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Express Scripts Medicare (PDP) 2021 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID Number: 21095, Version 10

This formulary was updated on 9/1/2021. For more recent information or other questions, please contact Express Scripts Medicare® (PDP) Customer Service at 1.800.758.4574; New York State residents: 1.800.758.4570 or, for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week, or visit express-scripts.com.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located in New York State only). When it refers to “plan” or “our plan,” it means Express Scripts Medicare.

This document includes a list of the drugs (formulary) for our plan, which is current as of September 1, 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.

What is the Express Scripts Medicare Formulary? A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Express Scripts Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Y0046_F00SNV1B_C CRP2101_004084.3 F00SNV1CW2 This drug list was updated in September 2021 Can the formulary (drug list) change? Most changes in drug coverage happen on January 1, but Express Scripts Medicare may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the cases below, you will be affected by coverage changes during the year: • New generic drugs. We may immediately remove a brand-name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. ○ If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Express Scripts Medicare Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand-name drug currently on the formulary; or add new restrictions to the brand-name drug or move it to a different cost-sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. ○ If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Express Scripts Medicare Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs.

This drug list was updated in September 2021 i The enclosed formulary is current as of September 1, 2021. To get updated information about the drugs covered by Express Scripts Medicare, please contact us. Our contact information appears on the front and back cover pages. If there are additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time from when the changes are made.

How do I use the formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular, Hypertension/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 81. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Express Scripts Medicare covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Express Scripts Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Express Scripts Medicare before you fill your prescriptions. If you don’t get approval, Express Scripts Medicare may not cover the drug.

• Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drug that Express Scripts Medicare will cover. For example, Express Scripts Medicare provides two inhalers (17 grams) for a 1-month supply per prescription for albuterol HFA. This may be in addition to a standard 1-month or 3-month supply.

• Step Therapy: In some cases, Express Scripts Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Express Scripts Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Express Scripts Medicare will then cover Drug B.

This drug list was updated in September 2021 ii You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Express Scripts Medicare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section “How do I request an exception to the Express Scripts Medicare Formulary?” below for information about how to request an exception.

What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Express Scripts Medicare does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Express Scripts Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Express Scripts Medicare.

• You can ask Express Scripts Medicare to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Express Scripts Medicare Formulary? You can ask Express Scripts Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Express Scripts Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously

This drug list was updated in September 2021 iii harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary, or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Other times when we will cover a temporary 30-day transition supply (or less, if you have a prescription written for fewer days) include: • When you leave a long-term care facility • When you are discharged from a hospital • When you leave a skilled nursing facility • When you cancel hospice care • When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized If you are entering a long-term care facility, we will cover a 31-day transition supply.

The plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

For more information For more detailed information about your Express Scripts Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Express Scripts Medicare, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048. Or, visit http://www.medicare.gov.

This drug list was updated in September 2021 iv Express Scripts Medicare’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 81.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., JANUMET®) and generic drugs are listed in lowercase italics (e.g., omeprazole).

The information in the Requirements/Limits column tells you if Express Scripts Medicare has any special requirements for coverage of your drug.

B/D PA: Part B or Part D Prior Authorization. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1.800.758.4574 (New York State residents: 1.800.758.4570), 24 hours a day, 7 days a week. TTY users should call 1.800.716.3231.

NDS: Non-Extended Day Supply Medication. This drug is only available as a 30-day supply or less.

MO: Mail-Order Drug. This prescription drug is available through our home delivery pharmacy service, as well as through our retail network pharmacies. Consider using mail order for your long-term medications (the kind you take regularly, such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Your costs The amount you pay for a covered drug will depend on:

• Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage, the amount you pay for a drug may change.

• The drug tier for your drug. Each covered drug is in one of six drug tiers. Each tier may have a different copayment or coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier.

The Evidence of Coverage has more information about the plan’s coverage stages and lists the copayment and coinsurance amounts for each tier.

This drug list was updated in September 2021 v If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be lower. Please refer to the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider)” to find out what your costs are or you may contact Customer Service for more information.

Drug Tiers Tier Description Tier 1: This tier includes commonly prescribed generic drugs. Use Tier 1 drugs for the Preferred lowest copayments, unless you have the conditions described in Tier 6. Generic Drugs Tier 2: This tier includes generic drugs. Use Tier 2 drugs to keep your copayments low. Generic Drugs Tier 3: This tier includes preferred brand-name drugs as well as generic drugs. Drugs in Preferred this tier will generally have lower copayments than non-preferred drugs. Brand Drugs Tier 4: This tier includes non-preferred brand-name drugs as well as generic drugs. Non-Preferred There may be lower-cost alternatives for you. Ask your doctor if switching to a Drugs lower-cost generic or preferred brand drug may be right for you. Tier 5: This tier includes very high-cost brand-name and generic drugs. To learn more Specialty about medications in this tier, you may contact a pharmacist at the numbers Tier Drugs listed on the front and back covers of this document. Drugs in this tier are limited to up to a 30-day supply from either your local retail network pharmacy or from our network home delivery service. Tier 6: This tier includes most of the plan’s covered insulins, as well as select highly Select Care utilized generic drugs used to treat diabetes and cardiovascular conditions. Tier Drugs Use Tier 6 drugs for the lowest copayment if you have these conditions.

Key The abbreviations listed below may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on these tables mean by going to page v.

B/D PA: Part B or Part D Prior Authorization LA: Limited Availability MO: Mail-Order Drug NDS: Non-Extended Day Supply Medication PA: Prior Authorization QL: Quantity Limit ST: Step Therapy

This drug list was updated in September 2021 vi Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ANTI - itraconazole oral 3 MO INFECTIVES solution ketoconazole oral 2 MO ANTIFUNGAL micafungin 5 MO AGENTS nystatin oral 2 MO ABELCET 4 B/D PA; posaconazole oral 5 MO; QL MO tablet,delayed (96 per 30 AMBISOME 5 B/D PA; release (dr/ec) days) MO terbinafine hcl oral 2 MO amphotericin b 4 B/D PA; voriconazole 4 PA; MO MO intravenous caspofungin 5 B/D PA voriconazole oral 5 MO clotrimazole mucous 3 MO suspension for membrane reconstitution CRESEMBA 4 voriconazole oral 5 MO ORAL tablet 200 mg fluconazole in nacl 4 PA; MO voriconazole oral 4 MO (iso-osm) tablet 50 mg intravenous ANTIVIRALS piggyback 200 mg/100 ml abacavir oral 3 MO; QL fluconazole in nacl 4 PA solution (960 per 30 (iso-osm) days) intravenous abacavir oral tablet 4 MO; QL piggyback 400 (60 per 30 mg/200 ml days) fluconazole oral 3 MO abacavir-lamivudine 3 MO; QL suspension for (30 per 30 reconstitution days) fluconazole oral 2 MO abacavir­ 5 MO; QL tablet lamivudine­ (60 per 30 flucytosine 5 MO zidovudine days) griseofulvin 4 MO acyclovir oral 2 MO microsize capsule griseofulvin 4 MO acyclovir oral 3 MO ultramicrosize suspension 200 mg/5 ml itraconazole oral 3 MO; QL capsule (120 per 30 acyclovir oral tablet 2 MO days) acyclovir sodium 4 B/D PA; intravenous solution MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 1 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits amantadine hcl oral 4MO EDURANT 4 MO; QL capsule (30 per 30 amantadine hcl oral 2MO days) solution efavirenz oral 5 MO; QL amantadine hcl oral 4MO capsule 200 mg (120 per 30 tablet days) APTIVUS 4 MO; QL efavirenz oral 4 MO; QL (120 per 30 capsule 50 mg (180 per 30 days) days) atazanavir oral 4 MO; QL efavirenz oral tablet 5 MO; QL capsule 150 mg, 300 (30 per 30 (30 per 30 mg days) days) atazanavir oral 4 MO; QL efavirenz­ 5 MO; QL capsule 200 mg (60 per 30 emtricitabin-tenofov (30 per 30 days) days) ATRIPLA 5 MO; QL efavirenz-lamivu­ 4 MO; QL (30 per 30 tenofov disop oral (30 per 30 days) tablet 400-300-300 days) mg BARACLUDE 5 MO; QL ORAL (630 per 30 efavirenz-lamivu­ 4MO SOLUTION days) tenofov disop oral tablet 600-300-300 BIKTARVY 5 MO mg CABENUVA 4 MO emtricitabine 3 MO; QL cidofovir 4 B/D PA; (30 per 30 MO days) CIMDUO 4 MO emtricitabine­ 5 MO; QL COMPLERA 4 MO; QL tenofovir (tdf) (30 per 30 (30 per 30 days) days) EMTRIVA ORAL 3 MO; QL DELSTRIGO 4 MO CAPSULE (30 per 30 DESCOVY 5 MO; QL days) (30 per 30 EMTRIVA ORAL 3 MO; QL days) SOLUTION (680 per 28 didanosine oral 4 MO; QL days) capsule,delayed (30 per 30 entecavir 4 MO; QL release(dr/ec) 250 days) (30 per 30 mg, 400 mg days) DOVATO 5 MO EPCLUSA ORAL 5 PA; MO; TABLET 200-50 QL (56 per MG 28 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 2 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits EPCLUSA ORAL 5 PA; MO; INTELENCE 4 MO; QL TABLET 400-100 QL (28 per ORAL TABLET (120 per 30 MG 28 days) 25 MG days) EPIVIR HBV 4MO INVIRASE ORAL 4 MO; QL ORAL TABLET (120 per 30 SOLUTION days) EVOTAZ 4 MO; QL ISENTRESS HD 5 MO (30 per 30 ISENTRESS 4 MO; QL days) ORAL POWDER (60 per 30 famciclovir 4 MO; QL IN PACKET days) (60 per 30 ISENTRESS 5 MO; QL days) ORAL TABLET (120 per 30 fosamprenavir 5 MO; QL days) (120 per 30 ISENTRESS 5 MO; QL days) ORAL (180 per 30 FUZEON 5 MO; QL TABLET,CHEWA days) SUBCUTANEOU (60 per 30 BLE 100 MG S RECON SOLN days) ISENTRESS 3 MO; QL ganciclovir sodium 4 B/D PA; ORAL (180 per 30 MO TABLET,CHEWA days) GENVOYA 5 MO; QL BLE 25 MG (30 per 30 JULUCA 5 MO days) KALETRA ORAL 4 MO; QL HARVONI ORAL 5 PA; MO; TABLET 100-25 (300 per 30 PELLETS IN QL (28 per MG days) PACKET 33.75­ 28 days) KALETRA ORAL 5 MO; QL 150 MG TABLET 200-50 (120 per 30 HARVONI ORAL 5 PA; MO; MG days) PELLETS IN QL (56 per lamivudine oral 3 MO; QL PACKET 45-200 28 days) solution (900 per 30 MG days) HARVONI ORAL 5 PA; MO; lamivudine oral 4 MO; QL TABLET 45-200 QL (30 per tablet 100 mg (30 per 30 MG 30 days) days) HARVONI ORAL 5 PA; MO; lamivudine oral 3 MO; QL TABLET 90-400 QL (28 per tablet 150 mg (60 per 30 MG 28 days) days) INTELENCE 5 MO; QL lamivudine oral 3 MO; QL ORAL TABLET (60 per 30 tablet 300 mg (30 per 30 100 MG, 200 MG days) days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 3 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits lamivudine­ 3 MO; QL PREVYMIS 5 MO; QL zidovudine (60 per 30 ORAL (30 per 30 days) days) LEXIVA ORAL 4 MO; QL PREZCOBIX 4 MO; QL SUSPENSION (1575 per (30 per 30 28 days) days) lopinavir-ritonavir 4MO PREZISTA ORAL 5 MO; QL oral solution SUSPENSION (400 per 30 MAVYRET 5 PA; MO; days) QL (84 per PREZISTA ORAL 4 MO; QL 28 days) TABLET 150 MG (240 per 30 nevirapine oral 4 QL (1200 days) suspension per 30 days) PREZISTA ORAL 5 MO; QL nevirapine oral 3 MO; QL TABLET 600 MG (60 per 30 tablet (60 per 30 days) days) PREZISTA ORAL 4 MO; QL nevirapine oral 4 MO; QL TABLET 75 MG (480 per 30 tablet extended (90 per 30 days) release 24 hr 100 mg days) PREZISTA ORAL 5 MO; QL nevirapine oral 4 MO; QL TABLET 800 MG (30 per 30 tablet extended (30 per 30 days) release 24 hr 400 mg days) RELENZA 4 MO; QL NORVIR ORAL 4MO DISKHALER (60 per 180 POWDER IN days) PACKET RETROVIR 3MO NORVIR ORAL 3 MO; QL INTRAVENOUS SOLUTION (480 per 30 REYATAZ ORAL 5 MO; QL days) POWDER IN (240 per 30 ODEFSEY 5 MO; QL PACKET days) (30 per 30 ribavirin oral 3 days) capsule oseltamivir oral 3 MO; QL ribavirin oral tablet 3MO capsule 30 mg (168 per 200 mg 365 days) rimantadine 4MO oseltamivir oral 3 MO; QL ritonavir 3 MO; QL capsule 45 mg, 75 (84 per 365 (360 per 30 mg days) days) oseltamivir oral 3 MO; QL RUKOBIA 4 MO suspension for (1080 per SELZENTRY 5MO reconstitution 365 days) ORAL PIFELTRO 4 MO SOLUTION

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 4 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits SELZENTRY 5 MO; QL valacyclovir oral 4 MO; QL ORAL TABLET (60 per 30 tablet 1 gram (120 per 30 150 MG, 75 MG days) days) SELZENTRY 4 MO; QL valacyclovir oral 4 MO; QL ORAL TABLET (120 per 30 tablet 500 mg (60 per 30 25 MG days) days) SELZENTRY 5 MO; QL valganciclovir 5MO ORAL TABLET (120 per 30 VEMLIDY 5 MO 300 MG days) VIRACEPT 4 MO; QL stavudine oral 4 MO; QL ORAL TABLET (270 per 30 capsule (60 per 30 250 MG days) days) VIRACEPT 4 MO; QL STRIBILD 5 MO; QL ORAL TABLET (120 per 30 (30 per 30 625 MG days) days) VIREAD ORAL 5 MO; QL SYMFI 4 MO POWDER (240 per 30 SYMFI LO 4 MO; QL days) (30 per 30 VIREAD ORAL 5 MO; QL days) TABLET 150 MG, (30 per 30 SYMTUZA 4 MO 200 MG, 250 MG days) TEMIXYS 4 MO VOSEVI 5 PA; MO; tenofovir disoproxil 3 MO; QL QL (28 per fumarate (30 per 30 28 days) days) zidovudine oral 4 MO; QL TIVICAY ORAL 4 MO; QL capsule (180 per 30 TABLET 10 MG (60 per 30 days) days) zidovudine oral 4 MO; QL TIVICAY ORAL 5 MO; QL syrup (1680 per TABLET 25 MG, (60 per 30 28 days) 50 MG days) zidovudine oral 2 MO; QL TIVICAY PD 4 MO; QL tablet (60 per 30 (180 per 30 days) days) CEPHALOSPO TRIUMEQ 5 MO; QL RINS (30 per 30 cefaclor oral capsule 3MO days) cefadroxil oral 2MO TROGARZO 5 MO; LA capsule TRUVADA 5 MO; QL (30 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 5 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits cefadroxil oral 4MO cefoxitin 4PA suspension for intravenous recon reconstitution 250 soln 10 gram mg/5 ml, 500 mg/5 cefpodoxime 4MO ml CEFTAZIDIME 4PA cefadroxil oral 4MO IN D5W tablet ceftazidime injection 4 PA; MO cefazolin in dextrose 4MO recon soln 1 gram, 2 (iso-os) intravenous gram piggyback 1 ceftazidime injection 4PA gram/50 ml recon soln 6 gram cefazolin in dextrose 2MO ceftriaxone in 4MO (iso-os) intravenous dextrose,iso-os piggyback 2 gram/50 ml ceftriaxone injection 4MO recon soln 1 gram, 2 cefazolin injection 4MO gram, 250 mg, 500 recon soln 1 gram, mg 500 mg ceftriaxone injection 4 cefazolin injection 4 recon soln 10 gram recon soln 10 gram, 100 gram, 300 g CEFTRIAXONE 4 INJECTION cefazolin 4 RECON SOLN intravenous 100 GRAM cefdinir oral capsule 2MO ceftriaxone 4MO cefdinir oral 3MO intravenous suspension for cefuroxime axetil 3MO reconstitution oral tablet CEFEPIME IN 4MO cefuroxime sodium 4 PA; MO DEXTROSE 5 % injection recon soln cefepime in 4 750 mg dextrose,iso-osm cefuroxime sodium 4 PA; MO cefepime injection 4MO intravenous recon CEFEPIME 4 soln 1.5 gram INTRAVENOUS cefuroxime sodium 4PA cefixime 4MO intravenous recon cefoxitin in 4PA soln 7.5 gram dextrose, iso-osm cephalexin oral 2MO cefoxitin 4 PA; MO capsule 250 mg, 500 intravenous recon mg soln 1 gram, 2 gram

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 6 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits cephalexin oral 2MO clarithromycin oral 4MO suspension for tablet reconstitution clarithromycin oral 4MO SUPRAX ORAL 4 tablet extended SUSPENSION release 24 hr FOR DIFICID ORAL 5 QL (136 per RECONSTITUTI SUSPENSION 10 days) ON 500 MG/5 ML FOR tazicef injection 4PA RECONSTITUTI recon soln 1 gram, 2 ON gram DIFICID ORAL 5 MO; QL tazicef injection 4 PA; MO TABLET (20 per 10 recon soln 6 gram days) tazicef intravenous 4PA erythrocin (as 4MO TEFLARO 4 PA; MO stearate) oral tablet 250 mg ERYTHROMYC INS / OTHER ERYTHROCIN 4 PA; MO INTRAVENOUS MACROLIDES RECON SOLN azithromycin 4 PA; MO 500 MG intravenous erythromycin 4MO azithromycin oral 3 MO ethylsuccinate oral packet suspension for azithromycin oral 4 MO reconstitution suspension for erythromycin 4 reconstitution ethylsuccinate oral azithromycin oral 2 tablet tablet 250 mg (6 erythromycin oral 4MO pack), 500 mg (3 MISCELLANEO pack) US azithromycin oral 2 MO ANTIINFECTIV tablet 250 mg, 500 ES mg, 600 mg albendazole 5MO clarithromycin oral 2 MO suspension for amikacin injection 4 PA; MO reconstitution 125 solution 1,000 mg/4 mg/5 ml ml, 500 mg/2 ml clarithromycin oral 4 MO ARIKAYCE 4 PA; LA suspension for atovaquone 5MO reconstitution 250 mg/5 ml

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 7 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits atovaquone­ 3MO colistin 4 PA; MO proguanil oral tablet (colistimethate na) 250-100 mg dapsone oral 3MO atovaquone­ 2MO DAPTOMYCIN 5MO proguanil oral tablet INTRAVENOUS 62.5-25 mg RECON SOLN aztreonam injection 4 PA; MO 350 MG recon soln 1 gram daptomycin 5MO aztreonam injection 3 PA; MO intravenous recon recon soln 2 gram soln 500 mg BENZNIDAZOLE 4 MO EMVERM 5 MO CAYSTON 5 PA; MO; ertapenem 4MO LA; QL (84 ethambutol oral 2MO per 28 days) tablet 100 mg chloramphenicol sod 4 ethambutol oral 4MO succinate tablet 400 mg chloroquine 2MO gentamicin in nacl 4 PA; MO phosphate oral (iso-osm) tablet 250 mg intravenous chloroquine 4MO piggyback 100 phosphate oral mg/100 ml tablet 500 mg GENTAMICIN IN 2 PA; MO clindamycin hcl 2MO NACL (ISO-OSM) CLINDAMYCIN 4PA INTRAVENOUS IN 0.9 % SOD PIGGYBACK 100 CHLOR MG/50 ML clindamycin in 5 % 4 PA; MO GENTAMICIN IN 2PA dextrose NACL (ISO-OSM) INTRAVENOUS clindamycin 2MO PIGGYBACK 120 pediatric MG/100 ML clindamycin 4 PA; MO gentamicin in nacl 2 PA; MO phosphate injection (iso-osm) clindamycin 4 PA; MO intravenous phosphate piggyback 60 mg/50 intravenous solution ml, 80 mg/50 ml 600 mg/4 ml gentamicin in nacl 2PA COARTEM 4 MO; QL (iso-osm) (24 per 30 intravenous days) piggyback 80 mg/100 ml

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 8 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits gentamicin injection 2 PA; MO pentamidine 3 B/D PA; solution 40 mg/ml inhalation MO; QL (1 gentamicin sulfate 2 PA; MO per 28 days) (ped) (pf) pentamidine 3MO hydroxychloroquine 3MO injection imipenem-cilastatin 4MO praziquantel 3MO IMPAVIDO 5 PA; MO PRIFTIN 4 MO isoniazid oral 4MO PRIMAQUINE 3 MO solution pyrazinamide 4MO isoniazid oral tablet 2MO pyrimethamine 5 PA; MO ivermectin oral 3MO quinine sulfate 3 PA; MO; linezolid in dextrose 4PA QL (42 per 5% 30 days) linezolid oral 5 MO; QL rifabutin 4MO suspension for (1800 per rifampin 2MO reconstitution 30 days) intravenous linezolid oral tablet 4 MO; QL rifampin oral 4MO (60 per 30 SIRTURO 5 PA; LA days) STREPTOMYCIN 4 PA; MO linezolid-0.9% 4PA SYNERCID 5 sodium chloride tigecycline 5 PA; MO mefloquine 2MO tobramycin in 0.225 5 B/D PA; meropenem 4MO % nacl MO; QL MEROPENEM­ 4 (280 per 28 0.9% SODIUM days) CHLORIDE tobramycin sulfate 4PA metro i.v. 2 PA; MO injection recon soln metronidazole in 2 PA; MO tobramycin sulfate 2 PA; MO nacl (iso-os) injection solution 10 metronidazole oral 2MO mg/ml tablet tobramycin sulfate 4 PA; MO neomycin 2MO injection solution 40 nitazoxanide 5 MO; QL mg/ml (20 per 10 TRECATOR 4 MO days) VANCOMYCIN 4 paromomycin 4MO IN 0.9 % SODIUM PASER 4 MO CHL INTRAVENOUS PENTAM 4 MO PIGGYBACK

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 9 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits VANCOMYCIN 4 PENICILLINS IN DEXTROSE 5 amoxicillin oral 2 MO % capsule INTRAVENOUS PIGGYBACK amoxicillin oral 2 MO suspension for VANCOMYCIN 4 reconstitution INJECTION amoxicillin oral 2 MO vancomycin 2MO tablet intravenous recon soln 1,000 mg amoxicillin oral 2 MO tablet,chewable 125 VANCOMYCIN 2 mg, 250 mg INTRAVENOUS RECON SOLN amoxicillin-pot 2 MO 1.25 GRAM clavulanate oral suspension for vancomycin 4 reconstitution 200­ intravenous recon 28.5 mg/5 ml, 600­ soln 1.5 gram, 10 42.9 mg/5 ml gram amoxicillin-pot 3 MO VANCOMYCIN 4 clavulanate oral INTRAVENOUS suspension for RECON SOLN reconstitution 250­ 250 MG 62.5 mg/5 ml, 400­ vancomycin 2 57 mg/5 ml intravenous recon amoxicillin-pot 2 MO soln 5 gram clavulanate oral vancomycin 4MO tablet intravenous recon amoxicillin-pot 4 MO soln 500 mg, 750 mg clavulanate oral vancomycin oral 4 PA; MO; tablet extended capsule 125 mg QL (40 per release 12 hr 10 days) amoxicillin-pot 2 MO vancomycin oral 4 PA; MO; clavulanate oral capsule 250 mg QL (80 per tablet,chewable 10 days) ampicillin oral 2 MO VIBATIV 5PA capsule 500 mg INTRAVENOUS ampicillin sodium 4 PA; MO RECON SOLN injection 750 MG ampicillin sodium 4 PA XIFAXAN ORAL 4 PA; MO; intravenous TABLET 550 MG QL (90 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 10 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ampicillin­ 4 PA; MO piperacillin­ 4MO sulbactam injection tazobactam recon soln 1.5 gram, intravenous recon 3 gram soln 2.25 gram, ampicillin­ 4PA 3.375 gram, 4.5 sulbactam injection gram recon soln 15 gram piperacillin­ 4 ampicillin­ 4PA tazobactam sulbactam intravenous recon intravenous soln 40.5 gram BICILLIN L-A 4 PA; MO ZOSYN IN 3 DEXTROSE (ISO­ dicloxacillin 2MO OSM) nafcillin in dextrose 4PA INTRAVENOUS iso-osm PIGGYBACK 4.5 nafcillin injection 4 PA; MO GRAM/100 ML recon soln 1 gram, 2 QUINOLONES gram CIPRO ORAL 4 nafcillin injection 5PA SUSPENSION,MI recon soln 10 gram CROCAPSULE nafcillin intravenous 4PA RECON recon soln 1 gram ciprofloxacin hcl 2 MO nafcillin intravenous 4 PA; MO oral recon soln 2 gram ciprofloxacin in 5 % 4 PA; MO penicillin g 4 PA; MO dextrose potassium levofloxacin in d5w 4 PA penicillin g procaine 2 PA; MO intravenous penicillin g sodium 4 PA; MO piggyback 250 penicillin v 2MO mg/50 ml potassium levofloxacin in d5w 4 PA; MO pfizerpen-g 4PA intravenous piggyback 500 PIPERACILLIN­ 4 mg/100 ml, 750 TAZOBACTAM mg/150 ml INTRAVENOUS RECON SOLN levofloxacin 4 PA; MO 13.5 GRAM intravenous levofloxacin oral 4MO solution levofloxacin oral 2MO tablet

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 11 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits SULFA'S / tetracycline 4MO RELATED URINARY AGENTS TRACT sulfadiazine 4MO AGENTS sulfamethoxazole­ 4 PA; MO methenamine 4 MO trimethoprim hippurate intravenous methenamine 3 MO sulfamethoxazole­ 2MO mandelate trimethoprim oral nitrofurantoin 3 MO TETRACYCLIN nitrofurantoin 3 MO ES macrocrystal oral doxy-100 4 PA; MO capsule 100 mg, 25 mg doxycycline hyclate 4 PA intravenous nitrofurantoin 2 MO macrocrystal oral doxycycline hyclate 3 MO capsule 50 mg oral capsule nitrofurantoin 4 MO doxycycline hyclate 3 MO monohyd/m-cryst oral tablet 100 mg, 20 mg trimethoprim 2 MO doxycycline hyclate 2 MO ANTINEOPL oral tablet 50 mg ASTIC / doxycycline 4 MO IMMUNOSUP monohydrate oral PRESSANT capsule 100 mg, 50 mg DRUGS doxycycline 4 MO ADJUNCTIVE monohydrate oral AGENTS suspension for KEPIVANCE 5 reconstitution KHAPZORY 4 B/D PA doxycycline 4 MO monohydrate oral leucovorin calcium 2 B/D PA; tablet injection recon soln MO 100 mg, 200 mg, minocycline oral 2 MO 350 mg, 50 mg capsule leucovorin calcium 2 B/D PA mondoxyne nl oral 4 MO injection recon soln capsule 100 mg, 75 500 mg mg leucovorin calcium 3MO morgidox oral 2 MO oral capsule 100 mg

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 12 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits levoleucovorin 3 B/D PA; adrucil intravenous 4 B/D PA calcium intravenous MO solution 2.5 gram/50 recon soln 50 mg ml levoleucovorin 4 B/D PA AFINITOR 5 PA; MO; calcium intravenous DISPERZ ORAL QL (150 per solution TABLET FOR 30 days) mesna 4 B/D PA; SUSPENSION 2 MO MG MESNEX ORAL 5 MO AFINITOR 5 PA; MO; DISPERZ ORAL QL (56 per VISTOGARD 5 TABLET FOR 28 days) XGEVA 5 B/D PA; SUSPENSION 3 MO; QL MG, 5 MG (1.7 per 28 AFINITOR ORAL 5 PA; MO; days) TABLET 10 MG QL (30 per ANTINEOPLAS 30 days) TIC / ALECENSA 5 PA; MO; IMMUNOSUPP QL (240 per RESSANT 30 days) DRUGS ALIMTA 5 B/D PA; abiraterone oral 4 PA; MO; MO tablet 250 mg QL (120 per ALIQOPA 4 B/D PA; 30 days) LA abiraterone oral 4 PA; MO; ALUNBRIG 5 PA; QL (30 tablet 500 mg QL (60 per ORAL TABLET per 30 days) 30 days) 180 MG, 90 MG ABRAXANE 5 B/D PA; ALUNBRIG 5 PA; QL (60 MO ORAL TABLET per 30 days) ADCETRIS 4 B/D PA; 30 MG MO ALUNBRIG 5 PA; QL (30 adriamycin 3 B/D PA; ORAL per 30 days) intravenous recon MO TABLETS,DOSE soln 10 mg PACK adriamycin 3 B/D PA; anastrozole 2MO intravenous solution MO ARRANON 3 B/D PA 10 mg/5 ml arsenic trioxide 4 B/D PA adriamycin 3 B/D PA intravenous solution intravenous solution 1 mg/ml 2 mg/ml, 20 mg/10 arsenic trioxide 4 B/D PA; ml, 50 mg/25 ml intravenous solution MO 2 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 13 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ARZERRA 5 B/D PA; CABOMETYX 5 PA; MO; MO ORAL TABLET LA; QL (30 AYVAKIT 5 PA; LA; 20 MG, 60 MG per 30 days) QL (30 per CABOMETYX 5 PA; MO; 30 days) ORAL TABLET LA; QL (60 azacitidine 5 B/D PA; 40 MG per 30 days) MO CALQUENCE 5 PA; LA; azathioprine 2 B/D PA; QL (60 per MO 30 days) azathioprine sodium 3 B/D PA CAPRELSA 5 PA; LA; ORAL TABLET QL (60 per BALVERSA 5 PA; LA 100 MG 30 days) BAVENCIO 5 B/D PA; CAPRELSA 5 PA; LA; LA ORAL TABLET QL (30 per BELEODAQ 5 B/D PA 300 MG 30 days) BENDEKA 4 B/D PA; carboplatin 4 B/D PA; MO intravenous solution MO BESPONSA 5 B/D PA; carmustine 3 B/D PA; MO; LA MO bexarotene 5 PA; MO cisplatin intravenous 3 B/D PA; bicalutamide 3MO solution MO BLENREP 4 PA cladribine 4 B/D PA; bleomycin 4 B/D PA; MO MO clofarabine 3 B/D PA BLINCYTO 5 B/D PA COMETRIQ 5 PA; MO; INTRAVENOUS ORAL CAPSULE QL (56 per KIT 100 MG/DAY(80 28 days) BORTEZOMIB 4 B/D PA MG X1-20 MG X1) BOSULIF ORAL 5 PA; MO; TABLET 100 MG QL (90 per COMETRIQ 5 PA; MO; 30 days) ORAL CAPSULE QL (112 per 140 MG/DAY(80 28 days) BOSULIF ORAL 5 PA; MO; MG X1-20 MG TABLET 400 MG, QL (30 per X3) 500 MG 30 days) COMETRIQ 5 PA; MO; BRAFTOVI 5 PA; MO; ORAL CAPSULE QL (84 per ORAL CAPSULE LA; QL 60 MG/DAY (20 28 days) 75 MG (180 per 30 MG X 3/DAY) days) COPIKTRA 5 PA; LA; BRUKINSA 5 PA; LA QL (60 per busulfan 5 B/D PA 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 14 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits COTELLIC 5 PA; MO; dacarbazine 2 B/D PA; LA; QL (63 MO per 28 days) dactinomycin 3 B/D PA cyclophosphamide 3 B/D PA; DANYELZA 4 PA intravenous recon MO DARZALEX 3 B/D PA; soln MO; LA CYCLOPHOSPH 3 B/D PA; DARZALEX 5 B/D PA; AMIDE MO FASPRO MO INTRAVENOUS SOLUTION daunorubicin 2 B/D PA intravenous solution cyclophosphamide 3 B/D PA; oral capsule MO DAURISMO 5 PA; MO; ORAL TABLET QL (30 per CYCLOPHOSPH 3 B/D PA; 100 MG 30 days) AMIDE ORAL MO TABLET DAURISMO 5 PA; MO; ORAL TABLET QL (60 per cyclosporine 4 B/D PA 25 MG 30 days) intravenous decitabine 5 B/D PA; cyclosporine 3 B/D PA; MO modified oral MO capsule docetaxel 3 B/D PA intravenous solution cyclosporine 3 B/D PA 160 mg/16 ml (10 modified oral mg/ml), 20 mg/2 ml solution (10 mg/ml), 80 cyclosporine oral 3 B/D PA; mg/8 ml (10 mg/ml) capsule MO docetaxel 3 B/D PA; CYRAMZA 5 B/D PA; intravenous solution MO MO 160 mg/8 ml (20 cytarabine 4 B/D PA; mg/ml), 20 mg/ml MO (1 ml), 80 mg/4 ml cytarabine (pf) 2 B/D PA; (20 mg/ml) injection solution MO doxorubicin 2 B/D PA 100 mg/5 ml (20 intravenous recon mg/ml) soln 10 mg cytarabine (pf) 4 B/D PA; doxorubicin 2 B/D PA; injection solution 2 MO intravenous recon MO gram/20 ml (100 soln 50 mg mg/ml) doxorubicin 2 B/D PA; cytarabine (pf) 4 B/D PA intravenous solution MO injection solution 20 10 mg/5 ml, 20 mg/ml mg/10 ml, 50 mg/25 ml

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 15 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits doxorubicin 2 B/D PA everolimus 5 B/D PA; intravenous solution (immunosuppressive MO; QL 2 mg/ml ) oral tablet 0.25 (60 per 30 doxorubicin, peg­ 5 B/D PA; mg, 0.75 mg days) liposomal MO everolimus 5 B/D PA; DROXIA 3 MO (immunosuppressive MO; QL ) oral tablet 0.5 mg (120 per 30 ELLENCE 4 B/D PA; days) MO EVOMELA 5 B/D PA ELZONRIS 5 PA; LA exemestane 3MO EMCYT 4 MO FARYDAK 5 PA; MO; EMPLICITI 4 B/D PA; QL (6 per MO 21 days) ENHERTU 5 PA; MO FIRMAGON KIT 4 B/D PA; ENVARSUS XR 4 B/D PA; W DILUENT MO MO SYRINGE epirubicin 4 B/D PA; floxuridine 4 B/D PA intravenous solution MO fludarabine 3 B/D PA; ERBITUX 5 B/D PA; intravenous recon MO MO soln ERIVEDGE 5 PA; MO; fludarabine 3 B/D PA QL (30 per intravenous solution 30 days) fluorouracil 2 B/D PA; ERLEADA 4 PA; MO; intravenous solution MO QL (120 per 1 gram/20 ml, 500 30 days) mg/10 ml erlotinib oral tablet 5 PA; MO; fluorouracil 4 B/D PA; 100 mg, 150 mg QL (30 per intravenous solution MO 30 days) 2.5 gram/50 ml, 5 erlotinib oral tablet 5 PA; MO; gram/100 ml 25 mg QL (60 per flutamide 4MO 30 days) FOLOTYN 5 B/D PA; ETOPOPHOS 4 B/D PA; MO MO FOTIVDA 5 PA; LA; etoposide 2 B/D PA; QL (21 per intravenous MO 28 days) everolimus 5 PA; MO; fulvestrant 5 B/D PA; (antineoplastic) QL (28 per MO 28 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 16 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits GAVRETO 4 PA; MO; ICLUSIG ORAL 5 PA; QL (30 LA; QL TABLET 45 MG per 30 days) (120 per 30 idarubicin 4 B/D PA; days) MO GAZYVA 5 B/D PA; IDHIFA 5 PA; MO; MO LA; QL (30 gemcitabine 3 B/D PA; per 30 days) intravenous recon MO ifosfamide 4 B/D PA; soln 1 gram, 200 mg intravenous recon MO gemcitabine 3 B/D PA soln intravenous recon ifosfamide 4 B/D PA; soln 2 gram intravenous solution MO gemcitabine 3 B/D PA; 1 gram/20 ml intravenous solution MO ifosfamide 4 B/D PA 1 gram/26.3 ml (38 intravenous solution mg/ml), 2 3 gram/60 ml gram/52.6 ml (38 imatinib oral tablet 5 PA; MO; mg/ml), 200 100 mg QL (180 per mg/5.26 ml (38 30 days) mg/ml) imatinib oral tablet 5 PA; MO; GEMCITABINE 3 B/D PA 400 mg QL (60 per INTRAVENOUS 30 days) SOLUTION 100 MG/ML IMBRUVICA 5 PA; QL ORAL CAPSULE (120 per 30 gengraf 4 B/D PA; 140 MG days) MO IMBRUVICA 5 PA; QL (30 GILOTRIF 5 PA; MO; ORAL CAPSULE per 30 days) QL (30 per 70 MG 30 days) IMBRUVICA 5 PA; QL (30 HALAVEN 3 B/D PA; ORAL TABLET per 30 days) MO IMFINZI 4 B/D PA; hydroxyurea 2MO MO; LA IBRANCE 5 PA; MO; INFUGEM 4 B/D PA QL (21 per 28 days) INLYTA ORAL 5 PA; MO; TABLET 1 MG QL (180 per ICLUSIG ORAL 5PA 30 days) TABLET 10 MG, 30 MG INLYTA ORAL 5 PA; MO; TABLET 5 MG QL (120 per ICLUSIG ORAL 5 PA; QL (60 30 days) TABLET 15 MG per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 17 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits INQOVI 5 PA; MO; KISQALI 5 PA; MO; QL (5 per FEMARA CO­ QL (91 per 28 days) PACK ORAL 28 days) INREBIC 5 PA; MO; TABLET 600 LA; QL MG/DAY(200 MG (120 per 30 X 3)-2.5 MG days) KISQALI ORAL 5 PA; MO; IRESSA 5 PA; MO; TABLET 200 QL (21 per QL (30 per MG/DAY (200 28 days) 30 days) MG X 1) irinotecan 4 B/D PA; KISQALI ORAL 5 PA; MO; intravenous solution MO TABLET 400 QL (42 per 100 mg/5 ml, 40 MG/DAY (200 28 days) mg/2 ml MG X 2) irinotecan 4 B/D PA KISQALI ORAL 5 PA; MO; intravenous solution TABLET 600 QL (63 per 300 mg/15 ml, 500 MG/DAY (200 28 days) mg/25 ml MG X 3) IXEMPRA 5 B/D PA; KYPROLIS 5 B/D PA MO lapatinib 5 PA; MO; JAKAFI 5 PA; MO; QL (180 per QL (60 per 30 days) 30 days) LENVIMA ORAL 5 PA; MO; JEVTANA 4 B/D PA; CAPSULE 10 QL (30 per MO MG/DAY (10 MG 30 days) X 1), 4 MG KADCYLA 5 PA; MO LENVIMA ORAL 5 PA; MO; KANJINTI 5 B/D PA; CAPSULE 12 QL (90 per MO MG/DAY (4 MG 30 days) KEYTRUDA 5 PA X 3), 18 MG/DAY KISQALI 5 PA; MO; (10 MG X 1-4 MG FEMARA CO­ QL (49 per X2), 24 PACK ORAL 28 days) MG/DAY(10 MG TABLET 200 X 2-4 MG X 1) MG/DAY(200 MG LENVIMA ORAL 5 PA; MO; X 1)-2.5 MG CAPSULE 14 QL (60 per KISQALI 5 PA; MO; MG/DAY(10 MG 30 days) FEMARA CO­ QL (70 per X 1-4 MG X 1), 20 PACK ORAL 28 days) MG/DAY (10 MG TABLET 400 X 2), 8 MG/DAY MG/DAY(200 MG (4 MG X 2) X 2)-2.5 MG letrozole 2MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 18 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits LEUKERAN 4 MO megestrol oral 4 PA; MO leuprolide 4 PA; MO suspension 400 subcutaneous kit mg/10 ml (40 mg/ml), 625 mg/5 LIBTAYO 5 PA; LA ml (125 mg/ml) LONSURF ORAL 5 PA; MO; megestrol oral 4 PA; MO TABLET 15-6.14 QL (100 per tablet MG 28 days) MEKINIST 5 PA; MO; LONSURF ORAL 5 PA; MO; ORAL TABLET QL (90 per TABLET 20-8.19 QL (80 per 0.5 MG 30 days) MG 28 days) MEKINIST 5 PA; MO; LORBRENA 5 PA; MO; ORAL TABLET 2 QL (30 per ORAL TABLET QL (30 per MG 30 days) 100 MG 30 days) MEKTOVI 5 PA; MO; LORBRENA 5 PA; MO; LA; QL ORAL TABLET QL (90 per (180 per 30 25 MG 30 days) days) LUMOXITI 4 PA; LA melphalan 3 B/D PA; LUPRON DEPOT 5 PA; MO MO LUPRON DEPOT 5 PA; MO melphalan hcl 3 B/D PA (3 MONTH) mercaptopurine 2MO LUPRON DEPOT 5 PA; MO methotrexate 3 B/D PA; (4 MONTH) sodium MO LUPRON DEPOT 5 PA; MO methotrexate 3 B/D PA (6 MONTH) sodium (pf) LUPRON 5 PA; MO injection recon soln DEPOT-PED methotrexate 3 B/D PA; LUPRON 5 PA; MO sodium (pf) MO DEPOT-PED (3 injection solution MONTH) mitomycin 4 B/D PA; LYNPARZA 5 PA; MO; intravenous MO ORAL TABLET QL (120 per mitoxantrone 2 B/D PA; 30 days) MO LYSODREN 5 MONJUVI 4 PA; LA MARQIBO 5 B/D PA MVASI 5 B/D PA; MATULANE 5 MO megestrol oral 4PA mycophenolate 3 B/D PA suspension 400 mofetil (hcl) mg/10 ml (10 ml) mycophenolate 3 B/D PA; mofetil oral capsule MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 19 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits mycophenolate 5 B/D PA; octreotide acetate 3 PA; MO mofetil oral MO injection syringe 50 suspension for mcg/ml (1 ml) reconstitution ODOMZO 5 PA; MO; mycophenolate 3 B/D PA; LA; QL (30 mofetil oral tablet MO per 30 days) mycophenolate 4 B/D PA; OGIVRI 5 B/D PA; sodium MO MO MYLOTARG 4 B/D PA; ONCASPAR 5 B/D PA MO; LA ONIVYDE 5 B/D PA NERLYNX 5 PA; MO; ONTRUZANT 5 B/D PA LA ONUREG 4 PA; MO; NEXAVAR 5 PA; MO; QL (14 per LA; QL 28 days) (120 per 30 OPDIVO 5 PA; MO days) ORGOVYX 4 PA; LA; nilutamide 5MO QL (32 per NINLARO 5 PA; MO; 30 days) QL (3 per oxaliplatin 4 B/D PA; 28 days) intravenous recon MO NIPENT 4 B/D PA; soln 100 mg MO oxaliplatin 4 B/D PA NUBEQA 4 PA; MO; intravenous recon LA; QL soln 50 mg (120 per 30 oxaliplatin 4 B/D PA; days) intravenous solution MO NULOJIX 5 B/D PA; 100 mg/20 ml, 50 MO mg/10 ml (5 mg/ml) octreotide acetate 5 PA; MO oxaliplatin 4 B/D PA injection solution intravenous solution 1,000 mcg/ml, 500 200 mg/40 ml mcg/ml paclitaxel 4 B/D PA; octreotide acetate 3 PA; MO MO injection solution PADCEV 4 PA; MO 100 mcg/ml, 200 mcg/ml, 50 mcg/ml PEMAZYRE 4 PA; LA; QL (14 per octreotide acetate 5 PA; MO 21 days) injection syringe 100 mcg/ml (1 ml), 500 PEPAXTO 4 PA mcg/ml (1 ml) PERJETA 5 B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 20 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits PHESGO 5 PA; MO SANDIMMUNE 3 B/D PA; PIQRAY 5 PA; MO ORAL MO SOLUTION POLIVY 5 PA; MO SARCLISA 4 PA; LA POMALYST 5 PA; MO; LA; QL (21 SIGNIFOR 5 PA per 28 days) SIMULECT 3 B/D PA PORTRAZZA 4 B/D PA; INTRAVENOUS MO RECON SOLN 10 MG POTELIGEO 5 PA SIMULECT 3 B/D PA; PROGRAF 3 B/D PA; INTRAVENOUS MO INTRAVENOUS MO RECON SOLN 20 PROGRAF ORAL 3 B/D PA; MG GRANULES IN MO sirolimus oral 5 B/D PA; PACKET solution MO PURIXAN 5 sirolimus oral tablet 4 B/D PA; QINLOCK 5 PA; LA MO RETEVMO 5 PA; MO; SOLTAMOX 4 MO LA SOMATULINE 5 PA; MO REVLIMID 5 PA; MO; DEPOT LA; QL (28 SPRYCEL ORAL 5 PA; MO; per 28 days) TABLET 100 MG, QL (30 per ROMIDEPSIN 4 B/D PA 140 MG, 50 MG, 30 days) INTRAVENOUS 80 MG SOLUTION SPRYCEL ORAL 5 PA; MO; ROZLYTREK 4 PA; MO; TABLET 20 MG, QL (60 per ORAL CAPSULE QL (150 per 70 MG 30 days) 100 MG 30 days) STIVARGA 5 PA; MO; ROZLYTREK 4 PA; MO; QL (84 per ORAL CAPSULE QL (90 per 28 days) 200 MG 30 days) SUTENT 5 PA; MO; RUBRACA 5 PA; MO; QL (30 per LA; QL 30 days) (120 per 30 SYNRIBO 4 B/D PA days) TABLOID 4 MO RUXIENCE 5 PA; MO TABRECTA 5 PA; MO RYDAPT 5 PA; MO; QL (240 per tacrolimus oral 3 B/D PA; 30 days) MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 21 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits TAFINLAR 5 PA; MO; thiotepa injection 5 B/D PA; QL (120 per recon soln 15 mg MO 30 days) TIBSOVO 5 PA TAGRISSO 5 PA; MO; toposar 4 B/D PA; LA; QL (30 MO per 30 days) topotecan 4 B/D PA TALZENNA 5 PA; MO; intravenous recon ORAL CAPSULE QL (90 per soln 0.25 MG 30 days) topotecan 4 B/D PA; TALZENNA 5 PA; MO; intravenous solution MO ORAL CAPSULE QL (30 per 4 mg/4 ml (1 1 MG 30 days) mg/ml) tamoxifen 2MO toremifene 5MO TARGRETIN 5 PA; MO TRAZIMERA 5 B/D PA; TOPICAL MO TASIGNA ORAL 5 PA; MO; TREANDA 4 B/D PA; CAPSULE 150 QL (112 per MO MG, 200 MG 28 days) TRELSTAR 5 B/D PA; TASIGNA ORAL 5 PA; MO; INTRAMUSCUL MO CAPSULE 50 MG QL (120 per AR SUSPENSION 30 days) FOR TAZVERIK 4 PA; LA RECONSTITUTI TECENTRIQ 5 B/D PA; ON MO; LA tretinoin 5MO TEMODAR 5 B/D PA; (antineoplastic) INTRAVENOUS MO TRODELVY 4 PA; LA temsirolimus 5 B/D PA; TRUXIMA 5 PA; MO MO TUKYSA ORAL 5 PA; LA; TEPMETKO 5 PA; LA; TABLET 150 MG QL (120 per QL (60 per 30 days) 30 days) TUKYSA ORAL 5 PA; LA; THALOMID 5 PA; MO; TABLET 50 MG QL (300 per ORAL CAPSULE QL (28 per 30 days) 100 MG, 150 MG, 28 days) TURALIO 5 PA; LA; 50 MG QL (120 per THALOMID 5 PA; MO; 30 days) ORAL CAPSULE QL (56 per TYKERB 5 PA; MO; 200 MG 28 days) LA; QL thiotepa injection 5 B/D PA (180 per 30 recon soln 100 mg days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 22 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits UKONIQ 5 PA; LA; VITRAKVI ORAL 5 PA; MO; QL (120 per CAPSULE 25 MG LA; QL 30 days) (180 per 30 UNITUXIN 5 B/D PA days) valrubicin 4 B/D PA; VITRAKVI ORAL 5 PA; MO; MO SOLUTION LA; QL (300 per 30 VANTAS 4 B/D PA; days) MO VIZIMPRO 5 PA; MO; VECTIBIX 5 B/D PA; QL (30 per MO 30 days) VELCADE 5 B/D PA; VOTRIENT 5 PA; MO; MO QL (120 per VENCLEXTA 4 PA; LA; 30 days) ORAL TABLET QL (60 per VYXEOS 5 B/D PA 10 MG 30 days) XALKORI 5 PA; MO; VENCLEXTA 5 PA; LA; QL (60 per ORAL TABLET QL (120 per 30 days) 100 MG 30 days) XATMEP 4 B/D PA; VENCLEXTA 5 PA; LA; MO ORAL TABLET QL (30 per 50 MG 30 days) XOSPATA 5 PA; LA VENCLEXTA 5 PA; LA; XPOVIO 4 PA; LA STARTING QL (42 per XTANDI ORAL 4 PA; MO; PACK 30 days) CAPSULE QL (120 per VERZENIO 5 PA; MO; 30 days) LA; QL (60 XTANDI ORAL 4 PA; MO; per 30 days) TABLET 40 MG QL (120 per vinblastine 2 B/D PA; 30 days) MO XTANDI ORAL 4 PA; MO; vincasar pfs 2 B/D PA; TABLET 80 MG QL (60 per MO 30 days) vincristine 2 B/D PA; YERVOY 3 B/D PA; MO MO vinorelbine 3 B/D PA; YONDELIS 5 B/D PA MO ZALTRAP 4 B/D PA; VITRAKVI ORAL 5 PA; MO; MO CAPSULE 100 LA; QL (60 ZANOSAR 4 B/D PA; MG per 30 days) MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 23 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ZEJULA 5 PA; LA; BRIVIACT 4 QL (90 per INTRAVENOUS 30 days) BRIVIACT ORAL 4 MO; QL ZELBORAF 5 PA; MO; SOLUTION (600 per 30 QL (240 per days) 30 days) BRIVIACT ORAL 4 MO; QL ZEPZELCA 4 PA TABLET (60 per 30 ZIRABEV 5 B/D PA; days) MO carbamazepine oral 4MO ZOLADEX 4 B/D PA; capsule, er MO multiphase 12 hr ZOLINZA 5 PA; MO; carbamazepine oral 4MO QL (120 per suspension 100 mg/5 30 days) ml ZORTRESS 5 B/D PA; carbamazepine oral 4 ORAL TABLET 1 MO suspension 200 MG mg/10 ml ZYDELIG 5 PA; MO; carbamazepine oral 3MO QL (60 per tablet 30 days) carbamazepine oral 4MO ZYKADIA ORAL 5 PA; MO; tablet extended TABLET QL (90 per release 12 hr 30 days) carbamazepine oral 3MO AUTONOMIC tablet,chewable / CNS DRUGS, CELONTIN 3MO ORAL CAPSULE NEUROLOGY 300 MG / PSYCH clobazam oral 4 PA; MO; ANTICONVULS suspension QL (480 per ANTS 30 days) clobazam oral tablet 4 PA; MO; APTIOM ORAL 4 MO; QL QL (60 per TABLET 200 MG (180 per 30 30 days) days) clonazepam oral 2 MO; QL APTIOM ORAL 4 MO; QL tablet 0.5 mg, 1 mg (90 per 30 TABLET 400 MG (90 per 30 days) days) clonazepam oral 2 MO; QL APTIOM ORAL 4 MO; QL tablet 2 mg (300 per 30 TABLET 600 MG, (60 per 30 days) 800 MG days) BANZEL 5 PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 24 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits clonazepam oral 4 MO; QL FYCOMPA 4 PA; MO; tablet,disintegrating (90 per 30 ORAL QL (720 per 0.125 mg, 0.25 mg, days) SUSPENSION 30 days) 0.5 mg, 1 mg FYCOMPA 4 PA; MO; clonazepam oral 4 MO; QL ORAL TABLET QL (30 per tablet,disintegrating (300 per 30 10 MG, 12 MG, 8 30 days) 2 mg days) MG DIACOMIT 4 PA; LA; FYCOMPA 4 PA; MO; ORAL CAPSULE QL (360 per ORAL TABLET 2 QL (60 per 250 MG 30 days) MG, 4 MG, 6 MG 30 days) DIACOMIT 4 PA; LA; gabapentin oral 2 MO; QL ORAL CAPSULE QL (180 per capsule 100 mg, 400 (270 per 30 500 MG 30 days) mg days) DIACOMIT 4 PA; LA; gabapentin oral 2 MO; QL ORAL POWDER QL (360 per capsule 300 mg (360 per 30 IN PACKET 250 30 days) days) MG gabapentin oral 4 MO; QL DIACOMIT 4 PA; LA; solution 250 mg/5 (2160 per ORAL POWDER QL (180 per ml 30 days) IN PACKET 500 30 days) gabapentin oral 4 QL (2160 MG solution 250 mg/5 per 30 days) diazepam rectal 4MO ml (5 ml), 300 mg/6 DILANTIN 30 4MO ml (6 ml) MG gabapentin oral 2 MO; QL divalproex oral 4 tablet 600 mg (180 per 30 capsule, delayed rel days) sprinkle gabapentin oral 2 MO; QL divalproex oral 4MO tablet 800 mg (120 per 30 tablet extended days) release 24 hr lamotrigine oral 2MO divalproex oral 2MO tablet tablet,delayed lamotrigine oral 2MO release (dr/ec) tablet, chewable EPIDIOLEX 5 PA; MO; dispersible LA lamotrigine oral 3MO epitol 3MO tablets,dose pack ethosuximide 4MO felbamate 4MO FINTEPLA 4 PA; LA fosphenytoin 3MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 25 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits levetiracetam in 3MO phenobarbital 3 nacl (iso-os) sodium injection intravenous solution 65 mg/ml piggyback 1,000 phenytoin oral 2 mg/100 ml, 500 suspension 100 mg/4 mg/100 ml ml levetiracetam in 3 phenytoin oral 2MO nacl (iso-os) suspension 125 mg/5 intravenous ml piggyback 1,500 phenytoin oral 3MO mg/100 ml tablet,chewable levetiracetam 3MO phenytoin sodium 2MO intravenous extended levetiracetam oral 3MO phenytoin sodium 3 solution 100 mg/ml intravenous solution levetiracetam oral 3 pregabalin oral 3 MO; QL solution 500 mg/5 capsule 100 mg, 150 (90 per 30 ml (5 ml) mg, 200 mg, 25 mg, days) levetiracetam oral 2MO 50 mg, 75 mg tablet pregabalin oral 3 MO; QL NAYZILAM 4 PA; MO; capsule 225 mg, 300 (60 per 30 QL (10 per mg days) 30 days) pregabalin oral 3 MO; QL oxcarbazepine oral 4MO solution (900 per 30 suspension days) oxcarbazepine oral 3MO primidone 2MO tablet roweepra 2MO phenobarbital oral 3 PA; MO; rufinamide 5 PA; MO elixir QL (1500 per 30 days) SPRITAM 4 MO phenobarbital oral 3 PA; QL subvenite 3MO tablet 100 mg, 15 (120 per 30 subvenite starter 3MO mg, 30 mg, 60 mg days) (blue) kit phenobarbital oral 3 PA; MO; subvenite starter 3MO tablet 16.2 mg, 32.4 QL (120 per (green) kit mg, 64.8 mg, 97.2 30 days) subvenite starter 3MO mg (orange) kit phenobarbital 3MO SYMPAZAN 4 PA; MO; sodium injection QL (60 per solution 130 mg/ml 30 days) tiagabine 4MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 26 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits topiramate oral 3 PA; MO XCOPRI 4 PA; MO capsule, sprinkle TITRATION topiramate oral 3 PA; MO PACK tablet zonisamide 3 PA; MO valproate sodium 3MO ANTIPARKINS valproic acid 2MO ONISM valproic acid (as 2MO AGENTS sodium salt) oral APOKYN 5 PA; MO; solution 250 mg/5 LA; QL (60 ml per 30 days) valproic acid (as 2 benztropine 4 MO sodium salt) oral injection solution 250 mg/5 benztropine oral 3 PA; MO ml (5 ml), 500 mg/10 ml (10 ml) bromocriptine 4 MO VALTOCO 4 PA; MO; carbidopa 5 MO QL (10 per carbidopa-levodopa 2 MO 30 days) oral tablet vigabatrin 5 PA; MO; carbidopa-levodopa 3 MO LA; QL oral tablet extended (180 per 30 release days) carbidopa-levodopa 4 MO vigadrone 5 PA; LA; oral QL (180 per tablet,disintegrating 30 days) entacapone 3 MO VIMPAT 4MO GOCOVRI 4 ST INTRAVENOUS KYNMOBI 5 PA; MO; VIMPAT ORAL 4 MO; QL SUBLINGUAL QL (150 per SOLUTION (1200 per FILM 10 MG, 15 30 days) 30 days) MG, 20 MG, 25 VIMPAT ORAL 4 MO; QL MG, 30 MG TABLET 100 MG, (60 per 30 NEUPRO 4 MO 150 MG, 200 MG days) pramipexole oral 2 MO VIMPAT ORAL 4 MO; QL tablet TABLET 50 MG (120 per 30 rasagiline 2 MO days) ropinirole oral 2 MO XCOPRI 4 PA; MO tablet XCOPRI 4 PA; MO RYTARY 4 ST; MO MAINTENANCE PACK selegiline hcl 3 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 27 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits MIGRAINE / MISCELLANEO CLUSTER US HEADACHE NEUROLOGICA THERAPY L THERAPY AIMOVIG 3 PA; MO; AUSTEDO ORAL 5 PA; MO; AUTOINJECTOR QL (1 per TABLET 12 MG, 9 LA; QL 30 days) MG (120 per 30 dihydroergotamine 2 days) injection AUSTEDO ORAL 5 PA; MO; dihydroergotamine 4 PA; QL (8 TABLET 6 MG LA; QL (60 nasal per 28 days) per 30 days) ergotamine-caffeine 3 MO COPAXONE 5 PA; MO; SUBCUTANEOU QL (30 per naratriptan 4 MO; QL S SYRINGE 20 30 days) (18 per 28 MG/ML days) COPAXONE 5 PA; MO; rizatriptan 4 MO; QL SUBCUTANEOU QL (12 per (36 per 28 S SYRINGE 40 28 days) days) MG/ML sumatriptan nasal 4 MO; QL dalfampridine 5 PA; MO; spray,non-aerosol (18 per 28 QL (60 per 20 mg/actuation days) 30 days) sumatriptan nasal 4 MO; QL dimethyl fumarate 5 PA; MO; spray,non-aerosol 5 (36 per 28 oral capsule,delayed QL (14 per mg/actuation days) release(dr/ec) 120 30 days) sumatriptan 2 MO; QL mg succinate oral (18 per 28 dimethyl fumarate 5 PA; MO; days) oral capsule,delayed QL (120 per sumatriptan 3 MO; QL (8 release(dr/ec) 120 180 days) succinate per 28 days) mg (14)- 240 mg subcutaneous (46) cartridge dimethyl fumarate 5 PA; MO; sumatriptan 3 MO; QL (8 oral capsule,delayed QL (60 per succinate per 28 days) release(dr/ec) 240 30 days) subcutaneous pen mg injector donepezil oral tablet 2 MO; QL sumatriptan 3 MO; QL (8 10 mg (60 per 30 succinate per 28 days) days) subcutaneous donepezil oral tablet 2 MO; QL solution 5 mg (30 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 28 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits donepezil oral 2 MO; QL memantine oral 3 PA; MO; tablet,disintegrating (60 per 30 tablet 5 mg QL (90 per 10 mg days) 30 days) donepezil oral 2 MO; QL MEMANTINE 3 PA; MO; tablet,disintegrating (30 per 30 ORAL QL (98 per 5 mg days) TABLETS,DOSE 28 days) galantamine oral 4 MO; QL PACK capsule,ext rel. (30 per 30 NAMZARIC 4 PA; MO pellets 24 hr days) NUEDEXTA 4 PA; MO galantamine oral 4 MO; QL OCREVUS 5 PA; MO; solution (200 per 30 LA days) RADICAVA 5 PA galantamine oral 4 MO; QL rivastigmine 4MO tablet (60 per 30 days) rivastigmine tartrate 4 MO; QL (60 per 30 GILENYA ORAL 5 PA; MO; days) CAPSULE 0.5 MG QL (30 per 30 days) TECFIDERA 5 PA; MO; ORAL LA; QL (14 glatiramer 5 PA; QL (30 CAPSULE,DELA per 30 days) subcutaneous per 30 days) YED syringe 20 mg/ml RELEASE(DR/EC glatiramer 5 PA; QL (12 ) 120 MG subcutaneous per 28 days) TECFIDERA 5 PA; MO; syringe 40 mg/ml ORAL LA; QL glatopa 5 PA; MO; CAPSULE,DELA (120 per subcutaneous QL (30 per YED 180 days) syringe 20 mg/ml 30 days) RELEASE(DR/EC glatopa 5 PA; MO; ) 120 MG (14)- 240 subcutaneous QL (12 per MG (46) syringe 40 mg/ml 28 days) TECFIDERA 5 PA; MO; LEMTRADA 5 PA; MO ORAL LA; QL (60 memantine oral 4 PA; MO CAPSULE,DELA per 30 days) capsule,sprinkle,er YED 24hr RELEASE(DR/EC ) 240 MG memantine oral 4 PA; MO; solution QL (300 per tetrabenazine oral 5 PA; MO; 30 days) tablet 12.5 mg QL (240 per 30 days) memantine oral 3 PA; MO; tablet 10 mg QL (60 per tetrabenazine oral 5 PA; MO; 30 days) tablet 25 mg QL (120 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 29 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits TYSABRI 5 PA; MO; NARCOTIC LA ANALGESICS MUSCLE acetaminophen- 2 QL (4500 RELAXANTS / codeine oral solution per 30 ANTISPASMOD 120 mg-12 mg /5 ml days); NDS IC THERAPY (5 ml), 300 mg-30 mg /12.5 ml baclofen oral 3 MO acetaminophen- 2 MO; QL cyclobenzaprine 4 PA; MO codeine oral solution (4500 per oral tablet 10 mg, 5 120-12 mg/5 ml 30 days); mg NDS dantrolene oral 4 MO acetaminophen- 2 MO; QL LIORESAL 5 B/D PA; codeine oral tablet (360 per 30 INTRATHECAL MO 300-15 mg, 300-30 days); NDS SOLUTION 2,000 mg MCG/ML acetaminophen- 2 MO; QL LIORESAL 3 B/D PA codeine oral tablet (180 per 30 INTRATHECAL 300-60 mg days); NDS SOLUTION 50 buprenorphine hcl 4 MO; NDS MCG/ML injection solution LIORESAL 3 B/D PA; buprenorphine hcl 4 NDS INTRATHECAL MO injection syringe SOLUTION 500 MCG/ML buprenorphine hcl 3 PA; MO sublingual neostigmine 3 methylsulfate codeine sulfate 4 MO; QL intravenous solution (180 per 30 days); NDS pyridostigmine 4 MO bromide oral syrup endocet oral tablet 3 MO; QL 10-325 mg, 5-325 (360 per 30 pyridostigmine 3 MO mg, 7.5-325 mg days); NDS bromide oral tablet 60 mg endocet oral tablet 4 MO; QL 2.5-325 mg (360 per 30 pyridostigmine 3 MO days); NDS bromide oral tablet extended release fentanyl citrate (pf) 3 QL (400 per injection solution 30 days); regonol 3 NDS revonto 3 fentanyl citrate 5 PA; MO; tizanidine oral 2MO buccal lozenge on a QL (120 per tablet handle 30 days); NDS

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 30 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits fentanyl 4 PA; MO; methadone oral 4 PA; MO; transdermal patch QL (10 per solution 5 mg/5 ml QL (1200 72 hour 100 mcg/hr, 30 days); per 30 12 mcg/hr, 25 NDS days); NDS mcg/hr, 50 mcg/hr, methadone oral 2 PA; MO; 75 mcg/hr tablet 10 mg QL (120 per hydrocodone­ 4 QL (5550 30 days); acetaminophen oral per 30 NDS solution 10-325 days); NDS methadone oral 2 PA; MO; mg/15 ml(15 ml) tablet 5 mg QL (240 per hydrocodone­ 4 MO; QL 30 days); acetaminophen oral (5550 per NDS solution 7.5-325 30 days); morphine (pf) 4 QL (4000 mg/15 ml NDS injection solution per 30 hydrocodone­ 4 MO; QL 0.5 mg/ml days); NDS acetaminophen oral (360 per 30 morphine (pf) 4 MO; QL tablet 10-325 mg, 5­ days); NDS injection solution 1 (2000 per 325 mg, 7.5-325 mg mg/ml 30 days); hydrocodone­ 4 MO; QL NDS ibuprofen oral tablet (50 per 30 morphine 4 MO; QL 7.5-200 mg days); NDS concentrate oral (900 per 30 hydromorphone oral 4 MO; QL solution days); NDS liquid (2400 per MORPHINE 4 QL (1000 30 days); INJECTION per 30 NDS SOLUTION 2 days); NDS hydromorphone oral 4 MO; QL MG/ML tablet (180 per 30 MORPHINE 4 QL (500 per days); NDS INJECTION 30 days); methadone injection 4 QL (150 per SOLUTION 4 NDS solution 30 days); MG/ML NDS morphine injection 4 MO; QL methadone intensol 4 PA; MO; syringe 4 mg/ml (500 per 30 QL (90 per days); NDS 30 days); MORPHINE 4 MO; QL NDS INTRAVENOUS (500 per 30 methadone oral 4 PA; QL (90 SOLUTION 4 days); NDS concentrate per 30 MG/ML days); NDS morphine 4 QL (1000 methadone oral 4 PA; MO; intravenous syringe per 30 solution 10 mg/5 ml QL (600 per 2 mg/ml days); NDS 30 days); NDS

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 31 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits morphine 4 QL (500 per butorphanol nasal 4 MO; QL intravenous syringe 30 days); (10 per 28 4 mg/ml NDS days); NDS morphine oral 4 MO; QL celecoxib 4 MO; QL solution (900 per 30 (60 per 30 days); NDS days) morphine oral tablet 3 MO; QL diclofenac 2MO (180 per 30 potassium days); NDS diclofenac sodium 2MO morphine oral tablet 3 PA; MO; oral extended release QL (120 per diclofenac sodium 3 MO; QL 30 days); topical gel 1 % (1000 per NDS 28 days) oxycodone- 4 MO; QL diflunisal 4MO acetaminophen oral (360 per 30 ec-naproxen oral 2 tablet 10-325 mg, days); NDS tablet,delayed 2.5-325 mg, 5-325 release (dr/ec) 375 mg, 7.5-325 mg mg oxymorphone oral 3 PA; MO; ec-naproxen oral 2MO tablet extended QL (90 per tablet,delayed release 12 hr 30 days); release (dr/ec) 500 NDS mg NON- flurbiprofen oral 2MO NARCOTIC tablet 100 mg ANALGESICS ibu 1MO buprenorphine- 2 MO; QL ibuprofen oral 2MO naloxone sublingual (60 per 30 suspension film 12-3 mg days) ibuprofen oral tablet 2MO buprenorphine- 2 MO; QL 400 mg, 600 mg, naloxone sublingual (360 per 30 800 mg film 2-0.5 mg days) ketoprofen oral 2MO buprenorphine- 2 MO; QL capsule 25 mg naloxone sublingual (90 per 30 ketoprofen oral 2 film 4-1 mg, 8-2 mg days) capsule 50 mg, 75 buprenorphine- 2 MO; QL mg naloxone sublingual (360 per 30 meloxicam oral 1 MO; QL tablet 2-0.5 mg days) tablet (30 per 30 buprenorphine- 2 MO; QL days) naloxone sublingual (90 per 30 naloxone injection 2MO tablet 8-2 mg days) solution

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 32 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits naloxone injection 2MO ZUBSOLV 3 MO; QL syringe SUBLINGUAL (60 per 30 naltrexone 2MO TABLET 8.6-2.1 days) MG naproxen oral 2MO suspension PSYCHOTHER naproxen oral tablet 1MO APEUTIC DRUGS naproxen oral 2MO tablet,delayed ABILIFY 4 MO; QL (1 release (dr/ec) 375 MAINTENA per 28 days) mg ADASUVE 4 LA naproxen oral 2 amitriptyline 2 MO tablet,delayed amoxapine 4 MO release (dr/ec) 500 mg aripiprazole oral 4 MO solution NARCAN 3 MO aripiprazole oral 3 MO; QL salsalate 3MO tablet (30 per 30 SUBOXONE 4 MO; QL days) SUBLINGUAL (60 per 30 aripiprazole oral 5 MO; QL FILM 12-3 MG days) tablet,disintegrating (60 per 30 SUBOXONE 4 MO; QL days) SUBLINGUAL (360 per 30 ARISTADA 4 MO FILM 2-0.5 MG days) INITIO SUBOXONE 4 MO; QL ARISTADA 4 MO; QL SUBLINGUAL (90 per 30 INTRAMUSCUL (3.9 per 28 FILM 4-1 MG, 8-2 days) AR days) MG SUSPENSION,EX sulindac 2MO TENDED REL tramadol oral tablet 2 MO; QL SYRING 1,064 50 mg (240 per 30 MG/3.9 ML days); NDS ARISTADA 4 MO; QL VIVITROL 5 MO INTRAMUSCUL (1.6 per 28 ZUBSOLV 3 MO; QL AR days) SUBLINGUAL (30 per 30 SUSPENSION,EX TABLET 0.7-0.18 days) TENDED REL MG, 1.4-0.36 MG, SYRING 441 11.4-2.9 MG, 2.9­ MG/1.6 ML 0.71 MG, 5.7-1.4 MG

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 33 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ARISTADA 4 MO; QL chlorpromazine 4MO INTRAMUSCUL (2.4 per 28 injection AR days) chlorpromazine oral 4MO SUSPENSION,EX tablet TENDED REL citalopram oral 4 MO; QL SYRING 662 solution (600 per 30 MG/2.4 ML days) ARISTADA 4 MO; QL citalopram oral 6 MO; QL INTRAMUSCUL (3.2 per 28 tablet (30 per 30 AR days) days) SUSPENSION,EX TENDED REL clomipramine 4MO SYRING 882 clorazepate 4 PA; MO; MG/3.2 ML dipotassium oral QL (180 per asenapine maleate 4 MO; QL tablet 15 mg 30 days) (60 per 30 clorazepate 4 PA; MO; days) dipotassium oral QL (90 per atomoxetine oral 3 MO; QL tablet 3.75 mg 30 days) capsule 10 mg, 18 (60 per 30 clorazepate 4 PA; MO; mg, 25 mg, 40 mg days) dipotassium oral QL (360 per atomoxetine oral 3 MO; QL tablet 7.5 mg 30 days) capsule 100 mg, 60 (30 per 30 clozapine oral tablet 4 mg, 80 mg days) 100 mg, 200 mg bupropion hcl oral 2 MO; QL clozapine oral tablet 3 tablet 100 mg (120 per 30 25 mg, 50 mg days) clozapine oral 4 bupropion hcl oral 2 MO; QL tablet,disintegrating tablet 75 mg (180 per 30 desipramine 4MO days) desvenlafaxine 4 MO; QL bupropion hcl oral 3 MO; QL succinate (30 per 30 tablet extended (90 per 30 days) release 24 hr 150 mg days) dexmethylphenidate 3MO bupropion hcl oral 3 MO; QL oral tablet tablet extended (30 per 30 dextroamphetamine 4MO release 24 hr 300 mg days) oral capsule, bupropion hcl oral 3 MO; QL extended release tablet sustained- (60 per 30 dextroamphetamine 4MO release 12 hr days) oral tablet 10 mg, 5 buspirone 2MO mg CAPLYTA 4 PA; MO; QL (30 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 34 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits dextroamphetamine 4 MO; QL duloxetine oral 3 MO; QL -amphetamine oral (60 per 30 capsule,delayed (60 per 30 capsule,extended days) release(dr/ec) 20 days) release 24hr mg, 30 mg, 60 mg dextroamphetamine 3MO EMSAM 4 MO; QL -amphetamine oral (30 per 30 tablet 10 mg, 15 mg, days) 20 mg, 5 mg escitalopram 4 MO; QL dextroamphetamine 3 MO; QL oxalate oral solution (600 per 30 -amphetamine oral (60 per 30 days) tablet 12.5 mg, 30 days) escitalopram 2 MO; QL mg, 7.5 mg oxalate oral tablet (30 per 30 diazepam injection 2PA days) diazepam intensol 2 PA; QL FANAPT ORAL 4 PA; MO; (240 per 30 TABLET QL (60 per days) 30 days) diazepam oral 2 PA; MO; FANAPT ORAL 4 PA; MO; concentrate QL (240 per TABLETS,DOSE QL (8 per 30 days) PACK 28 days) diazepam oral 2 PA; MO; FETZIMA ORAL 4 ST; MO; solution 5 mg/5 ml QL (1200 CAPSULE,EXT QL (28 per (1 mg/ml) per 30 days) REL 24HR DOSE 28 days) diazepam oral tablet 2 PA; MO; PACK QL (120 per FETZIMA ORAL 4 ST; MO; 30 days) CAPSULE,EXTE QL (30 per doxepin oral capsule 4MO NDED RELEASE 30 days) 24 HR doxepin oral 4MO concentrate fluoxetine (pmdd) 2 QL (30 per oral tablet 10 mg 30 days) DRIZALMA 4 MO; QL SPRINKLE (60 per 30 fluoxetine (pmdd) 2 ORAL CAPSULE, days) oral tablet 20 mg DELAYED REL fluoxetine oral 2 MO; QL SPRINKLE 20 capsule 10 mg (30 per 30 MG, 30 MG, 60 days) MG fluoxetine oral 2MO DRIZALMA 4 MO; QL capsule 20 mg SPRINKLE (90 per 30 fluoxetine oral 2 MO; QL ORAL CAPSULE, days) capsule 40 mg (60 per 30 DELAYED REL days) SPRINKLE 40 fluoxetine oral 2MO MG solution

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 35 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits fluoxetine oral 2 MO; QL INVEGA 4 MO; QL (1 tablet 10 mg (30 per 30 SUSTENNA per 28 days) days) INTRAMUSCUL fluoxetine oral 2MO AR SYRINGE 156 tablet 20 mg MG/ML fluphenazine 4MO INVEGA 4 MO; QL decanoate SUSTENNA (1.5 per 28 INTRAMUSCUL days) fluphenazine hcl 4MO AR SYRINGE 234 injection MG/1.5 ML fluphenazine hcl 2MO INVEGA 4 MO; QL oral concentrate SUSTENNA (0.25 per 28 fluphenazine hcl 4MO INTRAMUSCUL days) oral elixir AR SYRINGE 39 fluphenazine hcl 2MO MG/0.25 ML oral tablet INVEGA 4 MO; QL fluvoxamine oral 3 MO; QL SUSTENNA (0.5 per 28 tablet 100 mg (90 per 30 INTRAMUSCUL days) days) AR SYRINGE 78 fluvoxamine oral 3 MO; QL MG/0.5 ML tablet 25 mg (30 per 30 INVEGA 4 MO; QL days) TRINZA (0.88 per 28 fluvoxamine oral 3 MO; QL INTRAMUSCUL days) tablet 50 mg (60 per 30 AR SYRINGE 273 days) MG/0.875 ML haloperidol 2MO INVEGA 4 MO; QL TRINZA (1.32 per 28 haloperidol 4MO INTRAMUSCUL days) decanoate AR SYRINGE 410 haloperidol lactate 2MO MG/1.315 ML injection INVEGA 4 MO; QL haloperidol lactate 2MO TRINZA (1.75 per 28 oral INTRAMUSCUL days) HETLIOZ 5 PA; MO; AR SYRINGE 546 QL (30 per MG/1.75 ML 30 days) INVEGA 4 MO; QL imipramine hcl 4MO TRINZA (2.63 per 28 INVEGA 4 MO; QL INTRAMUSCUL days) SUSTENNA (0.75 per 28 AR SYRINGE 819 INTRAMUSCUL days) MG/2.625 ML AR SYRINGE 117 MG/0.75 ML

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 36 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits LATUDA ORAL 4 MO; QL methylphenidate hcl 4 MO; QL TABLET 120 MG, (30 per 30 oral tablet (90 per 30 20 MG, 40 MG, 60 days) days) MG methylphenidate hcl 4MO LATUDA ORAL 4 MO; QL oral tablet extended TABLET 80 MG (60 per 30 release days) methylphenidate hcl 4 lithium carbonate 2MO oral tablet extended lithium citrate oral 3MO release 24hr 18 mg solution 8 meq/5 ml (bx rating), 27 mg (bx rating), 36 mg lorazepam injection 4 PA; MO (bx rating), 54 mg solution (bx rating) lorazepam injection 4 PA; MO methylphenidate hcl 4MO syringe 2 mg/ml oral tablet extended lorazepam injection 4PA release 24hr 18 mg, syringe 4 mg/ml 27 mg, 36 mg, 54 lorazepam intensol 3 PA; QL mg (150 per 30 mirtazapine oral 2 MO; QL days) tablet (30 per 30 lorazepam oral 3 PA; MO; days) concentrate QL (150 per mirtazapine oral 3 MO; QL 30 days) tablet,disintegrating (30 per 30 lorazepam oral 2 PA; MO; days) tablet 0.5 mg, 1 mg QL (90 per modafinil oral tablet 3 PA; MO; 30 days) 100 mg QL (30 per lorazepam oral 2 PA; MO; 30 days) tablet 2 mg QL (150 per modafinil oral tablet 3 PA; MO; 30 days) 200 mg QL (60 per loxapine succinate 3MO 30 days) maprotiline 2MO molindone 3MO MARPLAN 4 MO; QL nefazodone 4MO (180 per 30 nortriptyline 2MO days) NUPLAZID 4 PA; MO; methylphenidate hcl 4 MO; QL ORAL CAPSULE QL (30 per oral solution 10 (900 per 30 30 days) mg/5 ml days) NUPLAZID 4 PA; MO; methylphenidate hcl 4 MO; QL ORAL TABLET QL (30 per oral solution 5 mg/5 (1800 per 10 MG 30 days) ml 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 37 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits olanzapine 4 MO; QL quetiapine oral 4 MO; QL intramuscular (30 per 30 tablet extended (60 per 30 days) release 24 hr 300 days) olanzapine oral 3 MO; QL mg, 400 mg, 50 mg tablet (30 per 30 ramelteon 4 MO; QL days) (30 per 30 olanzapine oral 4 MO; QL days) tablet,disintegrating (30 per 30 REXULTI 4 MO; QL days) (30 per 30 paliperidone oral 4 PA; MO; days) tablet extended QL (30 per RISPERDAL 4 MO; QL (2 release 24hr 1.5 mg, 30 days) CONSTA per 28 days) 3 mg, 9 mg risperidone oral 4MO paliperidone oral 4 PA; MO; solution tablet extended QL (60 per risperidone oral 2 MO; QL release 24hr 6 mg 30 days) tablet 0.25 mg, 0.5 (60 per 30 paroxetine hcl oral 2 MO; QL mg, 1 mg, 2 mg, 3 days) tablet 10 mg, 20 mg, (30 per 30 mg 40 mg days) risperidone oral 2 MO; QL paroxetine hcl oral 2 MO; QL tablet 4 mg (120 per 30 tablet 30 mg (60 per 30 days) days) risperidone oral 4 MO; QL PAXIL ORAL 4 ST; MO; tablet,disintegrating (60 per 30 SUSPENSION QL (900 per 0.25 mg, 0.5 mg, 1 days) 30 days) mg, 2 mg, 3 mg perphenazine 4MO risperidone oral 4 MO; QL PERSERIS 4 MO; QL (1 tablet,disintegrating (120 per 30 per 30 days) 4 mg days) phenelzine 3MO SAPHRIS 4 MO; QL (60 per 30 pimozide 4MO days) protriptyline 4MO SECUADO 4 MO; QL quetiapine oral 2 MO; QL (30 per 30 tablet 100 mg, 200 (90 per 30 days) mg, 25 mg, 50 mg days) sertraline oral 4MO quetiapine oral 2 MO; QL concentrate tablet 300 mg, 400 (60 per 30 sertraline oral tablet 1 MO; QL mg days) 100 mg, 50 mg (60 per 30 quetiapine oral 4 MO; QL days) tablet extended (30 per 30 release 24 hr 150 days) mg, 200 mg

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 38 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits sertraline oral tablet 1 MO; QL zaleplon oral 3 MO; QL 25 mg (30 per 30 capsule 10 mg (60 per 30 days) days) thioridazine 4MO zaleplon oral 3 MO; QL thiothixene 4MO capsule 5 mg (30 per 30 days) tranylcypromine 4MO ziprasidone hcl 4 MO; QL trazodone 2MO (60 per 30 trifluoperazine 3MO days) trimipramine 4MO ziprasidone 4 QL (6 per TRINTELLIX 4 ST; MO; mesylate 30 days) QL (30 per ZYPREXA 4 PA; MO; 30 days) RELPREVV QL (2 per venlafaxine oral 2 MO; QL INTRAMUSCUL 28 days) capsule,extended (30 per 30 AR SUSPENSION release 24hr 150 days) FOR mg, 37.5 mg RECONSTITUTI venlafaxine oral 2 MO; QL ON 210 MG, 300 capsule,extended (90 per 30 MG release 24hr 75 mg days) ZYPREXA 4 PA; MO; venlafaxine oral 2 MO; QL RELPREVV QL (1 per tablet (90 per 30 INTRAMUSCUL 28 days) days) AR SUSPENSION FOR VERSACLOZ 5 RECONSTITUTI VIIBRYD ORAL 4 ST; MO; ON 405 MG TABLET QL (30 per 30 days) CARDIOVAS VIIBRYD ORAL 4 ST; MO; CULAR, TABLETS,DOSE QL (30 per HYPERTENSI PACK 10 MG (7)- 30 days) ON / LIPIDS 20 MG (23) ANTIARRHYTH VRAYLAR ORAL 4 PA; MO; CAPSULE QL (30 per MIC AGENTS 30 days) adenosine 3 VRAYLAR ORAL 4 PA; MO; amiodarone 2 B/D PA; CAPSULE,DOSE QL (7 per intravenous solution MO PACK 30 days) amiodarone 2 B/D PA XYREM 5 PA; LA; intravenous syringe QL (540 per amiodarone oral 2 30 days) tablet 100 mg

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 39 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits amiodarone oral 2MO ANTIHYPERTE tablet 200 mg NSIVE amiodarone oral 4 THERAPY tablet 400 mg acebutolol 2 MO dofetilide 3MO amiloride 3 MO flecainide 2MO amiloride­ 2 MO lidocaine (pf) 4 hydrochlorothiazide intravenous solution amlodipine 6 MO lidocaine (pf) 2 amlodipine­ 2 MO intravenous syringe benazepril mexiletine 2MO amlodipine­ 2 MO pacerone oral tablet 2MO valsartan 100 mg, 200 mg atenolol 6 MO procainamide 2 benazepril 6 MO injection benazepril­ 6 MO propafenone oral 4MO hydrochlorothiazide capsule,extended release 12 hr BIDIL 3 MO propafenone oral 2MO bisoprolol fumarate 2 MO tablet 150 mg, 225 bisoprolol­ 1 MO mg hydrochlorothiazide propafenone oral 4MO bumetanide 4 MO tablet 300 mg injection quinidine sulfate 2MO bumetanide oral 2 MO oral tablet BYSTOLIC 4 MO sorine oral tablet 2MO candesartan oral 2 MO; QL 120 mg, 160 mg, 80 tablet 16 mg, 4 mg, (60 per 30 mg 8 mg days) sorine oral tablet 2 candesartan oral 2 MO; QL 240 mg tablet 32 mg (30 per 30 sotalol af 2 days) sotalol oral tablet 2MO cartia xt 3 MO 120 mg, 160 mg, 80 carvedilol 6 MO mg chlorothiazide 2 MO sotalol oral tablet 4MO sodium 240 mg chlorthalidone oral 2 MO SOTYLIZE 4 MO tablet 25 mg, 50 mg clonidine 4 MO; QL (4 per 28 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 40 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits clonidine hcl oral 2MO fosinopril­ 2MO tablet hydrochlorothiazide DEMSER 4 PA; MO furosemide injection 4MO diltiazem hcl 4 furosemide oral 2MO intravenous solution 10 mg/ml, diltiazem hcl oral 3MO 40 mg/5 ml (8 capsule,ext.rel 24h mg/ml) degradable 120 mg, furosemide oral 1MO 240 mg tablet diltiazem hcl oral 3MO hydralazine 4MO capsule,extended injection release 24 hr 120 hydralazine oral 6MO mg, 240 mg, 300 mg hydrochlorothiazide 6MO diltiazem hcl oral 3 indapamide 2MO capsule,extended release 24hr 120 irbesartan 1 MO; QL mg, 240 mg, 300 mg (30 per 30 days) diltiazem hcl oral 2MO tablet irbesartan­ 2 MO; QL hydrochlorothiazide (30 per 30 diltiazem hcl oral 3 days) tablet extended release 24 hr labetalol 2 intravenous syringe dilt-xr 3MO 20 mg/4 ml (5 doxazosin oral 2 MO; QL mg/ml) tablet 1 mg, 2 mg, 4 (30 per 30 labetalol oral 6MO mg days) lisinopril 6MO doxazosin oral 2 MO; QL tablet 8 mg (60 per 30 lisinopril­ 6MO days) hydrochlorothiazide EDARBI 4 MO losartan 1 MO; QL (60 per 30 EDARBYCLOR 4 MO days) enalapril maleate 2MO losartan­ 1 MO; QL oral tablet hydrochlorothiazide (30 per 30 enalaprilat 3 oral tablet 100-12.5 days) intravenous solution mg, 100-25 mg enalapril­ 2MO losartan­ 1 MO; QL hydrochlorothiazide hydrochlorothiazide (60 per 30 eplerenone 4MO oral tablet 50-12.5 days) felodipine 3MO mg fosinopril 2MO mannitol 20 % 3

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 41 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits mannitol 25 % 3MO propranolol­ 4MO intravenous solution hydrochlorothiazid methyldopa 4MO quinapril 6MO metolazone 3MO quinapril­ 2MO metoprolol 2MO hydrochlorothiazide succinate ramipril 1MO metoprolol ta­ 3MO SODIUM 3 hydrochlorothiaz EDECRIN metoprolol tartrate 2 spironolactone oral 2MO intravenous solution tablet 100 mg, 50 metoprolol tartrate 6MO mg oral tablet 100 mg, spironolactone oral 1MO 25 mg, 50 mg tablet 25 mg metyrosine 5 PA; MO spironolacton­ 2MO minoxidil oral 2MO hydrochlorothiaz nicardipine oral 2MO telmisartan 2MO nifedipine oral 3MO telmisartan­ 2MO tablet extended amlodipine release terazosin oral 6 MO; QL nifedipine oral 3MO capsule 1 mg, 2 mg, (30 per 30 tablet extended 5 mg days) release 24hr terazosin oral 6 MO; QL nimodipine 4MO capsule 10 mg (60 per 30 days) olmesartan 3MO timolol maleate oral 4MO osmitrol 15 % 3 torsemide oral 2MO osmitrol 20 % 3 triamterene 3MO phentolamine 3 triamterene­ 2MO pindolol 4MO hydrochlorothiazid prazosin 2MO oral capsule 37.5-25 propranolol 2 mg intravenous triamterene­ 2MO propranolol oral 4MO hydrochlorothiazid capsule,extended oral tablet release 24 hr UPTRAVI ORAL 4 PA; MO; propranolol oral 2MO LA solution valsartan oral tablet 2 MO; QL propranolol oral 2MO 160 mg, 40 mg, 80 (60 per 30 tablet mg days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 42 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits valsartan oral tablet 2 MO; QL ELIQUIS 3 MO 320 mg (30 per 30 ELIQUIS DVT-PE 3MO days) TREAT 30D valsartan­ 2 MO; QL START hydrochlorothiazide (30 per 30 enoxaparin 4MO days) subcutaneous verapamil 2 solution intravenous enoxaparin 4 MO; QL verapamil oral 2MO subcutaneous (28 per 28 capsule, 24 hr er syringe 100 mg/ml, days) pellet ct 150 mg/ml verapamil oral 2MO enoxaparin 4 MO; QL capsule,ext rel. subcutaneous (22.4 per 28 pellets 24 hr 120 syringe 120 mg/0.8 days) mg, 180 mg, 240 mg ml, 80 mg/0.8 ml verapamil oral 3MO enoxaparin 4 MO; QL capsule,ext rel. subcutaneous (16.8 per 28 pellets 24 hr 360 mg syringe 30 mg/0.3 days) verapamil oral 1MO ml, 60 mg/0.6 ml tablet enoxaparin 4 MO; QL verapamil oral 2MO subcutaneous (11.2 per 28 tablet extended syringe 40 mg/0.4 days) release ml COAGULATION fondaparinux 5MO THERAPY subcutaneous syringe 10 mg/0.8 aminocaproic acid 3 MO ml, 5 mg/0.4 ml, 7.5 BRILINTA 4 MO; QL mg/0.6 ml (60 per 30 fondaparinux 3MO days) subcutaneous CEPROTIN 3 MO syringe 2.5 mg/0.5 (BLUE BAR) ml CEPROTIN 3 MO heparin (porcine) in 4 (GREEN BAR) 5 % dex intravenous cilostazol 2 MO parenteral solution 20,000 unit/500 ml clopidogrel oral 4 MO (40 unit/ml) tablet 300 mg clopidogrel oral 6 MO; QL tablet 75 mg (30 per 30 days) dipyridamole oral 3 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 43 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits heparin (porcine) in 4MO HEPARIN, 3MO 5 % dex intravenous PORCINE (PF) parenteral solution SUBCUTANEOU 25,000 unit/250 S ml(100 unit/ml), jantoven 1MO 25,000 unit/500 ml NPLATE 5 MO (50 unit/ml) pentoxifylline 2MO heparin (porcine) in 3 nacl (pf) prasugrel 4MO heparin (porcine) 4MO PROMACTA 5 PA; MO; injection cartridge ORAL POWDER LA; QL IN PACKET 12.5 (360 per 30 heparin (porcine) 3MO MG days) injection solution PROMACTA 5 PA; MO; heparin (porcine) 4MO ORAL POWDER LA; QL injection syringe IN PACKET 25 (180 per 30 5,000 unit/ml MG days) HEPARIN(PORCI 4 PROMACTA 5 PA; MO; NE) IN 0.45% ORAL TABLET LA; QL (30 NACL 12.5 MG, 25 MG, per 30 days) INTRAVENOUS 50 MG PARENTERAL SOLUTION 12,500 PROMACTA 5 PA; MO; UNIT/250 ML ORAL TABLET LA; QL (60 75 MG per 30 days) heparin(porcine) in 4MO 0.45% nacl warfarin 1MO intravenous XARELTO 3 MO parenteral solution XARELTO DVT­ 3MO 25,000 unit/250 ml, PE TREAT 30D 25,000 unit/500 ml START heparin, porcine 4 LIPID/CHOLES (pf) injection TEROL solution 1,000 LOWERING unit/ml AGENTS heparin, porcine 3MO (pf) injection atorvastatin 1 MO; QL solution 5,000 (30 per 30 unit/0.5 ml days) heparin, porcine 3MO cholestyramine 3MO (pf) injection (with sugar) syringe 5,000 cholestyramine light 3 unit/0.5 ml colestipol oral 4MO granules

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 44 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits colestipol oral 4MO NIACOR 3 MO packet pravastatin 6 MO; QL colestipol oral tablet 3MO (30 per 30 ezetimibe 3 MO; QL days) (30 per 30 prevalite 3MO days) REPATHA 3 PA; QL (3 fenofibrate 3 MO; QL per 28 days) micronized oral (30 per 30 REPATHA 3 PA; QL capsule 134 mg, 200 days) PUSHTRONEX (3.5 per 28 mg days) fenofibrate 3 MO; QL REPATHA 3 PA; QL (3 micronized oral (60 per 30 SURECLICK per 28 days) capsule 67 mg days) rosuvastatin 2 MO; QL fenofibrate 3 MO; QL (30 per 30 nanocrystallized (30 per 30 days) oral tablet 145 mg days) simvastatin oral 6 MO; QL fenofibrate 3 MO; QL tablet (30 per 30 nanocrystallized (60 per 30 days) oral tablet 48 mg days) VASCEPA 3 MO fenofibrate oral 3 MO; QL MISCELLANEO tablet 160 mg (30 per 30 days) US CARDIOVASCU fenofibrate oral 3 MO; QL LAR AGENTS tablet 54 mg (60 per 30 days) CORLANOR 4 PA; MO; fenofibric acid 4MO ORAL TABLET QL (60 per (choline) 30 days) gemfibrozil 2 MO; QL digitek oral tablet 3 MO; QL (60 per 30 125 mcg (0.125 mg) (30 per 30 days) days) lovastatin oral 6 MO; QL digitek oral tablet 3MO tablet 10 mg (30 per 30 250 mcg (0.25 mg) days) digox oral tablet 2 MO; QL lovastatin oral 6 MO; QL 125 mcg (0.125 mg) (30 per 30 tablet 20 mg, 40 mg (60 per 30 days) days) digox oral tablet 2MO niacin oral tablet 3MO 250 mcg (0.25 mg) 500 mg digoxin oral solution 3MO niacin oral tablet 4 digoxin oral tablet 2 MO; QL extended release 24 125 mcg (0.125 mg) (30 per 30 hr days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 45 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits digoxin oral tablet 2MO LANOXIN ORAL 4MO 250 mcg (0.25 mg) TABLET 62.5 dobutamine in d5w 3 B/D PA MCG (0.0625 MG) intravenous LANOXIN 3 parenteral solution PEDIATRIC 1,000 mg/250 ml milrinone 3 B/D PA (4,000 mcg/ml), milrinone in 5 % 3 B/D PA 250 mg/250 ml (1 dextrose mg/ml), 500 mg/250 ml (2,000 mcg/ml) ranolazine 3 MO; QL (60 per 30 dobutamine 3 B/D PA days) intravenous solution 250 mg/20 ml (12.5 VERQUVO 3 PA; MO; mg/ml) QL (30 per 30 days) dopamine in 5 % 3 B/D PA dextrose VYNDAMAX 4 PA; MO intravenous solution VYNDAQEL 4 PA; MO 200 mg/250 ml (800 NITRATES mcg/ml), 400 mg/250 ml (1,600 isosorbide dinitrate 4 MO mcg/ml), 400 oral tablet 10 mg, mg/500 ml (800 20 mg, 40 mg, 5 mg mcg/ml), 800 isosorbide dinitrate 3 MO mg/500 ml (1,600 oral tablet 30 mg mcg/ml) isosorbide 2 MO dopamine in 5 % 3 B/D PA; mononitrate dextrose MO nitro-bid 3 MO intravenous solution nitroglycerin in 5 % 3 B/D PA 800 mg/250 ml dextrose (3,200 mcg/ml) intravenous solution dopamine 3 B/D PA 100 mg/250 ml (400 intravenous solution mcg/ml), 25 mg/250 200 mg/5 ml (40 ml (100 mcg/ml), mg/ml) 50 mg/250 ml (200 dopamine 3 B/D PA; mcg/ml) intravenous solution MO nitroglycerin 2MO 400 mg/10 ml (40 sublingual mg/ml) nitroglycerin 2MO ENTRESTO 3 MO; QL transdermal patch (60 per 30 24 hour days) nitroglycerin 2MO translingual

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 46 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits DERMATOL STELARA 5 PA; MO; OGICALS/TO SUBCUTANEOU QL (1 per S SYRINGE 90 28 days) PICAL MG/ML THERAPY TALTZ SYRINGE 5 PA; MO; ANTIPSORIATI QL (4 per C / 28 days) ANTISEBORRH MISCELLANEO EIC US DERMATOLOG acitretin 4 MO ICALS calcipotriene scalp 3 MO; QL (120 per 30 ammonium lactate 2 MO days) DUPIXENT PEN 5 PA; QL calcipotriene topical 4 MO; QL SUBCUTANEOU (4.56 per 28 cream (120 per 30 S PEN INJECTOR days) days) 200 MG/1.14 ML calcipotriene topical 4 MO; QL DUPIXENT PEN 5 PA; MO; ointment (120 per 30 SUBCUTANEOU QL (8 per days) S PEN INJECTOR 28 days) 300 MG/2 ML selenium sulfide 2 MO topical lotion DUPIXENT 5 PA; MO; SYRINGE QL (4.56 SKYRIZI 5 PA; QL (2 SUBCUTANEOU per 28 days) SUBCUTANEOU per 28 days) S SYRINGE 200 S PEN INJECTOR MG/1.14 ML SKYRIZI 5 PA; QL (2 DUPIXENT 5 PA; MO; SUBCUTANEOU per 28 days) SYRINGE QL (8 per S SYRINGE 150 SUBCUTANEOU 28 days) MG/ML S SYRINGE 300 SKYRIZI 5 PA; MO; MG/2 ML SUBCUTANEOU QL (2 per fluorouracil topical 3 MO S SYRINGE KIT 28 days) cream 5 % STELARA 5 PA; MO; fluorouracil topical 3 MO SUBCUTANEOU QL (0.5 per solution S SOLUTION 28 days) glydo 3 MO; QL STELARA 5 PA; MO; (60 per 30 SUBCUTANEOU QL (0.5 per days) S SYRINGE 45 28 days) MG/0.5 ML imiquimod topical 3 MO cream in packet

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 47 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits lidocaine (pf) 4 lidocaine viscous 2MO injection solution 10 lidocaine-prilocaine 4 MO; QL mg/ml (1 %), 20 topical cream (30 per 30 mg/ml (2 %) days) lidocaine (pf) 2 methoxsalen 5MO injection solution 15 PANRETIN 5 MO mg/ml (1.5 %), 40 mg/ml (4 %) podofilox 4MO lidocaine (pf) 1 REGRANEX 5 PA; MO injection solution 5 SANTYL 4 MO mg/ml (0.5 %) silver sulfadiazine 2MO lidocaine hcl 2 ssd 3MO injection solution 10 tacrolimus topical 3 PA; MO; mg/ml (1 %) QL (100 per lidocaine hcl 4 30 days) injection solution 20 UVADEX 4 B/D PA mg/ml (2 %) VALCHLOR 5 PA; MO lidocaine hcl 1 injection solution 5 ZTLIDO 3 PA; MO; mg/ml (0.5 %) QL (90 per 30 days) lidocaine hcl 2MO laryngotracheal THERAPY FOR lidocaine hcl mucous 3 MO; QL ACNE membrane jelly (60 per 30 claravis 4 days) clindamycin 4 MO; QL lidocaine hcl mucous 3 MO; QL phosphate topical (120 per 30 membrane jelly in (60 per 30 gel days) applicator days) CLINDAMYCIN 4 QL (150 per lidocaine hcl mucous 2 PHOSPHATE 30 days) membrane solution TOPICAL GEL, 2 % ONCE DAILY lidocaine hcl mucous 2MO clindamycin 4 MO; QL membrane solution phosphate topical (120 per 30 4 % (40 mg/ml) lotion days) lidocaine topical 3 PA; MO; clindamycin 4 MO; QL adhesive QL (90 per phosphate topical (120 per 30 patch,medicated 5 30 days) solution days) % clindamycin 2 MO; QL lidocaine topical 4 MO; QL phosphate topical (60 per 30 ointment (50 per 30 swab days) days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 48 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits clindamycin-benzoyl 4MO TOPICAL peroxide topical gel ANTIBACTERIA with pump 1.2-2.5 % LS ery pads 4MO gentamicin topical 3MO erythromycin with 2MO mafenide acetate 2MO ethanol topical gel mupirocin 2 MO; QL erythromycin with 2MO (30 per 30 ethanol topical days) solution sulfacetamide 4MO erythromycin­ 4MO sodium (acne) benzoyl peroxide SULFAMYLON 4MO isotretinoin 4 TOPICAL metronidazole 4MO CREAM topical cream TOPICAL metronidazole 4MO ANTIFUNGALS topical gel 0.75 % ciclopirox topical 4 MO; QL metronidazole 2MO cream (90 per 28 topical gel 1 % days) metronidazole 2MO ciclopirox topical 4 MO; QL topical gel with gel (45 per 28 pump days) metronidazole 4MO ciclopirox topical 4 MO; QL topical lotion shampoo (120 per 28 rosadan topical 4MO days) cream ciclopirox topical 2 MO rosadan topical gel 4MO solution tazarotene topical 3 PA; MO ciclopirox topical 4 MO; QL cream suspension (60 per 28 TAZORAC 3 PA; MO days) TOPICAL clotrimazole topical 2 MO; QL CREAM 0.05 % cream (45 per 28 tretinoin topical 4 PA; MO days) cream 0.025 %, 0.05 clotrimazole topical 2 MO; QL %, 0.1 % solution (30 per 28 tretinoin topical 3 PA; MO days) topical gel 0.01 % ketoconazole topical 2 MO; QL tretinoin topical 4 PA; MO cream (60 per 28 topical gel 0.025 %, days) 0.05 %

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 49 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ketoconazole topical 2 MO; QL betamethasone 2MO shampoo (120 per 28 valerate topical days) ointment nyamyc 4MO betamethasone, 2MO nystatin topical 2 MO; QL augmented topical cream (30 per 28 cream days) betamethasone, 4MO nystatin topical 2 MO; QL augmented topical ointment (30 per 28 gel days) betamethasone, 4MO nystatin topical 3 augmented topical powder lotion nystatin­ 4 MO; QL betamethasone, 4MO triamcinolone (60 per 28 augmented topical days) ointment nystop 4MO fluocinolone 4MO TOPICAL fluocinolone and 4MO ANTIVIRALS shower cap fluticasone 4MO acyclovir topical 4 PA; MO; propionate topical ointment QL (30 per cream 30 days) fluticasone 4MO DENAVIR 4 MO propionate topical TOPICAL ointment CORTICOSTER hydrocortisone 4 MO; QL OIDS butyrate topical (120 per 30 alclometasone 4MO cream days) topical cream hydrocortisone 2MO alclometasone 2MO butyrate topical topical ointment ointment beser 3MO hydrocortisone 4 MO; QL butyr-emollient (120 per 30 betamethasone 4MO days) dipropionate hydrocortisone 2MO betamethasone 2MO topical cream 1 %, valerate topical 2.5 % cream hydrocortisone 4MO betamethasone 4MO topical lotion 2.5 % valerate topical lotion hydrocortisone 2MO topical ointment 2.5 %

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 50 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits hydrocortisone 2MO MISCELLANEO valerate topical US AGENTS cream acamprosate 4 MO hydrocortisone 4MO valerate topical anagrelide 3 MO ointment AURYXIA 4 PA; MO; prednicarbate 4MO QL (360 per topical ointment 30 days) triamcinolone 2MO caffeine citrate oral 3 MO acetonide topical CARBAGLU 5 PA; MO; cream LA triamcinolone 3MO CHEMET 4 PA acetonide topical d10 %-0.45 % 4 lotion sodium chloride triamcinolone 2MO d2.5 %-0.45 % 4 acetonide topical sodium chloride ointment d5 % and 0.9 % 4 MO triderm topical 2MO sodium chloride cream d5 %-0.45 % sodium 4 MO tritocin 2 chloride TOPICAL deferasirox oral 5 PA; MO SCABICIDES / tablet PEDICULICIDE dextrose 10 % and 4 S 0.2 % nacl crotan 3MO dextrose 10 % in 3 lindane topical 4MO water (d10w) shampoo dextrose 5 % in 3 MO malathion 4MO water (d5w) permethrin 3MO dextrose 5 %­ 4 MO lactated ringers DIAGNOSTIC dextrose 5%-0.2 % 4 S / sod chloride MISCELLAN disulfiram 4 MO EOUS droxidopa oral 4 PA; MO; AGENTS capsule 100 mg QL (90 per 30 days) ANTIDOTES droxidopa oral 4 PA; MO; acetylcysteine 3 capsule 200 mg, 300 QL (180 per intravenous mg 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 51 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits INCRELEX 5 PA; MO; sps (with sorbitol) 4 LA rectal levocarnitine (with 4MO trientine 5 PA; MO; sugar) QL (240 per levocarnitine oral 4MO 30 days) solution 100 mg/ml VELPHORO 4 MO levocarnitine oral 4MO VELTASSA 3 MO tablet XIAFLEX 5 PA midodrine oral 4MO XURIDEN 5 tablet 10 mg, 5 mg zoledronic acid­ 3 PA; MO midodrine oral 3MO mannitol-water tablet 2.5 mg intravenous nitisinone 5MO piggyback 5 mg/100 NORTHERA 5 PA; MO; ml ORAL CAPSULE QL (90 per SMOKING 100 MG 30 days) DETERRENTS NORTHERA 5 PA; MO; bupropion hcl 3 MO; QL ORAL CAPSULE QL (180 per (smoking deter) (60 per 30 200 MG, 300 MG 30 days) days) pilocarpine hcl oral 4MO CHANTIX 4 MO PROLASTIN-C 5 PA; LA CHANTIX 4MO REVCOVI 5 PA; LA CONTINUING riluzole 3MO MONTH BOX sevelamer carbonate 5MO CHANTIX 4MO oral powder in STARTING packet MONTH BOX sevelamer carbonate 3 MO; QL NICOTROL 4 MO oral tablet (540 per 30 EAR, NOSE / days) THROAT sodium chloride 0.9 4MO MEDICATIO % intravenous NS sodium chloride 3MO irrigation MISCELLANEO sodium polystyrene 4MO US AGENTS sulfonate oral azelastine 0.1% 4 MO; QL powder (137 mcg) spry (60 per 30 SOLIRIS 5 PA; MO days) sps (with sorbitol) 4MO oral

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 52 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits azelastine 0.15% 2 MO; QL OTIC STEROID nasal spray (60 per 30 / ANTIBIOTIC days) CIPRODEX 3 MO chlorhexidine 2MO gluconate mucous ciprofloxacin­ 3MO membrane dexamethasone denta 5000 plus 3MO CORTISPORIN­ 3MO TC dentagel 3MO neomycin­ 3MO fluoride (sodium) 3MO polymyxin-hc otic dental gel (ear) ipratropium 2 MO; QL ENDOCRINE/ bromide nasal (30 per 30 days) DIABETES oralone 4MO ADRENAL paroex oral rinse 2MO HORMONES periogard 2MO decadron oral tablet 3 sf 3MO 0.5 mg sf 5000 plus 3MO DEPO-MEDROL 3 MO sodium fluoride 3 dexamethasone 2 MO 5000 plus dexamethasone 2 MO triamcinolone 4MO intensol acetonide dental dexamethasone 4 MO MISCELLANEO sodium phos (pf) US OTIC injection solution PREPARATION dexamethasone 4 MO S sodium phosphate injection solution acetic acid otic 3MO (ear) dexamethasone 2 MO sodium phosphate ciprofloxacin hcl 3MO injection syringe otic (ear) fludrocortisone 2 MO flac otic oil 4 hidex 3 fluocinolone 4MO acetonide oil hydrocortisone oral 3 MO hydrocortisone­ 4MO methylprednisolone 2 MO acetic acid acetate ofloxacin otic (ear) 3MO methylprednisolone 2 B/D PA; oral tablet MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 53 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits methylprednisolone 2MO SOLU-CORTEF 3MO oral tablets,dose ACT-O-VIAL (PF) pack INJECTION methylprednisolone 4MO RECON SOLN sodium succ 1,000 MG/8 ML, injection recon soln 250 MG/2 ML, 500 125 mg MG/4 ML methylprednisolone 2MO triamcinolone 2MO sodium succ acetonide injection injection recon soln suspension 40 mg/ml 40 mg ANTITHYROID methylprednisolone 4MO AGENTS sodium succ methimazole oral 2MO intravenous tablet 10 mg, 5 mg prednisolone oral 2MO propylthiouracil 3MO solution DIABETES prednisolone sodium 2MO THERAPY phosphate oral solution 15 mg/5 ml acarbose oral tablet 2 MO; QL (3 mg/ml), 25 mg/5 100 mg (90 per 30 ml (5 mg/ml), 5 mg days) base/5 ml (6.7 mg/5 acarbose oral tablet 2 MO; QL ml) 25 mg (360 per 30 prednisolone sodium 2 days) phosphate oral acarbose oral tablet 2 MO; QL solution 15 mg/5 ml 50 mg (180 per 30 (5 ml) days) prednisone intensol 4 B/D PA; alcohol pads 2 MO BAQSIMI 3 MO prednisone oral 2MO BYDUREON 4 MO; QL (4 solution BCISE per 28 days) prednisone oral 2 B/D PA; diazoxide 4MO tablet MO GAUZE PADS 2 3 prednisone oral 2MO X 2 tablets,dose pack glimepiride oral 1 MO; QL SOLU-CORTEF 3 tablet 1 mg (240 per 30 days) glimepiride oral 1 MO; QL tablet 2 mg (120 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 54 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits glimepiride oral 1 MO; QL GVOKE PFS 1­ 3MO tablet 4 mg (60 per 30 PACK SYRINGE days) GVOKE PFS 2­ 3MO glipizide oral tablet 6 MO; QL PACK SYRINGE 10 mg (120 per 30 HUMALOG 6MO days) JUNIOR glipizide oral tablet 6 MO; QL KWIKPEN U-100 5 mg (240 per 30 HUMALOG 6MO days) KWIKPEN glipizide oral tablet 2 MO; QL INSULIN extended release (60 per 30 HUMALOG MIX 6MO 24hr 10 mg days) 50-50 INSULN U­ glipizide oral tablet 2 MO; QL 100 extended release (240 per 30 HUMALOG MIX 6MO 24hr 2.5 mg days) 50-50 KWIKPEN glipizide oral tablet 2 MO; QL HUMALOG MIX 6MO extended release (120 per 30 75-25 KWIKPEN 24hr 5 mg days) HUMALOG MIX 6MO glipizide-metformin 2 MO; QL 75-25(U­ oral tablet 2.5-250 (240 per 30 100)INSULN mg days) HUMALOG U­ 6MO glipizide-metformin 2 MO; QL 100 INSULIN oral tablet 2.5-500 (120 per 30 HUMULIN 70/30 6MO mg, 5-500 mg days) U-100 INSULIN GLUCAGEN 3MO HUMULIN 70/30 6MO HYPOKIT U-100 KWIKPEN GLUCAGON 3 HUMULIN N 6MO (HCL) NPH INSULIN EMERGENCY KWIKPEN KIT HUMULIN N 6MO glucagon emergency 3MO NPH U-100 kit (human) INSULIN GLYXAMBI 4 MO; QL HUMULIN R 6MO (30 per 30 REGULAR U-100 days) INSULN GVOKE 3MO HUMULIN R U­ 5MO HYPOPEN 1­ 500 (CONC) PACK INSULIN GVOKE 3MO HUMULIN R U­ 5MO HYPOPEN 2­ 500 (CONC) PACK KWIKPEN

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 55 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits INSULIN PEN 3MO JENTADUETO 3 MO; QL NEEDLE (60 per 30 INSULIN 3 days) SYRINGE (DISP) JENTADUETO 3 MO; QL U-100 SYRINGE XR ORAL (60 per 30 0.3 ML 29 TABLET, IR - ER, days) GAUGE, 1/2 ML BIPHASIC 24HR 28 GAUGE 2.5-1,000 MG INSULIN 3MO JENTADUETO 3 MO; QL SYRINGE (DISP) XR ORAL (30 per 30 U-100 SYRINGE 1 TABLET, IR - ER, days) ML 29 GAUGE X BIPHASIC 24HR 1/2" 5-1,000 MG INVOKAMET 3 MO; QL LANTUS 6MO (60 per 30 SOLOSTAR U-100 days) INSULIN INVOKAMET XR 3 MO; QL LANTUS U-100 6MO (60 per 30 INSULIN days) LYUMJEV 6MO INVOKANA 3 MO; QL KWIKPEN U-100 (30 per 30 INSULIN days) LYUMJEV 6MO JANUMET 3 MO; QL KWIKPEN U-200 (60 per 30 INSULIN days) LYUMJEV U-100 6MO JANUMET XR 3 MO; QL INSULIN ORAL TABLET, (30 per 30 metformin oral 4 MO; QL ER days) solution (765 per 30 MULTIPHASE 24 days) HR 100-1,000 MG metformin oral 6 MO; QL JANUMET XR 3 MO; QL tablet 1,000 mg (75 per 30 ORAL TABLET, (60 per 30 days) ER days) metformin oral 6 MO; QL MULTIPHASE 24 tablet 500 mg (150 per 30 HR 50-1,000 MG, days) 50-500 MG metformin oral 6 MO; QL JANUVIA 3 MO; QL tablet 850 mg (90 per 30 (30 per 30 days) days) metformin oral 6 MO; QL JARDIANCE 3 MO; QL tablet extended (120 per 30 (30 per 30 release 24 hr 500 mg days) days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 56 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits metformin oral 6 MO; QL pioglitazone 2 MO; QL tablet extended (60 per 30 (30 per 30 release 24 hr 750 mg days) days) metformin oral 4 MO; QL PROGLYCEM 5 MO tablet extended (60 per 30 repaglinide oral 2 MO; QL release (osm) 24 hr days) tablet 0.5 mg (960 per 30 1,000 mg days) nateglinide oral 2 MO; QL repaglinide oral 2 MO; QL tablet 120 mg (90 per 30 tablet 1 mg (480 per 30 days) days) nateglinide oral 2 MO; QL repaglinide oral 2 MO; QL tablet 60 mg (180 per 30 tablet 2 mg (240 per 30 days) days) NEEDLES, 3MO RYBELSUS 3 MO; QL INSULIN (30 per 30 DISP.,SAFETY days) OMNIPOD DASH 3 MO; QL SOLIQUA 100/33 3 MO; QL 5 PACK POD (30 per 30 (90 per 30 days) days) OMNIPOD 3 MO; QL (1 SYNJARDY 3 MO; QL INSULIN per 365 (60 per 30 MANAGEMENT days) days) OMNIPOD 3 MO; QL SYNJARDY XR 3 MO; QL INSULIN (30 per 30 ORAL TABLET, (60 per 30 REFILL days) IR - ER, days) OZEMPIC 3 MO; QL BIPHASIC 24HR SUBCUTANEOU (1.5 per 28 10-1,000 MG, 12.5­ S PEN INJECTOR days) 1,000 MG, 5-1,000 0.25 MG OR 0.5 MG MG(2 MG/1.5 ML) SYNJARDY XR 3 MO; QL OZEMPIC 3 QL (3 per ORAL TABLET, (30 per 30 SUBCUTANEOU 28 days) IR - ER, days) S PEN INJECTOR BIPHASIC 24HR 1 MG/DOSE (2 25-1,000 MG MG/1.5 ML) TOUJEO MAX U­ 6MO OZEMPIC 3MO 300 SOLOSTAR SUBCUTANEOU TOUJEO 6MO S PEN INJECTOR SOLOSTAR U-300 1 MG/DOSE (4 INSULIN MG/3 ML)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 57 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits TRADJENTA 3 MO; QL CEREZYME 5 PA; MO (30 per 30 INTRAVENOUS days) RECON SOLN TRIJARDY XR 3 MO; QL 400 UNIT ORAL TABLET, (30 per 30 CHORIONIC 3 PA; MO IR - ER, days) GONADOTROPI BIPHASIC 24HR N, HUMAN 10-5-1,000 MG, 25­ INTRAMUSCUL 5-1,000 MG AR TRIJARDY XR 3 MO; QL cinacalcet oral 4 MO; QL ORAL TABLET, (60 per 30 tablet 30 mg, 60 mg (60 per 30 IR - ER, days) days) BIPHASIC 24HR cinacalcet oral 4 MO; QL 12.5-2.5-1,000 MG, tablet 90 mg (120 per 30 5-2.5-1,000 MG days) TRULICITY 3 MO; QL (2 CRYSVITA 5 PA; MO; per 28 days) LA V-GO 20 3 MO danazol 4MO V-GO 30 3 MO desmopressin 3MO V-GO 40 3 MO injection VICTOZA 2-PAK 3 MO; QL (9 desmopressin nasal 3MO per 30 days) spray with pump VICTOZA 3-PAK 3 MO; QL (9 desmopressin nasal 3 per 30 days) spray,non-aerosol MISCELLANEO desmopressin oral 3MO US HORMONES ELAPRASE 5 PA; MO ALDURAZYME 5 PA; MO FABRAZYME 5 MO cabergoline 4MO KANUMA 5 MO calcitonin (salmon) 3MO KORLYM 5 PA; QL nasal (120 per 30 calcitriol 2 days) intravenous solution KUVAN 5 PA; MO 1 mcg/ml LUMIZYME 4 PA; MO calcitriol oral 2MO MEPSEVII 5 MO capsule 0.25 mcg MIACALCIN 4MO calcitriol oral 3MO INJECTION capsule 0.5 mcg MYALEPT 5 PA; MO; calcitriol oral 3 LA solution NAGLAZYME 5 PA; MO; LA

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 58 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits NATPARA 5 PA; MO; testosterone 4 PA; MO LA; QL (2 enanthate per 28 days) testosterone 3 PA; MO; oxandrolone oral 5 PA; MO; transdermal gel in QL (150 per tablet 10 mg QL (60 per metered-dose pump 30 days) 30 days) 20.25 mg/1.25 gram oxandrolone oral 3 PA; MO; (1.62 %) tablet 2.5 mg QL (120 per testosterone 3 PA; MO; 30 days) transdermal gel in QL (300 per PARICALCITOL 4 packet 1 % (25 30 days) HEMODIALYSIS mg/2.5gram) PORT testosterone 3 PA; MO; INJECTION transdermal gel in QL (37.5 paricalcitol 4 packet 1.62 % per 30 days) intravenous solution (20.25 mg/1.25 2 mcg/ml gram) paricalcitol 4MO testosterone 3 PA; MO; intravenous solution transdermal gel in QL (150 per 5 mcg/ml packet 1.62 % (40.5 30 days) mg/2.5 gram) paricalcitol oral 4MO tolvaptan oral tablet 5 PA; MO; SAMSCA ORAL 5 PA; MO; 30 mg QL (60 per TABLET 15 MG QL (30 per 30 days) 30 days) VIMIZIM 5 MO; LA SAMSCA ORAL 5 PA; MO; TABLET 30 MG QL (60 per zoledronic acid 3 B/D PA; 30 days) intravenous solution MO sapropterin 5 PA; MO zoledronic acid­ 3 B/D PA; mannitol-water MO SOMAVERT 5 PA; MO; intravenous QL (30 per piggyback 4 mg/100 30 days) ml STRENSIQ 4 PA; LA ZOLEDRONIC 3 B/D PA; SYNAREL 4 MO AC-MANNITOL­ MO testosterone 3 PA; MO 0.9NACL cypionate THYROID intramuscular oil HORMONES 100 mg/ml, 200 mg/ml euthyrox 3MO testosterone 3PA levo-t 3 cypionate levothyroxine oral 2 intramuscular oil tablet 200 mg/ml (1 ml)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 59 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits levoxyl oral tablet 3MO MISCELLANEO 100 mcg, 112 mcg, US 125 mcg, 137 mcg, GASTROINTES 150 mcg, 175 mcg, TINAL AGENTS 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 alosetron 5 PA; MO mcg aprepitant 3 B/D PA; liothyronine oral 2MO MO unithroid 3MO balsalazide 4MO GASTROENT budesonide oral 4MO capsule,delayed,exte EROLOGY nd.release ANTIDIARRHE budesonide oral 4 ALS / tablet,delayed and ANTISPASMOD ext.release ICS CHENODAL 5 PA; LA atropine injection 4 CHOLBAM 5PA solution 0.4 mg/ml ORAL CAPSULE 250 MG atropine injection 4 syringe 0.05 mg/ml CHOLBAM 5 PA; QL ORAL CAPSULE (120 per 30 atropine injection 2 50 MG days) syringe 0.1 mg/ml compro 4MO dicyclomine 2MO intramuscular constulose 2MO dicyclomine oral 2MO CORTIFOAM 3 MO capsule CREON 3 MO dicyclomine oral 2MO cromolyn oral 3MO solution CYSTADANE 5 dicyclomine oral 2MO dronabinol 4 B/D PA; tablet MO; QL glycopyrrolate 4MO (60 per 30 injection days) glycopyrrolate oral 2MO EMEND ORAL 4 B/D PA tablet 1 mg SUSPENSION glycopyrrolate oral 4MO FOR tablet 2 mg RECONSTITUTI ON loperamide oral 2MO capsule ENTYVIO 5 PA; MO opium tincture 3MO enulose 2MO fosaprepitant 3MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 60 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits GATTEX 30-VIAL 5 PA; MO mesalamine rectal 4MO GATTEX ONE­ 5 PA; MO enema VIAL mesalamine with 4MO gavilyte-c 2MO cleansing wipe gavilyte-n 2MO metoclopramide hcl 2MO oral solution generlac 2MO metoclopramide hcl 2MO granisetron (pf) 3MO oral tablet intravenous solution 1 mg/ml (1 ml) MOVANTIK 4 MO; QL (30 per 30 granisetron hcl 3MO days) intravenous OCALIVA 4 PA; MO; granisetron hcl oral 4 B/D PA; LA; QL (30 MO; QL per 30 days) (60 per 30 days) ondansetron 2 B/D PA; MO hydrocortisone 3MO rectal ondansetron hcl 3MO (pf) injection hydrocortisone 2MO solution topical cream with perineal applicator ondansetron hcl 3MO intravenous lactulose oral 2MO solution 10 gram/15 ondansetron hcl oral 3 B/D PA; ml solution MO; QL (450 per 30 lactulose oral 2 days) solution 10 gram/15 ml (15 ml), 20 ondansetron hcl oral 2 B/D PA gram/30 ml tablet 24 mg LINZESS 3 MO; QL ondansetron hcl oral 2 B/D PA; (30 per 30 tablet 4 mg, 8 mg MO days) palonosetron 4MO meclizine oral tablet 2MO intravenous solution 12.5 mg, 25 mg 0.25 mg/5 ml mesalamine oral 3 peg 3350­ 2MO capsule,extended electrolytes oral release 24hr recon soln 236­ 22.74-6.74 -5.86 mesalamine oral 4MO gram tablet,delayed release (dr/ec) 1.2 peg-electrolyte 2MO gram PENTASA 4 MO PLENVU 4 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 61 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits polyethylene glycol 3MO ZENPEP ORAL 3MO 3350 oral powder CAPSULE,DELA prochlorperazine 4MO YED RELEASE(DR/EC prochlorperazine 2MO ) 10,000-32,000 ­ edisylate 42,000 UNIT, prochlorperazine 2MO 15,000-47,000 ­ maleate oral 63,000 UNIT, procto-med hc 2MO 20,000-63,000- procto-pak 2MO 84,000 UNIT, 25,000-79,000- proctosol hc topical 2MO 105,000 UNIT, proctozone-hc 2MO 3,000-10,000 ­ RECTIV 4 MO 14,000-UNIT, RELISTOR 5 PA; MO 40,000-126,000- SUBCUTANEOU 168,000 UNIT, S SOLUTION 5,000-17,000- 24,000 UNIT RELISTOR 5 PA; MO SUBCUTANEOU ULCER S SYRINGE THERAPY REMICADE 5 PA; MO cimetidine 2 MO scopolamine base 3 MO; QL cimetidine hcl oral 2 MO (10 per 30 DEXILANT 4 MO; QL days) (30 per 30 sulfasalazine 2MO days) SUPREP BOWEL 4MO esomeprazole 3 MO; QL PREP KIT magnesium oral (30 per 30 SUTAB 4 MO capsule,delayed days) release(dr/ec) 20 trilyte with flavor 2MO mg packets esomeprazole 3MO ursodiol 3MO magnesium oral VIOKACE 4 MO capsule,delayed release(dr/ec) 40 mg esomeprazole 4MO sodium intravenous recon soln 40 mg famotidine oral 3MO suspension famotidine oral 4MO tablet 20 mg, 40 mg

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 62 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits misoprostol 3MO ARANESP (IN 4 PA; MO omeprazole oral 4 MO; QL POLYSORBATE) capsule,delayed (30 per 30 INJECTION release(dr/ec) 10 days) SYRINGE mg, 20 mg ARCALYST 5 PA; MO omeprazole oral 4 MO; QL BETASERON 5 PA; MO; capsule,delayed (60 per 30 SUBCUTANEOU QL (14 per release(dr/ec) 40 days) S KIT 28 days) mg GENOTROPIN 5 PA; MO pantoprazole oral 2 MO; QL GENOTROPIN 5 PA; MO tablet,delayed (30 per 30 MINIQUICK release (dr/ec) 20 days) ILARIS (PF) 5 PA; MO; mg LA pantoprazole oral 2 MO; QL INTRON A 5 B/D PA; tablet,delayed (60 per 30 INJECTION MO release (dr/ec) 40 days) mg MOZOBIL 5 B/D PA; MO sucralfate oral 2MO tablet NIVESTYM 5 PA; MO IMMUNOLO PROCRIT 4 PA; MO GY, ZARXIO 5 PA; MO VACCINES / ZIEXTENZO 4 PA; MO BIOTECHNO VACCINES / LOGY MISCELLANEO US BIOTECHNOLO IMMUNOLOGI GY DRUGS CALS ACTIMMUNE 5 B/D PA; ACTHIB (PF) 3 MO MO ADACEL(TDAP 3MO ARANESP (IN 4 PA; MO ADOLESN/ADUL POLYSORBATE) T)(PF) INJECTION ATGAM 4 B/D PA SOLUTION 100 BCG VACCINE, 3 MO MCG/ML, 200 LIVE (PF) MCG/ML, 25 MCG/ML, 300 BEXSERO 3 MO MCG/ML, 40 BOOSTRIX TDAP 3 MO MCG/ML, 60 BOTOX 4 PA; MO MCG/ML DAPTACEL 3MO (DTAP PEDIATRIC) (PF)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 63 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ENGERIX-B (PF) 3 B/D PA; KINRIX (PF) 3 MO INTRAMUSCUL ENGERIX-B 3 B/D PA; AR SUSPENSION PEDIATRIC (PF) MO KINRIX (PF) 3MO GAMASTAN 3 MO INTRAMUSCUL AR SYRINGE GAMASTAN S/D 3 MENACTRA (PF) 3MO GARDASIL 9 (PF) 4 MO INTRAMUSCUL HAVRIX (PF) 3MO AR SOLUTION INTRAMUSCUL MENQUADFI 3MO AR SUSPENSION (PF) 1,440 ELISA UNIT/ML MENVEO A-C-Y­ 3MO W-135-DIP (PF) HAVRIX (PF) 3MO INTRAMUSCUL M-M-R II (PF) 3 MO AR SYRINGE PEDIARIX (PF) 3 MO HIBERIX (PF) 3 MO PEDVAX HIB 3 HIZENTRA 5 B/D PA; (PF) MO PENTACEL (PF) 3 HYPERHEP B 3 PRIVIGEN 5 PA; MO INTRAMUSCUL PROQUAD (PF) 3 AR SOLUTION QUADRACEL 3 220 UNIT/ML (PF) HYPERHEP B 3MO RABAVERT (PF) 3 MO INTRAMUSCUL AR SOLUTION RECOMBIVAX 3 B/D PA; 220 UNIT/ML (5 HB (PF) MO ML) INTRAMUSCUL AR SUSPENSION HYPERHEP B 3 INTRAMUSCUL RECOMBIVAX 3 B/D PA; AR SYRINGE HB (PF) MO INTRAMUSCUL HYPERHEP B 3 AR SYRINGE 10 NEONATAL MCG/ML IMOVAX RABIES 4 RECOMBIVAX 3 B/D PA VACCINE (PF) HB (PF) INFANRIX 3MO INTRAMUSCUL (DTAP) (PF) AR SYRINGE 5 INTRAMUSCUL MCG/0.5 ML AR SYRINGE ROTARIX 3 IPOL 3 ROTATEQ 3MO IXIARO (PF) 4 VACCINE

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 64 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits SHINGRIX (PF) 4 MO; QL (2 probenecid 3MO per 999 probenecid­ 3MO days) colchicine STAMARIL (PF) 3 OSTEOPOROSI TDVAX 3 MO S THERAPY TENIVAC (PF) 3 MO alendronate oral 1 MO; QL TETANUS,DIPH 3MO tablet 10 mg, 5 mg (30 per 30 THERIA TOX days) PED(PF) alendronate oral 1 MO; QL (4 TICE BCG 3 B/D PA; tablet 35 mg, 70 mg per 28 days) MO ibandronate oral 3 MO; QL (1 TRUMENBA 3 MO per 30 days) TWINRIX (PF) 3 MO PROLIA 4 MO; QL (1 TYPHIM VI 3 per 180 INTRAMUSCUL days) AR SOLUTION raloxifene 3 MO; QL TYPHIM VI 3MO (30 per 30 INTRAMUSCUL days) AR SYRINGE TERIPARATIDE 5 PA; MO; VAQTA (PF) 3 MO QL (2.48 VARIVAX (PF) 3 per 28 days) VARIZIG 5 MO TYMLOS 5 PA; MO; QL (1.56 YF-VAX (PF) 3 per 30 days) ZOSTAVAX (PF) 4 OTHER MUSCULOSK RHEUMATOLO ELETAL / GICALS RHEUMATO BENLYSTA 5 PA; MO LOGY DEPEN 5MO GOUT TITRATABS THERAPY ENBREL MINI 5 PA; MO; QL (8 per allopurinol 1MO 28 days) colchicine oral 4 MO; QL ENBREL 5 PA; MO; tablet (120 per 30 SUBCUTANEOU QL (16 per days) S RECON SOLN 28 days) febuxostat 3 ST; MO ENBREL 5 PA; MO; KRYSTEXXA 5 MO SUBCUTANEOU QL (8 per MITIGARE 3 MO S SOLUTION 28 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 65 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits ENBREL 5 PA; MO; HUMIRA(CF) 5 PA; MO; SUBCUTANEOU QL (8 per PEN QL (4 per S SYRINGE 28 days) SUBCUTANEOU 28 days) ENBREL 5 PA; MO; S PEN INJECTOR SURECLICK QL (8 per KIT 40 MG/0.4 28 days) ML HUMIRA PEN 5 PA; MO; HUMIRA(CF) 5 PA; MO; QL (4 per PEN QL (2 per 28 days) SUBCUTANEOU 28 days) S PEN INJECTOR HUMIRA PEN 5 PA; MO; KIT 80 MG/0.8 CROHNS-UC-HS QL (6 per ML START 180 days) HUMIRA(CF) 5 PA; MO; HUMIRA PEN 5 PA; MO; SUBCUTANEOU QL (2 per PSOR-UVEITS­ QL (4 per S SYRINGE KIT 28 days) ADOL HS 180 days) 10 MG/0.1 ML, 20 HUMIRA 5 PA; MO; MG/0.2 ML SUBCUTANEOU QL (4 per HUMIRA(CF) 5 PA; MO; S SYRINGE KIT 28 days) SUBCUTANEOU QL (4 per 40 MG/0.8 ML S SYRINGE KIT 28 days) HUMIRA(CF) 5 PA; MO; 40 MG/0.4 ML PEDI CROHNS QL (3 per leflunomide 3 MO; QL STARTER 180 days) (30 per 30 SUBCUTANEOU days) S SYRINGE KIT 80 MG/0.8 ML ORENCIA (WITH 5 PA; MO MALTOSE) HUMIRA(CF) 5 PA; MO; PEDI CROHNS QL (2 per ORENCIA 5 PA; MO; STARTER 180 days) CLICKJECT QL (4 per SUBCUTANEOU 28 days) S SYRINGE KIT ORENCIA 5 PA; MO; 80 MG/0.8 ML-40 SUBCUTANEOU QL (4 per MG/0.4 ML S SYRINGE 125 28 days) HUMIRA(CF) 5 PA; MO; MG/ML PEN CROHNS­ QL (3 per ORENCIA 5 PA; MO; UC-HS 180 days) SUBCUTANEOU QL (1.6 per HUMIRA(CF) 5 PA; MO; S SYRINGE 50 28 days) PEN PEDIATRIC QL (4 per MG/0.4 ML UC 28 days) ORENCIA 5 PA; MO; HUMIRA(CF) 5 PA; MO; SUBCUTANEOU QL (2.8 per PEN PSOR-UV­ QL (3 per S SYRINGE 87.5 28 days) ADOL HS 180 days) MG/0.7 ML penicillamine 5MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 66 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits RINVOQ 5 PA; MO; hydroxyprogesteron 5 QL (30 per e caproate 30 days) incassia 3MO XELJANZ ORAL 5 PA; MO; jencycla 3MO SOLUTION QL (300 per lyleq 3MO 30 days) lyza 3 XELJANZ ORAL 5 PA; MO; TABLET QL (60 per medroxyprogesteron 3MO 30 days) e intramuscular XELJANZ XR 5 PA; MO; medroxyprogesteron 2MO QL (30 per e oral 30 days) nora-be 2MO OBSTETRICS norethindrone 2 / (contraceptive) GYNECOLOG norethindrone 4MO acetate Y norlyda 3MO ESTROGENS / PREMARIN 3MO PROGESTINS ORAL camila 2MO PREMARIN 4MO deblitane 3MO VAGINAL dotti 3 MO; QL (8 PREMPRO 3 MO per 28 days) sharobel 3MO errin 2 MO tulana 3MO estradiol oral 3 MO yuvafem 3MO estradiol 3 MO; QL (8 MISCELLANEO transdermal patch per 28 days) US OB/GYN semiweekly clindamycin 4MO estradiol 3 QL (4 per phosphate vaginal transdermal patch 28 days) metronidazole 2MO weekly vaginal estradiol vaginal 2 MO miconazole-3 4MO cream vaginal suppository estradiol vaginal 3 MO MIRENA 3 LA tablet NEXPLANON 3 estradiol valerate 2 MO intramuscular oil 20 terconazole vaginal 3MO mg/ml, 40 mg/ml cream heather 3 MO terconazole vaginal 4MO suppository

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 67 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits tranexamic acid 3MO cyclafem 7/7/7 (28) 4MO oral desog­ 4 vandazole 3MO e.estradiol/e.estradi xulane 2MO ol ORAL desogestrel-ethinyl 4 CONTRACEPTI estradiol VES / RELATED dolishale 4 AGENTS drospirenone­ 4 e.estradiol-lm.fa afirmelle 4MO oral tablet 3-0.03­ alyacen 1/35 (28) 4MO 0.451 mg (21) (7) amethia 4MO drospirenone-ethinyl 4MO apri 4MO estradiol oral tablet aranelle (28) 4MO 3-0.02 mg ashlyna 4MO drospirenone-ethinyl 4 estradiol oral tablet aubra 4 3-0.03 mg aubra eq 4MO emoquette 4MO aurovela 1.5/30 4MO enpresse 4MO (21) estarylla 4MO aurovela 1/20 (21) 4MO ethynodiol diac-eth 4 aurovela 24 fe 4MO estradiol aurovela fe 1.5/30 4MO falmina (28) 4MO (28) fayosim 4MO aurovela fe 1-20 4MO (28) femynor 4MO aviane 4MO hailey 4MO ayuna 4 hailey 24 fe 4MO balziva (28) 4MO iclevia 4 blisovi 24 fe 4MO introvale 4MO blisovi fe 1.5/30 4MO isibloom 4MO (28) jasmiel (28) 4MO blisovi fe 1/20 (28) 4MO juleber 4MO briellyn 4MO junel 1.5/30 (21) 4MO camrese lo 4MO junel 1/20 (21) 4MO caziant (28) 4MO junel fe 1.5/30 (28) 4MO chateal eq (28) 4MO junel fe 1/20 (28) 4MO cryselle (28) 4MO junel fe 24 4MO cyclafem 1/35 (28) 4MO kaitlib fe 4MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 68 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits kalliga 4 lillow (28) 4MO kariva (28) 4MO loryna (28) 4MO kelnor 1/35 (28) 4MO low-ogestrel (28) 4MO kelnor 1-50 (28) 4MO lo-zumandimine 4MO l norgest/e.estradiol­ 4MO (28) e.estrad oral lutera (28) 4MO tablets,dose pack,3 marlissa (28) 4MO month 0.15 mg-20 mibelas 24 fe 4MO mcg/ 0.15 mg-25 mcg microgestin 1.5/30 4MO (21) l norgest/e.estradiol­ 4 e.estrad oral microgestin 1/20 4MO tablets,dose pack,3 (21) month 0.15 mg-30 microgestin fe 4MO mcg (84)/10 mcg 1.5/30 (28) (7) microgestin fe 1/20 4MO larin 1.5/30 (21) 4MO (28) larin 1/20 (21) 4MO mili 4MO larin fe 1.5/30 (28) 4MO necon 0.5/35 (28) 4MO larin fe 1/20 (28) 4MO nikki (28) 4MO larissia 4MO noreth-ethinyl 4 layolis fe 4MO estradiol-iron leena 28 4MO norethindrone ac­ 4MO eth estradiol oral lessina 4MO tablet 1-20 mg-mcg levonest (28) 4MO norethindrone­ 4 levonorgestrel­ 4MO e.estradiol-iron oral ethinyl estrad oral tablet,chewable tablet 0.1-20 mg­ norgestimate-ethinyl 4 mcg estradiol oral tablet levonorgestrel­ 4 0.18/0.215/0.25 mg­ ethinyl estrad oral 25 mcg, 0.25-35 mg­ tablet 90-20 mcg mcg (28) norgestimate-ethinyl 4MO levonorgestrel­ 4MO estradiol oral tablet ethinyl estrad oral 0.18/0.215/0.25 mg­ tablets,dose pack,3 35 mcg (28) month nortrel 0.5/35 (28) 4MO levonorg-eth estrad 4MO nortrel 1/35 (21) 4MO triphasic nortrel 1/35 (28) 4MO levora-28 4MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 69 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits nortrel 7/7/7 (28) 4MO velivet triphasic 4MO nylia 7/7/7 (28) 4 regimen (28) nymyo 4MO vestura (28) 4 ocella 4MO vienva 4MO orsythia 4MO vyfemla (28) 4MO pimtrea (28) 4MO vylibra 4MO pirmella oral tablet 4MO wymzya fe 4MO 1-35 mg-mcg zarah 4MO portia 28 4MO zovia 1/35e (28) 4MO previfem 4MO zovia 1-35 (28) 4 reclipsen (28) 4MO zumandimine (28) 4MO rivelsa 4MO OXYTOCICS setlakin 4MO methylergonovine 5 PA simliya (28) 4MO oral simpesse 4MO OPHTHALM sprintec (28) 4MO OLOGY sronyx 4MO ANTIBIOTICS syeda 4MO ak-poly-bac 2MO tarina 24 fe 4MO bacitracin 4MO tarina fe 1/20 (28) 4 ophthalmic (eye) tarina fe 1-20 eq 4MO bacitracin­ 2MO (28) polymyxin b tilia fe 4MO ophthalmic (eye) tri-estarylla 4MO BESIVANCE 4 MO tri-legest fe 4MO ciprofloxacin hcl 2 MO tri-lo-estarylla 4MO ophthalmic (eye) tri-lo-mili 4MO erythromycin 2 MO tri-lo-sprintec 4MO ophthalmic (eye) tri-mili 4MO gentak ophthalmic 2 MO (eye) ointment tri-nymyo 4 gentamicin 2 MO tri-previfem (28) 4MO ophthalmic (eye) tri-sprintec (28) 4MO drops trivora (28) 4MO levofloxacin 4 MO tri-vylibra 4MO ophthalmic (eye) tri-vylibra lo 4MO tydemy 4MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 70 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits moxifloxacin 3MO MISCELLANEO ophthalmic (eye) US drops OPHTHALMOL moxifloxacin 3 OGICS ophthalmic (eye) atropine ophthalmic 4 MO drops, viscous (eye) drops NATACYN 4 azelastine 4 MO neomycin­ 4MO ophthalmic (eye) bacitracin­ cromolyn 2 MO polymyxin ophthalmic (eye) neomycin­ 3MO CYSTARAN 5 PA polymyxin­ gramicidin epinastine 4 MO neo-polycin 4MO EYLEA 5 PA; MO ofloxacin 2MO LUCENTIS 5 PA; MO ophthalmic (eye) OXERVATE 4 PA; MO; polycin 2MO QL (112 per 999 days) polymyxin b sulf­ 2MO trimethoprim pilocarpine hcl 3 MO ophthalmic (eye) tobramycin 2MO drops 1 %, 2 %, 4 % ophthalmic (eye) RESTASIS 3 MO; QL ANTIVIRALS (60 per 30 trifluridine 3MO days) ZIRGAN 4 MO RESTASIS 3 MO; QL BETA­ MULTIDOSE (5.5 per 30 BLOCKERS days) sulfacetamide 2 MO carteolol 2MO sodium ophthalmic levobunolol 6MO (eye) drops ophthalmic (eye) sulfacetamide 4 MO drops 0.5 % sodium ophthalmic timolol maleate 1MO (eye) ointment ophthalmic (eye) sulfacetamide­ 2 MO drops prednisolone timolol maleate 3MO ZERVIATE 4 MO ophthalmic (eye) gel forming solution

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 71 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits NON­ STEROID­ STEROIDAL ANTIBIOTIC ANTI­ COMBINATION INFLAMMATO S RY AGENTS neomycin­ 4MO diclofenac sodium 2MO bacitracin-poly-hc ophthalmic (eye) neomycin­ 2MO flurbiprofen sodium 2MO polymyxin b­ ketorolac 2MO dexameth ophthalmic (eye) neomycin­ 4MO PROLENSA 4 MO polymyxin-hc ophthalmic (eye) ORAL DRUGS neo-polycin hc 4MO FOR GLAUCOMA tobramycin­ 3MO dexamethasone acetazolamide 3MO STEROIDS acetazolamide 3MO sodium dexamethasone 2MO sodium phosphate methazolamide 4MO ophthalmic (eye) OTHER DUREZOL 3 MO GLAUCOMA fluorometholone 3 MO DRUGS INVELTYS 4 MO AZOPT 4 MO LOTEMAX 4MO brinzolamide 4MO OPHTHALMIC COMBIGAN 3 MO (EYE) dorzolamide 2MO DROPS,GEL dorzolamide-timolol 2MO LOTEMAX 4MO OPHTHALMIC dorzolamide-timolol 3MO (EYE) (pf) ophthalmic OINTMENT (eye) dropperette LOTEMAX SM 4 MO latanoprost 6MO loteprednol 4MO LUMIGAN 3MO etabonate OPHTHALMIC ophthalmic (eye) (EYE) DROPS drops,suspension 0.01 % OZURDEX 5 MO RHOPRESSA 4 ST; MO prednisolone acetate 3MO ROCKLATAN 4 ST; MO SIMBRINZA 4 MO travoprost 3MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 72 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits prednisolone sodium 4MO diphenhydramine 2 phosphate hcl oral elixir ophthalmic (eye) EPINEPHRINE 3 MO; QL (2 SYMPATHOMI INJECTION per 30 days) METICS AUTO­ INJECTOR 0.15 ALPHAGAN P 3MO MG/0.15 ML OPHTHALMIC (EYE) DROPS 0.1 epinephrine injection 3 MO; QL (2 % auto-injector 0.15 per 30 days) mg/0.3 ml, 0.3 apraclonidine 4MO mg/0.3 ml brimonidine 4 EPINEPHRINE 3 QL (2 per ophthalmic (eye) INJECTION 30 days) drops 0.15 % AUTO­ brimonidine 2MO INJECTOR 0.3 ophthalmic (eye) MG/0.3 ML drops 0.2 % epinephrine injection 2 RESPIRATOR solution 1 mg/ml Y AND hydroxyzine hcl oral 2 PA; MO ALLERGY tablet levocetirizine oral 4MO ANTIHISTAMI solution NE / levocetirizine oral 2 MO; QL ANTIALLERGE tablet (30 per 30 NIC AGENTS days) adrenalin injection 2 PULMONARY solution 1 mg/ml AGENTS adrenalin injection 2 MO acetylcysteine 2 B/D PA; solution 1 mg/ml (1 MO ml) ADEMPAS 5 PA; MO; cetirizine oral 2 MO LA; QL (90 solution 1 mg/ml per 30 days) dexchlorpheniramin 3 ADVAIR DISKUS 3 MO; QL e maleate oral (60 per 30 solution days) diphenhydramine 2 MO ADVAIR HFA 3 MO; QL hcl injection solution (12 per 30 50 mg/ml days) diphenhydramine 2 MO hcl injection syringe

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 73 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits albuterol sulfate 3 QL (17 per budesonide 4 B/D PA; inhalation hfa 30 days) inhalation MO; QL aerosol inhaler 90 suspension for (60 per 30 mcg/actuation nebulization 1 mg/2 days) albuterol sulfate 3 QL (13.4 ml inhalation hfa per 30 days) COMBIVENT 4 MO; QL (8 aerosol inhaler 90 RESPIMAT per 30 days) mcg/actuation cromolyn inhalation 2 B/D PA; (nda020503) MO albuterol sulfate 2 B/D PA; DALIRESP 4 PA; MO; inhalation solution MO QL (30 per for nebulization 30 days) albuterol sulfate 2MO ESBRIET ORAL 5 PA; MO; oral syrup CAPSULE QL (270 per albuterol sulfate 4MO 30 days) oral tablet ESBRIET ORAL 5 PA; MO; alyq 5 PA; QL (60 TABLET 267 MG QL (270 per per 30 days) 30 days) ambrisentan 5 PA; MO; ESBRIET ORAL 5 PA; MO; LA; QL (30 TABLET 801 MG QL (90 per per 30 days) 30 days) ANORO 3 MO; QL FLOVENT 3 MO; QL ELLIPTA (60 per 30 DISKUS (60 per 30 days) INHALATION days) ARNUITY 3 MO; QL BLISTER WITH ELLIPTA (30 per 30 DEVICE 100 days) MCG/ACTUATIO N, 50 ATROVENT HFA 4 MO; QL MCG/ACTUATIO (25.8 per 30 N days) FLOVENT 3 MO; QL BREO ELLIPTA 3 MO; QL DISKUS (240 per 30 (60 per 30 INHALATION days) days) BLISTER WITH budesonide 4 B/D PA; DEVICE 250 inhalation MO; QL MCG/ACTUATIO suspension for (120 per 30 N nebulization 0.25 days) FLOVENT HFA 3 MO; QL mg/2 ml, 0.5 mg/2 AEROSOL (12 per 30 ml INHALER 110 days) MCG/ACTUATIO N

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 74 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits FLOVENT HFA 3 MO; QL montelukast oral 2 MO; QL AEROSOL (24 per 30 tablet,chewable (30 per 30 INHALER 220 days) days) MCG/ACTUATIO OFEV 5 PA; MO; N QL (60 per FLOVENT HFA 3 MO; QL 30 days) AEROSOL (10.6 per 30 ORKAMBI ORAL 5 PA; MO; INHALER 44 days) GRANULES IN QL (56 per MCG/ACTUATIO PACKET 28 days) N ORKAMBI ORAL 5 PA; MO; flunisolide 3 MO; QL TABLET QL (112 per (50 per 30 28 days) days) PERFOROMIST 4 B/D PA; fluticasone 4 MO; QL MO; QL propionate nasal (16 per 30 (120 per 30 days) days) HAEGARDA 5 PA; MO; PULMOZYME 5 B/D PA; LA MO; QL icatibant 5 PA; MO; (150 per 30 QL (18 per days) 30 days) SEREVENT 3 MO; QL INCRUSE 3 MO; QL DISKUS (60 per 30 ELLIPTA (30 per 30 days) days) sildenafil 3 PA; MO; ipratropium 2 B/D PA; (pulmonary arterial QL (90 per bromide inhalation MO hypertension) oral 30 days) ipratropium­ 2 B/D PA; tablet albuterol MO SYMDEKO 5 PA; MO; KALYDECO 5 PA; MO; QL (56 per ORAL QL (56 per 28 days) GRANULES IN 28 days) tadalafil (pulm. 5 PA; QL (60 PACKET hypertension) per 30 days) KALYDECO 5 PA; MO; terbutaline oral 4MO ORAL TABLET QL (60 per terbutaline 5MO 30 days) subcutaneous montelukast oral 3 MO; QL theophylline oral 2MO granules in packet (30 per 30 tablet extended days) release 12 hr 300 montelukast oral 2 MO; QL mg, 450 mg tablet (30 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 75 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits theophylline oral 2 MO UROLOGICA tablet extended LS release 24 hr TRELEGY 3 MO; QL ANTICHOLINE ELLIPTA (60 per 30 RGICS / days) ANTISPASMOD TRIKAFTA 5 PA; MO ICS TYVASO 5 B/D PA; MYRBETRIQ 4MO MO ORAL TABLET TYVASO 5 B/D PA EXTENDED INSTITUTIONAL RELEASE 24 HR START KIT oxybutynin chloride 2MO TYVASO REFILL 5 B/D PA; oral syrup KIT MO oxybutynin chloride 2MO TYVASO 5 B/D PA; oral tablet STARTER KIT MO oxybutynin chloride 3 MO; QL VENTOLIN HFA 3 MO; QL oral tablet extended (60 per 30 (36 per 30 release 24hr days) days) tolterodine 4 MO XOLAIR 5 PA; MO; TOVIAZ 4 MO; QL SUBCUTANEOU LA; QL (6 (30 per 30 S RECON SOLN per 28 days) days) XOLAIR 5 PA; MO; BENIGN SUBCUTANEOU LA; QL (8 PROSTATIC S SYRINGE 150 per 28 days) HYPERPLASIA( MG/ML BPH) THERAPY XOLAIR 5 PA; MO; alfuzosin 2MO SUBCUTANEOU LA; QL (1 S SYRINGE 75 per 28 days) finasteride oral 2 MO; QL MG/0.5 ML tablet 5 mg (30 per 30 days) zafirlukast 4 MO; QL (60 per 30 tamsulosin 2 MO; QL days) (60 per 30 days) MISCELLANEO US UROLOGICALS bethanechol chloride 4MO oral tablet 10 mg, 25 mg, 50 mg

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 76 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits bethanechol chloride 3MO klor-con 10 3MO oral tablet 5 mg klor-con 8 3MO CYSTAGON 4 LA klor-con m10 2MO ELMIRON 4 MO klor-con m15 2MO K-PHOS NO 2 3 MO klor-con m20 2MO K-PHOS 3MO klor-con/ef 3MO ORIGINAL lactated ringers 4MO potassium citrate 4MO intravenous RENACIDIN 3 MO MAGNESIUM 3 VITAMINS, SULFATE IN HEMATINICS D5W INTRAVENOUS / PIGGYBACK 1 ELECTROLY GRAM/100 ML TES magnesium sulfate 3 in water BLOOD DERIVATIVES magnesium sulfate 4MO injection solution albumin, human 25 3 magnesium sulfate 4 % injection syringe albuminar 25 % 3 PHOSLYRA 4 MO alburx (human) 25 3 potassium acetate 3 % potassium chlorid­ 4 alburx (human) 5 3 d5-0.45%nacl % potassium chloride 4 albutein 25 % 3 in 0.9%nacl albutein 5 % 3 intravenous plasbumin 25 % 3 parenteral solution plasbumin 5 % 3 20 meq/l, 40 meq/l ELECTROLYTE potassium chloride 4 S in 5 % dex intravenous calcium 3MO parenteral solution acetate(phosphat 20 meq/l, 30 meq/l, bind) 40 meq/l calcium gluconate 3 potassium chloride 4 intravenous in lr-d5 intravenous effer-k oral tablet, 3MO parenteral solution effervescent 25 meq 20 meq/l klor-con 2MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 77 Drug Name Drug Requiremen Drug Name Drug Requiremen Tier ts/Limits Tier ts/Limits potassium chloride 4 ringer's intravenous 4 in water intravenous sodium acetate 3 piggyback sodium bicarbonate 3 potassium chloride 4 intravenous solution intravenous 1 meq/ml (8.4 %) potassium chloride 2MO sodium bicarbonate 3 oral capsule, intravenous syringe extended release 10 meq/10 ml (8.4 potassium chloride 4MO %), 7.5 % (0.9 oral liquid meq/ml), 8.4 % (1 potassium chloride 2 meq/ml) oral packet sodium chloride 0.45 4MO potassium chloride 2MO % intravenous oral tablet extended parenteral solution release 10 meq, 8 sodium chloride 3 % 4 meq sodium chloride 5 % 4MO potassium chloride 2 sodium chloride 4 oral tablet extended intravenous release 20 meq parenteral solution potassium chloride 2MO 2.5 meq/ml oral tablet,er sodium chloride 2 particles/crystals 10 intravenous meq parenteral solution 4 potassium chloride 2 meq/ml oral tablet,er sodium phosphate 3MO particles/crystals 20 meq MISCELLANEO US NUTRITION potassium chloride­ 4 PRODUCTS 0.45 % nacl potassium chloride- 4 AMINOSYN II 15 3 B/D PA d5-0.2%nacl % intravenous AMINOSYN-PF 7 3 B/D PA parenteral solution % (SULFITE­ 20 meq/l, 30 meq/l, FREE) 40 meq/l electrolyte-48 in 3 potassium chloride- 4 d5w d5-0.9%nacl freamine iii 10 % 3 B/D PA potassium 3 HEPATAMINE 3 B/D PA phosphate m-/d­ 8% basic intravenous solution 3 mmol/ml

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 78 Drug Name Drug Requiremen Tier ts/Limits intralipid 4 B/D PA intravenous emulsion 20 % INTRALIPID 3 B/D PA INTRAVENOUS EMULSION 30 % NORMOSOL-R 3 PH 7.4 plenamine 4 B/D PA premasol 10 % 2 B/D PA travasol 10 % 4 B/D PA TROPHAMINE 3 B/D PA 10 % VITAMINS / HEMATINICS fluoride (sodium) 2 oral tablet fluoride (sodium) 2MO oral tablet,chewable 1 mg (2.2 mg sod. fluoride) prenatal vitamin 1 oral tablet

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 79 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 80 Index abacavir...... 1 alcohol pads...... 54 ARANESP (IN abacavir-lamivudine...... 1 ALDURAZYME...... 58 POLYSORBATE)...... 63 abacavir-lamivudine­ ALECENSA...... 13 ARCALYST...... 63 zidovudine...... 1 alendronate ...... 65 ARIKAYCE...... 7 ABELCET...... 1 alfuzosin...... 76 aripiprazole...... 33 ABILIFY MAINTENA...... 33 ALIMTA...... 13 ARISTADA...... 33, 34 abiraterone...... 13 ALIQOPA...... 13 ARISTADA INITIO...... 33 ABRAXANE...... 13 allopurinol...... 65 ARNUITY ELLIPTA...... 74 acamprosate...... 51 alosetron...... 60 ARRANON...... 13 acarbose...... 54 ALPHAGAN P...... 73 arsenic trioxide...... 13 acebutolol...... 40 ALUNBRIG...... 13 ARZERRA...... 14 acetaminophen-codeine...... 30 alyacen 1/35 (28)...... 68 asenapine maleate...... 34 acetazolamide...... 72 alyq...... 74 ashlyna...... 68 acetazolamide sodium...... 72 amantadine hcl...... 2 atazanavir...... 2 acetic acid...... 53 AMBISOME...... 1 atenolol...... 40 acetylcysteine...... 51, 73 ambrisentan...... 74 ATGAM...... 63 acitretin...... 47 amethia...... 68 atomoxetine...... 34 ACTHIB (PF)...... 63 amikacin...... 7 atorvastatin...... 44 ACTIMMUNE...... 63 amiloride...... 40 atovaquone...... 7 acyclovir...... 1, 50 amiloride-hydrochlorothiazide 40 atovaquone-proguanil...... 8 acyclovir sodium...... 1 aminocaproic acid...... 43 ATRIPLA...... 2 ADACEL(TDAP AMINOSYN II 15 %...... 78 atropine...... 60, 71 ADOLESN/ADULT)(PF).... 63 AMINOSYN-PF 7 % ATROVENT HFA...... 74 ADASUVE...... 33 (SULFITE-FREE)...... 78 aubra...... 68 ADCETRIS...... 13 amiodarone...... 39, 40 aubra eq...... 68 ADEMPAS...... 73 amitriptyline...... 33 aurovela 1.5/30 (21)...... 68 adenosine...... 39 amlodipine...... 40 aurovela 1/20 (21)...... 68 adrenalin...... 73 amlodipine-benazepril...... 40 aurovela 24 fe...... 68 adriamycin...... 13 amlodipine-valsartan...... 40 aurovela fe 1.5/30 (28)...... 68 adrucil...... 13 ammonium lactate...... 47 aurovela fe 1-20 (28)...... 68 ADVAIR DISKUS...... 73 amoxapine...... 33 AURYXIA...... 51 ADVAIR HFA...... 73 amoxicillin...... 10 AUSTEDO...... 28 AFINITOR...... 13 amoxicillin-pot clavulanate..... 10 aviane...... 68 AFINITOR DISPERZ...... 13 amphotericin b...... 1 ayuna...... 68 afirmelle...... 68 ampicillin...... 10 AYVAKIT...... 14 AIMOVIG ampicillin sodium...... 10 azacitidine...... 14 AUTOINJECTOR...... 28 ampicillin-sulbactam...... 11 azathioprine...... 14 ak-poly-bac...... 70 anagrelide...... 51 azathioprine sodium...... 14 albendazole...... 7 anastrozole...... 13 azelastine...... 52, 53, 71 albumin, human 25 %...... 77 ANORO ELLIPTA...... 74 azithromycin...... 7 albuminar 25 %...... 77 APOKYN...... 27 AZOPT...... 72 alburx (human) 25 %...... 77 apraclonidine...... 73 aztreonam...... 8 alburx (human) 5 %...... 77 aprepitant...... 60 bacitracin...... 70 albutein 25 %...... 77 apri...... 68 bacitracin-polymyxin b...... 70 albutein 5 %...... 77 APTIOM...... 24 baclofen...... 30 albuterol sulfate...... 74 APTIVUS...... 2 balsalazide...... 60 alclometasone...... 50 aranelle (28)...... 68 BALVERSA...... 14 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 81 balziva (28)...... 68 bromocriptine...... 27 CEFEPIME...... 6 BANZEL...... 24 BRUKINSA...... 14 CEFEPIME IN BAQSIMI...... 54 budesonide...... 60, 74 DEXTROSE 5 %...... 6 BARACLUDE...... 2 bumetanide...... 40 cefepime in dextrose,iso-osm.... 6 BAVENCIO...... 14 buprenorphine hcl...... 30 cefixime...... 6 BCG VACCINE, LIVE (PF). 63 buprenorphine-naloxone...... 32 cefoxitin...... 6 BELEODAQ...... 14 bupropion hcl...... 34 cefoxitin in dextrose, iso-osm....6 benazepril...... 40 bupropion hcl (smoking cefpodoxime...... 6 benazepril­ deter)...... 52 ceftazidime...... 6 hydrochlorothiazide...... 40 buspirone...... 34 CEFTAZIDIME IN D5W...... 6 BENDEKA...... 14 busulfan...... 14 ceftriaxone...... 6 BENLYSTA...... 65 butorphanol...... 32 CEFTRIAXONE...... 6 BENZNIDAZOLE...... 8 BYDUREON BCISE...... 54 ceftriaxone in dextrose,iso-os... 6 benztropine...... 27 BYSTOLIC...... 40 cefuroxime axetil...... 6 beser...... 50 CABENUVA...... 2 cefuroxime sodium...... 6 BESIVANCE...... 70 cabergoline...... 58 celecoxib...... 32 BESPONSA...... 14 CABOMETYX...... 14 CELONTIN...... 24 betamethasone dipropionate....50 caffeine citrate...... 51 cephalexin...... 6, 7 betamethasone valerate...... 50 calcipotriene...... 47 CEPROTIN (BLUE BAR).... 43 betamethasone, augmented..... 50 calcitonin (salmon)...... 58 CEPROTIN (GREEN BAR) 43 BETASERON...... 63 calcitriol...... 58 CEREZYME...... 58 bethanechol chloride...... 76, 77 calcium acetate(phosphat cetirizine...... 73 bexarotene...... 14 bind)...... 77 CHANTIX...... 52 BEXSERO...... 63 calcium gluconate...... 77 CHANTIX CONTINUING bicalutamide...... 14 CALQUENCE...... 14 MONTH BOX...... 52 BICILLIN L-A...... 11 camila...... 67 CHANTIX STARTING BIDIL...... 40 camrese lo...... 68 MONTH BOX...... 52 BIKTARVY...... 2 candesartan...... 40 chateal eq (28)...... 68 bisoprolol fumarate...... 40 CAPLYTA...... 34 CHEMET...... 51 bisoprolol­ CAPRELSA...... 14 CHENODAL...... 60 hydrochlorothiazide...... 40 CARBAGLU...... 51 chloramphenicol sod succinate.. 8 BLENREP...... 14 carbamazepine...... 24 chlorhexidine gluconate...... 53 bleomycin...... 14 carbidopa...... 27 chloroquine phosphate...... 8 BLINCYTO...... 14 carbidopa-levodopa...... 27 chlorothiazide sodium...... 40 blisovi 24 fe...... 68 carboplatin...... 14 chlorpromazine...... 34 blisovi fe 1.5/30 (28)...... 68 carmustine...... 14 chlorthalidone...... 40 blisovi fe 1/20 (28)...... 68 carteolol...... 71 CHOLBAM...... 60 BOOSTRIX TDAP...... 63 cartia xt...... 40 cholestyramine (with sugar)...44 BORTEZOMIB...... 14 carvedilol...... 40 cholestyramine light...... 44 BOSULIF...... 14 caspofungin...... 1 CHORIONIC BOTOX...... 63 CAYSTON...... 8 GONADOTROPIN, BRAFTOVI...... 14 caziant (28)...... 68 HUMAN...... 58 BREO ELLIPTA...... 74 cefaclor...... 5 ciclopirox...... 49 briellyn...... 68 cefadroxil...... 5, 6 cidofovir...... 2 BRILINTA...... 43 cefazolin...... 6 cilostazol...... 43 brimonidine...... 73 cefazolin in dextrose (iso-os)... 6 CIMDUO...... 2 brinzolamide...... 72 cefdinir...... 6 cimetidine...... 62 BRIVIACT...... 24 cefepime...... 6 cimetidine hcl...... 62 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 82 cinacalcet...... 58 CRESEMBA...... 1 dentagel...... 53 CIPRO...... 11 cromolyn...... 60, 71, 74 DEPEN TITRATABS...... 65 CIPRODEX...... 53 crotan...... 51 DEPO-MEDROL...... 53 ciprofloxacin hcl...... 11, 53, 70 cryselle (28)...... 68 DESCOVY...... 2 ciprofloxacin in 5 % dextrose..11 CRYSVITA...... 58 desipramine...... 34 ciprofloxacin-dexamethasone..53 cyclafem 1/35 (28)...... 68 desmopressin...... 58 cisplatin...... 14 cyclafem 7/7/7 (28)...... 68 desog-e.estradiol/e.estradiol....68 citalopram...... 34 cyclobenzaprine...... 30 desogestrel-ethinyl estradiol....68 cladribine...... 14 cyclophosphamide...... 15 desvenlafaxine succinate...... 34 claravis...... 48 CYCLOPHOSPHAMIDE.... 15 dexamethasone...... 53 clarithromycin...... 7 cyclosporine...... 15 dexamethasone intensol...... 53 clindamycin hcl...... 8 cyclosporine modified...... 15 dexamethasone sodium phos CLINDAMYCIN IN 0.9 % CYRAMZA...... 15 (pf)...... 53 SOD CHLOR...... 8 CYSTADANE...... 60 dexamethasone sodium clindamycin in 5 % dextrose..... 8 CYSTAGON...... 77 phosphate...... 53, 72 clindamycin pediatric...... 8 CYSTARAN...... 71 dexchlorpheniramine maleate.73 clindamycin phosphate.. 8, 48, 67 cytarabine...... 15 DEXILANT...... 62 CLINDAMYCIN cytarabine (pf)...... 15 dexmethylphenidate...... 34 PHOSPHATE...... 48 d10 %-0.45 % sodium chloride 51 dextroamphetamine...... 34 clindamycin-benzoyl peroxide.49 d2.5 %-0.45 % sodium dextroamphetamine­ clobazam...... 24 chloride...... 51 amphetamine...... 35 clofarabine...... 14 d5 % and 0.9 % sodium dextrose 10 % and 0.2 % nacl.51 clomipramine...... 34 chloride...... 51 dextrose 10 % in water clonazepam...... 24, 25 d5 %-0.45 % sodium chloride.. 51 (d10w)...... 51 clonidine...... 40 dacarbazine...... 15 dextrose 5 % in water (d5w)...51 clonidine hcl...... 41 dactinomycin...... 15 dextrose 5 %-lactated ringers..51 clopidogrel...... 43 dalfampridine...... 28 dextrose 5%-0.2 % sod clorazepate dipotassium...... 34 DALIRESP...... 74 chloride...... 51 clotrimazole...... 1, 49 danazol...... 58 DIACOMIT...... 25 clozapine...... 34 dantrolene...... 30 diazepam...... 25, 35 COARTEM...... 8 DANYELZA...... 15 diazepam intensol...... 35 codeine sulfate...... 30 dapsone...... 8 diazoxide...... 54 colchicine...... 65 DAPTACEL (DTAP diclofenac potassium...... 32 colestipol...... 44, 45 PEDIATRIC) (PF)...... 63 diclofenac sodium...... 32, 72 colistin (colistimethate na)...... 8 DAPTOMYCIN...... 8 dicloxacillin...... 11 COMBIGAN...... 72 daptomycin...... 8 dicyclomine...... 60 COMBIVENT RESPIMAT.. 74 DARZALEX...... 15 didanosine...... 2 COMETRIQ...... 14 DARZALEX FASPRO...... 15 DIFICID...... 7 COMPLERA...... 2 daunorubicin...... 15 diflunisal...... 32 compro...... 60 DAURISMO...... 15 digitek...... 45 constulose...... 60 deblitane...... 67 digox...... 45 COPAXONE...... 28 decadron...... 53 digoxin...... 45, 46 COPIKTRA...... 14 decitabine...... 15 dihydroergotamine...... 28 CORLANOR...... 45 deferasirox...... 51 DILANTIN 30 MG...... 25 CORTIFOAM...... 60 DELSTRIGO...... 2 diltiazem hcl...... 41 CORTISPORIN-TC...... 53 DEMSER...... 41 dilt-xr...... 41 COTELLIC...... 15 DENAVIR...... 50 dimethyl fumarate...... 28 CREON...... 60 denta 5000 plus...... 53 diphenhydramine hcl...... 73 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 83 dipyridamole...... 43 ELMIRON...... 77 erythrocin (as stearate)...... 7 disulfiram...... 51 ELZONRIS...... 16 erythromycin...... 7, 70 divalproex...... 25 EMCYT...... 16 erythromycin ethylsuccinate..... 7 dobutamine...... 46 EMEND...... 60 erythromycin with ethanol...... 49 dobutamine in d5w...... 46 emoquette...... 68 erythromycin-benzoyl docetaxel...... 15 EMPLICITI...... 16 peroxide...... 49 dofetilide...... 40 EMSAM...... 35 ESBRIET...... 74 dolishale...... 68 emtricitabine...... 2 escitalopram oxalate...... 35 donepezil...... 28, 29 emtricitabine-tenofovir (tdf).... 2 esomeprazole magnesium...... 62 dopamine...... 46 EMTRIVA...... 2 esomeprazole sodium...... 62 dopamine in 5 % dextrose...... 46 EMVERM...... 8 estarylla...... 68 dorzolamide...... 72 enalapril maleate...... 41 estradiol...... 67 dorzolamide-timolol...... 72 enalaprilat...... 41 estradiol valerate...... 67 dorzolamide-timolol (pf)...... 72 enalapril-hydrochlorothiazide.41 ethambutol...... 8 dotti...... 67 ENBREL...... 65, 66 ethosuximide...... 25 DOVATO...... 2 ENBREL MINI...... 65 ethynodiol diac-eth estradiol... 68 doxazosin...... 41 ENBREL SURECLICK...... 66 ETOPOPHOS...... 16 doxepin...... 35 endocet...... 30 etoposide...... 16 doxorubicin...... 15, 16 ENGERIX-B (PF)...... 64 euthyrox...... 59 doxorubicin, peg-liposomal..... 16 ENGERIX-B PEDIATRIC everolimus (antineoplastic).... 16 doxy-100...... 12 (PF)...... 64 everolimus doxycycline hyclate...... 12 ENHERTU...... 16 (immunosuppressive)...... 16 doxycycline monohydrate...... 12 enoxaparin...... 43 EVOMELA...... 16 DRIZALMA SPRINKLE.... 35 enpresse...... 68 EVOTAZ...... 3 dronabinol...... 60 entacapone...... 27 exemestane...... 16 drospirenone-e.estradiol-lm.fa.68 entecavir...... 2 EYLEA...... 71 drospirenone-ethinyl estradiol.68 ENTRESTO...... 46 ezetimibe...... 45 DROXIA...... 16 ENTYVIO...... 60 FABRAZYME...... 58 droxidopa...... 51 enulose...... 60 falmina (28)...... 68 duloxetine...... 35 ENVARSUS XR...... 16 famciclovir...... 3 DUPIXENT PEN...... 47 EPCLUSA...... 2, 3 famotidine...... 62 DUPIXENT SYRINGE...... 47 EPIDIOLEX...... 25 FANAPT...... 35 DUREZOL...... 72 epinastine...... 71 FARYDAK...... 16 ec-naproxen...... 32 EPINEPHRINE...... 73 fayosim...... 68 EDARBI...... 41 epinephrine...... 73 febuxostat...... 65 EDARBYCLOR...... 41 epirubicin...... 16 felbamate...... 25 EDURANT...... 2 epitol...... 25 felodipine...... 41 efavirenz...... 2 EPIVIR HBV...... 3 femynor...... 68 efavirenz-emtricitabin-tenofov.. 2 eplerenone...... 41 fenofibrate...... 45 efavirenz-lamivu-tenofov ERBITUX...... 16 fenofibrate micronized...... 45 disop...... 2 ergotamine-caffeine...... 28 fenofibrate nanocrystallized....45 effer-k...... 77 ERIVEDGE...... 16 fenofibric acid (choline)...... 45 ELAPRASE...... 58 ERLEADA...... 16 fentanyl...... 31 electrolyte-48 in d5w...... 78 erlotinib...... 16 fentanyl citrate...... 30 ELIQUIS...... 43 errin...... 67 fentanyl citrate (pf)...... 30 ELIQUIS DVT-PE TREAT ertapenem...... 8 FETZIMA...... 35 30D START...... 43 ery pads...... 49 finasteride...... 76 ELLENCE...... 16 ERYTHROCIN...... 7 FINTEPLA...... 25 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 84 FIRMAGON KIT W GATTEX ONE-VIAL...... 61 GVOKE PFS 2-PACK DILUENT SYRINGE...... 16 GAUZE PAD...... 54 SYRINGE...... 55 flac otic oil...... 53 gavilyte-c...... 61 HAEGARDA...... 75 flecainide...... 40 gavilyte-n...... 61 hailey...... 68 FLOVENT DISKUS...... 74 GAVRETO...... 17 hailey 24 fe...... 68 FLOVENT HFA...... 74, 75 GAZYVA...... 17 HALAVEN...... 17 floxuridine...... 16 gemcitabine...... 17 haloperidol...... 36 fluconazole...... 1 GEMCITABINE...... 17 haloperidol decanoate...... 36 fluconazole in nacl (iso-osm)....1 gemfibrozil...... 45 haloperidol lactate...... 36 flucytosine...... 1 generlac...... 61 HARVONI...... 3 fludarabine...... 16 gengraf...... 17 HAVRIX (PF)...... 64 fludrocortisone...... 53 GENOTROPIN...... 63 heather...... 67 flunisolide...... 75 GENOTROPIN heparin (porcine)...... 44 fluocinolone...... 50 MINIQUICK...... 63 heparin (porcine) in 5 % dex fluocinolone acetonide oil...... 53 gentak...... 70 ...... 43, 44 fluocinolone and shower cap....50 gentamicin...... 9, 49, 70 heparin (porcine) in nacl (pf) 44 fluoride (sodium)...... 53, 79 gentamicin in nacl (iso-osm).... 8 HEPARIN(PORCINE) IN fluorometholone...... 72 GENTAMICIN IN NACL 0.45% NACL...... 44 fluorouracil...... 16, 47 (ISO-OSM)...... 8 heparin(porcine) in 0.45% fluoxetine...... 35, 36 gentamicin sulfate (ped) (pf)...9 nacl...... 44 fluoxetine (pmdd)...... 35 GENVOYA...... 3 heparin, porcine (pf)...... 44 fluphenazine decanoate...... 36 GILENYA...... 29 HEPARIN, PORCINE (PF). 44 fluphenazine hcl...... 36 GILOTRIF...... 17 HEPATAMINE 8%...... 78 flurbiprofen...... 32 glatiramer...... 29 HETLIOZ...... 36 flurbiprofen sodium...... 72 glatopa...... 29 HIBERIX (PF)...... 64 flutamide...... 16 glimepiride...... 54, 55 hidex...... 53 fluticasone propionate...... 50, 75 glipizide...... 55 HIZENTRA...... 64 fluvoxamine...... 36 glipizide-metformin...... 55 HUMALOG JUNIOR FOLOTYN...... 16 GLUCAGEN HYPOKIT..... 55 KWIKPEN U-100...... 55 fondaparinux...... 43 GLUCAGON (HCL) HUMALOG KWIKPEN fosamprenavir...... 3 EMERGENCY KIT...... 55 INSULIN...... 55 fosaprepitant...... 60 glucagon emergency kit HUMALOG MIX 50-50 fosinopril...... 41 (human)...... 55 INSULN U-100...... 55 fosinopril-hydrochlorothiazide 41 glycopyrrolate...... 60 HUMALOG MIX 50-50 fosphenytoin...... 25 glydo...... 47 KWIKPEN...... 55 FOTIVDA...... 16 GLYXAMBI...... 55 HUMALOG MIX 75-25 freamine iii 10 %...... 78 GOCOVRI...... 27 KWIKPEN...... 55 fulvestrant...... 16 granisetron (pf)...... 61 HUMALOG MIX 75-25(U­ furosemide...... 41 granisetron hcl...... 61 100)INSULN...... 55 FUZEON...... 3 griseofulvin microsize...... 1 HUMALOG U-100 FYCOMPA...... 25 griseofulvin ultramicrosize...... 1 INSULIN...... 55 gabapentin...... 25 GVOKE HYPOPEN 1­ HUMIRA...... 66 galantamine...... 29 PACK...... 55 HUMIRA PEN...... 66 GAMASTAN...... 64 GVOKE HYPOPEN 2­ HUMIRA PEN CROHNS­ GAMASTAN S/D...... 64 PACK...... 55 UC-HS START...... 66 ganciclovir sodium...... 3 GVOKE PFS 1-PACK HUMIRA PEN PSOR­ GARDASIL 9 (PF)...... 64 SYRINGE...... 55 UVEITS-ADOL HS...... 66 GATTEX 30-VIAL...... 61 HUMIRA(CF)...... 66 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 85 HUMIRA(CF) PEDI ICLUSIG...... 17 isibloom...... 68 CROHNS STARTER...... 66 idarubicin...... 17 isoniazid...... 9 HUMIRA(CF) PEN...... 66 IDHIFA...... 17 isosorbide dinitrate ...... 46 HUMIRA(CF) PEN ifosfamide...... 17 isosorbide mononitrate...... 46 CROHNS-UC-HS...... 66 ILARIS (PF)...... 63 isotretinoin...... 49 HUMIRA(CF) PEN imatinib...... 17 itraconazole...... 1 PEDIATRIC UC...... 66 IMBRUVICA...... 17 ivermectin...... 9 HUMIRA(CF) PEN PSOR­ IMFINZI...... 17 IXEMPRA...... 18 UV-ADOL HS...... 66 imipenem-cilastatin...... 9 IXIARO (PF)...... 64 HUMULIN 70/30 U-100 imipramine hcl...... 36 JAKAFI...... 18 INSULIN...... 55 imiquimod...... 47 jantoven...... 44 HUMULIN 70/30 U-100 IMOVAX RABIES JANUMET...... 56 KWIKPEN...... 55 VACCINE (PF)...... 64 JANUMET XR...... 56 HUMULIN N NPH IMPAVIDO...... 9 JANUVIA...... 56 INSULIN KWIKPEN...... 55 incassia...... 67 JARDIANCE...... 56 HUMULIN N NPH U-100 INCRELEX...... 52 jasmiel (28)...... 68 INSULIN...... 55 INCRUSE ELLIPTA...... 75 jencycla...... 67 HUMULIN R REGULAR indapamide...... 41 JENTADUETO...... 56 U-100 INSULN...... 55 INFANRIX (DTAP) (PF).... 64 JENTADUETO XR...... 56 HUMULIN R U-500 INFUGEM...... 17 JEVTANA...... 18 (CONC) INSULIN...... 55 INLYTA...... 17 juleber...... 68 HUMULIN R U-500 INQOVI...... 18 JULUCA...... 3 (CONC) KWIKPEN...... 55 INREBIC...... 18 junel 1.5/30 (21)...... 68 hydralazine...... 41 INSULIN PEN NEEDLE.... 56 junel 1/20 (21)...... 68 hydrochlorothiazide...... 41 INSULIN SYRINGE junel fe 1.5/30 (28)...... 68 hydrocodone-acetaminophen...31 (DISP) U-100...... 56 junel fe 1/20 (28)...... 68 hydrocodone-ibuprofen...... 31 INTELENCE...... 3 junel fe 24...... 68 hydrocortisone...... 50, 53, 61 intralipid...... 79 KADCYLA...... 18 hydrocortisone butyrate...... 50 INTRALIPID...... 79 kaitlib fe...... 68 hydrocortisone butyr­ INTRON A...... 63 KALETRA...... 3 emollient...... 50 introvale...... 68 kalliga...... 69 hydrocortisone valerate...... 51 INVEGA SUSTENNA...... 36 KALYDECO...... 75 hydrocortisone-acetic acid...... 53 INVEGA TRINZA...... 36 KANJINTI...... 18 hydromorphone...... 31 INVELTYS...... 72 KANUMA...... 58 hydroxychloroquine...... 9 INVIRASE...... 3 kariva (28)...... 69 hydroxyprogesterone INVOKAMET...... 56 kelnor 1/35 (28)...... 69 caproate...... 67 INVOKAMET XR...... 56 kelnor 1-50 (28)...... 69 hydroxyurea...... 17 INVOKANA...... 56 KEPIVANCE...... 12 hydroxyzine hcl...... 73 IPOL...... 64 ketoconazole...... 1, 49, 50 HYPERHEP B...... 64 ipratropium bromide...... 53, 75 ketoprofen...... 32 HYPERHEP B ipratropium-albuterol...... 75 ketorolac...... 72 NEONATAL...... 64 irbesartan...... 41 KEYTRUDA...... 18 ibandronate...... 65 irbesartan­ KHAPZORY...... 12 IBRANCE...... 17 hydrochlorothiazide...... 41 KINRIX (PF)...... 64 ibu...... 32 IRESSA...... 18 KISQALI...... 18 ibuprofen...... 32 irinotecan...... 18 KISQALI FEMARA CO­ icatibant...... 75 ISENTRESS...... 3 PACK...... 18 iclevia...... 68 ISENTRESS HD...... 3 klor-con...... 77 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 86 klor-con 10...... 77 levocetirizine...... 73 LUMIGAN...... 72 klor-con 8...... 77 levofloxacin...... 11, 70 LUMIZYME...... 58 klor-con m10...... 77 levofloxacin in d5w...... 11 LUMOXITI...... 19 klor-con m15...... 77 levoleucovorin calcium...... 13 LUPRON DEPOT...... 19 klor-con m20...... 77 levonest (28)...... 69 LUPRON DEPOT (3 klor-con/ef...... 77 levonorgestrel-ethinyl estrad... 69 MONTH)...... 19 KORLYM...... 58 levonorg-eth estrad triphasic...69 LUPRON DEPOT (4 K-PHOS NO 2...... 77 levora-28...... 69 MONTH)...... 19 K-PHOS ORIGINAL...... 77 levo-t...... 59 LUPRON DEPOT (6 KRYSTEXXA...... 65 levothyroxine...... 59 MONTH)...... 19 KUVAN...... 58 levoxyl...... 60 LUPRON DEPOT-PED...... 19 KYNMOBI...... 27 LEXIVA...... 4 LUPRON DEPOT-PED (3 KYPROLIS...... 18 LIBTAYO...... 19 MONTH)...... 19 l norgest/e.estradiol-e.estrad... 69 lidocaine...... 48 lutera (28)...... 69 labetalol...... 41 lidocaine (pf)...... 40, 48 lyleq...... 67 lactated ringers...... 77 lidocaine hcl...... 48 LYNPARZA...... 19 lactulose...... 61 lidocaine viscous...... 48 LYSODREN...... 19 lamivudine...... 3 lidocaine-prilocaine...... 48 LYUMJEV KWIKPEN U­ lamivudine-zidovudine...... 4 lillow (28)...... 69 100 INSULIN...... 56 lamotrigine...... 25 lindane...... 51 LYUMJEV KWIKPEN U­ LANOXIN...... 46 linezolid...... 9 200 INSULIN...... 56 LANOXIN PEDIATRIC...... 46 linezolid in dextrose 5%...... 9 LYUMJEV U-100 LANTUS SOLOSTAR U­ linezolid-0.9% sodium INSULIN...... 56 100 INSULIN...... 56 chloride...... 9 lyza...... 67 LANTUS U-100 INSULIN.. 56 LINZESS...... 61 mafenide acetate...... 49 lapatinib...... 18 LIORESAL...... 30 magnesium sulfate...... 77 larin 1.5/30 (21)...... 69 liothyronine...... 60 MAGNESIUM SULFATE larin 1/20 (21)...... 69 lisinopril...... 41 IN D5W...... 77 larin fe 1.5/30 (28)...... 69 lisinopril-hydrochlorothiazide.41 magnesium sulfate in water.....77 larin fe 1/20 (28)...... 69 lithium carbonate...... 37 malathion...... 51 larissia...... 69 lithium citrate...... 37 mannitol 20 %...... 41 latanoprost...... 72 LONSURF...... 19 mannitol 25 %...... 42 LATUDA...... 37 loperamide...... 60 maprotiline...... 37 layolis fe...... 69 lopinavir-ritonavir...... 4 marlissa (28)...... 69 leena 28...... 69 lorazepam...... 37 MARPLAN...... 37 leflunomide...... 66 lorazepam intensol...... 37 MARQIBO...... 19 LEMTRADA...... 29 LORBRENA...... 19 MATULANE...... 19 LENVIMA...... 18 loryna (28)...... 69 MAVYRET...... 4 lessina...... 69 losartan...... 41 meclizine...... 61 letrozole...... 18 losartan-hydrochlorothiazide.. 41 medroxyprogesterone...... 67 leucovorin calcium...... 12 LOTEMAX...... 72 mefloquine...... 9 LEUKERAN...... 19 LOTEMAX SM...... 72 megestrol...... 19 leuprolide...... 19 loteprednol etabonate...... 72 MEKINIST...... 19 levetiracetam...... 26 lovastatin...... 45 MEKTOVI...... 19 levetiracetam in nacl (iso-os).26 low-ogestrel (28)...... 69 meloxicam...... 32 levobunolol...... 71 loxapine succinate...... 37 melphalan...... 19 levocarnitine...... 52 lo-zumandimine (28)...... 69 melphalan hcl...... 19 levocarnitine (with sugar)...... 52 LUCENTIS...... 71 memantine...... 29 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 87 MEMANTINE...... 29 microgestin 1/20 (21)...... 69 NATPARA...... 59 MENACTRA (PF)...... 64 microgestin fe 1.5/30 (28)...... 69 NAYZILAM...... 26 MENQUADFI (PF)...... 64 microgestin fe 1/20 (28)...... 69 necon 0.5/35 (28)...... 69 MENVEO A-C-Y-W-135­ midodrine...... 52 NEEDLES, INSULIN DIP (PF)...... 64 mili...... 69 DISP.,SAFETY...... 57 MEPSEVII...... 58 milrinone...... 46 nefazodone...... 37 mercaptopurine...... 19 milrinone in 5 % dextrose...... 46 neomycin...... 9 meropenem...... 9 minocycline...... 12 neomycin-bacitracin-poly-hc... 72 MEROPENEM-0.9% minoxidil...... 42 neomycin-bacitracin­ SODIUM CHLORIDE...... 9 MIRENA...... 67 polymyxin...... 71 mesalamine...... 61 mirtazapine...... 37 neomycin-polymyxin b­ mesalamine with cleansing misoprostol...... 63 dexameth...... 72 wipe...... 61 MITIGARE...... 65 neomycin-polymyxin­ mesna...... 13 mitomycin...... 19 gramicidin...... 71 MESNEX...... 13 mitoxantrone...... 19 neomycin-polymyxin-hc.... 53, 72 metformin...... 56, 57 M-M-R II (PF)...... 64 neo-polycin...... 71 methadone...... 31 modafinil...... 37 neo-polycin hc...... 72 methadone intensol...... 31 molindone...... 37 neostigmine methylsulfate...... 30 methazolamide...... 72 mondoxyne nl...... 12 NERLYNX...... 20 methenamine hippurate...... 12 MONJUVI...... 19 NEUPRO...... 27 methenamine mandelate...... 12 montelukast...... 75 nevirapine...... 4 methimazole...... 54 morgidox...... 12 NEXAVAR...... 20 methotrexate sodium...... 19 MORPHINE...... 31 NEXPLANON...... 67 methotrexate sodium (pf)...... 19 morphine...... 31, 32 niacin...... 45 methoxsalen...... 48 morphine (pf)...... 31 NIACOR...... 45 methyldopa...... 42 morphine concentrate...... 31 nicardipine...... 42 methylergonovine...... 70 MOVANTIK...... 61 NICOTROL...... 52 methylphenidate hcl...... 37 moxifloxacin...... 71 nifedipine...... 42 methylprednisolone...... 53, 54 MOZOBIL...... 63 nikki (28)...... 69 methylprednisolone acetate.....53 mupirocin...... 49 nilutamide...... 20 methylprednisolone sodium MVASI...... 19 nimodipine...... 42 succ...... 54 MYALEPT...... 58 NINLARO...... 20 metoclopramide hcl...... 61 mycophenolate mofetil...... 19, 20 NIPENT...... 20 metolazone...... 42 mycophenolate mofetil (hcl)...19 nitazoxanide...... 9 metoprolol succinate...... 42 mycophenolate sodium...... 20 nitisinone...... 52 metoprolol ta­ MYLOTARG...... 20 nitro-bid...... 46 hydrochlorothiaz...... 42 MYRBETRIQ...... 76 nitrofurantoin...... 12 metoprolol tartrate...... 42 nafcillin...... 11 nitrofurantoin macrocrystal.... 12 metro i.v...... 9 nafcillin in dextrose iso-osm....11 nitrofurantoin monohyd/m­ metronidazole...... 9, 49, 67 NAGLAZYME...... 58 cryst...... 12 metronidazole in nacl (iso-os).. 9 naloxone...... 32, 33 nitroglycerin...... 46 metyrosine...... 42 naltrexone...... 33 nitroglycerin in 5 % dextrose.. 46 mexiletine...... 40 NAMZARIC...... 29 NIVESTYM...... 63 MIACALCIN...... 58 naproxen...... 33 nora-be...... 67 mibelas 24 fe...... 69 naratriptan...... 28 noreth-ethinyl estradiol-iron... 69 micafungin...... 1 NARCAN...... 33 norethindrone (contraceptive) 67 miconazole-3...... 67 NATACYN...... 71 norethindrone acetate...... 67 microgestin 1.5/30 (21)...... 69 nateglinide...... 57 norethindrone ac-eth estradiol.69 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 88 norethindrone-e.estradiol-iron.69 opium tincture...... 60 PENTASA...... 61 norgestimate-ethinyl estradiol.69 oralone...... 53 pentoxifylline...... 44 norlyda...... 67 ORENCIA...... 66 PEPAXTO...... 20 NORMOSOL-R PH 7.4...... 79 ORENCIA (WITH PERFOROMIST...... 75 NORTHERA...... 52 MALTOSE)...... 66 periogard...... 53 nortrel 0.5/35 (28)...... 69 ORENCIA CLICKJECT...... 66 PERJETA...... 20 nortrel 1/35 (21)...... 69 ORGOVYX...... 20 permethrin...... 51 nortrel 1/35 (28)...... 69 ORKAMBI...... 75 perphenazine...... 38 nortrel 7/7/7 (28)...... 70 orsythia...... 70 PERSERIS...... 38 nortriptyline...... 37 oseltamivir...... 4 pfizerpen-g...... 11 NORVIR...... 4 osmitrol 15 %...... 42 phenelzine...... 38 NPLATE...... 44 osmitrol 20 %...... 42 phenobarbital...... 26 NUBEQA...... 20 oxaliplatin...... 20 phenobarbital sodium...... 26 NUEDEXTA...... 29 oxandrolone...... 59 phentolamine...... 42 NULOJIX...... 20 oxcarbazepine...... 26 phenytoin...... 26 NUPLAZID...... 37 OXERVATE...... 71 phenytoin sodium...... 26 nyamyc...... 50 oxybutynin chloride...... 76 phenytoin sodium extended..... 26 nylia 7/7/7 (28)...... 70 oxycodone-acetaminophen...... 32 PHESGO...... 21 nymyo...... 70 oxymorphone...... 32 PHOSLYRA...... 77 nystatin...... 1, 50 OZEMPIC...... 57 PIFELTRO...... 4 nystatin-triamcinolone...... 50 OZURDEX...... 72 pilocarpine hcl...... 52, 71 nystop...... 50 pacerone...... 40 pimozide...... 38 OCALIVA...... 61 paclitaxel...... 20 pimtrea (28)...... 70 ocella...... 70 PADCEV...... 20 pindolol...... 42 OCREVUS...... 29 paliperidone...... 38 pioglitazone...... 57 octreotide acetate...... 20 palonosetron...... 61 PIPERACILLIN­ ODEFSEY...... 4 PANRETIN...... 48 TAZOBACTAM...... 11 ODOMZO...... 20 pantoprazole...... 63 piperacillin-tazobactam...... 11 OFEV...... 75 PARICALCITOL...... 59 PIQRAY...... 21 ofloxacin...... 53, 71 paricalcitol...... 59 pirmella...... 70 OGIVRI...... 20 paroex oral rinse...... 53 plasbumin 25 %...... 77 olanzapine...... 38 paromomycin...... 9 plasbumin 5 %...... 77 olmesartan...... 42 paroxetine hcl...... 38 plenamine...... 79 omeprazole...... 63 PASER...... 9 PLENVU...... 61 OMNIPOD DASH 5 PACK PAXIL...... 38 podofilox...... 48 POD...... 57 PEDIARIX (PF)...... 64 POLIVY...... 21 OMNIPOD INSULIN PEDVAX HIB (PF)...... 64 polycin...... 71 MANAGEMENT...... 57 peg 3350-electrolytes...... 61 polyethylene glycol 3350...... 62 OMNIPOD INSULIN peg-electrolyte...... 61 polymyxin b sulf­ REFILL...... 57 PEMAZYRE...... 20 trimethoprim...... 71 ONCASPAR...... 20 penicillamine...... 66 POMALYST...... 21 ondansetron...... 61 penicillin g potassium...... 11 portia 28...... 70 ondansetron hcl...... 61 penicillin g procaine...... 11 PORTRAZZA...... 21 ondansetron hcl (pf)...... 61 penicillin g sodium...... 11 posaconazole...... 1 ONIVYDE...... 20 penicillin v potassium...... 11 potassium acetate...... 77 ONTRUZANT...... 20 PENTACEL (PF)...... 64 potassium chlorid-d5­ ONUREG...... 20 PENTAM...... 9 0.45%nacl...... 77 OPDIVO...... 20 pentamidine...... 9 potassium chloride...... 78 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 89 potassium chloride in procto-med hc...... 62 REPATHA 0.9%nacl...... 77 procto-pak...... 62 PUSHTRONEX...... 45 potassium chloride in 5 % dex.77 proctosol hc ...... 62 REPATHA SURECLICK.... 45 potassium chloride in lr-d5...... 77 proctozone-hc...... 62 RESTASIS...... 71 potassium chloride in water.....78 PROGLYCEM...... 57 RESTASIS MULTIDOSE.... 71 potassium chloride-0.45 % PROGRAF...... 21 RETEVMO...... 21 nacl...... 78 PROLASTIN-C...... 52 RETROVIR...... 4 potassium chloride-d5­ PROLENSA...... 72 REVCOVI...... 52 0.2%nacl...... 78 PROLIA...... 65 REVLIMID...... 21 potassium chloride-d5­ PROMACTA...... 44 revonto...... 30 0.9%nacl...... 78 propafenone...... 40 REXULTI...... 38 potassium citrate...... 77 propranolol...... 42 REYATAZ...... 4 potassium phosphate m-/d­ propranolol­ RHOPRESSA...... 72 basic...... 78 hydrochlorothiazid...... 42 ribavirin...... 4 POTELIGEO...... 21 propylthiouracil...... 54 rifabutin...... 9 pramipexole...... 27 PROQUAD (PF)...... 64 rifampin...... 9 prasugrel...... 44 protriptyline...... 38 riluzole...... 52 pravastatin...... 45 PULMOZYME...... 75 rimantadine...... 4 praziquantel...... 9 PURIXAN...... 21 ringer's...... 78 prazosin...... 42 pyrazinamide...... 9 RINVOQ...... 67 prednicarbate...... 51 pyridostigmine bromide...... 30 RISPERDAL CONSTA...... 38 prednisolone...... 54 pyrimethamine...... 9 risperidone...... 38 prednisolone acetate...... 72 QINLOCK...... 21 ritonavir...... 4 prednisolone sodium QUADRACEL (PF)...... 64 rivastigmine...... 29 phosphate...... 54, 73 quetiapine...... 38 rivastigmine tartrate...... 29 prednisone...... 54 quinapril...... 42 rivelsa...... 70 prednisone intensol...... 54 quinapril-hydrochlorothiazide.42 rizatriptan...... 28 pregabalin...... 26 quinidine sulfate...... 40 ROCKLATAN...... 72 PREMARIN...... 67 quinine sulfate...... 9 ROMIDEPSIN...... 21 premasol 10 %...... 79 RABAVERT (PF)...... 64 ropinirole...... 27 PREMPRO...... 67 RADICAVA...... 29 rosadan...... 49 prenatal vitamin oral tablet.....79 raloxifene...... 65 rosuvastatin...... 45 prevalite...... 45 ramelteon...... 38 ROTARIX...... 64 previfem...... 70 ramipril...... 42 ROTATEQ VACCINE...... 64 PREVYMIS...... 4 ranolazine...... 46 roweepra...... 26 PREZCOBIX...... 4 rasagiline...... 27 ROZLYTREK...... 21 PREZISTA...... 4 reclipsen (28)...... 70 RUBRACA...... 21 PRIFTIN...... 9 RECOMBIVAX HB (PF)..... 64 rufinamide...... 26 PRIMAQUINE...... 9 RECTIV...... 62 RUKOBIA...... 4 primidone...... 26 regonol...... 30 RUXIENCE...... 21 PRIVIGEN...... 64 REGRANEX...... 48 RYBELSUS...... 57 probenecid...... 65 RELENZA DISKHALER...... 4 RYDAPT...... 21 probenecid-colchicine...... 65 RELISTOR...... 62 RYTARY...... 27 procainamide...... 40 REMICADE...... 62 salsalate...... 33 prochlorperazine...... 62 RENACIDIN...... 77 SAMSCA...... 59 prochlorperazine edisylate...... 62 repaglinide...... 57 SANDIMMUNE...... 21 prochlorperazine maleate oral.62 REPATHA...... 45 SANTYL...... 48 PROCRIT...... 63 SAPHRIS...... 38 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 90 sapropterin...... 59 sotalol af...... 40 SYNJARDY...... 57 SARCLISA...... 21 SOTYLIZE...... 40 SYNJARDY XR...... 57 scopolamine base...... 62 spironolactone...... 42 SYNRIBO...... 21 SECUADO...... 38 spironolacton­ TABLOID...... 21 selegiline hcl...... 27 hydrochlorothiaz...... 42 TABRECTA...... 21 selenium sulfide...... 47 sprintec (28)...... 70 tacrolimus...... 21, 48 SELZENTRY...... 4, 5 SPRITAM...... 26 tadalafil (pulm. hypertension) 75 SEREVENT DISKUS...... 75 SPRYCEL...... 21 TAFINLAR...... 22 sertraline...... 38, 39 sps (with sorbitol)...... 52 TAGRISSO...... 22 setlakin...... 70 sronyx...... 70 TALTZ SYRINGE...... 47 sevelamer carbonate...... 52 ssd...... 48 TALZENNA...... 22 sf...... 53 STAMARIL (PF)...... 65 tamoxifen...... 22 sf 5000 plus...... 53 stavudine...... 5 tamsulosin...... 76 sharobel...... 67 STELARA...... 47 TARGRETIN...... 22 SHINGRIX (PF)...... 65 STIVARGA...... 21 tarina 24 fe...... 70 SIGNIFOR...... 21 STRENSIQ...... 59 tarina fe 1/20 (28)...... 70 sildenafil (pulmonary arterial STREPTOMYCIN...... 9 tarina fe 1-20 eq (28)...... 70 hypertension)...... 75 STRIBILD...... 5 TASIGNA...... 22 silver sulfadiazine...... 48 SUBOXONE...... 33 tazarotene...... 49 SIMBRINZA...... 72 subvenite...... 26 tazicef...... 7 simliya (28)...... 70 subvenite starter (blue) kit..... 26 TAZORAC...... 49 simpesse...... 70 subvenite starter (green) kit... 26 TAZVERIK...... 22 SIMULECT...... 21 subvenite starter (orange) kit.26 TDVAX...... 65 simvastatin...... 45 sucralfate...... 63 TECENTRIQ...... 22 sirolimus...... 21 sulfacetamide sodium...... 71 TECFIDERA...... 29 SIRTURO...... 9 sulfacetamide sodium (acne).. 49 TEFLARO...... 7 SKYRIZI...... 47 sulfacetamide-prednisolone..... 71 telmisartan...... 42 sodium acetate...... 78 sulfadiazine...... 12 telmisartan-amlodipine...... 42 sodium bicarbonate...... 78 sulfamethoxazole­ TEMIXYS...... 5 sodium chloride...... 52, 78 trimethoprim...... 12 TEMODAR...... 22 sodium chloride 0.45 %...... 78 SULFAMYLON...... 49 temsirolimus...... 22 sodium chloride 0.9 %...... 52 sulfasalazine...... 62 TENIVAC (PF)...... 65 sodium chloride 3 %...... 78 sulindac...... 33 tenofovir disoproxil fumarate....5 sodium chloride 5 %...... 78 sumatriptan...... 28 TEPMETKO...... 22 SODIUM EDECRIN...... 42 sumatriptan succinate...... 28 terazosin...... 42 sodium fluoride 5000 plus...... 53 SUPRAX...... 7 terbinafine hcl...... 1 sodium phosphate...... 78 SUPREP BOWEL PREP terbutaline...... 75 sodium polystyrene sulfonate.. 52 KIT...... 62 terconazole...... 67 SOLIQUA 100/33...... 57 SUTAB...... 62 TERIPARATIDE...... 65 SOLIRIS...... 52 SUTENT...... 21 testosterone...... 59 SOLTAMOX...... 21 syeda...... 70 testosterone cypionate...... 59 SOLU-CORTEF...... 54 SYMDEKO...... 75 testosterone enanthate...... 59 SOLU-CORTEF ACT-O­ SYMFI...... 5 TETANUS,DIPHTHERIA VIAL (PF)...... 54 SYMFI LO...... 5 TOX PED(PF)...... 65 SOMATULINE DEPOT...... 21 SYMPAZAN...... 26 tetrabenazine...... 29 SOMAVERT...... 59 SYMTUZA...... 5 tetracycline...... 12 sorine...... 40 SYNAREL...... 59 THALOMID...... 22 sotalol...... 40 SYNERCID...... 9 theophylline...... 75, 76 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 91 thioridazine...... 39 trientine...... 52 UPTRAVI...... 42 thiotepa...... 22 tri-estarylla...... 70 ursodiol...... 62 thiothixene...... 39 trifluoperazine...... 39 UVADEX...... 48 tiagabine...... 26 trifluridine...... 71 valacyclovir...... 5 TIBSOVO...... 22 TRIJARDY XR...... 58 VALCHLOR...... 48 TICE BCG...... 65 TRIKAFTA...... 76 valganciclovir...... 5 tigecycline...... 9 tri-legest fe...... 70 valproate sodium...... 27 tilia fe...... 70 tri-lo-estarylla...... 70 valproic acid...... 27 timolol maleate...... 42, 71 tri-lo-mili...... 70 valproic acid (as sodium salt).27 TIVICAY...... 5 tri-lo-sprintec...... 70 valrubicin...... 23 TIVICAY PD...... 5 trilyte with flavor packets...... 62 valsartan...... 42, 43 tizanidine...... 30 trimethoprim...... 12 valsartan-hydrochlorothiazide.43 tobramycin...... 71 tri-mili...... 70 VALTOCO...... 27 tobramycin in 0.225 % nacl...... 9 trimipramine...... 39 VANCOMYCIN...... 10 tobramycin sulfate...... 9 TRINTELLIX...... 39 vancomycin...... 10 tobramycin-dexamethasone.... 72 tri-nymyo...... 70 VANCOMYCIN IN 0.9 % tolterodine...... 76 tri-previfem (28)...... 70 SODIUM CHL...... 9 tolvaptan...... 59 tri-sprintec (28)...... 70 VANCOMYCIN IN topiramate...... 27 tritocin...... 51 DEXTROSE 5 %...... 10 toposar...... 22 TRIUMEQ...... 5 vandazole...... 68 topotecan...... 22 trivora (28)...... 70 VANTAS...... 23 toremifene...... 22 tri-vylibra...... 70 VAQTA (PF)...... 65 torsemide...... 42 tri-vylibra lo...... 70 VARIVAX (PF)...... 65 TOUJEO MAX U-300 TRODELVY...... 22 VARIZIG...... 65 SOLOSTAR...... 57 TROGARZO...... 5 VASCEPA...... 45 TOUJEO SOLOSTAR U­ TROPHAMINE 10 %...... 79 VECTIBIX...... 23 300 INSULIN...... 57 TRULICITY...... 58 VELCADE...... 23 TOVIAZ...... 76 TRUMENBA...... 65 velivet triphasic regimen (28).70 TRADJENTA...... 58 TRUVADA...... 5 VELPHORO...... 52 tramadol...... 33 TRUXIMA...... 22 VELTASSA...... 52 tranexamic acid...... 68 TUKYSA...... 22 VEMLIDY...... 5 tranylcypromine...... 39 tulana...... 67 VENCLEXTA...... 23 travasol 10 %...... 79 TURALIO...... 22 VENCLEXTA STARTING travoprost...... 72 TWINRIX (PF)...... 65 PACK...... 23 TRAZIMERA...... 22 tydemy...... 70 venlafaxine...... 39 trazodone...... 39 TYKERB...... 22 VENTOLIN HFA...... 76 TREANDA...... 22 TYMLOS...... 65 verapamil...... 43 TRECATOR...... 9 TYPHIM VI...... 65 VERQUVO...... 46 TRELEGY ELLIPTA...... 76 TYSABRI...... 30 VERSACLOZ...... 39 TRELSTAR...... 22 TYVASO...... 76 VERZENIO...... 23 tretinoin (antineoplastic)...... 22 TYVASO vestura (28)...... 70 tretinoin topical...... 49 INSTITUTIONAL START V-GO 20...... 58 triamcinolone acetonide KIT...... 76 V-GO 30...... 58 ...... 51, 53, 54 TYVASO REFILL KIT...... 76 V-GO 40...... 58 triamterene...... 42 TYVASO STARTER KIT.... 76 VIBATIV...... 10 triamterene­ UKONIQ...... 23 VICTOZA 2-PAK...... 58 hydrochlorothiazid...... 42 unithroid...... 60 VICTOZA 3-PAK...... 58 triderm...... 51 UNITUXIN...... 23 vienva...... 70 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 92 vigabatrin...... 27 XYREM...... 39 vigadrone...... 27 YERVOY...... 23 VIIBRYD...... 39 YF-VAX (PF)...... 65 VIMIZIM...... 59 YONDELIS...... 23 VIMPAT...... 27 yuvafem...... 67 vinblastine...... 23 zafirlukast...... 76 vincasar pfs...... 23 zaleplon...... 39 vincristine...... 23 ZALTRAP...... 23 vinorelbine...... 23 ZANOSAR...... 23 VIOKACE...... 62 zarah...... 70 VIRACEPT...... 5 ZARXIO...... 63 VIREAD...... 5 ZEJULA...... 24 VISTOGARD...... 13 ZELBORAF...... 24 VITRAKVI...... 23 ZENPEP...... 62 VIVITROL...... 33 ZEPZELCA...... 24 VIZIMPRO...... 23 ZERVIATE...... 71 voriconazole...... 1 zidovudine...... 5 VOSEVI...... 5 ZIEXTENZO...... 63 VOTRIENT...... 23 ziprasidone hcl...... 39 VRAYLAR...... 39 ziprasidone mesylate...... 39 vyfemla (28)...... 70 ZIRABEV...... 24 vylibra...... 70 ZIRGAN...... 71 VYNDAMAX...... 46 ZOLADEX...... 24 VYNDAQEL...... 46 zoledronic acid...... 59 VYXEOS...... 23 zoledronic acid-mannitol­ warfarin...... 44 water...... 52, 59 wymzya fe...... 70 ZOLEDRONIC AC­ XALKORI...... 23 MANNITOL-0.9NACL...... 59 XARELTO...... 44 ZOLINZA...... 24 XARELTO DVT-PE zonisamide...... 27 TREAT 30D START...... 44 ZORTRESS...... 24 XATMEP...... 23 ZOSTAVAX (PF)...... 65 XCOPRI...... 27 ZOSYN IN DEXTROSE XCOPRI MAINTENANCE (ISO-OSM)...... 11 PACK...... 27 zovia 1/35e (28)...... 70 XCOPRI TITRATION zovia 1-35 (28)...... 70 PACK...... 27 ZTLIDO...... 48 XELJANZ...... 67 ZUBSOLV...... 33 XELJANZ XR...... 67 zumandimine (28)...... 70 XGEVA...... 13 ZYDELIG...... 24 XIAFLEX...... 52 ZYKADIA...... 24 XIFAXAN...... 10 ZYPREXA RELPREVV...... 39 XOLAIR...... 76 XOSPATA...... 23 XPOVIO...... 23 XTANDI...... 23 xulane...... 68 XURIDEN...... 52 You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in September 2021. 93 This formulary was updated on 9/1/2021. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at 1.800.758.4574; New York State residents: 1.800.758.4570 or, for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week, or visit express-scripts.com.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.800.758.4574; para residentes del estado de New York: 1.800.758.4570 (TTY: 1.800.716.3231).

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F00SNV1CW2 This drug list was updated in September 2021