamate...... 131 methylergonovine maleate...... 274 MAGNESIUM SULFATE MEPRON...... 15 methylfol-algae-b12-acetylcyst335 ...... 85, 123, 250 MEPSEVII...... 184 methylphenidate hcl...... 154 magnesium-oxide...... 197 mercaptopurine...... 38, 265 methylphenidate hcl er...... 154 mag-oxide...... 197 meropenem...... 17 methylphenidate hcl er (cd).....154 MAKENA...... 241 MEROPENEM-SODIUM methylphenidate hcl er (la)...... 154 MALARONE...... 14 CHLORIDE...... 17 methylphenidate hcl er (xr)..... 154 malathion...... 319 Merzee...... 221 methylprednisolone...... 210 maprotiline hcl...... 159 mesalamine...... 199 METHYLPREDNISOLONE MARGENZA...... 38 mesalamine er...... 199 ACETATE...... 210 marlissa...... 221 mesalamine-cleanser...... 199 methylprednisolone acetate.... 210 MARPLAN...... 142 mesna...... 273 methyltestosterone...... 213 MARQIBO...... 38 MESNEX...... 273 metoclopramide hcl...... 204 MARVONA SUIK.... 164, 248, 298 MESQUITE...... 47, 169, 270 metolazone...... 113, 183 MAS CARE-PAK...... 210 MESTINON...... 60 METOPIRONE...... 172 MATULANE...... 38 metafolbic...... 335 metoprolol succinate er Matzim La90, 92, 94, 95, 100, 115 metafolbic plus...... 335 ...... 64, 87, 88, 99 MAVENCLAD...... 265 METAFOLBIC PLUS RF...... 335 metoprolol tartrate...64, 87, 88, 99 MAVYRET...... 19 METANX...... 335 metoprolol-hydrochlorothiazide MAXICOMFORT SYR 27G X metaxalone...... 57 ...... 64, 87, 88, 99, 112, 182 1/2"...... 164 metformin hcl...... 215 metronidazole...... 12, 15, 290 MAXIDEX...... 190 metformin hcl er...... 215 metyrosine...... 270 maxi-tuss ac...... 145, 277, 278 metformin hcl er (mod)...... 215 mexiletine hcl...... 98 MAXZIDE...... 110, 112, 178, 182 metformin hcl er (osm)...... 215 MIACALCIN...... 214, 239, 253 MAXZIDE-25...110, 112, 178, 182 METHACHOLINE CHLORIDE 172 Mibelas 24 Fe...... 221 MAYZENT...... 262 methadone hcl...... 145 micafungin sodium...... 18 me/naphos/mb/hyo1...... 30 Methadone Hcl Intensol...... 145 MICARDIS...... 80, 82 MEADOW FESCUE GRASS methadose...... 145 MICARDIS HCT.. 80, 82, 112, 182 POLLEN...... 47, 169, 270 Methadose...... 146 miconazole 3...... 301 meclizine hcl...... 10, 198 methadose sugar-free...... 146 MICONAZOLE-ZINC OXIDE- meclofenamate sodium...... 151 methamphetamine hcl...... 118 PETROLAT...... 301 MEDROL...... 210 METHAVER...... 335 MICRHOGAM ULTRA- MEDROLOAN II SUIK methazolamide...... 189 FILTERED PLUS...... 51 ...... 164, 210, 298 methenamine hippurate...... 30 MICRODOT TEST...... 171 MEDROLOAN SUIK164, 210, 298 methenamine mandelate...... 30 Microgestin 1.5/30...... 221 medroxyprogesterone acetate 241 Methergine...... 274 Microgestin 1/20...... 221 mefenamic acid...... 151 methimazole...... 214 Microgestin 24 Fe...... 222 mefloquine hcl...... 14 METHITEST...... 213 Microgestin Fe 1.5/30...... 222

361 Microgestin Fe 1/20...... 222 MIXED VESPID VENOM MULTIGEN PLUS..... 74, 336, 340 MICROLET NEXT LANCING PROTEIN...... 47, 169 MULTIPRO...... 74, 329, 336 DEVICE...... 164 MKO MELT DOSE PACK multi-vit/iron/fluoride..74, 253, 329 MICROPLEGIA MSA-MSG.....179 ...... 137, 141, 197 multivitamin/fluoride...... 253, 329 midazolam hcl...... 137 M-NATAL PLUS 73, 179, 329, 335 MULTIVITAMIN/FLUORIDE MIDAZOLAM HCL-SODIUM MOBIC...... 151 ...... 253, 329 CHLORIDE...... 137 modafinil...... 160 multi-vitamin/fluoride...... 253, 329 midodrine hcl...... 53 moexipril hcl...... 83, 84 multi-vitamin/fluoride/iron MIFEPREX...... 274 molindone hcl...... 130 ...... 74, 254, 329 mifepristone...... 274 mometasone furoate mupirocin...... 290 MIGERGOT...... 60, 130 ...... 190, 281, 294, 308 mupirocin calcium...... 290 miglitol...... 212 Mondoxyne Nl...... 29 MUSE...... 115 miglustat...... 270 MONJUVI...... 39 Mutamycin...... 39 MIGRANAL...... 60, 130 MONOFERRIC...... 73 MVASI...... 39 MIGRANOW...... 157, 324 Mono-Linyah...... 222 MYALEPT...... 238 Mili...... 222 MONONINE...... 70 MYCAPSSA...... 245 MILLIPRED...... 210 MONOVISC...... 164 mycophenolate mofetil...... 266 milrinone lactate...... 96 monsels ferric subsulfate.. 70, 275 mycophenolate mofetil hcl...... 266 milrinone lactate in dextrose..... 96 montelukast sodium...... 280 mycophenolate sodium...... 266 Mimvey...... 229, 241 MORGIDOX...... 29, 324 MYDAYIS...... 118 MIMYX...... 164 Morgidox...... 29 myferon 150 forte...... 74, 336 MINASTRIN 24 FE...... 222 MORPHINE SULFATE...... 146 MYLERAN...... 39 mineral oil heavy...... 200 morphine sulfate...... 146 MYLOTARG...... 39 MINIMED PUMP RESERVOIR morphine sulfate (concentrate)146 mynephrocaps...... 336, 340 3ML...... 164 morphine sulfate (pf)...... 146 Mynephron...... 336, 340 MINIPRESS...... 59, 78, 79 morphine sulfate er...... 146 MYOBLOC...... 64, 270 Minitran...... 109 morphine sulfate er beads...... 146 Myorisan...... 324 MINIVELLE...... 229 MORPHINE SULFATE-NACL.146 MYRBETRIQ...... 328 minocycline hcl...... 29 MOTEGRITY...... 204 MYTESI...... 198 MINOCYCLINE HCL ER...29, 324 motion sickness relief MYXREDLIN...... 235, 243 minocycline hcl er...... 29, 324 ...... 9, 10, 198, 279 na ferric gluc cplx in sucrose.....74 MINOLIRA...... 29, 324 MOTOFEN...... 198 NABI-HB...... 51 minoxidil...... 104 MOTRIN IB...... 151 nabumetone...... 151 MIRCERA...... 67 MOTRIN INFANTS DROPS....151 n-acetyl-l-cysteine...... 270 MIRCETTE...... 222 MOUNTAIN CEDAR. 47, 169, 270 nadolol...... 59, 87, 88, 99 MIRENA (52 MG)...... 222 MOUSE EPITHELIUM nafcillin sodium...... 27 mirtazapine...... 124 ...... 47, 169, 270 NAFRINSE DAILY/NEUTRAL.254 MIRVASO...... 324 MOVANTIK...... 202 naftifine hcl...... 288 misoprostol...... 204 MOVIPREP...... 200 NAFTIN...... 288 MITE (D. FARINAE)..47, 169, 270 moxifloxacin hcl...... 16, 28, 186 NAGLAZYME...... 184 MITE (D. PTERONYSSINUS) moxifloxacin hcl (2x day)...... 186 nalbuphine hcl...... 148 ...... 47, 169, 270 moxifloxacin hcl in nacl...... 16, 28 NALFON...... 151 MITIGARE...... 251 MOZOBIL...... 67 NALOCET...... 120, 146 Mitigo...... 146 MSUD EASY...... 175 naloxone hcl...... 148, 250 mitomycin...... 39 MUCOR...... 47, 169, 270 naltrexone hcl...... 148, 249 MITOMYCIN...... 39 MUCOSITISRX...... 164 NAMENDA TITRATION PAK..139 MITOSOL...... 187 MUCOTROL...... 324 NAMENDA XR TITRATION mitoxantrone hcl...... 39 MUGARD...... 164 PACK...... 139 MIXED ASPERGILLUS MUGWORT...... 47, 169, 270 NAMZARIC...... 60, 139 ...... 47, 169, 270 MULPLETA...... 67 NAPRELAN...... 151, 251 MIXED FEATHERS.. 47, 169, 270 MULTAQ...... 100 NAPROSYN...... 151, 251 MIXED RAGWEED... 47, 169, 270 MULTIGEN...... 74 naproxen...... 151, 251 MULTIGEN FOLIC....73, 336, 340 naproxen sodium...... 152, 251

362 naproxen sodium er...... 151, 251 nevirapine...... 21 nitisinone...... 271 NAPROXEN SODIUM ER nevirapine er...... 21 NITRO-BID...... 109 ...... 152, 251 NEXAVAR...... 39 NITRO-DUR...... 109 naproxen-esomeprazole. 152, 205 NEXIUM...... 205 nitrofurantoin...... 30 naratriptan hcl...... 157 NEXLETOL...... 85 nitrofurantoin macrocrystal...... 30 NARCAN...... 148, 250 NEXLIZET...... 85, 97 nitrofurantoin monohydrate NARDIL...... 142 NEXPLANON...... 222 macrocrystals...... 30 NASCOBAL...... 336 niacin (antihyperlipidemic)...... 85 nitroglycerin...... 109 NATACYN...... 187 niacin er (antihyperlipidemic).... 85 NITROMIST...... 109 NATAZIA...... 222 NIACINAMIDE- NITROSTAT...... 109 nateglinide...... 238 SPIRONOLACTONE...... 324 NITRO-TIME...... 109 NATESTO...... 213 NIACINAMIDE- NITYR...... 271 NATPARA...... 238, 239, 252 SULFACETAMIDE...... 315 NIVESTYM...... 67 NATURE-THROID...... 247 NIACINAMIDE-TACROLIMUS 324 nizatidine...... 203 NAVELBINE...... 39 NIACINAMIDE-TAZAROTENE NOCDURNA...... 70, 239 NAYZILAM...... 136, 137 ...... 324 Nolix...... 294, 308 NEBUPENT...... 15 NIACINAMIDE-TRETINOIN....303 NOPIOID-LMC KIT...... 58, 299 Necon 0.5/35 (28)...... 222 NIACINAMIDE- Nora-Be...... 222 nefazodone hcl...... 158 TRIAMCINOLONE ACET...... 308 NORDIPEN 5 INJECTION neomycin sulfate...... 13 NIACIN-SPIRONOLACTON- DEVICE...... 165 neomycin-bacitracin zn- TRETINOIN...... 303 NORDITROPIN FLEXPRO..... 239 polymyx...... 186 niacor...... 85 norethin ace-eth estrad-fe...... 222 neomycin-polymyxin b gu...... 290 NIASPAN...... 85 norethindrone...... 222 neomycin-polymyxin-dexameth NICADAN...... 270, 336 norethindrone acetate...... 241 ...... 186, 190 NICAPRIN...... 270, 336 norethindrone acet-ethinyl est.222 neomycin-polymyxin- nicardipine hcl norethindrone-eth estradiol gramicidin...... 186 ...... 92, 102, 103, 107, 115 ...... 229, 241 neomycin-polymyxin-hc.. 186, 190 NICAZEL...... 270, 336 norethin-eth estradiol-fe...... 222 Neo-Polycin...... 186 NICAZEL FORTE...... 270, 336 NORGESIC FORTE...... 64, 155 Neo-Polycin Hc...... 186, 190 NICAZYME...... 270, 336 norgestimate-eth estradiol...... 222 NEORAL...... 257, 262, 266 NICOMIDE...... 336 norgestimate-ethinyl estradiol NEOSALUS...... 164, 165 NICORETTE...... 57 triphasic...... 222 NEOSTIGMINE nicotine polacrilex...... 57 NORITATE...... 290 METHYLSULFATE...... 60, 172 nicotine step 1...... 57 Norlyda...... 222 NEO-SYNALAR...... 290, 294, 308 nicotine step 2...... 57 Norlyroc...... 222 NEOTUSS PLUS 10, 54, 277, 279 nicotine step 3...... 57 NORPACE CR...... 97 NEOVITE...... 329, 336 NICOTROL...... 57 NORPRAMIN...... 159 NEPHPLEX RX...... 336, 340 NICOTROL NS...... 57 NORTHERA...... 53 Nephronex...... 336, 340, 342 nifedipine...92, 102, 103, 107, 115 Nortrel 0.5/35 (28)...... 222 NEPHRO-VITE RX...... 336, 341 nifedipine er Nortrel 1/35 (21)...... 223 NERLYNX...... 39 ...... 92, 102, 103, 107, 115 Nortrel 1/35 (28)...... 223 NESINA...... 226 nifedipine er osmotic release Nortrel 7/7/7...... 223 NESTABS...... 74, 179, 329, 336 ...... 92, 102, 103, 107, 115 nortriptyline hcl...... 159 NESTABS ONE...... 74, 329, 336 NIFEREX...... 74, 336, 341 NORVASC 92, 102, 103, 107, 115 Neuac...... 290, 312 Nikki...... 222 NORVIR...... 23 NEUAC...... 290, 312 NILANDRON...... 39 NOURIANZ...... 139 NEULASTA...... 67 nilutamide...... 39 NOVACORT...... 294, 299, 308 NEULASTA ONPRO...... 67 nimodipine.92, 102, 103, 107, 115 novarel...... 231, 232 NEUPOGEN...... 67 NINLARO...... 39 NOVAREL...... 231, 232 NEUPRO...... 143 NIPENT...... 39 NOVOEIGHT...... 70 NEURAPTINE...... 324 nisoldipine er NOVOFINE AUTOCOVER NEURIN-SL...... 336 ...... 92, 102, 103, 107, 115 PEN NEEDLE...... 165 NEVANAC...... 193 nitazoxanide...... 15 NOVOFINE PEN NEEDLE..... 165

363 NOVOFINE PLUS PEN NUFERA...... 74, 336, 341, 342 olmesartan-amlodipine-hctz NEEDLE...... 165 Nulev...... 56 80, 82, 92, 102, 104, 112, 115, NOVOLIN 70/30 FLEXPEN NULIBRY...... 271 182 ...... 235, 237, 244 NULOJIX...... 266 olopatadine hcl...... 185 NOVOLIN 70/30 FLEXPEN NULYTELY LEMON-LIME...... 200 OLUMIANT...... 257, 262 RELION...... 235, 237, 244 NUMBRINO...... 195 OMECLAMOX-PAK.... 14, 26, 205 NOVOLIN 70/30 RELION NUPLAZID...... 133 omega-3-acid ethyl esters...... 86 ...... 235, 237, 244 NURTEC...... 138 omeprazole...... 205 NOVOLIN 70/30 VIAL NUSURGEPAK SURGICAL omeprazole magnesium...... 205 ...... 235, 237, 244 PREP/CARE...... 290, 316, 325 OMEPRAZOLE+SYRSPEND NOVOLIN N FLEXPEN...235, 237 NUTRASEB...... 302 SF ALKA...... 205 NOVOLIN N FLEXPEN Nutriarx Creampak...... 295, 309 omeprazole-sodium RELION...... 235, 237 NUTRICAP...... 74, 329, 336 bicarbonate...... 205 NOVOLIN N RELION...... 235, 237 NUTRIDOX...... 29 OMNARIS...... 190, 281 NOVOLIN N VIAL...... 235, 237 NUTRIVIT...... 74, 329, 336 OMNITROPE...... 240 NOVOLIN R FLEXPEN...236, 244 NUTROPIN AQ NUSPIN 10... 239 OMNIVEX...... 329, 336 NOVOLIN R FLEXPEN NUTROPIN AQ NUSPIN 20... 239 ONCASPAR...... 39 RELION...... 236, 244 NUTROPIN AQ NUSPIN 5..... 240 ondansetron hcl...... 197 NOVOLIN R RELION...... 236, 244 NUVAIL...... 165 ondansetron odt...... 197 NOVOLIN R VIAL...... 236, 244 Nuvakaan...... 299 ONETOUCH DELICA NOVOLOG FLEXPEN.... 236, 243 NUVAKAAN-II...... 299 LANCING DEV...... 165 NOVOLOG MIX 70/30 NUVARING...... 223 ONETOUCH DELICA PLUS FLEXPEN...... 236, 237, 243 NUVESSA...... 290 LANCING...... 165 NOVOLOG MIX 70/30 VIAL NUWIQ...... 70 ONETOUCH ULTRA...... 171 ...... 236, 238, 243 NUZYRA...... 13 ONETOUCH ULTRA 2...... 165 NOVOLOG PENFILL...... 236, 243 Nyamyc...... 319 ONETOUCH ULTRA MINI...... 165 NOVOLOG U-100 VIAL.. 236, 243 Nylia 7/7/7...... 223 ONETOUCH VERIO...... 165, 171 NOVOPEN ECHO...... 165 NYMALIZE 92, 102, 103, 107, 115 ONETOUCH VERIO FLEX NOVOSEVEN RT...... 70 Nymyo...... 223 SYSTEM KIT W/DEVICE...... 165 NOVOTWIST PEN NEEDLE.. 165 nystatin...... 27, 319 ONETOUCH VERIO IQ NOXAFIL...... 17 nystatin-triamcinolone...... 319 SYSTEM...... 165 np thyroid...... 247 Nystop...... 319 ONETOUCH VERIO NPLATE...... 67 NYVEPRIA...... 67 REFLECT...... 165 NUBEQA...... 39 OBIZUR...... 70 ONETOUCH VERIO SYNC NUCALA...... 277, 280 OCALIVA...... 202 SYSTEM KIT W/DEVICE...... 165 NUCARACLINPAK...... 290, 327 Ocella...... 223 ONEVITE...... 329, 336 NUCARARXPAK.....290, 312, 327 OCREVUS...... 262 ONEXTON...... 290, 313 NUCORT...... 294, 309 OCTAGAM...... 51 ONGENTYS...... 139 NUCYNTA...... 146 octreotide acetate...... 245, 271 ONGLYZA...... 226 NUCYNTA ER...... 146 OCUVEL...... 329, 336, 341, 343 ONIVYDE...... 39 NUDERMRXPAK 120 ODACTRA...... 47 ONPATTRO...... 271 ...... 302, 314, 324 ODEFSEY...... 21, 22 ONTRUZANT...... 39 NUDERMRXPAK 60 ODOMZO...... 39 ONUREG...... 39 ...... 302, 314, 324 OFEV...... 277 ONZDEOXIA...... 290, 313 Nudiclo Solupak...... 152, 318, 324 ofloxacin...... 28, 186 ONZETRA XSAIL...... 157 Nudiclo Tabpak...... 152, 324 OGIVRI...... 39 OPDIVO...... 40 NUDROXIPAK...... 140, 324 olanzapine...... 127, 133 opium...... 146, 198 NUDROXIPAK DSDR-50 152, 324 olanzapine-fluoxetine hcl 133, 158 OPSUMIT...... 115, 287 NUDROXIPAK DSDR-75 152, 324 OLIVE TREE...... 47, 169, 271 ORACIT...... 173 NUDROXIPAK E-400...... 152, 324 olmesartan medoxomil...... 80, 82 ORALAIR...... 48, 271 NUDROXIPAK I-800...... 152, 324 olmesartan medoxomil-hctz ORALAIR ADULT STARTER NUDROXIPAK N-500..... 152, 325 ...... 80, 82, 112, 182 PACK...... 47, 271 NUEDEXTA...... 140, 277

364 ORALAIR CHILDRENS OXISTAT...... 301 PARSABIV...... 214, 271 STARTER PACK...... 48, 271 OXLUMO...... 271 PASER...... 16 Oralone...... 295, 309 OXTELLAR XR...... 123 PAXIL...... 158 ORAMAGICRX...... 165 oxybutynin chloride...... 327 PAXIL CR...... 158 ORAVIG...... 301 oxybutynin chloride er...... 327 pb-hyoscy-atropine- ORCHARD GRASS POLLEN oxycodone hcl...... 146, 147 scopolamine...... 56, 134, 135 ...... 48, 169, 271 OXYCODONE HCL ER...... 146 P-CARE K40...... 210 ORENCIA...... 257, 258, 262 oxycodone-acetaminophen P-CARE K40G...... 165, 211 ORENCIA CLICKJECT... 257, 262 ...... 120, 147 P-CARE K80...... 211 ORENITRAM...... 115, 287 OXYCODONE- P-CARE K80G...... 165, 211 ORFADIN...... 271 ACETAMINOPHEN...... 120, 147 PEDIZOLPAK...... 301 ORGOVYX...... 40, 214 oxycodone-aspirin...... 147, 155 peg 3350-kcl-na bicarb-nacl....200 ORIAHNN...... 214, 229, 241 OXYCONTIN...... 147 peg-3350/electrolytes...... 200 ORILISSA...... 214 oxymorphone hcl...... 147 peg-3350/electrolytes/ascorbat ORKAMBI...... 278 oxymorphone hcl er...... 147 ...... 200 ORLADEYO...... 255 OXYTOCIN-LACTATED PEGASYS...... 24 orphenadrine citrate er...... 64 RINGERS...... 274 PEGINTRON...... 24 orphenadrine-asa-caffeine 64, 155 OXYTOCIN-SODIUM peg-kcl-nacl-nasulf-na asc-c... 200 Orphengesic Forte...... 64, 155 CHLORIDE...... 274 Peg-Prep...... 200 Orsythia...... 223 OXYTROL...... 327 PEMAZYRE...... 40 ORTHO DF...... 336, 342 OZEMPIC...... 233 penicillamine...... 207, 258 ORTHO MICRONOR...... 223 OZOBAX...... 58 penicillin g potassium...... 25 ORTHOVISC...... 165 OZURDEX...... 190 penicillin g procaine...... 25 ORTIKOS...... 210 paclitaxel...... 40 penicillin g sodium...... 25 oscimin...... 56 PADCEV...... 40 penicillin v potassium...... 25 oscimin sr...... 56 PAINGO KFT...... 299 PENICILLIUM NOTATUM oseltamivir phosphate...... 25 PALFORZIA...... 48 ...... 48, 170, 271 OSENI...... 226, 246 paliperidone er...... 133 PENLEN...... 166 OSMOLEX ER...... 12, 117 palonosetron hcl...... 197 PENNSAID...... 152, 318, 325 OSMOPREP...... 200 PALYNZIQ...... 184 PENTAM...... 15 OSPHENA...... 227 PAMELOR...... 159 pentamidine isethionate...... 15 OTEZLA...... 258, 262, 325 pamidronate disodium...... 253 PENTASA...... 199 OTIPRIO...... 186 PANCREAZE...... 201 pentazocine-naloxone hcl...... 148 OTOVEL...... 186, 190 PANDEL...... 295, 309 pentoxifylline er...... 68 OTREXUP...... 40, 258, 262, 266 PANHEMATIN...... 271 PEPAXTO...... 40 OVACE PLUS...... 316 PANRETIN...... 40, 325 PEPCID...... 203 OVACE PLUS WASH...... 316 pantoprazole sodium...... 205 PERFOROMIST...... 62, 286 OVACE WASH...... 316 PANZYGA...... 51 perindopril erbumine...... 83, 84 OVEEZA...... 271 papaverine hcl...... 115 Periogard...... 192 OVIDREL...... 231, 232 PARAGARD INTRAUTERINE PERJETA...... 40 oxacillin sodium...... 27 COPPER...... 274 permethrin...... 319 oxaliplatin...... 40 paraplatin...... 40 perphenazine...... 153 oxandrolone...... 213 Paraplatin...... 40 perphenazine-amitriptyline oxaprozin...... 152 PAREMYD...... 195 ...... 153, 159 OXAYDO...... 146 PARI ALTERA NEBULIZER PERSERIS...... 127, 133 oxazepam...... 137 HANDSET...... 165 PERTZYE...... 201 OXBRYTA...... 65 PARI TREK S COMBO PACK 165 PEXEVA...... 158 oxcarbazepine...... 123 paricalcitol...... 342 Phenazo...... 299 OXERVATE...... 193 PARNATE...... 142 phenazopyridine hcl...... 299 OXIANUJO...... 325 paromomycin sulfate...... 12, 13 phendimetrazine tartrate...... 118 OXIATAR...... 303 paroxetine hcl...... 158 phendimetrazine tartrate er.....118 OXIAVARRY...... 303 paroxetine hcl er...... 158 phenelzine sulfate...... 142 oxiconazole nitrate...... 301 paroxetine mesylate...... 158 PHENERGAN...... 10, 131, 279

365 phenobarbital...... 134, 135 PIQRAY...... 40 pramipexole dihydrochloride er phenobarbital-belladonna alk Pirmella 1/35...... 223 ...... 143 ...... 56, 134, 135 Pirmella 7/7/7...... 223 pramosone...... 295, 299, 309 Phenohytro...... 56, 134, 135 piroxicam...... 152 PRAMOSONE...... 295, 299, 309 phenoxybenzamine hcl..... 60, 107 PKU EASY...... 175 PRAMOTIC...... 192, 195 phentermine hcl...... 118 PKU EASY MICROTABS...... 175 pramox...... 299 phentolamine mesylate..... 60, 107 PKU GO...... 175 prasugrel hcl...... 77 phenylephrine hcl...... 196 PLAN B ONE-STEP...... 223 pravastatin sodium...... 105 PHENYLEPHRINE HCL-NACL.54 PLAQUENIL...... 14, 258, 262 PRAXBIND...... 65 phenytoin...... 98, 141 PLASMA-LYTE 148...... 180 praziquantel...... 14 Phenytoin Infatabs...... 98, 141 PLASMA-LYTE A...... 180 prazosin hcl...... 59, 78, 79 phenytoin sodium extended PLAVIX...... 77 PRECEDEX...... 131 ...... 98, 141 PLEGRIDY...... 262, 263 PRECISION PCX PLUS TEST171 PHEODOYO...... 301, 309, 316 PLEGRIDY STARTER PACK. 262 PRECISION QID TEST...... 171 PHESGO...... 40 PLENVU...... 200 PRECISION SOF-TACT TEST PHEXXI...... 274 PLEXION...... 313, 316 ...... 171 PHEYO...... 301, 309 PLEXION CLEANSER.... 313, 316 PRECISION XTRA...... 166 Philith...... 223 PLEXION CLEANSING PRECISION XTRA BLOOD PHLAG SPRAY...... 166, 302 CLOTH...... 313, 316 GLUCOSE...... 171 PHOMA EXIGUA...... 48, 170, 271 PLIAGLIS...... 299 PRECOSE...... 212 PHOSLYRA...... 177 PNV TABS 20-1...... 74, 329, 336 PRED FORTE...... 190 Phospha 250 Neutral...... 173 POD-CARE 100K...... 211 PRED MILD...... 190 Phosphasal...... 30 PODIAPN...... 337 PRED-G...... 186, 190 PHOSPHOLINE IODIDE...... 195 podocon...... 325 PRED-G S.O.P...... 186, 190 phosphorous...... 173 podofilox...... 325 prednicarbate...... 295, 309 phosphorus supplement...... 179 POLIVY...... 40 PREDNISOL ACE- phosphorus w/sod & Polycin...... 186 MOXIFLOX-BROMFEN potassium...... 179 poly-iron 150 forte...... 74, 337 ...... 187, 190, 193 Phospho-Trin 250 Neutral...... 173 polymyxin b sulfate...... 27 prednisolone...... 211 PHOTOFRIN...... 40 polymyxin b-trimethoprim...... 186 prednisolone acetate...... 191 PHOTREXA-PHOTREXA polysaccharide iron forte...74, 337 prednisolone acetate p-f...... 191 VISCOUS KIT...... 193 POLY-VI-FLOR...... 254, 329 PREDNISOLONE ACETATE- PHOXILLUM B22K4/0...... 179 POLY-VI-FLOR/IRON NEPAFENAC...... 191, 194 PHOXILLUM BK4/2.5...... 179 ...... 74, 254, 329 PREDNISOLONE ACET- PHYSICIANS EZ USE B-12....336 POMALYST...... 40, 263 MOXIFLOXACIN...... 187, 191 physicians ez use joint/tunnel PONVORY...... 263 prednisolone sodium ...... 211, 248 PONVORY STARTER PACK. 263 phosphate...... 191, 211 PHYSICIANS EZ USE M- Portia-28...... 223 PREDNISOLONE- PRED...... 211 PORTRAZZA...... 40 BROMFENAC...... 191, 194 Physiolyte...... 176 posaconazole...... 17 PREDNISOLONE- Physiosol Irrigation...... 176 POTABA...... 271 GATIFLOXACIN...... 187, 191 phytonadione...... 250, 343 potassium chloride...... 180 PREDNISOLONE- PIFELTRO...... 21 potassium chloride crys er...... 180 MOXIFLOXACIN...... 187, 191 pilocarpine hcl...... 60, 195 potassium chloride er...... 180 PREDNISOLON-GATIFLOX- pimecrolimus...... 266, 325 potassium chloride in nacl...... 180 BROMFENAC...... 187, 191, 194 pimozide...... 130 potassium citrate er...... 173 PREDNISOLON-MOXIFLOX- Pimtrea...... 223 potassium citrate-citric acid.....173 BROMFENAC...... 187, 191, 194 pindolol...... 59, 87, 88, 99, 107 POTELIGEO...... 41 PREDNISOLON-MOXIFLOX- pioglitazone hcl...... 246 Pr Benzoyl Peroxide Wash..... 313 NEPAFENAC...... 187, 191, 194 pioglitazone hcl-glimepiride.....246 PR CREAM...... 166 prednisone...... 211 pioglitazone hcl-metformin hcl PRADAXA...... 66 prednisone intensol...... 211 ...... 216, 246 PRALUENT...... 109 PREFEST...... 229 piperacillin sod-tazobactam so..18 pramipexole dihydrochloride... 143 pregabalin...... 120, 123, 141

366 pregabalin er...... 120, 123, 141 PREZCOBIX...... 23, 271 PROGLYCEM...... 214 PREGEN DHA...... 74, 329, 337 PREZISTA...... 23 PROGRAF...... 266 PREGENNA...... 74, 329, 337 PRIALT...... 120 PROLASTIN-C...... 284 pregnyl...... 231, 232 PRIFTIN...... 16, 28 PROLATE...... 120, 147 PREMARIN...... 229 PRILO PATCH...... 299 PROLENSA...... 194 PREMPHASE...... 229 PRILO PATCH II...... 299 PROLEUKIN...... 41, 263 PREMPRO...... 229 PRILOLID...... 299 PROLIA...... 253 PRENAISSANCE PRILOSEC...... 206 PROMACTA...... 67 ...... 74, 180, 200, 330, 337 PRILOVIX...... 299 PROMELLA IN PREBIOTIC... 202 prenatal...... 74, 180, 330, 337 PRILOVIX LITE...... 299 promethazine hcl...... 10, 131, 279 prenatal plus iron PRILOVIX LITE PLUS...... 299 promethazine vc...... 10, 54, 279 ...... 74, 180, 330, 337 PRILOVIX PLUS...... 299 promethazine vc/codeine prenatal vitamin plus low iron PRILOVIX ULTRALITE...... 299 ...... 10, 54, 147, 277, 279 ...... 74, 180, 330, 337 PRILOVIX ULTRALITE PLUS.299 promethazine-codeine PRENATE...... 180, 330, 337 PRILOVIXIL...... 299 ...... 147, 277, 279 PRENATE DHA...... 74, 330, 337 PRIMACARE...... 75, 330, 337 promethazine-dm...... 10, 278, 279 PRENATE ELITE...... 74, 330, 337 primaquine phosphate...... 14 promethazine-phenyleph- PRENATE ENHANCE primidone...... 134 codeine...... 10, 54, 147, 278, 280 ...... 74, 330, 337 PRIMSOL...... 30 promethazine-phenylephrine PRENATE ESSENTIAL PRINIVIL...... 83, 84 ...... 10, 54, 280 ...... 74, 330, 337 PRISTIQ...... 156 Promethegan...... 10, 131 PRENATE MINI...... 75, 330, 337 PRIVET...... 48, 170, 271 promethegan...... 10, 131 PRENATE PIXIE...... 75, 330, 337 PRIVIGEN...... 51 PROMETRIUM...... 241 PRENATE RESTORE PRIZOPAK II...... 299 PROMISEB...... 166 ...... 75, 330, 337 PRIZOTRAL-II...... 299 propafenone hcl...... 98 PRENATRIX...... 75, 330, 337 PROAIR DIGIHALER...... 62, 286 propafenone hcl er...... 98 PRENATRYL...... 75, 330, 337 PROAIR HFA...... 63, 286 proparacaine hcl...... 195 PREPIDIL...... 274 PROAIR RESPICLICK...... 63, 286 proparacaine-fluorescein 172, 195 preplus...... 75, 180, 330, 337 probenecid...... 183, 251 propranolol hcl PRESERA...... 166 PROBICHEW...... 202 ...... 59, 87, 88, 99, 107, 130 PRESTALIA PROBUPHINE IMPLANT KIT. 148 propranolol hcl er ...... 83, 84, 92, 94, 102, 104, 115 procainamide hcl...... 97 ...... 59, 87, 88, 99, 107, 130 PRETAB...... 75, 180, 330, 337 PROCARDIA propranolol-hctz PRETOMANID...... 16 ...... 93, 102, 104, 107, 115 ...... 59, 87, 88, 99, 112, 182 PREVACID...... 205 PROCARDIA XL propylthiouracil...... 214 PREVACID 24HR...... 205 ...... 93, 102, 104, 107, 115 PROSILK...... 166 PREVACID SOLUTAB...... 206 PRO-C-DURE 5...... 211 PROSTIN E2...... 274 Prevalite...... 89 PRO-C-DURE 6...... 211 PROTONIX...... 206 PREVIDENT...... 254 prochlorperazine...... 153, 198 protriptyline hcl...... 159 PREVIDENT 5000 BOOSTER prochlorperazine maleate153, 198 PROVENGE...... 117 PLUS...... 254 PROCORT...... 295, 299, 309 PROVENTIL HFA...... 63, 286 PREVIDENT 5000 DRY PROCRIT...... 67 PROVERA...... 241 MOUTH...... 254 PROCTOCORT...... 295, 309 PROZAC...... 158 PREVIDENT 5000 ENAMEL PROCTOFOAM HC 295, 299, 309 PRUCLAIR...... 166, 302 PROTECT...... 254 Procto-Med Hc...... 295, 309 PRUMYX...... 166 PREVIDENT 5000 ORTHO Procto-Pak...... 295, 309 pseudoephedrine-bromphen- DEFENSE...... 254 Proctozone-Hc...... 295, 309 dm...... 53, 276, 278, 280 PREVIDENT 5000 PLUS...... 254 PROCYSBI...... 271 PSORCON...... 295, 309 PREVIDENT 5000 SENSITIVE PRODIGEN...... 202 PULMICORT FLEXHALER ...... 254 PROFESSIONAL DNA ...... 211, 283 previdolrx plus analgesic.152, 325 COLLECTION...... 195 PULMICORT SUSPENSION Previfem...... 223 PROFILNINE...... 70 ...... 211, 283 PREVYMIS...... 16, 25 progesterone...... 241 PULMOZYME...... 184, 281

367 purevit dualfe plus...... 75 RADIOGARDASE...... 177, 250 REMICADE PURIXAN...... 41, 266 RAGWITEK...... 48, 272 ...... 203, 258, 263, 272, 325 PYLERA...... 12, 15, 26, 29, 199 raloxifene hcl...... 227, 253 REMODULIN...... 115, 287 pyrazinamide...... 16 ramelteon...... 131 RENACIDIN...... 176 PYRIDIUM...... 299 ramipril...... 83, 84 RENAGEL...... 177, 250 pyridostigmine bromide...... 60 ranolazine er...... 96 Renal...... 337, 341 pyridostigmine bromide er...... 60 RAPAMUNE...... 266 RENATABS WITH IRON 337, 341 pyridoxine hcl...... 337 RAPIVAB...... 25 RENFLEXIS.... 203, 258, 263, 325 pyrimethamine...... 15 rasagiline mesylate...... 142 RENVELA...... 177, 250 PYROGALLIC ACID...... 325 RASUVO...... 41, 258, 263, 266 repaglinide...... 238 QBRELIS...... 83, 84 RAVICTI...... 174 REPATHA...... 109 QBREXZA...... 56, 325 RAYALDEE...... 342 REPATHA PUSHTRONEX qc magnesium citrate...... 200 RAYOS...... 211 SYSTEM...... 109 QDOLO...... 147 READYSHARP REPATHA SURECLICK...... 109 QELBREE...... 140 BETAMETHASONE...... 211 REQ 49+...... 331 QINLOCK...... 41 READYSHARP RESECTISOL...... 176 QMIIZ ODT...... 152 DEXAMETHASONE...... 211 RESTASIS...... 192 QNASL...... 191, 281 REBIF...... 263 RESTASIS MULTIDOSE...... 192 QNASL CHILDRENS...... 191, 281 REBIF REBIDOSE...... 263 RESTORA RX...... 203, 338 QSYMIA...... 118, 120, 123 REBIF REBIDOSE RETACRIT...... 67 QTERN...... 226, 244 TITRATION PACK...... 263 RETEVMO...... 41 QUALAQUIN...... 15 REBIF TITRATION PACK...... 263 RETIN-A...... 303 QUARTETTE...... 223 REBINYN...... 70 RETIN-A MICRO...... 303 quazepam...... 137 REBLOZYL...... 65, 67 RETIN-A MICRO PUMP. 303, 304 QUEEN PALM...... 48, 170, 271 RECARBRIO...... 17 RETISERT...... 191 QUESTRAN...... 89 RECEDO...... 166 RETROVIR...... 22 QUESTRAN LIGHT...... 89 Reclipsen...... 223 REVATIO...... 110, 287 quetiapine fumarate...... 127, 133 RECOMBINATE...... 70 REVCOVI...... 184 quetiapine fumarate er.... 127, 133 RECOTHROM...... 70 REVESTA...... 338, 342 QUFLORA FE...... 75, 254, 330 RECOTHROM SPRAY KIT...... 70 REVLIMID...... 41, 263 QUFLORA FE PEDIATRIC RECTIV...... 325 REXULTI...... 133 ...... 75, 254, 330 RECURA...... 275 REYATAZ...... 23 QUFLORA GUMMIES.... 254, 330 RED MAPLE...... 48, 170, 272 REYVOW...... 157 QUFLORA PEDIATRIC.. 254, 330 RED MULBERRY..... 48, 170, 272 RHEUMATE...... 272 QUILLICHEW ER...... 154 RED TOP GRASS POLLEN RHIZOPUS...... 48, 170, 272 QUILLIVANT XR...... 154 ...... 48, 170, 272 RHOFADE...... 325 quinapril hcl...... 83, 84 REDITREX...... 258, 263, 266 RHOGAM ULTRA-FILTERED quinapril-hydrochlorothiazide REGIOCIT...... 65, 173, 180 PLUS...... 51 ...... 83, 84, 112, 182 REGLAN...... 204 RHOPHYLAC...... 51 quinidine gluconate er...... 15, 97 Relador Pak...... 299 RHOPRESSA...... 187, 196 quinidine sulfate...... 15, 97 Relador Pak Plus...... 300 RIABNI...... 41 quinine sulfate...... 15 Relafen...... 152 RIASTAP...... 71 QUINIXIL...... 191, 309 RELAFEN DS...... 152 RIAX...... 313 QUINJA...... 316 RELENZA DISKHALER...... 25 ribavirin...... 25, 26 QUTENZA...... 325 relexxii...... 154 RIBOZEL...... 338, 341 QUTENZA (2 PATCH)...... 325 RELION BLOOD GLUCOSE RIDAURA...... 206, 258, 263 QUTENZA (4 PATCH)...... 325 TEST...... 171 rifabutin...... 16, 28 QVAR REDIHALER...... 211, 283 RELISTOR...... 202, 203 rifampin...... 16, 28 RABBIT EPITHELIUM RELNATE DHA...... 75, 330, 337 riluzole...... 140 ...... 48, 170, 272 RELTONE...... 201 rimantadine hcl...... 12 RABEPRAZOLE SODIUM...... 206 REMEDIENT...... 75, 330, 337 RIMSO-50...... 176, 295 rabeprazole sodium...... 206 REMERON...... 124 ringers irrigation...... 176 RADICAVA...... 140 REMERON SOLTAB...... 125 RINVOQ...... 258, 263

368 RIOMET...... 216 SALIMEZ FORTE...... 313 sf 5000 plus...... 254 risedronate sodium...... 253 SALIVAMAX...... 166 SFROWASA...... 199 RISPERDAL...... 127, 133 salsalate...... 155 SHAGBARK HICKORY RISPERDAL CONSTA....127, 133 SALVAX...... 313 ...... 48, 170, 272 risperidone...... 127, 133 SALVAX DUO PLUS...... 313 Sharobel...... 223 ritonavir...... 23 SAMSCA...... 183 SHARPS CONTAINER...... 166 RITUXAN...... 41 SANADERMRX SKIN REPAIR SHEEP SORREL...... 48, 170, 272 RITUXAN HYCELA...... 41 ...... 295, 309 SHORT RAGWEED POLLEN rivastigmine...... 60 SANCUSO...... 197 EXT...... 48, 170, 272 rivastigmine tartrate...... 60 SANDIMMUNE...... 258, 263, 266 SIDEROL...... 75, 338, 341 Rivelsa...... 223 SANDOSTATIN LAR DEPOT SIGNIFOR...... 245 RIXUBIS...... 71 ...... 245, 272 SIGNIFOR LAR...... 245 rizatriptan benzoate...... 157 SANTYL...... 325 SIKLOS...... 41 ROAOXIA...... 152, 193, 318, 325 SAPHRIS...... 127, 133 SILA III...... 309 ROCALTROL...... 342 sapropterin dihydrochloride.....272 sildenafil citrate...... 110, 287 ROCKLATAN...... 187, 196 SARCLISA...... 41 SILIPAC...... 166 ROMIDEPSIN...... 41 SAVAYSA...... 66 SILIQ...... 325 ropinirole hcl...... 143 SAVELLA...... 141, 156 silodosin...... 61 ropinirole hcl er...... 143 SAVELLA TITRATION PACK silver nitrate...... 313, 316 Rosadan...... 290 ...... 141, 156 silver sulfadiazine...... 316 ROSADAN...... 290 SAXENDA...... 233 SIMBRINZA...... 184, 189 rosuvastatin calcium...... 105 SCALACORT DK...... 295, 309 Simliya...... 224 ROSZET...... 97, 106 SCARCIN...... 166 Simpesse...... 224 ROUGH MARSH ELDER SCARSILK...... 166 SIMPONI...... 203, 258, 264 ...... 48, 170, 272 SCENESSE...... 325 SIMPONI ARIA...... 203, 258, 264 Roweepra...... 123 scopolamine...... 198 SIMULECT...... 267 ROZLYTREK...... 41 SEASONIQUE...... 223 simvastatin...... 106 RUBRACA...... 41 SECUADO...... 127, 133 SINGULAIR...... 280 RUCONEST...... 255 SEEBRI NEOHALER...... 56 SINUVA...... 191, 281 rufinamide...... 123 SEGLUROMET...... 216, 244 sirolimus...... 267 RUKOBIA...... 20 SELECT-OB...... 75, 331, 338 SIRTURO...... 16 RUSSIAN THISTLE.. 48, 170, 272 selegiline hcl...... 142 SITAVIG...... 26 RUXIENCE...... 41 selenium sulfide...... 316 SIVEXTRO...... 27 RUZURGI...... 272 SELRX...... 316 SKYADERM-LP...... 300 RYBELSUS...... 233 SELZENTRY...... 20 SKYLA...... 224 RYDAPT...... 41 SEMGLEE...... 236, 238 SKYRIZI (150 MG DOSE)...... 325 RYTARY...... 140 SENSIPAR...... 214, 272 SLYND...... 224, 241 ryvent...... 9, 280 Sensorcaine...... 248 sod citrate-citric acid...... 173 SABRIL...... 123 Sensorcaine-Mpf...... 248 sodium bicarbonate...... 173 SACCHAROMYCES SEREVENT DISKUS...... 63, 286 SODIUM BICARBONATE CEREVISIAE...... 48, 170, 272 SERNIVO...... 295, 309 ...... 173, 197 SAFYRAL...... 223 SEROQUEL...... 127, 133 sodium chloride...... 166, 180 SAIZEN...... 240 SEROQUEL XR...... 127, 133 sodium chloride (pf)...... 180 SAIZENPREP...... 240 SEROSTIM...... 240 sodium fluoride...... 255 SALEX...... 313 sertraline hcl...... 158 sodium fluoride 5000 enamel..254 SALICEPT...... 166 se-tan plus...... 75 sodium fluoride 5000 plus...... 254 salicylic acid...... 313 Setlakin...... 223 sodium fluoride 5000 ppm salicylic acid er...... 313 sevelamer carbonate...... 177, 250 ...... 254, 255 salicylic acid wart remover...... 313 sevelamer hcl...... 177, 250 sodium fluoride 5000 sensitive255 salicylic acid-cleanser...... 313 SEVENFACT...... 71 sodium phenylbutyrate...... 174 SALICYLIC ACID- sevoflurane...... 142 sodium polystyrene sulfonate SULFACETAMIDE...... 313, 316 SEYSARA...... 13, 29 ...... 177, 250 salimez...... 313 sf...... 254 sodium sulfacetamide...... 316

369 sodium sulfacetamide wash....316 STERILE TOPICAL L.E.T. SUMADAN WASH...... 314, 317 SODIUM SULFACETAMIDE- GEL...... 300 SUMADAN XLT...... 314, 317, 327 BAKUCHIOL...... 316 STERITALC...... 111 sumatriptan...... 157 SOFOSBUVIR-VELPATASVIR.19 STIMATE...... 71, 240 sumatriptan succinate...... 157 SOLARAVIX...... 41, 318 STIOLTO RESPIMAT sumatriptan succinate refill..... 157 solifenacin succinate...... 327 ...... 56, 63, 277, 286 sumatriptan-naproxen sodium SOLIQUA...... 233, 236, 238 STIVARGA...... 41 ...... 152, 157 SOLIRIS...... 255 stomach relief...... 197, 198 SUMAXIN...... 314, 317 SOLODYN...... 29, 325 stool softener...... 200 SUMAXIN CP...... 314, 317 SOLOSEC...... 15 stool softener laxative...... 200 SUMAXIN WASH...... 314, 317 SOLTAMOX...... 41, 227 STRATA CTX...... 275 SUNOSI...... 160 SOLU-CORTEF...... 211 STRATA MARK...... 303 SUPARTZ FX...... 166 SOMATULINE DEPOT...... 245 Strata Triz...... 303 SUPERVITE...... 338 SOMAVERT...... 245 STRATA XRT...... 275 support...... 331 SOOLANTRA...... 325 STRATTERA...... 140 SUPPORT-500...... 338, 341 SORBITOL...... 176 STRENSIQ...... 184 SUPPRELIN LA...... 42, 231, 232 sorbitol-mannitol...... 176, 177 streptomycin sulfate...... 13, 16 SUPRAX...... 12 SORILUX...... 326 STRIBILD...... 20, 22 SUPREP BOWEL PREP KIT..201 SORREL/DOCK MIX 48, 170, 272 STRIVERDI RESPIMAT... 63, 286 sure result dss premium pack sotalol hcl 59, 87, 88, 99, 100, 108 STROVITE FORTE...75, 331, 338 ...... 152, 318, 326 sotalol hcl (af) STROVITE ONE..... 331, 338, 342 SURESTEP PRO HIGH ...... 59, 87, 88, 99, 100, 107 SUBLOCADE...... 148 GLUCOSE...... 166 SOTYLIZE SUBSYS...... 147 SURESTEP PRO LOW ...... 59, 87, 88, 99, 100, 108 Subvenite...... 123, 127 GLUCOSE...... 166 SOVALDI...... 19 Subvenite Starter Kit-Blue SURESTEP PRO NORMAL spinosad...... 319 ...... 123, 127 GLUCOSE...... 166 SPINRAZA...... 252, 272 Subvenite Starter Kit-Green SURVANTA...... 284 SPINY PIGWEED..... 48, 170, 272 ...... 123, 127 SUSTOL...... 197 SPIRIVA HANDIHALER....56, 276 Subvenite Starter Kit-Orange SUTAB...... 201 SPIRIVA RESPIMAT...... 56, 277 ...... 123, 128 SUTENT...... 42 spironolactone...... 108, 110, 178 SUCCINYLCHOLINE SUVICORT...... 166 spironolactone-hctz CHLORIDE...... 58 SWEET GUM...... 48, 170, 272 ...... 108, 110, 112, 178, 182 SUCRAID...... 184 SWEET VERNAL GRASS SPORANOX...... 17 sucralfate...... 204 POLLEN...... 48, 170, 272 SPRAVATO (56 MG DOSE)... 125 SULAR...... 93, 102, 104, 108, 115 Syeda...... 224 SPRAVATO (84 MG DOSE)... 125 SULCONAZOLE NITRATE.....301 SYLVANT...... 42 Sprintec 28...... 224 sulfacetamide sodium..... 187, 317 SYMAX DUOTAB...... 56 SPRITAM...... 123 sulfacetamide sodium (acne).. 317 Symax-Sl...... 56 SPRIX...... 152 sulfacetamide sodium-sulfur Symax-Sr...... 56 SPRYCEL...... 41 ...... 313, 314, 317 SYMBICORT.....63, 211, 283, 286 sps...... 177, 250 sulfacetamide sod-sulfur wash SYMBYAX...... 133, 158 Sronyx...... 224 ...... 314, 317 SYMDEKO...... 278 Ssd...... 316 sulfacetamide-prednisolone.... 187 SYMJEPI...... 53, 276 SSKI...... 14, 215, 250, 279 sulfacetamide-sulfur in urea SYMLINPEN 120...... 212 sss 10-5...... 313, 316, 317 ...... 314, 317 SYMLINPEN 60...... 212 ST JOSEPH LOW DOSE Sulfacleanse 8/4...... 314, 317 SYMPAZAN...... 136, 137 ...... 77, 78, 130, 155 sulfadiazine...... 28 SYMPROIC...... 203 STARLIX...... 238 sulfamethoxazole-trimethoprim.28 SYMTUZA...... 22, 23, 26, 272 stavudine...... 22 SULFAMYLON...... 317 SYNAGIS...... 24 STEGLATRO...... 244 sulfasalazine..... 28, 199, 259, 264 SYNALAR (CREAM)...... 295, 309 STEGLUJAN...... 226, 244 Sulfatrim Pediatric...... 28 SYNALAR (OINTMENT). 295, 309 STELARA...... 259, 264, 326 sulindac...... 152 SYNALAR TS...... 295, 309 STENDRA...... 110 SUMADAN...... 314, 317 SYNAPRYN FUSEPAQ...... 147

370 SYNAREL...... 231, 232 TAZVERIK...... 42 thiamine hcl...... 338 SYNDROS...... 198 TECARTUS...... 42, 117 THIOLA...... 273 SYNERA...... 300 TECENTRIQ...... 42 THIOLA EC...... 273 SYNERDERM...... 166, 302 TECFIDERA...... 264 thioridazine hcl...... 153 SYNJARDY...... 216, 244 TEFLARO...... 12 thiotepa...... 43 SYNJARDY XR...... 216, 245 TEGRETOL-XR...... 123, 128 thiothixene...... 159 SYNRIBO...... 42 TEGSEDI...... 252 THROMBATE III...... 65 SYNVISC...... 166 TEKTURNA...... 110 THROMBI-GEL 10...... 167 SYNVISC ONE...... 166 TEKTURNA HCT.... 110, 112, 182 THROMBI-GEL 100...... 167 SYRINGE AVITENE...... 71 telmisartan...... 80, 82 THROMBI-GEL 40...... 167 TABLOID...... 42 telmisartan-amlodipine THROMBIN-JMI...... 71 TABRECTA...... 42 ...... 80, 82, 93, 102, 104, 116 THROMBIN-JMI EPISTAXIS.... 71 TACHOSIL...... 71 telmisartan-hctz...80, 82, 112, 182 THROMBI-PAD...... 167 TACLONEX...... 295, 310, 326 temazepam...... 137 THYMOGLOBULIN...... 267 tacrolimus...... 267, 326 TEMIXYS...... 22 THYQUIDITY...... 247 TACROLIMUS...... 326 TEMODAR...... 42 THYROGEN...... 172 tadalafil...... 110 temozolomide...... 42 Tiadylt Er.90, 93, 94, 95, 101, 116 tadalafil (pah)...... 110, 287 temsirolimus...... 42 tiagabine hcl...... 123 TAFINLAR...... 42 TENCON...... 120, 135 TIAZAC... 90, 93, 94, 96, 101, 116 TAGRISSO...... 42 teniposide...... 42 TIBSOVO...... 43 TAKHZYRO...... 255 tenofovir disoproxil fumarate.....22 TICE BCG...... 43, 52 TALICIA...... 14, 28, 199, 206 TENORETIC 100 TIGAN...... 198 TALIVA...... 272 ...... 64, 87, 88, 99, 113, 183 tigecycline...... 18 TALL RAGWEED...... 49, 170, 272 TENORETIC 50 TIGLUTIK...... 140 TALTZ...... 326 ...... 64, 87, 88, 99, 113, 183 Tilia Fe...... 224 TALZENNA...... 42 TENORMIN...... 64, 87, 89, 99 timolol maleate TAMIFLU...... 25 TEPADINA...... 42 ...... 59, 87, 89, 99, 108, 130, 188 tamoxifen citrate...... 42, 227 TEPEZZA...... 193 timolol maleate pf...... 188 tamsulosin hcl...... 61 TEPMETKO...... 43 TIMOLOL-BRIMON-DORZOL- TAPERDEX 12-DAY...... 212 terazosin hcl...... 59, 78, 79, 108 LATANOPR.....184, 188, 189, 196 Taperdex 6-Day...... 212 terbinafine hcl...... 12 TIMOLOL-BRIMONIDINE- TAPERDEX 7-DAY...... 212 terbutaline sulfate...... 63, 286 DORZOLAMID...... 184, 188, 189 TARCEVA...... 42 terconazole...... 301 TIMOLOL-DORZOLAMID- TARDEOXIA...... 290, 304 TERIPARATIDE LATANOPROST..... 188, 189, 196 TARDIMAXIA...... 304 (RECOMBINANT)...... 239, 252 TIMOPTIC OCUDOSE...... 188 TARGRETIN...... 42, 326 Terrell...... 142 TIMOTHY GRASS POLLEN Tarina 24 Fe...... 224 TESTONE CIK...... 213 ALLERGEN...... 49, 170, 273 Tarina Fe 1/20...... 224 TESTOPEL...... 213 tinidazole...... 15 Tarina Fe 1/20 Eq...... 224 TESTOSTERONE...... 213 TIROSINT...... 247 TARKA...... 83, 84, 90, 93, 95, 115 testosterone...... 213 TIROSINT-SOL...... 247 TAROXIA...... 304 TESTOSTERONE TISSEEL...... 326 TASIGNA...... 42 CYPIONATE...... 213 Tis-U-Sol...... 176 TASMAR...... 139 testosterone cypionate...... 213 TIVICAY...... 20 TASOPROL...... 310 testosterone enanthate...... 213 TIVICAY PD...... 20 tavaborole...... 318 tetrabenazine...... 140, 160 TIVORBEX...... 152, 251 TAVALISSE...... 65 tetracaine hcl...... 195 tizanidine hcl...... 58 TAYTULLA...... 224 tetracycline hcl...... 29 tl-hem 150...... 75, 338, 341 tazarotene...... 326 TETRIX...... 303 TOBAKIENT....331, 338, 341, 343 TAZAROTENE...... 326 TEXACORT...... 295, 310 TOBI PODHALER...... 13 Tazicef...... 12 THALOMID...... 264 TOBRADEX...... 187, 191 tazicef...... 12 THEO-24...... 104, 176, 288, 328 TOBRADEX ST...... 187, 191 TAZORAC...... 326 theophylline.....104, 176, 288, 328 tobramycin...... 13, 187 Taztia Xt..90, 93, 94, 95, 100, 116 theophylline er.104, 176, 288, 328 TOBRAMYCIN...... 13

371 tobramycin-dexamethasone TRECATOR...... 16 Tri-Lo-Marzia...... 224 ...... 187, 191 TRELEGY ELLIPTA Tri-Lo-Mili...... 224 TOBREX...... 187 ...... 56, 63, 212, 277, 283, 286 Tri-Lo-Sprintec...... 224 tolbutamide...... 246 TRELSTAR MIXJECT...... 43, 231 TRILURON...... 167 tolcapone...... 139 TREMFYA...... 326 trimethobenzamide hcl...... 198 tolmetin sodium...... 152 treprostinil...... 116, 287 trimethoprim...... 30 TOLSURA...... 17 TRESIBA...... 236, 238 Tri-Mili...... 224 tolterodine tartrate...... 327 TRESIBA FLEXTOUCH..236, 238 trimipramine maleate...... 159 tolterodine tartrate er...... 327 tretinoin...... 43, 304 TRI-MIX...... 60, 116 TOLVAPTAN...... 183 tretinoin microsphere...... 304 TRINATE...... 75, 180, 331, 338 tolvaptan...... 183 tretinoin microsphere pump.... 304 TRINAZ...... 75, 331, 338 TOPICORT SPRAY...... 295, 310 TRETTEN...... 71 TRINTELLIX...... 158 topiramate...... 124 TREXALL...... 43, 259, 264, 267 Tri-Nymyo...... 224 topiramate er...... 124 Tri Femynor...... 224 Tri-Previfem...... 225 Toposar...... 43 TRIAMCINOLONE TRIPTODUR...... 43, 231, 232 topotecan hcl...... 43 ACETONIDE...... 212 TRISENOX...... 43 TOPROL XL...... 64, 87, 89, 99 triamcinolone acetonide Tri-Sprintec...... 225 toremifene citrate...... 43, 227 ...... 212, 296, 310 TRISTART DHA...... 75, 331, 338 TORISEL...... 43 triamterene...... 110, 178 TRIUMEQ...... 20, 22 TORONOVA II SUIK...... 152, 167 triamterene-hctz TRI-VI-FLOR...... 255, 331 TORONOVA SUIK...... 153, 167 ...... 110, 112, 178, 182 TRI-VI-FLORO...... 255, 331 torsemide...... 108, 177 Trianex...... 296, 310 tri-vite/fluoride TOSYMRA...... 157 triazolam...... 137 ...... 255, 331, 332, 341, 343 TOTECT...... 273 TRIBENZOR Trivix...... 296, 310 TOUJEO MAX SOLOSTAR 80, 82, 93, 102, 104, 112, 116, Trivora (28)...... 225 ...... 236, 238 182 Tri-Vylibra...... 225 TOUJEO SOLOSTAR.....236, 238 tri-buffered aspirin Tri-Vylibra Lo...... 225 Tovet...... 295, 310 ...... 77, 78, 130, 155 TRODELVY...... 43 TOVET...... 310 TRICARE PRENATAL DHA TROGARZO...... 20 TOVIAZ...... 327 ONE...... 75, 201, 331, 338 TROKENDI XR...... 124 TRACLEER...... 116, 287 TRI-CHLOR...... 326 TRONVITE...... 338, 341 TRADJENTA...... 226 TRICHOPHYTON..... 49, 170, 273 tropicamide...... 195 tramadol hcl...... 147 TRICHOPHYTON TROPICAMIDE- TRAMADOL HCL ER...... 147 MENTAGROPHYTES...... 49, 170 CYCLOPENTOLATE-PE 195, 196 tramadol hcl er...... 147 TRICITRASOL...... 65, 173 TROPICAMIDE- tramadol hcl er (biphasic)...... 147 tricitrates...... 173 PHENYLEPHRINE...... 195 tramadol-acetaminophen Tricon...... 75 TROPIC-CYCLOPENT-PE- ...... 120, 130, 147 TRICOR...... 105 KETOROLAC...... 194, 195, 196 trandolapril...... 83, 84 Triderm...... 296, 310 TROPIC-CYCLOP-PE-KETO- trandolapril-verapamil hcl er trientine hcl...... 207 PROPAR...... 194, 195, 196 ...... 83, 84, 90, 93, 96, 116 Tri-Estarylla...... 224 TROPIC-PROPARACA-PE- tranexamic acid...... 71 TRIFERIC...... 75 KETOROLAC...... 194, 195, 196 TRANEXAMIC ACID-NACL...... 71 trifluoperazine hcl...... 153 trospium chloride...... 327 TRANSDERM SCOP (1.5 MG) trifluridine...... 187 trospium chloride er...... 327 ...... 198 trihexyphenidyl hcl...... 57, 120 TRUE METRIX BLOOD TRANSDERM-SCOP (1.5 MG) TRIJARDY XR...... 216, 227, 245 GLUCOSE TEST...... 171 ...... 198 Tri-Legest Fe...... 224 TRUE METRIX LEVEL 1...... 167 TRANXENE-T...... 136, 137 Tri-Linyah...... 224 TRUE METRIX LEVEL 2...... 167 tranylcypromine sulfate...... 142 TRILIPIX...... 105 TRUE METRIX LEVEL 3...... 167 travoprost (bak free)...... 196 TRILOAN II SUIK...... 167, 212 TRUE METRIX PRO BLOOD TRAZIMERA...... 43 TRILOAN SUIK...... 167, 212 GLUCOSE...... 171 trazodone hcl...... 158 TRILOCICLO...... 310, 311 TRUETRACK TEST...... 171 TREANDA...... 43 Tri-Lo-Estarylla...... 224 TRULANCE...... 203

372 TRULICITY...... 233 Urelle...... 30 VELCADE...... 44 TRUSTEEL INFUSION SET... 167 Uretron D/S...... 30 Velivet...... 225 TRUVADA...... 22 Uribel...... 30 VELPHORO...... 177 TRUXIMA...... 43 URIMAR-T...... 30 VELTASSA...... 177 TUDORZA PRESSAIR..... 56, 277 urin ds...... 30 VELTIN...... 290, 304 TUKYSA...... 43 URO-458...... 30 VEMLIDY...... 26 Tulana...... 225 UROGESIC-BLUE...... 30 VENCLEXTA...... 44 TURALIO...... 43 uro-mp...... 30 VENCLEXTA STARTING TURPENTINE...... 275 urosex...... 331, 338 PACK...... 44 TUSSICAPS...... 10, 147, 278, 280 URSO FORTE...... 201 VENEXA...... 331, 338 TUXARIN ER.... 10, 147, 278, 280 ursodiol...... 201 venlafaxine hcl...... 156 TUZISTRA XR.. 10, 148, 278, 280 Ustell...... 30 venlafaxine hcl er...... 156 TWIRLA...... 225 UTIBRON NEOHALER VENNGEL ONE...... 153, 318, 326 TWYNSTA ...... 57, 63, 277, 286 VENOFER...... 75 ...... 80, 82, 93, 102, 104, 116 Utira-C...... 30 VENTAVIS...... 116, 288 tyblume...... 225 UTOPIC...... 314 VENTOLIN HFA...... 63, 287 TYBOST...... 273 VAGIFEM...... 229 verapamil hcl Tydemy...... 225 valacyclovir hcl...... 26 ...... 90, 93, 94, 96, 101, 116 TYKERB...... 43 VALCHLOR...... 44, 326 verapamil hcl er TYLACTIN BUILD 20PE TYR. 175 VALCYTE...... 26 ...... 90, 93, 94, 96, 101, 116 TYLACTIN COMPLETE 15 PE valganciclovir hcl...... 26 VERDESO...... 296, 310 ...... 175 VALIUM...... 136, 138 VEREGEN...... 326 TYLACTIN RESTORE 10...... 175 valproic acid...... 124, 128, 130 VERELAN91, 93, 94, 96, 101, 116 TYLACTIN RESTORE 5PE.... 175 valrubicin...... 44 VERELAN PM TYLACTIN RTD 15...... 175 valsartan...... 80, 82 ...... 91, 93, 95, 96, 101, 117 TYMLOS...... 239, 252 valsartan-hydrochlorothiazide VERQUVO...... 117 TYR EASY...... 175 ...... 80, 82, 112, 182 VERSACLOZ...... 133 TYROS 2...... 175 VALTOCO...... 136, 138 VERZENIO...... 44 TYSABRI...... 264 VALTREX...... 26 VESICARE LS...... 327 TYVASO...... 116, 287 vancomycin hcl...... 18 Vestura...... 225 TYVASO REFILL...... 116, 287 vancomycin hcl in nacl...... 18 VFEND...... 17 TYVASO STARTER...... 116, 287 Vandazole...... 290 VIBERZI...... 203 UBRELVY...... 138 Vanoxide-Hc...... 296, 310 VIBRAMYCIN...... 30 UCERIS...... 212 VANTAS...... 44, 231, 232 Vic-Forte...... 331, 338 UDAMIN SP...... 331, 338 vardenafil hcl...... 110 VICTOZA...... 233 UDENYCA...... 67 VARDIMAXIA...... 304 VIEKIRA PAK...... 19, 23 UKONIQ...... 43 VARISOFT INFUSION SET....167 Vienva...... 225 ULORIC...... 251 VARIZIG...... 51 vigabatrin...... 124 ULTOMIRIS...... 255 VAROPHEN...... 153, 318 Vigadrone...... 124 ULTRA HIS...... 273 VAROXIA...... 304 VIIBRYD...... 158 ULTRASAL-ER...... 314 VARUBI (180 MG DOSE)...... 204 VIIBRYD STARTER PACK..... 158 ULTRAVATE...... 296, 310 VASCEPA...... 86 VILACTIN AA PLUS...... 175 Umecta Mousse...... 314 VASCULERA...... 273 Vilamit Mb...... 30 UNISTRIP CONTROL...... 167 VASERETIC...... 83, 85, 112, 182 Vilevev Mb...... 30 Unithroid...... 247 VASOTEC...... 83, 85 VILTEPSO...... 252 UNITUXIN...... 43 v-c forte...... 331, 338 VIMIZIM...... 184 UPLIZNA...... 264 VCF VAGINAL VIMPAT...... 124 UPNEEQ...... 196 CONTRACEPTIVE...... 274 VINATE ONE.... 76, 180, 331, 338 UPTRAVI...... 116, 287, 288 vcf vaginal contraceptive...... 274 vinblastine sulfate...... 44 URAMAXIN...... 314 VECAMYL...... 108 vincristine sulfate...... 44 urea...... 314 VECTIBIX...... 44 vinorelbine tartrate...... 44 urea hydrating...... 314 VECTICAL...... 326 VIOKACE...... 201 urea nail...... 314 VECURONIUM BROMIDE...... 58 viorele...... 225

373 VIRACEPT...... 23 VRAYLAR...... 134 WPR PLUS WOUND VIRAMUNE...... 21 VTOL LQ...... 120, 130, 135, 154 HEALING SYSTEM...... 156, 300 VIRASAL...... 314 VUMERITY...... 264 Wymzya Fe...... 225 VIRAZOLE...... 26 VUSION...... 301 WYNZORA...... 310, 326 VIREAD...... 22 VYEPTI...... 138 XADAGO...... 142 virt-caps...... 338, 341 Vyfemla...... 225 XALIX...... 314 VIRT-FEFA PLUS..... 76, 338, 341 VYLEESI...... 140 XALKORI...... 44 Virt-Gard...... 338 Vylibra...... 225 XANAX...... 138 virt-phos 250 neutral...... 173 VYNDAMAX...... 96 XANAX XR...... 138 virtussin ac w/alc.....148, 278, 279 VYNDAQEL...... 96 XAQUIL XR...... 339 VISBIOME...... 203 VYONDYS 53...... 252 XARACOLL...... 248 VISIONBLUE...... 172 VYTONE...... 296, 310, 317 XARELTO...... 66 VISTOGARD...... 250 VYTORIN...... 97, 106 XARELTO STARTER PACK.....66 VISUDYNE...... 193 VYVANSE...... 118, 119 XATMEP...... 44, 259, 264, 267 Vita S Forte...... 76, 331, 338 VYXEOS...... 44 XCOPRI...... 124 Vitacel...... 331, 338 VYZULTA...... 196 XELJANZ...... 259, 264 VITAFOL FE+...... 76, 331, 338 WAKIX...... 160 XELJANZ XR...... 259, 264 VITAFOL-NANO...... 76, 331, 338 warfarin sodium...... 66 XELODA...... 44 VITAFOL-OB+DHA WASP VENOM PROTEIN 49, 170 XELPROS...... 196 ...... 76, 180, 331, 339 weekly-d...... 343 XEMBIFY...... 51 VITAL-D RX...... 339, 341, 343 WELCHOL...... 89, 214 XENICAL...... 203 vitamin b complex 100...... 339 WELLBUTRIN SR...... 125 XENLETA...... 27 vitamin b-complex 100...... 339 WELLBUTRIN XL...... 125 XEOMIN...... 64, 273 vitamin d (ergocalciferol)...... 343 Wera...... 225 XEPI...... 290 vitamin k1...... 250, 343 westab max...... 339 XERAC AC...... 300 vitamins acd-fluoride westab mini...... 339 XERESE...... 296, 300, 310 ...... 255, 331, 332, 341, 343 westab one...... 339 XERMELO...... 198 VITA-RX DIABETIC VITAMIN WESTAB PLUS 76, 180, 332, 339 XEROSTOMIA RELIEF ...... 331, 339 WESTERN JUNIPER 49, 170, 273 SPRAY...... 167 VITASURE...... 339, 341 WESTGEL DHA...... 76, 332, 339 XGEVA...... 253 VITRAKVI...... 44 WESTHROID...... 247 XHANCE...... 191, 281 VITRANOL FE...... 76, 331, 339 WHEAT GERM OIL...... 343 XIAFLEX...... 184 VITRASE...... 184 WHITE BIRCH...... 49, 170, 273 XIFAXAN...... 28 VITREXATE...... 331, 339 WHITE FACED HORNET XIGDUO XR...... 216, 245 VITREXATE FE...... 76, 331, 339 VENOM...... 49, 170 XIIDRA...... 192 VITREXYL...... 332, 339 WHITE MULBERRY. 49, 170, 273 XIMINO...... 30, 326 VITREXYL + IRON....76, 332, 339 WHITE OAK...... 49, 171, 273 XOFIGO...... 275 VIVELLE-DOT...... 229 WHITE PINE...... 49, 171, 273 XOFLUZA (40 MG DOSE)...... 16 VIVITROL...... 148, 249 WIDE-SEAL DIAPHRAGM 60 274 XOFLUZA (80 MG DOSE)...... 16 VIVLODEX...... 153 WIDE-SEAL DIAPHRAGM 65 274 XOLAIR...... 284 VIZIMPRO...... 44 WIDE-SEAL DIAPHRAGM 70 274 XOLEGEL...... 302 VOCABRIA...... 20 WIDE-SEAL DIAPHRAGM 75 274 XOPENEX HFA...... 63, 287 VOGELXO PUMP...... 213 WIDE-SEAL DIAPHRAGM 80 274 XOSPATA...... 44 Volnea...... 225 WIDE-SEAL DIAPHRAGM 85 274 XPOVIO (100 MG ONCE VOLTAREN...... 153, 318, 326 WIDE-SEAL DIAPHRAGM 90 274 WEEKLY)...... 44 VONVENDI...... 71 WIDE-SEAL DIAPHRAGM 95 274 XPOVIO (40 MG ONCE VORAXAZE...... 184, 251 WILATE...... 71 WEEKLY)...... 44 voriconazole...... 17 WILZIN...... 207 XPOVIO (40 MG TWICE VOSEVI...... 19 WINLEVI...... 326 WEEKLY)...... 44 VOTRIENT...... 44 WINRHO SDF...... 51 XPOVIO (60 MG ONCE vp-pnv-dha...... 76, 332, 339 Wixela Inhub..... 63, 212, 283, 287 WEEKLY)...... 44 VPRIV...... 184 WP THYROID...... 247 XPOVIO (60 MG TWICE vp-vite rx...... 339, 341 WEEKLY)...... 44

374 XPOVIO (80 MG ONCE ZEMDRI...... 13 ZOMACTON (FOR ZOMA-JET WEEKLY)...... 44 Zenatane...... 327 10)...... 240 XPOVIO (80 MG TWICE ZENPEP...... 201 ZOMIG...... 157 WEEKLY)...... 45 ZENZEDI...... 119 zonisamide...... 124 XRYLIX...... 153, 318, 327 ZEPATIER...... 19 ZONTIVITY...... 77 XTAMPZA ER...... 148 ZEPOSIA...... 264 ZORBTIVE...... 240 XTANDI...... 45 ZEPOSIA 7-DAY STARTER ZORTRESS...... 267 Xulane...... 225 PACK...... 264 ZORVOLEX...... 153 XULTOPHY...... 233, 236, 238 ZEPOSIA STARTER KIT...... 264 Zovia 1/35 (28)...... 225 xurea...... 314 ZEPZELCA...... 45 Zovia 1/35E (28)...... 226 XURIDEN...... 273 ZERUVIA...... 300 ZOVIRAX...... 26, 300 XVITE...... 339, 341 ZERVIATE...... 185 ZTLIDO...... 300 XYNTHA...... 71 ZESTORETIC..... 83, 85, 113, 182 ZUBSOLV...... 149 XYNTHA SOLOFUSE...... 71 ZESTRIL...... 83, 85 ZULRESSO...... 125 XYOSTED...... 213 ZETIA...... 97 Zumandimine...... 226 XYREM...... 140 ZETONNA...... 192, 281 ZUPLENZ...... 197 XYWAV...... 140 ZEVALIN Y-90...... 45 ZYCLARA PUMP...... 327 XYZBAC...... 332, 339 ZIAC...... 64, 87, 89, 99, 113, 182 ZYDELIG...... 45 XYZMUNE...... 273 ZIAGEN...... 22 ZYFLO...... 280 YASMIN 28...... 225 zidovudine...... 22 ZYKADIA...... 45 YAZ...... 225 ZIEXTENZO...... 68 ZYLET...... 187, 192 YELLOW DOCK...... 49, 171, 273 ZILACAINE PATCH...... 300 ZYLOPRIM...... 251 YELLOW HORNET VENOM zileuton er...... 280 ZYMAXID...... 187 PROTEIN...... 49, 171 ZILRETTA...... 212 ZYPITAMAG...... 106 YELLOW JACKET VENOM ZILXI...... 290 ZYPREXA...... 128, 134 PROTEIN...... 49, 171 zinc sulfate...... 180 ZYPREXA RELPREVV... 128, 134 YERVOY...... 45 ZINGO...... 248 ZYPREXA ZYDIS...... 128, 134 YESCARTA...... 45, 117 ZINPLAVA...... 51 ZYTIGA...... 45 YONDELIS...... 45 ZIONODIL...... 300 ZYVANA...... 332, 339, 341, 343 YONSA...... 45 ZIONODIL 100...... 300 ZYVIT...... 332, 339 YOSPRALA...... 77, 78, 156, 206 ZIOPTAN...... 196 ZYVOX...... 27 YUPELRI...... 57 ziprasidone hcl...... 128, 134 YUTIQ...... 191 ziprasidone mesylate...... 128, 134 Yuvafem...... 229 ZIPSOR...... 153 ZACARE...... 314 ZIRABEV...... 45 zaclir cleansing...... 314 ZIRGAN...... 188 Zafemy...... 225 ZITHRANOL...... 315 zafirlukast...... 280 ZITHROMAX...... 26 zaleplon...... 131 ZOCOR...... 106 ZALTRAP...... 45 ZOFRAN...... 197 ZALVIT...... 76, 332, 339 ZOKINVY...... 273 ZANOSAR...... 45 zoledronic acid...... 253 Zarah...... 225 ZOLGENSMA...... 117 ZARXIO...... 68 ZOLINZA...... 45 ZCORT 7-DAY...... 212 ZOLMITRIPTAN...... 157 ZEGALOGUE...... 230 zolmitriptan...... 157 ZEJULA...... 45 ZOLOFT...... 158 ZELAC...... 203 ZOLPAK...... 302 ZELAPAR...... 142 zolpidem tartrate...... 131 ZELBORAF...... 45 zolpidem tartrate er...... 131 ZELNORM...... 203, 204 ZOLPIMIST...... 131 ZEMAIRA...... 284 ZOMACTON...... 240 ZEMBRACE SYMTOUCH...... 157

375 Kaiser Permanente Insurance Company Notice of Language Assistance

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-213-3062. For more help call the CA Dept. of Insurance at 1-800-927-4357. TTY users call 711. English

Servicios en otros idiomas sin ningún costo. Puede conseguir un intérprete. Puede conseguir que le lean los documentos y que algunos se le envíen en su idioma. Para obtener ayuda, llámenos al número que aparece en su tarjeta de identificación o al 1-866-213-3062. Para obtener más ayuda, llame al Departamento de Seguro de CA al 1-800-927-4357. Los usuarios de la línea TTY deben llamar al 711. Spanish

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No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the number listed on your ID card or 1-866-213-3062. For more help call the CA Dept. of Insurance at 1-800-927-4357. TTY users call 711. English

Doo b33h7l7n8g00 h1 ata’ hane. Ata’ halne’7 h1 sh0n1ot’eeh d00 naaltsoos t’11 hazaad bee bik’i’ ashch98go hach’8’ y7d0oltah biniiy4 hach’8’ 1n1l’88h [eh. Sh7k1 i’doolwo[ n7n7zingo nihich’8’ hod77lnih koj8’ 1-866-2143-3062 47 bee n44h0zin biniiy4 neiy7t1n7g77 bik11’. !k1 e’4lyeed jin7zingo CA Dept. of Insurance bich’8’ hojilnih kwe’4 1-800-927-4357. TTY chojoo[‘98go 47 711 bi[ azhdilchi’. Navajo

Dịch vụ ngôn ngữ miễn phí. Quý vị có thể được cấp thông dịch viên và được người đọc giấy tờ, tài liệu cho quý vị bằng ngôn ngữ của quý vị. Để được giúp đỡ, xin gọi cho chúng tôi ở số điện thoại ghi trên thẻ ID hội viên hoặc số 1-866-213-3062. Để được giúp đỡ thêm, xin gọi Bộ Bảo hiểm CA ở số 1-800-927-4357. Người sử dụng TTY gọi số 711. Vietnamese

무료 언어 서비스. 한국어 통역 서비스 및 한국어로 서류를 낭독해 드리는 서비스를 제공하고 있습니다. 도움이 필요하신 분은 귀하의 ID 카드에 나와 있는 전화번호 또는1-866-213-3062번으로 문의하십시오. 보다 자세한 사항은 캘리포니아 주 보험국, 전화번호 1-800-927-4357번으로 문의하십시오. TTY 사용자 번호 711. Korean

Mga Libreng Serbisyo kaugnay sa Wika. Maaari kayong kumuha ng tagasalin-wika at hingin na basahin sa inyo ang mga dokumento sa sarili ninyong wika. Para humingi ng tulong, tawagan kami sa numerong nakasulat sa inyong ID card o sa 1-866-213-3062. Para sa karagdagang tulong tawagan ang CA Dept. of Insurance sa 1-800-927-4357. Dapat tumawag ang mga gumagamit ng TTY sa 711. Tagalog

Անվճար լեզվական ծառայություններ: Դուք կարող եք օգտվել բանավոր թարգմանչի ծառայություններից և խնդրել, որ փաստաթղթերը Ձեր լեզվով կարդան Ձեզ համար: Օգնության համար զանգահարեք մեզ` Ձեր ID քարտի վրա նշված կամ 1-866-213-3062 հեռախոսահամարով: Լրացուցիչ օգնության համար զանգահարեք Կալիֆոռնիայի ապահովագրության դեպարտամենտ` 1-800-927-4357 հեռախոսահամարով: TTY-ից օգտվողները պետք է զանգահարեն 711: Armenian

Бесплатные переводческие услуги. Вы можете воспользоваться услугами переводчика, который переведет вам документы на ваш язык. Если вам нужна помощь, позвоните нам по номеру телефону, указанному в вашей идентификационной карточке или 1-866-213-3062. За дополнительной помощью обращайтесь в Департамент страхования штата Калифорния (CA Dept. of Insurance) по телефону 1-800-927-4357. Пользователи TTY, звоните по номеру 711. Russian

KPIC-TL18-001-CA 無料の言語サービス。通訳に日本語で書類を読んでもらうことができます。通訳サービスが必要な際は、ID カードに 記載の番号、または1-866-213-3062 にお電話ください。さらにヘルプが必要な場合は、カリフォルニア州保険庁 (1-800-927-4357)にお電話ください。TTY ユーザーの方は、711 をご使用ください。Japanese

خدمات زبان به صورت رایگان. می توانید از خدمات مترجم شفاهی بهره مند شوید و ترتیب خواندن متن ها برای شما به زبان خودتان را بدهید. برای دریافت کمک و راهنمایی، با ما به شماره ای که روی کارت شناسایی شما قید شده یا شماره 3062-213-866-1 تماس حاصل نمایند. برای دریافت کمک و راهنمایی بیشتر با اداره بیمه کالیفرنیا به شماره 4357-927-800-1 تماس بگیرید. کاربران TTY با شماره 711 تماس حاصل نمایند. Persian

ਤੇﹱਚ ꩍ牍ਹਵਾ ਸਿਦੇ ਹੋ। ਮਦਦ ਲਈ, ਆꩍਣੇ ਆਈਡ ਿਾਰਡ 'ਤੇ ਕਦﹱਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸੇਵਾਵਾ拓. ਤੁਸ 拓 ਕਿਸੇ ਦੁਭਾਸ਼ਏ ਨੰ ꩍਰਾꩍਤ ਿਰ ਸਿਦੇ ਹੋ ਅਤੇ ਤੁਸ 拓 ਦਸਤਾਵੇਜ਼ਾ拓 ਨੰ ਆꩍਣ ਭਾਸ਼ਾ ਕਵ ਫ ਇਨਸ਼ੋਰ∂ਸ ਨੰ 1-800-927-4357 ਤੇ ਿਾਲ ਿਰੋ । TTY ਦੇﹱਨੰ ਬ ਰ ' ‘ਤੇ ਜਾ拓 1-866-213-3062 ‘ਤੇ ਸਾਨੰ ਿਾਲ ਿਰੋ । ਵਧੇਰ ਮਦਦ ਲਈ CA ਕਡꩍਾਰਟਮ∂ਟ ਆ ਉꩍਯੋਗਿਰਤਾ 711 ਤੇ ਿਾਲ ਿਰੋ । Punjabi

សេវាភាសាឥតគិតថ្លៃ។សេ玶徶羶ឥតគិត䏒លៃ។ 诒នក讶ចទទួល厶ន诒នកបក叒របអ្នកអាចទទួលបានអ្នកបកប្រែ និងឲ្យគេអានឯកសារជូនអ្នក និង쯒យគេ讶នឯក羶រជូន诒នក ជាភាសាខ្មែរ។ ᾶ徶羶叒មែរ។ សំរាប់ជំនួយសំ殶ប់ជំនួយ សូមទូរស័寒ទមក សូមទូរស័ព្ទមកយើងគយើង 㾶មគលម叒ែល掶នគៅគលើប័㯒ណ តាមលេខដែលមាននៅលើប័ណ្ណ ID របស់诒នក ឬID 1 -របស់អ្នក866-213-3062 ឬ 1-866-213-3062។ សំ殶ប់ជំនួយ叒ែមគទៀត។ សំរាប់ជំនួយថែមទៀត ទូរស័寒ទគៅរកសួង䮶侶殶➶ប់រង រែឋζ ទូរស័ព្ទទៅក្រសួងធានារ៉ាប់រងលី菒វ័រនីញ➶ 㾶មគលម 1 800- 927រដ្ឋកាលីហ្វ័រនីញ៉ា-4357។ 诒នកគរបើ TTYតាមលេខ គៅគលម 1 800-927-4357 711។ Khmer។ អ្នកប្រើ TTY ហៅលេខ 711។ Khmer

خدمات ترجمة بدون تكلفة. یمكنك الحصول على مترجم وقراءة الوثائق لك باللغة العربیة. للحصول على المساعدة، اتصل بنا على الرقم المبین على بطاقة عضویتك أو على الرقم 3062-213-866-1. للحصول على مزید من المعلومات اتصل بإدارة التأمین لوالیة كالیفورنیا على الرقم 4357-927-800-1. لمستخدمي خدمة الهاتف النصي یرجى االتصال على Arabic .711

Cov Kev Pab Txhais Lus Tsis Raug Nqi Dab Tsi. Koj muaj tau ib tug neeg txhais lus thiab hais tau kom nyeem cov ntaub ntawv ua koj hom lus rau koj. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj teev muaj nyob rau ntawm koj daim yuaj ID los yog 1-866-213-3062. Yog xav tau kev pab ntxiv hu rau CA Tuam Tsev Tswj Kev Pov Hwm ntawm 1 800-927-4357. Cov neeg siv TTY hu rau 711. Hmong

मु굍त भाषा सेवाएँ। आप एक दभाषियाु प्राप्त कर सकते हℂ और आपको दतावेज़ आपकी भािा मᴂ पढ़ कर सुनाए जा सकते हℂ। सहायता के षिए, अपने आईडी काडड पर षदए न륍बर या 1-866-213-3062 पर हमᴂ फोन करᴂ। अषिक सहायता के षिए कैषिफोषनडया षडपा셍डमᴂ셍 ऑफ इꅍशरꅍसु को 1-800-927-4357। TTY प्रयोक्ता 711 पर फोन करᴂ। Hindi

บริการด ้านภาษาที่ไม่คิดค่าบริการ คุณสามารถขอรับบริการล่ามแปลภาษาและขอให ้อ่านเอกสารให ้คุณฟังเป็นภาษาของคุณได ้ หากต ้องการความ ชวยเหลือ่ โปรดโทรติดต่อหาเราตามหมายเลขที่ระบุอยู่บนบัตร ID ของคุณหรือหมายเลข 1-866-213-3062 หากต ้องการความชวยเหลือในเรื่องอื่นๆ่ เพิ่มเติม โปรดโทรติดต่อฝ่ายประกันโรคมะเร็งที่หมายเลข 1 800-927-4357 ผ ู ้ใ ช ้ TTY โปรดโทรไปที่หมายเลข 711. Thai

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