Drug Formulary January 2020

Plus Drug Formulary January 2020

Blue Shield of California

This formulary corresponds with the following plans: Shield Savings℠ 2400/4800-G, Shield Spectrum PPO℠ Plan 2000-G

This formulary was last updated on 12/01/2019. This formulary is subject to change and all previous versions of the formulary no longer apply. For the most current information about the Plus Drug Formulary, visit www.blueshieldca.com/pharmacy.

You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue Shield Summary of Benefits and Evidence of Coverage. For plan and coverage documents, visit https://www.blueshieldca.com/bsca/bsc/wcm/connect/employer/employer_contents_en/policies. For additional information about your plan, call the customer service number on your Blue Shield member ID card.

blueshieldca.com Introduction to the formulary drug list

The Blue Shield Plus Drug Formulary is a list of medications that are approved by the Food and Drug Administration (FDA) and are selected based on safety, effectiveness, and cost. This list of generic and brand drugs is covered by your health insurance policy under the prescription drug benefit of the policy.

Definitions The following words and definitions will be used throughout the formulary drug list. Term “Brand name drug” is a drug that is marketed under a proprietary, trademark protected name. The brand name drug shall be listed in all CAPITAL letters. “Coinsurance” is a percentage of the cost of a covered health care benefit that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. “Copayment” is a fixed dollar amount that an enrollee pays for a covered health care benefit after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. “Deductible” is the amount an enrollee pays for covered health care benefits before the enrollee's health plan begins payment for all or part of the cost of the health care benefit under the terms of the policy. “Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health plan's prescription drug coverage. The tier in which a prescription drug is placed determines the enrollee's portion of the cost for the drug. “Enrollee” is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this this formulary template shall also include subscriber as defined in this section below. “Exception request” is a request for coverage of a prescription drug. If an enrollee, his or her designee, or prescribing health care provider submits an exception request for coverage of a prescription drug, the health plan must cover the prescription drug when the drug is determined to be medically necessary to treat the enrollee's condition. “Exigent circumstances” are when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a non-formulary drug. “Formulary” is the complete list of drugs preferred for use and eligible for coverage under a health plan product, and includes all drugs covered under the outpatient prescription drug benefit of the health plan product. Formulary is also known as a prescription drug list. “Generic drug” is the same drug as its brand name equivalent in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters. “Non-formulary drug” is a prescription drug that is not listed on the health plan's formulary. “Out-of-pocket costs” are copayments, coinsurance, and the applicable deductible, plus all costs for health care services that are not covered by the health plan. “Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee. “Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for which the drug is being prescribed. “Prescription drug” is a drug that is prescribed by the enrollee's prescribing provider and requires a prescription under applicable law.

i Term “Prior authorization” is a health plan's requirement that the enrollee or the enrollee's prescribing provider obtain the health plan's authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee to obtain the drug. “Step therapy” is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the enrollee to try one or more drugs to treat the enrollee's medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request. If the enrollee's prescribing provider submits a request for step therapy exception, the health plans shall make exceptions to step therapy when the criteria is met. “Subscriber” means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

How do I find a drug on this list? The drugs are listed alphabetically under the column titled “Prescription Drug Name” by its brand or generic name under the therapeutic category and class to which it belongs. You can search this list using the brand or generic name of the drug by: • Searching for the category or class to which the drug belongs and search for the name of the drug in alphabetical order or • Searching the Alphabetical Index of Drugs by the name of the drug.

Listing a drug on the formulary does not guarantee that it will be prescribed by your doctor or prescriber.

How do I know if the drug listed is a brand or generic drug? • A generic name for a brand name drug is listed after the brand name of the drug in all lowercase bold italics o If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all lowercase bold italics o When a generic drug is marketed with a brand name, the brand name will be listed after the generic name in parentheses in all CAPITALS. • A brand name drug is listed in all CAPITALS followed by the generic name in parentheses in lowercase bold italics.

Example Drug Type How the drug name will appear in the formulary drug list generic drug atorvastatin calcium generic drug marketed with a brand name oxycodone/acetaminophen (ENDOCET) brand drug LIPITOR (atorvastatin calcium)

What are drug tiers? Drugs are placed into drug tiers based on defined categories. The amount you pay for drugs in different tiers will vary. You can find information about what you pay by drug tier in the Summary of Benefits of your Blue Shield Evidence of Coverage (EOC).

The column titled “Drug Tier” is the cost level you pay for a drug.

Drug Tier name Description Tier† 1 Formulary generic Formulary generic drugs

2 Formulary brand Formulary brand drugs 3 Non-formulary brand Non-formulary brand drugs 4 Specialty or home self- Specialty drugs or self-administered injectables* injectable † Affordable Care Act (ACA) are preventive health drugs, including contraceptive drugs and devices. These drugs are covered at $0 when specific criteria are met.

* See your Evidence of Coverage or Certificate of Insurance for further details about coverage of specialty or self-administered injectables in your benefit.

Note about multi-source brand drugs: If you or your doctor choose a brand drug when a generic drug equivalent is available, you will pay the difference in cost, plus the Tier 1 copayment or coinsurance. You or your doctor can ask for an exception to the difference in cost through the Blue Shield prior authorization process. (See “What is the prior authorization/exception request process?” below for more information.)

You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue Shield Evidence of Coverage. For additional information about specific plans, call the customer service number on your Blue Shield member ID card.

Note: Blue Shield drug formularies apply to outpatient prescription drug benefits available through plans underwritten by Blue Shield of California (individually and collectively referred to as Blue Shield throughout this document).

How to read the formulary The column titled “Coverage Requirements and Limits” identifies coverage restrictions or limits for drugs when applicable.

Coverage Requirements and Limits Description AL1 Age Limit Prior authorization may be required if your age does not fall within the FDA, manufacturer, or treatment guideline recommendations. GL Gender Limit Prior authorization may be required if the FDA, manufacturer, or treatment guidelines do not recommend the drug for a gender. OAC Oral Anti-Cancer There is a maximum limit on the copayment/coinsurance amount for orally administered anti-cancer drugs. Please see your Summary of Benefits for more detailed information. PA Prior Authorization Prior authorization is required to determine coverage. PH Preventive Drugs Affordable Care Act (ACA) preventive health drugs, including contraceptive drugs and devices, are covered at $0 when specific criteria are met.* QLC Quantity Limit The prescription quantity covered is limited. Prior authorization is required for amounts greater than the limit. RO Retail Only This prescription can be dispensed at retail pharmacies only. It is not covered through mail service. C Short Cycle Blue Shield’s Short Cycle Specialty Drug Program allows initial prescriptions for select specialty drugs to be filled for a 15-day supply. When this occurs, the copayment or coinsurance will be prorated. SP Specialty Pharmacy These drugs are available exclusively through select specialty pharmacies.

iii

ST Step Therapy A specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical

* Does not apply to grandfathered plans, plans purchasedcondition. on or before March 23, 2010.

How often will the formulary change? This formulary is subject to change monthly. Formulary changes that may not have prior notice include the following: • A brand name drug may be moved to a higher tier or removed from the formulary if a new generic drug is added to the formulary, • A drug may be removed from the formulary when is it removed from the market because the Food and Drug Administration (FDA) deems a drug to be unsafe or the drug’s manufacturer removes the drug from the market, or • A drug is added to the formulary, moved to a lower tier, or has a utilization management requirement removed.

Formulary changes that will have at least 30-day prior notice to an affected insured before the change is effective include the following: • Moving a drug or dosage form to a higher tier, • Removal of a drug or dosage form from the formulary, • Adding or changing utilization management requirements or limits for a drug. o When a step therapy utilization management requirement changes, the new requirement will not require you to repeat the step therapy if you are already taking the drug for your condition as long as the drugs is still appropriate, your provider continues to prescribe the drug, and the drug is still considered safe and effective for your condition.

When a drug or dosage form is removed from the formulary and a drug was previously approved for coverage for your medical condition, coverage for the drug will continue if your provider continues to prescribe the drug for your condition and the drug is prescribed appropriately and is safe and effective for your condition.

For the most current information about the Blue Shield Plus Drug Formulary, visit blueshieldca.com/pharmacy.

What is a medical benefit drug versus a drug covered under the Outpatient Prescription Drug Benefit? A medical benefit drug is a drug that is not generally self-administered and administered by a health care professional. The outpatient prescription drug benefit includes FDA-approved drugs that are self- administered, commonly oral or self-injectable drugs, not otherwise excluded from coverage.

For additional information, check your Blue Shield Evidence of Coverage or call the customer service number on your Blue Shield member ID card.

What are preventive health drugs? Preventive health drugs are select drugs required by health reform legislation to be covered at no charge to the insured.* Preventive health drugs are determined based on evidence-based recommendations by the United States Preventive Services Task Force. For more details about preventive health drugs, visit blueshieldca.com/pharmacy.

What is a contraceptive drug or device? Contraceptives are drugs or devices, such as diaphragms or cervical caps, that help prevent pregnancy.

Most generic drug contraceptives and contraceptive devices are covered at no charge to the insured.* Most

iv brand drug contraceptives require a copayment, which may be waived based on medical necessity. Physicians or members may provide medical necessity information using the prior authorization process by calling or faxing a form to Blue Shield Pharmacy Services. (See “What is the prior authorization/exception request process?” below.)

What diabetes care drugs and products are covered under the Outpatient Prescription Drug Benefit? FDA-approved drugs for the treatment of diabetes are included in the formulary drug list. Diabetic testing supplies such as blood glucose test strips, urine test strips, lancets, insulin syringes/pens covered under the Outpatient Prescription Drug Benefit are also included in the formulary drug list.

What is step therapy? Step therapy means a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical condition.

Step therapy requirements are based on how the FDA recommends that a drug should be used, nationally recognized treatment guidelines, medical studies, information from the drug manufacturer, and the relative cost of treatment for a condition. Your provider may submit a request for an exception to the step therapy requirement.

To request an exception, please call the customer service number on your Blue Shield member ID card. You, your representative, or your doctor may submit an exception request to Blue Shield.

What is the prior authorization/exception request process? Drug prior authorization involves getting advance approval of coverage for a prescription medication based on medical necessity. Some drugs require review of the patient’s prescription and medical history to determine coverage.

The exception process involves requesting coverage of a non-formulary drug. A formulary exception, which allows coverage of a non-formulary drug is based on medical necessity.

To request prior authorization or a non-formulary coverage exception, please call the customer service number on your Blue Shield member ID card. You, your representative, or your doctor may submit an exception request to Blue Shield.

Once we receive all the needed supporting information, we will approve or deny the exception request based on medical necessity within 72 hours for non-urgent requests, or within 24 hours in urgent or exigent circumstances. If Blue Shield denies a request for prior authorization or an exception request, the member, an authorized representative, or the provider can file an appeal/grievance with Blue Shield, as described in the “Grievance Process” section of the EOC.

Participating retail pharmacies You can fill prescriptions at any participating (network) pharmacy, unless it is a prescription for a specialty drug. Blue Shield contracts with a wide network of retail pharmacies. To find a network pharmacy, visit blueshieldca.com/pharmacy.

What are specialty drugs? Specialty drugs are drugs that may require coordination of care, close monitoring, or extensive patient training for self- administration. These requirements generally cannot be met by a retail pharmacy. Specialty drugs may also require special handling or manufacturing processes (such as biotechnology), restriction to certain physicians or pharmacies, or reporting of certain clinical events to the FDA. Specialty drugs are usually high- cost.

Specialty drugs may require prior authorization for medical necessity by Blue Shield. Most specialty drugs are

v available exclusively from a Network Specialty Pharmacy. If coverage is approved, a Network Specialty Pharmacy can provide specialty drugs by mail or, upon your request, can transfer the specialty drug to an associated retail store for pickup. Call the customer service number on your Blue Shield member ID card or visit blueshieldca.com/pharmacy if you have questions about specialty drugs.

Mail service pharmacy Blue Shield offers an easy-to-use mail service prescription drug program through our contracted mail service pharmacy. You can save time and money using the mail service drug program. It can be a convenient way to fill maintenance medications for up to a 90-day supply. Maintenance medications are drugs that doctors prescribe on an ongoing, regular basis to maintain health. For more information on using the mail service prescription benefit, visit blueshieldca.com/pharmacy.

Table of Contents ANALGESICS (Drugs for Pain) 1 ANESTHETICS (Drugs for Numbing) 13 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs for Addiction/Substance Abuse) 14 ANTIBACTERIALS (Drugs for Bacterial Infections) 16 ANTICONVULSANTS (Drugs for Seizures) 24 ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease and Dementia) 30 ANTIDEPRESSANTS (Drugs for Depression) 31 ANTIEMETICS (Drugs for Nausea and Vomiting) 35 ANTIFUNGALS (Drugs for Fungal Infections) 37 ANTIGOUT AGENTS (Drugs for Gout) 39 ANTIMIGRAINE AGENTS (Drugs for Migraine) 40 ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 41 ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 42 ANTINEOPLASTICS (Drugs for Cancer) 43 ANTIPARASITICS (Drugs for Parasitic Infections) 51 ANTIPARKINSON AGENTS (Drugs for Parkinson's Disease) 52 ANTIPSYCHOTICS (Drugs for Mental Health) 55 ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 57 ANTIVIRALS (Drugs for Viral Infections) 57 ANXIOLYTICS (Drugs for Anxiety) 66 BIPOLAR AGENTS (Drugs for Bipolar Disorder) 67 BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 68 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (Drugs for Blood Disorders) 74 CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 77 CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 94 DENTAL AND ORAL AGENTS (Drugs for the Mouth) 104 DERMATOLOGICAL AGENTS (Drugs for the Skin) 104 ELECTROLYTES/MINERALS/METALS/VITAMINS 112 GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 123 GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT (Drugs for Genetic or Enzyme Disorders) 129 GENITOURINARY AGENTS (Drugs for the Genital, Bladder, and Kidney) 130 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Drugs for Replacing/Stimulating Adrenal Gland Hormones) 135 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs for Replacing/Stimulating Pituitary Gland Hormones) 141 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) (Drugs for Replacing/Stimulating Sex Hormones) 142 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs for the Thyroid) 156 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary Gland) 157 HORMONAL AGENTS, SUPPRESSANT (THYROID) (Drugs for the Thyroid) 158

LAST UPDATED 12/01/2019 IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 158 INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 161 METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 162 MISCELLANEOUS THERAPEUTIC AGENTS 164 OPHTHALMIC AGENTS (Drugs for the Eyes) 166 OTIC AGENTS (Drugs for the Ears) 172 RESPIRATORY TRACT/PULMONARY AGENTS (Drugs for the Lungs) 172 SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 183 SLEEP DISORDER AGENTS (Drugs for Insomnia) 184

LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANALGESICS (Drugs for Pain) NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and Arthritis Drugs) ANAPROX (naproxen sodium) TIER 3 ANAPROX DS (naproxen sodium) TIER 3 ARTHROTEC 50 (diclofenac TIER 3 sodium/misoprostol) ARTHROTEC 75 (diclofenac TIER 3 sodium/misoprostol) butalbital/aspirin/caffeine 50-325-40 TIER 1 QLC (6 caps/day) capsule butalbital/aspirin/caffeine 50-325-40 TIER 1 QLC (6 tabs/day) tablet CAMBIA (diclofenac potassium) TIER 3 PA, QLC (9 packs/month) CELEBREX (celecoxib) 400 MG CAPSULE TIER 3 QLC (1 cap/day) CELEBREX (celecoxib) 50 MG CAPSULE, TIER 3 QLC (2 caps/day) 100 MG CAPSULE, 200 MG CAPSULE celecoxib 400 mg capsule TIER 1 QLC (1 cap/day) celecoxib 50 mg capsule, 100 mg TIER 1 QLC (2 caps/day) capsule, 200 mg capsule DAYPRO (oxaprozin) TIER 3 diclofenac epolamine TIER 1 PA, QLC (2 patches/day) diclofenac potassium TIER 1 diclofenac sodium (KLOFENSAID II) TIER 1 PA, QLC (1 bottle/month) diclofenac sodium 1.5 % drops TIER 1 PA, QLC (1 bottle/month) diclofenac sodium 25 mg tablet dr, 50 mg TIER 1 tablet dr, 75 mg tablet dr, 100 mg tab er 24h diclofenac sodium/misoprostol TIER 1 diflunisal TIER 1 DISALCID (salsalate) TIER 3 DUEXIS (ibuprofen/famotidine) TIER 3 PA, QLC (3 tabs/day) EC-NAPROSYN (naproxen) TIER 3

AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization; PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle; SP – Specialty Pharmacy; ST – Step Therapy

1 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS etodolac TIER 1 FELDENE (piroxicam) TIER 3 fenoprofen calcium (FENORTHO) TIER 3 PA, QLC (8 caps/day) fenoprofen calcium (PROFENO) TIER 1 PA, QLC (4 tabs/day) fenoprofen calcium 200 mg capsule, 400 TIER 1 PA, QLC (8 caps/day) mg capsule fenoprofen calcium 600 mg tablet TIER 1 PA, QLC (4 tabs/day) FENORTHO (fenoprofen calcium) TIER 3 PA, QLC (8 caps/day) FIORINAL (butalbital/aspirin/caffeine) TIER 3 QLC (6 caps/day) FLECTOR (diclofenac epolamine) TIER 3 PA, QLC (2 patches/day) flurbiprofen TIER 1 ibuprofen (IBU) TIER 1 ibuprofen 400 mg tablet, 600 mg tablet, TIER 1 800 mg tablet INDOCIN (indomethacin) TIER 3 indomethacin TIER 1 ketoprofen TIER 1 ketorolac tromethamine 10 mg tablet TIER 1 QLC (4 tabs/day, not to exceed 20 tabs/30 days) LODINE (etodolac) TIER 3 meclofenamate sodium TIER 1 mefenamic acid TIER 1 meloxicam TIER 1 MOBIC (meloxicam) TIER 3 nabumetone TIER 1 NALFON (fenoprofen calcium) 400 MG TIER 3 PA, QLC (8 caps/day) CAPSULE NALFON (fenoprofen calcium) 600 MG TIER 3 PA, QLC (4 tabs/day) TABLET NAPRELAN (naproxen sodium) CR 375 MG TIER 3 ST, QLC (1 tab/day) TABLET NAPRELAN (naproxen sodium) CR 500 MG TIER 3 ST, QLC (2 tabs/day) TABLET, CR 750 MG TABLET NAPROSYN (naproxen) TIER 3

2 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS naproxen TIER 1 naproxen sodium 275 mg tablet, 550 mg TIER 1 tablet naproxen sodium 375 mg tbmp 24hr TIER 1 ST, QLC (1 tab/day) naproxen sodium 500 mg tbmp 24hr TIER 1 ST, QLC (2 tabs/day) oxaprozin TIER 1 PENNSAID (diclofenac sodium) TIER 3 PA, QLC (1 bottle/month) piroxicam TIER 1 PONSTEL (mefenamic acid) TIER 3 QMIIZ ODT (meloxicam) TIER 3 PA, QLC (1 tab/day) RELAFEN DS (nabumetone) TIER 3 PA, QLC (2 tabs/day) salsalate TIER 1 SPRIX (ketorolac tromethamine) TIER 3 PA, QLC (5 bottles/month) sulindac TIER 1 TIVORBEX (indomethacin, submicronized) TIER 3 ST, QLC (3 caps/day) tolmetin sodium TIER 1 VIMOVO (naproxen/esomeprazole TIER 3 PA, QLC (2 tabs/day) magnesium) VIVLODEX (meloxicam, submicronized) TIER 3 PA, QLC (1 cap/day) VOLTAREN-XR (diclofenac sodium) TIER 3 ZIPSOR (diclofenac potassium) TIER 3 ST, QLC (4 caps/day) ZORVOLEX (diclofenac submicronized) TIER 3 ST, QLC (3 caps/day) OPIOID ANALGESICS, LONG-ACTING (Long-acting Narcotic Pain Relievers) ARYMO ER (morphine sulfate) TIER 3 PA, QLC (3 tabs/day) BELBUCA (buprenorphine hcl) TIER 3 PA, QLC (2 films/day) buprenorphine TIER 1 PA, QLC (4 patches/28 days) BUTRANS (buprenorphine) TIER 3 PA, QLC (4 patches/28 days) CONZIP (tramadol hcl) TIER 3 ST, QLC (1 cap/day) DISKETS (methadone hcl) TIER 3 PA, QLC (5 tabs/day) DOLOPHINE HCL (methadone hcl) 10 MG TIER 3 PA, QLC (18 tabs/day) TABLET

3 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DOLOPHINE HCL (methadone hcl) 5 MG TIER 3 PA, QLC (36 tabs/day) TABLET DURAGESIC (fentanyl) TIER 3 PA, QLC (20 patches/month) EMBEDA (morphine sulfate/naltrexone TIER 3 PA, QLC (4 caps/day) hcl) ER 20-0.8 MG CAPSULE EMBEDA (morphine sulfate/naltrexone TIER 3 PA, QLC (2 caps/day) hcl) ER 30-1.2 MG CAPSULE, ER 50-2 MG CAPSULE, ER 60-2.4 MG CAPSULE EMBEDA (morphine sulfate/naltrexone TIER 3 PA, QLC (1 cap/day) hcl) ER 80-3.2 MG CAPSULE, ER 100-4 MG CAPSULE EXALGO (hydromorphone hcl) ER 12 MG TIER 3 PA, QLC (5 tabs/day) TABLET EXALGO (hydromorphone hcl) ER 16 MG TIER 3 PA, QLC (4 tabs/day) TABLET EXALGO (hydromorphone hcl) ER 32 MG TIER 3 PA, QLC (2 tabs/day) TABLET EXALGO (hydromorphone hcl) ER 8 MG TIER 3 PA, QLC (1 tab/day) TABLET fentanyl 12 mcg/hr patch, 25 mcg/hr TIER 1 PA, QLC (20 patches/month) patch, 50mcg/hr patch, 75mcg/hr patch, 100 mcg/hr patch fentanyl 37.5mcg/hr patch, 62.5mcg/hr TIER 4 PA, QLC (10 patches/month) patch, 87.5mcg/hr patch hydromorphone hcl 12 mg tab er 24h TIER 1 PA, QLC (5 tabs/day) hydromorphone hcl 16 mg tab er 24h TIER 1 PA, QLC (4 tabs/day) hydromorphone hcl 32 mg tab er 24h TIER 1 PA, QLC (2 tabs/day) hydromorphone hcl 8 mg tab er 24h TIER 1 PA, QLC (1 tab/day) HYSINGLA ER (hydrocodone bitartrate) ER TIER 3 PA, QLC (1 cap/day) 20 MG TABLET, ER 30 MG TABLET, ER 40 MG TABLET, ER 60 MG TABLET HYSINGLA ER (hydrocodone bitartrate) ER TIER 4 PA, QLC (1 cap/day) 80 MG TABLET, ER 100 MG TABLET, ER 120 MG TABLET KADIAN (morphine sulfate) ER 10 MG TIER 3 PA, QLC (2 caps/day) CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE, ER 100 MG CAPSULE KADIAN (morphine sulfate) ER 20 MG TIER 3 PA, QLC (4 caps/day) CAPSULE

4 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS KADIAN (morphine sulfate) ER 60 MG TIER 3 PA, QLC (3 caps/day) CAPSULE, ER 80 MG CAPSULE, ER 200 MG CAPSULE levorphanol tartrate 2 mg tablet TIER 1 PA, QLC (9 tabs/day) levorphanol tartrate 3 mg tablet TIER 1 PA, QLC (4 tabs/day) methadone hcl (METHADONE INTENSOL) TIER 1 PA, QLC (18 ml/day) methadone hcl (METHADOSE) TIER 1 PA, QLC (5 tabs/day) methadone hcl 10 mg tablet TIER 1 PA, QLC (18 tabs/day) methadone hcl 10 mg/5 ml solution TIER 1 PA, QLC (90 ml/day) methadone hcl 10 mg/ml oral conc TIER 1 PA, QLC (18 ml/day) methadone hcl 40 mg tablet sol TIER 1 PA, QLC (5 tabs/day) methadone hcl 5 mg tablet TIER 1 PA, QLC (36 tabs/day) methadone hcl 5 mg/5 ml solution TIER 1 PA, QLC (180 ml/day) METHADOSE (methadone hcl) TIER 3 PA, QLC (18 ml/day) MORPHABOND ER (morphine sulfate) TIER 3 PA, QLC (2 tabs/day) morphine sulfate 10 mg cap er, 30 mg TIER 1 PA, QLC (2 caps/day) cap er, 50 mg cap er, 100 mg cap er morphine sulfate 100 mg tablet er, 200 TIER 1 QLC (3 tabs/day) mg tablet er morphine sulfate 120 mg cpmp 24hr TIER 1 PA, QLC (13 caps/day) morphine sulfate 15 mg tablet er, 30 mg TIER 1 QLC (6 tabs/day) tablet er morphine sulfate 20 mg cap er pel TIER 1 PA, QLC (4 caps/day) morphine sulfate 30 mg, 45 mg, 60 mg, 75 TIER 1 PA, QLC (1 cap/day) mg morphine sulfate 40 mg cap er pel TIER 1 PA, QLC (2 caps/day) morphine sulfate 60 mg cap er pel, 80 mg TIER 1 PA, QLC (3 caps/day) cap er pel, 90 mg cpmp 24hr morphine sulfate 60 mg tablet er TIER 1 QLC (5 tabs/day) MS CONTIN (morphine sulfate) ER 100 MG TIER 3 QLC (3 tabs/day) TABLET, ER 200 MG TABLET MS CONTIN (morphine sulfate) ER 15 MG TIER 3 QLC (6 tabs/day) TABLET, ER 30 MG TABLET MS CONTIN (morphine sulfate) ER 60 MG TIER 3 QLC (5 tabs/day) TABLET

5 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NUCYNTA ER (tapentadol hcl) TIER 3 PA, QLC (2 tabs/day) OPANA ER (oxymorphone hcl) 40 MG TIER 3 PA, QLC (4 tabs/day) TABLET OPANA ER (oxymorphone hcl) ER 5 MG TIER 3 PA, QLC (2 tabs/day) TABLET, ER 7.5 MG TABLET, ER 10 MG TABLET, ER 15 MG TABLET, ER 20 MG TABLET, ER 30 MG TABLET oxycodone hcl 10 mg tab er 12h TIER 1 PA, QLC (9 tabs/day) oxycodone hcl 15 mg tab er, 20 mg tab TIER 1 PA, QLC (6 tabs/day) er, 30 mg tab er oxycodone hcl 40 mg tab er, 80 mg tab TIER 1 PA, QLC (4 tabs/day) er oxycodone hcl 60 mg tab er 12h TIER 1 PA, QLC (2 tabs/day) OXYCONTIN (oxycodone hcl) ER 10 MG TIER 3 PA, QLC (9 tabs/day) TABLET OXYCONTIN (oxycodone hcl) ER 15 MG TIER 3 PA, QLC (6 tabs/day) TABLET, ER 20 MG TABLET, ER 30 MG TABLET OXYCONTIN (oxycodone hcl) ER 40 MG TIER 3 PA, QLC (4 tabs/day) TABLET, ER 80 MG TABLET OXYCONTIN (oxycodone hcl) ER 60 MG TIER 3 PA, QLC (2 tabs/day) TABLET oxymorphone hcl 40 mg tab er 12h TIER 1 PA, QLC (4 tabs/day) oxymorphone hcl 5 mg tab er, 7.5 mg tab TIER 1 PA, QLC (2 tabs/day) er, 10 mg tab er, 15 mg tab er, 20 mg tab er, 30 mg tab er tramadol hcl 100 mg 25-75, 200 mg 25-75, TIER 1 ST, QLC (1 cap/day) 300 mg 17-83 tramadol hcl 100 mg tab er 24h TIER 1 ST, QLC (3 tabs/day) tramadol hcl 100 mg tbmp 24hr, 200 mg TIER 1 ST, QLC (1 tab/day) tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr tramadol hcl 150 mg cpbp 25-75 TIER 1 ST, QLC (2 caps/day) ULTRAM ER (tramadol hcl) 100 MG TABLET TIER 3 ST, QLC (3 tabs/day) ULTRAM ER (tramadol hcl) ER 200 MG TIER 3 ST, QLC (1 tab/day) TABLET, ER 300 MG TABLET XTAMPZA ER (oxycodone myristate) TIER 3 PA, QLC (2 caps/day) ZOHYDRO ER (hydrocodone bitartrate) TIER 3 PA, QLC (2 caps/day)

6 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS OPIOID ANALGESICS, SHORT-ACTING (Short-acting Narcotic Pain Relievers) ABSTRAL (fentanyl citrate) 100 MCG TAB TIER 3 PA, QLC (56 tabs/month) SUBLINGUAL ABSTRAL (fentanyl citrate) 200 MCG TAB TIER 3 PA, QLC (42 tabs/month) SUBLINGUAL ABSTRAL (fentanyl citrate) 300 MCG TAB, TIER 3 PA, QLC (28 tabs/month) 400 MCG TAB ABSTRAL (fentanyl citrate) 600 MCG TAB, TIER 3 PA, QLC (14 tabs/month) 800 MCG TAB acetaminophen with codeine phosphate TIER 1 QLC (168 tabs/month) -15mg tablet, -30mg tablet acetaminophen with codeine phosphate TIER 1 QLC (840 ml/month) 120-12mg/5, 300mg/12.5 acetaminophen with codeine phosphate TIER 1 QLC (84 tabs/month) 300mg-60mg tablet acetaminophen/caffeine/dihydrocodein TIER 1 PA, QLC (140 tabs/month) e bitartrate (DVORAH) acetaminophen/caffeine/dihydrocodein TIER 1 PA, QLC (140 tabs/month) e bitartrate (PANLOR) acetaminophen/caffeine/dihydrocodein TIER 1 PA, QLC (140 caps/month) e bitartrate acetaminophen/caff/dihydrocod 320.5- 30mg capsule acetaminophen/caffeine/dihydrocodein TIER 1 PA, QLC (140 tabs/month) e bitartrate acetaminophen/caff/dihydrocod 325-30- 16 tablet ACTIQ (fentanyl citrate) TIER 3 PA, QLC (56 lozenges/month) APADAZ (benzhydrocodone TIER 3 PA, QLC (12 tabs/day; not to hcl/acetaminophen) 4.08-325 MG TABLET exceed 168 tabs/30 days) APADAZ (benzhydrocodone TIER 3 PA, QLC (12 tabs/day; not to hcl/acetaminophen) 6.12-325 MG TABLET exceed 168 tabs/30 days) APADAZ (benzhydrocodone TIER 3 PA, QLC (9 tabs/day; not to hcl/acetaminophen) 8.16-325 MG TABLET exceed 126 tabs/30 days) benzhydrocodone hcl/acetaminophen TIER 1 PA, QLC (12 tabs/day; not to benzhydrocodone/acetaminophen 4.08- exceed 168 tabs/30 days) 325mg tablet benzhydrocodone hcl/acetaminophen TIER 1 PA, QLC (12 tabs/day; not to benzhydrocodone/acetaminophen 6.12- exceed 168 tabs/30 days) 325mg tablet

7 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS benzhydrocodone hcl/acetaminophen TIER 1 PA, QLC (9 tabs/day; not to benzhydrocodone/acetaminophen 8.16- exceed 126 tabs/30 days) 325mg tablet butalbital/acetaminophen/caffeine/cod TIER 1 QLC (84 caps/month) eine phosphate butorphanol tartrate 10 mg/ml spray TIER 1 QLC (4 canisters/month at 2 canisters/fill) CAPITAL W-CODEINE (acetaminophen TIER 3 QLC (2380 ml/month) with codeine phosphate) carisoprodol/aspirin/codeine phosphate TIER 1 AL1 (Up to 65 yrs old), QLC (8 tabs/day) codeine TIER 1 QLC (84 caps/month) phosphate/butalbital/aspirin/caffeine codeine TIER 1 QLC (84 caps/month) phosphate/butalbital/aspirin/caffeine (ASCOMP WITH CODEINE) codeine sulfate 15 mg tablet TIER 1 QLC (336 tabs/month) codeine sulfate 30 mg tablet TIER 1 QLC (168 tabs/month) codeine sulfate 60 mg tablet TIER 1 QLC (84 tabs/month) DEMEROL (meperidine hcl) 100 MG TIER 3 AL1 (Up to 65 yrs old), QLC (126 TABLET tabs/month) DEMEROL (meperidine hcl) 50 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (252 tabs/month) DILAUDID (hydromorphone hcl) 2 MG TIER 3 QLC (154 tabs/month) TABLET DILAUDID (hydromorphone hcl) 4 MG TIER 3 QLC (84 tabs/month) TABLET DILAUDID (hydromorphone hcl) 5 MG/5 TIER 3 QLC (56 ml/month) ML ORAL LIQUID DILAUDID (hydromorphone hcl) 8 MG TIER 3 QLC (42 tabs/month) TABLET fentanyl citrate 100 mcg tablet eff TIER 1 PA, QLC (56 tabs/month) fentanyl citrate 200 mcg tablet eff TIER 1 PA, QLC (42 tabs/month) fentanyl citrate 200 mcg, 400 mcg, 600 TIER 1 PA, QLC (56 lozenges/month) mcg, 800 mcg, 1200 mcg, 1600 mcg fentanyl citrate 400 mcg tablet eff TIER 1 PA, QLC (28 tabs/month) fentanyl citrate 600 mcg tablet, 800 mcg TIER 1 PA, QLC (14 tabs/month) tablet

8 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS FENTORA (fentanyl citrate) 100 MCG TIER 3 PA, QLC (56 tabs/month) BUCCAL TABLET FENTORA (fentanyl citrate) 200 MCG TIER 3 PA, QLC (42 tabs/month) BUCCAL TABLET FENTORA (fentanyl citrate) 400 MCG TIER 3 PA, QLC (28 tabs/month) BUCCAL TABLET FENTORA (fentanyl citrate) 600 MCG TIER 3 PA, QLC (14 tabs/month) TABLET, 800 MCG TABLET FIORICET WITH CODEINE TIER 3 QLC (84 caps/month) (butalbital/acetaminophen/caffeine/cod eine phosphate) FIORINAL WITH CODEINE #3 (codeine TIER 3 QLC (84 caps/month) phosphate/butalbital/aspirin/caffeine) HYCET (hydrocodone TIER 3 QLC (90 ml/day; max 1260 ml/30 bitartrate/acetaminophen) days) hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) (LORCET HD) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (LORCET PLUS) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (LORCET) hydrocodone bitartrate/acetaminophen TIER 1 QLC (945 ml/month) (LORTAB) hydrocodone/acetaminophen 10-300/15 solution hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) (LORTAB) hydrocodone/acetaminophen 10mg-325mg tablet hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (LORTAB) hydrocodone/acetaminophen 5 mg-325mg tablet, hydrocodone/acetaminophen 7.5-325 mg tablet hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (VERDROCET) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (VICODIN ES) hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) (VICODIN HP) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (VICODIN)

9 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) hydrocodone/acetaminophen -300mg tablet, hydrocodone/acetaminophen - 325mg tablet hydrocodone bitartrate/acetaminophen TIER 1 PA, QLC (868 ml/month) hydrocodone/acetaminophen 10-325/15 solution hydrocodone bitartrate/acetaminophen TIER 1 PA, QLC (90 ml/day; max 1260 hydrocodone/acetaminophen 2.5-108/5, ml/30 days) hydrocodone/acetaminophen 5- 217mg/10 hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) hydrocodone/acetaminophen 2.5-325 mg tablet, hydrocodone/acetaminophen 5 mg- 325mg tablet, hydrocodone/acetaminophen 5 mg- 300mg tablet, hydrocodone/acetaminophen 7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-300 mg tablet hydrocodone bitartrate/acetaminophen TIER 1 QLC (90 ml/day; max 1260 ml/30 hydrocodone/acetaminophen 7.5-325/15 days) solution hydrocodone/ibuprofen (IBUDONE) TIER 1 QLC (112 tabs/month) hydrocodone/ibuprofen (XYLON 10) TIER 1 QLC (70 tabs/month) hydrocodone/ibuprofen 5mg-200mg TIER 1 QLC (112 tabs/month) tablet hydrocodone/ibuprofen 7.5-200 mg TIER 1 QLC (70 tabs/month) tablet, 10mg-200mg tablet hydromorphone hcl 1 mg/ml liquid TIER 1 QLC (56 ml/month) hydromorphone hcl 2 mg tablet TIER 1 QLC (154 tabs/month) hydromorphone hcl 3 mg supp.rect TIER 1 QLC (112 suppositories/month) hydromorphone hcl 4 mg tablet TIER 1 QLC (84 tabs/month) hydromorphone hcl 8 mg tablet TIER 1 QLC (42 tabs/month) IBUDONE (hydrocodone/ibuprofen) TIER 3 QLC (70 tabs/month) ibuprofen/oxycodone hcl TIER 1 QLC (56 tabs/month) LAZANDA (fentanyl citrate) TIER 3 PA, QLC (14 bottles/month) meperidine hcl 100 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (126 tabs/month)

10 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS meperidine hcl 50 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (252 tabs/month) meperidine hcl 50 mg/5 ml solution TIER 1 AL1 (Up to 65 yrs old), QLC (1260 ml/month) morphine sulfate 10 mg supp.rect TIER 1 QLC (126 suppositories/month) morphine sulfate 10 mg/5 ml solution TIER 1 QLC (630 ml/month) morphine sulfate 100 mg/5ml solution TIER 1 QLC (70 ml/month) morphine sulfate 15 mg tablet TIER 1 QLC (84 tabs/month) morphine sulfate 20 mg supp.rect TIER 1 QLC (70 suppositories/month) morphine sulfate 20 mg/5 ml solution TIER 1 QLC (84 ml/month) morphine sulfate 30 mg supp.rect TIER 1 QLC (42 suppositories/month) morphine sulfate 30 mg tablet TIER 1 QLC (42 tabs/month) morphine sulfate 5 mg supp.rect TIER 1 QLC (168 suppositories/month) NORCO (hydrocodone TIER 3 QLC (126 tabs/month) bitartrate/acetaminophen) 10-325 TABLET NORCO (hydrocodone TIER 3 QLC (168 tabs/month) bitartrate/acetaminophen) 5-325 TABLET, 7.5-325 TABLET NUCYNTA (tapentadol hcl) 50 MG TABLET TIER 3 PA, QLC (70 tabs/month) NUCYNTA (tapentadol hcl) 75 MG TABLET, TIER 3 PA, QLC (56 tabs/month) 100 MG TABLET OPANA (oxymorphone hcl) 10 MG TABLET TIER 3 PA, QLC (56 tabs/month) OPANA (oxymorphone hcl) 5 MG TABLET TIER 3 PA, QLC (84 tabs/month) OXAYDO (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month) OXAYDO (oxycodone hcl) 7.5 MG TABLET TIER 3 PA, QLC (112 tabs/month) oxycodone hcl 10 mg tablet TIER 1 QLC (84 tabs/month) oxycodone hcl 15 mg tablet TIER 1 QLC (56 tabs/month) oxycodone hcl 20 mg tablet TIER 1 QLC (42 tabs/month) oxycodone hcl 20 mg/ml oral conc TIER 1 QLC (42 ml/month) oxycodone hcl 30 mg tablet TIER 1 QLC (28 tabs/month) oxycodone hcl 5 mg capsule TIER 1 QLC (168 caps/month) oxycodone hcl 5 mg tablet TIER 1 QLC (168 tabs/month) oxycodone hcl 5 mg/5 ml solution TIER 1 QLC (840 ml/month)

11 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS oxycodone hcl/acetaminophen TIER 1 QLC (84 tabs/month) (ENDOCET) 10mg-325mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (168 tabs/month) (ENDOCET) 2.5-325 mg tablet, 5 mg- 325mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (112 tabs/month) (ENDOCET) 7.5-325 mg tablet oxycodone hcl/acetaminophen TIER 1 PA, QLC (12 tabs/day; not to (NALOCET) exceed 168 tabs/month) oxycodone hcl/acetaminophen TIER 1 QLC (84 tabs/month) (PRIMLEV) 10mg-300mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (168 tabs/month) (PRIMLEV) 5 mg-300mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (112 tabs/month) (PRIMLEV) 7.5-300 mg tablet oxycodone hcl/acetaminophen 10mg- TIER 1 QLC (84 tabs/month) 325mg tablet oxycodone hcl/acetaminophen 2.5-325 TIER 1 QLC (168 tabs/month) mg tablet, 5 mg-325mg tablet oxycodone hcl/acetaminophen 5-325/5 TIER 1 QLC (840 ml/month) ml solution oxycodone hcl/acetaminophen 7.5-325 TIER 1 QLC (112 tabs/month) mg tablet oxycodone hcl/aspirin TIER 1 QLC (168 tabs/month) oxymorphone hcl 10 mg tablet TIER 1 PA, QLC (56 tabs/month) oxymorphone hcl 5 mg tablet TIER 1 PA, QLC (84 tabs/month) pentazocine hcl/naloxone hcl TIER 1 AL1 (Up to 65 yrs old), QLC (18 tabs/day) PERCOCET (oxycodone TIER 3 QLC (84 tabs/month) hcl/acetaminophen) 10-325 MG TABLET PERCOCET (oxycodone TIER 3 QLC (168 tabs/month) hcl/acetaminophen) 2.5-325 MG TABLET, 5-325 MG TABLET PERCOCET (oxycodone TIER 3 QLC (112 tabs/month) hcl/acetaminophen) 7.5-325 MG TABLET ROXICODONE (oxycodone hcl) 15 MG TIER 3 QLC (56 tabs/month) TABLET ROXICODONE (oxycodone hcl) 30 MG TIER 3 QLC (28 tabs/month) TABLET

12 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ROXICODONE (oxycodone hcl) 5 MG TIER 3 QLC (168 tabs/month) TABLET ROXYBOND (oxycodone hcl) 15 MG TIER 3 PA, QLC (56 tabs/month, not to TABLET exceed 4 tabs/day) ROXYBOND (oxycodone hcl) 30 MG TIER 3 PA, QLC (28 tabs/month, not to TABLET exceed 2 tabs/day) ROXYBOND (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month; not to exceed 12 tabs/day) SKYRIZI (2 SYRINGES) KIT (risankizumab- TIER 4 PA, SP, QLC (1 kit/84 days) rzaa) SUBSYS (fentanyl) 100 MCG SPRAY, 1,200 TIER 3 PA, QLC (56 doses/month) MCG SPRAY, 1,600 MCG SPRAY SUBSYS (fentanyl) 200 MCG SPRAY TIER 3 PA, QLC (42 doses/month) SUBSYS (fentanyl) 400 MCG SPRAY, 600 TIER 3 PA, QLC (14 doses/month) MCG SPRAY, 800 MCG SPRAY tramadol hcl 50 mg tablet TIER 1 QLC (112 tabs/month) tramadol hcl/acetaminophen TIER 1 QLC (112 tabs/month) TREZIX TIER 3 PA, QLC (140 caps/month) (acetaminophen/caffeine/dihydrocodein e bitartrate) TYLENOL-CODEINE NO.3 (acetaminophen TIER 3 QLC (168 tabs/month) with codeine phosphate) TYLENOL-CODEINE NO.4 (acetaminophen TIER 3 QLC (84 tabs/month) with codeine phosphate) ULTRACET (tramadol hcl/acetaminophen) TIER 3 QLC (112 tabs/month) ULTRAM (tramadol hcl) TIER 3 XARTEMIS XR (oxycodone TIER 3 PA, QLC (4 tabs/day) hcl/acetaminophen)

ANESTHETICS (Drugs for Numbing) LOCAL ANESTHETICS (Skin Numbing Drugs) EMLA (lidocaine/prilocaine) TIER 3 QLC (30 gm/month) lidocaine 5 % adh. patch TIER 1 QLC (90 patches/month) lidocaine 5 % oint. (g) TIER 1 QLC (50 gm/month) lidocaine hcl (GLYDO) TIER 1 lidocaine hcl 2 % jelly(ml), 2 % jel/pf app, TIER 1 2 % solution, 40 mg/ml solution

13 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lidocaine/prilocaine 2.5 %-2.5% cream (g) TIER 1 QLC (30 gm/month) LIDODERM (lidocaine) TIER 3 QLC (90 patches/month) NAYZILAM (midazolam) TIER 3 QLC (2 sprayers/fill; max 5 fills/30 days) SYNERA (lidocaine/tetracaine) TIER 3 PA, QLC (1 patch/month) XYLOCAINE (lidocaine hcl) 4% SOLUTION TIER 3 ZTLIDO (lidocaine) TIER 3 PA, QLC (3 patches/day)

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs for Addiction/Substance Abuse) ALCOHOL DETERRENTS/ANTI-CRAVING (Drugs for Alcohol Dependence) acamprosate calcium TIER 1 ANTABUSE (disulfiram) TIER 3 disulfiram TIER 1 naltrexone hcl TIER 1 OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence) BUNAVAIL (buprenorphine hcl/naloxone TIER 3 QLC (1 film/day) hcl) 2.1-0.3 MG FILM BUNAVAIL (buprenorphine hcl/naloxone TIER 3 QLC (2 films/day) hcl) 4.2-0.7 MG FILM, 6.3-1 MG FILM buprenorphine hcl 2 mg tab subl TIER 1 QLC (12 tabs/day; not to exceed 7 days therapy/90 days) buprenorphine hcl 8 mg tab subl TIER 1 QLC (3 tabs/day; not to exceed 7 days supply over 90 days) buprenorphine hcl/naloxone hcl TIER 1 QLC (2 films/day) /naloxone 12 mg-3 mg film buprenorphine hcl/naloxone hcl TIER 1 QLC (12 tabs/day) /naloxone 2 mg-0.5mg tab subl buprenorphine hcl/naloxone hcl TIER 1 QLC (5 films/day) /naloxone 2 mg-0.5mg, /naloxone 4mg- 1mg buprenorphine hcl/naloxone hcl TIER 1 QLC (3 films/day) /naloxone 8 mg-2 mg film buprenorphine hcl/naloxone hcl TIER 1 QLC (3 tabs/day) /naloxone 8 mg-2 mg tab subl

14 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LUCEMYRA (lofexidine hcl) TIER 3 PA, QLC (16 tabs/day, not to exceed 224 tabs/6 months) SUBOXONE (buprenorphine hcl/naloxone TIER 3 QLC (2 films/day) hcl) 12 MG-3 MG SL FILM SUBOXONE (buprenorphine hcl/naloxone TIER 3 QLC (5 films/day) hcl) 2 MG-0.5 MG FILM, 4 MG-1 MG FILM SUBOXONE (buprenorphine hcl/naloxone TIER 3 QLC (3 films/day) hcl) 8 MG-2 MG SL FILM ZUBSOLV (buprenorphine hcl/naloxone TIER 3 QLC (3 tabs/day) hcl) 0.7-0.18 MG TABLET, 1.4-0.36 MG TABLET, 5.7-1.4 MG TABLET ZUBSOLV (buprenorphine hcl/naloxone TIER 3 QLC (1 tab/day) hcl) 2.9-0.71 MG TABLET, 11.4-2.9 MG TABLET ZUBSOLV (buprenorphine hcl/naloxone TIER 3 QLC (2 tabs/day) hcl) 8.6-2.1 MG TABLET SL OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose) EVZIO (naloxone hcl) TIER 3 PA, QLC (2 injections [1 pack]/6 months) naloxone hcl 0.4 mg/ml vial TIER 1 QLC (two 1 ml vials/month) naloxone hcl 1 mg/ml syringe TIER 1 QLC (2 syringes/month) NARCAN (naloxone hcl) TIER 2 QLC (2 doses/month) SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking) bupropion hcl 150 mg tab er 12h TIER 1 ACA (Preventive Health), QLC (2 tabs/day) CHANTIX (varenicline tartrate) 0.5 MG TIER 2 ACA (Preventive Health), QLC (2 TABLET, 1 MG TABLET, 1 MG CONT MONTH tabs/day) BOX CHANTIX (varenicline tartrate) STARTING TIER 2 ACA (Preventive Health), QLC (1 MONTH BOX starting month box/28 days) NICOTROL (nicotine) TIER 2 ACA (Preventive Health), QLC (16 cartridges/day) NICOTROL NS (nicotine) TIER 2 ACA (Preventive Health), QLC (2 ml/day) ZYBAN (bupropion hcl) TIER 3 ACA (Preventive Health), QLC (2 tabs/day)

15 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANTIBACTERIALS (Drugs for Bacterial Infections) AMINOGLYCOSIDES ARIKAYCE (amikacin sulfate liposomal TIER 4 PA, SP, QLC (1 vial/day) with nebulizer accessories) gentamicin sulfate (GENTAK) TIER 1 gentamicin sulfate 0.1 % oint. (g), 0.1 % TIER 1 cream (g), 0.3 % oint. (g), 0.3 % drops neomycin sulfate TIER 1 paromomycin sulfate TIER 1 tobramycin TIER 1 TOBREX (tobramycin) 0.3% EYE DROP TIER 3 TOBREX (tobramycin) 0.3% EYE OINTMENT TIER 2 ANTIBACTERIALS, OTHER AEMCOLO (rifamycin sodium) TIER 3 PA, QLC (12 tabs/30 days) AKTIPAK (erythromycin base/benzoyl TIER 3 peroxide) ALTABAX (retapamulin) TIER 3 ST bacitracin 500 unit/g oint. (g) TIER 1 BACTROBAN (mupirocin calcium) TIER 3 BACTROBAN (mupirocin) TIER 3 BACTROBAN NASAL (mupirocin calcium) TIER 3 BENZAMYCIN (erythromycin base/benzoyl TIER 3 peroxide) CENTANY (mupirocin) TIER 3 CLEOCIN (clindamycin phosphate) 100 TIER 2 QLC (3 suppositories/fill) MG VAGINAL OVULE CLEOCIN (clindamycin phosphate) 2% TIER 3 VAGINAL CREAM CLEOCIN HCL (clindamycin hcl) TIER 3 CLEOCIN PALMITATE (clindamycin TIER 3 palmitate hcl) CLEOCIN T (clindamycin phosphate) TIER 3

16 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CLINDAGEL (clindamycin phosphate) TIER 3 PA, QLC (1 bottle/month) clindamycin hcl TIER 1 clindamycin palmitate hcl TIER 1 clindamycin phosphate (CLINDACIN ETZ) TIER 1 clindamycin phosphate (CLINDACIN P) TIER 1 clindamycin phosphate 1 % foam TIER 1 QLC (1 can/month) clindamycin phosphate 1 % gel (gram), 1 TIER 1 % lotion, 1 % med. swab, 1 % solution, 2 % cream/appl clindamycin phosphate 1 % gel daily TIER 1 PA, QLC (1 bottle/month) CLINDESSE (clindamycin phosphate) TIER 2 erythromycin base/benzoyl peroxide TIER 1 EVOCLIN (clindamycin phosphate) TIER 3 QLC (1 can/month) FIRVANQ (vancomycin hcl) 25 MG/ML TIER 3 PA, QLC (300 ml/month) SOLUTION FIRVANQ (vancomycin hcl) 50 MG/ML TIER 3 PA, QLC (450 ml/30 days) SOLUTION FLAGYL (metronidazole) TIER 3 FURADANTIN (nitrofurantoin) TIER 3 HIPREX (methenamine hippurate) TIER 3 linezolid TIER 1 PA MACROBID (nitrofurantoin TIER 3 monohydrate/macrocrystals) MACRODANTIN (nitrofurantoin TIER 3 macrocrystal) mafenide acetate TIER 1 methenamine hippurate TIER 1 METROGEL-VAGINAL (metronidazole) TIER 3 metronidazole 0.75 % gel w/appl, 250 mg TIER 1 tablet, 375 mg capsule, 500 mg tablet MONUROL (fosfomycin tromethamine) TIER 3 QLC (1 packet/month) mupirocin TIER 1 mupirocin calcium TIER 1 neomycin sulfate/polymyxin b sulfate TIER 1 PA, QLC (1 ml/day)

17 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NEOSPORIN G.U. IRRIGANT (neomycin TIER 3 PA, QLC (1 ml/day) sulfate/polymyxin b sulfate) nitrofurantoin TIER 1 nitrofurantoin macrocrystal TIER 1 nitrofurantoin TIER 1 monohydrate/macrocrystals NUVESSA (metronidazole) TIER 3 QLC (2 tubes/month) PRIMSOL (trimethoprim) TIER 3 SIVEXTRO (tedizolid phosphate) 200 MG TIER 3 PA, QLC (6 tabs/month) TABLET SOLOSEC (secnidazole) TIER 3 PA, QLC (1 pack/month) SULFAMYLON (mafenide acetate) TIER 3 TINDAMAX (tinidazole) TIER 3 QLC (20 tabs/fill) tinidazole 250 mg tablet TIER 1 QLC (40 tabs/fill) tinidazole 500 mg tablet TIER 1 QLC (20 tabs/fill) trimethoprim TIER 1 TRIMPEX (trimethoprim) TIER 3 VANCOCIN HCL (vancomycin hcl) TIER 3 vancomycin hcl 125 mg capsule, 250 mg TIER 1 capsule vancomycin hcl 50 mg/ml soln recon TIER 1 PA, QLC (450 ml/30 days) VANDAZOLE (metronidazole) TIER 3 XIFAXAN (rifaximin) 200 MG TABLET TIER 3 PA, QLC (8 tabs/day) XIFAXAN (rifaximin) 550 MG TABLET TIER 3 PA, QLC (3 tabs/day) ZYVOX (linezolid) TIER 3 PA BETA-LACTAM, CEPHALOSPORINS CEDAX (ceftibuten) TIER 3 cefaclor 125 mg/5ml susp recon, 250 TIER 1 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg capsule cefaclor 500 mg tab er 12h TIER 1 QLC (14 tabs/fill) cefadroxil TIER 1 cefdinir TIER 1

18 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS cefditoren pivoxil TIER 1 cefixime TIER 1 cefpodoxime proxetil TIER 1 cefprozil TIER 1 ceftibuten TIER 1 CEFTIN (cefuroxime axetil) TIER 3 cefuroxime axetil TIER 1 cephalexin TIER 1 DAXBIA (cephalexin) TIER 3 PA, QLC (12 caps/day) KEFLEX (cephalexin) TIER 3 SPECTRACEF (cefditoren pivoxil) TIER 3 SUPRAX (cefixime) TIER 3 BETA-LACTAM, PENICILLINS amoxicillin 125 mg/5ml susp recon, 125 TIER 1 mg tab chew, 200 mg/5ml susp recon, 250 mg tab chew, 250 mg/5ml susp recon, 250 mg capsule, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet amoxicillin 775 mg tbmp 24hr TIER 1 QLC (10 tabs/fill) amoxicillin/potassium clavulanate 200- TIER 1 28.5/5 susp recon, 200-28.5mg tab chew, 250-62.5/5 susp recon, 250-125 mg tablet, 400-57mg/5 susp recon, 400-57mg tab chew, 500-125 mg tablet, 600-42.9/5 susp recon, 1000-62.5 tab er 12h amoxicillin/potassium clavulanate 875- TIER 1 QLC (2 tabs/day) 125 mg tablet ampicillin trihydrate TIER 1 AUGMENTIN (amoxicillin/potassium TIER 2 clavulanate) 125-31.25 MG/5 ML AUGMENTIN (amoxicillin/potassium TIER 3 clavulanate) 250-62.5 MG/5 ML, 500-125 TABLET AUGMENTIN (amoxicillin/potassium TIER 3 QLC (2 tabs/day) clavulanate) 875-125 TABLET AUGMENTIN ES-600 (amoxicillin/potassium TIER 3 clavulanate)

19 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS AUGMENTIN XR (amoxicillin/potassium TIER 3 clavulanate) dicloxacillin sodium TIER 1 MOXATAG (amoxicillin) TIER 3 QLC (10 tabs/fill) penicillin v potassium TIER 1 MACROLIDES AZASITE (azithromycin) TIER 3 azithromycin 1 g packet, 100 mg/5ml susp TIER 1 recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet BIAXIN (clarithromycin) 250 MG TABLET, TIER 3 QLC (42 tabs/fill) 500 MG TABLET BIAXIN (clarithromycin) 250 MG/5 ML TIER 3 SUSPENSION clarithromycin 125 mg/5ml, 250 mg/5ml TIER 1 clarithromycin 250 mg tablet, 500 mg TIER 1 QLC (42 tabs/fill) tablet, 500 mg tab er 24h DIFICID (fidaxomicin) TIER 3 PA, QLC (20 tabs/month) E.E.S. 200 (erythromycin ethylsuccinate) TIER 3 E.E.S. 400 (erythromycin ethylsuccinate) TIER 3 ERY-TAB (erythromycin base) TIER 3 ERYGEL (erythromycin base in ethanol) TIER 3 ERYPED 200 (erythromycin ethylsuccinate) TIER 3 ERYPED 400 (erythromycin ethylsuccinate) TIER 3 ERYTHROCIN STEARATE (erythromycin TIER 2 stearate) erythromycin base TIER 1 erythromycin base in ethanol TIER 1 erythromycin base in ethanol (ERY) TIER 1 erythromycin ethylsuccinate TIER 1 KETEK (telithromycin) TIER 3 QLC (20 tabs/fill) PCE (erythromycin base) TIER 3

20 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZITHROMAX (azithromycin) 1 GM POWDER TIER 3 PACKET, 100 MG/5 ML SUSP, 200 MG/5 ML SUSP, 250 MG TABLET, 250 MG Z-PAK TABLET, 500 MG TABLET, 600 MG TABLET ZITHROMAX TRI-PAK (azithromycin) TIER 3 ZMAX (azithromycin) TIER 3 QLC (1 bottle/fill) QUINOLONES AVELOX (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill) AVELOX ABC PACK (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill) BAXDELA (delafloxacin meglumine) 450 TIER 3 PA, QLC (28 tabs/month) MG TABLET BESIVANCE (besifloxacin hcl) TIER 3 QLC (5 ml/month) CETRAXAL (ciprofloxacin hcl) TIER 3 CILOXAN (ciprofloxacin hcl) 0.3% EYE TIER 3 DROPS CILOXAN (ciprofloxacin hcl) 0.3% TIER 2 OINTMENT CIPRO (ciprofloxacin hcl) TIER 3 QLC (2 tabs/day) CIPRO (ciprofloxacin) 10% SUSPENSION TIER 3 QLC (3 bottles/fill) CIPRO (ciprofloxacin) 5% SUSPENSION TIER 3 QLC (2 bottles/fill) CIPRO XR (ciprofloxacin/ciprofloxacin hcl) TIER 3 QLC (14 tabs/fill) 1,000 MG TABLET CIPRO XR (ciprofloxacin/ciprofloxacin hcl) TIER 3 QLC (3 tabs/fill) 500 MG TABLET ciprofloxacin 250 mg/5ml sus mc rec TIER 1 QLC (2 bottles/fill) ciprofloxacin 500 mg/5ml sus mc rec TIER 1 QLC (3 bottles/fill) ciprofloxacin hcl 0.2 % droperette, 0.3 % TIER 1 drops ciprofloxacin hcl 100 mg tablet, 250 mg TIER 1 QLC (2 tabs/day) tablet, 500 mg tablet, 750 mg tablet ciprofloxacin/ciprofloxacin hcl 1000 mg TIER 1 QLC (14 tabs/fill) tbmp 24hr ciprofloxacin/ciprofloxacin hcl 500 mg TIER 1 QLC (3 tabs/fill) tbmp 24hr FACTIVE (gemifloxacin mesylate) TIER 3 QLC (1 box/fill) gatifloxacin TIER 1 QLC (one 2.5 ml bottle/month)

21 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LEVAQUIN (levofloxacin) TIER 3 QLC (10 tabs/fill) levofloxacin 0.5 % drops TIER 1 levofloxacin 250 mg tablet, 500 mg tablet, TIER 1 QLC (10 tabs/fill) 750 mg tablet levofloxacin 250mg/10ml, 500mg/20ml TIER 1 QLC (300 ml/fill) MOXEZA (moxifloxacin hcl) TIER 2 moxifloxacin hcl 0.5 % drops TIER 1 moxifloxacin hcl 400 mg tablet TIER 1 QLC (10 tabs/fill) OCUFLOX (ofloxacin) TIER 3 ofloxacin TIER 1 VIGAMOX (moxifloxacin hcl) TIER 3 ZYMAXID (gatifloxacin) TIER 3 QLC (one 2.5 ml bottle/month) SULFONAMIDES AVC (sulfanilamide) TIER 2 BACTRIM (sulfamethoxazole/trimethoprim) TIER 3 BACTRIM DS TIER 3 (sulfamethoxazole/trimethoprim) BLEPH-10 (sulfacetamide sodium) TIER 3 KLARON (sulfacetamide sodium) TIER 3 SILVADENE (silver sulfadiazine) TIER 3 silver sulfadiazine TIER 1 SSD (silver sulfadiazine) TIER 3 sulfacetamide sodium 10 % suspension, 10 TIER 1 % oint. (g), 10 % drops sulfadiazine TIER 1 sulfamethoxazole/trimethoprim 200- TIER 1 40mg/5 oral susp, 400mg-80mg tablet, 800-160 mg tablet sulfamethoxazole/trimethoprim 800- TIER 1 PA 160/20 oral susp SULFATRIM TIER 3 (sulfamethoxazole/trimethoprim) THERMAZENE (silver sulfadiazine) TIER 3

22 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TETRACYCLINES ACTICLATE (doxycycline hyclate) TIER 3 PA, QLC (1 tab/day) ADOXA (doxycycline monohydrate) TIER 3 AMZEEQ (minocycline hcl) TIER 3 PA, QLC (30 gm/30 days) demeclocycline hcl TIER 1 DORYX (doxycycline hyclate) DR 200 MG TIER 3 PA, QLC (1 tab/day) TABLET DORYX (doxycycline hyclate) DR 50 MG TIER 3 PA, QLC (2 tabs/day) TABLET DORYX MPC (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day) doxycycline hyclate (MORGIDOX) TIER 1 doxycycline hyclate (SOLOXIDE) TIER 1 PA, QLC (1 tab/day) doxycycline hyclate 20 mg tablet TIER 1 QLC (2 tabs/day) doxycycline hyclate 50 mg capsule, 100 TIER 1 mg capsule, 100 mg tablet doxycycline hyclate 50 mg tablet, 50 mg TIER 1 PA, QLC (2 tabs/day) tablet dr doxycycline hyclate 75 mg tablet dr, 100 TIER 1 PA mg tablet dr doxycycline hyclate 75 mg tablet, 150 mg TIER 1 PA, QLC (1 tab/day) tablet dr, 150 mg tablet, 200 mg tablet dr doxycycline hyclate 80 mg tablet dr TIER 3 PA, QLC (2 tabs/day) doxycycline monohydrate (AVIDOXY) TIER 1 doxycycline monohydrate (MONDOXYNE TIER 1 NL) doxycycline monohydrate (OKEBO) TIER 1 doxycycline monohydrate 25 mg/5 ml TIER 1 susp recon, 50 mg capsule, 50 mg tablet, 75 mg tablet, 75 mg capsule, 100 mg capsule, 100 mg tablet, 150 mg capsule, 150 mg tablet doxycycline monohydrate 40 mg cap ir TIER 1 PA, QLC (1 cap/day; max 120 caps/5 months) MINOCIN (minocycline hcl) 50 MG CAP, TIER 3 75 MG CAP, 100 MG CAP minocycline hcl (COREMINO) TIER 1 PA, QLC (1 tab/day)

23 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS minocycline hcl 45 mg tab er, 65 mg tab TIER 1 PA, QLC (1 tab/day) er, 90 mg tab er, 115mg tab er, 135 mg tab er minocycline hcl 50 mg tablet, 50 mg TIER 1 capsule, 75 mg capsule, 75 mg tablet, 100 mg tablet, 100 mg capsule minocycline hcl 55 mg tab er 24h TIER 1 PA, QLC (1 tab/day) minocycline hcl 80 mg tab er, 105 mg tab TIER 1 PA, QLC (1 tab/day) er MINOLIRA ER (minocycline hcl) TIER 3 PA, QLC (1 tab/day) MONODOX (doxycycline monohydrate) TIER 3 NUZYRA (omadacycline tosylate) 150 MG TIER 4 PA, QLC (6 tabs/28 days) TABLET NUZYRA (omadacycline tosylate) 150 MG TIER 4 PA, QLC (28 tabs/28 days) TABLET-7 DAY NUZYRA (omadacycline tosylate) 150 MG- TIER 4 PA, QLC (32 tabs/28 days) 7 DAY WITH LOAD ORACEA (doxycycline monohydrate) TIER 3 PA, QLC (1 cap/day; max 120 caps/5 months) SEYSARA (sarecycline hcl) TIER 4 PA, QLC (1 tab/day) SOLODYN (minocycline hcl) TIER 3 PA, QLC (1 tab/day) TARGADOX (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day) tetracycline hcl TIER 1 VIBRAMYCIN (doxycycline calcium) TIER 2 VIBRAMYCIN (doxycycline hyclate) TIER 3 VIBRAMYCIN (doxycycline monohydrate) TIER 3 XIMINO (minocycline hcl) TIER 3 PA, QLC (1 cap/day)

ANTICONVULSANTS (Drugs for Seizures) ANTICONVULSANTS, OTHER (Other Seizure Control Drugs) BRIVIACT (brivaracetam) 10 MG TABLET, TIER 3 ST, QLC (2 tabs/day) 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET BRIVIACT (brivaracetam) 10 MG/ML ORAL TIER 3 ST, QLC (20 ml/day) SOLN DIACOMIT (stiripentol) 250 MG CAPSULE TIER 4 PA, SP, QLC (3 caps/day)

24 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DIACOMIT (stiripentol) 250 MG POWDER TIER 4 PA, SP, QLC (3 packets/day) PACKET DIACOMIT (stiripentol) 500 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day) DIACOMIT (stiripentol) 500 MG POWDER TIER 4 PA, SP, QLC (6 packets/day) PACKET EPIDIOLEX (cannabidiol (cbd)) TIER 4 PA, SP, QLC (4 bottles/28 days) KEPPRA (levetiracetam) 100 MG/ML ORAL TIER 3 SOLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET KEPPRA XR (levetiracetam) 500 MG TIER 3 QLC (6 tabs/day) TABLET KEPPRA XR (levetiracetam) 750 MG TIER 3 QLC (4 tabs/day) TABLET levetiracetam (ROWEEPRA XR) 500 mg TIER 1 QLC (6 tabs/day) tab er 24h levetiracetam (ROWEEPRA XR) 750 mg TIER 1 QLC (4 tabs/day) tab er 24h levetiracetam (ROWEEPRA) TIER 1 levetiracetam 100 mg/ml solution, 250 mg TIER 1 tablet, 500 mg tablet, 500 mg/5ml solution, 750 mg tablet, 1000 mg tablet levetiracetam 500 mg tab er 24h TIER 1 QLC (6 tabs/day) levetiracetam 750 mg tab er 24h TIER 1 QLC (4 tabs/day) POTIGA (ezogabine) 200 MG TABLET, 300 TIER 3 QLC (3 tabs/day) MG TABLET, 400 MG TABLET POTIGA (ezogabine) 50 MG TABLET TIER 3 QLC (9 tabs/day) SPRITAM (levetiracetam) 1,000 MG TABLET TIER 3 PA, QLC (3 tabs/day) SPRITAM (levetiracetam) 250 MG TABLET, TIER 3 PA, QLC (2 tabs/day) 500 MG TABLET SPRITAM (levetiracetam) 750 MG TABLET TIER 3 PA, QLC (4 tabs/day) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN (methsuximide) TIER 3 ethosuximide TIER 1 ZARONTIN (ethosuximide) TIER 3 ZONEGRAN (zonisamide) TIER 3 zonisamide TIER 1

25 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS clobazam 10 mg tablet, 20 mg tablet TIER 1 ST, QLC (2 tabs/day) clobazam 2.5 mg/ml oral susp TIER 1 ST, QLC (16 ml/day) DEPAKENE (valproic acid (as sodium salt) TIER 3 (valproate sodium)) DEPAKENE (valproic acid) TIER 3 DEPAKOTE (divalproex sodium) TIER 3 DEPAKOTE ER (divalproex sodium) TIER 3 DEPAKOTE SPRINKLE (divalproex sodium) TIER 3 DIASTAT (diazepam) TIER 3 QLC (1 kit [2 doses]/fill) DIASTAT ACUDIAL (diazepam) TIER 3 QLC (1 kit [2 doses]/fill) diazepam 2.5 mg, 5-7.5-10mg, 12.5-15-20 TIER 1 QLC (1 kit [2 doses]/fill) divalproex sodium TIER 1 gabapentin 100 mg capsule, 300 mg TIER 1 capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet gabapentin 250 mg/5ml, 300 mg/6ml TIER 1 PA GABITRIL (tiagabine hcl) TIER 3 GRALISE (gabapentin) 30-DAY STARTER TIER 3 PA, QLC (1 pack/month) PACK GRALISE (gabapentin) ER 300 MG TABLET TIER 3 PA, QLC (1 tab/day) GRALISE (gabapentin) ER 600 MG TABLET TIER 3 PA, QLC (3 tabs/day) MYSOLINE (primidone) TIER 3 NEURONTIN (gabapentin) TIER 3 ONFI (clobazam) 10 MG TABLET, 20 MG TIER 3 ST, QLC (2 tabs/day) TABLET ONFI (clobazam) 2.5 MG/ML SUSPENSION TIER 3 ST, QLC (16 ml/day) phenobarbital TIER 1 primidone TIER 1 SABRIL (vigabatrin) 500 MG POWDER TIER 4 PA, SP, QLC (6 packs/day) PACKET SABRIL (vigabatrin) 500 MG TABLET TIER 4 PA, SP, QLC (6 tabs/day) SYMPAZAN (clobazam) TIER 3 PA, QLC (2 films/day)

26 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tiagabine hcl TIER 1 valproic acid TIER 1 valproic acid (as sodium salt) (valproate TIER 1 PA sodium) 250 mg/5ml solution valproic acid (as sodium salt) (valproate TIER 1 sodium) 500mg/10ml solution vigabatrin (VIGADRONE) TIER 4 PA, SP, QLC (6 packs/day) vigabatrin 500 mg powd pack TIER 4 PA, SP, QLC (6 packs/day) vigabatrin 500 mg tablet TIER 4 PA, SP, QLC (6 tabs/day) GLUTAMATE REDUCING AGENTS felbamate TIER 1 FELBATOL (felbamate) TIER 3 FYCOMPA (perampanel) 0.5 MG/ML TIER 3 ST, QLC (24 ml/day) ORAL SUSP FYCOMPA (perampanel) 2 MG TABLET TIER 3 ST, QLC (3 tabs/day) FYCOMPA (perampanel) 4 MG TABLET, 6 TIER 3 ST, QLC (1 tab/day) MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET LAMICTAL (BLUE) (lamotrigine) TIER 3 LAMICTAL (GREEN) (lamotrigine) TIER 3 LAMICTAL (lamotrigine) TIER 3 LAMICTAL (ORANGE) (lamotrigine) TIER 3 LAMICTAL ODT (BLUE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month) LAMICTAL ODT (GREEN) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month) LAMICTAL ODT (lamotrigine) TIER 3 PA LAMICTAL ODT (ORANGE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month) LAMICTAL XR (BLUE) (lamotrigine) TIER 3 ST, QLC (1 kit/month) LAMICTAL XR (GREEN) (lamotrigine) TIER 3 ST, QLC (1 kit/month) LAMICTAL XR (lamotrigine) 200 MG TABLET TIER 3 ST, QLC (3 tabs/day) LAMICTAL XR (lamotrigine) 25 MG TABLET, TIER 3 ST, QLC (1 tab/day) 50 MG TABLET, 100 MG TABLET LAMICTAL XR (lamotrigine) 250 MG TIER 3 ST, QLC (2 tabs/day) TABLET, 300 MG TABLET LAMICTAL XR (ORANGE) (lamotrigine) TIER 3 ST, QLC (1 kit/month)

27 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lamotrigine (SUBVENITE (BLUE)) TIER 1 lamotrigine (SUBVENITE (GREEN)) TIER 1 lamotrigine (SUBVENITE (ORANGE)) TIER 1 lamotrigine (SUBVENITE) TIER 1 lamotrigine 200 mg tab er 24 TIER 1 ST, QLC (3 tabs/day) lamotrigine 25 mg tab er 24, 50 mg tab er TIER 1 ST, QLC (1 tab/day) 24, 100 mg tab er 24 lamotrigine 25 mg tab rapdis, 50 mg tab TIER 1 PA rapdis, 100 mg tab rapdis, 200 mg tab rapdis lamotrigine 25-50-100, 25(21)-50, 50(42)- TIER 1 PA, QLC (1 starter pack/month) 100 lamotrigine 250 mg tab er 24, 300 mg tab TIER 1 ST, QLC (2 tabs/day) er 24 lamotrigine 5 mg tb chw dsp, 25(84)-100 TIER 1 tab ds pk, 25 mg tb chw dsp, 25 mg tablet, 25(42)-100 tab ds pk, 25mg (35) tab ds pk, 100 mg tablet, 150 mg tablet, 200 mg tablet QUDEXY XR (topiramate) 150 MG TIER 3 PA, QLC (2 caps/day) CAPSULE, 200 MG CAPSULE QUDEXY XR (topiramate) 25 MG CAPSULE, TIER 3 PA, QLC (1 cap/day) 50 MG CAPSULE, 100 MG CAPSULE TOPAMAX (topiramate) TIER 3 topiramate 15 mg cap sprink, 25 mg TIER 1 tablet, 25 mg cap sprink, 50 mg tablet, 100 mg tablet, 200 mg tablet topiramate 150 mg cap 24, 200 mg cap TIER 1 PA, QLC (2 caps/day) 24 topiramate 25 mg cap 24, 50 mg cap 24, TIER 1 PA, QLC (1 cap/day) 100 mg cap 24 TROKENDI XR (topiramate) 200 MG TIER 3 PA, QLC (2 caps/day) CAPSULE TROKENDI XR (topiramate) 25 MG TIER 3 PA, QLC (3 caps/day) CAPSULE, 100 MG CAPSULE TROKENDI XR (topiramate) 50 MG TIER 3 PA, QLC (7 caps/day) CAPSULE

28 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SODIUM CHANNEL AGENTS APTIOM (eslicarbazepine acetate) 200 TIER 3 ST, QLC (1 tab/day) MG TABLET, 400 MG TABLET APTIOM (eslicarbazepine acetate) 600 TIER 3 ST, QLC (2 tabs/day) MG TABLET, 800 MG TABLET BANZEL (rufinamide) 200 MG TABLET TIER 3 ST, QLC (2 tabs/day) BANZEL (rufinamide) 40 MG/ML TIER 3 ST, QLC (80 ml/day) SUSPENSION BANZEL (rufinamide) 400 MG TABLET TIER 3 ST, QLC (8 tabs/day) carbamazepine TIER 1 carbamazepine (EPITOL) TIER 1 CARBATROL (carbamazepine) TIER 3 DILANTIN (phenytoin sodium extended) TIER 2 DILANTIN (phenytoin) TIER 2 DILANTIN-125 (phenytoin) TIER 2 oxcarbazepine 150 mg tablet, 300 mg TIER 1 QLC (2 tabs/day) tablet oxcarbazepine 300 mg/5ml oral susp TIER 1 QLC (40 ml/day) oxcarbazepine 600 mg tablet TIER 1 QLC (4 tabs/day) OXTELLAR XR (oxcarbazepine) 150 MG TIER 3 ST, QLC (1 tab/day) TABLET, 300 MG TABLET OXTELLAR XR (oxcarbazepine) 600 MG TIER 3 ST, QLC (4 tabs/day) TABLET PEGANONE (ethotoin) TIER 3 PHENYTEK (phenytoin sodium extended) TIER 3 phenytoin TIER 1 phenytoin sodium extended TIER 1 TEGRETOL (carbamazepine) TIER 3 TEGRETOL XR (carbamazepine) TIER 3 TRILEPTAL (oxcarbazepine) 150 MG TIER 3 QLC (2 tabs/day) TABLET, 300 MG TABLET TRILEPTAL (oxcarbazepine) 300 MG/5 ML TIER 3 QLC (40 ml/day) SUSP TRILEPTAL (oxcarbazepine) 600 MG TABLET TIER 3 QLC (4 tabs/day)

29 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VIMPAT (lacosamide) 10 MG/ML TIER 3 ST, QLC (40 ml/day) SOLUTION VIMPAT (lacosamide) 50 MG TABLET, 100 TIER 3 ST, QLC (2 tabs/day) MG TABLET, 150 MG TABLET, 200 MG TABLET

ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease and Dementia) ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates TIER 1 CHOLINESTERASE INHIBITORS ARICEPT (donepezil hcl) 23 MG TABLET TIER 3 ST, QLC (1 tab/day) ARICEPT (donepezil hcl) 5 MG TABLET, 10 TIER 3 MG TABLET donepezil hcl 23 mg tablet TIER 1 ST, QLC (1 tab/day) donepezil hcl 5 mg tab rapdis, 5 mg TIER 1 tablet, 10 mg tab rapdis, 10 mg tablet EXELON (rivastigmine tartrate) TIER 3 EXELON (rivastigmine) TIER 3 QLC (1 patch/day) galantamine hbr TIER 1 NAMZARIC (memantine hcl/donepezil TIER 2 QLC (1 cap/day) hcl) 7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG- 10 MG CAPSULE NAMZARIC (memantine hcl/donepezil TIER 2 QLC (1 dose-pack/6 months) hcl) TITRATION PACK RAZADYNE (galantamine hbr) TIER 3 RAZADYNE ER (galantamine hbr) TIER 3 rivastigmine TIER 1 QLC (1 patch/day) rivastigmine tartrate TIER 1 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl 2 mg/ml solution, 5 mg-10 TIER 1 mg tab ds pk memantine hcl 5 mg tablet, 10 mg tablet TIER 1 QLC (2 tabs/day)

30 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS memantine hcl 7 mg cap 24, 14 mg cap TIER 1 QLC (1 cap/day) 24, 21 mg cap 24, 28 mg cap 24 NAMENDA (memantine hcl) 2 MG/ML TIER 3 SOLUTION, 5-10 MG TITRATION PK NAMENDA (memantine hcl) 5 MG TABLET, TIER 3 QLC (2 tabs/day) 10 MG TABLET NAMENDA XR (memantine hcl) 7 MG TIER 3 QLC (1 cap/day) CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE NAMENDA XR (memantine hcl) TITRATION TIER 2 QLC (1 cap/day) PACK

ANTIDEPRESSANTS (Drugs for Depression) ANTIDEPRESSANTS, OTHER amitriptyline hcl/chlordiazepoxide TIER 1 APLENZIN (bupropion hbr) TIER 3 ST, QLC (1 tab/day) bupropion hcl 100 mg tab sr 12h, 100 mg TIER 1 QLC (4 tabs/day) tablet bupropion hcl 150 mg tab sr 12h, 150 mg TIER 1 QLC (3 tabs/day) tab er 24h bupropion hcl 200 mg tab sr 12h TIER 1 QLC (2 tabs/day) bupropion hcl 300 mg tab er 24h TIER 1 QLC (1 tab/day) bupropion hcl 450 mg tab er 24h TIER 1 ST, QLC (1 tab/day) bupropion hcl 75 mg tablet TIER 1 QLC (6 tabs/day) FORFIVO XL (bupropion hcl) TIER 3 ST, QLC (1 tab/day) mirtazapine TIER 1 olanzapine/fluoxetine hcl TIER 1 perphenazine/amitriptyline hcl TIER 1 REMERON (mirtazapine) TIER 3 SYMBYAX (olanzapine/fluoxetine hcl) TIER 3 WELLBUTRIN (bupropion hcl) 100 MG TIER 3 QLC (4 tabs/day) TABLET WELLBUTRIN (bupropion hcl) 75 MG TABLET TIER 3 QLC (6 tabs/day) WELLBUTRIN SR (bupropion hcl) 100 MG TIER 3 QLC (4 tabs/day) TABLET

31 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS WELLBUTRIN SR (bupropion hcl) 150 MG TIER 3 QLC (3 tabs/day) TABLET WELLBUTRIN SR (bupropion hcl) 200 MG TIER 3 QLC (2 tabs/day) TABLET WELLBUTRIN XL (bupropion hcl) 150 MG TIER 3 QLC (3 tabs/day) TABLET WELLBUTRIN XL (bupropion hcl) 300 MG TIER 3 QLC (1 tab/day) TABLET MONOAMINE OXIDASE INHIBITORS EMSAM (selegiline) TIER 3 MARPLAN (isocarboxazid) TIER 3 NARDIL (phenelzine sulfate) TIER 3 PARNATE (tranylcypromine sulfate) TIER 3 phenelzine sulfate TIER 1 tranylcypromine sulfate TIER 1 SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR) BRISDELLE (paroxetine mesylate) TIER 3 QLC (1 cap/day) CELEXA (citalopram hydrobromide) 10 TIER 3 QLC (4 tabs/day) MG TABLET CELEXA (citalopram hydrobromide) 20 TIER 3 QLC (2 tabs/day) MG TABLET CELEXA (citalopram hydrobromide) 40 TIER 3 QLC (1 tab/day) MG TABLET citalopram hydrobromide 10 mg tablet TIER 1 QLC (4 tabs/day) citalopram hydrobromide 10 mg/5 ml, 20 TIER 1 QLC (40 mg/day) mg/10ml citalopram hydrobromide 20 mg tablet TIER 1 QLC (2 tabs/day) citalopram hydrobromide 40 mg tablet TIER 1 QLC (1 tab/day) desvenlafaxine TIER 3 ST, QLC (1 tab/day) desvenlafaxine fumarate TIER 3 ST, QLC (1 tab/day) desvenlafaxine succinate TIER 1 QLC (1 tab/day) EFFEXOR XR (venlafaxine hcl) 37.5 MG TIER 3 QLC (2 caps/day) CAPSULE, 150 MG CAPSULE

32 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EFFEXOR XR (venlafaxine hcl) 75 MG TIER 3 QLC (3 caps/day) CAPSULE escitalopram oxalate 10 mg tablet TIER 1 QLC (4 tabs/day) escitalopram oxalate 20 mg tablet TIER 1 QLC (2 tabs/day) escitalopram oxalate 5 mg tablet TIER 1 QLC (8 tabs/day) escitalopram oxalate 5 mg/5 ml solution TIER 1 QLC (24 ml/day) FETZIMA (levomilnacipran hcl) TIER 3 PA, QLC (1 cap/day) fluoxetine hcl 10 mg capsule, 10 mg TIER 1 tablet, 20 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 40 mg capsule fluoxetine hcl 60 mg tablet TIER 3 fluoxetine hcl 90 mg capsule dr TIER 1 QLC (4 caps/month) fluvoxamine maleate 100 mg cap er 24h TIER 1 ST, QLC (3 caps/day) fluvoxamine maleate 150 mg cap er 24h TIER 1 ST, QLC (2 caps/day) fluvoxamine maleate 25 mg tablet, 50 mg TIER 1 tablet, 100 mg tablet KHEDEZLA (desvenlafaxine) TIER 3 ST, QLC (1 tab/day) LEXAPRO (escitalopram oxalate) 10 MG TIER 3 QLC (4 tabs/day) TABLET LEXAPRO (escitalopram oxalate) 20 MG TIER 3 QLC (2 tabs/day) TABLET LEXAPRO (escitalopram oxalate) 5 MG TIER 3 QLC (8 tabs/day) TABLET LEXAPRO (escitalopram oxalate) 5 MG/5 TIER 3 QLC (24 ml/day) ML SOLUTION maprotiline hcl TIER 1 nefazodone hcl TIER 1 paroxetine hcl TIER 1 paroxetine mesylate TIER 1 QLC (1 cap/day) PAXIL (paroxetine hcl) 10 MG TABLET, 20 TIER 3 MG TABLET, 30 MG TABLET, 40 MG TABLET PAXIL (paroxetine hcl) 10 MG/5 ML TIER 3 QLC (30 ml/day) SUSPENSION PAXIL CR (paroxetine hcl) TIER 3 PEXEVA (paroxetine mesylate) 10 MG TIER 3 PA, QLC (1 tab/day) TABLET, 20 MG TABLET, 40 MG TABLET

33 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PEXEVA (paroxetine mesylate) 30 MG TIER 3 PA, QLC (2 tabs/day) TABLET PRISTIQ (desvenlafaxine succinate) TIER 3 QLC (1 tab/day) PROZAC (fluoxetine hcl) TIER 3 PROZAC WEEKLY (fluoxetine hcl) TIER 3 QLC (4 caps/month) SARAFEM (fluoxetine hcl) TIER 3 QLC (1 tab/day) sertraline hcl TIER 1 trazodone hcl TIER 1 TRINTELLIX (vortioxetine hydrobromide) TIER 3 ST, QLC (1 tab/day) venlafaxine hcl 225 mg tab er 24 TIER 3 QLC (1 tab/day) venlafaxine hcl 25 mg tablet, 37.5 mg TIER 1 tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet venlafaxine hcl 37.5 mg cap er, 150 mg TIER 1 QLC (2 caps/day) cap er venlafaxine hcl 37.5 mg tab er 24, 75 mg TIER 1 QLC (1 tab/day) tab er 24, 150 mg tab er 24 venlafaxine hcl 75 mg cap er 24h TIER 1 QLC (3 caps/day) VENLAFAXINE HCL ER (venlafaxine hcl) TIER 3 QLC (1 tab/day) VIIBRYD (vilazodone hcl) 10 MG TABLET, 20 TIER 3 ST, QLC (1 tab/day) MG TABLET, 40 MG TABLET VIIBRYD (vilazodone hcl) 10-20 MG TIER 3 ST, QLC (1 pack/month) STARTER PACK ZOLOFT (sertraline hcl) TIER 3 TRICYCLICS amitriptyline hcl TIER 1 amoxapine TIER 1 ANAFRANIL (clomipramine hcl) TIER 3 clomipramine hcl TIER 1 desipramine hcl TIER 1 doxepin hcl 10 mg/ml oral conc, 10 mg TIER 1 capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule imipramine hcl TIER 1

34 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS imipramine pamoate TIER 1 NORPRAMIN (desipramine hcl) TIER 3 nortriptyline hcl 10 mg capsule, 10 mg/5 TIER 1 ml solution, 25 mg capsule, 50 mg capsule, 75 mg capsule nortriptyline hcl 20 mg/10ml solution TIER 1 PA PAMELOR (nortriptyline hcl) TIER 3 protriptyline hcl TIER 1 SURMONTIL (trimipramine maleate) TIER 3 TOFRANIL (imipramine hcl) TIER 3 trimipramine maleate TIER 1

ANTIEMETICS (Drugs for Nausea and Vomiting) ANTIEMETICS, OTHER (Other Drugs for Nausea and Vomiting) BONJESTA (doxylamine TIER 3 PA, QLC (2 tabs/day) succinate/pyridoxine hcl (b6)) COMPAZINE (prochlorperazine maleate) TIER 3 COMPAZINE (prochlorperazine) TIER 3 DICLEGIS (doxylamine TIER 3 PA, QLC (4 tabs/day) succinate/pyridoxine hcl (b6)) doxylamine succinate/pyridoxine hcl (b6) TIER 1 PA, QLC (4 tabs/day) metoclopramide hcl 5 mg tab rapdis, 10 TIER 1 PA, QLC (4 tabs/day) mg tab rapdis metoclopramide hcl 5 mg tablet, 5 mg/5 TIER 1 ml solution, 10 mg tablet, 10 mg/10ml solution METOZOLV ODT (metoclopramide hcl) TIER 3 PA, QLC (4 tabs/day) MOTEGRITY (prucalopride succinate) TIER 3 PA, QLC (1 tab/day) perphenazine TIER 1 PHENERGAN (promethazine hcl) 12.5 MG, TIER 3 25 MG, 50 MG prochlorperazine TIER 1 prochlorperazine (COMPRO) TIER 1 prochlorperazine maleate TIER 1

35 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS promethazine hcl (PHENADOZ) TIER 1 promethazine hcl (PROMETHEGAN) TIER 1 promethazine hcl 12.5 mg supp.rect, 25 TIER 1 mg supp.rect, 50 mg tablet, 50 mg supp.rect REGLAN (metoclopramide hcl) TIER 3 scopolamine TIER 1 TIGAN (trimethobenzamide hcl) 300 MG TIER 3 CAPSULE TRANSDERM-SCOP (scopolamine) TIER 3 trimethobenzamide hcl TIER 1 EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting) AKYNZEO (netupitant/palonosetron hcl) TIER 3 QLC (1 capsule/14 days) ANZEMET (dolasetron mesylate) 50 MG TIER 2 QLC (1 tab/fill) TABLET, 100 MG TABLET aprepitant 125 mg capsule TIER 1 PA, QLC (1 cap/7 days) aprepitant 125mg-80mg cap ds pk TIER 1 QLC (3 caps/7 days) aprepitant 40 mg capsule TIER 1 PA, QLC (1 cap/month) aprepitant 80 mg capsule TIER 1 PA, QLC (2 caps/7 days) CESAMET (nabilone) TIER 3 QLC (6 caps/day) dronabinol TIER 1 QLC (6 caps/day) EMEND (aprepitant) 125 MG CAPSULE TIER 3 PA, QLC (1 cap/7 days) EMEND (aprepitant) 125 MG POWDER TIER 3 PA, QLC (3 packets/7 days) PACKET EMEND (aprepitant) 40 MG CAPSULE TIER 3 PA, QLC (1 cap/month) EMEND (aprepitant) 80 MG CAPSULE TIER 3 PA, QLC (2 caps/7 days) EMEND (aprepitant) TRIPACK TIER 3 QLC (3 caps/7 days) granisetron hcl 1 mg tablet TIER 1 QLC (2 tabs/fill) MARINOL (dronabinol) TIER 3 QLC (6 caps/day) ondansetron TIER 1 QLC (3 tabs/day) ondansetron hcl 24 mg tablet TIER 1 QLC (1 tab/fill) ondansetron hcl 4 mg tablet, 8 mg tablet TIER 1 QLC (3 tabs/day) ondansetron hcl 4 mg/5 ml solution TIER 1 QLC (1 bottle/fill)

36 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SANCUSO (granisetron) TIER 3 PA, QLC (2 patches/28 days) SYNDROS (dronabinol) TIER 4 PA, QLC (4 bottles/month) VARUBI (rolapitant hcl) 90 MG TABLET TIER 3 SP, QLC (2 tabs/14 days) ZOFRAN (ondansetron hcl) 4 MG TABLET, 8 TIER 3 QLC (3 tabs/day) MG TABLET ZOFRAN (ondansetron hcl) 4 MG/5 ML TIER 3 QLC (1 bottle/fill) ORAL SOLN ZOFRAN ODT (ondansetron) TIER 3 QLC (3 tabs/day) ZUPLENZ (ondansetron) TIER 3 PA, QLC (3 films/day)

ANTIFUNGALS (Drugs for Fungal Infections) ANTIFUNGALS ANCOBON (flucytosine) TIER 3 butoconazole nitrate (GYNAZOLE 1) TIER 1 ciclopirox TIER 1 ciclopirox (CICLODAN) TIER 1 ciclopirox olamine TIER 1 ciclopirox olamine (CICLODAN) TIER 1 clotrimazole 10 mg troche TIER 1 CRESEMBA (isavuconazonium sulfate) 186 TIER 4 PA, QLC (2 caps/day) MG CAPSULE DIFLUCAN (fluconazole) TIER 3 econazole nitrate TIER 1 ECOZA (econazole nitrate) TIER 3 ST, QLC (1 bottle/month) ERTACZO (sertaconazole nitrate) TIER 3 ST, QLC (1 tube/fill) EXELDERM (sulconazole nitrate) TIER 3 EXTINA (ketoconazole) TIER 3 ST fluconazole TIER 1 flucytosine TIER 1 GRIS-PEG (griseofulvin ultramicrosize) TIER 3 griseofulvin ultramicrosize TIER 1 griseofulvin, microsize TIER 1

37 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS itraconazole TIER 1 PA JUBLIA (efinaconazole) TIER 3 PA, QLC (1 bottle/month) KERYDIN (tavaborole) TIER 3 PA, QLC (1 bottle/month) ketoconazole (KETODAN) TIER 1 ST ketoconazole 2 % cream (g), 2 % TIER 1 shampoo, 200 mg tablet ketoconazole 2 % foam TIER 1 ST LAMISIL (terbinafine hcl) 250 MG TABLET TIER 3 QLC (30 tabs/month) LOPROX (ciclopirox) TIER 3 luliconazole TIER 1 ST, QLC (1 bottle/month) LUZU (luliconazole) TIER 3 ST, QLC (1 bottle/month) miconazole nitrate 200 mg supp.vag TIER 1 miconazole nitrate/zinc TIER 1 ST oxide/petrolatum,white naftifine hcl TIER 1 ST NAFTIN (naftifine hcl) TIER 3 ST NATACYN (natamycin) TIER 3 NIZORAL (ketoconazole) TIER 3 NOXAFIL (posaconazole) 40 MG/ML TIER 3 PA SUSPENSION NOXAFIL (posaconazole) DR 100 MG TIER 3 PA, QLC (3 tabs/day) TABLET nystatin TIER 1 nystatin (NYAMYC) TIER 1 nystatin (NYATA) TIER 1 nystatin (NYSTOP) TIER 1 nystatin/triamcinolone acetonide TIER 1 ONMEL (itraconazole) TIER 3 PA, QLC (1 tab/day) ORAVIG (miconazole) TIER 3 PA, QLC (14 tabs/month) oxiconazole nitrate TIER 1 ST OXISTAT (oxiconazole nitrate) TIER 3 ST PENLAC (ciclopirox) TIER 3 posaconazole 100 mg tablet dr TIER 1 PA, QLC (3 tabs/day)

38 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS posaconazole 200 mg/5ml oral susp TIER 1 PA SPORANOX (itraconazole) TIER 3 PA TERAZOL 3 (terconazole) TIER 3 TERAZOL 7 (terconazole) TIER 3 terbinafine hcl 250 mg tablet TIER 1 QLC (30 tabs/month) terconazole TIER 1 TOLSURA (itraconazole) TIER 4 PA, QLC (4 caps/day) VFEND (voriconazole) TIER 3 PA voriconazole 50 mg tablet, 200 mg tablet, TIER 1 PA 200 mg/5ml susp recon VUSION (miconazole nitrate/zinc TIER 3 ST oxide/petrolatum,white) XOLEGEL (ketoconazole) TIER 3 ST

ANTIGOUT AGENTS (Drugs for Gout) ANTIGOUT AGENTS allopurinol TIER 1 colchicine 0.6 mg capsule TIER 1 QLC (2 caps/day) colchicine 0.6 mg tablet TIER 1 QLC (4 tabs/day) COLCRYS (colchicine) TIER 3 QLC (4 tabs/day) DUZALLO (lesinurad/allopurinol) TIER 3 ST, QLC (1 tab/day) febuxostat TIER 1 ST, QLC (1 tab/day) GLOPERBA (colchicine) TIER 3 PA, QLC (10 ml/day) MITIGARE (colchicine) TIER 3 QLC (2 caps/day) probenecid TIER 1 probenecid/colchicine TIER 1 ULORIC (febuxostat) TIER 3 ST, QLC (1 tab/day) ZURAMPIC (lesinurad) TIER 3 ST, QLC (1 tab/day) ZYLOPRIM (allopurinol) TIER 3

39 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANTIMIGRAINE AGENTS (Drugs for Migraine) ANTIMIGRAINE AGENTS, OTHER AIMOVIG AUTOINJECTOR (erenumab- TIER 2 PA, QLC (1 injection/28 days) aooe) 140 MG/ML - AIMOVIG AUTOINJECTOR (erenumab- TIER 2 PA, QLC (1 injection/28 days) aooe) 70 MG/ML - AJOVY (fremanezumab-vfrm) TIER 3 PA, QLC (3 syringes/84 days) EMGALITY PEN (galcanezumab-gnlm) TIER 2 PA, QLC (1 pen injector/30 days) EMGALITY SYRINGE (galcanezumab-gnlm) TIER 2 PA, QLC (1 syringe/30 days) 120 MG/ML - ERGOT ALKALOIDS CAFERGOT (ergotamine TIER 3 QLC (10 tabs/week) tartrate/caffeine) D.H.E.45 (dihydroergotamine mesylate) TIER 3 PA, QLC (24 ml/28 days) dihydroergotamine mesylate 0.5mg/spry TIER 1 PA, QLC (8 vials/month) spray/pump dihydroergotamine mesylate 1 mg/ml TIER 1 PA, QLC (24 ml/28 days) ampul, 1 mg/ml vial ERGOMAR (ergotamine tartrate) TIER 3 QLC (20 tabs/28 days) ergotamine tartrate/caffeine TIER 1 QLC (10 tabs/week) ergotamine tartrate/caffeine TIER 1 QLC (5 suppositories/week) (MIGERGOT) MIGRANAL (dihydroergotamine mesylate) TIER 3 PA, QLC (8 vials/month) SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS almotriptan malate TIER 1 ST, QLC (24 tabs/month) AMERGE (naratriptan hcl) TIER 3 QLC (18 tabs/month) AXERT (almotriptan malate) TIER 3 ST, QLC (24 tabs/month) eletriptan hydrobromide TIER 1 ST, QLC (18 tabs/month) FROVA (frovatriptan succinate) TIER 3 ST, QLC (27 tabs/month) frovatriptan succinate TIER 1 ST, QLC (27 tabs/month) IMITREX (sumatriptan succinate) 25 MG TIER 3 QLC (18 tabs/month) TABLET, 50 MG TABLET, 100 MG TABLET

40 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS IMITREX (sumatriptan succinate) 4 MG/0.5 TIER 3 QLC (16 injections/month at 4 ML PEN INJECT, 4 MG/0.5 ML CARTRIDGES, injections/fill) 6 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML VIAL IMITREX (sumatriptan) TIER 3 QLC (18 doses/month) MAXALT (rizatriptan benzoate) TIER 3 QLC (24 tabs/month) MAXALT MLT (rizatriptan benzoate) TIER 3 QLC (24 tabs/month) naratriptan hcl TIER 1 QLC (18 tabs/month) ONZETRA XSAIL (sumatriptan succinate) TIER 3 PA, QLC (1 box/month) RELPAX (eletriptan hydrobromide) TIER 3 ST, QLC (18 tabs/month) rizatriptan benzoate TIER 1 QLC (24 tabs/month) sumatriptan TIER 1 QLC (18 nasal sprays/month) sumatriptan succinate 25 mg tablet, 50 TIER 1 QLC (18 tabs/month) mg tablet, 100 mg tablet sumatriptan succinate 4 mg/0.5ml TIER 1 QLC (16 injections/month at 4 cartridge, 4 mg/0.5ml pen injctr, 6 injections/fill) mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml vial, 6 mg/0.5ml syringe sumatriptan succinate/naproxen sodium TIER 1 PA, QLC (9 tabs/month) SUMAVEL DOSEPRO (sumatriptan TIER 3 ST, QLC (18 injections/month at 6 succinate) injections/fill) TOSYMRA (sumatriptan) TIER 3 PA, QLC (12 bottles/30 days) TREXIMET (sumatriptan TIER 3 PA, QLC (9 tabs/month) succinate/naproxen sodium) ZEMBRACE SYMTOUCH (sumatriptan TIER 3 ST, QLC (16 injections/month at 4 succinate) injections/fill) zolmitriptan TIER 1 QLC (18 tabs/month) ZOMIG (zolmitriptan) 2.5 MG SPRAY, 5 MG TIER 3 ST, QLC (18 doses/month) SPRAY ZOMIG (zolmitriptan) 2.5 MG TABLET, 5 MG TIER 3 QLC (18 tabs/month) TABLET ZOMIG ZMT (zolmitriptan) TIER 3 QLC (18 tabs/month)

ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) PARASYMPATHOMIMETICS guanidine hcl TIER 1

41 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MESTINON (pyridostigmine bromide) 180 TIER 3 QLC (6 tabs/day) MG TIMESPAN MESTINON (pyridostigmine bromide) 60 TIER 3 QLC (25 tabs/day) MG TABLET MESTINON (pyridostigmine bromide) 60 TIER 3 QLC (50 ml/day) MG/5 ML SYRUP pyridostigmine bromide 30 mg tablet, 180 TIER 1 QLC (6 tabs/day) mg tablet er pyridostigmine bromide 60 mg tablet TIER 1 QLC (25 tabs/day) pyridostigmine bromide 60 mg/5 ml syrup TIER 1 QLC (50 ml/day)

ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) ANTIMYCOBACTERIALS, OTHER (Other Drugs for Mycobacterial Infection) dapsone 25 mg tablet, 100 mg tablet TIER 1 MYCOBUTIN (rifabutin) TIER 3 rifabutin TIER 1 ANTITUBERCULARS (Drugs for Tuberculosis) cycloserine TIER 3 ethambutol hcl TIER 1 isoniazid 50 mg/5 ml solution, 100 mg TIER 1 tablet, 300 mg tablet MYAMBUTOL (ethambutol hcl) TIER 3 PASER (aminosalicylic acid) TIER 3 PRETOMANID (pretomanid) TIER 3 QLC (1 tab/day) PRIFTIN (rifapentine) TIER 2 pyrazinamide TIER 1 RIFADIN (rifampin) 150 MG CAPSULE, 300 TIER 3 MG CAPSULE RIFAMATE (rifampin/isoniazid) TIER 3 rifampin 150 mg capsule, 300 mg capsule TIER 1 RIFATER (rifampin/isoniazid/pyrazinamide) TIER 3 TRECATOR (ethionamide) TIER 3

42 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANTINEOPLASTICS (Drugs for Cancer) ALKYLATING AGENTS ALKERAN (melphalan) TIER 3 OAC cyclophosphamide 25 mg capsule, 50 TIER 2 OAC mg capsule GLEOSTINE (lomustine) TIER 2 OAC HEXALEN (altretamine) TIER 3 OAC LEUKERAN (chlorambucil) TIER 2 OAC MATULANE (procarbazine hcl) TIER 2 SP, OAC melphalan TIER 1 OAC MYLERAN (busulfan) TIER 2 OAC TEMODAR (temozolomide) 5 MG TIER 4 SP, OAC CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE temozolomide TIER 4 SP, OAC VALCHLOR (mechlorethamine hcl) TIER 4 PA, SP, QLC (1 tube/month) ANTIANDROGENS abiraterone acetate TIER 4 PA, SP, QLC (4 tabs/day), OAC bicalutamide TIER 1 GL (Male), OAC CASODEX (bicalutamide) TIER 3 GL (Male), OAC ERLEADA (apalutamide) TIER 4 PA, SP, QLC (4 tabs/day), OAC flutamide TIER 1 OAC NILANDRON (nilutamide) TIER 4 QLC (1 tab/day), OAC nilutamide TIER 4 QLC (1 tab/day), OAC NUBEQA (darolutamide) TIER 4 PA, SP, QLC (4 tabs/day), OAC XTANDI (enzalutamide) TIER 4 PA, SP, C (Short Cycle), QLC (4 caps/day), OAC YONSA (abiraterone acetate, TIER 4 PA, SP, QLC (4 tabs/day), OAC submicronized) ZYTIGA (abiraterone acetate) 250 MG TIER 4 PA, SP, C (Short Cycle), QLC (4 TABLET tabs/day), OAC

43 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZYTIGA (abiraterone acetate) 500 MG TIER 4 PA, SP, C (Short Cycle), QLC (2 TABLET tabs/day), OAC ANTIANGIOGENIC AGENTS POMALYST (pomalidomide) TIER 4 PA, SP, QLC (1 cap/day), OAC REVLIMID (lenalidomide) TIER 4 PA, SP, QLC (1 cap/day), OAC THALOMID (thalidomide) 150 MG TIER 4 PA, SP, QLC (2 caps/day) CAPSULE, 200 MG CAPSULE THALOMID (thalidomide) 50 MG CAPSULE, TIER 4 PA, SP, QLC (1 cap/day) 100 MG CAPSULE ANTIESTROGENS/MODIFIERS EMCYT (estramustine phosphate sodium) TIER 2 OAC FARESTON (toremifene citrate) TIER 3 OAC SOLTAMOX (tamoxifen citrate) TIER 3 ACA (Preventive Health), OAC tamoxifen citrate TIER 1 ACA (Preventive Health), OAC toremifene citrate TIER 1 OAC ANTIMETABOLITES capecitabine TIER 4 SP, OAC DROXIA (hydroxyurea) TIER 2 EFUDEX (fluorouracil) TIER 3 fluorouracil 2 % solution, 5 % cream (g), 5 TIER 1 % solution HYDREA (hydroxyurea) TIER 3 OAC hydroxyurea TIER 1 OAC LONSURF (trifluridine/tipiracil hcl) 15 MG- TIER 4 PA, SP, QLC (100 tabs/28 days), 6.14 MG TABLET OAC LONSURF (trifluridine/tipiracil hcl) 20 MG- TIER 4 PA, SP, QLC (80 tabs/28 days), 8.19 MG TABLET OAC mercaptopurine TIER 1 OAC PURIXAN (mercaptopurine) TIER 4 SP, AL1 (Up to 10 yrs old), QLC (1 bottle/month), OAC SIKLOS (hydroxyurea) TIER 3 PA TABLOID (thioguanine) TIER 2 OAC XELODA (capecitabine) TIER 4 SP, OAC

44 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ANTINEOPLASTICS, OTHER ALUNBRIG (brigatinib) 30 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC ALUNBRIG (brigatinib) 90 MG TABLET, 90 TIER 4 PA, SP, QLC (1 tab/day), OAC MG-180 MG TAB PACK, 180 MG TABLET BALVERSA (erdafitinib) 3 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day), OAC BALVERSA (erdafitinib) 4 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC BALVERSA (erdafitinib) 5 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC BRUKINSA (zanubrutinib) TIER 4 PA, SP, QLC (4 caps/day) COPIKTRA (duvelisib) TIER 4 PA, SP, QLC (56 caps/28 days), OAC HEMANGEOL (propranolol hcl) TIER 3 PA, SP, QLC (2 bottles/month) IDHIFA (enasidenib mesylate) TIER 4 PA, SP, QLC (1 tab/day), OAC INREBIC (fedratinib dihydrochloride) TIER 4 PA, SP, QLC (4 caps/day), OAC leucovorin calcium 5 mg tablet, 10 mg TIER 1 tablet, 15 mg tablet, 25 mg tablet LYSODREN (mitotane) TIER 2 OAC NINLARO (ixazomib citrate) TIER 4 PA, SP, QLC (3 caps/21 days), OAC ROZLYTREK (entrectinib) 100 MG CAPSULE TIER 4 PA, SP, QLC (5 caps/day), OAC ROZLYTREK (entrectinib) 200 MG CAPSULE TIER 4 PA, SP, QLC (3 caps/day), OAC RUBRACA (rucaparib camsylate) 200 MG TIER 4 PA, SP, C (Short Cycle), QLC (4 TABLET, 250 MG TABLET tabs/day), OAC RUBRACA (rucaparib camsylate) 300 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 TABLET tab/month), OAC RYDAPT (midostaurin) TIER 4 PA, SP, QLC (56 caps/21 days [#56 package size] or 224 caps/28 days), OAC SYLATRON (peginterferon alfa-2b) TIER 4 PA, SP SYNRIBO (omacetaxine mepesuccinate) TIER 4 PA, SP, QLC (2 vials/day) TIBSOVO (ivosidenib) TIER 4 PA, SP, QLC (2 tabs/day), OAC TURALIO (pexidartinib hydrochloride) TIER 4 PA, SP, QLC (4 caps/day), OAC VITRAKVI (larotrectinib sulfate) 100 MG TIER 4 PA, SP, QLC (2 caps/day), OAC CAPSULE VITRAKVI (larotrectinib sulfate) 20 MG/ML TIER 4 PA, SP, QLC (10 ml/day), OAC SOLUTION

45 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VITRAKVI (larotrectinib sulfate) 25 MG TIER 4 PA, SP, QLC (6 caps/day), OAC CAPSULE VIZIMPRO (dacomitinib) TIER 4 PA, SP, QLC (1 tab/day), OAC XOSPATA (gilteritinib fumarate) TIER 4 PA, SP, QLC (3 tabs/day), OAC XPOVIO (selinexor) 100 MG ONCE WEEKLY TIER 4 PA, SP, QLC (5 tabs/7 days), OAC DOSE XPOVIO (selinexor) 60 MG ONCE WEEKLY TIER 4 PA, SP, QLC (3 tabs/7 days), OAC DOSE XPOVIO (selinexor) 80 MG ONCE WEEKLY TIER 4 PA, SP, QLC (4 tabs/7 days), OAC DOSE XPOVIO (selinexor) 80 MG TWICE WEEKLY TIER 4 PA, SP, QLC (8 tabs/7 days), OAC DOSE ZOLINZA (vorinostat) TIER 4 PA, C (Short Cycle), SP, QLC (4 caps/day), OAC AROMATASE INHIBITORS, 3RD GENERATION anastrozole TIER 1 GL (Female), OAC ARIMIDEX (anastrozole) TIER 3 GL (Female), OAC AROMASIN (exemestane) TIER 3 GL (Female), OAC exemestane TIER 1 GL (Female), OAC FEMARA (letrozole) TIER 3 GL (Female), OAC letrozole TIER 1 GL (Female), OAC ENZYME INHIBITORS etoposide 50 mg capsule TIER 4 OAC HYCAMTIN (topotecan hcl) 0.25 MG TIER 4 RO (Retail Only), SP, OAC CAPSULE, 1 MG CAPSULE LORBRENA (lorlatinib) 100 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC LORBRENA (lorlatinib) 25 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day), OAC PIQRAY (alpelisib) 200 MG DAILY DOSE TIER 4 PA, SP, QLC (1 tab/day), OAC PIQRAY (alpelisib) 250 MG DAILY, 300 MG TIER 4 PA, SP, QLC (2 tabs/day), OAC DAILY MOLECULAR TARGET INHIBITORS AFINITOR (everolimus) 2.5 MG TABLET, 5 TIER 4 PA, C (Short Cycle), SP, QLC (1 MG TABLET tab/day), OAC AFINITOR (everolimus) 7.5 MG TABLET, 10 TIER 4 PA, C (Short Cycle), SP, QLC (2 MG TABLET tabs/day), OAC

46 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS AFINITOR DISPERZ (everolimus) 2 MG TIER 4 PA, C (Short Cycle), SP, QLC (2 TABLET tabs/day), OAC AFINITOR DISPERZ (everolimus) 3 MG TIER 4 PA, C (Short Cycle), SP, QLC (4 TABLET tabs/day), OAC AFINITOR DISPERZ (everolimus) 5 MG TIER 4 PA, C (Short Cycle), SP, QLC (1 TABLET tab/day), OAC ALECENSA (alectinib hcl) TIER 4 PA, SP, QLC (8 caps/day), OAC BOSULIF (bosutinib) 100 MG TABLET TIER 4 PA, C (Short Cycle), SP, QLC (4 tabs/day), OAC BOSULIF (bosutinib) 400 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC BOSULIF (bosutinib) 500 MG TABLET TIER 4 PA, C (Short Cycle), SP, QLC (1 tab/day), OAC BRAFTOVI (encorafenib) 50 MG CAPSULE TIER 4 PA, SP, QLC (4 caps/day), OAC BRAFTOVI (encorafenib) 75 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day), OAC CABOMETYX (cabozantinib s-malate) TIER 4 PA, SP, QLC (1 tab/day), OAC CALQUENCE (acalabrutinib) TIER 4 PA, SP, QLC (2 caps/day), OAC CAPRELSA (vandetanib) 100 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC CAPRELSA (vandetanib) 300 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC COMETRIQ (cabozantinib s-malate) 100 TIER 4 PA, C (Short Cycle), SP, QLC (56 MG DAILY-DOSE PK - caps/28 days), OAC COMETRIQ (cabozantinib s-malate) 140 TIER 4 PA, C (Short Cycle), SP, QLC (112 MG DAILY-DOSE PK - caps/28 days), OAC COMETRIQ (cabozantinib s-malate) 60 TIER 4 PA, C (Short Cycle), SP, QLC (84 MG DAILY-DOSE PACK - caps/28 days), OAC COTELLIC (cobimetinib fumarate) TIER 4 PA, SP, QLC (63 tabs/28 days), OAC DAURISMO (glasdegib maleate) 100 MG TIER 4 PA, SP, QLC (1 tab/day), OAC TABLET DAURISMO (glasdegib maleate) 25 MG TIER 4 PA, SP, QLC (2 tabs/day), OAC TABLET ERIVEDGE (vismodegib) TIER 4 PA, SP, C (Short Cycle), QLC (1 cap/day), OAC erlotinib hcl 100 mg tablet, 150 mg tablet TIER 4 PA, C (Short Cycle), SP, QLC (1 tab/day), OAC erlotinib hcl 25 mg tablet TIER 4 PA, C (Short Cycle), SP, QLC (3 tabs/day), OAC FARYDAK (panobinostat lactate) TIER 4 PA, SP, QLC (6 caps/12 days, not to exceed 6 caps every 21 days), OAC

47 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GILOTRIF (afatinib dimaleate) TIER 4 PA, SP, QLC (1 tab/day), OAC GLEEVEC (imatinib mesylate) 100 MG TIER 4 PA, SP, QLC (8 tabs/day), OAC TABLET GLEEVEC (imatinib mesylate) 400 MG TIER 4 PA, SP, QLC (2 tabs/day), OAC TABLET IBRANCE (palbociclib) TIER 4 PA, SP, QLC (1 cap/day, max 21 caps/28 days), OAC ICLUSIG (ponatinib hcl) 15 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC ICLUSIG (ponatinib hcl) 45 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC imatinib mesylate 100 mg tablet TIER 4 PA, SP, QLC (8 tabs/day), OAC imatinib mesylate 400 mg tablet TIER 4 PA, SP, QLC (2 tabs/day), OAC IMBRUVICA (ibrutinib) 140 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (4 caps/day), OAC IMBRUVICA (ibrutinib) 140 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day), OAC IMBRUVICA (ibrutinib) 280 MG TABLET, 420 TIER 4 PA, SP, C (Short Cycle), QLC (1 MG TABLET, 560 MG TABLET tab/day), OAC IMBRUVICA (ibrutinib) 70 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (1 cap/day), OAC INLYTA (axitinib) 1 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (6 tabs/day), OAC INLYTA (axitinib) 5 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (4 tabs/day), OAC IRESSA (gefitinib) TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day), OAC JAKAFI (ruxolitinib phosphate) TIER 4 PA, SP, C (Short Cycle), QLC (2 tabs/day), OAC KISQALI (ribociclib succinate) TIER 4 PA, SP, QLC (1 pack/28 days), OAC KISQALI FEMARA CO-PACK (ribociclib TIER 4 PA, SP, QLC (1 pack/28 days), succinate/letrozole) OAC LENVIMA (lenvatinib mesylate) 10 MG TIER 4 PA, SP, QLC (30 caps/month), DAILY DOSE OAC LENVIMA (lenvatinib mesylate) 12 MG TIER 4 PA, SP, QLC (3 caps/day), OAC DAILY DOSE LENVIMA (lenvatinib mesylate) 18 MG TIER 4 PA, SP, QLC (90 caps/month), DAILY, 24 MG DAILY OAC LENVIMA (lenvatinib mesylate) 4 MG TIER 4 PA, SP, QLC (1 cap/day), OAC CAPSULE

48 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LENVIMA (lenvatinib mesylate) 8 MG TIER 4 PA, SP, QLC (60 caps/month), DAILY, 14 MG DAILY, 20 MG DAILY OAC LYNPARZA (olaparib) 100 MG TABLET, 150 TIER 4 PA, SP, C (Short Cycle), QLC (4 MG TABLET tabs/day), OAC LYNPARZA (olaparib) 50 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (16 caps/day), OAC MEKINIST (trametinib dimethyl sulfoxide) TIER 4 PA, SP, QLC (3 tabs/day), OAC 0.5 MG TABLET MEKINIST (trametinib dimethyl sulfoxide) 2 TIER 4 PA, SP, QLC (1 tab/day), OAC MG TABLET MEKTOVI (binimetinib) TIER 4 PA, SP, QLC (6 tabs/day), OAC NERLYNX (neratinib maleate) TIER 4 PA, SP, C (Short Cycle), QLC (6 tabs/day), OAC NEXAVAR (sorafenib tosylate) TIER 4 PA, SP, C (Short Cycle), QLC (4 tabs/day), OAC ODOMZO (sonidegib phosphate) TIER 4 PA, SP, QLC (1 cap/day), OAC SPRYCEL (dasatinib) 100 MG TABLET, 140 TIER 4 PA, C (Short Cycle), SP, QLC (1 MG TABLET tab/day), OAC SPRYCEL (dasatinib) 20 MG TABLET, 50 MG TIER 4 PA, C (Short Cycle), SP, QLC (3 TABLET tabs/day), OAC SPRYCEL (dasatinib) 70 MG TABLET, 80 MG TIER 4 PA, C (Short Cycle), SP, QLC (2 TABLET tabs/day), OAC STIVARGA (regorafenib) TIER 4 PA, SP, QLC (4 tabs/day), OAC SUTENT (sunitinib malate) 12.5 MG TIER 4 PA, C (Short Cycle), SP, QLC (3 CAPSULE caps/day), OAC SUTENT (sunitinib malate) 25 MG CAPSULE, TIER 4 PA, C (Short Cycle), SP, QLC (1 37.5 MG CAPSULE, 50 MG CAPSULE cap/day), OAC TAFINLAR (dabrafenib mesylate) TIER 4 PA, SP, QLC (4 caps/day), OAC TAGRISSO (osimertinib mesylate) TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day), OAC TALZENNA (talazoparib tosylate) 0.25 MG TIER 4 PA, SP, QLC (3 caps/day), OAC CAPSULE TALZENNA (talazoparib tosylate) 1 MG TIER 4 PA, SP, QLC (1 cap/day), OAC CAPSULE TARCEVA (erlotinib hcl) 100 MG TABLET, TIER 4 PA, SP, C (Short Cycle), QLC (1 150 MG TABLET tab/day), OAC TARCEVA (erlotinib hcl) 25 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (3 tabs/day), OAC

49 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TASIGNA (nilotinib hcl) 150 MG CAPSULE, TIER 4 PA, C (Short Cycle), SP, QLC (4 200 MG CAPSULE caps/day), OAC TASIGNA (nilotinib hcl) 50 MG CAPSULE TIER 4 PA, SP, QLC (4 caps/day), OAC TYKERB (lapatinib ditosylate) TIER 4 PA, SP, QLC (6 tabs/day), OAC VENCLEXTA (venetoclax) 10 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC VENCLEXTA (venetoclax) 100 MG TABLET TIER 4 PA, SP, QLC (6 tabs/day), OAC VENCLEXTA (venetoclax) 50 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC VENCLEXTA STARTING PACK (venetoclax) TIER 4 PA, SP, QLC (1 starter pack/year), OAC VERZENIO (abemaciclib) TIER 4 PA, SP, QLC (2 tabs/day), OAC VOTRIENT (pazopanib hcl) TIER 4 PA, SP, C (Short Cycle), QLC (4 tabs/day), OAC XALKORI (crizotinib) TIER 4 PA, SP, C (Short Cycle), QLC (2 caps/day), OAC ZEJULA (niraparib tosylate) TIER 4 PA, SP, QLC (3 caps/day), OAC ZELBORAF (vemurafenib) TIER 4 PA, SP, QLC (8 tabs/day), OAC ZYDELIG (idelalisib) TIER 4 PA, SP, QLC (2 tabs/day), OAC ZYKADIA (ceritinib) 150 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (3 caps/day), OAC ZYKADIA (ceritinib) 150 MG TABLET TIER 4 PA, C (Short Cycle), SP, QLC (3 tabs/day), OAC RETINOIDS bexarotene TIER 4 PA, C (Short Cycle), SP, QLC (8 caps/day), OAC PANRETIN (alitretinoin) TIER 3 PA TARGRETIN (bexarotene) 1% GEL TIER 4 PA, SP, QLC (1 tube/month) TARGRETIN (bexarotene) 75 MG CAPSULE TIER 4 PA, C (Short Cycle), SP, QLC (8 caps/day), OAC tretinoin 10 mg capsule TIER 1 QLC (9 caps/day), OAC TREATMENT ADJUNCTS (Supportive Treatment Drugs for Cancer) MESNEX (mesna) 400 MG TABLET TIER 2

50 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANTIPARASITICS (Drugs for Parasitic Infections) ANTIHELMINTHICS (Drugs for Worm Infection) albendazole TIER 1 QLC (4 tabs/day) ALBENZA (albendazole) TIER 3 QLC (4 tabs/day) BILTRICIDE (praziquantel) TIER 3 ivermectin 3 mg tablet TIER 1 QLC (20 tabs/fill) mebendazole (EMVERM) TIER 3 PA, QLC (2 tabs/month) praziquantel TIER 1 SKLICE (ivermectin) TIER 3 STROMECTOL (ivermectin) TIER 3 QLC (20 tabs/fill) ANTIPROTOZOALS (Drugs for Protozoal Infection) ALINIA (nitazoxanide) 100 MG/5 ML TIER 3 PA, QLC (1 bottle/fill) SUSPENSION ALINIA (nitazoxanide) 500 MG TABLET TIER 3 PA, QLC (6 tabs/fill) ARAKODA (tafenoquine succinate) TIER 3 PA, QLC (12 tabs/28 days) atovaquone TIER 1 PA atovaquone/proguanil hcl 250-100 mg TIER 1 QLC (1 tab/day) tablet atovaquone/proguanil hcl 62.5-25 mg TIER 1 QLC (3 tabs/day) tablet benznidazole 100 mg tablet TIER 3 QLC (4 tabs/day; not to exceed 240 tabs/year) benznidazole 12.5 mg tablet TIER 3 QLC (12 tabs/day; not to exceed 720 tabs/year) chloroquine phosphate TIER 1 COARTEM (artemether/lumefantrine) TIER 2 QLC (24 tabs/fill) DARAPRIM (pyrimethamine) TIER 2 PA hydroxychloroquine sulfate TIER 1 IMPAVIDO (miltefosine) TIER 4 PA, SP, QLC (84 tabs/28 days) KRINTAFEL (tafenoquine succinate) TIER 3 QLC (2 tabs/28 days) MALARONE (atovaquone/proguanil hcl) TIER 3 QLC (1 tab/day) 250-100 MG TABLET

51 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MALARONE (atovaquone/proguanil hcl) TIER 3 QLC (3 tabs/day) 62.5-25 MG PED TAB mefloquine hcl TIER 1 QLC (5 tabs/fill) MEPRON (atovaquone) TIER 3 PA PLAQUENIL (hydroxychloroquine sulfate) TIER 3 primaquine phosphate TIER 1 QUALAQUIN (quinine sulfate) TIER 3 QLC (6 caps/day) quinine sulfate TIER 1 QLC (6 caps/day) PEDICULICIDES/SCABICIDES (Drugs for Scabies and Lice) crotamiton (CROTAN) TIER 1 ELIMITE (permethrin) TIER 3 EURAX (crotamiton) TIER 3 lindane TIER 1 malathion TIER 1 OVIDE (malathion) TIER 3 permethrin TIER 1

ANTIPARKINSON AGENTS (Drugs for Parkinson's Disease) ANTICHOLINERGICS benztropine mesylate 0.5 mg tablet, 1 mg TIER 1 tablet, 2 mg tablet trihexyphenidyl hcl TIER 1 ANTIPARKINSON AGENTS, OTHER amantadine hcl TIER 1 carbidopa/levodopa/entacapone TIER 1 COMTAN (entacapone) TIER 3 QLC (8 tabs/day) entacapone TIER 1 QLC (8 tabs/day) GOCOVRI (amantadine hcl) ER 137 MG TIER 4 PA, QLC (2 caps/day) CAPSULE GOCOVRI (amantadine hcl) ER 68.5 MG TIER 4 PA, QLC (1 cap/day) CAPSULE NOURIANZ (istradefylline) TIER 4 PA, SP, QLC (1 tab/day)

52 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS OSMOLEX ER (amantadine hcl) TIER 3 PA, QLC (1 tab/day) STALEVO 100 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 125 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 150 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 200 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 50 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 75 TIER 3 (carbidopa/levodopa/entacapone) TASMAR (tolcapone) TIER 3 QLC (6 tabs/day) tolcapone TIER 1 ST, QLC (6 tabs/day) DOPAMINE AGONISTS APOKYN (apomorphine hcl) TIER 4 PA, SP bromocriptine mesylate TIER 1 MIRAPEX (pramipexole di-hcl) TIER 3 MIRAPEX ER (pramipexole di-hcl) TIER 3 QLC (1 tab/day) NEUPRO (rotigotine) TIER 3 QLC (1 patch/day) PARLODEL (bromocriptine mesylate) TIER 3 pramipexole di-hcl -0.125 mg tablet, -0.25 TIER 1 mg tablet, -0.5 mg tablet, -0.75 mg tablet, -1 mg tablet, -1.5 mg tablet pramipexole di-hcl -0.375 mg tab er, -0.75 TIER 1 QLC (1 tab/day) mg tab er, -1.5 mg tab er, -2.25 mg tab er, -3 mg tab er, -3.75 mg tab er, -4.5 mg tab er REQUIP (ropinirole hcl) TIER 3 REQUIP XL (ropinirole hcl) 12 MG TABLET TIER 3 QLC (2 tabs/day) REQUIP XL (ropinirole hcl) 2 MG TABLET, 4 TIER 3 QLC (1 tab/day) MG TABLET, 6 MG TABLET REQUIP XL (ropinirole hcl) 8 MG TABLET TIER 3 QLC (3 tabs/day) ropinirole hcl 0.25 mg tablet, 0.5 mg TIER 1 tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet

53 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ropinirole hcl 12 mg tab er 24h TIER 1 QLC (2 tabs/day) ropinirole hcl 2 mg tab er, 4 mg tab er, 6 TIER 1 QLC (1 tab/day) mg tab er ropinirole hcl 8 mg tab er 24h TIER 1 QLC (3 tabs/day) DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa TIER 1 carbidopa/levodopa 10mg-100mg tab TIER 1 QLC (8 tabs/day) rapdis, 25mg-100mg tab rapdis, 25mg- 250mg tab rapdis carbidopa/levodopa 10mg-100mg TIER 1 tablet, 25mg-100mg tablet, 25mg-100mg tablet er, 25mg-250mg tablet, 50mg- 200mg tablet er LODOSYN (carbidopa) TIER 3 RYTARY (carbidopa/levodopa) ER 23.75 TIER 3 ST, QLC (25 caps/day) MG-95 MG CAP RYTARY (carbidopa/levodopa) ER 36.25 TIER 3 ST, QLC (16 caps/day) MG-145 MG CAP RYTARY (carbidopa/levodopa) ER 48.75 TIER 3 ST, QLC (12 caps/day) MG-195 MG CAP RYTARY (carbidopa/levodopa) ER 61.25 TIER 3 ST, QLC (10 caps/day) MG-245 MG CAP SINEMET 10-100 (carbidopa/levodopa) TIER 3 SINEMET 25-100 (carbidopa/levodopa) TIER 3 SINEMET 25-250 (carbidopa/levodopa) TIER 3 SINEMET CR (carbidopa/levodopa) TIER 3 MONOAMINE OXIDASE B (MAO-B) INHIBITORS AZILECT (rasagiline mesylate) TIER 3 QLC (1 tab/day) ELDEPRYL (selegiline hcl) TIER 3 rasagiline mesylate TIER 1 QLC (1 tab/day) selegiline hcl TIER 1 XADAGO (safinamide mesylate) TIER 3 ST, QLC (1 tab/day) ZELAPAR (selegiline hcl) TIER 3

54 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANTIPSYCHOTICS (Drugs for Mental Health) 1ST GENERATION/TYPICAL chlorpromazine hcl 10 mg tablet, 25 mg TIER 1 tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet fluphenazine hcl 1 mg tablet, 2.5 mg TIER 1 tablet, 2.5 mg/5ml elixir, 5 mg/ml oral conc, 5 mg tablet, 10 mg tablet haloperidol TIER 1 haloperidol lactate 2 mg/ml oral conc TIER 1 loxapine succinate TIER 1 molindone hcl 10 mg tablet TIER 1 QLC (8 tabs/day) molindone hcl 25 mg tablet TIER 1 QLC (9 tabs/day) molindone hcl 5 mg tablet TIER 1 QLC (12 tabs/day) ORAP (pimozide) TIER 3 pimozide TIER 1 thioridazine hcl TIER 1 thiothixene TIER 1 trifluoperazine hcl TIER 1 2ND GENERATION/ATYPICAL ABILIFY (aripiprazole) 10 MG TABLET, 15 TIER 3 QLC (1 tab/day) MG TABLET, 20 MG TABLET, 30 MG TABLET ABILIFY (aripiprazole) 2 MG TABLET TIER 3 QLC (4 tabs/day) ABILIFY (aripiprazole) 5 MG TABLET TIER 3 QLC (2 tabs/day) ABILIFY MYCITE (aripiprazole) 2 MG KIT TIER 4 PA, QLC (4 tabs/day) ABILIFY MYCITE (aripiprazole) 5 MG KIT, 10 TIER 4 PA, QLC (1 tab/day) MG KIT, 15 MG KIT, 20 MG KIT, 30 MG KIT aripiprazole 1 mg/ml solution TIER 1 QLC (25 ml/day) aripiprazole 10 mg tablet, 15 mg tablet, TIER 1 QLC (1 tab/day) 20 mg tablet, 30 mg tablet aripiprazole 2 mg tablet TIER 1 QLC (4 tabs/day) aripiprazole 5 mg tablet, 10 mg tab TIER 1 QLC (2 tabs/day) rapdis, 15 mg tab rapdis

55 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS FANAPT (iloperidone) 1 MG TABLET, 2 MG TIER 3 QLC (2 tabs/day) TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET FANAPT (iloperidone) TITRATION PACK TIER 3 QLC (1 pack/month) GEODON (ziprasidone hcl) TIER 3 INVEGA (paliperidone) ER 1.5 MG TABLET, TIER 3 PA, QLC (1 tab/day) ER 3 MG TABLET, ER 9 MG TABLET INVEGA (paliperidone) ER 6 MG TABLET TIER 3 PA, QLC (2 tabs/day) LATUDA (lurasidone hcl) TIER 3 ST, QLC (1 tab/day) NUPLAZID (pimavanserin tartrate) 10 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 TABLET tab/day) NUPLAZID (pimavanserin tartrate) 17 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 TABLET tab/day) NUPLAZID (pimavanserin tartrate) 34 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 CAPSULE cap/day) olanzapine 2.5 mg tablet, 5 mg tablet, 5 TIER 1 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis paliperidone 1.5 mg tab er 24, 3 mg tab TIER 1 PA, QLC (1 tab/day) er 24, 9 mg tab er 24 paliperidone 6 mg tab 24 TIER 1 PA, QLC (2 tabs/day) quetiapine fumarate 25 mg tablet, 50 mg TIER 1 tablet, 100 mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet quetiapine fumarate 50 mg tab er, 150 TIER 1 ST mg tab er, 200 mg tab er, 300 mg tab er, 400 mg tab er REXULTI (brexpiprazole) TIER 4 PA, QLC (1 tab/day) RISPERDAL (risperidone) TIER 3 RISPERDAL M-TAB (risperidone) TIER 3 risperidone TIER 1 SAPHRIS (asenapine maleate) TIER 3 QLC (2 tabs/day) SEROQUEL (quetiapine fumarate) TIER 3 SEROQUEL XR (quetiapine fumarate) TIER 3 ST VRAYLAR (cariprazine hcl) 1.5 MG TIER 3 PA, QLC (1 cap/day) CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE

56 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VRAYLAR (cariprazine hcl) 1.5 MG-3 MG TIER 3 PA, QLC (1 pack/month) PACK ziprasidone hcl TIER 1 ZYPREXA (olanzapine) 2.5 MG TABLET, 5 TIER 3 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET ZYPREXA ZYDIS (olanzapine) TIER 3 TREATMENT-RESISTANT clozapine TIER 1 CLOZARIL (clozapine) TIER 3 FAZACLO (clozapine) TIER 3 VERSACLOZ (clozapine) TIER 3 QLC (18 ml/day)

ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) baclofen 10 mg tablet TIER 1 QLC (8 tabs/day) baclofen 20 mg tablet TIER 1 QLC (4 tabs/day) baclofen 5 mg tablet TIER 1 QLC (3 tabs/day) DANTRIUM (dantrolene sodium) 25 MG TIER 3 CAPSULE, 50 MG CAPSULE dantrolene sodium 25 mg capsule, 50 mg TIER 1 capsule, 100 mg capsule OZOBAX (baclofen) TIER 3 PA, QLC (80 ml/day) tizanidine hcl TIER 1 ZANAFLEX (tizanidine hcl) TIER 3

ANTIVIRALS (Drugs for Viral Infections) ANTI-CYTOMEGALOVIRUS (CMV) AGENTS PREVYMIS (letermovir) 240 MG TABLET, 480 TIER 3 PA, QLC (1 tab/day) MG TABLET VALCYTE (valganciclovir hcl) 450 MG TIER 3 QLC (2 tabs/day) TABLET VALCYTE (valganciclovir hcl) 50 MG/ML TIER 3 QLC (18 ml/day) SOLUTION valganciclovir hcl 450 mg tablet TIER 1 QLC (2 tabs/day)

57 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS valganciclovir hcl 50 mg/ml soln recon TIER 1 QLC (18 ml/day) ZIRGAN (ganciclovir) TIER 3 QLC (1 tube/month) ANTI-HEPATITIS B (HBV) AGENTS adefovir dipivoxil TIER 1 QLC (1 tab/day) BARACLUDE (entecavir) 0.05 MG/ML TIER 2 QLC (3 bottles/month) SOLUTION BARACLUDE (entecavir) 0.5 MG TABLET, 1 TIER 3 QLC (1 tab/day) MG TABLET entecavir TIER 1 QLC (1 tab/day) EPIVIR HBV (lamivudine) 100 MG TABLET TIER 3 QLC (1 tab/day) EPIVIR HBV (lamivudine) 25 MG/5 ML TIER 2 QLC (3 bottles/month) SOLN HEPSERA (adefovir dipivoxil) TIER 3 QLC (1 tab/day) lamivudine 100 mg tablet TIER 1 QLC (1 tab/day) VEMLIDY (tenofovir alafenamide) TIER 3 PA, QLC (1 tab/day) ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS DAKLINZA (daclatasvir dihydrochloride) TIER 4 PA, SP, QLC (1 tab/day) EPCLUSA (sofosbuvir/velpatasvir) TIER 4 PA, SP, QLC (1 tab/day) HARVONI (ledipasvir/sofosbuvir) TIER 4 PA, SP, QLC (1 tab/day) ledipasvir/sofosbuvir TIER 4 PA, SP, QLC (1 tab/day) MAVYRET (glecaprevir/pibrentasvir) TIER 4 PA, SP, QLC (3 tabs/day) OLYSIO (simeprevir sodium) TIER 4 PA, SP, QLC (1 cap/day) sofosbuvir/velpatasvir TIER 4 PA, SP, QLC (1 tab/day) SOVALDI (sofosbuvir) TIER 4 PA, SP, QLC (1 tab/day) TECHNIVIE TIER 4 PA, SP, QLC (2 tabs/day) (ombitasvir/paritaprevir/ritonavir) VIEKIRA PAK TIER 4 PA, SP, QLC (4 tabs/day) (ombitasvir/paritaprevir/ritonavir/dasabuv ir sodium) VIEKIRA XR TIER 4 PA, SP, QLC (3 tabs/day) (ombitasvir/paritaprevir/ritonavir/dasabuv ir sodium) VOSEVI TIER 4 PA, SP, QLC (1 tab/day) (sofosbuvir/velpatasvir/voxilaprevir)

58 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZEPATIER (elbasvir/grazoprevir) TIER 4 PA, SP, QLC (1 tab/day) ANTI-HEPATITIS C (HCV) AGENTS, OTHER COPEGUS (ribavirin) TIER 3 RO (Retail Only) INTRON A (interferon alfa-2b,recomb.) TIER 4 PA, SP PEGASYS (peginterferon alfa-2a) 180 TIER 4 PA, SP, QLC (1 syringe/week) MCG/0.5 ML SYRINGE - PEGASYS (peginterferon alfa-2a) 180 TIER 4 PA, SP, QLC (1 vial/week) MCG/ML VIAL - PEGASYS PROCLICK (peginterferon alfa- TIER 4 PA, SP, QLC (1 pen/week) 2a) PEGINTRON (peginterferon alfa-2b) TIER 4 PA, SP PEGINTRON REDIPEN (peginterferon alfa- TIER 4 PA, SP 2b) REBETOL (ribavirin) 200 MG CAPSULE TIER 3 RO (Retail Only) REBETOL (ribavirin) 40 MG/ML SOLUTION TIER 3 PA, RO (Retail Only) RIBASPHERE RIBAPAK (ribavirin) TIER 3 PA, RO (Retail Only) RIBATAB (ribavirin) TIER 3 PA, RO (Retail Only) ribavirin (MODERIBA) 200 mg tablet TIER 1 RO (Retail Only) ribavirin (MODERIBA) 200-400 mg tab, 400- TIER 3 PA, RO (Retail Only) 400 mg tab, 600-400 mg tab, 600-600 mg tab ribavirin (RIBASPHERE) TIER 1 RO (Retail Only) ribavirin 200 mg capsule, 200 mg tablet TIER 1 RO (Retail Only) ANTI-HIV AGENTS CIMDUO (lamivudine/tenofovir disoproxil TIER 2 QLC (1 tab/day) fumarate) SYMFI (efavirenz/lamivudine/tenofovir TIER 2 QLC (1 tab/day) disoproxil fumarate) TEMIXYS (lamivudine/tenofovir disoproxil TIER 2 QLC (1 tab/day) fumarate) ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) BIKTARVY (bictegravir TIER 2 QLC (1 tab/day) sodium/emtricitabine/tenofovir alafenamide fumar)

59 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GENVOYA TIER 3 QLC (1 tab/day) (elvitegravir/cobicistat/emtricitabine/ten ofovir alafenamide) ISENTRESS (raltegravir potassium) 100 MG TIER 2 QLC (2 packets/day) POWDER PACKET ISENTRESS (raltegravir potassium) 25 MG TIER 2 QLC (6 tabs/day) TABLET CHEW, 100 MG TABLET CHEW ISENTRESS (raltegravir potassium) 400 MG TIER 2 QLC (4 tabs/day) TABLET ISENTRESS HD (raltegravir potassium) TIER 2 QLC (2 tabs/day) STRIBILD TIER 2 QLC (1 tab/day) (elvitegravir/cobicistat/emtricitabine/ten ofovir disoproxil) TIVICAY (dolutegravir sodium) TIER 2 QLC (2 tabs/day) VITEKTA (elvitegravir) TIER 3 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA TIER 3 PA, QLC (1 tab/day) (efavirenz/emtricitabine/tenofovir disoproxil fumarate) COMPLERA (emtricitabine/rilpivirine TIER 2 QLC (1 tab/day) hcl/tenofovir disoproxil fumarate) DELSTRIGO TIER 3 QLC (1 tab/day) (doravirine/lamivudine/tenofovir disoproxil fumarate) EDURANT (rilpivirine hcl) TIER 2 QLC (2 tabs/day) efavirenz 200 mg capsule TIER 1 QLC (3 caps/day) efavirenz 50 mg capsule TIER 1 QLC (6 caps/day) efavirenz 600 mg tablet TIER 1 QLC (1 tab/day) INTELENCE (etravirine) 100 MG TABLET TIER 2 QLC (4 tabs/day) INTELENCE (etravirine) 200 MG TABLET TIER 2 QLC (2 tabs/day) INTELENCE (etravirine) 25 MG TABLET TIER 2 QLC (12 tabs/day) nevirapine 100 mg tab er 24h TIER 1 QLC (3 tabs/day) nevirapine 200 mg tablet TIER 1 QLC (2 tabs/day) nevirapine 400 mg tab er 24h TIER 1 QLC (1 tab/day) nevirapine 50 mg/5 ml oral susp TIER 1 QLC (40 ml/day)

60 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ODEFSEY (emtricitabine/rilpivirine TIER 2 QLC (1 tab/day) hcl/tenofovir alafenamide fumarate) PIFELTRO (doravirine) TIER 3 QLC (2 tabs/day) RESCRIPTOR (delavirdine mesylate) 100 TIER 2 QLC (12 tabs/day) MG TABLET RESCRIPTOR (delavirdine mesylate) 200 TIER 2 QLC (6 tabs/day) MG TABLET SUSTIVA (efavirenz) 200 MG CAPSULE TIER 3 QLC (3 caps/day) SUSTIVA (efavirenz) 50 MG CAPSULE TIER 3 QLC (6 caps/day) SUSTIVA (efavirenz) 600 MG TABLET TIER 3 QLC (1 tab/day) SYMFI LO (efavirenz/lamivudine/tenofovir TIER 2 QLC (1 tab/day) disoproxil fumarate) VIRAMUNE (nevirapine) 200 MG TABLET TIER 3 QLC (2 tabs/day) VIRAMUNE (nevirapine) 50 MG/5 ML SUSP TIER 3 QLC (40 ml/day) VIRAMUNE XR (nevirapine) 100 MG TABLET TIER 3 QLC (3 tabs/day) VIRAMUNE XR (nevirapine) 400 MG TABLET TIER 3 QLC (1 tab/day) ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate 20 mg/ml solution TIER 1 QLC (30 ml/day) abacavir sulfate 300 mg tablet TIER 1 QLC (2 tabs/day) abacavir sulfate/lamivudine TIER 1 QLC (1 tab/day) abacavir sulfate/lamivudine/zidovudine TIER 1 QLC (2 tabs/day) COMBIVIR (lamivudine/zidovudine) TIER 3 QLC (2 tabs/day) didanosine TIER 1 QLC (1 cap/day) EMTRIVA (emtricitabine) 10 MG/ML TIER 2 QLC (24 ml/day) SOLUTION EMTRIVA (emtricitabine) 200 MG CAPSULE TIER 2 QLC (1 cap/day) EPIVIR (lamivudine) 10 MG/ML ORAL SOLN TIER 3 QLC (30 ml/day) EPIVIR (lamivudine) 150 MG TABLET TIER 3 QLC (2 tabs/day) EPIVIR (lamivudine) 300 MG TABLET TIER 3 QLC (1 tab/day) EPZICOM (abacavir sulfate/lamivudine) TIER 3 QLC (1 tab/day) lamivudine 10 mg/ml solution TIER 1 QLC (30 ml/day) lamivudine 150 mg tablet TIER 1 QLC (2 tabs/day)

61 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lamivudine 300 mg tablet TIER 1 QLC (1 tab/day) lamivudine/zidovudine TIER 1 QLC (2 tabs/day) RETROVIR (zidovudine) 10 MG/ML SYRUP TIER 3 QLC (60 ml/day) RETROVIR (zidovudine) 100 MG CAPSULE TIER 3 QLC (5 caps/day) stavudine 1 mg/ml soln recon TIER 1 QLC (80 ml/day) stavudine 15 mg capsule, 20 mg capsule, TIER 1 QLC (2 caps/day) 30 mg capsule, 40 mg capsule tenofovir disoproxil fumarate TIER 1 QLC (1 tab/day) TRIZIVIR (abacavir TIER 3 QLC (2 tabs/day) sulfate/lamivudine/zidovudine) TRUVADA (emtricitabine/tenofovir TIER 2 QLC (1 tab/day) disoproxil fumarate) VIDEX (didanosine) TIER 2 VIDEX EC (didanosine) TIER 3 QLC (1 cap/day) VIREAD (tenofovir disoproxil fumarate) 150 TIER 2 QLC (1 tab/day) MG TABLET, 200 MG TABLET, 250 MG TABLET VIREAD (tenofovir disoproxil fumarate) 300 TIER 3 QLC (1 tab/day) MG TABLET VIREAD (tenofovir disoproxil fumarate) TIER 2 QLC (3 bottles/month) POWDER ZERIT (stavudine) 1 MG/ML SOLUTION TIER 3 QLC (80 ml/day) ZERIT (stavudine) 15 MG CAPSULE, 20 MG TIER 3 QLC (2 caps/day) CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE ZIAGEN (abacavir sulfate) 20 MG/ML TIER 3 QLC (30 ml/day) SOLUTION ZIAGEN (abacavir sulfate) 300 MG TABLET TIER 3 QLC (2 tabs/day) zidovudine 10 mg/ml syrup TIER 1 QLC (60 ml/day) zidovudine 100 mg capsule TIER 1 QLC (5 caps/day) zidovudine 300 mg tablet TIER 1 QLC (2 tabs/day) ANTI-HIV AGENTS, OTHER DESCOVY (emtricitabine/tenofovir TIER 2 QLC (1 tab/day) alafenamide fumarate) DOVATO (dolutegravir TIER 3 QLC (1 tab/day) sodium/lamivudine)

62 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS FUZEON (enfuvirtide) TIER 4 SP, QLC (1 kit/month) JULUCA (dolutegravir sodium/rilpivirine TIER 3 QLC (1 tab/day) hcl) SELZENTRY (maraviroc) 20 MG/ML ORAL TIER 2 PA, QLC (60 ml/day) SOLN SELZENTRY (maraviroc) 25 MG TABLET TIER 2 PA, QLC (8 tabs/day) SELZENTRY (maraviroc) 300 MG TABLET TIER 2 PA, QLC (4 tabs/day) SELZENTRY (maraviroc) 75 MG TABLET, 150 TIER 2 PA, QLC (2 tabs/day) MG TABLET TRIUMEQ (abacavir sulfate/dolutegravir TIER 3 QLC (1 tab/day) sodium/lamivudine) TYBOST (cobicistat) TIER 3 QLC (1 tab/day) ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS (tipranavir) TIER 2 QLC (4 caps/day) APTIVUS (tipranavir/vitamin e tpgs) TIER 2 QLC (10 ml/day) atazanavir sulfate 150 mg capsule, 200 TIER 1 QLC (2 caps/day) mg capsule atazanavir sulfate 300 mg capsule TIER 1 QLC (1 cap/day) CRIXIVAN (indinavir sulfate) 200 MG TIER 2 QLC (9 caps/day) CAPSULE CRIXIVAN (indinavir sulfate) 400 MG TIER 2 QLC (6 caps/day) CAPSULE EVOTAZ (atazanavir sulfate/cobicistat) TIER 3 QLC (1 tab/day) fosamprenavir calcium TIER 1 QLC (4 tabs/day) INVIRASE (saquinavir mesylate) 200 MG TIER 2 QLC (4 caps/day) CAPSULE INVIRASE (saquinavir mesylate) 500 MG TIER 2 QLC (4 tabs/day) TABLET KALETRA (lopinavir/ritonavir) 100-25 MG TIER 2 QLC (4 tabs/day) TABLET, 200-50 MG TABLET KALETRA (lopinavir/ritonavir) 80 MG-20 TIER 3 QLC (10 ml/day) MG/ML SOLN LEXIVA (fosamprenavir calcium) 50 TIER 2 QLC (56 ml/day) MG/ML SUSPENSION LEXIVA (fosamprenavir calcium) 700 MG TIER 3 QLC (4 tabs/day) TABLET

63 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lopinavir/ritonavir TIER 1 QLC (10 ml/day) NORVIR (ritonavir) 100 MG POWDER TIER 2 QLC (12 packets/day) PACKET NORVIR (ritonavir) 100 MG SOFTGEL CAP TIER 2 QLC (12 caps/day) NORVIR (ritonavir) 100 MG TABLET TIER 3 QLC (12 tabs/day) NORVIR (ritonavir) 80 MG/ML SOLUTION TIER 2 QLC (15 ml/day) PREZCOBIX (darunavir TIER 2 QLC (1 tab/day) ethanolate/cobicistat) PREZISTA (darunavir ethanolate) 100 TIER 2 QLC (12 ml/day) MG/ML SUSPENSION PREZISTA (darunavir ethanolate) 150 MG TIER 2 QLC (4 tabs/day) TABLET PREZISTA (darunavir ethanolate) 400 MG TIER 2 QLC (2 tabs/day) TABLET PREZISTA (darunavir ethanolate) 75 MG TIER 2 QLC (2 tabs/day) TABLET, 600 MG TABLET PREZISTA (darunavir ethanolate) 800 MG TIER 2 QLC (1 tab/day) TABLET REYATAZ (atazanavir sulfate) 150 MG TIER 3 QLC (2 caps/day) CAPSULE, 200 MG CAPSULE REYATAZ (atazanavir sulfate) 300 MG TIER 3 QLC (1 cap/day) CAPSULE REYATAZ (atazanavir sulfate) 50 MG TIER 2 QLC (5 packs/day) POWDER PACKET ritonavir TIER 1 QLC (12 tabs/day) SYMTUZA (darunavir TIER 3 QLC (1 tab/day) eth/cobicistat/emtricitabine/tenofovir alafenamide) VIRACEPT (nelfinavir mesylate) 250 MG TIER 2 QLC (9 tabs/day) TABLET VIRACEPT (nelfinavir mesylate) 625 MG TIER 2 QLC (4 tabs/day) TABLET ANTI-INFLUENZA AGENTS FLUMADINE (rimantadine hcl) TIER 3 oseltamivir phosphate 30 mg capsule TIER 1 QLC (40 caps/6 months) oseltamivir phosphate 45 mg capsule, 75 TIER 1 QLC (20 caps/6 months) mg capsule

64 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS oseltamivir phosphate 6 mg/ml susp TIER 1 QLC (6 bottles/6 months) recon RELENZA (zanamivir) TIER 2 QLC (2 inhalers/6 months) rimantadine hcl TIER 1 TAMIFLU (oseltamivir phosphate) 30 MG TIER 3 QLC (40 caps/6 months) CAPSULE TAMIFLU (oseltamivir phosphate) 45 MG TIER 3 QLC (20 caps/6 months) CAPSULE, 75 MG CAPSULE TAMIFLU (oseltamivir phosphate) 6 MG/ML TIER 3 QLC (6 bottles/6 months) SUSPENSION XENLETA (lefamulin acetate) 600 MG TIER 3 PA, QLC (10 tabs/month) TABLET ANTIHERPETIC AGENTS acyclovir 200 mg capsule, 200 mg/5ml TIER 1 oral susp, 400 mg tablet, 800 mg tablet acyclovir 5 % cream (g) TIER 1 PA, QLC (1 tube/fill) acyclovir 5 % oint. (g) TIER 1 PA, QLC (1 tube/fill) DENAVIR (penciclovir) TIER 3 PA, QLC (1 tube/month) famciclovir TIER 1 FAMVIR (famciclovir) TIER 3 SITAVIG (acyclovir) TIER 3 PA, QLC (2 tabs/2 months) trifluridine TIER 1 valacyclovir hcl TIER 1 VALTREX (valacyclovir hcl) TIER 3 VIROPTIC (trifluridine) TIER 3 XERESE (acyclovir/hydrocortisone) TIER 3 PA, QLC (5 gm tube/fill) ZOVIRAX (acyclovir) 200 MG CAPSULE, TIER 3 200 MG/5 ML SUSP, 400 MG TABLET, 800 MG TABLET ZOVIRAX (acyclovir) 5% CREAM, 5% TIER 3 PA, QLC (1 tube/fill) OINTMENT

65 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANXIOLYTICS (Drugs for Anxiety) ANXIOLYTICS, OTHER (Other Drugs for Anxiety) buspirone hcl TIER 1 meprobamate TIER 1 AL1 (Up to 65 yrs old) BENZODIAZEPINES alprazolam (ALPRAZOLAM INTENSOL) TIER 1 QLC (4 ml/day) alprazolam 0.25 mg tab rapdis, 0.25 mg TIER 1 QLC (4 tabs/day) tablet, 0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg tablet alprazolam 0.5 mg tab er, 1 mg tab er, 3 TIER 1 QLC (1 tab/day) mg tab er alprazolam 2 mg tab er 24h, 2 mg tablet, TIER 1 QLC (2 tabs/day) 2 mg tab rapdis ATIVAN (lorazepam) 0.5 MG TABLET TIER 3 QLC (20 tabs/day) ATIVAN (lorazepam) 1 MG TABLET TIER 3 QLC (10 tabs/day) ATIVAN (lorazepam) 2 MG TABLET TIER 3 QLC (5 tabs/day) chlordiazepoxide hcl 10 mg capsule TIER 1 QLC (30 caps/day) chlordiazepoxide hcl 25 mg capsule TIER 1 QLC (12 caps/day) chlordiazepoxide hcl 5 mg capsule TIER 1 QLC (60 caps/day) clonazepam 0.125 mg tab rapdis, 0.25 TIER 1 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tab rapdis, 2 mg tab rapdis clonazepam 0.5 mg tablet TIER 1 QLC (40 tabs/day) clonazepam 1 mg tablet TIER 1 QLC (20 tabs/day) clonazepam 2 mg tablet TIER 1 QLC (10 tabs/day) clorazepate dipotassium 15 mg tablet TIER 1 QLC (6 tabs/day) clorazepate dipotassium 3.75 mg tablet TIER 1 QLC (24 tabs/day) clorazepate dipotassium 7.5 mg tablet TIER 1 QLC (12 tabs/day) diazepam 10 mg tablet TIER 1 QLC (6 tabs/day) diazepam 2 mg tablet TIER 1 QLC (30 tabs/day) diazepam 5 mg tablet TIER 1 QLC (12 tabs/day) diazepam 5 mg/5 ml solution TIER 1 PA, QLC (60 ml/day)

66 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS diazepam 5 mg/ml oral conc TIER 1 QLC (12 bottles/month) KLONOPIN (clonazepam) 0.5 MG TABLET TIER 3 QLC (40 tabs/day) KLONOPIN (clonazepam) 1 MG TABLET TIER 3 QLC (20 tabs/day) KLONOPIN (clonazepam) 2 MG TABLET TIER 3 QLC (10 tabs/day) lorazepam (LORAZEPAM INTENSOL) TIER 1 QLC (150 ml/month) lorazepam 0.5 mg tablet TIER 1 QLC (20 tabs/day) lorazepam 1 mg tablet TIER 1 QLC (10 tabs/day) lorazepam 2 mg tablet TIER 1 QLC (5 tabs/day) lorazepam 2 mg/ml oral conc TIER 1 QLC (150 ml/month) oxazepam 10 mg capsule TIER 1 QLC (12 caps/day) oxazepam 15 mg capsule TIER 1 QLC (8 caps/day) oxazepam 30 mg capsule TIER 1 QLC (4 caps/day) TRANXENE T-TAB (clorazepate TIER 3 QLC (24 tabs/day) dipotassium) RANXENE -AB 3.75 MG TRANXENE T-TAB (clorazepate TIER 3 QLC (12 tabs/day) dipotassium) RANXENE -AB 7.5 MG VALIUM (diazepam) 10 MG TABLET TIER 3 QLC (6 tabs/day) VALIUM (diazepam) 2 MG TABLET TIER 3 QLC (30 tabs/day) VALIUM (diazepam) 5 MG TABLET TIER 3 QLC (12 tabs/day) XANAX (alprazolam) 0.25 MG TABLET, 0.5 TIER 3 QLC (4 tabs/day) MG TABLET, 1 MG TABLET XANAX (alprazolam) 2 MG TABLET TIER 3 QLC (2 tabs/day) XANAX XR (alprazolam) 0.5 MG TABLET, 1 TIER 3 QLC (1 tab/day) MG TABLET, 3 MG TABLET XANAX XR (alprazolam) 2 MG TABLET TIER 3 QLC (2 tabs/day)

BIPOLAR AGENTS (Drugs for Bipolar Disorder) MOOD STABILIZERS EQUETRO (carbamazepine) TIER 2 lithium carbonate TIER 1 lithium citrate TIER 1 LITHOBID (lithium carbonate) TIER 3

67 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) ANTIDIABETIC AGENTS (Drugs for High Blood Sugar) acarbose TIER 1 ACTOPLUS MET (pioglitazone TIER 3 ST, QLC (3 tabs/day) hcl/metformin hcl) ACTOPLUS MET XR (pioglitazone TIER 2 ST, QLC (1 tab/day) hcl/metformin hcl) ACTOS (pioglitazone hcl) TIER 3 ADLYXIN (lixisenatide) TIER 3 PA, QLC (1 pack/month) alogliptin benzoate TIER 1 PA, QLC (1 tab/day) alogliptin benzoate/metformin hcl TIER 1 PA, QLC (2 tabs/day) alogliptin benzoate/pioglitazone hcl TIER 1 PA, QLC (1 tab/day) AMARYL (glimepiride) TIER 3 AVANDIA (rosiglitazone maleate) TIER 3 ST BYDUREON (exenatide microspheres) TIER 3 PA, QLC (4 vials/month) BYDUREON BCISE (exenatide TIER 3 PA, QLC (1 injection/week) microspheres) BYDUREON PEN (exenatide microspheres) TIER 3 PA, QLC (4 pens/month) BYETTA (exenatide) TIER 3 PA, QLC (1 pen/month) chlorpropamide TIER 1 CYCLOSET (bromocriptine mesylate) TIER 3 ST, QLC (6 tabs/day) DIABETA (glyburide) TIER 3 DUETACT (pioglitazone hcl/glimepiride) TIER 3 ST, QLC (1 tab/day) FARXIGA (dapagliflozin propanediol) TIER 2 ST, QLC (1 tab/day) FORTAMET (metformin hcl) TIER 3 PA glimepiride TIER 1 glipizide TIER 1 glipizide/metformin hcl TIER 1 GLUCOPHAGE (metformin hcl) TIER 3 GLUCOPHAGE XR (metformin hcl) TIER 3 GLUCOTROL (glipizide) TIER 3

68 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GLUCOTROL XL (glipizide) TIER 3 GLUCOVANCE (glyburide/metformin hcl) TIER 3 GLUMETZA (metformin hcl) ER 1,000 MG TIER 3 PA, QLC (2 tabs/day) TABLET GLUMETZA (metformin hcl) ER 500 MG TIER 3 PA, QLC (3 tabs/day) TABLET glyburide TIER 1 glyburide,micronized TIER 1 glyburide/metformin hcl TIER 1 GLYNASE (glyburide,micronized) TIER 3 GLYSET (miglitol) TIER 3 QLC (3 tabs/day) GLYXAMBI (empagliflozin/linagliptin) TIER 2 ST, QLC (1 tab/day) INVOKAMET (canagliflozin/metformin hcl) TIER 3 PA, QLC (2 tabs/day) 50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MG TABLET INVOKAMET (canagliflozin/metformin hcl) TIER 3 PA, QLC (4 tabs/day) 50-500 MG TABLET INVOKAMET XR (canagliflozin/metformin TIER 3 PA, QLC (2 tabs/day) hcl) INVOKANA (canagliflozin) TIER 3 PA, QLC (1 tab/day) JANUMET (sitagliptin TIER 2 ST, QLC (2 tabs/day) phosphate/metformin hcl) JANUMET XR (sitagliptin TIER 2 ST, QLC (2 tabs/day) phosphate/metformin hcl) 50-1,000 MG TABLET JANUMET XR (sitagliptin TIER 2 ST, QLC (1 tab/day) phosphate/metformin hcl) 50-500 MG TABLET, 100-1,000 MG TABLET JANUVIA (sitagliptin phosphate) TIER 2 ST, QLC (1 tab/day) JARDIANCE (empagliflozin) TIER 2 ST, QLC (1 tab/day) JENTADUETO (linagliptin/metformin hcl) TIER 3 PA, QLC (2 tabs/day) JENTADUETO XR (linagliptin/metformin hcl) TIER 3 PA, QLC (2 tabs/day) 2.5 MG-1,000 MG JENTADUETO XR (linagliptin/metformin hcl) TIER 3 PA, QLC (1 tab/day) 5 MG-1,000 MG TB KAZANO (alogliptin benzoate/metformin TIER 3 PA, QLC (2 tabs/day) hcl)

69 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS KOMBIGLYZE XR (saxagliptin TIER 3 PA, QLC (2 tabs/day) hcl/metformin hcl) 2.5-1,000 MG TAB KOMBIGLYZE XR (saxagliptin TIER 3 PA, QLC (1 tab/day) hcl/metformin hcl) 5-500 MG TABLET, 5- 1,000 MG TAB metformin hcl 1000 mg tabergr24h TIER 1 PA, QLC (2 tabs/day) metformin hcl 500 mg tab er 24, 1000 mg TIER 1 PA tab er 24 metformin hcl 500 mg tabergr24h TIER 1 PA, QLC (3 tabs/day) metformin hcl 500 mg tablet, 500 mg tab TIER 1 er 24h, 500 mg/5ml solution, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet miglitol TIER 1 QLC (3 tabs/day) nateglinide TIER 1 NESINA (alogliptin benzoate) TIER 3 PA, QLC (1 tab/day) ONGLYZA (saxagliptin hcl) TIER 3 PA, QLC (1 tab/day) OSENI (alogliptin benzoate/pioglitazone TIER 3 PA, QLC (1 tab/day) hcl) OZEMPIC (semaglutide) 0.25-0.5 MG DOSE TIER 2 ST, QLC (1 pen/28 days) PEN OZEMPIC (semaglutide) 1 MG DOSE PEN TIER 2 ST, QLC (2 pens/28 days) pioglitazone hcl TIER 1 pioglitazone hcl/glimepiride TIER 1 ST, QLC (1 tab/day) pioglitazone hcl/metformin hcl TIER 1 ST, QLC (3 tabs/day) PRANDIN (repaglinide) 0.5 MG TABLET TIER 2 PRANDIN (repaglinide) 1 MG TABLET, 2 TIER 3 MG TABLET PRECOSE (acarbose) TIER 3 QTERN (dapagliflozin TIER 3 PA, QLC (1 tab/day) propanediol/saxagliptin hcl) repaglinide TIER 1 repaglinide/metformin hcl TIER 1 PA, QLC (5 tabs/day) RIOMET (metformin hcl) TIER 3 RYBELSUS (semaglutide) TIER 2 ST, QLC (1 tab/day)

70 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SEGLUROMET (ertugliflozin TIER 3 PA, QLC (2 tabs/day) pidolate/metformin hcl) 2.5-1,000 MG TABLET, 7.5-1,000 MG TABLET, 7.5-500 MG TABLET SEGLUROMET (ertugliflozin TIER 3 PA, QLC (4 tabs/day) pidolate/metformin hcl) 2.5-500 MG TABLET STARLIX (nateglinide) TIER 3 STEGLATRO (ertugliflozin pidolate) 15 MG TIER 3 PA, QLC (1 tab/day) TABLET STEGLATRO (ertugliflozin pidolate) 5 MG TIER 3 PA, QLC (2 tabs/day) TABLET STEGLUJAN (ertugliflozin TIER 3 PA, QLC (1 tab/day) pidolate/sitagliptin phosphate) SYMLINPEN 120 (pramlintide acetate) TIER 3 PA SYMLINPEN 60 (pramlintide acetate) TIER 3 PA SYNJARDY (empagliflozin/metformin hcl) TIER 2 ST, QLC (2 tabs/day) SYNJARDY XR (empagliflozin/metformin TIER 2 ST, QLC (1 tab/day) hcl) 25-1,000 MG TABLET SYNJARDY XR (empagliflozin/metformin TIER 2 ST, QLC (2 tabs/day) hcl) 5-MG TABLET, 10-MG TABLET, 12.5-MG TAB TANZEUM (albiglutide) TIER 3 PA, QLC (4 pens/month) tolazamide TIER 1 tolbutamide TIER 1 TRADJENTA (linagliptin) TIER 3 PA, QLC (1 tab/day) TRULICITY (dulaglutide) TIER 2 ST, QLC (1 pen/week) VICTOZA 2-PAK (liraglutide) TIER 2 ST, QLC (3 pens/month) VICTOZA 3-PAK (liraglutide) TIER 2 ST, QLC (3 pens/month) XIGDUO XR (dapagliflozin TIER 2 ST, QLC (2 tabs/day) propanediol/metformin hcl) 2.5 MG-MG TAB, 5 MG-MG TABLET XIGDUO XR (dapagliflozin TIER 2 ST, QLC (1 tab/day) propanediol/metformin hcl) 5 MG-500 MG TABLET, 10 MG-500 MG TABLET, 10 MG-1,000 MG TAB

71 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GLYCEMIC AGENTS (Drugs for Low Blood Sugar) BAQSIMI (glucagon) TIER 3 QLC (2 sprayers/30 days) GLUCAGEN (glucagon,human TIER 2 QLC (2 injections/fill) recombinant) 1 MG HYPOKIT GLUCAGON EMERGENCY KIT TIER 2 QLC (2 kits/fill) (glucagon,human recombinant) GVOKE HYPOPEN (glucagon) TIER 3 QLC (2 injectors/30 days) GVOKE SYRINGE (glucagon) TIER 3 QLC (2 syringes/30 days) PROGLYCEM (diazoxide) TIER 3 INSULINS ADMELOG (insulin lispro) TIER 3 PA ADMELOG SOLOSTAR (insulin lispro) TIER 3 PA AFREZZA (insulin regular, human) 4 /8 /12, TIER 3 PA, QLC (1 box/month) 90-4 / 90-8, 90-8 / 90-12 AFREZZA (insulin regular, human) 4 TIER 3 PA, QLC (3 boxes/month) CARTRIDGE, 8 CARTRIDGE, 12 CARTRIDGE, 30-4 / 60-8, 60-8 / 30-12 APIDRA (insulin glulisine) TIER 3 APIDRA SOLOSTAR (insulin glulisine) TIER 3 BASAGLAR KWIKPEN U-100 (insulin TIER 3 PA, QLC (15 pens/month) glargine,human recombinant analog) FIASP (insulin aspart (niacinamide)) TIER 3 FIASP FLEXTOUCH (insulin aspart TIER 3 (niacinamide)) FIASP PENFILL (insulin aspart TIER 3 (niacinamide)) HUMALOG (insulin lispro) TIER 2 HUMALOG JUNIOR KWIKPEN (insulin lispro) TIER 2 HUMALOG KWIKPEN U-100 (insulin lispro) TIER 2 HUMALOG KWIKPEN U-200 (insulin lispro) TIER 2 HUMALOG MIX 50-50 (insulin lispro TIER 2 protamine and insulin lispro) HUMALOG MIX 50-50 KWIKPEN (insulin TIER 2 lispro protamine and insulin lispro)

72 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS HUMALOG MIX 75-25 (insulin lispro TIER 2 protamine and insulin lispro) HUMALOG MIX 75-25 KWIKPEN (insulin TIER 2 lispro protamine and insulin lispro) HUMULIN 70-30 (insulin nph human TIER 2 isophane/insulin regular, human) HUMULIN 70/30 KWIKPEN (insulin nph TIER 3 human isophane/insulin regular, human) HUMULIN N (insulin nph human isophane) TIER 2 HUMULIN N KWIKPEN (insulin nph human TIER 3 isophane) HUMULIN R (insulin regular, human) TIER 2 HUMULIN R U-500 (insulin regular, human) TIER 2 HUMULIN R U-500 KWIKPEN (insulin regular, TIER 3 human) insulin lispro TIER 3 PA LANTUS (insulin glargine,human TIER 2 QLC (40 ml/month) recombinant analog) LANTUS SOLOSTAR (insulin glargine,human TIER 2 QLC (45 ml/month) recombinant analog) LEVEMIR (insulin detemir) TIER 2 QLC (40 ml/month) LEVEMIR FLEXTOUCH (insulin detemir) TIER 2 QLC (45 ml/month) NOVOLIN 70-30 (insulin nph human TIER 2 isophane/insulin regular, human) NOVOLIN 70-30 FLEXPEN (insulin nph TIER 3 human isophane/insulin regular, human) NOVOLIN N (insulin nph human isophane) TIER 2 NOVOLIN R (insulin regular, human) TIER 2 NOVOLOG (insulin aspart) TIER 2 NOVOLOG FLEXPEN (insulin aspart) TIER 2 NOVOLOG MIX 70-30 (insulin aspart TIER 2 protamine human/insulin aspart) NOVOLOG MIX 70-30 FLEXPEN (insulin TIER 2 aspart protamine human/insulin aspart) SOLIQUA 100-33 (insulin glargine,human TIER 3 PA, QLC (6 pens/month) recombinant analog/lixisenatide)

73 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TOUJEO MAX SOLOSTAR (insulin TIER 2 QLC (6 pens/month) glargine,human recombinant analog) TOUJEO SOLOSTAR (insulin TIER 2 QLC (12 pens/month) glargine,human recombinant analog) TRESIBA (insulin degludec) TIER 2 QLC (3 vials/30 days) TRESIBA FLEXTOUCH U-100 (insulin TIER 2 QLC (10 pens/month) degludec) TRESIBA FLEXTOUCH U-200 (insulin TIER 2 QLC (9 pens/month) degludec) XULTOPHY 100-3.6 (insulin TIER 3 PA, QLC (5 pens/month) degludec/liraglutide)

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (Drugs for Blood Disorders) ANTICOAGULANTS (Blood Thinners) ARIXTRA (fondaparinux sodium) TIER 4 QLC (1 syringe/day) BEVYXXA (betrixaban maleate) TIER 3 PA, QLC (1 cap/day) COUMADIN (warfarin sodium) TIER 3 ELIQUIS (apixaban) 2.5 MG TABLET TIER 2 QLC (2 tabs/day; not to exceed 70 tabs/6 months) ELIQUIS (apixaban) 5 MG TABLET TIER 2 QLC (2 tabs/day) ELIQUIS (apixaban) DVT-PE TREAT START TIER 2 QLC (1 pack/6 months) 5MG enoxaparin sodium 300mg/3ml vial TIER 4 QLC (2 ml/day) enoxaparin sodium 30mg/0.3ml, TIER 4 QLC (2 syringes/day) 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100 mg/ml, 120mg/.8ml, 150 mg/ml fondaparinux sodium TIER 4 QLC (1 syringe/day) FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (1 syringe/day) 10,000 UNITS/ML SYRING, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (1 syringe/day) 12,500 UNITS/0.5 ML FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (2 syringes/day) 2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (0.72 ml/day) 95,000 UNITS/3.8 ML VL

74 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS heparin sodium,porcine 1000/ml vial, TIER 1 5000/ml vial, 10000/ml vial, 20000/ml vial heparin sodium,porcine/pf 5000/ml, TIER 1 5000/0.5ml IPRIVASK (desirudin) TIER 4 QLC (2 vials/day; 24 vials/68 days) LOVENOX (enoxaparin sodium) 30 MG/0.3 TIER 4 QLC (2 syringes/day) ML SYRINGE, 40 MG/0.4 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE LOVENOX (enoxaparin sodium) 300 MG/3 TIER 4 QLC (2 ml/day) ML VIAL LOVENOX (enoxaparin sodium) 60 MG/0.6 TIER 4 QLC (2 syringes/day) ML SYRINGE PRADAXA (dabigatran etexilate TIER 3 PA, QLC (2 caps/day) mesylate) SAVAYSA (edoxaban tosylate) TIER 3 PA, QLC (1 tab/day) warfarin sodium TIER 1 warfarin sodium (JANTOVEN) TIER 1 XARELTO (rivaroxaban) 10 MG TABLET, 15 TIER 2 QLC (1 tab/day) MG TABLET, 20 MG TABLET XARELTO (rivaroxaban) 2.5 MG TABLET TIER 2 QLC (2 tabs/day) XARELTO (rivaroxaban) STARTER PACK TIER 2 QLC (1 starter pack/6 months) ZONTIVITY (vorapaxar sulfate) TIER 3 PA, QLC (1 tab/day) BLOOD FORMATION MODIFIERS (Blood Formation Drugs) AGRYLIN (anagrelide hcl) TIER 3 anagrelide hcl TIER 1 ARANESP (darbepoetin alfa in TIER 4 PA, SP, QLC (1 syringe or polysorbate 80) vial/week) CABLIVI (caplacizumab-yhdp) TIER 4 PA, SP, QLC (1 kit/day) DOPTELET (avatrombopag maleate) (10 TIER 4 PA, SP, QLC (2 tabs/day, not to TAB PK) 20 MG TAB exceed 10 tabs/4 months) DOPTELET (avatrombopag maleate) (15 TIER 4 PA, SP, QLC (3 tabs/day, not to TAB PK) 20 MG TAB exceed 15 tabs/4 months) DOPTELET (avatrombopag maleate) (30 TIER 4 PA, SP, QLC (2 tabs/day) TAB PK) 20 MG TAB

75 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EPOGEN (epoetin alfa) TIER 4 PA, SP FULPHILA (pegfilgrastim-jmdb) TIER 4 PA, SP GRANIX (tbo-filgrastim) TIER 4 PA, SP LEUKINE (sargramostim) TIER 4 PA, SP MIRCERA (methoxy polyethylene glycol- TIER 4 PA, SP, QLC (2 syringes/28 days) epoetin beta) MOZOBIL (plerixafor) TIER 4 PA, SP MULPLETA (lusutrombopag) TIER 4 PA, SP, QLC (1 tab/day, not to exceed 7 tabs/120 days) NEULASTA (pegfilgrastim) 6 MG/0.6 ML TIER 4 PA, SP SYRINGE NEUPOGEN (filgrastim) TIER 4 PA, SP NIVESTYM (filgrastim-aafi) TIER 4 PA, SP PROCRIT (epoetin alfa) TIER 4 PA, SP PROMACTA (eltrombopag olamine) 12.5 TIER 4 PA, SP, QLC (1 packet/day) MG SUSPEN PACKET PROMACTA (eltrombopag olamine) 12.5 TIER 4 PA, SP, QLC (1 tab/day) MG TABLET PROMACTA (eltrombopag olamine) 25 TIER 4 PA, SP, QLC (3 tabs/day) MG TABLET, 50 MG TABLET PROMACTA (eltrombopag olamine) 75 TIER 4 PA, SP, QLC (2 tabs/day) MG TABLET RETACRIT (epoetin alfa-epbx) TIER 4 PA, SP TAVALISSE (fostamatinib disodium) TIER 4 PA, SP, QLC (2 tabs/day) UDENYCA (pegfilgrastim-cbqv) TIER 4 PA, SP ZARXIO (filgrastim-sndz) TIER 4 PA, SP ZIEXTENZO (pegfilgrastim-bmez) TIER 4 PA, SP HEMOSTASIS AGENTS (Drugs to Stop Bleeding) AMICAR (aminocaproic acid) TIER 3 aminocaproic acid 250 mg/ml solution, TIER 1 500 mg tablet, 1000 mg tablet LYSTEDA (tranexamic acid) TIER 3 QLC (30 tabs/month) MEPHYTON (phytonadione (vit k1)) TIER 3 QLC (5 tabs/week) phytonadione (vit k1) 5 mg tablet TIER 1 QLC (5 tabs/week)

76 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tranexamic acid 650 mg tablet TIER 1 QLC (30 tabs/month) PLATELET MODIFYING AGENTS AGGRENOX (aspirin/dipyridamole) TIER 3 aspirin/dipyridamole TIER 1 aspirin/omeprazole TIER 3 PA, QLC (1 tab/day) BRILINTA (ticagrelor) TIER 2 QLC (2 tabs/day) cilostazol TIER 1 clopidogrel bisulfate 75 mg tablet TIER 1 QLC (1 tab/day) dipyridamole 25 mg tablet, 50 mg tablet, TIER 1 75 mg tablet DURLAZA (aspirin) TIER 3 PA, QLC (1 cap/day) EFFIENT (prasugrel hcl) TIER 3 QLC (1 tab/day) PERSANTINE (dipyridamole) TIER 3 AL1 (Up to 65 yrs old) PLAVIX (clopidogrel bisulfate) 75 MG TIER 3 QLC (1 tab/day) TABLET PLETAL (cilostazol) TIER 3 prasugrel hcl TIER 1 QLC (1 tab/day) ticlopidine hcl TIER 1 YOSPRALA (aspirin/omeprazole) TIER 3 PA, QLC (1 tab/day)

CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) ALPHA-ADRENERGIC AGONISTS CATAPRES (clonidine hcl) TIER 3 CATAPRES-TTS 1 (clonidine) TIER 3 CATAPRES-TTS 2 (clonidine) TIER 3 CATAPRES-TTS 3 (clonidine) TIER 3 clonidine TIER 1 clonidine hcl 0.1 mg tablet, 0.2 mg tablet, TIER 1 0.3 mg tablet guanfacine hcl 1 mg tablet, 2 mg tablet TIER 1 methyldopa TIER 1

77 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS midodrine hcl TIER 1 NORTHERA (droxidopa) 100 MG CAPSULE TIER 4 PA, SP, QLC (18 caps/day) NORTHERA (droxidopa) 200 MG CAPSULE TIER 4 PA, SP, QLC (9 caps/day) NORTHERA (droxidopa) 300 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day) TENEX (guanfacine hcl) TIER 3 ALPHA-ADRENERGIC BLOCKING AGENTS CARDURA (doxazosin mesylate) TIER 3 DIBENZYLINE (phenoxybenzamine hcl) TIER 4 PA doxazosin mesylate TIER 1 MINIPRESS (prazosin hcl) TIER 3 phenoxybenzamine hcl TIER 4 PA prazosin hcl TIER 1 terazosin hcl TIER 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND (candesartan cilexetil) 16 MG TIER 3 ST, QLC (2 tabs/day) TABLET ATACAND (candesartan cilexetil) 32 MG TIER 3 ST, QLC (1 tab/day) TABLET ATACAND (candesartan cilexetil) 4 MG TIER 3 ST, QLC (8 tabs/day) TABLET ATACAND (candesartan cilexetil) 8 MG TIER 3 ST, QLC (4 tabs/day) TABLET AVAPRO (irbesartan) TIER 3 QLC (1 tab/day) BENICAR (olmesartan medoxomil) 20 MG TIER 3 QLC (1 tab/day) TABLET, 40 MG TABLET BENICAR (olmesartan medoxomil) 5 MG TIER 3 QLC (3 tabs/day) TABLET candesartan cilexetil 16 mg tablet TIER 1 ST, QLC (2 tabs/day) candesartan cilexetil 32 mg tablet TIER 1 ST, QLC (1 tab/day) candesartan cilexetil 4 mg tablet TIER 1 ST, QLC (8 tabs/day) candesartan cilexetil 8 mg tablet TIER 1 ST, QLC (4 tabs/day) COZAAR (losartan potassium) 100 MG TIER 3 QLC (1 tab/day) TABLET

78 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS COZAAR (losartan potassium) 25 MG TIER 3 QLC (4 tabs/day) TABLET COZAAR (losartan potassium) 50 MG TIER 3 QLC (2 tabs/day) TABLET DIOVAN (valsartan) 320 MG TABLET TIER 3 QLC (1 tab/day) DIOVAN (valsartan) 40 MG TABLET, 80 MG TIER 3 QLC (2 tabs/day) TABLET, 160 MG TABLET EDARBI (azilsartan medoxomil) TIER 3 ST, QLC (1 tab/day) eprosartan mesylate TIER 1 ST, QLC (1 tab/day) irbesartan TIER 1 QLC (1 tab/day) losartan potassium 100 mg tablet TIER 1 QLC (1 tab/day) losartan potassium 25 mg tablet TIER 1 QLC (4 tabs/day) losartan potassium 50 mg tablet TIER 1 QLC (2 tabs/day) MICARDIS (telmisartan) 20 MG TABLET, 40 TIER 3 QLC (1 tab/day) MG TABLET MICARDIS (telmisartan) 80 MG TABLET TIER 3 QLC (2 tabs/day) olmesartan medoxomil 20 mg tablet, 40 TIER 1 QLC (1 tab/day) mg tablet olmesartan medoxomil 5 mg tablet TIER 1 QLC (3 tabs/day) telmisartan 20 mg tablet, 40 mg tablet TIER 1 QLC (1 tab/day) telmisartan 80 mg tablet TIER 1 QLC (2 tabs/day) valsartan 320 mg tablet TIER 1 QLC (1 tab/day) valsartan 40 mg tablet, 80 mg tablet, 160 TIER 1 QLC (2 tabs/day) mg tablet ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ACCUPRIL (quinapril hcl) TIER 3 ACEON (perindopril erbumine) 4 MG TIER 3 QLC (1 tab/day) TABLET ACEON (perindopril erbumine) 8 MG TIER 3 QLC (2 tabs/day) TABLET ALTACE (ramipril) TIER 3 benazepril hcl 40 mg tablet TIER 1 QLC (2 tabs/day) benazepril hcl 5 mg tablet, 10 mg tablet, TIER 1 QLC (1 tab/day) 20 mg tablet

79 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS captopril TIER 1 enalapril maleate TIER 1 EPANED (enalapril maleate) TIER 3 QLC (40 ml/day) fosinopril sodium 10 mg tablet, 20 mg TIER 1 QLC (1 tab/day) tablet fosinopril sodium 40 mg tablet TIER 1 QLC (2 tabs/day) lisinopril TIER 1 LOTENSIN (benazepril hcl) 10 MG TABLET TIER 3 QLC (1 tab/day) LOTENSIN (benazepril hcl) 20 MG TABLET TIER 3 QLC (1 tab/day) LOTENSIN (benazepril hcl) 40 MG TABLET TIER 3 QLC (2 tabs/day) MAVIK (trandolapril) TIER 3 moexipril hcl TIER 1 perindopril erbumine 2 mg tablet, 4 mg TIER 1 QLC (1 tab/day) tablet perindopril erbumine 8 mg tablet TIER 1 QLC (2 tabs/day) PRINIVIL (lisinopril) TIER 3 QBRELIS (lisinopril) TIER 3 PA, QLC (80 ml/day) quinapril hcl TIER 1 ramipril TIER 1 trandolapril TIER 1 VASOTEC (enalapril maleate) TIER 3 ZESTRIL (lisinopril) TIER 3 ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm) amiodarone hcl (PACERONE) TIER 1 amiodarone hcl 100 mg tablet, 200 mg TIER 1 tablet, 400 mg tablet BETAPACE (sotalol hcl) TIER 3 BETAPACE AF (sotalol hcl) TIER 3 CORDARONE (amiodarone hcl) TIER 3 disopyramide phosphate TIER 1 dofetilide TIER 1 flecainide acetate TIER 1

80 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS mexiletine hcl TIER 1 MULTAQ (dronedarone hcl) TIER 2 QLC (2 tabs/day) NORPACE (disopyramide phosphate) TIER 3 NORPACE CR (disopyramide phosphate) TIER 2 QLC (8 caps/day) 100 MG CAPSULE NORPACE CR (disopyramide phosphate) TIER 2 QLC (5 caps/day) 150 MG CAPSULE PACERONE (amiodarone hcl) TIER 3 propafenone hcl TIER 1 quinidine gluconate 324 mg tablet er TIER 1 quinidine sulfate TIER 1 RYTHMOL (propafenone hcl) TIER 3 RYTHMOL SR (propafenone hcl) TIER 3 sotalol hcl (SORINE) TIER 1 sotalol hcl 80 mg tablet, 120 mg tablet, TIER 1 160 mg tablet, 240 mg tablet SOTYLIZE (sotalol hcl) TIER 3 PA, QLC (64 ml/day) TIKOSYN (dofetilide) TIER 3 BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl TIER 1 atenolol TIER 1 betaxolol hcl 10 mg tablet, 20 mg tablet TIER 1 bisoprolol fumarate TIER 1 BYSTOLIC (nebivolol hcl) 2.5 MG TABLET, 5 TIER 2 QLC (1 tab/day) MG TABLET, 10 MG TABLET BYSTOLIC (nebivolol hcl) 20 MG TABLET TIER 2 QLC (2 tabs/day) carvedilol TIER 1 carvedilol phosphate TIER 1 ST COREG (carvedilol) TIER 3 COREG CR (carvedilol phosphate) TIER 3 ST CORGARD (nadolol) TIER 3 INDERAL LA (propranolol hcl) TIER 3

81 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS INDERAL XL (propranolol hcl) TIER 3 INNOPRAN XL (propranolol hcl) TIER 3 KAPSPARGO SPRINKLE (metoprolol TIER 3 QLC (1 cap/day) succinate) labetalol hcl 100 mg tablet, 200 mg TIER 1 tablet, 300 mg tablet LEVATOL (penbutolol sulfate) TIER 3 LOPRESSOR (metoprolol tartrate) 50 MG TIER 3 TABLET, 100 MG TABLET metoprolol succinate TIER 1 metoprolol tartrate 25 mg tablet, 37.5 mg TIER 1 tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet nadolol TIER 1 pindolol TIER 1 propranolol hcl 10 mg tablet, 20 mg/5 ml TIER 1 solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 60 mg tablet, 60 mg cap sa 24h, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h SECTRAL (acebutolol hcl) TIER 3 TENORMIN (atenolol) TIER 3 timolol maleate 5 mg tablet, 10 mg TIER 1 tablet, 20 mg tablet TOPROL XL (metoprolol succinate) TIER 3 ZEBETA (bisoprolol fumarate) TIER 3 CALCIUM CHANNEL BLOCKING AGENTS ADALAT CC (nifedipine) TIER 3 amlodipine besylate TIER 1 CALAN (verapamil hcl) TIER 3 CALAN SR (verapamil hcl) TIER 3 CARDIZEM (diltiazem hcl) TIER 3 CARDIZEM CD (diltiazem hcl) TIER 3 CARDIZEM LA (diltiazem hcl) TIER 3

82 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS diltiazem hcl (CARTIA XT) TIER 1 diltiazem hcl (DILT-XR) TIER 1 diltiazem hcl (MATZIM LA) TIER 1 diltiazem hcl (TAZTIA XT) TIER 1 diltiazem hcl (TIADYLT ER) TIER 1 diltiazem hcl 30 mg tablet, 60 mg cap er TIER 1 12h, 60 mg tablet, 90 mg tablet, 90 mg cap er 12h, 120 mg tablet, 120 mg cap er 24h, 120 mg cap er 12h, 120 mg cap sa 24h, 120 mg cap er deg, 180 mg tab er 24h, 180 mg cap er deg, 180 mg cap sa 24h, 180 mg cap er 24h, 240 mg cap er deg, 240 mg tab er 24h, 240 mg cap er 24h, 240 mg cap sa 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300 mg tab er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 360 mg cap er 24h, 420 mg tab er 24h, 420 mg cap sa 24h felodipine TIER 1 isradipine TIER 1 KATERZIA (amlodipine benzoate) TIER 3 PA, QLC (10 ml/day) nicardipine hcl 20 mg capsule, 30 mg TIER 1 capsule nifedipine TIER 1 nifedipine (AFEDITAB CR) TIER 1 nifedipine (NIFEDICAL XL) TIER 1 nimodipine TIER 1 nisoldipine TIER 1 NORVASC (amlodipine besylate) TIER 3 NYMALIZE (nimodipine) 30 MG/10 ML TIER 3 PA, QLC (60 ml/day, max of 21 SOLUTION days in 6 months) NYMALIZE (nimodipine) 60 MG/20 ML TIER 3 QLC (120 ml per day, max of 21 SOLUTION days in 6 months) PROCARDIA (nifedipine) TIER 3 PROCARDIA XL (nifedipine) TIER 3 SULAR (nisoldipine) TIER 3 TIAZAC (diltiazem hcl) TIER 3

83 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS verapamil hcl 40 mg tablet, 80 mg tablet, TIER 1 100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet, 120 mg tablet er, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24h pct, 240 mg tablet er, 240 mg cap24h pel, 300 mg cap24h pct, 360 mg cap24h pel VERELAN (verapamil hcl) TIER 3 VERELAN PM (verapamil hcl) TIER 3 CARDIOVASCULAR AGENTS, OTHER ACCURETIC (quinapril TIER 3 hcl/hydrochlorothiazide) ALDACTAZIDE TIER 3 (spironolactone/hydrochlorothiazide) aliskiren hemifumarate TIER 1 ST, QLC (1 tab/day) amiloride hcl/hydrochlorothiazide TIER 1 amlodipine besylate/atorvastatin calcium TIER 1 PA, QLC (1 tab/day) amlodipine besylate/benazepril hcl 10 TIER 1 QLC (1 cap/day) mg-20mg capsule, 10 mg-40mg capsule amlodipine besylate/benazepril hcl TIER 1 2.5mg-10mg capsule, 5 mg-20 mg capsule, 5 mg-10 mg capsule amlodipine besylate/benazepril hcl 5 mg- TIER 1 QLC (2 caps/day) 40 mg capsule amlodipine besylate/olmesartan TIER 1 QLC (1 tab/day) medoxomil amlodipine besylate/valsartan TIER 1 QLC (1 tab/day) amlodipine TIER 1 QLC (1 tab/day) besylate/valsartan/hydrochlorothiazide ATACAND HCT (candesartan TIER 3 ST, QLC (2 tabs/day) cilexetil/hydrochlorothiazide) 16-12.5 MG TAB ATACAND HCT (candesartan TIER 3 ST, QLC (1 tab/day) cilexetil/hydrochlorothiazide) 32-12.5 MG TAB, 32-25 MG TABLET atenolol/chlorthalidone TIER 1 AVALIDE (irbesartan/hydrochlorothiazide) TIER 3 QLC (2 tabs/day) 150-12.5 MG TABLET AVALIDE (irbesartan/hydrochlorothiazide) TIER 3 QLC (1 tab/day) 300-12.5 MG TABLET

84 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS AZOR (amlodipine besylate/olmesartan TIER 3 QLC (1 tab/day) medoxomil) benazepril hcl/hydrochlorothiazide TIER 1 BENICAR HCT (olmesartan TIER 3 QLC (1 tab/day) medoxomil/hydrochlorothiazide) BIDIL (isosorbide dinitrate/hydralazine hcl) TIER 3 QLC (6 tabs/day) bisoprolol fumarate/hydrochlorothiazide TIER 1 BYVALSON (nebivolol hcl/valsartan) TIER 3 ST, QLC (1 tab/day) CADUET (amlodipine TIER 3 PA, QLC (1 tab/day) besylate/atorvastatin calcium) candesartan cilexetil/hydrochlorothiazide TIER 1 ST, QLC (2 tabs/day) candesartan/hydrochlorothiazid 16- 12.5mg tablet candesartan cilexetil/hydrochlorothiazide TIER 1 ST, QLC (1 tab/day) candesartan/hydrochlorothiazid 32mg- 25mg tablet, candesartan/hydrochlorothiazid 32- 12.5mg tablet captopril/hydrochlorothiazide TIER 1 CORLANOR (ivabradine hcl) 5 MG TABLET, TIER 3 PA, QLC (2 tabs/day) 7.5 MG TABLET CORLANOR (ivabradine hcl) 5 MG/5 ML TIER 3 PA, QLC (20 ml/day) ORAL SOLN CORZIDE (nadolol/bendroflumethiazide) TIER 3 DEMSER (metyrosine) TIER 3 digoxin (DIGITEK) 125 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) digoxin (DIGITEK) 250 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) digoxin (DIGOX) 125 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) digoxin (DIGOX) 250 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) digoxin 125 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) digoxin 250 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) digoxin 50 mcg/ml solution TIER 1 AL1 (Up to 65 yrs old), QLC (2.5 ml/day)

85 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DIOVAN HCT TIER 3 QLC (1 tab/day) (valsartan/hydrochlorothiazide) 320-12.5 MG TAB, 320-25 MG TABLET DIOVAN HCT TIER 3 QLC (2 tabs/day) (valsartan/hydrochlorothiazide) 80-12.5 MG TABLET, 160-25 MG TABLET, 160-12.5 MG TAB DUTOPROL (metoprolol TIER 3 PA, QLC (2 tabs/day) succinate/hydrochlorothiazide) 100-12.5 MG TABLET DUTOPROL (metoprolol TIER 3 PA, QLC (1 tab/day) succinate/hydrochlorothiazide) 25-12.5 MG TABLET, 50-12.5 MG TABLET DYAZIDE TIER 3 (triamterene/hydrochlorothiazide) EDARBYCLOR (azilsartan TIER 3 ST, QLC (1 tab/day) medoxomil/chlorthalidone) enalapril maleate/hydrochlorothiazide TIER 1 ENTRESTO (sacubitril/valsartan) TIER 3 PA, QLC (2 tabs/day) EXFORGE (amlodipine besylate/valsartan) TIER 3 QLC (1 tab/day) EXFORGE HCT (amlodipine TIER 3 QLC (1 tab/day) besylate/valsartan/hydrochlorothiazide) fosinopril sodium/hydrochlorothiazide TIER 1 HYZAAR (losartan TIER 3 QLC (1 tab/day) potassium/hydrochlorothiazide) 100-25 TABLET, 100-12.5 TABLET HYZAAR (losartan TIER 3 QLC (2 tabs/day) potassium/hydrochlorothiazide) 50-12.5 TABLET irbesartan/hydrochlorothiazide 150- TIER 1 QLC (2 tabs/day) 12.5mg tablet irbesartan/hydrochlorothiazide 300- TIER 1 QLC (1 tab/day) 12.5mg tablet LANOXIN (digoxin) 125 MCG TABLET, 187.5 TIER 3 AL1 (Up to 65 yrs old), QLC (1 MCG TABLET tab/day) LANOXIN (digoxin) 250 MCG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) LANOXIN (digoxin) 62.5 MCG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (2 tabs/day) lisinopril/hydrochlorothiazide TIER 1

86 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LOPRESSOR HCT (metoprolol TIER 3 tartrate/hydrochlorothiazide) losartan potassium/hydrochlorothiazide TIER 1 QLC (1 tab/day) losartan/hydrochlorothiazide 100mg- 25mg tablet, losartan/hydrochlorothiazide 100-12.5mg tablet losartan potassium/hydrochlorothiazide TIER 1 QLC (2 tabs/day) losartan/hydrochlorothiazide 50-12.5 mg tablet LOTENSIN HCT (benazepril TIER 3 hcl/hydrochlorothiazide) LOTREL (amlodipine besylate/benazepril TIER 3 QLC (1 cap/day) hcl) 10-20 MG CAPSULE, 10-40 MG CAPSULE LOTREL (amlodipine besylate/benazepril TIER 3 hcl) 5-20 MG CAPSULE, 5-10 MG CAPSULE LOTREL (amlodipine besylate/benazepril TIER 3 QLC (2 caps/day) hcl) 5-40 MG CAPSULE MAXZIDE TIER 3 (triamterene/hydrochlorothiazide) MAXZIDE-25 MG TIER 3 (triamterene/hydrochlorothiazide) mecamylamine hcl (VECAMYL) TIER 1 methyldopa/hydrochlorothiazide TIER 1 metoprolol TIER 3 PA, QLC (2 tabs/day) succinate/hydrochlorothiazide su/hydrochlorothiaz 100-12.5mg tab er 24h metoprolol TIER 3 PA, QLC (1 tab/day) succinate/hydrochlorothiazide su/hydrochlorothiaz 25-12.5 mg tab er, su/hydrochlorothiaz 50-12.5 mg tab er metoprolol tartrate/hydrochlorothiazide TIER 1 MICARDIS HCT TIER 3 ST, QLC (3 tabs/day) (telmisartan/hydrochlorothiazide) 40-12.5 MG TABLET MICARDIS HCT TIER 3 ST, QLC (2 tabs/day) (telmisartan/hydrochlorothiazide) 80-25 MG TABLET, 80-12.5 MG TABLET moexipril hcl/hydrochlorothiazide TIER 1 nadolol/bendroflumethiazide TIER 1

87 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS olmesartan medoxomil/amlodipine TIER 1 ST, QLC (1 tab/day) besylate/hydrochlorothiazide olmesartan TIER 1 QLC (1 tab/day) medoxomil/hydrochlorothiazide pentoxifylline TIER 1 PRESTALIA (perindopril TIER 3 ST, QLC (1 tab/day) arginine/amlodipine besylate) propranolol hcl/hydrochlorothiazide TIER 1 quinapril hcl/hydrochlorothiazide TIER 1 RANEXA (ranolazine) TIER 3 PA, QLC (2 tabs/day) ranolazine TIER 1 PA, QLC (2 tabs/day) reserpine TIER 1 spironolactone/hydrochlorothiazide TIER 1 TARKA (trandolapril/verapamil hcl) TIER 3 TEKTURNA (aliskiren hemifumarate) TIER 3 ST, QLC (1 tab/day) TEKTURNA HCT (aliskiren TIER 3 ST, QLC (1 tab/day) hemifumarate/hydrochlorothiazide) telmisartan/amlodipine besylate TIER 1 ST, QLC (1 tab/day) telmisartan/hydrochlorothiazide 40-12.5 TIER 1 ST, QLC (3 tabs/day) mg tablet telmisartan/hydrochlorothiazide 80 mg- TIER 1 ST, QLC (2 tabs/day) 25mg tablet, 80-12.5mg tablet TENORETIC 100 (atenolol/chlorthalidone) TIER 3 TENORETIC 50 (atenolol/chlorthalidone) TIER 3 trandolapril/verapamil hcl TIER 1 triamterene/hydrochlorothiazide TIER 1 TRIBENZOR (olmesartan TIER 3 ST, QLC (1 tab/day) medoxomil/amlodipine besylate/hydrochlorothiazide) TWYNSTA (telmisartan/amlodipine TIER 3 ST, QLC (1 tab/day) besylate) valsartan/hydrochlorothiazide 320-12.5mg TIER 1 QLC (1 tab/day) tablet, 320mg-25mg tablet valsartan/hydrochlorothiazide 80-12.5mg TIER 1 QLC (2 tabs/day) tablet, 160-12.5mg tablet, 160-25mg tablet

88 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VASERETIC (enalapril TIER 3 maleate/hydrochlorothiazide) VYNDAMAX (tafamidis) TIER 4 PA, SP, QLC (1 cap/day) VYNDAQEL (tafamidis meglumine) TIER 4 PA, SP, QLC (4 caps/day) ZESTORETIC (lisinopril/hydrochlorothiazide) TIER 3 ZIAC (bisoprolol TIER 3 fumarate/hydrochlorothiazide) DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide TIER 1 DIAMOX SEQUELS (acetazolamide) TIER 3 KEVEYIS (dichlorphenamide) TIER 4 PA, SP, QLC (4 tabs/day) DIURETICS, LOOP bumetanide 0.5 mg tablet, 1 mg tablet, 2 TIER 1 mg tablet DEMADEX (torsemide) TIER 3 EDECRIN (ethacrynic acid) TIER 3 PA ethacrynic acid TIER 1 PA furosemide 10 mg/ml solution, 20 mg TIER 1 tablet, 40mg/5ml solution, 40 mg tablet, 80 mg tablet LASIX (furosemide) TIER 3 torsemide TIER 1 DIURETICS, POTASSIUM-SPARING ALDACTONE (spironolactone) TIER 3 amiloride hcl TIER 1 CAROSPIR (spironolactone) TIER 3 PA, QLC (20 ml/day) DYRENIUM (triamterene) TIER 3 ST eplerenone TIER 1 INSPRA (eplerenone) TIER 3 spironolactone TIER 1 triamterene TIER 1 ST

89 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DIURETICS, THIAZIDE chlorothiazide TIER 1 chlorthalidone TIER 1 DIURIL (chlorothiazide) TIER 3 hydrochlorothiazide TIER 1 indapamide TIER 1 methyclothiazide TIER 1 metolazone TIER 1 MICROZIDE (hydrochlorothiazide) TIER 3 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES (Drugs for High Cholesterol) ANTARA (fenofibrate,micronized) 30 MG TIER 3 ST, QLC (2 caps/day) CAPSULE ANTARA (fenofibrate,micronized) 90 MG TIER 3 ST, QLC (1 cap/day) CAPSULE fenofibrate (LOFIBRA) 160 mg tablet TIER 1 QLC (1 tab/day) fenofibrate (LOFIBRA) 54 mg tablet TIER 1 QLC (2 tabs/day) fenofibrate 120 mg tablet TIER 1 ST, QLC (1 tab/day) fenofibrate 150 mg capsule TIER 1 ST, QLC (1 cap/day) fenofibrate 160 mg tablet TIER 1 QLC (1 tab/day) fenofibrate 40 mg tablet TIER 1 ST, QLC (2 tabs/day) fenofibrate 50 mg capsule TIER 1 ST, QLC (2 caps/day) fenofibrate 54 mg tablet TIER 1 QLC (2 tabs/day) fenofibrate nanocrystallized 145 mg TIER 1 QLC (1 tab/day) tablet, 145mg tablet fenofibrate nanocrystallized 160 mg TIER 1 ST, QLC (1 tab/day) tablet fenofibrate nanocrystallized 48 mg tablet TIER 1 QLC (2 tabs/day) fenofibrate,micronized (LOFIBRA) 200 mg TIER 1 QLC (1 cap/day) capsule fenofibrate,micronized (LOFIBRA) 67 mg TIER 1 QLC (1 cap/day) capsule, 134 mg capsule fenofibrate,micronized 130 mg capsule TIER 1 ST, QLC (1 cap/day)

90 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS fenofibrate,micronized 43 mg capsule TIER 1 ST, QLC (2 caps/day) fenofibrate,micronized 67 mg capsule, TIER 1 QLC (1 cap/day) 134 mg capsule, 200 mg capsule fenofibric acid (choline) TIER 1 QLC (1 cap/day) fenofibric acid 105 mg tablet TIER 1 QLC (1 tab/day) fenofibric acid 35 mg tablet TIER 1 QLC (2 tabs/day) FENOGLIDE (fenofibrate) 120 MG TABLET TIER 3 ST, QLC (1 tab/day) FENOGLIDE (fenofibrate) 40 MG TABLET TIER 3 ST, QLC (2 tabs/day) FIBRICOR (fenofibric acid) 105 MG TABLET TIER 3 QLC (1 tab/day) FIBRICOR (fenofibric acid) 35 MG TABLET TIER 3 QLC (2 tabs/day) gemfibrozil TIER 1 QLC (2.5 tabs/day) LIPOFEN (fenofibrate) 150 MG CAPSULE TIER 3 ST, QLC (1 cap/day) LIPOFEN (fenofibrate) 50 MG CAPSULE TIER 3 ST, QLC (2 caps/day) LOPID (gemfibrozil) TIER 3 QLC (2.5 tabs/day) TRICOR (fenofibrate nanocrystallized) 145 TIER 3 QLC (1 tab/day) MG TABLET TRICOR (fenofibrate nanocrystallized) 48 TIER 3 QLC (2 tabs/day) MG TABLET TRIGLIDE (fenofibrate nanocrystallized) TIER 3 ST, QLC (1 tab/day) TRILIPIX (fenofibric acid (choline)) TIER 3 QLC (1 cap/day) DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS (Drugs for High Cholesterol) ALTOPREV (lovastatin) TIER 3 QLC (1 tab/day) atorvastatin calcium 10 mg tablet, 20 mg TIER 1 ACA (Preventive Health), QLC (1 tablet tab/day) atorvastatin calcium 40 mg tablet, 80 mg TIER 1 QLC (1 tab/day) tablet CRESTOR (rosuvastatin calcium) TIER 3 QLC (1 tab/day) EZALLOR SPRINKLE (rosuvastatin calcium) TIER 3 PA, QLC (1 cap/day) FLOLIPID (simvastatin) 20 MG/5 ML ORAL TIER 3 PA, QLC (5 ml/day) SUSP FLOLIPID (simvastatin) 40 MG/5 ML ORAL TIER 3 PA, QLC (10 ml/day) SUSP fluvastatin sodium 20 mg capsule, 40 mg TIER 1 PA, QLC (1 cap/day) capsule

91 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS fluvastatin sodium 80 mg tab er 24h TIER 1 PA, QLC (1 tab/day) LESCOL (fluvastatin sodium) TIER 3 PA, QLC (1 cap/day) LESCOL XL (fluvastatin sodium) TIER 3 PA, QLC (1 tab/day) LIPITOR (atorvastatin calcium) TIER 3 QLC (1 tab/day) LIVALO (pitavastatin calcium) TIER 3 ST, QLC (1 tab/day) lovastatin 10 mg tablet, 20 mg tablet TIER 1 QLC (1 tab/day) lovastatin 40 mg tablet TIER 1 QLC (2 tabs/day) PRAVACHOL (pravastatin sodium) TIER 3 QLC (1 tab/day) pravastatin sodium TIER 1 QLC (1 tab/day) rosuvastatin calcium TIER 1 QLC (1 tab/day) simvastatin 5 mg tablet, 10 mg tablet, 20 TIER 1 ACA (Preventive Health), QLC (1 mg tablet, 40 mg tablet tab/day) simvastatin 80 mg tablet TIER 1 QLC (1 tab/day) ZOCOR (simvastatin) TIER 3 QLC (1 tab/day) ZYPITAMAG (pitavastatin magnesium) TIER 3 ST, QLC (1 tab/day) DYSLIPIDEMICS, OTHER (Other Drugs for High Cholesterol) cholestyramine (with sugar) TIER 1 cholestyramine/aspartame TIER 1 cholestyramine/aspartame (PREVALITE) TIER 1 colesevelam hcl TIER 1 COLESTID (colestipol hcl) TIER 3 colestipol hcl TIER 1 ezetimibe TIER 1 QLC (1 tab/day) ezetimibe/simvastatin TIER 1 ST, QLC (1 tab/day) JUXTAPID (lomitapide mesylate) TIER 4 PA, SP, QLC (1 cap/day) KYNAMRO (mipomersen sodium) TIER 4 PA, SP, QLC (1 syringe/week) LOVAZA (omega-3 acid ethyl esters) TIER 3 QLC (4 caps/day) niacin (NIACOR) TIER 1 niacin 500 mg tab er 24h TIER 1 QLC (4 tabs/day) niacin 750 mg tab er, 1000 mg tab er TIER 1 QLC (2 tabs/day) NIASPAN (niacin) ER 500 MG TABLET TIER 3 QLC (4 tabs/day)

92 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NIASPAN (niacin) ER 750 MG TABLET, ER TIER 3 QLC (2 tabs/day) 1,000 MG TABLET omega-3 acid ethyl esters TIER 1 QLC (4 caps/day) omega-3 acid ethyl esters (TRIKLO) TIER 1 QLC (4 caps/day) PRALUENT PEN (alirocumab) TIER 4 PA, QLC (2 pens/month) PRALUENT SYRINGE (alirocumab) TIER 4 PA, QLC (2 syringes/month) QUESTRAN (cholestyramine (with sugar)) TIER 3 QUESTRAN LIGHT TIER 3 (cholestyramine/aspartame) REPATHA PUSHTRONEX (evolocumab) TIER 4 PA, QLC (1 injector/month) REPATHA SURECLICK (evolocumab) TIER 4 PA, QLC (2 pens/month) REPATHA SYRINGE (evolocumab) TIER 4 PA, QLC (2 syringes/month) VASCEPA (icosapent ethyl) 0.5 GM TIER 3 PA, QLC (2 caps/day) CAPSULE VASCEPA (icosapent ethyl) 1 GM TIER 3 PA, QLC (4 caps/day) CAPSULE VYTORIN (ezetimibe/simvastatin) TIER 3 ST, QLC (1 tab/day) WELCHOL (colesevelam hcl) TIER 3 ZETIA (ezetimibe) TIER 3 QLC (1 tab/day) VASODILATORS, DIRECT-ACTING ARTERIAL (Drugs for Relaxing Arteries) hydralazine hcl 10 mg tablet, 25 mg TIER 1 tablet, 50 mg tablet, 100 mg tablet minoxidil 2.5 mg tablet, 10 mg tablet TIER 1 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS (Drugs for Relaxing Arteries and Veins) DILATRATE-SR (isosorbide dinitrate) TIER 3 GONITRO (nitroglycerin) TIER 3 PA, QLC (36 packs/month) ISORDIL (isosorbide dinitrate) TIER 3 ISORDIL TITRADOSE (isosorbide dinitrate) TIER 3 isosorbide dinitrate TIER 1 isosorbide dinitrate (ISOCHRON) TIER 1 isosorbide mononitrate TIER 1

93 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NITRO-BID (nitroglycerin) TIER 2 NITRO-DUR (nitroglycerin) -0.1 MG/HR TIER 3 PATCH, -0.2 MG/HR PATCH, -0.4 MG/HR PATCH, -0.6 MG/HR PATCH NITRO-DUR (nitroglycerin) -0.3 MG/HR TIER 2 PATCH, -0.8 MG/HR PATCH nitroglycerin (MINITRAN) TIER 1 nitroglycerin (NITRO-TIME) TIER 1 nitroglycerin 0.1mg/hr patch td24, TIER 1 0.2mg/hr patch td24, 0.3 mg tab subl, 0.4mg/hr patch td24, 0.4 mg tab subl, 0.6 mg tab subl, 0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er, 400mcg/spr spray NITROLINGUAL (nitroglycerin) TIER 3 NITROMIST (nitroglycerin) TIER 3 NITROSTAT (nitroglycerin) TIER 3

CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (5 saccharate/amphetamine sulf-aspartate) tabs/day) 12.5 MG TABLET -- ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (3 saccharate/amphetamine sulf-aspartate) tabs/day) 20 MG TABLET -- ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate) tabs/day) 30 MG TABLET -- ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (4 saccharate/amphetamine sulf-aspartate) tabs/day) 5 MG TABLET --, 7.5 MG TABLET --, 10 MG TABLET --, 15 MG TABLET -- ADDERALL XR (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate) caps/day) ADZENYS ER (amphetamine) TIER 3 PA, QLC (15 ml/day) ADZENYS XR-ODT (amphetamine) TIER 3 PA, QLC (1 tab/day)

94 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS amphetamine sulfate 10 mg tablet TIER 1 ST, AL1 (Up to 17 yrs old), QLC (6 tabs/day) amphetamine sulfate 5 mg tablet TIER 1 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day) DESOXYN (methamphetamine hcl) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day) DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 10 MG TABLET tabs/day) DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (6 SPANSULE 10 MG caps/day) DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 SPANSULE 15 MG caps/day) DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (12 SPANSULE 5 MG caps/day) dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (5 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 12.5 mg tablet dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (3 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 20 mg tablet dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 30 mg tablet dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate caps/day) dextroamphetamine/amphetamine 5 mg cap er, dextroamphetamine/amphetamine 10 mg cap er, dextroamphetamine/amphetamine 15 mg cap er, dextroamphetamine/amphetamine 20 mg cap er, dextroamphetamine/amphetamine 25 mg cap er, dextroamphetamine/amphetamine 30 mg cap er

95 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (4 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 15 mg tablet dextroamphetamine sulfate TIER 1 ST, AL1 (Up to 18 yrs old), QLC (40 (PROCENTRA) ml/day) dextroamphetamine sulfate (ZENZEDI) 10 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 mg tablet tabs/day) dextroamphetamine sulfate (ZENZEDI) 5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (8 mg tablet tabs/day) dextroamphetamine sulfate 10 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (6 capsule er caps/day) dextroamphetamine sulfate 10 mg tablet TIER 1 ST, AL1 (Up to 18 yrs old), QLC (4 tabs/day) dextroamphetamine sulfate 15 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (4 capsule er caps/day) dextroamphetamine sulfate 5 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (12 capsule er caps/day) dextroamphetamine sulfate 5 mg tablet TIER 1 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day) dextroamphetamine sulfate 5 mg/5 ml TIER 1 ST, AL1 (Up to 18 yrs old), QLC (40 solution ml/day) DYANAVEL XR (amphetamine) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (8 ml/day) EVEKEO (amphetamine sulfate) 10 MG TIER 3 ST, AL1 (Up to 17 yrs old), QLC (6 TABLET tabs/day) EVEKEO (amphetamine sulfate) 5 MG TIER 3 ST, AL1 (Up to 17 yrs old), QLC (8 TABLET tabs/day) EVEKEO ODT (amphetamine sulfate) TIER 3 ST, AL1 (Up to 17 yrs old), QLC (2 tabs/day) methamphetamine hcl TIER 1 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day) MYDAYIS (dextroamphetamine sulf- TIER 3 PA, QLC (1 cap/day) saccharate/amphetamine sulf-aspartate)

96 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VYVANSE (lisdexamfetamine dimesylate) TIER 2 AL1 (Up to 18 yrs old), QLC (1 10 MG CAPSULE, 20 MG CAPSULE, 30 MG cap/day) CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MG CAPSULE VYVANSE (lisdexamfetamine dimesylate) TIER 2 AL1 (Up to 18 yrs old), QLC (1 10 MG TABLET, 20 MG TABLET, 30 MG tab/day) TABLET, 40 MG TABLET, 50 MG TABLET, 60 MG TABLET ZENZEDI (dextroamphetamine sulfate) 15 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (3 MG TABLET, 20 MG TABLET tabs/day) ZENZEDI (dextroamphetamine sulfate) 2.5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (2 MG TABLET, 30 MG TABLET tabs/day) ZENZEDI (dextroamphetamine sulfate) 7.5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 MG TABLET tabs/day) ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON- AMPHETAMINES ADHANSIA XR (methylphenidate hcl) TIER 3 PA, AL1 (Up to 18 yrs old), QLC (1 cap/day) APTENSIO XR (methylphenidate hcl) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 cap/day) atomoxetine hcl 10 mg capsule, 18 mg TIER 1 AL1 (Up to 18 yrs old), QLC (4 capsule, 25 mg capsule caps/day) atomoxetine hcl 40 mg capsule TIER 1 AL1 (Up to 18 yrs old), QLC (2 caps/day) atomoxetine hcl 60 mg capsule, 80 mg TIER 1 AL1 (Up to 18 yrs old), QLC (1 capsule, 100 mg capsule cap/day) clonidine hcl 0.1 mg tab er 12h TIER 1 PA, AL1 (Up to 18 yrs old), QLC (4 tabs/day) CONCERTA (methylphenidate hcl) TIER 3 AL1 (Up to 18 yrs old), QLC (2 CONCTA 36 MG TABLET tabs/day) CONCERTA (methylphenidate hcl) ER 18 TIER 3 AL1 (Up to 18 yrs old), QLC (1 MG TABLET, ER 27 MG TABLET, ER 54 MG tab/day) TABLET COTEMPLA XR-ODT (methylphenidate) - TIER 3 PA, AL1 (Up to 18 yrs old), QLC (2 17.3 MG TABLET tabs/day) COTEMPLA XR-ODT (methylphenidate) - TIER 3 PA, AL1 (Up to 18 yrs old) 25.9 MG TABLET COTEMPLA XR-ODT (methylphenidate) - TIER 3 PA, AL1 (Up to 18 yrs old), QLC (5 8.6 MG TABLET tabs/day)

97 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DAYTRANA (methylphenidate) 10 MG/9 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 HR PATCH, 15 MG/9 HR PATCH, 20 MG/9 patch/day) HOUR PATCH, 30 MG/9 HOUR PATCH dexmethylphenidate hcl 2.5 mg tablet, 5 TIER 1 AL1 (Up to 18 yrs old), QLC (2 mg tablet, 10 mg tablet tabs/day) dexmethylphenidate hcl 5 mg 50-50, 10 TIER 1 ST, AL1 (Up to 18 yrs old), QLC (1 mg 50-50, 15 mg 50-50, 20 mg 50-50, 25 cap/day) mg 50-50, 30 mg 50-50, 35 mg 50-50, 40 mg 50-50 FOCALIN (dexmethylphenidate hcl) TIER 3 AL1 (Up to 18 yrs old), QLC (2 tabs/day) FOCALIN XR (dexmethylphenidate hcl) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 cap/day) guanfacine hcl 1 mg tab er, 2 mg tab er, TIER 1 AL1 (Up to 18 yrs old), QLC (1 3 mg tab er, 4 mg tab er tab/day) INTUNIV (guanfacine hcl) TIER 3 AL1 (Up to 18 yrs old), QLC (1 tab/day) JORNAY PM (methylphenidate hcl) TIER 3 PA, AL1 (Up to 18 yrs old), QLC (1 cap/day) KAPVAY (clonidine hcl) TIER 3 PA, AL1 (Up to 18 yrs old), QLC (4 tabs/day) METADATE CD (methylphenidate hcl) 10 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (2 MG CAPSULE, 20 MG CAPSULE, 30 MG caps/day) CAPSULE METADATE CD (methylphenidate hcl) 40 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 MG CAPSULE, 50 MG CAPSULE, 60 MG cap/day) CAPSULE METHYLIN (methylphenidate hcl) 10 MG/5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (30 ML SOLUTION ml/day) METHYLIN (methylphenidate hcl) 2.5 MG TIER 3 AL1 (Up to 18 yrs old), QLC (6 TAB, 5 MG TABLET, 10 MG TABLET tabs/day) METHYLIN (methylphenidate hcl) 5 MG/5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (60 ML SOLUTION ml/day) methylphenidate hcl (METADATE ER) TIER 1 ST, AL1 (Up to 18 yrs old), QLC (3 tabs/day) methylphenidate hcl (RELEXXII) TIER 1 PA, AL1 (Up to 18 yrs old), QLC (1 tab/day) methylphenidate hcl 10 mg 30-70, 20 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (2 30-70, 30 mg 30-70 caps/day) methylphenidate hcl 10 mg 50-50, 20 mg TIER 1 AL1 (Up to 18 yrs old), QLC (2 50-50 caps/day)

98 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS methylphenidate hcl 10 mg tablet er TIER 1 ST, AL1 (Up to 18 yrs old), QLC (6 tabs/day) methylphenidate hcl 10 mg/5 ml solution TIER 1 ST, AL1 (Up to 18 yrs old), QLC (30 ml/day) methylphenidate hcl 18 mg tab er 24, 27 TIER 1 AL1 (Up to 18 yrs old), QLC (1 mg tab er 24, 54 mg tab er 24 tab/day) methylphenidate hcl 2.5 mg tab chew, 5 TIER 1 AL1 (Up to 18 yrs old), QLC (6 mg tab chew, 10 mg tab chew, 10 mg tabs/day) tablet methylphenidate hcl 20 mg tablet TIER 1 AL1 (Up to 18 yrs old), QLC (3 tabs/day) methylphenidate hcl 20 mg tablet er TIER 1 ST, AL1 (Up to 18 yrs old), QLC (3 tabs/day) methylphenidate hcl 30 mg cpbp 50-50 TIER 1 AL1 (Up to 17 yrs old), QLC (2 caps/day) methylphenidate hcl 36 mg tab er 24 TIER 1 AL1 (Up to 18 yrs old), QLC (2 tabs/day) methylphenidate hcl 40 mg 30-70, 50 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (1 30-70, 60 mg 30-70 cap/day) methylphenidate hcl 40 mg 50-50, 60 mg TIER 1 AL1 (Up to 18 yrs old), QLC (1 50-50 cap/day) methylphenidate hcl 5 mg tablet TIER 1 AL1 (Up to 18 yrs old), QLC (12 tabs/day) methylphenidate hcl 5 mg/5 ml solution TIER 1 ST, AL1 (Up to 18 yrs old), QLC (60 ml/day) methylphenidate hcl 72 mg tab er 24 TIER 1 PA, AL1 (Up to 18 yrs old), QLC (1 tab/day) QUILLICHEW ER (methylphenidate hcl) 30 TIER 3 PA, AL1 (Up to 18 yrs old), QLC (2 MG TAB tabs/day) QUILLICHEW ER (methylphenidate hcl) ER TIER 3 PA, AL1 (Up to 18 yrs old), QLC (1 20 MG CHEW TAB, ER 40 MG CHEW TAB tab/day) QUILLIVANT XR (methylphenidate hcl) TIER 3 PA, QLC (12 ml/day) RITALIN (methylphenidate hcl) 10 MG TIER 3 AL1 (Up to 18 yrs old), QLC (6 TABLET tabs/day) RITALIN (methylphenidate hcl) 20 MG TIER 3 AL1 (Up to 18 yrs old), QLC (3 TABLET tabs/day) RITALIN (methylphenidate hcl) 5 MG TIER 3 AL1 (Up to 18 yrs old), QLC (12 TABLET tabs/day) RITALIN LA (methylphenidate hcl) 10 MG TIER 3 AL1 (Up to 18 yrs old), QLC (2 CAPSULE, 20 MG CAPSULE, 30 MG caps/day) CAPSULE

99 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS RITALIN LA (methylphenidate hcl) 40 MG TIER 3 AL1 (Up to 18 yrs old), QLC (1 CAPSULE cap/day) RITALIN LA (methylphenidate hcl) 60 MG TIER 3 AL1 (Up to 18 yrs old), QLC (1 CAPSULE cap/day) STRATTERA (atomoxetine hcl) 10 MG TIER 3 AL1 (Up to 18 yrs old), QLC (4 CAPSULE, 18 MG CAPSULE, 25 MG caps/day) CAPSULE STRATTERA (atomoxetine hcl) 40 MG TIER 3 AL1 (Up to 18 yrs old), QLC (2 CAPSULE caps/day) STRATTERA (atomoxetine hcl) 60 MG TIER 3 AL1 (Up to 18 yrs old), QLC (1 CAPSULE, 80 MG CAPSULE, 100 MG cap/day) CAPSULE CENTRAL NERVOUS SYSTEM, OTHER ADIPEX-P (phentermine hcl) TIER 3 PA ALLZITAL (butalbital/acetaminophen) TIER 3 ST, QLC (12 tabs/day) AUSTEDO (deutetrabenazine) TIER 4 PA, SP, QLC (4 tabs/day) BELVIQ (lorcaserin hcl) TIER 3 PA, QLC (2 tabs/day) BELVIQ XR (lorcaserin hcl) TIER 3 PA, QLC (1 tab/day) benzphetamine hcl 25 mg tablet TIER 1 PA, QLC (3 tabs/day) benzphetamine hcl 50 mg tablet TIER 1 PA butalbital/acetaminophen (BUPAP) TIER 1 QLC (6 tabs/day) butalbital/acetaminophen (TENCON) TIER 1 QLC (6 tabs/day) butalbital/acetaminophen -300mg tablet, TIER 1 QLC (6 tabs/day) -325mg tablet butalbital/acetaminophen 50mg-300mg TIER 1 PA, QLC (6 caps/day) capsule butalbital/acetaminophen/caffeine TIER 1 QLC (6 caps/day) (FIORICET) butalbital/acetaminophen/caffeine TIER 1 QLC (6 caps/day) (PHRENILIN FORTE) butalbital/acetaminophen/caffeine TIER 1 PA, QLC (90 ml/day) (VANATOL LQ) butalbital/acetaminophen/caffeine TIER 1 PA, QLC (90 ml/day) (VANATOL S)

100 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS butalbital/acetaminophen/caffeine TIER 1 QLC (6 caps/day) butalb/acetaminophen/caffeine 50-300- 40 capsule, butalb/acetaminophen/caffeine 50-325- 40 capsule butalbital/acetaminophen/caffeine TIER 1 QLC (6 tabs/day) butalb/acetaminophen/caffeine 50-325- 40 tablet CONTRAVE (naltrexone hcl/bupropion TIER 3 PA, QLC (4 tabs/day) hcl) diethylpropion hcl TIER 1 PA ESGIC TIER 3 QLC (6 tabs/day) (butalbital/acetaminophen/caffeine) 50- 325-40 MG TABLET ESGIC TIER 3 QLC (6 caps/day) (butalbital/acetaminophen/caffeine) CAPSULE HORIZANT (gabapentin enacarbil) TIER 3 PA, QLC (2 tabs/day) INGREZZA (valbenazine tosylate) TIER 4 PA, SP, QLC (1 cap/day) INGREZZA INITIATION PACK (valbenazine TIER 4 PA, SP, QLC (1 packet/6 months) tosylate) MARTEN-TAB (butalbital/acetaminophen) TIER 3 QLC (6 tabs/day) NUEDEXTA (dextromethorphan TIER 2 PA, QLC (2 caps/day) hbr/quinidine sulfate) phendimetrazine tartrate TIER 1 PA phentermine hcl TIER 1 PA phentermine hcl (ADIPEX-P) TIER 1 PA phentermine hcl (LOMAIRA) TIER 1 PA QSYMIA (phentermine hcl/topiramate) TIER 3 PA, QLC (1 cap/day) REGIMEX (benzphetamine hcl) TIER 3 PA, QLC (3 tabs/day) RILUTEK (riluzole) TIER 3 riluzole TIER 1 SUPRENZA ODT (phentermine hcl) TIER 3 PA TEGSEDI (inotersen sodium) TIER 4 PA, SP, QLC (1 syringe/week) tetrabenazine 12.5 mg tablet TIER 4 PA, SP, QLC (8 tabs/day) tetrabenazine 25 mg tablet TIER 4 PA, SP, QLC (4 tabs/day)

101 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TIGLUTIK (riluzole) TIER 4 PA, SP, QLC (20 ml/day) XENAZINE (tetrabenazine) 12.5 MG TABLET TIER 4 PA, SP, QLC (8 tabs/day) XENAZINE (tetrabenazine) 25 MG TABLET TIER 4 PA, SP, QLC (4 tabs/day) ZEBUTAL TIER 3 QLC (6 caps/day) (butalbital/acetaminophen/caffeine) FIBROMYALGIA AGENTS CYMBALTA (duloxetine hcl) 20 MG TIER 3 QLC (2 caps/day) CAPSULE, 60 MG CAPSULE CYMBALTA (duloxetine hcl) 30 MG TIER 3 QLC (3 caps/day) CAPSULE DRIZALMA SPRINKLE (duloxetine hcl) 30 TIER 3 PA, QLC (3 caps/day) MG CAP DRIZALMA SPRINKLE (duloxetine hcl) DR 20 TIER 3 PA, QLC (2 caps/day) MG CAP, DR 40 MG CAP, DR 60 MG CAP duloxetine hcl 20 mg capsule dr, 40 mg TIER 1 QLC (2 caps/day) capsule dr, 60 mg capsule dr duloxetine hcl 30 mg capsule dr TIER 1 QLC (3 caps/day) IRENKA (duloxetine hcl) TIER 3 QLC (2 caps/day) LYRICA (pregabalin) 20 MG/ML ORAL TIER 3 QLC (30 ml/day) SOLUTION LYRICA (pregabalin) 225 MG CAPSULE, TIER 3 QLC (2 caps/day) 300 MG CAPSULE LYRICA (pregabalin) 25 MG CAPSULE, 50 TIER 3 QLC (3 caps/day) MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE LYRICA CR (pregabalin) 330 MG TABLET TIER 3 PA, QLC (2 tabs/day) LYRICA CR (pregabalin) CR 82.5 MG TIER 3 PA, QLC (3 tabs/day) TABLET, CR 165 MG TABLET pregabalin 20 mg/ml solution TIER 1 QLC (30 ml/day) pregabalin 225 mg capsule, 300 mg TIER 1 QLC (2 caps/day) capsule pregabalin 25 mg capsule, 50 mg TIER 1 QLC (3 caps/day) capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule, 200 mg capsule SAVELLA (milnacipran hcl) 12.5 MG TIER 3 ST, QLC (2 tabs/day) TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET

102 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SAVELLA (milnacipran hcl) TITRATION TIER 3 ST, QLC (1 pack/28 days) PACK MULTIPLE SCLEROSIS AGENTS AMPYRA (dalfampridine) TIER 4 PA, SP, QLC (2 tabs/day) AUBAGIO (teriflunomide) TIER 4 PA, SP, QLC (1 tab/day) AVONEX (interferon beta-1a) TIER 4 PA, SP, QLC (4 injections/month) AVONEX (interferon beta-1a/albumin TIER 4 PA, SP, QLC (4 injections/month) human) AVONEX PEN (interferon beta-1a) TIER 4 PA, SP, QLC (4 injections/month) BETASERON (interferon beta-1b) TIER 4 PA, SP, QLC (15 injections/month) COPAXONE (glatiramer acetate) 20 TIER 4 SP, QLC (1 syringe/day) MG/ML SYRINGE COPAXONE (glatiramer acetate) 40 TIER 4 SP, QLC (12 syringes/month) MG/ML SYRINGE dalfampridine TIER 4 PA, SP, QLC (2 tabs/day) EXTAVIA (interferon beta-1b) TIER 3 SP, QLC (1 kit/month) FIRDAPSE (amifampridine phosphate) TIER 4 PA, SP, QLC (8 tabs/day) GILENYA (fingolimod hcl) TIER 3 SP, QLC (1 cap/day) glatiramer acetate (GLATOPA) 20 mg/ml TIER 2 SP, QLC (1 syringe/day) syringe glatiramer acetate (GLATOPA) 40 mg/ml TIER 2 SP, QLC (12 syringes/month) syringe glatiramer acetate 20 mg/ml syringe TIER 2 SP, QLC (1 syringe/day) glatiramer acetate 40 mg/ml syringe TIER 2 SP, QLC (12 syringes/month) MAVENCLAD (cladribine) TIER 4 PA, SP, QLC (20 tabs/year) MAYZENT (siponimod) 0.25 MG TABLET TIER 4 PA, SP, QLC (4 tabs/day) MAYZENT (siponimod) 2 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) PLEGRIDY (peginterferon beta-1a) 125 TIER 4 PA, SP, QLC (2 syringes/28 days) MCG/0.5 ML SYRING - PLEGRIDY (peginterferon beta-1a) TIER 4 PA, SP, QLC (1 starter pack/12 SYRINGE STARTER PACK - months) PLEGRIDY PEN (peginterferon beta-1a) TIER 4 PA, SP, QLC (2 pens/28 days) 125 MCG/0.5 ML - PLEGRIDY PEN (peginterferon beta-1a) INJ TIER 4 PA, SP, QLC (1 starter pack/12 STARTER PACK - months)

103 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS REBIF (interferon beta-1a/albumin human) TIER 4 PA, SP, QLC (12 injections/month) 22 MCG/0.5 ML SYRINGE -, 44 MCG/0.5 ML SYRINGE - REBIF (interferon beta-1a/albumin human) TIER 4 PA, SP, QLC (1 pack/month) TITRATION PACK - REBIF REBIDOSE (interferon beta- TIER 4 PA, SP, QLC (12 injections/month) 1a/albumin human) TECFIDERA (dimethyl fumarate) DR 120 TIER 3 SP, QLC (2 caps/day) MG CAPSULE, DR 240 MG CAPSULE TECFIDERA (dimethyl fumarate) STARTER TIER 3 SP, QLC (1 pack/month) PACK VUMERITY (diroximel fumarate) TIER 4 PA, SP, QLC (4 caps/day)

DENTAL AND ORAL AGENTS (Drugs for the Mouth) DENTAL AND ORAL AGENTS cevimeline hcl TIER 1 EVOXAC (cevimeline hcl) TIER 3 pilocarpine hcl 5 mg tablet, 7.5 mg tablet TIER 1 SALAGEN (pilocarpine hcl) TIER 3 triamcinolone acetonide (ORALONE) TIER 1 triamcinolone acetonide 0.1 % paste (g) TIER 1

DERMATOLOGICAL AGENTS (Drugs for the Skin) 8-MOP (methoxsalen) TIER 3 ABSORICA (isotretinoin) TIER 3 PA ACANYA (clindamycin TIER 3 ST phosphate/benzoyl peroxide) acitretin TIER 1 ACZONE (dapsone) TIER 3 PA, QLC (90 gm/month) adapalene (PLIXDA) TIER 1 PA adapalene 0.1 % cream (g), 0.1 % lotion, TIER 1 AL1 (Up to 40 yrs old) 0.3 % gel w/pump, 0.3 % gel (gram) adapalene 0.1 % solution, 0.1 % med. TIER 1 PA swab

104 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS adapalene/benzoyl peroxide TIER 1 ST, AL1 (Up to 40 yrs old) AKLIEF (trifarotene) TIER 3 PA, QLC (45 gm/30 days) ALDARA (imiquimod) TIER 3 QLC (24 packs/month, max of 48 packs/6 months) ALTRENO (tretinoin) TIER 3 PA ANALPRAM HC (hydrocortisone TIER 3 acetate/pramoxine hcl) 1% CREAM ANALPRAM HC (hydrocortisone TIER 2 acetate/pramoxine hcl) 2.5%-1% LOTION ATRALIN (tretinoin) TIER 3 AL1 (Up to 40 yrs old) AVAR (sulfacetamide sodium/sulfur) 9.5- TIER 3 PA 5% CLEANSING PADS AVAR LS (sulfacetamide sodium/sulfur) 10- TIER 3 PA 2% CLEANSING PADS AVAR LS (sulfacetamide sodium/sulfur) TIER 3 CLEANSER AVAR-E LS (sulfacetamide sodium/sulfur) TIER 3 AVITA (tretinoin) TIER 3 AL1 (Up to 40 yrs old) azelaic acid TIER 1 QLC (1 tube/month) AZELEX (azelaic acid) TIER 3 BENZACLIN (clindamycin TIER 3 phosphate/benzoyl peroxide) GEL BENZACLIN (clindamycin TIER 3 ST phosphate/benzoyl peroxide) GEL 35G PUMP, GEL 50G PUMP calcipotriene TIER 1 calcipotriene (CALCITRENE) TIER 1 calcipotriene/betamethasone TIER 1 PA, QLC (400 gm/month) dipropionate calcitriol 3 mcg/g oint. (g) TIER 1 CARAC (fluorouracil) TIER 3 PA, QLC (1 tube/month) clindamycin phosphate/benzoyl peroxide TIER 3 (NEUAC) clindamycin phosphate/benzoyl peroxide TIER 1 phos/benzoyl 1 %-5 % gel (gram), phos/benzoyl 1.2(1)%-5% gel (gram)

105 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS clindamycin phosphate/benzoyl peroxide TIER 1 ST phos/benzoyl 1 %-5 % gel w/pump, phos/benzoyl 1.2%-2.5% gel w/pump clindamycin phosphate/tretinoin TIER 1 ST, AL1 (Up to 40 yrs old) clotrimazole/betamethasone TIER 1 dipropionate CONDYLOX (podofilox) 0.5% GEL TIER 2 CONDYLOX (podofilox) 0.5% TOPICAL TIER 3 SOLN CORTISPORIN (neomycin TIER 3 sulfate/polymyxin b sulfate/hydrocortisone) CORTISPORIN TIER 3 (neomycin/bacitracin/polymyxin b/hydrocortisone) COSENTYX (2 SYRINGES) (secukinumab) TIER 4 PA, SP, QLC (2 syringes/28 days) COSENTYX PEN (2 PENS) (secukinumab) TIER 4 PA, SP, QLC (2 pens/28 days) COSENTYX PEN (secukinumab) TIER 4 PA, SP, QLC (1 pen/28 days) COSENTYX SYRINGE (secukinumab) TIER 4 PA, SP, QLC (1 syringe/28 days) dapsone 5 % gel (gram) TIER 1 PA, QLC (90 gm/month) diclofenac sodium 1 % gel (gram) TIER 1 QLC (5 tubes/month) diclofenac sodium 3 % gel (gram) TIER 1 PA, QLC (1 tube/month; max 3 tubes/year) DIFFERIN (adapalene) 0.1% CREAM, 0.1% TIER 3 AL1 (Up to 40 yrs old) LOTION, 0.3% GEL, 0.3% GEL PUMP DOVONEX (calcipotriene) TIER 3 doxepin hcl 5 % cream (g) TIER 1 DUAC (clindamycin phosphate/benzoyl TIER 3 peroxide) DUOBRII (halobetasol TIER 3 PA, QLC (200 gm/28 days) propionate/tazarotene) DUPIXENT (dupilumab) 200 MG/1.14 ML TIER 4 PA, SP, QLC (2 syringes/28 days) SYRING DUPIXENT (dupilumab) 300 MG/2 ML TIER 4 PA, SP, QLC (2 syringes/28 days) SYRINGE ELIDEL (pimecrolimus) TIER 3 ST, AL1 (Up to 12 yrs old), QLC (1 tube/fill)

106 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ENSTILAR (calcipotriene/betamethasone TIER 3 PA, QLC (7 bottles/month) dipropionate) EPIDUO (adapalene/benzoyl peroxide) TIER 3 ST, AL1 (Up to 40 yrs old) EPIDUO FORTE (adapalene/benzoyl TIER 2 ST, AL1 (Up to 40 yrs old) peroxide) EPIFOAM (hydrocortisone TIER 2 acetate/pramoxine hcl) EUCRISA (crisaborole) TIER 3 PA, QLC (1 tube/month) FABIOR (tazarotene) TIER 3 AL1 (Up to 40 yrs old), QLC (100 gm/month) FINACEA (azelaic acid) 15% FOAM TIER 3 QLC (1 bottle/month) FINACEA (azelaic acid) 15% GEL TIER 3 QLC (1 tube/month) FLUOROPLEX (fluorouracil) TIER 3 PA, QLC (1 tube/month) fluorouracil 0.5 % cream (g) TIER 1 PA, QLC (1 tube/month) GORDON'S UREA (urea) TIER 3 HYDRO 35 (urea) TIER 3 ST HYDRO 40 (urea) TIER 3 ST hydrocortisone acetate (MICORT-HC) TIER 1 hydrocortisone acetate/pramoxine hcl TIER 1 hydrocortisone/pramoxine 1 %-1 % cream/appl imiquimod 3.75 % crm md pmp TIER 1 ST, QLC (1 bottle/month, max of 2 bottles/6 months) imiquimod 5 % cream pack TIER 1 QLC (24 packs/month, max of 48 packs/6 months) isotretinoin TIER 1 isotretinoin (AMNESTEEM) TIER 1 isotretinoin (CLARAVIS) TIER 1 isotretinoin (MYORISAN) TIER 1 isotretinoin (ZENATANE) TIER 1 ivermectin 1 % cream (g) TIER 1 QLC (1 tube/month) KERAFOAM (urea) TIER 3 ST KERALAC (urea) TIER 3 ST, QLC (1 tube/month) LOTRISONE (clotrimazole/betamethasone TIER 3 dipropionate)

107 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS methoxsalen TIER 1 METROCREAM (metronidazole) TIER 3 METROGEL (metronidazole) TIER 3 METROLOTION (metronidazole) TIER 3 metronidazole (ROSADAN) TIER 1 metronidazole 0.75 % lotion, 0.75 % cream TIER 1 (g), 0.75 % gel (gram), 1 % gel w/pump, 1 % gel (gram) MIRVASO (brimonidine tartrate) TIER 3 QLC (1 tube/month) NATROBA (spinosad) TIER 3 QLC (1 bottle/fill) NEO-SYNALAR (neomycin TIER 3 PA, QLC (1 tube/month) sulfate/fluocinolone acetonide) NORITATE (metronidazole) TIER 3 PA ONEXTON (clindamycin TIER 3 ST, QLC (1 bottle/month) phosphate/benzoyl peroxide) OVACE (sulfacetamide sodium) TIER 3 OVACE PLUS (sulfacetamide sodium) 10% TIER 3 WASH, 10% SHAMPOO, 10% CREAM OVACE PLUS (sulfacetamide sodium) 9.8% TIER 3 QLC (1 bottle/month) LOTION OVACE PLUS WASH (sulfacetamide TIER 3 PA, QLC (1 bottle/month) sodium) OXSORALEN-ULTRA (methoxsalen) TIER 3 PICATO (ingenol mebutate) 0.015% GEL TIER 2 QLC (3 doses/month) PICATO (ingenol mebutate) 0.05% GEL TIER 2 QLC (2 doses/month) pimecrolimus TIER 1 ST, AL1 (Up to 12 yrs old), QLC (1 tube/fill) PLEXION (sulfacetamide sodium/sulfur) TIER 3 PA, QLC (1 bottle/month) 9.8-4.8% CLEANSER, 9.8-4.8% LOTION, 9.8- 4.8% CREAM PLEXION (sulfacetamide sodium/sulfur) TIER 3 PA, QLC (1 box/month) 9.8-4.8% CLNSING CLOTH podofilox TIER 1 PRAMOSONE (hydrocortisone TIER 2 acetate/pramoxine hcl) 1% LOTION, 2.5%- 1% LOTION

108 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PRAMOSONE (hydrocortisone TIER 3 acetate/pramoxine hcl) 1%-1% CREAM PROCTOFOAM-HC (hydrocortisone TIER 2 acetate/pramoxine hcl) PROTOPIC (tacrolimus) 0.03% OINTMENT TIER 3 ST, AL1 (Up to 13 yrs old), QLC (1 tube/fill) PROTOPIC (tacrolimus) 0.1% OINTMENT TIER 3 ST, AL1 (At least 15 yrs old), QLC (1 tube/fill) PRUDOXIN (doxepin hcl) TIER 3 QBREXZA (glycopyrronium tosylate) TIER 3 PA, QLC (1 towelette/day) RECTIV (nitroglycerin) TIER 3 PA REGRANEX (becaplermin) TIER 2 PA, QLC (15 gm/30 days) RETIN-A (tretinoin) TIER 3 AL1 (Up to 40 yrs old) RETIN-A MICRO (tretinoin microspheres) TIER 3 ST, AL1 (Up to 40 yrs old) RETIN-A MICRO PUMP (tretinoin TIER 3 ST, AL1 (Up to 40 yrs old) microspheres) -PUMP 0.04% GEL, -PUMP 0.1% GEL RETIN-A MICRO PUMP (tretinoin TIER 3 ST, AL1 (Up to 40 yrs old), QLC (1 microspheres) -PUMP 0.06% GEL, -PUMP bottle/month) 0.08% GEL RHOFADE (oxymetazoline hcl) TIER 3 PA, QLC (one 30 gm tube/month) ROSULA (sulfacetamide sodium/sulfur) TIER 3 PA, QLC (1 bottle/month) SALEX (salicylic acid) TIER 3 salicylic acid 6 % lotion er TIER 1 QLC (400 gm/month) salicylic acid 6 % lotion, 6 % crm er (g), 6 TIER 1 % foam, 6 % shampoo, 26 % liquid, 27.5 % liq-film SALVAX (salicylic acid) TIER 3 SANTYL (collagenase clostridium TIER 2 QLC (180 grams/month) histolyticum) selenium sulfide 2.5 % lotion TIER 1 QLC (1 bottle/month) SILIQ (brodalumab) TIER 4 PA, SP, QLC (2 syringes/28 days) SOLARAZE (diclofenac sodium) TIER 3 PA, QLC (1 tube/month; max 3 tubes/year) SOOLANTRA (ivermectin) TIER 3 QLC (1 tube/month) SORIATANE (acitretin) TIER 3

109 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SORILUX (calcipotriene) TIER 3 PA spinosad TIER 1 QLC (1 bottle/fill) STELARA (ustekinumab) 45 MG/0.5 ML TIER 4 PA, SP, QLC (1 syringe/84 days) SYRINGE, 90 MG/ML SYRINGE STELARA (ustekinumab) 45 MG/0.5 ML TIER 4 PA, SP, QLC (1 vial/84 days) VIAL sulfacetamide sodium (SEB-PREV) TIER 1 sulfacetamide sodium 10 % clnsr gel TIER 1 PA, QLC (1 bottle/month) sulfacetamide sodium 10 % shampoo, 10 TIER 1 % cleanser sulfacetamide sodium/sulfur (AVAR) TIER 1 sulfacetamide sodium/sulfur (AVAR-E TIER 1 GREEN) sulfacetamide sodium/sulfur (AVAR-E) TIER 1 sulfacetamide sodium/sulfur (BP 10-1) TIER 1 sulfacetamide sodium/sulfur (ROSANIL) TIER 1 sulfacetamide sodium/sulfur (ROSULA) TIER 3 QLC (60 pads/month) sulfacetamide sodium/sulfur (SSS 10-5) TIER 1 sulfacetamide sodium/sulfur TIER 1 PA (SULFACLEANSE 8-4) sulfacetamide sodium/sulfur 8 %-4 % TIER 1 PA suspension sulfacetamide sodium/sulfur 9 %-4 % TIER 1 cleanser, 10 %-2 % cream (g), 10-5%(w/v) lotion, 10 %-2 % cleanser, 10-5%(w/w) cream (g), 10-5%(w/w) lotion, 10-5%(w/w) cleanser, 10 %-4 % med. pad, 10-5%(w/w) suspension sulfacetamide sodium/sulfur 9.8%-4.8% TIER 1 PA, QLC (1 bottle/month) cleanser, 9.8%-4.8% lotion, 9.8%-4.8% cream (g) SUMAXIN (sulfacetamide sodium/sulfur) TIER 3 SUMAXIN TS (sulfacetamide sodium/sulfur) TIER 3 PA TACLONEX TIER 3 PA (calcipotriene/betamethasone dipropionate) 0.005%-0.064% SUSPENS TACLONEX TIER 3 PA, QLC (400 gm/28 days) (calcipotriene/betamethasone dipropionate) OINTMENT

110 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tacrolimus 0.03 % oint. (g) TIER 1 ST, AL1 (Up to 13 yrs old), QLC (1 tube/fill) tacrolimus 0.1 % oint. (g) TIER 1 ST, AL1 (At least 15 yrs old), QLC (1 tube/fill) TALTZ AUTOINJECTOR (2 PACK) TIER 4 PA, SP, QLC (1 pen/28 days) (ixekizumab) TALTZ AUTOINJECTOR (3 PACK) TIER 4 PA, SP, QLC (1 pen/28 days) (ixekizumab) TALTZ AUTOINJECTOR (ixekizumab) TIER 4 PA, SP, QLC (1 pen/28 days) TALTZ SYRINGE (2 PACK) (ixekizumab) TIER 4 PA, SP, QLC (1 syringe/28 days) TALTZ SYRINGE (3 PACK) (ixekizumab) TIER 4 PA, SP, QLC (1 syringe/28 days) TALTZ SYRINGE (ixekizumab) TIER 4 PA, SP, QLC (1 syringe/28 days) tazarotene TIER 1 AL1 (Up to 40 yrs old) TAZORAC (tazarotene) TIER 3 AL1 (Up to 40 yrs old) TOLAK (fluorouracil) TIER 2 QLC (1 tube/month) TREMFYA (guselkumab) 100 MG/ML TIER 4 PA, SP, QLC (1 injection/8 weeks) INJECTOR TREMFYA (guselkumab) 100 MG/ML TIER 4 PA, SP, QLC (1 syringe/8 weeks) SYRINGE TRETIN-X (tretinoin) -0.075% CREAM TIER 3 ST, AL1 (Up to 40 yrs old) tretinoin 0.01 % gel (gram), 0.025 % gel TIER 1 AL1 (Up to 40 yrs old) (gram), 0.025 % cream (g), 0.05 % cream (g), 0.05 % gel (gram), 0.1 % cream (g) tretinoin microspheres TIER 1 ST, AL1 (Up to 40 yrs old) ULESFIA (benzyl alcohol) TIER 3 URAMAXIN (urea) 20% FOAM, 45% UREA TIER 3 CREAM URAMAXIN (urea) 45% NAIL GEL, 45% TIER 3 ST LOTION URAMAXIN GT (urea) TIER 3 ST urea (CEM-UREA) TIER 1 ST urea (METOPIC) TIER 1 ST, QLC (2 bottles/month) urea (UMECTA) TIER 1 ST urea (URE-K) TIER 1 PA urea (UREDEB) TIER 1 PA

111 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS urea (XUREA) TIER 1 PA urea 35 % foam, 39 % cream (g), 45 % gel TIER 1 ST (ml), 45 % lotion urea 40 % cream (g), 40 % lotion, 45 % TIER 1 cream (g), 50 % sol/pf app, 50 % cream (g) urea 41 % cream (g) TIER 1 ST, QLC (2 bottles/month) urea 47 % cream (g) TIER 1 ST, QLC (1 bottle/month) UTOPIC (urea) TIER 3 ST, QLC (2 bottles/month) VECTICAL (calcitriol) TIER 3 VELTIN (clindamycin phosphate/tretinoin) TIER 3 ST, AL1 (Up to 40 yrs old) VEREGEN (sinecatechins) TIER 3 ST, QLC (1 tube/month, not to exceed 4 tubes/6 months) VIRASAL (salicylic acid) TIER 3 VOLTAREN (diclofenac sodium) TIER 3 QLC (5 tubes/month) XEPI (ozenoxacin) TIER 3 ST, QLC (1 tube/60 days) ZIANA (clindamycin phosphate/tretinoin) TIER 3 ST, AL1 (Up to 40 yrs old) ZONALON (doxepin hcl) TIER 3 ZYCLARA (imiquimod) 2.5% CREAM PUMP, TIER 3 ST, QLC (1 bottle/month, max of 2 3.75% CREAM PUMP bottles/6 months) ZYCLARA (imiquimod) 3.75% CREAM TIER 3 ST, QLC (28 packets/month, max of 56 packets/6 months)

ELECTROLYTES/MINERALS/METALS/VITAMINS ELECTROLYTE/MINERAL/METAL MODIFIERS FERRIPROX (deferiprone) 1,000 MG TABLET TIER 4 PA, SP, QLC (9 tabs/day) JADENU SPRINKLE (deferasirox) TIER 4 SP JYNARQUE (tolvaptan) 45 MG-15 MG TIER 4 PA, SP, QLC (2 tabs/day) TABLET, 60 MG-30 MG TABLET, 90 MG-30 MG TABLET ATABEX EC (prenatal vits with calcium TIER 3 43/iron/folic acid/docusate sod.) AZESCO (prenatal vitamins no.147/ferrous TIER 3 PA, QLC (2 tabs/day) gluconate/folic acid) CADEAU DHA (prenatal vitamins TIER 3 no.83/iron fumarate/folate combo no.6/dha)

112 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CARNITOR (levocarnitine (with sugar)) TIER 3 CARNITOR (levocarnitine) 330 MG TABLET TIER 3 CARNITOR SF (levocarnitine) TIER 3 CHEMET (succimer) TIER 2 CITRANATAL HARMONY (prenatal vitamin TIER 3 no.59/iron carb,fum/folic acid/docusate/dha) CITRANATAL RX (prenatal vits no.81/iron TIER 3 carbonyl,gluc/folic acid/docusate) CONCEPT DHA (prenatal vit no.16/iron TIER 3 fum,ps complex/folic acid/omega-3) CONCEPT OB (prenatal vitamin no.15/iron TIER 3 fumarate,polysac comp/folic acid) cyanocobalamin (vitamin b-12) TIER 1 cyanocoalamin -1000mcg/ml vial deferasirox 125 mg tab, 250 mg tab, 500 TIER 4 SP mg tab deferasirox 90 mg tablet, 360 mg tablet TIER 4 SP EFFER-K (potassium bicarbonate/citric TIER 3 acid) ENBRACE HR (multivit no.41/iron cysteine TIER 3 glycinat/folate no.8/phosph-dha) ENDARI (glutamine) TIER 4 PA, QLC (6 packets/day) ESCAVITE (pediatric multivitamin TIER 3 ACA (Preventive Health) no.47/ferrous fumarate/sod fluoride) ESCAVITE D (pediatric multivitamin no.78 TIER 3 with iron and sodium fluoride) ESCAVITE LQ (pediatric multivitamin no.86 TIER 3 with iron and sodium fluoride) EXJADE (deferasirox) TIER 4 SP, C (Short Cycle) FERRIPROX (deferiprone) 100 MG/ML TIER 4 PA, SP, QLC (90 ml/day) SOLUTION FERRIPROX (deferiprone) 500 MG TABLET TIER 4 PA, SP, QLC (18 tabs/day) FLORIVA (pediatric multivitamin no.85 with TIER 3 ACA (Preventive Health) sodium fluoride) FLORIVA PLUS (pediatric multivitamin TIER 3 ACA (Preventive Health) no.130/sodium fluoride)

113 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS fluoride/iron/vitamins a,c,and d TIER 1 ACA (Preventive Health) FOLET ONE (multivitamin no.39/iron TIER 3 carb,bisgl/methylfolate/docusate/dha) folic acid 1 mg tablet TIER 1 folic acid/pyridoxine hcl/ca phos dibasic TIER 1 & tribasic/ginger (VP-GGR-B6) folic acid/pyridoxine hcl/ca phos dibasic TIER 1 & tribasic/ginger (ZINGIBER) GALZIN (zinc acetate) TIER 3 JADENU (deferasirox) TIER 4 SP, C (Short Cycle) JYNARQUE (tolvaptan) 15 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) JYNARQUE (tolvaptan) 30 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) K-TAB ER (potassium chloride) TIER 3 KAYEXALATE (sodium polystyrene TIER 3 sulfonate) KLOR-CON (potassium chloride) TIER 3 KLOR-CON 10 (potassium chloride) TIER 3 KLOR-CON 8 (potassium chloride) TIER 3 KLOR-CON M15 (potassium chloride) TIER 3 KOSHER PRENATAL PLUS IRON (prenatal TIER 3 vitamins no.108/iron,carbonyl/folic acid) levocarnitine (with sugar) TIER 1 levocarnitine 100 mg/ml solution, 330 mg TIER 1 tablet MARNATAL-F (prenatal vits with calcium TIER 3 no.65/iron polysacchar/folic acid) multivitamin no.39/iron TIER 1 carb,bisgl/methylfolate/docusate/dha (OBSTETRIX ONE) multivitamin with minerals TIER 1 no.69/iron,carbonyl/folic acid (ELITE-OB) MVC-FLUORIDE (pediatric multivitamin TIER 3 ACA (Preventive Health) no.12 with sodium fluoride) MYNATAL (prenatal vitamins with TIER 3 calcium/ferrous fumarate/folic acid) NASCOBAL (cyanocobalamin (vitamin b- TIER 3 QLC (1 bottle/week) 12))

114 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NATACHEW (prenatal vitamin no.55/iron TIER 3 fumarate,bisglycinate/folic acid) NATELLE ONE (prenatal vit, calcium TIER 3 no.70/ferrous fumarate/folic acid/dha) NEEVODHA (multivit no.37/iron/l-mefolate TIER 3 calc./algal oil/soy lecithin) NESTABS (prenatal vitamin no.86/iron bis- TIER 3 glycinate/folic acid) NESTABS ONE (multivit 42/iron carbonyl,b- TIER 3 g che/methyltetrahydrofolate/dha) NEXA PLUS (prenatal vits no.53/iron TIER 3 fum/folic acid/docusate calcium/dha) O-CAL PRENATAL (prenatal vit with TIER 3 calcium no.127/ferrous fumarate/folic acid) OB COMPLETE (multivitamin with minerals TIER 3 no.69/iron,carbonyl/folic acid) OB COMPLETE ONE (prenatal vit TIER 3 no.85/iron carb,asp.gly/folic acid/dha/fish oil) OB COMPLETE PETITE (prenatal no56/iron TIER 3 carbonyl,asparto glycinate/folic acid/dha) OB COMPLETE PREMIER (prenatal vits TIER 3 no.83/iron,carbonyl,iron aspart.gly/folic acid) OB COMPLETE WITH DHA (prenatal vit TIER 3 no.30/iron carbonyl,asp glyc/folic acid/omega-3) OBSTETRIX EC (prenatal vitamins TIER 3 no.127/iron,carbonyl/folic acid/docusate) pediatric multivit with a,c,d3 TIER 1 ACA (Preventive Health) no.21/sodium fluoride pediatric multivit with a,c,d3 TIER 1 ACA (Preventive Health) no.21/sodium fluoride (TRI-VITE WITH FLUORIDE) pediatric multivitamin no.16/sodium TIER 1 ACA (Preventive Health) fluoride pediatric multivitamin no.2/sodium TIER 1 ACA (Preventive Health) fluoride

115 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS pediatric multivitamin no.45/sodium TIER 1 ACA (Preventive Health) fluoride/ferrous sulfate pediatric multivitamin no.75/sodium TIER 1 ACA (Preventive Health) fluoride/ferrous sulfate pediatric multivitamin no.82 with sodium TIER 1 ACA (Preventive Health) fluoride pediatric multivitamins no.17 with sodium TIER 1 ACA (Preventive Health) fluoride POLY-VI-FLOR (pediatric multivitamin TIER 3 ACA (Preventive Health) no.33 with sodium fluoride) POLY-VI-FLOR (pediatric multivitamin TIER 3 ACA (Preventive Health) no.37 with sodium fluoride) POLY-VI-FLOR WITH IRON (pediatric TIER 3 ACA (Preventive Health) multivit no.37/sodium fluoride/iron bisglycin.hcl) POLY-VI-FLOR WITH IRON (pediatric TIER 3 ACA (Preventive Health) multivitamin no.33/sodium fluoride/iron carbonyl) potassium bicarbonate/citric acid TIER 1 potassium bicarbonate/citric acid (EFFER- TIER 1 K) potassium bicarbonate/citric acid (K TIER 1 EFFERVESCENT) potassium bicarbonate/citric acid (KLOR- TIER 1 CON-EF) potassium chloride (KLOR-CON M10) TIER 1 potassium chloride (KLOR-CON M20) TIER 1 potassium chloride (KLOR-CON SPRINKLE) TIER 1 potassium chloride (KLOR-CON) TIER 1 potassium chloride 8 meq capsule er, 8 TIER 1 meq tablet er, 10 meq tablet er, 10 meq capsule er, 10 meq tab er prt, 20 meq tablet er, 20 meq packet, 20 meq tab er prt, 20meq/15ml liquid, 40meq/15ml liquid potassium chloride/potassium TIER 1 bicarbonate/citric acid PREFERA OB (prenatal vit no.21/iron TIER 3 polysacch,heme polypep/folic acid) PREFERA-OB ONE (prenatal vitamin TIER 3 no.19/iron polysac,iron heme/folic acid/dha)

116 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PRENA1 CHEW (prenatal vitamins TIER 3 combination no.42/folic acid) PRENATA (prenatal vitamins no.37/ferrous TIER 3 fumarate/folic acid) PRENATABS FA (prenatal vits with calcium TIER 3 no.78/ferrous fumarate/folic acid) PRENATABS RX (prenatal vitamin with TIER 3 calcium no.76/iron,carbonyl/folic acid) prenatal vit no.16/iron fum,ps TIER 1 complex/folic acid/omega-3 (DOTHELLE DHA) prenatal vit no.16/iron fum,ps TIER 1 complex/folic acid/omega-3 (TARON-C DHA) prenatal vit no.16/iron fum,ps TIER 1 complex/folic acid/omega-3 (VIRT-C DHA) prenatal vit no.21/iron polysacch,heme TIER 1 polypep/folic acid (HEMENATAL OB) prenatal vit no.21/iron polysacch,heme TIER 1 polypep/folic acid (VP-HEME OB) prenatal vit no.71/iron fum-sodium TIER 1 feredetate/folic acid/dha (PRENA1 PEARL) prenatal vit with calcium 15/iron/folic TIER 1 acid/docusate sodium (MYNATAL ADVANCE) prenatal vit with calcium TIER 1 no.37/iron,aspg/folic acid/omega-3 (ULTIMATECARE ONE) prenatal vit with calcium no.40/iron TIER 1 fumarate/folate no.1 (PNV-SELECT) prenatal vit with calcium no.40/iron TIER 1 fumarate/folate no.1 (VIRT-PN) prenatal vit with calcium no.68/iron TIER 1 fum/folic acid no.1/dha (PNV-OMEGA) prenatal vit with calcium no.68/iron TIER 1 fum/folic acid no.1/dha (VIRT-PN PLUS) prenatal vit with calcium no.68/iron TIER 1 fum/folic acid no.1/dha (ZATEAN-PN PLUS)

117 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prenatal vit with calcium no.69/iron/folic TIER 1 acid/docusate/dha (PRENAISSANCE PLUS) prenatal vit,calcium no.35/iron/folic TIER 1 acid/docusate/omega-3 (ULTIMATECARE ONE NF) prenatal vitamin 27 with calcium/ferrous TIER 1 fumarate/folic acid (TRINATAL RX 1) prenatal vitamin 27 with calcium/ferrous TIER 1 fumarate/folic acid (VINATE ONE) prenatal vitamin no.15/iron TIER 1 fumarate,polysac comp/folic acid (FOLIVANE-OB) prenatal vitamin no.19/iron polysac,iron TIER 1 heme/folic acid/dha (VP-HEME ONE) prenatal vitamin no.86/iron bis- TIER 1 glycinate/folic acid (NEWGEN) prenatal vitamin with calcium TIER 1 no.76/iron,carbonyl/folic acid (PNV 29-1) prenatal vitamin with calcium TIER 1 no.76/iron,carbonyl/folic acid (THRIVITE RX) prenatal vitamins no.11/ferrous TIER 1 fumarate/folic acid/omega-3 (C-NATE DHA) prenatal vitamins no.11/ferrous TIER 1 fumarate/folic acid/omega-3 (VIRT-NATE DHA) prenatal vitamins no.14/ferrous TIER 1 fumarate/folic acid (COMPLETENATE) prenatal vitamins no.147/ferrous TIER 3 PA, QLC (2 tabs/day) gluconate/folic acid (ZALVIT) prenatal vitamins no.5/ferrous TIER 1 fumarate/folic acid prenatal vitamins no.5/ferrous TIER 1 fumarate/folic acid (PNV-VP-U) prenatal vitamins TIER 1 no.66/iron,carbonyl/folic acid/dha (R- NATAL OB) prenatal vitamins no.79/iron fum/folic TIER 1 acid/levomefolate/dha

118 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prenatal vitamins with calcium/ferrous TIER 1 fum/docusate/folic ac (MYNATE 90 PLUS) prenatal vitamins with calcium/ferrous TIER 1 fumarate/folic acid (MYNATAL PLUS) prenatal vitamins with calcium/ferrous TIER 1 fumarate/folic acid (MYNATAL-Z) prenatal vitamins with TIER 1 calcium/iron,carb/docusate/folic acid (MYNATAL) prenatal vits no.115/iron fumarate/folic TIER 1 acid/docusate sod. prenatal vits no.119/iron fumarate/folic TIER 1 acid/docusate sod. prenatal vits no.34/iron,carb/folic TIER 1 acid/docusate sodium/dha (VP-CH-PNV) prenatal vits with calcium 118/ferrous TIER 1 fumarate/folic acid prenatal vits with calcium 136/ferrous TIER 1 fumarate/folic acid (VINATE-M) prenatal vits with calcium no.115/iron TIER 1 fumarate/folic acid prenatal vits with calcium no.47/ferrous TIER 1 fum/folate no.1/dha (PNV-DHA) prenatal vits with calcium no.47/ferrous TIER 1 fum/folate no.1/dha (VIRT-PN DHA) prenatal vits with calcium no.47/ferrous TIER 1 fum/folate no.1/dha (ZATEAN-PN DHA) prenatal vits with calcium no.72/ferrous TIER 1 fumarate/folic acid prenatal vits with calcium no.72/ferrous TIER 1 fumarate/folic acid (M-NATAL PLUS) prenatal vits with calcium no.72/ferrous TIER 1 fumarate/folic acid (PREPLUS) prenatal vits with calcium TIER 1 no.72/iron,carbonyl/folic acid prenatal vits with calcium no.73/ferrous TIER 1 fumarate/folic acid (VIRT-NATE) prenatal vits with calcium no.74/ferrous TIER 1 fumarate/folic acid

119 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prenatal vits with calcium no.78/ferrous TIER 1 fumarate/folic acid (PRETAB) prenatal vits with calcium no.80/iron TIER 1 fum/folic acid/dss/dha (PRENAISSANCE) prenatal vits,calcium no.39/iron fum/folic TIER 1 acid/docusate/dha (TARON-PREX PRENATAL) prenatal vits,calcium no.66/iron fum/folic TIER 1 acid/docusate/dha (PNV-DHA + DOCUSATE) prenatal vits,calcium no.66/iron fum/folic TIER 1 acid/docusate/dha (VEMAVITE-PRX 2) PRENATE AM (multivit TIER 3 no.38/methyltetrahydfolate glucos,folic acid/ginger) PRENATE CHEWABLE (multivitamin TIER 3 no.36/methyltetrahydrofolate gluc,folic acid) PRENATE DHA (multivitamin no.45/iron TIER 3 fumarate/folate comb no.6/dha) PRENATE DHA (prenatal vitamins TIER 3 no.78/iron asparto glycin/folate no.1/dha) PRENATE ELITE (prenatal vitamins TIER 3 no.36/ferrous fumarate/folate comb. no.6) PRENATE ELITE (prenatal vits no.114/ferrous TIER 3 aspart glycinate/folate no.1) PRENATE ENHANCE (prenatal vitamins TIER 3 no.68/iron fumarate/folate no.6/dha) PRENATE ESSENTIAL (multivitamin TIER 3 no.40/iron asparto glycinate/folate no.1/dha) PRENATE ESSENTIAL (multivitamin TIER 3 no.46/iron fumarate/folate comb. no.6/dha) PRENATE MINI (prenatal vits no.87/iron TIER 3 carb-asp.glycinate/folate no.1/dha) PRENATE PIXIE (prenatal vitamins TIER 3 no.85/iron asparto glycin/folate no.1/dha)

120 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PRENATE RESTORE (prenatal vitamins TIER 3 no.69/iron fumarate/folate comb no.6/dha) PRENATE STAR (prenatal vitamins TIER 3 no.77/ferrous asparto glycinate/folic acid) PRIMACARE (prenatal vits no.118/iron TIER 3 asparto glycinate/folate no.6/dha) PROVIDA DHA (prenatal vitamins TIER 3 no.90/iron fum,polysac comp/folic acid/dha) PROVIDA OB (prenatal vits no.65/iron TIER 3 fumarate,polysac complex/folic acid) PUREFE OB PLUS (prenatal vits no.4/iron TIER 3 fumarate,polysacc complex/folic acid) QUFLORA (pediatric multivitamin no.63 TIER 3 ACA (Preventive Health), QLC (1 with sodium fluoride) tab/day) QUFLORA (pediatric multivitamin no.83 TIER 3 ACA (Preventive Health) with sodium fluoride) QUFLORA (pediatric multivitamin no.84 TIER 3 ACA (Preventive Health) with sodium fluoride) QUFLORA FE (pediatric multivitamin TIER 3 ACA (Preventive Health), QLC (1 no.142/iron,carbonyl/sodium fluoride) tab/day) RADIOGARDASE (prussian blue TIER 3 (insoluble)) SAMSCA (tolvaptan) 15 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) SAMSCA (tolvaptan) 30 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) SELECT-OB (prenatal vit no.128/iron TIER 3 polysaccharide complex/folic acid) SELECT-OB (prenatal vitamin no.13/iron TIER 3 polysaccharides/folate comb no.1) sodium polystyrene sulfonate TIER 1 sodium polystyrene sulfonate (KIONEX) TIER 1 sodium polystyrene sulfonate/sorbitol TIER 1 solution (KIONEX) SPS (sodium polystyrene sulfonate/sorbitol TIER 3 solution) SYPRINE (trientine hcl) TIER 4 PA, QLC (8 caps/day) TRI-VI-FLOR (pediatric multivitamin TIER 3 ACA (Preventive Health) a,c,and d3 no.38 with sodium fluoride)

121 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TRICARE (prenatal vits with calcium TIER 3 103/ferrous fumarate/folic acid) TRICARE PRENATAL (prenatal vitamins TIER 3 no.113/iron pyrophosphate/levomefolate) TRICARE PRENATAL DHA ONE (prenatal vit TIER 3 no.20/iron/folic acid/docusate/fish oil/dha/epa) trientine hcl TIER 4 PA, QLC (8 caps/day) trientine hcl (CLOVIQUE) TIER 4 PA, QLC (8 caps/day) TRINATE (prenatal vits with calcium TIER 3 no.73/ferrous fumarate/folic acid) TRISTART DHA (prenatal vitamins TIER 3 no.93/iron carbonyl/folate comb no.9/dha) VELTASSA (patiromer calcium sorbitex) TIER 4 PA, SP, QLC (1 packet/day) VINATE CARE (multivitamin combination TIER 1 no.43/ferrous fumarate/folic acid) VINATE DHA RF (multivit no.37/iron/l- TIER 3 mefolate calc./algal oil/soy lecithin) VITAFOL GUMMIES (prenatal vit TIER 3 no.112/iron phosph/folic acid/omega- 3s/dha/epa) VITAFOL NANO (prenatal vitamins TIER 3 no.75/ferrous fumarate/folate comb. no.1) VITAFOL ULTRA (prenatal vit no.67/iron TIER 3 polysaccharides/folate comb.no.1/dha) VITAFOL-OB (prenatal vits with calcium TIER 3 no.10/ferrous fumarate/folic acid) VITAFOL-ONE (prenatal vits no.26/iron TIER 3 polysaccharide cplex/folic acid/dha) VITAMEDMD ONE RX (prenatal vits TIER 3 no.25/ferrous fumarate/folate comb. no.6/dha) VITAMEDMD REDICHEW RX (prenatal TIER 3 vitamins combination no.42/folic acid) VITAPEARL (prenatal vit no.71/iron fum- TIER 3 sodium feredetate/folic acid/dha) VP-PNV-DHA (prenatal vitamins TIER 3 no.52/ferrous fumarate/folic acid/dha)

122 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS XURIDEN (uridine triacetate) TIER 4 PA, SP, QLC (4 packets/day) VITAMINS QUFLORA FE (pediatric multivitamin TIER 3 ACA (Preventive Health) no.151/ferrous sulfate/sod fluoride)

GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) ANTISPASMODICS, GASTROINTESTINAL (Drugs to Prevent Bowel and Stomach Spasam) ANASPAZ (hyoscyamine sulfate) TIER 3 BENTYL (dicyclomine hcl) 10 MG CAPSULE, TIER 3 20 MG TABLET chlordiazepoxide/clidinium bromide TIER 1 CUVPOSA (glycopyrrolate) TIER 3 PA, QLC (45 ml/day) dicyclomine hcl 10 mg/5 ml solution, 10 TIER 1 mg capsule, 20 mg tablet DONNATAL (phenobarbital/hyoscyamine TIER 3 PA, QLC (40 ml/day) sulf/atropine sulf/scopolamine hb) ELIXIR DONNATAL (phenobarbital/hyoscyamine TIER 3 sulf/atropine sulf/scopolamine hb) TABLET GLYCATE (glycopyrrolate) TIER 3 PA, QLC (3 tabs/day) glycopyrrolate 1 mg tablet, 2 mg tablet TIER 1 glycopyrrolate 1.5 mg tablet TIER 1 PA, QLC (3 tabs/day) hyoscyamine sulfate TIER 1 hyoscyamine sulfate (ED-SPAZ) TIER 1 hyoscyamine sulfate (HYOSYNE) TIER 1 hyoscyamine sulfate (NULEV) TIER 1 hyoscyamine sulfate (OSCIMIN SL) TIER 1 hyoscyamine sulfate (OSCIMIN SR) TIER 1 hyoscyamine sulfate (OSCIMIN) TIER 1 hyoscyamine sulfate (SYMAX) TIER 1 hyoscyamine sulfate (SYMAX-SL) TIER 1 hyoscyamine sulfate (SYMAX-SR) TIER 1

123 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LEVBID (hyoscyamine sulfate) TIER 3 LEVSIN (hyoscyamine sulfate) 0.125 MG TIER 3 TABLET LEVSIN-SL (hyoscyamine sulfate) TIER 3 LIBRAX (chlordiazepoxide/clidinium TIER 3 bromide) methscopolamine bromide TIER 1 phenobarbital/hyoscyamine sulf/atropine TIER 1 sulf/scopolamine hb (PHENOHYTRO) phenobarb/hyoscy/atropine/scop 16.2 mg tablet phenobarbital/hyoscyamine sulf/atropine TIER 1 QLC (40 ml/day) sulf/scopolamine hb (PHENOHYTRO) phenobarb/hyoscy/atropine/scop 16.2mg/5ml elixir phenobarbital/hyoscyamine sulf/atropine TIER 1 sulf/scopolamine hb phenobarb/hyoscy/atropine/scop 16.2 mg tablet phenobarbital/hyoscyamine sulf/atropine TIER 1 PA, QLC (40 ml/day) sulf/scopolamine hb phenobarb/hyoscy/atropine/scop 16.2mg/5ml elixir propantheline bromide TIER 1 ROBINUL (glycopyrrolate) 1 MG TABLET TIER 3 ROBINUL FORTE (glycopyrrolate) TIER 3 SYMAX DUOTAB (hyoscyamine sulfate) TIER 3 GASTROINTESTINAL AGENTS, OTHER (Other Drugs for the Bowel and Stomach) ACTIGALL (ursodiol) TIER 3 CHENODAL (chenodiol) TIER 4 PA, SP, QLC (6 tabs/day) CHOLBAM (cholic acid) 250 MG CAPSULE TIER 4 PA, SP, QLC (5 caps/day) CHOLBAM (cholic acid) 50 MG CAPSULE TIER 4 PA, SP, QLC (4 caps/day) cromolyn sodium 20 mg/ml oral conc TIER 1 diphenoxylate hcl/atropine sulfate TIER 1 GASTROCROM (cromolyn sodium) TIER 3 lansoprazole/amoxicillin TIER 1 QLC (one 14-day course/month) trihydrate/clarithromycin

124 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LOMOTIL (diphenoxylate hcl/atropine TIER 3 sulfate) MOTOFEN (difenoxin hcl/atropine sulfate) TIER 3 MOVANTIK (naloxegol oxalate) TIER 3 QLC (1 tab/day) MYALEPT (metreleptin) TIER 4 PA, SP, QLC (1 vial/day) MYTESI (crofelemer) TIER 3 PA, QLC (2 tabs/day) OCALIVA (obeticholic acid) TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day) OMECLAMOX-PAK TIER 3 QLC (1 pack/month) (omeprazole/clarithromycin/amoxicillin trihydrate) PREVPAC (lansoprazole/amoxicillin TIER 3 QLC (one 14-day course/month) trihydrate/clarithromycin) PYLERA (colloidal bismuth TIER 3 QLC (120 caps/month) subcitrate/metronidazole/tetracycline hcl) RELISTOR (methylnaltrexone bromide) 150 TIER 4 PA, QLC (3 tabs/day) MG TABLET RELISTOR (methylnaltrexone bromide) 8 TIER 4 PA MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 ML VIAL SYMPROIC (naldemedine tosylate) TIER 3 PA, QLC (1 tab/day) URSO (ursodiol) TIER 3 URSO FORTE (ursodiol) TIER 3 ursodiol TIER 1 XENICAL (orlistat) TIER 3 PA XERMELO (telotristat etiprate) TIER 4 PA, SP, QLC (3 tabs/day) HISTAMINE2 (H2) RECEPTOR ANTAGONISTS cimetidine 300 mg tablet, 400 mg tablet, TIER 1 800 mg tablet cimetidine hcl TIER 1 famotidine (PEPCID) 40 mg tablet TIER 1 famotidine 40mg/5ml oral susp, 40 mg TIER 1 tablet nizatidine TIER 1 PEPCID (famotidine) 40 MG TABLET TIER 1

125 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PEPCID (famotidine) 40 MG/5 ML ORAL TIER 3 SUSP ranitidine hcl 15 mg/ml syrup, 150 mg TIER 1 capsule, 300 mg tablet, 300 mg capsule ZANTAC (ranitidine hcl) 300 MG TABLET TIER 3 IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl TIER 1 PA AMITIZA (lubiprostone) 24 MCG CAPSULES TIER 3 PA, AL1 (At least 18 yrs old), QLC (2 caps/day) AMITIZA (lubiprostone) 8 MCG CAPSULE TIER 3 PA, ST, AL1 (At least 18 yrs old), QLC (2 caps/day) LINZESS (linaclotide) TIER 2 QLC (1 cap/day) LOTRONEX (alosetron hcl) TIER 3 PA TRULANCE (plecanatide) TIER 3 PA, QLC (1 tab/day) VIBERZI (eluxadoline) TIER 4 PA, QLC (2 tabs/day) ZELNORM (tegaserod hydrogen maleate) TIER 3 PA, QLC (2 tabs/day) LAXATIVES (Drugs for Bowel Cleansing and Constipation) bisacodyl/sodium chlor/sodium TIER 1 ACA (Preventive Health) bicarb/potassium chl/peg 3350 (PEG- PREP) CLENPIQ (sodium picosulfate/magnesium TIER 3 PA oxide/citric acid) COLYTE WITH FLAVOR PACKETS (peg TIER 3 PA, ACA (Preventive Health) 3350/sod sulf/sod bicarb/sod chloride/potassium chloride) GOLYTELY (peg 3350/sod sulf/sod TIER 3 PA, ACA (Preventive Health) bicarb/sod chloride/potassium chloride) KRISTALOSE (lactulose) 10 GM PACKET TIER 3 PA, QLC (1 pack/day) KRISTALOSE (lactulose) 20 GM PACKET TIER 3 PA, QLC (2 packs/day) lactulose (CONSTULOSE) TIER 1 lactulose (ENULOSE) TIER 1 lactulose (GENERLAC) TIER 1 lactulose 10 g packet TIER 1 PA, QLC (1 pack/day) lactulose 10 g/15 ml, 20 g/30 ml TIER 1

126 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MOVIPREP (peg 3350/sodium sulfate/sod TIER 3 PA, ACA (Preventive Health) chloride/kcl/ascorbate sod/vit c) NULYTELY WITH FLAVOR PACKS (sodium TIER 3 ACA (Preventive Health) chloride/sodium bicarbonate/potassium chloride/peg) OSMOPREP (sodium TIER 3 PA, ACA (Preventive Health) phosphate,monobasic/sodium phosphate,dibasic) peg 3350/sod sulf/sod bicarb/sod TIER 1 ACA (Preventive Health) chloride/potassium chloride peg 3350/sod sulf/sod bicarb/sod TIER 1 ACA (Preventive Health) chloride/potassium chloride (GAVILYTE-C) peg 3350/sod sulf/sod bicarb/sod TIER 1 ACA (Preventive Health) chloride/potassium chloride (GAVILYTE-G) PLENVU (peg 3350/sodium sulfate/sod TIER 3 PA chloride/kcl/ascorbate sod/vit c) PREPOPIK (sodium TIER 3 PA, ACA (Preventive Health) picosulfate/magnesium oxide/citric acid) sodium chloride/sodium TIER 1 ACA (Preventive Health) bicarbonate/potassium chloride/peg sodium chloride/sodium TIER 1 ACA (Preventive Health) bicarbonate/potassium chloride/peg (GAVILYTE-N) sodium chloride/sodium TIER 1 ACA (Preventive Health) bicarbonate/potassium chloride/peg (TRILYTE WITH FLAVOR PACKETS) SUPREP (sodium sulfate/potassium TIER 2 ACA (Preventive Health) sulfate/magnesium sulfate) PROTECTANTS CARAFATE (sucralfate) 1 GM TABLET TIER 3 CARAFATE (sucralfate) 1 GM/10 ML SUSP TIER 2 CYTOTEC (misoprostol) TIER 3 misoprostol TIER 1 sucralfate 1 g tablet TIER 1 PROTON PUMP INHIBITORS ACIPHEX (rabeprazole sodium) TIER 3 ACIPHEX SPRINKLE (rabeprazole sodium) TIER 3 ST, QLC (1 cap/day)

127 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DEXILANT (dexlansoprazole) TIER 2 ST, QLC (1 cap/day) esomeprazole magnesium 40 mg capsule TIER 1 PA dr esomeprazole strontium TIER 1 ST, QLC (6 caps/day) lansoprazole 15 mg tab dr, 30 mg tab dr TIER 1 ST lansoprazole 30 mg capsule dr TIER 1 NEXIUM (esomeprazole magnesium) DR TIER 3 ST, QLC (1 packet/day) 10 MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET NEXIUM (esomeprazole magnesium) DR TIER 3 PA, QLC (1 packet/day) 2.5 MG PACKET, DR 5 MG PACKET NEXIUM (esomeprazole magnesium) DR TIER 3 PA 40 MG CAPSULE omeprazole 10 mg capsule dr, 20 mg TIER 1 capsule dr, 40 mg capsule dr omeprazole/sodium bicarbonate TIER 1 PA (OMEPPI) 40mg-1.1g capsule omeprazole/sodium bicarbonate 20- TIER 1 PA, QLC (2 packs/day) 1680mg packet omeprazole/sodium bicarbonate 40- TIER 1 PA, QLC (1 pack/day) 1680mg packet omeprazole/sodium bicarbonate 40mg- TIER 1 PA, QLC (1 cap/day) 1.1g capsule pantoprazole sodium 20 mg tablet dr, 40 TIER 1 mg tablet dr PREVACID (lansoprazole) 15 MG, 30 MG TIER 3 ST PREVACID (lansoprazole) DR 30 MG TIER 3 CAPSULE PRILOSEC (omeprazole magnesium) DR TIER 3 QLC (2 packs/day) 10 MG SUSPENSION PRILOSEC (omeprazole magnesium) DR TIER 3 QLC (3 packs/day) 2.5 MG SUSPENSION PROTONIX (pantoprazole sodium) 40 MG TIER 2 SUSPENSION PROTONIX (pantoprazole sodium) DR 20 TIER 3 MG TABLET, DR 40 MG TABLET rabeprazole sodium 10 mg cap dr spr TIER 3 ST, QLC (1 cap/day) rabeprazole sodium 20 mg tablet dr TIER 1

128 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZEGERID (omeprazole/sodium TIER 3 PA, QLC (2 packs/day) bicarbonate) 20 MG PACKET ZEGERID (omeprazole/sodium TIER 3 PA, QLC (1 cap/day) bicarbonate) 40 MG CAPSULE ZEGERID (omeprazole/sodium TIER 3 PA, QLC (1 pack/day) bicarbonate) 40 MG PACKET

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT (Drugs for Genetic or Enzyme Disorders) GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT BUPHENYL (sodium phenylbutyrate) 500 TIER 4 PA, SP, QLC (40 tabs/day) MG TABLET BUPHENYL (sodium phenylbutyrate) TIER 4 PA, SP, QLC (20 gm/day) POWDER CARBAGLU (carglumic acid) TIER 4 PA, SP, QLC (35 tabs/day) CERDELGA (eliglustat tartrate) TIER 4 PA, SP, QLC (2 caps/day) CREON (lipase/protease/amylase) TIER 2 CYSTADANE (betaine) TIER 3 SP GALAFOLD (migalastat hcl) TIER 4 PA, SP, QLC (14 caps/28 days) KUVAN (sapropterin dihydrochloride) 100 TIER 4 PA, SP, QLC (14 packs/day) MG POWDER PACKET KUVAN (sapropterin dihydrochloride) 100 TIER 4 PA, SP, QLC (14 tabs/day) MG TABLET KUVAN (sapropterin dihydrochloride) 500 TIER 4 PA, SP, QLC (3 packets/day) MG POWDER PACKET miglustat TIER 4 PA, SP, QLC (3 caps/day) nitisinone 10 mg capsule TIER 4 PA, SP, QLC (14 caps/day) nitisinone 2 mg capsule TIER 4 PA, SP, QLC (10 caps/day) nitisinone 5 mg capsule TIER 4 PA, SP, QLC (2 caps/day) NITYR (nitisinone) 10 MG TABLET TIER 4 PA, SP, QLC (14 tabs/day) NITYR (nitisinone) 2 MG TABLET TIER 4 PA, SP, QLC (70 tabs/day) NITYR (nitisinone) 5 MG TABLET TIER 4 PA, SP, QLC (28 tabs/day) ORFADIN (nitisinone) 10 MG CAPSULE TIER 4 PA, SP, QLC (14 caps/day)

129 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ORFADIN (nitisinone) 2 MG CAPSULE TIER 4 PA, SP, QLC (10 caps/day) ORFADIN (nitisinone) 20 MG CAPSULE TIER 4 PA, SP, QLC (8 caps/day) ORFADIN (nitisinone) 4 MG/ML TIER 4 PA, SP, QLC (35 ml/day) SUSPENSION ORFADIN (nitisinone) 5 MG CAPSULE TIER 4 PA, SP, QLC (2 caps/day) PALYNZIQ (pegvaliase-pqpz) 10 MG/0.5 TIER 4 PA, SP, QLC (1 syringe/day) ML SYRINGE - PALYNZIQ (pegvaliase-pqpz) 2.5 MG/0.5 TIER 4 PA, SP, QLC (4 syringes/28 days) ML SYRINGE - PALYNZIQ (pegvaliase-pqpz) 20 MG/ML TIER 4 PA, SP, QLC (2 syringes/day) SYRINGE - PANCREAZE (lipase/protease/amylase) TIER 3 PERTZYE (lipase/protease/amylase) TIER 3 PROCYSBI (cysteamine bitartrate) DR 25 TIER 4 PA, SP, QLC (4 caps/day) MG CAPSULE PROCYSBI (cysteamine bitartrate) DR 75 TIER 4 PA, SP, QLC (26 caps/day) MG CAPSULE RAVICTI (glycerol phenylbutyrate) TIER 4 PA, SP, QLC (17.5 ml/day) sodium phenylbutyrate 0.94 g/g powder TIER 4 PA, SP, QLC (20 gm/day) sodium phenylbutyrate 500 mg tablet TIER 4 PA, SP, QLC (40 tabs/day) STRENSIQ (asfotase alfa) TIER 4 PA, SP, QLC (24 vials/28 days) SUCRAID (sacrosidase) TIER 4 PA, SP, QLC (12 ml/day) VIOKACE (lipase/protease/amylase) TIER 3 ZAVESCA (miglustat) TIER 4 PA, SP, QLC (3 caps/day) ZENPEP (lipase/protease/amylase) TIER 2

GENITOURINARY AGENTS (Drugs for the Genital, Bladder, and Kidney) ANTISPASMODICS, URINARY (Drugs for Bladder Spasms) darifenacin hydrobromide 15 mg tab er TIER 1 ST, QLC (1 tab/day) 24h darifenacin hydrobromide 7.5 mg tab er TIER 1 ST, QLC (2 tabs/day) 24h DETROL (tolterodine tartrate) TIER 3 ST, QLC (2 tabs/day)

130 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DETROL LA (tolterodine tartrate) TIER 3 ST, QLC (1 tab/day) DITROPAN XL (oxybutynin chloride) 10 MG TIER 3 QLC (3 tabs/day) TABLET DITROPAN XL (oxybutynin chloride) 15 MG TIER 3 QLC (2 tabs/day) TABLET DITROPAN XL (oxybutynin chloride) 5 MG TIER 3 QLC (1 tab/day) TABLET ENABLEX (darifenacin hydrobromide) 15 TIER 3 ST, QLC (1 tab/day) MG TABLET ENABLEX (darifenacin hydrobromide) 7.5 TIER 3 ST, QLC (2 tabs/day) MG TABLET flavoxate hcl TIER 1 GELNIQUE (oxybutynin chloride) 10% GEL TIER 3 ST, QLC (1 pack/day) SACHET, 10% GEL SACHETS GELNIQUE (oxybutynin chloride) 10% TIER 3 ST, QLC (one 30 gm gel PUMP pump/month) MYRBETRIQ (mirabegron) TIER 2 ST, QLC (1 tab/day) oxybutynin chloride 10 mg tab er 24 TIER 1 QLC (3 tabs/day) oxybutynin chloride 15 mg tab er 24 TIER 1 QLC (2 tabs/day) oxybutynin chloride 5 mg tab er 24 TIER 1 QLC (1 tab/day) oxybutynin chloride 5 mg/5 ml syrup, 5 mg TIER 1 tablet OXYTROL (oxybutynin) TIER 3 ST, QLC (8 patches/month) solifenacin succinate TIER 1 ST, QLC (1 tab/day) tolterodine tartrate 1 mg tablet, 2 mg TIER 1 ST, QLC (2 tabs/day) tablet tolterodine tartrate 2 mg cap er, 4 mg TIER 1 ST, QLC (1 tab/day) cap er TOVIAZ (fesoterodine fumarate) TIER 3 ST, QLC (1 tab/day) trospium chloride 20 mg tablet TIER 1 QLC (2 tabs/day) trospium chloride 60 mg cap er 24h TIER 1 QLC (1 cap/day) VESICARE (solifenacin succinate) TIER 3 ST, QLC (1 tab/day) BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl TIER 1 AVODART (dutasteride) TIER 3 QLC (1 cap/day)

131 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CARDURA XL (doxazosin mesylate) TIER 3 ST, QLC (1 tab/day) CIALIS (tadalafil) 2.5 MG TABLET, 5 MG TIER 3 PA, GL (Male), RO (Retail Only), TABLET QLC (6 tabs/month) dutasteride TIER 1 QLC (1 cap/day) dutasteride/tamsulosin hcl TIER 1 PA, QLC (1 cap/day) finasteride 5 mg tablet TIER 1 FLOMAX (tamsulosin hcl) TIER 3 JALYN (dutasteride/tamsulosin hcl) TIER 3 PA, QLC (1 cap/day) PROSCAR (finasteride) TIER 3 RAPAFLO (silodosin) TIER 3 ST, QLC (1 cap/day) silodosin TIER 1 ST, QLC (1 cap/day) tadalafil 2.5 mg tablet, 5 mg tablet TIER 1 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) tamsulosin hcl TIER 1 UROXATRAL (alfuzosin hcl) TIER 3 GENITOURINARY AGENTS, OTHER (Other Drugs for the Genital, Bladder, and Kidney) ADDYI (flibanserin) TIER 3 PA, GL (Female), QLC (1 tab/day) bethanechol chloride TIER 1 CAVERJECT (alprostadil) IMPULSE 10 MCG TIER 3 PA, GL (Male), QLC (6 KIT, 20 MCG VIAL, IMPULSE 20 MCG KIT, 40 injections/month) MCG VIAL CIALIS (tadalafil) 10 MG TABLET, 20 MG TIER 3 PA, GL (Male), RO (Retail Only), TABLET QLC (6 tabs/month) citric acid/sodium citrate TIER 1 citric acid/sodium citrate (CYTRA-2) TIER 1 citric acid/sodium citrate (VIRTRATE-2) TIER 1 CUPRIMINE (penicillamine) TIER 4 PA, QLC (16 caps/day) CYSTAGON (cysteamine bitartrate) 150 TIER 4 PA, SP, QLC (26 caps/day) MG CAPSULE CYSTAGON (cysteamine bitartrate) 50 TIER 4 PA, SP, QLC (4 caps/day) MG CAPSULE D-PENAMINE (penicillamine) TIER 4 PA, QLC (32 tabs/day) DEPEN (penicillamine) TIER 4 PA, QLC (16 tabs/day)

132 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EDEX (alprostadil) TIER 3 PA, GL (Male), QLC (6 injections/month) ELMIRON (pentosan polysulfate sodium) TIER 2 K-PHOS NEUTRAL (sodium TIER 3 phosphate,dibasic/pot phos,monob/sod phosphate mono) K-PHOS NO.2 (sodium TIER 3 phosphate,monobasic/potassium phosphate,monobasic) K-PHOS ORIGINAL (potassium TIER 3 phosphate,monobasic) LEVITRA (vardenafil hcl) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) LITHOSTAT (acetohydroxamic acid) TIER 3 MUSE (alprostadil) TIER 2 PA, GL (Male), QLC (6 suppositories/month) ORACIT (citric acid/sodium citrate) TIER 3 penicillamine TIER 4 PA, QLC (16 caps/day) phenazopyridine hcl TIER 1 potassium citrate TIER 1 potassium citrate/citric acid TIER 1 potassium citrate/citric acid (CYTRA-K) TIER 1 potassium citrate/citric acid (VIRTRATE-K) TIER 1 PYRIDIUM (phenazopyridine hcl) TIER 3 RENACIDIN (citric TIER 3 PA, QLC (180 ml/day) acid/gluconolactone/magnesium carbonate) sildenafil citrate 25 mg tablet, 50 mg TIER 1 PA, GL (Male), RO (Retail Only), tablet, 100 mg tablet QLC (6 tabs/month) sodium phosphate,dibasic/pot TIER 1 phos,monob/sod phosphate mono (PHOSPHA 250 NEUTRAL) sodium phosphate,dibasic/pot TIER 1 phos,monob/sod phosphate mono (VIRT- PHOS 250 NEUTRAL) sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac (CYTRA-3)

133 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac (TRICITRATES) sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac (VIRTRATE-3) STAXYN (vardenafil hcl) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) STENDRA (avanafil) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) tadalafil 10 mg tablet TIER 1 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) tadalafil 20 mg tablet TIER 1 PA, GL (Male), RO (Retail Only), SP, QLC (2 tabs/day) THIOLA (tiopronin) TIER 4 PA, SP THIOLA EC (tiopronin) TIER 4 PA, SP URECHOLINE (bethanechol chloride) TIER 3 UROCIT-K (potassium citrate) TIER 3 UROQID-ACID NO.2 (methenamine TIER 3 mandelate/sodium phosphate,monobasic) vardenafil hcl TIER 1 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) VIAGRA (sildenafil citrate) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) VYLEESI (bremelanotide acetate) TIER 4 PA, SP, GL (Female), QLC (8 doses/30 days) PHOSPHATE BINDERS (Drugs to Lower Phosphate) AURYXIA (ferric citrate) TIER 3 calcium acetate 667 mg capsule TIER 1 FOSRENOL (lanthanum carbonate) TIER 3 lanthanum carbonate TIER 1 PHOSLYRA (calcium acetate) TIER 3 RENAGEL (sevelamer hcl) TIER 3 RENVELA (sevelamer carbonate) TIER 3 sevelamer carbonate TIER 1 sevelamer hcl TIER 1

134 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VELPHORO (sucroferric oxyhydroxide) TIER 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Drugs for Replacing/Stimulating Adrenal Gland Hormones) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Glucocorticoids) ALA-SCALP (hydrocortisone) TIER 3 ST alclometasone dipropionate TIER 1 amcinonide TIER 1 ST betamethasone dipropionate TIER 1 betamethasone dipropionate/propylene TIER 1 glycol betamethasone valerate 0.1 % lotion, 0.1 TIER 1 % cream (g), 0.1 % oint. (g) betamethasone valerate 0.12 % foam TIER 1 ST BRYHALI (halobetasol propionate) TIER 3 PA, QLC (200 gm/28 days) CAPEX SHAMPOO (fluocinolone TIER 3 PA acetonide) clobetasol propionate (CLODAN) TIER 1 ST clobetasol propionate (CORMAX) TIER 1 clobetasol propionate 0.05 % foam TIER 1 PA clobetasol propionate 0.05 % gel (gram), TIER 1 0.05 % solution, 0.05 % cream (g), 0.05 % oint. (g) clobetasol propionate 0.05 % shampoo, TIER 1 ST 0.05 % lotion clobetasol propionate 0.05 % spray TIER 1 ST, QLC (125 ml/month) clobetasol propionate/emollient base TIER 1 PA (TOVET EMOLLIENT) clobetasol propionate/emollient base TIER 1 0.05 % cream (g) clobetasol propionate/emollient base TIER 1 PA 0.05 % foam CLOBEX (clobetasol propionate) 0.05% TIER 3 ST SHAMPOO, 0.05% TOPICAL LOTION

135 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CLOBEX (clobetasol propionate) 0.05% TIER 3 ST, QLC (125 ml/month) SPRAY clocortolone pivalate TIER 1 ST CLODERM (clocortolone pivalate) TIER 3 ST CORDRAN (flurandrenolide) TIER 3 PA CORTEF (hydrocortisone) TIER 3 cortisone acetate TIER 1 CUTIVATE (fluticasone propionate) 0.05% TIER 3 CREAM CUTIVATE (fluticasone propionate) 0.05% TIER 3 ST LOTION DELTASONE (prednisone) TIER 3 DERMA-SMOOTHE-FS (fluocinolone TIER 3 acetonide) DERMA-SMOOTHE-FS (fluocinolone TIER 3 acetonide/shower cap) DERMATOP (prednicarbate) TIER 3 DESONATE (desonide) TIER 3 PA desonide 0.05 % lotion TIER 1 ST desonide 0.05 % oint. (g), 0.05 % cream TIER 1 (g) DESOWEN (desonide) 0.05% CREAM TIER 3 DESOWEN (desonide) 0.05% LOTION TIER 3 ST desoximetasone 0.05 % oint. (g), 0.05 % TIER 1 ST gel (gram), 0.05 % cream (g), 0.25 % cream (g), 0.25 % oint. (g) desoximetasone 0.25 % spray TIER 1 ST, QLC (1 bottle/month) dexamethasone (21) tab, (35) tab, (51) TIER 1 PA tab dexamethasone (DECADRON) TIER 1 dexamethasone (DEXAMETHASONE TIER 1 INTENSOL) dexamethasone (HIDEX) TIER 1 PA dexamethasone (LOCORT) 1.5mg (27) TIER 1 PA tab ds pk dexamethasone (LOCORT) 1.5mg (41) TIER 1 PA, QLC (1 pack/month) tab ds pk

136 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS dexamethasone (TAPERDEX) TIER 1 PA dexamethasone (ZODEX) TIER 3 PA dexamethasone 0.5 mg/5ml solution, 0.5 TIER 1 mg tablet, 0.5 mg/5ml elixir, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet DEXPAK (dexamethasone) TIER 3 PA diflorasone diacetate TIER 1 ST diflorasone diacetate (PSORCON) TIER 1 ST diflorasone diacetate/emollient base TIER 1 ST (APEXICON E) DIPROLENE (betamethasone TIER 3 dipropionate/propylene glycol) DIPROLENE AF (betamethasone TIER 3 dipropionate/propylene glycol) DXEVO (dexamethasone) TIER 3 PA ELOCON (mometasone furoate) TIER 3 EMFLAZA (deflazacort) 18 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) EMFLAZA (deflazacort) 22.75 MG/ML TIER 4 PA, SP, QLC (6 bottles/month) ORAL SUSP EMFLAZA (deflazacort) 6 MG TABLET, 30 TIER 4 PA, SP, QLC (2 tabs/day) MG TABLET, 36 MG TABLET fludrocortisone acetate TIER 1 fluocinolone acetonide TIER 1 fluocinolone acetonide/shower cap TIER 1 fluocinonide 0.05 % cream (g), 0.05 % oint. TIER 1 (g), 0.05 % gel (gram), 0.05 % solution fluocinonide 0.1 % cream (g) TIER 1 PA fluocinonide/emollient base TIER 1 flurandrenolide TIER 1 PA flurandrenolide (NOLIX) 0.05 % cream (g) TIER 3 PA flurandrenolide (NOLIX) 0.05 % lotion TIER 1 PA fluticasone propionate (BESER) TIER 1 ST fluticasone propionate 0.005 % oint. (g), TIER 1 0.05 % cream (g)

137 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS fluticasone propionate 0.05 % lotion TIER 1 ST halcinonide TIER 1 PA halobetasol propionate 0.05 % cream (g), TIER 1 0.05 % oint. (g) halobetasol propionate 0.05 % foam TIER 3 PA, QLC (50 grams/week) HALOG (halcinonide) 0.1% CREAM TIER 3 PA HALOG (halcinonide) 0.1% OINTMENT TIER 3 hydrocortisone (ALA-CORT) TIER 1 hydrocortisone (ANUSOL-HC) TIER 1 hydrocortisone (PROCTO-MED HC) TIER 1 hydrocortisone (PROCTO-PAK) TIER 1 hydrocortisone (PROCTOSOL-HC) TIER 1 hydrocortisone (PROCTOZONE-HC) TIER 1 hydrocortisone (SCALACORT) TIER 1 ST hydrocortisone 1 % crm/pe app, 2.5 % TIER 1 cream (g), 2.5 % crm/pe app, 2.5 % oint. (g), 2.5 % lotion, 5 mg tablet, 10 mg tablet, 20 mg tablet hydrocortisone acetate (ANUCORT-HC) TIER 1 hydrocortisone acetate (ANUSOL-HC) TIER 1 hydrocortisone acetate (HEMMOREX-HC) TIER 1 25 mg supp.rect - hydrocortisone acetate 25 mg supp.rect TIER 1 hydrocortisone acetate/urea (U-CORT) TIER 1 hydrocortisone butyrate 0.1 % cream (g), TIER 1 0.1 % solution, 0.1 % oint. (g) hydrocortisone butyrate 0.1 % lotion TIER 1 ST hydrocortisone butyrate/emollient base TIER 1 ST hydrocortisone valerate TIER 1 hydrocortisone/mineral TIER 1 PA, QLC (110 gm/month) oil/petrolatum,white IMPOYZ (clobetasol propionate) TIER 3 PA, QLC (1 tube/month) KENALOG (triamcinolone acetonide) TIER 3 ST KORLYM (mifepristone) TIER 4 PA, SP, QLC (4 tabs/day)

138 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LEXETTE (halobetasol propionate) TIER 3 PA, QLC (200 gm/28 days) LOCOID (hydrocortisone butyrate) 0.1% TIER 3 ST LOTION LOCOID (hydrocortisone butyrate) 0.1% TIER 3 SOLUTION, 0.1% OINTMENT, 0.1% CREAM LOCOID LIPOCREAM (hydrocortisone TIER 3 ST butyrate/emollient base) LUXIQ (betamethasone valerate) TIER 3 ST MEDROL (methylprednisolone) 2 MG TIER 2 TABLET MEDROL (methylprednisolone) 4 MG TIER 3 TABLET, 4 MG DOSEPAK, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET methylprednisolone TIER 1 MICORT-HC (hydrocortisone acetate) TIER 3 PA, QLC (56 tubes/month) MILLIPRED (prednisolone sodium TIER 3 phosphate) mometasone furoate 0.1 % cream (g), 0.1 TIER 1 % oint. (g), 0.1 % solution OLUX (clobetasol propionate) TIER 3 PA OLUX-E (clobetasol propionate/emollient TIER 3 PA base) ORAPRED ODT (prednisolone sodium TIER 3 phosphate) PANDEL (hydrocortisone probutate) TIER 3 PA prednicarbate TIER 1 prednisolone TIER 1 prednisolone (MILLIPRED DP) TIER 1 prednisolone (MILLIPRED) TIER 1 prednisolone sodium phosphate TIER 3 (PEDIAPRED) prednisolone sodium phosphate 5 mg/5 TIER 1 ml solution, 10 mg/5 ml solution, 10 mg tab rapdis, 15 mg/5 ml solution, 15 mg tab rapdis, 20 mg/5 ml solution, 25 mg/5 ml solution, 30 mg tab rapdis prednisone TIER 1

139 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prednisone (PREDNISONE INTENSOL) TIER 1 RAYOS (prednisone) DR 1 MG TABLET TIER 3 PA, QLC (3 tabs/day) RAYOS (prednisone) DR 2 MG TABLET TIER 3 PA, QLC (2 tabs/day) RAYOS (prednisone) DR 5 MG TABLET TIER 3 PA, QLC (12 tabs/day) SERNIVO (betamethasone dipropionate) TIER 3 PA, QLC (1 bottle/month) SYNALAR (fluocinolone acetonide) TIER 3 TEMOVATE (clobetasol propionate) TIER 3 TEXACORT (hydrocortisone) TIER 3 TOPICORT (desoximetasone) 0.05% GEL, TIER 3 ST 0.05% OINTMENT, 0.05% CREAM, 0.25% CREAM, 0.25% OINTMENT TOPICORT (desoximetasone) 0.25% SPRAY TIER 3 ST, QLC (1 bottle/month) triamcinolone acetonide (TRIANEX) TIER 1 ST triamcinolone acetonide (TRIDERM) TIER 1 triamcinolone acetonide 0.025 % oint. (g), TIER 1 0.025 % cream (g), 0.025 % lotion, 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint. (g) triamcinolone acetonide 0.147mg/g TIER 1 ST aerosol ULTRAVATE (halobetasol propionate) TIER 3 0.05% CREAM, 0.05% OINTMENT ULTRAVATE (halobetasol propionate) TIER 3 ST, QLC (1 bottle/month) 0.05% LOTION VANOS (fluocinonide) TIER 3 PA VERDESO (desonide) TIER 3 PA VERIPRED 20 (prednisolone sodium TIER 3 phosphate) ZONACORT (dexamethasone) 11 DAY 1.5 TIER 3 PA, QLC (1 pack/month) MG TABLET ZONACORT (dexamethasone) 7 DAY 1.5 TIER 3 PA MG TABLET

140 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs for Replacing/Stimulating Pituitary Gland Hormones) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs to Replace/Stimulate Pituitary Gland Hormones) ACTHAR (corticotropin) TIER 4 PA, SP chorionic gonadotropin, human 10000 TIER 4 PA, SP unit vial DDAVP (desmopressin acetate (non- TIER 3 refrigerated)) DDAVP (desmopressin acetate) 0.1 MG TIER 3 TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION desmopressin acetate (non-refrigerated) TIER 1 desmopressin acetate 0.1 mg/ml solution, TIER 1 0.1 mg tablet, 0.2 mg tablet, 10/spray spray/pump FOLLISTIM AQ (follitropin TIER 4 PA, SP beta,recombinant) 300, 900 FOLLISTIM AQ (follitropin TIER 4 PA beta,recombinant) 600 UNIT CARTRIDG GENOTROPIN (somatropin) TIER 4 PA, SP GONAL-F (follitropin alfa, recombinant) TIER 4 PA, SP GONAL-F RFF (follitropin alfa, TIER 4 PA, SP recombinant) GONAL-F RFF REDI-JECT (follitropin alfa, TIER 4 PA, SP recombinant) HUMATROPE (somatropin) TIER 4 PA, SP INCRELEX (mecasermin) TIER 4 PA, SP MENOPUR (menotropins) TIER 4 PA, GL (Female), SP NOCDURNA (desmopressin acetate) 27.7 TIER 3 PA, QLC (1 tab/day) MCG TABLET SL NOCDURNA (desmopressin acetate) 55.3 TIER 3 PA, QLC (1 tab/day) MCG TABLET SL NOCTIVA (desmopressin acetate) TIER 3 PA, QLC (1 bottle/month)

141 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NORDITROPIN FLEXPRO (somatropin) TIER 4 PA, SP NOVAREL (chorionic gonadotropin, TIER 4 PA, SP human) 10,000 UNITS VIAL NUTROPIN AQ NUSPIN (somatropin) TIER 4 PA, SP OMNITROPE (somatropin) TIER 4 PA, SP OVIDREL (choriogonadotropin alfa) TIER 4 PA, SP, QLC (1 syringe/28 days) PREGNYL (chorionic gonadotropin, TIER 4 PA, SP human) SAIZEN (somatropin) TIER 4 PA, SP SAIZEN-SAIZENPREP (somatropin) TIER 4 PA, SP SEROSTIM (somatropin) TIER 4 PA, SP STIMATE (desmopressin acetate) TIER 4 SP, QLC (2.5 ml/month) ZOMACTON (somatropin) TIER 4 PA, SP ZORBTIVE (somatropin) TIER 4 PA, SP

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) (Drugs for Replacing/Stimulating Sex Hormones) ANABOLIC STEROIDS ANADROL-50 (oxymetholone) TIER 3 PA OXANDRIN (oxandrolone) TIER 3 PA oxandrolone TIER 1 PA ANDROGENS ANDRODERM (testosterone) TIER 3 PA, QLC (1 patch/day) ANDROGEL (testosterone) 1% PUMP TIER 3 PA, QLC (300 grams/month) ANDROGEL (testosterone) 1%(5G) GEL TIER 3 PA, QLC (300 grams/month) PACKET, 1%(2.5G) GEL PACKET ANDROGEL (testosterone) 1.62% PUMP TIER 3 PA, QLC (2 bottles/month) ANDROGEL (testosterone) 1.62%(1.25G) TIER 3 PA, QLC (1 packet/day) PCKT ANDROGEL (testosterone) 1.62%(2.5G) TIER 3 PA, QLC (2 packets/day) PCKT ANDROID (methyltestosterone) TIER 2 PA

142 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS AXIRON (testosterone) TIER 3 PA, QLC (2 bottles/month) danazol TIER 1 DEPO-TESTOSTERONE (testosterone TIER 3 QLC (10 ml/month) cypionate) fluoxymesterone (ANDROXY) TIER 1 PA, QLC (4 tabs/day) FORTESTA (testosterone) TIER 3 PA, QLC (2 bottles/month) METHITEST (methyltestosterone) TIER 2 PA methyltestosterone TIER 1 PA NATESTO (testosterone) TIER 3 PA, QLC (3 bottles/month) STRIANT (testosterone) TIER 3 PA, QLC (2 tabs/day) TESTIM (testosterone) TIER 3 PA, QLC (10 grams/day) testosterone 1.25g-1.62 gel packet TIER 1 PA, QLC (1 packet/day) testosterone 10 mg (2%) gel, 30mg/1.5ml TIER 1 PA, QLC (2 bottles/month) sol testosterone 12.5/1.25g gel md pmp, TIER 1 PA, QLC (300 grams/month) 25mg(1%) gel packet, 50 mg (1%) gel packet testosterone 2.5g-1.62% gel packet TIER 1 PA, QLC (2 packets/day) testosterone 20.25/1.25 gel md pmp TIER 1 PA, QLC (2 bottles/month) testosterone 50 mg (1%) gel (gram) TIER 1 PA, QLC (10 grams/day) testosterone cypionate 100 mg/ml vial, TIER 1 QLC (10 ml/month) 200 mg/ml vial testosterone enanthate TIER 1 QLC (5 ml/month) TESTRED (methyltestosterone) TIER 3 PA VOGELXO (testosterone) 12.5 MG/1.25 TIER 3 PA, QLC (300 grams/month) PUMP, 50 MG/5 GEL PACKT VOGELXO (testosterone) 50 MG/5 GRAM TIER 3 PA, QLC (10 grams/day) XYOSTED (testosterone enanthate) TIER 3 PA, QLC (1 injection/week) ESTROGENS (Contraceptives and Drugs for Menopause) ACTIVELLA (estradiol/norethindrone TIER 3 QLC (1 tab/day) acetate) ALORA (estradiol) TIER 3 QLC (16 patches/28 days) ANGELIQ (drospirenone/estradiol) TIER 3 QLC (1 tab/day) ANNOVERA (segesterone acetate/ethinyl TIER 3 PA, QLC (1 ring/364 days) estradiol)

143 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS BALCOLTRA (levonorgestrel/ethinyl TIER 3 PA estradiol/ferrous bisglycinate) BEYAZ (drospirenone/ethinyl TIER 3 estradiol/levomefolate calcium) BIJUVA (estradiol/progesterone) TIER 3 QLC (1 cap/day) CLIMARA (estradiol) TIER 3 QLC (8 patches/28 days) CLIMARA PRO (estradiol/levonorgestrel) TIER 2 QLC (4 patches/month) COMBIPATCH (estradiol/norethindrone TIER 3 QLC (8 patches/month) acetate) DELESTROGEN (estradiol valerate) TIER 3 DEPO-ESTRADIOL (estradiol cypionate) TIER 3 desogestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (APRI) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (CAZIANT) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (CYRED EQ) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (CYRED) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (EMOQUETTE) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (ENSKYCE) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (ISIBLOOM) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (JULEBER) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (KALLIGA) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (RECLIPSEN) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (VELIVET) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (AZURETTE) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (BEKYREE) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (KARIVA) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (KIMIDESS) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (PIMTREA)

144 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (SIMLIYA) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (VIORELE) DIVIGEL (estradiol) 0.25 MG GEL PACKET, TIER 3 QLC (1 pack/day) 0.5 MG GEL PACKET, 1 MG GEL PACKET DIVIGEL (estradiol) 0.75 MG PACKET TIER 3 QLC (1 pack/day) drospirenone/ethinyl TIER 1 ACA (Preventive Health) estradiol/levomefolate calcium drospirenone/ethinyl TIER 1 ACA (Preventive Health) estradiol/levomefolate calcium (RAJANI) drospirenone/ethinyl TIER 1 ACA (Preventive Health) estradiol/levomefolate calcium (TYDEMY) DUAVEE (estrogens, TIER 2 QLC (1 tab/day) conjugated/bazedoxifene acetate) ELESTRIN (estradiol) TIER 3 QLC (1 bottle/month) ESTRACE (estradiol) TIER 3 estradiol (DOTTI) TIER 1 QLC (16 patches/28 days) estradiol (YUVAFEM) TIER 1 estradiol .025mg/24h patch, .0375mg/24 TIER 1 QLC (16 patches/28 days) patch, 0.05mg/24h patch, .075mg/24h patch, 0.1mg/24hr patch estradiol .025mg/24h patch, .0375mg/24 TIER 1 QLC (8 patches/28 days) patch, 0.05mg/24h patch, 0.06mg/24h patch, .075mg/24h patch, 0.1mg/24hr patch estradiol 0.01 % cream/appl, 0.5 mg TIER 1 tablet, 1 mg tablet, 2 mg tablet, 10 mcg tablet estradiol valerate TIER 1 estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) (AMABELZ) estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) (LOPREEZA) estradiol/norethindrone acetate (MIMVEY TIER 1 QLC (1 tab/day) LO) estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) (MIMVEY)

145 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ESTRING (estradiol) TIER 2 ESTROGEL (estradiol) TIER 3 QLC (1 bottle/month) estrogens,esterified/methyltestosterone TIER 1 estrogens,esterified/methyltestosterone TIER 1 (COVARYX H.S.) estrogens,esterified/methyltestosterone TIER 1 (COVARYX) estrogens,esterified/methyltestosterone TIER 1 (EEMT H.S.) estrogens,esterified/methyltestosterone TIER 1 (EEMT) estropipate TIER 1 ESTROSTEP FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) ethinyl estradiol/drospirenone TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (GIANVI) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (JASMIEL) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (LO- TIER 1 ACA (Preventive Health) ZUMANDIMINE) ethinyl estradiol/drospirenone (LORYNA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (NIKKI) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (OCELLA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (SYEDA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (VESTURA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (ZARAH) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone TIER 1 ACA (Preventive Health) (ZUMANDIMINE) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (KELNOR 1-35) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (KELNOR 1-50) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (ZOVIA 1-35E) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (ZOVIA 1-50E)

146 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EVAMIST (estradiol) TIER 3 QLC (2 bottles/month) FEMHRT (norethindrone acetate-ethinyl TIER 3 QLC (1 tab/day) estradiol) FEMRING (estradiol acetate) TIER 3 QLC (1 ring/3 months) GENERESS FE (norethindrone-ethinyl TIER 3 estradiol/ferrous fumarate) IMVEXXY (estradiol) 4 MCG PACK, 10 TIER 3 PA, QLC (18 inserts/28 days) MCG PACK IMVEXXY (estradiol) 4 MCG PACK, 10 TIER 3 PA, QLC (8 inserts/28 days) MCG PAK LAYOLIS FE (norethindrone-ethinyl TIER 3 estradiol/ferrous fumarate) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (AFIRMELLE) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (ALTAVERA) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health), QLC (1 (AMETHYST) pack/month) levonorgestrel-ethinyl estradiol (AUBRA TIER 1 ACA (Preventive Health) EQ) levonorgestrel-ethinyl estradiol (AUBRA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (AVIANE) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (AYUNA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (CHATEAL TIER 1 ACA (Preventive Health) EQ) levonorgestrel-ethinyl estradiol (CHATEAL) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (DELYLA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (ENPRESSE) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (FALMINA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (INTROVALE) levonorgestrel-ethinyl estradiol (JOLESSA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (KURVELO) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (LARISSIA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (LESSINA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (LEVONEST)

147 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS levonorgestrel-ethinyl estradiol (LEVORA- TIER 1 ACA (Preventive Health) 28) levonorgestrel-ethinyl estradiol (LILLOW) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (LUTERA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (MARLISSA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (MYZILRA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (ORSYTHIA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (PORTIA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (QUASENSE) levonorgestrel-ethinyl estradiol (SETLAKIN) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (SRONYX) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (TRIVORA- TIER 1 ACA (Preventive Health) 28) levonorgestrel-ethinyl estradiol (VIENVA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol -0.1- TIER 1 ACA (Preventive Health) 0.02mg tablet, -0.15-0.03 tbdspk 3mo, - 0.15-0.03 tablet, -6-5-10 tablet levonorgestrel-ethinyl estradiol -90-20 mcg TIER 1 ACA (Preventive Health), QLC (1 tablet pack/month) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (AMETHIA LO) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (AMETHIA) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (ASHLYNA) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (CAMRESE LO) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (CAMRESE) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (DAYSEE) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (FAYOSIM) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (RIVELSA)

148 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (SIMPESSE) LO LOESTRIN FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) LO MINASTRIN FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) LOESTRIN (norethindrone acetate-ethinyl TIER 3 estradiol) LOESTRIN FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) LOSEASONIQUE (levonorgestrel/ethinyl TIER 3 estradiol and ethinyl estradiol) MENEST (estrogens,esterified) TIER 3 MENOSTAR (estradiol) TIER 3 QLC (4 patches/28 days) MICROGESTIN 24 FE (norethindrone TIER 3 acetate-ethinyl estradiol/ferrous fumarate) MINASTRIN 24 FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) MINIVELLE (estradiol) TIER 3 QLC (16 patches/28 days) MIRCETTE (desogestrel-ethinyl TIER 3 estradiol/ethinyl estradiol) NATAZIA (estradiol valerate/dienogest) TIER 3 norelgestromin/ethinyl estradiol (XULANE) TIER 1 ACA (Preventive Health), QLC (3 patches/month) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (AUROVELA) norethindrone acetate-ethinyl estradiol TIER 1 QLC (1 tab/day) (FYAVOLV) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (GILDESS) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (HAILEY) norethindrone acetate-ethinyl estradiol TIER 1 QLC (1 tab/day) (JEVANTIQUE LO) norethindrone acetate-ethinyl estradiol TIER 1 QLC (1 tab/day) (JINTELI) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (JUNEL)

149 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (LARIN) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (MICROGESTIN) norethindrone acetate-ethinyl estradiol - TIER 1 QLC (1 tab/day) 0.5mg-2.5 tablet, -1mg-5mcg tablet norethindrone acetate-ethinyl estradiol - TIER 1 ACA (Preventive Health) 1mg-20mcg tablet, -1.5-0.03mg tablet norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (AUROVELA 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (AUROVELA FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (BLISOVI 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (BLISOVI FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (GILDESS 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (HAILEY 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (JUNEL FE 24) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (JUNEL FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (LARIN 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (LARIN FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (LOMEDIA 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (MELODETTA 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (MIBELAS 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (MICROGESTIN FE)

150 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TARINA 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TARINA FE 1-20 EQ) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TARINA FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TILIA FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TRI-LEGEST FE) norethindrone-ethinyl estradiol (ALYACEN) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (ARANELLE) norethindrone-ethinyl estradiol (BALZIVA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (BRIELLYN) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (CYCLAFEM) norethindrone-ethinyl estradiol (DASETTA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (GILDAGIA) norethindrone-ethinyl estradiol (LEENA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (NECON) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (NORTREL) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (PHILITH) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (PIRMELLA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (VYFEMLA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (WERA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (ZENCHENT) norethindrone-ethinyl estradiol/ferrous TIER 1 ACA (Preventive Health) fumarate norethindrone-ethinyl estradiol/ferrous TIER 1 ACA (Preventive Health) fumarate (KAITLIB FE) norethindrone-ethinyl estradiol/ferrous TIER 1 ACA (Preventive Health) fumarate (WYMZYA FE)

151 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norgestimate-ethinyl estradiol TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (ESTARYLLA) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (FEMYNOR) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (MILI) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (MONO- TIER 1 ACA (Preventive Health) LINYAH) norgestimate-ethinyl estradiol TIER 1 ACA (Preventive Health) (MONONESSA) norgestimate-ethinyl estradiol (PREVIFEM) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (SPRINTEC) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI TIER 1 ACA (Preventive Health) FEMYNOR) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) ESTARYLLA) norgestimate-ethinyl estradiol (TRI-LINYAH) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI-LO- TIER 1 ACA (Preventive Health) ESTARYLLA) norgestimate-ethinyl estradiol (TRI-LO- TIER 1 ACA (Preventive Health) MARZIA) norgestimate-ethinyl estradiol (TRI-LO-MILI) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI-LO- TIER 1 ACA (Preventive Health) SPRINTEC) norgestimate-ethinyl estradiol (TRI-MILI) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) PREVIFEM) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) SPRINTEC) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) VYLIBRA LO) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) VYLIBRA) norgestimate-ethinyl estradiol (TRINESSA TIER 1 ACA (Preventive Health) LO) norgestimate-ethinyl estradiol (TRINESSA) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (VYLIBRA) TIER 1 ACA (Preventive Health) norgestrel-ethinyl estradiol (CRYSELLE) TIER 1 ACA (Preventive Health)

152 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norgestrel-ethinyl estradiol (ELINEST) TIER 1 ACA (Preventive Health) norgestrel-ethinyl estradiol (LOW- TIER 1 ACA (Preventive Health) OGESTREL) norgestrel-ethinyl estradiol (OGESTREL) TIER 1 ACA (Preventive Health) NUVARING (etonogestrel/ethinyl estradiol) TIER 2 ACA (Preventive Health), QLC (1 ring/month) ORTHO TRI-CYCLEN (norgestimate-ethinyl TIER 3 estradiol) ORTHO TRI-CYCLEN LO (norgestimate- TIER 3 ethinyl estradiol) ORTHO-CYCLEN (norgestimate-ethinyl TIER 3 estradiol) ORTHO-NOVUM (norethindrone-ethinyl TIER 3 estradiol) PREFEST (estradiol/norgestimate) TIER 3 QLC (1 tab/day) PREMARIN (estrogens, conjugated) 0.3 TIER 3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET PREMARIN (estrogens, conjugated) TIER 2 VAGINAL CREAM-APPL PREMPHASE (estrogens, TIER 2 QLC (28 tabs/month) conjugated/medroxyprogesterone acetate) PREMPRO (estrogens, TIER 2 QLC (28 tabs/month) conjugated/medroxyprogesterone acetate) QUARTETTE (levonorgestrel/ethinyl TIER 3 estradiol and ethinyl estradiol) SAFYRAL (drospirenone/ethinyl TIER 3 estradiol/levomefolate calcium) SEASONIQUE (levonorgestrel/ethinyl TIER 3 estradiol and ethinyl estradiol) TAYTULLA (norethindrone acetate-ethinyl TIER 3 estradiol/ferrous fumarate) TRI-NORINYL (norethindrone-ethinyl TIER 3 estradiol) VAGIFEM (estradiol) TIER 3 VIVELLE-DOT (estradiol) TIER 3 QLC (16 patches/28 days) YASMIN 28 (ethinyl TIER 3 estradiol/drospirenone)

153 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS YAZ (ethinyl estradiol/drospirenone) TIER 3 PROGESTERONE AGONISTS/ANTAGONISTS ELLA (ulipristal acetate) TIER 3 ACA (Preventive Health), QLC (1 tab/fill) PROGESTINS AYGESTIN (norethindrone acetate) TIER 3 CRINONE (progesterone, micronized) TIER 2 PA ENDOMETRIN (progesterone, micronized) TIER 3 PA hydroxyprogesterone caproate TIER 4 PA, SP, QLC (5 ml/month) hydroxyprogesterone caproate/pf TIER 4 PA, SP, QLC (1 vial/week) levonorgestrel TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (AFTERA) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (ECONTRA EZ) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (ECONTRA ONE-STEP) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (FALLBACK SOLO) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (MY CHOICE) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (MY WAY) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (NEW DAY) TIER 1 ACA (Preventive Health), QLC (1 tab/faill) levonorgestrel (NEXT CHOICE ONE DOSE) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (OPCICON ONE-STEP) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (OPTION 2) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (TAKE ACTION) TIER 3 QLC (1 tab/fill) MAKENA (hydroxyprogesterone TIER 4 PA, SP, QLC (5 ml/month) caproate) MAKENA (hydroxyprogesterone TIER 4 PA, SP, QLC (1 vial/week) caproate/pf) 250 MG/ML VIAL

154 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MAKENA (hydroxyprogesterone TIER 4 PA, SP, QLC (1 injection/week) caproate/pf) 275 MG/1.1 ML AUTOINJCT medroxyprogesterone acetate 2.5 mg TIER 1 tablet, 5 mg tablet, 10 mg tablet MEGACE (megestrol acetate) TIER 3 MEGACE ES (megestrol acetate) TIER 3 megestrol acetate 20 mg tablet, 40 mg TIER 1 OAC tablet megestrol acetate 400mg/10ml oral susp TIER 1 PA megestrol acetate 625mg/5ml oral susp TIER 1 NOR-Q-D (norethindrone) TIER 3 norethindrone TIER 1 ACA (Preventive Health) norethindrone (CAMILA) TIER 1 ACA (Preventive Health) norethindrone (DEBLITANE) TIER 1 ACA (Preventive Health) norethindrone (ERRIN) TIER 1 ACA (Preventive Health) norethindrone (HEATHER) TIER 1 ACA (Preventive Health) norethindrone (INCASSIA) TIER 1 ACA (Preventive Health) norethindrone (JENCYCLA) TIER 1 ACA (Preventive Health) norethindrone (JOLIVETTE) TIER 1 ACA (Preventive Health) norethindrone (LYZA) TIER 1 ACA (Preventive Health) norethindrone (NORA-BE) TIER 1 ACA (Preventive Health) norethindrone (NORLYDA) TIER 1 ACA (Preventive Health) norethindrone (NORLYROC) TIER 1 ACA (Preventive Health) norethindrone (SHAROBEL) TIER 1 ACA (Preventive Health) norethindrone (TULANA) TIER 1 ACA (Preventive Health) norethindrone acetate TIER 1 ORTHO MICRONOR (norethindrone) TIER 3 PLAN B ONE-STEP (levonorgestrel) TIER 3 QLC (1 tab/fill) progesterone TIER 1 progesterone, micronized TIER 1 PROMETRIUM (progesterone, micronized) TIER 3 PROVERA (medroxyprogesterone TIER 3 acetate)

155 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SLYND (drospirenone) TIER 3 ST TAKE ACTION (levonorgestrel) TIER 3 QLC (1 tab/fill) SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS clomiphene citrate TIER 1 GL (Female), QLC (10 tabs/28 days) EVISTA (raloxifene hcl) TIER 3 GL (Female), ACA (Preventive Health), QLC (1 tab/day) OSPHENA (ospemifene) TIER 3 PA, QLC (1 tab/day) raloxifene hcl TIER 1 GL (Female), ACA (Preventive Health), QLC (1 tab/day) SEROPHENE (clomiphene citrate) TIER 3 GL (Female), QLC (10 tabs/28 days)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs for the Thyroid) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs to Replace Thyroid Hormone) ARMOUR THYROID (thyroid,pork) TIER 2 CYTOMEL (liothyronine sodium) TIER 3 EUTHYROX (levothyroxine sodium) TIER 3 LEVO-T (levothyroxine sodium) TIER 3 levothyroxine sodium 25 mcg tablet, 50 TIER 1 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet LEVOXYL (levothyroxine sodium) TIER 3 liothyronine sodium 5 mcg tablet, 25 mcg TIER 1 tablet, 50 mcg tablet NATURE-THROID (thyroid,pork) TIER 3 SYNTHROID (levothyroxine sodium) TIER 2 thyroid,pork TIER 2 thyroid,pork (NP THYROID) TIER 2 thyroid,pork (THYROID) TIER 2

156 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS THYROLAR-1 (liotrix) TIER 2 THYROLAR-1/2 (liotrix) TIER 2 THYROLAR-1/4 (liotrix) TIER 2 THYROLAR-2 (liotrix) TIER 2 THYROLAR-3 (liotrix) TIER 2 TIROSINT (levothyroxine sodium) TIER 3 TIROSINT-SOL (levothyroxine sodium) TIER 3 UNITHROID (levothyroxine sodium) TIER 3 WESTHROID (thyroid,pork) TIER 3 WP THYROID (thyroid,pork) TIER 3

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary Gland) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs to Suppress Pituitary Hormones) cabergoline TIER 1 QLC (16 tabs/month) CETROTIDE (cetrorelix acetate) TIER 4 PA, GL (Female), SP EGRIFTA (tesamorelin acetate) 1 MG VIAL TIER 4 PA, SP, QLC (2 vials/day) EGRIFTA (tesamorelin acetate) 2 MG VIAL TIER 4 PA, SP, QLC (1 vial/day) ganirelix acetate TIER 4 PA, GL (Female), SP leuprolide acetate TIER 4 PA, SP octreotide acetate TIER 4 PA, SP ORILISSA (elagolix sodium) 150 MG TABLET TIER 3 PA, QLC (1 tab/day) ORILISSA (elagolix sodium) 200 MG TABLET TIER 3 PA, QLC (2 tabs/day) SANDOSTATIN (octreotide acetate) TIER 4 PA, SP SIGNIFOR (pasireotide diaspartate) TIER 4 PA, SP, QLC (2 ampules/day) SOMAVERT (pegvisomant) TIER 4 PA, SP, QLC (1 vial/day) SYNAREL (nafarelin acetate) TIER 4 PA, QLC (16 ml/30 days)

157 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

HORMONAL AGENTS, SUPPRESSANT (THYROID) (Drugs for the Thyroid) ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone) methimazole TIER 1 potassium iodide (SSKI) TIER 1 propylthiouracil TIER 1 TAPAZOLE (methimazole) TIER 3

IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) ANGIOEDEMA AGENTS FIRAZYR (icatibant acetate) TIER 4 PA, SP, QLC (2 syringes per fill; not to exceed 12 syringes/2 months) HAEGARDA (c1 esterase inhibitor) TIER 4 PA, SP icatibant acetate TIER 4 PA, SP, QLC (2 syringes/fill; max 12 syringes/2 months) TAKHZYRO (lanadelumab-flyo) TIER 4 PA, SP, QLC (1 vial/14 days) IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System) ASTAGRAF XL (tacrolimus) TIER 3 AZASAN (azathioprine) TIER 3 azathioprine TIER 1 CELLCEPT (mycophenolate mofetil) TIER 3 CIMZIA (certolizumab pegol) 2X200 TIER 4 PA, SP, QLC (1 kit/28 days) MG/ML SYRINGE KIT CIMZIA (certolizumab pegol) 2X200 TIER 4 PA, SP, QLC (3 kits/180 days per MG/ML(X3)START KT year) cyclosporine 25 mg capsule, 100 mg TIER 1 capsule cyclosporine, modified TIER 1 cyclosporine, modified (GENGRAF) TIER 1 ENBREL (etanercept) 25 MG KIT TIER 4 PA, SP, QLC (8 vials/28 days)

158 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ENBREL (etanercept) 25 MG/0.5 ML TIER 4 PA, SP, QLC (4 ml/28 days) SYRINGE, 50 MG/ML SYRINGE ENBREL MINI (etanercept) TIER 4 PA, SP, QLC (4 ml/ 28 days) ENBREL SURECLICK (etanercept) TIER 4 PA, SP, QLC (4 ml/28 days) ENVARSUS XR (tacrolimus) 0.75 MG TABLET TIER 3 ST, QLC (11 tabs/day) ENVARSUS XR (tacrolimus) 1 MG TABLET TIER 3 ST, QLC (8 tabs/day) ENVARSUS XR (tacrolimus) 4 MG TABLET TIER 3 ST, QLC (2 tabs/day) HUMIRA (adalimumab) TIER 4 PA, SP, QLC (2 syringes/28 days) HUMIRA PEDIATRIC CROHN'S TIER 4 PA, SP, QLC (3 or 6 syringes/year (adalimumab) depending upon package size) HUMIRA PEN (adalimumab) TIER 4 PA, SP, QLC (2 syringes/28 days) HUMIRA PEN CROHN'S-UC-HS TIER 4 PA, SP, QLC (6 syringes/year) (adalimumab) HUMIRA PEN PSOR-UVEITS-ADOL HS TIER 4 PA, SP, QLC (4 syringes/year) (adalimumab) HUMIRA(CF) (adalimumab) TIER 4 PA, SP, QLC (2 syringes [1 kit]/28 days) HUMIRA(CF) PEDIATRIC CROHN'S TIER 4 PA, SP, QLC (2 syr [1 kit]/year) (adalimumab) 80-40 MG HUMIRA(CF) PEDIATRIC CROHN'S TIER 4 PA, SP, QLC (3 syr [1 kit]/year) (adalimumab) 80MG/0.8 HUMIRA(CF) PEN (adalimumab) TIER 4 PA, SP, QLC (2 pens [1 kit]/28 days) HUMIRA(CF) PEN CROHN'S-UC-HS TIER 4 PA, SP, QLC (1 carton/year) (adalimumab) HUMIRA(CF) PEN PSOR-UV-ADOL HS TIER 4 PA, SP, QLC (1 carton/year) (adalimumab) IMURAN (azathioprine) TIER 3 KINERET (anakinra) TIER 4 PA, SP, QLC (1 syringe/day) methotrexate sodium 2.5 mg tablet TIER 1 OAC methotrexate sodium 25 mg/ml vial TIER 1 QLC (8 ml/month) methotrexate sodium/pf 25 mg/ml vial TIER 1 QLC (8 ml/month) mycophenolate mofetil TIER 1 mycophenolate sodium TIER 1 MYFORTIC (mycophenolate sodium) TIER 3

159 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NEORAL (cyclosporine, modified) TIER 3 OLUMIANT (baricitinib) 1 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) OLUMIANT (baricitinib) 2 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) ORENCIA (abatacept) TIER 4 PA, SP, QLC (1 syringe/week) ORENCIA CLICKJECT (abatacept) TIER 4 PA, SP, QLC (1 syringe/week) OTREXUP (methotrexate/pf) 10 MG/0.4 ML TIER 4 PA, SP, QLC (1 syringe/week) AUTO-INJ, 12.5 MG/0.4 ML AUTOINJ, 15 MG/0.4 ML AUTO-INJ, 17.5 MG/0.4 ML AUTOINJ, 20 MG/0.4 ML AUTO-INJ, 22.5 MG/0.4 ML AUTOINJ, 25 MG/0.4 ML AUTO- INJ PROGRAF (tacrolimus) 0.2 MG GRANULE TIER 3 PA PACKET, 1 MG GRANULE PACKET PROGRAF (tacrolimus) 0.5 MG CAPSULE, 1 TIER 3 MG CAPSULE, 5 MG CAPSULE RAPAMUNE (sirolimus) TIER 3 RASUVO (methotrexate/pf) TIER 4 PA, SP, QLC (1 syringe/week) RHEUMATREX (methotrexate sodium) TIER 3 RINVOQ ER (upadacitinib) TIER 4 PA, SP, QLC (1 tab/day) SANDIMMUNE (cyclosporine) 100 MG/ML TIER 2 SOLN SANDIMMUNE (cyclosporine) 25 MG TIER 3 CAPSULE, 100 MG CAPSULE SIMPONI (golimumab) TIER 4 PA, SP, QLC (1 syringe/4 weeks) sirolimus TIER 1 tacrolimus 0.5 mg capsule, 1 mg capsule, TIER 1 5 mg capsule TREXALL (methotrexate sodium) TIER 3 OAC XATMEP (methotrexate) TIER 4 AL1 (Up to 8 yrs old), QLC (1 bottle/month), OAC XELJANZ (tofacitinib citrate) TIER 4 PA, SP, QLC (2 tabs/day) XELJANZ XR (tofacitinib citrate) TIER 4 PA, SP, QLC (1 tab/day) ZORTRESS (everolimus) 0.25 MG TABLET, TIER 2 QLC (2 tabs/day) 0.75 MG TABLET ZORTRESS (everolimus) 0.5 MG TABLET TIER 2 QLC (4 tabs/day) ZORTRESS (everolimus) 1 MG TABLET TIER 2 QLC (2 tabs/day)

160 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS IMMUNOMODULATORS (Drugs that Changes the Immune System) ACTEMRA (tocilizumab) 162 MG/0.9 ML TIER 4 PA, SP, QLC (1 syringe/week) SYRINGE ACTEMRA ACTPEN (tocilizumab) TIER 4 PA, SP, QLC (1 pen injector/week) ACTIMMUNE (interferon gamma- TIER 4 PA, SP 1b,recomb.) ARAVA (leflunomide) TIER 3 ARCALYST (rilonacept) TIER 4 PA, SP BENLYSTA (belimumab) 200 MG/ML TIER 4 PA, SP, QLC (1 syringe/week) AUTOINJECT, 200 MG/ML SYRINGE KEVZARA (sarilumab) 150 MG/1.14 ML PEN TIER 4 PA, SP, QLC (1 pen/14 days) INJ, 200 MG/1.14 ML PEN INJ KEVZARA (sarilumab) 150 MG/1.14 ML TIER 4 PA, SP, QLC (2 syringes/28 days) SYRINGE, 200 MG/1.14 ML SYRINGE leflunomide TIER 1 OTEZLA (apremilast) 28 DAY PACK, PACK TIER 4 PA, SP, QLC (1 pack/month) OTEZLA (apremilast) 30 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) RIDAURA (auranofin) TIER 2 VACCINES XOFLUZA (baloxavir marboxil) 20 MG TAB TIER 3 QLC (2 tabs/day, max 2 courses (40 MG DOSE) (4 tabs)/180 days) XOFLUZA (baloxavir marboxil) 40 MG TAB TIER 3 QLC (2 tabs/day, max 2 courses (80 MG DOSE) (4 tabs)/180 days)

INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) AMINOSALICYLATES APRISO (mesalamine) TIER 2 QLC (4 caps/day) ASACOL HD (mesalamine) TIER 3 ST, QLC (6 tabs/day) balsalazide disodium TIER 1 QLC (9 caps/day) CANASA (mesalamine) TIER 3 COLAZAL (balsalazide disodium) TIER 3 QLC (9 caps/day) DELZICOL (mesalamine) TIER 3 ST, QLC (12 caps/day)

161 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DIPENTUM (olsalazine sodium) TIER 3 ST, QLC (12 caps/day) GIAZO (balsalazide disodium) TIER 3 ST, QLC (6 tabs/day) LIALDA (mesalamine) TIER 3 QLC (4 tabs/day) mesalamine 1.2 g tablet dr TIER 1 QLC (4 tabs/day) mesalamine 4 g/60 ml enema, 1000 mg TIER 1 supp.rect mesalamine 400 mg cap(drtab) TIER 1 ST, QLC (12 caps/day) mesalamine 800 mg tablet dr TIER 1 ST, QLC (6 tabs/day) PENTASA (mesalamine) 250 MG CAPSULE TIER 3 ST, QLC (4 caps/day) PENTASA (mesalamine) 500 MG CAPSULE TIER 3 ST, QLC (8 caps/day) SFROWASA (mesalamine) TIER 3 GLUCOCORTICOIDS budesonide 3 mg capdr - er TIER 1 PA, QLC (3 caps/day) budesonide 9 mg tabdr - er TIER 1 PA, QLC (1 tab/day) CORTENEMA (hydrocortisone) TIER 3 CORTIFOAM (hydrocortisone acetate) TIER 2 ENTOCORT EC (budesonide) TIER 3 PA, QLC (3 caps/day) hydrocortisone (COLOCORT) TIER 1 hydrocortisone 100mg/60ml enema TIER 1 UCERIS (budesonide) 2 MG RECTAL FOAM TIER 3 QLC (4 cans/6 weeks; not to exceed 6 weeks therapy/6 months) UCERIS (budesonide) 9 MG TABLET TIER 3 PA, QLC (1 tab/day) SULFONAMIDES AZULFIDINE (sulfasalazine) TIER 3 sulfasalazine TIER 1

METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) METABOLIC BONE DISEASE AGENTS ACTONEL (risedronate sodium) 150 MG TIER 3 ST, QLC (1 tab/month) TABLET ACTONEL (risedronate sodium) 30 MG TIER 3 PA TABLET

162 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ACTONEL (risedronate sodium) 35 MG TIER 3 ST, QLC (4 tabs/month) TABLET ACTONEL (risedronate sodium) 5 MG TIER 3 ST, QLC (1 tab/day) TABLET alendronate sodium 35 mg tablet, 70 mg TIER 1 QLC (4 tabs/month) tablet alendronate sodium 40 mg tablet TIER 1 QLC (1 tab/day) alendronate sodium 5 mg tablet, 10 mg TIER 1 tablet alendronate sodium 70 mg/75ml solution TIER 1 QLC (4 bottles/month) ATELVIA (risedronate sodium) TIER 3 ST, QLC (4 tabs/month) BINOSTO (alendronate sodium) TIER 3 ST, QLC (4 tabs/month) BONIVA (ibandronate sodium) 150 MG TIER 3 ST, QLC (1 tab/month) TABLET calcitonin,salmon,synthetic TIER 1 QLC (1 bottle/month) calcitriol 0.25 mcg capsule, 0.5 mcg TIER 1 capsule, 1 mcg/ml solution cinacalcet hcl TIER 1 PA doxercalciferol 0.5 mcg capsule, 1 mcg TIER 1 capsule, 2.5 mcg capsule DRISDOL (ergocalciferol (vitamin d2)) TIER 3 ergocalciferol (vitamin d2) 1250 mcg TIER 1 capsule etidronate disodium TIER 1 FORTEO (teriparatide) TIER 4 PA, SP, QLC (1 pen/month) FORTICAL (calcitonin,salmon,synthetic) TIER 3 QLC (1 bottle/month) FOSAMAX (alendronate sodium) TIER 3 QLC (4 tabs/month) FOSAMAX PLUS D (alendronate TIER 2 QLC (4 tabs/month) sodium/cholecalciferol (vitamin d3)) 70 MG-2,800 IU FOSAMAX PLUS D (alendronate TIER 3 QLC (4 tabs/month) sodium/cholecalciferol (vitamin d3)) 70 MG-5,600 IU HECTOROL (doxercalciferol) 0.5 MCG TIER 3 CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE ibandronate sodium 150 mg tablet TIER 1 ST, QLC (1 tab/month)

163 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MIACALCIN (calcitonin,salmon,synthetic) TIER 3 QLC (1 bottle/month) 200 UNIT NASAL SPRAY MIACALCIN (calcitonin,salmon,synthetic) TIER 4 400 UNIT/2 ML VIAL NATPARA (parathyroid hormone) TIER 4 PA, SP, QLC (2 cartridges/month) paricalcitol 1 mcg capsule, 2 mcg TIER 1 capsule, 4 mcg capsule RAYALDEE (calcifediol) TIER 3 PA risedronate sodium 150 mg tablet TIER 1 ST, QLC (1 tab/month) risedronate sodium 30 mg tablet TIER 1 PA risedronate sodium 35 mg tablet, 35 mg TIER 1 ST, QLC (4 tabs/month) tablet dr risedronate sodium 5 mg tablet TIER 1 ST, QLC (1 tab/day) ROCALTROL (calcitriol) TIER 3 SENSIPAR (cinacalcet hcl) TIER 3 PA TYMLOS (abaloparatide) TIER 4 PA, SP, QLC (1 pen/month) XGEVA (denosumab) TIER 4 PA, SP, QLC (1 vial/month) ZEMPLAR (paricalcitol) 1 MCG CAPSULE, 2 TIER 3 MCG CAPSULE

MISCELLANEOUS THERAPEUTIC AGENTS accu-chek blood glucose test strips TIER 2 QLC (200 strips/month) blood ketone test, strips TIER 2 blood sugar diagnostic TIER 3 PA, QLC (200 strips/month) cervical cap TIER 2 ACA (Preventive Health) diaphragms, contoured TIER 2 ACA (Preventive Health) diaphragms, wide seal TIER 2 ACA (Preventive Health) INBRIJA (levodopa) TIER 4 PA, SP, QLC (10 caps/day) inhaler, assist devices TIER 2 inhaler, assist devices, accessories TIER 2 inhaler,assist device with large mask TIER 2 inhaler,assist device with medium mask TIER 2 inhaler,assist device with small mask TIER 2

164 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS insulin admin. supplies TIER 2 PA, QLC (1 pen/year) insulin pump cartridge TIER 3 PA, QLC (1 pod/2 days) insulin syringe-needle,safety,disposal TIER 2 unit,0.5 ml INTRAROSA (prasterone (dhea)) TIER 3 PA, QLC (1 insert/day) lancets TIER 2 QLC (200 lancets/month) LOKELMA (sodium zirconium cyclosilicate) TIER 4 PA, QLC (1 pack/day) 10 GRAM POWDER PACKET LOKELMA (sodium zirconium cyclosilicate) TIER 4 PA, QLC (3 packs/day) 5 GRAM POWDER PACKET methylergonovine maleate (METHERGINE) TIER 1 methylergonovine maleate 0.2 mg tablet TIER 1 nebulizer and compressor TIER 2 needles, safety 25gx1 1/2" dis TIER 2 non accu-chek blood glucose test strips TIER 3 PA, QLC (200 strips/month) ODACTRA (allergenic extract, mite- TIER 3 PA, QLC (1 tab/day) d.farinae-d.pteronyssinus,standard) pen needle, diabetic TIER 2 pen needle, diabetic disposable, safety TIER 2 pen needle, diabetic, safety TIER 2 RUZURGI (amifampridine) TIER 4 PA, SP, QLC (10 tabs/day) SAXENDA (liraglutide) TIER 4 PA, QLC (5 pens/month) sub-q insulin delivery device, 20 TIER 3 PA, QLC (1 device/day) unit,disposable sub-q insulin delivery device, 30 unit, TIER 3 PA, QLC (1 device/day) disposable sub-q insulin delivery device, 40 unit, TIER 3 PA, QLC (1 device/day) disposable syringe w-needle 0.3 ml,insulin,safety w- TIER 2 self-cont.dis.unit syringe with needle 1 ml,insulin,safety w- TIER 2 self-con.disp.unit syringe with needle, insulin, safety, 0.3 ml TIER 2 syringe with needle, insulin, safety, 0.5 ml TIER 2 syringe with needle, insulin, safety, 1 ml TIER 2

165 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS syringe with needle,disposable,insulin 1 ml TIER 2 syringe with needle,insulin 0.3 ml (half unit TIER 2 mark) syringe with needle,insulin 0.5 ml (half unit TIER 2 mark) syringe with needle,insulin disposable TIER 2 syringe with needle,insulin,0.3 ml TIER 2 syringe with needle,insulin,0.5 ml TIER 2 syringe without needle,insulin disposible, 1 TIER 2 ml syringe, insulin u-500 with needle, TIER 2 disposable, 0.5 ml urine acetone test,strips TIER 2 urine glucose-acet test strip TIER 2 VISTOGARD (uridine triacetate) TIER 4 SP, QLC (20 packets/month)

OPHTHALMIC AGENTS (Drugs for the Eyes) OPHTHALMIC AGENTS, OTHER (Other Drugs for the Eyes) ALCAINE (proparacaine hcl) TIER 3 atropine sulfate 1 % drops TIER 1 bacitracin/polymyxin b sulfate (AK-POLY- TIER 1 BAC) bacitracin/polymyxin b sulfate (POLYCIN) TIER 1 bacitracin/polymyxin b sulfate 500-10k/g TIER 1 oint. (g) BLEPHAMIDE (sulfacetamide TIER 2 sodium/prednisolone acetate) BLEPHAMIDE S.O.P. (sulfacetamide TIER 2 sodium/prednisolone acetate) CEQUA (cyclosporine) TIER 3 PA, QLC (60 droperettes/30 days) CYCLOGYL (cyclopentolate hcl) TIER 3 CYCLOMYDRIL (cyclopentolate TIER 3 hcl/phenylephrine hcl) cyclopentolate hcl TIER 1

166 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CYSTARAN (cysteamine hcl) TIER 4 PA, SP, QLC (4 bottles/28 days) homatropine hbr TIER 1 homatropine hbr (HOMATROPAIRE) TIER 1 ISOPTO ATROPINE (atropine sulfate) TIER 3 LACRISERT (hydroxypropyl cellulose) TIER 3 MAXITROL (neomycin/polymyxin b TIER 3 sulfate/dexamethasone) MYDRIACYL (tropicamide) TIER 3 naphazoline hcl TIER 1 neomycin sulfate/bacitracin TIER 1 zinc/polymyxin b/hydrocortisone neomycin sulfate/bacitracin TIER 1 zinc/polymyxin b/hydrocortisone (NEO- POLYCIN HC) neomycin sulfate/bacitracin/polymyxin b TIER 1 neomycin sulfate/bacitracin/polymyxin b TIER 1 (NEO-POLYCIN) neomycin sulfate/polymyxin b TIER 1 sulfate/gramicidin d neomycin sulfate/polymyxin b TIER 1 sulfate/hydrocortisone neomycin/polymyxin b/hydrocort 3.5-10k- 10 drops susp neomycin/polymyxin b TIER 1 sulfate/dexamethasone OXERVATE (cenegermin-bkbj) TIER 4 PA, SP, QLC (28 ml/28 days) phenylephrine hcl 2.5 % drops, 10 % drops TIER 1 polymyxin b sulfate/trimethoprim TIER 1 POLYTRIM (polymyxin b TIER 3 sulfate/trimethoprim) PRED-G (gentamicin sulfate/prednisolone TIER 3 acetate) proparacaine hcl TIER 1 RESTASIS (cyclosporine) TIER 2 QLC (2 droperettes/day) RESTASIS MULTIDOSE (cyclosporine) TIER 2 QLC (1 bottle/month) sulfacetamide sodium/prednisolone TIER 1 sodium phosphate

167 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TOBRADEX (tobramycin/dexamethasone) TIER 3 EYE DROPS TOBRADEX (tobramycin/dexamethasone) TIER 2 EYE OINTMENT TOBRADEX ST TIER 3 QLC (1 bottle/fill) (tobramycin/dexamethasone) tobramycin/dexamethasone TIER 1 tropicamide TIER 1 XIIDRA (lifitegrast) TIER 2 QLC (2 droperettes/day) ZYLET (tobramycin/loteprednol TIER 2 etabonate) OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies) ALOCRIL (nedocromil sodium) TIER 3 ALOMIDE (lodoxamide tromethamine) TIER 2 azelastine hcl 0.05 % drops TIER 1 BEPREVE (bepotastine besilate) TIER 3 QLC (5 ml/month) cromolyn sodium 4 % drops TIER 1 ELESTAT (epinastine hcl) TIER 3 EMADINE (emedastine difumarate) TIER 3 ST epinastine hcl TIER 1 LASTACAFT (alcaftadine) TIER 2 QLC (1 bottle/month) olopatadine hcl 0.1 % drops TIER 1 QLC (10 ml/month) olopatadine hcl 0.2 % drops TIER 1 QLC (1 bottle/month) PATADAY (olopatadine hcl) TIER 3 QLC (1 bottle/month) PATANOL (olopatadine hcl) TIER 3 QLC (10 ml/month) PAZEO (olopatadine hcl) TIER 2 QLC (1 bottle/month) OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce Eye Swelling) ACULAR (ketorolac tromethamine) TIER 3 ACULAR LS (ketorolac tromethamine) TIER 3 ACUVAIL (ketorolac tromethamine/pf) TIER 2 ALREX (loteprednol etabonate) TIER 3

168 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS bromfenac sodium TIER 1 BROMSITE (bromfenac sodium) TIER 3 PA, QLC (1 bottle/month) dexamethasone sodium phosphate 0.1 % TIER 1 drops diclofenac sodium 0.1 % drops TIER 1 DUREZOL (difluprednate) TIER 3 FLAREX (fluorometholone acetate) TIER 3 fluorometholone TIER 1 flurbiprofen sodium TIER 1 FML (fluorometholone) TIER 3 FML FORTE (fluorometholone) TIER 2 FML S.O.P. (fluorometholone) TIER 2 ILEVRO (nepafenac) TIER 3 QLC (1 bottle/month) INVELTYS (loteprednol etabonate) TIER 3 PA ketorolac tromethamine 0.4 % drops, 0.5 TIER 1 % drops LOTEMAX (loteprednol etabonate) 0.5% TIER 3 EYE DROPS LOTEMAX (loteprednol etabonate) 0.5% TIER 3 QLC (1 tube/month) EYE OINTMENT LOTEMAX (loteprednol etabonate) 0.5% TIER 2 OPHTHALMIC GEL LOTEMAX SM (loteprednol etabonate) TIER 3 loteprednol etabonate TIER 1 MAXIDEX (dexamethasone) TIER 3 NEVANAC (nepafenac) TIER 3 OCUFEN (flurbiprofen sodium) TIER 3 OMNIPRED (prednisolone acetate) TIER 3 PRED FORTE (prednisolone acetate) TIER 3 PRED MILD (prednisolone acetate) TIER 2 prednisolone acetate TIER 1 prednisolone sodium phosphate 1 % TIER 1 drops

169 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PROLENSA (bromfenac sodium) TIER 3 QLC (1 bottle/month) VEXOL (rimexolone) TIER 3 OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma) ALPHAGAN P (brimonidine tartrate) TIER 2 ALHAGAN 0.1% DROS ALPHAGAN P (brimonidine tartrate) TIER 3 ALHAGAN 0.15% EYE DROS apraclonidine hcl TIER 1 AZOPT (brinzolamide) TIER 2 BETAGAN (levobunolol hcl) TIER 3 betaxolol hcl 0.5 % drops TIER 1 BETIMOL (timolol) TIER 2 BETOPTIC S (betaxolol hcl) TIER 2 brimonidine tartrate TIER 1 carteolol hcl TIER 1 COMBIGAN (brimonidine tartrate/timolol TIER 2 maleate) COSOPT (dorzolamide hcl/timolol TIER 3 maleate) COSOPT PF (dorzolamide hcl/timolol TIER 3 QLC (2 droperettes/day) maleate/pf) dorzolamide hcl TIER 1 dorzolamide hcl/timolol maleate TIER 1 dorzolamide hcl/timolol maleate/pf TIER 1 QLC (2 droperettes/day) dorzolamide/timolol/pf 2 %-0.5 % droperette IOPIDINE (apraclonidine hcl) 0.5% EYE TIER 3 DROPS IOPIDINE (apraclonidine hcl) 1% EYE TIER 2 DROPS ISOPTO CARPINE (pilocarpine hcl) TIER 3 ISTALOL (timolol maleate) TIER 3 levobunolol hcl TIER 1 methazolamide TIER 1

170 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS metipranolol TIER 1 NEPTAZANE (methazolamide) TIER 3 PHOSPHOLINE IODIDE (echothiophate TIER 3 iodide) pilocarpine hcl 1 % drops, 2 % drops, 4 % TIER 1 drops RHOPRESSA (netarsudil mesylate) TIER 3 PA, QLC (1 bottle/month) ROCKLATAN (netarsudil TIER 3 PA, QLC (2.5 ml/25 days) mesylate/latanoprost) SIMBRINZA (brinzolamide/brimonidine TIER 2 tartrate) timolol maleate 0.25 % sol-gel, 0.25 % TIER 1 drops, 0.5 % drops, 0.5 % drop daily, 0.5 % sol-gel TIMOPTIC (timolol maleate) TIER 3 TIMOPTIC OCUDOSE (timolol maleate/pf) TIER 3 0.25% DROP TIMOPTIC OCUDOSE (timolol maleate/pf) TIER 2 0.5% DROP TIMOPTIC-XE (timolol maleate) TIER 3 TRUSOPT (dorzolamide hcl) TIER 3 VYZULTA (latanoprostene bunod) TIER 3 PA, QLC (1 bottle/month) OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugs for Glaucoma) bimatoprost 0.03 % drops TIER 1 ST, QLC (5 ml/month) latanoprost TIER 1 QLC (5 ml/month) LUMIGAN (bimatoprost) TIER 2 ST, QLC (5 ml/month) TRAVATAN Z (travoprost) TIER 2 ST, QLC (5 ml/month) travoprost (benzalkonium) TIER 1 ST, QLC (1 bottle/month) XALATAN (latanoprost) TIER 3 QLC (5 ml/month) XELPROS (latanoprost) TIER 3 ST, QLC (1 bottle/month) ZIOPTAN (tafluprost/pf) TIER 3 PA, QLC (1 droperette/day)

171 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

OTIC AGENTS (Drugs for the Ears) OTIC AGENTS (Drugs for Ear Infection) acetic acid 2 % solution TIER 1 acetic acid/aluminum acetate TIER 1 CIPRO HC (ciprofloxacin TIER 3 hcl/hydrocortisone) CIPRODEX (ciprofloxacin TIER 3 hcl/dexamethasone) ciprofloxacin hcl/fluocinolone acetonide TIER 1 QLC (14 vials/7 days) COLY-MYCIN S (neomycin sulf/colistin TIER 3 sul/hydrocortisone ac/thonzonium brom) CORTISPORIN-TC (neomycin sulf/colistin TIER 3 sul/hydrocortisone ac/thonzonium brom) DERMOTIC (fluocinolone acetonide oil) TIER 2 fluocinolone acetonide oil TIER 1 PA fluocinolone acetonide oil (FLAC OTIC TIER 1 PA OIL) hydrocortisone/acetic acid TIER 1 hydrocortisone/acetic acid (ACETASOL TIER 1 HC) neomycin sulfate/polymyxin b TIER 1 sulfate/hydrocortisone neomycin/polymyxin b/hydrocort 3.5--1 solution, neomycin/polymyxin b/hydrocort 3.5--1 drops susp OTOVEL (ciprofloxacin hcl/fluocinolone TIER 3 QLC (14 vials/7 days) acetonide)

RESPIRATORY TRACT/PULMONARY AGENTS (Drugs for the Lungs) ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS (Inhaled Drugs to Prevent Swelling of the Airways) AEROSPAN (flunisolide) TIER 3 ST, QLC (2 inhalers/month) ALVESCO (ciclesonide) 160 MCG INHALER TIER 3 ST, QLC (2 inhalers/month) ALVESCO (ciclesonide) 80 MCG INHALER TIER 3 ST, QLC (1 inhaler/month)

172 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ARMONAIR RESPICLICK (fluticasone TIER 3 PA, QLC (1 inhaler/month) propionate) ARNUITY ELLIPTA (fluticasone furoate) TIER 2 QLC (1 inhaler/month) ASMANEX (mometasone furoate) TIER 3 ST, QLC (1 inhaler/month) TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #14, TWISTHALER 220 MCG #60, TWISTHALR 220 MCG #120 ASMANEX HFA (mometasone furoate) TIER 3 ST, QLC (1 inhaler/month) BECONASE AQ (beclomethasone TIER 3 ST, QLC (1 bottle/month) dipropionate) budesonide 0.25mg/2ml -, 0.5 mg/2ml - TIER 1 QLC (4 ml/day) budesonide 1 mg/2 ml ampul-neb TIER 1 QLC (2 ml/day) FLOVENT DISKUS (fluticasone propionate) TIER 2 QLC (4 inhalers/month) 250 MCG FLOVENT DISKUS (fluticasone propionate) TIER 2 QLC (1 inhaler/month) 50 MCG, 100 MCG FLOVENT HFA (fluticasone propionate) TIER 2 QLC (2 inhalers/month) flunisolide TIER 1 QLC (2 bottles/month) fluticasone propionate 50 mcg spray susp TIER 1 QLC (1 bottle/month) mometasone furoate 50 mcg TIER 1 ST, QLC (1 bottle/month) spray/pump NASONEX (mometasone furoate) TIER 3 ST, QLC (1 bottle/month) OMNARIS (ciclesonide) TIER 3 ST, QLC (1 bottle/month) PULMICORT (budesonide) 0.25 MG/2 ML TIER 3 QLC (4 doses/day) RESPUL, 0.5 MG/2 ML RESPULE PULMICORT (budesonide) 1 MG/2 ML TIER 3 QLC (2 ml/day) RESPULE PULMICORT FLEXHALER (budesonide) TIER 2 QLC (2 inhalers/month) QNASL (beclomethasone dipropionate) TIER 3 ST, QLC (1 bottle/month) QNASL CHILDREN (beclomethasone TIER 3 ST, QLC (1 bottle/month) dipropionate) QVAR (beclomethasone dipropionate) 40 TIER 2 QLC (4 inhalers/month) MCG ORAL INHALER QVAR (beclomethasone dipropionate) 80 TIER 2 QLC (2 inhalers/month) MCG ORAL INHALER QVAR REDIHALER (beclomethasone TIER 2 QLC (2 inhalers/month) dipropionate)

173 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS XHANCE (fluticasone propionate) TIER 3 PA, QLC (2 bottles/month) ZETONNA (ciclesonide) TIER 3 ST, QLC (1 bottle/month) ANTIHISTAMINES ASTEPRO (azelastine hcl) TIER 3 QLC (1 bottle/month) azelastine hcl 137 mcg spray/pump TIER 1 QLC (1 bottle/25 days) azelastine hcl 205.5 mcg spray/pump TIER 1 QLC (1 bottle/25 days) carbinoxamine maleate (ARBINOXA) TIER 1 carbinoxamine maleate 4 mg/5 ml liquid, TIER 1 4 mg tablet carbinoxamine maleate 6 mg tablet TIER 1 PA, QLC (4 tabs/day) CLARINEX (desloratadine) TIER 3 ST clemastine fumarate TIER 1 cyproheptadine hcl 2 mg/5 ml syrup, 4 TIER 1 mg tablet cyproheptadine hcl 4 mg/10 ml syrup TIER 1 PA desloratadine TIER 1 ST dexchlorpheniramine maleate TIER 1 PA, AL1 (Up to 65 yrs old), QLC (30 ml/day) hydroxyzine hcl 10 mg tablet, 10 mg/5 ml TIER 1 solution, 25 mg tablet, 50 mg tablet, 50 mg/25ml solution hydroxyzine pamoate TIER 1 KARBINAL ER (carbinoxamine maleate) TIER 3 PA, QLC (40 ml/day) olopatadine hcl 0.6 % spray/pump TIER 1 ST, QLC (1 bottle/month) PATANASE (olopatadine hcl) TIER 3 ST, QLC (1 bottle/month) promethazine hcl 6.25mg/5ml syrup, 12.5 TIER 1 mg tablet, 25 mg tablet RYCLORA (dexchlorpheniramine TIER 1 PA, AL1 (Up to 65 yrs old), QLC (30 maleate) ml/day) RYVENT (carbinoxamine maleate) TIER 3 PA, QLC (4 tabs/day) VISTARIL (hydroxyzine pamoate) TIER 3 ANTILEUKOTRIENES ACCOLATE (zafirlukast) TIER 3

174 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS montelukast sodium 4 mg gran pack TIER 1 QLC (1 pack/day) montelukast sodium 4 mg tab chew, 5 mg TIER 1 QLC (1 tab/day) tab chew, 10 mg tablet SINGULAIR (montelukast sodium) 4 MG TIER 3 QLC (1 pack/day) GRANULES SINGULAIR (montelukast sodium) 4 MG TIER 3 QLC (1 tab/day) TABLET CHEW, 5 MG TABLET CHEW, 10 MG TABLET zafirlukast TIER 1 zileuton TIER 1 PA ZYFLO (zileuton) TIER 3 PA ZYFLO CR (zileuton) TIER 3 PA BRONCHODILATORS (Drugs to Open the Airway) AUVI-Q (epinephrine) -0.1 MG AUTO- TIER 4 PA, QLC (4 injections/fill; max 6 fills INJECTOR per year) BRONCHODILATORS, ANTICHOLINERGIC (Anticholinergic Drugs to Open the Airway) ATROVENT (ipratropium bromide) 0.03% TIER 3 QLC (1 bottle/month) SPRAY ATROVENT (ipratropium bromide) 0.06% TIER 3 QLC (3 bottles/month) SPRAY ATROVENT HFA (ipratropium bromide) TIER 2 QLC (2 inhalers/month) INCRUSE ELLIPTA (umeclidinium bromide) TIER 2 QLC (1 inhaler/month) ipratropium bromide 0.2 mg/ml solution TIER 1 QLC (120 doses/month) ipratropium bromide 21 mcg spray TIER 1 QLC (1 bottle/month) ipratropium bromide 42 mcg spray TIER 1 QLC (3 bottles/month) LONHALA MAGNAIR REFILL TIER 4 PA, QLC (2 vials/day) (glycopyrrolate/nebulizer accessories) LONHALA MAGNAIR STARTER TIER 4 PA, QLC (2 vials/day) (glycopyrrolate/nebulizer and accessories) SEEBRI NEOHALER (glycopyrrolate) TIER 3 ST, QLC (1 inhaler[60 caps]/month) SPIRIVA (tiotropium bromide) TIER 2 QLC (30 caps/month) SPIRIVA RESPIMAT (tiotropium bromide) TIER 2 QLC (1 inhaler/month)

175 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TUDORZA PRESSAIR (aclidinium bromide) TIER 3 ST, QLC (1 inhaler/month) YUPELRI (revefenacin) TIER 4 PA, QLC (3 ml/day) BRONCHODILATORS, SYMPATHOMIMETIC (Sympathomimetic Drugs to Open the Airway) albuterol hfa (generic proair hfa) TIER 1 QLC (2 inhalers/month) albuterol hfa (generic proventil hfa) TIER 1 QLC (2 inhalers/month) albuterol hfa (generic ventolin hfa) TIER 3 PA, QLC (2 inhalers/month) albuterol sulfate 0.63mg/3ml vial-, TIER 1 QLC (5 boxes/month) 1.25mg/3ml vial-, 2.5 mg/0.5 vial- albuterol sulfate 2 mg tablet, 2 mg/5 ml TIER 1 syrup, 4 mg tab er 12h, 4 mg tablet, 8 mg tab er 12h albuterol sulfate 2.5 mg/3ml vial-neb TIER 1 QLC (375 ml/month) albuterol sulfate 5 mg/ml solution TIER 1 QLC (4 bottles/month) ARCAPTA NEOHALER (indacaterol TIER 3 ST, QLC (1 cap/day) maleate) AUVI-Q (epinephrine) -0.15 MG AUTO-, - TIER 4 PA, QLC (4 injections/fill; max 6 fills 0.3 MG AUTO- per year) BROVANA (arformoterol tartrate) TIER 3 QLC (120 ml/month) epinephrine 0.15mg/0.3, 0.15/0.15, TIER 1 QLC (4 injections/fill; max 6 fills per 0.3mg/0.3 year) EPIPEN 2-PAK (epinephrine) TIER 2 QLC (4 injections/fill; max 6 fills per year) EPIPEN JR 2-PAK (epinephrine) TIER 2 QLC (4 injections/fill; max 6 fills per year) FORADIL (formoterol fumarate) TIER 3 PA levalbuterol hcl 0.31mg/3ml vial-, TIER 1 QLC (90 nebs/month) 0.63mg/3ml vial-, 1.25mg/3ml vial- levalbuterol hcl 1.25mg/0.5 vial-neb TIER 1 QLC (90 vials/month) levalbuterol tartrate TIER 1 QLC (2 inhalers/month at retail, 5 inhalers/3 months at mail order) metaproterenol sulfate TIER 1 PERFOROMIST (formoterol fumarate) TIER 3 QLC (1 box/month) PROAIR DIGIHALER (albuterol sulfate) TIER 3 PA, QLC (2 inhalers/month) PROAIR HFA (albuterol sulfate) TIER 3 QLC (2 inhalers/month)

176 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PROAIR RESPICLICK (albuterol sulfate) TIER 3 ST, QLC (2 inhalers/month) PROVENTIL HFA (albuterol sulfate) TIER 3 QLC (2 inhalers/month) SEREVENT DISKUS (salmeterol xinafoate) TIER 2 QLC (1 inhaler/month) STRIVERDI RESPIMAT (olodaterol hcl) TIER 2 QLC (1 inhaler/month) SYMJEPI (epinephrine) TIER 3 PA, QLC (4 injections/fill; max 6 fills/year) terbutaline sulfate 2.5 mg tablet, 5 mg TIER 1 tablet VENTOLIN HFA (albuterol sulfate) TIER 2 QLC (2 inhalers/month) XOPENEX (levalbuterol hcl) TIER 3 QLC (90 nebs/month) XOPENEX CONCENTRATE (levalbuterol TIER 3 QLC (90 vials/month) hcl) XOPENEX HFA (levalbuterol tartrate) TIER 3 QLC (2 inhalers/month at retail, 5 inhalers/3 months at mail order) CYSTIC FIBROSIS AGENTS BETHKIS (tobramycin) TIER 4 PA, SP, QLC (1 box/2 months) CAYSTON (aztreonam lysine) TIER 4 PA, SP, QLC (1 box/2 months) KALYDECO (ivacaftor) 150 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) KALYDECO (ivacaftor) 25 MG GRANULES TIER 4 PA, SP, QLC (2 packets/day) PACKET KALYDECO (ivacaftor) 50 MG GRANULES TIER 4 PA, SP, QLC (2 packs/day) PACKET, 75 MG GRANULES PACKET KITABIS PAK (tobramycin/nebulizer) TIER 4 PA, SP, QLC (1 pack/56 days) ORKAMBI (lumacaftor/ivacaftor) 100 MG- TIER 4 PA, SP, QLC (4 tabs/day) 125 MG TABLET, 200 MG-125 MG TABLET ORKAMBI (lumacaftor/ivacaftor) 100-125 TIER 4 PA, SP, QLC (2 packs/day) MG GRANULE PKT, 150-188 MG GRANULE PKT SYMDEKO (tezacaftor/ivacaftor) TIER 4 PA, SP, QLC (2 tabs/day) TOBI PODHALER (tobramycin) TIER 4 PA, SP, QLC (224 caps/2 months) tobramycin in 0.225 % sodium chloride TIER 4 PA, SP, QLC (1 box/2 months) tobramycin/nebulizer TIER 4 PA, SP, QLC (1 pack/56 days) TRIKAFTA TIER 4 PA, SP, QLC (3 tabs/day) (elexacaftor/tezacaftor/ivacaftor)

177 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MAST CELL STABILIZERS (Drugs to Block Mast Cells) cromolyn sodium 20 mg/2 ml ampul-neb TIER 1 QLC (2 boxes/month) PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE (Drugs that Block Phosphodiesterase) caffeine citrate 60 mg/3 ml solution TIER 1 DALIRESP (roflumilast) 250 MCG TABLET TIER 3 PA, QLC (1 tab/day, not to exceed 28 days therapy/6 months) DALIRESP (roflumilast) 500 MCG TABLET TIER 3 PA, QLC (1 tab/day) ELIXOPHYLLIN (theophylline anhydrous) TIER 3 THEO-24 (theophylline anhydrous) TIER 2 theophylline anhydrous TIER 1 theophylline anhydrous (THEOCHRON) TIER 1 PULMONARY ANTIHYPERTENSIVES (Drugs for Pulmonary Hypertension) ADCIRCA (tadalafil) TIER 4 PA, SP, QLC (2 tabs/day) ADEMPAS (riociguat) TIER 4 PA, SP, QLC (3 tabs/day) ambrisentan TIER 4 PA, SP, QLC (1 tab/day) bosentan TIER 4 PA, SP, QLC (2 tabs/day) LETAIRIS (ambrisentan) TIER 4 PA, SP, QLC (1 tab/day) OPSUMIT (macitentan) TIER 4 PA, SP, QLC (1 tab/day) ORENITRAM ER (treprostinil diolamine) 1 TIER 4 PA, SP, QLC (42 tabs/day) MG TABLET ORENITRAM ER (treprostinil diolamine) 2.5 TIER 4 PA, SP, QLC (16 tabs/day) MG TABLET ORENITRAM ER (treprostinil diolamine) 5 TIER 4 PA, SP, QLC (8 tabs/day) MG TABLET ORENITRAM ER (treprostinil diolamine) ER TIER 4 PA, SP, QLC (9 tabs/day) 0.125 MG TABLET, ER 0.25 MG TABLET REVATIO (sildenafil citrate) 10 MG/ML TIER 4 PA, SP, QLC (6 ml/day) ORAL SUSP REVATIO (sildenafil citrate) 20 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day) sildenafil citrate 10 mg/ml susp recon TIER 4 PA, SP, QLC (6 ml/day)

178 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS sildenafil citrate 20 mg tablet TIER 4 PA, SP, QLC (3 tabs/day) tadalafil (ALYQ) TIER 4 PA, SP, QLC (2 tabs/day) TRACLEER (bosentan) 32 MG TABLET FOR TIER 4 PA, SP, QLC (4 tabs/day) SUSP TRACLEER (bosentan) 62.5 MG TABLET, 125 TIER 4 PA, SP, QLC (2 tabs/day) MG TABLET UPTRAVI (selexipag) 200 MCG TABLET, 400 TIER 4 PA, SP, QLC (2 tabs/day) MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET UPTRAVI (selexipag) 200-800 TITRATION TIER 4 PA, SP, QLC (200 tabs/6 months) PACK RESPIRATORY TRACT AGENTS, OTHER (Other Drugs for Breathing Conditions) acetylcysteine 100 mg/ml vial, 200 mg/ml TIER 1 vial ADVAIR DISKUS (fluticasone TIER 3 QLC (1 inhaler/month) propionate/salmeterol xinafoate) ADVAIR HFA (fluticasone TIER 2 QLC (1 inhaler/month) propionate/salmeterol xinafoate) AIRDUO RESPICLICK (fluticasone TIER 3 QLC (1 inhaler/month) propionate/salmeterol xinafoate) ANORO ELLIPTA (umeclidinium TIER 2 QLC (1 inhaler/month) bromide/vilanterol trifenatate) benzonatate TIER 1 BEVESPI AEROSPHERE TIER 3 ST, QLC (1 inhaler/month) (glycopyrrolate/formoterol fumarate) BREO ELLIPTA (fluticasone TIER 2 QLC (1 inhaler/month) furoate/vilanterol trifenatate) brompheniramine TIER 1 maleate/pseudoephedrine hcl/dextromethorphan brompheniramine TIER 1 maleate/pseudoephedrine hcl/dextromethorphan (BROMFED DM) CLARINEX-D 12 HOUR TIER 3 ST (desloratadine/pseudoephedrine sulfate) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 ml/day; max 7 days therapy/month)

179 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (CHERATUSSIN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin (G TIER 1 AL1 (At least 18 yrs old), QLC (60 TUSSIN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (GUAIATUSSIN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (GUAIFENESIN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (ROBAFEN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (VIRTUSSIN AC) ml/day; max 7 days therapy/month) COMBIVENT RESPIMAT (ipratropium TIER 2 QLC (1 inhaler/month) bromide/albuterol sulfate) DUAKLIR PRESSAIR (aclidinium TIER 3 ST, QLC (1 inhaler/30 days) bromide/formoterol fumarate) DULERA (mometasone furoate/formoterol TIER 3 PA, QLC (1 inhaler/month) fumarate) DYMISTA (azelastine hcl/fluticasone TIER 3 ST, QLC (1 bottle/month) propionate) ESBRIET (pirfenidone) 267 MG CAPSULE TIER 4 PA, SP, QLC (9 caps/day) ESBRIET (pirfenidone) 267 MG TABLET TIER 4 PA, SP, QLC (9 tabs/day) ESBRIET (pirfenidone) 801 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day) FASENRA PEN (benralizumab) TIER 4 PA, SP, QLC (1 pen/56 days) FLOWTUSS (guaifenesin/hydrocodone TIER 3 PA, AL1 (At least 18 yrs old), QLC bitartrate) (60 ml/day, max 7 days therapy/month) fluticasone propionate/salmeterol TIER 1 QLC (1 inhaler/month) xinafoate (WIXELA INHUB) fluticasone propionate/salmeterol TIER 1 QLC (1 inhaler/month) xinafoate propion/salmeterol 250-50 mcg w/dev, propion/salmeterol 500-50 mcg w/dev

180 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS fluticasone propionate/salmeterol TIER 1 QLC (1 inhaler/month) xinafoate propion/salmeterol 55-14 mcg aer pow ba, propion/salmeterol 100-50 mcg blst w/dev, propion/salmeterol 113- 14 mcg aer pow ba, propion/salmeterol 232-14 mcg aer pow ba GRASTEK (allergenic extract,grass pollen- TIER 3 PA, QLC (1 tab/day) timothy,standard) guaifenesin/hydrocodone bitartrate TIER 1 PA, AL1 (At least 18 yrs old), QLC (60 ml/day, max 7 days therapy/month) HYCOFENIX (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (40 bitartrate/pseudoephedrine ml/day; max 7 days hcl/guaifenesin) therapy/month) hydrocodone bitart/chlorpheniramine TIER 1 AL1 (At least 18 yrs old), QLC (20 maleate/pseudoephedrine ml/day; max 7 days therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (30 methylbromide (HYDROMET) ml/day; max 7 days therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (6 methylbromide (TUSSIGON) tabs/day; max 7 days therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (6 methylbromide bit/homatrop -5 mg- tabs/day; max 7 days 1.5mg tablet therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (30 methylbromide bit/homatrop -5-1.5 mg/5 ml/day; max 7 days syrup therapy/month) hydrocodone polistirex/chlorpheniramine TIER 1 AL1 (At least 18 yrs old), QLC (10 polistirex ml/day; max 7 days therapy/month) HYPER-SAL (sodium chloride for inhalation) TIER 3 ipratropium bromide/albuterol sulfate TIER 1 QLC (6 boxes [30 doses/box]/month) NEBUSAL (sodium chloride for inhalation) TIER 3 NUCALA (mepolizumab) 100 MG/ML TIER 4 PA, SP, QLC (3 auto-injectors/28 AUTO-INJECTOR days) NUCALA (mepolizumab) 100 MG/ML TIER 4 PA, SP, QLC (3 syringes/28 days) SYRINGE OBREDON (guaifenesin/hydrocodone TIER 3 PA, AL1 (At least 18 yrs old), QLC bitartrate) (60 ml/day, max 7 days therapy/month)

181 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS OFEV (nintedanib esylate) TIER 4 PA, SP, QLC (2 caps/day) ORALAIR (grass pollen-orchard/sweet TIER 3 PA, SP, RO (Retail Only), QLC (1 vernal/rye/kentucky/timothy, std.) tab/day) phenylephrine hcl/promethazine hcl TIER 1 promethazine hcl/codeine TIER 1 AL1 (At least 18 yrs old), QLC (30 ml/day; max 7 days therapy/month) promethazine hcl/dextromethorphan hbr TIER 1 promethazine/phenylephrine TIER 1 AL1 (At least 18 yrs old), QLC (30 hcl/codeine ml/day; max 7 days therapy/month) PULMOZYME (dornase alfa) TIER 4 SP, QLC (5 ml/day) RAGWITEK (allergenic extract-weed TIER 3 PA, QLC (1 tab/day) pollen-short ragweed) sodium chloride for inhalation TIER 1 sodium chloride for inhalation (NEBUSAL) TIER 1 sodium chloride for inhalation TIER 1 (PULMOSAL) STIOLTO RESPIMAT (tiotropium TIER 3 ST, QLC (1 inhaler/month) bromide/olodaterol hcl) SYMBICORT (budesonide/formoterol TIER 2 QLC (1 inhaler/month) fumarate) TESSALON PERLE (benzonatate) TIER 3 TOBI (tobramycin in 0.225 % sodium TIER 4 PA, SP, QLC (1 box/2 months) chloride) TRELEGY ELLIPTA (fluticasone TIER 2 QLC (1 inhaler/month) furoate/umeclidinium bromide/vilanterol trifenat) TUSSICAPS (hydrocodone TIER 3 PA, AL1 (At least 18 yrs old), QLC polistirex/chlorpheniramine polistirex) (2 caps/day; max 7 days therapy/month) TUSSIONEX (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (10 polistirex/chlorpheniramine polistirex) ml/day; max 7 days therapy/month) TUXARIN ER (chlorpheniramine TIER 3 AL1 (At least 18 yrs old), QLC (2 maleate/codeine phosphate) tabs/day; max 14 tabs/30 days) TUZISTRA XR (codeine TIER 3 AL1 (At least 18 yrs old), QLC (20 polistirex/chlorpheniramine polistirex) ml/day; max 7 days therapy/month)

182 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS UTIBRON NEOHALER (indacaterol TIER 3 ST, QLC (1 inhaler[60 maleate/glycopyrrolate) caps]/month) VITUZ (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (20 bitartrate/chlorpheniramine maleate) ml/day; max 7 days therapy/month) ZUTRIPRO (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (20 bitart/chlorpheniramine ml/day; max 7 days maleate/pseudoephedrine) therapy/month)

SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles) AMRIX (cyclobenzaprine hcl) TIER 3 ST, AL1 (Up to 65 yrs old), QLC (1 cap/day) carisoprodol TIER 1 AL1 (Up to 65 yrs old), QLC (4 tabs/day) carisoprodol/aspirin TIER 1 AL1 (Up to 65 yrs old), QLC (8 tabs/day) chlorzoxazone 250 mg tablet, 500 mg TIER 1 AL1 (Up to 65 yrs old), QLC (4 tablet tabs/day) chlorzoxazone 375 mg tablet, 750 mg TIER 1 QLC (4 tabs/day) tablet cyclobenzaprine hcl 15 mg cap er 24h TIER 1 ST, AL1 (Up to 65 yrs old), QLC (1 cap/day) cyclobenzaprine hcl 30 mg cap er 24h TIER 1 ST, AL1 (Up to 65 yrs old), QLC (1 CAP/DAY) cyclobenzaprine hcl 5 mg tablet, 10 mg TIER 1 AL1 (Up to 65 yrs old) tablet cyclobenzaprine hcl 7.5 mg tablet TIER 1 ST, AL1 (Up to 65 yrs old), QLC (3 tabs/day) FEXMID (cyclobenzaprine hcl) TIER 3 ST, AL1 (Up to 65 yrs old), QLC (3 tabs/day) LORZONE (chlorzoxazone) TIER 3 QLC (4 tabs/day) metaxalone TIER 1 AL1 (Up to 65 yrs old), QLC (4 tabs/day) metaxalone (METAXALL) TIER 1 AL1 (Up to 65 yrs old), QLC (4 tabs/day) methocarbamol 500 mg tablet, 750 mg TIER 1 AL1 (Up to 65 yrs old) tablet

183 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NORGESIC FORTE (orphenadrine TIER 3 QLC (4 tabs/day) citrate/aspirin/caffeine) orphenadrine citrate 100 mg tablet er TIER 1 AL1 (Up to 65 yrs old) orphenadrine citrate/aspirin/caffeine TIER 1 QLC (4 tabs/day) orphenadrine citrate/aspirin/caffeine TIER 1 QLC (4 tabs/day) (ORPHENGESIC FORTE) PARAFON FORTE DSC (chlorzoxazone) TIER 3 AL1 (Up to 65 yrs old), QLC (4 tabs/day) ROBAXIN (methocarbamol) 500 MG TIER 3 AL1 (Up to 65 yrs old) TABLET ROBAXIN-750 (methocarbamol) TIER 3 AL1 (Up to 65 yrs old) SKELAXIN (metaxalone) TIER 3 AL1 (Up to 65 yrs old), QLC (4 tabs/day) SOMA (carisoprodol) TIER 3 AL1 (Up to 65 yrs old), QLC (4 tabs/day)

SLEEP DISORDER AGENTS (Drugs for Insomnia) GABA RECEPTOR MODULATORS AMBIEN (zolpidem tartrate) 10 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (1 tab/day) AMBIEN (zolpidem tartrate) 5 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (2 tabs/day) AMBIEN CR (zolpidem tartrate) 12.5 MG TIER 3 AL1 (Up to 65 yrs old), QLC (1 TABLET tab/day) AMBIEN CR (zolpidem tartrate) 6.25 MG TIER 3 AL1 (Up to 65 yrs old), QLC (2 TABLET tabs/day) DORAL (quazepam) TIER 3 AL1 (Up to 65 yrs old), QLC (1 tab/day) EDLUAR (zolpidem tartrate) TIER 3 PA, AL1 (Up to 65 yrs old), QLC (1 tab/day) estazolam 1 mg tablet TIER 1 QLC (2 tabs/day) estazolam 2 mg tablet TIER 1 QLC (1 tab/day) eszopiclone TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) flurazepam hcl 15 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (2 caps/day)

184 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS flurazepam hcl 30 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (1 cap/day) HALCION (triazolam) TIER 3 QLC (2 tabs/day) INTERMEZZO (zolpidem tartrate) TIER 3 PA, AL1 (Up to 65 yrs old), QLC (1 tab/day) LUNESTA (eszopiclone) TIER 3 AL1 (Up to 65 yrs old), QLC (1 tab/day) quazepam TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) RESTORIL (temazepam) 15 MG CAPSULE TIER 3 QLC (2 caps/day) RESTORIL (temazepam) 22.5 MG CAPSULE, TIER 3 QLC (1 cap/day) 30 MG CAPSULE RESTORIL (temazepam) 7.5 MG CAPSULE TIER 3 QLC (4 caps/day) SONATA (zaleplon) 10 MG CAPSULE TIER 3 AL1 (Up to 65 yrs old), QLC (2 caps/day) SONATA (zaleplon) 5 MG CAPSULE TIER 3 AL1 (Up to 65 yrs old), QLC (4 caps/day) temazepam 15 mg capsule TIER 1 QLC (2 caps/day) temazepam 22.5 mg capsule, 30 mg TIER 1 QLC (1 cap/day) capsule temazepam 7.5 mg capsule TIER 1 QLC (4 caps/day) triazolam 0.125 mg tablet TIER 1 QLC (4 tabs/day) triazolam 0.25 mg tablet TIER 1 QLC (2 tabs/day) zaleplon 10 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (2 caps/day) zaleplon 5 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (4 caps/day) zolpidem tartrate 1.75 mg tab, 3.5 mg tab TIER 1 PA, AL1 (Up to 65 yrs old), QLC (1 tab/day) zolpidem tartrate 10 mg tablet, 12.5 mg TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab mphase tab/day) zolpidem tartrate 5 mg tablet, 6.25 mg TIER 1 AL1 (Up to 65 yrs old), QLC (2 tab mphase tabs/day) ZOLPIMIST (zolpidem tartrate) TIER 3 PA, AL1 (Up to 65 yrs old), QLC (1 bottle/month)

185 LAST UPDATED 12/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SLEEP DISORDER AGENTS, OTHERS WAKIX (pitolisant hcl) TIER 4 PA, SP, QLC (2 tabs/day) SLEEP DISORDERS, OTHER armodafinil 150 mg tablet, 200 mg tablet, TIER 1 PA, QLC (1 tab/day) 250 mg tablet armodafinil 50 mg tablet TIER 1 PA, QLC (2 tabs/day) BELSOMRA (suvorexant) TIER 3 ST, QLC (1 tab/day) BUTISOL SODIUM (butabarbital sodium) TIER 3 HETLIOZ (tasimelteon) TIER 4 PA, SP, QLC (1 cap/day) modafinil 100 mg tablet TIER 1 PA, QLC (3 tabs/day) modafinil 200 mg tablet TIER 1 PA, QLC (2 tabs/day) NUVIGIL (armodafinil) 150 MG TABLET, 200 TIER 3 PA, QLC (1 tab/day) MG TABLET, 250 MG TABLET NUVIGIL (armodafinil) 50 MG TABLET TIER 3 PA, QLC (2 tabs/day) PROVIGIL (modafinil) 100 MG TABLET TIER 3 PA, QLC (3 tabs/day) PROVIGIL (modafinil) 200 MG TABLET TIER 3 PA, QLC (2 tabs/day) ramelteon TIER 1 ST, AL1 (At least 65 yrs old), QLC (1 tab/day) ROZEREM (ramelteon) TIER 3 ST, AL1 (At least 65 yrs old), QLC (1 tab/day) SECONAL SODIUM (secobarbital sodium) TIER 3 QLC (1 cap/day, not to exceed 14 caps/30 days) SILENOR (doxepin hcl) TIER 3 QLC (1 tab/day) SUNOSI (solriamfetol hcl) TIER 3 PA, QLC (1 tab/day) XYREM (sodium oxybate) TIER 4 PA, SP, QLC (3 bottles/month)

186 LAST UPDATED 12/01/2019 Alphabetical Index of Prescription Drugs ACTICLATE (doxycycline hyclate) 23 8 ACTIGALL (ursodiol) 124 8-MOP (methoxsalen) 104 ACTIMMUNE (interferon gamma- 1b,recomb.) 161 A ACTIQ (fentanyl citrate) 7 abacavir sulfate 61 ACTIVELLA (estradiol/norethindrone abacavir sulfate/lamivudine 61 acetate) 143 abacavir sulfate/lamivudine/zidovudine 61 ACTONEL (risedronate sodium) 162,163 ABILIFY (aripiprazole) 55 ACTOPLUS MET (pioglitazone hcl/metformin ABILIFY MYCITE (aripiprazole) 55 hcl) 68 abiraterone acetate 43 ACTOPLUS MET XR (pioglitazone ABSORICA (isotretinoin) 104 hcl/metformin hcl) 68 ABSTRAL (fentanyl citrate) 7 ACTOS (pioglitazone hcl) 68 acamprosate calcium 14 ACULAR (ketorolac tromethamine) 168 ACANYA (clindamycin phosphate/benzoyl ACULAR LS (ketorolac tromethamine) 168 peroxide) 104 ACUVAIL (ketorolac tromethamine/pf) 168 acarbose 68 acyclovir 65 ACCOLATE (zafirlukast) 174 ACZONE (dapsone) 104 accu-chek blood glucose test strips 164 ADALAT CC (nifedipine) 82 ACCUPRIL (quinapril hcl) 79 adapalene 104 ACCURETIC (quinapril adapalene (PLIXDA) 104 hcl/hydrochlorothiazide) 84 adapalene/benzoyl peroxide 105 acebutolol hcl 81 ADCIRCA (tadalafil) 178 ACEON (perindopril erbumine) 79 ADDERALL (dextroamphetamine sulf- acetaminophen with codeine phosphate 7 saccharate/amphetamine sulf-aspartate) 94 acetaminophen/caffeine/dihydrocodeine ADDERALL XR (dextroamphetamine sulf- bitartrate 7 saccharate/amphetamine sulf-aspartate) 94 acetaminophen/caffeine/dihydrocodeine ADDYI (flibanserin) 132 bitartrate (DVORAH) 7 adefovir dipivoxil 58 acetaminophen/caffeine/dihydrocodeine ADEMPAS (riociguat) 178 bitartrate (PANLOR) 7 ADHANSIA XR (methylphenidate hcl) 97 acetazolamide 89 ADIPEX-P (phentermine hcl) 100 acetic acid 172 ADLYXIN (lixisenatide) 68 acetic acid/aluminum acetate 172 ADMELOG (insulin lispro) 72 acetylcysteine 179 ADMELOG SOLOSTAR (insulin lispro) 72 ACIPHEX (rabeprazole sodium) 127 ADOXA (doxycycline monohydrate) 23 ACIPHEX SPRINKLE (rabeprazole sodium) 127 ADVAIR DISKUS (fluticasone acitretin 104 propionate/salmeterol xinafoate) 179 ACTEMRA (tocilizumab) 161 ADVAIR HFA (fluticasone ACTEMRA ACTPEN (tocilizumab) 161 propionate/salmeterol xinafoate) 179 ACTHAR (corticotropin) 141 ADZENYS ER (amphetamine) 94

187 LAST UPDATED 12/01/2019 ADZENYS XR-ODT (amphetamine) 94 alogliptin benzoate/metformin hcl 68 AEMCOLO (rifamycin sodium) 16 alogliptin benzoate/pioglitazone hcl 68 AEROSPAN (flunisolide) 172 ALOMIDE (lodoxamide tromethamine) 168 AFINITOR (everolimus) 46 ALORA (estradiol) 143 AFINITOR DISPERZ (everolimus) 47 alosetron hcl 126 AFREZZA (insulin regular, human) 72 ALPHAGAN P (brimonidine tartrate) 170 AGGRENOX (aspirin/dipyridamole) 77 alprazolam 66 AGRYLIN (anagrelide hcl) 75 alprazolam (ALPRAZOLAM INTENSOL) 66 AIMOVIG AUTOINJECTOR (erenumab- ALREX (loteprednol etabonate) 168 aooe) 40 ALTABAX (retapamulin) 16 AIRDUO RESPICLICK (fluticasone ALTACE (ramipril) 79 propionate/salmeterol xinafoate) 179 ALTOPREV (lovastatin) 91 AJOVY (fremanezumab-vfrm) 40 ALTRENO (tretinoin) 105 AKLIEF (trifarotene) 105 ALUNBRIG (brigatinib) 45 AKTIPAK (erythromycin base/benzoyl ALVESCO (ciclesonide) 172 peroxide) 16 amantadine hcl 52 AKYNZEO (netupitant/palonosetron hcl) 36 AMARYL (glimepiride) 68 ALA-SCALP (hydrocortisone) 135 AMBIEN (zolpidem tartrate) 184 albendazole 51 AMBIEN CR (zolpidem tartrate) 184 ALBENZA (albendazole) 51 ambrisentan 178 albuterol hfa (generic proair hfa) 176 amcinonide 135 albuterol hfa (generic proventil hfa) 176 AMERGE (naratriptan hcl) 40 albuterol hfa (generic ventolin hfa) 176 AMICAR (aminocaproic acid) 76 albuterol sulfate 176 amiloride hcl 89 ALCAINE (proparacaine hcl) 166 amiloride hcl/hydrochlorothiazide 84 alclometasone dipropionate 135 aminocaproic acid 76 ALDACTAZIDE amiodarone hcl 80 (spironolactone/hydrochlorothiazide) 84 amiodarone hcl (PACERONE) 80 ALDACTONE (spironolactone) 89 AMITIZA (lubiprostone) 126 ALDARA (imiquimod) 105 amitriptyline hcl 34 ALECENSA (alectinib hcl) 47 amitriptyline hcl/chlordiazepoxide 31 alendronate sodium 163 amlodipine besylate 82 alfuzosin hcl 131 amlodipine besylate/atorvastatin calcium 84 ALINIA (nitazoxanide) 51 amlodipine besylate/benazepril hcl 84 aliskiren hemifumarate 84 amlodipine besylate/olmesartan ALKERAN (melphalan) 43 medoxomil 84 allopurinol 39 amlodipine besylate/valsartan 84 ALLZITAL (butalbital/acetaminophen) 100 amlodipine almotriptan malate 40 besylate/valsartan/hydrochlorothiazide 84 ALOCRIL (nedocromil sodium) 168 amoxapine 34 alogliptin benzoate 68 amoxicillin 19

188 LAST UPDATED 12/01/2019 amoxicillin/potassium clavulanate 19 ARANESP (darbepoetin alfa in polysorbate amphetamine sulfate 95 80) 75 ampicillin trihydrate 19 ARAVA (leflunomide) 161 AMPYRA (dalfampridine) 103 ARCALYST (rilonacept) 161 AMRIX (cyclobenzaprine hcl) 183 ARCAPTA NEOHALER (indacaterol AMZEEQ (minocycline hcl) 23 maleate) 176 ANADROL-50 (oxymetholone) 142 ARICEPT (donepezil hcl) 30 ANAFRANIL (clomipramine hcl) 34 ARIKAYCE (amikacin sulfate liposomal with anagrelide hcl 75 nebulizer accessories) 16 ANALPRAM HC (hydrocortisone ARIMIDEX (anastrozole) 46 acetate/pramoxine hcl) 105 aripiprazole 55 ANAPROX (naproxen sodium) 1 ARIXTRA (fondaparinux sodium) 74 ANAPROX DS (naproxen sodium) 1 armodafinil 186 ANASPAZ (hyoscyamine sulfate) 123 ARMONAIR RESPICLICK (fluticasone anastrozole 46 propionate) 173 ANCOBON (flucytosine) 37 ARMOUR THYROID (thyroid,pork) 156 ANDRODERM (testosterone) 142 ARNUITY ELLIPTA (fluticasone furoate) 173 ANDROGEL (testosterone) 142 AROMASIN (exemestane) 46 ANDROID (methyltestosterone) 142 ARTHROTEC 50 (diclofenac ANGELIQ (drospirenone/estradiol) 143 sodium/misoprostol) 1 ANNOVERA (segesterone acetate/ethinyl ARTHROTEC 75 (diclofenac estradiol) 143 sodium/misoprostol) 1 ANORO ELLIPTA (umeclidinium ARYMO ER (morphine sulfate) 3 bromide/vilanterol trifenatate) 179 ASACOL HD (mesalamine) 161 ANTABUSE (disulfiram) 14 ASMANEX (mometasone furoate) 173 ANTARA (fenofibrate,micronized) 90 ASMANEX HFA (mometasone furoate) 173 ANZEMET (dolasetron mesylate) 36 aspirin/dipyridamole 77 APADAZ (benzhydrocodone aspirin/omeprazole 77 hcl/acetaminophen) 7 ASTAGRAF XL (tacrolimus) 158 APIDRA (insulin glulisine) 72 ASTEPRO (azelastine hcl) 174 APIDRA SOLOSTAR (insulin glulisine) 72 ATABEX EC (prenatal vits with calcium APLENZIN (bupropion hbr) 31 43/iron/folic acid/docusate sod.) 112 APOKYN (apomorphine hcl) 53 ATACAND (candesartan cilexetil) 78 apraclonidine hcl 170 ATACAND HCT (candesartan aprepitant 36 cilexetil/hydrochlorothiazide) 84 APRISO (mesalamine) 161 atazanavir sulfate 63 APTENSIO XR (methylphenidate hcl) 97 ATELVIA (risedronate sodium) 163 APTIOM (eslicarbazepine acetate) 29 atenolol 81 APTIVUS (tipranavir) 63 atenolol/chlorthalidone 84 APTIVUS (tipranavir/vitamin e tpgs) 63 ATIVAN (lorazepam) 66 ARAKODA (tafenoquine succinate) 51 atomoxetine hcl 97

189 LAST UPDATED 12/01/2019 atorvastatin calcium 91 azelastine hcl 168,174 atovaquone 51 AZELEX (azelaic acid) 105 atovaquone/proguanil hcl 51 AZESCO (prenatal vitamins no.147/ferrous ATRALIN (tretinoin) 105 gluconate/folic acid) 112 ATRIPLA (efavirenz/emtricitabine/tenofovir AZILECT (rasagiline mesylate) 54 disoproxil fumarate) 60 azithromycin 20 atropine sulfate 166 AZOPT (brinzolamide) 170 ATROVENT (ipratropium bromide) 175 AZOR (amlodipine besylate/olmesartan ATROVENT HFA (ipratropium bromide) 175 medoxomil) 85 AUBAGIO (teriflunomide) 103 AZULFIDINE (sulfasalazine) 162 AUGMENTIN (amoxicillin/potassium clavulanate) 19 B AUGMENTIN ES-600 (amoxicillin/potassium bacitracin 16 clavulanate) 19 bacitracin/polymyxin b sulfate 166 AUGMENTIN XR (amoxicillin/potassium bacitracin/polymyxin b sulfate (AK-POLY- clavulanate) 20 BAC) 166 AURYXIA (ferric citrate) 134 bacitracin/polymyxin b sulfate (POLYCIN) 166 AUSTEDO (deutetrabenazine) 100 baclofen 57 AUVI-Q (epinephrine) 175,176 BACTRIM (sulfamethoxazole/trimethoprim) 22 AVALIDE (irbesartan/hydrochlorothiazide) 84 BACTRIM DS AVANDIA (rosiglitazone maleate) 68 (sulfamethoxazole/trimethoprim) 22 AVAPRO (irbesartan) 78 BACTROBAN (mupirocin calcium) 16 AVAR (sulfacetamide sodium/sulfur) 105 BACTROBAN (mupirocin) 16 AVAR LS (sulfacetamide sodium/sulfur) 105 BACTROBAN NASAL (mupirocin calcium) 16 AVAR-E LS (sulfacetamide sodium/sulfur) 105 BALCOLTRA (levonorgestrel/ethinyl AVC (sulfanilamide) 22 estradiol/ferrous bisglycinate) 144 AVELOX (moxifloxacin hcl) 21 balsalazide disodium 161 AVELOX ABC PACK (moxifloxacin hcl) 21 BALVERSA (erdafitinib) 45 AVITA (tretinoin) 105 BANZEL (rufinamide) 29 AVODART (dutasteride) 131 BAQSIMI (glucagon) 72 AVONEX (interferon beta-1a) 103 BARACLUDE (entecavir) 58 AVONEX (interferon beta-1a/albumin BASAGLAR KWIKPEN U-100 (insulin human) 103 glargine,human recombinant analog) 72 AVONEX PEN (interferon beta-1a) 103 BAXDELA (delafloxacin meglumine) 21 AXERT (almotriptan malate) 40 BECONASE AQ (beclomethasone AXIRON (testosterone) 143 dipropionate) 173 AYGESTIN (norethindrone acetate) 154 BELBUCA (buprenorphine hcl) 3 AZASAN (azathioprine) 158 BELSOMRA (suvorexant) 186 AZASITE (azithromycin) 20 BELVIQ (lorcaserin hcl) 100 azathioprine 158 BELVIQ XR (lorcaserin hcl) 100 azelaic acid 105 benazepril hcl 79

190 LAST UPDATED 12/01/2019 benazepril hcl/hydrochlorothiazide 85 BIKTARVY (bictegravir BENICAR (olmesartan medoxomil) 78 sodium/emtricitabine/tenofovir alafenamide BENICAR HCT (olmesartan fumar) 59 medoxomil/hydrochlorothiazide) 85 BILTRICIDE (praziquantel) 51 BENLYSTA (belimumab) 161 bimatoprost 171 BENTYL (dicyclomine hcl) 123 BINOSTO (alendronate sodium) 163 BENZACLIN (clindamycin phosphate/benzoyl bisacodyl/sodium chlor/sodium peroxide) 105 bicarb/potassium chl/peg 3350 (PEG- BENZAMYCIN (erythromycin base/benzoyl PREP) 126 peroxide) 16 bisoprolol fumarate 81 benzhydrocodone hcl/acetaminophen 7,8 bisoprolol fumarate/hydrochlorothiazide 85 benznidazole 51 BLEPH-10 (sulfacetamide sodium) 22 benzonatate 179 BLEPHAMIDE (sulfacetamide benzphetamine hcl 100 sodium/prednisolone acetate) 166 benztropine mesylate 52 BLEPHAMIDE S.O.P. (sulfacetamide BEPREVE (bepotastine besilate) 168 sodium/prednisolone acetate) 166 BESIVANCE (besifloxacin hcl) 21 blood ketone test, strips 164 BETAGAN (levobunolol hcl) 170 blood sugar diagnostic 164 betamethasone dipropionate 135 BONIVA (ibandronate sodium) 163 betamethasone dipropionate/propylene BONJESTA (doxylamine succinate/pyridoxine glycol 135 hcl (b6)) 35 betamethasone valerate 135 bosentan 178 BETAPACE (sotalol hcl) 80 BOSULIF (bosutinib) 47 BETAPACE AF (sotalol hcl) 80 BRAFTOVI (encorafenib) 47 BETASERON (interferon beta-1b) 103 BREO ELLIPTA (fluticasone furoate/vilanterol betaxolol hcl 81,170 trifenatate) 179 bethanechol chloride 132 BRILINTA (ticagrelor) 77 BETHKIS (tobramycin) 177 brimonidine tartrate 170 BETIMOL (timolol) 170 BRISDELLE (paroxetine mesylate) 32 BETOPTIC S (betaxolol hcl) 170 BRIVIACT (brivaracetam) 24 BEVESPI AEROSPHERE bromfenac sodium 169 (glycopyrrolate/formoterol fumarate) 179 bromocriptine mesylate 53 BEVYXXA (betrixaban maleate) 74 brompheniramine maleate/pseudoephedrine bexarotene 50 hcl/dextromethorphan 179 BEYAZ (drospirenone/ethinyl brompheniramine maleate/pseudoephedrine estradiol/levomefolate calcium) 144 hcl/dextromethorphan (BROMFED DM) 179 BIAXIN (clarithromycin) 20 BROMSITE (bromfenac sodium) 169 bicalutamide 43 BROVANA (arformoterol tartrate) 176 BIDIL (isosorbide dinitrate/hydralazine hcl) 85 BRUKINSA (zanubrutinib) 45 BIJUVA (estradiol/progesterone) 144 BRYHALI (halobetasol propionate) 135 budesonide 162,173

191 LAST UPDATED 12/01/2019 bumetanide 89 CADUET (amlodipine besylate/atorvastatin BUNAVAIL (buprenorphine hcl/naloxone calcium) 85 hcl) 14 CAFERGOT (ergotamine tartrate/caffeine) 40 BUPHENYL (sodium phenylbutyrate) 129 caffeine citrate 178 buprenorphine 3 CALAN (verapamil hcl) 82 buprenorphine hcl 14 CALAN SR (verapamil hcl) 82 buprenorphine hcl/naloxone hcl 14 calcipotriene 105 bupropion hcl 15,31 calcipotriene (CALCITRENE) 105 buspirone hcl 66 calcipotriene/betamethasone butalbital/acetaminophen 100 dipropionate 105 butalbital/acetaminophen (BUPAP) 100 calcitonin,salmon,synthetic 163 butalbital/acetaminophen (TENCON) 100 calcitriol 105,163 butalbital/acetaminophen/caffeine 101 calcium acetate 134 butalbital/acetaminophen/caffeine CALQUENCE (acalabrutinib) 47 (FIORICET) 100 CAMBIA (diclofenac potassium) 1 butalbital/acetaminophen/caffeine CANASA (mesalamine) 161 (PHRENILIN FORTE) 100 candesartan cilexetil 78 butalbital/acetaminophen/caffeine candesartan cilexetil/hydrochlorothiazide 85 (VANATOL LQ) 100 capecitabine 44 butalbital/acetaminophen/caffeine CAPEX SHAMPOO (fluocinolone (VANATOL S) 100 acetonide) 135 butalbital/acetaminophen/caffeine/codeine CAPITAL W-CODEINE (acetaminophen with phosphate 8 codeine phosphate) 8 butalbital/aspirin/caffeine 1 CAPRELSA (vandetanib) 47 BUTISOL SODIUM (butabarbital sodium) 186 captopril 80 butoconazole nitrate (GYNAZOLE 1) 37 captopril/hydrochlorothiazide 85 butorphanol tartrate 8 CARAC (fluorouracil) 105 BUTRANS (buprenorphine) 3 CARAFATE (sucralfate) 127 BYDUREON (exenatide microspheres) 68 CARBAGLU (carglumic acid) 129 BYDUREON BCISE (exenatide microspheres) 68 carbamazepine 29 BYDUREON PEN (exenatide microspheres) 68 carbamazepine (EPITOL) 29 BYETTA (exenatide) 68 CARBATROL (carbamazepine) 29 BYSTOLIC (nebivolol hcl) 81 carbidopa 54 BYVALSON (nebivolol hcl/valsartan) 85 carbidopa/levodopa 54 carbidopa/levodopa/entacapone 52 C carbinoxamine maleate 174 cabergoline 157 carbinoxamine maleate (ARBINOXA) 174 CABLIVI (caplacizumab-yhdp) 75 CARDIZEM (diltiazem hcl) 82 CABOMETYX (cabozantinib s-malate) 47 CARDIZEM CD (diltiazem hcl) 82 CADEAU DHA (prenatal vitamins no.83/iron CARDIZEM LA (diltiazem hcl) 82 fumarate/folate combo no.6/dha) 112 CARDURA (doxazosin mesylate) 78

192 LAST UPDATED 12/01/2019 CARDURA XL (doxazosin mesylate) 132 CETROTIDE (cetrorelix acetate) 157 carisoprodol 183 cevimeline hcl 104 carisoprodol/aspirin 183 CHANTIX (varenicline tartrate) 15 carisoprodol/aspirin/codeine phosphate 8 CHEMET (succimer) 113 CARNITOR (levocarnitine (with sugar)) 113 CHENODAL (chenodiol) 124 CARNITOR (levocarnitine) 113 chlordiazepoxide hcl 66 CARNITOR SF (levocarnitine) 113 chlordiazepoxide/clidinium bromide 123 CAROSPIR (spironolactone) 89 chloroquine phosphate 51 carteolol hcl 170 chlorothiazide 90 carvedilol 81 chlorpromazine hcl 55 carvedilol phosphate 81 chlorpropamide 68 CASODEX (bicalutamide) 43 chlorthalidone 90 CATAPRES (clonidine hcl) 77 chlorzoxazone 183 CATAPRES-TTS 1 (clonidine) 77 CHOLBAM (cholic acid) 124 CATAPRES-TTS 2 (clonidine) 77 cholestyramine (with sugar) 92 CATAPRES-TTS 3 (clonidine) 77 cholestyramine/aspartame 92 CAVERJECT (alprostadil) 132 cholestyramine/aspartame (PREVALITE) 92 CAYSTON (aztreonam lysine) 177 chorionic gonadotropin, human 141 CEDAX (ceftibuten) 18 CIALIS (tadalafil) 132 cefaclor 18 ciclopirox 37 cefadroxil 18 ciclopirox (CICLODAN) 37 cefdinir 18 ciclopirox olamine 37 cefditoren pivoxil 19 ciclopirox olamine (CICLODAN) 37 cefixime 19 cilostazol 77 cefpodoxime proxetil 19 CILOXAN (ciprofloxacin hcl) 21 cefprozil 19 CIMDUO (lamivudine/tenofovir disoproxil ceftibuten 19 fumarate) 59 CEFTIN (cefuroxime axetil) 19 cimetidine 125 cefuroxime axetil 19 cimetidine hcl 125 CELEBREX (celecoxib) 1 CIMZIA (certolizumab pegol) 158 celecoxib 1 cinacalcet hcl 163 CELEXA (citalopram hydrobromide) 32 CIPRO (ciprofloxacin hcl) 21 CELLCEPT (mycophenolate mofetil) 158 CIPRO (ciprofloxacin) 21 CELONTIN (methsuximide) 25 CIPRO HC (ciprofloxacin CENTANY (mupirocin) 16 hcl/hydrocortisone) 172 cephalexin 19 CIPRO XR (ciprofloxacin/ciprofloxacin hcl) 21 CEQUA (cyclosporine) 166 CIPRODEX (ciprofloxacin CERDELGA (eliglustat tartrate) 129 hcl/dexamethasone) 172 cervical cap 164 ciprofloxacin 21 CESAMET (nabilone) 36 ciprofloxacin hcl 21 CETRAXAL (ciprofloxacin hcl) 21 ciprofloxacin hcl/fluocinolone acetonide 172

193 LAST UPDATED 12/01/2019 ciprofloxacin/ciprofloxacin hcl 21 clobetasol propionate/emollient base (TOVET citalopram hydrobromide 32 EMOLLIENT) 135 CITRANATAL HARMONY (prenatal vitamin CLOBEX (clobetasol propionate) 135,136 no.59/iron carb,fum/folic clocortolone pivalate 136 acid/docusate/dha) 113 CLODERM (clocortolone pivalate) 136 CITRANATAL RX (prenatal vits no.81/iron clomiphene citrate 156 carbonyl,gluc/folic acid/docusate) 113 clomipramine hcl 34 citric acid/sodium citrate 132 clonazepam 66 citric acid/sodium citrate (CYTRA-2) 132 clonidine 77 citric acid/sodium citrate (VIRTRATE-2) 132 clonidine hcl 77,97 CLARINEX (desloratadine) 174 clopidogrel bisulfate 77 CLARINEX-D 12 HOUR clorazepate dipotassium 66 (desloratadine/pseudoephedrine sulfate) 179 clotrimazole 37 clarithromycin 20 clotrimazole/betamethasone clemastine fumarate 174 dipropionate 106 CLENPIQ (sodium picosulfate/magnesium clozapine 57 oxide/citric acid) 126 CLOZARIL (clozapine) 57 CLEOCIN (clindamycin phosphate) 16 COARTEM (artemether/lumefantrine) 51 CLEOCIN HCL (clindamycin hcl) 16 codeine CLEOCIN PALMITATE (clindamycin palmitate phosphate/butalbital/aspirin/caffeine 8 hcl) 16 codeine CLEOCIN T (clindamycin phosphate) 16 phosphate/butalbital/aspirin/caffeine CLIMARA (estradiol) 144 (ASCOMP WITH CODEINE) 8 CLIMARA PRO (estradiol/levonorgestrel) 144 codeine phosphate/guaifenesin 179 CLINDAGEL (clindamycin phosphate) 17 codeine phosphate/guaifenesin clindamycin hcl 17 (CHERATUSSIN AC) 180 clindamycin palmitate hcl 17 codeine phosphate/guaifenesin (G TUSSIN clindamycin phosphate 17 AC) 180 clindamycin phosphate (CLINDACIN ETZ) 17 codeine phosphate/guaifenesin clindamycin phosphate (CLINDACIN P) 17 (GUAIATUSSIN AC) 180 clindamycin phosphate/benzoyl codeine phosphate/guaifenesin peroxide 105,106 (GUAIFENESIN AC) 180 clindamycin phosphate/benzoyl peroxide codeine phosphate/guaifenesin (ROBAFEN (NEUAC) 105 AC) 180 clindamycin phosphate/tretinoin 106 codeine phosphate/guaifenesin (VIRTUSSIN CLINDESSE (clindamycin phosphate) 17 AC) 180 clobazam 26 codeine sulfate 8 clobetasol propionate 135 COLAZAL (balsalazide disodium) 161 clobetasol propionate (CLODAN) 135 colchicine 39 clobetasol propionate (CORMAX) 135 COLCRYS (colchicine) 39 clobetasol propionate/emollient base 135 colesevelam hcl 92

194 LAST UPDATED 12/01/2019 COLESTID (colestipol hcl) 92 CORTISPORIN (neomycin sulfate/polymyxin b colestipol hcl 92 sulfate/hydrocortisone) 106 COLY-MYCIN S (neomycin sulf/colistin CORTISPORIN sul/hydrocortisone ac/thonzonium brom) 172 (neomycin/bacitracin/polymyxin COLYTE WITH FLAVOR PACKETS (peg 3350/sod b/hydrocortisone) 106 sulf/sod bicarb/sod chloride/potassium CORTISPORIN-TC (neomycin sulf/colistin chloride) 126 sul/hydrocortisone ac/thonzonium brom) 172 COMBIGAN (brimonidine tartrate/timolol CORZIDE (nadolol/bendroflumethiazide) 85 maleate) 170 COSENTYX (2 SYRINGES) (secukinumab) 106 COMBIPATCH (estradiol/norethindrone COSENTYX PEN (2 PENS) (secukinumab) 106 acetate) 144 COSENTYX PEN (secukinumab) 106 COMBIVENT RESPIMAT (ipratropium COSENTYX SYRINGE (secukinumab) 106 bromide/albuterol sulfate) 180 COSOPT (dorzolamide hcl/timolol COMBIVIR (lamivudine/zidovudine) 61 maleate) 170 COMETRIQ (cabozantinib s-malate) 47 COSOPT PF (dorzolamide hcl/timolol COMPAZINE (prochlorperazine maleate) 35 maleate/pf) 170 COMPAZINE (prochlorperazine) 35 COTELLIC (cobimetinib fumarate) 47 COMPLERA (emtricitabine/rilpivirine COTEMPLA XR-ODT (methylphenidate) 97 hcl/tenofovir disoproxil fumarate) 60 COUMADIN (warfarin sodium) 74 COMTAN (entacapone) 52 COZAAR (losartan potassium) 78,79 CONCEPT DHA (prenatal vit no.16/iron fum,ps CREON (lipase/protease/amylase) 129 complex/folic acid/omega-3) 113 CRESEMBA (isavuconazonium sulfate) 37 CONCEPT OB (prenatal vitamin no.15/iron CRESTOR (rosuvastatin calcium) 91 fumarate,polysac comp/folic acid) 113 CRINONE (progesterone, micronized) 154 CONCERTA (methylphenidate hcl) 97 CRIXIVAN (indinavir sulfate) 63 CONDYLOX (podofilox) 106 cromolyn sodium 124,168,178 CONTRAVE (naltrexone hcl/bupropion hcl)101 crotamiton (CROTAN) 52 CONZIP (tramadol hcl) 3 CUPRIMINE (penicillamine) 132 COPAXONE (glatiramer acetate) 103 CUTIVATE (fluticasone propionate) 136 COPEGUS (ribavirin) 59 CUVPOSA (glycopyrrolate) 123 COPIKTRA (duvelisib) 45 cyanocobalamin (vitamin b-12) 113 CORDARONE (amiodarone hcl) 80 cyclobenzaprine hcl 183 CORDRAN (flurandrenolide) 136 CYCLOGYL (cyclopentolate hcl) 166 COREG (carvedilol) 81 CYCLOMYDRIL (cyclopentolate COREG CR (carvedilol phosphate) 81 hcl/phenylephrine hcl) 166 CORGARD (nadolol) 81 cyclopentolate hcl 166 CORLANOR (ivabradine hcl) 85 cyclophosphamide 43 CORTEF (hydrocortisone) 136 cycloserine 42 CORTENEMA (hydrocortisone) 162 CYCLOSET (bromocriptine mesylate) 68 CORTIFOAM (hydrocortisone acetate) 162 cyclosporine 158 cortisone acetate 136 cyclosporine, modified 158

195 LAST UPDATED 12/01/2019 cyclosporine, modified (GENGRAF) 158 DEPAKENE (valproic acid) 26 CYMBALTA (duloxetine hcl) 102 DEPAKOTE (divalproex sodium) 26 cyproheptadine hcl 174 DEPAKOTE ER (divalproex sodium) 26 CYSTADANE (betaine) 129 DEPAKOTE SPRINKLE (divalproex sodium) 26 CYSTAGON (cysteamine bitartrate) 132 DEPEN (penicillamine) 132 CYSTARAN (cysteamine hcl) 167 DEPO-ESTRADIOL (estradiol cypionate) 144 CYTOMEL (liothyronine sodium) 156 DEPO-TESTOSTERONE (testosterone CYTOTEC (misoprostol) 127 cypionate) 143 DERMA-SMOOTHE-FS (fluocinolone D acetonide) 136 D-PENAMINE (penicillamine) 132 DERMA-SMOOTHE-FS (fluocinolone D.H.E.45 (dihydroergotamine mesylate) 40 acetonide/shower cap) 136 DAKLINZA (daclatasvir dihydrochloride) 58 DERMATOP (prednicarbate) 136 dalfampridine 103 DERMOTIC (fluocinolone acetonide oil) 172 DALIRESP (roflumilast) 178 DESCOVY (emtricitabine/tenofovir danazol 143 alafenamide fumarate) 62 DANTRIUM (dantrolene sodium) 57 desipramine hcl 34 dantrolene sodium 57 desloratadine 174 dapsone 42,106 desmopressin acetate 141 DARAPRIM (pyrimethamine) 51 desmopressin acetate (non-refrigerated) 141 darifenacin hydrobromide 130 desogestrel-ethinyl estradiol 144 DAURISMO (glasdegib maleate) 47 desogestrel-ethinyl estradiol (APRI) 144 DAXBIA (cephalexin) 19 desogestrel-ethinyl estradiol (CAZIANT) 144 DAYPRO (oxaprozin) 1 desogestrel-ethinyl estradiol (CYRED EQ) 144 DAYTRANA (methylphenidate) 98 desogestrel-ethinyl estradiol (CYRED) 144 DDAVP (desmopressin acetate (non- desogestrel-ethinyl estradiol (EMOQUETTE) 144 refrigerated)) 141 desogestrel-ethinyl estradiol (ENSKYCE) 144 DDAVP (desmopressin acetate) 141 desogestrel-ethinyl estradiol (ISIBLOOM) 144 deferasirox 113 desogestrel-ethinyl estradiol (JULEBER) 144 DELESTROGEN (estradiol valerate) 144 desogestrel-ethinyl estradiol (KALLIGA) 144 DELSTRIGO (doravirine/lamivudine/tenofovir desogestrel-ethinyl estradiol (RECLIPSEN) 144 disoproxil fumarate) 60 desogestrel-ethinyl estradiol (VELIVET) 144 DELTASONE (prednisone) 136 desogestrel-ethinyl estradiol/ethinyl DELZICOL (mesalamine) 161 estradiol 144 DEMADEX (torsemide) 89 desogestrel-ethinyl estradiol/ethinyl estradiol demeclocycline hcl 23 (AZURETTE) 144 DEMEROL (meperidine hcl) 8 desogestrel-ethinyl estradiol/ethinyl estradiol DEMSER (metyrosine) 85 (BEKYREE) 144 DENAVIR (penciclovir) 65 desogestrel-ethinyl estradiol/ethinyl estradiol DEPAKENE (valproic acid (as sodium salt) (KARIVA) 144 (valproate sodium)) 26

196 LAST UPDATED 12/01/2019 desogestrel-ethinyl estradiol/ethinyl estradiol diaphragms, contoured 164 (KIMIDESS) 144 diaphragms, wide seal 164 desogestrel-ethinyl estradiol/ethinyl estradiol DIASTAT (diazepam) 26 (PIMTREA) 144 DIASTAT ACUDIAL (diazepam) 26 desogestrel-ethinyl estradiol/ethinyl estradiol diazepam 26,66,67 (SIMLIYA) 145 DIBENZYLINE (phenoxybenzamine hcl) 78 desogestrel-ethinyl estradiol/ethinyl estradiol DICLEGIS (doxylamine succinate/pyridoxine (VIORELE) 145 hcl (b6)) 35 DESONATE (desonide) 136 diclofenac epolamine 1 desonide 136 diclofenac potassium 1 DESOWEN (desonide) 136 diclofenac sodium 1,106,169 desoximetasone 136 diclofenac sodium (KLOFENSAID II) 1 DESOXYN (methamphetamine hcl) 95 diclofenac sodium/misoprostol 1 desvenlafaxine 32 dicloxacillin sodium 20 desvenlafaxine fumarate 32 dicyclomine hcl 123 desvenlafaxine succinate 32 didanosine 61 DETROL (tolterodine tartrate) 130 diethylpropion hcl 101 DETROL LA (tolterodine tartrate) 131 DIFFERIN (adapalene) 106 dexamethasone 136,137 DIFICID (fidaxomicin) 20 dexamethasone (DECADRON) 136 diflorasone diacetate 137 dexamethasone (DEXAMETHASONE diflorasone diacetate (PSORCON) 137 INTENSOL) 136 diflorasone diacetate/emollient base dexamethasone (HIDEX) 136 (APEXICON E) 137 dexamethasone (LOCORT) 136 DIFLUCAN (fluconazole) 37 dexamethasone (TAPERDEX) 137 diflunisal 1 dexamethasone (ZODEX) 137 digoxin 85 dexamethasone sodium phosphate 169 digoxin (DIGITEK) 85 dexchlorpheniramine maleate 174 digoxin (DIGOX) 85 DEXEDRINE (dextroamphetamine sulfate) 95 dihydroergotamine mesylate 40 DEXILANT (dexlansoprazole) 128 DILANTIN (phenytoin sodium extended) 29 dexmethylphenidate hcl 98 DILANTIN (phenytoin) 29 DEXPAK (dexamethasone) 137 DILANTIN-125 (phenytoin) 29 dextroamphetamine sulf- DILATRATE-SR (isosorbide dinitrate) 93 saccharate/amphetamine sulf- DILAUDID (hydromorphone hcl) 8 aspartate 95,96 diltiazem hcl 83 dextroamphetamine sulfate 96 diltiazem hcl (CARTIA XT) 83 dextroamphetamine sulfate (PROCENTRA) 96 diltiazem hcl (DILT-XR) 83 dextroamphetamine sulfate (ZENZEDI) 96 diltiazem hcl (MATZIM LA) 83 DIABETA (glyburide) 68 diltiazem hcl (TAZTIA XT) 83 DIACOMIT (stiripentol) 24,25 diltiazem hcl (TIADYLT ER) 83 DIAMOX SEQUELS (acetazolamide) 89 DIOVAN (valsartan) 79

197 LAST UPDATED 12/01/2019 DIOVAN HCT doxycycline monohydrate (OKEBO) 23 (valsartan/hydrochlorothiazide) 86 doxylamine succinate/pyridoxine hcl (b6) 35 DIPENTUM (olsalazine sodium) 162 DRISDOL (ergocalciferol (vitamin d2)) 163 diphenoxylate hcl/atropine sulfate 124 DRIZALMA SPRINKLE (duloxetine hcl) 102 DIPROLENE (betamethasone dronabinol 36 dipropionate/propylene glycol) 137 drospirenone/ethinyl estradiol/levomefolate DIPROLENE AF (betamethasone calcium 145 dipropionate/propylene glycol) 137 drospirenone/ethinyl estradiol/levomefolate dipyridamole 77 calcium (RAJANI) 145 DISALCID (salsalate) 1 drospirenone/ethinyl estradiol/levomefolate DISKETS (methadone hcl) 3 calcium (TYDEMY) 145 disopyramide phosphate 80 DROXIA (hydroxyurea) 44 disulfiram 14 DUAC (clindamycin phosphate/benzoyl DITROPAN XL (oxybutynin chloride) 131 peroxide) 106 DIURIL (chlorothiazide) 90 DUAKLIR PRESSAIR (aclidinium divalproex sodium 26 bromide/formoterol fumarate) 180 DIVIGEL (estradiol) 145 DUAVEE (estrogens, dofetilide 80 conjugated/bazedoxifene acetate) 145 DOLOPHINE HCL (methadone hcl) 3,4 DUETACT (pioglitazone hcl/glimepiride) 68 donepezil hcl 30 DUEXIS (ibuprofen/famotidine) 1 DONNATAL (phenobarbital/hyoscyamine DULERA (mometasone furoate/formoterol sulf/atropine sulf/scopolamine hb) 123 fumarate) 180 DOPTELET (avatrombopag maleate) 75 duloxetine hcl 102 DORAL (quazepam) 184 DUOBRII (halobetasol DORYX (doxycycline hyclate) 23 propionate/tazarotene) 106 DORYX MPC (doxycycline hyclate) 23 DUPIXENT (dupilumab) 106 dorzolamide hcl 170 DURAGESIC (fentanyl) 4 dorzolamide hcl/timolol maleate 170 DUREZOL (difluprednate) 169 dorzolamide hcl/timolol maleate/pf 170 DURLAZA (aspirin) 77 DOVATO (dolutegravir sodium/lamivudine) 62 dutasteride 132 DOVONEX (calcipotriene) 106 dutasteride/tamsulosin hcl 132 doxazosin mesylate 78 DUTOPROL (metoprolol doxepin hcl 34,106 succinate/hydrochlorothiazide) 86 doxercalciferol 163 DUZALLO (lesinurad/allopurinol) 39 doxycycline hyclate 23 DXEVO (dexamethasone) 137 doxycycline hyclate (MORGIDOX) 23 DYANAVEL XR (amphetamine) 96 doxycycline hyclate (SOLOXIDE) 23 DYAZIDE (triamterene/hydrochlorothiazide) 86 doxycycline monohydrate 23 DYMISTA (azelastine hcl/fluticasone doxycycline monohydrate (AVIDOXY) 23 propionate) 180 doxycycline monohydrate (MONDOXYNE DYRENIUM (triamterene) 89 NL) 23

198 LAST UPDATED 12/01/2019 EMTRIVA (emtricitabine) 61 E ENABLEX (darifenacin hydrobromide) 131 E.E.S. 200 (erythromycin ethylsuccinate) 20 enalapril maleate 80 E.E.S. 400 (erythromycin ethylsuccinate) 20 enalapril maleate/hydrochlorothiazide 86 EC-NAPROSYN (naproxen) 1 ENBRACE HR (multivit no.41/iron cysteine econazole nitrate 37 glycinat/folate no.8/phosph-dha) 113 ECOZA (econazole nitrate) 37 ENBREL (etanercept) 158,159 EDARBI (azilsartan medoxomil) 79 ENBREL MINI (etanercept) 159 EDARBYCLOR (azilsartan ENBREL SURECLICK (etanercept) 159 medoxomil/chlorthalidone) 86 ENDARI (glutamine) 113 EDECRIN (ethacrynic acid) 89 ENDOMETRIN (progesterone, micronized) 154 EDEX (alprostadil) 133 enoxaparin sodium 74 EDLUAR (zolpidem tartrate) 184 ENSTILAR (calcipotriene/betamethasone EDURANT (rilpivirine hcl) 60 dipropionate) 107 efavirenz 60 entacapone 52 EFFER-K (potassium bicarbonate/citric entecavir 58 acid) 113 ENTOCORT EC (budesonide) 162 EFFEXOR XR (venlafaxine hcl) 32,33 ENTRESTO (sacubitril/valsartan) 86 EFFIENT (prasugrel hcl) 77 ENVARSUS XR (tacrolimus) 159 EFUDEX (fluorouracil) 44 EPANED (enalapril maleate) 80 EGRIFTA (tesamorelin acetate) 157 EPCLUSA (sofosbuvir/velpatasvir) 58 ELDEPRYL (selegiline hcl) 54 EPIDIOLEX (cannabidiol (cbd)) 25 ELESTAT (epinastine hcl) 168 EPIDUO (adapalene/benzoyl peroxide) 107 ELESTRIN (estradiol) 145 EPIDUO FORTE (adapalene/benzoyl eletriptan hydrobromide 40 peroxide) 107 ELIDEL (pimecrolimus) 106 EPIFOAM (hydrocortisone acetate/pramoxine ELIMITE (permethrin) 52 hcl) 107 ELIQUIS (apixaban) 74 epinastine hcl 168 ELIXOPHYLLIN (theophylline anhydrous) 178 epinephrine 176 ELLA (ulipristal acetate) 154 EPIPEN 2-PAK (epinephrine) 176 ELMIRON (pentosan polysulfate sodium) 133 EPIPEN JR 2-PAK (epinephrine) 176 ELOCON (mometasone furoate) 137 EPIVIR (lamivudine) 61 EMADINE (emedastine difumarate) 168 EPIVIR HBV (lamivudine) 58 EMBEDA (morphine sulfate/naltrexone hcl) 4 eplerenone 89 EMCYT (estramustine phosphate sodium) 44 EPOGEN (epoetin alfa) 76 EMEND (aprepitant) 36 eprosartan mesylate 79 EMFLAZA (deflazacort) 137 EPZICOM (abacavir sulfate/lamivudine) 61 EMGALITY PEN (galcanezumab-gnlm) 40 EQUETRO (carbamazepine) 67 EMGALITY SYRINGE (galcanezumab-gnlm) 40 ergocalciferol (vitamin d2) 163 EMLA (lidocaine/prilocaine) 13 ergoloid mesylates 30 EMSAM (selegiline) 32 ERGOMAR (ergotamine tartrate) 40

199 LAST UPDATED 12/01/2019 ergotamine tartrate/caffeine 40 estradiol/norethindrone acetate (MIMVEY ergotamine tartrate/caffeine (MIGERGOT) 40 LO) 145 ERIVEDGE (vismodegib) 47 estradiol/norethindrone acetate (MIMVEY)145 ERLEADA (apalutamide) 43 ESTRING (estradiol) 146 erlotinib hcl 47 ESTROGEL (estradiol) 146 ERTACZO (sertaconazole nitrate) 37 estrogens,esterified/methyltestosterone 146 ERY-TAB (erythromycin base) 20 estrogens,esterified/methyltestosterone ERYGEL (erythromycin base in ethanol) 20 (COVARYX H.S.) 146 ERYPED 200 (erythromycin ethylsuccinate) 20 estrogens,esterified/methyltestosterone ERYPED 400 (erythromycin ethylsuccinate) 20 (COVARYX) 146 ERYTHROCIN STEARATE (erythromycin estrogens,esterified/methyltestosterone (EEMT stearate) 20 H.S.) 146 erythromycin base 20 estrogens,esterified/methyltestosterone erythromycin base in ethanol 20 (EEMT) 146 erythromycin base in ethanol (ERY) 20 estropipate 146 erythromycin base/benzoyl peroxide 17 ESTROSTEP FE (norethindrone acetate-ethinyl erythromycin ethylsuccinate 20 estradiol/ferrous fumarate) 146 ESBRIET (pirfenidone) 180 eszopiclone 184 ESCAVITE (pediatric multivitamin no.47/ferrous ethacrynic acid 89 fumarate/sod fluoride) 113 ethambutol hcl 42 ESCAVITE D (pediatric multivitamin no.78 with ethinyl estradiol/drospirenone 146 iron and sodium fluoride) 113 ethinyl estradiol/drospirenone (GIANVI) 146 ESCAVITE LQ (pediatric multivitamin no.86 ethinyl estradiol/drospirenone (JASMIEL) 146 with iron and sodium fluoride) 113 ethinyl estradiol/drospirenone (LO- escitalopram oxalate 33 ZUMANDIMINE) 146 ESGIC ethinyl estradiol/drospirenone (LORYNA) 146 (butalbital/acetaminophen/caffeine) 101 ethinyl estradiol/drospirenone (NIKKI) 146 esomeprazole magnesium 128 ethinyl estradiol/drospirenone (OCELLA) 146 esomeprazole strontium 128 ethinyl estradiol/drospirenone (SYEDA) 146 estazolam 184 ethinyl estradiol/drospirenone (VESTURA) 146 ESTRACE (estradiol) 145 ethinyl estradiol/drospirenone (ZARAH) 146 estradiol 145 ethinyl estradiol/drospirenone estradiol (DOTTI) 145 (ZUMANDIMINE) 146 estradiol (YUVAFEM) 145 ethosuximide 25 estradiol valerate 145 ethynodiol diacetate-ethinyl estradiol 146 estradiol/norethindrone acetate 145 ethynodiol diacetate-ethinyl estradiol estradiol/norethindrone acetate (KELNOR 1-35) 146 (AMABELZ) 145 ethynodiol diacetate-ethinyl estradiol estradiol/norethindrone acetate (KELNOR 1-50) 146 (LOPREEZA) 145 ethynodiol diacetate-ethinyl estradiol (ZOVIA 1-35E) 146

200 LAST UPDATED 12/01/2019 ethynodiol diacetate-ethinyl estradiol (ZOVIA FARYDAK (panobinostat lactate) 47 1-50E) 146 FASENRA PEN (benralizumab) 180 etidronate disodium 163 FAZACLO (clozapine) 57 etodolac 2 febuxostat 39 etoposide 46 felbamate 27 EUCRISA (crisaborole) 107 FELBATOL (felbamate) 27 EURAX (crotamiton) 52 FELDENE (piroxicam) 2 EUTHYROX (levothyroxine sodium) 156 felodipine 83 EVAMIST (estradiol) 147 FEMARA (letrozole) 46 EVEKEO (amphetamine sulfate) 96 FEMHRT (norethindrone acetate-ethinyl EVEKEO ODT (amphetamine sulfate) 96 estradiol) 147 EVISTA (raloxifene hcl) 156 FEMRING (estradiol acetate) 147 EVOCLIN (clindamycin phosphate) 17 fenofibrate 90 EVOTAZ (atazanavir sulfate/cobicistat) 63 fenofibrate (LOFIBRA) 90 EVOXAC (cevimeline hcl) 104 fenofibrate nanocrystallized 90 EVZIO (naloxone hcl) 15 fenofibrate,micronized 90,91 EXALGO (hydromorphone hcl) 4 fenofibrate,micronized (LOFIBRA) 90 EXELDERM (sulconazole nitrate) 37 fenofibric acid 91 EXELON (rivastigmine tartrate) 30 fenofibric acid (choline) 91 EXELON (rivastigmine) 30 FENOGLIDE (fenofibrate) 91 exemestane 46 fenoprofen calcium 2 EXFORGE (amlodipine besylate/valsartan) 86 fenoprofen calcium (FENORTHO) 2 EXFORGE HCT (amlodipine fenoprofen calcium (PROFENO) 2 besylate/valsartan/hydrochlorothiazide) 86 FENORTHO (fenoprofen calcium) 2 EXJADE (deferasirox) 113 fentanyl 4 EXTAVIA (interferon beta-1b) 103 fentanyl citrate 8 EXTINA (ketoconazole) 37 FENTORA (fentanyl citrate) 9 EZALLOR SPRINKLE (rosuvastatin calcium) 91 FERRIPROX (deferiprone) 112,113 ezetimibe 92 FETZIMA (levomilnacipran hcl) 33 ezetimibe/simvastatin 92 FEXMID (cyclobenzaprine hcl) 183 FIASP (insulin aspart (niacinamide)) 72 F FIASP FLEXTOUCH (insulin aspart FABIOR (tazarotene) 107 (niacinamide)) 72 FACTIVE (gemifloxacin mesylate) 21 FIASP PENFILL (insulin aspart (niacinamide)) 72 famciclovir 65 FIBRICOR (fenofibric acid) 91 famotidine 125 FINACEA (azelaic acid) 107 famotidine (PEPCID) 125 finasteride 132 FAMVIR (famciclovir) 65 FIORICET WITH CODEINE FANAPT (iloperidone) 56 (butalbital/acetaminophen/caffeine/codein FARESTON (toremifene citrate) 44 e phosphate) 9 FARXIGA (dapagliflozin propanediol) 68 FIORINAL (butalbital/aspirin/caffeine) 2

201 LAST UPDATED 12/01/2019 FIORINAL WITH CODEINE #3 (codeine flurazepam hcl 184,185 phosphate/butalbital/aspirin/caffeine) 9 flurbiprofen 2 FIRAZYR (icatibant acetate) 158 flurbiprofen sodium 169 FIRDAPSE (amifampridine phosphate) 103 flutamide 43 FIRVANQ (vancomycin hcl) 17 fluticasone propionate 137,138,173 FLAGYL (metronidazole) 17 fluticasone propionate (BESER) 137 FLAREX (fluorometholone acetate) 169 fluticasone propionate/salmeterol flavoxate hcl 131 xinafoate 180,181 flecainide acetate 80 fluticasone propionate/salmeterol xinafoate FLECTOR (diclofenac epolamine) 2 (WIXELA INHUB) 180 FLOLIPID (simvastatin) 91 fluvastatin sodium 91,92 FLOMAX (tamsulosin hcl) 132 fluvoxamine maleate 33 FLORIVA (pediatric multivitamin no.85 with FML (fluorometholone) 169 sodium fluoride) 113 FML FORTE (fluorometholone) 169 FLORIVA PLUS (pediatric multivitamin FML S.O.P. (fluorometholone) 169 no.130/sodium fluoride) 113 FOCALIN (dexmethylphenidate hcl) 98 FLOVENT DISKUS (fluticasone propionate) 173 FOCALIN XR (dexmethylphenidate hcl) 98 FLOVENT HFA (fluticasone propionate) 173 FOLET ONE (multivitamin no.39/iron FLOWTUSS (guaifenesin/hydrocodone carb,bisgl/methylfolate/docusate/dha) 114 bitartrate) 180 folic acid 114 fluconazole 37 folic acid/pyridoxine hcl/ca phos dibasic & flucytosine 37 tribasic/ginger (VP-GGR-B6) 114 fludrocortisone acetate 137 folic acid/pyridoxine hcl/ca phos dibasic & FLUMADINE (rimantadine hcl) 64 tribasic/ginger (ZINGIBER) 114 flunisolide 173 FOLLISTIM AQ (follitropin fluocinolone acetonide 137 beta,recombinant) 141 fluocinolone acetonide oil 172 fondaparinux sodium 74 fluocinolone acetonide oil (FLAC OTIC FORADIL (formoterol fumarate) 176 OIL) 172 FORFIVO XL (bupropion hcl) 31 fluocinolone acetonide/shower cap 137 FORTAMET (metformin hcl) 68 fluocinonide 137 FORTEO (teriparatide) 163 fluocinonide/emollient base 137 FORTESTA (testosterone) 143 fluoride/iron/vitamins a,c,and d 114 FORTICAL (calcitonin,salmon,synthetic) 163 fluorometholone 169 FOSAMAX (alendronate sodium) 163 FLUOROPLEX (fluorouracil) 107 FOSAMAX PLUS D (alendronate fluorouracil 44,107 sodium/cholecalciferol (vitamin d3)) 163 fluoxetine hcl 33 fosamprenavir calcium 63 fluoxymesterone (ANDROXY) 143 fosinopril sodium 80 fluphenazine hcl 55 fosinopril sodium/hydrochlorothiazide 86 flurandrenolide 137 FOSRENOL (lanthanum carbonate) 134 flurandrenolide (NOLIX) 137 FRAGMIN (dalteparin sodium,porcine) 74

202 LAST UPDATED 12/01/2019 FROVA (frovatriptan succinate) 40 GLUCAGON EMERGENCY KIT frovatriptan succinate 40 (glucagon,human recombinant) 72 FULPHILA (pegfilgrastim-jmdb) 76 GLUCOPHAGE (metformin hcl) 68 FURADANTIN (nitrofurantoin) 17 GLUCOPHAGE XR (metformin hcl) 68 furosemide 89 GLUCOTROL (glipizide) 68 FUZEON (enfuvirtide) 63 GLUCOTROL XL (glipizide) 69 FYCOMPA (perampanel) 27 GLUCOVANCE (glyburide/metformin hcl) 69 GLUMETZA (metformin hcl) 69 G glyburide 69 gabapentin 26 glyburide,micronized 69 GABITRIL (tiagabine hcl) 26 glyburide/metformin hcl 69 GALAFOLD (migalastat hcl) 129 GLYCATE (glycopyrrolate) 123 galantamine hbr 30 glycopyrrolate 123 GALZIN (zinc acetate) 114 GLYNASE (glyburide,micronized) 69 ganirelix acetate 157 GLYSET (miglitol) 69 GASTROCROM (cromolyn sodium) 124 GLYXAMBI (empagliflozin/linagliptin) 69 gatifloxacin 21 GOCOVRI (amantadine hcl) 52 GELNIQUE (oxybutynin chloride) 131 GOLYTELY (peg 3350/sod sulf/sod bicarb/sod gemfibrozil 91 chloride/potassium chloride) 126 GENERESS FE (norethindrone-ethinyl GONAL-F (follitropin alfa, recombinant) 141 estradiol/ferrous fumarate) 147 GONAL-F RFF (follitropin alfa, GENOTROPIN (somatropin) 141 recombinant) 141 gentamicin sulfate 16 GONAL-F RFF REDI-JECT (follitropin alfa, gentamicin sulfate (GENTAK) 16 recombinant) 141 GENVOYA GONITRO (nitroglycerin) 93 (elvitegravir/cobicistat/emtricitabine/tenofovi GORDON'S UREA (urea) 107 r alafenamide) 60 GRALISE (gabapentin) 26 GEODON (ziprasidone hcl) 56 granisetron hcl 36 GIAZO (balsalazide disodium) 162 GRANIX (tbo-filgrastim) 76 GILENYA (fingolimod hcl) 103 GRASTEK (allergenic extract,grass pollen- GILOTRIF (afatinib dimaleate) 48 timothy,standard) 181 glatiramer acetate 103 GRIS-PEG (griseofulvin ultramicrosize) 37 glatiramer acetate (GLATOPA) 103 griseofulvin ultramicrosize 37 GLEEVEC (imatinib mesylate) 48 griseofulvin, microsize 37 GLEOSTINE (lomustine) 43 guaifenesin/hydrocodone bitartrate 181 glimepiride 68 guanfacine hcl 77,98 glipizide 68 guanidine hcl 41 glipizide/metformin hcl 68 GVOKE HYPOPEN (glucagon) 72 GLOPERBA (colchicine) 39 GVOKE SYRINGE (glucagon) 72 GLUCAGEN (glucagon,human recombinant) 72

203 LAST UPDATED 12/01/2019 HUMIRA PEN PSOR-UVEITS-ADOL HS H (adalimumab) 159 HAEGARDA (c1 esterase inhibitor) 158 HUMIRA(CF) (adalimumab) 159 halcinonide 138 HUMIRA(CF) PEDIATRIC CROHN'S HALCION (triazolam) 185 (adalimumab) 159 halobetasol propionate 138 HUMIRA(CF) PEN (adalimumab) 159 HALOG (halcinonide) 138 HUMIRA(CF) PEN CROHN'S-UC-HS haloperidol 55 (adalimumab) 159 haloperidol lactate 55 HUMIRA(CF) PEN PSOR-UV-ADOL HS HARVONI (ledipasvir/sofosbuvir) 58 (adalimumab) 159 HECTOROL (doxercalciferol) 163 HUMULIN 70-30 (insulin nph human HEMANGEOL (propranolol hcl) 45 isophane/insulin regular, human) 73 heparin sodium,porcine 75 HUMULIN 70/30 KWIKPEN (insulin nph human heparin sodium,porcine/pf 75 isophane/insulin regular, human) 73 HEPSERA (adefovir dipivoxil) 58 HUMULIN N (insulin nph human isophane) 73 HETLIOZ (tasimelteon) 186 HUMULIN N KWIKPEN (insulin nph human HEXALEN (altretamine) 43 isophane) 73 HIPREX (methenamine hippurate) 17 HUMULIN R (insulin regular, human) 73 homatropine hbr 167 HUMULIN R U-500 (insulin regular, human) 73 homatropine hbr (HOMATROPAIRE) 167 HUMULIN R U-500 KWIKPEN (insulin regular, HORIZANT (gabapentin enacarbil) 101 human) 73 HUMALOG (insulin lispro) 72 HYCAMTIN (topotecan hcl) 46 HUMALOG JUNIOR KWIKPEN (insulin lispro) 72 HYCET (hydrocodone HUMALOG KWIKPEN U-100 (insulin lispro) 72 bitartrate/acetaminophen) 9 HUMALOG KWIKPEN U-200 (insulin lispro) 72 HYCOFENIX (hydrocodone HUMALOG MIX 50-50 (insulin lispro protamine bitartrate/pseudoephedrine and insulin lispro) 72 hcl/guaifenesin) 181 HUMALOG MIX 50-50 KWIKPEN (insulin lispro hydralazine hcl 93 protamine and insulin lispro) 72 HYDREA (hydroxyurea) 44 HUMALOG MIX 75-25 (insulin lispro protamine HYDRO 35 (urea) 107 and insulin lispro) 73 HYDRO 40 (urea) 107 HUMALOG MIX 75-25 KWIKPEN (insulin lispro hydrochlorothiazide 90 protamine and insulin lispro) 73 hydrocodone bitart/chlorpheniramine HUMATROPE (somatropin) 141 maleate/pseudoephedrine 181 HUMIRA (adalimumab) 159 hydrocodone bitartrate/acetaminophen 10 HUMIRA PEDIATRIC CROHN'S hydrocodone bitartrate/acetaminophen (adalimumab) 159 (LORCET HD) 9 HUMIRA PEN (adalimumab) 159 hydrocodone bitartrate/acetaminophen HUMIRA PEN CROHN'S-UC-HS (LORCET PLUS) 9 (adalimumab) 159 hydrocodone bitartrate/acetaminophen (LORCET) 9

204 LAST UPDATED 12/01/2019 hydrocodone bitartrate/acetaminophen hydrocortisone/acetic acid (ACETASOL (LORTAB) 9 HC) 172 hydrocodone bitartrate/acetaminophen hydrocortisone/mineral (VERDROCET) 9 oil/petrolatum,white 138 hydrocodone bitartrate/acetaminophen hydromorphone hcl 4,10 (VICODIN ES) 9 hydroxychloroquine sulfate 51 hydrocodone bitartrate/acetaminophen hydroxyprogesterone caproate 154 (VICODIN HP) 9 hydroxyprogesterone caproate/pf 154 hydrocodone bitartrate/acetaminophen hydroxyurea 44 (VICODIN) 9 hydroxyzine hcl 174 hydrocodone bitartrate/homatropine hydroxyzine pamoate 174 methylbromide 181 hyoscyamine sulfate 123 hydrocodone bitartrate/homatropine hyoscyamine sulfate (ED-SPAZ) 123 methylbromide (HYDROMET) 181 hyoscyamine sulfate (HYOSYNE) 123 hydrocodone bitartrate/homatropine hyoscyamine sulfate (NULEV) 123 methylbromide (TUSSIGON) 181 hyoscyamine sulfate (OSCIMIN SL) 123 hydrocodone polistirex/chlorpheniramine hyoscyamine sulfate (OSCIMIN SR) 123 polistirex 181 hyoscyamine sulfate (OSCIMIN) 123 hydrocodone/ibuprofen 10 hyoscyamine sulfate (SYMAX) 123 hydrocodone/ibuprofen (IBUDONE) 10 hyoscyamine sulfate (SYMAX-SL) 123 hydrocodone/ibuprofen (XYLON 10) 10 hyoscyamine sulfate (SYMAX-SR) 123 hydrocortisone 138,162 HYPER-SAL (sodium chloride for inhalation) 181 hydrocortisone (ALA-CORT) 138 HYSINGLA ER (hydrocodone bitartrate) 4 hydrocortisone (ANUSOL-HC) 138 HYZAAR (losartan hydrocortisone (COLOCORT) 162 potassium/hydrochlorothiazide) 86 hydrocortisone (PROCTO-MED HC) 138 hydrocortisone (PROCTO-PAK) 138 I hydrocortisone (PROCTOSOL-HC) 138 ibandronate sodium 163 hydrocortisone (PROCTOZONE-HC) 138 IBRANCE (palbociclib) 48 hydrocortisone (SCALACORT) 138 IBUDONE (hydrocodone/ibuprofen) 10 hydrocortisone acetate 138 ibuprofen 2 hydrocortisone acetate (ANUCORT-HC) 138 ibuprofen (IBU) 2 hydrocortisone acetate (ANUSOL-HC) 138 ibuprofen/oxycodone hcl 10 hydrocortisone acetate (HEMMOREX-HC) 138 icatibant acetate 158 hydrocortisone acetate (MICORT-HC) 107 ICLUSIG (ponatinib hcl) 48 hydrocortisone acetate/pramoxine hcl 107 IDHIFA (enasidenib mesylate) 45 hydrocortisone acetate/urea (U-CORT) 138 ILEVRO (nepafenac) 169 hydrocortisone butyrate 138 imatinib mesylate 48 hydrocortisone butyrate/emollient base 138 IMBRUVICA (ibrutinib) 48 hydrocortisone valerate 138 imipramine hcl 34 hydrocortisone/acetic acid 172 imipramine pamoate 35

205 LAST UPDATED 12/01/2019 imiquimod 107 INVOKAMET XR (canagliflozin/metformin IMITREX (sumatriptan succinate) 40,41 hcl) 69 IMITREX (sumatriptan) 41 INVOKANA (canagliflozin) 69 IMPAVIDO (miltefosine) 51 IOPIDINE (apraclonidine hcl) 170 IMPOYZ (clobetasol propionate) 138 ipratropium bromide 175 IMURAN (azathioprine) 159 ipratropium bromide/albuterol sulfate 181 IMVEXXY (estradiol) 147 IPRIVASK (desirudin) 75 INBRIJA (levodopa) 164 irbesartan 79 INCRELEX (mecasermin) 141 irbesartan/hydrochlorothiazide 86 INCRUSE ELLIPTA (umeclidinium bromide) 175 IRENKA (duloxetine hcl) 102 indapamide 90 IRESSA (gefitinib) 48 INDERAL LA (propranolol hcl) 81 ISENTRESS (raltegravir potassium) 60 INDERAL XL (propranolol hcl) 82 ISENTRESS HD (raltegravir potassium) 60 INDOCIN (indomethacin) 2 isoniazid 42 indomethacin 2 ISOPTO ATROPINE (atropine sulfate) 167 INGREZZA (valbenazine tosylate) 101 ISOPTO CARPINE (pilocarpine hcl) 170 INGREZZA INITIATION PACK (valbenazine ISORDIL (isosorbide dinitrate) 93 tosylate) 101 ISORDIL TITRADOSE (isosorbide dinitrate) 93 inhaler, assist devices 164 isosorbide dinitrate 93 inhaler, assist devices, accessories 164 isosorbide dinitrate (ISOCHRON) 93 inhaler,assist device with large mask 164 isosorbide mononitrate 93 inhaler,assist device with medium mask 164 isotretinoin 107 inhaler,assist device with small mask 164 isotretinoin (AMNESTEEM) 107 INLYTA (axitinib) 48 isotretinoin (CLARAVIS) 107 INNOPRAN XL (propranolol hcl) 82 isotretinoin (MYORISAN) 107 INREBIC (fedratinib dihydrochloride) 45 isotretinoin (ZENATANE) 107 INSPRA (eplerenone) 89 isradipine 83 insulin admin. supplies 165 ISTALOL (timolol maleate) 170 insulin lispro 73 itraconazole 38 insulin pump cartridge 165 ivermectin 51,107 insulin syringe-needle,safety,disposal unit,0.5 ml 165 J INTELENCE (etravirine) 60 JADENU (deferasirox) 114 INTERMEZZO (zolpidem tartrate) 185 JADENU SPRINKLE (deferasirox) 112 INTRAROSA (prasterone (dhea)) 165 JAKAFI (ruxolitinib phosphate) 48 INTRON A (interferon alfa-2b,recomb.) 59 JALYN (dutasteride/tamsulosin hcl) 132 INTUNIV (guanfacine hcl) 98 JANUMET (sitagliptin phosphate/metformin INVEGA (paliperidone) 56 hcl) 69 INVELTYS (loteprednol etabonate) 169 JANUMET XR (sitagliptin phosphate/metformin INVIRASE (saquinavir mesylate) 63 hcl) 69 INVOKAMET (canagliflozin/metformin hcl) 69 JANUVIA (sitagliptin phosphate) 69

206 LAST UPDATED 12/01/2019 JARDIANCE (empagliflozin) 69 ketoprofen 2 JENTADUETO (linagliptin/metformin hcl) 69 ketorolac tromethamine 2,169 JENTADUETO XR (linagliptin/metformin hcl) 69 KEVEYIS (dichlorphenamide) 89 JORNAY PM (methylphenidate hcl) 98 KEVZARA (sarilumab) 161 JUBLIA (efinaconazole) 38 KHEDEZLA (desvenlafaxine) 33 JULUCA (dolutegravir sodium/rilpivirine hcl) 63 KINERET (anakinra) 159 JUXTAPID (lomitapide mesylate) 92 KISQALI (ribociclib succinate) 48 JYNARQUE (tolvaptan) 112,114 KISQALI FEMARA CO-PACK (ribociclib succinate/letrozole) 48 K KITABIS PAK (tobramycin/nebulizer) 177 K-PHOS NEUTRAL (sodium KLARON (sulfacetamide sodium) 22 phosphate,dibasic/pot phos,monob/sod KLONOPIN (clonazepam) 67 phosphate mono) 133 KLOR-CON (potassium chloride) 114 K-PHOS NO.2 (sodium KLOR-CON 10 (potassium chloride) 114 phosphate,monobasic/potassium KLOR-CON 8 (potassium chloride) 114 phosphate,monobasic) 133 KLOR-CON M15 (potassium chloride) 114 K-PHOS ORIGINAL (potassium KOMBIGLYZE XR (saxagliptin hcl/metformin phosphate,monobasic) 133 hcl) 70 K-TAB ER (potassium chloride) 114 KORLYM (mifepristone) 138 KADIAN (morphine sulfate) 4,5 KOSHER PRENATAL PLUS IRON (prenatal KALETRA (lopinavir/ritonavir) 63 vitamins no.108/iron,carbonyl/folic acid) 114 KALYDECO (ivacaftor) 177 KRINTAFEL (tafenoquine succinate) 51 KAPSPARGO SPRINKLE (metoprolol KRISTALOSE (lactulose) 126 succinate) 82 KUVAN (sapropterin dihydrochloride) 129 KAPVAY (clonidine hcl) 98 KYNAMRO (mipomersen sodium) 92 KARBINAL ER (carbinoxamine maleate) 174 KATERZIA (amlodipine benzoate) 83 L KAYEXALATE (sodium polystyrene labetalol hcl 82 sulfonate) 114 LACRISERT (hydroxypropyl cellulose) 167 KAZANO (alogliptin benzoate/metformin lactulose 126 hcl) 69 lactulose (CONSTULOSE) 126 KEFLEX (cephalexin) 19 lactulose (ENULOSE) 126 KENALOG (triamcinolone acetonide) 138 lactulose (GENERLAC) 126 KEPPRA (levetiracetam) 25 LAMICTAL (BLUE) (lamotrigine) 27 KEPPRA XR (levetiracetam) 25 LAMICTAL (GREEN) (lamotrigine) 27 KERAFOAM (urea) 107 LAMICTAL (lamotrigine) 27 KERALAC (urea) 107 LAMICTAL (ORANGE) (lamotrigine) 27 KERYDIN (tavaborole) 38 LAMICTAL ODT (BLUE) (lamotrigine) 27 KETEK (telithromycin) 20 LAMICTAL ODT (GREEN) (lamotrigine) 27 ketoconazole 38 LAMICTAL ODT (lamotrigine) 27 ketoconazole (KETODAN) 38 LAMICTAL ODT (ORANGE) (lamotrigine) 27

207 LAST UPDATED 12/01/2019 LAMICTAL XR (BLUE) (lamotrigine) 27 levalbuterol tartrate 176 LAMICTAL XR (GREEN) (lamotrigine) 27 LEVAQUIN (levofloxacin) 22 LAMICTAL XR (lamotrigine) 27 LEVATOL (penbutolol sulfate) 82 LAMICTAL XR (ORANGE) (lamotrigine) 27 LEVBID (hyoscyamine sulfate) 124 LAMISIL (terbinafine hcl) 38 LEVEMIR (insulin detemir) 73 lamivudine 58,61,62 LEVEMIR FLEXTOUCH (insulin detemir) 73 lamivudine/zidovudine 62 levetiracetam 25 lamotrigine 28 levetiracetam (ROWEEPRA XR) 25 lamotrigine (SUBVENITE (BLUE)) 28 levetiracetam (ROWEEPRA) 25 lamotrigine (SUBVENITE (GREEN)) 28 LEVITRA (vardenafil hcl) 133 lamotrigine (SUBVENITE (ORANGE)) 28 LEVO-T (levothyroxine sodium) 156 lamotrigine (SUBVENITE) 28 levobunolol hcl 170 lancets 165 levocarnitine 114 LANOXIN (digoxin) 86 levocarnitine (with sugar) 114 lansoprazole 128 levofloxacin 22 lansoprazole/amoxicillin levonorgestrel 154 trihydrate/clarithromycin 124 levonorgestrel (AFTERA) 154 lanthanum carbonate 134 levonorgestrel (ECONTRA EZ) 154 LANTUS (insulin glargine,human recombinant levonorgestrel (ECONTRA ONE-STEP) 154 analog) 73 levonorgestrel (FALLBACK SOLO) 154 LANTUS SOLOSTAR (insulin glargine,human levonorgestrel (MY CHOICE) 154 recombinant analog) 73 levonorgestrel (MY WAY) 154 LASIX (furosemide) 89 levonorgestrel (NEW DAY) 154 LASTACAFT (alcaftadine) 168 levonorgestrel (NEXT CHOICE ONE DOSE) 154 latanoprost 171 levonorgestrel (OPCICON ONE-STEP) 154 LATUDA (lurasidone hcl) 56 levonorgestrel (OPTION 2) 154 LAYOLIS FE (norethindrone-ethinyl levonorgestrel (TAKE ACTION) 154 estradiol/ferrous fumarate) 147 levonorgestrel-ethinyl estradiol 148 LAZANDA (fentanyl citrate) 10 levonorgestrel-ethinyl estradiol ledipasvir/sofosbuvir 58 (AFIRMELLE) 147 leflunomide 161 levonorgestrel-ethinyl estradiol LENVIMA (lenvatinib mesylate) 48,49 (ALTAVERA) 147 LESCOL (fluvastatin sodium) 92 levonorgestrel-ethinyl estradiol (AMETHYST)147 LESCOL XL (fluvastatin sodium) 92 levonorgestrel-ethinyl estradiol (AUBRA LETAIRIS (ambrisentan) 178 EQ) 147 letrozole 46 levonorgestrel-ethinyl estradiol (AUBRA) 147 leucovorin calcium 45 levonorgestrel-ethinyl estradiol (AVIANE) 147 LEUKERAN (chlorambucil) 43 levonorgestrel-ethinyl estradiol (AYUNA) 147 LEUKINE (sargramostim) 76 levonorgestrel-ethinyl estradiol (CHATEAL leuprolide acetate 157 EQ) 147 levalbuterol hcl 176 levonorgestrel-ethinyl estradiol (CHATEAL) 147

208 LAST UPDATED 12/01/2019 levonorgestrel-ethinyl estradiol (DELYLA) 147 levonorgestrel/ethinyl estradiol and ethinyl levonorgestrel-ethinyl estradiol (ENPRESSE) 147 estradiol (RIVELSA) 148 levonorgestrel-ethinyl estradiol (FALMINA) 147 levonorgestrel/ethinyl estradiol and ethinyl levonorgestrel-ethinyl estradiol estradiol (SIMPESSE) 149 (INTROVALE) 147 levorphanol tartrate 5 levonorgestrel-ethinyl estradiol (JOLESSA) 147 levothyroxine sodium 156 levonorgestrel-ethinyl estradiol (KURVELO) 147 LEVOXYL (levothyroxine sodium) 156 levonorgestrel-ethinyl estradiol (LARISSIA) 147 LEVSIN (hyoscyamine sulfate) 124 levonorgestrel-ethinyl estradiol (LESSINA) 147 LEVSIN-SL (hyoscyamine sulfate) 124 levonorgestrel-ethinyl estradiol (LEVONEST) 147 LEXAPRO (escitalopram oxalate) 33 levonorgestrel-ethinyl estradiol (LEVORA- LEXETTE (halobetasol propionate) 139 28) 148 LEXIVA (fosamprenavir calcium) 63 levonorgestrel-ethinyl estradiol (LILLOW) 148 LIALDA (mesalamine) 162 levonorgestrel-ethinyl estradiol (LUTERA) 148 LIBRAX (chlordiazepoxide/clidinium levonorgestrel-ethinyl estradiol (MARLISSA) 148 bromide) 124 levonorgestrel-ethinyl estradiol (MYZILRA) 148 lidocaine 13 levonorgestrel-ethinyl estradiol (ORSYTHIA) 148 lidocaine hcl 13 levonorgestrel-ethinyl estradiol (PORTIA) 148 lidocaine hcl (GLYDO) 13 levonorgestrel-ethinyl estradiol lidocaine/prilocaine 14 (QUASENSE) 148 LIDODERM (lidocaine) 14 levonorgestrel-ethinyl estradiol (SETLAKIN) 148 lindane 52 levonorgestrel-ethinyl estradiol (SRONYX) 148 linezolid 17 levonorgestrel-ethinyl estradiol (TRIVORA- LINZESS (linaclotide) 126 28) 148 liothyronine sodium 156 levonorgestrel-ethinyl estradiol (VIENVA) 148 LIPITOR (atorvastatin calcium) 92 levonorgestrel/ethinyl estradiol and ethinyl LIPOFEN (fenofibrate) 91 estradiol 148 lisinopril 80 levonorgestrel/ethinyl estradiol and ethinyl lisinopril/hydrochlorothiazide 86 estradiol (AMETHIA LO) 148 lithium carbonate 67 levonorgestrel/ethinyl estradiol and ethinyl lithium citrate 67 estradiol (AMETHIA) 148 LITHOBID (lithium carbonate) 67 levonorgestrel/ethinyl estradiol and ethinyl LITHOSTAT (acetohydroxamic acid) 133 estradiol (ASHLYNA) 148 LIVALO (pitavastatin calcium) 92 levonorgestrel/ethinyl estradiol and ethinyl LO LOESTRIN FE (norethindrone acetate- estradiol (CAMRESE LO) 148 ethinyl estradiol/ferrous fumarate) 149 levonorgestrel/ethinyl estradiol and ethinyl LO MINASTRIN FE (norethindrone acetate- estradiol (CAMRESE) 148 ethinyl estradiol/ferrous fumarate) 149 levonorgestrel/ethinyl estradiol and ethinyl LOCOID (hydrocortisone butyrate) 139 estradiol (DAYSEE) 148 LOCOID LIPOCREAM (hydrocortisone levonorgestrel/ethinyl estradiol and ethinyl butyrate/emollient base) 139 estradiol (FAYOSIM) 148 LODINE (etodolac) 2

209 LAST UPDATED 12/01/2019 LODOSYN (carbidopa) 54 LOVENOX (enoxaparin sodium) 75 LOESTRIN (norethindrone acetate-ethinyl loxapine succinate 55 estradiol) 149 LUCEMYRA (lofexidine hcl) 15 LOESTRIN FE (norethindrone acetate-ethinyl luliconazole 38 estradiol/ferrous fumarate) 149 LUMIGAN (bimatoprost) 171 LOKELMA (sodium zirconium cyclosilicate) 165 LUNESTA (eszopiclone) 185 LOMOTIL (diphenoxylate hcl/atropine LUXIQ (betamethasone valerate) 139 sulfate) 125 LUZU (luliconazole) 38 LONHALA MAGNAIR REFILL LYNPARZA (olaparib) 49 (glycopyrrolate/nebulizer accessories) 175 LYRICA (pregabalin) 102 LONHALA MAGNAIR STARTER LYRICA CR (pregabalin) 102 (glycopyrrolate/nebulizer and LYSODREN (mitotane) 45 accessories) 175 LYSTEDA (tranexamic acid) 76 LONSURF (trifluridine/tipiracil hcl) 44 LOPID (gemfibrozil) 91 M lopinavir/ritonavir 64 MACROBID (nitrofurantoin LOPRESSOR (metoprolol tartrate) 82 monohydrate/macrocrystals) 17 LOPRESSOR HCT (metoprolol MACRODANTIN (nitrofurantoin tartrate/hydrochlorothiazide) 87 macrocrystal) 17 LOPROX (ciclopirox) 38 mafenide acetate 17 lorazepam 67 MAKENA (hydroxyprogesterone caproate)154 lorazepam (LORAZEPAM INTENSOL) 67 MAKENA (hydroxyprogesterone LORBRENA (lorlatinib) 46 caproate/pf) 154,155 LORZONE (chlorzoxazone) 183 MALARONE (atovaquone/proguanil hcl) 51,52 losartan potassium 79 malathion 52 losartan potassium/hydrochlorothiazide 87 maprotiline hcl 33 LOSEASONIQUE (levonorgestrel/ethinyl MARINOL (dronabinol) 36 estradiol and ethinyl estradiol) 149 MARNATAL-F (prenatal vits with calcium LOTEMAX (loteprednol etabonate) 169 no.65/iron polysacchar/folic acid) 114 LOTEMAX SM (loteprednol etabonate) 169 MARPLAN (isocarboxazid) 32 LOTENSIN (benazepril hcl) 80 MARTEN-TAB (butalbital/acetaminophen) 101 LOTENSIN HCT (benazepril MATULANE (procarbazine hcl) 43 hcl/hydrochlorothiazide) 87 MAVENCLAD (cladribine) 103 loteprednol etabonate 169 MAVIK (trandolapril) 80 LOTREL (amlodipine besylate/benazepril MAVYRET (glecaprevir/pibrentasvir) 58 hcl) 87 MAXALT (rizatriptan benzoate) 41 LOTRISONE (clotrimazole/betamethasone MAXALT MLT (rizatriptan benzoate) 41 dipropionate) 107 MAXIDEX (dexamethasone) 169 LOTRONEX (alosetron hcl) 126 MAXITROL (neomycin/polymyxin b lovastatin 92 sulfate/dexamethasone) 167 LOVAZA (omega-3 acid ethyl esters) 92 MAXZIDE (triamterene/hydrochlorothiazide) 87

210 LAST UPDATED 12/01/2019 MAXZIDE-25 MG methimazole 158 (triamterene/hydrochlorothiazide) 87 METHITEST (methyltestosterone) 143 MAYZENT (siponimod) 103 methocarbamol 183 mebendazole (EMVERM) 51 methotrexate sodium 159 mecamylamine hcl (VECAMYL) 87 methotrexate sodium/pf 159 meclofenamate sodium 2 methoxsalen 108 MEDROL (methylprednisolone) 139 methscopolamine bromide 124 medroxyprogesterone acetate 155 methyclothiazide 90 mefenamic acid 2 methyldopa 77 mefloquine hcl 52 methyldopa/hydrochlorothiazide 87 MEGACE (megestrol acetate) 155 methylergonovine maleate 165 MEGACE ES (megestrol acetate) 155 methylergonovine maleate (METHERGINE) 165 megestrol acetate 155 METHYLIN (methylphenidate hcl) 98 MEKINIST (trametinib dimethyl sulfoxide) 49 methylphenidate hcl 98,99 MEKTOVI (binimetinib) 49 methylphenidate hcl (METADATE ER) 98 meloxicam 2 methylphenidate hcl (RELEXXII) 98 melphalan 43 methylprednisolone 139 memantine hcl 30,31 methyltestosterone 143 MENEST (estrogens,esterified) 149 metipranolol 171 MENOPUR (menotropins) 141 metoclopramide hcl 35 MENOSTAR (estradiol) 149 metolazone 90 meperidine hcl 10,11 metoprolol succinate 82 MEPHYTON (phytonadione (vit k1)) 76 metoprolol succinate/hydrochlorothiazide 87 meprobamate 66 metoprolol tartrate 82 MEPRON (atovaquone) 52 metoprolol tartrate/hydrochlorothiazide 87 mercaptopurine 44 METOZOLV ODT (metoclopramide hcl) 35 mesalamine 162 METROCREAM (metronidazole) 108 MESNEX (mesna) 50 METROGEL (metronidazole) 108 MESTINON (pyridostigmine bromide) 42 METROGEL-VAGINAL (metronidazole) 17 METADATE CD (methylphenidate hcl) 98 METROLOTION (metronidazole) 108 metaproterenol sulfate 176 metronidazole 17,108 metaxalone 183 metronidazole (ROSADAN) 108 metaxalone (METAXALL) 183 mexiletine hcl 81 metformin hcl 70 MIACALCIN (calcitonin,salmon,synthetic) 164 methadone hcl 5 MICARDIS (telmisartan) 79 methadone hcl (METHADONE INTENSOL) 5 MICARDIS HCT methadone hcl (METHADOSE) 5 (telmisartan/hydrochlorothiazide) 87 METHADOSE (methadone hcl) 5 miconazole nitrate 38 methamphetamine hcl 96 miconazole nitrate/zinc methazolamide 170 oxide/petrolatum,white 38 methenamine hippurate 17 MICORT-HC (hydrocortisone acetate) 139

211 LAST UPDATED 12/01/2019 MICROGESTIN 24 FE (norethindrone acetate- MOVANTIK (naloxegol oxalate) 125 ethinyl estradiol/ferrous fumarate) 149 MOVIPREP (peg 3350/sodium sulfate/sod MICROZIDE (hydrochlorothiazide) 90 chloride/kcl/ascorbate sod/vit c) 127 midodrine hcl 78 MOXATAG (amoxicillin) 20 miglitol 70 MOXEZA (moxifloxacin hcl) 22 miglustat 129 moxifloxacin hcl 22 MIGRANAL (dihydroergotamine mesylate) 40 MOZOBIL (plerixafor) 76 MILLIPRED (prednisolone sodium MS CONTIN (morphine sulfate) 5 phosphate) 139 MULPLETA (lusutrombopag) 76 MINASTRIN 24 FE (norethindrone acetate- MULTAQ (dronedarone hcl) 81 ethinyl estradiol/ferrous fumarate) 149 multivitamin no.39/iron MINIPRESS (prazosin hcl) 78 carb,bisgl/methylfolate/docusate/dha MINIVELLE (estradiol) 149 (OBSTETRIX ONE) 114 MINOCIN (minocycline hcl) 23 multivitamin with minerals minocycline hcl 24 no.69/iron,carbonyl/folic acid (ELITE-OB) 114 minocycline hcl (COREMINO) 23 mupirocin 17 MINOLIRA ER (minocycline hcl) 24 mupirocin calcium 17 minoxidil 93 MUSE (alprostadil) 133 MIRAPEX (pramipexole di-hcl) 53 MVC-FLUORIDE (pediatric multivitamin no.12 MIRAPEX ER (pramipexole di-hcl) 53 with sodium fluoride) 114 MIRCERA (methoxy polyethylene glycol- MYALEPT (metreleptin) 125 epoetin beta) 76 MYAMBUTOL (ethambutol hcl) 42 MIRCETTE (desogestrel-ethinyl estradiol/ethinyl MYCOBUTIN (rifabutin) 42 estradiol) 149 mycophenolate mofetil 159 mirtazapine 31 mycophenolate sodium 159 MIRVASO (brimonidine tartrate) 108 MYDAYIS (dextroamphetamine sulf- misoprostol 127 saccharate/amphetamine sulf-aspartate) 96 MITIGARE (colchicine) 39 MYDRIACYL (tropicamide) 167 MOBIC (meloxicam) 2 MYFORTIC (mycophenolate sodium) 159 modafinil 186 MYLERAN (busulfan) 43 moexipril hcl 80 MYNATAL (prenatal vitamins with moexipril hcl/hydrochlorothiazide 87 calcium/ferrous fumarate/folic acid) 114 molindone hcl 55 MYRBETRIQ (mirabegron) 131 mometasone furoate 139,173 MYSOLINE (primidone) 26 MONODOX (doxycycline monohydrate) 24 MYTESI (crofelemer) 125 montelukast sodium 175 MONUROL (fosfomycin tromethamine) 17 N MORPHABOND ER (morphine sulfate) 5 nabumetone 2 morphine sulfate 5,11 nadolol 82 MOTEGRITY (prucalopride succinate) 35 nadolol/bendroflumethiazide 87 MOTOFEN (difenoxin hcl/atropine sulfate) 125 naftifine hcl 38

212 LAST UPDATED 12/01/2019 NAFTIN (naftifine hcl) 38 neomycin sulfate/bacitracin zinc/polymyxin NALFON (fenoprofen calcium) 2 b/hydrocortisone (NEO-POLYCIN HC) 167 naloxone hcl 15 neomycin sulfate/bacitracin/polymyxin b 167 naltrexone hcl 14 neomycin sulfate/bacitracin/polymyxin b NAMENDA (memantine hcl) 31 (NEO-POLYCIN) 167 NAMENDA XR (memantine hcl) 31 neomycin sulfate/polymyxin b sulfate 17 NAMZARIC (memantine hcl/donepezil hcl) 30 neomycin sulfate/polymyxin b naphazoline hcl 167 sulfate/gramicidin d 167 NAPRELAN (naproxen sodium) 2 neomycin sulfate/polymyxin b NAPROSYN (naproxen) 2 sulfate/hydrocortisone 167,172 naproxen 3 neomycin/polymyxin b naproxen sodium 3 sulfate/dexamethasone 167 naratriptan hcl 41 NEORAL (cyclosporine, modified) 160 NARCAN (naloxone hcl) 15 NEOSPORIN G.U. IRRIGANT (neomycin NARDIL (phenelzine sulfate) 32 sulfate/polymyxin b sulfate) 18 NASCOBAL (cyanocobalamin (vitamin b- NEPTAZANE (methazolamide) 171 12)) 114 NERLYNX (neratinib maleate) 49 NASONEX (mometasone furoate) 173 NESINA (alogliptin benzoate) 70 NATACHEW (prenatal vitamin no.55/iron NESTABS (prenatal vitamin no.86/iron bis- fumarate,bisglycinate/folic acid) 115 glycinate/folic acid) 115 NATACYN (natamycin) 38 NESTABS ONE (multivit 42/iron carbonyl,b-g NATAZIA (estradiol valerate/dienogest) 149 che/methyltetrahydrofolate/dha) 115 nateglinide 70 NEULASTA (pegfilgrastim) 76 NATELLE ONE (prenatal vit, calcium NEUPOGEN (filgrastim) 76 no.70/ferrous fumarate/folic acid/dha) 115 NEUPRO (rotigotine) 53 NATESTO (testosterone) 143 NEURONTIN (gabapentin) 26 NATPARA (parathyroid hormone) 164 NEVANAC (nepafenac) 169 NATROBA (spinosad) 108 nevirapine 60 NATURE-THROID (thyroid,pork) 156 NEXA PLUS (prenatal vits no.53/iron fum/folic NAYZILAM (midazolam) 14 acid/docusate calcium/dha) 115 nebulizer and compressor 165 NEXAVAR (sorafenib tosylate) 49 NEBUSAL (sodium chloride for inhalation) 181 NEXIUM (esomeprazole magnesium) 128 needles, safety 165 niacin 92 NEEVODHA (multivit no.37/iron/l-mefolate niacin (NIACOR) 92 calc./algal oil/soy lecithin) 115 NIASPAN (niacin) 92,93 nefazodone hcl 33 nicardipine hcl 83 NEO-SYNALAR (neomycin sulfate/fluocinolone NICOTROL (nicotine) 15 acetonide) 108 NICOTROL NS (nicotine) 15 neomycin sulfate 16 nifedipine 83 neomycin sulfate/bacitracin zinc/polymyxin nifedipine (AFEDITAB CR) 83 b/hydrocortisone 167 nifedipine (NIFEDICAL XL) 83

213 LAST UPDATED 12/01/2019 NILANDRON (nilutamide) 43 norethindrone (SHAROBEL) 155 nilutamide 43 norethindrone (TULANA) 155 nimodipine 83 norethindrone acetate 155 NINLARO (ixazomib citrate) 45 norethindrone acetate-ethinyl estradiol 150 nisoldipine 83 norethindrone acetate-ethinyl estradiol nitisinone 129 (AUROVELA) 149 NITRO-BID (nitroglycerin) 94 norethindrone acetate-ethinyl estradiol NITRO-DUR (nitroglycerin) 94 (FYAVOLV) 149 nitrofurantoin 18 norethindrone acetate-ethinyl estradiol nitrofurantoin macrocrystal 18 (GILDESS) 149 nitrofurantoin monohydrate/macrocrystals 18 norethindrone acetate-ethinyl estradiol nitroglycerin 94 (HAILEY) 149 nitroglycerin (MINITRAN) 94 norethindrone acetate-ethinyl estradiol nitroglycerin (NITRO-TIME) 94 (JEVANTIQUE LO) 149 NITROLINGUAL (nitroglycerin) 94 norethindrone acetate-ethinyl estradiol NITROMIST (nitroglycerin) 94 (JINTELI) 149 NITROSTAT (nitroglycerin) 94 norethindrone acetate-ethinyl estradiol NITYR (nitisinone) 129 (JUNEL) 149 NIVESTYM (filgrastim-aafi) 76 norethindrone acetate-ethinyl estradiol nizatidine 125 (LARIN) 150 NIZORAL (ketoconazole) 38 norethindrone acetate-ethinyl estradiol NOCDURNA (desmopressin acetate) 141 (MICROGESTIN) 150 NOCTIVA (desmopressin acetate) 141 norethindrone acetate-ethinyl non accu-chek blood glucose test strips 165 estradiol/ferrous fumarate 150 NOR-Q-D (norethindrone) 155 norethindrone acetate-ethinyl NORCO (hydrocodone estradiol/ferrous fumarate (AUROVELA 24 bitartrate/acetaminophen) 11 FE) 150 NORDITROPIN FLEXPRO (somatropin) 142 norethindrone acetate-ethinyl norelgestromin/ethinyl estradiol (XULANE) 149 estradiol/ferrous fumarate (AUROVELA FE) 150 norethindrone 155 norethindrone acetate-ethinyl norethindrone (CAMILA) 155 estradiol/ferrous fumarate (BLISOVI 24 FE) 150 norethindrone (DEBLITANE) 155 norethindrone acetate-ethinyl norethindrone (ERRIN) 155 estradiol/ferrous fumarate (BLISOVI FE) 150 norethindrone (HEATHER) 155 norethindrone acetate-ethinyl norethindrone (INCASSIA) 155 estradiol/ferrous fumarate (GILDESS 24 FE) 150 norethindrone (JENCYCLA) 155 norethindrone acetate-ethinyl norethindrone (JOLIVETTE) 155 estradiol/ferrous fumarate (HAILEY 24 FE) 150 norethindrone (LYZA) 155 norethindrone acetate-ethinyl norethindrone (NORA-BE) 155 estradiol/ferrous fumarate (JUNEL FE 24) 150 norethindrone (NORLYDA) 155 norethindrone acetate-ethinyl norethindrone (NORLYROC) 155 estradiol/ferrous fumarate (JUNEL FE) 150

214 LAST UPDATED 12/01/2019 norethindrone acetate-ethinyl norethindrone-ethinyl estradiol estradiol/ferrous fumarate (LARIN 24 FE) 150 (ZENCHENT) 151 norethindrone acetate-ethinyl norethindrone-ethinyl estradiol/ferrous estradiol/ferrous fumarate (LARIN FE) 150 fumarate 151 norethindrone acetate-ethinyl norethindrone-ethinyl estradiol/ferrous estradiol/ferrous fumarate (LOMEDIA 24 fumarate (KAITLIB FE) 151 FE) 150 norethindrone-ethinyl estradiol/ferrous norethindrone acetate-ethinyl fumarate (WYMZYA FE) 151 estradiol/ferrous fumarate (MELODETTA 24 NORGESIC FORTE (orphenadrine FE) 150 citrate/aspirin/caffeine) 184 norethindrone acetate-ethinyl norgestimate-ethinyl estradiol 152 estradiol/ferrous fumarate (MIBELAS 24 FE) 150 norgestimate-ethinyl estradiol (ESTARYLLA) 152 norethindrone acetate-ethinyl norgestimate-ethinyl estradiol (FEMYNOR) 152 estradiol/ferrous fumarate (MICROGESTIN norgestimate-ethinyl estradiol (MILI) 152 FE) 150 norgestimate-ethinyl estradiol (MONO- norethindrone acetate-ethinyl LINYAH) 152 estradiol/ferrous fumarate (TARINA 24 FE) 151 norgestimate-ethinyl estradiol norethindrone acetate-ethinyl (MONONESSA) 152 estradiol/ferrous fumarate (TARINA FE 1-20 norgestimate-ethinyl estradiol (PREVIFEM) 152 EQ) 151 norgestimate-ethinyl estradiol (SPRINTEC) 152 norethindrone acetate-ethinyl norgestimate-ethinyl estradiol (TRI estradiol/ferrous fumarate (TARINA FE) 151 FEMYNOR) 152 norethindrone acetate-ethinyl norgestimate-ethinyl estradiol (TRI- estradiol/ferrous fumarate (TILIA FE) 151 ESTARYLLA) 152 norethindrone acetate-ethinyl norgestimate-ethinyl estradiol (TRI-LINYAH) 152 estradiol/ferrous fumarate (TRI-LEGEST FE) 151 norgestimate-ethinyl estradiol (TRI-LO- norethindrone-ethinyl estradiol (ALYACEN) 151 ESTARYLLA) 152 norethindrone-ethinyl estradiol (ARANELLE)151 norgestimate-ethinyl estradiol (TRI-LO- norethindrone-ethinyl estradiol (BALZIVA) 151 MARZIA) 152 norethindrone-ethinyl estradiol (BRIELLYN) 151 norgestimate-ethinyl estradiol (TRI-LO-MILI) 152 norethindrone-ethinyl estradiol norgestimate-ethinyl estradiol (TRI-LO- (CYCLAFEM) 151 SPRINTEC) 152 norethindrone-ethinyl estradiol (DASETTA) 151 norgestimate-ethinyl estradiol (TRI-MILI) 152 norethindrone-ethinyl estradiol (GILDAGIA)151 norgestimate-ethinyl estradiol (TRI- norethindrone-ethinyl estradiol (LEENA) 151 PREVIFEM) 152 norethindrone-ethinyl estradiol (NECON) 151 norgestimate-ethinyl estradiol (TRI- norethindrone-ethinyl estradiol (NORTREL) 151 SPRINTEC) 152 norethindrone-ethinyl estradiol (PHILITH) 151 norgestimate-ethinyl estradiol (TRI-VYLIBRA norethindrone-ethinyl estradiol (PIRMELLA) 151 LO) 152 norethindrone-ethinyl estradiol (VYFEMLA) 151 norgestimate-ethinyl estradiol (TRI- norethindrone-ethinyl estradiol (WERA) 151 VYLIBRA) 152

215 LAST UPDATED 12/01/2019 norgestimate-ethinyl estradiol (TRINESSA NULYTELY WITH FLAVOR PACKS (sodium LO) 152 chloride/sodium bicarbonate/potassium norgestimate-ethinyl estradiol (TRINESSA) 152 chloride/peg) 127 norgestimate-ethinyl estradiol (VYLIBRA) 152 NUPLAZID (pimavanserin tartrate) 56 norgestrel-ethinyl estradiol (CRYSELLE) 152 NUTROPIN AQ NUSPIN (somatropin) 142 norgestrel-ethinyl estradiol (ELINEST) 153 NUVARING (etonogestrel/ethinyl estradiol) 153 norgestrel-ethinyl estradiol (LOW- NUVESSA (metronidazole) 18 OGESTREL) 153 NUVIGIL (armodafinil) 186 norgestrel-ethinyl estradiol (OGESTREL) 153 NUZYRA (omadacycline tosylate) 24 NORITATE (metronidazole) 108 NYMALIZE (nimodipine) 83 NORPACE (disopyramide phosphate) 81 nystatin 38 NORPACE CR (disopyramide phosphate) 81 nystatin (NYAMYC) 38 NORPRAMIN (desipramine hcl) 35 nystatin (NYATA) 38 NORTHERA (droxidopa) 78 nystatin (NYSTOP) 38 nortriptyline hcl 35 nystatin/triamcinolone acetonide 38 NORVASC (amlodipine besylate) 83 NORVIR (ritonavir) 64 O NOURIANZ (istradefylline) 52 O-CAL PRENATAL (prenatal vit with calcium NOVAREL (chorionic gonadotropin, no.127/ferrous fumarate/folic acid) 115 human) 142 OB COMPLETE (multivitamin with minerals NOVOLIN 70-30 (insulin nph human no.69/iron,carbonyl/folic acid) 115 isophane/insulin regular, human) 73 OB COMPLETE ONE (prenatal vit no.85/iron NOVOLIN 70-30 FLEXPEN (insulin nph human carb,asp.gly/folic acid/dha/fish oil) 115 isophane/insulin regular, human) 73 OB COMPLETE PETITE (prenatal no56/iron NOVOLIN N (insulin nph human isophane) 73 carbonyl,asparto glycinate/folic NOVOLIN R (insulin regular, human) 73 acid/dha) 115 NOVOLOG (insulin aspart) 73 OB COMPLETE PREMIER (prenatal vits NOVOLOG FLEXPEN (insulin aspart) 73 no.83/iron,carbonyl,iron aspart.gly/folic NOVOLOG MIX 70-30 (insulin aspart acid) 115 protamine human/insulin aspart) 73 OB COMPLETE WITH DHA (prenatal vit NOVOLOG MIX 70-30 FLEXPEN (insulin aspart no.30/iron carbonyl,asp glyc/folic protamine human/insulin aspart) 73 acid/omega-3) 115 NOXAFIL (posaconazole) 38 OBREDON (guaifenesin/hydrocodone NUBEQA (darolutamide) 43 bitartrate) 181 NUCALA (mepolizumab) 181 OBSTETRIX EC (prenatal vitamins NUCYNTA (tapentadol hcl) 11 no.127/iron,carbonyl/folic acid/docusate) 115 NUCYNTA ER (tapentadol hcl) 6 OCALIVA (obeticholic acid) 125 NUEDEXTA (dextromethorphan hbr/quinidine octreotide acetate 157 sulfate) 101 OCUFEN (flurbiprofen sodium) 169 OCUFLOX (ofloxacin) 22

216 LAST UPDATED 12/01/2019 ODACTRA (allergenic extract, mite-d.farinae- OPANA ER (oxymorphone hcl) 6 d.pteronyssinus,standard) 165 OPSUMIT (macitentan) 178 ODEFSEY (emtricitabine/rilpivirine ORACEA (doxycycline monohydrate) 24 hcl/tenofovir alafenamide fumarate) 61 ORACIT (citric acid/sodium citrate) 133 ODOMZO (sonidegib phosphate) 49 ORALAIR (grass pollen-orchard/sweet OFEV (nintedanib esylate) 182 vernal/rye/kentucky/timothy, std.) 182 ofloxacin 22 ORAP (pimozide) 55 olanzapine 56 ORAPRED ODT (prednisolone sodium olanzapine/fluoxetine hcl 31 phosphate) 139 olmesartan medoxomil 79 ORAVIG (miconazole) 38 olmesartan medoxomil/amlodipine ORENCIA (abatacept) 160 besylate/hydrochlorothiazide 88 ORENCIA CLICKJECT (abatacept) 160 olmesartan ORENITRAM ER (treprostinil diolamine) 178 medoxomil/hydrochlorothiazide 88 ORFADIN (nitisinone) 129,130 olopatadine hcl 168,174 ORILISSA (elagolix sodium) 157 OLUMIANT (baricitinib) 160 ORKAMBI (lumacaftor/ivacaftor) 177 OLUX (clobetasol propionate) 139 orphenadrine citrate 184 OLUX-E (clobetasol propionate/emollient orphenadrine citrate/aspirin/caffeine 184 base) 139 orphenadrine citrate/aspirin/caffeine OLYSIO (simeprevir sodium) 58 (ORPHENGESIC FORTE) 184 OMECLAMOX-PAK ORTHO MICRONOR (norethindrone) 155 (omeprazole/clarithromycin/amoxicillin ORTHO TRI-CYCLEN (norgestimate-ethinyl trihydrate) 125 estradiol) 153 omega-3 acid ethyl esters 93 ORTHO TRI-CYCLEN LO (norgestimate-ethinyl omega-3 acid ethyl esters (TRIKLO) 93 estradiol) 153 omeprazole 128 ORTHO-CYCLEN (norgestimate-ethinyl omeprazole/sodium bicarbonate 128 estradiol) 153 omeprazole/sodium bicarbonate ORTHO-NOVUM (norethindrone-ethinyl (OMEPPI) 128 estradiol) 153 OMNARIS (ciclesonide) 173 oseltamivir phosphate 64,65 OMNIPRED (prednisolone acetate) 169 OSENI (alogliptin benzoate/pioglitazone OMNITROPE (somatropin) 142 hcl) 70 ondansetron 36 OSMOLEX ER (amantadine hcl) 53 ondansetron hcl 36 OSMOPREP (sodium ONEXTON (clindamycin phosphate/benzoyl phosphate,monobasic/sodium peroxide) 108 phosphate,dibasic) 127 ONFI (clobazam) 26 OSPHENA (ospemifene) 156 ONGLYZA (saxagliptin hcl) 70 OTEZLA (apremilast) 161 ONMEL (itraconazole) 38 OTOVEL (ciprofloxacin hcl/fluocinolone ONZETRA XSAIL (sumatriptan succinate) 41 acetonide) 172 OPANA (oxymorphone hcl) 11 OTREXUP (methotrexate/pf) 160

217 LAST UPDATED 12/01/2019 OVACE (sulfacetamide sodium) 108 PARAFON FORTE DSC (chlorzoxazone) 184 OVACE PLUS (sulfacetamide sodium) 108 paricalcitol 164 OVACE PLUS WASH (sulfacetamide PARLODEL (bromocriptine mesylate) 53 sodium) 108 PARNATE (tranylcypromine sulfate) 32 OVIDE (malathion) 52 paromomycin sulfate 16 OVIDREL (choriogonadotropin alfa) 142 paroxetine hcl 33 OXANDRIN (oxandrolone) 142 paroxetine mesylate 33 oxandrolone 142 PASER (aminosalicylic acid) 42 oxaprozin 3 PATADAY (olopatadine hcl) 168 OXAYDO (oxycodone hcl) 11 PATANASE (olopatadine hcl) 174 oxazepam 67 PATANOL (olopatadine hcl) 168 oxcarbazepine 29 PAXIL (paroxetine hcl) 33 OXERVATE (cenegermin-bkbj) 167 PAXIL CR (paroxetine hcl) 33 oxiconazole nitrate 38 PAZEO (olopatadine hcl) 168 OXISTAT (oxiconazole nitrate) 38 PCE (erythromycin base) 20 OXSORALEN-ULTRA (methoxsalen) 108 pediatric multivit with a,c,d3 no.21/sodium OXTELLAR XR (oxcarbazepine) 29 fluoride 115 oxybutynin chloride 131 pediatric multivit with a,c,d3 no.21/sodium oxycodone hcl 6,11 fluoride (TRI-VITE WITH FLUORIDE) 115 oxycodone hcl/acetaminophen 12 pediatric multivitamin no.16/sodium oxycodone hcl/acetaminophen fluoride 115 (ENDOCET) 12 pediatric multivitamin no.2/sodium oxycodone hcl/acetaminophen fluoride 115 (NALOCET) 12 pediatric multivitamin no.45/sodium oxycodone hcl/acetaminophen (PRIMLEV) 12 fluoride/ferrous sulfate 116 oxycodone hcl/aspirin 12 pediatric multivitamin no.75/sodium OXYCONTIN (oxycodone hcl) 6 fluoride/ferrous sulfate 116 oxymorphone hcl 6,12 pediatric multivitamin no.82 with sodium OXYTROL (oxybutynin) 131 fluoride 116 OZEMPIC (semaglutide) 70 pediatric multivitamins no.17 with sodium OZOBAX (baclofen) 57 fluoride 116 peg 3350/sod sulf/sod bicarb/sod P chloride/potassium chloride 127 PACERONE (amiodarone hcl) 81 peg 3350/sod sulf/sod bicarb/sod paliperidone 56 chloride/potassium chloride (GAVILYTE-C) 127 PALYNZIQ (pegvaliase-pqpz) 130 peg 3350/sod sulf/sod bicarb/sod PAMELOR (nortriptyline hcl) 35 chloride/potassium chloride (GAVILYTE-G) 127 PANCREAZE (lipase/protease/amylase) 130 PEGANONE (ethotoin) 29 PANDEL (hydrocortisone probutate) 139 PEGASYS (peginterferon alfa-2a) 59 PANRETIN (alitretinoin) 50 PEGASYS PROCLICK (peginterferon alfa-2a) 59 pantoprazole sodium 128 PEGINTRON (peginterferon alfa-2b) 59

218 LAST UPDATED 12/01/2019 PEGINTRON REDIPEN (peginterferon alfa- PHOSLYRA (calcium acetate) 134 2b) 59 PHOSPHOLINE IODIDE (echothiophate pen needle, diabetic 165 iodide) 171 pen needle, diabetic disposable, safety 165 phytonadione (vit k1) 76 pen needle, diabetic, safety 165 PICATO (ingenol mebutate) 108 penicillamine 133 PIFELTRO (doravirine) 61 penicillin v potassium 20 pilocarpine hcl 104,171 PENLAC (ciclopirox) 38 pimecrolimus 108 PENNSAID (diclofenac sodium) 3 pimozide 55 PENTASA (mesalamine) 162 pindolol 82 pentazocine hcl/naloxone hcl 12 pioglitazone hcl 70 pentoxifylline 88 pioglitazone hcl/glimepiride 70 PEPCID (famotidine) 125,126 pioglitazone hcl/metformin hcl 70 PERCOCET (oxycodone PIQRAY (alpelisib) 46 hcl/acetaminophen) 12 piroxicam 3 PERFOROMIST (formoterol fumarate) 176 PLAN B ONE-STEP (levonorgestrel) 155 perindopril erbumine 80 PLAQUENIL (hydroxychloroquine sulfate) 52 permethrin 52 PLAVIX (clopidogrel bisulfate) 77 perphenazine 35 PLEGRIDY (peginterferon beta-1a) 103 perphenazine/amitriptyline hcl 31 PLEGRIDY PEN (peginterferon beta-1a) 103 PERSANTINE (dipyridamole) 77 PLENVU (peg 3350/sodium sulfate/sod PERTZYE (lipase/protease/amylase) 130 chloride/kcl/ascorbate sod/vit c) 127 PEXEVA (paroxetine mesylate) 33,34 PLETAL (cilostazol) 77 phenazopyridine hcl 133 PLEXION (sulfacetamide sodium/sulfur) 108 phendimetrazine tartrate 101 podofilox 108 phenelzine sulfate 32 POLY-VI-FLOR (pediatric multivitamin no.33 PHENERGAN (promethazine hcl) 35 with sodium fluoride) 116 phenobarbital 26 POLY-VI-FLOR (pediatric multivitamin no.37 phenobarbital/hyoscyamine sulf/atropine with sodium fluoride) 116 sulf/scopolamine hb 124 POLY-VI-FLOR WITH IRON (pediatric multivit phenobarbital/hyoscyamine sulf/atropine no.37/sodium fluoride/iron bisglycin.hcl) 116 sulf/scopolamine hb (PHENOHYTRO) 124 POLY-VI-FLOR WITH IRON (pediatric phenoxybenzamine hcl 78 multivitamin no.33/sodium fluoride/iron phentermine hcl 101 carbonyl) 116 phentermine hcl (ADIPEX-P) 101 polymyxin b sulfate/trimethoprim 167 phentermine hcl (LOMAIRA) 101 POLYTRIM (polymyxin b phenylephrine hcl 167 sulfate/trimethoprim) 167 phenylephrine hcl/promethazine hcl 182 POMALYST (pomalidomide) 44 PHENYTEK (phenytoin sodium extended) 29 PONSTEL (mefenamic acid) 3 phenytoin 29 posaconazole 38,39 phenytoin sodium extended 29 potassium bicarbonate/citric acid 116

219 LAST UPDATED 12/01/2019 potassium bicarbonate/citric acid (EFFER- prednisolone sodium phosphate 139,169 K) 116 prednisolone sodium phosphate potassium bicarbonate/citric acid (K (PEDIAPRED) 139 EFFERVESCENT) 116 prednisone 139 potassium bicarbonate/citric acid (KLOR- prednisone (PREDNISONE INTENSOL) 140 CON-EF) 116 PREFERA OB (prenatal vit no.21/iron potassium chloride 116 polysacch,heme polypep/folic acid) 116 potassium chloride (KLOR-CON M10) 116 PREFERA-OB ONE (prenatal vitamin no.19/iron potassium chloride (KLOR-CON M20) 116 polysac,iron heme/folic acid/dha) 116 potassium chloride (KLOR-CON SPRINKLE) 116 PREFEST (estradiol/norgestimate) 153 potassium chloride (KLOR-CON) 116 pregabalin 102 potassium chloride/potassium PREGNYL (chorionic gonadotropin, bicarbonate/citric acid 116 human) 142 potassium citrate 133 PREMARIN (estrogens, conjugated) 153 potassium citrate/citric acid 133 PREMPHASE (estrogens, potassium citrate/citric acid (CYTRA-K) 133 conjugated/medroxyprogesterone potassium citrate/citric acid (VIRTRATE-K) 133 acetate) 153 potassium iodide (SSKI) 158 PREMPRO (estrogens, POTIGA (ezogabine) 25 conjugated/medroxyprogesterone PRADAXA (dabigatran etexilate mesylate) 75 acetate) 153 PRALUENT PEN (alirocumab) 93 PRENA1 CHEW (prenatal vitamins PRALUENT SYRINGE (alirocumab) 93 combination no.42/folic acid) 117 pramipexole di-hcl 53 PRENATA (prenatal vitamins no.37/ferrous PRAMOSONE (hydrocortisone fumarate/folic acid) 117 acetate/pramoxine hcl) 108,109 PRENATABS FA (prenatal vits with calcium PRANDIN (repaglinide) 70 no.78/ferrous fumarate/folic acid) 117 prasugrel hcl 77 PRENATABS RX (prenatal vitamin with calcium PRAVACHOL (pravastatin sodium) 92 no.76/iron,carbonyl/folic acid) 117 pravastatin sodium 92 prenatal vit no.16/iron fum,ps complex/folic praziquantel 51 acid/omega-3 (DOTHELLE DHA) 117 prazosin hcl 78 prenatal vit no.16/iron fum,ps complex/folic PRECOSE (acarbose) 70 acid/omega-3 (TARON-C DHA) 117 PRED FORTE (prednisolone acetate) 169 prenatal vit no.16/iron fum,ps complex/folic PRED MILD (prednisolone acetate) 169 acid/omega-3 (VIRT-C DHA) 117 PRED-G (gentamicin sulfate/prednisolone prenatal vit no.21/iron polysacch,heme acetate) 167 polypep/folic acid (HEMENATAL OB) 117 prednicarbate 139 prenatal vit no.21/iron polysacch,heme prednisolone 139 polypep/folic acid (VP-HEME OB) 117 prednisolone (MILLIPRED DP) 139 prenatal vit no.71/iron fum-sodium prednisolone (MILLIPRED) 139 feredetate/folic acid/dha (PRENA1 PEARL)117 prednisolone acetate 169

220 LAST UPDATED 12/01/2019 prenatal vit with calcium 15/iron/folic prenatal vitamins no.147/ferrous acid/docusate sodium (MYNATAL gluconate/folic acid (ZALVIT) 118 ADVANCE) 117 prenatal vitamins no.5/ferrous fumarate/folic prenatal vit with calcium no.37/iron,aspg/folic acid 118 acid/omega-3 (ULTIMATECARE ONE) 117 prenatal vitamins no.5/ferrous fumarate/folic prenatal vit with calcium no.40/iron acid (PNV-VP-U) 118 fumarate/folate no.1 (PNV-SELECT) 117 prenatal vitamins no.66/iron,carbonyl/folic prenatal vit with calcium no.40/iron acid/dha (R-NATAL OB) 118 fumarate/folate no.1 (VIRT-PN) 117 prenatal vitamins no.79/iron fum/folic prenatal vit with calcium no.68/iron fum/folic acid/levomefolate/dha 118 acid no.1/dha (PNV-OMEGA) 117 prenatal vitamins with calcium/ferrous prenatal vit with calcium no.68/iron fum/folic fum/docusate/folic ac (MYNATE 90 PLUS) 119 acid no.1/dha (VIRT-PN PLUS) 117 prenatal vitamins with calcium/ferrous prenatal vit with calcium no.68/iron fum/folic fumarate/folic acid (MYNATAL PLUS) 119 acid no.1/dha (ZATEAN-PN PLUS) 117 prenatal vitamins with calcium/ferrous prenatal vit with calcium no.69/iron/folic fumarate/folic acid (MYNATAL-Z) 119 acid/docusate/dha (PRENAISSANCE PLUS) 118 prenatal vitamins with prenatal vit,calcium no.35/iron/folic calcium/iron,carb/docusate/folic acid acid/docusate/omega-3 (ULTIMATECARE (MYNATAL) 119 ONE NF) 118 prenatal vits no.115/iron fumarate/folic prenatal vitamin 27 with calcium/ferrous acid/docusate sod. 119 fumarate/folic acid (TRINATAL RX 1) 118 prenatal vits no.119/iron fumarate/folic prenatal vitamin 27 with calcium/ferrous acid/docusate sod. 119 fumarate/folic acid (VINATE ONE) 118 prenatal vits no.34/iron,carb/folic prenatal vitamin no.15/iron fumarate,polysac acid/docusate sodium/dha (VP-CH-PNV) 119 comp/folic acid (FOLIVANE-OB) 118 prenatal vits with calcium 118/ferrous prenatal vitamin no.19/iron polysac,iron fumarate/folic acid 119 heme/folic acid/dha (VP-HEME ONE) 118 prenatal vits with calcium 136/ferrous prenatal vitamin no.86/iron bis-glycinate/folic fumarate/folic acid (VINATE-M) 119 acid (NEWGEN) 118 prenatal vits with calcium no.115/iron prenatal vitamin with calcium fumarate/folic acid 119 no.76/iron,carbonyl/folic acid (PNV 29-1) 118 prenatal vits with calcium no.47/ferrous prenatal vitamin with calcium fum/folate no.1/dha (PNV-DHA) 119 no.76/iron,carbonyl/folic acid (THRIVITE prenatal vits with calcium no.47/ferrous RX) 118 fum/folate no.1/dha (VIRT-PN DHA) 119 prenatal vitamins no.11/ferrous fumarate/folic prenatal vits with calcium no.47/ferrous acid/omega-3 (C-NATE DHA) 118 fum/folate no.1/dha (ZATEAN-PN DHA) 119 prenatal vitamins no.11/ferrous fumarate/folic prenatal vits with calcium no.72/ferrous acid/omega-3 (VIRT-NATE DHA) 118 fumarate/folic acid 119 prenatal vitamins no.14/ferrous fumarate/folic prenatal vits with calcium no.72/ferrous acid (COMPLETENATE) 118 fumarate/folic acid (M-NATAL PLUS) 119

221 LAST UPDATED 12/01/2019 prenatal vits with calcium no.72/ferrous PRENATE MINI (prenatal vits no.87/iron carb- fumarate/folic acid (PREPLUS) 119 asp.glycinate/folate no.1/dha) 120 prenatal vits with calcium PRENATE PIXIE (prenatal vitamins no.85/iron no.72/iron,carbonyl/folic acid 119 asparto glycin/folate no.1/dha) 120 prenatal vits with calcium no.73/ferrous PRENATE RESTORE (prenatal vitamins fumarate/folic acid (VIRT-NATE) 119 no.69/iron fumarate/folate comb prenatal vits with calcium no.74/ferrous no.6/dha) 121 fumarate/folic acid 119 PRENATE STAR (prenatal vitamins no.77/ferrous prenatal vits with calcium no.78/ferrous asparto glycinate/folic acid) 121 fumarate/folic acid (PRETAB) 120 PREPOPIK (sodium picosulfate/magnesium prenatal vits with calcium no.80/iron fum/folic oxide/citric acid) 127 acid/dss/dha (PRENAISSANCE) 120 PRESTALIA (perindopril arginine/amlodipine prenatal vits,calcium no.39/iron fum/folic besylate) 88 acid/docusate/dha (TARON-PREX PRETOMANID (pretomanid) 42 PRENATAL) 120 PREVACID (lansoprazole) 128 prenatal vits,calcium no.66/iron fum/folic PREVPAC (lansoprazole/amoxicillin acid/docusate/dha (PNV-DHA + trihydrate/clarithromycin) 125 DOCUSATE) 120 PREVYMIS (letermovir) 57 prenatal vits,calcium no.66/iron fum/folic PREZCOBIX (darunavir acid/docusate/dha (VEMAVITE-PRX 2) 120 ethanolate/cobicistat) 64 PRENATE AM (multivit PREZISTA (darunavir ethanolate) 64 no.38/methyltetrahydfolate glucos,folic PRIFTIN (rifapentine) 42 acid/ginger) 120 PRILOSEC (omeprazole magnesium) 128 PRENATE CHEWABLE (multivitamin PRIMACARE (prenatal vits no.118/iron asparto no.36/methyltetrahydrofolate gluc,folic glycinate/folate no.6/dha) 121 acid) 120 primaquine phosphate 52 PRENATE DHA (multivitamin no.45/iron primidone 26 fumarate/folate comb no.6/dha) 120 PRIMSOL (trimethoprim) 18 PRENATE DHA (prenatal vitamins no.78/iron PRINIVIL (lisinopril) 80 asparto glycin/folate no.1/dha) 120 PRISTIQ (desvenlafaxine succinate) 34 PRENATE ELITE (prenatal vitamins no.36/ferrous PROAIR DIGIHALER (albuterol sulfate) 176 fumarate/folate comb. no.6) 120 PROAIR HFA (albuterol sulfate) 176 PRENATE ELITE (prenatal vits no.114/ferrous PROAIR RESPICLICK (albuterol sulfate) 177 aspart glycinate/folate no.1) 120 probenecid 39 PRENATE ENHANCE (prenatal vitamins probenecid/colchicine 39 no.68/iron fumarate/folate no.6/dha) 120 PROCARDIA (nifedipine) 83 PRENATE ESSENTIAL (multivitamin no.40/iron PROCARDIA XL (nifedipine) 83 asparto glycinate/folate no.1/dha) 120 prochlorperazine 35 PRENATE ESSENTIAL (multivitamin no.46/iron prochlorperazine (COMPRO) 35 fumarate/folate comb. no.6/dha) 120 prochlorperazine maleate 35 PROCRIT (epoetin alfa) 76

222 LAST UPDATED 12/01/2019 PROCTOFOAM-HC (hydrocortisone PUREFE OB PLUS (prenatal vits no.4/iron acetate/pramoxine hcl) 109 fumarate,polysacc complex/folic acid) 121 PROCYSBI (cysteamine bitartrate) 130 PURIXAN (mercaptopurine) 44 progesterone 155 PYLERA (colloidal bismuth progesterone, micronized 155 subcitrate/metronidazole/tetracycline hcl)125 PROGLYCEM (diazoxide) 72 pyrazinamide 42 PROGRAF (tacrolimus) 160 PYRIDIUM (phenazopyridine hcl) 133 PROLENSA (bromfenac sodium) 170 pyridostigmine bromide 42 PROMACTA (eltrombopag olamine) 76 promethazine hcl 36,174 Q promethazine hcl (PHENADOZ) 36 QBRELIS (lisinopril) 80 promethazine hcl (PROMETHEGAN) 36 QBREXZA (glycopyrronium tosylate) 109 promethazine hcl/codeine 182 QMIIZ ODT (meloxicam) 3 promethazine hcl/dextromethorphan hbr 182 QNASL (beclomethasone dipropionate) 173 promethazine/phenylephrine hcl/codeine 182 QNASL CHILDREN (beclomethasone PROMETRIUM (progesterone, micronized) 155 dipropionate) 173 propafenone hcl 81 QSYMIA (phentermine hcl/topiramate) 101 propantheline bromide 124 QTERN (dapagliflozin propanediol/saxagliptin proparacaine hcl 167 hcl) 70 propranolol hcl 82 QUALAQUIN (quinine sulfate) 52 propranolol hcl/hydrochlorothiazide 88 QUARTETTE (levonorgestrel/ethinyl estradiol propylthiouracil 158 and ethinyl estradiol) 153 PROSCAR (finasteride) 132 quazepam 185 PROTONIX (pantoprazole sodium) 128 QUDEXY XR (topiramate) 28 PROTOPIC (tacrolimus) 109 QUESTRAN (cholestyramine (with sugar)) 93 protriptyline hcl 35 QUESTRAN LIGHT PROVENTIL HFA (albuterol sulfate) 177 (cholestyramine/aspartame) 93 PROVERA (medroxyprogesterone quetiapine fumarate 56 acetate) 155 QUFLORA (pediatric multivitamin no.63 with PROVIDA DHA (prenatal vitamins no.90/iron sodium fluoride) 121 fum,polysac comp/folic acid/dha) 121 QUFLORA (pediatric multivitamin no.83 with PROVIDA OB (prenatal vits no.65/iron sodium fluoride) 121 fumarate,polysac complex/folic acid) 121 QUFLORA (pediatric multivitamin no.84 with PROVIGIL (modafinil) 186 sodium fluoride) 121 PROZAC (fluoxetine hcl) 34 QUFLORA FE (pediatric multivitamin PROZAC WEEKLY (fluoxetine hcl) 34 no.142/iron,carbonyl/sodium fluoride) 121 PRUDOXIN (doxepin hcl) 109 QUFLORA FE (pediatric multivitamin PULMICORT (budesonide) 173 no.151/ferrous sulfate/sod fluoride) 123 PULMICORT FLEXHALER (budesonide) 173 QUILLICHEW ER (methylphenidate hcl) 99 PULMOZYME (dornase alfa) 182 QUILLIVANT XR (methylphenidate hcl) 99 quinapril hcl 80

223 LAST UPDATED 12/01/2019 quinapril hcl/hydrochlorothiazide 88 RENACIDIN (citric quinidine gluconate 81 acid/gluconolactone/magnesium quinidine sulfate 81 carbonate) 133 quinine sulfate 52 RENAGEL (sevelamer hcl) 134 QVAR (beclomethasone dipropionate) 173 RENVELA (sevelamer carbonate) 134 QVAR REDIHALER (beclomethasone repaglinide 70 dipropionate) 173 repaglinide/metformin hcl 70 REPATHA PUSHTRONEX (evolocumab) 93 R REPATHA SURECLICK (evolocumab) 93 rabeprazole sodium 128 REPATHA SYRINGE (evolocumab) 93 RADIOGARDASE (prussian blue (insoluble)) 121 REQUIP (ropinirole hcl) 53 RAGWITEK (allergenic extract-weed pollen- REQUIP XL (ropinirole hcl) 53 short ragweed) 182 RESCRIPTOR (delavirdine mesylate) 61 raloxifene hcl 156 reserpine 88 ramelteon 186 RESTASIS (cyclosporine) 167 ramipril 80 RESTASIS MULTIDOSE (cyclosporine) 167 RANEXA (ranolazine) 88 RESTORIL (temazepam) 185 ranitidine hcl 126 RETACRIT (epoetin alfa-epbx) 76 ranolazine 88 RETIN-A (tretinoin) 109 RAPAFLO (silodosin) 132 RETIN-A MICRO (tretinoin microspheres) 109 RAPAMUNE (sirolimus) 160 RETIN-A MICRO PUMP (tretinoin rasagiline mesylate 54 microspheres) 109 RASUVO (methotrexate/pf) 160 RETROVIR (zidovudine) 62 RAVICTI (glycerol phenylbutyrate) 130 REVATIO (sildenafil citrate) 178 RAYALDEE (calcifediol) 164 REVLIMID (lenalidomide) 44 RAYOS (prednisone) 140 REXULTI (brexpiprazole) 56 RAZADYNE (galantamine hbr) 30 REYATAZ (atazanavir sulfate) 64 RAZADYNE ER (galantamine hbr) 30 RHEUMATREX (methotrexate sodium) 160 REBETOL (ribavirin) 59 RHOFADE (oxymetazoline hcl) 109 REBIF (interferon beta-1a/albumin human) 104 RHOPRESSA (netarsudil mesylate) 171 REBIF REBIDOSE (interferon beta-1a/albumin RIBASPHERE RIBAPAK (ribavirin) 59 human) 104 RIBATAB (ribavirin) 59 RECTIV (nitroglycerin) 109 ribavirin 59 REGIMEX (benzphetamine hcl) 101 ribavirin (MODERIBA) 59 REGLAN (metoclopramide hcl) 36 ribavirin (RIBASPHERE) 59 REGRANEX (becaplermin) 109 RIDAURA (auranofin) 161 RELAFEN DS (nabumetone) 3 rifabutin 42 RELENZA (zanamivir) 65 RIFADIN (rifampin) 42 RELISTOR (methylnaltrexone bromide) 125 RIFAMATE (rifampin/isoniazid) 42 RELPAX (eletriptan hydrobromide) 41 rifampin 42 REMERON (mirtazapine) 31 RIFATER (rifampin/isoniazid/pyrazinamide) 42

224 LAST UPDATED 12/01/2019 RILUTEK (riluzole) 101 SAFYRAL (drospirenone/ethinyl riluzole 101 estradiol/levomefolate calcium) 153 rimantadine hcl 65 SAIZEN (somatropin) 142 RINVOQ ER (upadacitinib) 160 SAIZEN-SAIZENPREP (somatropin) 142 RIOMET (metformin hcl) 70 SALAGEN (pilocarpine hcl) 104 risedronate sodium 164 SALEX (salicylic acid) 109 RISPERDAL (risperidone) 56 salicylic acid 109 RISPERDAL M-TAB (risperidone) 56 salsalate 3 risperidone 56 SALVAX (salicylic acid) 109 RITALIN (methylphenidate hcl) 99 SAMSCA (tolvaptan) 121 RITALIN LA (methylphenidate hcl) 99,100 SANCUSO (granisetron) 37 ritonavir 64 SANDIMMUNE (cyclosporine) 160 rivastigmine 30 SANDOSTATIN (octreotide acetate) 157 rivastigmine tartrate 30 SANTYL (collagenase clostridium rizatriptan benzoate 41 histolyticum) 109 ROBAXIN (methocarbamol) 184 SAPHRIS (asenapine maleate) 56 ROBAXIN-750 (methocarbamol) 184 SARAFEM (fluoxetine hcl) 34 ROBINUL (glycopyrrolate) 124 SAVAYSA (edoxaban tosylate) 75 ROBINUL FORTE (glycopyrrolate) 124 SAVELLA (milnacipran hcl) 102,103 ROCALTROL (calcitriol) 164 SAXENDA (liraglutide) 165 ROCKLATAN (netarsudil scopolamine 36 mesylate/latanoprost) 171 SEASONIQUE (levonorgestrel/ethinyl estradiol ropinirole hcl 53,54 and ethinyl estradiol) 153 ROSULA (sulfacetamide sodium/sulfur) 109 SECONAL SODIUM (secobarbital sodium) 186 rosuvastatin calcium 92 SECTRAL (acebutolol hcl) 82 ROXICODONE (oxycodone hcl) 12,13 SEEBRI NEOHALER (glycopyrrolate) 175 ROXYBOND (oxycodone hcl) 13 SEGLUROMET (ertugliflozin pidolate/metformin ROZEREM (ramelteon) 186 hcl) 71 ROZLYTREK (entrectinib) 45 SELECT-OB (prenatal vit no.128/iron RUBRACA (rucaparib camsylate) 45 polysaccharide complex/folic acid) 121 RUZURGI (amifampridine) 165 SELECT-OB (prenatal vitamin no.13/iron RYBELSUS (semaglutide) 70 polysaccharides/folate comb no.1) 121 RYCLORA (dexchlorpheniramine maleate) 174 selegiline hcl 54 RYDAPT (midostaurin) 45 selenium sulfide 109 RYTARY (carbidopa/levodopa) 54 SELZENTRY (maraviroc) 63 RYTHMOL (propafenone hcl) 81 SENSIPAR (cinacalcet hcl) 164 RYTHMOL SR (propafenone hcl) 81 SEREVENT DISKUS (salmeterol xinafoate) 177 RYVENT (carbinoxamine maleate) 174 SERNIVO (betamethasone dipropionate) 140 SEROPHENE (clomiphene citrate) 156 S SEROQUEL (quetiapine fumarate) 56 SABRIL (vigabatrin) 26 SEROQUEL XR (quetiapine fumarate) 56

225 LAST UPDATED 12/01/2019 SEROSTIM (somatropin) 142 sodium phenylbutyrate 130 sertraline hcl 34 sodium phosphate,dibasic/pot sevelamer carbonate 134 phos,monob/sod phosphate mono sevelamer hcl 134 (PHOSPHA 250 NEUTRAL) 133 SEYSARA (sarecycline hcl) 24 sodium phosphate,dibasic/pot SFROWASA (mesalamine) 162 phos,monob/sod phosphate mono (VIRT- SIGNIFOR (pasireotide diaspartate) 157 PHOS 250 NEUTRAL) 133 SIKLOS (hydroxyurea) 44 sodium polystyrene sulfonate 121 sildenafil citrate 133,178,179 sodium polystyrene sulfonate (KIONEX) 121 SILENOR (doxepin hcl) 186 sodium polystyrene sulfonate/sorbitol solution SILIQ (brodalumab) 109 (KIONEX) 121 silodosin 132 sodium/potassium/potassium citrate/sodium SILVADENE (silver sulfadiazine) 22 citrate/cit ac 133 silver sulfadiazine 22 sodium/potassium/potassium citrate/sodium SIMBRINZA (brinzolamide/brimonidine citrate/cit ac (CYTRA-3) 133 tartrate) 171 sodium/potassium/potassium citrate/sodium SIMPONI (golimumab) 160 citrate/cit ac (TRICITRATES) 134 simvastatin 92 sodium/potassium/potassium citrate/sodium SINEMET 10-100 (carbidopa/levodopa) 54 citrate/cit ac (VIRTRATE-3) 134 SINEMET 25-100 (carbidopa/levodopa) 54 sofosbuvir/velpatasvir 58 SINEMET 25-250 (carbidopa/levodopa) 54 SOLARAZE (diclofenac sodium) 109 SINEMET CR (carbidopa/levodopa) 54 solifenacin succinate 131 SINGULAIR (montelukast sodium) 175 SOLIQUA 100-33 (insulin glargine,human sirolimus 160 recombinant analog/lixisenatide) 73 SITAVIG (acyclovir) 65 SOLODYN (minocycline hcl) 24 SIVEXTRO (tedizolid phosphate) 18 SOLOSEC (secnidazole) 18 SKELAXIN (metaxalone) 184 SOLTAMOX (tamoxifen citrate) 44 SKLICE (ivermectin) 51 SOMA (carisoprodol) 184 SKYRIZI (2 SYRINGES) KIT (risankizumab-rzaa) 13 SOMAVERT (pegvisomant) 157 SLYND (drospirenone) 156 SONATA (zaleplon) 185 sodium chloride for inhalation 182 SOOLANTRA (ivermectin) 109 sodium chloride for inhalation (NEBUSAL) 182 SORIATANE (acitretin) 109 sodium chloride for inhalation (PULMOSAL)182 SORILUX (calcipotriene) 110 sodium chloride/sodium sotalol hcl 81 bicarbonate/potassium chloride/peg 127 sotalol hcl (SORINE) 81 sodium chloride/sodium SOTYLIZE (sotalol hcl) 81 bicarbonate/potassium chloride/peg SOVALDI (sofosbuvir) 58 (GAVILYTE-N) 127 SPECTRACEF (cefditoren pivoxil) 19 sodium chloride/sodium spinosad 110 bicarbonate/potassium chloride/peg (TRILYTE SPIRIVA (tiotropium bromide) 175 WITH FLAVOR PACKETS) 127 SPIRIVA RESPIMAT (tiotropium bromide) 175

226 LAST UPDATED 12/01/2019 spironolactone 89 sub-q insulin delivery device, 20 spironolactone/hydrochlorothiazide 88 unit,disposable 165 SPORANOX (itraconazole) 39 sub-q insulin delivery device, 30 unit, SPRITAM (levetiracetam) 25 disposable 165 SPRIX (ketorolac tromethamine) 3 sub-q insulin delivery device, 40 unit, SPRYCEL (dasatinib) 49 disposable 165 SPS (sodium polystyrene sulfonate/sorbitol SUBOXONE (buprenorphine hcl/naloxone solution) 121 hcl) 15 SSD (silver sulfadiazine) 22 SUBSYS (fentanyl) 13 STALEVO 100 SUCRAID (sacrosidase) 130 (carbidopa/levodopa/entacapone) 53 sucralfate 127 STALEVO 125 SULAR (nisoldipine) 83 (carbidopa/levodopa/entacapone) 53 sulfacetamide sodium 22,110 STALEVO 150 sulfacetamide sodium (SEB-PREV) 110 (carbidopa/levodopa/entacapone) 53 sulfacetamide sodium/prednisolone sodium STALEVO 200 phosphate 167 (carbidopa/levodopa/entacapone) 53 sulfacetamide sodium/sulfur 110 STALEVO 50 sulfacetamide sodium/sulfur (AVAR) 110 (carbidopa/levodopa/entacapone) 53 sulfacetamide sodium/sulfur (AVAR-E STALEVO 75 GREEN) 110 (carbidopa/levodopa/entacapone) 53 sulfacetamide sodium/sulfur (AVAR-E) 110 STARLIX (nateglinide) 71 sulfacetamide sodium/sulfur (BP 10-1) 110 stavudine 62 sulfacetamide sodium/sulfur (ROSANIL) 110 STAXYN (vardenafil hcl) 134 sulfacetamide sodium/sulfur (ROSULA) 110 STEGLATRO (ertugliflozin pidolate) 71 sulfacetamide sodium/sulfur (SSS 10-5) 110 STEGLUJAN (ertugliflozin pidolate/sitagliptin sulfacetamide sodium/sulfur (SULFACLEANSE phosphate) 71 8-4) 110 STELARA (ustekinumab) 110 sulfadiazine 22 STENDRA (avanafil) 134 sulfamethoxazole/trimethoprim 22 STIMATE (desmopressin acetate) 142 SULFAMYLON (mafenide acetate) 18 STIOLTO RESPIMAT (tiotropium sulfasalazine 162 bromide/olodaterol hcl) 182 SULFATRIM (sulfamethoxazole/trimethoprim)22 STIVARGA (regorafenib) 49 sulindac 3 STRATTERA (atomoxetine hcl) 100 sumatriptan 41 STRENSIQ (asfotase alfa) 130 sumatriptan succinate 41 STRIANT (testosterone) 143 sumatriptan succinate/naproxen sodium 41 STRIBILD SUMAVEL DOSEPRO (sumatriptan (elvitegravir/cobicistat/emtricitabine/tenofovi succinate) 41 r disoproxil) 60 SUMAXIN (sulfacetamide sodium/sulfur) 110 STRIVERDI RESPIMAT (olodaterol hcl) 177 SUMAXIN TS (sulfacetamide sodium/sulfur) 110 STROMECTOL (ivermectin) 51 SUNOSI (solriamfetol hcl) 186

227 LAST UPDATED 12/01/2019 SUPRAX (cefixime) 19 syringe with needle,disposable,insulin 1 ml 166 SUPRENZA ODT (phentermine hcl) 101 syringe with needle,insulin 0.3 ml (half unit SUPREP (sodium sulfate/potassium mark) 166 sulfate/magnesium sulfate) 127 syringe with needle,insulin 0.5 ml (half unit SURMONTIL (trimipramine maleate) 35 mark) 166 SUSTIVA (efavirenz) 61 syringe with needle,insulin disposable 166 SUTENT (sunitinib malate) 49 syringe with needle,insulin,0.3 ml 166 SYLATRON (peginterferon alfa-2b) 45 syringe with needle,insulin,0.5 ml 166 SYMAX DUOTAB (hyoscyamine sulfate) 124 syringe without needle,insulin disposible, 1 SYMBICORT (budesonide/formoterol ml 166 fumarate) 182 syringe, insulin u-500 with needle, disposable, SYMBYAX (olanzapine/fluoxetine hcl) 31 0.5 ml 166 SYMDEKO (tezacaftor/ivacaftor) 177 SYMFI (efavirenz/lamivudine/tenofovir T disoproxil fumarate) 59 TABLOID (thioguanine) 44 SYMFI LO (efavirenz/lamivudine/tenofovir TACLONEX (calcipotriene/betamethasone disoproxil fumarate) 61 dipropionate) 110 SYMJEPI (epinephrine) 177 tacrolimus 111,160 SYMLINPEN 120 (pramlintide acetate) 71 tadalafil 132,134 SYMLINPEN 60 (pramlintide acetate) 71 tadalafil (ALYQ) 179 SYMPAZAN (clobazam) 26 TAFINLAR (dabrafenib mesylate) 49 SYMPROIC (naldemedine tosylate) 125 TAGRISSO (osimertinib mesylate) 49 SYMTUZA (darunavir TAKE ACTION (levonorgestrel) 156 eth/cobicistat/emtricitabine/tenofovir TAKHZYRO (lanadelumab-flyo) 158 alafenamide) 64 TALTZ AUTOINJECTOR (2 PACK) SYNALAR (fluocinolone acetonide) 140 (ixekizumab) 111 SYNAREL (nafarelin acetate) 157 TALTZ AUTOINJECTOR (3 PACK) SYNDROS (dronabinol) 37 (ixekizumab) 111 SYNERA (lidocaine/tetracaine) 14 TALTZ AUTOINJECTOR (ixekizumab) 111 SYNJARDY (empagliflozin/metformin hcl) 71 TALTZ SYRINGE (2 PACK) (ixekizumab) 111 SYNJARDY XR (empagliflozin/metformin hcl) 71 TALTZ SYRINGE (3 PACK) (ixekizumab) 111 SYNRIBO (omacetaxine mepesuccinate) 45 TALTZ SYRINGE (ixekizumab) 111 SYNTHROID (levothyroxine sodium) 156 TALZENNA (talazoparib tosylate) 49 SYPRINE (trientine hcl) 121 TAMIFLU (oseltamivir phosphate) 65 syringe w-needle 0.3 ml,insulin,safety w-self- tamoxifen citrate 44 cont.dis.unit 165 tamsulosin hcl 132 syringe with needle 1 ml,insulin,safety w-self- TANZEUM (albiglutide) 71 con.disp.unit 165 TAPAZOLE (methimazole) 158 syringe with needle, insulin, safety, 0.3 ml 165 TARCEVA (erlotinib hcl) 49 syringe with needle, insulin, safety, 0.5 ml 165 TARGADOX (doxycycline hyclate) 24 syringe with needle, insulin, safety, 1 ml 165 TARGRETIN (bexarotene) 50

228 LAST UPDATED 12/01/2019 TARKA (trandolapril/verapamil hcl) 88 TESTRED (methyltestosterone) 143 TASIGNA (nilotinib hcl) 50 tetrabenazine 101 TASMAR (tolcapone) 53 tetracycline hcl 24 TAVALISSE (fostamatinib disodium) 76 TEXACORT (hydrocortisone) 140 TAYTULLA (norethindrone acetate-ethinyl THALOMID (thalidomide) 44 estradiol/ferrous fumarate) 153 THEO-24 (theophylline anhydrous) 178 tazarotene 111 theophylline anhydrous 178 TAZORAC (tazarotene) 111 theophylline anhydrous (THEOCHRON) 178 TECFIDERA (dimethyl fumarate) 104 THERMAZENE (silver sulfadiazine) 22 TECHNIVIE (ombitasvir/paritaprevir/ritonavir)58 THIOLA (tiopronin) 134 TEGRETOL (carbamazepine) 29 THIOLA EC (tiopronin) 134 TEGRETOL XR (carbamazepine) 29 thioridazine hcl 55 TEGSEDI (inotersen sodium) 101 thiothixene 55 TEKTURNA (aliskiren hemifumarate) 88 thyroid,pork 156 TEKTURNA HCT (aliskiren thyroid,pork (NP THYROID) 156 hemifumarate/hydrochlorothiazide) 88 thyroid,pork (THYROID) 156 telmisartan 79 THYROLAR-1 (liotrix) 157 telmisartan/amlodipine besylate 88 THYROLAR-1/2 (liotrix) 157 telmisartan/hydrochlorothiazide 88 THYROLAR-1/4 (liotrix) 157 temazepam 185 THYROLAR-2 (liotrix) 157 TEMIXYS (lamivudine/tenofovir disoproxil THYROLAR-3 (liotrix) 157 fumarate) 59 tiagabine hcl 27 TEMODAR (temozolomide) 43 TIAZAC (diltiazem hcl) 83 TEMOVATE (clobetasol propionate) 140 TIBSOVO (ivosidenib) 45 temozolomide 43 ticlopidine hcl 77 TENEX (guanfacine hcl) 78 TIGAN (trimethobenzamide hcl) 36 tenofovir disoproxil fumarate 62 TIGLUTIK (riluzole) 102 TENORETIC 100 (atenolol/chlorthalidone) 88 TIKOSYN (dofetilide) 81 TENORETIC 50 (atenolol/chlorthalidone) 88 timolol maleate 82,171 TENORMIN (atenolol) 82 TIMOPTIC (timolol maleate) 171 TERAZOL 3 (terconazole) 39 TIMOPTIC OCUDOSE (timolol maleate/pf) 171 TERAZOL 7 (terconazole) 39 TIMOPTIC-XE (timolol maleate) 171 terazosin hcl 78 TINDAMAX (tinidazole) 18 terbinafine hcl 39 tinidazole 18 terbutaline sulfate 177 TIROSINT (levothyroxine sodium) 157 terconazole 39 TIROSINT-SOL (levothyroxine sodium) 157 TESSALON PERLE (benzonatate) 182 TIVICAY (dolutegravir sodium) 60 TESTIM (testosterone) 143 TIVORBEX (indomethacin, submicronized) 3 testosterone 143 tizanidine hcl 57 testosterone cypionate 143 TOBI (tobramycin in 0.225 % sodium testosterone enanthate 143 chloride) 182

229 LAST UPDATED 12/01/2019 TOBI PODHALER (tobramycin) 177 trazodone hcl 34 TOBRADEX (tobramycin/dexamethasone) 168 TRECATOR (ethionamide) 42 TOBRADEX ST TRELEGY ELLIPTA (fluticasone (tobramycin/dexamethasone) 168 furoate/umeclidinium bromide/vilanterol tobramycin 16 trifenat) 182 tobramycin in 0.225 % sodium chloride 177 TREMFYA (guselkumab) 111 tobramycin/dexamethasone 168 TRESIBA (insulin degludec) 74 tobramycin/nebulizer 177 TRESIBA FLEXTOUCH U-100 (insulin TOBREX (tobramycin) 16 degludec) 74 TOFRANIL (imipramine hcl) 35 TRESIBA FLEXTOUCH U-200 (insulin TOLAK (fluorouracil) 111 degludec) 74 tolazamide 71 TRETIN-X (tretinoin) 111 tolbutamide 71 tretinoin 50,111 tolcapone 53 tretinoin microspheres 111 tolmetin sodium 3 TREXALL (methotrexate sodium) 160 TOLSURA (itraconazole) 39 TREXIMET (sumatriptan succinate/naproxen tolterodine tartrate 131 sodium) 41 TOPAMAX (topiramate) 28 TREZIX TOPICORT (desoximetasone) 140 (acetaminophen/caffeine/dihydrocodeine topiramate 28 bitartrate) 13 TOPROL XL (metoprolol succinate) 82 TRI-NORINYL (norethindrone-ethinyl toremifene citrate 44 estradiol) 153 torsemide 89 TRI-VI-FLOR (pediatric multivitamin a,c,and d3 TOSYMRA (sumatriptan) 41 no.38 with sodium fluoride) 121 TOUJEO MAX SOLOSTAR (insulin triamcinolone acetonide 104,140 glargine,human recombinant analog) 74 triamcinolone acetonide (ORALONE) 104 TOUJEO SOLOSTAR (insulin glargine,human triamcinolone acetonide (TRIANEX) 140 recombinant analog) 74 triamcinolone acetonide (TRIDERM) 140 TOVIAZ (fesoterodine fumarate) 131 triamterene 89 TRACLEER (bosentan) 179 triamterene/hydrochlorothiazide 88 TRADJENTA (linagliptin) 71 triazolam 185 tramadol hcl 6,13 TRIBENZOR (olmesartan tramadol hcl/acetaminophen 13 medoxomil/amlodipine trandolapril 80 besylate/hydrochlorothiazide) 88 trandolapril/verapamil hcl 88 TRICARE (prenatal vits with calcium tranexamic acid 77 103/ferrous fumarate/folic acid) 122 TRANSDERM-SCOP (scopolamine) 36 TRICARE PRENATAL (prenatal vitamins TRANXENE T-TAB (clorazepate dipotassium) 67 no.113/iron pyrophosphate/levomefolate) 122 tranylcypromine sulfate 32 TRICARE PRENATAL DHA ONE (prenatal vit TRAVATAN Z (travoprost) 171 no.20/iron/folic acid/docusate/fish travoprost (benzalkonium) 171 oil/dha/epa) 122

230 LAST UPDATED 12/01/2019 TRICOR (fenofibrate nanocrystallized) 91 TUZISTRA XR (codeine trientine hcl 122 polistirex/chlorpheniramine polistirex) 182 trientine hcl (CLOVIQUE) 122 TWYNSTA (telmisartan/amlodipine besylate)88 trifluoperazine hcl 55 TYBOST (cobicistat) 63 trifluridine 65 TYKERB (lapatinib ditosylate) 50 TRIGLIDE (fenofibrate nanocrystallized) 91 TYLENOL-CODEINE NO.3 (acetaminophen trihexyphenidyl hcl 52 with codeine phosphate) 13 TRIKAFTA TYLENOL-CODEINE NO.4 (acetaminophen (elexacaftor/tezacaftor/ivacaftor) 177 with codeine phosphate) 13 TRILEPTAL (oxcarbazepine) 29 TYMLOS (abaloparatide) 164 TRILIPIX (fenofibric acid (choline)) 91 trimethobenzamide hcl 36 U trimethoprim 18 UCERIS (budesonide) 162 trimipramine maleate 35 UDENYCA (pegfilgrastim-cbqv) 76 TRIMPEX (trimethoprim) 18 ULESFIA (benzyl alcohol) 111 TRINATE (prenatal vits with calcium ULORIC (febuxostat) 39 no.73/ferrous fumarate/folic acid) 122 ULTRACET (tramadol hcl/acetaminophen) 13 TRINTELLIX (vortioxetine hydrobromide) 34 ULTRAM (tramadol hcl) 13 TRISTART DHA (prenatal vitamins no.93/iron ULTRAM ER (tramadol hcl) 6 carbonyl/folate comb no.9/dha) 122 ULTRAVATE (halobetasol propionate) 140 TRIUMEQ (abacavir sulfate/dolutegravir UNITHROID (levothyroxine sodium) 157 sodium/lamivudine) 63 UPTRAVI (selexipag) 179 TRIZIVIR (abacavir URAMAXIN (urea) 111 sulfate/lamivudine/zidovudine) 62 URAMAXIN GT (urea) 111 TROKENDI XR (topiramate) 28 urea 112 tropicamide 168 urea (CEM-UREA) 111 trospium chloride 131 urea (METOPIC) 111 TRULANCE (plecanatide) 126 urea (UMECTA) 111 TRULICITY (dulaglutide) 71 urea (URE-K) 111 TRUSOPT (dorzolamide hcl) 171 urea (UREDEB) 111 TRUVADA (emtricitabine/tenofovir disoproxil urea (XUREA) 112 fumarate) 62 URECHOLINE (bethanechol chloride) 134 TUDORZA PRESSAIR (aclidinium bromide) 176 urine acetone test,strips 166 TURALIO (pexidartinib hydrochloride) 45 urine glucose-acet test strip 166 TUSSICAPS (hydrocodone UROCIT-K (potassium citrate) 134 polistirex/chlorpheniramine polistirex) 182 UROQID-ACID NO.2 (methenamine TUSSIONEX (hydrocodone mandelate/sodium polistirex/chlorpheniramine polistirex) 182 phosphate,monobasic) 134 TUXARIN ER (chlorpheniramine UROXATRAL (alfuzosin hcl) 132 maleate/codeine phosphate) 182 URSO (ursodiol) 125 URSO FORTE (ursodiol) 125

231 LAST UPDATED 12/01/2019 ursodiol 125 VERELAN (verapamil hcl) 84 UTIBRON NEOHALER (indacaterol VERELAN PM (verapamil hcl) 84 maleate/glycopyrrolate) 183 VERIPRED 20 (prednisolone sodium UTOPIC (urea) 112 phosphate) 140 VERSACLOZ (clozapine) 57 V VERZENIO (abemaciclib) 50 VAGIFEM (estradiol) 153 VESICARE (solifenacin succinate) 131 valacyclovir hcl 65 VEXOL (rimexolone) 170 VALCHLOR (mechlorethamine hcl) 43 VFEND (voriconazole) 39 VALCYTE (valganciclovir hcl) 57 VIAGRA (sildenafil citrate) 134 valganciclovir hcl 57,58 VIBERZI (eluxadoline) 126 VALIUM (diazepam) 67 VIBRAMYCIN (doxycycline calcium) 24 valproic acid 27 VIBRAMYCIN (doxycycline hyclate) 24 valproic acid (as sodium salt) (valproate VIBRAMYCIN (doxycycline monohydrate) 24 sodium) 27 VICTOZA 2-PAK (liraglutide) 71 valsartan 79 VICTOZA 3-PAK (liraglutide) 71 valsartan/hydrochlorothiazide 88 VIDEX (didanosine) 62 VALTREX (valacyclovir hcl) 65 VIDEX EC (didanosine) 62 VANCOCIN HCL (vancomycin hcl) 18 VIEKIRA PAK vancomycin hcl 18 (ombitasvir/paritaprevir/ritonavir/dasabuvir VANDAZOLE (metronidazole) 18 sodium) 58 VANOS (fluocinonide) 140 VIEKIRA XR vardenafil hcl 134 (ombitasvir/paritaprevir/ritonavir/dasabuvir VARUBI (rolapitant hcl) 37 sodium) 58 VASCEPA (icosapent ethyl) 93 vigabatrin 27 VASERETIC (enalapril vigabatrin (VIGADRONE) 27 maleate/hydrochlorothiazide) 89 VIGAMOX (moxifloxacin hcl) 22 VASOTEC (enalapril maleate) 80 VIIBRYD (vilazodone hcl) 34 VECTICAL (calcitriol) 112 VIMOVO (naproxen/esomeprazole VELPHORO (sucroferric oxyhydroxide) 135 magnesium) 3 VELTASSA (patiromer calcium sorbitex) 122 VIMPAT (lacosamide) 30 VELTIN (clindamycin phosphate/tretinoin) 112 VINATE CARE (multivitamin combination VEMLIDY (tenofovir alafenamide) 58 no.43/ferrous fumarate/folic acid) 122 VENCLEXTA (venetoclax) 50 VINATE DHA RF (multivit no.37/iron/l-mefolate VENCLEXTA STARTING PACK (venetoclax) 50 calc./algal oil/soy lecithin) 122 venlafaxine hcl 34 VIOKACE (lipase/protease/amylase) 130 VENLAFAXINE HCL ER (venlafaxine hcl) 34 VIRACEPT (nelfinavir mesylate) 64 VENTOLIN HFA (albuterol sulfate) 177 VIRAMUNE (nevirapine) 61 verapamil hcl 84 VIRAMUNE XR (nevirapine) 61 VERDESO (desonide) 140 VIRASAL (salicylic acid) 112 VEREGEN (sinecatechins) 112 VIREAD (tenofovir disoproxil fumarate) 62

232 LAST UPDATED 12/01/2019 VIROPTIC (trifluridine) 65 VYNDAQEL (tafamidis meglumine) 89 VISTARIL (hydroxyzine pamoate) 174 VYTORIN (ezetimibe/simvastatin) 93 VISTOGARD (uridine triacetate) 166 VYVANSE (lisdexamfetamine dimesylate) 97 VITAFOL GUMMIES (prenatal vit no.112/iron VYZULTA (latanoprostene bunod) 171 phosph/folic acid/omega-3s/dha/epa) 122 VITAFOL NANO (prenatal vitamins W no.75/ferrous fumarate/folate comb. no.1)122 WAKIX (pitolisant hcl) 186 VITAFOL ULTRA (prenatal vit no.67/iron warfarin sodium 75 polysaccharides/folate comb.no.1/dha) 122 warfarin sodium (JANTOVEN) 75 VITAFOL-OB (prenatal vits with calcium WELCHOL (colesevelam hcl) 93 no.10/ferrous fumarate/folic acid) 122 WELLBUTRIN (bupropion hcl) 31 VITAFOL-ONE (prenatal vits no.26/iron WELLBUTRIN SR (bupropion hcl) 31,32 polysaccharide cplex/folic acid/dha) 122 WELLBUTRIN XL (bupropion hcl) 32 VITAMEDMD ONE RX (prenatal vits WESTHROID (thyroid,pork) 157 no.25/ferrous fumarate/folate comb. WP THYROID (thyroid,pork) 157 no.6/dha) 122 VITAMEDMD REDICHEW RX (prenatal vitamins X combination no.42/folic acid) 122 XADAGO (safinamide mesylate) 54 VITAPEARL (prenatal vit no.71/iron fum-sodium XALATAN (latanoprost) 171 feredetate/folic acid/dha) 122 XALKORI (crizotinib) 50 VITEKTA (elvitegravir) 60 XANAX (alprazolam) 67 VITRAKVI (larotrectinib sulfate) 45,46 XANAX XR (alprazolam) 67 VITUZ (hydrocodone XARELTO (rivaroxaban) 75 bitartrate/chlorpheniramine maleate) 183 XARTEMIS XR (oxycodone VIVELLE-DOT (estradiol) 153 hcl/acetaminophen) 13 VIVLODEX (meloxicam, submicronized) 3 XATMEP (methotrexate) 160 VIZIMPRO (dacomitinib) 46 XELJANZ (tofacitinib citrate) 160 VOGELXO (testosterone) 143 XELJANZ XR (tofacitinib citrate) 160 VOLTAREN (diclofenac sodium) 112 XELODA (capecitabine) 44 VOLTAREN-XR (diclofenac sodium) 3 XELPROS (latanoprost) 171 voriconazole 39 XENAZINE (tetrabenazine) 102 VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) 58 XENICAL (orlistat) 125 VOTRIENT (pazopanib hcl) 50 XENLETA (lefamulin acetate) 65 VP-PNV-DHA (prenatal vitamins no.52/ferrous XEPI (ozenoxacin) 112 fumarate/folic acid/dha) 122 XERESE (acyclovir/hydrocortisone) 65 VRAYLAR (cariprazine hcl) 56,57 XERMELO (telotristat etiprate) 125 VUMERITY (diroximel fumarate) 104 XGEVA (denosumab) 164 VUSION (miconazole nitrate/zinc XHANCE (fluticasone propionate) 174 oxide/petrolatum,white) 39 XIFAXAN (rifaximin) 18 VYLEESI (bremelanotide acetate) 134 XIGDUO XR (dapagliflozin VYNDAMAX (tafamidis) 89 propanediol/metformin hcl) 71

233 LAST UPDATED 12/01/2019 XIIDRA (lifitegrast) 168 ZELBORAF (vemurafenib) 50 XIMINO (minocycline hcl) 24 ZELNORM (tegaserod hydrogen maleate) 126 XOFLUZA (baloxavir marboxil) 161 ZEMBRACE SYMTOUCH (sumatriptan XOLEGEL (ketoconazole) 39 succinate) 41 XOPENEX (levalbuterol hcl) 177 ZEMPLAR (paricalcitol) 164 XOPENEX CONCENTRATE (levalbuterol hcl) 177 ZENPEP (lipase/protease/amylase) 130 XOPENEX HFA (levalbuterol tartrate) 177 ZENZEDI (dextroamphetamine sulfate) 97 XOSPATA (gilteritinib fumarate) 46 ZEPATIER (elbasvir/grazoprevir) 59 XPOVIO (selinexor) 46 ZERIT (stavudine) 62 XTAMPZA ER (oxycodone myristate) 6 ZESTORETIC (lisinopril/hydrochlorothiazide) 89 XTANDI (enzalutamide) 43 ZESTRIL (lisinopril) 80 XULTOPHY 100-3.6 (insulin ZETIA (ezetimibe) 93 degludec/liraglutide) 74 ZETONNA (ciclesonide) 174 XURIDEN (uridine triacetate) 123 ZIAC (bisoprolol XYLOCAINE (lidocaine hcl) 14 fumarate/hydrochlorothiazide) 89 XYOSTED (testosterone enanthate) 143 ZIAGEN (abacavir sulfate) 62 XYREM (sodium oxybate) 186 ZIANA (clindamycin phosphate/tretinoin) 112 zidovudine 62 Y ZIEXTENZO (pegfilgrastim-bmez) 76 YASMIN 28 (ethinyl estradiol/drospirenone) 153 zileuton 175 YAZ (ethinyl estradiol/drospirenone) 154 ZIOPTAN (tafluprost/pf) 171 YONSA (abiraterone acetate, ziprasidone hcl 57 submicronized) 43 ZIPSOR (diclofenac potassium) 3 YOSPRALA (aspirin/omeprazole) 77 ZIRGAN (ganciclovir) 58 YUPELRI (revefenacin) 176 ZITHROMAX (azithromycin) 21 ZITHROMAX TRI-PAK (azithromycin) 21 Z ZMAX (azithromycin) 21 zafirlukast 175 ZOCOR (simvastatin) 92 zaleplon 185 ZOFRAN (ondansetron hcl) 37 ZANAFLEX (tizanidine hcl) 57 ZOFRAN ODT (ondansetron) 37 ZANTAC (ranitidine hcl) 126 ZOHYDRO ER (hydrocodone bitartrate) 6 ZARONTIN (ethosuximide) 25 ZOLINZA (vorinostat) 46 ZARXIO (filgrastim-sndz) 76 zolmitriptan 41 ZAVESCA (miglustat) 130 ZOLOFT (sertraline hcl) 34 ZEBETA (bisoprolol fumarate) 82 zolpidem tartrate 185 ZEBUTAL ZOLPIMIST (zolpidem tartrate) 185 (butalbital/acetaminophen/caffeine) 102 ZOMACTON (somatropin) 142 ZEGERID (omeprazole/sodium ZOMIG (zolmitriptan) 41 bicarbonate) 129 ZOMIG ZMT (zolmitriptan) 41 ZEJULA (niraparib tosylate) 50 ZONACORT (dexamethasone) 140 ZELAPAR (selegiline hcl) 54 ZONALON (doxepin hcl) 112

234 LAST UPDATED 12/01/2019 ZONEGRAN (zonisamide) 25 zonisamide 25 ZONTIVITY (vorapaxar sulfate) 75 ZORBTIVE (somatropin) 142 ZORTRESS (everolimus) 160 ZORVOLEX (diclofenac submicronized) 3 ZOVIRAX (acyclovir) 65 ZTLIDO (lidocaine) 14 ZUBSOLV (buprenorphine hcl/naloxone hcl) 15 ZUPLENZ (ondansetron) 37 ZURAMPIC (lesinurad) 39 ZUTRIPRO (hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine) 183 ZYBAN (bupropion hcl) 15 ZYCLARA (imiquimod) 112 ZYDELIG (idelalisib) 50 ZYFLO (zileuton) 175 ZYFLO CR (zileuton) 175 ZYKADIA (ceritinib) 50 ZYLET (tobramycin/loteprednol etabonate) 168 ZYLOPRIM (allopurinol) 39 ZYMAXID (gatifloxacin) 22 ZYPITAMAG (pitavastatin magnesium) 92 ZYPREXA (olanzapine) 57 ZYPREXA ZYDIS (olanzapine) 57 ZYTIGA (abiraterone acetate) 43,44 ZYVOX (linezolid) 18

235 LAST UPDATED 12/01/2019

Blue Shield Association PLUS ( 01 /20 20) member of the ent

Blue Shield Pharmacy Services P.O. Box 7168 San Francisco, CA 94120-7168 An independ Blue Shield of California Notice Informing Individuals about Nondiscrimination and Accessibility Requirements

Discrimination is against the law Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Blue Shield of California does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability.

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- Qualified interpreters A20275(3/18) - Information written in other languages

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Blue Shield of California Civil Rights Coordinator P.O. Box 629007 El Dorado Hills, CA 95762-9007 Phone: (844) 831-4133 (TTY: 711) Fax: (844) 696-6070 Email: [email protected]

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U.S. Department of Health and Human Services 200 Independence Avenue SW.

Room 509F, HHH Building BlueShield of California is an independent memberof theBlue Shield Association Washington, DC 20201 (800) 368-1019; TTY: (800) 537-7697

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Blue Shield of California 50 Beale Street, San Francisco, CA 94105 Notice of the Availability of Language Assistance Services Blue Shield of California

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For help at no cost, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198. (Spanish)

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。這封信也可以用您所講的語言書寫。如需免费幫助，請立即撥打登列在您的Blue Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話 (866) 346-7198。(Chinese)

QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số (866) 346-7198. (Vietnamese)

MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sa numerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard, o (866) 346-7198. (Tagalog) Baa’ ákohwiindzindoo7g7: D77 naaltsoos7sh y77ni ta’go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich’8’ yiid0o[tah7g77 a’ nihee hól=. D77 naaltsoos a[d0’ t’11 Din4 k’ehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0 sh7k1’ adoowo[ n7n7zing0 nihich’8’ b44sh bee hod7ilnihł d00 n1mboo 47 d77 Blue Shield bee n47ho’d7lzin7g7 bine’d44’ bik11’ł 47 doodag0 47 (866) 346-7198 j8’ hod77lnih. (Navajo)

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ԿԱՐԵՎՈՐ Է․ Կարողանում ե՞ք կարդալ այս նամակը։ Եթե ոչ, ապա մենք կօգնենք ձեզ։ Դուք պետք է նաև կարողանաք ստանալ այս նամակը ձեր լեզվով։ Ծառայությունն անվճար է։ Խնդրում ենք անմիջապես զանգահարել Հաճախորդների սպասարկման բաժնի հեռախոսահամարով, որը նշված է ձեր Blue Shield ID քարտի ետևի մասում, կամ (866) 346-7198 համարով։ (Armenian)

ВАЖНО: Не можете прочесть данное письмо? Мы поможем вам, если необходимо. Вы также можете получить это письмо написанное на вашем родном языке. Позвоните в Службу клиентской/членской поддержки прямо сейчас по телефону, указанному сзади идентификационной карты Blue Shield, или по телефону (866) 346-7198, и вам помогут совершенно бесплатно. (Russian)

重要：お客様は、この手紙を読むことができますか？もし読むことができない場合、弊社が、お客様をサポートする人物を手配いたします。また、お客様の母国語で書かれた手紙をお送りすることも可能です。無料のサポートを希望される場合は、Blue Shield IDカードの裏面に記載されている会員/お客様サービスの電話番号、または、(866) 346-7198にお電話をおかけください。 (Japanese) blueshieldca.com ﻣﮭﻢ: آﯾﺎ ﻣﯽﺗﻮاﻧﯿﺪ اﯾﻦ ﻧﺎﻣﮫ را ﺑﺨﻮاﻧﯿﺪ؟ اﮔﺮ ﭘﺎﺳﺨﺘﺎن ﻣﻨﻔﯽ اﺳﺖ، ﻣﯽﺗﻮاﻧﯿﻢ ﮐﺴﯽ را ﺑﺮای ﮐﻤﮏ ﺑﮫ ﺷﻤﺎ در اﺧﺘﯿﺎرﺗﺎن ﻗﺮار دھﯿﻢ. ﺣﺘﯽ ﻣﯽﺗﻮاﻧﯿﺪ ﻧﺴﺨﮫ ﻣﮑﺘﻮب اﯾﻦ ﻧﺎﻣﮫ را ﺑﮫ زﺑﺎن ﺧﻮدﺗﺎن درﯾﺎﻓﺖ ﮐﻨﯿﺪ. ﺑﺮای درﯾﺎﻓﺖ ﮐﻤﮏ راﯾﮕﺎن، ﻟﻄﻔﺎً ﺑﺪون ﻓﻮت وﻗﺖ از طﺮﯾﻖ ﺷﻤﺎره ﺗﻠﻔﻨﯽ ﮐﮫ در ﭘﺸﺖ ﮐﺎرت ﺷﻨﺎﺳﯽ Blue Shield ﺗﺎن درج ﺷﺪه اﺳﺖ و ﯾﺎ از طﺮﯾﻖ ﺷﻤﺎره ﺗﻠﻔﻦ 7198-346 (866) ﺑﺎ ﺧﺪﻣﺎت اﻋﻀﺎ/ﻣﺸﺘﺮی ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ. (Persian)

ਮ ਹੱ ਤ ਵ ਪ ਰੂ ਨ : ਕੀ ਤੁਸ� ਇਸ ਪੱ ਤ ਰ ਨ ੂੰ ਪੜ� ਸਕਦੇ ਹੋ? ਜੇ ਨਹ� ਤ� ਇਸ ਨ ੂੰ ਪੜ�ਨ ਿਵਚ ਮਦਦ ਲਈ ਅਸ� ਿਕਸੇ ਿਵਅਕਤੀ ਦਾ ਪ ਬੰ� ਧ ਕਰ ਸਕਦੇ ਹ�। ਤੁਸ� ਇਹ ਪੱ ਤ ਰ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵਚ ਿਲਿਖਆ ਹੋਇਆ ਵੀ ਪ�ਾਪਤ ਕਰ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਿਵਚ ਮਦਦ ਪ�ਾਪਤ ਕਰਨ ਲਈ ਤੁਹਾਡੇ Blue Shield ID ਕਾਰਡ ਦੇ ਿ ਪੱ ਛ ੇ ਿ ਦੱ ਤ ੇ ਮ�ਬਰ/ਕਸਟਮਰ ਸਰਿਵਸ ਟੈਲੀਫ਼ੋਨ ਨੰ ਬ ਰ ਤੇ, ਜ� (866) 346-7198 ਤੇ ਕਾੱਲ ਕਰੋ। (Punjabi)

䮚ប�រសំ�ន់៖ េតើអ�ក�ចលិខិតេនះ �នែដរឬេទ? េបើមិន�ចេទ េយើង�ចឲ䮙េគជួយអ�កក��ង�រ�នលិ ខិតេនះ។ អ�កក៏�ចទទួល�នលិខិតេនះ��របស់អ�កផងែដរ។ ស䮚�ប់ជំនួយេ�យឥតគិតៃថ� សូមេ�ទូរស័ព��មៗេ��ន់េលខទូរស័ព�េស�ស�ជិក/អតិថិជនែដល�នេ�េលើខ�ងប័ណ�ស��ល់ Blue Shield របស់អ� ក ឬ�មរយៈេលខ (866) 346-7198។ (Khmer)

اﻟﻤﮭﻢ :ھﻞ ﺗﺴﺘﻄﯿﻊ ﻗﺮاءة ھﺬا اﻟﺨﻄﺎب؟ أن ﻟﻢ ﺗﺴﺘﻄﻊ ﻗﺮاءﺗﮫ، ﯾﻤﻜﻨﻨﺎ إﺣﻀﺎر ﺷﺨﺺ ﻣﺎ ﻟﯿﺴﺎﻋﺪك ﻓﻲ ﻗﺮاءﺗﮫ. ﻗﺪ ﺗﺤﺘﺎج أﯾﻀﺎً إﻟﻰ اﻟﺤﺼﻮل ﻋﻠﻰ ھﺬا اﻟﺨﻄﺎب ﻣﻜﺘﻮﺑﺎً ﺑﻠﻐﺘﻚ. ﻟﻠﺤﺼﻮل ﻋﻠﻰ اﻟﻤﺴﺎﻋﺪة ﺑﺪون ﺗﻜﻠﻔﺔ، ﯾﺮﺟﻰ اﻻﺗﺼﺎل اﻵن ﻋﻠﻰ رﻗﻢ ھﺎﺗﻒ ﺧﺪﻣﺔ اﻟﻌﻤﻼء/أﺣﺪ اﻷﻋﻀﺎء اﻟﻤﺪون ﻋﻠﻰ اﻟﺠﺎﻧﺐ اﻟﺨﻠﻔﻲ ﻣﻦ ﺑﻄﺎﻗﺔ اﻟﮭﻮﯾﺔ Blue Shield أو ﻋﻠﻰ اﻟﺮﻗﻢ Arabic).(866) 346-7198)

TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)

สําคัญ: คุณอ่านจดหมายฉบับนีได้หรือไม่้ หากไม่ได้ โปรดขอคงามช่วยจากผู้อ่านได้ คุณอาจได้รับจดหมายฉบับนีเป็นภาษาของคุณ้ หากต้องการความช่วยเหลือโดยไม่มีค่าใช ้จ่าย โปรดติดต่อฝ่ายบริการลูกค้า/สมาชิกทางเบอร ์โทรศัพท ์ในบัตรประจําตัว Blue Shield ของคุณ หรือโทร (866) 346-7198 (Thai)

मह配वपण셍ू : 啍या आप इस पत्र को पढ़ सकते ह�? य�द नह�ं, तो हम इसे पढ़ने म� आपक� मदद के �लए �कसी 핍यि啍त का प्रबंध कर सकते ह�। आप इस पत्र को अपनी भाषा म� भी प्राꥍत कर सकते ह�। �न:श쥍कु मदद प्राꥍत करने के �लए अपने Blue Shield ID काड셍 के पीछे �दए गये म�बर/कटमर स�व셍स टेल�फोन नंबर, या (866) 346-7198 पर कॉल कर� । (Hindi)

ິ່ສງໍສາຄັ ນ: ທ່ ານສາມາດອ່ ານຈົ ດໝາຍນີ ້ ໄດ້ ໍບ? ຖ້ າອ່ ານບໍ່ ໄດ້ , ພວກເຮົ າສາມາດໃຫ້ ບາງຄົ ນຊ່ ວຍອ່ ານໃຫ້ ທ່ ານຟັ ງໄດ້ . ທ່ ານຍັ ງສາມາດໍຂໃຫ້ ແປຈົ ດໝາຍນີ ້ ເປັ ນພາສາຂອງທ່ ານໄດ້ .ໍສາລັ ບຄວາມຊ່ ວຍເຫືຼ ອແບບໍ່ບເສຍຄ່ າ, ກະລຸ ນາ ໂທຫາເບີ ໂທຂອງຝ່ າຍໍບິລການສະມາິຊກ/ລູ ກຄ້ າໃນທັ ນທີ ເບີ ໂທລະສັ ບຢູ່ ດ້ ານຫຼັ ງບັ ດສະມາິຊກ Blue Shield ຂອງທ່ ານ, ືຫຼ ໂທໄປຫາເບີ (866) 346-7198. (Laotian)

blueshieldca.com Notice of the Availability of Language Assistance Services Blue Shield of California Life & Health Insurance Company

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help call the CA Dept. of Insurance at 1-800-927-4357. English

Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de CA al 1-800-927-4357. Spanish 免費語言服務。您可獲得口譯員服務。可以用中文把文件唸給您聽，有些文件有中文的版本，也可以把這些文件寄給您。欲取得協助，請致電您的保險卡所列的電話號碼，或撥打 1-866-346-7198 與我們聯絡。欲取得其他協助，請致電 1-800-927-4357 與加州保險部聯絡。Chinese Các Dịch Vụ Trợ Giúp Ngôn Ngữ Miễn Phí. Quý vị có thể được nhận dịch vụ thông dịch. Quý vị có thể được người khác đọc giúp các tài liệu và nhận một số tài liệu bằng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi tại số điện thoại ghi trên thẻ hội viên của quý vị hoặc 1-866-346-7198. Để được trợ giúp thêm, xin gọi Sở Bảo Hiểm California tại số 1-800-927-4357. Vietnamese

무료 통역 서비스. 귀하는 한국어 통역 서비스를 받으실 수 있으며 한국어로 서류를 낭독해주는 서비스를 받으실 수 있습니다. 도움이 필요하신 분은 귀하의 ID 카드에 나와있는 안내 전화: 1-866-346-7198번으로 문의해 주십시오. 보다 자세한 사항을 문의하실 분은 캘리포니아 주 보험국, 안내 전화 1-800-927-4357번으로 연락해 주십시오. Korean

Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357 Tagalog

Անվճար Լեզվական Ծառայություններ։ Դուք կարող եք թարգման ձեռք բերել և փաստաթղթերը ընթերցել տալ ձեզ համար հայերեն լեզվով։ Օգնության համար մեզ զանգահարեք ձեր ինքնության (ID) տոմսի վրա նշված կամ 1-866-346-7198 համարով։ Լրացուցիչ օգնության համար 1-800-927-4357 համարով զանգահարեք Կալիֆորնիայի Ապահովագրության Բաժանմունք։ Armenian Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния (Department of Insurance), по телефону 1-800-927-4357. Russian 無料の言語サービス日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、ＩＤカード記載の番号または1-866-346-7198までお問い合わせください。更なるお問い合わせは、カリフォルニア州保険庁、1-800-927-4357までご連絡ください。Japanese ﻣﺠﺎﻧﺧﺪﻣﺎت ﯽ ﻣﺮﺑﻮط ﺑﮫ زﺑﺎن . ﻣﯿﺘﻮاﻧﯿﺪ از ﺧﺪﻣﺎت ﯾﮏ ﻣﺘﺮﺟﻢ ﺷﻔﺎھﯽ اﺳﺘﻔﺎده ﮐﻨﯿﺪ و ﺑﮕﻮﺋﯿﺪ ﻣﺪارک ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﺑﺮاﯾﺘﺎن ﺧﻮاﻧﺪه ﺷﻮﻧﺪ.ﺑﺮای درﯾﺎﻓﺖ ﮐﻤﮏ،ﺑﺎ ﻣﺎ از طﺮﯾﻖ ﺷﻤﺎره ﺗﻠﻔﻨﯽ ﮐﮫ روی ﮐﺎرت ﺷﻨﺎﺳﺎﺋﯽ ﺷﻤﺎ ﻗﯿﺪ ﺷﺪه اﺳﺖ و ﯾﺎ اﯾﻦ ﺷﻤﺎره 7198-346-866-1 ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ.ﺑﺮای درﯾﺎﻓﺖ ﮐﻤﮏ ﺑﯿﺸﺘﺮ، ﺑﮫ CA Dept. of Insurance(اداره ﺑﯿﻤﮫ ﮐﺎﻟﯿﻔﺮﻧﯿﺎ) ﺑﮫ ﺷﻤﺎره 4357-927-800-1 ﺗﻠﻔﻦ ﮐﻨﯿﺪ.Persian

blueshieldca.com ਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸੇਵਾਵਾਂ: ਤੁਸੀ ਂ ਦੁਭਾਸ਼ੀਏ ਦੀਆਂ ਸੇਵਾਵਾਂ ਹਾਸਲ ਕਰ ਸਕਦੇ ਹੋ ਅਤੇ ਦਸਤਾਵੇਜ਼ਾਂ ਨ ੂੰ ਪੰਜਾਬੀ ਿਵੱਚ ਸੁਣ ਸਕਦੇ ਹੋ। ਕੁਝ ਦਸਤਾਵੇਜ਼ ਤ ੁਹ ਾ ਨ ੂੰ ਪੰਜਾਬੀ ਿਵੱਚ ਭੇਜੇ ਜਾ ਸਕਦੇ ਹਨ। ਮਦਦ ਲਈ ਤੁਹਾਡੇ ਆਈਡੀ (ID) ਕਾਰਡ 'ਤੇ ਿਦੱਤੇ ਨੰ ਬ ਰ 'ਤੇ ਜਾਂ 1-866-346-7198 'ਤੇ ' ਸ ਾ ਨੂੰ ਫ਼ੋਨ ਕਰੋ। ਵਧੇਰੇ ਮਦਦ ਲਈ ਕੈਲੀਫ਼ੋਰਨੀਆ ਿਡਪਾਰਟਮ�ਟ ਆਫ਼ ਇਨਸ਼ੋਰ�ਸ ਨੂੰ 1-800-927-4357 'ਤੇ ਫ਼ੋਨ ਕਰੋ। Punjabi

េស�កម��ឥតគិតៃថ�។ អ�ក�ចទទួល�នអ�កបកែ䮚ប�� និង�នឯក�រជូនអ�ក� ��ែខ� រ ។ ស䮚�ប់ជំនួយ សូមទូរស័ព�មកេយើងខ��ំ�មេលខែដល�នប��ញេលើប័ណ�សំ�ល់ខ� �នរបស់អ�ក ឬេលខ 1-866-346-7198 ។ ស䮚�ប់ជំនួយបែន�មេទៀត សូមទូរស័ព�េ�䮚កសួង��ប់រងរដ��លីហ��រ�៉ �មេលខ 1-800-927-4357 Khmer ﺧﺪﻣﺎت ﺗﺮﺟﻤﺔ ﺑﺪون ﺗﻜﻠﻘﺔ. ﯾﻤﻜﻨﻚ اﻟﺤﺼﻮل ﻋﻠﻲ ﻣﺘﺮﺟﻢ و ﻗﺮاءة اﻟﻮﺛﺎﺋﻖ ﻟﻚ ﺑﺎﻟﻠﻐﺔ اﻟﻌﺮﺑﯿﺔ. ﻟﻠﺤﺼﻮل ﻋﻠﻲ اﻟﻤﺴﺎﻋﺪة، اﺗﺼﻞ ﺑﻨﺎ ﻋﻠﻲ اﻟﺮﻗﻢ اﻟﻤﺒﯿﻦ ﻋﻠﻲ ﺑﻄﺎﻗﺔ ﻋﻀﻮﯾﺘﻚ أو ﻋﻠﻲ اﻟﺮﻗﻢ 7198-346-866-1. ﻟﻠﺤﺼﻮل ﻋﻠﻲ اﻟﻤﺰﯾﺪ ﻣﻦ اﻟﻤﻌﻠﻮﻣﺎت، اﺗﺼﻞ ﺑﺈدارة اﻟﺘﺄﻣﯿﻦ ﻟﻮﻻﯾﺔ ﻛﺎﻟﯿﻔﻮرﻧﯿﺎ ﻋﻠﻲ اﻟﺮﻗﻢ Arabic .1-800-927-4357

Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357 Hmong

บริการทางภาษาอย่างไม่เสียค่าใช ้จ่าย คุณสามารถรับบริการจากล่าม รวมถึงให้เจ ้าหน้าทีอ่านเอกสารให้คุณฟัง่ หรือส่งเอกสารบางส่วนในภาษาของคุณไปหาคุณได้ หากต้องการความช่วยเหลือ กรุณาโทรศัพท ์ตามหมายเลขทีระบุอยู่ด้านหลังบัตรประจําตัวของคุณ่ หร ือ ทีหมายเลข่ 1-866-346-7198 หากต้องการความช่วยเหลือเพิมเติม่ โปรดโทรมาที ่ กรมการประกันภัยแห่งมลรัฐแคลิฟอร ์เนียทีหมายเลข่ 1-800-927-4357 Thai

िनःशु� भाषा स ेव ा एँ । आप एक दुभािषया की सेवा प्रा� कर सकते ह�। आप द�ावेजों को पढ़वा के सुन सकते ह� और कु छ को अपनी भाषा म� �यं को िभजवा सकते ह�। सहायता के िलए, अपने ID काड� पर िदए गए नंबर पर, या 1-866-346-7198 पर हम� फ़ोन कर� । अिधक सहायता के िलए कैलीफोिन�या बीमा िवभाग (CA Dept. of Insurance) को 1-800-927-4357 पर फ़ोन कर� । Hindi Doo b11h 7l7n7g0 saad bee y1t’i’ bee an1’1wo’. D77 sh1 ata’halne’doo7g7 h0l=-doo n7n7zingo 47 b7ighah. Naaltsoos naanin1h1jeeh7g7 shich’8’ y7idooltah 47 doodag0 [a’ shich’8’ 1dooln77[ n7n7zingo b7ighah. Sh7k1 a’doowo[ n7n7zingo nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 ninaaltsoos doot[‘7zh7g7 bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0 47 (866)346-7198j8’ hod77lnih. H0zh= sh7k1 an11’doowo[ n7n7zingo 47 d77 b4eso 1ch’22h naa’nil bi[ haz’32j8’ 1-800-927-4357j8’ hod77lnih. Navajo

ໍບິລການແປພາສາໂດຍໍ່ບເສຍຄ່ າ. ທ່ ານສາມາດໍຂເອົ າຜູ້ ແປພາສາໄດ້ . ທ່ ານສາມາດໍຂໃຫ້ ອ່ ານເອກະສານໃຫ້ ທ່ ານຟັ ງ ແລະ ສົ່ ງເອກະສານບາງຢ່ າງີ່ທເປັ ນພາສາຂອງທ່ ານ. ໍສາລັ ບຄວາມຊ່ ວຍເຫືຼ ອ, ໃຫ້ ໂທຫາພວກເຮົ າຕາມເບີ ໂທລະສັ ບີ່ທີ ມ ໃນບັ ດປະໍຈາຕົ ວຂອງທ່ ານ ືຫຼ ໂທຫາເບີ 1-866-346-7198. ໍສາລັ ບຄວາມຊ່ ວຍເຫືຼ ອເພີ່ ມເ ຕີ ມ ໂທຫາ ພະແນກ ປະກັ ນໄພຂອງ ລັ ດຄາີລຟໍ ເນຍໄດ້ ີ່ທເບີ 1-800-927-4357. Laotian

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