Metallic M1 - List of Covered (Formulary)

Effective Date: 09-01-2021

The Metallic M1 Formulary is used by these plans:

Plus HSA Qualified Bronze 5950

Plus HSA Qualified Gold 1500

Plus HSA Qualified Silver 2800

Plus HSA Qualified Silver 3500

Plus HSA Qualified Bronze 6900

What is the list of covered drugs (Formulary)? This document contains a list of generic, brand and specialty drugs covered under your plan.

How is the list of covered drugs developed? The list is developed with an independent committee of physicians, pharmacists and other healthcare providers called the Pharmacy and Therapeutics Committee. This independent committee reviews and selects drugs for coverage based on each drugs safety, effectiveness and cost. The committee meets at least quarterly to review new drugs to market to determine placement on this list and also reviews updated safety, effectiveness and cost information for existing drugs to ensure the formulary remains up to date with current medical evidence.

How do I use the Formulary? Drugs are listed by categories depending on the type of medical conditions that they are used to treat. If you know what your drug is used for, look for the category name in the list that begins below. Then look under the category name for your drug.

If you are not sure what category to look under, you can also search for the drug in the Index. The Index provides an alphabetical list of all of the drugs included in this document. Next to the name of the drug in the Index, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

052152_2021 Last Updated: 09-02-2021 How does this drug list help me understand my drug coverage? Drug coverage is based on your coverage contract. Coverage for a specific drug is subject to the rules outlined in your member booklet. This document will tell you if a drug is included on the formulary attached to your plan.

Will this drug list (Formulary) change? This drug list (Formulary) is updated throughout the year. If you are taking a drug and it will be removed from the formulary or moved to a higher cost sharing tier we will notify you of this change via letter. We also post information on upcoming formulary changes on our website on the “Upcoming Formulary Changes” page.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These can be seen in the column next to the drug name on the list. These requirements and limits may include: • Prior Authorization: some drugs require prior approval before they are covered. • Quantity Limits: for some drugs, we limit the amount of the drug that we will cover. For example, we will cover 18 per 30 day supply of zolmitriptan oral tablets. • Step Therapy: for some drugs we require that you first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then we will then cover Drug B.

Drugs subject to these restrictions will generally mean that your physician or healthcare provider may need to provide additional information on your medical condition before the drug will be covered at the pharmacy. Information on this process is on our website on the “Drugs Requiring Approval” page.

Metallic Formulary The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., metformin oral ). The information in the Requirements/Limits column tells you if we have any special requirements for coverage of your drug.

ii COVERAGE NOTES ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug.

QL Quantity Limit Restriction We limit the amount of this drug that is covered per prescription, or within a specific time frame.

ST Step Therapy Restriction Before we will provide coverage for this drug, you must first try another drug to treat your medical condition. This drug may only be covered if the other drug does not work for you.

Other Special Requirements for Coverage

LA Limited Access Drug Some drugs under your plan may only be filled at an in-network specialty pharmacy. These are drugs where the FDA has restricted distribution or are drugs that require special handling, provider coordination, or patient education that cannot be met by a network retail pharmacy.

Vac Vaccines For more information on the coverage of vaccines administered at a Pharmacy, please see your member booklet or contact Customer Service.

OCh Oral Chemo Oral Chemotherapy Drug. Certain oral chemotherapy drugs may be covered under your medical plan. Please check your member booklet for more details.

iii The amount you pay for a covered drug will depend on if you have met any applicable deductible for the plan year, if you have met any applicable maximum out of pocket for the plan year and what tier the medication is on. More information on applicable deductibles and maximum out of pockets can be found in your member booklet.

Metallic M1 Formulary

Drug Tier Includes

Formulary Drugs (1) Formulary Drugs include Preferred Generic, Preferred Brand, Non- Preferred and Specialty Drugs. Medical plan cost shares apply to formulary drugs. Once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out of pocket maximum limit.

ACA PV The ACA PV tier includes Affordable Care Act (ACA) Preventive medications. The ACA makes certain preventive medications available to you at no cost. Coverage of any medication as ACA PV (including over- the-counter (OTC) medications) requires a prescription from a licensed health care provider.

MB (Medical Benefit) The MB tier includes medical benefit drugs normally administered in a clinic, infusion center or provided by a home infusion service. These drugs and their services are covered under the medical benefit, not under the pharmacy benefit. This drug may require prior authorization.

iv Drug Name Drug Tier Requirements / Limits ANTI - INFECTIVES ANTIFUNGAL AGENTS AMBISOME INTRAVENOUS MB FOR RECONSTITUTION 50 MG amphotericin b recon soln 50 mg MB CANCIDAS INTRAVENOUS RECON SOLN 50 MB MG, 70 MG clotrimazole mucous membrane troche 10 mg 1 CRESEMBA INTRAVENOUS RECON SOLN MB 372 MG CRESEMBA ORAL 186 MG 1 PA ERAXIS(WATER DILUENT) INTRAVENOUS MB RECON SOLN 100 MG, 50 MG fluconazole oral suspension for reconstitution 10 1 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 1 50 mg flucytosine oral capsule 250 mg, 500 mg 1 griseofulvin microsize oral suspension 125 mg/5 1 ml griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 1 mg itraconazole oral capsule 100 mg 1 itraconazole oral 10 mg/ml 1 ketoconazole oral tablet 200 mg 1 MYCAMINE INTRAVENOUS RECON SOLN MB 100 MG, 50 MG NOXAFIL ORAL SUSPENSION 200 MG/5 ML 1 (40 MG/ML) nystatin oral suspension 100,000 unit/ml 1 nystatin oral tablet 500,000 unit 1 ORAVIG BUCCAL MUCO-ADHESIVE 1 BUCCAL TABLET 50 MG posaconazole oral tablet,delayed release (dr/ec) 1 100 mg terbinafine hcl oral tablet 250 mg 1 voriconazole intravenous recon soln 200 mg MB

1 Drug Name Drug Tier Requirements / Limits voriconazole oral suspension for reconstitution 1 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg 1 ANTIVIRALS abacavir oral solution 20 mg/ml 1 QL (60 per 30 days) abacavir oral tablet 300 mg 1 QL (60 per 30 days) abacavir-lamivudine oral tablet 600-300 mg 1 QL (30 per 30 days) abacavir-lamivudine-zidovudine oral tablet 300- 1 QL (60 per 30 days) 150-300 mg acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 400 mg, 800 mg 1 adefovir oral tablet 10 mg 1 amantadine hcl oral capsule 100 mg 1 amantadine hcl oral solution 50 mg/5 ml 1 amantadine hcl oral tablet 100 mg 1 APTIVUS ORAL CAPSULE 250 MG 1 QL (120 per 30 days) atazanavir oral capsule 150 mg, 300 mg 1 QL (30 per 30 days) atazanavir oral capsule 200 mg 1 QL (60 per 30 days) BARACLUDE ORAL SOLUTION 0.05 MG/ML 1 BIKTARVY ORAL TABLET 50-200-25 MG 1 QL (30 per 30 days) CABENUVA INTRAMUSCULAR 1 PA SUSPENSION,EXTENDED RELEASE 400 MG/2 ML- 600 MG/2 ML, 600 MG/3 ML- 900 MG/3 ML cidofovir intravenous solution 75 mg/ml MB CIMDUO ORAL TABLET 300-300 MG 1 QL (30 per 30 days) COMPLERA ORAL TABLET 200-25-300 MG 1 QL (30 per 30 days) CYTOVENE INTRAVENOUS RECON SOLN MB 500 MG DESCOVY ORAL TABLET 200-25 MG 1 QL (30 per 30 days) didanosine oral capsule,delayed release(dr/ec) 1 QL (30 per 30 days) 250 mg, 400 mg DOVATO ORAL TABLET 50-300 MG 1 QL (30 per 30 days) EDURANT ORAL TABLET 25 MG 1 QL (30 per 30 days) efavirenz oral capsule 200 mg, 50 mg 1 QL (30 per 30 days) efavirenz oral tablet 600 mg 1 QL (30 per 30 days)

2 Drug Name Drug Tier Requirements / Limits efavirenz-emtricitabin-tenofov oral tablet 600- 1 200-300 mg efavirenz-lamivu-tenofov disop oral tablet 400- 1 300-300 mg, 600-300-300 mg emtricitabine oral capsule 200 mg 1 QL (30 per 30 days) emtricitabine-tenofovir (tdf) oral tablet 100-150 1 QL (30 per 30 days) mg, 133-200 mg, 167-250 mg, 200-300 mg EMTRIVA ORAL SOLUTION 10 MG/ML 1 QL (720 per 30 days) entecavir oral tablet 0.5 mg, 1 mg 1 EPCLUSA ORAL TABLET 200-50 MG, 400-100 1 PA; LA MG EPIVIR HBV ORAL SOLUTION 25 MG/5 ML 1 (5 MG/ML) etravirine oral tablet 100 mg, 200 mg 1 QL (60 per 30 days) EVOTAZ ORAL TABLET 300-150 MG 1 QL (30 per 30 days) famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 fosamprenavir oral tablet 700 mg 1 QL (60 per 30 days) FUZEON SUBCUTANEOUS RECON SOLN 90 1 QL (30 per 30 days) MG GANCICLOVIR INTRAVENOUS SOLUTION MB 500 MG/250 ML (2 MG/ML) ganciclovir sodium intravenous recon soln 500 mg MB GENVOYA ORAL TABLET 150-150-200-10 1 QL (30 per 30 days) MG HARVONI ORAL PELLETS IN PACKET 33.75- 1 LA 150 MG, 45-200 MG HARVONI ORAL TABLET 45-200 MG, 90-400 1 PA; LA MG INTELENCE ORAL TABLET 100 MG, 200 MG, 1 QL (60 per 30 days) 25 MG INVIRASE ORAL TABLET 500 MG 1 QL (120 per 30 days) ISENTRESS HD ORAL TABLET 600 MG 1 QL (60 per 30 days) ISENTRESS ORAL IN PACKET 100 1 QL (60 per 30 days) MG ISENTRESS ORAL TABLET 400 MG 1 QL (60 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 100 1 QL (60 per 30 days) MG, 25 MG JULUCA ORAL TABLET 50-25 MG 1 QL (30 per 30 days) KALETRA ORAL TABLET 100-25 MG 1 QL (60 per 30 days)

3 Drug Name Drug Tier Requirements / Limits KALETRA ORAL TABLET 200-50 MG 1 QL (120 per 30 days) lamivudine oral solution 10 mg/ml 1 QL (900 per 30 days) lamivudine oral tablet 100 mg 1 lamivudine oral tablet 150 mg, 300 mg 1 QL (60 per 30 days) lamivudine-zidovudine oral tablet 150-300 mg 1 QL (60 per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML 1 QL (60 per 30 days) lopinavir-ritonavir oral solution 400-100 mg/5 ml 1 QL (320 per 30 days) lopinavir-ritonavir oral tablet 100-25 mg, 200-50 1 QL (120 per 30 days) mg MAVYRET ORAL TABLET 100-40 MG 1 PA; LA nevirapine oral suspension 50 mg/5 ml 1 QL (60 per 30 days) nevirapine oral tablet 200 mg 1 QL (60 per 30 days) nevirapine oral tablet extended release 24 hr 100 1 QL (30 per 30 days) mg, 400 mg NORVIR ORAL POWDER IN PACKET 100 MG 1 QL (360 per 30 days) NORVIR ORAL SOLUTION 80 MG/ML 1 QL (480 per 30 days) ODEFSEY ORAL TABLET 200-25-25 MG 1 QL (30 per 30 days) oseltamivir oral capsule 30 mg 1 QL (40 per 365 days) oseltamivir oral capsule 45 mg, 75 mg 1 QL (20 per 365 days) oseltamivir oral suspension for reconstitution 6 1 QL (180 per 30 days) mg/ml PREVYMIS INTRAVENOUS SOLUTION 240 MB PA MG/12 ML, 480 MG/24 ML PREZCOBIX ORAL TABLET 800-150 MG-MG 1 QL (30 per 30 days) PREZISTA ORAL SUSPENSION 100 MG/ML 1 QL (30 per 30 days) PREZISTA ORAL TABLET 150 MG, 600 MG, 1 QL (60 per 30 days) 75 MG PREZISTA ORAL TABLET 800 MG 1 QL (30 per 30 days) RAPIVAB (PF) INTRAVENOUS SOLUTION MB 200 MG/20 ML (10 MG/ML) RELENZA DISKHALER 1 QL (2 per 30 days) BLISTER WITH DEVICE 5 MG/ACTUATION REYATAZ ORAL POWDER IN PACKET 50 1 QL (150 per 30 days) MG ribavirin inhalation recon soln 6 gram MB rimantadine oral tablet 100 mg 1 ritonavir oral tablet 100 mg 1 QL (360 per 30 days)

4 Drug Name Drug Tier Requirements / Limits SELZENTRY ORAL SOLUTION 20 MG/ML 1 QL (8 per 30 days) SELZENTRY ORAL TABLET 150 MG, 25 MG, 1 QL (60 per 30 days) 300 MG, 75 MG SOVALDI ORAL PELLETS IN PACKET 150 1 LA MG, 200 MG SOVALDI ORAL TABLET 200 MG, 400 MG 1 PA; LA stavudine oral capsule 15 mg, 20 mg, 40 mg 1 QL (120 per 30 days) STRIBILD ORAL TABLET 150-150-200-300 1 QL (30 per 30 days) MG SYNAGIS INTRAMUSCULAR SOLUTION 100 MB LA MG/ML, 50 MG/0.5 ML tenofovir disoproxil fumarate oral tablet 300 mg 1 QL (30 per 30 days) TIVICAY ORAL TABLET 10 MG, 25 MG, 50 1 QL (60 per 30 days) MG TIVICAY PD ORAL TABLET FOR 1 QL (60 per 30 days) SUSPENSION 5 MG TRIUMEQ ORAL TABLET 600-50-300 MG 1 QL (30 per 30 days) TROGARZO INTRAVENOUS SOLUTION 200 MB PA MG/1.33 ML (150 MG/ML) TYBOST ORAL TABLET 150 MG 1 QL (30 per 30 days) valacyclovir oral tablet 1 gram, 500 mg 1 valganciclovir oral recon soln 50 mg/ml 1 valganciclovir oral tablet 450 mg 1 VEMLIDY ORAL TABLET 25 MG 1 VIEKIRA PAK ORAL TABLETS,DOSE PACK 1 PA 12.5 MG-75 MG -50 MG/250 MG VIRACEPT ORAL TABLET 250 MG 1 QL (90 per 30 days) VIRACEPT ORAL TABLET 625 MG 1 QL (60 per 30 days) VIREAD ORAL POWDER 40 MG/SCOOP (40 1 QL (4 per 30 days) MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 1 QL (30 per 30 days) MG VOSEVI ORAL TABLET 400-100-100 MG 1 PA; LA ZEPATIER ORAL TABLET 50-100 MG 1 PA; LA zidovudine oral capsule 100 mg 1 QL (60 per 30 days) zidovudine oral 10 mg/ml 1 QL (960 per 30 days) zidovudine oral tablet 300 mg 1 QL (60 per 30 days) CEPHALOSPORINS

5 Drug Name Drug Tier Requirements / Limits AVYCAZ INTRAVENOUS RECON SOLN 2.5 MB GRAM cefaclor oral capsule 250 mg, 500 mg 1 cefaclor oral suspension for reconstitution 125 1 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 500 mg 1 cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension for reconstitution 250 1 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram 1 cefazolin in dextrose (iso-os) intravenous MB piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, MB 100 gram, 20 gram, 300 g, 500 mg cefazolin intravenous recon soln 1 gram MB cefdinir oral capsule 300 mg 1 cefdinir oral suspension for reconstitution 125 1 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg 1 CEFEPIME IN DEXTROSE 5 % MB INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefepime in dextrose,iso-osm intravenous MB piggyback 1 gram/50 ml, 2 gram/100 ml cefepime injection recon soln 1 gram, 2 gram MB cefixime oral capsule 400 mg 1 cefixime oral suspension for reconstitution 100 1 mg/5 ml, 200 mg/5 ml CEFOTAN INJECTION RECON SOLN 1 MB GRAM, 2 GRAM cefotaxime injection recon soln 1 gram MB CEFOTETAN IN DEXTROSE, ISO-OSM MB INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML cefotetan injection recon soln 1 gram, 2 gram MB cefotetan intravenous recon soln 10 gram MB cefoxitin intravenous recon soln 10 gram MB cefpodoxime oral suspension for reconstitution 1 100 mg/5 ml, 50 mg/5 ml

6 Drug Name Drug Tier Requirements / Limits cefpodoxime oral tablet 100 mg, 200 mg 1 cefprozil oral suspension for reconstitution 125 1 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg 1 CEFTAZIDIME IN D5W INTRAVENOUS MB PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML ceftazidime injection recon soln 1 gram, 2 gram, 6 MB gram ceftriaxone in dextrose,iso-os intravenous MB piggyback 1 gram/50 ml, 2 gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, MB 2 gram, 250 mg, 500 mg CEFTRIAXONE INJECTION RECON SOLN MB 100 GRAM ceftriaxone intravenous recon soln 1 gram, 2 gram MB cefuroxime axetil oral tablet 250 mg, 500 mg 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 cephalexin oral suspension for reconstitution 125 1 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg 1 SUPRAX ORAL SUSPENSION FOR 1 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 100 1 MG, 200 MG tazicef injection recon soln 1 gram, 2 gram, 6 MB gram tazicef intravenous recon soln 1 gram, 2 gram MB TEFLARO INTRAVENOUS RECON SOLN 400 MB MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 1.5 MB GRAM ERYTHROMYCINS & OTHER MACROLIDES azithromycin oral packet 1 gram 1 azithromycin oral suspension for reconstitution 1 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 clarithromycin oral suspension for reconstitution 1 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg 1

7 Drug Name Drug Tier Requirements / Limits clarithromycin oral tablet extended release 24 hr 1 500 mg DIFICID ORAL TABLET 200 MG 1 e.e.s. 400 oral tablet 400 mg 1 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 1 333 mg erythrocin (as stearate) oral tablet 250 mg 1 erythromycin ethylsuccinate oral suspension for 1 reconstitution 200 mg/5 ml, 400 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg 1 erythromycin oral capsule,delayed release(dr/ec) 1 250 mg erythromycin oral tablet 250 mg, 500 mg 1 erythromycin oral tablet,delayed release (dr/ec) 1 250 mg, 333 mg, 500 mg MISCELLANEOUS ANTIINFECTIVES albendazole oral tablet 200 mg 1 ALINIA ORAL SUSPENSION FOR 1 PA; ST RECONSTITUTION 100 MG/5 ML amikacin injection solution 500 mg/2 ml MB atovaquone oral suspension 750 mg/5 ml 1 atovaquone-proguanil oral tablet 250-100 mg, 1 62.5-25 mg bacitracin intramuscular recon soln 50,000 unit 1 CAPASTAT INJECTION RECON SOLN 1 1 GRAM CAYSTON INHALATION SOLUTION FOR 1 PA; LA; QL (84 per 30 days) NEBULIZATION 75 MG/ML chloramphenicol sod succinate intravenous recon MB soln 1 gram chloroquine phosphate oral tablet 250 mg, 500 mg 1 clindamycin hcl oral capsule 150 mg, 300 mg, 75 1 mg clindamycin pediatric oral recon soln 75 mg/5 ml 1 clindamycin phosphate injection solution 150 MB mg/ml COARTEM ORAL TABLET 20-120 MG 1 CUBICIN INTRAVENOUS RECON SOLN 500 MB MG

8 Drug Name Drug Tier Requirements / Limits CUBICIN RF INTRAVENOUS RECON SOLN MB 500 MG CYCLOSERINE ORAL CAPSULE 250 MG 1 dapsone oral tablet 100 mg, 25 mg 1 EMVERM ORAL TABLET,CHEWABLE 100 1 MG ethambutol oral tablet 100 mg, 400 mg 1 gentamicin injection solution 20 mg/2 ml, 40 MB mg/ml gentamicin sulfate (ped) (pf) injection solution 20 MB mg/2 ml hydroxychloroquine oral tablet 200 mg 1 imipenem-cilastatin intravenous recon soln 250 MB mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM MB isoniazid injection solution 100 mg/ml 1 isoniazid oral solution 50 mg/5 ml 1 isoniazid oral tablet 100 mg, 300 mg 1 ivermectin oral tablet 3 mg 1 LINCOCIN INJECTION SOLUTION 300 MB MG/ML linezolid in dextrose 5% intravenous piggyback MB 600 mg/300 ml linezolid oral suspension for reconstitution 100 1 mg/5 ml linezolid oral tablet 600 mg 1 linezolid-0.9% sodium chloride intravenous MB parenteral solution 600 mg/300 ml mefloquine oral tablet 250 mg 1 meropenem intravenous recon soln 1 gram, 500 MB mg MEROPENEM-0.9% SODIUM CHLORIDE MB INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 500 MG/50 ML metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 neomycin oral tablet 500 mg 1 nitazoxanide oral tablet 500 mg 1

9 Drug Name Drug Tier Requirements / Limits paromomycin oral capsule 250 mg 1 PASER ORAL GRANULES DR FOR SUSP IN 1 PACKET 4 GRAM PENTAM INJECTION RECON SOLN 300 MG MB pentamidine inhalation recon soln 300 mg 1 pentamidine injection recon soln 300 mg MB polymyxin b sulfate injection recon soln 500,000 MB unit praziquantel oral tablet 600 mg 1 PRIFTIN ORAL TABLET 150 MG 1 primaquine oral tablet 26.3 mg 1 pyrazinamide oral tablet 500 mg 1 pyrimethamine oral tablet 25 mg 1 PA quinine sulfate oral capsule 324 mg 1 rifabutin oral capsule 150 mg 1 rifampin oral capsule 150 mg, 300 mg 1 SIRTURO ORAL TABLET 100 MG 1 PA SIRTURO ORAL TABLET 20 MG 1 SIVEXTRO ORAL TABLET 200 MG 1 QL (6 per 30 days) STREPTOMYCIN INTRAMUSCULAR RECON 1 SOLN 1 GRAM tinidazole oral tablet 250 mg, 500 mg 1 tobramycin in 0.225 % nacl inhalation solution for 1 nebulization 300 mg/5 ml tobramycin inhalation solution for nebulization 1 300 mg/4 ml tobramycin sulfate injection recon soln 1.2 gram 1 tobramycin sulfate injection solution 10 mg/ml MB tobramycin sulfate injection solution 40 mg/ml 1 TOBRAMYCIN WITH 1 PA; ST INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML TRECATOR ORAL TABLET 250 MG 1 TYGACIL INTRAVENOUS RECON SOLN 50 MB MG XENLETA INTRAVENOUS SOLUTION 150 MB MG/15 ML XIFAXAN ORAL TABLET 200 MG, 550 MG 1 PA; QL (60 per 30 days)

10 Drug Name Drug Tier Requirements / Limits PENICILLINS amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension for reconstitution 125 1 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet,chewable 125 mg, 250 mg 1 amoxicillin-pot clavulanate oral suspension for 1 reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-125 1 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended 1 release 12 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 1 200-28.5 mg, 400-57 mg ampicillin oral capsule 500 mg 1 ampicillin-sulbactam injection recon soln 15 gram MB BICILLIN C-R INTRAMUSCULAR MB 1,200,000 UNIT/ 2 ML(900K/300K) dicloxacillin oral capsule 250 mg, 500 mg 1 MOXATAG ORAL TABLET, ER 1 MULTIPHASE 24 HR 775 MG nafcillin in dextrose iso-osm intravenous MB piggyback 1 gram/50 ml, 2 gram/100 ml nafcillin injection recon soln 1 gram, 10 gram, 2 MB gram nafcillin intravenous recon soln 1 gram, 2 gram MB oxacillin in dextrose(iso-osm) intravenous MB piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 1 gram, 10 gram, 2 MB gram penicillin g procaine intramuscular syringe 1.2 MB million unit/2 ml, 600,000 unit/ml penicillin v potassium oral recon soln 125 mg/5 1 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg 1 piperacillin-tazobactam intravenous recon soln MB 13.5 gram, 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

11 Drug Name Drug Tier Requirements / Limits QUINOLONES BAXDELA INTRAVENOUS RECON SOLN 300 MB MG BAXDELA ORAL TABLET 450 MG 1 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 1 mg, 750 mg ciprofloxacin oral suspension,microcapsule recon 1 250 mg/5 ml, 500 mg/5 ml FACTIVE ORAL TABLET 320 MG 1 ST levofloxacin oral solution 250 mg/10 ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin oral tablet 400 mg 1 ofloxacin oral tablet 300 mg, 400 mg 1 SULFA'S & RELATED AGENTS sulfadiazine oral tablet 500 mg 1 sulfamethoxazole-trimethoprim oral suspension 1 200-40 mg/5 ml sulfamethoxazole-trimethoprim oral tablet 400-80 1 mg, 800-160 mg sulfatrim oral suspension 200-40 mg/5 ml 1 TETRACYCLINES avidoxy oral tablet 100 mg 1 ST demeclocycline oral tablet 150 mg, 300 mg 1 doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 150 mg, 20 1 mg, 50 mg, 75 mg doxycycline hyclate oral tablet,delayed release 1 (dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 1 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for 1 reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 mg, 150 1 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg 1 minocycline oral tablet 100 mg, 50 mg, 75 mg 1 mondoxyne nl oral capsule 100 mg, 75 mg 1 tetracycline oral capsule 250 mg, 500 mg 1

12 Drug Name Drug Tier Requirements / Limits URINARY TRACT AGENTS fosfomycin tromethamine oral packet 3 gram 1 methenamine hippurate oral tablet 1 gram 1 methenamine mandelate oral tablet 0.5 g, 1 gram 1 nitrofurantoin macrocrystal oral capsule 100 mg, 1 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 1 mg nitrofurantoin oral suspension 25 mg/5 ml 1 PRIMSOL ORAL SOLUTION 50 MG/5 ML 1 trimethoprim oral tablet 100 mg 1 VANCOMYCIN vancomycin oral capsule 125 mg, 250 mg 1 vancomycin oral recon soln 50 mg/ml 1 VIBATIV INTRAVENOUS RECON SOLN 750 MB MG ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS KEPIVANCE INTRAVENOUS RECON SOLN MB 6.25 MG leucovorin calcium injection recon soln 100 mg, MB 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium injection solution 10 mg/ml MB leucovorin calcium oral tablet 10 mg, 15 mg, 25 1 mg, 5 mg VISTOGARD ORAL GRANULES IN PACKET 1 10 GRAM VORAXAZE INTRAVENOUS RECON SOLN MB 1,000 UNIT XGEVA SUBCUTANEOUS SOLUTION 120 1 LA MG/1.7 ML (70 MG/ML) ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS abiraterone oral tablet 250 mg 1 PA; OCh; LA abiraterone oral tablet 500 mg 1 PA; ST; OCh; LA ABRAXANE INTRAVENOUS SUSPENSION MB PA; LA FOR RECONSTITUTION 100 MG ADAKVEO INTRAVENOUS SOLUTION 10 MB PA MG/ML

13 Drug Name Drug Tier Requirements / Limits ADCETRIS INTRAVENOUS RECON SOLN 50 MB PA; LA MG AFINITOR ORAL TABLET 10 MG 1 OCh; LA ALECENSA ORAL CAPSULE 150 MG 1 PA; OCh; LA ALIMTA INTRAVENOUS RECON SOLN 100 MB PA MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MB PA MG anastrozole oral tablet 1 mg ACA PV OCh; QL (30 per 30 days) ARRANON INTRAVENOUS SOLUTION 250 MB LA MG/50 ML ARZERRA INTRAVENOUS SOLUTION 1,000 MB PA; LA MG/50 ML, 100 MG/5 ML ASPARLAS INTRAVENOUS SOLUTION 750 MB PA UNIT/ML AVASTIN INTRAVENOUS SOLUTION 25 MB PA; LA MG/ML azathioprine oral tablet 50 mg 1 BALVERSA ORAL TABLET 3 MG, 4 MG, 5 1 PA; OCh MG BAVENCIO INTRAVENOUS SOLUTION 20 MB PA MG/ML BELEODAQ INTRAVENOUS RECON SOLN MB PA 500 MG BELRAPZO INTRAVENOUS SOLUTION 25 MB PA; LA MG/ML BENDAMUSTINE INTRAVENOUS SOLUTION MB PA; LA 25 MG/ML BENDEKA INTRAVENOUS SOLUTION 25 MB PA; LA MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MB PA; LA MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 mg 1 PA; ST; OCh bicalutamide oral tablet 50 mg 1 OCh; QL (30 per 30 days) BLINCYTO INTRAVENOUS KIT 35 MCG MB PA BORTEZOMIB INTRAVENOUS RECON SOLN MB 3.5 MG BOSULIF ORAL TABLET 100 MG, 400 MG, 1 PA; ST; OCh; LA 500 MG BRAFTOVI ORAL CAPSULE 50 MG, 75 MG 1 PA; OCh; LA

14 Drug Name Drug Tier Requirements / Limits BUSULFEX INTRAVENOUS SOLUTION 60 MB MG/10 ML CABOMETYX ORAL TABLET 20 MG, 40 MG, 1 PA; ST; OCh; LA 60 MG CALQUENCE ORAL CAPSULE 100 MG 1 PA; ST; OCh capecitabine oral tablet 150 mg 1 OCh; LA; QL (210 per 30 days) capecitabine oral tablet 500 mg 1 OCh; LA; QL (84 per 30 days) CAPRELSA ORAL TABLET 100 MG, 300 MG 1 PA; OCh CLOLAR INTRAVENOUS SOLUTION 20 MB PA MG/20 ML COMETRIQ ORAL CAPSULE 100 MG/DAY(80 1 PA; OCh MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COPIKTRA ORAL CAPSULE 15 MG, 25 MG 1 PA; OCh COTELLIC ORAL TABLET 20 MG 1 PA; OCh; LA cyclophosphamide intravenous recon soln 1 gram, MB 2 gram, 500 mg cyclophosphamide oral capsule 25 mg, 50 mg 1 OCh CYCLOPHOSPHAMIDE ORAL TABLET 25 1 OCh MG, 50 MG cyclosporine modified oral capsule 100 mg, 25 1 mg, 50 mg cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 CYRAMZA INTRAVENOUS SOLUTION 10 MB PA; LA MG/ML DACOGEN INTRAVENOUS RECON SOLN 50 MB PA; LA MG DARZALEX INTRAVENOUS SOLUTION 20 MB PA; LA MG/ML DAURISMO ORAL TABLET 100 MG, 25 MG 1 PA; OCh; LA decitabine intravenous recon soln 50 mg MB LA ELIGARD (3 MONTH) SUBCUTANEOUS 1 PA SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS 1 PA SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS 1 PA SYRINGE 45 MG

15 Drug Name Drug Tier Requirements / Limits ELIGARD SUBCUTANEOUS SYRINGE 7.5 1 PA MG (1 MONTH) ELZONRIS INTRAVENOUS SOLUTION 1,000 MB PA MCG/ML EMCYT ORAL CAPSULE 140 MG 1 OCh EMPLICITI INTRAVENOUS RECON SOLN MB PA; LA 300 MG, 400 MG ENHERTU INTRAVENOUS RECON SOLN 100 MB PA; LA MG ERBITUX INTRAVENOUS SOLUTION 100 MB PA; LA MG/50 ML, 200 MG/100 ML ERLEADA ORAL TABLET 60 MG 1 PA; OCh; LA erlotinib oral tablet 100 mg, 150 mg, 25 mg 1 PA; OCh; LA ERWINAZE INJECTION RECON SOLN 10,000 MB UNIT etoposide intravenous solution 20 mg/ml MB etoposide oral capsule 50 mg 1 OCh everolimus (antineoplastic) oral tablet 2.5 mg, 5 1 PA; ST; OCh; LA mg, 7.5 mg everolimus (immunosuppressive) oral tablet 0.25 1 PA mg, 0.5 mg, 0.75 mg exemestane oral tablet 25 mg ACA PV OCh; QL (30 per 30 days) FASLODEX INTRAMUSCULAR SYRINGE 250 MB PA MG/5 ML FIRMAGON KIT W DILUENT SYRINGE 1 PA; LA SUBCUTANEOUS RECON SOLN 120 MG, 80 MG fludarabine intravenous recon soln 50 mg MB fluorouracil intravenous solution 2.5 gram/50 ml, MB PA 5 gram/100 ml, 500 mg/10 ml flutamide oral capsule 125 mg 1 OCh; QL (180 per 30 days) FOLOTYN INTRAVENOUS SOLUTION 20 MB PA; LA MG/ML (1 ML), 40 MG/2 ML (20 MG/ML) fulvestrant intramuscular syringe 250 mg/5 ml MB GAMIFANT INTRAVENOUS SOLUTION 5 MB PA MG/ML GAZYVA INTRAVENOUS SOLUTION 1,000 MB PA; LA MG/40 ML gemcitabine intravenous recon soln 1 gram, 2 MB gram, 200 mg

16 Drug Name Drug Tier Requirements / Limits gemcitabine intravenous solution 2 gram/52.6 ml MB (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gengraf oral capsule 100 mg, 25 mg 1 gengraf oral solution 100 mg/ml 1 GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 1 PA; OCh; LA MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 1 PA; OCh 40 MG HALAVEN INTRAVENOUS SOLUTION 1 MB PA; LA MG/2 ML (0.5 MG/ML) HERCEPTIN HYLECTA SUBCUTANEOUS MB LA SOLUTION 600 MG-10,000 UNIT/5 ML HERCEPTIN INTRAVENOUS RECON SOLN MB PA; LA 150 MG HERZUMA INTRAVENOUS RECON SOLN MB PA; LA 150 MG HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG 1 OCh; LA hydroxyurea oral capsule 500 mg 1 OCh IBRANCE ORAL CAPSULE 100 MG, 125 MG, 1 PA; OCh; LA 75 MG IBRANCE ORAL TABLET 100 MG, 125 MG, 75 1 OCh; LA MG ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 1 PA; ST; OCh MG, 45 MG IDHIFA ORAL TABLET 100 MG, 50 MG 1 PA; OCh; LA imatinib oral tablet 100 mg 1 OCh; LA; QL (90 per 30 days) imatinib oral tablet 400 mg 1 OCh; LA; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 140 MG, 70 MG 1 PA; ST; OCh IMBRUVICA ORAL TABLET 140 MG, 280 MG, 1 PA; ST; OCh 420 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 50 MB PA; LA MG/ML IMLYGIC INJECTION SUSPENSION 10EXP6 MB (1 MILLION) PFU/ML, 10EXP8 (100 MILLION) PFU/ML

17 Drug Name Drug Tier Requirements / Limits INFUGEM INTRAVENOUS PIGGYBACK 1,200 MB MG/120 ML (10 MG/ML), 1,300 MG/130 ML (10 MG/ML), 1,400 MG/140 ML (10 MG/ML), 1,500 MG/150 ML (10 MG/ML), 1,600 MG/160 ML (10 MG/ML), 1,700 MG/170 ML (10 MG/ML), 1,800 MG/180 ML (10 MG/ML), 1,900 MG/190 ML (10 MG/ML), 2,000 MG/200 ML (10 MG/ML), 2,200 MG/220 ML (10 MG/ML) INLYTA ORAL TABLET 1 MG, 5 MG 1 PA; OCh; LA IRESSA ORAL TABLET 250 MG 1 PA; OCh; LA ISTODAX INTRAVENOUS RECON SOLN 10 MB PA; LA MG/2 ML IXEMPRA INTRAVENOUS RECON SOLN 15 MB PA; LA MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 1 PA; OCh; LA MG, 25 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 10 MB PA; LA MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON SOLN 100 MB PA; LA MG, 160 MG KANJINTI INTRAVENOUS RECON SOLN 150 MB PA; LA MG, 420 MG KEYTRUDA INTRAVENOUS SOLUTION 25 MB PA MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 1 PA; ST; OCh; LA 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 1 PA; ST; OCh; LA MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) KYMRIAH INTRAVENOUS SUSPENSION MB PA 0.2X10EXP6 TO 2.5X10EXP8 CELL, 0.6 TO 6 X 10EXP8 CELL KYPROLIS INTRAVENOUS RECON SOLN 10 MB PA MG, 30 MG, 60 MG lapatinib oral tablet 250 mg 1 PA; OCh; LA; QL (180 per 30 days) LENVIMA ORAL CAPSULE 10 MG/DAY (10 1 PA; ST; OCh; LA MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2)

18 Drug Name Drug Tier Requirements / Limits letrozole oral tablet 2.5 mg ACA PV OCh; QL (30 per 30 days) LEUKERAN ORAL TABLET 2 MG 1 OCh leuprolide subcutaneous kit 1 mg/0.2 ml 1 PA LIBTAYO INTRAVENOUS SOLUTION 50 MB PA MG/ML LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 1 PA; ST; OCh; LA MG LUMOXITI INTRAVENOUS RECON SOLN 1 MB MG LUPKYNIS ORAL CAPSULE 7.9 MG 1 PA; ST LUPRON DEPOT (3 MONTH) 1 PA INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) 1 PA INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) 1 PA INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR 1 PA SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED (3 MONTH) 1 PA INTRAMUSCULAR SYRINGE KIT 11.25 MG, 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 1 PA 11.25 MG, 15 MG, 7.5 MG (PED) LYNPARZA ORAL TABLET 100 MG, 150 MG 1 PA; ST; OCh; LA LYSODREN ORAL TABLET 500 MG 1 OCh MARQIBO INTRAVENOUS KIT 5 MG/31 MB PA ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG 1 OCh megestrol oral suspension 400 mg/10 ml (40 1 QL (2 per 30 days) mg/ml) megestrol oral suspension 625 mg/5 ml (125 1 QL (1 per 30 days) mg/ml) megestrol oral tablet 20 mg 1 OCh; QL (480 per 30 days) megestrol oral tablet 40 mg 1 OCh; QL (240 per 30 days) MEKINIST ORAL TABLET 0.5 MG, 2 MG 1 PA; ST; OCh; LA MEKTOVI ORAL TABLET 15 MG 1 PA; OCh; LA melphalan hcl intravenous recon soln 50 mg MB melphalan oral tablet 2 mg 1 OCh

19 Drug Name Drug Tier Requirements / Limits mercaptopurine oral tablet 50 mg 1 OCh; QL (300 per 30 days) methotrexate sodium (pf) injection recon soln 1 1 gram methotrexate sodium (pf) injection solution 25 1 mg/ml methotrexate sodium injection solution 25 mg/ml 1 methotrexate sodium oral tablet 2.5 mg 1 OCh mitoxantrone intravenous concentrate 2 mg/ml MB PA; LA mycophenolate mofetil oral capsule 250 mg 1 mycophenolate mofetil oral tablet 500 mg 1 mycophenolate sodium oral tablet,delayed release 1 (dr/ec) 180 mg, 360 mg MYLOTARG INTRAVENOUS RECON SOLN MB PA; LA 4.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG 1 PA; OCh; LA; QL (180 per 30 days) NEXAVAR ORAL TABLET 200 MG 1 PA; ST; OCh; LA nilutamide oral tablet 150 mg 1 OCh; QL (60 per 30 days) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 1 PA; ST; OCh; LA MG NULOJIX INTRAVENOUS RECON SOLN 250 MB PA MG octreotide acetate injection solution 1,000 mcg/ml, 1 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) OGIVRI INTRAVENOUS RECON SOLN 150 MB PA; LA MG, 420 MG ONCASPAR INJECTION SOLUTION 750 MB UNIT/ML ONIVYDE INTRAVENOUS DISPERSION 4.3 MB PA MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MB PA; LA MG/10 ML, 240 MG/24 ML, 40 MG/4 ML PADCEV INTRAVENOUS RECON SOLN 20 MB PA; LA MG, 30 MG PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 1 PA; ST; OCh 9 MG PERJETA INTRAVENOUS SOLUTION 420 MB PA; LA MG/14 ML (30 MG/ML)

20 Drug Name Drug Tier Requirements / Limits PIQRAY ORAL TABLET 200 MG/DAY (200 1 PA; OCh; LA MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) POLIVY INTRAVENOUS RECON SOLN 140 MB PA; LA MG PORTRAZZA INTRAVENOUS SOLUTION 800 MB PA; LA MG/50 ML (16 MG/ML) POTELIGEO INTRAVENOUS SOLUTION 4 MB PA MG/ML PROGRAF INTRAVENOUS SOLUTION 5 MB MG/ML QINLOCK ORAL TABLET 50 MG 1 OCh RETEVMO ORAL CAPSULE 40 MG 1 PA; OCh; LA; QL (240 per 30 days) RETEVMO ORAL CAPSULE 80 MG 1 PA; OCh; LA; QL (120 per 30 days) RITUXAN HYCELA SUBCUTANEOUS MB LA SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE MB PA; LA 10 MG/ML RUBRACA ORAL TABLET 200 MG, 250 MG, 1 PA; ST; OCh; LA 300 MG RYDAPT ORAL CAPSULE 25 MG 1 PA; ST; OCh; LA SARCLISA INTRAVENOUS SOLUTION 20 MB MG/ML SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 1 PA; ST MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SIMULECT INTRAVENOUS RECON SOLN 10 MB MG, 20 MG sirolimus oral solution 1 mg/ml 1 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 SOLTAMOX ORAL SOLUTION 20 MG/10 ML 1 OCh SOMATULINE DEPOT SUBCUTANEOUS 1 PA; LA SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 1 PA; ST; OCh; LA MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG 1 PA; ST; OCh; LA SUPPRELIN LA IMPLANT KIT 50 MG (65 MB LA MCG/DAY)

21 Drug Name Drug Tier Requirements / Limits SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 1 PA; ST; OCh; LA 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MB PA; LA MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 1 PA; ST 3.5 MG TABLOID ORAL TABLET 40 MG 1 OCh tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 TAFINLAR ORAL CAPSULE 50 MG, 75 MG 1 PA; OCh; LA TAGRISSO ORAL TABLET 40 MG, 80 MG 1 PA; OCh; LA TALZENNA ORAL CAPSULE 0.25 MG, 1 MG 1 PA; OCh; LA tamoxifen oral tablet 10 mg, 20 mg 1 OCh; QL (60 per 30 days) TARGRETIN TOPICAL 1 % 1 PA; ST TASIGNA ORAL CAPSULE 150 MG, 200 MG, 1 PA; ST; OCh; LA 50 MG TECENTRIQ INTRAVENOUS SOLUTION MB PA; LA 1,200 MG/20 ML (60 MG/ML), 840 MG/14 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN MB PA; LA 100 MG temozolomide oral capsule 100 mg, 140 mg, 180 1 OCh; LA mg, 20 mg, 250 mg, 5 mg temsirolimus intravenous recon soln 30 mg/3 ml MB PA; LA (10 mg/ml) (first) THALOMID ORAL CAPSULE 100 MG, 150 1 OCh; LA MG, 200 MG, 50 MG TIBSOVO ORAL TABLET 250 MG 1 PA; OCh toremifene oral tablet 60 mg 1 OCh TORISEL INTRAVENOUS RECON SOLN 30 MB PA; LA MG/3 ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MB PA; LA MG, 25 MG TRELSTAR INTRAMUSCULAR SUSPENSION MB PA FOR RECONSTITUTION 11.25 MG, 22.5 MG, 3.75 MG tretinoin (antineoplastic) oral capsule 10 mg 1 OCh TREXALL ORAL TABLET 10 MG, 15 MG, 5 1 PA; ST; OCh; QL (15 per 30 days) MG, 7.5 MG TRUXIMA INTRAVENOUS SOLUTION 10 MB PA; LA MG/ML

22 Drug Name Drug Tier Requirements / Limits TUKYSA ORAL TABLET 150 MG, 50 MG 1 PA; ST; OCh; QL (120 per 30 days) UNITUXIN INTRAVENOUS SOLUTION 3.5 MB PA MG/ML VANTAS IMPLANT KIT 50 MG (50 MB LA MCG/DAY) VECTIBIX INTRAVENOUS SOLUTION 100 MB PA; LA MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG MB LA VENCLEXTA ORAL TABLET 10 MG, 100 MG, 1 PA; ST; OCh 50 MG VENCLEXTA STARTING PACK ORAL 1 PA; OCh TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 1 PA; ST; OCh; LA 200 MG, 50 MG VIDAZA INJECTION RECON SOLN 100 MG MB PA; LA VITRAKVI ORAL CAPSULE 100 MG 1 PA; OCh; LA VITRAKVI ORAL CAPSULE 25 MG 1 PA; ST; OCh; LA VITRAKVI ORAL SOLUTION 20 MG/ML 1 PA; OCh; LA VOTRIENT ORAL TABLET 200 MG 1 PA; ST; OCh; LA VYXEOS INTRAVENOUS RECON SOLN 44- MB PA 100 MG XALKORI ORAL CAPSULE 200 MG, 250 MG 1 PA; OCh; LA XERMELO ORAL TABLET 250 MG 1 PA; ST XOSPATA ORAL TABLET 40 MG 1 PA; OCh XTANDI ORAL CAPSULE 40 MG 1 PA; OCh; LA XTANDI ORAL TABLET 40 MG, 80 MG 1 PA; OCh; LA YERVOY INTRAVENOUS SOLUTION 200 MB PA; LA MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YESCARTA INTRAVENOUS SUSPENSION MB PA YONDELIS INTRAVENOUS RECON SOLN 1 MB PA MG YONSA ORAL TABLET 125 MG 1 PA; OCh; LA ZALTRAP INTRAVENOUS SOLUTION 100 MB PA; LA MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) ZANOSAR INTRAVENOUS RECON SOLN 1 MB GRAM

23 Drug Name Drug Tier Requirements / Limits ZEJULA ORAL CAPSULE 100 MG 1 OCh ZELBORAF ORAL TABLET 240 MG 1 PA; ST; OCh; LA ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MB PA; LA MG, 3.6 MG ZOLINZA ORAL CAPSULE 100 MG 1 PA; ST; OCh; LA ZYKADIA ORAL TABLET 150 MG 1 PA; ST; OCh; LA AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS BANZEL ORAL TABLET 200 MG, 400 MG 1 PA; ST BRIVIACT ORAL SOLUTION 10 MG/ML 1 ST; QL (150 per 30 days) BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 1 ST; QL (60 per 30 days) MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 1 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml, 200 1 mg/10 ml carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet extended release 12 hr 1 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg 1 CELONTIN ORAL CAPSULE 300 MG 1 clobazam oral suspension 2.5 mg/ml 1 clobazam oral tablet 10 mg, 20 mg 1 clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet,disintegrating 0.125 mg, 1 0.25 mg, 0.5 mg, 1 mg, 2 mg diazepam rectal kit 2.5 mg 1 DILANTIN EXTENDED ORAL CAPSULE 100 1 MG DILANTIN INFATABS ORAL 1 TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG 1 DILANTIN-125 ORAL SUSPENSION 125 MG/5 1 ML divalproex oral capsule, delayed rel sprinkle 125 1 mg divalproex oral tablet extended release 24 hr 250 1 mg, 500 mg

24 Drug Name Drug Tier Requirements / Limits divalproex oral tablet,delayed release (dr/ec) 125 1 mg, 250 mg, 500 mg EPIDIOLEX ORAL SOLUTION 100 MG/ML 1 PA; LA; QL (400 per 30 days) epitol oral tablet 200 mg 1 ethosuximide oral capsule 250 mg 1 ethosuximide oral solution 250 mg/5 ml 1 felbamate oral suspension 600 mg/5 ml 1 felbamate oral tablet 400 mg, 600 mg 1 FINTEPLA ORAL SOLUTION 2.2 MG/ML 1 gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5 ml, 300 mg/6 1 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg 1 lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 1 25 mg lamotrigine oral tablet disintegrating, dose pk 25 1 mg (21) -50 mg (7), 25 mg(14)-50 mg (14)-100 mg (7), 50 mg (42) -100 mg (14) lamotrigine oral tablet extended release 24hr 100 1 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 1 mg, 5 mg lamotrigine oral tablet,disintegrating 100 mg, 200 1 mg, 25 mg, 50 mg lamotrigine oral tablets,dose pack 25 mg (35), 25 1 mg (42) -100 mg (7), 25 mg (84) -100 mg (14) levetiracetam oral solution 100 mg/ml, 500 mg/5 1 ml (5 ml) levetiracetam oral tablet 1,000 mg, 250 mg, 500 1 mg, 750 mg levetiracetam oral tablet extended release 24 hr 1 500 mg, 750 mg LYRICA CR ORAL TABLET EXTENDED 1 PA; ST RELEASE 24 HR 165 MG, 330 MG, 82.5 MG oxcarbazepine oral suspension 300 mg/5 ml (60 1 mg/ml) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 phenobarbital oral 20 mg/5 ml (4 mg/ml) 1

25 Drug Name Drug Tier Requirements / Limits phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 1 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenytoin oral suspension 100 mg/4 ml, 125 mg/5 1 ml phenytoin oral tablet,chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 1 200 mg, 300 mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 1 PA; ST 225 mg, 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml 1 PA; ST pregabalin oral tablet extended release 24 hr 165 1 PA; ST mg, 330 mg, 82.5 mg primidone oral tablet 250 mg, 50 mg 1 roweepra oral tablet 1,000 mg, 500 mg, 750 mg 1 rufinamide oral suspension 40 mg/ml 1 PA rufinamide oral tablet 200 mg, 400 mg 1 PA subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 1 mg subvenite starter (blue) kit oral tablets,dose pack 1 25 mg (35) subvenite starter (green) kit oral tablets,dose pack 1 25 mg (84) -100 mg (14) subvenite starter (orange) kit oral tablets,dose 1 pack 25 mg (42) -100 mg (7) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG 1 PA; QL (30 per 30 days) tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1 topiramate oral capsule, sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 1 mg valproic acid (as sodium salt) oral solution 250 1 mg/5 ml, 500 mg/10 ml (10 ml) valproic acid oral capsule 250 mg 1 vigabatrin oral powder in packet 500 mg 1 PA; LA vigabatrin oral tablet 500 mg 1 PA; LA vigadrone oral powder in packet 500 mg 1 PA; ST VIMPAT ORAL SOLUTION 10 MG/ML 1 PA; ST; QL (6 per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 1 ST; QL (60 per 30 days) MG, 50 MG

26 Drug Name Drug Tier Requirements / Limits XCOPRI MAINTENANCE PACK ORAL 1 PA; ST TABLET 250MG/DAY(150 MG X1-100MG X1) XCOPRI MAINTENANCE PACK ORAL 1 TABLET 350 MG/DAY (200 MG X1-150MG X1) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 1 MG, 50 MG XCOPRI TITRATION PACK ORAL 1 TABLETS,DOSE PACK 12.5 MG (14)- 25 MG (14), 150 MG (14)- 200 MG (14), 50 MG (14)- 100 MG (14) zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 10 1 PA; LA; QL (1 per 30 days) MG/ML benztropine injection solution 1 mg/ml 1 benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 bromocriptine oral capsule 5 mg 1 bromocriptine oral tablet 2.5 mg 1 carbidopa oral tablet 25 mg 1 carbidopa-levodopa oral tablet 10-100 mg, 25-100 1 mg, 25-250 mg carbidopa-levodopa oral tablet extended release 1 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet,disintegrating 10- 1 100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5- 1 50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg entacapone oral tablet 200 mg 1 pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 1 mg, 0.75 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release 24 hr 1 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg rasagiline oral tablet 0.5 mg, 1 mg 1 ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 1 3 mg, 4 mg, 5 mg

27 Drug Name Drug Tier Requirements / Limits ropinirole oral tablet extended release 24 hr 12 1 mg, 2 mg, 4 mg, 6 mg, 8 mg selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 tolcapone oral tablet 100 mg 1 trihexyphenidyl oral elixir 0.4 mg/ml 1 trihexyphenidyl oral tablet 2 mg, 5 mg 1 MIGRAINE & CLUSTER HEADACHE THERAPY AIMOVIG SUBCUTANEOUS 1 PA; ST AUTO-INJECTOR 140 MG/ML, 70 MG/ML AJOVY AUTOINJECTOR SUBCUTANEOUS 1 ST AUTO-INJECTOR 225 MG/1.5 ML AJOVY SYRINGE SUBCUTANEOUS 1 PA; ST SYRINGE 225 MG/1.5 ML almotriptan malate oral tablet 12.5 mg, 6.25 mg 1 QL (18 per 30 days) dihydroergotamine injection solution 1 mg/ml 1 dihydroergotamine ,non-aerosol 0.5 1 QL (8 per 30 days) mg/pump act. (4 mg/ml) eletriptan oral tablet 20 mg, 40 mg 1 QL (18 per 30 days) EMGALITY PEN SUBCUTANEOUS PEN 1 PA; ST INJECTOR 120 MG/ML EMGALITY SYRINGE SUBCUTANEOUS 1 PA; ST SYRINGE 120 MG/ML, 300 MG/3 ML (100 MG/ML X 3) ergotamine-caffeine oral tablet 1-100 mg 1 frovatriptan oral tablet 2.5 mg 1 QL (18 per 30 days) migergot rectal 2-100 mg 1 naratriptan oral tablet 1 mg, 2.5 mg 1 QL (18 per 30 days) ONZETRA XSAIL NASAL AEROSOL POWDR 1 ST; QL (16 per 30 days) BREATH ACTIVATED 11 MG rizatriptan oral tablet 10 mg, 5 mg 1 QL (18 per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg 1 QL (18 per 30 days) sumatriptan nasal spray,non-aerosol 20 1 QL (18 per 30 days) mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 1 QL (18 per 30 days) 50 mg sumatriptan succinate subcutaneous cartridge 4 1 QL (8 per 30 days) mg/0.5 ml, 6 mg/0.5 ml

28 Drug Name Drug Tier Requirements / Limits sumatriptan succinate subcutaneous pen injector 4 1 QL (8 per 30 days) mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 1 QL (8 per 30 days) mg/0.5 ml sumatriptan succinate subcutaneous syringe 6 1 QL (8 per 30 days) mg/0.5 ml UBRELVY ORAL TABLET 100 MG, 50 MG 1 QL (16 per 30 days) VYEPTI INTRAVENOUS SOLUTION 100 MB PA MG/ML zolmitriptan oral tablet 2.5 mg, 5 mg 1 QL (18 per 30 days) zolmitriptan oral tablet,disintegrating 2.5 mg, 5 1 QL (18 per 30 days) mg ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 1 ST; QL (18 per 30 days) MG, 5 MG MISCELLANEOUS NEUROLOGICAL THERAPY AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 1 PA; LA MG dalfampridine oral tablet extended release 12 hr 1 PA; LA; QL (60 per 30 days) 10 mg donepezil oral tablet 10 mg, 23 mg, 5 mg 1 donepezil oral tablet,disintegrating 10 mg, 5 mg 1 EXONDYS-51 INTRAVENOUS SOLUTION 50 MB PA MG/ML galantamine oral capsule,ext rel. pellets 24 hr 16 1 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml 1 galantamine oral tablet 12 mg, 4 mg, 8 mg 1 memantine oral capsule,sprinkle,er 24hr 14 mg, 1 21 mg, 28 mg, 7 mg memantine oral solution 2 mg/ml 1 memantine oral tablet 10 mg, 5 mg 1 NUEDEXTA ORAL CAPSULE 20-10 MG 1 ONPATTRO INTRAVENOUS SOLUTION 2 MB PA MG/ML RADICAVA INTRAVENOUS SOLUTION 30 MB PA MG/100 ML rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 1 4.5 mg, 6 mg

29 Drug Name Drug Tier Requirements / Limits rivastigmine patch 24 hour 13.3 1 mg/24 hour, 4.6 mg/24 hour, 9.5 mg/24 hour tetrabenazine oral tablet 12.5 mg, 25 mg 1 LA TYSABRI INTRAVENOUS SOLUTION 300 MB PA; ST; LA MG/15 ML VYONDYS-53 INTRAVENOUS SOLUTION 50 MB PA MG/ML ZOLGENSMA INTRAVENOUS KIT 2 X MB LA 10EXP13 VG/ML MUSCLE RELAXANTS & ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 20 mg, 5 mg 1 carisoprodol oral tablet 250 mg, 350 mg 1 carisoprodol-aspirin oral tablet 200-325 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325- 1 PA; ST 16 mg chlorzoxazone oral tablet 250 mg, 375 mg, 750 mg 1 ST chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg 1 dantrolene oral capsule 100 mg, 25 mg, 50 mg 1 meprobamate oral tablet 200 mg, 400 mg 1 metaxalone oral tablet 400 mg, 800 mg 1 methocarbamol oral tablet 500 mg, 750 mg 1 orphenadrine citrate injection solution 30 mg/ml 1 orphenadrine citrate oral tablet extended release 1 100 mg pyridostigmine bromide oral syrup 60 mg/5 ml 1 pyridostigmine bromide oral tablet 60 mg 1 pyridostigmine bromide oral tablet extended 1 release 180 mg tizanidine oral capsule 2 mg, 4 mg, 6 mg 1 tizanidine oral tablet 2 mg, 4 mg 1 vanadom oral tablet 350 mg 1 NARCOTIC ANALGESICS acetaminophen-caff-dihydrocod oral capsule 1 PA; ST 320.5-30-16 mg acetaminophen-caff-dihydrocod oral tablet 325- 1 PA; ST 30-16 mg

30 Drug Name Drug Tier Requirements / Limits acetaminophen-codeine oral solution 120-12 mg/5 1 PA; ST ml, 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet 300-15 mg, 1 PA; ST 300-30 mg, 300-60 mg ascomp with codeine oral capsule 30-50-325-40 1 PA; ST mg buprenorphine hcl injection solution 0.3 mg/ml 1 PA; ST buprenorphine hcl injection syringe 0.3 mg/ml 1 PA; ST buprenorphine hcl sublingual tablet 2 mg, 8 mg 1 buprenorphine weekly 10 1 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule 30- 1 PA; ST 50-325-40 mg butalbital-acetaminop-caf-cod oral capsule 50- 1 PA; ST 300-40-30 mg, 50-325-40-30 mg butalbital-acetaminophen-caff oral capsule 50- 1 300-40 mg, 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325- 1 40 mg butalbital-aspirin-caffeine oral capsule 50-325-40 1 mg butalbital-aspirin-caffeine oral tablet 50-325-40 1 mg codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 PA; ST codeine-butalbital-asa-caff oral capsule 30-50- 1 PA; ST 325-40 mg diskets oral tablet,soluble 40 mg 1 PA; ST DSUVIA SUBLINGUAL TABLET IN MB APPLICATOR 30 MCG duramorph (pf) injection solution 0.5 mg/ml, 1 MB PA; ST mg/ml dvorah oral tablet 325-30-16 mg 1 PA; ST endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 1 PA; ST mg, 7.5-325 mg fentanyl citrate buccal lozenge on a handle 1,200 1 PA mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg

31 Drug Name Drug Tier Requirements / Limits fentanyl transdermal patch 72 hour 100 mcg/hr, 1 PA; ST 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone bitartrate oral capsule, oral only, er 1 PA; ST; QL (60 per 30 days) 12hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone bitartrate oral tablet,oral 1 PA; ST only,ext.rel.24 hr 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg hydrocodone-acetaminophen oral solution 10-325 1 PA; ST mg/15 ml(15 ml), 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 1 PA; ST mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 1 PA; ST 200 mg, 7.5-200 mg HYDROMORPHONE INJECTION SYRINGE 1 PA; ST 0.5 MG/0.5 ML hydromorphone oral 1 mg/ml 1 PA; ST hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 PA; ST hydromorphone oral tablet extended release 24 hr 1 PA; ST; QL (60 per 30 days) 12 mg, 16 mg, 32 mg, 8 mg hydromorphone rectal suppository 3 mg 1 PA; ST levorphanol tartrate oral tablet 2 mg, 3 mg 1 PA; ST meperidine oral solution 50 mg/5 ml 1 PA; ST meperidine oral tablet 50 mg 1 PA; ST methadone injection solution 10 mg/ml 1 PA; ST methadone oral concentrate 10 mg/ml 1 PA; ST methadone oral solution 10 mg/5 ml, 5 mg/5 ml 1 PA; ST methadone oral tablet 10 mg, 5 mg 1 PA; ST methadone oral tablet,soluble 40 mg 1 PA; ST methadose oral concentrate 10 mg/ml 1 PA; ST methadose oral tablet,soluble 40 mg 1 PA; ST morphine (pf) injection solution 0.5 mg/ml MB PA; ST morphine concentrate oral solution 100 mg/5 ml 1 PA; ST (20 mg/ml) morphine oral capsule, er multiphase 24 hr 120 1 PA; ST; QL (60 per 30 days) mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.release pellets 10 1 PA; ST; QL (90 per 30 days) mg, 100 mg, 20 mg, 50 mg, 80 mg

32 Drug Name Drug Tier Requirements / Limits morphine oral capsule,extend.release pellets 30 1 PA; ST; QL (60 per 30 days) mg, 60 mg morphine oral capsule,extend.release pellets 40 1 PA; QL (90 per 30 days) mg morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 1 PA; ST mg/ml) morphine oral tablet 15 mg, 30 mg 1 PA; ST morphine oral tablet extended release 100 mg, 15 1 PA; ST; QL (120 per 30 days) mg, 200 mg, 30 mg, 60 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 1 PA; ST 5 mg oxycodone oral capsule 5 mg 1 PA; ST oxycodone oral concentrate 20 mg/ml 1 PA; ST oxycodone oral solution 5 mg/5 ml 1 PA; ST oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 1 PA; ST mg, 5 mg oxycodone-acetaminophen oral tablet 10-325 mg, 1 PA; ST 2.5-300 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg OXYCONTIN ORAL TABLET,ORAL 1 PA; ST; QL (90 per 30 days) ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG OXYCONTIN ORAL TABLET,ORAL 1 PA; ST; QL (120 per 30 days) ONLY,EXT.REL.12 HR 60 MG, 80 MG oxymorphone oral tablet 10 mg, 5 mg 1 PA; ST oxymorphone oral tablet extended release 12 hr 10 1 PA; ST; QL (90 per 30 days) mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg SUBLOCADE SUBCUTANEOUS SOLUTION, MB EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML tencon oral tablet 50-325 mg 1 NON-NARCOTIC ANALGESICS adult aspirin regimen oral tablet,delayed release ACA PV (dr/ec) 81 mg aspirin low dose oral tablet,delayed release ACA PV (dr/ec) 81 mg aspirin oral tablet 325 mg ACA PV aspirin oral tablet,chewable 81 mg ACA PV aspirin oral tablet,delayed release (dr/ec) 325 mg, ACA PV 81 mg

33 Drug Name Drug Tier Requirements / Limits aspir-trin oral tablet,delayed release (dr/ec) 325 ACA PV mg bayer aspirin oral tablet 325 mg ACA PV BAYER CHEWABLE ASPIRIN ORAL ACA PV TABLET,CHEWABLE 81 MG buprenorphine-naloxone sublingual film 12-3 mg 1 QL (60 per 30 days) buprenorphine-naloxone sublingual film 2-0.5 mg, 1 QL (90 per 30 days) 4-1 mg, 8-2 mg buprenorphine-naloxone sublingual tablet 2-0.5 1 QL (90 per 30 days) mg, 8-2 mg butorphanol nasal spray,non-aerosol 10 mg/ml 1 PA; ST; QL (5 per 30 days) cataflam oral tablet 50 mg 1 celecoxib oral capsule 100 mg, 200 mg, 400 mg, 1 50 mg children's aspirin oral tablet,chewable 81 mg ACA PV choline,magnesium salicylate oral liquid 500 mg/5 1 ml diclofenac potassium oral tablet 50 mg 1 diclofenac sodium oral tablet extended release 24 1 hr 100 mg diclofenac sodium oral tablet,delayed release 1 (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical drops 1.5 % 1 diclofenac sodium topical gel 1 % 1 diclofenac-misoprostol oral tablet,ir,delayed 1 rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg diflunisal oral tablet 500 mg 1 DUEXIS ORAL TABLET 800-26.6 MG 1 ST ecotrin low strength oral tablet,delayed release ACA PV (dr/ec) 81 mg ecotrin oral tablet,delayed release (dr/ec) 325 mg ACA PV etodolac oral capsule 200 mg, 300 mg 1 etodolac oral tablet 400 mg, 500 mg 1 etodolac oral tablet extended release 24 hr 400 1 mg, 500 mg, 600 mg EUFLEXXA INTRA-ARTICULAR SYRINGE 10 MB MG/ML(MW 2.4 -3.6 MILLION) fenoprofen oral tablet 600 mg 1

34 Drug Name Drug Tier Requirements / Limits flurbiprofen oral tablet 100 mg 1 ibu oral tablet 400 mg, 600 mg, 800 mg 1 ibuprofen oral suspension 100 mg/5 ml 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 indomethacin oral capsule, extended release 75 1 mg ketoprofen oral capsule 25 mg, 50 mg, 75 mg 1 ketoprofen oral capsule,ext rel. pellets 24 hr 200 1 mg ketorolac injection cartridge 15 mg/ml, 30 mg/ml 1 ketorolac injection solution 15 mg/ml, 30 mg/ml MB ketorolac injection solution 30 mg/ml (1 ml) 1 ketorolac intramuscular cartridge 60 mg/2 ml 1 ketorolac intramuscular solution 60 mg/2 ml 1 ketorolac intramuscular syringe 60 mg/2 ml 1 ketorolac oral tablet 10 mg 1 KLOXXADO NASAL SPRAY,NON-AEROSOL 1 8 MG/ACTUATION meclofenamate oral capsule 100 mg, 50 mg 1 mefenamic acid oral capsule 250 mg 1 meloxicam oral tablet 15 mg, 7.5 mg 1 MONOVISC INTRA-ARTICULAR SYRINGE MB LA 88 MG/4 ML nabumetone oral tablet 500 mg, 750 mg 1 nalbuphine injection solution 10 mg/ml MB PA; ST naloxone injection solution 0.4 mg/ml 1 naloxone injection syringe 0.4 mg/ml, 1 mg/ml 1 naltrexone oral tablet 50 mg 1 naproxen oral suspension 125 mg/5 ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet,delayed release (dr/ec) 375 1 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg 1 NARCAN NASAL SPRAY,NON-AEROSOL 4 1 MG/ACTUATION

35 Drug Name Drug Tier Requirements / Limits NUCYNTA ER ORAL TABLET EXTENDED 1 PA; ST; QL (60 per 30 days) RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG ORTHOVISC INTRA-ARTICULAR SYRINGE MB 30 MG/2 ML oxaprozin oral tablet 600 mg 1 pentazocine-naloxone oral tablet 50-0.5 mg 1 PA; ST piroxicam oral capsule 10 mg, 20 mg 1 salsalate oral tablet 500 mg, 750 mg 1 st joseph aspirin oral tablet,chewable 81 mg ACA PV st. joseph aspirin oral tablet,delayed release ACA PV (dr/ec) 81 mg sulindac oral tablet 150 mg, 200 mg 1 tolmetin oral capsule 400 mg 1 tolmetin oral tablet 200 mg, 600 mg 1 tramadol oral tablet 50 mg 1 PA; ST tramadol oral tablet extended release 24 hr 100 1 PA; ST mg, 200 mg, 300 mg tramadol oral tablet, er multiphase 24 hr 100 mg, 1 PA; ST 200 mg, 300 mg tramadol-acetaminophen oral tablet 37.5-325 mg 1 PA; ST VIVITROL INTRAMUSCULAR MB SUSPENSION,EXTENDED REL RECON 380 MG PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR 1 SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR 1 SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG ADHANSIA XR ORAL CAPSULE, ER 1 PA; ST BIPHASIC 20-80 25 MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG ADZENYS ER ORAL SUSPEN, IR - ER, 1 ST BIPHASIC 24HR 1.25 MG/ML ADZENYS XR-ODT ORAL 1 ST TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG

36 Drug Name Drug Tier Requirements / Limits alprazolam intensol oral concentrate 1 mg/ml 1 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 1 mg alprazolam oral tablet extended release 24 hr 0.5 1 mg, 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating 0.25 mg, 0.5 1 mg, 1 mg, 2 mg amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 1 25 mg, 50 mg, 75 mg amitriptyline-chlordiazepoxide oral tablet 12.5-5 1 mg, 25-10 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 1 mg AMPHETAMINE ORAL SUSPEN, IR - ER, 1 ST BIPHASIC 24HR 1.25 MG/ML amphetamine sulfate oral tablet 10 mg, 5 mg 1 APLENZIN ORAL TABLET EXTENDED 1 ST RELEASE 24 HR 174 MG, 348 MG, 522 MG aripiprazole oral solution 1 mg/ml 1 aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 1 mg, 30 mg, 5 mg aripiprazole oral tablet,disintegrating 10 mg, 15 1 mg ARISTADA INITIO INTRAMUSCULAR MB SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML ARISTADA INTRAMUSCULAR MB SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML armodafinil oral tablet 150 mg, 200 mg, 250 mg, 1 50 mg asenapine maleate sublingual tablet 10 mg, 2.5 1 mg, 5 mg atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 1 25 mg, 40 mg, 60 mg, 80 mg BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 1 ST MG, 5 MG bupropion hcl oral tablet 100 mg, 75 mg 1 bupropion hcl oral tablet extended release 24 hr 1 150 mg, 300 mg

37 Drug Name Drug Tier Requirements / Limits bupropion hcl oral tablet sustained-release 12 hr 1 100 mg, 150 mg, 200 mg buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 1 7.5 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 1 mg chlorpromazine injection solution 25 mg/ml 1 chlorpromazine oral tablet 10 mg, 100 mg, 200 1 mg, 25 mg, 50 mg citalopram oral solution 10 mg/5 ml 1 citalopram oral tablet 10 mg, 20 mg, 40 mg 1 clomipramine oral capsule 25 mg, 50 mg, 75 mg 1 clonidine hcl oral tablet extended release 12 hr 0.1 1 mg clorazepate dipotassium oral tablet 15 mg, 3.75 1 mg, 7.5 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 1 mg clozapine oral tablet,disintegrating 100 mg, 12.5 1 mg, 150 mg, 200 mg, 25 mg COTEMPLA XR-ODT ORAL 1 ST TABLET,DISINTEG ER BIPHASE 24H 17.3 MG, 25.9 MG, 8.6 MG DAYTRANA TRANSDERMAL PATCH 24 1 ST HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR desipramine oral tablet 10 mg, 100 mg, 150 mg, 1 25 mg, 50 mg, 75 mg DESVENLAFAXINE ORAL TABLET 1 ST EXTENDED RELEASE 24 HR 100 MG, 50 MG desvenlafaxine succinate oral tablet extended 1 release 24 hr 100 mg, 25 mg, 50 mg dexmethylphenidate oral capsule,er biphasic 50- 1 50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 1 mg dextroamphetamine oral capsule, extended release 1 10 mg, 15 mg, 5 mg dextroamphetamine oral solution 5 mg/5 ml 1

38 Drug Name Drug Tier Requirements / Limits dextroamphetamine oral tablet 10 mg, 5 mg 1 dextroamphetamine-amphetamine oral 1 capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg dextroamphetamine-amphetamine oral tablet 10 1 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg diazepam injection solution 5 mg/ml MB diazepam injection syringe 5 mg/ml MB diazepam intensol oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 1 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml 1 duloxetine oral capsule,delayed release(dr/ec) 20 1 mg, 30 mg, 40 mg, 60 mg DYANAVEL XR ORAL SUSPEN, IR - ER, 1 ST BIPHASIC 24HR 2.5 MG/ML EDLUAR SUBLINGUAL TABLET 10 MG, 5 1 ST MG EMSAM TRANSDERMAL PATCH 24 HOUR 1 ST 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR ergoloid oral tablet 1 mg 1 escitalopram oxalate oral solution 5 mg/5 ml 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 1 mg estazolam oral tablet 1 mg, 2 mg 1 eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 FANAPT ORAL TABLET 1 MG, 10 MG, 12 1 PA; ST MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1 PA; ST 1MG(2)-2MG(2)- 4MG(2)-6MG(2) FETZIMA ORAL CAPSULE,EXT REL 24HR 1 ST DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED 1 ST RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg 1

39 Drug Name Drug Tier Requirements / Limits fluoxetine oral capsule,delayed release(dr/ec) 90 1 mg fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 1 fluoxetine oral tablet 10 mg, 20 mg 1 fluoxetine oral tablet 60 mg 1 PA fluphenazine hcl injection solution 2.5 mg/ml 1 fluphenazine hcl oral concentrate 5 mg/ml 1 fluphenazine hcl oral elixir 2.5 mg/5 ml 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 1 mg flurazepam oral capsule 15 mg, 30 mg 1 fluvoxamine oral capsule,extended release 24hr 1 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg 1 guanfacine oral tablet extended release 24 hr 1 1 mg, 2 mg, 3 mg, 4 mg haloperidol decanoate intramuscular solution 100 1 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml 1 haloperidol lactate oral concentrate 2 mg/ml 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 1 20 mg, 5 mg HETLIOZ LQ ORAL SUSPENSION 4 MG/ML 1 PA; ST; LA HETLIOZ ORAL CAPSULE 20 MG 1 PA; ST; LA imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 imipramine pamoate oral capsule 100 mg, 125 mg, 1 150 mg, 75 mg INVEGA SUSTENNA INTRAMUSCULAR 1 SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML JORNAY PM ORAL CAPSULE,DEL REL,EXT 1 ST REL SPRINK 100 MG, 20 MG, 40 MG, 60 MG, 80 MG LATUDA ORAL TABLET 120 MG, 20 MG, 40 1 PA; ST MG, 60 MG, 80 MG lithium carbonate oral capsule 150 mg, 300 mg, 1 600 mg lithium carbonate oral tablet 300 mg 1

40 Drug Name Drug Tier Requirements / Limits lithium carbonate oral tablet extended release 300 1 mg, 450 mg lorazepam intensol oral concentrate 2 mg/ml 1 lorazepam oral concentrate 2 mg/ml 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 loxapine succinate oral capsule 10 mg, 25 mg, 5 1 mg, 50 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg 1 MARPLAN ORAL TABLET 10 MG 1 methamphetamine oral tablet 5 mg 1 METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 1 MG/5 ML methylphenidate hcl oral cap,er sprinkle,biphasic 1 40-60 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule, er biphasic 30- 1 70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic 50- 1 50 10 mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl oral solution 10 mg/5 ml, 5 1 mg/5 ml methylphenidate hcl oral tablet 10 mg, 20 mg, 5 1 mg methylphenidate hcl oral tablet extended release 1 10 mg, 20 mg methylphenidate hcl oral tablet extended release 1 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet,chewable 10 mg, 1 2.5 mg, 5 mg midazolam oral syrup 2 mg/ml 1 mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 1 mg mirtazapine oral tablet,disintegrating 15 mg, 30 1 mg, 45 mg modafinil oral tablet 100 mg, 200 mg 1 molindone oral tablet 10 mg, 25 mg, 5 mg 1 MYDAYIS ORAL CAPSULE, ER TRIPHASIC 1 ST 24 HR 12.5 MG, 25 MG, 37.5 MG, 50 MG nefazodone oral tablet 100 mg, 150 mg, 200 mg, 1 250 mg, 50 mg

41 Drug Name Drug Tier Requirements / Limits nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 1 mg nortriptyline oral solution 10 mg/5 ml 1 NUPLAZID ORAL CAPSULE 34 MG 1 PA; LA NUPLAZID ORAL TABLET 10 MG 1 PA; LA olanzapine intramuscular recon soln 10 mg 1 olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 1 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating 10 mg, 15 1 mg, 20 mg, 5 mg olanzapine-fluoxetine oral capsule 12-25 mg, 12- 1 50 mg, 3-25 mg, 6-25 mg, 6-50 mg oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 paliperidone oral tablet extended release 24hr 1.5 1 mg, 3 mg, 6 mg, 9 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 1 mg paroxetine hcl oral tablet extended release 24 hr 1 12.5 mg, 25 mg, 37.5 mg paroxetine mesylate(menop.sym) oral capsule 7.5 1 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2- 1 25 mg, 4-10 mg, 4-25 mg, 4-50 mg phenelzine oral tablet 15 mg 1 pimozide oral tablet 1 mg, 2 mg 1 procentra oral solution 5 mg/5 ml 1 protriptyline oral tablet 10 mg, 5 mg 1 quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 1 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 1 mg, 200 mg, 300 mg, 400 mg, 50 mg QUILLICHEW ER ORAL TABLET,CHEW,IR- 1 ST ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG QUILLIVANT XR ORAL SUSPENSION,EXT 1 ST REL 24HR,RECON 5 MG/ML (25 MG/5 ML) ramelteon oral tablet 8 mg 1 RELEXXII ORAL TABLET EXTENDED 1 ST RELEASE 24HR 72 MG

42 Drug Name Drug Tier Requirements / Limits REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 1 PA; ST MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR 1 SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml 1 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 1 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 1 mg, 1 mg, 2 mg, 3 mg, 4 mg seconal sodium oral capsule 100 mg 1 sertraline oral concentrate 20 mg/ml 1 sertraline oral tablet 100 mg, 25 mg, 50 mg 1 SPRAVATO NASAL SPRAY,NON-AEROSOL MB PA 56 MG (28 MG X 2), 84 MG (28 MG X 3) SUNOSI ORAL TABLET 150 MG 1 PA; QL (30 per 30 days) SUNOSI ORAL TABLET 75 MG 1 PA; QL (60 per 30 days) temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 1 7.5 mg thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 1 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 tranylcypromine oral tablet 10 mg 1 trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 1 mg triazolam oral tablet 0.125 mg, 0.25 mg 1 trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 1 mg trimipramine oral capsule 100 mg, 25 mg, 50 mg 1 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 1 ST MG venlafaxine oral capsule,extended release 24hr 1 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 1 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 1 mg, 225 mg, 37.5 mg, 75 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML 1 PA; ST

43 Drug Name Drug Tier Requirements / Limits VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 1 PA; ST MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 1 PA; ST MG (1)- 3 MG (6) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 1 PA; ST MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 1 PA; ST MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG XYREM ORAL SOLUTION 500 MG/ML 1 PA; QL (540 per 30 days) zaleplon oral capsule 10 mg, 5 mg 1 ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 1 ST MG, 30 MG, 7.5 MG ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 1 80 mg zolpidem oral tablet 10 mg, 5 mg 1 zolpidem oral tablet,ext release multiphase 12.5 1 mg, 6.25 mg zolpidem sublingual tablet 1.75 mg, 3.5 mg 1 ZOLPIMIST ORAL SPRAY,NON-AEROSOL 5 1 ST MG/SPRAY (0.1 ML) ZULRESSO INTRAVENOUS SOLUTION 5 MB MG/ML CARDIOVASCULAR, HYPERTENSION & LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet 100 mg, 200 mg, 400 mg 1 disopyramide phosphate oral capsule 100 mg, 150 1 mg dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 flecainide oral tablet 100 mg, 150 mg, 50 mg 1 mexiletine oral capsule 150 mg, 200 mg, 250 mg 1 MULTAQ ORAL TABLET 400 MG 1 NORPACE CR ORAL CAPSULE, EXTENDED 1 RELEASE 100 MG, 150 MG pacerone oral tablet 100 mg, 200 mg, 400 mg 1 procainamide injection solution 100 mg/ml, 500 MB mg/ml propafenone oral capsule,extended release 12 hr 1 225 mg, 325 mg, 425 mg

44 Drug Name Drug Tier Requirements / Limits propafenone oral tablet 150 mg, 225 mg, 300 mg 1 quinidine gluconate oral tablet extended release 1 324 mg quinidine sulfate oral tablet 200 mg, 300 mg 1 sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 sotalol af oral tablet 120 mg, 160 mg, 80 mg 1 sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 ANTIHYPERTENSIVE THERAPY acebutolol oral capsule 200 mg, 400 mg 1 aliskiren oral tablet 150 mg, 300 mg 1 amiloride oral tablet 5 mg 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine-benazepril oral capsule 10-20 mg, 10- 1 ST 40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-olmesartan oral tablet 10-20 mg, 10- 1 ST 40 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet 10-160 mg, 10- 1 ST 320 mg, 5-160 mg, 5-320 mg amlodipine-valsartan-hcthiazid oral tablet 10-160- 1 12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50- 1 25 mg benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 1 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg betaxolol oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 1 mg, 2.5-6.25 mg, 5-6.25 mg bumetanide injection solution 0.25 mg/ml 1 bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 1 ST MG, 5 MG candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1

45 Drug Name Drug Tier Requirements / Limits candesartan-hydrochlorothiazid oral tablet 16- 1 12.5 mg, 32-12.5 mg, 32-25 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 1 mg captopril-hydrochlorothiazide oral tablet 25-15 1 mg, 25-25 mg, 50-15 mg, 50-25 mg cartia xt oral capsule,extended release 24hr 120 1 mg, 180 mg, 240 mg, 300 mg carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 1 6.25 mg carvedilol phosphate oral capsule, er multiphase 1 24 hr 10 mg, 20 mg, 40 mg, 80 mg chlorthalidone oral tablet 25 mg, 50 mg 1 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24 hr, 1 0.2 mg/24 hr, 0.3 mg/24 hr diltiazem hcl oral capsule,ext.rel 24h degradable 1 120 mg, 180 mg, 240 mg diltiazem hcl oral capsule,extended release 12 hr 1 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24 hr 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 24hr 1 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 1 mg diltiazem hcl oral tablet extended release 24 hr 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext.rel 24h degradable 120 1 mg, 180 mg, 240 mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 EDARBI ORAL TABLET 40 MG, 80 MG 1 ST EDARBYCLOR ORAL TABLET 40-12.5 MG, 1 ST 40-25 MG enalapril maleate oral tablet 10 mg, 2.5 mg, 20 1 mg, 5 mg enalaprilat intravenous solution 1.25 mg/ml MB enalapril-hydrochlorothiazide oral tablet 10-25 1 mg, 5-12.5 mg EPANED ORAL SOLUTION 1 MG/ML 1

46 Drug Name Drug Tier Requirements / Limits eplerenone oral tablet 25 mg, 50 mg 1 epoprostenol (glycine) intravenous recon soln 0.5 MB PA; LA mg, 1.5 mg eprosartan oral tablet 600 mg 1 ethacrynic acid oral tablet 25 mg 1 felodipine oral tablet extended release 24 hr 10 1 mg, 2.5 mg, 5 mg FLOLAN INTRAVENOUS RECON SOLN 0.5 MB PA; LA MG, 1.5 MG fosinopril oral tablet 10 mg, 20 mg, 40 mg 1 fosinopril-hydrochlorothiazide oral tablet 10-12.5 1 mg, 20-12.5 mg furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 1 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg 1 guanfacine oral tablet 1 mg, 2 mg 1 hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 1 mg hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 1 mg indapamide oral tablet 1.25 mg, 2.5 mg 1 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 irbesartan-hydrochlorothiazide oral tablet 150- 1 12.5 mg, 300-12.5 mg isradipine oral capsule 2.5 mg, 5 mg 1 labetalol oral tablet 100 mg, 200 mg, 300 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 1 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 1 mg, 20-12.5 mg, 20-25 mg losartan oral tablet 100 mg, 25 mg, 50 mg 1 losartan-hydrochlorothiazide oral tablet 100-12.5 1 mg, 100-25 mg, 50-12.5 mg matzim la oral tablet extended release 24 hr 180 1 mg, 240 mg, 300 mg, 360 mg, 420 mg methyldopa oral tablet 250 mg, 500 mg 1 methyldopa-hydrochlorothiazide oral tablet 250- 1 15 mg, 250-25 mg

47 Drug Name Drug Tier Requirements / Limits methyldopate intravenous solution 250 mg/5 ml MB metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 metoprolol succinate oral tablet extended release 1 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet 100-25 1 mg, 100-50 mg, 50-25 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 1 37.5 mg, 50 mg, 75 mg metyrosine oral capsule 250 mg 1 minoxidil oral tablet 10 mg, 2.5 mg 1 moexipril oral tablet 15 mg, 7.5 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 nadolol-bendroflumethiazide oral tablet 80-5 mg 1 nicardipine oral capsule 20 mg, 30 mg 1 nifedipine oral capsule 10 mg, 20 mg 1 nifedipine oral tablet extended release 24hr 30 mg, 1 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 1 mg, 90 mg nimodipine oral capsule 30 mg 1 nisoldipine oral tablet extended release 24 hr 17 1 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg olmesartan oral tablet 20 mg, 40 mg, 5 mg 1 olmesartan-amlodipin-hcthiazid oral tablet 20-5- 1 12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg olmesartan-hydrochlorothiazide oral tablet 20- 1 ST 12.5 mg, 40-12.5 mg, 40-25 mg ORENITRAM ORAL TABLET EXTENDED 1 PA; LA RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 phenoxybenzamine oral capsule 10 mg 1 pindolol oral tablet 10 mg, 5 mg 1 prazosin oral capsule 1 mg, 2 mg, 5 mg 1 propranolol oral capsule,extended release 24 hr 1 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 1 40 mg/5 ml (8 mg/ml)

48 Drug Name Drug Tier Requirements / Limits propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 1 mg, 80 mg propranolol-hydrochlorothiazid oral tablet 40-25 1 mg, 80-25 mg QBRELIS ORAL SOLUTION 1 MG/ML 1 quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 1 mg, 20-12.5 mg, 20-25 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 1 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolacton-hydrochlorothiaz oral tablet 25-25 1 mg taztia xt oral capsule,extended release 24 hr 120 1 mg, 180 mg, 240 mg, 300 mg, 360 mg TEKTURNA HCT ORAL TABLET 150-12.5 1 MG, 150-25 MG, 300-12.5 MG, 300-25 MG telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 telmisartan-amlodipine oral tablet 40-10 mg, 40-5 1 ST mg, 80-10 mg, 80-5 mg telmisartan-hydrochlorothiazid oral tablet 40-12.5 1 mg, 80-12.5 mg, 80-25 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 tiadylt er oral capsule,extended release 24 hr 120 1 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 trandolapril-verapamil oral tablet, ir - er, biphasic 1 ST 24hr 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg triamterene oral capsule 100 mg, 50 mg 1 triamterene-hydrochlorothiazid oral capsule 37.5- 1 25 mg triamterene-hydrochlorothiazid oral tablet 37.5-25 1 mg, 75-50 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 1 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 1 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

49 Drug Name Drug Tier Requirements / Limits veletri intravenous recon soln 0.5 mg, 1.5 mg MB PA; LA verapamil oral capsule, 24 hr er pellet ct 100 mg, 1 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 hr 120 1 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg 1 verapamil oral tablet extended release 120 mg, 1 180 mg, 240 mg CARDIAC GLYCOSIDES digitek oral tablet 125 mcg (0.125 mg), 250 mcg 1 (0.25 mg) digox oral tablet 125 mcg (0.125 mg), 250 mcg 1 (0.25 mg) digoxin oral solution 50 mcg/ml (0.05 mg/ml) 1 digoxin oral tablet 125 mcg (0.125 mg), 250 mcg 1 (0.25 mg) COAGULATION THERAPY ADVATE INTRAVENOUS RECON SOLN 1,000 MB (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT ADYNOVATE INTRAVENOUS SOLUTION MB LA 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/- ) UNIT, 750 (+/-) UNIT AFSTYLA INTRAVENOUS RECON SOLN MB LA 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE ALPHANATE INTRAVENOUS RECON SOLN MB LA 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML ALPHANINE SD INTRAVENOUS RECON MB LA SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT ALPROLIX INTRAVENOUS RECON SOLN MB LA 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT aminocaproic acid oral solution 250 mg/ml (25 %) 1

50 Drug Name Drug Tier Requirements / Limits aminocaproic acid oral tablet 1,000 mg, 500 mg 1 ANDEXXA INTRAVENOUS RECON SOLN MB 200 MG aspirin-dipyridamole oral capsule, er multiphase 1 12 hr 25-200 mg BENEFIX INTRAVENOUS RECON SOLN MB LA 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT BRILINTA ORAL TABLET 60 MG, 90 MG 1 CABLIVI INJECTION KIT 11 MG 1 PA cilostazol oral tablet 100 mg, 50 mg 1 clopidogrel oral tablet 300 mg, 75 mg 1 COAGADEX INTRAVENOUS RECON SOLN MB 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE CORIFACT INTRAVENOUS RECON SOLN MB LA 1,000-1,600 UNIT dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 DOPTELET (15 TAB PACK) ORAL TABLET 20 1 PA; LA MG ELIQUIS DVT-PE TREAT 30D START ORAL 1 TABLETS,DOSE PACK 5 MG (74 TABS) ELIQUIS ORAL TABLET 2.5 MG, 5 MG 1 ELOCTATE INTRAVENOUS RECON SOLN MB LA 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT enoxaparin subcutaneous solution 300 mg/3 ml 1 enoxaparin subcutaneous syringe 100 mg/ml, 120 1 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml ESPEROCT INTRAVENOUS RECON SOLN MB LA 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT FEIBA NF INTRAVENOUS RECON SOLN MB LA 1,750-3,250 UNIT, 350-650 UNIT, 700-1,300 UNIT FIBRYGA INTRAVENOUS RECON SOLN 1 MB GRAM (700 MG- 1,300 MG) fondaparinux subcutaneous syringe 10 mg/0.8 ml, 1 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

51 Drug Name Drug Tier Requirements / Limits FRAGMIN SUBCUTANEOUS SOLUTION 1 25,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 10,000 1 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML HEMLIBRA SUBCUTANEOUS SOLUTION 105 1 PA; LA MG/0.7 ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML HEMOFIL M HIGH INTRAVENOUS RECON MB SOLN 801-1,500 UNIT HEMOFIL M LOW INTRAVENOUS RECON MB SOLN 220-400 UNIT HEMOFIL M MID INTRAVENOUS RECON MB SOLN 401-800 UNIT HEMOFIL M SUPER HIGH INTRAVENOUS MB RECON SOLN 1,501-2,000 UNIT hep flush-10 (pf) intravenous solution 10 unit/ml MB heparin (porcine) in 5 % dex intravenous MB parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection cartridge 5,000 unit/ml 1 (1 ml) heparin (porcine) injection solution 1,000 unit/ml, 1 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin lock flush (porcine) intravenous solution MB 100 unit/ml heparin lockflush(porcine)(pf) intravenous syringe MB 100 unit/ml HEPARIN(PORCINE) IN 0.45% NACL MB INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous MB parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution 1,000 MB unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 1 unit/0.5 ml

52 Drug Name Drug Tier Requirements / Limits heparin, porcine (pf) intravenous solution 100 MB unit/ml (1 ml) heparin, porcine (pf) intravenous syringe 10 MB unit/ml, 100 unit/ml HUMATE-P INTRAVENOUS RECON SOLN MB LA 1,000-2,400 UNIT, 250-600 UNIT, 500-1,200 UNIT IDELVION INTRAVENOUS RECON SOLN MB LA 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,500 (+/-) UNIT, 500 (+/-) UNIT IXINITY INTRAVENOUS RECON SOLN 1,000 MB LA UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 1 mg, 4 mg, 5 mg, 6 mg, 7.5 mg JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) MB LA UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT KOATE INTRAVENOUS RECON SOLN 1,000 MB (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT KOGENATE FS INTRAVENOUS RECON MB SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT KOVALTRY INTRAVENOUS RECON SOLN MB 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT MONONINE INTRAVENOUS RECON SOLN MB LA 1,000 (+/-) UNIT MULPLETA ORAL TABLET 3 MG 1 PA; LA NOVOEIGHT INTRAVENOUS RECON SOLN MB LA 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/- ) UNIT NOVOSEVEN RT INTRAVENOUS RECON MB LA SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG) NPLATE SUBCUTANEOUS RECON SOLN 125 MB LA MCG, 250 MCG, 500 MCG NUWIQ INTRAVENOUS RECON SOLN 1000 MB LA (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT

53 Drug Name Drug Tier Requirements / Limits OBIZUR INTRAVENOUS RECON SOLN 500 MB (+/-) UNIT RANGE pentoxifylline oral tablet extended release 400 mg 1 phytonadione (vitamin k1) oral tablet 5 mg 1 prasugrel oral tablet 10 mg, 5 mg 1 PROFILNINE INTRAVENOUS RECON SOLN MB LA 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT PROMACTA ORAL POWDER IN PACKET 12.5 1 PA; ST; LA MG PROMACTA ORAL POWDER IN PACKET 25 1 LA MG PROMACTA ORAL TABLET 12.5 MG, 25 MG, 1 PA; ST; LA 50 MG, 75 MG REBINYN INTRAVENOUS RECON SOLN MB LA 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT RECOMBINATE INTRAVENOUS RECON MB LA SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT RIASTAP INTRAVENOUS RECON SOLN 1 MB LA GRAM (900MG-1,300MG) RIXUBIS INTRAVENOUS RECON SOLN 1,000 MB LA UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT tranexamic acid intravenous solution 1,000 mg/10 MB ml (100 mg/ml) TRETTEN INTRAVENOUS RECON SOLN MB LA 2,500 UNIT VONVENDI INTRAVENOUS RECON SOLN MB LA 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 1 mg, 4 mg, 5 mg, 6 mg, 7.5 mg WILATE INTRAVENOUS RECON SOLN MB LA 1,000-1,000 UNIT, 500-500 UNIT XARELTO DVT-PE TREAT 30D START ORAL 1 TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 1 MG, 20 MG

54 Drug Name Drug Tier Requirements / Limits XYNTHA INTRAVENOUS SOLUTION 1,000 MB LA (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT XYNTHA SOLOFUSE INTRAVENOUS MB LA SYRINGE 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT ZONTIVITY ORAL TABLET 2.08 MG 1 LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin oral tablet 10-10 mg, 10- 1 ST 20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin oral tablet 10 mg, 20 mg ACA PV atorvastatin oral tablet 40 mg, 80 mg 1 cholestyramine (with sugar) oral powder 4 gram 1 cholestyramine (with sugar) oral powder in packet 1 4 gram cholestyramine light oral powder 4 gram 1 cholestyramine light oral powder in packet 4 gram 1 colesevelam oral powder in packet 3.75 gram 1 colesevelam oral tablet 625 mg 1 colestipol oral granules 5 gram 1 colestipol oral packet 5 gram 1 colestipol oral tablet 1 gram 1 ezetimibe oral tablet 10 mg 1 ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 1 mg, 10-40 mg, 10-80 mg fenofibrate micronized oral capsule 130 mg, 134 1 mg, 200 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 1 mg FENOFIBRATE ORAL CAPSULE 150 MG, 50 1 MG fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 1 mg fenofibric acid (choline) oral capsule,delayed 1 release(dr/ec) 135 mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg 1 fluvastatin oral capsule 20 mg, 40 mg ACA PV

55 Drug Name Drug Tier Requirements / Limits fluvastatin oral tablet extended release 24 hr 80 ACA PV mg gemfibrozil oral tablet 600 mg 1 icosapent ethyl oral capsule 1 gram 1 PA; ST; QL (120 per 30 days) JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 1 PA; LA; QL (30 per 30 days) MG, 40 MG, 5 MG, 60 MG LIPOFEN ORAL CAPSULE 150 MG, 50 MG 1 lovastatin oral tablet 10 mg, 20 mg, 40 mg ACA PV niacin oral tablet 500 mg 1 niacin oral tablet extended release 24 hr 1,000 mg, 1 500 mg, 750 mg NIACOR ORAL TABLET 500 MG 1 omega-3 acid ethyl esters oral capsule 1 gram 1 pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 ACA PV mg prevalite oral powder 4 gram 1 prevalite oral powder in packet 4 gram 1 REPATHA PUSHTRONEX SUBCUTANEOUS 1 PA; ST WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS 1 PA; ST PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS 1 PA; ST SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 5 mg ACA PV rosuvastatin oral tablet 20 mg, 40 mg 1 simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg ACA PV simvastatin oral tablet 80 mg 1 VASCEPA ORAL CAPSULE 0.5 GRAM, 1 1 PA; ST; QL (120 per 30 days) GRAM ZYPITAMAG ORAL TABLET 2 MG, 4 MG 1 PA; ST MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL SOLUTION 5 MG/5 ML 1 PA CORLANOR ORAL TABLET 5 MG, 7.5 MG 1 PA ENTRESTO ORAL TABLET 24-26 MG, 49-51 1 PA; ST MG, 97-103 MG GIAPREZA INTRAVENOUS SOLUTION 2.5 MB MG/ML

56 Drug Name Drug Tier Requirements / Limits ranolazine oral tablet extended release 12 hr 1 ST 1,000 mg, 500 mg NITRATES GONITRO SUBLINGUAL POWDER IN 1 PACKET 400 MCG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 1 mg, 40 mg, 5 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 1 isosorbide mononitrate oral tablet extended 1 release 24 hr 120 mg, 30 mg, 60 mg MINITRAN TRANSDERMAL PATCH 24 1 PA; ST; QL (30 per 30 days) HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR nitro-bid transdermal ointment 2 % 1 NITRO-DUR TRANSDERMAL PATCH 24 1 PA; ST; QL (30 per 30 days) HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR nitroglycerin in 5 % dextrose intravenous solution MB 25 mg/250 ml (100 mcg/ml), 50 mg/500 ml (100 mcg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 1 mg nitroglycerin transdermal patch 24 hour 0.1 1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual spray,non-aerosol 400 1 mcg/spray nitro-time oral capsule, extended release 2.5 mg, 1 6.5 mg, 9 mg DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 calcipotriene scalp solution 0.005 % 1 calcipotriene topical 0.005 % 1 calcipotriene topical ointment 0.005 % 1 calcipotriene-betamethasone topical ointment 1 0.005-0.064 % calcitriol topical ointment 3 mcg/gram 1 COSENTYX (2 ) SUBCUTANEOUS 1 PA; ST; LA SYRINGE 150 MG/ML

57 Drug Name Drug Tier Requirements / Limits COSENTYX PEN (2 PENS) SUBCUTANEOUS 1 PA; ST; LA PEN INJECTOR 150 MG/ML COSENTYX PEN SUBCUTANEOUS PEN 1 PA; ST; LA INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS SYRINGE 150 1 PA; ST; LA MG/ML COSENTYX SUBCUTANEOUS SYRINGE 75 1 PA; LA MG/0.5 ML hydrocortisone-pramoxine topical cream 2.5-1 % 1 ILUMYA SUBCUTANEOUS SYRINGE 100 1 PA; ST; LA MG/ML selenium sulfide topical 2.5 % 1 selenium sulfide topical 2.25 %, 2.3 % 1 SILIQ SUBCUTANEOUS SYRINGE 210 1 PA; ST; LA MG/1.5 ML SKYRIZI SUBCUTANEOUS PEN INJECTOR 1 PA; ST; LA 150 MG/ML SKYRIZI SUBCUTANEOUS SYRINGE 150 1 PA; ST; LA MG/ML SKYRIZI SUBCUTANEOUS SYRINGE KIT 1 PA; ST; LA 150MG/1.66ML(75 MG/0.83 ML X2) STELARA INTRAVENOUS SOLUTION 130 MB PA; LA MG/26 ML STELARA SUBCUTANEOUS SOLUTION 45 1 PA; ST; LA MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 1 PA; ST; LA MG/0.5 ML, 90 MG/ML sulfacetamide sodium topical cleanser 10 % 1 sulfacetamide sodium topical cleanser, gel 10 % 1 sulfacetamide sodium topical shampoo 10 % 1 TALTZ AUTOINJECTOR (2 PACK) 1 PA; ST; LA SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ AUTOINJECTOR (3 PACK) 1 PA; ST; LA SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ AUTOINJECTOR SUBCUTANEOUS 1 PA; ST; LA AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS 1 PA; ST; LA SYRINGE 80 MG/ML

58 Drug Name Drug Tier Requirements / Limits TREMFYA SUBCUTANEOUS AUTO- 1 PA; ST; LA INJECTOR 100 MG/ML TREMFYA SUBCUTANEOUS SYRINGE 100 1 PA; ST; LA MG/ML BURN THERAPY silver sulfadiazine topical cream 1 % 1 ssd topical cream 1 % 1 MISCELLANEOUS DERMATOLOGICALS ammonium lactate topical cream 12 % 1 ammonium lactate topical lotion 12 % 1 diclofenac sodium topical gel 3 % 1 DUPIXENT PEN SUBCUTANEOUS PEN 1 PA; LA INJECTOR 200 MG/1.14 ML DUPIXENT PEN SUBCUTANEOUS PEN 1 LA INJECTOR 300 MG/2 ML DUPIXENT SYRINGE SUBCUTANEOUS 1 PA; ST; LA SYRINGE 200 MG/1.14 ML, 300 MG/2 ML EUCRISA TOPICAL OINTMENT 2 % 1 PA; ST FLUOROURACIL TOPICAL CREAM 0.5 % 1 PA; ST fluorouracil topical cream 5 % 1 PA; ST fluorouracil topical solution 2 %, 5 % 1 LEVULAN TOPICAL SOLUTION 20 % 1 methoxsalen oral capsule,liqd-filled,rapid rel 10 1 mg PANRETIN TOPICAL GEL 0.1 % 1 PICATO TOPICAL GEL 0.015 %, 0.05 % 1 pimecrolimus topical cream 1 % 1 podofilox topical solution 0.5 % 1 prudoxin topical cream 5 % 1 REGRANEX TOPICAL GEL 0.01 % 1 SCENESSE SUBCUTANEOUS IMPLANT 16 MB PA MG tacrolimus topical ointment 0.03 %, 0.1 % 1 UVADEX INJECTION SOLUTION 20 MCG/ML 1 VALCHLOR TOPICAL GEL 0.016 % 1 PA; ST; LA THERAPY FOR ACNE accutane oral capsule 20 mg, 30 mg, 40 mg 1

59 Drug Name Drug Tier Requirements / Limits adapalene topical cream 0.1 % 1 ST adapalene topical gel 0.3 % 1 ST adapalene topical gel with pump 0.3 % 1 ST ADAPALENE TOPICAL LOTION 0.1 % 1 ST adapalene topical solution 0.1 % 1 ST adapalene topical swab 0.1 % 1 ST adapalene-benzoyl peroxide topical gel with pump 1 0.1-2.5 % amnesteem oral capsule 10 mg, 20 mg, 40 mg 1 PA; ST avita topical cream 0.025 % 1 AVITA TOPICAL GEL 0.025 % 1 ST azelaic acid topical gel 15 % 1 AZELEX TOPICAL CREAM 20 % 1 ST claravis oral capsule 10 mg, 20 mg, 30 mg 1 PA; ST claravis oral capsule 40 mg 1 clindacin p topical swab 1 % 1 clindamycin phosphate topical foam 1 % 1 clindamycin phosphate topical gel 1 % 1 clindamycin phosphate topical lotion 1 % 1 clindamycin phosphate topical solution 1 % 1 clindamycin phosphate topical swab 1 % 1 clindamycin-benzoyl peroxide topical gel 1-5 %, 1 1.2 %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel with 1 pump 1-5 % clindamycin-tretinoin topical gel 1.2-0.025 % 1 dapsone topical gel 5 % 1 ery pads topical swab 2 % 1 erygel topical gel 2 % 1 erythromycin with ethanol topical gel 2 % 1 erythromycin with ethanol topical solution 2 % 1 erythromycin-benzoyl peroxide topical gel 3-5 % 1 isotretinoin oral capsule 10 mg, 20 mg, 25 mg, 30 1 mg, 35 mg, 40 mg metronidazole topical cream 0.75 % 1 metronidazole topical gel 0.75 %, 1 % 1

60 Drug Name Drug Tier Requirements / Limits metronidazole topical gel with pump 1 % 1 metronidazole topical lotion 0.75 % 1 myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 1 mg rosadan topical cream 0.75 % 1 rosadan topical gel 0.75 % 1 tazarotene topical cream 0.1 % 1 ST tretinoin microspheres topical gel 0.04 %, 0.1 % 1 tretinoin microspheres topical gel with pump 0.04 1 %, 0.1 % tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 1 tretinoin topical gel 0.01 %, 0.025 %, 0.05 % 1 zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 TOPICAL ANESTHETICS lidocaine hcl injection solution 10 mg/ml (1 %) 1 lidocaine hcl laryngotracheal solution 4 % 1 lidocaine hcl mucous membrane jelly 2 % 1 lidocaine hcl mucous membrane jelly in applicator 1 2 % lidocaine hcl mucous membrane solution 4 % (40 1 mg/ml) lidocaine hcl-hydrocortison ac topical cream 3-0.5 1 % lidocaine topical adhesive patch,medicated 5 % 1 lidocaine topical ointment 5 % 1 lidocaine viscous mucous membrane solution 2 % 1 lidocaine-prilocaine topical cream 2.5-2.5 % 1 lidocaine-prilocaine topical kit 2.5-2.5 % 1 LIDOCAINE-TETRACAINE TOPICAL CREAM 1 ST 7-7 % SYNERA TOPICAL PATCH, MEDICATED 1 ST SELF-HEATING 70-70 MG TOPICAL ANTIBACTERIALS ALCORTIN A TOPICAL GEL 2-1-1 % 1 ST ALCORTIN A TOPICAL GEL IN PACKET 2-1- 1 ST 1 % ALTABAX TOPICAL OINTMENT 1 % 1

61 Drug Name Drug Tier Requirements / Limits gentamicin topical cream 0.1 % 1 gentamicin topical ointment 0.1 % 1 mafenide acetate topical packet 50 gram 1 mupirocin calcium topical cream 2 % 1 mupirocin topical ointment 2 % 1 sulfacetamide sodium (acne) topical suspension 10 1 % SULFAMYLON TOPICAL CREAM 85 MG/G 1 TOPICAL ANTIFUNGALS ciclodan topical cream 0.77 % 1 ciclodan topical solution 8 % 1 ciclopirox topical cream 0.77 % 1 ciclopirox topical gel 0.77 % 1 ciclopirox topical shampoo 1 % 1 ciclopirox topical solution 8 % 1 ciclopirox topical suspension 0.77 % 1 ciclopirox-ure-camph-menth-euc topical solution 8 1 % clotrimazole topical cream 1 % 1 clotrimazole topical solution 1 % 1 clotrimazole-betamethasone topical cream 1-0.05 1 % clotrimazole-betamethasone topical lotion 1-0.05 1 % econazole topical cream 1 % 1 EXELDERM TOPICAL CREAM 1 % 1 EXELDERM TOPICAL SOLUTION 1 % 1 JUBLIA TOPICAL SOLUTION WITH 1 PA; ST APPLICATOR 10 % ketoconazole topical cream 2 % 1 ketoconazole topical foam 2 % 1 ketoconazole topical shampoo 2 % 1 ketodan topical foam 2 % 1 LULICONAZOLE TOPICAL CREAM 1 % 1 LUZU TOPICAL CREAM 1 % 1 MENTAX TOPICAL CREAM 1 % 1

62 Drug Name Drug Tier Requirements / Limits naftifine topical cream 1 %, 2 % 1 naftifine topical gel 1 % 1 nyamyc topical powder 100,000 unit/gram 1 nystatin topical cream 100,000 unit/gram 1 nystatin topical ointment 100,000 unit/gram 1 nystatin topical powder 100,000 unit/gram 1 nystatin-triamcinolone topical cream 100,000-0.1 1 unit/g-% nystatin-triamcinolone topical ointment 100,000- 1 0.1 unit/gram-% nystop topical powder 100,000 unit/gram 1 oxiconazole topical cream 1 % 1 OXISTAT TOPICAL LOTION 1 % 1 tavaborole topical solution with applicator 5 % 1 PA; ST TOPICAL ANTIVIRALS acyclovir topical cream 5 % 1 acyclovir topical ointment 5 % 1 DENAVIR TOPICAL CREAM 1 % 1 TOPICAL CORTICOSTEROIDS ala-cort topical cream 1 % 1 alclometasone topical cream 0.05 % 1 alclometasone topical ointment 0.05 % 1 amcinonide topical cream 0.1 % 1 amcinonide topical lotion 0.1 % 1 apexicon e topical cream 0.05 % 1 beser topical lotion 0.05 % 1 betamethasone dipropionate topical cream 0.05 % 1 betamethasone dipropionate topical lotion 0.05 % 1 betamethasone dipropionate topical ointment 0.05 1 % betamethasone valerate topical cream 0.1 % 1 betamethasone valerate topical foam 0.12 % 1 betamethasone valerate topical lotion 0.1 % 1 betamethasone valerate topical ointment 0.1 % 1 betamethasone, augmented topical cream 0.05 % 1 betamethasone, augmented topical gel 0.05 % 1

63 Drug Name Drug Tier Requirements / Limits betamethasone, augmented topical lotion 0.05 % 1 betamethasone, augmented topical ointment 0.05 1 % clobetasol scalp solution 0.05 % 1 clobetasol topical cream 0.05 % 1 clobetasol topical foam 0.05 % 1 clobetasol topical gel 0.05 % 1 clobetasol topical lotion 0.05 % 1 clobetasol topical ointment 0.05 % 1 clobetasol topical shampoo 0.05 % 1 clobetasol topical spray,non-aerosol 0.05 % 1 clobetasol-emollient topical cream 0.05 % 1 clobetasol-emollient topical foam 0.05 % 1 CLOCORTOLONE PIVALATE TOPICAL 1 ST CREAM 0.1 % CLODERM TOPICAL CREAM 0.1 % 1 ST desonide topical cream 0.05 % 1 desonide topical lotion 0.05 % 1 desonide topical ointment 0.05 % 1 desoximetasone topical cream 0.05 %, 0.25 % 1 desoximetasone topical gel 0.05 % 1 desoximetasone topical ointment 0.05 %, 0.25 % 1 desoximetasone topical spray,non-aerosol 0.25 % 1 diflorasone topical cream 0.05 % 1 diflorasone topical ointment 0.05 % 1 fluocinolone and shower cap scalp oil 0.01 % 1 fluocinolone topical cream 0.01 %, 0.025 % 1 fluocinolone topical oil 0.01 % 1 fluocinolone topical ointment 0.025 % 1 fluocinolone topical solution 0.01 % 1 fluocinonide topical cream 0.05 %, 0.1 % 1 fluocinonide topical gel 0.05 % 1 fluocinonide topical ointment 0.05 % 1 fluocinonide topical solution 0.05 % 1 fluocinonide-e topical cream 0.05 % 1

64 Drug Name Drug Tier Requirements / Limits flurandrenolide topical cream 0.05 % 1 flurandrenolide topical lotion 0.05 % 1 flurandrenolide topical ointment 0.05 % 1 fluticasone propionate topical cream 0.05 % 1 fluticasone propionate topical lotion 0.05 % 1 fluticasone propionate topical ointment 0.005 % 1 halcinonide topical cream 0.1 % 1 halobetasol propionate topical cream 0.05 % 1 halobetasol propionate topical ointment 0.05 % 1 hydrocortisone butyrate topical cream 0.1 % 1 hydrocortisone butyrate topical lotion 0.1 % 1 hydrocortisone butyrate topical ointment 0.1 % 1 hydrocortisone butyrate topical solution 0.1 % 1 hydrocortisone butyr-emollient topical cream 0.1 1 % hydrocortisone topical cream 1 %, 2.5 % 1 hydrocortisone topical lotion 2.5 % 1 hydrocortisone topical ointment 1 %, 2.5 % 1 hydrocortisone valerate topical cream 0.2 % 1 hydrocortisone valerate topical ointment 0.2 % 1 mometasone topical cream 0.1 % 1 mometasone topical ointment 0.1 % 1 mometasone topical solution 0.1 % 1 prednicarbate topical cream 0.1 % 1 prednicarbate topical ointment 0.1 % 1 scalacort topical lotion 2 % 1 triamcinolone acetonide topical aerosol 0.147 1 mg/gram triamcinolone acetonide topical cream 0.025 %, 1 0.1 %, 0.5 % triamcinolone acetonide topical lotion 0.025 %, 1 0.1 % triamcinolone acetonide topical ointment 0.025 %, 1 0.05 %, 0.1 %, 0.5 % triderm topical cream 0.1 %, 0.5 % 1 TOPICAL ENZYMES

65 Drug Name Drug Tier Requirements / Limits SANTYL TOPICAL OINTMENT 250 1 QL (2 per 30 days) UNIT/GRAM TOPICAL SCABICIDES / PEDICULICIDES crotan topical lotion 10 % 1 EURAX TOPICAL CREAM 10 % 1 EURAX TOPICAL LOTION 10 % 1 ivermectin topical lotion 0.5 % 1 lindane topical shampoo 1 % 1 malathion topical lotion 0.5 % 1 permethrin topical cream 5 % 1 spinosad topical suspension 0.9 % 1 ULESFIA TOPICAL LOTION 5 % 1 DIAGNOSTICS & MISCELLANEOUS AGENTS IRRIGATING PHYSIOLYTE IRRIGATION SOLUTION 140-5- MB 3-98 MEQ/L PHYSIOSOL IRRIGATION IRRIGATION MB SOLUTION 140-5-3-98 MEQ/L MISCELLANEOUS AGENTS acamprosate oral tablet,delayed release (dr/ec) 1 333 mg acetic acid irrigation solution 0.25 % 1 anagrelide oral capsule 0.5 mg, 1 mg 1 ARALAST NP INTRAVENOUS RECON SOLN MB PA; LA 1,000 MG, 500 MG CARBAGLU ORAL TABLET, DISPERSIBLE 1 PA; LA 200 MG cevimeline oral capsule 30 mg 1 CHEMET ORAL CAPSULE 100 MG 1 clovique oral capsule 250 mg 1 PA; QL (240 per 30 days) deferasirox oral granules in packet 180 mg, 360 1 PA; LA mg, 90 mg deferasirox oral tablet 180 mg 1 PA; LA deferasirox oral tablet 360 mg, 90 mg 1 ST; LA deferasirox oral tablet, dispersible 125 mg, 250 1 ST; LA mg, 500 mg deferiprone oral tablet 500 mg 1 PA

66 Drug Name Drug Tier Requirements / Limits disulfiram oral tablet 250 mg, 500 mg 1 EMPAVELI SUBCUTANEOUS SOLUTION 1 PA 1,080 MG/20 ML FERRIPROX ORAL SOLUTION 100 MG/ML 1 PA FERRIPROX ORAL TABLET 1,000 MG, 500 1 PA MG GIVLAARI SUBCUTANEOUS SOLUTION 189 MB PA; LA MG/ML GLASSIA INTRAVENOUS SOLUTION 1 MB LA GRAM/50 ML (2 %) INCRELEX SUBCUTANEOUS SOLUTION 10 1 PA; LA MG/ML levocarnitine (with sugar) oral solution 100 mg/ml 1 levocarnitine oral solution 100 mg/ml 1 levocarnitine oral tablet 330 mg 1 midodrine oral tablet 10 mg, 2.5 mg, 5 mg 1 nitisinone oral capsule 10 mg, 2 mg, 5 mg 1 PA; LA NITYR ORAL TABLET 10 MG, 2 MG, 5 MG 1 PA; LA pilocarpine hcl oral tablet 5 mg 1 PROLASTIN-C INTRAVENOUS SOLUTION MB 1,000 MG (+/-)/20 ML RAVICTI ORAL LIQUID 1.1 GRAM/ML 1 PA; ST; LA; QL (10 per 30 days) RECLAST INTRAVENOUS PIGGYBACK 5 MB MG/100 ML riluzole oral tablet 50 mg 1 risedronate oral tablet 30 mg 1 sodium chloride 0.9 % injection solution MB sodium chloride 0.9 % intravenous parenteral MB solution sodium chloride 0.9 % intravenous piggyback MB sodium phenylbutyrate oral powder 0.94 1 PA gram/gram sodium phenylbutyrate oral tablet 500 mg 1 PA SOLIRIS INTRAVENOUS SOLUTION 300 MB PA; LA MG/30 ML trientine oral capsule 250 mg 1 PA; QL (240 per 30 days) XURIDEN ORAL GRANULES IN PACKET 2 1 PA; QL (120 per 30 days) GRAM

67 Drug Name Drug Tier Requirements / Limits ZEMAIRA INTRAVENOUS RECON SOLN MB LA 1,000 MG ZOKINVY ORAL CAPSULE 50 MG, 75 MG 1 PA; ST DETERRENTS bupropion hcl (smoking deter) oral tablet extended ACA PV release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL ACA PV QL (180 per 365 days) TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG ACA PV QL (180 per 365 days) CHANTIX STARTING MONTH BOX ORAL ACA PV QL (180 per 365 days) TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) nicorette buccal gum 4 mg ACA PV nicotine (polacrilex) buccal gum 2 mg, 4 mg ACA PV nicotine (polacrilex) buccal lozenge 2 mg, 4 mg ACA PV nicotine (polacrilex) buccal mini lozenge 2 mg, 4 ACA PV mg nicotine transdermal patch 24 hour 14 mg/24 hr, ACA PV 21 mg/24 hr, 7 mg/24 hr nicotine transdermal patch, td daily, sequential ACA PV 21-14-7 mg/24 hr NICOTROL INHALATION CARTRIDGE 10 ACA PV MG NICOTROL NS NASAL SPRAY,NON- ACA PV AEROSOL 10 MG/ML quit 2 buccal gum 2 mg ACA PV quit 2 buccal lozenge 2 mg ACA PV quit 4 buccal gum 4 mg ACA PV quit 4 buccal lozenge 4 mg ACA PV stop smoking aid buccal lozenge 2 mg, 4 mg ACA PV VARENICLINE ORAL TABLET 0.5 MG, 1 MG ACA PV QL (180 per 365 days) EAR, NOSE & THROAT MEDICATIONS MISCELLANEOUS AGENTS ARESTIN DENTAL CARTRIDGE 1 MG MB azelastine nasal aerosol,spray 137 mcg (0.1 %) 1 azelastine nasal spray,non-aerosol 205.5 mcg 1 (0.15 %) chlorhexidine gluconate mucous membrane 1 0.12 %

68 Drug Name Drug Tier Requirements / Limits denta 5000 plus dental cream 1.1 % 1 dentagel dental gel 1.1 % 1 fluoride (sodium) dental cream 1.1 % 1 fluoride (sodium) dental gel 1.1 % 1 fluoride (sodium) dental 1.1 % 1 ipratropium bromide nasal spray,non-aerosol 21 1 mcg (0.03 %), 42 mcg (0.06 %) olopatadine nasal spray,non-aerosol 0.6 % 1 oralone dental paste 0.1 % 1 paroex oral rinse mucous membrane mouthwash 1 0.12 % periogard mucous membrane mouthwash 0.12 % 1 pilocarpine hcl oral tablet 7.5 mg 1 sf 5000 plus dental cream 1.1 % 1 sf dental gel 1.1 % 1 sodium fluoride 5000 dry mouth dental gel 1.1 % 1 sodium fluoride 5000 plus dental cream 1.1 % 1 sodium fluoride-pot nitrate dental paste 1.1-5 % 1 triamcinolone acetonide dental paste 0.1 % 1 MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) solution 2 % 1 ciprofloxacin hcl otic (ear) dropperette 0.2 % 1 flac otic oil otic (ear) drops 0.01 % 1 fluocinolone acetonide oil otic (ear) drops 0.01 % 1 hydrocortisone-acetic acid otic (ear) drops 1-2 % 1 ofloxacin otic (ear) drops 0.3 % 1 OTIC STEROID / ANTIBIOTIC CIPRO HC OTIC (EAR) DROPS,SUSPENSION 1 0.2-1 % ciprofloxacin-dexamethasone otic (ear) 1 drops,suspension 0.3-0.1 % neomycin-polymyxin-hc otic (ear) 1 drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5- 1 10,000-1 mg/ml-unit/ml-% OTOVEL OTIC (EAR) SOLUTION 0.3-0.025 % 1 (0.25 ML)

69 Drug Name Drug Tier Requirements / Limits ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR INJECTION GEL 80 UNIT/ML 1 PA; LA decadron oral tablet 0.5 mg 1 dexamethasone intensol oral drops 1 mg/ml 1 dexamethasone oral elixir 0.5 mg/5 ml 1 dexamethasone oral solution 0.5 mg/5 ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone oral tablets,dose pack 1.5 mg (21 1 tabs), 1.5 mg (35 tabs), 1.5 mg (51 tabs) dexamethasone sodium phos (pf) injection solution 1 10 mg/ml dexamethasone sodium phosphate injection 1 solution 10 mg/ml, 4 mg/ml dexamethasone sodium phosphate injection 1 syringe 4 mg/ml fludrocortisone oral tablet 0.1 mg 1 hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 methylprednisolone acetate injection suspension 1 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 1 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg 1 millipred dp oral tablets,dose pack 5 mg (21 tabs), 1 5 mg (48 tabs) millipred oral tablet 5 mg 1 prednisolone oral solution 15 mg/5 ml 1 prednisolone sodium phosphate oral solution 10 1 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral 1 tablet,disintegrating 10 mg, 15 mg, 30 mg prednisone intensol oral concentrate 5 mg/ml 1 prednisone oral solution 5 mg/5 ml 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 1 mg, 5 mg, 50 mg

70 Drug Name Drug Tier Requirements / Limits prednisone oral tablets,dose pack 10 mg, 5 mg 1 triamcinolone acetonide injection suspension 40 MB mg/ml ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1 SSKI ORAL SOLUTION 1 GRAM/ML 1 BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES CONTOUR NEXT TEST STRIPS STRIP 1 CONTOUR TEST STRIPS STRIP 1 ONETOUCH ULTRA TEST STRIP 1 ONETOUCH VERIO TEST STRIPS STRIP 1 DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT AEROCHAMBER MINI SPACER 1 AEROCHAMBER PLUS FLOW-VU SPACER 1 GLUCAGEN DIAGNOSTIC KIT INJECTION 1 RECON SOLN 1 MG/ML GLUCAGON HCL INJECTION RECON SOLN 1 1 MG/ML INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1 0.5 ML 29 GAUGE X 1/2" TRIJARDY XR ORAL TABLET, IR - ER, 1 PA; ST BIPHASIC 24HR 10-5-1,000 MG, 12.5-2.5-1,000 MG, 25-5-1,000 MG, 5-2.5-1,000 MG GLUCOSE ELEVATING AGENTS BAQSIMI NASAL SPRAY,NON-AEROSOL 3 1 MG/ACTUATION diazoxide oral suspension 50 mg/ml 1 GLUCAGEN HYPOKIT INJECTION RECON 1 SOLN 1 MG GLUCAGON (HCL) EMERGENCY KIT 1 INJECTION RECON SOLN 1 MG glucagon emergency kit (human) injection recon 1 soln 1 mg INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU FREESTYLE LIBRE 14 DAY SENSOR KIT 1 FREESTYLE LIBRE 2 SENSOR KIT 1

71 Drug Name Drug Tier Requirements / Limits NOVOPEN ECHO SUBCUTANEOUS INSULIN 1 PEN PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE 1 X 1/2" INSULIN THERAPY FIASP FLEXTOUCH U-100 INSULIN 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP PENFILL U-100 INSULIN 1 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML (3 ML) FIASP U-100 INSULIN SUBCUTANEOUS 1 SOLUTION 100 UNIT/ML HUMALOG JUNIOR KWIKPEN U-100 1 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN INSULIN 1 ST SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN INSULIN 1 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) HUMALOG MIX 50-50 INSULN U-100 1 ST SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX 50-50 KWIKPEN 1 ST SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX 75-25 KWIKPEN 1 ST SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U-100)INSULN 1 ST SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG U-100 INSULIN SUBCUTANEOUS 1 ST CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN SUBCUTANEOUS 1 ST SOLUTION 100 UNIT/ML HUMULIN 70/30 U-100 INSULIN 1 ST SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

72 Drug Name Drug Tier Requirements / Limits HUMULIN 70/30 U-100 KWIKPEN 1 ST SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN N NPH INSULIN KWIKPEN 1 ST SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N NPH U-100 INSULIN 1 ST SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 INSULN 1 ST INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN 1 SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN 1 SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) INSULIN ASP PRT-INSULIN ASPART 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) INSULIN ASP PRT-INSULIN ASPART 1 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) INSULIN ASPART U-100 SUBCUTANEOUS 1 CARTRIDGE 100 UNIT/ML INSULIN ASPART U-100 SUBCUTANEOUS 1 INSULIN PEN 100 UNIT/ML (3 ML) INSULIN ASPART U-100 SUBCUTANEOUS 1 SOLUTION 100 UNIT/ML LANTUS SOLOSTAR U-100 INSULIN 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN SUBCUTANEOUS 1 SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS 1 SOLUTION 100 UNIT/ML NOVOLIN 70-30 FLEXPEN U-100 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLIN N FLEXPEN SUBCUTANEOUS 1 INSULIN PEN 100 UNIT/ML (3 ML)

73 Drug Name Drug Tier Requirements / Limits NOVOLIN R FLEXPEN SUBCUTANEOUS 1 INSULIN PEN 100 UNIT/ML (3 ML) NOVOLOG FLEXPEN U-100 INSULIN 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) NOVOLOG MIX 70-30 U-100 INSULN 1 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-100 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U-100 INSULIN 1 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART 1 SUBCUTANEOUS SOLUTION 100 UNIT/ML RELION NOVOLIN 70/30 SUBCUTANEOUS 1 SUSPENSION 100 UNIT/ML (70-30) RELION NOVOLIN N SUBCUTANEOUS 1 SUSPENSION 100 UNIT/ML RELION NOVOLIN R INJECTION SOLUTION 1 100 UNIT/ML SOLIQUA 100/33 SUBCUTANEOUS INSULIN 1 PA; ST PEN 100 UNIT-33 MCG/ML TOUJEO MAX U-300 SOLOSTAR 1 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN 1 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 1 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 1 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) TRESIBA U-100 INSULIN SUBCUTANEOUS 1 SOLUTION 100 UNIT/ML XULTOPHY 100/3.6 SUBCUTANEOUS 1 PA; ST INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) MISCELLANEOUS HORMONES ALDURAZYME INTRAVENOUS SOLUTION MB PA; LA 2.9 MG/5 ML

74 Drug Name Drug Tier Requirements / Limits ANDRODERM TRANSDERMAL PATCH 24 1 ST; QL (30 per 30 days) HOUR 2 MG/24 HOUR, 4 MG/24 HR BRINEURA INTRAVENTRICULAR KIT 300 MB PA MG/10 ML (150MG/5ML X2) cabergoline oral tablet 0.5 mg 1 calcitonin (salmon) injection solution 200 unit/ml 1 calcitonin (salmon) nasal spray,non-aerosol 200 1 unit/actuation calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 calcitriol oral solution 1 mcg/ml 1 CERDELGA ORAL CAPSULE 84 MG 1 PA; LA CEREZYME INTRAVENOUS RECON SOLN MB PA; LA 400 UNIT cinacalcet oral tablet 30 mg, 60 mg, 90 mg 1 PA CRYSVITA SUBCUTANEOUS SOLUTION 10 MB PA; LA MG/ML, 20 MG/ML, 30 MG/ML danazol oral capsule 100 mg, 200 mg, 50 mg 1 DEPO-TESTOSTERONE INTRAMUSCULAR 1 OIL 100 MG/ML desmopressin nasal spray,non-aerosol 10 1 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg 1 doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 1 mcg ELAPRASE INTRAVENOUS SOLUTION 6 MB PA; LA MG/3 ML ELELYSO INTRAVENOUS RECON SOLN 200 MB PA; LA UNIT FABRAZYME INTRAVENOUS RECON SOLN MB PA; LA 35 MG, 5 MG GALAFOLD ORAL CAPSULE 123 MG 1 PA; LA JYNARQUE ORAL TABLET 15 MG, 30 MG 1 PA; QL (60 per 30 days) JYNARQUE ORAL TABLETS, SEQUENTIAL 1 PA; QL (60 per 30 days) 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) KANUMA INTRAVENOUS SOLUTION 2 MB PA; LA MG/ML KORLYM ORAL TABLET 300 MG 1 PA; ST

75 Drug Name Drug Tier Requirements / Limits LUMIZYME INTRAVENOUS RECON SOLN 50 MB PA; LA MG MEPSEVII INTRAVENOUS SOLUTION 2 MB PA; LA MG/ML methyltestosterone oral capsule 10 mg 1 MIACALCIN INJECTION SOLUTION 200 1 UNIT/ML miglustat oral capsule 100 mg 1 PA; LA MYALEPT SUBCUTANEOUS RECON SOLN 5 1 PA; LA MG/ML (FINAL CONC.) NAGLAZYME INTRAVENOUS SOLUTION 5 MB PA; LA MG/5 ML NATPARA SUBCUTANEOUS CARTRIDGE 1 PA; ST; LA 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE oxandrolone oral tablet 10 mg, 2.5 mg 1 PALYNZIQ SUBCUTANEOUS SYRINGE 10 1 PA; LA MG/0.5 ML, 2.5 MG/0.5 ML, 20 MG/ML pamidronate intravenous solution 30 mg/10 ml (3 MB mg/ml) PARICALCITOL HEMODIALYSIS PORT MB INJECTION SOLUTION 5 MCG/ML paricalcitol intravenous solution 5 mcg/ml MB paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 PARSABIV INTRAVENOUS SOLUTION 5 MB PA MG/ML SAMSCA ORAL TABLET 15 MG 1 PA; LA; QL (60 per 30 days) sapropterin oral powder in packet 100 mg, 500 mg 1 PA; LA sapropterin oral tablet,soluble 100 mg 1 PA; LA SOMAVERT SUBCUTANEOUS RECON SOLN 1 PA; LA; QL (30 per 30 days) 10 MG, 15 MG, 20 MG, 25 MG, 30 MG STRENSIQ SUBCUTANEOUS SOLUTION 18 1 PA MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML, 80 MG/0.8 ML SYNAREL NASAL SPRAY,NON-AEROSOL 2 1 MG/ML TEPEZZA INTRAVENOUS RECON SOLN 500 MB PA; LA MG testosterone cypionate intramuscular oil 100 1 mg/ml, 200 mg/ml

76 Drug Name Drug Tier Requirements / Limits testosterone enanthate intramuscular oil 200 1 mg/ml testosterone transdermal gel 50 mg/5 gram (1 %) 1 QL (60 per 30 days) testosterone transdermal gel in metered-dose 1 QL (2 per 30 days) pump 10 mg/0.5 gram /actuation, 20.25 mg/1.25 gram (1.62 %) testosterone transdermal gel in metered-dose 1 QL (4 per 30 days) pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 1 QL (30 per 30 days) mg/2.5gram), 1.62 % (20.25 mg/1.25 gram) testosterone transdermal gel in packet 1 % (50 1 QL (60 per 30 days) mg/5 gram), 1.62 % (40.5 mg/2.5 gram) testosterone transdermal solution in metered pump 1 QL (2 per 30 days) w/app 30 mg/actuation (1.5 ml) VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 MB PA; LA ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 MB PA; LA UNIT NON-INSULIN HYPOGLYCEMIC AGENTS acarbose oral tablet 100 mg, 25 mg, 50 mg 1 ALOGLIPTIN-PIOGLITAZONE ORAL 1 PA; ST TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG BYDUREON BCISE SUBCUTANEOUS AUTO- 1 PA; ST INJECTOR 2 MG/0.85 ML BYETTA SUBCUTANEOUS PEN INJECTOR 1 PA; ST 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 MG 1 FARXIGA ORAL TABLET 10 MG, 5 MG 1 PA; ST glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide oral tablet 10 mg, 5 mg 1 glipizide oral tablet extended release 24hr 10 mg, 1 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5-250 mg, 2.5- 1 500 mg, 5-500 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 1 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1

77 Drug Name Drug Tier Requirements / Limits glyburide-metformin oral tablet 1.25-250 mg, 2.5- 1 500 mg, 5-500 mg GLYXAMBI ORAL TABLET 10-5 MG, 25-5 1 PA; ST MG JANUMET ORAL TABLET 50-1,000 MG, 50- 1 PA; ST 500 MG JANUMET XR ORAL TABLET, ER 1 PA; ST MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 1 PA; ST MG JARDIANCE ORAL TABLET 10 MG, 25 MG 1 PA; ST JENTADUETO ORAL TABLET 2.5-1,000 MG, 1 PA; ST 2.5-500 MG, 2.5-850 MG JENTADUETO XR ORAL TABLET, IR - ER, 1 PA; ST BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG metformin oral solution 500 mg/5 ml 1 PA metformin oral tablet 1,000 mg, 500 mg, 850 mg 1 metformin oral tablet extended release 24 hr 500 1 mg, 750 mg metformin oral tablet extended release 24hr 1,000 1 PA; ST mg, 500 mg metformin oral tablet,er gast.retention 24 hr 1,000 1 ST mg, 500 mg miglitol oral tablet 100 mg, 25 mg, 50 mg 1 nateglinide oral tablet 120 mg, 60 mg 1 OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 PA; ST 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/DOSE (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML) pioglitazone oral tablet 15 mg, 30 mg, 45 mg 1 pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 1 mg pioglitazone-metformin oral tablet 15-500 mg, 15- 1 850 mg QTERN ORAL TABLET 10-5 MG, 5-5 MG 1 PA; ST repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1 repaglinide-metformin oral tablet 1-500 mg, 2-500 1 mg

78 Drug Name Drug Tier Requirements / Limits RIOMET ER ORAL SUSPENSION,EXTENDED 1 PA; ST REL RECON 500 MG/5 ML RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 1 PA; ST MG SYMLINPEN 120 SUBCUTANEOUS PEN 1 PA; ST INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN 1 PA; ST INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 12.5-1,000 MG, 1 PA; ST 12.5-500 MG, 5-1,000 MG, 5-500 MG SYNJARDY XR ORAL TABLET, IR - ER, 1 PA; ST BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG 1 PA; ST TRULICITY SUBCUTANEOUS PEN 1 PA; ST INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML XIGDUO XR ORAL TABLET, IR - ER, 1 PA; ST BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 2.5- 1,000 MG, 5-1,000 MG, 5-500 MG THYROID HORMONES ARMOUR THYROID ORAL TABLET 120 MG, 1 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG levothyroxine oral tablet 100 mcg, 112 mcg, 125 1 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 1 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1 np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 1 mg, 90 mg SYNTHROID ORAL TABLET 100 MCG, 112 1 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG THYROLAR-1 ORAL TABLET 12.5-50 MCG 1 THYROLAR-1/2 ORAL TABLET 6.25-25 MCG 1 THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG 1 THYROLAR-2 ORAL TABLET 25-100 MCG 1

79 Drug Name Drug Tier Requirements / Limits THYROLAR-3 ORAL TABLET 37.5-150 MCG 1 unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 1 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 1 mg, 97.5 mg GASTROENTEROLOGY ANTIDIARRHEALS & ANTISPASMODICS anaspaz oral tablet,disintegrating 0.125 mg 1 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 1 belladonna alkaloids-opium rectal suppository 1 PA; ST 16.2-30 mg, 16.2-60 mg chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 dicyclomine intramuscular solution 10 mg/ml MB dicyclomine oral capsule 10 mg 1 dicyclomine oral solution 10 mg/5 ml 1 dicyclomine oral tablet 20 mg 1 diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 1 ml diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 DONNATAL ORAL TABLET 16.2-0.1037 - 1 0.0194 MG ed-spaz oral tablet,disintegrating 0.125 mg 1 glycopyrrolate injection solution 0.2 mg/ml 1 glycopyrrolate oral tablet 1 mg, 2 mg 1 hyoscyamine sulfate oral drops 0.125 mg/ml 1 hyoscyamine sulfate oral elixir 0.125 mg/5 ml 1 hyoscyamine sulfate oral tablet 0.125 mg 1 hyoscyamine sulfate oral tablet extended release 1 12 hr 0.375 mg hyoscyamine sulfate oral tablet,disintegrating 1 0.125 mg hyoscyamine sulfate sublingual tablet 0.125 mg 1 hyosyne oral drops 0.125 mg/ml 1 hyosyne oral elixir 0.125 mg/5 ml 1 loperamide oral capsule 2 mg 1 methscopolamine oral tablet 2.5 mg, 5 mg 1

80 Drug Name Drug Tier Requirements / Limits MOTOFEN ORAL TABLET 1-0.025 MG 1 opium oral tincture 10 mg/ml (morphine) 1 oscimin oral tablet 0.125 mg 1 oscimin sl sublingual tablet 0.125 mg 1 oscimin sr oral tablet extended release 12 hr 0.375 1 mg phenobarb-hyoscy-atropine-scop oral elixir 16.2- 1 0.1037 -0.0194 mg/5 ml phenobarb-hyoscy-atropine-scop oral tablet 16.2- 1 0.1037 -0.0194 mg phenohytro oral elixir 16.2-0.1037 -0.0194 mg/5 1 ml phenohytro oral tablet 16.2-0.1037 -0.0194 mg 1 symax fastabs oral tablet,disintegrating 0.125 mg 1 symax-sl sublingual tablet 0.125 mg 1 symax-sr oral tablet extended release 12 hr 0.375 1 mg MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO (NETUPITANT) ORAL CAPSULE 1 QL (1 per 30 days) 300-0.5 MG alosetron oral tablet 0.5 mg, 1 mg 1 ALOXI INTRAVENOUS SOLUTION 0.25 MG/5 MB ML AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 1 PA anucort-hc rectal suppository 25 mg 1 aprepitant oral capsule 125 mg, 40 mg 1 QL (1 per 30 days) aprepitant oral capsule 80 mg 1 QL (2 per 30 days) aprepitant oral capsule,dose pack 125 mg (1)- 80 1 QL (1 per 30 days) mg (2) balsalazide oral capsule 750 mg 1 budesonide oral capsule,delayed,extend.release 3 1 mg calcium acetate(phosphat bind) oral capsule 667 1 mg calcium acetate(phosphat bind) oral tablet 667 mg 1 CHOLBAM ORAL CAPSULE 250 MG, 50 MG 1

81 Drug Name Drug Tier Requirements / Limits CIMZIA POWDER FOR RECONST 1 PA; ST; LA SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 1 PA; ST; LA MG/2 ML (200 MG/ML X 2) CLENPIQ ORAL SOLUTION 10 MG-3.5 GRAM ACA PV -12 GRAM/160 ML compro rectal suppository 25 mg 1 constulose oral solution 10 gram/15 ml 1 CORTIFOAM RECTAL FOAM 10 % (80 MG) 1 CREON ORAL CAPSULE,DELAYED 1 PA RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT cromolyn oral concentrate 100 mg/5 ml 1 DIPENTUM ORAL CAPSULE 250 MG 1 PA; ST doxylamine-pyridoxine (vit b6) oral tablet,delayed 1 release (dr/ec) 10-10 mg dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 EMEND ORAL SUSPENSION FOR 1 RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) ENTYVIO INTRAVENOUS RECON SOLN 300 MB PA; LA MG enulose oral solution 10 gram/15 ml 1 gavilyte-c oral recon soln 240-22.72-6.72 -5.84 ACA PV gram gavilyte-g oral recon soln 236-22.74-6.74 -5.86 ACA PV gram gavilyte-n oral recon soln 420 gram ACA PV generlac oral solution 10 gram/15 ml 1 granisetron hcl oral tablet 1 mg 1 QL (6 per 30 days) hemmorex-hc rectal suppository 25 mg 1 hydrocortisone acetate rectal suppository 25 mg, 1 30 mg hydrocortisone rectal 100 mg/60 ml 1 hydrocortisone topical cream with perineal 1 applicator 1 %, 2.5 %

82 Drug Name Drug Tier Requirements / Limits hydrocortisone-pramoxine rectal cream 1-1 %, 1 2.5-1 %, 2.5-1 % (4g) INFLECTRA INTRAVENOUS RECON SOLN MB PA; LA 100 MG lactulose oral packet 10 gram 1 lactulose oral solution 10 gram/15 ml, 20 gram/30 1 ml lanthanum oral tablet,chewable 1,000 mg, 500 mg, 1 750 mg lidocaine hcl-hydrocortison ac rectal cream 3-0.5 1 % LIDOCAINE HCL-HYDROCORTISON AC 1 RECTAL GEL 3 %-2.5 % (7 GRAM) lidocaine hcl-hydrocortison ac rectal kit 2 %-2 % 1 ST (7 gram) lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 1 PA; ST 3-1 % (7 gram) lidocaine-hydrocortisone-aloe rectal gel 2.8-0.55 1 % lidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 1 PA; ST gram) LINZESS ORAL CAPSULE 145 MCG, 290 1 PA MCG, 72 MCG meclizine oral tablet 12.5 mg, 25 mg 1 mesalamine oral capsule,extended release 24hr 1 0.375 gram mesalamine oral tablet,delayed release (dr/ec) 1.2 1 gram, 800 mg mesalamine rectal enema 4 gram/60 ml 1 mesalamine rectal suppository 1,000 mg 1 mesalamine with cleansing wipe rectal enema kit 4 1 ST gram/60 ml metoclopramide hcl injection solution 5 mg/ml MB metoclopramide hcl injection syringe 5 mg/ml MB metoclopramide hcl oral solution 5 mg/5 ml 1 metoclopramide hcl oral tablet 10 mg, 5 mg 1 metoclopramide hcl oral tablet,disintegrating 10 1 mg, 5 mg MOVANTIK ORAL TABLET 12.5 MG, 25 MG 1 PA; ST

83 Drug Name Drug Tier Requirements / Limits NULYTELY LEMON-LIME ORAL RECON ACA PV SOLN 420 GRAM ondansetron hcl intravenous solution 2 mg/ml MB ondansetron hcl oral solution 4 mg/5 ml 1 QL (100 per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg 1 QL (9 per 30 days) ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 QL (9 per 30 days) OSMOPREP ORAL TABLET 1.5 GRAM ACA PV peg 3350-electrolytes oral recon soln 236-22.74- ACA PV 6.74 -5.86 gram peg3350-sod sul-nacl-kcl-asb-c oral powder in ACA PV packet 100-7.5-2.691 gram peg-electrolyte soln oral recon soln 420 gram ACA PV peg-prep oral kit 5-210 mg-gram ACA PV PLENVU ORAL POWDER IN PACKET, ACA PV SEQUENTIAL 140-9-5.2 GRAM prochlorperazine edisylate injection solution 10 1 mg/2 ml (5 mg/ml), 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 procto-med hc topical cream with perineal 1 applicator 2.5 % procto-pak topical cream with perineal applicator 1 1 % proctosol hc topical cream with perineal 1 applicator 2.5 % proctozone-hc topical cream with perineal 1 applicator 2.5 % RECTIV RECTAL OINTMENT 0.4 % (W/W) 1 RELISTOR ORAL TABLET 150 MG 1 RELISTOR SUBCUTANEOUS SOLUTION 12 1 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 1 MG/0.6 ML, 8 MG/0.4 ML REMICADE INTRAVENOUS RECON SOLN MB PA; LA 100 MG RENFLEXIS INTRAVENOUS RECON SOLN MB PA; LA 100 MG scopolamine base transdermal patch 3 day 1 mg 1 over 3 days

84 Drug Name Drug Tier Requirements / Limits sevelamer carbonate oral powder in packet 0.8 1 gram, 2.4 gram sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1 sodium polystyrene sulfonate oral powder 1 sps (with sorbitol) oral suspension 15-20 gram/60 1 ml sps (with sorbitol) rectal enema 30-40 gram/120 1 ml SUCRAID ORAL SOLUTION 8,500 UNIT/ML 1 PA; ST; QL (2 per 30 days) sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet,delayed release (dr/ec) 1 500 mg SUPREP BOWEL PREP KIT ORAL RECON ACA PV ST SOLN 17.5-3.13-1.6 GRAM trilyte with flavor packets oral recon soln 420 ACA PV gram trimethobenzamide oral capsule 300 mg 1 ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 VARUBI ORAL TABLET 90 MG 1 VELPHORO ORAL TABLET,CHEWABLE 500 1 ST MG VIBERZI ORAL TABLET 100 MG, 75 MG 1 PA; ST ZENPEP ORAL CAPSULE,DELAYED 1 PA RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT ZENPEP ORAL CAPSULE,DELAYED 1 RELEASE(DR/EC) 25,000-79,000- 105,000 UNIT ULCER THERAPY amoxicil-clarithromy-lansopraz oral combo pack 1 500-500-30 mg cimetidine hcl oral solution 300 mg/5 ml 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 1 800 mg

85 Drug Name Drug Tier Requirements / Limits DEXILANT ORAL CAPSULE,BIPHASE 1 ST DELAYED RELEAS 30 MG, 60 MG esomeprazole magnesium oral capsule,delayed 1 release(dr/ec) 20 mg, 40 mg famotidine (pf) intravenous solution 20 mg/2 ml MB famotidine oral suspension 40 mg/5 ml (8 mg/ml) 1 famotidine oral tablet 20 mg, 40 mg 1 lansoprazole oral capsule,delayed release(dr/ec) 1 15 mg, 30 mg lansoprazole oral tablet,disintegrat, delay rel 15 1 mg, 30 mg misoprostol oral tablet 100 mcg, 200 mcg 1 nizatidine oral capsule 150 mg, 300 mg 1 nizatidine oral solution 150 mg/10 ml 1 omeprazole oral capsule,delayed release(dr/ec) 10 1 mg, 20 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 1 mg, 40 mg rabeprazole oral tablet,delayed release (dr/ec) 20 1 mg sucralfate oral suspension 100 mg/ml 1 sucralfate oral tablet 1 gram 1 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ARANESP (IN POLYSORBATE) INJECTION 1 LA SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION 1 LA SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML EPOGEN INJECTION SOLUTION 10,000 1 LA UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SOLUTION 300 1 MCG/ML, 480 MCG/1.6 ML

86 Drug Name Drug Tier Requirements / Limits GRANIX SUBCUTANEOUS SYRINGE 300 1 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG 1 PA; ST MIRCERA INJECTION SYRINGE 100 MCG/0.3 MB ML, 150 MCG/0.3 ML, 200 MCG/0.3 ML, 30 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 24 MB LA MG/1.2 ML (20 MG/ML) NEUPOGEN INJECTION SOLUTION 300 1 PA; ST MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 1 PA; ST MCG/0.5 ML, 480 MCG/0.8 ML NIVESTYM INJECTION SOLUTION 300 1 MCG/ML, 480 MCG/1.6 ML NIVESTYM SUBCUTANEOUS SYRINGE 300 1 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 1 LA UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML UDENYCA SUBCUTANEOUS SYRINGE 6 1 PA; ST MG/0.6 ML ZARXIO INJECTION SYRINGE 300 MCG/0.5 1 PA; ST ML, 480 MCG/0.8 ML ZIEXTENZO SUBCUTANEOUS SYRINGE 6 1 PA; ST MG/0.6 ML GROWTH HORMONES GENOTROPIN MINIQUICK SUBCUTANEOUS 1 PA; ST; LA SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS 1 PA; ST; LA CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) OMNITROPE SUBCUTANEOUS CARTRIDGE 1 PA; ST; LA 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON 1 PA; ST; LA SOLN 5.8 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 1 PA; ST; LA MG, 5 MG, 6 MG

87 Drug Name Drug Tier Requirements / Limits ZORBTIVE SUBCUTANEOUS RECON SOLN 1 PA; ST; LA 8.8 MG INTERFERONS AUBAGIO ORAL TABLET 14 MG, 7 MG 1 PA; LA AVONEX INTRAMUSCULAR PEN INJECTOR 1 PA; ST; LA; QL (4 per 30 days) KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 1 PA; ST; LA; QL (4 per 30 days) 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG 1 PA; LA; QL (14 per 30 days) dimethyl fumarate oral capsule,delayed 1 PA; LA; QL (14 per 365 days) release(dr/ec) 120 mg dimethyl fumarate oral capsule,delayed 1 PA; LA; QL (1 per 365 days) release(dr/ec) 120 mg (14)- 240 mg (46) dimethyl fumarate oral capsule,delayed 1 PA; LA; QL (60 per 30 days) release(dr/ec) 240 mg GILENYA ORAL CAPSULE 0.5 MG 1 PA; LA; QL (30 per 30 days) glatiramer subcutaneous syringe 20 mg/ml 1 PA; LA; QL (30 per 30 days) glatiramer subcutaneous syringe 40 mg/ml 1 PA; LA; QL (12 per 30 days) glatopa subcutaneous syringe 20 mg/ml 1 PA; LA; QL (30 per 30 days) glatopa subcutaneous syringe 40 mg/ml 1 PA; LA; QL (12 per 30 days) LEMTRADA INTRAVENOUS SOLUTION 12 MB PA; ST; LA MG/1.2 ML MAVENCLAD (10 TABLET PACK) ORAL 1 LA TABLET 10 MG MAVENCLAD (4 TABLET PACK) ORAL 1 PA; ST; LA; QL (1 per 30 days) TABLET 10 MG MAVENCLAD (5 TABLET PACK) ORAL 1 PA; ST; LA; QL (1 per 30 days) TABLET 10 MG MAVENCLAD (6 TABLET PACK) ORAL 1 PA; ST; LA; QL (1 per 30 days) TABLET 10 MG MAVENCLAD (7 TABLET PACK) ORAL 1 PA; ST; LA; QL (1 per 30 days) TABLET 10 MG MAVENCLAD (8 TABLET PACK) ORAL 1 PA; ST; LA; QL (1 per 30 days) TABLET 10 MG MAVENCLAD (9 TABLET PACK) ORAL 1 PA; ST; LA; QL (1 per 30 days) TABLET 10 MG MAYZENT ORAL TABLET 0.25 MG, 2 MG 1 PA; ST; LA; QL (30 per 30 days) MAYZENT STARTER PACK ORAL 1 PA; ST; LA; QL (1 per 365 days) TABLETS,DOSE PACK 0.25 MG (12 TABS)

88 Drug Name Drug Tier Requirements / Limits OCREVUS INTRAVENOUS SOLUTION 30 MB PA; LA MG/ML PEGASYS SUBCUTANEOUS SOLUTION 180 1 PA; LA MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 1 PA; LA MCG/0.5 ML PLEGRIDY INTRAMUSCULAR SYRINGE 125 1 PA; LA; QL (1 per 30 days) MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 1 PA; LA; QL (1 per 30 days) 125 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 1 PA; LA; QL (1 per 365 days) 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 1 PA; LA; QL (1 per 30 days) MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 1 PA; LA; QL (1 per 365 days) MCG/0.5 ML- 94 MCG/0.5 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 1 PA; ST; OCh; LA MG, 4 MG PONVORY 14-DAY STARTER PACK ORAL 1 PA; LA; QL (1 per 365 days) TABLETS,DOSE PACK 2 MG (2) - 10 MG (3) PONVORY ORAL TABLET 20 MG 1 PA; LA; QL (30 per 30 days) REBIF (WITH ALBUMIN) SUBCUTANEOUS 1 PA; LA; QL (6 per 30 days) SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN 1 PA; LA; QL (6 per 30 days) INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN 1 PA; LA; QL (5 per 30 days) INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS 1 PA; LA; QL (5 per 30 days) SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 1 PA; ST; OCh; LA 2.5 MG, 20 MG, 25 MG, 5 MG ribavirin oral capsule 200 mg 1 LA ribavirin oral tablet 200 mg 1 LA ZEPOSIA ORAL CAPSULE 0.92 MG 1 LA; QL (30 per 30 days) ZEPOSIA STARTER KIT ORAL 1 LA; QL (30 per 30 days) CAPSULE,DOSE PACK 0.23-0.46-0.92 MG ZEPOSIA STARTER PACK ORAL 1 LA; QL (30 per 30 days) CAPSULE,DOSE PACK 0.23 MG (4)- 0.46 MG (3) INTERLEUKINS

89 Drug Name Drug Tier Requirements / Limits ACTIMMUNE SUBCUTANEOUS SOLUTION 1 PA; LA 100 MCG/0.5 ML ARCALYST SUBCUTANEOUS RECON SOLN 1 LA 220 MG ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MB PA; LA MG/ML imiquimod topical cream in packet 5 % 1 INTRON A INJECTION RECON SOLN 10 1 PA; LA MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 1 PA; LA MILLION UNIT/ML, 6 MILLION UNIT/ML PROLEUKIN INTRAVENOUS RECON SOLN MB LA 22 MILLION UNIT VACCINES & MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) INTRAMUSCULAR RECON 1 Vac SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) 1 Vac INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5- 3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) 1 Vac INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML AFLURIA QD 2021-22(3YR UP)(PF) 1 Vac INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML AFLURIA QD 2021-22(6-35MO)(PF) 1 Vac INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML AFLURIA QUAD 2021-2022(6MO UP) 1 Vac INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML ASCENIV INTRAVENOUS SOLUTION 10 % MB PA; LA ATGAM INTRAVENOUS SOLUTION 50 MB MG/ML BCG VACCINE, LIVE (PF) PERCUTANEOUS 1 Vac SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE 50- 1 Vac 50-50-25 MCG/0.5 ML BIOTHRAX INTRAMUSCULAR SUSPENSION 1 Vac 0.5 ML/DOSE

90 Drug Name Drug Tier Requirements / Limits BIVIGAM INTRAVENOUS SOLUTION 10 % MB PA; LA BOOSTRIX TDAP INTRAMUSCULAR 1 Vac SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR 1 Vac SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML BOTOX INJECTION RECON SOLN 100 UNIT, MB 200 UNIT CUTAQUIG SUBCUTANEOUS SOLUTION MB LA 16.5 % CUVITRU SUBCUTANEOUS SOLUTION 1 MB LA GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %) DAPTACEL (DTAP PEDIATRIC) (PF) 1 Vac INTRAMUSCULAR SUSPENSION 15-10-5 LF- MCG-LF/0.5ML DYSPORT INTRAMUSCULAR RECON SOLN MB LA 300 UNIT, 500 UNIT ENGERIX-B (PF) INTRAMUSCULAR 1 Vac SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR 1 Vac SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) 1 Vac INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML FLEBOGAMMA DIF INTRAVENOUS MB PA SOLUTION 10 %, 5 % FLUAD QUAD 2021-22(65Y UP)(PF) 1 Vac INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUARIX QUAD 2021-2022 (PF) 1 Vac INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUBLOK QUAD 2021-2022 (PF) 1 Vac INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML FLUCELVAX QUAD 2021-2022 (PF) 1 Vac INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUCELVAX QUAD 2021-2022 1 Vac INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

91 Drug Name Drug Tier Requirements / Limits FLULAVAL QUAD 2021-2022 (PF) 1 Vac INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUZONE HIGHDOSE QUAD 21-22 PF 1 Vac INTRAMUSCULAR SYRINGE 240 MCG/0.7 ML FLUZONE QUAD 2021-2022 (PF) 1 Vac INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML FLUZONE QUAD 2021-2022 (PF) 1 Vac INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML FLUZONE QUAD 2021-2022 1 Vac INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML GAMASTAN INTRAMUSCULAR SOLUTION MB 15-18 % RANGE GAMASTAN S/D INTRAMUSCULAR MB SOLUTION 15-18 % RANGE GAMMAGARD LIQUID INJECTION MB LA SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) MB PA; LA INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAKED INJECTION SOLUTION 1 MB LA GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) GAMMAPLEX (WITH SORBITOL) MB PA; LA INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 10 MB PA; LA % GAMUNEX-C INJECTION SOLUTION 1 MB LA GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %) GARDASIL 9 (PF) INTRAMUSCULAR 1 Vac SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR 1 Vac SYRINGE 0.5 ML GRASTEK SUBLINGUAL TABLET 2,800 BAU 1 PA

92 Drug Name Drug Tier Requirements / Limits HAVRIX (PF) INTRAMUSCULAR 1 Vac SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1 Vac 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HEPLISAV-B (PF) INTRAMUSCULAR 1 Vac SYRINGE 20 MCG/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON 1 Vac SOLN 10 MCG/0.5 ML HIZENTRA SUBCUTANEOUS SOLUTION 1 MB LA GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) HYQVIA SUBCUTANEOUS SOLUTION 10 MB LA GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) IMOVAX RABIES VACCINE (PF) 1 Vac INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR 1 Vac SYRINGE 25-58-10 LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION 40-8-32 1 Vac UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 1 Vac MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 1 Vac LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR 1 Vac SOLUTION 4 MCG/0.5 ML MENQUADFI (PF) INTRAMUSCULAR 1 Vac SOLUTION 10 MCG/0.5 ML MENVEO A-C-Y-W-135-DIP (PF) 1 Vac INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON 1 Vac SOLN 1,000-12,500 TCID50/0.5 ML MYOBLOC INTRAMUSCULAR SOLUTION MB LA 10,000 UNIT/2 ML, 2,500 UNIT/0.5 ML, 5,000 UNIT/ML OCTAGAM INTRAVENOUS SOLUTION 10 %, MB PA; LA 5 % ORALAIR SUBLINGUAL TABLET 300 INDX 1 PA REACTIVITY PANZYGA INTRAVENOUS SOLUTION 10 % MB PA

93 Drug Name Drug Tier Requirements / Limits PEDIARIX (PF) INTRAMUSCULAR SYRINGE 1 Vac 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR 1 Vac SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 1 Vac LF UNIT-20 MCG-5 LF/0.5 ML, 15LF-48MCG- 62DU -10 MCG/0.5ML PENTACEL ACTHIB COMPONENT (PF) 1 Vac INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML PNEUMOVAX-23 INJECTION SOLUTION 25 1 Vac MCG/0.5 ML PNEUMOVAX-23 INJECTION SYRINGE 25 1 Vac MCG/0.5 ML PREVNAR 13 (PF) INTRAMUSCULAR 1 Vac SYRINGE 0.5 ML PRIVIGEN INTRAVENOUS SOLUTION 10 % MB PA; LA PROQUAD (PF) SUBCUTANEOUS 1 Vac SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5 PROVENGE INTRAVENOUS SUSPENSION 50 MB PA MILLION CELL/250 ML QUADRACEL (PF) INTRAMUSCULAR 1 Vac SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR 1 Vac SUSPENSION FOR RECONSTITUTION 2.5 UNIT RAGWITEK SUBLINGUAL TABLET 12 AMB 1 PA A 1 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR 1 Vac SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR 1 Vac SYRINGE 10 MCG/ML, 5 MCG/0.5 ML SHINGRIX (PF) INTRAMUSCULAR 1 Vac SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML STAMARIL (PF) SUBCUTANEOUS 1 Vac SUSPENSION FOR RECONSTITUTION 1,000 UNIT/0.5 ML

94 Drug Name Drug Tier Requirements / Limits TDVAX INTRAMUSCULAR SUSPENSION 2-2 1 Vac LF UNIT/0.5 ML TENIVAC (PF) INTRAMUSCULAR 1 Vac SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 1 Vac 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) 1 Vac INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML THYMOGLOBULIN INTRAVENOUS RECON MB SOLN 25 MG TRUMENBA INTRAMUSCULAR SYRINGE 1 Vac 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 1 Vac 720 ELISA UNIT- 20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 1 Vac MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 1 Vac MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR 1 Vac SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 1 Vac UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS 1 Vac SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML VAXELIS (PF) INTRAMUSCULAR 1 Vac SUSPENSION 15 UNIT-5 UNIT- 10 MCG/0.5 ML VAXELIS (PF) INTRAMUSCULAR SYRINGE 1 Vac 15 UNIT-5 UNIT- 10 MCG/0.5 ML XEMBIFY SUBCUTANEOUS SOLUTION 1 MB LA GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) XEOMIN INTRAMUSCULAR RECON SOLN MB LA 100 UNIT, 200 UNIT, 50 UNIT YF-VAX (PF) SUBCUTANEOUS SUSPENSION 1 Vac FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS 1 Vac SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

95 Drug Name Drug Tier Requirements / Limits MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY allopurinol oral tablet 100 mg, 300 mg 1 COLCHICINE ORAL CAPSULE 0.6 MG 1 colchicine oral tablet 0.6 mg 1 febuxostat oral tablet 40 mg, 80 mg 1 KRYSTEXXA INTRAVENOUS SOLUTION 8 MB PA; LA MG/ML MITIGARE ORAL CAPSULE 0.6 MG 1 probenecid oral tablet 500 mg 1 probenecid-colchicine oral tablet 500-0.5 mg 1 OSTEOPOROSIS THERAPY alendronate oral solution 70 mg/75 ml 1 alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg 1 EVENITY SUBCUTANEOUS SYRINGE 105 1 PA; ST; LA MG/1.17 ML, 210MG/2.34ML ( 105MG/1.17MLX2) FORTEO SUBCUTANEOUS PEN INJECTOR 20 1 PA; ST; LA; QL (1 per 30 days) MCG/DOSE (620MCG/2.48ML) FOSAMAX PLUS D ORAL TABLET 70 MG- 1 2,800 UNIT, 70 MG- 5,600 UNIT ibandronate oral tablet 150 mg 1 PROLIA SUBCUTANEOUS SYRINGE 60 1 ST; LA MG/ML raloxifene oral tablet 60 mg 1 OCh risedronate oral tablet 150 mg, 35 mg, 5 mg 1 risedronate oral tablet,delayed release (dr/ec) 35 1 mg TYMLOS SUBCUTANEOUS PEN INJECTOR 1 PA; ST; LA 80 MCG (3,120 MCG/1.56 ML) OTHER RHEUMATOLOGICALS ACTEMRA ACTPEN SUBCUTANEOUS PEN 1 PA; ST; LA INJECTOR 162 MG/0.9 ML ACTEMRA INTRAVENOUS SOLUTION 200 MB PA; LA MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 1 PA; ST; LA MG/0.9 ML

96 Drug Name Drug Tier Requirements / Limits BENLYSTA INTRAVENOUS RECON SOLN MB PA; LA 120 MG, 400 MG BENLYSTA SUBCUTANEOUS AUTO- 1 PA; LA INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 200 1 PA; LA MG/ML ENBREL MINI SUBCUTANEOUS 1 PA; ST; LA CARTRIDGE 50 MG/ML (1 ML) ENBREL SUBCUTANEOUS RECON SOLN 25 1 PA; ST; LA MG (1 ML) ENBREL SUBCUTANEOUS SOLUTION 25 1 PA; ST; LA MG/0.5 ML ENBREL SUBCUTANEOUS SYRINGE 25 1 PA; ST; LA MG/0.5 ML (0.5), 50 MG/ML (1 ML) ENBREL SURECLICK SUBCUTANEOUS PEN 1 PA; ST; LA INJECTOR 50 MG/ML (1 ML) HUMIRA PEN CROHNS-UC-HS START 1 PA; ST; LA SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSOR-UVEITS-ADOL HS 1 PA; ST; LA SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN 1 PA; ST; LA INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 1 PA; ST; LA MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER 1 PA; ST; LA SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN CROHNS-UC-HS 1 PA; ST; LA SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PEDIATRIC UC 1 PA; ST; LA SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PSOR-UV-ADOL HS 1 PA; ST; LA SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN SUBCUTANEOUS PEN 1 PA; ST; LA INJECTOR KIT 40 MG/0.4 ML

97 Drug Name Drug Tier Requirements / Limits HUMIRA(CF) SUBCUTANEOUS SYRINGE 1 PA; ST; LA KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML KEVZARA SUBCUTANEOUS PEN INJECTOR 1 PA; ST; LA 150 MG/1.14 ML, 200 MG/1.14 ML KEVZARA SUBCUTANEOUS SYRINGE 150 1 PA; ST; LA MG/1.14 ML, 200 MG/1.14 ML leflunomide oral tablet 10 mg, 20 mg 1 OLUMIANT ORAL TABLET 1 MG, 2 MG 1 PA; ST; LA ORENCIA (WITH MALTOSE) INTRAVENOUS MB PA; LA RECON SOLN 250 MG ORENCIA CLICKJECT SUBCUTANEOUS 1 PA; ST; LA AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 1 PA; ST; LA MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG 1 PA; ST; LA OTEZLA STARTER ORAL TABLETS,DOSE 1 PA; ST; LA PACK 10 MG (4)-20 MG (4)-30 MG (47) penicillamine oral capsule 250 mg 1 PA penicillamine oral tablet 250 mg 1 PA RIDAURA ORAL CAPSULE 3 MG 1 RINVOQ ORAL TABLET EXTENDED 1 PA; ST; LA RELEASE 24 HR 15 MG SAVELLA ORAL TABLET 100 MG, 12.5 MG, 1 PA; ST 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 1 PA; ST MG (5)-25 MG(8)-50 MG(42) SIMPONI ARIA INTRAVENOUS SOLUTION MB PA; LA 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 1 PA; ST; LA 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 1 PA; ST; LA MG/ML, 50 MG/0.5 ML XELJANZ ORAL SOLUTION 1 MG/ML 1 PA; ST; LA XELJANZ ORAL TABLET 10 MG, 5 MG 1 PA; ST; LA XELJANZ XR ORAL TABLET EXTENDED 1 PA; ST; LA RELEASE 24 HR 11 MG, 22 MG OBSTETRICS & GYNECOLOGY DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES

98 Drug Name Drug Tier Requirements / Limits CAYA CONTOURED VAGINAL DIAPHRAGM ACA PV 65-80 MM FC2 FEMALE CONDOM ACA PV FEMCAP VAGINAL DEVICE 22 MM ACA PV KYLEENA INTRAUTERINE INTRAUTERINE ACA PV DEVICE 17.5 MCG/24 HRS (5 YRS) 19.5 MG LILETTA INTRAUTERINE INTRAUTERINE ACA PV ST DEVICE 20.1 MCG/24 HRS (6 YRS) 52 MG MIRENA INTRAUTERINE INTRAUTERINE ACA PV DEVICE 20 MCG/24 HOURS (6 YRS) 52 MG PARAGARD T 380A INTRAUTERINE ACA PV 380 SQUARE MM SKYLA INTRAUTERINE INTRAUTERINE ACA PV DEVICE 14 MCG/24 HRS (3 YRS) 13.5 MG WIDE-SEAL DIAPHRAGM 60 VAGINAL ACA PV DIAPHRAGM 60 MM ESTROGENS & PROGESTINS amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 1 MG camila oral tablet 0.35 mg ACA PV COMBIPATCH TRANSDERMAL PATCH 1 SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR covaryx h.s. oral tablet 0.625-1.25 mg 1 covaryx oral tablet 1.25-2.5 mg 1 CRINONE VAGINAL GEL 4 % 1 deblitane oral tablet 0.35 mg ACA PV DEPO- INTRAMUSCULAR OIL 5 1 MG/ML DEPO-PROVERA INTRAMUSCULAR MB SUSPENSION 150 MG/ML DEPO-PROVERA INTRAMUSCULAR MB SYRINGE 150 MG/ML DEPO-SUBQ PROVERA 104 ACA PV SUBCUTANEOUS SYRINGE 104 MG/0.65 ML

99 Drug Name Drug Tier Requirements / Limits DIVIGEL TRANSDERMAL GEL IN PACKET 1 QL (30 per 30 days) 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %), 0.75 MG/0.75 GRAM (0.1%), 1 MG/GRAM (0.1 %), 1.25 MG/1.25 GRAM (0.1 %) dotti transdermal patch semiweekly 0.025 mg/24 1 QL (8 per 30 days) hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr DUAVEE ORAL TABLET 0.45-20 MG 1 eemt hs oral tablet 0.625-1.25 mg 1 eemt oral tablet 1.25-2.5 mg 1 errin oral tablet 0.35 mg ACA PV estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch semiweekly 0.025 1 QL (8 per 30 days) mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly 0.025 mg/24 1 QL (4 per 30 days) hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol vaginal cream 0.01 % (0.1 mg/gram) 1 estradiol vaginal tablet 10 mcg 1 estradiol valerate intramuscular oil 20 mg/ml, 40 1 mg/ml estradiol-norethindrone acet oral tablet 0.5-0.1 1 mg, 1-0.5 mg ESTRING VAGINAL RING 2 MG (7.5 MCG /24 1 HOUR) estrogens-methyltestosterone oral tablet 0.625- 1 1.25 mg, 1.25-2.5 mg EVAMIST TRANSDERMAL SPRAY,NON- 1 QL (2 per 30 days) AEROSOL 1.53 MG/SPRAY (1.7%) FEMRING VAGINAL RING 0.05 MG/24 HR, 1 0.1 MG/24 HR fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 1 heather oral tablet 0.35 mg ACA PV hydroxyprogest(pf)(preg presv) intramuscular oil 1 250 mg/ml (1 ml) hydroxyprogesterone cap(ppres) intramuscular oil 1 250 mg/ml

100 Drug Name Drug Tier Requirements / Limits hydroxyprogesterone caproate intramuscular oil 1 250 mg/ml incassia oral tablet 0.35 mg ACA PV jencycla oral tablet 0.35 mg ACA PV jinteli oral tablet 1-5 mg-mcg 1 lyleq oral tablet 0.35 mg ACA PV lyllana transdermal patch semiweekly 0.025 mg/24 1 QL (8 per 30 days) hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr lyza oral tablet 0.35 mg ACA PV medroxyprogesterone intramuscular suspension ACA PV 150 mg/ml medroxyprogesterone intramuscular syringe 150 ACA PV mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 1 mg MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1 1.25 MG, 2.5 MG MENOSTAR TRANSDERMAL PATCH 1 QL (4 per 30 days) WEEKLY 14 MCG/24 HR mimvey oral tablet 1-0.5 mg 1 nora-be oral tablet 0.35 mg ACA PV norethindrone (contraceptive) oral tablet 0.35 mg ACA PV norethindrone acetate oral tablet 5 mg 1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 1 mg-mcg, 1-5 mg-mcg norlyda oral tablet 0.35 mg ACA PV PREMARIN INJECTION RECON SOLN 25 MG 1 PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 1 0.625 MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM 0.625 1 MG/GRAM PREMPHASE ORAL TABLET 0.625 MG (14)/ 1 0.625MG-5MG(14) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 1 MG, 0.625-2.5 MG, 0.625-5 MG progesterone intramuscular oil 50 mg/ml 1 progesterone micronized oral capsule 100 mg, 200 1 mg

101 Drug Name Drug Tier Requirements / Limits sharobel oral tablet 0.35 mg ACA PV tulana oral tablet 0.35 mg ACA PV yuvafem vaginal tablet 10 mcg 1 MISCELLANEOUS OB/GYN ANNOVERA VAGINAL RING 0.15-0.013 ACA PV MG/24 HOUR clindamycin phosphate vaginal cream 2 % 1 eluryng vaginal ring 0.12-0.015 mg/24 hr ACA PV etonogestrel-ethinyl estradiol vaginal ring 0.12- ACA PV 0.015 mg/24 hr fem ph vaginal gel 0.9-0.025 % 1 GYNAZOLE-1 VAGINAL CREAM 2 % 1 gynol ii vaginal gel 3 % ACA PV INTRAROSA VAGINAL INSERT 6.5 MG 1 isoxsuprine oral tablet 10 mg, 20 mg 1 LUPANETA PACK (1 MONTH) KIT. SYRINGE 1 PA; LA AND TABLET 3.75 MG -5 MG (30) LUPANETA PACK (3 MONTH) KIT. SYRINGE 1 PA; LA AND TABLET 11.25 MG -5 MG (90) metronidazole vaginal gel 0.75 % 1 NEXPLANON SUBDERMAL IMPLANT 68 MG ACA PV OSPHENA ORAL TABLET 60 MG 1 PHEXXI VAGINAL GEL 1.8-1-0.4 % ACA PV terconazole vaginal cream 0.4 %, 0.8 % 1 terconazole vaginal suppository 80 mg 1 TODAY CONTRACEPTIVE SPONGE ACA PV VAGINAL CONTRACEPTIVE SPONGE 1,000 MG tranexamic acid oral tablet 650 mg 1 TWIRLA TRANSDERMAL PATCH WEEKLY ACA PV 120-30 MCG/24 HR vandazole vaginal gel 0.75 % 1 VCF CONTRACEPTIVE FILM VAGINAL FILM ACA PV 28 % VCF CONTRACEPTIVE GEL VAGINAL GEL 4 ACA PV % xulane transdermal patch weekly 150-35 mcg/24 ACA PV hr

102 Drug Name Drug Tier Requirements / Limits zafemy transdermal patch weekly 150-35 mcg/24 ACA PV hr ORAL CONTRACEPTIVES & RELATED AGENTS afirmelle oral tablet 0.1-20 mg-mcg ACA PV altavera (28) oral tablet 0.15-0.03 mg ACA PV alyacen 1/35 (28) oral tablet 1-35 mg-mcg ACA PV alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 ACA PV mcg amethia oral tablets,dose pack,3 month 0.15 mg- ACA PV 30 mcg (84)/10 mcg (7) amethyst (28) oral tablet 90-20 mcg (28) ACA PV apri oral tablet 0.15-0.03 mg ACA PV aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg ACA PV ashlyna oral tablets,dose pack,3 month 0.15 mg-30 ACA PV mcg (84)/10 mcg (7) aubra eq oral tablet 0.1-20 mg-mcg ACA PV aubra oral tablet 0.1-20 mg-mcg ACA PV aurovela 1.5/30 (21) oral tablet 1.5-30 mg-mcg ACA PV aurovela 1/20 (21) oral tablet 1-20 mg-mcg ACA PV aurovela 24 fe oral tablet 1 mg-20 mcg (24)/75 mg ACA PV (4) aurovela fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg ACA PV (21)/75 mg (7) aurovela fe 1-20 (28) oral tablet 1 mg-20 mcg ACA PV (21)/75 mg (7) aviane oral tablet 0.1-20 mg-mcg ACA PV ayuna oral tablet 0.15-0.03 mg ACA PV azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 mg ACA PV x 5 BALCOLTRA ORAL TABLET 0.1 MG-0.02 MG ACA PV (21)/36.5 MG(7) balziva (28) oral tablet 0.4-35 mg-mcg ACA PV blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg ACA PV (4) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg ACA PV (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg ACA PV (21)/75 mg (7)

103 Drug Name Drug Tier Requirements / Limits briellyn oral tablet 0.4-35 mg-mcg ACA PV camrese lo oral tablets,dose pack,3 month 0.10 ACA PV mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg- ACA PV 30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg ACA PV charlotte 24 fe oral tablet,chewable 1 mg-20 ACA PV mcg(24) /75 mg (4) chateal (28) oral tablet 0.15-0.03 mg ACA PV chateal eq (28) oral tablet 0.15-0.03 mg ACA PV cryselle (28) oral tablet 0.3-30 mg-mcg ACA PV cyclafem 1/35 (28) oral tablet 1-35 mg-mcg ACA PV cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 ACA PV mcg cyred eq oral tablet 0.15-0.03 mg ACA PV cyred oral tablet 0.15-0.03 mg ACA PV dasetta 1/35 (28) oral tablet 1-35 mg-mcg ACA PV dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 ACA PV mcg daysee oral tablets,dose pack,3 month 0.15 mg-30 ACA PV mcg (84)/10 mcg (7) desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 ACA PV mgx21 /0.01 mg x 5 desogestrel-ethinyl estradiol oral tablet 0.15-0.03 ACA PV mg dolishale oral tablet 90-20 mcg (28) ACA PV drospirenone-e.estradiol-lm.fa oral tablet 3-0.02- ACA PV 0.451 mg (24) (4), 3-0.03-0.451 mg (21) (7) drospirenone-ethinyl estradiol oral tablet 3-0.02 ACA PV mg, 3-0.03 mg econtra ez oral tablet 1.5 mg ACA PV econtra one-step oral tablet 1.5 mg ACA PV elinest oral tablet 0.3-30 mg-mcg ACA PV ELLA ORAL TABLET 30 MG ACA PV emoquette oral tablet 0.15-0.03 mg ACA PV enpresse oral tablet 50-30 (6)/75-40 (5)/125- ACA PV 30(10) enskyce oral tablet 0.15-0.03 mg ACA PV

104 Drug Name Drug Tier Requirements / Limits estarylla oral tablet 0.25-35 mg-mcg ACA PV ethynodiol diac-eth estradiol oral tablet 1-35 mg- ACA PV mcg, 1-50 mg-mcg falmina (28) oral tablet 0.1-20 mg-mcg ACA PV fayosim oral tablets,dose pack,3 month 0.15 mg-20 ACA PV mcg/ 0.15 mg-25 mcg femynor oral tablet 0.25-35 mg-mcg ACA PV gemmily oral capsule 1 mg-20 mcg (24)/75 mg (4) ACA PV hailey 24 fe oral tablet 1 mg-20 mcg (24)/75 mg ACA PV (4) hailey fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg ACA PV (21)/75 mg (7) hailey fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 ACA PV mg (7) hailey oral tablet 1.5-30 mg-mcg ACA PV iclevia oral tablets,dose pack,3 month 0.15 mg-30 ACA PV mcg (91) isibloom oral tablet 0.15-0.03 mg ACA PV jaimiess oral tablets,dose pack,3 month 0.15 mg- ACA PV 30 mcg (84)/10 mcg (7) jasmiel (28) oral tablet 3-0.02 mg ACA PV jolessa oral tablets,dose pack,3 month 0.15 mg-30 ACA PV mcg (91) juleber oral tablet 0.15-0.03 mg ACA PV junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg ACA PV junel 1/20 (21) oral tablet 1-20 mg-mcg ACA PV junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg ACA PV (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 ACA PV mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) ACA PV kaitlib fe oral tablet,chewable 0.8mg-25mcg(24) ACA PV and 75 mg (4) kalliga oral tablet 0.15-0.03 mg ACA PV kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x ACA PV 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg ACA PV kelnor 1-50 (28) oral tablet 1-50 mg-mcg ACA PV

105 Drug Name Drug Tier Requirements / Limits kurvelo (28) oral tablet 0.15-0.03 mg ACA PV l norgest/e.estradiol-e.estrad oral tablets,dose ACA PV pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-20 mcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg ACA PV larin 1/20 (21) oral tablet 1-20 mg-mcg ACA PV larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) ACA PV larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg ACA PV (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 ACA PV mg (7) larissia oral tablet 0.1-20 mg-mcg ACA PV layolis fe oral tablet,chewable 0.8mg-25mcg(24) ACA PV and 75 mg (4) leena 28 oral tablet 0.5/1/0.5-35 mg-mcg ACA PV lessina oral tablet 0.1-20 mg-mcg ACA PV levonest (28) oral tablet 50-30 (6)/75-40 (5)/125- ACA PV 30(10) levonorgestrel oral tablet 1.5 mg ACA PV levonorgestrel-ethinyl estrad oral tablet 0.1-20 ACA PV mg-mcg, 0.15-0.03 mg, 90-20 mcg (28) levonorgestrel-ethinyl estrad oral tablets,dose ACA PV pack,3 month 0.15 mg-30 mcg (91) levonorg-eth estrad triphasic oral tablet 50-30 ACA PV (6)/75-40 (5)/125-30(10) levora-28 oral tablet 0.15-0.03 mg ACA PV lillow (28) oral tablet 0.15-0.03 mg ACA PV LO LOESTRIN FE ORAL TABLET 1 MG-10 ACA PV MCG (24)/10 MCG (2) lojaimiess oral tablets,dose pack,3 month 0.10 mg- ACA PV 20 mcg (84)/10 mcg (7) loryna (28) oral tablet 3-0.02 mg ACA PV low-ogestrel (28) oral tablet 0.3-30 mg-mcg ACA PV lo-zumandimine (28) oral tablet 3-0.02 mg ACA PV lutera (28) oral tablet 0.1-20 mg-mcg ACA PV marlissa (28) oral tablet 0.15-0.03 mg ACA PV merzee oral capsule 1 mg-20 mcg (24)/75 mg (4) ACA PV

106 Drug Name Drug Tier Requirements / Limits mibelas 24 fe oral tablet,chewable 1 mg-20 ACA PV mcg(24) /75 mg (4) microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg ACA PV microgestin 1/20 (21) oral tablet 1-20 mg-mcg ACA PV microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 ACA PV mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg ACA PV (21)/75 mg (7) mili oral tablet 0.25-35 mg-mcg ACA PV mono-linyah oral tablet 0.25-35 mg-mcg ACA PV my choice oral tablet 1.5 mg ACA PV my way oral tablet 1.5 mg ACA PV NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 ACA PV MG-3 MG/1 MG necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg ACA PV new day oral tablet 1.5 mg ACA PV NEXTSTELLIS ORAL TABLET 3 MG- 14.2 MG ACA PV (28) nikki (28) oral tablet 3-0.02 mg ACA PV noreth-ethinyl estradiol-iron oral tablet,chewable ACA PV 0.4mg-35mcg(21) and 75 mg (7), 0.8mg- 25mcg(24) and 75 mg (4) norethindrone ac-eth estradiol oral tablet 1-20 ACA PV mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron oral capsule 1 mg- ACA PV 20 mcg (24)/75 mg (4) norethindrone-e.estradiol-iron oral tablet 1 mg-20 ACA PV mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-e.estradiol-iron oral ACA PV tablet,chewable 1 mg-20 mcg(24) /75 mg (4) norgestimate-ethinyl estradiol oral tablet ACA PV 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg- 35 mcg (28), 0.25-35 mg-mcg nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg ACA PV nortrel 1/35 (21) oral tablet 1-35 mg-mcg (21) ACA PV nortrel 1/35 (28) oral tablet 1-35 mg-mcg ACA PV nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 ACA PV mcg nylia 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg ACA PV

107 Drug Name Drug Tier Requirements / Limits nymyo oral tablet 0.25-35 mg-mcg ACA PV ocella oral tablet 3-0.03 mg ACA PV opcicon one-step oral tablet 1.5 mg ACA PV option-2 oral tablet 1.5 mg ACA PV orsythia oral tablet 0.1-20 mg-mcg ACA PV philith oral tablet 0.4-35 mg-mcg ACA PV pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg ACA PV x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 ACA PV mg-mcg portia 28 oral tablet 0.15-0.03 mg ACA PV previfem oral tablet 0.25-35 mg-mcg ACA PV reclipsen (28) oral tablet 0.15-0.03 mg ACA PV rivelsa oral tablets,dose pack,3 month 0.15 mg-20 ACA PV mcg/ 0.15 mg-25 mcg setlakin oral tablets,dose pack,3 month 0.15 mg-30 ACA PV mcg (91) simliya (28) oral tablet 0.15-0.02 mgx21 /0.01 mg ACA PV x 5 simpesse oral tablets,dose pack,3 month 0.15 mg- ACA PV 30 mcg (84)/10 mcg (7) SLYND ORAL TABLET 4 MG (28) ACA PV sprintec (28) oral tablet 0.25-35 mg-mcg ACA PV sronyx oral tablet 0.1-20 mg-mcg ACA PV syeda oral tablet 3-0.03 mg ACA PV tarina 24 fe oral tablet 1 mg-20 mcg (24)/75 mg ACA PV (4) tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 ACA PV mg (7) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) ACA PV tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg ACA PV (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg ACA PV (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg- ACA PV 35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg ACA PV (28)

108 Drug Name Drug Tier Requirements / Limits tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 ACA PV mcg tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 ACA PV mcg tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg ACA PV tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 ACA PV mcg tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg (28) ACA PV tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg ACA PV (28) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 ACA PV mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 ACA PV mcg (28) trivora (28) oral tablet 50-30 (6)/75-40 (5)/125- ACA PV 30(10) tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 ACA PV mcg tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg ACA PV (28) TYBLUME ORAL TABLET,CHEWABLE 0.1 ACA PV MG- 20 MCG tydemy oral tablet 3-0.03-0.451 mg (21) (7) ACA PV velivet triphasic regimen (28) oral tablet ACA PV 0.1/.125/.15-25 mg-mcg vestura (28) oral tablet 3-0.02 mg ACA PV vienva oral tablet 0.1-20 mg-mcg ACA PV viorele (28) oral tablet 0.15-0.02 mgx21 /0.01 mg ACA PV x 5 volnea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x ACA PV 5 vyfemla (28) oral tablet 0.4-35 mg-mcg ACA PV vylibra oral tablet 0.25-35 mg-mcg ACA PV wera (28) oral tablet 0.5-35 mg-mcg ACA PV wymzya fe oral tablet,chewable 0.4mg-35mcg(21) ACA PV and 75 mg (7) zarah oral tablet 3-0.03 mg ACA PV zovia 1/35e (28) oral tablet 1-35 mg-mcg ACA PV zumandimine (28) oral tablet 3-0.03 mg ACA PV

109 Drug Name Drug Tier Requirements / Limits OXYTOCICS methergine oral tablet 0.2 mg 1 methylergonovine oral tablet 0.2 mg 1 OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac ophthalmic (eye) ointment 500-10,000 1 unit/gram AZASITE OPHTHALMIC (EYE) DROPS 1 % 1 bacitracin ophthalmic (eye) ointment 500 1 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 1 500-10,000 unit/gram BESIVANCE OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 0.6 % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % 1 erythromycin ophthalmic (eye) ointment 5 1 mg/gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 % 1 gentak ophthalmic (eye) ointment 0.3 % (3 1 mg/gram) gentamicin ophthalmic (eye) drops 0.3 % 1 levofloxacin ophthalmic (eye) drops 0.5 % 1 moxifloxacin ophthalmic (eye) drops 0.5 % 1 moxifloxacin ophthalmic (eye) drops, viscous 0.5 1 % NATACYN OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 5 % neomycin-bacitracin-polymyxin ophthalmic (eye) 1 ointment 3.5-400-10,000 mg-unit-unit/g neomycin-polymyxin-gramicidin ophthalmic (eye) 1 drops 1.75 mg-10,000 unit-0.025mg/ml neo-polycin ophthalmic (eye) ointment 3.5-400- 1 10,000 mg-unit-unit/g ofloxacin ophthalmic (eye) drops 0.3 % 1 polycin ophthalmic (eye) ointment 500-10,000 1 unit/gram polymyxin b sulf-trimethoprim ophthalmic (eye) 1 drops 10,000 unit- 1 mg/ml

110 Drug Name Drug Tier Requirements / Limits tobramycin ophthalmic (eye) drops 0.3 % 1 TOBREX OPHTHALMIC (EYE) OINTMENT 1 0.3 % ANTIVIRALS trifluridine ophthalmic (eye) drops 1 % 1 ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 1 BETA-BLOCKERS betaxolol ophthalmic (eye) drops 0.5 % 1 BETIMOL OPHTHALMIC (EYE) DROPS 0.25 1 %, 0.5 % BETOPTIC S OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 0.25 % carteolol ophthalmic (eye) drops 1 % 1 levobunolol ophthalmic (eye) drops 0.5 % 1 timolol maleate ophthalmic (eye) drops 0.25 %, 1 0.5 % timolol maleate ophthalmic (eye) drops, once daily 1 0.5 % timolol maleate ophthalmic (eye) gel forming 1 solution 0.25 %, 0.5 % CYCLOPLEGIC MYDRIATICS atropine ophthalmic (eye) drops 1 % 1 atropine ophthalmic (eye) ointment 1 % 1 cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, 1 2 % homatropaire ophthalmic (eye) drops 5 % 1 tropicamide ophthalmic (eye) drops 0.5 %, 1 % 1 DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 1 4 % MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL OPHTHALMIC (EYE) DROPS 2 % 1 ST ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % 1 ST altacaine ophthalmic (eye) drops 0.5 % 1 azelastine ophthalmic (eye) drops 0.05 % 1 BEOVU INTRAVITREAL SOLUTION 6 MB PA; LA MG/0.05 ML

111 Drug Name Drug Tier Requirements / Limits bepotastine besilate ophthalmic (eye) drops 1.5 % 1 ST BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % 1 ST cromolyn ophthalmic (eye) drops 4 % 1 CYSTARAN OPHTHALMIC (EYE) DROPS 1 PA 0.44 % epinastine ophthalmic (eye) drops 0.05 % 1 EYLEA INTRAVITREAL SOLUTION 2 MB PA; LA MG/0.05 ML EYLEA INTRAVITREAL SYRINGE 2 MG/0.05 MB PA; LA ML LACRISERT OPHTHALMIC (EYE) INSERT 5 1 MG LASTACAFT OPHTHALMIC (EYE) DROPS 1 ST 0.25 % LUCENTIS INTRAVITREAL SOLUTION 0.3 MB PA; LA MG/0.05 ML, 0.5 MG/0.05 ML LUCENTIS INTRAVITREAL SYRINGE 0.3 MB PA; LA MG/0.05 ML, 0.5 MG/0.05 ML LUXTURNA SUBRETINAL SUSPENSION 1.5 MB LA X 10EXP11 VG/0.3 ML (FNL) olopatadine ophthalmic (eye) drops 0.1 %, 0.2 % 1 OMIDRIA INTRAOCULAR CONCENTRATE 1- MB 0.3 % proparacaine ophthalmic (eye) drops 0.5 % 1 RESTASIS OPHTHALMIC (EYE) 1 QL (120 per 30 days) DROPPERETTE 0.05 % TETRACAINE HCL (PF) OPHTHALMIC (EYE) 1 DROPS 0.5 % tetracaine hcl ophthalmic (eye) drops 0.5 % 1 VISUDYNE INTRAVENOUS RECON SOLN 15 MB LA MG XIIDRA OPHTHALMIC (EYE) DROPPERETTE 1 PA; ST; QL (60 per 30 days) 5 % NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACUVAIL (PF) OPHTHALMIC (EYE) 1 ST DROPPERETTE 0.45 % bromfenac ophthalmic (eye) drops 0.09 % 1 diclofenac sodium ophthalmic (eye) drops 0.1 % 1

112 Drug Name Drug Tier Requirements / Limits flurbiprofen sodium ophthalmic (eye) drops 0.03 1 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 1 NEVANAC OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 0.1 % ORAL DRUGS FOR GLAUCOMA acetazolamide oral capsule, extended release 500 1 mg acetazolamide oral tablet 125 mg, 250 mg 1 methazolamide oral tablet 25 mg, 50 mg 1 OTHER GLAUCOMA DRUGS bimatoprost ophthalmic (eye) drops 0.03 % 1 brinzolamide ophthalmic (eye) drops,suspension 1 1 % COMBIGAN OPHTHALMIC (EYE) DROPS 0.2- 1 0.5 % dorzolamide ophthalmic (eye) drops 2 % 1 dorzolamide-timolol (pf) ophthalmic (eye) 1 dropperette 2-0.5 % dorzolamide-timolol ophthalmic (eye) drops 22.3- 1 6.8 mg/ml latanoprost ophthalmic (eye) drops 0.005 % 1 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 1 ST % RHOPRESSA OPHTHALMIC (EYE) DROPS 1 PA; ST 0.02 % SIMBRINZA OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 1-0.2 % travoprost ophthalmic (eye) drops 0.004 % 1 STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc ophthalmic (eye) 1 ointment 3.5-400-10,000 mg-unit/g-1% neomycin-polymyxin b-dexameth ophthalmic (eye) 1 drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) 1 ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-hc ophthalmic (eye) 1 drops,suspension 3.5-10,000-10 mg-unit-mg/ml

113 Drug Name Drug Tier Requirements / Limits neo-polycin hc ophthalmic (eye) ointment 3.5-400- 1 10,000 mg-unit/g-1% TOBRADEX OPHTHALMIC (EYE) 1 OINTMENT 0.3-0.1 % TOBRADEX ST OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 0.3-0.05 % tobramycin-dexamethasone ophthalmic (eye) 1 drops,suspension 0.3-0.1 % STEROIDS ALREX OPHTHALMIC (EYE) 1 ST DROPS,SUSPENSION 0.2 % dexamethasone sodium phosphate ophthalmic 1 (eye) drops 0.1 % DUREZOL OPHTHALMIC (EYE) DROPS 0.05 1 % fluorometholone ophthalmic (eye) 1 drops,suspension 0.1 % FML FORTE OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 0.25 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 1 0.1 % INVELTYS OPHTHALMIC (EYE) 1 ST DROPS,SUSPENSION 1 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 1 ST 0.5 % loteprednol etabonate ophthalmic (eye) drops,gel 1 0.5 % loteprednol etabonate ophthalmic (eye) 1 drops,suspension 0.5 % MAXIDEX OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 0.1 % OZURDEX INTRAVITREAL IMPLANT 0.7 MG MB LA PRED MILD OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic (eye) 1 drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) 1 drops 1 % RETISERT INTRAVITREAL IMPLANT 0.59 MB LA MG

114 Drug Name Drug Tier Requirements / Limits YUTIQ INTRAVITREAL IMPLANT 0.18 MG MB STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE OPHTHALMIC (EYE) 1 DROPS,SUSPENSION 10-0.2 % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) 1 OINTMENT 10-0.2 % sulfacetamide-prednisolone ophthalmic (eye) 1 drops 10 %-0.23 % (0.25 %) SULFONAMIDES sulfacetamide sodium ophthalmic (eye) drops 10 1 % sulfacetamide sodium ophthalmic (eye) ointment 1 10 % SYMPATHOMIMETICS apraclonidine ophthalmic (eye) drops 0.5 % 1 brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % 1 IOPIDINE OPHTHALMIC (EYE) 1 DROPPERETTE 1 % VASOCONSTRICTOR DECONGESTANTS phenylephrine hcl ophthalmic (eye) drops 10 %, 1 2.5 % RESPIRATORY, ALLERGY, COUGH & COLD ANTIHISTAMINE & ANTIALLERGENIC AGENTS adrenalin injection solution 1 mg/ml, 1 mg/ml (1 1 ml) carbinoxamine maleate oral liquid 4 mg/5 ml 1 PA; ST; QL (2 per 30 days) carbinoxamine maleate oral tablet 4 mg 1 PA; ST; QL (240 per 30 days) carbinoxamine maleate oral tablet 6 mg 1 PA; ST; QL (120 per 30 days) cetirizine oral solution 1 mg/ml 1 clemastine oral syrup 0.5 mg/5 ml 1 clemastine oral tablet 2.68 mg 1 cyproheptadine oral syrup 2 mg/5 ml 1 cyproheptadine oral tablet 4 mg 1 desloratadine oral tablet 5 mg 1 PA; ST; QL (30 per 30 days) desloratadine oral tablet,disintegrating 2.5 mg, 5 1 PA; ST mg diphenhydramine hcl injection solution 50 mg/ml 1

115 Drug Name Drug Tier Requirements / Limits diphenhydramine hcl injection syringe 50 mg/ml MB EPINEPHRINE INJECTION AUTO-INJECTOR 1 0.15 MG/0.15 ML epinephrine injection auto-injector 0.15 mg/0.3 ml, 1 0.3 mg/0.3 ml epinephrine injection solution 1 mg/ml, 1 mg/ml (1 1 ml) epinephrine injection syringe 0.1 mg/ml 1 hydroxyzine hcl intramuscular solution 25 mg/ml MB hydroxyzine hcl oral solution 10 mg/5 ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 1 50 mg levocetirizine oral solution 2.5 mg/5 ml 1 levocetirizine oral tablet 5 mg 1 promethazine injection solution 25 mg/ml MB promethazine oral syrup 6.25 mg/5 ml 1 promethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 1 50 mg COUGH & COLD THERAPY benzonatate oral capsule 100 mg, 150 mg, 200 mg 1 brompheniramine-pseudoeph-dm oral syrup 2-30- 1 10 mg/5 ml codeine-guaifenesin oral liquid 10-100 mg/5 ml 1 g tussin ac oral liquid 10-100 mg/5 ml 1 guaiatussin ac oral liquid 10-100 mg/5 ml 1 hydrocodone-chlorpheniramine oral 1 suspension,extended rel 12 hr 10-8 mg/5 ml hydrocodone-homatropine oral syrup 5-1.5 mg/5 1 ml hydrocodone-homatropine oral tablet 5-1.5 mg 1 hydromet oral syrup 5-1.5 mg/5 ml 1 maxi-tuss ac oral liquid 10-100 mg/5 ml 1 m-clear wc oral liquid 6.3-100 mg/5 ml 1 promethazine-codeine oral syrup 6.25-10 mg/5 ml 1

116 Drug Name Drug Tier Requirements / Limits promethazine-dm oral syrup 6.25-15 mg/5 ml 1 promethazine-phenyleph-codeine oral syrup 6.25- 1 5-10 mg/5 ml promethazine-phenylephrine oral syrup 6.25-5 1 mg/5 ml virtussin ac oral liquid 10-100 mg/5 ml 1 PULMONARY AGENTS acetylcysteine solution 100 mg/ml (10 %), 200 1 mg/ml (20 %) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 1 PA; LA MG, 2 MG, 2.5 MG ADVAIR HFA INHALATION HFA AEROSOL 1 QL (1 per 30 days) 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION ALBUTEROL HFA 90 MCG INHALER 90 1 QL (2 per 30 days) MCG/ACTUATION albuterol sulfate inhalation inhalation hfa aerosol 1 QL (2 per 30 days) inhaler 90 mcg/actuation albuterol sulfate inhalation inhalation solution for 1 nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate inhalation oral syrup 2 mg/5 ml 1 albuterol sulfate inhalation oral tablet 2 mg, 4 mg 1 albuterol sulfate inhalation oral tablet extended 1 release 12 hr 4 mg, 8 mg ALVESCO INHALATION HFA AEROSOL 1 PA; ST; QL (1 per 30 days) INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION alyq oral tablet 20 mg 1 PA ambrisentan oral tablet 10 mg, 5 mg 1 PA; LA aminophylline intravenous solution 250 mg/10 ml MB ANORO ELLIPTA INHALATION BLISTER 1 QL (1 per 30 days) WITH DEVICE 62.5-25 MCG/ACTUATION arformoterol inhalation solution for nebulization 1 15 mcg/2 ml ARNUITY ELLIPTA INHALATION BLISTER 1 QL (1 per 30 days) WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER 1 WITH DEVICE 50 MCG/ACTUATION

117 Drug Name Drug Tier Requirements / Limits ATROVENT HFA INHALATION HFA 1 QL (2 per 30 days) AEROSOL INHALER 17 MCG/ACTUATION BERINERT INTRAVENOUS KIT 500 UNIT (10 MB PA; LA ML) BEVESPI AEROSPHERE INHALATION HFA 1 AEROSOL INHALER 9-4.8 MCG bosentan oral tablet 125 mg, 62.5 mg 1 PA; LA BREO ELLIPTA INHALATION BLISTER 1 QL (1 per 30 days) WITH DEVICE 100-25 MCG/DOSE BREO ELLIPTA INHALATION BLISTER 1 WITH DEVICE 200-25 MCG/DOSE BROVANA INHALATION SOLUTION FOR 1 NEBULIZATION 15 MCG/2 ML budesonide inhalation suspension for nebulization 1 QL (120 per 30 days) 0.25 mg/2 ml, 0.5 mg/2 ml budesonide inhalation suspension for nebulization 1 QL (60 per 30 days) 1 mg/2 ml CINQAIR INTRAVENOUS SOLUTION 10 MB PA MG/ML CINRYZE INTRAVENOUS RECON SOLN 500 MB PA; LA UNIT (5 ML) COMBIVENT INHALATION MIST 1 QL (2 per 30 days) 20-100 MCG/ACTUATION cromolyn inhalation solution for nebulization 20 1 mg/2 ml DALIRESP ORAL TABLET 250 MCG, 500 1 MCG DULERA INHALATION HFA AEROSOL 1 QL (1 per 30 days) INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML 1 ESBRIET ORAL CAPSULE 267 MG 1 PA; LA; QL (270 per 30 days) ESBRIET ORAL TABLET 267 MG, 801 MG 1 PA; LA; QL (90 per 30 days) FASENRA PEN SUBCUTANEOUS AUTO- MB PA; LA INJECTOR 30 MG/ML FASENRA SUBCUTANEOUS SYRINGE 30 MB PA; LA MG/ML FLOVENT DISKUS INHALATION BLISTER 1 QL (1 per 30 days) WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

118 Drug Name Drug Tier Requirements / Limits FLOVENT DISKUS INHALATION BLISTER 1 QL (4 per 30 days) WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL 1 QL (1 per 30 days) INHALER 110 MCG/ACTUATION, 44 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL 1 QL (2 per 30 days) INHALER 220 MCG/ACTUATION fluticasone propionate nasal spray,suspension 50 1 mcg/actuation fluticasone propion-salmeterol inhalation blister 1 QL (1 per 30 days) with device 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose formoterol fumarate inhalation solution for 1 nebulization 20 mcg/2 ml HAEGARDA SUBCUTANEOUS RECON SOLN 1 PA; LA 2,000 UNIT, 3,000 UNIT icatibant subcutaneous syringe 30 mg/3 ml 1 PA INCRUSE ELLIPTA INHALATION BLISTER 1 QL (1 per 30 days) WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % 1 ipratropium-albuterol inhalation solution for 1 QL (180 per 30 days) nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml KALBITOR SUBCUTANEOUS SOLUTION 10 1 PA; LA MG/ML (1 ML) KALYDECO ORAL GRANULES IN PACKET 1 PA; LA 25 MG, 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG 1 PA; LA levalbuterol hcl inhalation solution for 1 nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml LEVALBUTEROL TARTRATE INHALATION 1 QL (2 per 30 days) HFA AEROSOL INHALER 45 MCG/ACTUATION metaproterenol oral syrup 10 mg/5 ml 1 montelukast oral granules in packet 4 mg 1 montelukast oral tablet 10 mg 1 montelukast oral tablet,chewable 4 mg, 5 mg 1 nebusal inhalation solution for nebulization 3 % 1 NUCALA SUBCUTANEOUS RECON SOLN MB PA; LA 100 MG

119 Drug Name Drug Tier Requirements / Limits OFEV ORAL CAPSULE 100 MG, 150 MG 1 PA; LA; QL (60 per 30 days) OPSUMIT ORAL TABLET 10 MG 1 PA; LA ORLADEYO ORAL CAPSULE 110 MG, 150 1 PA; ST; QL (28 per 28 days) MG PERFOROMIST INHALATION SOLUTION 1 FOR NEBULIZATION 20 MCG/2 ML pulmosal inhalation solution for nebulization 7 % 1 PULMOZYME INHALATION SOLUTION 1 1 PA; LA MG/ML QVAR REDIHALER INHALATION HFA 1 AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION REVATIO INTRAVENOUS SOLUTION 10 MB LA MG/12.5 ML RUCONEST INTRAVENOUS RECON SOLN MB PA; LA 2,100 UNIT SEREVENT DISKUS INHALATION BLISTER 1 WITH DEVICE 50 MCG/DOSE sildenafil (pulm.hypertension) intravenous solution MB 10 mg/12.5 ml sildenafil (pulm.hypertension) oral suspension for 1 reconstitution 10 mg/ml sildenafil (pulm.hypertension) oral tablet 20 mg 1 PA SINUVA SINUS IMPLANT 1,350 MCG MB sodium chloride inhalation solution for 1 nebulization 0.9 %, 10 %, 3 %, 7 % SPIRIVA RESPIMAT INHALATION MIST 1.25 1 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION MIST 2.5 1 QL (1 per 30 days) MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION 1 QL (30 per 30 days) CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST 2.5- 1 2.5 MCG/ACTUATION STRIVERDI RESPIMAT INHALATION MIST 1 2.5 MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL 1 QL (1 per 30 days) INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

120 Drug Name Drug Tier Requirements / Limits SYMDEKO ORAL TABLETS, SEQUENTIAL 1 PA; LA 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N) tadalafil (pulm. hypertension) oral tablet 20 mg 1 PA TAKHZYRO SUBCUTANEOUS SOLUTION 1 PA; LA 300 MG/2 ML (150 MG/ML) terbutaline oral tablet 2.5 mg, 5 mg 1 terbutaline subcutaneous solution 1 mg/ml 1 theophylline oral elixir 80 mg/15 ml 1 theophylline oral solution 80 mg/15 ml 1 theophylline oral tablet extended release 12 hr 300 1 mg, 450 mg theophylline oral tablet extended release 24 hr 400 1 mg, 600 mg TRACLEER ORAL TABLET FOR 1 PA; LA SUSPENSION 32 MG TRELEGY ELLIPTA INHALATION BLISTER 1 WITH DEVICE 100-62.5-25 MCG, 200-62.5-25 MCG TRIKAFTA ORAL TABLETS, SEQUENTIAL 1 PA; LA 100-50-75 MG(D) /150 MG (N), 50-25-37.5 MG (D)/75 MG (N) TYVASO INHALATION SOLUTION FOR 1 PA; LA NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT INHALATION 1 PA; LA SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION 1 PA; LA SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML VENTAVIS INHALATION SOLUTION FOR 1 PA; LA NEBULIZATION 10 MCG/ML, 20 MCG/ML wixela inhub inhalation blister with device 100-50 1 QL (1 per 30 days) mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose XOLAIR SUBCUTANEOUS RECON SOLN 150 MB LA MG XOLAIR SUBCUTANEOUS SYRINGE 150 MB PA; LA; QL (7 per 30 days) MG/ML, 75 MG/0.5 ML zafirlukast oral tablet 10 mg, 20 mg 1 zileuton oral tablet, er multiphase 12 hr 600 mg 1 ST

121 Drug Name Drug Tier Requirements / Limits ZYFLO ORAL TABLET 600 MG 1 ST UROLOGICALS ANTICHOLINERGICS & ANTISPASMODICS darifenacin oral tablet extended release 24 hr 15 1 mg, 7.5 mg flavoxate oral tablet 100 mg 1 MYRBETRIQ ORAL TABLET EXTENDED 1 ST RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml 1 oxybutynin chloride oral tablet 5 mg 1 oxybutynin chloride oral tablet extended release 1 24hr 10 mg, 15 mg, 5 mg solifenacin oral tablet 10 mg, 5 mg 1 tolterodine oral capsule,extended release 24hr 2 1 mg, 4 mg tolterodine oral tablet 1 mg, 2 mg 1 trospium oral capsule,extended release 24hr 60 1 mg trospium oral tablet 20 mg 1 BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY alfuzosin oral tablet extended release 24 hr 10 mg 1 dutasteride oral capsule 0.5 mg 1 dutasteride-tamsulosin oral capsule, er multiphase 1 24 hr 0.5-0.4 mg finasteride oral tablet 5 mg 1 silodosin oral capsule 4 mg, 8 mg 1 tadalafil oral tablet 2.5 mg, 5 mg 1 PA; ST tamsulosin oral capsule 0.4 mg 1 CHOLINERGIC STIMULANTS bethanechol chloride oral tablet 10 mg, 25 mg, 5 1 mg, 50 mg MISCELLANEOUS UROLOGICALS CYSTAGON ORAL CAPSULE 150 MG, 50 MG 1 PA ELMIRON ORAL CAPSULE 100 MG 1 hyophen oral tablet 81.6-0.12-10.8 mg 1 K-PHOS NO 2 ORAL TABLET 305-700 MG 1

122 Drug Name Drug Tier Requirements / Limits K-PHOS ORIGINAL ORAL TABLET,SOLUBLE 1 500 MG methen-sod phos-meth blue-hyos oral tablet 81.6- 1 40.8-0.12 mg OXLUMO SUBCUTANEOUS SOLUTION 94.5 1 PA MG/0.5 ML phosphasal oral tablet 81.6-10.8-40.8 mg 1 potassium citrate oral tablet extended release 10 1 meq (1,080 mg), 15 meq, 5 meq (540 mg) RENACIDIN IRRIGATION SOLUTION 1980.6 1 MG-59.4 MG-980.4MG/30ML URELLE ORAL TABLET 81-10.8-40.8 MG 1 uretron d-s oral tablet 81.6-10.8-40.8 mg 1 urimar-t oral tablet 120-0.12-10.8 mg 1 urogesic-blue oral tablet 81.6-40.8-0.12 mg 1 uryl oral tablet 81.6-40.8-0.12 mg 1 ustell oral capsule 120-0.12 mg 1 utira-c oral tablet 81.6-10.8-40.8 mg 1 URINARY ANESTHETICS phenazopyridine oral tablet 100 mg, 200 mg 1 VITAMINS, HEMATINICS & ELECTROLYTES ELECTROLYTES effer-k oral tablet, effervescent 25 meq 1 klor-con 10 oral tablet extended release 10 meq 1 klor-con 8 oral tablet extended release 8 meq 1 klor-con m10 oral tablet,er particles/crystals 10 1 meq klor-con m15 oral tablet,er particles/crystals 15 1 meq klor-con m20 oral tablet,er particles/crystals 20 1 meq klor-con oral packet 20 meq 1 klor-con/ef oral tablet, effervescent 25 meq 1 K-TAB ORAL TABLET EXTENDED RELEASE 1 10 MEQ k-tab oral tablet extended release 8 meq 1

123 Drug Name Drug Tier Requirements / Limits NORMOSOL-R INTRAVENOUS MB PARENTERAL SOLUTION potassium chloride oral capsule, extended release 1 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 1 meq/15 ml potassium chloride oral packet 20 meq 1 potassium chloride oral tablet extended release 10 1 meq, 20 meq, 8 meq potassium chloride oral tablet,er particles/crystals 1 10 meq, 20 meq sodium chloride 0.45 % intravenous parenteral MB solution 0.45 % MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES ISOLYTE-S INTRAVENOUS PARENTERAL MB SOLUTION PLASMA-LYTE 148 INTRAVENOUS MB PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS MB PARENTERAL SOLUTION VITAMINS & HEMATINICS cyanocobalamin (vitamin b-12) injection solution 1 1,000 mcg/ml ergocalciferol (vitamin d2) oral capsule 1,250 mcg 1 (50,000 unit) FA-8 ORAL CAPSULE 0.8 MG ACA PV FER-IN-SOL ORAL DROPS 15 MG IRON (75 ACA PV MG)/ML FLORIVA (FLUORIDE-VITAMIN D3) ORAL ACA PV DROPS 0.25 MG (0.55 MG)-400 UNIT/ML fluoride (sodium) oral drops 0.5 mg (1.1 mg ACA PV sod.fluorid)/ml fluoride (sodium) oral tablet,chewable 0.25 ACA PV mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride) folic acid injection solution 5 mg/ml 1 folic acid oral tablet 1 mg 1 folic acid oral tablet 400 mcg, 800 mcg ACA PV hydroxocobalamin intramuscular solution 1,000 1 mcg/ml

124 Drug Name Drug Tier Requirements / Limits INFED INJECTION SOLUTION 50 MG/ML MB ludent fluoride oral tablet,chewable 0.25 mg(0.55 ACA PV mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride) multi-vitamin with fluoride oral drops 0.25 mg/ml, ACA PV 0.5 mg/ml multi-vitamin with fluoride oral tablet,chewable ACA PV 0.25 mg, 0.5 mg, 1 mg multivitamins with fluoride oral tablet,chewable ACA PV 0.25 mg, 0.5 mg, 1 mg mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 ACA PV mg, 1 mg NOVAFERRUM ORAL DROPS 15 MG ACA PV IRON/ML tri-vitamin with fluoride oral drops 0.25 mg fluor. ACA PV (0.55 mg)/ml, 0.5 mg fluoride (1.1 mg)/ml vitamins a,c,d and fluoride oral drops 0.25 mg ACA PV fluor. (0.55 mg)/ml, 0.5 mg fluoride (1.1 mg)/ml

125 Index

A AFLURIA QD 2021-22(3YR alyacen 7/7/7 (28) ...... 103 abacavir ...... 2 UP)(PF) ...... 90 alyq ...... 117 abacavir-lamivudine ...... 2 AFLURIA QD 2021-22(6- amabelz ...... 99 abacavir-lamivudine- 35MO)(PF) ...... 90 amantadine hcl ...... 2 zidovudine ...... 2 AFLURIA QUAD 2021- AMBISOME ...... 1 ABILIFY MAINTENA ...... 36 2022(6MO UP) ...... 90 ambrisentan ...... 117 abiraterone ...... 13 AFSTYLA ...... 50 amcinonide ...... 63 ABRAXANE ...... 13 AIMOVIG AUTOINJECTOR amethia ...... 103 acamprosate ...... 66 ...... 28 amethyst (28) ...... 103 acarbose ...... 77 AJOVY AUTOINJECTOR .. 28 amikacin ...... 8 accutane ...... 59 AJOVY SYRINGE ...... 28 amiloride ...... 45 acebutolol ...... 45 ak-poly-bac ...... 110 amiloride-hydrochlorothiazide acetaminophen-caff- AKYNZEO (NETUPITANT) ...... 45 dihydrocod ...... 30 ...... 81 aminocaproic acid ...... 50, 51 acetaminophen-codeine ...... 31 ala-cort ...... 63 aminophylline ...... 117 acetazolamide ...... 113 albendazole ...... 8 amiodarone ...... 44 acetic acid ...... 66, 69 albuterol sulfate inhalation . 117 AMITIZA ...... 81 acetylcysteine ...... 117 ALBUTEROL SULFATE amitriptyline ...... 37 acitretin ...... 57 INHALATION ...... 117 amitriptyline-chlordiazepoxide ACTEMRA ...... 96 alclometasone ...... 63 ...... 37 ACTEMRA ACTPEN ...... 96 ALCORTIN A ...... 61 amlodipine ...... 45 ACTHAR ...... 70 ALDURAZYME ...... 74 amlodipine-atorvastatin ...... 55 ACTHIB (PF) ...... 90 ALECENSA ...... 14 amlodipine-benazepril ...... 45 ACTIMMUNE ...... 90 alendronate ...... 96 amlodipine-olmesartan ...... 45 ACUVAIL (PF) ...... 112 alfuzosin ...... 122 amlodipine-valsartan ...... 45 acyclovir ...... 2, 63 ALIMTA ...... 14 amlodipine-valsartan-hcthiazid ADACEL(TDAP ALINIA ...... 8 ...... 45 ADOLESN/ADULT)(PF) 90 ALIQOPA ...... 14 ammonium lactate ...... 59 ADAKVEO ...... 13 aliskiren ...... 45 amnesteem ...... 60 adapalene ...... 60 allopurinol ...... 96 amoxapine ...... 37 ADAPALENE ...... 60 almotriptan malate ...... 28 amoxicil-clarithromy-lansopraz adapalene-benzoyl peroxide . 60 ALOCRIL ...... 111 ...... 85 ADCETRIS ...... 14 ALOGLIPTIN- amoxicillin ...... 11 adefovir...... 2 PIOGLITAZONE ...... 77 amoxicillin-pot clavulanate .. 11 ADEMPAS ...... 117 ALOMIDE ...... 111 AMPHETAMINE ...... 37 ADHANSIA XR ...... 36 alosetron ...... 81 amphetamine sulfate ...... 37 adrenalin ...... 115 ALOXI ...... 81 amphotericin b ...... 1 adult aspirin regimen ...... 33 ALPHANATE ...... 50 ampicillin ...... 11 ADVAIR HFA ...... 117 ALPHANINE SD ...... 50 ampicillin-sulbactam ...... 11 ADVATE ...... 50 alprazolam ...... 37 anagrelide ...... 66 ADYNOVATE ...... 50 alprazolam intensol ...... 37 anaspaz ...... 80 ADZENYS ER ...... 36 ALPROLIX ...... 50 anastrozole ...... 14 ADZENYS XR-ODT ...... 36 ALREX ...... 114 ANDEXXA ...... 51 AEROCHAMBER MINI ..... 71 ALTABAX ...... 61 ANDRODERM ...... 75 AEROCHAMBER PLUS altacaine ...... 111 ANGELIQ ...... 99 FLOW-VU ...... 71 altavera (28) ...... 103 ANNOVERA ...... 102 AFINITOR ...... 14 ALVESCO ...... 117 ANORO ELLIPTA ...... 117 afirmelle ...... 103 alyacen 1/35 (28) ...... 103 anucort-hc ...... 81

126 apexicon e ...... 63 aviane ...... 103 betamethasone dipropionate . 63 APLENZIN ...... 37 avidoxy ...... 12 betamethasone valerate ...... 63 APOKYN ...... 27 avita ...... 60 betamethasone, augmented .. 63, apraclonidine ...... 115 AVITA ...... 60 64 aprepitant ...... 81 AVONEX ...... 88 BETASERON ...... 88 apri ...... 103 AVYCAZ ...... 6 betaxolol ...... 45, 111 APTIVUS ...... 2 ayuna ...... 103 bethanechol chloride ...... 122 ARALAST NP ...... 66 AZASITE ...... 110 BETIMOL ...... 111 aranelle (28)...... 103 azathioprine ...... 14 BETOPTIC S ...... 111 ARANESP (IN azelaic acid ...... 60 BEVESPI AEROSPHERE . 118 POLYSORBATE) ...... 86 azelastine ...... 68, 111 bexarotene ...... 14 ARCALYST ...... 90 AZELEX ...... 60 BEXSERO ...... 90 ARESTIN ...... 68 azithromycin ...... 7 bicalutamide ...... 14 arformoterol ...... 117 azurette (28) ...... 103 BICILLIN C-R ...... 11 aripiprazole ...... 37 B BIKTARVY ...... 2 ARISTADA ...... 37 bacitracin ...... 8, 110 bimatoprost ...... 113 ARISTADA INITIO ...... 37 bacitracin-polymyxin b ...... 110 BIOTHRAX ...... 90 armodafinil ...... 37 baclofen ...... 30 bisoprolol fumarate ...... 45 ARMOUR THYROID ...... 79 BALCOLTRA ...... 103 bisoprolol-hydrochlorothiazide ARNUITY ELLIPTA ...... 117 balsalazide ...... 81 ...... 45 ARRANON ...... 14 BALVERSA ...... 14 BIVIGAM ...... 91 ARZERRA ...... 14 balziva (28) ...... 103 BLEPHAMIDE ...... 115 ASCENIV ...... 90 BANZEL ...... 24 BLEPHAMIDE S.O.P...... 115 ascomp with codeine ...... 31 BAQSIMI ...... 71 BLINCYTO ...... 14 asenapine maleate ...... 37 BARACLUDE...... 2 blisovi 24 fe ...... 103 ashlyna ...... 103 BAVENCIO ...... 14 blisovi fe 1.5/30 (28) ...... 103 ASPARLAS ...... 14 BAXDELA ...... 12 blisovi fe 1/20 (28) ...... 103 aspirin ...... 33 bayer aspirin ...... 34 BOOSTRIX TDAP ...... 91 aspirin low dose ...... 33 BAYER CHEWABLE BORTEZOMIB ...... 14 aspirin-dipyridamole ...... 51 ASPIRIN ...... 34 bosentan ...... 118 aspir-trin ...... 34 BCG VACCINE, LIVE (PF) 90 BOSULIF ...... 14 atazanavir ...... 2 BELEODAQ ...... 14 BOTOX ...... 91 atenolol ...... 45 belladonna alkaloids-opium . 80 BRAFTOVI ...... 14 atenolol-chlorthalidone...... 45 BELRAPZO ...... 14 BREO ELLIPTA ...... 118 ATGAM ...... 90 BELSOMRA ...... 37 briellyn ...... 104 atomoxetine ...... 37 benazepril ...... 45 BRILINTA ...... 51 atorvastatin ...... 55 benazepril-hydrochlorothiazide brimonidine ...... 115 atovaquone ...... 8 ...... 45 BRINEURA ...... 75 atovaquone-proguanil ...... 8 BENDAMUSTINE ...... 14 brinzolamide ...... 113 atropine ...... 80, 111 BENDEKA ...... 14 BRIVIACT ...... 24 ATROVENT HFA ...... 118 BENEFIX ...... 51 bromfenac ...... 112 AUBAGIO ...... 88 BENLYSTA ...... 97 bromocriptine ...... 27 aubra ...... 103 benzonatate ...... 116 brompheniramine-pseudoeph- aubra eq ...... 103 benztropine ...... 27 dm ...... 116 aurovela 1.5/30 (21) ...... 103 BEOVU ...... 111 BROVANA ...... 118 aurovela 1/20 (21) ...... 103 bepotastine besilate ...... 112 budesonide ...... 81, 118 aurovela 24 fe ...... 103 BEPREVE ...... 112 bumetanide ...... 45 aurovela fe 1.5/30 (28) ...... 103 BERINERT ...... 118 buprenorphine ...... 31 aurovela fe 1-20 (28) ...... 103 beser ...... 63 buprenorphine hcl ...... 31 AUSTEDO ...... 29 BESIVANCE ...... 110 buprenorphine-naloxone ...... 34 AVASTIN ...... 14 BESPONSA...... 14 bupropion hcl ...... 37, 38

127 bupropion hcl (smoking deter) cartia xt ...... 46 chlordiazepoxide hcl ...... 38 ...... 68 carvedilol ...... 46 chlordiazepoxide-clidinium .. 80 buspirone ...... 38 carvedilol phosphate ...... 46 chlorhexidine gluconate ...... 68 BUSULFEX ...... 15 cataflam ...... 34 chloroquine phosphate ...... 8 butalbital compound w/codeine CAYA CONTOURED ...... 99 chlorpromazine ...... 38 ...... 31 CAYSTON ...... 8 chlorthalidone ...... 46 butalbital-acetaminop-caf-cod caziant (28) ...... 104 chlorzoxazone ...... 30 ...... 31 cefaclor ...... 6 CHOLBAM ...... 81 butalbital-acetaminophen-caff cefadroxil ...... 6 cholestyramine (with sugar) . 55 ...... 31 cefazolin ...... 6 cholestyramine light ...... 55 butalbital-aspirin-caffeine .... 31 cefazolin in dextrose (iso-os) . 6 choline,magnesium salicylate butorphanol...... 34 cefdinir ...... 6 ...... 34 BYDUREON BCISE ...... 77 cefditoren pivoxil ...... 6 ciclodan ...... 62 BYETTA ...... 77 cefepime ...... 6 ciclopirox ...... 62 BYSTOLIC ...... 45 CEFEPIME IN DEXTROSE 5 ciclopirox-ure-camph-menth- C % ...... 6 euc ...... 62 CABENUVA ...... 2 cefepime in dextrose,iso-osm . 6 cidofovir ...... 2 cabergoline ...... 75 cefixime ...... 6 cilostazol ...... 51 CABLIVI ...... 51 CEFOTAN ...... 6 CIMDUO ...... 2 CABOMETYX ...... 15 cefotaxime ...... 6 cimetidine ...... 85 calcipotriene ...... 57 cefotetan ...... 6 cimetidine hcl ...... 85 calcipotriene-betamethasone 57 CEFOTETAN IN CIMZIA ...... 82 calcitonin (salmon) ...... 75 DEXTROSE, ISO-OSM ..... 6 CIMZIA POWDER FOR calcitriol ...... 57, 75 cefoxitin ...... 6 RECONST ...... 82 calcium acetate(phosphat bind) cefpodoxime ...... 6, 7 cinacalcet ...... 75 ...... 81 cefprozil ...... 7 CINQAIR ...... 118 CALQUENCE ...... 15 ceftazidime ...... 7 CINRYZE ...... 118 camila ...... 99 CEFTAZIDIME IN D5W ...... 7 CIPRO HC ...... 69 camrese ...... 104 ceftriaxone ...... 7 ciprofloxacin ...... 12 camrese lo ...... 104 CEFTRIAXONE ...... 7 ciprofloxacin hcl ..... 12, 69, 110 CANCIDAS ...... 1 ceftriaxone in dextrose,iso-os . 7 ciprofloxacin-dexamethasone candesartan ...... 45 cefuroxime axetil ...... 7 ...... 69 candesartan-hydrochlorothiazid celecoxib ...... 34 citalopram ...... 38 ...... 46 CELONTIN ...... 24 claravis ...... 60 CAPASTAT ...... 8 cephalexin ...... 7 clarithromycin ...... 7, 8 capecitabine ...... 15 CERDELGA ...... 75 clemastine ...... 115 CAPRELSA ...... 15 CEREZYME ...... 75 CLENPIQ ...... 82 captopril ...... 46 cetirizine ...... 115 clindacin p ...... 60 captopril-hydrochlorothiazide cevimeline ...... 66 clindamycin hcl ...... 8 ...... 46 CHANTIX ...... 68 clindamycin pediatric ...... 8 CARBAGLU ...... 66 CHANTIX CONTINUING clindamycin phosphate .... 8, 60, carbamazepine ...... 24 MONTH BOX ...... 68 102 carbidopa ...... 27 CHANTIX STARTING clindamycin-benzoyl peroxide carbidopa-levodopa ...... 27 MONTH BOX ...... 68 ...... 60 carbidopa-levodopa- charlotte 24 fe ...... 104 clindamycin-tretinoin ...... 60 entacapone ...... 27 chateal (28) ...... 104 clobazam ...... 24 carbinoxamine maleate ...... 115 chateal eq (28) ...... 104 clobetasol ...... 64 carisoprodol ...... 30 CHEMET ...... 66 clobetasol-emollient ...... 64 carisoprodol-aspirin ...... 30 children's aspirin ...... 34 CLOCORTOLONE carisoprodol-aspirin-codeine 30 chloramphenicol sod succinate PIVALATE ...... 64 carteolol ...... 111 ...... 8 CLODERM ...... 64

128 CLOLAR ...... 15 CUBICIN RF ...... 9 DEPO-TESTOSTERONE .... 75 clomipramine ...... 38 CUTAQUIG ...... 91 DESCOVY ...... 2 clonazepam ...... 24 CUVITRU ...... 91 desipramine ...... 38 clonidine ...... 46 cyanocobalamin (vitamin b-12) desloratadine ...... 115 clonidine hcl ...... 38, 46 ...... 124 desmopressin ...... 75 clopidogrel ...... 51 cyclafem 1/35 (28) ...... 104 desog-e.estradiol/e.estradiol clorazepate dipotassium ...... 38 cyclafem 7/7/7 (28) ...... 104 ...... 104 clotrimazole ...... 1, 62 cyclobenzaprine ...... 30 desogestrel-ethinyl estradiol clotrimazole-betamethasone . 62 cyclopentolate ...... 111 ...... 104 clovique ...... 66 cyclophosphamide ...... 15 desonide ...... 64 clozapine...... 38 CYCLOPHOSPHAMIDE .... 15 desoximetasone ...... 64 COAGADEX ...... 51 CYCLOSERINE ...... 9 DESVENLAFAXINE ...... 38 COARTEM ...... 8 CYCLOSET ...... 77 desvenlafaxine succinate ...... 38 codeine sulfate ...... 31 cyclosporine ...... 15 dexamethasone ...... 70 codeine-butalbital-asa-caff ... 31 cyclosporine modified ...... 15 dexamethasone intensol ...... 70 codeine-guaifenesin ...... 116 cyproheptadine ...... 115 dexamethasone sodium phos colchicine ...... 96 CYRAMZA ...... 15 (pf) ...... 70 COLCHICINE ...... 96 cyred ...... 104 dexamethasone sodium colesevelam ...... 55 cyred eq ...... 104 phosphate ...... 70, 114 colestipol ...... 55 CYSTAGON ...... 122 DEXILANT ...... 86 COMBIGAN ...... 113 CYSTARAN ...... 112 dexmethylphenidate ...... 38 COMBIPATCH ...... 99 CYTOVENE ...... 2 dextroamphetamine ...... 38, 39 COMBIVENT RESPIMAT 118 D dextroamphetamine- COMETRIQ ...... 15 DACOGEN ...... 15 amphetamine ...... 39 COMPLERA ...... 2 dalfampridine ...... 29 diazepam ...... 24, 39 compro ...... 82 DALIRESP ...... 118 diazepam intensol ...... 39 constulose ...... 82 danazol ...... 75 diazoxide ...... 71 CONTOUR NEXT TEST dantrolene ...... 30 diclofenac potassium ...... 34 STRIPS ...... 71 dapsone ...... 9, 60 diclofenac sodium ... 34, 59, 112 CONTOUR TEST STRIPS .. 71 DAPTACEL (DTAP diclofenac-misoprostol ...... 34 COPIKTRA ...... 15 PEDIATRIC) (PF) ...... 91 dicloxacillin ...... 11 CORIFACT ...... 51 darifenacin ...... 122 dicyclomine ...... 80 CORLANOR ...... 56 DARZALEX ...... 15 didanosine ...... 2 CORTIFOAM ...... 82 dasetta 1/35 (28) ...... 104 DIFICID ...... 8 COSENTYX...... 58 dasetta 7/7/7 (28) ...... 104 diflorasone ...... 64 COSENTYX (2 SYRINGES) DAURISMO ...... 15 diflunisal ...... 34 ...... 57 daysee ...... 104 digitek ...... 50 COSENTYX PEN ...... 58 DAYTRANA ...... 38 digox ...... 50 COSENTYX PEN (2 PENS) 58 deblitane ...... 99 digoxin ...... 50 COTELLIC...... 15 decadron ...... 70 dihydroergotamine ...... 28 COTEMPLA XR-ODT ...... 38 decitabine ...... 15 DILANTIN ...... 24 covaryx ...... 99 deferasirox ...... 66 DILANTIN EXTENDED ..... 24 covaryx h.s...... 99 deferiprone ...... 66 DILANTIN INFATABS ...... 24 CREON ...... 82 demeclocycline ...... 12 DILANTIN-125 ...... 24 CRESEMBA ...... 1 DENAVIR ...... 63 diltiazem ...... 46 CRINONE ...... 99 denta 5000 plus ...... 69 dilt-xr ...... 46 cromolyn...... 82, 112, 118 dentagel ...... 69 dimethyl fumarate ...... 88 crotan ...... 66 DEPO-ESTRADIOL ...... 99 DIPENTUM ...... 82 cryselle (28) ...... 104 DEPO-PROVERA ...... 99 diphenhydramine hcl .. 115, 116 CRYSVITA ...... 75 DEPO-SUBQ PROVERA 104 diphenoxylate-atropine ...... 80 CUBICIN ...... 8 ...... 99 dipyridamole ...... 51

129 diskets ...... 31 EDLUAR ...... 39 ENHERTU ...... 16 disopyramide phosphate ...... 44 ed-spaz ...... 80 enoxaparin ...... 51 disulfiram ...... 67 EDURANT ...... 2 enpresse ...... 104 divalproex ...... 24, 25 eemt ...... 100 enskyce ...... 104 DIVIGEL ...... 100 eemt hs ...... 100 entacapone ...... 27 dofetilide...... 44 efavirenz ...... 2 entecavir ...... 3 dolishale ...... 104 efavirenz-emtricitabin-tenofov ENTRESTO ...... 56 donepezil ...... 29 ...... 3 ENTYVIO ...... 82 DONNATAL ...... 80 efavirenz-lamivu-tenofov disop enulose ...... 82 DOPTELET (15 TAB PACK) ...... 3 EPANED ...... 46 ...... 51 effer-k ...... 123 EPCLUSA ...... 3 dorzolamide ...... 113 ELAPRASE ...... 75 EPIDIOLEX ...... 25 dorzolamide-timolol ...... 113 ELELYSO ...... 75 epinastine ...... 112 dorzolamide-timolol (pf) .... 113 eletriptan ...... 28 epinephrine ...... 116 dotti ...... 100 ELIGARD ...... 16 EPINEPHRINE ...... 116 DOVATO ...... 2 ELIGARD (3 MONTH) ...... 15 epitol ...... 25 doxazosin ...... 46 ELIGARD (4 MONTH) ...... 15 EPIVIR HBV ...... 3 doxepin ...... 39 ELIGARD (6 MONTH) ...... 15 eplerenone ...... 47 doxercalciferol ...... 75 elinest ...... 104 EPOGEN ...... 86 doxycycline hyclate ...... 12 ELIQUIS ...... 51 epoprostenol (glycine) ...... 47 doxycycline monohydrate .... 12 ELIQUIS DVT-PE TREAT eprosartan ...... 47 doxylamine-pyridoxine (vit b6) 30D START ...... 51 ERAXIS(WATER DILUENT) ...... 82 ELIXOPHYLLIN ...... 118 ...... 1 dronabinol...... 82 ELLA ...... 104 ERBITUX ...... 16 drospirenone-e.estradiol-lm.fa ELMIRON ...... 122 ergocalciferol (vitamin d2) . 124 ...... 104 ELOCTATE ...... 51 ergoloid ...... 39 drospirenone-ethinyl estradiol eluryng ...... 102 ergotamine-caffeine ...... 28 ...... 104 ELZONRIS ...... 16 ERLEADA ...... 16 DSUVIA ...... 31 EMCYT ...... 16 erlotinib ...... 16 DUAVEE ...... 100 EMEND ...... 82 errin ...... 100 DUEXIS ...... 34 EMGALITY PEN ...... 28 ERWINAZE ...... 16 DULERA ...... 118 EMGALITY SYRINGE ...... 28 ery pads ...... 60 duloxetine ...... 39 emoquette ...... 104 erygel ...... 60 DUPIXENT PEN ...... 59 EMPAVELI ...... 67 ery-tab ...... 8 DUPIXENT SYRINGE ...... 59 EMPLICITI ...... 16 erythrocin (as stearate) ...... 8 duramorph (pf) ...... 31 EMSAM ...... 39 erythromycin ...... 8, 110 DUREZOL ...... 114 emtricitabine ...... 3 erythromycin ethylsuccinate ... 8 dutasteride ...... 122 emtricitabine-tenofovir (tdf) ... 3 erythromycin with ethanol .... 60 dutasteride-tamsulosin ...... 122 EMTRIVA ...... 3 erythromycin-benzoyl peroxide dvorah ...... 31 EMVERM ...... 9 ...... 60 DYANAVEL XR ...... 39 enalapril maleate ...... 46 ESBRIET ...... 118 DYSPORT ...... 91 enalaprilat ...... 46 escitalopram oxalate ...... 39 E enalapril-hydrochlorothiazide esomeprazole magnesium ..... 86 e.e.s. 400 ...... 8 ...... 46 ESPEROCT ...... 51 econazole ...... 62 ENBREL ...... 97 estarylla ...... 105 econtra ez...... 104 ENBREL MINI ...... 97 estazolam ...... 39 econtra one-step...... 104 ENBREL SURECLICK ...... 97 estradiol ...... 100 ecotrin ...... 34 endocet ...... 31 estradiol valerate ...... 100 ecotrin low strength ...... 34 ENGERIX-B (PF) ...... 91 estradiol-norethindrone acet EDARBI ...... 46 ENGERIX-B PEDIATRIC ...... 100 EDARBYCLOR ...... 46 (PF) ...... 91 ESTRING ...... 100

130 estrogens-methyltestosterone fenofibrate ...... 55 fluocinonide-e ...... 64 ...... 100 FENOFIBRATE ...... 55 fluoride (sodium) ...... 69, 124 eszopiclone ...... 39 fenofibrate micronized ...... 55 fluorometholone ...... 114 ethacrynic acid...... 47 fenofibrate nanocrystallized . 55 fluorouracil ...... 16, 59 ethambutol ...... 9 fenofibric acid ...... 55 FLUOROURACIL ...... 59 ethosuximide ...... 25 fenofibric acid (choline) ...... 55 fluoxetine ...... 39, 40 ethynodiol diac-eth estradiol fenoprofen ...... 34 fluphenazine hcl ...... 40 ...... 105 fentanyl ...... 32 flurandrenolide ...... 65 etodolac ...... 34 fentanyl citrate ...... 31 flurazepam ...... 40 etonogestrel-ethinyl estradiol FER-IN-SOL ...... 124 flurbiprofen ...... 35 ...... 102 FERRIPROX ...... 67 flurbiprofen sodium ...... 113 etoposide...... 16 FETZIMA ...... 39 flutamide ...... 16 etravirine...... 3 FIASP FLEXTOUCH U-100 fluticasone propionate .. 65, 119 EUCRISA ...... 59 INSULIN ...... 72 fluticasone propion-salmeterol EUFLEXXA ...... 34 FIASP PENFILL U-100 ...... 119 EURAX ...... 66 INSULIN ...... 72 fluvastatin ...... 55, 56 EVAMIST ...... 100 FIASP U-100 INSULIN ...... 72 fluvoxamine ...... 40 EVENITY...... 96 FIBRYGA ...... 51 FLUZONE HIGHDOSE everolimus (antineoplastic) .. 16 finasteride ...... 122 QUAD 21-22 PF ...... 92 everolimus FINTEPLA ...... 25 FLUZONE QUAD 2021-2022 (immunosuppressive) ...... 16 FIRMAGON KIT W ...... 92 EVOTAZ ...... 3 DILUENT SYRINGE ...... 16 FLUZONE QUAD 2021-2022 EXELDERM ...... 62 flac otic oil ...... 69 (PF) ...... 92 exemestane ...... 16 flavoxate ...... 122 FML FORTE ...... 114 EXONDYS-51 ...... 29 FLEBOGAMMA DIF ...... 91 FML S.O.P...... 114 EYLEA ...... 112 flecainide ...... 44 folic acid ...... 124 ezetimibe ...... 55 FLOLAN ...... 47 FOLOTYN ...... 16 ezetimibe-simvastatin ...... 55 FLORIVA (FLUORIDE- fondaparinux ...... 51 F VITAMIN D3) ...... 124 formoterol fumarate ...... 119 FA-8 ...... 124 FLOVENT DISKUS .. 118, 119 FORTEO ...... 96 FABRAZYME ...... 75 FLOVENT HFA ...... 119 FOSAMAX PLUS D ...... 96 FACTIVE ...... 12 FLUAD QUAD 2021-22(65Y fosamprenavir ...... 3 falmina (28) ...... 105 UP)(PF) ...... 91 fosfomycin tromethamine ..... 13 famciclovir ...... 3 FLUARIX QUAD 2021-2022 fosinopril ...... 47 famotidine...... 86 (PF) ...... 91 fosinopril-hydrochlorothiazide famotidine (pf)...... 86 FLUBLOK QUAD 2021-2022 ...... 47 FANAPT ...... 39 (PF) ...... 91 FRAGMIN ...... 52 FARXIGA ...... 77 FLUCELVAX QUAD 2021- FREESTYLE LIBRE 14 DAY FASENRA ...... 118 2022 ...... 91 SENSOR ...... 71 FASENRA PEN ...... 118 FLUCELVAX QUAD 2021- FREESTYLE LIBRE 2 FASLODEX ...... 16 2022 (PF) ...... 91 SENSOR ...... 71 fayosim ...... 105 fluconazole ...... 1 frovatriptan ...... 28 FC2 FEMALE CONDOM ... 99 flucytosine ...... 1 fulvestrant ...... 16 febuxostat ...... 96 fludarabine ...... 16 furosemide ...... 47 FEIBA NF ...... 51 fludrocortisone ...... 70 FUZEON ...... 3 felbamate ...... 25 FLULAVAL QUAD 2021- fyavolv ...... 100 felodipine ...... 47 2022 (PF) ...... 92 G fem ph ...... 102 fluocinolone ...... 64 g tussin ac ...... 116 FEMCAP ...... 99 fluocinolone acetonide oil .... 69 gabapentin ...... 25 FEMRING ...... 100 fluocinolone and shower cap 64 GALAFOLD ...... 75 femynor ...... 105 fluocinonide ...... 64 galantamine ...... 29

131 GAMASTAN ...... 92 glyburide micronized ...... 77 HETLIOZ LQ ...... 40 GAMASTAN S/D ...... 92 glyburide-metformin ...... 78 HIBERIX (PF) ...... 93 GAMIFANT ...... 16 glycopyrrolate ...... 80 HIZENTRA ...... 93 GAMMAGARD LIQUID .... 92 GLYXAMBI ...... 78 homatropaire ...... 111 GAMMAGARD S-D (IGA < 1 GONITRO ...... 57 HUMALOG JUNIOR MCG/ML) ...... 92 granisetron hcl ...... 82 KWIKPEN U-100 ...... 72 GAMMAKED ...... 92 GRANIX ...... 86, 87 HUMALOG KWIKPEN GAMMAPLEX ...... 92 GRASTEK ...... 92 INSULIN ...... 72 GAMMAPLEX (WITH griseofulvin microsize ...... 1 HUMALOG MIX 50-50 SORBITOL) ...... 92 griseofulvin ultramicrosize ..... 1 INSULN U-100 ...... 72 GAMUNEX-C ...... 92 guaiatussin ac ...... 116 HUMALOG MIX 50-50 GANCICLOVIR ...... 3 guanfacine ...... 40, 47 KWIKPEN ...... 72 ganciclovir sodium ...... 3 GYNAZOLE-1 ...... 102 HUMALOG MIX 75-25 GARDASIL 9 (PF) ...... 92 gynol ii ...... 102 KWIKPEN ...... 72 gatifloxacin ...... 110 H HUMALOG MIX 75-25(U- gavilyte-c ...... 82 HAEGARDA ...... 119 100)INSULN ...... 72 gavilyte-g ...... 82 hailey ...... 105 HUMALOG U-100 INSULIN gavilyte-n ...... 82 hailey 24 fe ...... 105 ...... 72 GAZYVA ...... 16 hailey fe 1.5/30 (28) ...... 105 HUMATE-P ...... 53 gemcitabine ...... 16, 17 hailey fe 1/20 (28) ...... 105 HUMIRA ...... 97 gemfibrozil ...... 56 HALAVEN ...... 17 HUMIRA PEN ...... 97 gemmily ...... 105 halcinonide ...... 65 HUMIRA PEN CROHNS-UC- generlac ...... 82 halobetasol propionate ...... 65 HS START ...... 97 gengraf ...... 17 haloperidol ...... 40 HUMIRA PEN PSOR- GENOTROPIN ...... 87 haloperidol decanoate ...... 40 UVEITS-ADOL HS ...... 97 GENOTROPIN MINIQUICK haloperidol lactate ...... 40 HUMIRA(CF) ...... 98 ...... 87 HARVONI ...... 3 HUMIRA(CF) PEDI gentak ...... 110 HAVRIX (PF) ...... 93 CROHNS STARTER ...... 97 gentamicin ...... 9, 62, 110 heather ...... 100 HUMIRA(CF) PEN ...... 97 gentamicin sulfate (ped) (pf) .. 9 HEMLIBRA ...... 52 HUMIRA(CF) PEN GENVOYA ...... 3 hemmorex-hc ...... 82 CROHNS-UC-HS ...... 97 GIAPREZA ...... 56 HEMOFIL M HIGH ...... 52 HUMIRA(CF) PEN GILENYA ...... 88 HEMOFIL M LOW ...... 52 PEDIATRIC UC ...... 97 GILOTRIF ...... 17 HEMOFIL M MID ...... 52 HUMIRA(CF) PEN PSOR- GIVLAARI...... 67 HEMOFIL M SUPER HIGH52 UV-ADOL HS ...... 97 GLASSIA ...... 67 hep flush-10 (pf) ...... 52 HUMULIN 70/30 U-100 glatiramer ...... 88 heparin (porcine) ...... 52 INSULIN ...... 72 glatopa ...... 88 heparin (porcine) in 5 % dex 52 HUMULIN 70/30 U-100 GLEOSTINE ...... 17 heparin lock flush (porcine) . 52 KWIKPEN ...... 73 glimepiride ...... 77 heparin lockflush(porcine)(pf) HUMULIN N NPH INSULIN glipizide ...... 77 ...... 52 KWIKPEN ...... 73 glipizide-metformin ...... 77 heparin(porcine) in 0.45% nacl HUMULIN N NPH U-100 GLUCAGEN DIAGNOSTIC ...... 52 INSULIN ...... 73 KIT ...... 71 HEPARIN(PORCINE) IN HUMULIN R REGULAR U- GLUCAGEN HYPOKIT ..... 71 0.45% NACL ...... 52 100 INSULN ...... 73 GLUCAGON (HCL) heparin, porcine (pf) ...... 52, 53 HUMULIN R U-500 (CONC) EMERGENCY KIT ...... 71 HEPLISAV-B (PF)...... 93 INSULIN ...... 73 glucagon emergency kit HERCEPTIN ...... 17 HUMULIN R U-500 (CONC) (human) ...... 71 HERCEPTIN HYLECTA .... 17 KWIKPEN ...... 73 GLUCAGON HCL ...... 71 HERZUMA ...... 17 HYCAMTIN ...... 17 glyburide...... 77 HETLIOZ ...... 40 hydralazine ...... 47

132 hydrochlorothiazide ...... 47 imipramine hcl ...... 40 IXINITY ...... 53 hydrocodone bitartrate...... 32 imipramine pamoate ...... 40 J hydrocodone-acetaminophen 32 imiquimod ...... 90 jaimiess ...... 105 hydrocodone-chlorpheniramine IMLYGIC ...... 17 JAKAFI ...... 18 ...... 116 IMOVAX RABIES VACCINE jantoven ...... 53 hydrocodone-homatropine . 116 (PF) ...... 93 JANUMET ...... 78 hydrocodone-ibuprofen ...... 32 incassia ...... 101 JANUMET XR ...... 78 hydrocortisone ...... 65, 70, 82 INCRELEX ...... 67 JANUVIA ...... 78 hydrocortisone acetate ...... 82 INCRUSE ELLIPTA ...... 119 JARDIANCE ...... 78 hydrocortisone butyrate ...... 65 indapamide ...... 47 jasmiel (28) ...... 105 hydrocortisone butyr-emollient indomethacin ...... 35 jencycla ...... 101 ...... 65 INFANRIX (DTAP) (PF) ..... 93 JENTADUETO ...... 78 hydrocortisone valerate ...... 65 INFED ...... 125 JENTADUETO XR ...... 78 hydrocortisone-acetic acid.... 69 INFLECTRA ...... 83 JEVTANA ...... 18 hydrocortisone-pramoxine .. 58, INFUGEM ...... 18 jinteli ...... 101 83 INLYTA ...... 18 JIVI ...... 53 hydromet...... 116 INSULIN ASP PRT-INSULIN jolessa ...... 105 hydromorphone ...... 32 ASPART ...... 73 JORNAY PM ...... 40 HYDROMORPHONE ...... 32 INSULIN ASPART U-100 .. 73 JUBLIA ...... 62 hydroxocobalamin ...... 124 INSULIN SYRINGE- juleber ...... 105 hydroxychloroquine ...... 9 NEEDLE U-100 ...... 71 JULUCA ...... 3 hydroxyprogest(pf)(preg presv) INTELENCE ...... 3 junel 1.5/30 (21) ...... 105 ...... 100 INTRAROSA ...... 102 junel 1/20 (21) ...... 105 hydroxyprogesterone INTRON A ...... 90 junel fe 1.5/30 (28) ...... 105 cap(ppres) ...... 100 INVANZ ...... 9 junel fe 1/20 (28) ...... 105 hydroxyprogesterone caproate INVEGA SUSTENNA ...... 40 junel fe 24 ...... 105 ...... 101 INVELTYS ...... 114 JUXTAPID ...... 56 hydroxyurea ...... 17 INVIRASE ...... 3 JYNARQUE ...... 75 hydroxyzine hcl ...... 116 IOPIDINE ...... 115 K hydroxyzine pamoate ...... 116 IPOL ...... 93 KADCYLA ...... 18 hyophen ...... 122 ipratropium bromide ..... 69, 119 kaitlib fe ...... 105 hyoscyamine sulfate ...... 80 ipratropium-albuterol ...... 119 KALBITOR ...... 119 hyosyne ...... 80 irbesartan ...... 47 KALETRA ...... 3, 4 HYQVIA ...... 93 irbesartan-hydrochlorothiazide kalliga ...... 105 I ...... 47 KALYDECO ...... 119 ibandronate ...... 96 IRESSA ...... 18 KANJINTI ...... 18 IBRANCE ...... 17 ISENTRESS ...... 3 KANUMA ...... 75 ibu ...... 35 ISENTRESS HD ...... 3 kariva (28) ...... 105 ibuprofen ...... 35 isibloom ...... 105 kelnor 1/35 (28) ...... 105 icatibant ...... 119 ISOLYTE-S ...... 124 kelnor 1-50 (28) ...... 105 iclevia ...... 105 isoniazid ...... 9 KEPIVANCE ...... 13 ICLUSIG ...... 17 isosorbide dinitrate ...... 57 ketoconazole ...... 1, 62 icosapent ethyl ...... 56 isosorbide mononitrate ...... 57 ketodan ...... 62 IDELVION ...... 53 isotretinoin ...... 60 ketoprofen ...... 35 IDHIFA ...... 17 isoxsuprine ...... 102 ketorolac ...... 35, 113 ILARIS (PF) ...... 90 isradipine ...... 47 KEVZARA ...... 98 ILUMYA ...... 58 ISTODAX ...... 18 KEYTRUDA ...... 18 imatinib ...... 17 itraconazole ...... 1 KINRIX (PF) ...... 93 IMBRUVICA ...... 17 ivermectin ...... 9, 66 KISQALI ...... 18 IMFINZI ...... 17 IXEMPRA ...... 18 KISQALI FEMARA CO- imipenem-cilastatin ...... 9 IXIARO (PF) ...... 93 PACK ...... 18

133 klor-con ...... 123 letrozole ...... 19 liothyronine ...... 79 klor-con 10 ...... 123 leucovorin calcium ...... 13 LIPOFEN ...... 56 klor-con 8 ...... 123 LEUKERAN ...... 19 lisinopril ...... 47 klor-con m10 ...... 123 LEUKINE ...... 87 lisinopril-hydrochlorothiazide klor-con m15 ...... 123 leuprolide ...... 19 ...... 47 klor-con m20 ...... 123 levalbuterol hcl ...... 119 lithium carbonate ...... 40, 41 klor-con/ef ...... 123 LEVALBUTEROL LO LOESTRIN FE ...... 106 KLOXXADO ...... 35 TARTRATE ...... 119 lojaimiess ...... 106 KOATE ...... 53 LEVEMIR FLEXTOUCH U- LONSURF ...... 19 KOGENATE FS ...... 53 100 INSULN ...... 73 loperamide ...... 80 KORLYM ...... 75 LEVEMIR U-100 INSULIN 73 lopinavir-ritonavir ...... 4 KOVALTRY ...... 53 levetiracetam ...... 25 lorazepam ...... 41 K-PHOS NO 2 ...... 122 levobunolol ...... 111 lorazepam intensol ...... 41 K-PHOS ORIGINAL ...... 123 levocarnitine ...... 67 loryna (28) ...... 106 KRYSTEXXA ...... 96 levocarnitine (with sugar) ..... 67 losartan ...... 47 k-tab ...... 123 levocetirizine ...... 116 losartan-hydrochlorothiazide 47 K-TAB ...... 123 levofloxacin ...... 12, 110 LOTEMAX ...... 114 kurvelo (28) ...... 106 levonest (28) ...... 106 loteprednol etabonate ...... 114 KYLEENA ...... 99 levonorgestrel ...... 106 lovastatin ...... 56 KYMRIAH ...... 18 levonorgestrel-ethinyl estrad low-ogestrel (28) ...... 106 KYPROLIS ...... 18 ...... 106 loxapine succinate ...... 41 L levonorg-eth estrad triphasic lo-zumandimine (28) ...... 106 l norgest/e.estradiol-e.estrad ...... 106 LUCENTIS ...... 112 ...... 106 levora-28 ...... 106 ludent fluoride ...... 125 labetalol ...... 47 levorphanol tartrate ...... 32 LULICONAZOLE ...... 62 LACRISERT ...... 112 levothyroxine ...... 79 LUMIGAN ...... 113 lactulose ...... 83 levoxyl ...... 79 LUMIZYME ...... 76 lamivudine ...... 4 LEVULAN ...... 59 LUMOXITI ...... 19 lamivudine-zidovudine ...... 4 LEXIVA ...... 4 LUPANETA PACK (1 lamotrigine ...... 25 LIBTAYO ...... 19 MONTH) ...... 102 lansoprazole ...... 86 lidocaine ...... 61 LUPANETA PACK (3 lanthanum ...... 83 lidocaine hcl ...... 61 MONTH) ...... 102 LANTUS SOLOSTAR U-100 lidocaine hcl-hydrocortison ac LUPKYNIS ...... 19 INSULIN ...... 73 ...... 61, 83 LUPRON DEPOT ...... 19 LANTUS U-100 INSULIN .. 73 LIDOCAINE HCL- LUPRON DEPOT (3 lapatinib ...... 18 HYDROCORTISON AC . 83 MONTH) ...... 19 larin 1.5/30 (21) ...... 106 lidocaine viscous ...... 61 LUPRON DEPOT (4 larin 1/20 (21) ...... 106 lidocaine-hydrocortisone-aloe MONTH) ...... 19 larin 24 fe ...... 106 ...... 83 LUPRON DEPOT (6 larin fe 1.5/30 (28) ...... 106 lidocaine-prilocaine ...... 61 MONTH) ...... 19 larin fe 1/20 (28) ...... 106 LIDOCAINE-TETRACAINE LUPRON DEPOT-PED ...... 19 larissia...... 106 ...... 61 LUPRON DEPOT-PED (3 LASTACAFT ...... 112 LILETTA ...... 99 MONTH) ...... 19 latanoprost ...... 113 lillow (28) ...... 106 lutera (28) ...... 106 LATUDA ...... 40 LINCOCIN ...... 9 LUXTURNA ...... 112 layolis fe ...... 106 lindane ...... 66 LUZU ...... 62 leena 28 ...... 106 linezolid ...... 9 lyleq ...... 101 leflunomide...... 98 linezolid in dextrose 5% ...... 9 lyllana ...... 101 LEMTRADA ...... 88 linezolid-0.9% sodium chloride LYNPARZA ...... 19 LENVIMA ...... 18 ...... 9 LYRICA CR ...... 25 lessina ...... 106 LINZESS ...... 83 LYSODREN ...... 19

134 lyza ...... 101 meprobamate ...... 30 microgestin fe 1.5/30 (28) .. 107 M MEPSEVII ...... 76 microgestin fe 1/20 (28) ..... 107 mafenide acetate ...... 62 mercaptopurine ...... 20 midazolam ...... 41 malathion ...... 66 meropenem ...... 9 midodrine ...... 67 maprotiline ...... 41 MEROPENEM-0.9% migergot ...... 28 marlissa (28) ...... 106 SODIUM CHLORIDE ...... 9 miglitol ...... 78 MARPLAN ...... 41 merzee ...... 106 miglustat ...... 76 MARQIBO ...... 19 mesalamine ...... 83 mili ...... 107 MATULANE ...... 19 mesalamine with cleansing millipred ...... 70 matzim la ...... 47 wipe ...... 83 millipred dp ...... 70 MAVENCLAD (10 TABLET metaproterenol ...... 119 mimvey ...... 101 PACK) ...... 88 metaxalone ...... 30 MINITRAN ...... 57 MAVENCLAD (4 TABLET metformin ...... 78 minocycline ...... 12 PACK) ...... 88 methadone ...... 32 minoxidil ...... 48 MAVENCLAD (5 TABLET methadose ...... 32 MIRCERA ...... 87 PACK) ...... 88 methamphetamine ...... 41 MIRENA ...... 99 MAVENCLAD (6 TABLET methazolamide ...... 113 mirtazapine ...... 41 PACK) ...... 88 methenamine hippurate ...... 13 misoprostol ...... 86 MAVENCLAD (7 TABLET methenamine mandelate ...... 13 MITIGARE ...... 96 PACK) ...... 88 methen-sod phos-meth blue- mitoxantrone ...... 20 MAVENCLAD (8 TABLET hyos ...... 123 M-M-R II (PF) ...... 93 PACK) ...... 88 methergine ...... 110 modafinil ...... 41 MAVENCLAD (9 TABLET methimazole ...... 71 moexipril ...... 48 PACK) ...... 88 methocarbamol ...... 30 molindone ...... 41 MAVYRET ...... 4 methotrexate sodium ...... 20 mometasone ...... 65 MAXIDEX ...... 114 methotrexate sodium (pf) ..... 20 mondoxyne nl ...... 12 maxi-tuss ac ...... 116 methoxsalen ...... 59 mono-linyah ...... 107 MAYZENT ...... 88 methscopolamine ...... 80 MONONINE ...... 53 MAYZENT STARTER PACK methyldopa ...... 47 MONOVISC ...... 35 ...... 88 methyldopa- montelukast ...... 119 m-clear wc ...... 116 hydrochlorothiazide ...... 47 morphine ...... 32, 33 meclizine ...... 83 methyldopate ...... 48 morphine (pf) ...... 32 meclofenamate ...... 35 methylergonovine ...... 110 morphine concentrate ...... 32 medroxyprogesterone ...... 101 METHYLIN ...... 41 MOTOFEN ...... 81 mefenamic acid ...... 35 methylphenidate hcl ...... 41 MOVANTIK ...... 83 mefloquine ...... 9 methylprednisolone ...... 70 MOXATAG ...... 11 megestrol ...... 19 methylprednisolone acetate .. 70 moxifloxacin ...... 12, 110 MEKINIST ...... 19 methyltestosterone ...... 76 MOZOBIL ...... 87 MEKTOVI ...... 19 metoclopramide hcl ...... 83 MULPLETA ...... 53 meloxicam ...... 35 metolazone ...... 48 MULTAQ ...... 44 melphalan ...... 19 metoprolol succinate ...... 48 multi-vitamin with fluoride 125 melphalan hcl ...... 19 metoprolol ta-hydrochlorothiaz multivitamins with fluoride 125 memantine ...... 29 ...... 48 mupirocin ...... 62 MENACTRA (PF) ...... 93 metoprolol tartrate ...... 48 mupirocin calcium ...... 62 MENEST ...... 101 metronidazole ..... 9, 60, 61, 102 mvc-fluoride ...... 125 MENOSTAR ...... 101 metyrosine ...... 48 my choice ...... 107 MENQUADFI (PF) ...... 93 mexiletine ...... 44 my way ...... 107 MENTAX ...... 62 MIACALCIN ...... 76 MYALEPT ...... 76 MENVEO A-C-Y-W-135-DIP mibelas 24 fe ...... 107 MYCAMINE ...... 1 (PF) ...... 93 microgestin 1.5/30 (21) ...... 107 mycophenolate mofetil ...... 20 meperidine ...... 32 microgestin 1/20 (21) ...... 107 mycophenolate sodium ...... 20

135 MYDAYIS ...... 41 nicorette ...... 68 NOVOLIN R FLEXPEN ...... 74 MYLOTARG ...... 20 nicotine ...... 68 NOVOLOG FLEXPEN U-100 MYOBLOC ...... 93 nicotine (polacrilex) ...... 68 INSULIN ...... 74 myorisan ...... 61 NICOTROL ...... 68 NOVOLOG MIX 70-30 U-100 MYRBETRIQ ...... 122 NICOTROL NS ...... 68 INSULN ...... 74 N nifedipine ...... 48 NOVOLOG MIX 70- nabumetone ...... 35 nikki (28) ...... 107 30FLEXPEN U-100 ...... 74 nadolol ...... 48 nilutamide ...... 20 NOVOLOG PENFILL U-100 nadolol-bendroflumethiazide 48 nimodipine ...... 48 INSULIN ...... 74 nafcillin...... 11 NINLARO ...... 20 NOVOLOG U-100 INSULIN nafcillin in dextrose iso-osm 11 nisoldipine ...... 48 ASPART ...... 74 naftifine ...... 63 nitazoxanide ...... 9 NOVOPEN ECHO ...... 72 NAGLAZYME...... 76 nitisinone ...... 67 NOVOSEVEN RT ...... 53 nalbuphine ...... 35 nitro-bid ...... 57 NOXAFIL ...... 1 naloxone ...... 35 NITRO-DUR ...... 57 np thyroid ...... 79 naltrexone ...... 35 nitrofurantoin ...... 13 NPLATE ...... 53 naproxen ...... 35 nitrofurantoin macrocrystal .. 13 NUCALA ...... 119 naproxen sodium ...... 35 nitrofurantoin monohyd/m- NUCYNTA ER ...... 36 naratriptan...... 28 cryst ...... 13 NUEDEXTA ...... 29 NARCAN ...... 35 nitroglycerin ...... 57 NULOJIX ...... 20 NATACYN ...... 110 nitroglycerin in 5 % dextrose 57 NULYTELY LEMON-LIME NATAZIA ...... 107 nitro-time ...... 57 ...... 84 nateglinide ...... 78 NITYR ...... 67 NUPLAZID ...... 42 NATPARA ...... 76 NIVESTYM ...... 87 NUWIQ ...... 53 nebusal ...... 119 nizatidine ...... 86 nyamyc ...... 63 necon 0.5/35 (28)...... 107 nora-be ...... 101 nylia 7/7/7 (28) ...... 107 nefazodone ...... 41 noreth-ethinyl estradiol-iron nymyo ...... 108 neomycin ...... 9 ...... 107 nystatin ...... 1, 63 neomycin-bacitracin-poly-hc norethindrone (contraceptive) nystatin-triamcinolone ...... 63 ...... 113 ...... 101 nystop ...... 63 neomycin-bacitracin- norethindrone acetate ...... 101 O polymyxin ...... 110 norethindrone ac-eth estradiol OBIZUR ...... 54 neomycin-polymyxin b- ...... 101, 107 ocella ...... 108 dexameth ...... 113 norethindrone-e.estradiol-iron OCREVUS ...... 89 neomycin-polymyxin- ...... 107 OCTAGAM ...... 93 gramicidin...... 110 norgestimate-ethinyl estradiol octreotide acetate ...... 20 neomycin-polymyxin-hc ..... 69, ...... 107 ODEFSEY ...... 4 113 norlyda ...... 101 OFEV ...... 120 neo-polycin ...... 110 NORMOSOL-R ...... 124 ofloxacin ...... 12, 69, 110 neo-polycin hc ...... 114 NORPACE CR ...... 44 OGIVRI ...... 20 NERLYNX ...... 20 nortrel 0.5/35 (28) ...... 107 olanzapine ...... 42 NEUPOGEN ...... 87 nortrel 1/35 (21) ...... 107 olanzapine-fluoxetine ...... 42 NEVANAC ...... 113 nortrel 1/35 (28) ...... 107 olmesartan ...... 48 nevirapine ...... 4 nortrel 7/7/7 (28) ...... 107 olmesartan-amlodipin- new day ...... 107 nortriptyline ...... 42 hcthiazid ...... 48 NEXAVAR ...... 20 NORVIR ...... 4 olmesartan- NEXPLANON ...... 102 NOVAFERRUM ...... 125 hydrochlorothiazide ...... 48 NEXTSTELLIS ...... 107 NOVOEIGHT ...... 53 olopatadine ...... 69, 112 niacin ...... 56 NOVOLIN 70-30 FLEXPEN OLUMIANT ...... 98 NIACOR ...... 56 U-100 ...... 73 omega-3 acid ethyl esters ..... 56 nicardipine ...... 48 NOVOLIN N FLEXPEN ..... 73 omeprazole ...... 86

136 OMIDRIA ...... 112 OXYCONTIN ...... 33 phenelzine ...... 42 OMNITROPE...... 87 oxymorphone ...... 33 phenobarb-hyoscy-atropine- ONCASPAR ...... 20 OZEMPIC ...... 78 scop ...... 81 ondansetron ...... 84 OZURDEX ...... 114 phenobarbital ...... 25, 26 ondansetron hcl ...... 84 P phenohytro ...... 81 ONETOUCH ULTRA TEST pacerone ...... 44 phenoxybenzamine ...... 48 ...... 71 PADCEV ...... 20 phenylephrine hcl ...... 115 ONETOUCH VERIO TEST paliperidone ...... 42 phenytoin ...... 26 STRIPS ...... 71 PALYNZIQ ...... 76 phenytoin sodium extended .. 26 ONIVYDE ...... 20 pamidronate ...... 76 PHEXXI ...... 102 ONPATTRO...... 29 PANRETIN ...... 59 philith ...... 108 ONZETRA XSAIL ...... 28 pantoprazole ...... 86 phosphasal ...... 123 opcicon one-step ...... 108 PANZYGA ...... 93 PHYSIOLYTE ...... 66 OPDIVO ...... 20 PARAGARD T 380A ...... 99 PHYSIOSOL IRRIGATION 66 opium tincture ...... 81 paricalcitol ...... 76 phytonadione (vitamin k1) ... 54 OPSUMIT ...... 120 PARICALCITOL ...... 76 PICATO ...... 59 option-2 ...... 108 paroex oral rinse ...... 69 pilocarpine hcl ...... 67, 69, 111 ORALAIR ...... 93 paromomycin ...... 10 pimecrolimus ...... 59 oralone ...... 69 paroxetine hcl ...... 42 pimozide ...... 42 ORAVIG ...... 1 paroxetine pimtrea (28) ...... 108 ORENCIA ...... 98 mesylate(menop.sym) ...... 42 pindolol ...... 48 ORENCIA (WITH PARSABIV ...... 76 pioglitazone ...... 78 MALTOSE) ...... 98 PASER ...... 10 pioglitazone-glimepiride ...... 78 ORENCIA CLICKJECT ...... 98 PEDIARIX (PF) ...... 94 pioglitazone-metformin ...... 78 ORENITRAM ...... 48 PEDVAX HIB (PF) ...... 94 piperacillin-tazobactam ...... 11 ORLADEYO ...... 120 peg 3350-electrolytes ...... 84 PIQRAY ...... 21 orphenadrine citrate ...... 30 peg3350-sod sul-nacl-kcl-asb-c pirmella ...... 108 orsythia ...... 108 ...... 84 piroxicam ...... 36 ORTHOVISC ...... 36 PEGASYS ...... 89 PLASMA-LYTE 148 ...... 124 oscimin ...... 81 peg-electrolyte soln ...... 84 PLASMA-LYTE A ...... 124 oscimin sl ...... 81 peg-prep ...... 84 PLEGRIDY ...... 89 oscimin sr ...... 81 PEMAZYRE ...... 20 PLENVU ...... 84 oseltamivir ...... 4 PEN NEEDLE, DIABETIC . 72 PNEUMOVAX-23 ...... 94 OSMOPREP ...... 84 penicillamine ...... 98 podofilox ...... 59 OSPHENA ...... 102 penicillin g procaine ...... 11 POLIVY ...... 21 OTEZLA ...... 98 penicillin v potassium ...... 11 polycin ...... 110 OTEZLA STARTER ...... 98 PENTACEL (PF) ...... 94 polymyxin b sulfate ...... 10 OTOVEL ...... 69 PENTACEL ACTHIB polymyxin b sulf-trimethoprim oxacillin ...... 11 COMPONENT (PF) ...... 94 ...... 110 oxacillin in dextrose(iso-osm) PENTAM ...... 10 POMALYST ...... 89 ...... 11 pentamidine ...... 10 PONVORY ...... 89 oxandrolone ...... 76 pentazocine-naloxone ...... 36 PONVORY 14-DAY oxaprozin ...... 36 pentoxifylline ...... 54 STARTER PACK ...... 89 oxazepam ...... 42 PERFOROMIST ...... 120 portia 28 ...... 108 oxcarbazepine ...... 25 perindopril erbumine ...... 48 PORTRAZZA ...... 21 oxiconazole...... 63 periogard ...... 69 posaconazole ...... 1 OXISTAT ...... 63 PERJETA ...... 20 potassium chloride ...... 124 OXLUMO ...... 123 permethrin ...... 66 potassium citrate ...... 123 oxybutynin chloride...... 122 perphenazine ...... 42 POTELIGEO ...... 21 oxycodone ...... 33 perphenazine-amitriptyline ... 42 pramipexole ...... 27 oxycodone-acetaminophen ... 33 phenazopyridine ...... 123 prasugrel ...... 54

137 pravastatin ...... 56 promethazine-phenylephrine RECLAST ...... 67 praziquantel ...... 10 ...... 117 reclipsen (28) ...... 108 prazosin ...... 48 promethegan ...... 116 RECOMBINATE ...... 54 PRED MILD ...... 114 propafenone ...... 44, 45 RECOMBIVAX HB (PF) ..... 94 prednicarbate ...... 65 proparacaine ...... 112 RECTIV ...... 84 prednisolone ...... 70 propranolol ...... 48, 49 REGRANEX ...... 59 prednisolone acetate ...... 114 propranolol-hydrochlorothiazid RELENZA DISKHALER ...... 4 prednisolone sodium phosphate ...... 49 RELEXXII ...... 42 ...... 70, 114 propylthiouracil ...... 71 RELION NOVOLIN 70/30 .. 74 prednisone ...... 70, 71 PROQUAD (PF)...... 94 RELION NOVOLIN N ...... 74 prednisone intensol ...... 70 protriptyline ...... 42 RELION NOVOLIN R ...... 74 pregabalin ...... 26 PROVENGE ...... 94 RELISTOR ...... 84 PREMARIN ...... 101 prudoxin ...... 59 REMICADE ...... 84 PREMPHASE ...... 101 pulmosal ...... 120 RENACIDIN ...... 123 PREMPRO ...... 101 PULMOZYME ...... 120 RENFLEXIS ...... 84 prevalite ...... 56 pyrazinamide ...... 10 repaglinide ...... 78 previfem ...... 108 pyridostigmine bromide ...... 30 repaglinide-metformin ...... 78 PREVNAR 13 (PF) ...... 94 pyrimethamine ...... 10 REPATHA PUSHTRONEX 56 PREVYMIS ...... 4 Q REPATHA SURECLICK .... 56 PREZCOBIX ...... 4 QBRELIS ...... 49 REPATHA SYRINGE ...... 56 PREZISTA ...... 4 QINLOCK ...... 21 RESTASIS ...... 112 PRIFTIN ...... 10 QTERN ...... 78 RETEVMO ...... 21 primaquine ...... 10 QUADRACEL (PF) ...... 94 RETISERT ...... 114 primidone ...... 26 quetiapine ...... 42 REVATIO ...... 120 PRIMSOL ...... 13 QUILLICHEW ER ...... 42 REVLIMID ...... 89 PRIVIGEN ...... 94 QUILLIVANT XR ...... 42 REXULTI ...... 43 probenecid ...... 96 quinapril ...... 49 REYATAZ ...... 4 probenecid-colchicine ...... 96 quinapril-hydrochlorothiazide RHOPRESSA ...... 113 procainamide ...... 44 ...... 49 RIASTAP ...... 54 procentra ...... 42 quinidine gluconate ...... 45 ribavirin ...... 4, 89 prochlorperazine ...... 84 quinidine sulfate ...... 45 RIDAURA ...... 98 prochlorperazine edisylate.... 84 quinine sulfate ...... 10 rifabutin ...... 10 prochlorperazine maleate ..... 84 quit 2 ...... 68 rifampin ...... 10 PROCRIT ...... 87 quit 4 ...... 68 riluzole ...... 67 procto-med hc ...... 84 QVAR REDIHALER ...... 120 rimantadine ...... 4 procto-pak...... 84 R RINVOQ ...... 98 proctosol hc ...... 84 RABAVERT (PF) ...... 94 RIOMET ER ...... 79 proctozone-hc ...... 84 rabeprazole ...... 86 risedronate ...... 67, 96 PROFILNINE ...... 54 RADICAVA ...... 29 RISPERDAL CONSTA ...... 43 progesterone ...... 101 RAGWITEK ...... 94 risperidone ...... 43 progesterone micronized .... 101 raloxifene ...... 96 ritonavir ...... 4 PROGRAF ...... 21 ramelteon ...... 42 RITUXAN ...... 21 PROLASTIN-C ...... 67 ramipril ...... 49 RITUXAN HYCELA ...... 21 PROLEUKIN ...... 90 ranolazine ...... 57 rivastigmine ...... 30 PROLIA ...... 96 RAPIVAB (PF) ...... 4 rivastigmine tartrate ...... 29 PROMACTA ...... 54 rasagiline ...... 27 rivelsa ...... 108 promethazine ...... 116 RAVICTI ...... 67 RIXUBIS ...... 54 promethazine-codeine ...... 116 REBIF (WITH ALBUMIN) . 89 rizatriptan ...... 28 promethazine-dm ...... 117 REBIF REBIDOSE ...... 89 ropinirole ...... 27, 28 promethazine-phenyleph- REBIF TITRATION PACK . 89 rosadan ...... 61 codeine ...... 117 REBINYN ...... 54 rosuvastatin ...... 56

138 roweepra ...... 26 sodium chloride 0.45 % ...... 124 sucralfate ...... 86 RUBRACA ...... 21 sodium chloride 0.9 % ...... 67 sulfacetamide sodium ... 58, 115 RUCONEST ...... 120 sodium fluoride 5000 dry sulfacetamide sodium (acne) 62 rufinamide ...... 26 mouth ...... 69 sulfacetamide-prednisolone 115 RYBELSUS ...... 79 sodium fluoride 5000 plus .... 69 sulfadiazine ...... 12 RYDAPT ...... 21 sodium fluoride-pot nitrate ... 69 sulfamethoxazole-trimethoprim S sodium phenylbutyrate ...... 67 ...... 12 salsalate ...... 36 sodium polystyrene sulfonate SULFAMYLON ...... 62 SAMSCA ...... 76 ...... 85 sulfasalazine ...... 85 SANTYL ...... 66 solifenacin ...... 122 sulfatrim ...... 12 sapropterin ...... 76 SOLIQUA 100/33 ...... 74 sulindac ...... 36 SARCLISA ...... 21 SOLIRIS ...... 67 sumatriptan ...... 28 SAVELLA ...... 98 SOLTAMOX ...... 21 sumatriptan succinate ..... 28, 29 scalacort ...... 65 SOMATULINE DEPOT ...... 21 SUNOSI ...... 43 SCENESSE ...... 59 SOMAVERT ...... 76 SUPPRELIN LA ...... 21 scopolamine base...... 84 sorine ...... 45 SUPRAX ...... 7 seconal sodium ...... 43 sotalol ...... 45 SUPREP BOWEL PREP KIT selegiline hcl ...... 28 sotalol af ...... 45 ...... 85 selenium sulfide...... 58 SOVALDI ...... 5 SUTENT ...... 22 SELZENTRY ...... 5 spinosad ...... 66 syeda ...... 108 SEREVENT DISKUS ...... 120 SPIRIVA RESPIMAT ...... 120 SYLVANT ...... 22 SEROSTIM ...... 87 SPIRIVA WITH symax fastabs ...... 81 sertraline ...... 43 HANDIHALER ...... 120 symax-sl ...... 81 setlakin ...... 108 spironolactone ...... 49 symax-sr ...... 81 sevelamer carbonate ...... 85 spironolacton-hydrochlorothiaz SYMBICORT ...... 120 sevelamer hcl ...... 85 ...... 49 SYMDEKO ...... 121 sf 69 SPRAVATO ...... 43 SYMLINPEN 120 ...... 79 sf 5000 plus ...... 69 sprintec (28) ...... 108 SYMLINPEN 60 ...... 79 sharobel ...... 102 SPRYCEL ...... 21 SYMPAZAN ...... 26 SHINGRIX (PF) ...... 94 sps (with sorbitol) ...... 85 SYNAGIS ...... 5 SIGNIFOR ...... 21 sronyx ...... 108 SYNAREL ...... 76 sildenafil (pulm.hypertension) ssd ...... 59 SYNERA ...... 61 ...... 120 SSKI ...... 71 SYNJARDY ...... 79 SILIQ ...... 58 st joseph aspirin ...... 36 SYNJARDY XR ...... 79 silodosin ...... 122 st. joseph aspirin ...... 36 SYNRIBO ...... 22 silver sulfadiazine ...... 59 STAMARIL (PF) ...... 94 SYNTHROID ...... 79 SIMBRINZA ...... 113 stavudine ...... 5 T simliya (28) ...... 108 STELARA ...... 58 TABLOID ...... 22 simpesse ...... 108 STIOLTO RESPIMAT...... 120 tacrolimus ...... 22, 59 SIMPONI ...... 98 STIVARGA ...... 21 tadalafil ...... 122 SIMPONI ARIA ...... 98 stop smoking aid ...... 68 tadalafil (pulm. hypertension) SIMULECT ...... 21 STRENSIQ ...... 76 ...... 121 simvastatin ...... 56 STREPTOMYCIN ...... 10 TAFINLAR ...... 22 SINUVA ...... 120 STRIBILD ...... 5 TAGRISSO ...... 22 sirolimus ...... 21 STRIVERDI RESPIMAT .. 120 TAKHZYRO ...... 121 SIRTURO ...... 10 SUBLOCADE ...... 33 TALTZ AUTOINJECTOR .. 58 SIVEXTRO ...... 10 subvenite ...... 26 TALTZ AUTOINJECTOR (2 SKYLA ...... 99 subvenite starter (blue) kit .... 26 PACK) ...... 58 SKYRIZI ...... 58 subvenite starter (green) kit .. 26 TALTZ AUTOINJECTOR (3 SLYND ...... 108 subvenite starter (orange) kit 26 PACK) ...... 58 sodium chloride ...... 120 SUCRAID ...... 85 TALTZ SYRINGE ...... 58

139 TALZENNA...... 22 tiagabine ...... 26 tretinoin (antineoplastic) ...... 22 tamoxifen ...... 22 TIBSOVO ...... 22 tretinoin microspheres ...... 61 tamsulosin ...... 122 tilia fe ...... 108 TRETTEN ...... 54 TARGRETIN ...... 22 timolol maleate ...... 49, 111 TREXALL ...... 22 tarina 24 fe ...... 108 tinidazole ...... 10 tri femynor ...... 108 tarina fe 1/20 (28) ...... 108 TIVICAY ...... 5 triamcinolone acetonide . 65, 69, TASIGNA ...... 22 TIVICAY PD ...... 5 71 tavaborole ...... 63 tizanidine ...... 30 triamterene ...... 49 tazarotene ...... 61 TOBRADEX ...... 114 triamterene-hydrochlorothiazid tazicef ...... 7 TOBRADEX ST ...... 114 ...... 49 taztia xt ...... 49 tobramycin ...... 10, 111 triazolam ...... 43 TDVAX ...... 95 tobramycin in 0.225 % nacl .. 10 triderm ...... 65 TECENTRIQ ...... 22 tobramycin sulfate ...... 10 trientine ...... 67 TEFLARO ...... 7 TOBRAMYCIN WITH tri-estarylla ...... 108 TEKTURNA HCT ...... 49 NEBULIZER ...... 10 trifluoperazine ...... 43 telmisartan ...... 49 tobramycin-dexamethasone 114 trifluridine ...... 111 telmisartan-amlodipine ...... 49 TOBREX ...... 111 trihexyphenidyl ...... 28 telmisartan-hydrochlorothiazid TODAY CONTRACEPTIVE TRIJARDY XR ...... 71 ...... 49 SPONGE ...... 102 TRIKAFTA ...... 121 temazepam ...... 43 tolcapone ...... 28 tri-legest fe ...... 108 TEMODAR ...... 22 tolmetin ...... 36 tri-linyah ...... 108 temozolomide ...... 22 tolterodine ...... 122 tri-lo-estarylla ...... 109 temsirolimus ...... 22 topiramate ...... 26 tri-lo-marzia ...... 109 tencon ...... 33 toremifene ...... 22 tri-lo-mili ...... 109 TENIVAC (PF) ...... 95 TORISEL ...... 22 tri-lo-sprintec ...... 109 tenofovir disoproxil fumarate . 5 torsemide ...... 49 trilyte with flavor packets ..... 85 TEPEZZA...... 76 TOUJEO MAX U-300 trimethobenzamide ...... 85 terazosin ...... 49 SOLOSTAR ...... 74 trimethoprim ...... 13 terbinafine hcl ...... 1 TOUJEO SOLOSTAR U-300 tri-mili ...... 109 terbutaline ...... 121 INSULIN ...... 74 trimipramine ...... 43 terconazole ...... 102 TRACLEER ...... 121 TRINTELLIX ...... 43 testosterone ...... 77 TRADJENTA ...... 79 tri-nymyo ...... 109 testosterone cypionate ...... 76 tramadol ...... 36 tri-previfem (28) ...... 109 testosterone enanthate ...... 77 tramadol-acetaminophen ...... 36 tri-sprintec (28) ...... 109 TETANUS,DIPHTHERIA trandolapril ...... 49 TRIUMEQ ...... 5 TOX PED(PF) ...... 95 trandolapril-verapamil ...... 49 tri-vitamin with fluoride ..... 125 tetrabenazine...... 30 tranexamic acid ...... 54, 102 trivora (28) ...... 109 tetracaine hcl ...... 112 tranylcypromine ...... 43 tri-vylibra ...... 109 TETRACAINE HCL (PF) .. 112 travoprost ...... 113 tri-vylibra lo ...... 109 tetracycline ...... 12 trazodone ...... 43 TROGARZO ...... 5 THALOMID...... 22 TREANDA ...... 22 tropicamide ...... 111 theophylline ...... 121 TRECATOR ...... 10 trospium ...... 122 thioridazine ...... 43 TRELEGY ELLIPTA ...... 121 TRULICITY ...... 79 thiothixene ...... 43 TRELSTAR ...... 22 TRUMENBA ...... 95 THYMOGLOBULIN ...... 95 TREMFYA ...... 59 TRUXIMA ...... 22 THYROLAR-1 ...... 79 TRESIBA FLEXTOUCH U- TUKYSA ...... 23 THYROLAR-1/2 ...... 79 100 ...... 74 tulana ...... 102 THYROLAR-1/4 ...... 79 TRESIBA FLEXTOUCH U- TWINRIX (PF) ...... 95 THYROLAR-2 ...... 79 200 ...... 74 TWIRLA ...... 102 THYROLAR-3 ...... 80 TRESIBA U-100 INSULIN . 74 TYBLUME ...... 109 tiadylt er...... 49 tretinoin ...... 61 TYBOST ...... 5

140 tydemy ...... 109 velivet triphasic regimen (28) WILATE ...... 54 TYGACIL ...... 10 ...... 109 wixela inhub ...... 121 TYMLOS ...... 96 VELPHORO ...... 85 wymzya fe ...... 109 TYPHIM VI ...... 95 VEMLIDY ...... 5 X TYSABRI ...... 30 VENCLEXTA ...... 23 XALKORI ...... 23 TYVASO ...... 121 VENCLEXTA STARTING XARELTO ...... 54 TYVASO REFILL KIT ..... 121 PACK ...... 23 XARELTO DVT-PE TREAT TYVASO STARTER KIT . 121 venlafaxine ...... 43 30D START ...... 54 U VENTAVIS ...... 121 XCOPRI ...... 27 UBRELVY ...... 29 verapamil ...... 50 XCOPRI MAINTENANCE UDENYCA ...... 87 VERSACLOZ ...... 43 PACK ...... 27 ULESFIA ...... 66 VERZENIO ...... 23 XCOPRI TITRATION PACK unithroid ...... 80 vestura (28) ...... 109 ...... 27 UNITUXIN ...... 23 VIBATIV ...... 13 XELJANZ ...... 98 URELLE...... 123 VIBERZI ...... 85 XELJANZ XR ...... 98 uretron d-s ...... 123 VIDAZA ...... 23 XEMBIFY ...... 95 urimar-t ...... 123 VIEKIRA PAK ...... 5 XENLETA ...... 10 urogesic-blue ...... 123 vienva ...... 109 XEOMIN ...... 95 ursodiol ...... 85 vigabatrin ...... 26 XERMELO ...... 23 uryl ...... 123 vigadrone ...... 26 XGEVA ...... 13 ustell ...... 123 VIMIZIM ...... 77 XIFAXAN ...... 10 utira-c ...... 123 VIMPAT ...... 26 XIGDUO XR ...... 79 UVADEX ...... 59 viorele (28) ...... 109 XIIDRA ...... 112 V VIRACEPT ...... 5 XOLAIR ...... 121 valacyclovir ...... 5 VIREAD ...... 5 XOSPATA ...... 23 VALCHLOR ...... 59 virtussin ac ...... 117 XTANDI ...... 23 valganciclovir ...... 5 VISTOGARD ...... 13 xulane ...... 102 valproic acid ...... 26 VISUDYNE ...... 112 XULTOPHY 100/3.6 ...... 74 valproic acid (as sodium salt) vitamins a,c,d and fluoride . 125 XURIDEN ...... 67 ...... 26 VITRAKVI ...... 23 XYNTHA ...... 55 valsartan ...... 49 VIVITROL ...... 36 XYNTHA SOLOFUSE ...... 55 valsartan-hydrochlorothiazide volnea (28) ...... 109 XYREM ...... 44 ...... 49 VONVENDI ...... 54 Y vanadom ...... 30 VORAXAZE ...... 13 YERVOY ...... 23 vancomycin ...... 13 voriconazole ...... 1, 2 YESCARTA ...... 23 vandazole ...... 102 VOSEVI ...... 5 YF-VAX (PF) ...... 95 VANTAS ...... 23 VOTRIENT ...... 23 YONDELIS ...... 23 VAQTA (PF) ...... 95 VPRIV ...... 77 YONSA ...... 23 VARENICLINE ...... 68 VRAYLAR ...... 44 YUTIQ ...... 115 VARIVAX (PF) ...... 95 VYEPTI ...... 29 yuvafem ...... 102 VARUBI ...... 85 vyfemla (28) ...... 109 Z VASCEPA ...... 56 vylibra ...... 109 zafemy ...... 103 VAXELIS (PF) ...... 95 VYONDYS-53 ...... 30 zafirlukast ...... 121 VCF CONTRACEPTIVE VYVANSE ...... 44 zaleplon ...... 44 FILM ...... 102 VYXEOS ...... 23 ZALTRAP ...... 23 VCF CONTRACEPTIVE GEL W ZANOSAR ...... 23 ...... 102 warfarin ...... 54 zarah ...... 109 VECTIBIX ...... 23 wera (28) ...... 109 ZARXIO ...... 87 VELCADE ...... 23 westhroid ...... 80 ZEJULA ...... 24 veletri ...... 50 WIDE-SEAL DIAPHRAGM ZELBORAF ...... 24 ...... 99 ZEMAIRA ...... 68

141 zenatane ...... 61 zileuton ...... 121 zonisamide ...... 27 ZENPEP ...... 85 ziprasidone hcl ...... 44 ZONTIVITY ...... 55 ZENZEDI ...... 44 ZIRGAN ...... 111 ZORBTIVE ...... 88 ZEPATIER ...... 5 ZOKINVY ...... 68 ZOSTAVAX (PF) ...... 95 ZEPOSIA ...... 89 ZOLADEX ...... 24 zovia 1/35e (28) ...... 109 ZEPOSIA STARTER KIT ... 89 ZOLGENSMA ...... 30 ZULRESSO ...... 44 ZEPOSIA STARTER PACK ZOLINZA ...... 24 zumandimine (28) ...... 109 ...... 89 zolmitriptan ...... 29 ZYFLO ...... 122 ZERBAXA ...... 7 zolpidem ...... 44 ZYKADIA ...... 24 zidovudine ...... 5 ZOLPIMIST ...... 44 ZYPITAMAG ...... 56 ZIEXTENZO ...... 87 ZOMIG ...... 29

142 Discrimination is Against the Law Premera Blue Cross Blue Shield of Alaska (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free: 855-332-4535, Fax: 425-918-5592, TTY: 711, Email [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language Assistance PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 800-508-4722 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-508-4722 (TTY: 711). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-508-4722 (TTY: 711) 번으로 전화해 주십시오. LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 800-508-4722 (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800-508-4722 (телетайп: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-508-4722 (TTY：711）。 MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: 800-508-4722 (TTY: 711). ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເ ວົ ້ າ ພາສາ ລາວ, ການບໍ ລິ ການຊ່ ວຍເ ຫຼ ື ອ ດ້ າ ນ ພາສາ, ໂ ດ ຍ ບໍ ່ ເ ສັ ຽ ຄ່ າ , ແ ມ ່ ນ ມີ ພ້ ອ ມ ໃ ຫ້ ທ່ ານ. ໂທຣ 800-508-4722 (TTY: 711). 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 800-508-4722 （TTY:711）まで、お電話にてご連絡ください。 PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 800-508-4722 (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 800-508-4722 (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 800-508-4722 (телетайп: 711). เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 800-508-4722 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-508-4722 (TTY: 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-508-4722 (TTY: 711). ﻣﻠﺤﻮظﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧ ﺪ ﻣ ﺎ ت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑ ﺮ ﻗ ﻢ 4722-508-800 ( ر ﻗ ﻢ ھﺎﺗﻒ ا ﻟ ﺼ ﻢ واﻟﺒﻜ ﻢ: 711 .) .) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-508-4722 (TTY: 711). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-508-4722 (ATS : 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-508-4722 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 800-508-4722 (TTY: 711). ﺗوﺟﮫ: اﮔر ﺑ ﮫ ز ﺑ ﺎ ن ﻓﺎرﺳﯽ ﮔ ﻔ ﺗ ﮕ و ﻣ ﯽ ﮐﻧﯾد، ﺗ ﺳ ﮭ ﯾ ﻼ ت زﺑﺎﻧ ﯽ ﺑ ﺻ و ر ت ر ا ﯾ ﮕ ﺎ ن ﺑ ر ا ی ﺷ ﻣ ﺎ ﻓ ر ا ھ م ﻣ ﯽ ﺑ ﺎ ﺷ د. ﺑﺎ (TTY: 711) 4722-508-800 ﺗﻣﺎس ﺑ ﮕ ﯾ ر ﯾ د.

An independent licensee of the Blue Cross Blue Shield Association 037398 (07-01-2021)