sign in sign up
<<
Home , Itraconazole, Vardenafil

3 Tier Drug Formulary - 2021

1

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with DAKOTACARE.

DAKOTACARE

2021 3-Tier Drug Formulary

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

Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs.

2

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with DAKOTACARE. What is the DAKOTACARE Drug Formulary? The Drug Formulary is a list of covered prescription drugs, which are approved for use for specific treatments and dispensed through participating pharmacies. DAKOTACARE works with a team of health care providers to choose drugs that provide quality treatment. DAKOTACARE covers drugs on the Drug Formulary that are:

 Medically necessary  Approved by the United States Food and Drug Administration (FDA)  Filled at a participating pharmacy

For more information on how to fill your prescriptions and determine if your drug is covered, please review your Certificate of Coverage, Master Contract, Plan Document or other plan materials.

Can the Drug Formulary change? The Drug Formulary may change from time to time as described in the Certificate of Coverage, Master Contract, Plan Document or other plan materials. The enclosed Drug Formulary is the most current Drug Formulary covered by DAKOTACARE. To get updated information about the drugs covered by DAKOTACARE, please visit us online at www.dakotacare.com or call our Service Center toll-free at 1-800-325-5598, 8 a.m. to 5 p.m. CT, Monday through Friday.

How do I use the Drug Formulary? There are two ways to find your drug on the drug list:

1. Drug Therapeutic Classification or Plain Language Medical Condition The Drug Formulary starts on page 6. The drugs on this Drug Formulary are grouped by the type of therapeutic class the drugs fall into. These classes of drugs are also grouped with plain language descriptions for the medical conditions for which these drugs aim to treat. For example, drugs used to treat high blood pressure are listed under “Antihypertensives” and “Drugs for the Heart.”

2. Alphabetical Listing If you are not sure what category to look under, look for your drug in the Index that starts near the end of the formulary document after the drug therapeutic classes have been presented. The Index is an alphabetical list of all the drugs in this document. Both brand-name drugs and generic drugs are in the Index.  Look in the Index and find your drug  Next to your drug, 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

3

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with DAKOTACARE. For more information about your DAKOTACARE coverage, please look at your Certificate of Coverage, Master Contract, Plan Document or other plan materials. If you have questions about this Drug Formulary, please call our Service Center toll-free at 1-800-325-5598, 8 a.m. to 5 p.m. CT, Monday through Friday. You may also visit us online at www.dakotacare.com

DAKOTACARE Drug Formulary The Drug Formulary that starts on page 6 gives you information about the drugs covered by DAKOTACARE. A generic drug is a drug that has the same active ingredients as its brand-name counterpart, and has been approved by the FDA as being interchangeable with the brand-name drug as approved by your provider. Upon release of a generic drug to the market, the generic drug will generally be added to the formulary and the associated brand drug will be considered non-preferred or not covered. However, some generic drugs do not cost less than brand-name drugs and may not be added to your formulary.

The first column of the chart lists the drug name. Brand-name drugs are bolded (e.g., Lipitor). Generic drugs are listed in lower-case italics (e.g., ).

The second column (labeled Drug Tier) will list what tier the drug is placed on in the Drug Formulary. Refer to your Summary of Benefits and Coverage to find the associated co-pay for that drug tier.

The information in the Requirements/Limits column tells you if DAKOTACARE has any special requirements for coverage of your drug. These requirements and limits may include:

 Preauthorization (PA): DAKOTACARE needs your healthcare provider to get preauthorization for certain drugs. This means that approval from DAKOTACARE must be obtained before you fill your drug. If you don’t get approval, DAKOTACARE will not cover the cost of the drug. Additional information can be found online at www.dakotacare.com.

 Quantity Limits (QL): For certain drugs, DAKOTACARE limits the amount of the drug that it will cover. For example, DAKOTACARE only covers 18 tablets of sumatriptan 50mg per 30 days. DAKOTACARE also limits the amount of drugs you may receive within a class of drugs. These classes have an “§” next to them on the drug list. For these classes, only one drug should be taken at a time for safety reasons. This may be in addition to a standard one-month or three-month supply.

 Step Therapy (ST): DAKOTACARE utilizes step therapy to provide the most cost-effective and safest drugs available for a specific medical condition. Step therapy programs require your healthcare provider to prescribe a step-one drug before a step-two drug will be covered. If the step-one drugs do not work for you, DAKOTACARE will cover the step-two drugs. Visit us online at www.dakotacare.com to review a list of Step Therapy Programs.

 Age Limits: Certain drugs approved by the FDA or other prescribing guidelines are not appropriate based on age. In some instances DAKOTACARE may restrict use of certain FDA approved drugs to people within a certain age range.

 Gender Limits: Certain drugs approved by the FDA or other prescribing guidelines are not

4

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with DAKOTACARE.

appropriate based on gender.

 Provider Restriction (PR): For certain drugs, Avera Health Plans limits the prescribing to certain provider specialties.

 Medical Benefit (MB): These drugs are covered under the medical benefit only. Drugs covered under the medical benefit require a higher-level of care and are typically administered by a provider or at a healthcare facility.

What if my drug is not on the Drug Formulary? If your drug is not on this Drug Formulary, you have two choices:

 Your healthcare provider can prescribe a drug that is similar that is covered on the Drug Formulary. Similar drugs that are preferred and covered on the Drug Formulary may be easier to obtain and lower cost to you.

 You can request a formulary exception if you believe the drug you take should be covered because other treatment options on the Drug Formulary do not work for you. To request a formulary exception, you or your healthcare provider must provide written documentation to include the following:

 Why no other prescription on the Drug Formulary will work as well as the requested drug,  A list of other drugs that have been tried and how you responded to these drugs  Medical documentation to support the medical necessity

How likely is it that I will get the formulary exception? We will review the information and when a decision has been made, you and your healthcare provider will receive a letter that states the decision. If a formulary exception is approved, the non- preferred co-pay (for the applicable drug type) will be applied. The prescription must be a covered benefit on your plan. Formulary exceptions do not include reductions on prescription co-pays.

What do the tiers mean on the Drug Formulary?

Tier Type of Drugs Included Tier 0 Preventive drugs (covered at no cost to you) Tier 1 Generic drugs Tier 2 Preferred brand drugs Tier 3 Non-preferred brand drugs Tier 10 Medical benefit drugs

5

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with DAKOTACARE.

Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* - Drugs For The Nervous System...... 8 *Allergenic Extracts/Biologicals Misc* - Biological Agents...... 9 *Aminoglycosides* - Drugs For Infections...... 10 *Analgesics - Anti-Inflammatory* - Drugs For Pain And Fever...... 10 *Analgesics - Nonnarcotic* - Drugs For Pain And Fever...... 13 *Analgesics - Opioid* - Drugs For Pain And Fever...... 13 *-Anabolic* - Hormones...... 16 *Anorectal And Related Products* - Rectal Preparations...... 17 *Anthelmintics* - Drugs For Infections...... 17 *Antianginal Agents* - Drugs For The Heart...... 17 *Antianxiety Agents* - Drugs For The Nervous System...... 18 *Antiarrhythmics* - Drugs For The Heart...... 18 *Antiasthmatic And Bronchodilator Agents* - Drugs For The Lungs...... 19 *Anticoagulants* - Drugs For The Blood...... 22 *Anticonvulsants* - Drugs For The Nervous System...... 23 *Antidepressants* - Drugs For The Nervous System...... 27 *Antidiabetics* - Hormones...... 29 *Antidiarrheal/Probiotic Agents* - Drugs For The Stomach...... 32 *Antidotes And Specific Antagonists* - Drugs For Overdose Or Poisoning...... 33 *Antiemetics* - Drugs For The Stomach...... 33 ** - Drugs For Infections...... 34 *Antihistamines* - Drugs For The Lungs...... 34 *Antihyperlipidemics* - Drugs For The Heart...... 35 *Antihypertensives* - Drugs For The Heart...... 37 *Anti-Infective Agents - Misc.* - Drugs For Infections...... 39 *Antimalarials* - Drugs For Infections...... 41 *Antimyasthenic/Cholinergic Agents* - Drugs For Nerves And Muscles...... 41 *Antimycobacterial Agents* - Drugs For Infections...... 41 *Antineoplastics And Adjunctive Therapies* - Drugs For Cancer...... 42 *Antiparkinson And Related Therapy Agents* - Drugs For The Nervous System...... 56 *Antipsychotics/Antimanic Agents* - Drugs For The Nervous System...... 58 *Antiseptics & Disinfectants* - Antiseptics And Disinfectants...... 60 *Antivirals* - Drugs For Infections...... 61 *Beta Blockers* - Drugs For The Heart...... 65 *Calcium Channel Blockers* - Drugs For The Heart...... 66 *Cardiotonics* - Drugs For The Heart...... 67 *Cardiovascular Agents - Misc.* - Drugs For The Heart...... 67 *Cephalosporins* - Drugs For Infections...... 69 *Chemicals*...... 70 *Contraceptives* - Drugs For Women...... 70 *Corticosteroids* - Hormones...... 72 *Cough/Cold/* - Drugs For The Lungs...... 73 *Dermatologicals* - Drugs For The Skin...... 74 *Diagnostic Products*...... 86 *Digestive Aids* - Drugs For The Stomach...... 86 *Diuretics* - Drugs For The Heart...... 86 *Endocrine And Metabolic Agents - Misc.* - Hormones...... 87 ** - Hormones...... 92 *Fluoroquinolones* - Drugs For Infections...... 93 *Gastrointestinal Agents - Misc.* - Drugs For The Stomach...... 94 *Genitourinary Agents - Miscellaneous* - Drugs For The Urinary System...... 96 *Gout Agents* - Drugs For Pain And Fever...... 97 *Hematological Agents - Misc.* - Drugs For The Blood...... 97 *Hematopoietic Agents* - Drugs For Nutrition...... 99 *Hemostatics* - Drugs For The Blood...... 100 *Hypnotics/Sedatives/Sleep Disorder Agents* - Drugs For The Nervous System...... 100 *Laxatives* - Drugs For The Stomach...... 101 *Macrolides* - Drugs For Infections...... 102 6 *Medical Devices And Supplies* - Medical Supplies And Durable Medical Equipment...... 103 *Migraine Products* - Drugs For The Nervous System...... 108 *Minerals & Electrolytes* - Drugs For Nutrition...... 110 *Miscellaneous Therapeutic Classes* - Vitamins And Minerals...... 111 *Mouth/Throat/Dental Agents* - Drugs For The Mouth And Throat...... 113 *Multivitamins* - Drugs For Nutrition...... 113 *Musculoskeletal Therapy Agents* - Drugs For Muscles, Ligaments, Tendons, And Bones...... 116 *Nasal Agents - Systemic And Topical* - Drugs For The Nose...... 117 *Neuromuscular Agents* - Drugs For Nerves And Muscles...... 118 *Nutrients* - Drugs For Nutrition...... 119 *Ophthalmic Agents* - Drugs For The Eye...... 119 *Otic Agents* - Drugs For The Ear...... 124 *Oxytocics* - Hormones...... 124 *Passive Immunizing And Treatment Agents* - Biological Agents...... 125 *Penicillins* - Drugs For Infections...... 126 *Pharmaceutical Adjuvants*...... 126 *Progestins* - Hormones...... 128 *Psychotherapeutic And Neurological Agents - Misc.* - Drugs For The Nervous System...... 128 *Respiratory Agents - Misc.* - Drugs For The Lungs...... 132 *Sulfonamides* - Drugs For Infections...... 133 *Tetracyclines* - Drugs For Infections...... 133 *Thyroid Agents* - Hormones...... 133 *Toxoids* - Biological Agents...... 134 *Ulcer Drugs/Antispasmodics/Anticholinergics* - Drugs For The Stomach...... 135 *Urinary Antispasmodics* - Drugs For The Urinary System...... 136 *Vaccines* - Biological Agents...... 137 *Vaginal And Related Products* - Drugs For Women...... 138 *Vasopressors* - Drugs For The Heart...... 139 *Vitamins* - Drugs For Nutrition...... 139

7 Drug Name Drug Tier Requirements / Limits *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* - Drugs For The Nervous System *Adhd Agent - Selective Alpha Adrenergic Agonists*** - Drugs For Attention Deficit Disorder clonidine hcl er oral tablet extended release 12 hour 1 QL 0.1 mg guanfacine hcl er oral tablet extended release 24 hour 1 Age Restriction Applies (Min 6 Years) 1 mg, 2 mg, 3 mg, 4 mg *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** - Drugs For Attention Deficit Disorder atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 1 QL 25 mg, 40 mg, 60 mg, 80 mg * Mixtures*** - Drugs For Attention Deficit Disorder amphetamine-dextroamphetamine oral tablet 10 mg, 1 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg Mydayis Oral Capsule Extended Release 24 Hour 3 QL 12.5 MG, 25 MG, 37.5 MG, 50 MG **** - Drugs For Attention Deficit Disorder Adzenys ER Oral Suspension Extended Release Age Restriction Applies (Max 12 3 1.25 MG/ML Years) Adzenys XR-ODT Oral Tablet Extended Release Age Restriction Applies (Max 12 Dispersible 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 3 Years) MG, 9.4 MG amphetamine sulfate oral tablet 10 mg, 5 mg 1 dextroamphetamine sulfate er oral capsule extended 1 release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral 5 mg/5ml 1 dextroamphetamine sulfate oral tablet 10 mg, 5 mg 1 Dyanavel XR Oral Suspension Extended Release 3 QL 2.5 MG/ML hcl oral tablet 5 mg 1 Vyvanse Oral Capsule 10 MG, 20 MG, 30 MG, 40 2 QL MG, 50 MG, 60 MG, 70 MG Vyvanse Oral Tablet Chewable 10 MG, 20 MG, 30 2 QL MG, 40 MG, 50 MG, 60 MG Zenzedi Oral Tablet 10 MG, 15 MG, 2.5 MG, 20 MG, 1 30 MG, 5 MG, 7.5 MG *Analeptics*** - Drugs For The Nervous System citrate oral solution 20 mg/ml, 60 mg/3ml 1 *Dopamine And Norepinephrine Reuptake Inhibitors (Dnris)*** - Drugs For Sleep Disorder Sunosi Oral Tablet 150 MG, 75 MG 3 PA; QL *Histamine H3-Receptor Antagonist/Inverse Agonists*** - Drugs For Sleep Disorder Wakix Oral Tablet 17.8 MG, 4.45 MG 3 PA

Last Published: 09/17/2021 8 Drug Name Drug Tier Requirements / Limits * - Misc.*** - Drugs For Attention Deficit Disorder armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 1 QL mg Daytrana Transdermal Patch 10 MG/9HR, 15 3 MG/9HR, 20 MG/9HR, 30 MG/9HR dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 1 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 1 mg hcl er (cd) oral capsule extended 1 release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended 1 release 24 hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 1 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 1 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 1 hour 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml 1 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg 1 methylphenidate hcl oral tablet chewable 10 mg, 2.5 1 mg, 5 mg modafinil oral tablet 100 mg, 200 mg 1 QL QuilliChew ER Oral Tablet Chewable Extended 3 Release 20 MG, 30 MG, 40 MG *Allergenic Extracts/Biologicals Misc* - Biological Agents *Allergenic Extracts*** - Biological Agents PR; QL; Age Restriction Applies (Min Grastek Sublingual Tablet Sublingual 2800 BAU 3 5 Years and Max 65 Years) Palforzia (12 MG Daily Dose) Oral 2 x 1 MG & 10 Age Restriction Applies (Min 4 Years 3 MG and Max 17 Years) Palforzia (120 MG Daily Dose) Oral 20 MG & 100 Age Restriction Applies (Min 4 Years 3 MG and Max 17 Years) Palforzia (160 MG Daily Dose) Oral 3 x 20 MG & Age Restriction Applies (Min 4 Years 3 100 MG and Max 17 Years) Age Restriction Applies (Min 4 Years Palforzia (20 MG Daily Dose) Oral 20 MG 3 and Max 17 Years) Age Restriction Applies (Min 4 Years Palforzia (200 MG Daily Dose) Oral 2 x 100 MG 3 and Max 17 Years) Palforzia (240 MG Daily Dose) Oral 2 x 20 MG & 2 x Age Restriction Applies (Min 4 Years 3 100 MG and Max 17 Years) Age Restriction Applies (Min 4 Years Palforzia (3 MG Daily Dose) Oral 3 x 1 MG 3 and Max 17 Years)

Last Published: 09/17/2021 9 Drug Name Drug Tier Requirements / Limits Palforzia (300 MG Maintenance) Oral Packet 300 Age Restriction Applies (Min 4 Years 3 MG and Max 17 Years) Age Restriction Applies (Min 4 Years Palforzia (300 MG Titration) Oral Packet 300 MG 3 and Max 17 Years) Age Restriction Applies (Min 4 Years Palforzia (40 MG Daily Dose) Oral 2 x 20 MG 3 and Max 17 Years) Age Restriction Applies (Min 4 Years Palforzia (6 MG Daily Dose) Oral 6 x 1 MG 3 and Max 17 Years) Age Restriction Applies (Min 4 Years Palforzia (80 MG Daily Dose) Oral 4 x 20 MG 3 and Max 17 Years) Palforzia Initial Escalation Oral 0.5 & 1 & 1.5 & 3 & Age Restriction Applies (Min 4 Years 3 6 MG and Max 17 Years) Ragwitek Sublingual Tablet Sublingual 12 AMB A PR; QL; Age Restriction Applies (Min 3 1-U 18 Years and Max 65 Years) *Mixed Allergenic Extracts*** - Biological Agents PR; QL; Age Restriction Applies (Min Odactra Sublingual Tablet Sublingual 12 SQ-HDM 3 18 Years and Max 65 Years) PR; QL; Age Restriction Applies (Min Oralair Sublingual Tablet Sublingual 300 IR 3 10 Years and Max 65 Years) *Aminoglycosides* - Drugs For Infections *Aminoglycosides*** - Antibiotics Arikayce Inhalation Suspension 590 MG/8.4ML 3 QL Bethkis Inhalation Nebulization Solution 300 3 QL MG/4ML Kitabis Pak Inhalation Nebulization Solution 300 3 QL MG/5ML neomycin sulfate oral tablet 500 mg 1 paromomycin sulfate oral capsule 250 mg 1 Tobi Inhalation Nebulization Solution 300 MG/5ML 3 QL Tobi Podhaler Inhalation Capsule 28 MG 3 QL tobramycin inhalation nebulization solution 300 1 QL mg/4ml, 300 mg/5ml *Analgesics - Anti-Inflammatory* - Drugs For Pain And Fever *Antirheumatic - Janus Kinase (Jak) Inhibitors*** - Arthritis And Pain Drugs Rinvoq Oral Tablet Extended Release 24 Hour 15 2 PA; QL MG Xeljanz Oral Solution 1 MG/ML 2 PA; QL Xeljanz Oral Tablet 10 MG, 5 MG 2 PA; QL Xeljanz XR Oral Tablet Extended Release 24 Hour 2 PA; QL 11 MG, 22 MG *Anti-Tnf-Alpha - Monoclonal Antibodies*** - Arthritis And Pain Drugs Humira Pediatric Crohns Start Subcutaneous Prefilled Syringe Kit 80 MG/0.8ML, 80 MG/0.8ML & 2 PA; QL 40MG/0.4ML

Last Published: 09/17/2021 10 Drug Name Drug Tier Requirements / Limits Humira Pen Subcutaneous Pen-Injector Kit 40 2 PA; QL MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML Humira Pen-CD/UC/HS Starter Subcutaneous Pen- 2 PA; QL Injector Kit 40 MG/0.8ML, 80 MG/0.8ML Humira Pen-Ps/UV/Adol HS Start Subcutaneous 2 PA; QL Pen-Injector Kit 40 MG/0.8ML Humira Pen-Psor/Uveit Starter Subcutaneous Pen- 2 PA; QL Injector Kit 80 MG/0.8ML & 40MG/0.4ML Humira Subcutaneous Prefilled Syringe Kit 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 2 PA; QL MG/0.8ML Simponi Aria Intravenous Solution 50 MG/4ML Tier 10 PA *Cyclooxygenase 2 (Cox-2) Inhibitors*** - Arthritis And Pain Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 1 QL mg *Gold Compounds*** - Arthritis And Pain Drugs Ridaura Oral Capsule 3 MG 2 *Interleukin-1 Blockers*** - Arthritis And Pain Drugs Arcalyst Subcutaneous Solution Reconstituted Tier 10 PA 220 MG *Interleukin-1Beta Blockers*** - Arthritis And Pain Drugs Ilaris Subcutaneous Solution 150 MG/ML Tier 10 PA *Interleukin-6 Receptor Inhibitors*** - Arthritis And Pain Drugs Actemra ACTPen Subcutaneous Solution Auto- 2 PA; QL Injector 162 MG/0.9ML Actemra Intravenous Solution 200 MG/10ML, 400 Tier 10 PA MG/20ML, 80 MG/4ML Actemra Subcutaneous Solution Prefilled Syringe 2 PA; QL 162 MG/0.9ML *Nonsteroidal Anti-Inflammatory Agent Combinations*** - Arthritis And Pain Drugs diclofenac-misoprostol oral tablet delayed release 50- 1 0.2 mg, 75-0.2 mg naproxen-esomeprazole oral tablet delayed release 1 QL 375-20 mg, 500-20 mg *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** - Arthritis And Pain Drugs diclofenac potassium oral tablet 50 mg 1 diclofenac sodium er oral tablet extended release 24 1 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 1 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 1 mg, 500 mg, 600 mg Last Published: 09/17/2021 11 Drug Name Drug Tier Requirements / Limits etodolac oral capsule 200 mg, 300 mg 1 etodolac oral tablet 400 mg, 500 mg 1 fenoprofen calcium oral capsule 200 mg 3 fenoprofen calcium oral capsule 400 mg 1 Fenortho Oral Capsule 200 MG 3 flurbiprofen oral tablet 100 mg, 50 mg 1 IBU Oral Tablet 400 MG, 600 MG, 800 MG 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 Indocin Oral Suspension 25 MG/5ML 2 Indocin Rectal 50 MG 2 indomethacin er oral capsule extended release 75 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 ketoprofen er oral capsule extended release 24 hour 1 200 mg ketorolac tromethamine injection solution 15 mg/ml, 30 Tier 10 mg/ml ketorolac tromethamine oral tablet 10 mg 1 meclofenamate sodium oral capsule 100 mg, 50 mg 1 mefenamic acid oral capsule 250 mg 1 meloxicam oral tablet 15 mg, 7.5 mg 1 nabumetone oral tablet 500 mg, 750 mg 1 Nalfon Oral Capsule 400 MG 3 naproxen oral suspension 125 mg/5ml 1 naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 1 hour 375 mg, 500 mg, 750 mg naproxen sodium oral tablet 275 mg, 550 mg 1 oxaprozin oral tablet 600 mg 1 piroxicam oral capsule 10 mg, 20 mg 1 Sprix Nasal Solution 15.75 MG/SPRAY 3 QL sulindac oral tablet 150 mg, 200 mg 1 Zipsor Oral Capsule 25 MG 3 * 4 (Pde4) Inhibitors*** - Arthritis And Pain Drugs Otezla Oral Tablet 30 MG 2 PA; QL Otezla Oral Tablet Therapy Pack 10 & 20 & 30 MG 2 PA; QL *Pyrimidine Synthesis Inhibitors*** - Arthritis And Pain Drugs leflunomide oral tablet 10 mg, 20 mg 1 *Selective Costimulation Modulators*** - Arthritis And Pain Drugs Orencia Intravenous Solution Reconstituted 250 Tier 10 PA MG

Last Published: 09/17/2021 12 Drug Name Drug Tier Requirements / Limits *Soluble Tumor Necrosis Factor Receptor Agents*** - Arthritis And Pain Drugs Enbrel Mini Subcutaneous Solution Cartridge 50 2 PA; QL MG/ML Enbrel Subcutaneous Solution 25 MG/0.5ML 2 PA; QL Enbrel Subcutaneous Solution Prefilled Syringe 25 2 PA; QL MG/0.5ML, 50 MG/ML Enbrel Subcutaneous Solution Reconstituted 25 2 PA; QL MG Enbrel SureClick Subcutaneous Solution Auto- 2 PA; QL Injector 50 MG/ML *Analgesics - Nonnarcotic* - Drugs For Pain And Fever *Analgesics-Sedatives*** - Arthritis And Pain Drugs Allzital Oral Tablet 25-325 MG 3 Bupap Oral Tablet 50-300 MG 1 QL butalbital-acetaminophen oral tablet 50-300 mg, 50- 1 QL 325 mg butalbital-apap-caffeine oral capsule 50-300-40 mg, 1 QL 50-325-40 mg butalbital-apap-caffeine oral tablet 50-325-40 mg 1 QL butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 Esgic Oral Capsule 50-325-40 MG 1 QL Tencon Oral Tablet 50-325 MG 1 QL Zebutal Oral Capsule 50-325-40 MG 1 QL *Salicylates*** - Arthritis And Pain Drugs diflunisal oral tablet 500 mg 1 salsalate oral tablet 500 mg, 750 mg 1 *Analgesics - Opioid* - Drugs For Pain And Fever *Codeine Combinations*** - Arthritis And Pain Drugs QL; Age Restriction Applies (Min 12 acetaminophen-codeine #2 oral tablet 300-15 mg 1 Years) QL; Age Restriction Applies (Min 12 acetaminophen-codeine #3 oral tablet 300-30 mg 1 Years) QL; Age Restriction Applies (Min 12 acetaminophen-codeine #4 oral tablet 300-60 mg 1 Years) QL; Age Restriction Applies (Min 12 acetaminophen-codeine oral solution 120-12 mg/5ml 1 Years) acetaminophen-codeine oral tablet 300-15 mg, 300-60 QL; Age Restriction Applies (Min 12 1 mg Years) QL; Age Restriction Applies (Min 12 Ascomp-Codeine Oral Capsule 50-325-40-30 MG 1 Years) QL; Age Restriction Applies (Min 12 butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 1 Years)

Last Published: 09/17/2021 13 Drug Name Drug Tier Requirements / Limits butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 QL butalbital-asa-caff-codeine oral capsule 50-325-40-30 QL; Age Restriction Applies (Min 12 1 mg Years) *Dihydrocodeine Combinations*** - Arthritis And Pain Drugs apap-caff-dihydrocodeine oral capsule 320.5-30-16 Age Restriction Applies (Min 12 1 mg Years) Age Restriction Applies (Min 12 Trezix Oral Capsule 320.5-30-16 MG 1 Years) *Hydrocodone Combinations*** - Arthritis And Pain Drugs hydrocodone-acetaminophen oral solution 2.5-108 1 QL mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 1 QL mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 1 QL mg, 7.5-200 mg Lortab Oral Elixir 10-300 MG/15ML 1 QL *Opioid Agonists*** - Arthritis And Pain Drugs QL; Age Restriction Applies (Min 12 codeine sulfate oral tablet 30 mg, 60 mg 1 Years) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1 QL 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 1 QL mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 1 QL mcg/hr, 75 mcg/hr, 87.5 mcg/hr Fentora Buccal Tablet 100 MCG 3 QL hydrocodone bitartrate er oral tablet er 24 hour abuse- deterrent 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 1 QL mg, 80 mg hydromorphone hcl oral liquid 1 mg/ml 1 QL hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg 1 QL hydromorphone hcl rectal suppository 3 mg 1 QL Lazanda Nasal Solution 100 MCG/ACT, 400 3 QL MCG/ACT levorphanol tartrate oral tablet 2 mg 1 QL meperidine hcl oral solution 50 mg/5ml 1 QL meperidine hcl oral tablet 50 mg 1 QL Methadone HCl Intensol Oral Concentrate 10 1 QL MG/ML methadone hcl oral concentrate 10 mg/ml 1 QL methadone hcl oral solution 10 mg/5ml, 5 mg/5ml 1 QL methadone hcl oral tablet 10 mg, 5 mg 1 QL methadone hcl oral tablet soluble 40 mg 1 QL Last Published: 09/17/2021 14 Drug Name Drug Tier Requirements / Limits Methadose Oral Tablet Soluble 40 MG 1 QL morphine sulfate (concentrate) oral solution 100 1 QL mg/5ml, 20 mg/ml morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 1 90 mg morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 1 QL mg, 80 mg morphine sulfate er oral tablet extended release 100 1 QL mg, 15 mg, 200 mg, 30 mg, 60 mg morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml 1 QL morphine sulfate oral tablet 15 mg, 30 mg 1 QL morphine sulfate rectal suppository 10 mg, 20 mg, 30 1 QL mg, 5 mg Nucynta ER Oral Tablet Extended Release 12 Hour 3 ST; QL 100 MG, 150 MG, 200 MG, 250 MG, 50 MG Nucynta Oral Tablet 100 MG, 50 MG, 75 MG 3 QL oxycodone hcl er oral tablet er 12 hour abuse- deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 1 QL 80 mg oxycodone hcl oral capsule 5 mg 1 QL oxycodone hcl oral concentrate 100 mg/5ml 1 QL oxycodone hcl oral solution 5 mg/5ml 1 QL oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 1 QL mg, 5 mg OxyCONTIN Oral Tablet ER 12 Hour Abuse- Deterrent 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 2 ST; QL MG, 80 MG oxymorphone hcl oral tablet 10 mg, 5 mg 1 QL Subsys Sublingual Liquid 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 3 MCG, 800 MCG tramadol hcl er (biphasic) oral tablet extended release QL; Age Restriction Applies (Min 12 1 24 hour 100 mg, 200 mg, 300 mg Years) tramadol hcl er oral tablet extended release 24 hour QL; Age Restriction Applies (Min 12 1 100 mg, 200 mg, 300 mg Years) QL; Age Restriction Applies (Min 12 tramadol hcl oral tablet 100 mg, 50 mg 1 Years) Xtampza ER Oral Capsule ER 12 Hour Abuse- 3 ST Deterrent 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG *Opioid Combinations*** - Arthritis And Pain Drugs Endocet Oral Tablet 10-325 MG, 2.5-325 MG, 5-325 1 QL MG Endocet Oral Tablet 7.5-325 MG 1 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- 1 QL 325 mg, 5-325 mg Last Published: 09/17/2021 15 Drug Name Drug Tier Requirements / Limits oxycodone-acetaminophen oral tablet 7.5-325 mg 1 *Opioid Partial Agonists*** - Arthritis And Pain Drugs Bunavail Buccal Film 4.2-0.7 MG 3 QL buprenorphine hcl sublingual tablet sublingual 2 mg, 8 1 mg buprenorphine hcl-naloxone hcl sublingual film 12-3 1 mg, 2-0.5 mg, 4-1 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet 1 sublingual 2-0.5 mg, 8-2 mg buprenorphine transdermal patch weekly 10 mcg/hr, 1 QL 15 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5 mcg/hr butorphanol tartrate nasal solution 10 mg/ml 1 QL pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 QL Suboxone Sublingual Film 12-3 MG, 2-0.5 MG, 4-1 3 MG, 8-2 MG Zubsolv Sublingual Tablet Sublingual 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 3 8.6-2.1 MG *Tramadol Combinations*** - Arthritis And Pain Drugs QL; Age Restriction Applies (Min 12 tramadol-acetaminophen oral tablet 37.5-325 mg 1 Years) *Androgens-Anabolic* - Hormones *Androgens*** - Drugs For Men Androderm Transdermal Patch 24 Hour 2 2 Male Only; QL MG/24HR, 4 MG/24HR AndroGel Pump Transdermal Gel 20.25 MG/ACT 2 Male Only; QL (1.62%) AndroGel Transdermal Gel 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM 2 Male Only; QL (1.62%), 50 MG/5GM (1%) danazol oral capsule 100 mg, 200 mg, 50 mg 1 Jatenzo Oral Capsule 158 MG, 198 MG, 237 MG 3 methitest oral tablet 10 mg 1 oral capsule 10 mg 1 cypionate intramuscular solution 100 1 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 200 1 mg/ml testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act 1 (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%) testosterone transdermal solution 30 mg/act 1 Male Only; QL

Last Published: 09/17/2021 16 Drug Name Drug Tier Requirements / Limits *Anorectal And Related Products* - Rectal Preparations *Intrarectal Steroids*** - Rectal Preparations hydrocortisone rectal enema 100 mg/60ml 1 Uceris Rectal Foam 2 MG/ACT 3 * Vasodilating Agents*** - Rectal Preparations Rectiv Rectal Ointment 0.4 % 3 *Rectal Local Anesthetics*** - Rectal Preparations Lidocaine (Anorectal) Rectal Suppository 50 MG 3 *Rectal Steroids*** - Rectal Preparations anucort-hc rectal suppository 25 mg 1 Anusol-HC Rectal Suppository 25 MG 1 Hemmorex-HC Rectal Suppository 25 MG 1 hydrocortisone acetate rectal suppository 25 mg, 30 1 mg *Anthelmintics* - Drugs For Infections *Anthelmintics*** - Drugs For Parasites albendazole oral tablet 200 mg 1 benznidazole oral tablet 100 mg, 12.5 mg 3 Emverm Oral Tablet Chewable 100 MG 3 ivermectin oral tablet 3 mg 1 praziquantel oral tablet 600 mg 1 *Antianginal Agents* - Drugs For The Heart *Antianginals-Other*** - Drugs For er oral tablet extended release 12 hour 1 QL 1000 mg, 500 mg **** - Drugs For Angina GoNitro Sublingual Packet 400 MCG 3 isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 1 40 mg, 5 mg isosorbide mononitrate er oral tablet extended release 1 24 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 1 Minitran Transdermal Patch 24 Hour 0.1 MG/HR, 1 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR Nitro-Bid Transdermal Ointment 2 % 1 Nitro-Dur Transdermal Patch 24 Hour 0.3 MG/HR, 3 0.8 MG/HR nitroglycerin er oral capsule extended release 2.5 mg 1 nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 1 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 1 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray 1 Last Published: 09/17/2021 17 Drug Name Drug Tier Requirements / Limits NitroMist Translingual Aerosol Solution 400 3 MCG/SPRAY Nitro-Time Oral Capsule Extended Release 2.5 MG, 1 6.5 MG, 9 MG *Antianxiety Agents* - Drugs For The Nervous System *Antianxiety Agents - Misc.*** - Drugs For Anxiety hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 1 7.5 mg hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 1 mg meprobamate oral tablet 200 mg, 400 mg 1 *Benzodiazepines*** - Drugs For Seizures /Personality Disorder/Nerve Pain er oral tablet extended release 24 hour 0.5 1 mg, 1 mg, 2 mg, 3 mg ALPRAZolam Intensol Oral Concentrate 1 MG/ML 1 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 1 mg, 2 mg alprazolam xr oral tablet extended release 24 hour 0.5 1 mg, 1 mg, 2 mg, 3 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg 1 clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 1 7.5 mg Intensol Oral Concentrate 5 MG/ML 1 diazepam oral concentrate 5 mg/ml 1 diazepam oral solution 5 mg/5ml 1 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 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 oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 *Antiarrhythmics* - Drugs For The Heart *Antiarrhythmics Type I-A*** - Drugs For Abnormal Heart Rhythms disopyramide phosphate oral capsule 100 mg, 150 mg 1 Norpace CR Oral Capsule Extended Release 12 3 Hour 100 MG, 150 MG gluconate er oral tablet extended release 1 324 mg quinidine sulfate oral tablet 200 mg, 300 mg 1

Last Published: 09/17/2021 18 Drug Name Drug Tier Requirements / Limits *Antiarrhythmics Type I-B*** - Drugs For Abnormal Heart Rhythms mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1 *Antiarrhythmics Type I-C*** - Drugs For Abnormal Heart Rhythms flecainide acetate oral tablet 100 mg, 150 mg, 50 mg 1 propafenone hcl er oral capsule extended release 12 1 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1 *Antiarrhythmics Type Iii*** - Drugs For Abnormal Heart Rhythms hcl oral tablet 100 mg, 200 mg, 400 mg 1 oral capsule 125 mcg, 250 mcg, 500 mcg 1 Multaq Oral Tablet 400 MG 3 QL Pacerone Oral Tablet 100 MG, 200 MG, 400 MG 1 *Antiasthmatic And Bronchodilator Agents* - Drugs For The Lungs *5-Lipoxygenase Inhibitors*** - Drugs For Asthma/Copd zileuton er oral tablet extended release 12 hour 600 1 QL mg Zyflo Oral Tablet 600 MG 3 QL *Adrenergic Combinations*** - Drugs For Asthma/Copd Advair Diskus Inhalation Aerosol Powder Breath Activated 100-50 MCG/DOSE, 250-50 MCG/DOSE, 1 QL 500-50 MCG/DOSE Advair HFA Inhalation Aerosol 115-21 MCG/ACT, 2 QL 230-21 MCG/ACT, 45-21 MCG/ACT Anoro Ellipta Inhalation Aerosol Powder Breath 2 QL Activated 62.5-25 MCG/INH Bevespi Aerosphere Inhalation Aerosol 9-4.8 2 QL MCG/ACT Breo Ellipta Inhalation Aerosol Powder Breath 2 QL Activated 100-25 MCG/INH, 200-25 MCG/INH budesonide-formoterol fumarate inhalation aerosol 1 QL 160-4.5 mcg/act, 80-4.5 mcg/act Combivent Respimat Inhalation Aerosol Solution 2 QL 20-100 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) 1 mg/3ml Stiolto Respimat Inhalation Aerosol Solution 2.5- 2 QL 2.5 MCG/ACT Symbicort Inhalation Aerosol 160-4.5 MCG/ACT, 2 QL 80-4.5 MCG/ACT Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/INH, 200-62.5-25 2 QL MCG/INH Last Published: 09/17/2021 19 Drug Name Drug Tier Requirements / Limits Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 MCG/DOSE, 250-50 MCG/DOSE, Not Covered 500-50 MCG/DOSE *Anti-Ige Monoclonal Antibodies*** - Drugs For Asthma/Copd Xolair Subcutaneous Solution Prefilled Syringe Tier 10 PA 150 MG/ML, 75 MG/0.5ML Xolair Subcutaneous Solution Reconstituted 150 Tier 10 PA MG *Anti-Inflammatory Agents*** - Drugs For Asthma/Copd cromolyn sodium inhalation nebulization solution 20 1 mg/2ml *Beta Adrenergics*** - Drugs For Asthma/Copd albuterol sulfate hfa inhalation aerosol solution 108 1 QL (90 base) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 1 mg/3ml albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 1 formoterol fumarate inhalation nebulization solution 20 1 QL mcg/2ml levalbuterol hcl inhalation nebulization solution 0.31 1 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate inhalation aerosol 45 mcg/act 1 QL ProAir Digihaler Inhalation Aerosol Powder Breath 2 QL Activated 108 (90 Base) MCG/ACT ProAir HFA Inhalation Aerosol Solution 108 (90 2 QL Base) MCG/ACT ProAir RespiClick Inhalation Aerosol Powder 2 QL Breath Activated 108 (90 Base) MCG/ACT Proventil HFA Inhalation Aerosol Solution 108 (90 3 ST; QL Base) MCG/ACT Serevent Diskus Inhalation Aerosol Powder Breath 2 QL Activated 50 MCG/DOSE Striverdi Respimat Inhalation Aerosol Solution 2.5 3 QL MCG/ACT terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 Ventolin HFA Inhalation Aerosol Solution 108 (90 2 QL Base) MCG/ACT *Bronchodilators - Anticholinergics*** - Drugs For Asthma/Copd Atrovent HFA Inhalation Aerosol Solution 17 2 QL MCG/ACT Incruse Ellipta Inhalation Aerosol Powder Breath 2 QL Activated 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % 1 Last Published: 09/17/2021 20 Drug Name Drug Tier Requirements / Limits Spiriva HandiHaler Inhalation Capsule 18 MCG 2 QL Spiriva Respimat Inhalation Aerosol Solution 1.25 2 QL MCG/ACT, 2.5 MCG/ACT Tudorza Pressair Inhalation Aerosol Powder 3 QL Breath Activated 400 MCG/ACT *Interleukin-5 Antagonists (Igg1 Kappa)*** - Drugs For Asthma/Copd Fasenra Pen Subcutaneous Solution Auto-Injector 3 PA 30 MG/ML Fasenra Subcutaneous Solution Prefilled Syringe Tier 10 PA 30 MG/ML Nucala Subcutaneous Solution Auto-Injector 100 3 PA MG/ML Nucala Subcutaneous Solution Prefilled Syringe 3 PA 100 MG/ML Nucala Subcutaneous Solution Reconstituted 100 Tier 10 PA MG *Interleukin-5 Antagonists (Igg4 Kappa)*** - Drugs For Asthma/Copd Cinqair Intravenous Solution 100 MG/10ML Tier 10 PA *Leukotriene Receptor Antagonists*** - Drugs For Asthma/Copd QL; Age Restriction Applies (Max 5 montelukast sodium oral packet 4 mg 1 Years) montelukast sodium oral tablet 10 mg 1 QL montelukast sodium oral tablet chewable 4 mg, 5 mg 1 zafirlukast oral tablet 10 mg, 20 mg 1 QL *Selective Phosphodiesterase 4 (Pde4) Inhibitors*** - Drugs For Asthma/Copd Daliresp Oral Tablet 250 MCG, 500 MCG 3 QL *Steroid Inhalants*** - Drugs For Asthma/Copd Arnuity Ellipta Inhalation Aerosol Powder Breath 2 QL Activated 100 MCG/ACT, 200 MCG/ACT Arnuity Ellipta Inhalation Aerosol Powder Breath QL; Age Restriction Applies (Min 5 2 Activated 50 MCG/ACT Years and Max 11 Years) Asmanex (120 Metered Doses) Inhalation Aerosol 2 Powder Breath Activated 220 MCG/INH Asmanex (14 Metered Doses) Inhalation Aerosol 2 Powder Breath Activated 220 MCG/INH Asmanex (30 Metered Doses) Inhalation Aerosol Powder Breath Activated 110 MCG/INH, 220 2 MCG/INH Asmanex (60 Metered Doses) Inhalation Aerosol 2 Powder Breath Activated 220 MCG/INH Asmanex (7 Metered Doses) Inhalation Aerosol 2 Powder Breath Activated 110 MCG/INH Asmanex HFA Inhalation Aerosol 100 MCG/ACT, 2 QL 200 MCG/ACT, 50 MCG/ACT Last Published: 09/17/2021 21 Drug Name Drug Tier Requirements / Limits budesonide inhalation suspension 0.25 mg/2ml, 0.5 1 QL mg/2ml, 1 mg/2ml Flovent Diskus Inhalation Aerosol Powder Breath Activated 100 MCG/BLIST, 250 MCG/BLIST, 50 2 QL MCG/BLIST Flovent HFA Inhalation Aerosol 110 MCG/ACT, 220 2 QL MCG/ACT, 44 MCG/ACT Pulmicort Flexhaler Inhalation Aerosol Powder 2 QL Breath Activated 180 MCG/ACT, 90 MCG/ACT Qvar RediHaler Inhalation Aerosol Breath 2 QL Activated 40 MCG/ACT, 80 MCG/ACT *Xanthines*** - Drugs For Asthma/Copd Elixophyllin Oral Elixir 80 MG/15ML 3 Theo-24 Oral Capsule Extended Release 24 Hour 3 100 MG, 200 MG, 300 MG, 400 MG er oral tablet extended release 12 hour 1 300 mg, 450 mg theophylline er oral tablet extended release 24 hour 1 400 mg, 600 mg theophylline oral solution 80 mg/15ml 1 *Anticoagulants* - Drugs For The Blood *Coumarin Anticoagulants*** - Drugs To Prevent Blood Clots Jantoven Oral Tablet 1 MG, 10 MG, 2 MG, 2.5 MG, 3 1 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 1 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors*** - Drugs To Prevent Blood Clots Eliquis Oral Tablet 2.5 MG, 5 MG 2 Xarelto Oral Tablet 10 MG, 15 MG, 2.5 MG, 20 MG 2 Xarelto Starter Pack Oral Tablet Therapy Pack 15 & 2 20 MG *Low Molecular Weight Heparins*** - Drugs To Prevent Blood Clots enoxaparin sodium injection solution 300 mg/3ml 1 QL enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 1 QL 60 mg/0.6ml, 80 mg/0.8ml *Synthetic Heparinoid-Like Agents*** - Drugs To Prevent Blood Clots fondaparinux sodium subcutaneous solution 10 1 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

Last Published: 09/17/2021 22 Drug Name Drug Tier Requirements / Limits *Anticonvulsants* - Drugs For The Nervous System *Ampa Glutamate Receptor Antagonists*** - Drugs For Seizures /Personality Disorder/Nerve Pain QL; Age Restriction Applies (Min 12 Fycompa Oral Suspension 0.5 MG/ML 3 Years) Fycompa Oral Tablet 10 MG, 12 MG, 2 MG, 4 MG, 6 QL; Age Restriction Applies (Min 12 3 MG, 8 MG Years) *Anticonvulsants - Benzodiazepines*** - Drugs For Seizures /Personality Disorder/Nerve Pain clobazam oral suspension 2.5 mg/ml 1 clobazam oral tablet 10 mg, 20 mg 1 oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 1 0.5 mg, 1 mg, 2 mg Diastat AcuDial Rectal Gel 10 MG, 20 MG 3 Diastat Pediatric Rectal Gel 2.5 MG 3 diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 Nayzilam Nasal Solution 5 MG/0.1ML 3 Onfi Oral Suspension 2.5 MG/ML 3 Onfi Oral Tablet 10 MG, 20 MG 3 Sympazan Oral Film 10 MG, 20 MG, 5 MG 3 PA Valtoco 10 MG Dose Nasal Liquid 10 MG/0.1ML 3 Valtoco 15 MG Dose Nasal Liquid Therapy Pack 3 7.5 MG/0.1ML Valtoco 20 MG Dose Nasal Liquid Therapy Pack 10 3 MG/0.1ML Valtoco 5 MG Dose Nasal Liquid 5 MG/0.1ML 3 *Anticonvulsants - Misc.*** - Drugs For Seizures /Personality Disorder/Nerve Pain Aptiom Oral Tablet 200 MG, 400 MG, 600 MG, 800 3 QL MG QL; Age Restriction Applies (Max 18 Banzel Oral Suspension 40 MG/ML 2 Years) Banzel Oral Tablet 200 MG, 400 MG 2 QL Age Restriction Applies (Min 16 Briviact Oral Solution 10 MG/ML 3 Years) Briviact Oral Tablet 10 MG, 100 MG, 25 MG, 50 MG, Age Restriction Applies (Min 16 3 75 MG Years) carbamazepine er oral capsule extended release 12 1 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 1 hour 100 mg, 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml 1 carbamazepine oral tablet 200 mg 1 carbamazepine oral tablet chewable 100 mg 1

Last Published: 09/17/2021 23 Drug Name Drug Tier Requirements / Limits Diacomit Oral Capsule 250 MG, 500 MG 3 PA Diacomit Oral Packet 250 MG, 500 MG 3 PA Epidiolex Oral Solution 100 MG/ML 3 PA Epitol Oral Tablet 200 MG 1 Fintepla Oral Solution 2.2 MG/ML 3 PA; QL gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml, 300 mg/6ml 1 gabapentin oral tablet 600 mg, 800 mg 1 Keppra Oral Solution 100 MG/ML 3 Keppra Oral Tablet 1000 MG, 250 MG, 500 MG, 750 3 MG Keppra XR Oral Tablet Extended Release 24 Hour 3 QL 500 MG, 750 MG LaMICtal ODT Oral Kit 21 x 25 MG & 7 x 50 MG, 25 3 QL & 50 & 100 MG, 42 x 50 MG & 14x100 MG LaMICtal ODT Oral Tablet Dispersible 100 MG, 200 3 MG, 25 MG, 50 MG LaMICtal Oral Tablet 100 MG, 150 MG, 200 MG, 25 3 MG LaMICtal Oral Tablet Chewable 25 MG, 5 MG 3 LaMICtal Starter Oral Kit 35 x 25 MG, 42 x 25 MG & 3 QL 7 x 100 MG, 84 x 25 MG & 14x100 MG LaMICtal XR Oral Kit 21 x 25 MG & 7 x 50 MG, 25 & 3 QL 50 & 100 MG, 50 & 100 & 200 MG LaMICtal XR Oral Tablet Extended Release 24 Hour 3 QL 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG er oral tablet extended release 24 hour 1 QL 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 1 mg lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 1 mg, 50 mg lamotrigine starter kit-blue oral kit 35 x 25 mg 1 QL lamotrigine starter kit-green oral kit 84 x 25 mg & 1 QL 14x100 mg lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 1 QL 100 mg levetiracetam er oral tablet extended release 24 hour 1 QL 500 mg, 750 mg levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 1 750 mg Mysoline Oral Tablet 250 MG, 50 MG 3 Neurontin Oral Capsule 100 MG, 300 MG, 400 MG 3 ST Neurontin Oral Solution 250 MG/5ML 3 ST

Last Published: 09/17/2021 24 Drug Name Drug Tier Requirements / Limits Neurontin Oral Tablet 600 MG, 800 MG 3 ST oxcarbazepine oral suspension 300 mg/5ml 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 Oxtellar XR Oral Tablet Extended Release 24 Hour 3 150 MG, 300 MG, 600 MG pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 1 QL mg, 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml 1 QL primidone oral tablet 250 mg, 50 mg 1 Qudexy XR Oral Capsule ER 24 Hour Sprinkle 100 3 QL MG, 150 MG, 200 MG, 25 MG, 50 MG QL; Age Restriction Applies (Max 18 rufinamide oral suspension 40 mg/ml 1 Years) rufinamide oral tablet 200 mg, 400 mg 1 QL Subvenite Oral Tablet 100 MG, 150 MG, 200 MG, 25 1 MG Subvenite Starter Kit-Blue Oral Kit 35 x 25 MG 1 QL Subvenite Starter Kit-Green Oral Kit 84 x 25 MG & 1 QL 14x100 MG Subvenite Starter Kit-Orange Oral Kit 42 x 25 MG & 1 QL 7 x 100 MG TEGretol Oral Suspension 100 MG/5ML 3 TEGretol Oral Tablet 200 MG 3 TEGretol-XR Oral Tablet Extended Release 12 3 Hour 100 MG, 200 MG, 400 MG Topamax Oral Tablet 100 MG, 200 MG, 25 MG, 50 3 MG Topamax Sprinkle Oral Capsule Sprinkle 15 MG, 3 25 MG topiramate er oral capsule er 24 hour sprinkle 100 mg, 1 QL 150 mg, 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 Trileptal Oral Suspension 300 MG/5ML 3 Trileptal Oral Tablet 150 MG, 300 MG, 600 MG 3 Trokendi XR Oral Capsule Extended Release 24 3 QL Hour 100 MG, 200 MG, 25 MG, 50 MG Vimpat Oral Solution 10 MG/ML 2 QL Vimpat Oral Tablet 100 MG, 150 MG, 200 MG, 50 2 QL MG Zonegran Oral Capsule 100 MG, 25 MG 3 zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 *Carbamates*** - Drugs For Seizures /Personality Disorder/Nerve Pain felbamate oral suspension 600 mg/5ml 1 felbamate oral tablet 400 mg, 600 mg 1 Last Published: 09/17/2021 25 Drug Name Drug Tier Requirements / Limits Felbatol Oral Suspension 600 MG/5ML 3 Felbatol Oral Tablet 400 MG, 600 MG 3 Xcopri (250 MG Daily Dose) Oral Tablet Therapy 3 QL Pack 100 & 150 MG Xcopri (350 MG Daily Dose) Oral Tablet Therapy 3 QL Pack 150 & 200 MG Xcopri Oral Tablet 100 MG, 150 MG, 200 MG, 50 3 QL MG Xcopri Oral Tablet Therapy Pack 14 x 12.5 MG & 14 x 25 MG, 14 x 150 MG & 14 x200 MG, 14 x 50 MG & 3 QL 14 x100 MG *Gaba Modulators*** - Drugs For Seizures /Personality Disorder/Nerve Pain Gabitril Oral Tablet 2 MG, 4 MG 3 Sabril Oral Packet 500 MG 3 QL Sabril Oral Tablet 500 MG 2 QL tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1 vigabatrin oral packet 500 mg 1 QL vigabatrin oral tablet 500 mg 1 QL Vigadrone Oral Packet 500 MG 1 QL *Hydantoins*** - Drugs For Seizures /Personality Disorder/Nerve Pain Dilantin Infatabs Oral Tablet Chewable 50 MG 3 Dilantin Oral Capsule 100 MG, 30 MG 3 Dilantin Oral Suspension 125 MG/5ML 3 Phenytek Oral Capsule 200 MG, 300 MG 1 Phenytoin Infatabs Oral Tablet Chewable 50 MG 1 phenytoin oral suspension 125 mg/5ml 1 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 1 mg, 300 mg *Succinimides*** - Drugs For Seizures /Personality Disorder/Nerve Pain Celontin Oral Capsule 300 MG 2 ethosuximide oral capsule 250 mg 1 ethosuximide oral solution 250 mg/5ml 1 Zarontin Oral Capsule 250 MG 3 Zarontin Oral Solution 250 MG/5ML 3 *Valproic Acid*** - Drugs For Seizures /Personality Disorder/Nerve Pain Depakote ER Oral Tablet Extended Release 24 3 Hour 250 MG, 500 MG Depakote Oral Tablet Delayed Release 125 MG, 3 250 MG, 500 MG

Last Published: 09/17/2021 26 Drug Name Drug Tier Requirements / Limits Depakote Sprinkles Oral Capsule Delayed Release 3 Sprinkle 125 MG divalproex sodium er oral tablet extended release 24 1 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release 1 sprinkle 125 mg divalproex sodium oral tablet delayed release 125 mg, 1 250 mg, 500 mg valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 *Antidepressants* - Drugs For The Nervous System *Alpha-2 Receptor Antagonists (Tetracyclics)*** - Drugs For Depression oral tablet 15 mg, 30 mg, 45 mg 1 mirtazapine oral tablet 7.5 mg 1 QL mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 1 QL mg *Antidepressants - Misc.*** - Drugs For Depression Aplenzin Oral Tablet Extended Release 24 Hour 3 QL 174 MG, 348 MG, 522 MG hcl er (sr) oral tablet extended release 12 1 hour 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 1 QL hour 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg 1 *Monoamine Oxidase Inhibitors (Maois)*** - Drugs For Depression Emsam Transdermal Patch 24 Hour 12 MG/24HR, 6 3 QL MG/24HR, 9 MG/24HR Marplan Oral Tablet 10 MG 3 phenelzine sulfate oral tablet 15 mg 1 tranylcypromine sulfate oral tablet 10 mg 1 *N-Methyl-D-Aspartic Acid (Nmda) Receptor Antagonists*** - Drugs For Depression Spravato (56 MG Dose) Nasal Solution Therapy Tier 10 Pack 28 MG/DEVICE Spravato (84 MG Dose) Nasal Solution Therapy Tier 10 Pack 28 MG/DEVICE *Selective Serotonin Reuptake Inhibitors (Ssris)*** - Drugs For Depression citalopram hydrobromide oral solution 10 mg/5ml 1 citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 1 mg escitalopram oxalate oral solution 5 mg/5ml 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1

Last Published: 09/17/2021 27 Drug Name Drug Tier Requirements / Limits fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 fluoxetine hcl oral capsule delayed release 90 mg 1 fluoxetine hcl oral solution 20 mg/5ml 1 fluoxetine hcl oral tablet 10 mg, 20 mg, 60 mg 1 fluvoxamine maleate er oral capsule extended release 1 QL 24 hour 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1 hcl er oral tablet extended release 24 hour 1 12.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 Paxil Oral Suspension 10 MG/5ML 3 Pexeva Oral Tablet 10 MG, 20 MG, 30 MG, 40 MG 3 QL sertraline hcl oral concentrate 20 mg/ml 1 sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 *Serotonin Modulators*** - Drugs For Depression hcl oral tablet 100 mg, 150 mg, 200 mg, 1 250 mg, 50 mg hcl oral tablet 100 mg, 150 mg, 300 mg, 50 1 mg Trintellix Oral Tablet 10 MG, 20 MG, 5 MG 2 QL Viibryd Oral Tablet 10 MG, 20 MG, 40 MG 2 QL Viibryd Starter Pack Oral Kit 10 & 20 MG 2 QL *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** - Drugs For Depression desvenlafaxine er oral tablet extended release 24 hour 3 ST; QL 100 mg, 50 mg desvenlafaxine succinate er oral tablet extended 1 QL release 24 hour 100 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 1 20 mg, 30 mg, 60 mg Fetzima Oral Capsule Extended Release 24 Hour 3 120 MG, 20 MG, 40 MG, 80 MG Fetzima Titration Oral Capsule ER 24 Hour 3 QL Therapy Pack 20 & 40 MG venlafaxine hcl er oral capsule extended release 24 1 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 1 150 mg, 225 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 1 mg, 75 mg * Agents*** - Drugs For Depression amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 1 mg, 50 mg, 75 mg oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 1

Last Published: 09/17/2021 28 Drug Name Drug Tier Requirements / Limits desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 1 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 1 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml 1 imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 imipramine pamoate oral capsule 100 mg, 125 mg, 1 150 mg, 75 mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 1 mg nortriptyline hcl oral solution 10 mg/5ml 1 protriptyline hcl oral tablet 10 mg, 5 mg 1 trimipramine maleate oral capsule 100 mg, 25 mg, 50 1 mg *Antidiabetics* - Hormones *Alpha-Glucosidase Inhibitors*** - Drugs For Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg 1 miglitol oral tablet 100 mg, 25 mg, 50 mg 1 *Antidiabetic - Amylin Analogs*** - Drugs For Diabetes SymlinPen 120 Subcutaneous Solution Pen- 3 QL Injector 2700 MCG/2.7ML SymlinPen 60 Subcutaneous Solution Pen-Injector 3 QL 1500 MCG/1.5ML *Biguanides*** - Drugs For Diabetes metformin hcl er oral tablet extended release 24 hour 1 500 mg, 750 mg metformin hcl oral solution 500 mg/5ml 3 metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1 *Diabetic Other*** - Drugs For Diabetes Baqsimi One Pack Nasal Powder 3 MG/DOSE 3 Baqsimi Two Pack Nasal Powder 3 MG/DOSE 3 diazoxide oral suspension 50 mg/ml 1 GlucaGen HypoKit Injection Solution 2 Reconstituted 1 MG glucagon emergency injection kit 1 mg 2 Gvoke HypoPen 1-Pack Subcutaneous Solution 3 Auto-Injector 0.5 MG/0.1ML, 1 MG/0.2ML Gvoke HypoPen 2-Pack Subcutaneous Solution 3 Auto-Injector 0.5 MG/0.1ML, 1 MG/0.2ML Gvoke PFS Subcutaneous Solution Prefilled 3 Syringe 0.5 MG/0.1ML, 1 MG/0.2ML

Last Published: 09/17/2021 29 Drug Name Drug Tier Requirements / Limits *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** - Drugs For Diabetes alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 1 QL mg Januvia Oral Tablet 100 MG, 25 MG, 50 MG 2 QL *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** - Drugs For Diabetes alogliptin-metformin hcl oral tablet 12.5-1000 mg, 1 QL 12.5-500 mg Janumet Oral Tablet 50-1000 MG, 50-500 MG 2 QL Janumet XR Oral Tablet Extended Release 24 Hour 2 QL 100-1000 MG, 50-1000 MG, 50-500 MG *Dopamine Receptor Agonists - Derivatives*** - Drugs For Diabetes Cycloset Oral Tablet 0.8 MG 3 *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** - Drugs For Diabetes alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 1 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg *Human Insulin*** - Drugs For Diabetes Fiasp FlexTouch Subcutaneous Solution Pen- 2 Injector 100 UNIT/ML Fiasp PenFill Subcutaneous Solution Cartridge 2 100 UNIT/ML Fiasp Subcutaneous Solution 100 UNIT/ML 2 HumuLIN R U-500 (CONCENTRATED) 2 Subcutaneous Solution 500 UNIT/ML HumuLIN R U-500 KwikPen Subcutaneous 2 Solution Pen-Injector 500 UNIT/ML Lantus SoloStar Subcutaneous Solution Pen- 2 Injector 100 UNIT/ML Lantus Subcutaneous Solution 100 UNIT/ML 2 NovoLIN 70/30 Subcutaneous Suspension (70-30) 2 100 UNIT/ML NovoLIN N FlexPen Subcutaneous Suspension 2 Pen-Injector 100 UNIT/ML NovoLIN N Subcutaneous Suspension 100 2 UNIT/ML NovoLIN R FlexPen Injection Solution Pen-Injector 2 100 UNIT/ML NovoLIN R Injection Solution 100 UNIT/ML 2 NovoLOG FlexPen Subcutaneous Solution Pen- 2 Injector 100 UNIT/ML NovoLOG Mix 70/30 FlexPen Subcutaneous 2 Suspension Pen-Injector (70-30) 100 UNIT/ML NovoLOG Mix 70/30 Subcutaneous Suspension 2 (70-30) 100 UNIT/ML

Last Published: 09/17/2021 30 Drug Name Drug Tier Requirements / Limits NovoLOG PenFill Subcutaneous Solution 2 Cartridge 100 UNIT/ML NovoLOG Subcutaneous Solution 100 UNIT/ML 2 Toujeo Max SoloStar Subcutaneous Solution Pen- 2 Injector 300 UNIT/ML Toujeo SoloStar Subcutaneous Solution Pen- 2 Injector 300 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** - Drugs For Diabetes Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous 2 QL Solution Pen-Injector 2 MG/1.5ML Ozempic (1 MG/DOSE) Subcutaneous Solution 2 QL Pen-Injector 2 MG/1.5ML, 4 MG/3ML Rybelsus Oral Tablet 14 MG, 3 MG, 7 MG 2 QL Trulicity Subcutaneous Solution Pen-Injector 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 2 QL MG/0.5ML Victoza Subcutaneous Solution Pen-Injector 18 2 QL MG/3ML *Insulin-Incretin Mimetic Combinations*** - Drugs For Diabetes Soliqua Subcutaneous Solution Pen-Injector 100- 2 QL 33 UNT-MCG/ML Xultophy Subcutaneous Solution Pen-Injector 100- 2 QL 3.6 UNIT-MG/ML *Meglitinide Analogues*** - Drugs For Diabetes nateglinide oral tablet 120 mg, 60 mg 1 oral tablet 0.5 mg, 1 mg, 2 mg 1 * Receptor Antagonists*** - Drugs For Diabetes PA; Age Restriction Applies (Min 18 Korlym Oral Tablet 300 MG 3 Years) *Sglt2 Inhibitor - Dpp-4 Inhibitor - Biguanide Comb*** - Drugs For Diabetes Trijardy XR Oral Tablet Extended Release 24 Hour 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, 5- 2 QL 2.5-1000 MG *Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations*** - Drugs For Diabetes Glyxambi Oral Tablet 10-5 MG, 25-5 MG 2 QL Qtern Oral Tablet 10-5 MG, 5-5 MG 2 QL *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** - Drugs For Diabetes Farxiga Oral Tablet 10 MG, 5 MG 2 QL Jardiance Oral Tablet 10 MG, 25 MG 2 QL

Last Published: 09/17/2021 31 Drug Name Drug Tier Requirements / Limits *Sodium-Glucose Co-Transporter 2 Inhibitor- Biguanide Comb*** - Drugs For Diabetes Synjardy Oral Tablet 12.5-1000 MG, 12.5-500 MG, 2 QL 5-1000 MG, 5-500 MG Synjardy XR Oral Tablet Extended Release 24 Hour 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5- 2 QL 1000 MG Xigduo XR Oral Tablet Extended Release 24 Hour 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, 2 QL 5-500 MG *Sulfonylurea-Biguanide Combinations*** - Drugs For Diabetes glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 1 mg, 5-500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 1 mg, 5-500 mg *Sulfonylureas*** - Drugs For Diabetes glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide er oral tablet extended release 24 hour 10 1 mg, 2.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg 1 glipizide xl oral tablet extended release 24 hour 10 1 mg, 2.5 mg, 5 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1 tolbutamide oral tablet 500 mg 1 *Sulfonylurea-Thiazolidinedione Combinations*** - Drugs For Diabetes pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 1 QL mg *Thiazolidinedione-Biguanide Combinations*** - Drugs For Diabetes pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 1 15-850 mg *Thiazolidinediones*** - Drugs For Diabetes pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 1 *Antidiarrheal/Probiotic Agents* - Drugs For The Stomach *Antidiarrheal - Chloride Channel Antagonists*** - Drugs For Mytesi Oral Tablet Delayed Release 125 MG 3 PA; QL *Antidiarrheal/Probiotic Combinations*** - Drugs For Diarrhea Restora RX Oral Capsule 60-1.25 MG 3 *Antiperistaltic Agents*** - Drugs For Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 Last Published: 09/17/2021 32 Drug Name Drug Tier Requirements / Limits Motofen Oral Tablet 1-0.025 MG 3 opium oral tincture 10 mg/ml (1%) 1 *Antidotes And Specific Antagonists* - Drugs For Overdose Or Poisoning *Antidotes - Chelating Agents*** - Drugs For Overdose Or Poisoning Chemet Oral Capsule 100 MG 3 deferasirox oral tablet 180 mg, 360 mg, 90 mg 1 PA deferasirox oral tablet soluble 125 mg, 250 mg, 500 1 PA mg deferiprone oral tablet 500 mg 1 PA Exjade Oral Tablet Soluble 125 MG, 250 MG, 500 2 PA MG Ferriprox Oral Solution 100 MG/ML 3 PA Ferriprox Oral Tablet 1000 MG, 500 MG 3 PA Ferriprox Twice-A-Day Oral Tablet 1000 MG 3 PA Jadenu Oral Tablet 180 MG, 360 MG, 90 MG 3 PA Jadenu Sprinkle Oral Packet 180 MG, 360 MG, 90 3 PA MG pentetate calcium trisodium combination solution 200 3 mg/ml pentetate zinc trisodium combination solution 200 3 mg/ml *Antidotes And Specific Antagonists*** - Drugs For Overdose Or Poisoning Vistogard Oral Packet 10 GM 3 QL *Opioid Antagonists*** - Drugs For Overdose Or Poisoning Kloxxado Nasal Liquid 8 MG/0.1ML 3 QL naltrexone hcl oral tablet 50 mg 1 Narcan Nasal Liquid 4 MG/0.1ML 3 QL Vivitrol Intramuscular Suspension Reconstituted Tier 10 PA 380 MG *Antiemetics* - Drugs For The Stomach *5-Ht3 Receptor Antagonists*** - Drugs For And granisetron hcl oral tablet 1 mg 1 QL ondansetron hcl oral solution 4 mg/5ml 1 QL ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 QL ondansetron oral tablet dispersible 4 mg, 8 mg 1 QL Sancuso Transdermal Patch 3.1 MG/24HR 3 QL *Antiemetic Combinations*** - Drugs For Vomiting And Nausea Akynzeo Oral Capsule 300-0.5 MG 3 QL

Last Published: 09/17/2021 33 Drug Name Drug Tier Requirements / Limits *Antiemetics - Anticholinergic*** - Drugs For Vomiting And Nausea scopolamine transdermal patch 72 hour 1 mg/3days 1 QL trimethobenzamide hcl oral capsule 300 mg 1 *Antiemetics - Miscellaneous*** - Drugs For Vomiting And Nausea dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 Syndros Oral Solution 5 MG/ML 3 *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** - Drugs For Vomiting And Nausea aprepitant oral capsule 125 mg, 80 & 125 mg 1 QL aprepitant oral capsule 40 mg, 80 mg 1 Emend Oral Suspension Reconstituted 125 2 QL MG/5ML *Antifungals* - Drugs For Infections *Antifungals*** - Drugs For Fungus oral capsule 250 mg, 500 mg 1 microsize oral suspension 125 mg/5ml 1 griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 oral tablet 500000 unit 1 hcl oral tablet 250 mg 1 **** - Drugs For Fungus oral tablet 200 mg 1 **** - Drugs For Fungus Cresemba Oral Capsule 186 MG 3 PR; QL oral suspension reconstituted 10 mg/ml, 1 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 1 mg oral capsule 100 mg 1 PR; QL itraconazole oral solution 10 mg/ml 1 PR; QL Noxafil Oral Suspension 40 MG/ML 2 PR; QL oral suspension reconstituted 40 mg/ml 1 PR; QL voriconazole oral tablet 200 mg, 50 mg 1 PR; QL *Antihistamines* - Drugs For The Lungs *Antihistamines - Alkylamines*** - Drugs For dexchlorpheniramine maleate oral solution 2 mg/5ml 1 RyClora Oral Solution 2 MG/5ML 1 *Antihistamines - Ethanolamines*** - Drugs For Allergies carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1

Last Published: 09/17/2021 34 Drug Name Drug Tier Requirements / Limits clemastine fumarate oral tablet 2.68 mg 1 Karbinal ER Oral Suspension Extended Release 4 3 MG/5ML *Antihistamines - Non-Sedating*** - Drugs For Allergies Age Restriction Applies (Max 12 hcl oral tablet 5 mg 1 Years) *Antihistamines - Phenothiazines*** - Drugs For Allergies promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 Promethegan Rectal Suppository 12.5 MG, 25 MG, 1 50 MG *Antihistamines - Piperidines*** - Drugs For Allergies hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 *Antihyperlipidemics* - Drugs For The Heart *Angiopoietin-Like Protein 3 (Angptl3) Inhibitors*** - Drugs For Cholesterol Evkeeza Intravenous Solution 1200 MG/8ML, 345 Tier 10 PA MG/2.3ML *Antihyperlipidemics - Misc.*** - Drugs For Cholesterol icosapent ethyl oral capsule 1 gm 1 QL omega-3-acid ethyl esters oral capsule 1 gm 1 QL Vascepa Oral Capsule 0.5 GM 3 QL *Bile Acid Sequestrants*** - Drugs For Cholesterol cholestyramine light oral packet 4 gm 1 cholestyramine light oral powder 4 gm/dose 1 cholestyramine oral packet 4 gm 1 cholestyramine oral powder 4 gm/dose 1 colesevelam hcl oral packet 3.75 gm 1 colesevelam hcl oral tablet 625 mg 1 colestipol hcl oral granules 5 gm 1 colestipol hcl oral packet 5 gm 1 colestipol hcl oral tablet 1 gm 1 Prevalite Oral Packet 4 GM 1 Prevalite Oral Powder 4 GM/DOSE 1 *Fibric Acid Derivatives*** - Drugs For Cholesterol Antara Oral Capsule 30 MG, 90 MG 3 fenofibrate micronized oral capsule 130 mg, 134 mg, 1 200 mg, 43 mg, 67 mg Last Published: 09/17/2021 35 Drug Name Drug Tier Requirements / Limits fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 1 mg, 67 mg fenofibrate oral tablet 120 mg, 145 mg, 160 mg, 40 1 mg, 48 mg, 54 mg fenofibric acid oral capsule delayed release 135 mg, 1 45 mg gemfibrozil oral tablet 600 mg 1 *Hmg Coa Reductase Inhibitors*** - Drugs For Cholesterol Altoprev Oral Tablet Extended Release 24 Hour 20 3 MG, 40 MG Altoprev Oral Tablet Extended Release 24 Hour 60 3 QL MG atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 1 80 mg flolipid oral suspension 20 mg/5ml 3 fluvastatin sodium er oral tablet extended release 24 1 hour 80 mg fluvastatin sodium oral capsule 20 mg, 40 mg 1 Livalo Oral Tablet 1 MG, 2 MG, 4 MG 3 QL oral tablet 10 mg, 20 mg, 40 mg 1 pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 1 80 mg rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 1 5 mg oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 1 mg *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** - Drugs For Cholesterol ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 1 10-40 mg, 10-80 mg *Intestinal Cholesterol Absorption Inhibitors*** - Drugs For Cholesterol ezetimibe oral tablet 10 mg 1 *Microsomal Triglyceride Transfer Protein Inhibitors*** - Drugs For Cholesterol Juxtapid Oral Capsule 10 MG, 20 MG, 30 MG, 5 MG 3 PA; QL *Nicotinic Acid Derivatives*** - Drugs For Cholesterol niacin er (antihyperlipidemic) oral tablet extended 1 QL release 1000 mg, 500 mg, 750 mg *Pcsk9 Inhibitors*** - Drugs For Cholesterol Praluent Subcutaneous Solution Auto-Injector 150 2 PA; QL MG/ML, 75 MG/ML Repatha Pushtronex System Subcutaneous 2 PA; QL Solution Cartridge 420 MG/3.5ML

Last Published: 09/17/2021 36 Drug Name Drug Tier Requirements / Limits Repatha Subcutaneous Solution Prefilled Syringe 2 PA; QL 140 MG/ML Repatha SureClick Subcutaneous Solution Auto- 2 PA; QL Injector 140 MG/ML *Antihypertensives* - Drugs For The Heart *Ace Inhibitor & Calcium Channel Blocker Combinations*** - Drugs For High Blood Pressure amlodipine besy-benazepril hcl oral capsule 10-20 mg, 1 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg Prestalia Oral Tablet 14-10 MG, 3.5-2.5 MG, 7-5 MG 3 trandolapril-verapamil hcl er oral tablet extended 1 release 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg *Ace Inhibitors & Thiazide/Thiazide-Like*** - Drugs For High Blood Pressure benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 1 20-12.5 mg, 20-25 mg, 5-6.25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5- 1 12.5 mg fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 1 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 1 20-12.5 mg, 20-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 1 20-12.5 mg, 20-25 mg *Ace Inhibitors*** - Drugs For High Blood Pressure benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral solution 1 mg/ml 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 1 mg fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 1 mg, 5 mg moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 Qbrelis Oral Solution 1 MG/ML 3 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 *Agents For Pheochromocytoma*** - Drugs For High Blood Pressure metyrosine oral capsule 250 mg 1 phenoxybenzamine hcl oral capsule 10 mg 1

Last Published: 09/17/2021 37 Drug Name Drug Tier Requirements / Limits *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** - Drugs For High Blood Pressure amlodipine besylate-valsartan oral tablet 10-160 mg, 1 10-320 mg, 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 1 mg, 5-20 mg, 5-40 mg telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 1 80-10 mg, 80-5 mg *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** - Drugs For High Blood Pressure candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32- 1 12.5 mg, 32-25 mg Edarbyclor Oral Tablet 40-12.5 MG, 40-25 MG 3 irbesartan-hydrochlorothiazide oral tablet 150-12.5 1 mg, 300-12.5 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100- 1 25 mg, 50-12.5 mg olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 1 40-12.5 mg, 40-25 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 1 80-25 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 1 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg *Angiotensin Ii Receptor Antagonists*** - Drugs For High Blood Pressure candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 1 mg Edarbi Oral Tablet 40 MG, 80 MG 3 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg 1 *Angiotensin Ii Receptor Ant-Ca Channel Blocker- Thiazides*** - Drugs For High Blood Pressure amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160- 1 25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 1 mg *Antiadrenergics - Centrally Acting*** - Drugs For High Blood Pressure clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 1 QL mg/24hr, 0.3 mg/24hr guanfacine hcl oral tablet 1 mg, 2 mg 1 Last Published: 09/17/2021 38 Drug Name Drug Tier Requirements / Limits methyldopa oral tablet 250 mg, 500 mg 1 *Antiadrenergics - Peripherally Acting*** - Drugs For High Blood Pressure doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 1 mg prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 *Antihypertensives - Misc.*** - Drugs For High Blood Pressure Vecamyl Oral Tablet 2.5 MG 2 *Beta Blocker & Diuretic Combinations*** - Drugs For High Blood Pressure atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 1 mg bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 1 2.5-6.25 mg, 5-6.25 mg Dutoprol Oral Tablet Extended Release 24 Hour 3 100-12.5 MG, 25-12.5 MG, 50-12.5 MG metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 1 100-50 mg, 50-25 mg Tenoretic 100 Oral Tablet 100-25 MG 3 Tenoretic 50 Oral Tablet 50-25 MG 3 *Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb*** - Drugs For High Blood Pressure Tekturna HCT Oral Tablet 150-12.5 MG, 150-25 MG, 3 QL 300-12.5 MG, 300-25 MG *Direct Renin Inhibitors*** - Drugs For High Blood Pressure fumarate oral tablet 150 mg, 300 mg 1 QL *Selective Aldosterone Receptor Antagonists (Saras)*** - Drugs For High Blood Pressure oral tablet 25 mg, 50 mg 1 QL *Vasodilators*** - Drugs For High Blood Pressure hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 1 mg minoxidil oral tablet 10 mg, 2.5 mg 1 *Anti-Infective Agents - Misc.* - Drugs For Infections *Anti-Infective Agents - Misc.*** - Drugs For Infections Aemcolo Oral Tablet Delayed Release 194 MG 3 Impavido Oral Capsule 50 MG 3 QL metronidazole oral capsule 375 mg 1 metronidazole oral tablet 250 mg, 500 mg 1 Primsol Oral Solution 50 MG/5ML 3 tinidazole oral tablet 250 mg, 500 mg 1

Last Published: 09/17/2021 39 Drug Name Drug Tier Requirements / Limits trimethoprim oral tablet 100 mg 1 Xifaxan Oral Tablet 200 MG, 550 MG 2 *Anti-Infective Misc. - Combinations*** - Antibiotics sulfamethoxazole-trimethoprim oral suspension 200- 1 40 mg/5ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 1 800-160 mg Sulfatrim Pediatric Oral Suspension 200-40 1 MG/5ML *Antiprotozoal Agents*** - Drugs For Parasites Alinia Oral Suspension Reconstituted 100 MG/5ML 2 oral suspension 750 mg/5ml 1 Lampit Oral Tablet 120 MG, 30 MG 3 nitazoxanide oral tablet 500 mg 1 *Glycopeptides*** - Antibiotics Firvanq Oral Solution Reconstituted 25 MG/ML, 50 3 MG/ML vancomycin hcl oral capsule 125 mg, 250 mg 1 *Leprostatics*** - Antibiotics oral tablet 100 mg, 25 mg 1 *Lincosamides*** - Antibiotics clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin palmitate hcl oral solution reconstituted 75 1 mg/5ml *Monobactams*** - Antibiotics Cayston Inhalation Solution Reconstituted 75 MG 3 PR; QL *Oxazolidinones*** - Antibiotics linezolid oral suspension reconstituted 100 mg/5ml 1 QL linezolid oral tablet 600 mg 1 QL Sivextro Oral Tablet 200 MG 2 QL *Pleuromutilins*** - Antibiotics Xenleta Oral Tablet 600 MG 3 *Urinary Anti-Infectives*** - Antibiotics fosfomycin tromethamine oral packet 3 gm 1 methenamine hippurate oral tablet 1 gm 1 methenamine mandelate oral tablet 0.5 gm, 1 gm 1 nitrofurantoin macrocrystal oral capsule 100 mg, 25 1 mg, 50 mg nitrofurantoin monohyd macro oral capsule 100 mg 1 nitrofurantoin oral suspension 25 mg/5ml 1 *Urinary Antiseptic-Antispasmodic &/Or Analgesics*** - Drugs For Infections Hyophen Oral Tablet 81.6 MG 1

Last Published: 09/17/2021 40 Drug Name Drug Tier Requirements / Limits me/naphos/mb/hyo1 oral tablet 81.6 mg 1 Phosphasal Oral Tablet 81.6 MG 1 Urelle Oral Tablet 81 MG 1 Uribel Oral Capsule 118 MG 1 uro-mp oral capsule 118 mg 1 Ustell Oral Capsule 120 MG 1 Utira-C Oral Tablet 81.6 MG 1 Vilamit MB Oral Capsule 118 MG 1 *Antimalarials* - Drugs For Infections *Antimalarial Combinations*** - Drugs For Parasites atovaquone-proguanil hcl oral tablet 250-100 mg, 1 62.5-25 mg Coartem Oral Tablet 20-120 MG 2 QL *Antimalarials*** - Drugs For Parasites chloroquine phosphate oral tablet 250 mg, 500 mg 1 Daraprim Oral Tablet 25 MG 3 hydroxychloroquine sulfate oral tablet 200 mg 1 mefloquine hcl oral tablet 250 mg 1 primaquine phosphate oral tablet 26.3 (15 base) mg 1 quinine sulfate oral capsule 324 mg 1 QL *Antimyasthenic/Cholinergic Agents* - Drugs For Nerves And Muscles *Antimyasthenic/Cholinergic Agents*** - Drugs For Nerves And Muscles Firdapse Oral Tablet 10 MG 3 PA pyridostigmine bromide er oral tablet extended release 1 180 mg pyridostigmine bromide oral solution 60 mg/5ml 1 pyridostigmine bromide oral tablet 60 mg 1 pyridostigmine bromide tablet 30 mg oral 30 mg 1 Ruzurgi Oral Tablet 10 MG 3 PA *Antimycobacterial Agents* - Drugs For Infections *Antimycobacterial Agents*** - Antibiotics cycloserine oral capsule 250 mg 1 ethambutol hcl oral tablet 100 mg, 400 mg 1 isoniazid oral syrup 50 mg/5ml 1 isoniazid oral tablet 100 mg, 300 mg 1 Paser Oral Packet 4 GM 1 Pretomanid Oral Tablet 200 MG 3 PR Priftin Oral Tablet 150 MG 3 pyrazinamide oral tablet 500 mg 1 rifabutin oral capsule 150 mg 1

Last Published: 09/17/2021 41 Drug Name Drug Tier Requirements / Limits rifampin oral capsule 150 mg, 300 mg 1 Sirturo Oral Tablet 100 MG, 20 MG 3 Trecator Oral Tablet 250 MG 3 *Antineoplastics And Adjunctive Therapies* - Drugs For Cancer *Alkylating Agents*** - Drugs For Cancer Belrapzo Intravenous Solution 100 MG/4ML Tier 10 PA Bendeka Intravenous Solution 100 MG/4ML Tier 10 PA intravenous solution 6 mg/ml Tier 10 Busulfex Intravenous Solution 6 MG/ML Tier 10 carboplatin intravenous solution 150 mg/15ml, 450 Tier 10 mg/45ml, 50 mg/5ml, 600 mg/60ml cisplatin intravenous solution 100 mg/100ml, 200 Tier 10 mg/200ml, 50 mg/50ml cisplatin intravenous solution reconstituted 50 mg Tier 10 Myleran Oral Tablet 2 MG 2 oxaliplatin intravenous solution 100 mg/20ml, 50 Tier 10 mg/10ml oxaliplatin intravenous solution reconstituted 100 mg, Tier 10 50 mg Paraplatin Intravenous Solution 1000 MG/100ML, 150 MG/15ML, 450 MG/45ML, 50 MG/5ML, 600 Tier 10 MG/60ML Tepadina Injection Solution Reconstituted 100 MG, Tier 10 PA 15 MG thiotepa injection solution reconstituted 15 mg Tier 10 PA Treanda Intravenous Solution Reconstituted 100 Tier 10 PA MG, 25 MG Zepzelca Intravenous Solution Reconstituted 4 MG Tier 10 PA * Biosynthesis Inhibitors*** - Drugs For Cancer abiraterone acetate oral tablet 250 mg, 500 mg 1 PA; QL Yonsa Oral Tablet 125 MG 3 PA; QL Zytiga Oral Tablet 250 MG, 500 MG 3 PA; QL *Antiadrenals*** - Drugs For Cancer Lysodren Oral Tablet 500 MG 2 *Antiandrogens*** - Drugs For Cancer bicalutamide oral tablet 50 mg 1 QL Erleada Oral Tablet 60 MG 3 PA; QL flutamide oral capsule 125 mg 1 Nilandron Oral Tablet 150 MG 2 PA nilutamide oral tablet 150 mg 1 PA Nubeqa Oral Tablet 300 MG 3 PA; QL Xtandi Oral Capsule 40 MG 3 PA; QL Xtandi Oral Tablet 40 MG, 80 MG 3 PA; QL Last Published: 09/17/2021 42 Drug Name Drug Tier Requirements / Limits *Antiestrogens*** - Drugs For Cancer Soltamox Oral Solution 10 MG/5ML 3 tamoxifen citrate oral tablet 10 mg, 20 mg 1 toremifene citrate oral tablet 60 mg 1 PA *Antimetabolites*** - Drugs For Cancer Alimta Intravenous Solution Reconstituted 100 Tier 10 PA MG, 500 MG Arranon Intravenous Solution 5 MG/ML Tier 10 PA azacitidine injection suspension reconstituted 100 mg Tier 10 capecitabine oral tablet 150 mg, 500 mg 1 cladribine intravenous solution 10 mg/10ml Tier 10 clofarabine intravenous solution 1 mg/ml Tier 10 PA Clolar Intravenous Solution 1 MG/ML Tier 10 PA cytarabine (pf) injection solution 100 mg/ml, 20 mg/ml Tier 10 cytarabine injection solution 20 mg/ml Tier 10 Dacogen Intravenous Solution Reconstituted 50 Tier 10 PA MG decitabine intravenous solution reconstituted 50 mg Tier 10 PA floxuridine injection solution reconstituted 0.5 gm Tier 10 PA fludarabine phosphate intravenous solution 50 mg/2ml Tier 10 fludarabine phosphate intravenous solution Tier 10 reconstituted 50 mg fluorouracil intravenous solution 1 gm/20ml, 2.5 Tier 10 gm/50ml, 5 gm/100ml, 500 mg/10ml Folotyn Intravenous Solution 20 MG/ML, 40 Tier 10 PA MG/2ML gemcitabine hcl intravenous solution 1 gm/10ml, 1 gm/26.3ml, 1.5 gm/15ml, 2 gm/20ml, 2 gm/52.6ml, Tier 10 200 mg/2ml, 200 mg/5.26ml gemcitabine hcl intravenous solution reconstituted 1 Tier 10 gm, 2 gm, 200 mg Infugem Intravenous Solution 1200-0.9 MG/120ML- %, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 MG/160ML-%, Tier 10 PA 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% mercaptopurine oral tablet 50 mg 1 methotrexate oral tablet 2.5 mg 1 methotrexate sodium (pf) injection solution 1 gm/40ml, Tier 10 250 mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, Tier 10 50 mg/2ml methotrexate sodium injection solution reconstituted 1 Tier 10 gm methotrexate sodium oral tablet 2.5 mg 1

Last Published: 09/17/2021 43 Drug Name Drug Tier Requirements / Limits Onureg Oral Tablet 200 MG, 300 MG 3 PA Purixan Oral Suspension 2000 MG/100ML 3 Tabloid Oral Tablet 40 MG 3 PA Trexall Oral Tablet 10 MG, 15 MG, 5 MG, 7.5 MG 2 Vidaza Injection Suspension Reconstituted 100 Tier 10 MG Xatmep Oral Solution 2.5 MG/ML 3 Xeloda Oral Tablet 150 MG, 500 MG 3 *Antineoplastic - Alk Inhibitors*** - Drugs For Cancer Alecensa Oral Capsule 150 MG 2 PA; QL Alunbrig Oral Tablet 180 MG, 30 MG, 90 MG 3 PA; QL Alunbrig Oral Tablet Therapy Pack 90 & 180 MG 3 PA; QL Lorbrena Oral Tablet 100 MG, 25 MG 3 PA; QL Xalkori Oral Capsule 200 MG, 250 MG 3 PA; QL Zykadia Tablet 150 MG Oral 150 MG 3 PA; QL *Antineoplastic - Anti-Bcma Antibody-Drug Complex*** - Drugs For Cancer Blenrep Intravenous Solution Reconstituted 100 Tier 10 PA MG *Antineoplastic - Anti-Ccr4 Antibodies*** - Drugs For Cancer Poteligeo Intravenous Solution 20 MG/5ML Tier 10 PA *Antineoplastic - Anti-Cd19 Antibodies*** - Drugs For Cancer Monjuvi Intravenous Solution Reconstituted 200 Tier 10 PA MG *Antineoplastic - Anti-Cd19 Antibody-Drug Complex*** - Drugs For Cancer Zynlonta Intravenous Solution Reconstituted 10 Tier 10 PA MG *Antineoplastic - Anti-Cd20 Antibodies*** - Drugs For Cancer Arzerra Intravenous Concentrate 100 MG/5ML, Tier 10 PA 1000 MG/50ML Gazyva Intravenous Solution 1000 MG/40ML Tier 10 PA Riabni Intravenous Solution 100 MG/10ML, 500 Tier 10 PA MG/50ML Rituxan Intravenous Solution 100 MG/10ML, 500 Tier 10 PA MG/50ML Ruxience Intravenous Solution 100 MG/10ML, 500 Tier 10 PA MG/50ML Truxima Intravenous Solution 100 MG/10ML, 500 Tier 10 PA MG/50ML

Last Published: 09/17/2021 44 Drug Name Drug Tier Requirements / Limits *Antineoplastic - Anti-Cd22 Antibodies*** - Drugs For Cancer Lumoxiti Intravenous Solution Reconstituted 1 MG Tier 10 PA *Antineoplastic - Anti-Cd22 Antibody-Drug Complex*** - Drugs For Cancer Besponsa Intravenous Solution Reconstituted 0.9 Tier 10 PA MG *Antineoplastic - Anti-Cd30 Antibody-Drug Complex*** - Drugs For Cancer Adcetris Intravenous Solution Reconstituted 50 Tier 10 MG *Antineoplastic - Anti-Cd33 Antibody-Drug Complex*** - Drugs For Cancer Mylotarg Intravenous Solution Reconstituted 4.5 Tier 10 PA MG *Antineoplastic - Anti-Cd38 Antibodies*** - Drugs For Cancer Darzalex Intravenous Solution 100 MG/5ML, 400 Tier 10 PA MG/20ML Sarclisa Intravenous Solution 100 MG/5ML, 500 Tier 10 PA MG/25ML *Antineoplastic - Anti-Cd79b Antibody-Drug Complex*** - Drugs For Cancer Polivy Intravenous Solution Reconstituted 140 MG Tier 10 PA *Antineoplastic - Anti-Ctla-4 Antibodies*** - Drugs For Cancer Yervoy Intravenous Solution 200 MG/40ML, 50 Tier 10 PA MG/10ML *Antineoplastic - Anti-Gd2 Antibodies*** - Drugs For Cancer Danyelza Intravenous Solution 40 MG/10ML Tier 10 PA Unituxin Intravenous Solution 17.5 MG/5ML Tier 10 PA *Antineoplastic - Anti-Her2 Agents*** - Drugs For Cancer Herceptin Intravenous Solution Reconstituted 150 Tier 10 PA MG Herzuma Intravenous Solution Reconstituted 150 Tier 10 PA MG, 420 MG Kanjinti Intravenous Solution Reconstituted 420 Tier 10 PA MG Margenza Intravenous Solution 250 MG/10ML Tier 10 PA Ogivri Intravenous Solution Reconstituted 150 MG, Tier 10 PA 420 MG Ontruzant Intravenous Solution Reconstituted 150 Tier 10 PA MG, 420 MG Perjeta Intravenous Solution 420 MG/14ML Tier 10 PA Trazimera Intravenous Solution Reconstituted 420 Tier 10 PA MG Last Published: 09/17/2021 45 Drug Name Drug Tier Requirements / Limits Tukysa Oral Tablet 150 MG, 50 MG 3 PA; QL *Antineoplastic - Anti-Nectin-4 Antibody-Drug Complex*** - Drugs For Cancer Padcev Intravenous Solution Reconstituted 20 Tier 10 PA MG, 30 MG *Antineoplastic - Anti-Pd-1 Antibodies*** - Drugs For Cancer Jemperli Intravenous Solution 500 MG/10ML Not Covered Keytruda Intravenous Solution 100 MG/4ML Tier 10 PA Libtayo Intravenous Solution 350 MG/7ML Tier 10 PA Opdivo Intravenous Solution 100 MG/10ML, 240 Tier 10 PA MG/24ML, 40 MG/4ML *Antineoplastic - Anti-Pd-L1 Antibodies*** - Drugs For Cancer Bavencio Intravenous Solution 200 MG/10ML Tier 10 PA Imfinzi Intravenous Solution 120 MG/2.4ML, 500 Tier 10 PA MG/10ML Tecentriq Intravenous Solution 1200 MG/20ML, 840 Tier 10 PA MG/14ML *Antineoplastic - Anti-Slamf7 Antibodies*** - Drugs For Cancer Empliciti Intravenous Solution Reconstituted 300 Tier 10 PA MG, 400 MG *Antineoplastic - Autologous Cellular Immunotherapy*** - Drugs For Cancer Abecma Intravenous Suspension Tier 10 PA Breyanzi Intravenous Suspension Tier 10 PA Kymriah Intravenous Suspension Tier 10 PA Provenge Intravenous Suspension Tier 10 PA Tecartus Intravenous Suspension Tier 10 PA Yescarta Intravenous Suspension Tier 10 PA *Antineoplastic - Bcl-2 Inhibitors*** - Drugs For Cancer Venclexta Oral Tablet 10 MG, 100 MG, 50 MG 3 PA; QL Venclexta Starting Pack Oral Tablet Therapy Pack 3 PA; QL 10 & 50 & 100 MG *Antineoplastic - Bcr-Abl Kinase Inhibitors*** - Drugs For Cancer Bosulif Oral Tablet 100 MG, 400 MG, 500 MG 3 PA; QL Gleevec Oral Tablet 100 MG, 400 MG 3 PA; QL Iclusig Oral Tablet 10 MG, 15 MG, 30 MG, 45 MG 2 PA; QL mesylate oral tablet 100 mg, 400 mg 1 PA; QL Sprycel Oral Tablet 100 MG, 140 MG, 20 MG, 50 2 PA MG, 70 MG, 80 MG Tasigna Oral Capsule 150 MG, 200 MG, 50 MG 3 PA; QL

Last Published: 09/17/2021 46 Drug Name Drug Tier Requirements / Limits *Antineoplastic - Bispecific T-Cell Engagers*** - Drugs For Cancer Blincyto Intravenous Solution Reconstituted 35 Tier 10 PA MCG *Antineoplastic - Braf Kinase Inhibitors*** - Drugs For Cancer Braftovi Oral Capsule 75 MG 3 PA; QL Tafinlar Oral Capsule 50 MG, 75 MG 3 PA; QL Zelboraf Oral Tablet 240 MG 3 PA; QL *Antineoplastic - Btk Inhibitors*** - Drugs For Cancer Brukinsa Oral Capsule 80 MG 3 PA Calquence Oral Capsule 100 MG 3 PA Imbruvica Oral Capsule 140 MG, 70 MG 3 PA; QL Imbruvica Oral Tablet 140 MG, 280 MG, 420 MG, 3 PA; QL 560 MG *Antineoplastic - Egfr Inhibitors*** - Drugs For Cancer Erbitux Intravenous Solution 100 MG/50ML Tier 10 PA erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg 1 PA; QL Gilotrif Oral Tablet 20 MG, 30 MG, 40 MG 3 PA; QL Iressa Oral Tablet 250 MG 3 PA Portrazza Intravenous Solution 800 MG/50ML Tier 10 PA Tagrisso Oral Tablet 40 MG, 80 MG 3 PA; QL Tarceva Oral Tablet 100 MG, 150 MG, 25 MG 2 PA; QL Vectibix Intravenous Solution 100 MG/5ML, 400 Tier 10 PA MG/20ML Vizimpro Oral Tablet 15 MG, 30 MG, 45 MG 3 PA; QL *Antineoplastic - Fgfr Kinase Inhibitors*** - Drugs For Cancer Balversa Oral Tablet 3 MG, 4 MG, 5 MG 3 PA Pemazyre Oral Tablet 13.5 MG, 4.5 MG, 9 MG 3 PA Truseltiq (100MG Daily Dose) Oral Capsule 3 PA Therapy Pack 100 MG Truseltiq (125MG Daily Dose) Oral Capsule 3 PA Therapy Pack 100 & 25 MG Truseltiq (50MG Daily Dose) Oral Capsule Therapy 3 PA Pack 25 MG Truseltiq (75MG Daily Dose) Oral Capsule Therapy 3 PA Pack 25 MG *Antineoplastic - Hedgehog Pathway Inhibitors*** - Drugs For Cancer Daurismo Oral Tablet 100 MG, 25 MG 3 PA Erivedge Oral Capsule 150 MG 3 PA; QL Odomzo Oral Capsule 200 MG 3 PA; QL

Last Published: 09/17/2021 47 Drug Name Drug Tier Requirements / Limits *Antineoplastic - Histone Deacetylase Inhibitors*** - Drugs For Cancer Beleodaq Intravenous Solution Reconstituted 500 Tier 10 PA MG Farydak Oral Capsule 10 MG, 20 MG 3 PA; QL Istodax (Overfill) Intravenous Solution Tier 10 PA Reconstituted 10 MG romidepsin intravenous solution 27.5 mg/5.5ml Tier 10 PA Zolinza Oral Capsule 100 MG 2 PA; QL *Antineoplastic - Immunomodulators*** - Drugs For Cancer Pomalyst Oral Capsule 1 MG, 2 MG, 3 MG, 4 MG 3 PA; QL *Antineoplastic - Kras Inhibitors*** - Drugs For Cancer Lumakras Oral Tablet 120 MG 3 PA *Antineoplastic - Mek Inhibitors*** - Drugs For Cancer Cotellic Oral Tablet 20 MG 3 PA; QL Koselugo Oral Capsule 10 MG, 25 MG 3 PA Mekinist Oral Tablet 0.5 MG, 2 MG 2 PA; QL Mektovi Oral Tablet 15 MG 3 PA; QL *Antineoplastic - Met Inhibitors*** - Drugs For Cancer Tabrecta Oral Tablet 150 MG, 200 MG 3 PA *Antineoplastic - Methyltransferase Inhibitors*** - Drugs For Cancer Tazverik Oral Tablet 200 MG 3 PA *Antineoplastic - Mtor Kinase Inhibitors*** - Drugs For Cancer Afinitor Disperz Oral Tablet Soluble 2 MG, 3 MG, 5 2 PA; QL MG Afinitor Oral Tablet 10 MG, 2.5 MG, 5 MG, 7.5 MG 2 PA; QL everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 1 PA; QL temsirolimus intravenous solution 25 mg/ml Tier 10 PA Torisel Intravenous Solution 25 MG/ML Tier 10 PA *Antineoplastic - Multikinase Inhibitors*** - Drugs For Cancer Cabometyx Oral Tablet 20 MG, 40 MG, 60 MG 3 PA Caprelsa Oral Tablet 100 MG, 300 MG 2 PA; QL Cometriq (60 MG Daily Dose) Oral Kit 20 MG 3 PA; QL lapatinib ditosylate oral tablet 250 mg 1 PA; QL Nerlynx Oral Tablet 40 MG 3 PA NexAVAR Oral Tablet 200 MG 2 PA; QL Qinlock Oral Tablet 50 MG 3 PA Rydapt Oral Capsule 25 MG 3 PA Last Published: 09/17/2021 48 Drug Name Drug Tier Requirements / Limits Stivarga Oral Tablet 40 MG 3 PA; QL sunitinib malate oral capsule 12.5 mg, 25 mg, 37.5 1 PA mg, 50 mg Sutent Oral Capsule 12.5 MG, 25 MG, 37.5 MG, 50 2 PA MG Tepmetko Oral Tablet 225 MG 3 PA; QL Turalio Oral Capsule 200 MG 3 PA; QL Tykerb Oral Tablet 250 MG 2 PA; QL Ukoniq Oral Tablet 200 MG 3 PA; QL Votrient Oral Tablet 200 MG 2 PA; QL Xospata Oral Tablet 40 MG 3 PA *Antineoplastic - Multiple Receptor Antibodies*** - Drugs For Cancer Rybrevant Intravenous Solution 350 MG/7ML Tier 10 PA *Antineoplastic - Pdgfr-Alpha Inhibitors*** - Drugs For Cancer Ayvakit Oral Tablet 100 MG, 200 MG, 25 MG, 300 3 PA; QL MG, 50 MG *Antineoplastic - Proteasome Inhibitors*** - Drugs For Cancer bortezomib intravenous solution reconstituted 3.5 mg Tier 10 PA Kyprolis Intravenous Solution Reconstituted 10 Tier 10 PA MG, 30 MG, 60 MG Ninlaro Oral Capsule 2.3 MG, 3 MG, 4 MG 3 PA; QL Velcade Injection Solution Reconstituted 3.5 MG Tier 10 PA *Antineoplastic - Ret Inhibitors*** - Drugs For Cancer Gavreto Oral Capsule 100 MG 3 PA Retevmo Oral Capsule 40 MG, 80 MG 3 PA; QL *Antineoplastic - Tropomyosin Receptor Kinase Inhibitors*** - Drugs For Cancer Rozlytrek Oral Capsule 100 MG 3 PA; QL Rozlytrek Oral Capsule 200 MG 3 PA Vitrakvi Oral Capsule 100 MG, 25 MG 3 PA Vitrakvi Oral Solution 20 MG/ML 3 PA *Antineoplastic - Xpo1 Inhibitors*** - Drugs For Cancer Xpovio (100 MG Once Weekly) Oral Tablet Therapy 3 PA Pack 50 MG Xpovio (40 MG Once Weekly) Oral Tablet Therapy 3 PA Pack 40 MG Xpovio (40 MG Twice Weekly) Oral Tablet Therapy 3 PA Pack 40 MG Xpovio (60 MG Once Weekly) Oral Tablet Therapy 3 PA Pack 60 MG

Last Published: 09/17/2021 49 Drug Name Drug Tier Requirements / Limits Xpovio (60 MG Twice Weekly) Oral Tablet Therapy 3 PA Pack 20 MG Xpovio (80 MG Once Weekly) Oral Tablet Therapy 3 PA Pack 40 MG Xpovio (80 MG Twice Weekly) Oral Tablet Therapy 3 PA Pack 20 MG *Antineoplastic Antibiotics*** - Drugs For Cancer Adriamycin Intravenous Solution 2 MG/ML Tier 10 adriamycin intravenous solution reconstituted 10 mg Tier 10 Adriamycin Intravenous Solution Reconstituted 50 Tier 10 MG bleomycin sulfate injection solution reconstituted 15 Tier 10 unit, 30 unit Cosmegen Intravenous Solution Reconstituted 0.5 Tier 10 PA MG dactinomycin intravenous solution reconstituted 0.5 Tier 10 PA mg daunorubicin hcl intravenous solution 20 mg/4ml, 50 Tier 10 mg/10ml Doxil Intravenous Injectable 2 MG/ML Tier 10 PA doxorubicin hcl intravenous solution 2 mg/ml Tier 10 doxorubicin hcl liposomal intravenous injectable 2 Tier 10 PA mg/ml Ellence Intravenous Solution 200 MG/100ML, 50 Tier 10 PA MG/25ML epirubicin hcl intravenous solution 200 mg/100ml, 50 Tier 10 PA mg/25ml Idamycin PFS Intravenous Solution 10 MG/10ML, Tier 10 20 MG/20ML, 5 MG/5ML idarubicin hcl intravenous solution 10 mg/10ml, 20 Tier 10 mg/20ml, 5 mg/5ml Jelmyto Solution Reconstituted 80 (2 x 40) MG Tier 10 PA mitomycin intravenous solution reconstituted 20 mg, Tier 10 40 mg, 5 mg mitomycin intravesical solution prefilled syringe 20 Tier 10 mg/40ml mitoxantrone hcl intravenous concentrate 20 mg/10ml, Tier 10 PA 25 mg/12.5ml, 30 mg/15ml Mutamycin Intravenous Solution Reconstituted 20 Tier 10 MG, 40 MG, 5 MG valrubicin intravesical solution 40 mg/ml Tier 10 PA Valstar Intravesical Solution 40 MG/ML Tier 10 PA *Antineoplastic Antibody-Drug Complexes*** - Drugs For Cancer Enhertu Intravenous Solution Reconstituted 100 Tier 10 PA MG

Last Published: 09/17/2021 50 Drug Name Drug Tier Requirements / Limits Kadcyla Intravenous Solution Reconstituted 100 Tier 10 PA MG, 160 MG *Antineoplastic Combinations*** - Drugs For Cancer Darzalex Faspro Subcutaneous Solution 1800- Tier 10 PA 30000 MG-UT/15ML Herceptin Hylecta Subcutaneous Solution 600- Tier 10 PA 10000 MG-UNT/5ML Inqovi Oral Tablet 35-100 MG 3 PA Kisqali Femara (400 MG Dose) Oral Tablet Therapy 3 PA Pack 200 & 2.5 MG Kisqali Femara (600 MG Dose) Oral Tablet Therapy 3 PA Pack 200 & 2.5 MG Kisqali Femara(200 MG Dose) Oral Tablet Therapy 3 PA Pack 200 & 2.5 MG Lonsurf Oral Tablet 15-6.14 MG, 20-8.19 MG 3 PA; QL Phesgo Subcutaneous Solution 60-60-2000 MG- Tier 10 PA MG-U/ML, 80-40-2000 MG-MG-U/ML Rituxan Hycela Subcutaneous Solution 1400- Tier 10 PA 23400 MG -UT/11.7ML, 1600-26800 MG -UT/13.4ML Vyxeos Intravenous Suspension Reconstituted 44- Tier 10 PA 100 MG *Antineoplastic Enzymes*** - Drugs For Cancer Asparlas Intravenous Solution 3750 UNIT/5ML Tier 10 PA Oncaspar Injection Solution 750 UNIT/ML Tier 10 PA Rylaze Intramuscular Solution 10 MG/0.5ML Tier 10 PA *Antineoplastics - Interleukins*** - Drugs For Cancer Elzonris Intravenous Solution 1000 MCG/ML Tier 10 PA Proleukin Intravenous Solution Reconstituted Tier 10 PA 22000000 UNIT *Antineoplastics - Photoactivated Agents*** - Drugs For Cancer Photofrin Intravenous Solution Reconstituted 75 Tier 10 PA MG *Antineoplastics Misc.*** - Drugs For Cancer Actimmune Subcutaneous Solution 2000000 3 PA UNIT/0.5ML Alferon N Injection Solution 5000000 UNIT/ML Tier 10 PA arsenic trioxide intravenous solution 10 mg/10ml, 12 Tier 10 mg/6ml dacarbazine intravenous solution reconstituted 100 Tier 10 mg, 200 mg hydroxyurea oral capsule 500 mg 1 Matulane Oral Capsule 50 MG 2 PA Nipent Intravenous Solution Reconstituted 10 MG Tier 10 PA

Last Published: 09/17/2021 51 Drug Name Drug Tier Requirements / Limits Synribo Subcutaneous Solution Reconstituted 3.5 Tier 10 PA MG Tice BCG Intravesical Suspension Reconstituted Tier 10 PA 50 MG Trisenox Intravenous Solution 12 MG/6ML Tier 10 *Aromatase Inhibitors*** - Drugs For Cancer anastrozole oral tablet 1 mg 1 QL exemestane oral tablet 25 mg 1 letrozole oral tablet 2.5 mg 1 *Cyclin-Dependent Kinases (Cdk) Inhibitors*** - Drugs For Cancer Ibrance Oral Capsule 100 MG, 125 MG, 75 MG 2 PA; QL Ibrance Oral Tablet 100 MG, 125 MG, 75 MG 2 PA; QL Kisqali (200 MG Dose) Oral Tablet Therapy Pack 3 PA 200 MG Kisqali (400 MG Dose) Oral Tablet Therapy Pack 3 PA 200 MG Kisqali (600 MG Dose) Oral Tablet Therapy Pack 3 PA 200 MG Verzenio Oral Tablet 100 MG, 150 MG, 200 MG, 50 3 PA MG * Receptor Antagonist*** - Drugs For Cancer Faslodex Intramuscular Solution 250 MG/5ML Tier 10 PA fulvestrant intramuscular solution 250 mg/5ml Tier 10 PA *Estrogens-Antineoplastic*** - Drugs For Cancer Emcyt Oral Capsule 140 MG 2 PA *Folic Acid Antagonists Rescue Agents*** - Drugs For Cancer leucovorin calcium injection solution 100 mg/10ml, 500 Tier 10 mg/50ml leucovorin calcium injection solution reconstituted 100 Tier 10 mg, 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 1 mg *Gonadotropin Releasing Hormone (Gnrh) Antagonists*** - Drugs For Cancer Firmagon Subcutaneous Solution Reconstituted Tier 10 PA 80 MG Orgovyx Oral Tablet 120 MG 3 PA *Imidazotetrazines*** - Drugs For Cancer Temodar Intravenous Solution Reconstituted 100 Tier 10 PA MG Temodar Oral Capsule 100 MG, 140 MG, 180 MG, 3 PA 250 MG

Last Published: 09/17/2021 52 Drug Name Drug Tier Requirements / Limits temozolomide oral capsule 100 mg, 140 mg, 180 mg, 1 PA 20 mg, 250 mg, 5 mg *Isocitrate Dehydrogenase-1 (Idh1) Inhibitors*** - Drugs For Cancer Tibsovo Oral Tablet 250 MG 3 PA *Isocitrate Dehydrogenase-2 (Idh2) Inhibitors*** - Drugs For Cancer IDHIFA Oral Tablet 100 MG, 50 MG 3 PA; QL *Janus Associated Kinase (Jak) Inhibitors*** - Drugs For Cancer Inrebic Oral Capsule 100 MG 3 PA; QL Jakafi Oral Tablet 10 MG, 15 MG, 20 MG, 25 MG, 5 3 PA; QL MG *Lhrh Analogs*** - Drugs For Cancer Eligard Subcutaneous Kit 30 MG Tier 10 PA leuprolide acetate injection kit 1 mg/0.2ml 1 PA Lupron Depot (1-Month) Intramuscular Kit 3.75 Tier 10 PA MG, 7.5 MG Lupron Depot (3-Month) Intramuscular Kit 11.25 Tier 10 PA MG, 22.5 MG Lupron Depot (4-Month) Intramuscular Kit 30 MG Tier 10 PA Lupron Depot (6-Month) Intramuscular Kit 45 MG Tier 10 PA Trelstar Mixject Intramuscular Suspension Tier 10 PA Reconstituted 11.25 MG, 22.5 MG, 3.75 MG Vantas Subcutaneous Kit 50 MG Tier 10 PA Zoladex Subcutaneous Implant 10.8 MG, 3.6 MG Tier 10 PA *Mitotic Inhibitors*** - Drugs For Cancer Abraxane Intravenous Suspension Reconstituted Tier 10 100 MG docetaxel intravenous concentrate 160 mg/8ml, 20 Tier 10 mg/ml, 80 mg/4ml docetaxel intravenous solution 160 mg/16ml, 20 Tier 10 mg/2ml, 80 mg/8ml Etopophos Intravenous Solution Reconstituted Tier 10 100 MG etoposide intravenous solution 1 gm/50ml, 100 Tier 10 mg/5ml, 500 mg/25ml etoposide oral capsule 50 mg 1 Halaven Intravenous Solution 1 MG/2ML Tier 10 PA Ixempra Kit Intravenous Solution Reconstituted 15 Tier 10 PA MG, 45 MG Jevtana Intravenous Solution 60 MG/1.5ML Tier 10 PA Marqibo Intravenous Suspension 5 MG/31ML Tier 10 PA Navelbine Intravenous Solution 10 MG/ML, 50 Tier 10 PA MG/5ML

Last Published: 09/17/2021 53 Drug Name Drug Tier Requirements / Limits paclitaxel intravenous concentrate 100 mg/16.7ml, Tier 10 150 mg/25ml, 30 mg/5ml, 300 mg/50ml Toposar Intravenous Solution 1 GM/50ML, 100 Tier 10 MG/5ML, 500 MG/25ML vinblastine sulfate intravenous solution 1 mg/ml Tier 10 vincristine sulfate intravenous solution 1 mg/ml Tier 10 vinorelbine tartrate intravenous solution 10 mg/ml, 50 Tier 10 PA mg/5ml *Myeloprotective Agents*** - Drugs For Cancer Cosela Intravenous Solution Reconstituted 300 Not Covered MG * Mustards*** - Drugs For Cancer Alkeran Intravenous Solution Reconstituted 50 MG Tier 10 Alkeran Oral Tablet 2 MG 3 cyclophosphamide injection solution reconstituted 1 Tier 10 gm, 2 gm, 500 mg cyclophosphamide oral capsule 25 mg, 50 mg 1 Evomela Intravenous Solution Reconstituted 50 Tier 10 PA MG Ifex Intravenous Solution Reconstituted 1 GM, 3 Tier 10 GM ifosfamide intravenous solution 1 gm/20ml, 3 gm/60ml Tier 10 ifosfamide intravenous solution reconstituted 1 gm, 3 Tier 10 gm Leukeran Oral Tablet 2 MG 2 melphalan hcl intravenous solution reconstituted 50 Tier 10 mg melphalan oral tablet 2 mg 1 Pepaxto Intravenous Solution Reconstituted 20 Not Covered MG *Nitrosoureas*** - Drugs For Cancer BiCNU Intravenous Solution Reconstituted 100 MG Tier 10 PA carmustine intravenous solution reconstituted 100 mg Tier 10 PA Gleostine Oral Capsule 10 MG, 100 MG, 40 MG 2 Gliadel Wafer Implant Wafer 7.7 MG Tier 10 PA Zanosar Intravenous Solution Reconstituted 1 GM Tier 10 PA *Oncolytic Viral Agents - Hsv1*** - Drugs For Cancer Imlygic Intralesional Suspension 1000000 Tier 10 PA UNIT/ML, 100000000 UNIT/ML *Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors*** - Drugs For Cancer Aliqopa Intravenous Solution Reconstituted 60 MG Tier 10 PA Copiktra Oral Capsule 15 MG, 25 MG 3 PA Piqray (200 MG Daily Dose) Oral Tablet Therapy 3 PA Pack 200 MG Last Published: 09/17/2021 54 Drug Name Drug Tier Requirements / Limits Piqray (250 MG Daily Dose) Oral Tablet Therapy 3 PA Pack 200 & 50 MG Piqray (300 MG Daily Dose) Oral Tablet Therapy 3 PA Pack 2 x 150 MG Zydelig Oral Tablet 100 MG, 150 MG 3 PA; QL *Poly (Adp-Ribose) Polymerase (Parp) Inhibitors*** - Drugs For Cancer Lynparza Oral Tablet 100 MG, 150 MG 3 PA; QL Rubraca Oral Tablet 200 MG, 250 MG, 300 MG 3 PA; QL Talzenna Oral Capsule 0.25 MG, 1 MG 3 PA Zejula Oral Capsule 100 MG 3 PA; QL *Progestins-Antineoplastic*** - Drugs For Cancer hydroxyprogesterone caproate intramuscular solution 1 1.25 gm/5ml megestrol acetate oral suspension 40 mg/ml, 400 1 mg/10ml megestrol acetate oral tablet 20 mg, 40 mg 1 *Retinoids*** - Drugs For Cancer tretinoin oral capsule 10 mg 1 *Selective Retinoid X Receptor Agonists*** - Drugs For Cancer bexarotene oral capsule 75 mg 1 PA Targretin Oral Capsule 75 MG 2 PA *Tetrahydroisoquinolines*** - Drugs For Cancer Yondelis Intravenous Solution Reconstituted 1 MG Tier 10 PA *Topoisomerase I Inhibitors - Antibody-Drug Complex*** - Drugs For Cancer Trodelvy Intravenous Solution Reconstituted 180 Tier 10 PA MG *Topoisomerase I Inhibitors*** - Drugs For Cancer Camptosar Intravenous Solution 100 MG/5ML, 300 Tier 10 MG/15ML, 40 MG/2ML Hycamtin Intravenous Solution Reconstituted 4 Tier 10 MG Hycamtin Oral Capsule 0.25 MG, 1 MG 3 PA irinotecan hcl intravenous solution 100 mg/5ml, 40 Tier 10 mg/2ml, 500 mg/25ml Onivyde Intravenous Injectable 43 MG/10ML Tier 10 PA hcl intravenous solution 4 mg/4ml Tier 10 topotecan hcl intravenous solution reconstituted 4 mg Tier 10 *Urinary Tract Protective Agents*** - Drugs For Cancer Mesnex Oral Tablet 400 MG 3

Last Published: 09/17/2021 55 Drug Name Drug Tier Requirements / Limits *Vascular Endothelial Growth Factor (Vegf) Inhibitors*** - Drugs For Cancer Avastin Intravenous Solution 100 MG/4ML, 400 Tier 10 PA MG/16ML Cyramza Intravenous Solution 100 MG/10ML, 500 Tier 10 PA MG/50ML Inlyta Oral Tablet 1 MG, 5 MG 3 PA; QL Lenvima (10 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 10 MG Lenvima (12 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 3 x 4 MG Lenvima (14 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 10 & 4 MG Lenvima (18 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 10 MG & 2 x 4 MG Lenvima (20 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 2 x 10 MG Lenvima (24 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 2 x 10 MG & 4 MG Lenvima (4 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 4 MG Lenvima (8 MG Daily Dose) Oral Capsule Therapy 3 PA; QL Pack 2 x 4 MG Mvasi Intravenous Solution 100 MG/4ML, 400 Tier 10 PA MG/16ML Zaltrap Intravenous Solution 100 MG/4ML, 200 Tier 10 PA MG/8ML Zirabev Intravenous Solution 100 MG/4ML, 400 Tier 10 PA MG/16ML *Antiparkinson And Related Therapy Agents* - Drugs For The Nervous System *Adenosine Receptor Antagonist*** - Drugs For Parkinson Nourianz Oral Tablet 20 MG, 40 MG 3 QL *Antiparkinson Anticholinergics*** - Drugs For Parkinson benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 *Antiparkinson Dopaminergics*** - Drugs For Parkinson hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 1 bromocriptine mesylate oral capsule 5 mg 1 bromocriptine mesylate oral tablet 2.5 mg 1 Inbrija Inhalation Capsule 42 MG 3 QL

Last Published: 09/17/2021 56 Drug Name Drug Tier Requirements / Limits Osmolex ER Oral Tablet ER 24 Hour Therapy Pack 3 QL 129 & 193 MG Osmolex ER Oral Tablet Extended Release 24 3 QL Hour 129 MG, 193 MG, 258 MG *Antiparkinson Monoamine Oxidase Inhibitors*** - Drugs For Parkinson rasagiline mesylate oral tablet 0.5 mg, 1 mg 1 QL selegiline hcl oral capsule 5 mg 1 selegiline hcl oral tablet 5 mg 1 Xadago Oral Tablet 100 MG, 50 MG 3 QL Zelapar Oral Tablet Dispersible 1.25 MG 3 *Central/Peripheral Comt Inhibitors*** - Drugs For Parkinson tolcapone oral tablet 100 mg 1 QL *Decarboxylase Inhibitors*** - Drugs For Parkinson carbidopa oral tablet 25 mg 1 *Levodopa Combinations*** - Drugs For Parkinson carbidopa-levodopa er oral tablet extended release 1 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 1 25-250 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 1 25-100 mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50- 200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25- 1 125-200 mg, 37.5-150-200 mg, 50-200-200 mg Duopa Enteral Suspension 4.63-20 MG/ML Tier 10 PA Rytary Oral Capsule Extended Release 23.75-95 3 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG *Nonergoline Dopamine Receptor Agonists*** - Drugs For Parkinson Kynmobi Sublingual Film 10 MG, 15 MG, 20 MG, 25 3 QL MG, 30 MG Neupro Transdermal Patch 24 Hour 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 3 MG/24HR dihydrochloride er oral tablet extended release 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 1 QL 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 1 QL mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg hcl er oral tablet extended release 24 hour 1 QL 12 mg, 2 mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 1 3 mg, 4 mg, 5 mg

Last Published: 09/17/2021 57 Drug Name Drug Tier Requirements / Limits *Peripheral Comt Inhibitors*** - Drugs For Parkinson entacapone oral tablet 200 mg 1 Ongentys Oral Capsule 25 MG, 50 MG 3 QL *Antipsychotics/Antimanic Agents* - Drugs For The Nervous System *Antimanic Agents*** - Drugs For Severe Mental Disorders lithium carbonate er oral tablet extended release 300 1 Age Restriction Applies (Min 5 Years) mg, 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 1 Age Restriction Applies (Min 5 Years) mg lithium carbonate oral tablet 300 mg 1 Age Restriction Applies (Min 5 Years) Lithobid Oral Tablet Extended Release 300 MG 3 Age Restriction Applies (Min 5 Years) *Antipsychotics - Misc.*** - Drugs For Severe Mental Disorders Caplyta Oral Capsule 42 MG 3 QL Equetro Oral Capsule Extended Release 12 Hour 3 Age Restriction Applies (Min 5 Years) 100 MG, 200 MG, 300 MG Latuda Oral Tablet 120 MG, 20 MG, 40 MG, 60 MG, QL; Age Restriction Applies (Min 5 3 80 MG Years) QL; Age Restriction Applies (Min 5 Nuplazid Oral Capsule 34 MG 3 Years) QL; Age Restriction Applies (Min 5 Nuplazid Oral Tablet 10 MG 3 Years) QL; Age Restriction Applies (Min 5 Vraylar Oral Capsule 1.5 MG, 3 MG, 4.5 MG, 6 MG 3 Years) QL; Age Restriction Applies (Min 5 Vraylar Oral Capsule Therapy Pack 1.5 & 3 MG 3 Years) hcl oral capsule 20 mg, 40 mg, 60 mg, 80 QL; Age Restriction Applies (Min 5 1 mg Years) *Benzisoxazoles*** - Drugs For Severe Mental Disorders Fanapt Oral Tablet 1 MG, 10 MG, 12 MG, 2 MG, 4 QL; Age Restriction Applies (Min 5 3 MG, 6 MG, 8 MG Years) QL; Age Restriction Applies (Min 5 Fanapt Titration Pack Oral Tablet 1 & 2 & 4 & 6 MG 3 Years) Invega Sustenna Intramuscular Suspension Prefilled Syringe 117 MG/0.75ML, 156 MG/ML, 234 Tier 10 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML Invega Trinza Intramuscular Suspension Prefilled Syringe 273 MG/0.875ML, 410 MG/1.315ML, 546 Tier 10 MG/1.75ML, 819 MG/2.625ML paliperidone er oral tablet extended release 24 hour QL; Age Restriction Applies (Min 5 1 1.5 mg, 3 mg, 6 mg, 9 mg Years) RisperDAL Consta Intramuscular Suspension Tier 10 Reconstituted ER 12.5 MG, 25 MG, 37.5 MG, 50 MG

Last Published: 09/17/2021 58 Drug Name Drug Tier Requirements / Limits QL; Age Restriction Applies (Min 5 risperidone oral solution 1 mg/ml 1 Years) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 1 Age Restriction Applies (Min 5 Years) mg QL; Age Restriction Applies (Min 5 risperidone oral tablet 4 mg 1 Years) risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 QL; Age Restriction Applies (Min 5 1 mg, 2 mg, 3 mg, 4 mg Years) *Butyrophenones*** - Drugs For Severe Mental Disorders haloperidol lactate oral concentrate 2 mg/ml 1 Age Restriction Applies (Min 5 Years) haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 1 Age Restriction Applies (Min 5 Years) mg, 5 mg *Dibenzodiazepines*** - Drugs For Severe Mental Disorders QL; Age Restriction Applies (Min 5 oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 Years) clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 QL; Age Restriction Applies (Min 5 1 mg Years) Versacloz Oral Suspension 50 MG/ML 3 Age Restriction Applies (Min 5 Years) *Dibenzo-Oxepino Pyrroles*** - Drugs For Severe Mental Disorders asenapine maleate sublingual tablet sublingual 10 mg, QL; Age Restriction Applies (Min 5 1 2.5 mg, 5 mg Years) *Dibenzothiazepines*** - Drugs For Severe Mental Disorders quetiapine fumarate er oral tablet extended release 24 QL; Age Restriction Applies (Min 5 1 hour 150 mg, 200 mg, 300 mg, 400 mg, 50 mg Years) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 1 Age Restriction Applies (Min 5 Years) mg, 300 mg, 400 mg, 50 mg *Dibenzoxazepines*** - Drugs For Severe Mental Disorders succinate oral capsule 10 mg, 25 mg, 5 mg, 1 Age Restriction Applies (Min 5 Years) 50 mg *Phenothiazines*** - Drugs For Severe Mental Disorders chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 1 Age Restriction Applies (Min 5 Years) 25 mg, 50 mg Compro Rectal Suppository 25 MG 1 Age Restriction Applies (Min 5 Years) hcl oral concentrate 5 mg/ml 1 Age Restriction Applies (Min 5 Years) fluphenazine hcl oral elixir 2.5 mg/5ml 1 Age Restriction Applies (Min 5 Years) fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 Age Restriction Applies (Min 5 Years) oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 Age Restriction Applies (Min 5 Years) maleate oral tablet 10 mg, 5 mg 1 Age Restriction Applies (Min 5 Years) prochlorperazine rectal suppository 25 mg 1 Age Restriction Applies (Min 5 Years) thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 1 Age Restriction Applies (Min 5 Years) mg

Last Published: 09/17/2021 59 Drug Name Drug Tier Requirements / Limits hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1 Age Restriction Applies (Min 5 Years) *Quinolinone Derivatives*** - Drugs For Severe Mental Disorders Abilify Maintena Intramuscular Prefilled Syringe Tier 10 300 MG, 400 MG Abilify Maintena Intramuscular Suspension Tier 10 Reconstituted ER 300 MG, 400 MG QL; Age Restriction Applies (Min 5 oral solution 1 mg/ml 1 Years) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 QL; Age Restriction Applies (Min 5 1 mg, 5 mg Years) QL; Age Restriction Applies (Min 5 aripiprazole oral tablet dispersible 10 mg, 15 mg 1 Years) Aristada Initio Intramuscular Prefilled Syringe 675 Tier 10 MG/2.4ML Aristada Intramuscular Prefilled Syringe 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 Tier 10 MG/3.2ML Rexulti Oral Tablet 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 QL; Age Restriction Applies (Min 5 3 MG, 4 MG Years) *Thienbenzodiazepines*** - Drugs For Severe Mental Disorders oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 1 Age Restriction Applies (Min 5 Years) mg, 7.5 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 QL; Age Restriction Applies (Min 5 1 mg, 5 mg Years) ZyPREXA Intramuscular Solution Reconstituted 10 Tier 10 MG ZyPREXA Relprevv Intramuscular Suspension Tier 10 Reconstituted 210 MG, 300 MG, 405 MG *Thioxanthenes*** - Drugs For Severe Mental Disorders thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 Age Restriction Applies (Min 5 Years) *Antiseptics & Disinfectants* - Antiseptics And Disinfectants *Antiseptics & Disinfectants*** - Antiseptics And Disinfectants formaldehyde external solution 10 % 1 formaldehyde external solution 37 % 3 glutaraldehyde external solution 25 % 2 Kerr Triple Dye Swabs External Swab 3 phenol external liquid 2 *Chlorine Antiseptics*** - Antiseptics And Disinfectants benzalkonium chloride external concentrate 50 % 2 benzalkonium chloride external solution , 50 % 2 chlorhexidine gluconate solution 20 % 2

Last Published: 09/17/2021 60 Drug Name Drug Tier Requirements / Limits *Iodine Antiseptics*** - Antiseptics And Disinfectants iodine tincture external tincture 2 % 3 *Antivirals* - Drugs For Infections *Antiretroviral Combinations*** - Drugs For Viral Infections abacavir sulfate-lamivudine oral tablet 600-300 mg 1 abacavir-lamivudine-zidovudine oral tablet 300-150- 1 300 mg Atripla Oral Tablet 600-200-300 MG 2 Biktarvy Oral Tablet 50-200-25 MG 3 QL cabenuva intramuscular suspension extended release Tier 10 400 & 600 mg/2ml, 600 & 900 mg/3ml Cimduo Oral Tablet 300-300 MG 3 QL Complera Oral Tablet 200-25-300 MG 2 QL Delstrigo Oral Tablet 100-300-300 MG 3 QL Descovy Oral Tablet 200-25 MG 3 QL Dovato Oral Tablet 50-300 MG 3 -emtricitab-tenofovir oral tablet 600-200-300 1 mg efavirenz-lamivudine-tenofovir oral tablet 400-300-300 1 QL mg, 600-300-300 mg emtricitabine-tenofovir df oral tablet 100-150 mg, 133- 1 200 mg, 167-250 mg, 200-300 mg Epzicom Oral Tablet 600-300 MG 3 Evotaz Oral Tablet 300-150 MG 2 QL Genvoya Oral Tablet 150-150-200-10 MG 3 Juluca Oral Tablet 50-25 MG 2 QL Kaletra Oral Solution 400-100 MG/5ML 3 Kaletra Oral Tablet 100-25 MG, 200-50 MG 2 lamivudine-zidovudine oral tablet 150-300 mg 1 lopinavir-ritonavir oral solution 400-100 mg/5ml 1 lopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg 1 Odefsey Oral Tablet 200-25-25 MG 2 QL Prezcobix Oral Tablet 800-150 MG 2 QL Stribild Oral Tablet 150-150-200-300 MG 2 QL Symfi Lo Oral Tablet 400-300-300 MG 3 QL Symfi Oral Tablet 600-300-300 MG 3 QL Symtuza Oral Tablet 800-150-200-10 MG 3 QL Triumeq Oral Tablet 600-50-300 MG 3 QL Trizivir Oral Tablet 300-150-300 MG 3 Truvada Oral Tablet 100-150 MG, 133-200 MG, 167- 2 250 MG, 200-300 MG

Last Published: 09/17/2021 61 Drug Name Drug Tier Requirements / Limits *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** - Drugs For Viral Infections Selzentry Oral Solution 20 MG/ML 3 QL Selzentry Oral Tablet 150 MG, 25 MG, 300 MG, 75 3 QL MG *Antiretrovirals - Fusion Inhibitors*** - Drugs For Viral Infections Fuzeon Subcutaneous Solution Reconstituted 90 3 QL MG *Antiretrovirals - Gp120-Directed Attachment Inhibitor*** - Drugs For Viral Infections Rukobia Oral Tablet Extended Release 12 Hour 3 600 MG *Antiretrovirals - Integrase Inhibitors*** - Drugs For Viral Infections Isentress HD Oral Tablet 600 MG 2 QL Isentress Oral Packet 100 MG 2 QL Isentress Oral Tablet 400 MG 2 QL Isentress Oral Tablet Chewable 100 MG, 25 MG 2 QL Tivicay Oral Tablet 10 MG, 25 MG, 50 MG 2 QL Tivicay PD Oral Tablet Soluble 5 MG 2 QL Vocabria Oral Tablet 30 MG 3 *Antiretrovirals - Protease Inhibitors*** - Drugs For Viral Infections Aptivus Oral Capsule 250 MG 3 atazanavir sulfate oral capsule 150 mg, 200 mg, 300 1 mg Crixivan Oral Capsule 400 MG 3 fosamprenavir calcium oral tablet 700 mg 1 Invirase Oral Tablet 500 MG 3 Lexiva Oral Suspension 50 MG/ML 2 Lexiva Oral Tablet 700 MG 2 Norvir Oral Packet 100 MG 3 Norvir Oral Solution 80 MG/ML 2 Norvir Oral Tablet 100 MG 3 Prezista Oral Suspension 100 MG/ML 2 Prezista Oral Tablet 150 MG, 600 MG, 75 MG, 800 2 QL MG Reyataz Oral Capsule 150 MG, 200 MG, 300 MG 3 Reyataz Oral Packet 50 MG 2 ritonavir oral tablet 100 mg 1 Viracept Oral Tablet 250 MG, 625 MG 3 *Antiretrovirals - Rti-Non-Nucleoside Analogues*** - Drugs For Viral Infections Edurant Oral Tablet 25 MG 3 QL Last Published: 09/17/2021 62 Drug Name Drug Tier Requirements / Limits efavirenz oral capsule 200 mg, 50 mg 1 efavirenz oral tablet 600 mg 1 etravirine oral tablet 100 mg, 200 mg 1 QL Intelence Oral Tablet 100 MG, 200 MG, 25 MG 3 QL nevirapine er oral tablet extended release 24 hour 100 1 QL mg, 400 mg nevirapine oral tablet 200 mg 1 Pifeltro Oral Tablet 100 MG 3 QL Sustiva Oral Capsule 200 MG, 50 MG 3 Sustiva Oral Tablet 600 MG 3 Viramune Oral Suspension 50 MG/5ML 3 Viramune XR Oral Tablet Extended Release 24 3 QL Hour 400 MG *Antiretrovirals - Rti-Nucleoside Analogues- Purines*** - Drugs For Viral Infections abacavir sulfate oral solution 20 mg/ml 1 abacavir sulfate oral tablet 300 mg 1 *Antiretrovirals - Rti-Nucleoside Analogues- Pyrimidines*** - Drugs For Viral Infections emtricitabine oral capsule 200 mg 1 QL Emtriva Oral Capsule 200 MG 3 QL Emtriva Oral Solution 10 MG/ML 3 QL lamivudine oral solution 10 mg/ml 1 lamivudine oral tablet 150 mg, 300 mg 1 *Antiretrovirals - Rti-Nucleoside Analogues- Thymidines*** - Drugs For Viral Infections Retrovir Oral Capsule 100 MG 3 Retrovir Oral Syrup 50 MG/5ML 3 stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 zidovudine oral capsule 100 mg 1 zidovudine oral syrup 50 mg/5ml 1 zidovudine oral tablet 300 mg 1 *Antiretrovirals - Rti-Nucleotide Analogues*** - Drugs For Viral Infections tenofovir disoproxil fumarate oral tablet 300 mg 1 Viread Oral Powder 40 MG/GM 2 Viread Oral Tablet 150 MG, 200 MG, 250 MG 2 Viread Oral Tablet 300 MG 3 *Antiretrovirals Adjuvants*** - Drugs For Viral Infections Tybost Oral Tablet 150 MG 3 QL *Cmv Agents*** - Drugs For Viral Infections Prevymis Oral Tablet 240 MG, 480 MG 3 QL Valcyte Oral Solution Reconstituted 50 MG/ML 3 Last Published: 09/17/2021 63 Drug Name Drug Tier Requirements / Limits Valcyte Oral Tablet 450 MG 3 valganciclovir hcl oral solution reconstituted 50 mg/ml 1 valganciclovir hcl oral tablet 450 mg 1 *Hepatitis B Agents*** - Drugs For Viral Infections adefovir dipivoxil oral tablet 10 mg 1 Baraclude Oral Solution 0.05 MG/ML 3 Baraclude Oral Tablet 0.5 MG, 1 MG 3 entecavir oral tablet 0.5 mg, 1 mg 1 Epivir HBV Oral Solution 5 MG/ML 2 Epivir HBV Oral Tablet 100 MG 3 Hepsera Oral Tablet 10 MG 3 lamivudine oral tablet 100 mg 1 Vemlidy Oral Tablet 25 MG 2 *Hepatitis C Agent - Combinations*** - Drugs For Viral Infections Epclusa Oral Tablet 200-50 MG, 400-100 MG 2 PA; QL Harvoni Oral Packet 33.75-150 MG, 45-200 MG 2 PA; QL Harvoni Oral Tablet 45-200 MG, 90-400 MG 2 PA; QL Mavyret Oral Tablet 100-40 MG 2 PA; QL Vosevi Oral Tablet 400-100-100 MG 2 PA; QL *Hepatitis C Agents*** - Drugs For Viral Infections Pegasys Subcutaneous Solution 180 MCG/0.5ML, 2 QL 180 MCG/ML ribavirin oral capsule 200 mg 1 ribavirin oral tablet 200 mg 1 *Herpes Agents - Purine Analogues*** - Drugs For Viral Infections acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5ml 1 acyclovir oral tablet 400 mg, 800 mg 1 Sitavig Buccal Tablet 50 MG 3 valacyclovir hcl oral tablet 1 gm, 500 mg 1 *Herpes Agents - Thymidine Analogues*** - Drugs For Viral Infections famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 *Influenza Agents*** - Drugs For Viral Infections rimantadine hcl oral tablet 100 mg 1 *Misc. Antivirals*** - Drugs For Viral Infections Veklury Intravenous Solution 100 MG/20ML Tier 10 Veklury Intravenous Solution Reconstituted 100 Tier 10 MG

Last Published: 09/17/2021 64 Drug Name Drug Tier Requirements / Limits *Neuraminidase Inhibitors*** - Drugs For Viral Infections oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 1 QL mg oseltamivir phosphate oral suspension reconstituted 6 1 QL mg/ml Relenza Diskhaler Inhalation Aerosol Powder 3 QL Breath Activated 5 MG/BLISTER Tamiflu Oral Capsule 30 MG, 45 MG, 75 MG 3 QL Tamiflu Oral Suspension Reconstituted 6 MG/ML 3 QL *Pa Endonuclease Inhibitors*** - Drugs For Viral Infections Xofluza (40 MG Dose) Oral Tablet Therapy Pack 1 x 3 QL 40 MG, 2 x 20 MG Xofluza (80 MG Dose) Oral Tablet Therapy Pack 1 x 3 QL 80 MG, 2 x 40 MG *Beta Blockers* - Drugs For The Heart *Alpha-Beta Blockers*** - Drugs For High Blood Pressure carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 1 mg carvedilol phosphate er oral capsule extended release 1 QL 24 hour 10 mg, 20 mg, 40 mg, 80 mg labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 *Beta Blockers Cardio-Selective*** - Drugs For High Blood Pressure acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 Bystolic Oral Tablet 10 MG, 2.5 MG, 20 MG, 5 MG 2 QL metoprolol succinate er oral tablet extended release 1 24 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 1 50 mg, 75 mg Tenormin Oral Tablet 100 MG, 50 MG 3 *Beta Blockers Non-Selective*** - Drugs For High Blood Pressure Hemangeol Oral Solution 4.28 MG/ML 3 Inderal XL Oral Capsule Extended Release 24 Hour 3 120 MG, 80 MG nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 1 hour 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1

Last Published: 09/17/2021 65 Drug Name Drug Tier Requirements / Limits propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 1 mg, 80 mg Sorine Oral Tablet 120 MG, 160 MG, 240 MG, 80 1 MG sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 Sotylize Oral Solution 5 MG/ML 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 *Calcium Channel Blockers* - Drugs For The Heart *Calcium Channel Blockers*** - Drugs For High Blood Pressure amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 Cardizem LA Oral Tablet Extended Release 24 3 Hour 120 MG Cartia XT Oral Capsule Extended Release 24 Hour 1 120 MG, 180 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 1 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 1 360 mg diltiazem hcl er oral capsule extended release 12 hour 1 120 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 1 120 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 1 180 mg, 240 mg er oral tablet extended release 24 hour 10 1 mg, 2.5 mg, 5 mg oral capsule 2.5 mg, 5 mg 1 Age Restriction Applies (Max 11 Katerzia Oral Suspension 1 MG/ML 3 Years) Matzim LA Oral Tablet Extended Release 24 Hour 1 180 MG, 240 MG, 300 MG, 360 MG, 420 MG nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 1 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended 1 release 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 1 er oral tablet extended release 24 hour 17 1 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg Nymalize Oral Solution 6 MG/ML 3

Last Published: 09/17/2021 66 Drug Name Drug Tier Requirements / Limits Taztia XT Oral Capsule Extended Release 24 Hour 1 120 MG, 180 MG, 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 1 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 1 180 mg, 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 *Cardiotonics* - Drugs For The Heart *Cardiac Glycosides*** - Drugs For The Heart Digitek Oral Tablet 125 MCG, 250 MCG 1 Digox Oral Tablet 125 MCG, 250 MCG 1 digoxin oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 Lanoxin Oral Tablet 125 MCG, 250 MCG, 62.5 MCG 3 *Cardiovascular Agents - Misc.* - Drugs For The Heart *Calcium Channel Blocker & Hmg Coa Reductase Inhibit Comb*** - Drugs For Cholesterol amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5- 1 40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb*** - Drugs For High Blood Pressure Entresto Oral Tablet 24-26 MG, 49-51 MG, 97-103 3 MG *Nitrate & Vasodilator Combinations*** - Drugs For High Blood Pressure BiDil Oral Tablet 20-37.5 MG 3 *Peripheral Vasodilators*** - Drugs For High Blood Pressure isoxsuprine hcl oral tablet 10 mg, 20 mg 1 * - Impotence Agents*** - Drugs For The Heart Caverject Impulse Intracavernosal Kit 10 MCG, 20 3 Male Only; QL MCG Caverject Intracavernosal Solution Reconstituted 3 Male Only; QL 40 MCG Edex Intracavernosal Kit 10 MCG, 20 MCG, 40 3 Male Only; QL MCG Muse Urethral Pellet 1000 MCG, 250 MCG, 500 3 Male Only; QL MCG *Prostaglandin Vasodilators*** - Drugs For High Blood Pressure epoprostenol sodium intravenous solution Tier 10 PA reconstituted 0.5 mg, 1.5 mg

Last Published: 09/17/2021 67 Drug Name Drug Tier Requirements / Limits Flolan Intravenous Solution Reconstituted 0.5 MG, Tier 10 PA 1.5 MG Orenitram Oral Tablet Extended Release 0.125 MG, 2 PA; QL 0.25 MG, 1 MG, 2.5 MG, 5 MG Remodulin Injection Solution 100 MG/20ML, 20 Tier 10 PA MG/20ML, 200 MG/20ML, 50 MG/20ML treprostinil injection solution 100 mg/20ml, 20 Tier 10 PA mg/20ml, 200 mg/20ml, 50 mg/20ml Tyvaso Inhalation Solution 0.6 MG/ML 3 PA Tyvaso Refill Inhalation Solution 0.6 MG/ML 3 PA Tyvaso Starter Inhalation Solution 0.6 MG/ML 3 PA Veletri Intravenous Solution Reconstituted 0.5 MG, Tier 10 PA 1.5 MG Ventavis Inhalation Solution 10 MCG/ML, 20 2 PA MCG/ML *Pulm Hyperten-Soluble Guanylate Cyclase Stimulator (Sgc)*** - Drugs For High Blood Pressure Adempas Oral Tablet 0.5 MG, 1 MG, 1.5 MG, 2 MG, 3 PA; QL 2.5 MG *Pulmonary Hypertension - Endothelin Receptor Antagonists*** - Drugs For High Blood Pressure ambrisentan oral tablet 10 mg, 5 mg 1 PA; QL bosentan oral tablet 125 mg, 62.5 mg 1 PA; QL Letairis Oral Tablet 10 MG, 5 MG 2 PA; QL Opsumit Oral Tablet 10 MG 3 PA; QL Tracleer Oral Tablet 125 MG, 62.5 MG 2 PA; QL Tracleer Oral Tablet Soluble 32 MG 2 PA; QL *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** - Drugs For High Blood Pressure Adcirca Oral Tablet 20 MG 3 PA; QL Alyq Oral Tablet 20 MG 1 PA; QL Revatio Intravenous Solution 10 MG/12.5ML Tier 10 PA PA; PR; Age Restriction Applies (Max Revatio Oral Suspension Reconstituted 10 MG/ML Tier 10 12 Years) citrate intravenous solution 10 mg/12.5ml Tier 10 PA sildenafil citrate oral suspension reconstituted 10 1 mg/ml sildenafil citrate oral tablet 20 mg 1 PR; QL (pah) oral tablet 20 mg 1 PA; QL *Pulmonary Hypertension - Prostacyclin Receptor Agonist*** - Drugs For High Blood Pressure Uptravi Intravenous Solution Reconstituted 1800 Tier 10 PA MCG

Last Published: 09/17/2021 68 Drug Name Drug Tier Requirements / Limits Uptravi Oral Tablet 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 3 PA; QL 800 MCG Uptravi Oral Tablet Therapy Pack 200 & 800 MCG 3 PA; QL *Selective Cgmp Phosphodiesterase Type 5 Inhibitors*** - Drugs For The Heart Levitra Oral Tablet 10 MG, 20 MG 3 Male Only; QL sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg 1 Male Only; QL Stendra Oral Tablet 100 MG, 200 MG, 50 MG 3 Male Only tadalafil oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 Male Only; QL hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 Male Only; QL vardenafil hcl oral tablet dispersible 10 mg 1 Male Only; QL *Sinus Node Inhibitors** - Drugs For High Blood Pressure Age Restriction Applies (Max 11 Corlanor Oral Solution 5 MG/5ML 3 Years) Corlanor Oral Tablet 5 MG, 7.5 MG 3 QL *Transthyretin Stabilizers*** - Drugs For The Heart Vyndamax Oral Capsule 61 MG 3 PA Vyndaqel Oral Capsule 20 MG 3 PA *Vasoactive Soluble Guanylate Cyclase Stimulator (Sgc)*** - Drugs For Angina Verquvo Oral Tablet 10 MG, 2.5 MG, 5 MG 3 QL *Cephalosporins* - Drugs For Infections *Cephalosporins - 1St Generation*** - Antibiotics cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension reconstituted 250 mg/5ml, 1 500 mg/5ml cefadroxil oral tablet 1 gm 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 cephalexin oral suspension reconstituted 125 mg/5ml, 1 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg 1 *Cephalosporins - 2Nd Generation*** - Antibiotics cefaclor er oral tablet extended release 12 hour 500 1 mg cefaclor oral capsule 250 mg, 500 mg 1 cefaclor oral suspension reconstituted 125 mg/5ml, 1 250 mg/5ml, 375 mg/5ml cefprozil oral suspension reconstituted 125 mg/5ml, 1 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 *Cephalosporins - 3Rd Generation*** - Antibiotics cefdinir oral capsule 300 mg 1 Last Published: 09/17/2021 69 Drug Name Drug Tier Requirements / Limits cefdinir oral suspension reconstituted 125 mg/5ml, 1 250 mg/5ml cefixime oral capsule 400 mg 1 cefixime oral suspension reconstituted 100 mg/5ml, 1 200 mg/5ml cefpodoxime proxetil oral suspension reconstituted 1 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg 1 Suprax Oral Suspension Reconstituted 100 3 MG/5ML, 200 MG/5ML, 500 MG/5ML Suprax Oral Tablet Chewable 100 MG, 200 MG 3 *Chemicals* *Fixed Oils*** almond oil (sweet) oil 2 base g almond oil (sweet) oil 2 castor oil oil 2 coconut oil oil 2 cottonseed oil oil 2 hm castor oil oil 2 linseed oil oil 2 olive oil oil 2 organic coconut oil oil 2 peanut oil oil 2 qc castor oil oil 2 qc sweet oil oil 2 safflower oil oil 2 sesame oil oil 2 sm sweet oil oil 2 soybean oil oil 2 sweet oil oil 2 *Liquids*** benzyl benzoate liquid 2 *Contraceptives* - Drugs For Women *Biphasic Contraceptives - Oral*** - Birth Control Pills Azurette Oral Tablet 0.15-0.02/0.01 MG (21/5) 1 -ethinyl oral tablet 0.15-0.02/0.01 1 mg (21/5) Kariva Oral Tablet 0.15-0.02/0.01 MG (21/5) 1 Lo Loestrin Fe Oral Tablet 1 MG-10 MCG / 10 MCG 2 ST Pimtrea Oral Tablet 0.15-0.02/0.01 MG (21/5) 1 viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1

Last Published: 09/17/2021 70 Drug Name Drug Tier Requirements / Limits *Combination Contraceptives - Oral*** - Birth Control Pills Balcoltra Oral Tablet 0.1-20 MG-MCG(21) 3 ST drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 1 mg FaLessa Oral Kit 20-1-0.1 MCG-MG 2 ST gemmily oral capsule 1-20 mg-mcg(24) 1 Kaitlib Fe Oral Tablet Chewable 0.8-25 MG-MCG 1 Layolis FE Oral Tablet Chewable 0.8-25 MG-MCG 1 Nextstellis Oral Tablet 3-14.2 MG 3 ST norethin ace-eth estrad-fe oral capsule 1-20 mg- 1 mcg(24) norethin-eth estradiol-fe oral tablet chewable 0.8-25 1 mg-mcg *Combination Contraceptives - Transdermal*** - Birth Control Pills Twirla Transdermal Patch Weekly 120-30 3 ST MCG/24HR xulane transdermal patch weekly 150-35 mcg/24hr 1 *Combination Contraceptives - Vaginal*** - Birth Control Pills Annovera Vaginal Ring 0.013-0.15 MG/24HR 3 Female Only; QL -ethinyl estradiol vaginal ring 0.12-0.015 1 QL mg/24hr NuvaRing Vaginal Ring 0.12-0.015 MG/24HR 2 QL *Emergency Contraceptives*** - Birth Control Pills Ella Oral Tablet 30 MG 2 *Four Phase Contraceptives - Oral*** - Birth Control Pills Natazia Oral Tablet 3/2-2/2-3/1 MG 2 ST *Progestin Contraceptives - Injectable*** - Birth Control Pills Depo-Provera Intramuscular Suspension 150 Tier 10 MG/ML Depo-Provera Intramuscular Suspension Prefilled Tier 10 Syringe 150 MG/ML medroxyprogesterone acetate intramuscular Tier 10 suspension 150 mg/ml medroxyprogesterone acetate intramuscular Tier 10 suspension prefilled syringe 150 mg/ml *Progestin Contraceptives - Oral*** - Birth Control Pills Slynd Oral Tablet 4 MG 3 ST; Female Only *Triphasic Contraceptives - Oral*** - Birth Control Pills Leena Oral Tablet 0.5/1/0.5-35 MG-MCG 3

Last Published: 09/17/2021 71 Drug Name Drug Tier Requirements / Limits norgestim-eth estrad triphasic oral tablet 1 0.18/0.215/0.25 mg-25 mcg Tri-Lo-Estarylla Oral Tablet 0.18/0.215/0.25 MG-25 1 MCG Tri-Lo-Marzia Oral Tablet 0.18/0.215/0.25 MG-25 1 MCG Tri-Lo-Sprintec Oral Tablet 0.18/0.215/0.25 MG-25 1 MCG Tri-VyLibra Lo Oral Tablet 0.18/0.215/0.25 MG-25 1 MCG *Corticosteroids* - Hormones *Glucocorticosteroids*** - Drugs For Inflammation Alkindi Sprinkle Oral Capsule Sprinkle 0.5 MG, 1 Age Restriction Applies (Max 12 3 MG, 2 MG, 5 MG Years) budesonide er oral tablet extended release 24 hour 9 1 mg budesonide oral capsule delayed release particles 3 1 mg Decadron Oral Tablet 0.5 MG, 0.75 MG, 4 MG, 6 MG 1 Dexamethasone Intensol Oral Concentrate 1 1 MG/ML dexamethasone oral elixir 0.5 mg/5ml 1 dexamethasone oral solution 0.5 mg/5ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 1 mg, 2 mg, 4 mg, 6 mg hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 Medrol Oral Tablet 2 MG 3 methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 1 mg methylprednisolone oral tablet therapy pack 4 mg 1 Millipred Oral Tablet 5 MG 1 prednisolone oral solution 15 mg/5ml 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 15 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 1 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 1 10 mg, 15 mg, 30 mg PredniSONE Intensol Oral Concentrate 5 MG/ML 1 prednisone oral solution 5 mg/5ml 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 1 mg, 50 mg prednisone oral tablet therapy pack 10 mg (21), 10 mg 1 (48), 5 mg (21), 5 mg (48) Rayos Oral Tablet Delayed Release 1 MG, 2 MG, 5 3 MG

Last Published: 09/17/2021 72 Drug Name Drug Tier Requirements / Limits *Mineralocorticoids*** - Drugs For Inflammation fludrocortisone acetate oral tablet 0.1 mg 1 *Cough/Cold/Allergy* - Drugs For The Lungs *Antitussive - Nonnarcotic*** - Drugs For Allergies benzonatate oral capsule 100 mg, 150 mg, 200 mg 1 *Antitussive - Opioid*** - Drugs For Cough And Cold hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 Age Restriction Applies (Min 6 Years) hydrocodone-homatropine oral tablet 5-1.5 mg 1 Age Restriction Applies (Min 6 Years) hydromet oral syrup 5-1.5 mg/5ml 1 Age Restriction Applies (Min 6 Years) *Antitussive-Expectorant*** - Drugs For Cough And Cold Age Restriction Applies (Min 12 g tussin ac oral solution 100-10 mg/5ml 1 Years) Age Restriction Applies (Min 12 guaiatussin ac oral syrup 100-10 mg/5ml 1 Years) Age Restriction Applies (Min 12 guaifenesin ac oral syrup 100-10 mg/5ml 1 Years) Age Restriction Applies (Min 12 guaifenesin-codeine oral solution 100-10 mg/5ml 1 Years) Age Restriction Applies (Min 12 virtussin a/c oral solution 100-10 mg/5ml 1 Years) *Antitussive-Expectorants-Decongestant*** - Drugs For Cough And Cold Actinel Pediatric Oral Liquid 15-5-50 MG/5ML 3 Tusnel Pediatric Oral Liquid 15-5-50 MG/5ML 3 Age Restriction Applies (Min 12 virtussin dac oral solution 30-10-100 mg/5ml 1 Years) *Decongestant & Antihistamine*** - Drugs For Cough And Cold promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 *Iodine Expectorants*** - Drugs For Cough And Cold SSKI Oral Solution 1 GM/ML 2 *Misc. Respiratory Inhalants*** - Drugs For Allergies HyperSal Inhalation Nebulization Solution 3.5 % 3 sodium chloride inhalation nebulization solution 0.9 %, 1 10 %, 3 %, 7 % *Mucolytics*** - Drugs For The Lungs acetylcysteine inhalation solution 10 %, 20 % 1 *Non-Narc Antitussive-Antihistamine*** - Drugs For Cough And Cold promethazine-dm oral syrup 6.25-15 mg/5ml 1

Last Published: 09/17/2021 73 Drug Name Drug Tier Requirements / Limits *Non-Narc Antitussive-Decongestant- Antihistamine*** - Drugs For Cough And Cold pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml 1 *Opioid Antitussive-Antihistamine*** - Drugs For Cough And Cold hydrocod polst-cpm polst er oral suspension extended 1 Age Restriction Applies (Min 6 Years) release 10-8 mg/5ml Age Restriction Applies (Min 12 promethazine-codeine oral solution 6.25-10 mg/5ml 1 Years) Age Restriction Applies (Min 12 promethazine-codeine oral syrup 6.25-10 mg/5ml 1 Years) TussiCaps Oral Capsule Extended Release 12 3 Age Restriction Applies (Min 6 Years) Hour 10-8 MG Tuzistra XR Oral Suspension Extended Release QL; Age Restriction Applies (Min 12 3 14.7-2.8 MG/5ML Years) *Opioid Antitussive-Decongestant- Antihistamine*** - Drugs For Cough And Cold Age Restriction Applies (Min 12 Histex-AC Oral Syrup 10-2.5-10 MG/5ML 2 Years) promethazine-phenyleph-codeine oral syrup 6.25-5-10 Age Restriction Applies (Min 12 1 mg/5ml Years) Age Restriction Applies (Min 12 Pro-Red AC Oral Syrup 5-1-9 MG/5ML 3 Years) *Dermatologicals* - Drugs For The Skin *Acne Antibiotics*** - Drugs For The Skin Amzeeq External Foam 4 % 3 Clindacin ETZ External Swab 1 % 1 Clindacin-P External Swab 1 % 1 clindamycin phosphate external foam 1 % 1 clindamycin phosphate external gel 1 % 1 clindamycin phosphate external lotion 1 % 1 clindamycin phosphate external solution 1 % 1 clindamycin phosphate external swab 1 % 1 dapsone external gel 5 %, 7.5 % 1 ery external pad 2 % 1 erythromycin external gel 2 % 1 erythromycin external solution 2 % 1 sulfacetamide sodium (acne) external lotion 10 % 1 *Acne Combinations*** - Drugs For The Skin adapalene-benzoyl peroxide external gel 0.1-2.5 % 1 QL Avar Cleanser External Emulsion 10-5 % 1 Avar-e Emollient External Cream 10-5 % 1 Avar-e Green External Cream 10-5 % 1 benzoyl perox-hydrocortisone external lotion 5-0.5 % 1 benzoyl peroxide-erythromycin external gel 5-3 % 1 Last Published: 09/17/2021 74 Drug Name Drug Tier Requirements / Limits bp 10-1 external emulsion 10-1 % 1 bp cleansing wash external emulsion 10-4 % 1 clindamycin phos-benzoyl perox external gel 1-5 %, 1 1.2-2.5 %, 1.2-5 % clindamycin-tretinoin external gel 1.2-0.025 % 1 QL Epiduo Forte External Gel 0.3-2.5 % 3 QL Neuac External Gel 1.2-5 % 1 Onexton External Gel 1.2-3.75 % 3 Plexion Cleansing Cloth External Pad 9.8-4.8 % 3 sss 10-5 external cream 10-5 % 1 sss 10-5 external foam 10-5 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 1 10-5 %, 9.8-4.8 % sulfacetamide sodium-sulfur external emulsion 10-5 % 1 sulfacetamide sodium-sulfur external liquid 10-2 %, 9- 1 4 %, 9-4.5 %, 9.8-4.8 % sulfacetamide sodium-sulfur external lotion 10-5 %, 1 9.8-4.8 % sulfacetamide sodium-sulfur external pad 10-4 % 1 sulfacetamide sodium-sulfur external suspension 10-5 1 %, 8-4 % SulfaCleanse 8/4 External Suspension 8-4 % 1 sulfamez wash external emulsion 10-1 % 1 Vanoxide-HC External Lotion 5-0.5 % 1 Veltin External Gel 1.2-0.025 % 3 *Acne Products*** - Drugs For The Skin Absorica LD Oral Capsule 16 MG, 24 MG, 32 MG, 8 3 MG adapalene external cream 0.1 % 1 adapalene external gel 0.1 %, 0.3 % 1 Aklief External Cream 0.005 % 3 Altreno External Lotion 0.05 % 3 Amnesteem Oral Capsule 10 MG, 20 MG, 40 MG 1 Avita External Cream 0.025 % 1 Avita External Gel 0.025 % 1 Azelex External Cream 20 % 3 BenzePrO Creamy Wash External Liquid 7 % 1 benzepro external 5.8 % 1 benzepro external foam 5.2 %, 9.7 % 1 BenzePrO External Foam 5.3 % 1 benzepro external liquid 6.8 % 1 BenzePrO Foaming Cloths External 6 % 1 BenzePrO Short Contact External Foam 9.8 % 1

Last Published: 09/17/2021 75 Drug Name Drug Tier Requirements / Limits benzoyl peroxide external foam 9.8 % 1 benzoyl peroxide external gel 8 % 1 bp wash external liquid 7 % 1 bpo external gel 4 %, 8 % 3 bpo foaming cloths external 6 % 1 Claravis Oral Capsule 10 MG, 20 MG, 30 MG, 40 1 MG cvs creamy acne face wash external liquid 4 % 1 Fabior External Foam 0.1 % 3 isotretinoin oral capsule 10 mg, 20 mg, 25 mg, 30 mg, 1 35 mg, 40 mg Myorisan Oral Capsule 10 MG, 20 MG, 30 MG, 40 1 MG PanOxyl Creamy Wash External Liquid 4 % 1 pr benzoyl peroxide external liquid 6.9 % 1 PR Benzoyl Peroxide Wash External Liquid 7 % 1 Retin-A Micro Pump External Gel 0.06 %, 0.08 % 3 tretinoin external cream 0.025 %, 0.05 %, 0.1 % 1 tretinoin external gel 0.01 %, 0.025 %, 0.05 % 1 tretinoin microsphere external gel 0.04 %, 0.1 % 1 Winlevi External Cream 1 % 3 Zenatane Oral Capsule 10 MG, 20 MG, 30 MG, 40 1 MG *Agents For External Genital And Perianal Warts*** - Drugs For The Skin Veregen External Ointment 15 % 3 QL *Antibiotic Steroid Combinations - Topical*** - Drugs For The Skin Neo-Synalar External Cream 0.5-0.025 % 3 *Antibiotics - Topical*** - Drugs For The Skin Altabax External Ointment 1 % 3 QL Centany External Ointment 2 % 3 gentamicin sulfate external cream 0.1 % 1 gentamicin sulfate external ointment 0.1 % 1 mupirocin calcium external cream 2 % 1 mupirocin external ointment 2 % 1 Xepi External Cream 1 % 3 *Antifungals - Topical Combinations*** - Drugs For The Skin Ala-Quin External Cream 3-0.5 % 2 -betamethasone external cream 1-0.05 % 1 clotrimazole-betamethasone external lotion 1-0.05 % 1 Dermazene External Cream 1-1 % 1 hydrocortisone-iodoquinol external cream 1-1 % 1 Last Published: 09/17/2021 76 Drug Name Drug Tier Requirements / Limits iodoquimez-hc external cream 1-1.9 % 1 iodoquinol-hydrocortisone-aloe external cream 1-1.9 1 % nystatin- external cream 100000-0.1 1 unit/gm-% nystatin-triamcinolone external ointment 100000-0.1 1 unit/gm-% *Antifungals - Topical*** - Drugs For The Skin Ciclodan External Solution 8 % 1 external gel 0.77 % 1 ciclopirox external shampoo 1 % 1 ciclopirox external solution 8 % 1 ciclopirox olamine external cream 0.77 % 1 ciclopirox olamine external suspension 0.77 % 1 hcl external cream 1 %, 2 % 1 Naftin External Gel 2 % 3 ST Nyamyc External Powder 100000 UNIT/GM 1 nystatin external cream 100000 unit/gm 1 nystatin external ointment 100000 unit/gm 1 nystatin external powder 100000 unit/gm 1 Nystop External Powder 100000 UNIT/GM 1 *Antineoplastic Alkylating Agents - Topical*** - Drugs For The Skin Valchlor External Gel 0.016 % 2 *Antineoplastic Antimetabolites - Topical*** - Drugs For The Skin Fluoroplex External Cream 1 % 2 fluorouracil external cream 0.5 %, 5 % 1 fluorouracil external solution 2 %, 5 % 1 *Antineoplastic Retinoids - Topical*** - Drugs For The Skin Panretin External Gel 0.1 % 3 *Antipruritics - Topical*** - Drugs For The Skin doxepin hcl external cream 5 % 1 *Antipsoriatics - Systemic*** - Drugs For The Skin acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 QL Cosentyx (300 MG Dose) Subcutaneous Solution 2 PA; QL Prefilled Syringe 150 MG/ML Cosentyx Sensoready (300 MG) Subcutaneous 2 PA; QL Solution Auto-Injector 150 MG/ML Cosentyx Sensoready Pen Subcutaneous Solution 2 PA; QL Auto-Injector 150 MG/ML Cosentyx Subcutaneous Solution Prefilled Syringe 2 PA; QL 150 MG/ML, 75 MG/0.5ML

Last Published: 09/17/2021 77 Drug Name Drug Tier Requirements / Limits Ilumya Subcutaneous Solution Prefilled Syringe Tier 10 PA 100 MG/ML methoxsalen rapid oral capsule 10 mg 1 Skyrizi (150 MG Dose) Subcutaneous Prefilled 2 PA; QL Syringe Kit 75 MG/0.83ML Skyrizi Pen Subcutaneous Solution Auto-Injector 2 PA; QL 150 MG/ML Skyrizi Subcutaneous Solution Prefilled Syringe 2 PA; QL 150 MG/ML Soriatane Oral Capsule 10 MG, 25 MG 3 QL Stelara Subcutaneous Solution 45 MG/0.5ML 2 PA; QL Stelara Subcutaneous Solution Prefilled Syringe 2 PA; QL 45 MG/0.5ML, 90 MG/ML Tremfya Subcutaneous Solution Pen-Injector 100 2 PA; QL MG/ML Tremfya Subcutaneous Solution Prefilled Syringe 2 PA; QL 100 MG/ML *Antipsoriatics*** - Drugs For The Skin calcipotriene external cream 0.005 % 1 QL calcipotriene external ointment 0.005 % 1 QL calcipotriene external solution 0.005 % 1 QL Calcitrene External Ointment 0.005 % 1 QL calcitriol external ointment 3 mcg/gm 1 Dritho-Creme HP External Cream 1 % 2 tazarotene external cream 0.1 % 1 Tazorac External Cream 0.05 % 3 Tazorac External Gel 0.05 %, 0.1 % 3 Zithranol External Shampoo 1 % 3 *Antiseborrheic Combinations*** - Drugs For The Skin Nutraseb External Cream 3 Promiseb External Cream 3 *Antiseborrheic Products*** - Drugs For The Skin glycolic acid solution 70 % 3 Ovace Plus External Cream 10 % 3 Ovace Plus External Foam 9.8 % 3 Ovace Plus External Lotion 9.8 % 3 selenium sulfide external lotion 2.5 % 1 selenium sulfide external shampoo 2.3 % 1 sodium sulfacetamide external shampoo 10 % 1 sodium sulfacetamide wash external liquid 10 % 1 sulfacetamide sodium external gel 10 % (cleans) 1 sulfacetamide sodium external liquid 10 % 1

Last Published: 09/17/2021 78 Drug Name Drug Tier Requirements / Limits *Antiviral Topical Combinations*** - Drugs For The Skin Xerese External Cream 5-1 % 3 QL *Antivirals - Topical*** - Drugs For The Skin acyclovir external cream 5 % 1 acyclovir external ointment 5 % 1 Denavir External Cream 1 % 3 *Atopic Dermatitis - Monoclonal Antibodies*** - Drugs For The Skin Dupixent Subcutaneous Solution Pen-Injector 200 3 PA; QL MG/1.14ML Dupixent Subcutaneous Solution Pen-Injector 300 3 PA MG/2ML Dupixent Subcutaneous Solution Prefilled Syringe 3 PA 200 MG/1.14ML, 300 MG/2ML *Burn Products*** - Drugs For The Skin mafenide acetate external packet 5 % 1 silver sulfadiazine external cream 1 % 1 SSD External Cream 1 % 1 Sulfamylon External Cream 85 MG/GM 3 *Cauterizing Agent Combinations*** - Drugs For The Skin Arzol Silver Nit Applicators External 75-25 % 1 *Cauterizing Agents*** - Drugs For The Skin silver nitrate external solution 0.5 %, 10 %, 25 %, 50 3 % Tri-Chlor External Liquid 80 % 3 *Corticosteroids - Topical*** - Drugs For The Skin Ala Scalp External Lotion 2 % 3 ala-cort external cream 2.5 % 1 alclometasone dipropionate external cream 0.05 % 1 alclometasone dipropionate external ointment 0.05 % 1 amcinonide external cream 0.1 % 1 amcinonide external lotion 0.1 % 1 amcinonide external ointment 0.1 % 1 ApexiCon E External Cream 0.05 % 1 betamethasone dipropionate aug external cream 0.05 1 % betamethasone dipropionate aug external gel 0.05 % 1 betamethasone dipropionate aug external lotion 0.05 1 % betamethasone dipropionate aug external ointment 1 0.05 % betamethasone dipropionate external cream 0.05 % 1 betamethasone dipropionate external lotion 0.05 % 1 Last Published: 09/17/2021 79 Drug Name Drug Tier Requirements / Limits betamethasone dipropionate external ointment 0.05 % 1 betamethasone valerate external cream 0.1 % 1 betamethasone valerate external foam 0.12 % 1 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 Bryhali External Lotion 0.01 % 3 Capex External Shampoo 0.01 % 3 clobetasol prop emollient base external cream 0.05 % 1 clobetasol propionate e external cream 0.05 % 1 clobetasol propionate emulsion external foam 0.05 % 1 clobetasol propionate external cream 0.05 % 1 clobetasol propionate external foam 0.05 % 1 clobetasol propionate external gel 0.05 % 1 clobetasol propionate external liquid 0.05 % 1 clobetasol propionate external lotion 0.05 % 1 clobetasol propionate external ointment 0.05 % 1 clobetasol propionate external shampoo 0.05 % 1 clobetasol propionate external solution 0.05 % 1 clocortolone pivalate external cream 0.1 % 1 Clodan External Shampoo 0.05 % 1 Cordran External Tape 4 MCG/SQCM 3 desonide external cream 0.05 % 1 desonide external gel 0.05 % 1 desonide external lotion 0.05 % 1 desonide external ointment 0.05 % 1 desoximetasone external cream 0.05 %, 0.25 % 1 desoximetasone external gel 0.05 % 1 desoximetasone external liquid 0.25 % 1 desoximetasone external ointment 0.05 %, 0.25 % 1 diflorasone diacetate external cream 0.05 % 1 diflorasone diacetate external ointment 0.05 % 1 fluocinolone acetonide body external oil 0.01 % 1 fluocinolone acetonide external cream 0.01 %, 0.025 1 % fluocinolone acetonide external ointment 0.025 % 1 fluocinolone acetonide external solution 0.01 % 1 fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 %, 0.1 % 1 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1

Last Published: 09/17/2021 80 Drug Name Drug Tier Requirements / Limits flurandrenolide external cream 0.05 % 1 flurandrenolide external lotion 0.05 % 1 flurandrenolide external ointment 0.05 % 1 external cream 0.05 % 1 fluticasone propionate external lotion 0.05 % 1 fluticasone propionate external ointment 0.005 % 1 halcinonide external cream 0.1 % 1 halobetasol propionate external cream 0.05 % 1 halobetasol propionate external ointment 0.05 % 1 Halog External Ointment 0.1 % 3 hydrocortisone butyr lipo base external cream 0.1 % 1 hydrocortisone butyrate external cream 0.1 % 1 hydrocortisone butyrate external lotion 0.1 % 1 hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1 hydrocortisone external cream 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 2.5 % 1 hydrocortisone valerate external cream 0.2 % 1 hydrocortisone valerate external ointment 0.2 % 1 mometasone furoate external cream 0.1 % 1 mometasone furoate external ointment 0.1 % 1 mometasone furoate external solution 0.1 % 1 Nolix External Cream 0.05 % 1 Nolix External Lotion 0.05 % 1 NuCort External Lotion 2 % 3 Pandel External Cream 0.1 % 2 prednicarbate external ointment 0.1 % 1 psorcon external cream 0.05 % 3 Sernivo External Emulsion 0.05 % 3 Texacort External Solution 2.5 % 3 triamcinolone acetonide external aerosol solution 1 0.147 mg/gm triamcinolone acetonide external cream 0.025 %, 0.1 1 % triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 triamcinolone acetonide external ointment 0.025 %, 1 0.1 %, 0.5 % Trianex External Ointment 0.05 % 3 Triderm External Cream 0.1 % 1 Ultravate External Lotion 0.05 % 3 Verdeso External Foam 0.05 % 3

Last Published: 09/17/2021 81 Drug Name Drug Tier Requirements / Limits *Emollient/Keratolytic Agents*** - Drugs For The Skin urea external cream 39 %, 45 % 1 Uredeb External Cream 39 % 1 *Emollients*** - Drugs For The Skin glycerin external liquid 2 hm glycerin external liquid 99.5 % 2 qc glycerin external liquid 99.5 % 2 ra glycerin external liquid 2 sm glycerin external liquid 99.5 % 2 *Enzymes - Topical*** - Drugs For The Skin Santyl External Ointment 250 UNIT/GM 3 QL *Eyelid Cleansers & Lubricants*** - Drugs For The Skin Avenova External Solution 0.01 % 3 *-Related Antifungals - Topical*** - Drugs For The Skin nitrate external cream 1 % 1 ST; Age Restriction Applies (Min 12 Ecoza External Foam 1 % 3 Years) Ertaczo External Cream 2 % 3 ST Jublia External Solution 10 % 3 ST; QL ketoconazole external cream 2 % 1 ketoconazole external foam 2 % 1 ketoconazole external shampoo 2 % 1 nitrate external cream 1 % 1 Oxistat External Lotion 1 % 3 ST nitrate external cream 1 % 1 Xolegel External Gel 2 % 3 ST *Immunomodulators Imidazoquinolinamines - Topical*** - Drugs For The Skin imiquimod external cream 5 % 1 QL; Age Restriction Applies (Min 12 Zyclara Pump External Cream 2.5 % 2 Years) *Keratolytic And/Or Antimitotic Combinations*** - Drugs For The Skin pyrogallic acid external ointment 25-2 % 3 *Keratolytic/Antimitotic Agents*** - Drugs For The Skin bensal hp external ointment 3 % 3 Condylox External Gel 0.5 % 3 podocon external solution 25 % 3 podofilox external solution 0.5 % 1 er external solution 28.5 % 1

Last Published: 09/17/2021 82 Drug Name Drug Tier Requirements / Limits salicylic acid external foam 6 % 1 salicylic acid external gel 6 % 1 salicylic acid external solution 26 % 1 salicylic acid wart remover external liquid 27.5 % 1 *Local Anesthetics - Topical*** - Drugs For The Skin 7T Lido External Gel 2 % 1 QL Anacaine External Ointment 10 % 3 Astero External Gel 4 % 3 LDO Plus External Gel 4 % 3 lidocaine external ointment 5 % 1 lidocaine external patch 5 % 1 QL lidocaine hcl external solution 4 % 1 lidocaine hcl urethral/mucosal external gel 2 % 1 QL premium lidocaine external ointment 5 % 1 *Macrolide Immunosuppressants - Topical*** - Drugs For The Skin QL; Age Restriction Applies (Min 2 pimecrolimus external cream 1 % 1 Years) tacrolimus external ointment 0.03 %, 0.1 % 1 Age Restriction Applies (Min 2 Years) * Receptor Agonists (Uv Protective)*** - Drugs For The Skin Scenesse Subcutaneous Implant 16 MG Tier 10 PA *Microtubule Inhibitors - Topical*** - Drugs For The Skin Klisyri External Ointment 1 % 3 QL *Misc. Dermatological Products*** - Drugs For The Skin alevamax external cream 3 Alevicyn Antipruritic External Gel 3 Alevicyn Antipruritic SG External Gel 3 atopaderm external cream 3 Atopiclair External Cream 3 Dexeryl External Cream 3 Eletone External Cream 3 HPR Plus External Cream 3 HPR Plus External Foam 3 HPR PLUS HydroGel External Kit 3 Hylatopic Plus External Cream 3 Hylatopic Plus External Lotion 3 Levicyn External Gel 3 MimyX External Cream 3 Neosalus External Cream 3

Last Published: 09/17/2021 83 Drug Name Drug Tier Requirements / Limits Neosalus External Foam 3 Neosalus External Lotion 3 PR Cream External Kit 3 Presera External Foam 3 remigen external cream 3 Sebuderm External Gel 3 Tetrix External Cream 3 Xeralux External Cream 3 *Misc. Topical*** - Drugs For The Skin arnica flower tincture 3 boric acid external granules 3 Drysol External Solution 20 % 3 Qbrexza External Pad 2.4 % 3 *Oxaborole-Related Antifungals - Topical*** - Drugs For The Skin external solution 5 % 1 *Phosphodiesterase 4 (Pde4) Inhibitors - Topical*** - Drugs For The Skin Eucrisa External Ointment 2 % 3 *Photodynamic Therapy Agents - Topical*** - Drugs For The Skin Ameluz External Gel 10 % 3 Levulan Kerastick External Solution Reconstituted 3 20 % * - Topical*** - Drugs For The Skin bimatoprost external solution 0.03 % 1 *Rosacea Agents*** - Drugs For The Skin azelaic acid external gel 15 % 1 doxycycline oral capsule delayed release 40 mg 1 Finacea External Foam 15 % 3 ivermectin external cream 1 % 1 metronidazole external cream 0.75 % 1 metronidazole external gel 0.75 %, 1 % 1 metronidazole external lotion 0.75 % 1 Mirvaso External Gel 0.33 % 3 PR; QL Noritate External Cream 1 % 3 Rhofade External Cream 1 % 3 PR; QL Rosadan External Cream 0.75 % 1 Rosadan External Gel 0.75 % 1 Zilxi External Foam 1.5 % 3 PR *Scabicides & Pediculicides*** - Drugs For The Skin Crotan External Lotion 10 % 1

Last Published: 09/17/2021 84 Drug Name Drug Tier Requirements / Limits ivermectin external lotion 0.5 % 1 QL lindane external shampoo 1 % 1 malathion external lotion 0.5 % 1 permethrin external cream 5 % 1 spinosad external suspension 0.9 % 1 *Skin Cleansers*** - Drugs For The Skin cvs isopropyl alcohol wipes external 70 % 1 Hyclodex External Solution 0.012 % 3 isopropyl alcohol external 70 % 1 isopropyl alcohol wipes external 70 % 1 ra isopropyl alcohol wipes external 70 % 1 *Skin Protectants*** - Drugs For The Skin benzoin external tincture 2 mineral oil light external oil 2 sm benzoin tincture external tincture 2 *Steroid-Local Anesthetic Combinations*** - Drugs For The Skin Cortane-B External Lotion 10-10-1 MG/ML 2 Epifoam External Foam 1-1 % 3 Pramosone External Cream 1-1 % 1 Pramosone External Lotion 1-1 %, 1-2.5 % 1 Pramosone External Ointment 1-1 %, 1-2.5 % 3 *Topical Anesthetic Combinations*** - Drugs For The Skin Cetacaine External Aerosol 2-2-14 % 3 lidocaine-prilocaine external cream 2.5-2.5 % 1 Synera External Patch 70-70 MG 3 *Topical Selective Retinoid X Receptor Agonists*** - Drugs For The Skin Targretin External Gel 1 % 2 *Topical Steroid Combinations*** - Drugs For The Skin calcipotriene-betameth diprop external ointment 1 0.005-0.064 % Duobrii Lotion 0.01-0.045 % External 0.01-0.045 % 3 Enstilar External Foam 0.005-0.064 % 3 Taclonex External Suspension 0.005-0.064 % 3 *Wound Care - Growth Factor Agents*** - Drugs For The Skin Regranex External Gel 0.01 % 2 QL *Wound Care Combinations*** - Drugs For The Skin balsam peru-castor oil external ointment 3 bpco external ointment 3 Last Published: 09/17/2021 85 Drug Name Drug Tier Requirements / Limits Venelex External Ointment 3 *Diagnostic Products* *Diagnostic Tests*** Chemstrip K In Vitro Strip 1 ketone test in vitro strip 1 Ketostix In Vitro Strip 1 in vitro strip 1 QL OneTouch Verio In Vitro Strip 1 QL ReliOn Ketone Test In Vitro Strip 1 *Multiple Tests*** Chemstrip uGK In Vitro Strip 3 CVS Ketone Care In Vitro Strip 3 Keto-Diastix In Vitro Strip 3 *Digestive Aids* - Drugs For The Stomach *Digestive Enzymes*** - Drugs For The Stomach Creon Oral Capsule Delayed Release Particles 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 2 UNIT, 36000-114000 UNIT, 6000-19000 UNIT Pancreaze Oral Capsule Delayed Release Particles 10500-35500 UNIT, 16800-56800 UNIT, 21000-54700 3 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200- 14200 UNIT Pertzye Oral Capsule Delayed Release Particles 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 2 UNIT, 8000-28750 UNIT Sucraid Oral Solution 8500 UNIT/ML 3 PA Viokace Oral Tablet 10440-39150 UNIT, 20880- 3 78300 UNIT Zenpep Oral Capsule Delayed Release Particles 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 3 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000- 126000 UNIT, 5000-24000 UNIT *Diuretics* - Drugs For The Heart *Carbonic Anhydrase Inhibitors*** - Drugs For High Blood Pressure acetazolamide er oral capsule extended release 12 1 hour 500 mg acetazolamide oral tablet 125 mg, 250 mg 1 Keveyis Oral Tablet 50 MG 3 PA; QL methazolamide oral tablet 25 mg, 50 mg 1 *Diuretic Combinations*** - Drugs For High Blood Pressure Aldactazide Oral Tablet 50-50 MG 3 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 triamterene-hctz oral capsule 37.5-25 mg 1 Last Published: 09/17/2021 86 Drug Name Drug Tier Requirements / Limits triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 *Loop Diuretics*** - Drugs For High Blood Pressure bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 ethacrynic acid oral tablet 25 mg 1 furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 *Potassium Sparing Diuretics*** - Drugs For High Blood Pressure amiloride hcl oral tablet 5 mg 1 Age Restriction Applies (Max 12 CaroSpir Oral Suspension 25 MG/5ML 3 Years) spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 1 *Thiazides And Thiazide-Like Diuretics*** - Drugs For High Blood Pressure chlorthalidone oral tablet 25 mg, 50 mg 1 Diuril Oral Suspension 250 MG/5ML 3 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 *Endocrine And Metabolic Agents - Misc.* - Hormones *Adenosine Deaminase Scid Treatment - Agents*** - Drugs For Menopause And Bone Loss Revcovi Intramuscular Solution 2.4 MG/1.5ML Tier 10 PA *Bisphosphonates*** - Drugs For Menopause And Bone Loss alendronate sodium oral solution 70 mg/75ml 1 alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 1 QL 70 mg Binosto Oral Tablet Effervescent 70 MG 3 Fosamax Plus D Oral Tablet 70-2800 MG-UNIT, 70- 3 5600 MG-UNIT ibandronate sodium oral tablet 150 mg 1 QL Reclast Intravenous Solution 5 MG/100ML Tier 10 risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 1 QL 5 mg risedronate sodium oral tablet delayed release 35 mg 1 QL zoledronic acid intravenous concentrate 4 mg/5ml Tier 10 zoledronic acid intravenous solution 4 mg/100ml, 5 Tier 10 mg/100ml

Last Published: 09/17/2021 87 Drug Name Drug Tier Requirements / Limits *Calcimimetic Agents*** - Drugs For Menopause And Bone Loss cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 1 Sensipar Oral Tablet 30 MG, 60 MG, 90 MG 2 *Calcitonins*** - Drugs For Menopause And Bone Loss calcitonin (salmon) injection solution 200 unit/ml 1 calcitonin (salmon) nasal solution 200 unit/act 1 *Carnitine Replenisher - Agents*** - Drugs For Menopause And Bone Loss levocarnitine oral solution 1 gm/10ml 1 levocarnitine oral tablet 330 mg 1 *Corticotropin*** - Hormones Acthar Injection Gel 80 UNIT/ML Tier 10 PA *Cortisol Synthesis Inhibitors*** - Hormones Isturisa Oral Tablet 1 MG, 10 MG, 5 MG 3 PA *Dopamine Receptor Agonists*** - Drugs For Women oral tablet 0.5 mg 1 *Fabry Disease - Agents*** - Drugs For Menopause And Bone Loss Fabrazyme Intravenous Solution Reconstituted 35 Tier 10 PA MG, 5 MG Galafold Oral Capsule 123 MG 3 PA; QL *Gaa Deficiency Treatment - Agents*** - Drugs For Menopause And Bone Loss Lumizyme Intravenous Solution Reconstituted 50 Tier 10 PA MG Nexviazyme Intravenous Solution Reconstituted Tier 10 PA 100 MG *Gnrh/Lhrh Antagonists*** - Drugs For Women Orilissa Oral Tablet 150 MG, 200 MG 3 QL *Growth Hormone Receptor Antagonists*** - Drugs For Growth Somavert Subcutaneous Solution Reconstituted 3 PA; QL 10 MG, 15 MG, 20 MG, 25 MG, 30 MG *Growth Hormones*** - Drugs For Growth Genotropin MiniQuick Subcutaneous Solution Reconstituted 0.2 MG, 0.4 MG, 0.6 MG, 0.8 MG, 1 3 PA MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG Genotropin Subcutaneous Solution Reconstituted 3 PA 12 MG, 5 MG Humatrope Injection Solution Reconstituted 12 2 PA MG, 24 MG, 5 MG, 6 MG

Last Published: 09/17/2021 88 Drug Name Drug Tier Requirements / Limits Norditropin FlexPro Subcutaneous Solution Pen- Injector 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 2 PA MG/1.5ML Omnitrope Subcutaneous Solution Reconstituted 3 PA 5.8 MG Saizen Injection Solution Reconstituted 5 MG, 8.8 3 PA MG Saizenprep Injection Solution Reconstituted 8.8 3 PA MG Serostim Subcutaneous Solution Reconstituted 4 3 PA MG Zomacton Subcutaneous Solution Reconstituted 3 PA 10 MG, 5 MG Zorbtive Subcutaneous Solution Reconstituted 8.8 3 PA MG *Hereditary Orotic Aciduria Treatment - Agents** - Drugs For Menopause And Bone Loss Xuriden Oral Packet 2 GM 3 PA *Hereditary Tyrosinemia Type 1 (Ht-1) Treatment - Agents*** - Drugs For Menopause And Bone Loss nitisinone oral capsule 10 mg, 2 mg, 5 mg 1 PA Nityr Oral Tablet 10 MG, 2 MG, 5 MG 3 PA Orfadin Oral Capsule 10 MG, 2 MG, 20 MG, 5 MG 3 PA Orfadin Oral Suspension 4 MG/ML 3 PA *Homocystinuria Treatment - Agents*** - Drugs For Menopause And Bone Loss Cystadane Oral Powder 2 *Hyperammonemia Treatment - Agents*** - Drugs For Menopause And Bone Loss Carbaglu Oral Tablet 200 MG 3 PA *Hyperparathyroid Treatment - Vitamin D Analogs*** - Drugs For Menopause And Bone Loss calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 calcitriol oral solution 1 mcg/ml 1 doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 1 paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 Rayaldee Oral Capsule Extended Release 30 MCG 3 *Hypophosphatasia (Hpp) Agents*** - Drugs For Menopause And Bone Loss Strensiq Subcutaneous Solution 18 MG/0.45ML, 28 3 PA MG/0.7ML, 40 MG/ML, 80 MG/0.8ML *Insulin-Like Growth Factor-1 Receptor Inhibitors(Igf-1R)*** - Drugs For Thyroid Tepezza Intravenous Solution Reconstituted 500 Tier 10 PA MG

Last Published: 09/17/2021 89 Drug Name Drug Tier Requirements / Limits *Insulin-Like Growth Factors (Somatomedins)*** - Hormones Increlex Subcutaneous Solution 40 MG/4ML 2 PA *Lhrh/Gnrh Agonist Analog Combinations*** - Drugs For Women Lupaneta Pack Combination Kit 11.25 & 5 MG, 3.75 Tier 10 PA & 5 MG *Lhrh/Gnrh Agonist Analog Pituitary Suppressants*** - Drugs For Women Fensolvi (6 Month) Subcutaneous Kit 45 MG (Ped) Tier 10 PA Lupron Depot-Ped (1-Month) Intramuscular Kit Tier 10 PA 11.25 MG, 15 MG, 7.5 MG Lupron Depot-Ped (3-Month) Intramuscular Kit Tier 10 PA 11.25 MG (Ped), 30 MG (Ped) Supprelin LA Subcutaneous Kit 50 MG Tier 10 PA Triptodur Intramuscular Suspension Tier 10 PA Reconstituted ER 22.5 MG *Lysosomal Acid Lipase (Lal) Deficiency - Agents*** - Drugs For Menopause And Bone Loss Kanuma Intravenous Solution 20 MG/10ML Tier 10 PA *Molybdenum Cofactor Deficiency (Mocd) - Agents*** - Drugs For Menopause And Bone Loss Nulibry Intravenous Solution Reconstituted 9.5 MG Tier 10 PA *Mucopolysaccharidosis I (Mps I) - Agents*** - Drugs For Menopause And Bone Loss Aldurazyme Intravenous Solution 2.9 MG/5ML Tier 10 PA *Mucopolysaccharidosis Ii (Mps Ii) - Agents*** - Drugs For Menopause And Bone Loss Elaprase Intravenous Solution 6 MG/3ML Tier 10 PA *Mucopolysaccharidosis Iv (Mps Iv) - Agents*** - Drugs For Menopause And Bone Loss Vimizim Intravenous Solution 5 MG/5ML Tier 10 PA *Mucopolysaccharidosis Vi (Mps Vi) - Agents*** - Drugs For Menopause And Bone Loss Naglazyme Intravenous Solution 1 MG/ML Tier 10 PA *Mucopolysaccharidosis Vii (Mps Vii) - Agents*** - Drugs For Menopause And Bone Loss Mepsevii Intravenous Solution 10 MG/5ML Tier 10 PA *Parathyroid Hormone And Derivatives*** - Drugs For Menopause And Bone Loss Natpara Subcutaneous Cartridge 100 MCG, 25 3 PA; QL MCG, 50 MCG, 75 MCG Teriparatide (Recombinant) Subcutaneous 3 PA Solution Pen-Injector 620 MCG/2.48ML Tymlos Subcutaneous Solution Pen-Injector 3120 2 PA MCG/1.56ML

Last Published: 09/17/2021 90 Drug Name Drug Tier Requirements / Limits *Phenylketonuria Treatment - Agents*** - Drugs For Menopause And Bone Loss Kuvan Oral Packet 100 MG, 500 MG 2 PA Kuvan Oral Tablet 100 MG 2 PA Palynziq Subcutaneous Solution Prefilled Syringe 3 PA 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML sapropterin dihydrochloride oral packet 100 mg, 500 1 PA mg sapropterin dihydrochloride oral tablet 100 mg 1 PA *Rank Ligand (Rankl) Inhibitors*** - Drugs For Menopause And Bone Loss Prolia Subcutaneous Solution Prefilled Syringe 60 Tier 10 PA MG/ML Xgeva Subcutaneous Solution 120 MG/1.7ML Tier 10 PA *Sclerostin Inhibitors*** - Drugs For Menopause And Bone Loss Evenity Subcutaneous Solution Prefilled Syringe Tier 10 PA 105 MG/1.17ML *Selective Estrogen Receptor Modulators (Serms)*** - Drugs For Menopause And Bone Loss Osphena Oral Tablet 60 MG 3 Female Only; QL raloxifene hcl oral tablet 60 mg 1 QL *Selective Vasopressin V2-Receptor Antagonists*** - Hormones Jynarque Oral Tablet Therapy Pack 15 MG, 30 & 15 3 PA MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG Samsca Oral Tablet 15 MG, 30 MG 3 PA; QL tolvaptan oral tablet 15 mg, 30 mg 1 PA; QL *Somatostatic Agents*** - Drugs For Growth Mycapssa Oral Capsule Delayed Release 20 MG 3 PA; QL octreotide acetate injection solution 100 mcg/ml, 1000 1 PA mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SandoSTATIN Injection Solution 100 MCG/ML, 50 Tier 10 PA MCG/ML, 500 MCG/ML SandoSTATIN LAR Depot Intramuscular Kit 10 MG, Tier 10 PA 20 MG, 30 MG Signifor LAR Intramuscular Suspension Reconstituted ER 10 MG, 20 MG, 30 MG, 40 MG, 60 Tier 10 PA MG Signifor Subcutaneous Solution 0.3 MG/ML, 0.6 3 PA MG/ML, 0.9 MG/ML Somatuline Depot Subcutaneous Solution 120 Tier 10 PA MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML *Tripeptidyl Peptidase 1 Deficiency Treatment - Agents*** - Drugs For Menopause And Bone Loss Brineura Kit 2 X 150 MG/5ML Tier 10 PA

Last Published: 09/17/2021 91 Drug Name Drug Tier Requirements / Limits *Urea Cycle Disorder - Agents*** - Drugs For Menopause And Bone Loss Buphenyl Oral Powder 3 GM/TSP 3 Buphenyl Oral Tablet 500 MG 3 Ravicti Oral Liquid 1.1 GM/ML 3 PA; QL sodium phenylbutyrate oral powder 3 gm/tsp 1 sodium phenylbutyrate oral tablet 500 mg 1 *Vasopressin*** - Hormones desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate spray nasal solution 0.01 % 1 Stimate Nasal Solution 1.5 MG/ML 2 *X-Linked Hypophosphatemia (Xlh) Treatment - Agents*** - Drugs For Menopause And Bone Loss Crysvita Subcutaneous Solution 10 MG/ML, 20 Tier 10 PA MG/ML, 30 MG/ML *Estrogens* - Hormones *Estrogen & Androgen*** - Drugs For Women Covaryx HS Oral Tablet 0.625-1.25 MG 1 Covaryx Oral Tablet 1.25-2.5 MG 1 EEMT HS Oral Tablet 0.625-1.25 MG 1 EEMT Oral Tablet 1.25-2.5 MG 1 est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 est estrogens-methyltest oral tablet 1.25-2.5 mg 1 *Estrogen & Progestin*** - Drugs For Women Amabelz Oral Tablet 0.5-0.1 MG, 1-0.5 MG 1 Angeliq Oral Tablet 0.25-0.5 MG, 0.5-1 MG 2 Climara Pro Transdermal Patch Weekly 0.045- 2 QL 0.015 MG/DAY CombiPatch Transdermal Patch Twice Weekly 3 QL 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1- 1 0.5 mg Jinteli Oral Tablet 1-5 MG-MCG 1 Mimvey Oral Tablet 1-0.5 MG 1 norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1 1-5 mg-mcg Prefest Oral Tablet 1/1-0.09 MG (15/15) 3 Premphase Oral Tablet 0.625-5 MG 2 Prempro Oral Tablet 0.3-1.5 MG, 0.45-1.5 MG, 2 0.625-2.5 MG, 0.625-5 MG

Last Published: 09/17/2021 92 Drug Name Drug Tier Requirements / Limits *Estrogen-Progestin-Gnrh Antagonist*** - Drugs For Woman Myfembree Oral Tablet 40-1-0.5 MG 3 QL Oriahnn Oral Capsule Therapy Pack 300-1-0.5 & 3 QL 300 MG *Estrogens*** - Drugs For Women Alora Transdermal Patch Twice Weekly 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 3 QL MG/24HR Divigel Transdermal Gel 0.25 MG/0.25GM, 0.5 3 QL MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM Divigel Transdermal Gel 1.25 MG/1.25GM 3 Elestrin Transdermal Gel 0.52 MG/0.87 GM (0.06%) 3 QL estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 1 QL mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 1 QL mg/24hr, 0.1 mg/24hr Estrogel Transdermal Gel 0.75 MG/1.25 GM (0.06%) 3 Evamist Transdermal Solution 1.53 MG/SPRAY 3 QL Menest Oral Tablet 0.3 MG, 0.625 MG, 1.25 MG 1 Menostar Transdermal Patch Weekly 14 3 QL MCG/24HR Premarin Oral Tablet 0.3 MG, 0.45 MG, 0.625 MG, 2 0.9 MG, 1.25 MG *Estrogen-Selective Estrogen Receptor Modulator Comb*** - Drugs For Women Female Only; Age Restriction Applies Duavee Oral Tablet 0.45-20 MG 3 (Max 74 Years) *Fluoroquinolones* - Drugs For Infections *Fluoroquinolones*** - Antibiotics Baxdela Oral Tablet 450 MG 3 Cipro Oral Suspension Reconstituted 250 MG/5ML 3 (5%), 500 MG/5ML (10%) hcl oral tablet 100 mg, 250 mg, 500 mg, 1 750 mg levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl oral tablet 400 mg 1 ofloxacin oral tablet 300 mg, 400 mg 1

Last Published: 09/17/2021 93 Drug Name Drug Tier Requirements / Limits *Gastrointestinal Agents - Misc.* - Drugs For The Stomach *Bile Acid Synthesis Disorder Agents*** - Drugs For The Stomach Cholbam Oral Capsule 250 MG, 50 MG 3 PA *Cic Agents - Guanylate Cyclase-C (Gc-C) Agonists*** - Drugs For Constipation Trulance Oral Tablet 3 MG 3 QL *Farnesoid X Receptor (Fxr) Agonists*** - Drugs For The Stomach Ocaliva Oral Tablet 10 MG, 5 MG 3 ST *Gallstone Solubilizing Agents*** - Drugs For The Stomach ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 *Gastrointestinal Antiallergy Agents*** - Drugs For The Stomach cromolyn sodium oral concentrate 100 mg/5ml 1 *Gastrointestinal Chloride Channel Activators*** - Drugs For Irritable Bowel Syndrome QL; Age Restriction Applies (Min 18 lubiprostone oral capsule 24 mcg, 8 mcg 1 Years) *Gastrointestinal Stimulants*** - Drugs For The Stomach metoclopramide hcl oral solution 10 mg/10ml, 5 1 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg 1 metoclopramide hcl oral tablet dispersible 10 mg 3 metoclopramide hcl oral tablet dispersible 5 mg 1 *Glucagon-Like Peptide-2 (Glp-2) Analogs*** - Drugs For The Stomach Gattex Subcutaneous Kit 5 MG 3 PA *Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists*** - Drugs For Constipation QL; Age Restriction Applies (Min 18 Linzess Oral Capsule 145 MCG, 290 MCG, 72 MCG 2 Years) *Ibs Agent - Mu-Opioid Receptor Agonists*** - Drugs For Irritable Bowel Syndrome Viberzi Oral Tablet 100 MG, 75 MG 2 QL *Ibs Agent - Selective 5-Ht3 Receptor Antagonists*** - Drugs For Irritable Bowel Syndrome Female Only; Age Restriction Applies alosetron hcl oral tablet 0.5 mg, 1 mg 1 (Min 18 Years) *Inflammatory Bowel Agents*** - Drugs For Inflammatory Bowel Disease balsalazide disodium oral capsule 750 mg 1 Last Published: 09/17/2021 94 Drug Name Drug Tier Requirements / Limits Dipentum Oral Capsule 250 MG 3 mesalamine er oral capsule extended release 24 hour 1 QL 0.375 gm mesalamine oral capsule delayed release 400 mg 1 QL mesalamine oral tablet delayed release 1.2 gm, 800 1 QL mg mesalamine rectal enema 4 gm 1 mesalamine rectal suppository 1000 mg 1 mesalamine-cleanser rectal kit 4 gm 1 Pentasa Oral Capsule Extended Release 250 MG, 2 QL 500 MG SfRowasa Rectal Enema 4 GM/60ML 3 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 *Integrin Receptor Antagonists*** - Drugs For Inflammatory Bowel Disease Entyvio Intravenous Solution Reconstituted 300 Tier 10 PA MG *Interleukin Antagonists*** - Drugs For Inflammatory Bowel Disease Stelara Intravenous Solution 130 MG/26ML Tier 10 PA *Intestinal Acidifiers*** - Drugs For The Stomach enulose oral solution 10 gm/15ml 1 generlac oral solution 10 gm/15ml 1 lactulose encephalopathy oral solution 10 gm/15ml 1 *Peripheral Opioid Receptor Antagonists*** - Drugs For The Stomach oral capsule 12 mg 1 Movantik Oral Tablet 12.5 MG, 25 MG 2 QL Relistor Oral Tablet 150 MG 3 QL Relistor Subcutaneous Solution 12 MG/0.6ML, 8 3 QL MG/0.4ML Symproic Oral Tablet 0.2 MG 3 *Phosphate Binder Agents*** - Drugs For The Stomach Auryxia Oral Tablet 1 GM 210 MG(Fe) 3 calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 Fosrenol Oral Packet 1000 MG, 750 MG 2 Phoslyra Oral Solution 667 MG/5ML 3 sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 1 Velphoro Oral Tablet Chewable 500 MG 3 QL

Last Published: 09/17/2021 95 Drug Name Drug Tier Requirements / Limits *Tryptophan Hydroxylase Inhibitors*** - Drugs For Diarrhea Xermelo Oral Tablet 250 MG 3 PA; QL *Tumor Necrosis Factor Alpha Blockers*** - Drugs For Inflammatory Bowel Disease Avsola Intravenous Solution Reconstituted 100 Tier 10 PA MG Inflectra Intravenous Solution Reconstituted 100 Tier 10 PA MG Remicade Intravenous Solution Reconstituted 100 Tier 10 PA MG Renflexis Intravenous Solution Reconstituted 100 Tier 10 PA MG *Genitourinary Agents - Miscellaneous* - Drugs For The Urinary System *5-Alpha Reductase Inhibitors*** - Drugs For The Prostate dutasteride oral capsule 0.5 mg 1 QL finasteride oral tablet 5 mg 1 Male Only; QL *Alpha 1-Adrenoceptor Antagonists*** - Drugs For The Prostate alfuzosin hcl er oral tablet extended release 24 hour 1 QL 10 mg Cardura XL Oral Tablet Extended Release 24 Hour 3 4 MG, 8 MG silodosin oral capsule 4 mg, 8 mg 1 QL tamsulosin hcl oral capsule 0.4 mg 1 *Citrates*** - Drugs For Infections cytra k crystals oral packet 3300-1002 mg 1 cytra-2 oral solution 500-334 mg/5ml 1 cytra-k oral solution 1100-334 mg/5ml 1 Oracit Oral Solution 490-640 MG/5ML 3 potassium citrate er oral tablet extended release 10 1 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 1 mg/5ml sod citrate-citric acid oral solution 500-334 mg/5ml 1 tricitrates oral solution 550-500-334 mg/5ml 1 *Cystinosis Agents*** - Drugs For The Urinary System Cystagon Oral Capsule 150 MG, 50 MG 2 PA Procysbi Oral Capsule Delayed Release 25 MG, 75 3 PA MG Procysbi Oral Packet 300 MG, 75 MG 3 PA

Last Published: 09/17/2021 96 Drug Name Drug Tier Requirements / Limits *Interstitial Cystitis Agents*** - Drugs For The Urinary System Elmiron Oral Capsule 100 MG 2 *Phosphates*** - Drugs For Infections K-Phos No 2 Oral Tablet 305-700 MG 3 *Prostatic Hypertrophy Agent Combinations*** - Drugs For The Prostate dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg 1 *Small Interfering Ribonucleic Acid Agents (Sirna)*** - Drugs For The Urinary System Oxlumo Subcutaneous Solution 94.5 MG/0.5ML Tier 10 PA *Urinary Analgesics*** - Drugs For Infections Phenazo Oral Tablet 200 MG 1 phenazopyridine hcl oral tablet 100 mg, 200 mg 1 *Urinary Stone Agents*** - Drugs For The Urinary System Lithostat Oral Tablet 250 MG 3 Thiola EC Oral Tablet Delayed Release 100 MG, 3 300 MG tiopronin oral tablet 100 mg 1 *Gout Agents* - Drugs For Pain And Fever *Gout Agent Combinations*** - Gout Drugs colchicine-probenecid oral tablet 0.5-500 mg 1 *Gout Agents*** - Gout Drugs allopurinol oral tablet 100 mg, 300 mg 1 colchicine oral capsule 0.6 mg 1 QL colchicine oral tablet 0.6 mg 1 QL febuxostat oral tablet 40 mg, 80 mg 1 QL Gloperba Oral Solution 0.6 MG/5ML 3 Krystexxa Intravenous Solution 8 MG/ML Tier 10 PA *Uricosurics*** - Gout Drugs probenecid oral tablet 500 mg 1 *Hematological Agents - Misc.* - Drugs For The Blood *Aminolevulinate Synthase 1-Directed Sirna*** - Drugs For The Blood Givlaari Subcutaneous Solution 189 MG/ML Tier 10 PA *Anti-Von Willebrand Factor Agents*** - Drugs For The Blood Cablivi Injection Kit 11 MG Tier 10 PA *Bradykinin B2 Receptor Antagonists*** - Drugs For The Blood Firazyr Subcutaneous Solution 30 MG/3ML Tier 10 PA icatibant acetate subcutaneous solution 30 mg/3ml Tier 10 PA

Last Published: 09/17/2021 97 Drug Name Drug Tier Requirements / Limits *C1 Inhibitors*** - Drugs For The Blood Berinert Intravenous Kit 500 UNIT Tier 10 PA Cinryze Intravenous Solution Reconstituted 500 Tier 10 PA UNIT Haegarda Subcutaneous Solution Reconstituted Tier 10 PA 2000 UNIT, 3000 UNIT Ruconest Intravenous Solution Reconstituted Tier 10 PA 2100 UNIT *Complement Inhibitors*** - Drugs For The Blood Empaveli Subcutaneous Solution 1080 MG/20ML Tier 10 PA Soliris Intravenous Solution 300 MG/30ML Tier 10 PA *Direct-Acting P2y12 Inhibitors*** - Drugs For The Blood Brilinta Oral Tablet 60 MG, 90 MG 2 QL *Hematorheologic Agents*** - Drugs For The Blood er oral tablet extended release 400 mg 1 *Phosphodiesterase Iii Inhibitors*** - Drugs For The Blood oral tablet 100 mg, 50 mg 1 *Plasma Kallikrein Inhibitors - Monoclonal Antibodies*** - Drugs For The Blood Takhzyro Subcutaneous Solution 300 MG/2ML Tier 10 PA *Plasma Kallikrein Inhibitors*** - Drugs For The Blood Kalbitor Subcutaneous Solution 10 MG/ML Tier 10 PA Orladeyo Oral Capsule 110 MG, 150 MG 3 PA *Platelet Aggregation Inhibitor Combinations*** - Drugs For The Blood aspirin- er oral capsule extended release 1 12 hour 25-200 mg Yosprala Oral Tablet Delayed Release 325-40 MG, 3 81-40 MG *Platelet Aggregation Inhibitors*** - Drugs For The Blood dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 *Protease-Activated Receptor-1 (Par-1) Antagonists*** - Drugs For The Blood Zontivity Oral Tablet 2.08 MG 3 QL *Quinazoline Agents*** - Drugs For The Blood hcl oral capsule 0.5 mg, 1 mg 1 *Spleen Tyrosine Kinase (Syk) Inhibitors*** - Drugs For The Blood Tavalisse Oral Tablet 100 MG, 150 MG 3 PA

Last Published: 09/17/2021 98 Drug Name Drug Tier Requirements / Limits *Thienopyridine Derivatives*** - Drugs For The Blood clopidogrel bisulfate oral tablet 300 mg, 75 mg 1 prasugrel hcl oral tablet 10 mg, 5 mg 1 QL *Hematopoietic Agents* - Drugs For Nutrition *Agents For Gaucher Disease*** - Drugs For Nutrition Cerdelga Oral Capsule 84 MG 3 PA; QL Cerezyme Intravenous Solution Reconstituted 400 Tier 10 PA UNIT Elelyso Intravenous Solution Reconstituted 200 Tier 10 PA UNIT miglustat oral capsule 100 mg 1 PA; QL Vpriv Intravenous Solution Reconstituted 400 Tier 10 PA UNIT Zavesca Oral Capsule 100 MG 3 PA; QL *Cobalamins*** - Drugs For Nutrition cyanocobalamin injection solution 1000 mcg/ml 1 *Cxcr4 Receptor Antagonist*** - Drugs For Nutrition Mozobil Subcutaneous Solution 24 MG/1.2ML Tier 10 PA *Cytotoxic Agents*** - Drugs For Nutrition Droxia Oral Capsule 200 MG, 300 MG, 400 MG 3 Siklos Oral Tablet 100 MG, 1000 MG 3 *Erythroid Maturation Agents*** - Drugs For Nutrition Reblozyl Subcutaneous Solution Reconstituted 25 Tier 10 PA MG, 75 MG *Folic Acid/Folates*** - Drugs For Nutrition folic acid oral tablet 1 mg 1 kp folic acid oral tablet 1 mg 1 *Granulocyte Colony-Stimulating Factors (G- Csf)*** - Drugs For Nutrition Fulphila Subcutaneous Solution Prefilled Syringe Tier 10 PA 6 MG/0.6ML Granix Subcutaneous Solution 300 MCG/ML, 480 Tier 10 MCG/1.6ML Granix Subcutaneous Solution Prefilled Syringe Tier 10 300 MCG/0.5ML, 480 MCG/0.8ML Neulasta Onpro Subcutaneous Prefilled Syringe Tier 10 Kit 6 MG/0.6ML Neulasta Subcutaneous Solution Prefilled Syringe Tier 10 6 MG/0.6ML Neupogen Injection Solution 300 MCG/ML, 480 Tier 10 PA MCG/1.6ML

Last Published: 09/17/2021 99 Drug Name Drug Tier Requirements / Limits Neupogen Injection Solution Prefilled Syringe 300 Tier 10 PA MCG/0.5ML, 480 MCG/0.8ML Nivestym Injection Solution 300 MCG/ML, 480 Tier 10 PA MCG/1.6ML Nivestym Injection Solution Prefilled Syringe 300 Tier 10 PA MCG/0.5ML, 480 MCG/0.8ML Nyvepria Subcutaneous Solution Prefilled Syringe Tier 10 PA 6 MG/0.6ML Udenyca Subcutaneous Solution Prefilled Syringe Tier 10 PA 6 MG/0.6ML Zarxio Injection Solution Prefilled Syringe 300 Tier 10 MCG/0.5ML, 480 MCG/0.8ML Ziextenzo Subcutaneous Solution Prefilled Tier 10 Syringe 6 MG/0.6ML *Granulocyte/Macrophage Colony-Stimulating Factor(Gm-Csf)*** - Drugs For Nutrition Leukine Injection Solution Reconstituted 250 MCG Tier 10 PA *Hemoglobin S (Hbs) Polymerization Inhibitors*** - Drugs For Nutrition Oxbryta Oral Tablet 500 MG 3 PA *Selectin Blockers*** - Drugs For Nutrition Adakveo Intravenous Solution 100 MG/10ML Tier 10 PA *Thrombopoietin (Tpo) Receptor Agonists*** - Drugs For Nutrition Doptelet Oral Tablet 20 MG 3 PA Mulpleta Oral Tablet 3 MG 3 PA Nplate Subcutaneous Solution Reconstituted 250 Tier 10 PA MCG, 500 MCG Promacta Oral Packet 12.5 MG, 25 MG 3 PA Promacta Oral Tablet 12.5 MG, 25 MG, 50 MG, 75 2 PA; QL MG *Hemostatics* - Drugs For The Blood *Hemostatics - Systemic*** - Drugs To Prevent Bleeding Amicar Oral Solution 0.25 GM/ML 3 aminocaproic acid oral solution 0.25 gm/ml 1 aminocaproic acid oral tablet 1000 mg, 500 mg 1 tranexamic acid oral tablet 650 mg 1 QL *Hemostatics - Topical*** - Drugs To Prevent Bleeding monsels ferric subsulfate external solution 2 *Hypnotics/Sedatives/Sleep Disorder Agents* - Drugs For The Nervous System *Barbiturate Hypnotics*** - Drugs For Insomnia phenobarbital oral elixir 20 mg/5ml 1

Last Published: 09/17/2021 100 Drug Name Drug Tier Requirements / Limits phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 1 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg *Benzodiazepine Hypnotics*** - Drugs For Seizures /Personality Disorder/Nerve Pain estazolam oral tablet 1 mg, 2 mg 1 flurazepam hcl oral capsule 15 mg, 30 mg 1 quazepam oral tablet 15 mg 1 oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 1 QL mg oral tablet 0.125 mg, 0.25 mg 1 *Hypnotics - Tricyclic Agents*** - Drugs For Insomnia Silenor Oral Tablet 3 MG, 6 MG 3 QL *Non-Benzodiazepine - Gaba-Receptor Modulators*** - Drugs For Insomnia Edluar Sublingual Tablet Sublingual 10 MG, 5 MG 3 QL oral tablet 1 mg, 2 mg, 3 mg 1 QL zaleplon oral capsule 10 mg, 5 mg 1 QL zolpidem tartrate er oral tablet extended release 12.5 1 QL mg, 6.25 mg zolpidem tartrate oral tablet 10 mg, 5 mg 1 QL zolpidem tartrate sublingual tablet sublingual 1.75 mg, 1 QL 3.5 mg *Orexin Receptor Antagonists*** - Drugs For Insomnia Belsomra Oral Tablet 10 MG, 15 MG, 20 MG, 5 MG 3 QL DayVigo Oral Tablet 10 MG, 5 MG 3 QL *Selective Melatonin Receptor Agonists*** - Drugs For Insomnia Hetlioz LQ Oral Suspension 4 MG/ML 3 PA; QL Hetlioz Oral Capsule 20 MG 3 PA; QL ramelteon oral tablet 8 mg 1 QL *Laxatives* - Drugs For The Stomach *Bowel Evacuant Combinations*** - Drugs To Prevent Constipation Clenpiq Oral Solution 10-3.5-12 MG-GM - 3 GM/160ML GaviLyte-C Oral Solution Reconstituted 240 GM 1 GaviLyte-N with Flavor Pack Oral Solution 1 Reconstituted 420 GM peg-3350/electrolytes oral solution reconstituted 236 1 gm peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 1 100 gm PEG-Prep Oral Kit 5-210 MG-GM 1 Plenvu Oral Solution Reconstituted 140 GM 3 Last Published: 09/17/2021 101 Drug Name Drug Tier Requirements / Limits Suprep Bowel Prep Kit Oral Solution 17.5-3.13-1.6 3 GM/177ML Sutab Oral Tablet 1479-225-188 MG 3 *Laxatives - Miscellaneous*** - Drugs To Prevent Constipation constulose oral solution 10 gm/15ml 1 Kristalose Oral Packet 10 GM, 20 GM 1 lactulose oral packet 10 gm 1 lactulose oral solution 10 gm/15ml, 20 gm/30ml 1 sorbitol oral solution 70 % 2 sorbitol rectal solution 70 % 2 *Lubricant Laxatives*** - Drugs To Prevent Constipation cvs mineral oil oral oil 2 eq mineral oil oral oil 2 goodsense mineral oil oral oil 2 hm mineral oil oral oil 2 mineral oil heavy oral oil 2 mineral oil oral oil 2 qc mineral oil heavy oral oil 2 ra mineral oil oral oil 2 sm mineral oil oral oil 2 *Saline Laxative Mixtures*** - Drugs To Prevent Constipation OsmoPrep Oral Tablet 1.102-0.398 GM 3 * Laxatives*** - Drugs To Prevent Constipation cascara sagrada oral fluid extract 1 gm/ml 3 *Macrolides* - Drugs For Infections *Azithromycin*** - Antibiotics azithromycin oral packet 1 gm 1 azithromycin oral suspension reconstituted 100 1 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 **** - Antibiotics clarithromycin er oral tablet extended release 24 hour 1 500 mg clarithromycin oral suspension reconstituted 125 1 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg 1 *Erythromycins*** - Antibiotics E.E.S. 400 Oral Tablet 400 MG 1 Ery-Tab Oral Tablet Delayed Release 250 MG, 333 1 MG, 500 MG

Last Published: 09/17/2021 102 Drug Name Drug Tier Requirements / Limits Erythrocin Stearate Oral Tablet 250 MG 1 erythromycin base oral capsule delayed release 1 particles 250 mg erythromycin base oral tablet 250 mg, 500 mg 1 erythromycin ethylsuccinate oral suspension 1 reconstituted 200 mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg 1 *Fidaxomicin*** - Antibiotics Dificid Oral Suspension Reconstituted 40 MG/ML 2 QL Dificid Oral Tablet 200 MG 2 QL *Medical Devices And Supplies* - Medical Supplies And Durable Medical Equipment *Applicators,Cotton Balls,Etc*** - Medical Supplies And Durable Medical Equipment Alcoh-Glove Contoured Wipe Pad 1 alcohol pads pad 70 % 1 alcohol prep pad 1 alcohol prep pad 70 % 1 alcohol swabs pad , 70 % 1 alcoh-wipe sheet 1 BD Swabs Single Use Butterfly Pad 1 CareTouch Alcohol Prep Pad 70 % 1 Curity Alcohol Preps Pad 70 % 1 Curity Alcohol Swabs Pad 1 cvs alcohol prep pads pad 70 % 1 cvs prep pad 70 % 1 Easy Touch Alcohol Prep Medium Pad 70 % 1 eql alcohol swabs pad 70 % 1 essentra wipes 9x9" sheet 70 % 1 Fifty50 Alcohol Prep Pad 70 % 1 global alcohol prep ease pad 70 % 1 gnp alcohol swabs pad 70 % 1 h-e-b incontrol alcohol pad 1 hm sterile alcohol prep pad 1 meijer alcohol swabs pad 70 % 1 Pharmacist Choice Alcohol Pad 1 pro comfort alcohol pad 70 % 1 qc alcohol swabs pad 70 % 1 ra alcohol swabs pad 70 % 1 reality swabs pad 1 ReliOn Alcohol Swabs Pad , 70 % 1 saps care alcohol prep pad 70 % 1 saps health alcohol prep pad 70 % 1

Last Published: 09/17/2021 103 Drug Name Drug Tier Requirements / Limits saps health care alcohol prep pad 70 % 1 sb alcohol prep pad 70 % 1 sm alcohol prep pad , 70 % 1 sure comfort alcohol prep pad 70 % 1 Sure-Prep Alcohol Prep Pad 70 % 1 true comfort alcohol prep pads pad 70 % 1 UltiCare Alcohol Swabs Pad , 70 % 1 ultilet alcohol swabs pad 1 ultra-care alcohol prep pads pad 70 % 1 Webcol Alcohol Prep Large Pad 70 % 1 Webcol Alcohol Prep Medium Pad 70 % 1 *Glucose Monitoring Test Supplies*** - Medical Supplies And Durable Medical Equipment Accu-Chek Aviva In Vitro Solution 2 Accu-Chek Compact Plus Control In Vitro Solution 2

Accu-Chek Guide Control In Vitro Liquid 2 Accu-Chek SmartView Control In Vitro Liquid 2 Accutrend Glucose Control In Vitro Solution 2 Advance Intuition Control In Vitro Liquid Normal 3 Advance Micro-Draw Control In Vitro Liquid 2 Advance Micro-Draw Normal In Vitro Liquid 2 Advocate Control Solution In Vitro Liquid High , 3 Low Advocate Redi-Code+ Control In Vitro Solution 3 High , Low AgaMatrix Control In Vitro Solution 2 AgaMatrix Control In Vitro Solution High , Normal 3 Assure 3 Control In Vitro Liquid 2 Assure 4 Control Level 1 & 2 In Vitro Liquid 2 Assure Dose Control In Vitro Solution Normal 3 Assure Dose Norm/High Control In Vitro Solution 2 Assure II Control In Vitro Liquid 2 Assure II Control Level 1 & 2 In Vitro Liquid 2 Assure Prism Control Level 1&2 In Vitro Solution 2 Assure Pro Control Level 1 & 2 In Vitro Liquid 2 CareSens Control A In Vitro Solution 2 Clever Choice Glucose Control In Vitro Liquid 3 High , Low Contour Next Control In Vitro Solution Low , 3 Normal control in vitro solution normal 3 Cool Control A In Vitro Solution 2

Last Published: 09/17/2021 104 Drug Name Drug Tier Requirements / Limits Cool Control B In Vitro Solution 2 Dexcom G4 Plat Ped Rcv/Share Device 2 ST Dexcom G4 Plat Ped Receiver Device 2 ST Dexcom G4 Platinum Rcv/Share Device 2 ST Dexcom G4 Platinum Receiver Device 2 ST Dexcom G4 Platinum Transmitter 2 ST Dexcom G4 Sensor 2 ST Dexcom G5 Mob/G4 Plat Sensor 2 ST Dexcom G5 Mobile Receiver Device 2 ST Dexcom G5 Mobile Transmitter 2 ST Dexcom G6 Receiver Device 2 ST Dexcom G6 Sensor 2 ST Dexcom G6 Transmitter 2 ST Diathrive Glucose Control Soln In Vitro Liquid 2 diatrue control level 1 in vitro solution low 3 diatrue control level 2 in vitro solution normal 3 diatrue control level 3 in vitro solution high 3 Duo-Care Control Solution In Vitro Liquid 2 easy plus ii control in vitro solution high , low 3 Easy Step Control In Vitro Solution High , Low , 3 Normal easy talk control in vitro solution high , low , normal 3 Easy Touch Control High & Low In Vitro Solution 2 easy trak control in vitro solution high , low , normal 3 EasyGluco Plus Level 1 In Vitro Solution 2 EasyMax 15 Level 2 Control In Vitro Solution 2 EasyMax Control In Vitro Solution Normal 3 element compact control 2 in vitro solution 2 element compact control 3 in vitro solution 2 Element Control In Vitro Liquid High , Low , 3 Normal Embrace Control In Vitro Solution Low 3 Embrace Evo Control Level 1 In Vitro Liquid Low 3 Embrace Glucose Control In Vitro Liquid High 3 Embrace Pro Glucose Control In Vitro Liquid 2 Embrace Talk Glucose Control In Vitro Solution 3 High , Low Evolution Control In Vitro Solution Normal 3 FORA Control In Vitro Solution High , Low , 3 Normal ForaCare GDH Control In Vitro Solution High , Low 3 , Normal

Last Published: 09/17/2021 105 Drug Name Drug Tier Requirements / Limits FortisCare Control In Vitro Solution High , Low , 3 Normal FreeStyle Control Solution In Vitro Liquid 2 FreeStyle Libre 14 Day Reader Device 2 ST FreeStyle Libre 14 Day Sensor 2 ST FreeStyle Libre Reader Device 2 ST ge100 control in vitro solution normal 3 Glucocard 01 Control In Vitro Liquid 2 Glucocard 01 Control In Vitro Solution Normal 3 Glucocard Expression Control In Vitro Solution 2 Glucocard Shine Control In Vitro Solution 2 Glucocard X-Sensor Control In Vitro Solution 3 Normal GlucoCom Control In Vitro Liquid High , Normal 3 glucose control in vitro solution 2 glucose control in vitro solution normal 3 GNP Easy Touch Cont High/Low In Vitro Solution 2 In Touch Glucose Control In Vitro Solution 2 Infinity Control In Vitro Solution Normal 3 Infinity Voice In Vitro Liquid Normal 3 Liberty Glucose Control In Vitro Liquid Normal 3 Liberty Glucose Control In Vitro Solution High , 3 Normal Liberty Glucose Control Mid In Vitro Solution 2 MediSense Glucose Ketone Contr In Vitro Liquid 2 Medisense Hi/Mid/Low Control In Vitro Liquid 2 Medisense High/Low Control In Vitro Liquid 2 Medisense Mid Control In Vitro Liquid 2 Microdot Control High/Low In Vitro Solution 2 MyGlucoHealth Control In Vitro Solution 2 Neutek 2Tek Control In Vitro Solution 2 Nova Max Plus Glu/Ket Control In Vitro Liquid 2 OneTouch Ultra Control In Vitro Solution 2 OneTouch Verio In Vitro Solution , High 2 PocketChem EZ Control In Vitro Solution 2 Precision Glucose Control In Vitro Liquid 2 Precision Glucose Control Soln In Vitro Solution 2 Precision Glucose Ketone Contr In Vitro Liquid 2 Precision Glucose/Ketone Contr In Vitro Liquid 2 Prodigy Control Solution In Vitro Solution High , 3 Low QuickTek Control Solution In Vitro Liquid 2 Quintet Control High/Normal In Vitro Solution 2

Last Published: 09/17/2021 106 Drug Name Drug Tier Requirements / Limits RefuAH Plus Glucose Control In Vitro Solution 2 Rightest GC300 Control In Vitro Liquid High , 3 Normal Smartest Control Medium In Vitro Solution 2 Solartek Glucose Control In Vitro Liquid 2 Solus V2 Control In Vitro Solution High , Low 3 supreme ii high/low control in vitro liquid 2 SureStep Glucose Control In Vitro Solution 2 SureStep Pro High Glucose In Vitro Liquid 3 SureStep Pro Low Glucose In Vitro Liquid 3 SureStep Pro Normal Glucose In Vitro Liquid 3 Tai Doc Control In Vitro Solution Normal 3 Unistrip Control In Vitro Solution High , Low 3 verasens glucose control in vitro liquid 2 *Insulin Administration Supplies*** - Medical Supplies And Durable Medical Equipment OmniPod 5 Pack 2 ST OmniPod Dash 5 Pack Pods 2 ST OmniPod Dash System Kit 2 ST OmniPod Starter Kit 2 ST *Peak Flow Meters*** - Medical Supplies And Durable Medical Equipment Aerogear Action Asthma Kit Kit 3 Airzone Peak Flow Meter Device 3 Assess Peak Flow Meter Device 3 lung perform peak flow meter device 3 Microlife Digital Peak Flow Device 3 Mini Wright Peak Flow Meter Device 3 Peak Air Peak Flow Meter Device 3 peak flow meter universal rang device 3 Personal Best Full Range Device 3 Piko 1 Device 3 Pocket Peak Flow Meter Device 3 Pocketpeak Peak Flow Meter Device 3 TruZone Peak Flow Meter Device 3 *Spacer/Aerosol-Holding Chambers & Supplies*** - Medical Supplies And Durable Medical Equipment AeroChamber Mini Chamber Device 2 AeroChamber MV 2 AeroChamber Plus Flo-Vu 2 AeroChamber Plus Flo-Vu Large 2 AeroChamber Plus Flo-Vu Medium 2 AeroChamber Plus Flo-Vu Small 2

Last Published: 09/17/2021 107 Drug Name Drug Tier Requirements / Limits AeroChamber Plus Flo-Vu w/Mask 2 AeroChamber Plus Flow VU 2 AeroChamber w/FLOWSIGnal 2 AeroChamber Z-Stat Plus 2 AeroChamber Z-Stat Plus Chambr 2 AeroChamber Z-Stat Plus/Large 2 AeroChamber Z-Stat Plus/Medium 2 AeroChamber Z-Stat Plus/Small 2 AeroVent Plus Device 2 breathe ease large device 2 breathe ease medium device 2 breathe ease small device 2 Clever Choice Holding Chamber Device 2 Compact Space Chamber Device 2 Compact Space Chamber/Lg Mask Device 2 Compact Space Chamber/Med Mask Device 2 Compact Space Chamber/Sm Mask Device 2 EasiVent 2 EasiVent Mask Large 2 EasiVent Mask Medium 2 EasiVent Mask Small 2 Flexichamber Adult Mask/Small 2 Flexichamber Child Mask/Large 2 Flexichamber Child Mask/Small 2 Flexichamber Device 2 InspiraChamber/Large Device 2 InspiraChamber/Medium Device 2 InspiraChamber/Mouthpiece Device 2 InspiraChamber/Small Device 2 Inspirease 2 OptiChamber Diamond 2 Pocket Chamber Device 2 Pocket Spacer Device 2 pro comfort spacer adult 2 pro comfort spacer child 2 RiteFlo Device 2 Vortex Valved Holding Chamber Device 2 *Migraine Products* - Drugs For The Nervous System *Calcitonin Gene-Related Peptide Receptor Antag (Cgrp)*** - Drugs For Migraine Headaches Nurtec Oral Tablet Dispersible 75 MG 3 PA; QL

Last Published: 09/17/2021 108 Drug Name Drug Tier Requirements / Limits Ubrelvy Oral Tablet 100 MG, 50 MG 3 PA; QL *Cgrp Receptor Antagonists - Monocolonal Antibodies*** - Drugs For Migraine Headaches Aimovig Subcutaneous Solution Auto-Injector 140 2 PA MG/ML, 70 MG/ML Ajovy Subcutaneous Solution Auto-Injector 225 2 PA MG/1.5ML Ajovy Subcutaneous Solution Prefilled Syringe 2 PA 225 MG/1.5ML Emgality (300 MG Dose) Subcutaneous Solution 2 PA Prefilled Syringe 100 MG/ML Emgality Subcutaneous Solution Auto-Injector 120 2 PA MG/ML Emgality Subcutaneous Solution Prefilled Syringe 2 PA 120 MG/ML Vyepti Intravenous Solution 100 MG/ML Tier 10 PA *Ergot Combinations*** - Drugs For Migraine Headaches -caffeine oral tablet 1-100 mg 1 Migergot Rectal Suppository 2-100 MG 1 *Migraine Products - Nsaids*** - Drugs For Migraine Headaches Cambia Oral Packet 50 MG 3 QL *Migraine Products*** - Drugs For Migraine Headaches mesylate injection solution 1 mg/ml 1 dihydroergotamine mesylate nasal solution 4 mg/ml 1 QL Ergomar Sublingual Tablet Sublingual 2 MG 3 *Selective Serotonin Agonists 5-Ht(1)*** - Drugs For Migraine Headaches almotriptan malate oral tablet 12.5 mg, 6.25 mg 1 QL eletriptan hydrobromide oral tablet 20 mg, 40 mg 1 QL frovatriptan succinate oral tablet 2.5 mg 1 QL naratriptan hcl oral tablet 1 mg, 2.5 mg 1 QL Onzetra Xsail Nasal Exhaler Powder 11 3 MG/NOSEPC Relpax Oral Tablet 40 MG 3 QL rizatriptan benzoate oral tablet 10 mg, 5 mg 1 QL rizatriptan benzoate oral tablet dispersible 10 mg, 5 1 QL mg sumatriptan nasal solution 20 mg/act, 5 mg/act 1 QL sumatriptan succinate oral tablet 100 mg, 25 mg, 50 1 QL mg sumatriptan succinate refill subcutaneous solution 1 QL cartridge 4 mg/0.5ml, 6 mg/0.5ml

Last Published: 09/17/2021 109 Drug Name Drug Tier Requirements / Limits sumatriptan succinate subcutaneous solution 6 1 QL mg/0.5ml sumatriptan succinate subcutaneous solution auto- 1 QL injector 4 mg/0.5ml, 6 mg/0.5ml Zembrace SymTouch Subcutaneous Solution 3 Auto-Injector 3 MG/0.5ML zolmitriptan nasal solution 2.5 mg, 5 mg 1 QL zolmitriptan oral tablet 2.5 mg, 5 mg 1 QL zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 1 QL *Selective Serotonin Agonists 5-Ht(1F)*** - Drugs For Migraine Headaches Reyvow Oral Tablet 100 MG, 50 MG 3 PA; QL *Minerals & Electrolytes* - Drugs For Nutrition *Calcium Combinations*** - Drugs For Nutrition calcium-folic acid plus d oral wafer 1342-1 mg 3 MagneBind 400 Oral Tablet 80-115 MG 3 *Fluoride Combinations*** - Drugs For Nutrition Floriva Oral Liquid 0.25-400 MG-UNIT/ML 3 *Iodine Products*** - Drugs For Nutrition iodine strong oral solution 5 % 1 *Phosphate*** - Drugs For Nutrition K-Phos Oral Tablet 500 MG 3 Phospha 250 Neutral Oral Tablet 155-852-130 MG 1 phosphorous oral tablet 155-852-130 mg 1 Phospho-Trin 250 Neutral Oral Tablet 155-852-130 1 MG virt-phos 250 neutral oral tablet 155-852-130 mg 1 *Potassium Combinations*** - Drugs For Nutrition Effer-K Oral Tablet Effervescent 10 MEQ, 20 MEQ 3 *Potassium*** - Drugs For Nutrition Effer-K Oral Tablet Effervescent 25 MEQ 1 Klor-Con 10 Oral Tablet Extended Release 10 MEQ 1 Klor-Con M10 Oral Tablet Extended Release 10 1 MEQ Klor-Con M15 Oral Tablet Extended Release 15 1 MEQ Klor-Con M20 Oral Tablet Extended Release 20 1 MEQ Klor-Con Oral Packet 20 MEQ 1 Klor-Con Oral Tablet Extended Release 8 MEQ 1 Klor-Con/EF Oral Tablet Effervescent 25 MEQ 1 K-Prime Oral Tablet Effervescent 25 MEQ 1 potassium chloride crys er oral tablet extended 1 release 10 meq, 20 meq

Last Published: 09/17/2021 110 Drug Name Drug Tier Requirements / Limits potassium chloride er oral capsule extended release 1 10 meq, 8 meq potassium chloride er oral tablet extended release 10 1 meq, 8 meq potassium chloride oral packet 20 meq 1 potassium chloride oral solution 20 meq/15ml (10%), 1 40 meq/15ml (20%) *Zinc*** - Drugs For Nutrition Galzin Oral Capsule 25 MG, 50 MG 3 *Miscellaneous Therapeutic Classes* - Vitamins And Minerals *Antileprotics*** - Vitamins And Minerals Thalomid Oral Capsule 100 MG, 150 MG, 200 MG, 3 PA; QL 50 MG *B-Lymphocyte Stimulator (Blys)-Specific Inhibitors*** - Vitamins And Minerals Benlysta Intravenous Solution Reconstituted 120 Tier 10 PA; QL MG, 400 MG Benlysta Subcutaneous Solution Auto-Injector 200 3 PA; QL MG/ML Benlysta Subcutaneous Solution Prefilled Syringe 3 PA; QL 200 MG/ML *Chelating Agents*** - Vitamins And Minerals penicillamine oral capsule 250 mg 1 penicillamine oral tablet 250 mg 1 Syprine Oral Capsule 250 MG 3 trientine hcl oral capsule 250 mg 1 *Cyclosporine Analogs*** - Vitamins And Minerals cyclosporine modified oral capsule 100 mg, 25 mg, 50 1 mg cyclosporine modified oral solution 100 mg/ml 1 cyclosporine oral capsule 100 mg, 25 mg 1 Gengraf Oral Capsule 100 MG, 25 MG 1 Gengraf Oral Solution 100 MG/ML 1 Lupkynis Oral Capsule 7.9 MG 3 PA Neoral Oral Capsule 100 MG, 25 MG 3 Neoral Oral Solution 100 MG/ML 3 SandIMMUNE Oral Capsule 100 MG, 25 MG 3 SandIMMUNE Oral Solution 100 MG/ML 3 *Farnesyltransferase Inhibitors*** - Vitamins And Minerals Zokinvy Oral Capsule 50 MG, 75 MG 3 PA

Last Published: 09/17/2021 111 Drug Name Drug Tier Requirements / Limits *Immunomodulators For Myelodysplastic Syndromes*** - Vitamins And Minerals Revlimid Oral Capsule 10 MG, 15 MG, 2.5 MG, 20 2 PA; QL MG, 25 MG, 5 MG *Inosine Monophosphate Dehydrogenase Inhibitors*** - Vitamins And Minerals mycophenolate mofetil oral capsule 250 mg 1 mycophenolate mofetil oral suspension reconstituted 1 200 mg/ml mycophenolate mofetil oral tablet 500 mg 1 mycophenolate sodium oral tablet delayed release 1 180 mg, 360 mg *Interleukin-6 (Il-6) Antagonists*** - Vitamins And Minerals Sylvant Intravenous Solution Reconstituted 100 Tier 10 PA MG, 400 MG *Macrolide Immunosuppressants*** - Vitamins And Minerals Astagraf XL Oral Capsule Extended Release 24 3 Hour 0.5 MG, 1 MG, 5 MG Envarsus XR Oral Tablet Extended Release 24 3 Hour 0.75 MG, 1 MG, 4 MG everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 1 Prograf Oral Capsule 0.5 MG, 1 MG, 5 MG 3 Age Restriction Applies (Max 12 Prograf Oral Packet 0.2 MG, 1 MG 3 Years) Rapamune Oral Solution 1 MG/ML 3 sirolimus oral solution 1 mg/ml 1 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 Zortress Oral Tablet 0.25 MG, 0.5 MG, 0.75 MG, 1 3 MG *Monoclonal Antibodies*** - Vitamins And Minerals Enspryng Subcutaneous Solution Prefilled 3 PA Syringe 120 MG/ML Gamifant Intravenous Solution 10 MG/2ML, 100 Tier 10 PA MG/20ML, 50 MG/10ML Uplizna Intravenous Solution 100 MG/10ML Tier 10 PA *Potassium Removing Agents*** - Vitamins And Minerals Lokelma Oral Packet 10 GM, 5 GM 3 sodium polystyrene sulfonate oral powder 1 SPS Oral Suspension 15 GM/60ML 1 Veltassa Oral Packet 16.8 GM, 25.2 GM, 8.4 GM 3 *Purine Analogs*** - Vitamins And Minerals Azasan Oral Tablet 100 MG, 75 MG 1

Last Published: 09/17/2021 112 Drug Name Drug Tier Requirements / Limits azathioprine oral tablet 50 mg 1 *Type I Interferon (Ifn) Receptor Antagonists*** - Vitamins And Minerals Saphnelo Intravenous Solution 300 MG/2ML Tier 10 PA *Mouth/Throat/Dental Agents* - Drugs For The Mouth And Throat *Anesthetics Topical Oral*** - Drugs For The Mouth And Throat lidocaine hcl mouth/throat solution 4 % 1 *Anti-Infectives - Throat*** - Drugs For The Mouth And Throat clotrimazole mouth/throat troche 10 mg 1 nystatin mouth/throat suspension 100000 unit/ml 1 Oravig Buccal Tablet 50 MG 3 *Antiseptic Combinations - Mouth/Throat*** - Drugs For The Mouth And Throat Debacterol Mouth/Throat Solution 30-50 % 3 *Antiseptics - Mouth/Throat*** - Drugs For The Mouth And Throat chlorhexidine gluconate mouth/throat solution 0.12 % 1 Paroex Mouth/Throat Solution 0.12 % 1 Periogard Mouth/Throat Solution 0.12 % 1 *Protectants - Mouth/Throat*** - Drugs For The Mouth And Throat Gelclair Mouth/Throat Gel 2 Orafate Mouth/Throat Paste 10 % 3 ProThelial Mouth/Throat Paste 10 % 3 *Saliva Stimulants*** - Drugs For The Mouth And Throat cevimeline hcl oral capsule 30 mg 1 pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 *Steroids - Mouth/Throat/Dental*** - Drugs For The Mouth And Throat Oralone Mouth/Throat Paste 0.1 % 1 triamcinolone acetonide mouth/throat paste 0.1 % 1 *Multivitamins* - Drugs For Nutrition *Prenatal Mv & Min W/Fe-Fa*** - Drugs For Nutrition Atabex EC Oral Tablet Delayed Release 29-1 MG 3 Atabex OB Oral Tablet 29-1 MG 3 CitraNatal Bloom Oral Tablet 90-1 MG 3 CitraNatal Rx Oral Tablet 27-1 MG 3 c-nate dha oral capsule 28-1-200 mg 3 Co-Natal FA Oral Tablet 3 Concept DHA Oral Capsule 53.5-38-1 MG 3 Last Published: 09/17/2021 113 Drug Name Drug Tier Requirements / Limits Concept OB Oral Capsule 130-92.4-1 MG 2 Duet DHA 400 Oral 25-1 & 400 MG 3 Duet DHA Balanced Oral 25-1 & 267 MG 3 EnBrace HR Oral Capsule 3 m-natal plus oral tablet 27-1 mg 3 Mynatal Oral Capsule 3 mynatal plus oral tablet 3 mynatal-z oral tablet 3 NataChew Oral Tablet Chewable 28-1 MG 3 Natalvit Oral Tablet 3 NeoNatal Plus Oral Tablet 27-1 MG 3 Nestabs DHA Oral 32-1 MG 3 Nestabs Oral Tablet 32-1 MG 3 Niva-Plus Oral Tablet 27-1 MG 3 OB Complete One Oral Capsule 50-1-476 MG 3 OB Complete Oral Tablet 50-1.25 MG 3 OB Complete Petite Oral Capsule 35-5-1-200 MG 3 OB Complete Premier Oral Tablet 30-20-1 MG 3 OB Complete/DHA Oral Capsule 30-10-1-200 MG 3 Obstetrix DHA Oral 29-1 & 387 MG 3 Obstetrix EC Oral Tablet 29-1 MG 3 Obtrex Oral Tablet 3 O-Cal Prenatal Oral Tablet 3 pnv prenatal plus multivitamin oral tablet 27-1 mg 3 pnv tabs 29-1 oral tablet 29-1 mg 3 pnv-omega oral capsule 28-0.6-0.4-340 mg 3 pnv-select oral tablet 27-0.6-0.4 mg 1 prena1 pearl oral capsule extended release 30-1.4- 3 200 mg prenatal 19 oral tablet 1 prenatal 19 oral tablet chewable 1 prenatal 19 oral tablet chewable 29-1 mg 3 prenatal oral tablet 27-1 mg 3 prenatal plus iron oral tablet 29-1 mg 3 prenatal vitamin plus low iron oral tablet 27-1 mg 3 Prenatal-U Oral Capsule 106.5-1 MG 3 Prenate Elite Oral Tablet 20-0.6-0.4 MG 3 preplus oral tablet 27-1 mg 3 pretab oral tablet 29-1 mg 3 PrimaCare Oral Capsule 30-1-470 MG 3 Provida OB Oral Capsule 20-20-1.25 MG 3 relnate dha oral capsule 28-1-200 mg 3

Last Published: 09/17/2021 114 Drug Name Drug Tier Requirements / Limits Select-OB Oral Tablet Chewable 29-0.6-0.4 MG, 29- 3 1 MG thrivite rx oral tablet 29-1 mg 3 TriCare Oral Tablet 3 TriCare Prenatal DHA ONE Oral Capsule 27-1-500 3 MG Vinate Care Oral Tablet Chewable 40-1 MG 1 Vinate II Oral Tablet 29-1 MG 3 Vinate One Oral Tablet 60-1 MG 3 virt-c dha oral capsule 53.5-38-1 mg 3 virt-nate dha oral capsule 28-1-200 mg 3 virt-pn plus oral capsule 28-0.6-0.4-340 mg 3 Vitafol-OB Oral Tablet 3 VitaPearl Oral Capsule Extended Release 30-1.4- 3 200 MG Viva DHA Oral Capsule 28-1-200 MG 3 *Prenatal Mv & Min W/Fe-Fa-Dha*** - Drugs For Nutrition CitraNatal 90 DHA Oral 90-1 & 300 MG 3 CitraNatal Assure Oral 35-1 & 300 MG 3 CitraNatal Bloom DHA Oral 90-1 & 300 MG 3 CitraNatal DHA Oral 27-1 & 250 MG 3 CitraNatal Harmony Oral Capsule 27-1-260 MG 3 Nestabs One Oral Capsule 38-1-225 MG 3 Obstetrix One Oral Capsule 38-1-225 MG 3 pnv-dha oral capsule 27-0.6-0.4-300 mg 1 pnv-dha+docusate oral capsule 27-1.25-300 mg 3 prena 1 true oral 30-1.4 & 300 mg 3 prenaissance oral capsule 29-1.25-325 mg 3 prenaissance plus oral capsule 28-1-250 mg 3 Prenate DHA Oral Capsule 18-0.6-0.4-300 MG 3 Prenate Enhance Oral Capsule 28-0.6-0.4-400 MG 3 Prenate Essential Oral Capsule 18-0.6-0.4-300 MG 3 Prenate Mini Oral Capsule 18-0.6-0.4-350 MG 3 Prenate Pixie Oral Capsule 10-0.6-0.4-200 MG 3 Prenate Restore Oral Capsule 27-0.6-0.4-400 MG 3 Select-OB+DHA Oral 29-1 & 250 MG 3 Taron-Prex Oral Capsule 30-1.2-265 MG 3 tristart dha oral capsule 31-0.6-0.4-200 mg 3 virt-pn dha oral capsule 27-0.6-0.4-300 mg 3 Vitafol Ultra Oral Capsule 29-0.6-0.4-200 MG 3 Vitafol-OB+DHA Oral 65-1 & 250 MG 3 Vitafol-One Oral Capsule 29-1-200 MG 3

Last Published: 09/17/2021 115 Drug Name Drug Tier Requirements / Limits VitaTrue Oral 30-1.4 & 300 MG 3 *Prenatal Mv & Minerals W/Fa Without Iron*** - Drugs For Nutrition Prenate Oral Tablet Chewable 0.6-0.4 MG 3 *Prenatal Vitamins*** - Drugs For Nutrition prena1 oral tablet chewable 1.4 mg 3 VitaMedMD RediChew Rx Oral Tablet Chewable 1.4 3 MG *Musculoskeletal Therapy Agents* - Drugs For Muscles, Ligaments, Tendons, And Bones *Central Muscle Relaxants*** - Drugs For Muscles, Ligaments, Tendons, And Bones baclofen oral tablet 10 mg, 20 mg 1 carisoprodol oral tablet 250 mg, 350 mg 1 QL chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine hcl er oral capsule extended release 1 24 hour 15 mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg 1 Lorzone Oral Tablet 375 MG, 750 MG 1 metaxalone oral tablet 400 mg, 800 mg 1 methocarbamol oral tablet 500 mg, 750 mg 1 orphenadrine citrate er oral tablet extended release 12 1 hour 100 mg Ozobax Oral Solution 5 MG/5ML 3 tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg 1 tizanidine hcl oral tablet 2 mg, 4 mg 1 *Direct Muscle Relaxants*** - Drugs For Muscles, Ligaments, Tendons, And Bones dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1 *Muscle Relaxant Combinations*** - Drugs For Muscles, Ligaments, Tendons, And Bones carisoprodol-aspirin-codeine oral tablet 200-325-16 QL; Age Restriction Applies (Min 12 1 mg Years) *Viscosupplements*** - Drugs For Muscles, Ligaments, Tendons, And Bones Durolane Intra-Articular Prefilled Syringe 60 Tier 10 PA MG/3ML Euflexxa Intra-Articular Solution Prefilled Syringe Tier 10 PA 20 MG/2ML Gel-One Intra-Articular Prefilled Syringe 30 Tier 10 PA MG/3ML Gelsyn-3 Intra-Articular Solution Prefilled Syringe Tier 10 PA 16.8 MG/2ML GenVisc 850 Intra-Articular Solution Prefilled Tier 10 PA Syringe 25 MG/2.5ML Hyalgan Intra-Articular Solution 20 MG/2ML Tier 10 PA

Last Published: 09/17/2021 116 Drug Name Drug Tier Requirements / Limits Hyalgan Intra-Articular Solution Prefilled Syringe Tier 10 PA 20 MG/2ML Hymovis Intra-Articular Solution Prefilled Syringe Tier 10 PA 24 MG/3ML Monovisc Intra-Articular Solution Prefilled Syringe Tier 10 88 MG/4ML OrthoVisc Intra-Articular Solution Prefilled Syringe Tier 10 30 MG/2ML Supartz FX Intra-Articular Solution Prefilled Tier 10 PA Syringe 25 MG/2.5ML Synvisc Intra-Articular Solution Prefilled Syringe Tier 10 16 MG/2ML Synvisc One Intra-Articular Solution Prefilled Tier 10 Syringe 48 MG/6ML Triluron Intra-Articular Solution Prefilled Syringe Tier 10 PA 20 MG/2ML TriVisc Intra-Articular Solution Prefilled Syringe 25 Tier 10 PA MG/2.5ML Visco-3 Intra-Articular Solution Prefilled Syringe Tier 10 PA 25 MG/2.5ML *Nasal Agents - Systemic And Topical* - Drugs For The Nose *Antihistamine-Steroid*** - Allergy azelastine-fluticasone nasal suspension 137-50 1 QL mcg/act *Nasal Anticholinergics*** - Allergy ipratropium bromide nasal solution 0.03 %, 0.06 % 1 QL *Nasal Antihistamines*** - Allergy azelastine hcl nasal solution 0.1 %, 0.15 %, 137 1 QL mcg/spray olopatadine hcl nasal solution 0.6 % 1 *Nasal Steroids*** - Allergy Beconase AQ Nasal Suspension 42 MCG/SPRAY 3 QL flunisolide nasal solution 25 mcg/act (0.025%) 1 fluticasone propionate nasal suspension 50 mcg/act 1 mometasone furoate nasal suspension 50 mcg/act 1 QL Omnaris Nasal Suspension 50 MCG/ACT 3 QL Propel Mini Nasal Implant 370 MCG Tier 10 PA Propel Nasal Implant 370 MCG Tier 10 PA Qnasl Childrens Nasal Aerosol Solution 40 3 QL MCG/ACT Qnasl Nasal Aerosol Solution 80 MCG/ACT 3 QL Sinuva Nasal Implant 1350 MCG Tier 10 PA QL; Age Restriction Applies (Min 12 Zetonna Nasal Aerosol Solution 37 MCG/ACT 3 Years)

Last Published: 09/17/2021 117 Drug Name Drug Tier Requirements / Limits *Neuromuscular Agents* - Drugs For Nerves And Muscles *Benzathiazoles*** - Drugs For Nerves And Muscles riluzole oral tablet 50 mg 1 Tiglutik Oral Suspension 50 MG/10ML 3 *Muscular Dystrophy Agents*** - Drugs For Nerves And Muscles amondys 45 intravenous solution 100 mg/2ml Not Covered Exondys 51 Intravenous Solution 100 MG/2ML, 500 Not Covered MG/10ML Viltepso Intravenous Solution 250 MG/5ML Not Covered Vyondys 53 Intravenous Solution 100 MG/2ML Not Covered *Neuromuscular Blocking Agent - Neurotoxins*** - Drugs For Nerves And Muscles Botox Injection Solution Reconstituted 100 UNIT, Tier 10 PA 200 UNIT Dysport Intramuscular Solution Reconstituted 300 Tier 10 PA UNIT, 500 UNIT Myobloc Intramuscular Solution 10000 UNIT/2ML, Tier 10 PA 2500 UNIT/0.5ML, 5000 UNIT/ML Xeomin Intramuscular Solution Reconstituted 100 Tier 10 PA UNIT, 200 UNIT, 50 UNIT *Spinal Muscular Atrophy-Antisense Oligonucleotides*** - Drugs For Nerves And Muscles Spinraza Intrathecal Solution 12 MG/5ML Tier 10 PA *Spinal Muscular Atrophy-Gene Therapy Agents*** - Drugs For Nerves And Muscles Zolgensma 10.1-10.5 kg Intravenous Kit 7x8.3 ML Tier 10 PA Zolgensma 10.6-11.0 kg Intravenous Kit 2x5.5ML & Tier 10 PA 6x8.3ML Zolgensma 11.1-11.5 kg Intravenous Kit 1x5.5ML & Tier 10 PA 7x8.3ML Zolgensma 11.6-12.0 kg Intravenous Kit 8x8.3 ML Tier 10 PA Zolgensma 12.1-12.5 kg Intravenous Kit 2x5.5ML & Tier 10 PA 7x8.3ML Zolgensma 12.6-13.0 kg Intravenous Kit 1x5.5ML & Tier 10 PA 8x8.3ML Zolgensma 13.1-13.5 kg Intravenous Kit 9x8.3 ML Tier 10 PA Zolgensma 2.6-3.0 kg Intravenous Kit 2x8.3 ML Tier 10 PA Zolgensma 3.1-3.5 kg Intravenous Kit 2x5.5ML & Tier 10 PA 1x8.3ML Zolgensma 3.6-4.0 kg Intravenous Kit 1x5.5ML & Tier 10 PA 2x8.3ML Zolgensma 4.1-4.5 kg Intravenous Kit 3x8.3 ML Tier 10 PA

Last Published: 09/17/2021 118 Drug Name Drug Tier Requirements / Limits Zolgensma 4.6-5.0 kg Intravenous Kit 2x5.5ML & Tier 10 PA 2x8.3ML Zolgensma 5.1-5.5 kg Intravenous Kit 1x5.5ML & Tier 10 PA 3x8.3ML Zolgensma 5.6-6.0 kg Intravenous Kit 4x8.3 ML Tier 10 PA Zolgensma 6.1-6.5 kg Intravenous Kit 2x5.5ML & Tier 10 PA 3x8.3ML Zolgensma 6.6-7.0 kg Intravenous Kit 1x5.5ML & Tier 10 PA 4x8.3ML Zolgensma 7.1-7.5 kg Intravenous Kit 5x8.3 ML Tier 10 PA Zolgensma 7.6-8.0 kg Intravenous Kit 2x5.5ML & Tier 10 PA 4x8.3ML Zolgensma 8.1-8.5 kg Intravenous Kit 1x5.5ML & Tier 10 PA 5x8.3ML Zolgensma 8.6-9.0 kg Intravenous Kit 6x8.3 ML Tier 10 PA Zolgensma 9.1-9.5 kg Intravenous Kit 2x5.5ML & Tier 10 PA 5x8.3ML Zolgensma 9.6-10.0 kg Intravenous Kit 1x5.5ML & Tier 10 PA 6x8.3ML *Spinal Muscular Atrophy-Smn2 Splicing Modifiers*** - Drugs For Nerves And Muscles Evrysdi Oral Solution Reconstituted 0.75 MG/ML 3 PA; QL *Nutrients* - Drugs For Nutrition *Lipids*** - Drugs For Nutrition MCT Oil Oral Oil 3 *Ophthalmic Agents* - Drugs For The Eye *Alpha Adrenergic Agonist & Carbonic Anhydrase Inhib Comb*** - Drugs For Glaucoma Simbrinza Ophthalmic Suspension 1-0.2 % 3 *Artificial Tear Inserts*** - Drugs For The Eye Lacrisert Ophthalmic Insert 5 MG 3 *Beta-Blockers - Ophthalmic Combinations*** - Drugs For Glaucoma Combigan Ophthalmic Solution 0.2-0.5 % 3 dorzolamide hcl-timolol mal ophthalmic solution 22.3- 1 6.8 mg/ml *Beta-Blockers - Ophthalmic*** - Drugs For Glaucoma betaxolol hcl ophthalmic solution 0.5 % 1 Betimol Ophthalmic Solution 0.25 %, 0.5 % 3 Betoptic-S Ophthalmic Suspension 0.25 % 3 carteolol hcl ophthalmic solution 1 % 1 levobunolol hcl ophthalmic solution 0.5 % 1 timolol maleate ophthalmic gel forming solution 0.25 1 %, 0.5 %

Last Published: 09/17/2021 119 Drug Name Drug Tier Requirements / Limits timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 1 % (daily) Timoptic Ocudose Ophthalmic Solution 0.25 % 3 *Cycloplegic Mydriatic Combinations*** - Drugs For The Eye Cyclomydril Ophthalmic Solution 0.2-1 % 1 *Cycloplegic Mydriatics*** - Drugs For The Eye Altafrin Ophthalmic Solution 10 %, 2.5 % 1 atropine sulfate ophthalmic ointment 1 % 1 atropine sulfate ophthalmic solution 1 % 1 cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % 1 Homatropaire Ophthalmic Solution 5 % 1 Isopto Atropine Ophthalmic Solution 1 % 1 phenylephrine hcl ophthalmic solution 10 %, 2.5 % 1 tropicamide ophthalmic solution 0.5 %, 1 % 1 *Lymphocyte Function-Associated Antigen-1 (Lfa- 1) Antag*** - Anti-Infective/Anti-Inflammatories Xiidra Ophthalmic Solution 5 % 2 QL *Miotics - Direct Acting*** - Drugs For Glaucoma pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 *Ophthalmic Antiallergic*** - Drugs For Itchy Eye Alocril Ophthalmic Solution 2 % 2 Alomide Ophthalmic Solution 0.1 % 2 azelastine hcl ophthalmic solution 0.05 % 1 bepotastine besilate ophthalmic solution 1.5 % 1 cromolyn sodium ophthalmic solution 4 % 1 epinastine hcl ophthalmic solution 0.05 % 1 Lastacaft Ophthalmic Solution 0.25 % 3 olopatadine hcl ophthalmic solution 0.1 %, 0.2 % 1 Zerviate Ophthalmic Solution 0.24 % 3 *Ophthalmic Antibiotics*** - Anti-Infective/Anti- Inflammatories AzaSite Ophthalmic Solution 1 % 3 bacitracin ophthalmic ointment 500 unit/gm 1 Besivance Ophthalmic Suspension 0.6 % 3 Ciloxan Ophthalmic Ointment 0.3 % 3 ciprofloxacin hcl ophthalmic solution 0.3 % 1 erythromycin ophthalmic ointment 5 mg/gm 1 gatifloxacin ophthalmic solution 0.5 % 1 Gentak Ophthalmic Ointment 0.3 % 1 gentamicin sulfate ophthalmic solution 0.3 % 1 levofloxacin ophthalmic solution 0.5 % 1 Mitosol Ophthalmic Kit 0.2 MG Tier 10

Last Published: 09/17/2021 120 Drug Name Drug Tier Requirements / Limits moxifloxacin hcl (2x day) ophthalmic solution 0.5 % 1 moxifloxacin hcl ophthalmic solution 0.5 % 1 ofloxacin ophthalmic solution 0.3 % 1 tobramycin ophthalmic solution 0.3 % 1 Tobrex Ophthalmic Ointment 0.3 % 3 *Ophthalmic *** - Drugs For The Eye Natacyn Ophthalmic Suspension 5 % 3 *Ophthalmic Anti-Infective Combinations*** - Anti- Infective/Anti-Inflammatories ak-poly-bac ophthalmic ointment 500-10000 unit/gm 1 bacitracin-polymyxin b ophthalmic ointment 500-10000 1 unit/gm neomycin-bacitracin zn-polymyx ophthalmic ointment 1 3.5-400-10000 , 5-400-10000 neomycin-polymyxin-gramicidin ophthalmic solution 1 1.75-10000-.025 Neo-Polycin Ophthalmic Ointment 3.5-400-10000 1 Polycin Ophthalmic Ointment 500-10000 UNIT/GM 1 polymyxin b-trimethoprim ophthalmic solution 10000- 1 0.1 unit/ml-% *Ophthalmic Antiseptics*** - Anti-Infective/Anti- Inflammatories Betadine Ophthalmic Prep Ophthalmic Solution 5 3 % *Ophthalmic Antivirals*** - Anti-Infective/Anti- Inflammatories trifluridine ophthalmic solution 1 % 1 Zirgan Ophthalmic Gel 0.15 % 3 *Ophthalmic Carbonic Anhydrase Inhibitors*** - Drugs For Glaucoma brinzolamide ophthalmic suspension 1 % 1 dorzolamide hcl ophthalmic solution 2 % 1 *Ophthalmic Gene Therapy*** - Drugs For The Eye Luxturna Intraocular Suspension 5000000000000 Tier 10 PA VG/ML *Ophthalmic Immunomodulators*** - Anti- Infective/Anti-Inflammatories Restasis Ophthalmic Emulsion 0.05 % 2 QL *Ophthalmic Local Anesthetics*** - Drugs For The Eye Akten Ophthalmic Gel 3.5 % 3 Altacaine Ophthalmic Solution 0.5 % 1 proparacaine hcl ophthalmic solution 0.5 % 1 tetracaine hcl ophthalmic solution 0.5 % 1

Last Published: 09/17/2021 121 Drug Name Drug Tier Requirements / Limits *Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** - Anti-Infective/Anti-Inflammatories bromfenac sodium (once-daily) ophthalmic solution Age Restriction Applies (Min 18 1 0.09 % Years) Age Restriction Applies (Min 18 BromSite Ophthalmic Solution 0.075 % 3 Years) diclofenac sodium ophthalmic solution 0.1 % 1 flurbiprofen sodium ophthalmic solution 0.03 % 1 Age Restriction Applies (Min 10 Ilevro Ophthalmic Suspension 0.3 % 3 Years) ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 1 % Age Restriction Applies (Min 10 Nevanac Ophthalmic Suspension 0.1 % 3 Years) Age Restriction Applies (Min 18 Prolensa Ophthalmic Solution 0.07 % 3 Years) *Ophthalmic Photoenhancer Combinations*** - Drugs For The Eye Photrexa Viscous Ophthalmic Solution Prefilled Tier 10 PA Syringe 0.146-20 % Photrexa-Photrexa Viscous Kit Ophthalmic Tier 10 PA Solution Prefilled Syringe 0.146 &0.146-20 % *Ophthalmic Selective Alpha Adrenergic Agonists*** - Drugs For Glaucoma Alphagan P Ophthalmic Solution 0.1 % 2 apraclonidine hcl ophthalmic solution 0.5 % 1 brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % 1 Iopidine Ophthalmic Solution 1 % 3 *Ophthalmic Steroid Combinations*** - Anti- Infective/Anti-Inflammatories bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 1 % Blephamide Ophthalmic Suspension 10-0.2 % 3 Blephamide S.O.P. Ophthalmic Ointment 10-0.2 % 3 neomycin-polymyxin-dexameth ophthalmic ointment 1 3.5-10000-0.1 neomycin-polymyxin-dexameth ophthalmic 1 suspension 3.5-10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5- 1 10000-1 Neo-Polycin HC Ophthalmic Ointment 1 % 1 Pred-G Ophthalmic Suspension 0.3-1 % 2 Pred-G S.O.P. Ophthalmic Ointment 0.3-0.6 % 2 sulfacetamide-prednisolone ophthalmic solution 10- 1 0.23 % TobraDex Ophthalmic Ointment 0.3-0.1 % 2

Last Published: 09/17/2021 122 Drug Name Drug Tier Requirements / Limits TobraDex ST Ophthalmic Suspension 0.3-0.05 % 3 tobramycin-dexamethasone ophthalmic suspension 1 0.3-0.1 % Zylet Ophthalmic Suspension 0.5-0.3 % 3 *Ophthalmic Steroids*** - Anti-Infective/Anti- Inflammatories Alrex Ophthalmic Suspension 0.2 % 2 dexamethasone sodium phosphate ophthalmic 1 solution 0.1 % Durezol Ophthalmic Emulsion 0.05 % 3 Flarex Ophthalmic Suspension 0.1 % 2 fluorometholone ophthalmic suspension 0.1 % 1 FML Forte Ophthalmic Suspension 0.25 % 2 FML Ophthalmic Ointment 0.1 % 2 Inveltys Ophthalmic Suspension 1 % 3 Lotemax Ophthalmic Ointment 0.5 % 2 Lotemax SM Ophthalmic Gel 0.38 % 3 loteprednol etabonate ophthalmic gel 0.5 % 1 loteprednol etabonate ophthalmic suspension 0.5 % 1 Maxidex Ophthalmic Suspension 0.1 % 3 Pred Mild Ophthalmic Suspension 0.12 % 3 prednisolone acetate ophthalmic suspension 1 % 1 prednisolone acetate p-f ophthalmic suspension 1 % 3 prednisolone sodium phosphate ophthalmic solution 1 1 % *Ophthalmic Sulfonamides*** - Anti-Infective/Anti- Inflammatories sulfacetamide sodium ophthalmic ointment 10 % 1 sulfacetamide sodium ophthalmic solution 10 % 1 *Ophthalmic Surgical Aids*** - Drugs For The Eye Gelfilm Ophthalmic Film 3 *Ophthalmics - Blepharoptosis Agents** - Drugs For The Eye Age Restriction Applies (Min 18 Upneeq Ophthalmic Solution 0.1 % 3 Years) *Ophthalmics - Cystinosis Agents** - Drugs For The Eye Cystaran Ophthalmic Solution 0.44 % 3 *Prostaglandins - Ophthalmic*** - Drugs For Glaucoma bimatoprost ophthalmic solution 0.03 % 1 Durysta Intraocular Implant 10 MCG Not Covered latanoprost ophthalmic solution 0.005 % 1 Lumigan Ophthalmic Solution 0.01 % 2 ST

Last Published: 09/17/2021 123 Drug Name Drug Tier Requirements / Limits Travatan Z Ophthalmic Solution 0.004 % 3 ST Zioptan Ophthalmic Solution 0.0015 % 3 ST *Vascular Endothelial Growth Factor (Vegf) Antagonists*** - Drugs For The Eye Beovu Intravitreal Solution 6 MG/0.05ML Tier 10 PA bevacizumab intraocular solution prefilled syringe 2.75 Tier 10 PA mg/0.11ml, 3.75 mg/0.15ml bevacizumab intravitreal solution prefilled syringe 2.5 Tier 10 PA mg/0.1ml, 3.25 mg/0.13ml, 3.75 mg/0.15ml Eylea Intravitreal Solution 2 MG/0.05ML Tier 10 PA Eylea Intravitreal Solution Prefilled Syringe 2 Tier 10 PA MG/0.05ML Lucentis Intravitreal Solution 0.3 MG/0.05ML, 0.5 Tier 10 PA MG/0.05ML Lucentis Intravitreal Solution Prefilled Syringe 0.3 Tier 10 PA MG/0.05ML, 0.5 MG/0.05ML *Otic Agents* - Drugs For The Ear *Otic Agents - Miscellaneous*** - Wax Removal acetic acid otic solution 2 % 1 *Otic Anti-Infectives*** - Antibiotics ciprofloxacin hcl otic solution 0.2 % 1 ofloxacin otic solution 0.3 % 1 *Otic Steroid-Anti-Infective Combinations*** - Anti- Infective/Anti-Inflammatories Cipro HC Otic Suspension 0.2-1 % 3 ciprofloxacin-dexamethasone otic suspension 0.3-0.1 1 % neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 Otovel Otic Solution 0.3-0.025 % 2 *Otic Steroids*** - Anti-Infective/Anti- Inflammatories Flac Otic Oil 0.01 % 1 fluocinolone acetonide otic oil 0.01 % 1 hydrocortisone-acetic acid otic solution 1-2 % 1 *Oxytocics* - Hormones *Abortifacients/Cervical Ripening - Prostaglandins*** - Drugs For Women Cervidil Vaginal Insert 10 MG 3 Prepidil Vaginal Gel 0.5 MG/3GM 3 *Oxytocics*** - Drugs For Women Methergine Oral Tablet 0.2 MG 1 methylergonovine maleate oral tablet 0.2 mg 1

Last Published: 09/17/2021 124 Drug Name Drug Tier Requirements / Limits *Passive Immunizing And Treatment Agents* - Biological Agents *Antiviral Monoclonal Antibodies*** - Biological Agents Synagis Intramuscular Solution 100 MG/ML, 50 Tier 10 PA MG/0.5ML *Bacterial Monoclonal Antibodies*** - Biological Agents Zinplava Intravenous Solution 1000 MG/40ML Tier 10 PA *Immune Serums*** - Biological Agents Asceniv Intravenous Solution 5 GM/50ML Tier 10 PA Bivigam Intravenous Solution 5 GM/50ML Tier 10 PA Cutaquig Subcutaneous Solution 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 Tier 10 PA GM/48ML Cuvitru Subcutaneous Solution 1 GM/5ML, 10 Tier 10 PA GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML Flebogamma DIF Intravenous Solution 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 Tier 10 PA GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML Gammagard Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 Tier 10 PA GM/300ML, 5 GM/50ML Gammagard S/D Less IgA Intravenous Solution Tier 10 PA Reconstituted 10 GM, 5 GM Gammaked Injection Solution 1 GM/10ML, 10 Tier 10 PA GM/100ML, 20 GM/200ML, 5 GM/50ML Gammaplex Intravenous Solution 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, 5 Tier 10 PA GM/100ML, 5 GM/50ML Gamunex-C Injection Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 Tier 10 PA GM/400ML, 5 GM/50ML Hizentra Subcutaneous Solution 1 GM/5ML, 10 Tier 10 PA GM/50ML, 2 GM/10ML, 4 GM/20ML Octagam Intravenous Solution 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 Tier 10 PA GM/50ML, 20 GM/200ML, 25 GM/500ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML Panzyga Intravenous Solution 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 Tier 10 PA GM/300ML, 5 GM/50ML Privigen Intravenous Solution 10 GM/100ML, 20 Tier 10 PA GM/200ML, 40 GM/400ML, 5 GM/50ML Xembify Subcutaneous Solution 1 GM/5ML, 10 Tier 10 PA GM/50ML, 2 GM/10ML, 4 GM/20ML

Last Published: 09/17/2021 125 Drug Name Drug Tier Requirements / Limits *Passive Immunizing Agents - Combinations*** - Biological Agents Hyqvia Subcutaneous Kit 10 GM/100ML, 2.5 Tier 10 PA GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML *Penicillins* - Drugs For Infections *Aminopenicillins*** - Antibiotics amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 1 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 ampicillin oral capsule 500 mg 1 *Natural Penicillins*** - Antibiotics penicillin v potassium oral solution reconstituted 125 1 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg 1 *Penicillin Combinations*** - Antibiotics amoxicillin-pot clavulanate er oral tablet extended 1 release 12 hour 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400- 1 57 mg/5ml, 600-42.9 mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 1 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200- 1 28.5 mg, 400-57 mg *Penicillinase-Resistant Penicillins*** - Antibiotics dicloxacillin sodium oral capsule 250 mg, 500 mg 1 *Pharmaceutical Adjuvants* *Antimicrobial Agents*** benzyl alcohol liquid 2 *Flavoring Agents*** benzaldehyde oral elixir 2 *Oral Vehicles*** cvs distilled water oral liquid 2 cvs purified water oral liquid 2 distillata distilled water oral liquid 2 distilled water oral liquid 2 Flavor Blend Oral Suspension 2 flavor plus oral liquid 2 flavor sweet oral syrup 2 flavor sweet-sf oral syrup 2 grape syrup oral syrup 3 MX-Sol Blend Oral Suspension 3

Last Published: 09/17/2021 126 Drug Name Drug Tier Requirements / Limits MX-Sol Blend SF Oral Suspension 3 MX-Sol Oral Syrup 3 MX-Sol SF Oral Syrup 3 MX-Sol Suspend Oral Suspension 3 Nice Distilled Water Oral Liquid 2 Ora-Blend Oral Suspension 2 Ora-Blend SF Oral Suspension 2 Oral Mix Oral Suspension 2 Oral Mix SF Oral Suspension 2 oral suspend oral liquid 2 oral syrup oral syrup 2 oral syrup sf oral syrup 2 Ora-Plus Oral Liquid 2 Ora-Sweet Oral Syrup 2 Ora-Sweet SF Oral Syrup 2 PCCA Sweet-SF Oral Syrup 2 PCCA Syrup Vehicle Oral Syrup 3 PCCA-Plus Oral Suspension 3 purified water oral liquid 2 px purified water oral liquid 2 simple syrup oral syrup 2 sorbitol solution , 70 % 2 SuspendRx w/BitterBloc Sweet Oral Suspension 3 SuspendRx w/BitterBloc Unsweet Oral 3 Suspension suspension vehicle oral suspension 2 Syrpalta (Red) Oral Syrup 2 syrpalta oral syrup , 85 % 2 SyrSpend SF Oral Liquid 2 syrup nf oral syrup 85 % 2 syrup vehicle oral syrup 2 syrup vehicle sf oral syrup 2 VersaFree Oral Syrup 2 VersaPlus Oral Syrup 2 *Pharmaceutical Excipients*** base x flakes 2 cocoa butter 2 Fattyblend 2 polypeg 2 spg supposi-base pellet 2 Supposiblend Pellet 2 Supposi-Plex R36 Pellet 2

Last Published: 09/17/2021 127 Drug Name Drug Tier Requirements / Limits Supposi-Plex V33 Pellet 2 Witepsol Pellet 2 Witepsol Wax 2 *Progestins* - Hormones *Progestins*** - Drugs For Women hydroxyprogesterone caproate intramuscular oil 250 1 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 1 mg, 5 mg megestrol acetate oral suspension 625 mg/5ml 1 norethindrone acetate oral tablet 5 mg 1 progesterone oral capsule 100 mg, 200 mg 1 *Psychotherapeutic And Neurological Agents - Misc.* - Drugs For The Nervous System *Alcohol Deterrents*** - Drugs For The Nervous System acamprosate calcium oral tablet delayed release 333 1 mg disulfiram oral tablet 250 mg, 500 mg 1 *Anti-Cataplectic Agents*** - Drugs For Sleep Disorder Xyrem Oral Solution 500 MG/ML 2 PA; QL *Antidementia Agent Combinations*** - Drugs For Alzheimer's Disease Namzaric Oral Capsule ER 24 Hour Therapy Pack 7 2 QL & 14 & 21 &28 -10 MG Namzaric Oral Capsule Extended Release 24 Hour 2 QL 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG *Antisense Oligonucleotide (Aso) Inhibitor Agents*** - Drugs For The Nervous System Tegsedi Subcutaneous Solution Prefilled Syringe 3 PA 284 MG/1.5ML *Benzodiazepines & Tricyclic Agents*** - Drugs For Seizures /Personality Disorder/Nerve Pain chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5- 1 12.5 mg *Cholinomimetics - Ache Inhibitors*** - Drugs For Alzheimer's Disease donepezil hcl oral tablet 10 mg, 5 mg 1 QL donepezil hcl oral tablet dispersible 10 mg, 5 mg 1 QL galantamine hydrobromide er oral capsule extended 1 QL release 24 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml 1 galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 1 mg

Last Published: 09/17/2021 128 Drug Name Drug Tier Requirements / Limits rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 1 QL mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 1 QL 4.6 mg/24hr, 9.5 mg/24hr *Fibromyalgia Agent - Snris*** - Drugs For Seizures /Personality Disorder/Nerve Pain Savella Oral Tablet 100 MG, 12.5 MG, 25 MG, 50 2 QL MG Savella Titration Pack Oral 12.5 & 25 & 50 MG 2 QL *Melanocortin Receptor Agonists*** - Drugs For The Nervous System Vyleesi Subcutaneous Solution Auto-Injector 1.75 3 Female Only; QL MG/0.3ML *Movement Disorder Drug Therapy*** - Drugs For The Nervous System Austedo Oral Tablet 12 MG, 6 MG, 9 MG 3 PA Ingrezza Capsule Therapy Pack 40 & 80 MG Oral 3 PA; QL 40 & 80 MG Ingrezza Oral Capsule 40 MG, 60 MG, 80 MG 3 PA; QL tetrabenazine oral tablet 12.5 mg, 25 mg 1 PA Xenazine Oral Tablet 12.5 MG, 25 MG 3 PA *Ms Agents - Pyrimidine Synthesis Inhibitors*** - Drugs For Multiple Sclerosis Aubagio Oral Tablet 14 MG, 7 MG 2 PA; QL *Multiple Sclerosis Agents - Antimetabolites*** - Drugs For Multiple Sclerosis Mavenclad (10 Tabs) Oral Tablet Therapy Pack 10 3 PA MG Mavenclad (4 Tabs) Oral Tablet Therapy Pack 10 3 PA MG Mavenclad (5 Tabs) Oral Tablet Therapy Pack 10 3 PA MG Mavenclad (6 Tabs) Oral Tablet Therapy Pack 10 3 PA MG Mavenclad (7 Tabs) Oral Tablet Therapy Pack 10 3 PA MG Mavenclad (8 Tabs) Oral Tablet Therapy Pack 10 3 PA MG Mavenclad (9 Tabs) Oral Tablet Therapy Pack 10 3 PA MG *Multiple Sclerosis Agents - Interferons*** - Drugs For Multiple Sclerosis Avonex Pen Intramuscular Auto-Injector Kit 30 2 PA; QL MCG/0.5ML Avonex Prefilled Intramuscular Prefilled Syringe 2 PA; QL Kit 30 MCG/0.5ML Extavia Subcutaneous Kit 0.3 MG 3 PA; QL

Last Published: 09/17/2021 129 Drug Name Drug Tier Requirements / Limits Plegridy Intramuscular Solution Prefilled Syringe 3 PA; QL 125 MCG/0.5ML Plegridy Starter Pack Subcutaneous Solution Pen- 3 PA; QL Injector 63 & 94 MCG/0.5ML Plegridy Starter Pack Subcutaneous Solution 3 PA; QL Prefilled Syringe 63 & 94 MCG/0.5ML Plegridy Subcutaneous Solution Pen-Injector 125 3 PA; QL MCG/0.5ML Plegridy Subcutaneous Solution Prefilled Syringe 3 PA; QL 125 MCG/0.5ML Rebif Rebidose Subcutaneous Solution Auto- 2 PA; QL Injector 22 MCG/0.5ML, 44 MCG/0.5ML Rebif Rebidose Titration Pack Subcutaneous 2 PA; QL Solution Auto-Injector 6X8.8 & 6X22 MCG Rebif Subcutaneous Solution Prefilled Syringe 22 2 PA; QL MCG/0.5ML, 44 MCG/0.5ML Rebif Titration Pack Subcutaneous Solution 2 PA; QL Prefilled Syringe 6X8.8 & 6X22 MCG *Multiple Sclerosis Agents - Monoclonal Antibodies*** - Drugs For Multiple Sclerosis Kesimpta Subcutaneous Solution Auto-Injector 20 3 PA MG/0.4ML Lemtrada Intravenous Solution 12 MG/1.2ML Tier 10 PA Ocrevus Intravenous Solution 300 MG/10ML Tier 10 PA Tysabri Intravenous Concentrate 300 MG/15ML Tier 10 PA *Multiple Sclerosis Agents - Nrf2 Pathway Activators*** - Drugs For Multiple Sclerosis Bafiertam Oral Capsule Delayed Release 95 MG 3 PA; QL dimethyl fumarate oral capsule delayed release 120 1 PA; QL mg, 240 mg dimethyl fumarate starter pack oral 120 & 240 mg 1 PA; QL Tecfidera Oral 120 & 240 MG Not Covered Tecfidera Oral Capsule Delayed Release 120 MG, Not Covered 240 MG Vumerity Oral Capsule Delayed Release 231 MG Not Covered *Multiple Sclerosis Agents - Potassium Channel Blockers*** - Drugs For Multiple Sclerosis Ampyra Oral Tablet Extended Release 12 Hour 10 3 PA; QL MG dalfampridine er oral tablet extended release 12 hour 1 PA; QL 10 mg *Multiple Sclerosis Agents*** - Drugs For Multiple Sclerosis Copaxone Subcutaneous Solution Prefilled 2 PA; QL Syringe 20 MG/ML, 40 MG/ML glatiramer acetate subcutaneous solution prefilled 1 PA; QL syringe 20 mg/ml, 40 mg/ml

Last Published: 09/17/2021 130 Drug Name Drug Tier Requirements / Limits Glatopa Subcutaneous Solution Prefilled Syringe 1 PA; QL 20 MG/ML, 40 MG/ML *N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** - Drugs For Alzheimer's Disease memantine hcl er oral capsule extended release 24 1 QL hour 14 mg, 21 mg, 28 mg, 7 mg memantine hcl oral solution 2 mg/ml 1 memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 1 QL mg, 5 mg *Phenothiazines & Tricyclic Agents*** - Drugs For Depression perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 1 Age Restriction Applies (Min 5 Years) mg, 4-10 mg, 4-25 mg, 4-50 mg *Postherpetic Neuralgia (Phn)/Neuropathic Pain Agents*** - Drugs For Seizures /Personality Disorder/Nerve Pain pregabalin er oral tablet extended release 24 hour 165 1 QL mg, 330 mg, 82.5 mg *Premenstrual Dysphoric Disorder (Pmdd) Agents - Ssris*** - Drugs For Depression fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg 1 *Pseudobulbar Affect Agent Combinations*** - Drugs For Severe Mental Disorders Nuedexta Oral Capsule 20-10 MG 3 *Psychotherapeutic And Neurological Agents - Misc.*** - Drugs For Severe Mental Disorders ergoloid mesylates oral tablet 1 mg 1 oral tablet 1 mg, 2 mg 1 *Serotonin 1A Recept Agonist/Serotonin 2A Recept Antag*** - Drugs For The Nervous System QL; Age Restriction Applies (Max 50 Addyi Oral Tablet 100 MG 3 Years) *Small Interfering Ribonucleic Acid (Sirna) Agents*** - Drugs For The Nervous System Onpattro Intravenous Solution 10 MG/5ML Tier 10 PA *Smoking Deterrents*** - Drugs For Depression bupropion hcl er (smoking det) oral tablet extended 1 release 12 hour 150 mg Chantix Continuing Month Pak Oral Tablet 1 MG 2 Chantix Oral Tablet 0.5 MG, 1 MG 2 Chantix Starting Month Pak Oral Tablet 0.5 MG X 2 11 & 1 MG X 42 *Sphingosine 1-Phosphate (S1p) Receptor Modulators*** - Drugs For Multiple Sclerosis Gilenya Oral Capsule 0.25 MG, 0.5 MG 2 PA Mayzent Oral Tablet 0.25 MG, 2 MG 2 PA

Last Published: 09/17/2021 131 Drug Name Drug Tier Requirements / Limits Mayzent Starter Pack Oral Tablet Therapy Pack 12 2 PA x 0.25 MG Ponvory Oral Tablet 20 MG 3 PA Ponvory Starter Pack Oral Tablet Therapy Pack 2- 3 PA 3-4-5-6-7-8-9 & 10 MG Zeposia 7-Day Starter Pack Oral Capsule Therapy 3 PA Pack 4 x 0.23MG & 3 x 0.46MG Zeposia Oral Capsule 0.92 MG 3 PA Zeposia Starter Kit Oral Capsule Therapy Pack 3 PA 0.23MG & 0.46MG & 0.92MG *Thienbenzodiazepines & Ssris*** - Drugs For Severe Mental Disorders olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12- QL; Age Restriction Applies (Min 5 1 50 mg, 3-25 mg, 6-25 mg, 6-50 mg Years) *Vasomotor Symptom Agents - Ssris*** - Drugs For The Nervous System paroxetine mesylate oral capsule 7.5 mg 1 QL *Respiratory Agents - Misc.* - Drugs For The Lungs *Alpha-Proteinase Inhibitor (Human)*** - Drugs For Asthma/Copd Aralast NP Intravenous Solution Reconstituted Tier 10 PA 1000 MG, 500 MG Glassia Intravenous Solution 1000 MG/50ML Tier 10 PA Prolastin-C Intravenous Solution 1000 MG/20ML Tier 10 PA Prolastin-C Intravenous Solution Reconstituted Tier 10 PA 1000 MG Zemaira Intravenous Solution Reconstituted 1000 Tier 10 PA MG *Cftr Potentiators*** - Drugs For Cystic Fibrosis Kalydeco Oral Packet 50 MG, 75 MG 2 PA; QL Kalydeco Packet 25 MG Oral 25 MG 2 PA; QL *Cystic Fibrosis Agent - Combinations*** - Drugs For Cystic Fibrosis PA; QL; Age Restriction Applies (Max Orkambi Oral Packet 100-125 MG, 150-188 MG 2 5 Years) Orkambi Oral Tablet 100-125 MG, 200-125 MG 2 PA; QL Symdeko Oral Tablet Therapy Pack 100-150 & 150 3 PA; QL MG, 50-75 & 75 MG Trikafta Oral Tablet Therapy Pack 100-50-75 & 150 3 PA MG, 50-25-37.5 & 75 MG *Cystic Fibrosis Agents - Miscellaneous*** - Drugs For Cystic Fibrosis Bronchitol Inhalation Capsule 40 MG 3 Bronchitol Tolerance Test Inhalation Capsule 40 3 MG

Last Published: 09/17/2021 132 Drug Name Drug Tier Requirements / Limits *Hydrolytic Enzymes*** - Drugs For The Lungs Pulmozyme Inhalation Solution 1 MG/ML 2 *Pulmonary Fibrosis Agents - Kinase Inhibitors*** - Drugs For The Lungs Ofev Oral Capsule 100 MG, 150 MG 3 PA; QL *Pulmonary Fibrosis Agents*** - Drugs For The Lungs Esbriet Oral Capsule 267 MG 3 PA; QL Esbriet Oral Tablet 267 MG, 801 MG 3 PA; QL *Sulfonamides* - Drugs For Infections *Sulfonamides*** - Antibiotics sulfadiazine oral tablet 500 mg 1 *Tetracyclines* - Drugs For Infections *Aminomethylcyclines*** - Antibiotics Nuzyra Oral Tablet 150 MG 3 PR *Tetracyclines*** - Antibiotics avidoxy oral tablet 100 mg 1 demeclocycline hcl oral tablet 150 mg, 300 mg 1 Doryx Oral Tablet Delayed Release 200 MG 3 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 100 1 mg, 150 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 150 1 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension 1 reconstituted 25 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 1 50 mg, 75 mg minocycline hcl er oral tablet extended release 24 1 hour 115 mg, 65 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg 1 minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 1 Minolira Oral Tablet Extended Release 24 Hour 105 3 MG, 135 MG Mondoxyne NL Oral Capsule 100 MG, 75 MG 1 Morgidox Oral Capsule 100 MG 1 tetracycline hcl oral capsule 250 mg, 500 mg 1 Vibramycin Oral Syrup 50 MG/5ML 3 *Thyroid Agents* - Hormones *Antithyroid Agents*** - Drugs For Thyroid methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1

Last Published: 09/17/2021 133 Drug Name Drug Tier Requirements / Limits *Thyroid Hormones*** - Drugs For Thyroid Armour Thyroid Oral Tablet 120 MG, 15 MG, 180 3 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG Cytomel Oral Tablet 25 MCG, 5 MCG, 50 MCG 3 Euthyrox Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 1 MCG, 50 MCG, 75 MCG, 88 MCG Levo-T Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 1 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral capsule 100 mcg, 112 mcg, 125 mcg, 13 mcg, 137 mcg, 150 mcg, 175 mcg, 200 1 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 1 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg Levoxyl Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 1 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1 Nature-Throid Oral Tablet 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 1 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG Synthroid Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 3 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG Thyquidity Oral Solution 100 MCG/5ML 3 Tirosint Oral Capsule 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 3 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG Tirosint-SOL Oral Solution 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 3 MCG/ML, 37.5 MCG/ML, 44 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML Unithroid Oral Tablet 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 1 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG Westhroid Oral Tablet 130 MG, 195 MG, 32.5 MG, 1 65 MG, 97.5 MG WP Thyroid Oral Tablet 113.75 MG, 130 MG, 16.25 1 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG *Toxoids* - Biological Agents *Toxoid Combinations*** - Vaccines Adacel Intramuscular Suspension 5-2-15.5 LF- 3 MCG/0.5 Boostrix Intramuscular Suspension 5-2.5-18.5 LF- 3 MCG/0.5

Last Published: 09/17/2021 134 Drug Name Drug Tier Requirements / Limits Age Restriction Applies (Max 18 Daptacel Intramuscular Suspension 23-15-5 3 Years) diphtheria-tetanus toxoids dt intramuscular suspension Age Restriction Applies (Max 18 3 25-5 lfu/0.5ml Years) Age Restriction Applies (Max 18 Infanrix Intramuscular Suspension 25-58-10 3 Years) Age Restriction Applies (Max 18 Kinrix Intramuscular Suspension 3 Years) Age Restriction Applies (Max 18 Pediarix Intramuscular Suspension 3 Years) Age Restriction Applies (Max 18 Pentacel Intramuscular Suspension Reconstituted 3 Years) Age Restriction Applies (Max 18 Quadracel Intramuscular Suspension 3 Years) Age Restriction Applies (Min 19 TDVAX Intramuscular Suspension 2-2 LF/0.5ML 3 Years) Age Restriction Applies (Min 19 Tenivac Intramuscular Injectable 5-2 LFU 3 Years) *Ulcer Drugs/Antispasmodics/Anticholinergics* - Drugs For The Stomach *Anticholinergic Combinations*** - Drugs For Stomach Cramps chlordiazepoxide-clidinium oral capsule 5-2.5 mg 1 phenobarbital-belladonna alk oral elixir 16.2 mg/5ml 1 Phenohytro Oral Elixir 16.2 MG/5ML 1 Phenohytro Oral Tablet 16.2 MG 1 *Antispasmodics*** - Drugs For Stomach Cramps dicyclomine hcl oral capsule 10 mg 1 dicyclomine hcl oral solution 10 mg/5ml 1 dicyclomine hcl oral tablet 20 mg 1 *Belladonna Alkaloids*** - Drugs For Stomach Cramps ed-spaz oral tablet dispersible 0.125 mg 1 hyoscyamine sulfate er oral tablet extended release 1 12 hour 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml 1 hyoscyamine sulfate oral solution 0.125 mg/ml 1 hyoscyamine sulfate oral tablet 0.125 mg 1 hyoscyamine sulfate oral tablet dispersible 0.125 mg 1 hyoscyamine sulfate sl sublingual tablet sublingual 1 0.125 mg hyoscyamine sulfate sublingual tablet sublingual 0.125 1 mg hyosyne oral elixir 0.125 mg/5ml 1 hyosyne oral solution 0.125 mg/ml 1 NuLev Oral Tablet Dispersible 0.125 MG 1

Last Published: 09/17/2021 135 Drug Name Drug Tier Requirements / Limits oscimin oral tablet 0.125 mg 1 oscimin sr oral tablet extended release 12 hour 0.375 1 mg oscimin sublingual tablet sublingual 0.125 mg 1 Symax Duotab Oral Tablet Extended Release 0.375 3 MG Symax-SL Sublingual Tablet Sublingual 0.125 MG 1 Symax-SR Oral Tablet Extended Release 12 Hour 1 0.375 MG *H-2 Antagonists*** - Drugs For Ulcers And Stomach Acid Age Restriction Applies (Max 12 hcl oral solution 300 mg/5ml 1 Years) Age Restriction Applies (Max 12 famotidine oral suspension reconstituted 40 mg/5ml 1 Years) *Misc. Anti-Ulcer*** - Drugs For Ulcers And Stomach Acid sucralfate oral suspension 1 gm/10ml 1 sucralfate oral tablet 1 gm 1 *Proton Pump Inhibitors*** - Drugs For Ulcers And Stomach Acid Dexilant Oral Capsule Delayed Release 30 MG, 60 2 QL MG esomeprazole magnesium oral capsule delayed 1 QL release 20 mg, 40 mg esomeprazole magnesium oral packet 10 mg, 20 mg, QL; Age Restriction Applies (Max 12 1 40 mg Years) oral capsule delayed release 15 mg, 30 1 QL mg omeprazole oral capsule delayed release 10 mg, 20 1 QL mg, 40 mg pantoprazole sodium oral packet 40 mg 1 pantoprazole sodium oral tablet delayed release 20 1 QL mg, 40 mg sodium oral tablet delayed release 20 mg 1 QL *Quaternary Anticholinergics*** - Drugs For Stomach Cramps glycopyrrolate oral tablet 1 mg, 2 mg 1 methscopolamine bromide oral tablet 2.5 mg, 5 mg 1 *Ulcer Drugs - Prostaglandins*** - Drugs For Ulcers And Stomach Acid misoprostol oral tablet 100 mcg, 200 mcg 1 *Urinary Antispasmodics* - Drugs For The Urinary System *Urinary Antispasmodic - Antimuscarinic (Anticholinergic)*** - Drugs For The Bladder Gelnique Transdermal Gel 10 % 3 QL Last Published: 09/17/2021 136 Drug Name Drug Tier Requirements / Limits oxybutynin chloride er oral tablet extended release 24 1 hour 10 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 1 oxybutynin chloride oral tablet 5 mg 1 solifenacin succinate oral tablet 10 mg, 5 mg 1 QL tolterodine tartrate oral tablet 1 mg, 2 mg 1 Toviaz Oral Tablet Extended Release 24 Hour 4 2 QL MG, 8 MG trospium chloride er oral capsule extended release 24 1 hour 60 mg trospium chloride oral tablet 20 mg 1 Age Restriction Applies (Min 2 Years VESIcare LS Oral Suspension 5 MG/5ML 3 and Max 12 Years) *Urinary Antispasmodics - Beta-3 Adrenergic Agonists*** - Drugs For The Bladder Myrbetriq Oral Suspension Reconstituted ER 8 QL; Age Restriction Applies (Min 3 2 MG/ML Years and Max 17 Years) Myrbetriq Oral Tablet Extended Release 24 Hour 2 QL 25 MG, 50 MG *Urinary Antispasmodics - Cholinergic Agonists*** - Drugs For The Bladder bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 1 50 mg *Urinary Antispasmodics - Direct Muscle Relaxants*** - Drugs For The Bladder flavoxate hcl oral tablet 100 mg 1 *Vaccines* - Biological Agents *Bacterial Vaccines*** - Vaccines Age Restriction Applies (Max 18 ActHIB Intramuscular Solution Reconstituted 3 Years) Bexsero Intramuscular Suspension Prefilled 3 Syringe Age Restriction Applies (Max 18 Hiberix Injection Solution Reconstituted 10 MCG 3 Years) Menactra Intramuscular Injectable 3 Menveo Intramuscular Solution Reconstituted 3 Pedvax HIB Intramuscular Suspension 7.5 Age Restriction Applies (Max 18 3 MCG/0.5ML Years) Pneumovax 23 Injection Injectable 25 MCG/0.5ML 2 Prevnar 13 Intramuscular Suspension 2 Trumenba Intramuscular Suspension Prefilled 3 Syringe *Viral Vaccine Combinations*** - Vaccines ProQuad Subcutaneous Suspension Age Restriction Applies (Max 18 3 Reconstituted Years)

Last Published: 09/17/2021 137 Drug Name Drug Tier Requirements / Limits Twinrix Intramuscular Suspension Prefilled Age Restriction Applies (Min 19 3 Syringe 720-20 ELU-MCG/ML Years) *Viral Vaccines*** - Vaccines Afluria Quadrivalent Intramuscular Suspension 2 Afluria Quadrivalent Intramuscular Suspension 2 Prefilled Syringe 0.5 ML Engerix-B Injection Suspension 10 MCG/0.5ML, 20 3 MCG/ML Fluarix Quadrivalent Intramuscular Suspension 2 Prefilled Syringe 0.5 ML Flulaval Quadrivalent Intramuscular Suspension 2 Prefilled Syringe 0.5 ML Gardasil 9 Intramuscular Suspension 2 Gardasil 9 Intramuscular Suspension Prefilled 2 Syringe Havrix Intramuscular Suspension 1440 EL U/ML, 3 720 EL U/0.5ML Age Restriction Applies (Max 18 Ipol Injection Injectable 3 Years) Recombivax HB Injection Suspension 10 MCG/ML, 3 40 MCG/ML, 5 MCG/0.5ML Age Restriction Applies (Max 18 Rotarix Oral Suspension Reconstituted 3 Years) Age Restriction Applies (Max 18 RotaTeq Oral Solution 3 Years) Vaqta Intramuscular Suspension 25 UNIT/0.5ML, 3 50 UNIT/ML Varivax Subcutaneous Injectable 1350 PFU/0.5ML 3 *Vaginal And Related Products* - Drugs For Women *Imidazole-Related Antifungals*** - Drugs For Infections Gynazole-1 Vaginal Cream 2 % 3 vaginal cream 0.4 %, 0.8 % 1 QL terconazole vaginal suppository 80 mg 1 QL *Miscellaneous Vaginal Products*** - Drugs For Women Intrarosa Vaginal Insert 6.5 MG 3 QL *Vaginal Anti-Infectives*** - Drugs For Infections Cleocin Vaginal Suppository 100 MG 3 clindamycin phosphate vaginal cream 2 % 1 Clindesse Vaginal Cream 2 % 3 metronidazole vaginal gel 0.75 % 1 Nuvessa Vaginal Gel 1.3 % 3 Vandazole Vaginal Gel 0.75 % 1

Last Published: 09/17/2021 138 Drug Name Drug Tier Requirements / Limits *Vaginal Estrogens*** - Drugs For Women estradiol vaginal cream 0.1 mg/gm 1 estradiol vaginal tablet 10 mcg 1 Estring Vaginal Ring 2 MG 2 QL Femring Vaginal Ring 0.05 MG/24HR, 0.1 MG/24HR 3 QL Imvexxy Maintenance Pack Vaginal Insert 10 MCG, 3 4 MCG Imvexxy Starter Pack Vaginal Insert 10 MCG, 4 3 MCG Premarin Vaginal Cream 0.625 MG/GM 2 Yuvafem Vaginal Tablet 10 MCG 1 *Vaginal Progestins*** - Drugs For Women Crinone Vaginal Gel 4 %, 8 % 3 *Vasopressors* - Drugs For The Heart * Therapy Agents*** - Drugs For Serious Allergic Reaction epinephrine injection solution auto-injector 0.15 1 QL mg/0.15ml, 0.15 mg/0.3ml, 0.3 mg/0.3ml EpiPen 2-Pak Injection Solution Auto-Injector 0.3 2 QL MG/0.3ML EpiPen Jr 2-Pak Injection Solution Auto-Injector 2 QL 0.15 MG/0.3ML *Vasopressors*** - Drugs For Serious Allergic Reaction midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 *Vitamins* - Drugs For Nutrition *Vitamin D*** - Drugs For Nutrition ergocalciferol oral capsule 1.25 mg (50000 ut) 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 1 ut) **** - Drugs For Nutrition wheat germ oil oral oil 2 *Vitamin K*** - Drugs For Nutrition phytonadione oral tablet 5 mg 1

Last Published: 09/17/2021 139 Index 7T Lido...... 83 AeroChamber Plus Flo-Vu alogliptin benzoate...... 30 abacavir sulfate...... 63 Medium...... 107 alogliptin-metformin hcl...... 30 abacavir sulfate-lamivudine...... 61 AeroChamber Plus Flo-Vu Small 107 alogliptin-pioglitazone...... 30 abacavir-lamivudine-zidovudine...... 61 AeroChamber Plus Flo-Vu Alomide...... 120 Abecma...... 46 w/Mask...... 108 Alora...... 93 Abilify Maintena...... 60 AeroChamber Plus Flow VU...... 108 alosetron hcl...... 94 abiraterone acetate...... 42 AeroChamber w/FLOWSIGnal.... 108 Alphagan P...... 122 Abraxane...... 53 AeroChamber Z-Stat Plus...... 108 alprazolam...... 18 Absorica LD...... 75 AeroChamber Z-Stat Plus alprazolam er...... 18 acamprosate calcium...... 128 Chambr...... 108 ALPRAZolam Intensol...... 18 acarbose...... 29 AeroChamber Z-Stat Plus/Large.108 alprazolam xr...... 18 Accu-Chek Aviva...... 104 AeroChamber Z-Stat Alrex...... 123 Accu-Chek Compact Plus Plus/Medium...... 108 Altabax...... 76 Control...... 104 AeroChamber Z-Stat Plus/Small.108 Altacaine...... 121 Accu-Chek Guide Control...... 104 Aerogear Action Asthma Kit...... 107 Altafrin...... 120 Accu-Chek SmartView Control... 104 AeroVent Plus...... 108 Altoprev...... 36 Accutrend Glucose Control...... 104 Afinitor...... 48 Altreno...... 75 acebutolol hcl...... 65 Afinitor Disperz...... 48 Alunbrig...... 44 acetaminophen-codeine...... 13 Afluria Quadrivalent...... 138 alvimopan...... 95 acetaminophen-codeine #2...... 13 AgaMatrix Control...... 104 Alyq...... 68 acetaminophen-codeine #3...... 13 Aimovig...... 109 Amabelz...... 92 acetaminophen-codeine #4...... 13 Airzone Peak Flow Meter...... 107 amantadine hcl...... 56 acetazolamide...... 86 Ajovy...... 109 ambrisentan...... 68 acetazolamide er...... 86 Aklief...... 75 amcinonide...... 79 acetic acid...... 124 ak-poly-bac...... 121 Ameluz...... 84 acetylcysteine...... 73 Akten...... 121 Amicar...... 100 acitretin...... 77 Akynzeo...... 33 amiloride hcl...... 87 Actemra...... 11 Ala Scalp...... 79 amiloride-hydrochlorothiazide...... 86 Actemra ACTPen...... 11 ala-cort...... 79 aminocaproic acid...... 100 Acthar...... 88 Ala-Quin...... 76 amiodarone hcl...... 19 ActHIB...... 137 albendazole...... 17 amitriptyline hcl...... 28 Actimmune...... 51 albuterol sulfate...... 20 amlodipine besy-benazepril hcl...... 37 Actinel Pediatric...... 73 albuterol sulfate hfa...... 20 amlodipine besylate...... 66 acyclovir...... 64, 79 alclometasone dipropionate...... 79 amlodipine besylate-valsartan...... 38 Adacel...... 134 Alcoh-Glove Contoured Wipe..... 103 amlodipine-atorvastatin...... 67 Adakveo...... 100 alcohol pads...... 103 amlodipine-olmesartan...... 38 adapalene...... 75 alcohol prep...... 103 amlodipine-valsartan-hctz...... 38 adapalene-benzoyl peroxide...... 74 alcohol swabs...... 103 Amnesteem...... 75 Adcetris...... 45 alcoh-wipe...... 103 amondys 45...... 118 Adcirca...... 68 Aldactazide...... 86 amoxapine...... 28 Addyi...... 131 Aldurazyme...... 90 amoxicillin...... 126 adefovir dipivoxil...... 64 Alecensa...... 44 amoxicillin-pot clavulanate...... 126 Adempas...... 68 alendronate sodium...... 87 amoxicillin-pot clavulanate er...... 126 Adriamycin...... 50 alevamax...... 83 amphetamine sulfate...... 8 adriamycin...... 50 Alevicyn Antipruritic...... 83 amphetamine-dextroamphetamine.... 8 Advair Diskus...... 19 Alevicyn Antipruritic SG...... 83 ampicillin...... 126 Advair HFA...... 19 Alferon N...... 51 Ampyra...... 130 Advance Intuition Control...... 104 alfuzosin hcl er...... 96 Amzeeq...... 74 Advance Micro-Draw Control...... 104 Alimta...... 43 Anacaine...... 83 Advance Micro-Draw Normal...... 104 Alinia...... 40 anagrelide hcl...... 98 Advocate Control Solution...... 104 Aliqopa...... 54 anastrozole...... 52 Advocate Redi-Code+ Control....104 aliskiren fumarate...... 39 Androderm...... 16 Adzenys ER...... 8 Alkeran...... 54 AndroGel...... 16 Adzenys XR-ODT...... 8 Alkindi Sprinkle...... 72 AndroGel Pump...... 16 Aemcolo...... 39 allopurinol...... 97 Angeliq...... 92 AeroChamber Mini Chamber...... 107 Allzital...... 13 Annovera...... 71 AeroChamber MV...... 107 almond oil (sweet)...... 70 Anoro Ellipta...... 19 AeroChamber Plus Flo-Vu...... 107 almotriptan malate...... 109 Antara...... 35 AeroChamber Plus Flo-Vu Large107 Alocril...... 120 anucort-hc...... 17 140 Anusol-HC...... 17 Austedo...... 129 benzoyl peroxide...... 76 apap-caff-dihydrocodeine...... 14 Avar Cleanser...... 74 benzoyl peroxide-erythromycin...... 74 ApexiCon E...... 79 Avar-e Emollient...... 74 benztropine mesylate...... 56 Aplenzin...... 27 Avar-e Green...... 74 benzyl alcohol...... 126 apraclonidine hcl...... 122 Avastin...... 56 benzyl benzoate...... 70 aprepitant...... 34 Avenova...... 82 Beovu...... 124 Aptiom...... 23 avidoxy...... 133 bepotastine besilate...... 120 Aptivus...... 62 Avita...... 75 Berinert...... 98 Aralast NP...... 132 Avonex Pen...... 129 Besivance...... 120 Arcalyst...... 11 Avonex Prefilled...... 129 Besponsa...... 45 Arikayce...... 10 Avsola...... 96 Betadine Ophthalmic Prep...... 121 aripiprazole...... 60 Ayvakit...... 49 betamethasone dipropionate..... 79, 80 Aristada...... 60 azacitidine...... 43 betamethasone dipropionate aug.... 79 Aristada Initio...... 60 Azasan...... 112 betamethasone valerate...... 80 armodafinil...... 9 AzaSite...... 120 betaxolol hcl...... 65, 119 Armour Thyroid...... 134 azathioprine...... 113 bethanechol chloride...... 137 arnica flower...... 84 azelaic acid...... 84 Bethkis...... 10 Arnuity Ellipta...... 21 azelastine hcl...... 117, 120 Betimol...... 119 Arranon...... 43 azelastine-fluticasone...... 117 Betoptic-S...... 119 arsenic trioxide...... 51 Azelex...... 75 bevacizumab...... 124 Arzerra...... 44 azithromycin...... 102 Bevespi Aerosphere...... 19 Arzol Silver Nit Applicators...... 79 Azurette...... 70 bexarotene...... 55 Asceniv...... 125 bacitracin...... 120 Bexsero...... 137 Ascomp-Codeine...... 13 bacitracin-polymyxin b...... 121 bicalutamide...... 42 asenapine maleate...... 59 bacitra-neomycin-polymyxin-hc..... 122 BiCNU...... 54 Asmanex (120 Metered Doses)..... 21 baclofen...... 116 BiDil...... 67 Asmanex (14 Metered Doses)...... 21 Bafiertam...... 130 Biktarvy...... 61 Asmanex (30 Metered Doses)...... 21 Balcoltra...... 71 bimatoprost...... 84, 123 Asmanex (60 Metered Doses)...... 21 balsalazide disodium...... 94 Binosto...... 87 Asmanex (7 Metered Doses)...... 21 balsam peru-castor oil...... 85 bisoprolol fumarate...... 65 Asmanex HFA...... 21 Balversa...... 47 bisoprolol-hydrochlorothiazide...... 39 Asparlas...... 51 Banzel...... 23 Bivigam...... 125 aspirin-dipyridamole er...... 98 Baqsimi One Pack...... 29 Blenrep...... 44 Assess Peak Flow Meter...... 107 Baqsimi Two Pack...... 29 bleomycin sulfate...... 50 Assure 3 Control...... 104 Baraclude...... 64 Blephamide...... 122 Assure 4 Control Level 1 & 2...... 104 base g almond oil (sweet)...... 70 Blephamide S.O.P...... 122 Assure Dose Control...... 104 base x...... 127 Blincyto...... 47 Assure Dose Norm/High Control 104 Bavencio...... 46 Boostrix...... 134 Assure II Control...... 104 Baxdela...... 93 boric acid...... 84 Assure II Control Level 1 & 2...... 104 BD Swabs Single Use Butterfly.. 103 bortezomib...... 49 Assure Prism Control Level 1 104 Beconase AQ...... 117 bosentan...... 68 Assure Pro Control Level 1 & 2.. 104 Beleodaq...... 48 Bosulif...... 46 Astagraf XL...... 112 Belrapzo...... 42 Botox...... 118 Astero...... 83 Belsomra...... 101 bp 10-1...... 75 Atabex EC...... 113 benazepril hcl...... 37 bp cleansing wash...... 75 Atabex OB...... 113 benazepril-hydrochlorothiazide...... 37 bp wash...... 76 atazanavir sulfate...... 62 Bendeka...... 42 bpco...... 85 atenolol...... 65 Benlysta...... 111 bpo...... 76 atenolol-chlorthalidone...... 39 bensal hp...... 82 bpo foaming cloths...... 76 atomoxetine hcl...... 8 benzaldehyde...... 126 Braftovi...... 47 atopaderm...... 83 benzalkonium chloride...... 60 breathe ease large...... 108 Atopiclair...... 83 benzepro...... 75 breathe ease medium...... 108 atorvastatin calcium...... 36 BenzePrO...... 75 breathe ease small...... 108 atovaquone...... 40 BenzePrO Creamy Wash...... 75 Breo Ellipta...... 19 atovaquone-proguanil hcl...... 41 BenzePrO Foaming Cloths...... 75 Breyanzi...... 46 Atripla...... 61 BenzePrO Short Contact...... 75 Brilinta...... 98 atropine sulfate...... 120 benznidazole...... 17 brimonidine tartrate...... 122 Atrovent HFA...... 20 benzoin...... 85 Brineura...... 91 Aubagio...... 129 benzonatate...... 73 brinzolamide...... 121 Auryxia...... 95 benzoyl perox-hydrocortisone...... 74 Briviact...... 23 141 bromfenac sodium (once-daily)...... 122 carbinoxamine maleate...... 34 cimetidine hcl...... 136 bromocriptine mesylate...... 56 carboplatin...... 42 cinacalcet hcl...... 88 BromSite...... 122 Cardizem LA...... 66 Cinqair...... 21 Bronchitol...... 132 Cardura XL...... 96 Cinryze...... 98 Bronchitol Tolerance Test...... 132 CareSens Control A...... 104 Cipro...... 93 Brukinsa...... 47 CareTouch Alcohol Prep...... 103 Cipro HC...... 124 Bryhali...... 80 carisoprodol...... 116 ciprofloxacin hcl...... 93, 120, 124 budesonide...... 22, 72 carisoprodol-aspirin-codeine...... 116 ciprofloxacin-dexamethasone...... 124 budesonide er...... 72 carmustine...... 54 cisplatin...... 42 budesonide-formoterol fumarate...... 19 CaroSpir...... 87 citalopram hydrobromide...... 27 bumetanide...... 87 carteolol hcl...... 119 CitraNatal 90 DHA...... 115 Bunavail...... 16 Cartia XT...... 66 CitraNatal Assure...... 115 Bupap...... 13 carvedilol...... 65 CitraNatal Bloom...... 113 Buphenyl...... 92 carvedilol phosphate er...... 65 CitraNatal Bloom DHA...... 115 buprenorphine...... 16 cascara sagrada...... 102 CitraNatal DHA...... 115 buprenorphine hcl...... 16 castor oil...... 70 CitraNatal Harmony...... 115 buprenorphine hcl-naloxone hcl...... 16 Caverject...... 67 CitraNatal Rx...... 113 bupropion hcl...... 27 Caverject Impulse...... 67 cladribine...... 43 bupropion hcl er (smoking det)...... 131 Cayston...... 40 Claravis...... 76 bupropion hcl er (sr)...... 27 cefaclor...... 69 clarithromycin...... 102 bupropion hcl er (xl)...... 27 cefaclor er...... 69 clarithromycin er...... 102 buspirone hcl...... 18 cefadroxil...... 69 clemastine fumarate...... 35 busulfan...... 42 cefdinir...... 69, 70 Clenpiq...... 101 Busulfex...... 42 cefixime...... 70 Cleocin...... 138 butalbital-acetaminophen...... 13 cefpodoxime proxetil...... 70 Clever Choice Glucose Control.. 104 butalbital-apap-caff-cod...... 13, 14 cefprozil...... 69 Clever Choice Holding Chamber 108 butalbital-apap-caffeine...... 13 cefuroxime axetil...... 69 Climara Pro...... 92 butalbital-asa-caff-codeine...... 14 celecoxib...... 11 Clindacin ETZ...... 74 butalbital-aspirin-caffeine...... 13 Celontin...... 26 Clindacin-P...... 74 butorphanol tartrate...... 16 Centany...... 76 clindamycin hcl...... 40 Bystolic...... 65 cephalexin...... 69 clindamycin palmitate hcl...... 40 cabenuva...... 61 Cerdelga...... 99 clindamycin phos-benzoyl perox...... 75 cabergoline...... 88 Cerezyme...... 99 clindamycin phosphate...... 74, 138 Cablivi...... 97 Cervidil...... 124 clindamycin-tretinoin...... 75 Cabometyx...... 48 Cetacaine...... 85 Clindesse...... 138 caffeine citrate...... 8 cetirizine hcl...... 35 clobazam...... 23 calcipotriene...... 78 cevimeline hcl...... 113 clobetasol prop emollient base...... 80 calcipotriene-betameth diprop...... 85 Chantix...... 131 clobetasol propionate...... 80 calcitonin (salmon)...... 88 Chantix Continuing Month Pak...131 clobetasol propionate e...... 80 Calcitrene...... 78 Chantix Starting Month Pak...... 131 clobetasol propionate emulsion...... 80 calcitriol...... 78, 89 Chemet...... 33 clocortolone pivalate...... 80 calcium acetate (phos binder)...... 95 Chemstrip K...... 86 Clodan...... 80 calcium-folic acid plus d...... 110 Chemstrip uGK...... 86 clofarabine...... 43 Calquence...... 47 chlordiazepoxide hcl...... 18 Clolar...... 43 Cambia...... 109 chlordiazepoxide-amitriptyline...... 128 clomipramine hcl...... 28 Camptosar...... 55 chlordiazepoxide-clidinium...... 135 clonazepam...... 23 candesartan cilexetil...... 38 chlorhexidine gluconate...... 60, 113 clonidine...... 38 candesartan cilexetil-hctz...... 38 chloroquine phosphate...... 41 clonidine hcl...... 38 capecitabine...... 43 chlorpromazine hcl...... 59 clonidine hcl er...... 8 Capex...... 80 chlorthalidone...... 87 clopidogrel bisulfate...... 99 Caplyta...... 58 chlorzoxazone...... 116 clorazepate dipotassium...... 18 Caprelsa...... 48 Cholbam...... 94 clotrimazole...... 113 captopril...... 37 cholestyramine...... 35 clotrimazole-betamethasone...... 76 Carbaglu...... 89 cholestyramine light...... 35 clozapine...... 59 carbamazepine...... 23 Ciclodan...... 77 c-nate dha...... 113 carbamazepine er...... 23 ciclopirox...... 77 Coartem...... 41 carbidopa...... 57 ciclopirox olamine...... 77 cocoa butter...... 127 carbidopa-levodopa...... 57 cilostazol...... 98 coconut oil...... 70 carbidopa-levodopa er...... 57 Ciloxan...... 120 codeine sulfate...... 14 carbidopa-levodopa-entacapone..... 57 Cimduo...... 61 colchicine...... 97 142 colchicine-probenecid...... 97 cyclobenzaprine hcl...... 116 dexamethasone...... 72 colesevelam hcl...... 35 cyclobenzaprine hcl er...... 116 Dexamethasone Intensol...... 72 colestipol hcl...... 35 Cyclomydril...... 120 dexamethasone sodium phosphate Combigan...... 119 cyclopentolate hcl...... 120 ...... 123 CombiPatch...... 92 cyclophosphamide...... 54 dexchlorpheniramine maleate...... 34 Combivent Respimat...... 19 cycloserine...... 41 Dexcom G4 Plat Ped Rcv/Share. 105 Cometriq (60 MG Daily Dose)...... 48 Cycloset...... 30 Dexcom G4 Plat Ped Receiver.... 105 Compact Space Chamber...... 108 cyclosporine...... 111 Dexcom G4 Platinum Rcv/Share 105 Compact Space Chamber/Lg cyclosporine modified...... 111 Dexcom G4 Platinum Receiver... 105 Mask...... 108 cyproheptadine hcl...... 35 Dexcom G4 Platinum Transmitter Compact Space Chamber/Med Cyramza...... 56 ...... 105 Mask...... 108 Cystadane...... 89 Dexcom G4 Sensor...... 105 Compact Space Chamber/Sm Cystagon...... 96 Dexcom G5 Mob/G4 Plat Sensor 105 Mask...... 108 Cystaran...... 123 Dexcom G5 Mobile Receiver...... 105 Complera...... 61 cytarabine...... 43 Dexcom G5 Mobile Transmitter.. 105 Compro...... 59 cytarabine (pf)...... 43 Dexcom G6 Receiver...... 105 Co-Natal FA...... 113 Cytomel...... 134 Dexcom G6 Sensor...... 105 Concept DHA...... 113 cytra k crystals...... 96 Dexcom G6 Transmitter...... 105 Concept OB...... 114 cytra-2...... 96 Dexeryl...... 83 Condylox...... 82 cytra-k...... 96 Dexilant...... 136 constulose...... 102 dacarbazine...... 51 dexmethylphenidate hcl...... 9 Contour Next Control...... 104 Dacogen...... 43 dexmethylphenidate hcl er...... 9 control...... 104 dactinomycin...... 50 dextroamphetamine sulfate...... 8 Cool Control A...... 104 dalfampridine er...... 130 dextroamphetamine sulfate er...... 8 Cool Control B...... 105 Daliresp...... 21 Diacomit...... 24 Copaxone...... 130 danazol...... 16 Diastat AcuDial...... 23 Copiktra...... 54 dantrolene sodium...... 116 Diastat Pediatric...... 23 Cordran...... 80 Danyelza...... 45 Diathrive Glucose Control Soln..105 Corlanor...... 69 dapsone...... 40, 74 diatrue control level 1...... 105 Cortane-B...... 85 Daptacel...... 135 diatrue control level 2...... 105 Cosela...... 54 Daraprim...... 41 diatrue control level 3...... 105 Cosentyx...... 77 Darzalex...... 45 diazepam...... 18, 23 Cosentyx (300 MG Dose)...... 77 Darzalex Faspro...... 51 Diazepam Intensol...... 18 Cosentyx Sensoready (300 MG)... 77 daunorubicin hcl...... 50 diazoxide...... 29 Cosentyx Sensoready Pen...... 77 Daurismo...... 47 diclofenac potassium...... 11 Cosmegen...... 50 Daytrana...... 9 diclofenac sodium...... 11, 122 Cotellic...... 48 DayVigo...... 101 diclofenac sodium er...... 11 cottonseed oil...... 70 Debacterol...... 113 diclofenac-misoprostol...... 11 Covaryx...... 92 Decadron...... 72 dicloxacillin sodium...... 126 Covaryx HS...... 92 decitabine...... 43 dicyclomine hcl...... 135 Creon...... 86 deferasirox...... 33 Dificid...... 103 Cresemba...... 34 deferiprone...... 33 diflorasone diacetate...... 80 Crinone...... 139 Delstrigo...... 61 diflunisal...... 13 Crixivan...... 62 demeclocycline hcl...... 133 Digitek...... 67 cromolyn sodium...... 20, 94, 120 Denavir...... 79 Digox...... 67 Crotan...... 84 Depakote...... 26 digoxin...... 67 Crysvita...... 92 Depakote ER...... 26 dihydroergotamine mesylate...... 109 Curity Alcohol Preps...... 103 Depakote Sprinkles...... 27 Dilantin...... 26 Curity Alcohol Swabs...... 103 Depo-Provera...... 71 Dilantin Infatabs...... 26 Cutaquig...... 125 Dermazene...... 76 diltiazem hcl...... 66 Cuvitru...... 125 Descovy...... 61 diltiazem hcl er...... 66 cvs alcohol prep pads...... 103 desipramine hcl...... 29 diltiazem hcl er beads...... 66 cvs creamy acne face wash...... 76 desmopressin ace spray refrig...... 92 diltiazem hcl er coated beads...... 66 cvs distilled water...... 126 desmopressin acetate...... 92 dilt-xr...... 66 cvs isopropyl alcohol wipes...... 85 desmopressin acetate spray...... 92 dimethyl fumarate...... 130 CVS Ketone Care...... 86 desogestrel-ethinyl estradiol...... 70 dimethyl fumarate starter pack...... 130 cvs mineral oil...... 102 desonide...... 80 Dipentum...... 95 cvs prep...... 103 desoximetasone...... 80 diphenoxylate-atropine...... 32 cvs purified water...... 126 desvenlafaxine er...... 28 diphtheria-tetanus toxoids dt...... 135 cyanocobalamin...... 99 desvenlafaxine succinate er...... 28 dipyridamole...... 98 143 disopyramide phosphate...... 18 EasyMax Control...... 105 Entresto...... 67 distillata distilled water...... 126 econazole nitrate...... 82 Entyvio...... 95 distilled water...... 126 Ecoza...... 82 enulose...... 95 disulfiram...... 128 Edarbi...... 38 Envarsus XR...... 112 Diuril...... 87 Edarbyclor...... 38 Epclusa...... 64 divalproex sodium...... 27 Edex...... 67 Epidiolex...... 24 divalproex sodium er...... 27 Edluar...... 101 Epiduo Forte...... 75 Divigel...... 93 ed-spaz...... 135 Epifoam...... 85 docetaxel...... 53 Edurant...... 62 epinastine hcl...... 120 dofetilide...... 19 EEMT...... 92 epinephrine...... 139 donepezil hcl...... 128 EEMT HS...... 92 EpiPen 2-Pak...... 139 Doptelet...... 100 efavirenz...... 63 EpiPen Jr 2-Pak...... 139 Doryx...... 133 efavirenz-emtricitab-tenofovir...... 61 epirubicin hcl...... 50 dorzolamide hcl...... 121 efavirenz-lamivudine-tenofovir...... 61 Epitol...... 24 dorzolamide hcl-timolol mal...... 119 Effer-K...... 110 Epivir HBV...... 64 Dovato...... 61 Elaprase...... 90 eplerenone...... 39 doxazosin mesylate...... 39 Elelyso...... 99 epoprostenol sodium...... 67 doxepin hcl...... 29, 77 element compact control 2...... 105 Epzicom...... 61 doxercalciferol...... 89 element compact control 3...... 105 eq mineral oil...... 102 Doxil...... 50 Element Control...... 105 eql alcohol swabs...... 103 doxorubicin hcl...... 50 Elestrin...... 93 Equetro...... 58 doxorubicin hcl liposomal...... 50 Eletone...... 83 Erbitux...... 47 doxycycline...... 84 eletriptan hydrobromide...... 109 ergocalciferol...... 139 doxycycline hyclate...... 133 Eligard...... 53 ergoloid mesylates...... 131 doxycycline monohydrate...... 133 Eliquis...... 22 Ergomar...... 109 Dritho-Creme HP...... 78 Elixophyllin...... 22 ergotamine-caffeine...... 109 dronabinol...... 34 Ella...... 71 Erivedge...... 47 drospiren-eth estrad-levomefol...... 71 Ellence...... 50 Erleada...... 42 Droxia...... 99 Elmiron...... 97 erlotinib hcl...... 47 Drysol...... 84 Elzonris...... 51 Ertaczo...... 82 Duavee...... 93 Embrace Control...... 105 ery...... 74 Duet DHA 400...... 114 Embrace Evo Control Level 1..... 105 Ery-Tab...... 102 Duet DHA Balanced...... 114 Embrace Glucose Control...... 105 Erythrocin Stearate...... 103 duloxetine hcl...... 28 Embrace Pro Glucose Control....105 erythromycin...... 74, 120 Duobrii...... 85 Embrace Talk Glucose Control...105 erythromycin base...... 103 Duo-Care Control Solution...... 105 Emcyt...... 52 erythromycin ethylsuccinate...... 103 Duopa...... 57 Emend...... 34 Esbriet...... 133 Dupixent...... 79 Emgality...... 109 escitalopram oxalate...... 27 Durezol...... 123 Emgality (300 MG Dose)...... 109 Esgic...... 13 Durolane...... 116 Empaveli...... 98 esomeprazole magnesium...... 136 Durysta...... 123 Empliciti...... 46 essentra wipes 9x9"...... 103 dutasteride...... 96 Emsam...... 27 est estrogens-methyltest...... 92 dutasteride-tamsulosin hcl...... 97 emtricitabine...... 63 est estrogens-methyltest ds...... 92 Dutoprol...... 39 emtricitabine-tenofovir df...... 61 est estrogens-methyltest hs...... 92 Dyanavel XR...... 8 Emtriva...... 63 estazolam...... 101 Dysport...... 118 Emverm...... 17 estradiol...... 93, 139 E.E.S. 400...... 102 enalapril maleate...... 37 estradiol-norethindrone acet...... 92 EasiVent...... 108 enalapril-hydrochlorothiazide...... 37 Estring...... 139 EasiVent Mask Large...... 108 EnBrace HR...... 114 Estrogel...... 93 EasiVent Mask Medium...... 108 Enbrel...... 13 eszopiclone...... 101 EasiVent Mask Small...... 108 Enbrel Mini...... 13 ethacrynic acid...... 87 easy plus ii control...... 105 Enbrel SureClick...... 13 ethambutol hcl...... 41 Easy Step Control...... 105 Endocet...... 15 ethosuximide...... 26 easy talk control...... 105 Engerix-B...... 138 etodolac...... 12 Easy Touch Alcohol Prep Enhertu...... 50 etodolac er...... 11 Medium...... 103 enoxaparin sodium...... 22 etonogestrel-ethinyl estradiol...... 71 Easy Touch Control High & Low 105 Enspryng...... 112 Etopophos...... 53 easy trak control...... 105 Enstilar...... 85 etoposide...... 53 EasyGluco Plus Level 1...... 105 entacapone...... 58 etravirine...... 63 EasyMax 15 Level 2 Control...... 105 entecavir...... 64 Eucrisa...... 84 144 Euflexxa...... 116 Flarex...... 123 fosinopril sodium-hctz...... 37 Euthyrox...... 134 Flavor Blend...... 126 Fosrenol...... 95 Evamist...... 93 flavor plus...... 126 FreeStyle Control Solution...... 106 Evenity...... 91 flavor sweet...... 126 FreeStyle Libre 14 Day Reader... 106 everolimus...... 48, 112 flavor sweet-sf...... 126 FreeStyle Libre 14 Day Sensor... 106 Evkeeza...... 35 flavoxate hcl...... 137 FreeStyle Libre Reader...... 106 Evolution Control...... 105 Flebogamma DIF...... 125 frovatriptan succinate...... 109 Evomela...... 54 flecainide acetate...... 19 Fulphila...... 99 Evotaz...... 61 Flexichamber...... 108 fulvestrant...... 52 Evrysdi...... 119 Flexichamber Adult Mask/Small. 108 furosemide...... 87 exemestane...... 52 Flexichamber Child Mask/Large. 108 Fuzeon...... 62 Exjade...... 33 Flexichamber Child Mask/Small. 108 Fycompa...... 23 Exondys 51...... 118 Flolan...... 68 g tussin ac...... 73 Extavia...... 129 flolipid...... 36 gabapentin...... 24 Eylea...... 124 Floriva...... 110 Gabitril...... 26 ezetimibe...... 36 Flovent Diskus...... 22 Galafold...... 88 ezetimibe-simvastatin...... 36 Flovent HFA...... 22 galantamine hydrobromide...... 128 Fabior...... 76 floxuridine...... 43 galantamine hydrobromide er...... 128 Fabrazyme...... 88 Fluarix Quadrivalent...... 138 Galzin...... 111 FaLessa...... 71 fluconazole...... 34 Gamifant...... 112 famciclovir...... 64 flucytosine...... 34 Gammagard...... 125 famotidine...... 136 fludarabine phosphate...... 43 Gammagard S/D Less IgA...... 125 Fanapt...... 58 fludrocortisone acetate...... 73 Gammaked...... 125 Fanapt Titration Pack...... 58 Flulaval Quadrivalent...... 138 Gammaplex...... 125 Farxiga...... 31 flunisolide...... 117 Gamunex-C...... 125 Farydak...... 48 fluocinolone acetonide...... 80, 124 Gardasil 9...... 138 Fasenra...... 21 fluocinolone acetonide body...... 80 gatifloxacin...... 120 Fasenra Pen...... 21 fluocinolone acetonide scalp...... 80 Gattex...... 94 Faslodex...... 52 fluocinonide...... 80 GaviLyte-C...... 101 Fattyblend...... 127 fluocinonide emulsified base...... 80 GaviLyte-N with Flavor Pack...... 101 febuxostat...... 97 fluorometholone...... 123 Gavreto...... 49 felbamate...... 25 Fluoroplex...... 77 Gazyva...... 44 Felbatol...... 26 fluorouracil...... 43, 77 ge100 control...... 106 felodipine er...... 66 fluoxetine hcl...... 28 Gelclair...... 113 Femring...... 139 fluoxetine hcl (pmdd)...... 131 Gelfilm...... 123 fenofibrate...... 36 fluphenazine hcl...... 59 Gelnique...... 136 fenofibrate micronized...... 35 flurandrenolide...... 81 Gel-One...... 116 fenofibric acid...... 36 flurazepam hcl...... 101 Gelsyn-3...... 116 fenoprofen calcium...... 12 flurbiprofen...... 12 gemcitabine hcl...... 43 Fenortho...... 12 flurbiprofen sodium...... 122 gemfibrozil...... 36 Fensolvi (6 Month)...... 90 flutamide...... 42 gemmily...... 71 fentanyl...... 14 fluticasone propionate...... 81, 117 generlac...... 95 fentanyl citrate...... 14 fluvastatin sodium...... 36 Gengraf...... 111 Fentora...... 14 fluvastatin sodium er...... 36 Genotropin...... 88 Ferriprox...... 33 fluvoxamine maleate...... 28 Genotropin MiniQuick...... 88 Ferriprox Twice-A-Day...... 33 fluvoxamine maleate er...... 28 Gentak...... 120 Fetzima...... 28 FML...... 123 gentamicin sulfate...... 76, 120 Fetzima Titration...... 28 FML Forte...... 123 GenVisc 850...... 116 Fiasp...... 30 folic acid...... 99 Genvoya...... 61 Fiasp FlexTouch...... 30 Folotyn...... 43 Gilenya...... 131 Fiasp PenFill...... 30 fondaparinux sodium...... 22 Gilotrif...... 47 Fifty50 Alcohol Prep...... 103 FORA Control...... 105 Givlaari...... 97 Finacea...... 84 ForaCare GDH Control...... 105 Glassia...... 132 finasteride...... 96 formaldehyde...... 60 glatiramer acetate...... 130 Fintepla...... 24 formoterol fumarate...... 20 Glatopa...... 131 Firazyr...... 97 FortisCare Control...... 106 Gleevec...... 46 Firdapse...... 41 Fosamax Plus D...... 87 Gleostine...... 54 Firmagon...... 52 fosamprenavir calcium...... 62 Gliadel Wafer...... 54 Firvanq...... 40 fosfomycin tromethamine...... 40 glimepiride...... 32 Flac...... 124 fosinopril sodium...... 37 glipizide...... 32 145 glipizide er...... 32 Hizentra...... 125 IDHIFA...... 53 glipizide xl...... 32 hm castor oil...... 70 Ifex...... 54 glipizide-metformin hcl...... 32 hm glycerin...... 82 ifosfamide...... 54 global alcohol prep ease...... 103 hm mineral oil...... 102 Ilaris...... 11 Gloperba...... 97 hm sterile alcohol prep...... 103 Ilevro...... 122 GlucaGen HypoKit...... 29 Homatropaire...... 120 Ilumya...... 78 glucagon emergency...... 29 HPR Plus...... 83 imatinib mesylate...... 46 Glucocard 01 Control...... 106 HPR PLUS HydroGel...... 83 Imbruvica...... 47 Glucocard Expression Control... 106 Humatrope...... 88 Imfinzi...... 46 Glucocard Shine Control...... 106 Humira...... 11 imipramine hcl...... 29 Glucocard X-Sensor Control...... 106 Humira Pediatric Crohns Start...... 10 imipramine pamoate...... 29 GlucoCom Control...... 106 Humira Pen...... 11 imiquimod...... 82 glucose control...... 106 Humira Pen-CD/UC/HS Starter...... 11 Imlygic...... 54 glutaraldehyde...... 60 Humira Pen-Ps/UV/Adol HS Start. 11 Impavido...... 39 glyburide...... 32 Humira Pen-Psor/Uveit Starter..... 11 Imvexxy Maintenance Pack...... 139 glyburide micronized...... 32 HumuLIN R U-500 Imvexxy Starter Pack...... 139 glyburide-metformin...... 32 (CONCENTRATED)...... 30 In Touch Glucose Control...... 106 glycerin...... 82 HumuLIN R U-500 KwikPen...... 30 Inbrija...... 56 glycolic acid...... 78 Hyalgan...... 116, 117 Increlex...... 90 glycopyrrolate...... 136 Hycamtin...... 55 Incruse Ellipta...... 20 Glyxambi...... 31 Hyclodex...... 85 indapamide...... 87 gnp alcohol swabs...... 103 hydralazine hcl...... 39 Inderal XL...... 65 GNP Easy Touch Cont High/Low106 hydrochlorothiazide...... 87 Indocin...... 12 GoNitro...... 17 hydrocod polst-cpm polst er...... 74 indomethacin...... 12 goodsense mineral oil...... 102 hydrocodone bitartrate er...... 14 indomethacin er...... 12 granisetron hcl...... 33 hydrocodone-acetaminophen...... 14 Infanrix...... 135 Granix...... 99 hydrocodone-homatropine...... 73 Infinity Control...... 106 grape syrup...... 126 hydrocodone-ibuprofen...... 14 Infinity Voice...... 106 Grastek...... 9 hydrocortisone...... 17, 72, 81 Inflectra...... 96 griseofulvin microsize...... 34 hydrocortisone acetate...... 17 Infugem...... 43 griseofulvin ultramicrosize...... 34 hydrocortisone butyr lipo base...... 81 Ingrezza...... 129 guaiatussin ac...... 73 hydrocortisone butyrate...... 81 Inlyta...... 56 guaifenesin ac...... 73 hydrocortisone valerate...... 81 Inqovi...... 51 guaifenesin-codeine...... 73 hydrocortisone-acetic acid...... 124 Inrebic...... 53 guanfacine hcl...... 38 hydrocortisone-iodoquinol...... 76 InspiraChamber/Large...... 108 guanfacine hcl er...... 8 hydromet...... 73 InspiraChamber/Medium...... 108 Gvoke HypoPen 1-Pack...... 29 hydromorphone hcl...... 14 InspiraChamber/Mouthpiece...... 108 Gvoke HypoPen 2-Pack...... 29 hydroxychloroquine sulfate...... 41 InspiraChamber/Small...... 108 Gvoke PFS...... 29 hydroxyprogesterone caproate 55, 128 Inspirease...... 108 Gynazole-1...... 138 hydroxyurea...... 51 Intelence...... 63 Haegarda...... 98 hydroxyzine hcl...... 18 Intrarosa...... 138 Halaven...... 53 hydroxyzine pamoate...... 18 Invega Sustenna...... 58 halcinonide...... 81 Hylatopic Plus...... 83 Invega Trinza...... 58 halobetasol propionate...... 81 Hymovis...... 117 Inveltys...... 123 Halog...... 81 Hyophen...... 40 Invirase...... 62 haloperidol...... 59 hyoscyamine sulfate...... 135 iodine strong...... 110 haloperidol lactate...... 59 hyoscyamine sulfate er...... 135 iodine tincture...... 61 Harvoni...... 64 hyoscyamine sulfate sl...... 135 iodoquimez-hc...... 77 Havrix...... 138 hyosyne...... 135 iodoquinol-hydrocortisone-aloe...... 77 h-e-b incontrol alcohol...... 103 HyperSal...... 73 Iopidine...... 122 Hemangeol...... 65 Hyqvia...... 126 Ipol...... 138 Hemmorex-HC...... 17 ibandronate sodium...... 87 ipratropium bromide...... 20, 117 Hepsera...... 64 Ibrance...... 52 ipratropium-albuterol...... 19 Herceptin...... 45 IBU...... 12 irbesartan...... 38 Herceptin Hylecta...... 51 ibuprofen...... 12 irbesartan-hydrochlorothiazide...... 38 Herzuma...... 45 icatibant acetate...... 97 Iressa...... 47 Hetlioz...... 101 Iclusig...... 46 irinotecan hcl...... 55 Hetlioz LQ...... 101 icosapent ethyl...... 35 Isentress...... 62 Hiberix...... 137 Idamycin PFS...... 50 Isentress HD...... 62 Histex-AC...... 74 idarubicin hcl...... 50 isoniazid...... 41 146 isopropyl alcohol...... 85 Kitabis Pak...... 10 letrozole...... 52 isopropyl alcohol wipes...... 85 Klisyri...... 83 leucovorin calcium...... 52 Isopto Atropine...... 120 Klor-Con...... 110 Leukeran...... 54 isosorbide dinitrate...... 17 Klor-Con 10...... 110 Leukine...... 100 isosorbide mononitrate...... 17 Klor-Con M10...... 110 leuprolide acetate...... 53 isosorbide mononitrate er...... 17 Klor-Con M15...... 110 levalbuterol hcl...... 20 isotretinoin...... 76 Klor-Con M20...... 110 levalbuterol tartrate...... 20 isoxsuprine hcl...... 67 Klor-Con/EF...... 110 levetiracetam...... 24 isradipine...... 66 Kloxxado...... 33 levetiracetam er...... 24 Istodax (Overfill)...... 48 Korlym...... 31 Levicyn...... 83 Isturisa...... 88 Koselugo...... 48 Levitra...... 69 itraconazole...... 34 kp folic acid...... 99 levobunolol hcl...... 119 ivermectin...... 17, 84, 85 K-Phos...... 110 levocarnitine...... 88 Ixempra Kit...... 53 K-Phos No 2...... 97 levofloxacin...... 93, 120 Jadenu...... 33 K-Prime...... 110 levorphanol tartrate...... 14 Jadenu Sprinkle...... 33 Kristalose...... 102 Levo-T...... 134 Jakafi...... 53 Krystexxa...... 97 levothyroxine sodium...... 134 Jantoven...... 22 Kuvan...... 91 Levoxyl...... 134 Janumet...... 30 Kymriah...... 46 Levulan Kerastick...... 84 Janumet XR...... 30 Kynmobi...... 57 Lexiva...... 62 Januvia...... 30 Kyprolis...... 49 Liberty Glucose Control...... 106 Jardiance...... 31 labetalol hcl...... 65 Liberty Glucose Control Mid...... 106 Jatenzo...... 16 Lacrisert...... 119 Libtayo...... 46 Jelmyto...... 50 lactulose...... 102 lidocaine...... 83 Jemperli...... 46 lactulose encephalopathy...... 95 Lidocaine (Anorectal)...... 17 Jevtana...... 53 LaMICtal...... 24 lidocaine hcl...... 83, 113 Jinteli...... 92 LaMICtal ODT...... 24 lidocaine hcl urethral/mucosal...... 83 Jublia...... 82 LaMICtal Starter...... 24 lidocaine-prilocaine...... 85 Juluca...... 61 LaMICtal XR...... 24 lindane...... 85 Juxtapid...... 36 lamivudine...... 63, 64 linezolid...... 40 Jynarque...... 91 lamivudine-zidovudine...... 61 linseed oil...... 70 Kadcyla...... 51 lamotrigine...... 24 Linzess...... 94 Kaitlib Fe...... 71 lamotrigine er...... 24 liothyronine sodium...... 134 Kalbitor...... 98 lamotrigine starter kit-blue...... 24 lisinopril...... 37 Kaletra...... 61 lamotrigine starter kit-green...... 24 lisinopril-hydrochlorothiazide...... 37 Kalydeco...... 132 lamotrigine starter kit-orange...... 24 lithium carbonate...... 58 Kanjinti...... 45 Lampit...... 40 lithium carbonate er...... 58 Kanuma...... 90 Lanoxin...... 67 Lithobid...... 58 Karbinal ER...... 35 lansoprazole...... 136 Lithostat...... 97 Kariva...... 70 Lantus...... 30 Livalo...... 36 Katerzia...... 66 Lantus SoloStar...... 30 Lo Loestrin Fe...... 70 Keppra...... 24 lapatinib ditosylate...... 48 Lokelma...... 112 Keppra XR...... 24 Lastacaft...... 120 Lonsurf...... 51 Kerr Triple Dye Swabs...... 60 latanoprost...... 123 lopinavir-ritonavir...... 61 Kesimpta...... 130 Latuda...... 58 lorazepam...... 18 ketoconazole...... 34, 82 Layolis FE...... 71 LORazepam Intensol...... 18 Keto-Diastix...... 86 Lazanda...... 14 Lorbrena...... 44 ketone test...... 86 LDO Plus...... 83 Lortab...... 14 ketoprofen er...... 12 Leena...... 71 Lorzone...... 116 ketorolac tromethamine...... 12, 122 leflunomide...... 12 losartan potassium...... 38 Ketostix...... 86 Lemtrada...... 130 losartan potassium-hctz...... 38 Keveyis...... 86 Lenvima (10 MG Daily Dose)...... 56 Lotemax...... 123 Keytruda...... 46 Lenvima (12 MG Daily Dose)...... 56 Lotemax SM...... 123 Kinrix...... 135 Lenvima (14 MG Daily Dose)...... 56 loteprednol etabonate...... 123 Kisqali (200 MG Dose)...... 52 Lenvima (18 MG Daily Dose)...... 56 lovastatin...... 36 Kisqali (400 MG Dose)...... 52 Lenvima (20 MG Daily Dose)...... 56 loxapine succinate...... 59 Kisqali (600 MG Dose)...... 52 Lenvima (24 MG Daily Dose)...... 56 lubiprostone...... 94 Kisqali Femara (400 MG Dose)..... 51 Lenvima (4 MG Daily Dose)...... 56 Lucentis...... 124 Kisqali Femara (600 MG Dose)..... 51 Lenvima (8 MG Daily Dose)...... 56 Lumakras...... 48 Kisqali Femara(200 MG Dose)...... 51 Letairis...... 68 Lumigan...... 123 147 Lumizyme...... 88 Mepsevii...... 90 mirtazapine...... 27 Lumoxiti...... 45 mercaptopurine...... 43 Mirvaso...... 84 lung perform peak flow meter...... 107 mesalamine...... 95 misoprostol...... 136 Lupaneta Pack...... 90 mesalamine er...... 95 mitomycin...... 50 Lupkynis...... 111 mesalamine-cleanser...... 95 Mitosol...... 120 Lupron Depot (1-Month)...... 53 Mesnex...... 55 mitoxantrone hcl...... 50 Lupron Depot (3-Month)...... 53 metaxalone...... 116 m-natal plus...... 114 Lupron Depot (4-Month)...... 53 metformin hcl...... 29 modafinil...... 9 Lupron Depot (6-Month)...... 53 metformin hcl er...... 29 moexipril hcl...... 37 Lupron Depot-Ped (1-Month)...... 90 methadone hcl...... 14 mometasone furoate...... 81, 117 Lupron Depot-Ped (3-Month)...... 90 Methadone HCl Intensol...... 14 Mondoxyne NL...... 133 Luxturna...... 121 Methadose...... 15 Monjuvi...... 44 Lynparza...... 55 methamphetamine hcl...... 8 Monovisc...... 117 Lysodren...... 42 methazolamide...... 86 monsels ferric subsulfate...... 100 mafenide acetate...... 79 methenamine hippurate...... 40 montelukast sodium...... 21 MagneBind 400...... 110 methenamine mandelate...... 40 Morgidox...... 133 malathion...... 85 Methergine...... 124 morphine sulfate...... 15 Margenza...... 45 methimazole...... 133 morphine sulfate (concentrate)...... 15 Marplan...... 27 methitest...... 16 morphine sulfate er...... 15 Marqibo...... 53 methocarbamol...... 116 morphine sulfate er beads...... 15 Matulane...... 51 methotrexate...... 43 Motofen...... 33 Matzim LA...... 66 methotrexate sodium...... 43 Movantik...... 95 Mavenclad (10 Tabs)...... 129 methotrexate sodium (pf)...... 43 moxifloxacin hcl...... 93, 121 Mavenclad (4 Tabs)...... 129 methoxsalen rapid...... 78 moxifloxacin hcl (2x day)...... 121 Mavenclad (5 Tabs)...... 129 methscopolamine bromide...... 136 Mozobil...... 99 Mavenclad (6 Tabs)...... 129 methyldopa...... 39 Mulpleta...... 100 Mavenclad (7 Tabs)...... 129 methylergonovine maleate...... 124 Multaq...... 19 Mavenclad (8 Tabs)...... 129 methylphenidate hcl...... 9 mupirocin...... 76 Mavenclad (9 Tabs)...... 129 methylphenidate hcl er...... 9 mupirocin calcium...... 76 Mavyret...... 64 methylphenidate hcl er (cd)...... 9 Muse...... 67 Maxidex...... 123 methylphenidate hcl er (la)...... 9 Mutamycin...... 50 Mayzent...... 131 methylphenidate hcl er (xr)...... 9 Mvasi...... 56 Mayzent Starter Pack...... 132 methylprednisolone...... 72 MX-Sol...... 127 MCT Oil...... 119 methyltestosterone...... 16 MX-Sol Blend...... 126 me/naphos/mb/hyo1...... 41 metoclopramide hcl...... 94 MX-Sol Blend SF...... 127 meclofenamate sodium...... 12 metolazone...... 87 MX-Sol SF...... 127 MediSense Glucose Ketone metoprolol succinate er...... 65 MX-Sol Suspend...... 127 Contr...... 106 metoprolol tartrate...... 65 Mycapssa...... 91 Medisense Hi/Mid/Low Control...106 metoprolol-hydrochlorothiazide...... 39 mycophenolate mofetil...... 112 Medisense High/Low Control...... 106 metronidazole...... 39, 84, 138 mycophenolate sodium...... 112 Medisense Mid Control...... 106 metyrosine...... 37 Mydayis...... 8 Medrol...... 72 mexiletine hcl...... 19 Myfembree...... 93 medroxyprogesterone acetate. 71, 128 Microdot Control High/Low...... 106 MyGlucoHealth Control...... 106 mefenamic acid...... 12 Microlife Digital Peak Flow...... 107 Myleran...... 42 mefloquine hcl...... 41 midodrine hcl...... 139 Mylotarg...... 45 megestrol acetate...... 55, 128 Migergot...... 109 Mynatal...... 114 meijer alcohol swabs...... 103 miglitol...... 29 mynatal plus...... 114 Mekinist...... 48 miglustat...... 99 mynatal-z...... 114 Mektovi...... 48 Millipred...... 72 Myobloc...... 118 meloxicam...... 12 Mimvey...... 92 Myorisan...... 76 melphalan...... 54 MimyX...... 83 Myrbetriq...... 137 melphalan hcl...... 54 mineral oil...... 102 Mysoline...... 24 memantine hcl...... 131 mineral oil heavy...... 102 Mytesi...... 32 memantine hcl er...... 131 mineral oil light...... 85 nabumetone...... 12 Menactra...... 137 Mini Wright Peak Flow Meter...... 107 nadolol...... 65 Menest...... 93 Minitran...... 17 naftifine hcl...... 77 Menostar...... 93 minocycline hcl...... 133 Naftin...... 77 Menveo...... 137 minocycline hcl er...... 133 Naglazyme...... 90 meperidine hcl...... 14 Minolira...... 133 Nalfon...... 12 meprobamate...... 18 minoxidil...... 39 naltrexone hcl...... 33 148 Namzaric...... 128 Nitro-Dur...... 17 OB Complete/DHA...... 114 naproxen...... 12 nitrofurantoin...... 40 Obstetrix DHA...... 114 naproxen sodium...... 12 nitrofurantoin macrocrystal...... 40 Obstetrix EC...... 114 naproxen sodium er...... 12 nitrofurantoin monohyd macro...... 40 Obstetrix One...... 115 naproxen-esomeprazole...... 11 nitroglycerin...... 17 Obtrex...... 114 naratriptan hcl...... 109 nitroglycerin er...... 17 O-Cal Prenatal...... 114 Narcan...... 33 NitroMist...... 18 Ocaliva...... 94 NataChew...... 114 Nitro-Time...... 18 Ocrevus...... 130 Natacyn...... 121 Nityr...... 89 Octagam...... 125 Natalvit...... 114 Niva-Plus...... 114 octreotide acetate...... 91 Natazia...... 71 Nivestym...... 100 Odactra...... 10 nateglinide...... 31 Nolix...... 81 Odefsey...... 61 Natpara...... 90 Norditropin FlexPro...... 89 Odomzo...... 47 Nature-Throid...... 134 norethin ace-eth estrad-fe...... 71 Ofev...... 133 Navelbine...... 53 norethindrone acetate...... 128 ofloxacin...... 93, 121, 124 Nayzilam...... 23 norethindrone-eth estradiol...... 92 Ogivri...... 45 nefazodone hcl...... 28 norethin-eth estradiol-fe...... 71 olanzapine...... 60 neomycin sulfate...... 10 norgestim-eth estrad triphasic...... 72 olanzapine-fluoxetine hcl...... 132 neomycin-bacitracin zn-polymyx....121 Noritate...... 84 olive oil...... 70 neomycin-polymyxin-dexameth..... 122 Norpace CR...... 18 olmesartan medoxomil...... 38 neomycin-polymyxin-gramicidin.....121 nortriptyline hcl...... 29 olmesartan medoxomil-hctz...... 38 neomycin-polymyxin-hc...... 122, 124 Norvir...... 62 olmesartan-amlodipine-hctz...... 38 NeoNatal Plus...... 114 Nourianz...... 56 olopatadine hcl...... 117, 120 Neo-Polycin...... 121 Nova Max Plus Glu/Ket Control.. 106 omega-3-acid ethyl esters...... 35 Neo-Polycin HC...... 122 NovoLIN 70/30...... 30 omeprazole...... 136 Neoral...... 111 NovoLIN N...... 30 Omnaris...... 117 Neosalus...... 83, 84 NovoLIN N FlexPen...... 30 OmniPod 5 Pack...... 107 Neo-Synalar...... 76 NovoLIN R...... 30 OmniPod Dash 5 Pack Pods...... 107 Nerlynx...... 48 NovoLIN R FlexPen...... 30 OmniPod Dash System...... 107 Nestabs...... 114 NovoLOG...... 31 OmniPod Starter...... 107 Nestabs DHA...... 114 NovoLOG FlexPen...... 30 Omnitrope...... 89 Nestabs One...... 115 NovoLOG Mix 70/30...... 30 Oncaspar...... 51 Neuac...... 75 NovoLOG Mix 70/30 FlexPen...... 30 ondansetron...... 33 Neulasta...... 99 NovoLOG PenFill...... 31 ondansetron hcl...... 33 Neulasta Onpro...... 99 Noxafil...... 34 onetouch ultra...... 86 Neupogen...... 99, 100 Nplate...... 100 OneTouch Ultra Control...... 106 Neupro...... 57 Nubeqa...... 42 OneTouch Verio...... 86, 106 Neurontin...... 24, 25 Nucala...... 21 Onexton...... 75 Neutek 2Tek Control...... 106 NuCort...... 81 Onfi...... 23 Nevanac...... 122 Nucynta...... 15 Ongentys...... 58 nevirapine...... 63 Nucynta ER...... 15 Onivyde...... 55 nevirapine er...... 63 Nuedexta...... 131 Onpattro...... 131 NexAVAR...... 48 NuLev...... 135 Ontruzant...... 45 Nextstellis...... 71 Nulibry...... 90 Onureg...... 44 Nexviazyme...... 88 Nuplazid...... 58 Onzetra Xsail...... 109 niacin er (antihyperlipidemic)...... 36 Nurtec...... 108 Opdivo...... 46 nicardipine hcl...... 66 Nutraseb...... 78 opium...... 33 Nice Distilled Water...... 127 NuvaRing...... 71 Opsumit...... 68 nifedipine...... 66 Nuvessa...... 138 OptiChamber Diamond...... 108 nifedipine er...... 66 Nuzyra...... 133 Ora-Blend...... 127 nifedipine er osmotic release...... 66 Nyamyc...... 77 Ora-Blend SF...... 127 Nilandron...... 42 Nymalize...... 66 Oracit...... 96 nilutamide...... 42 nystatin...... 34, 77, 113 Orafate...... 113 nimodipine...... 66 nystatin-triamcinolone...... 77 Oral Mix...... 127 Ninlaro...... 49 Nystop...... 77 Oral Mix SF...... 127 Nipent...... 51 Nyvepria...... 100 oral suspend...... 127 nisoldipine er...... 66 OB Complete...... 114 oral syrup...... 127 nitazoxanide...... 40 OB Complete One...... 114 oral syrup sf...... 127 nitisinone...... 89 OB Complete Petite...... 114 Oralair...... 10 Nitro-Bid...... 17 OB Complete Premier...... 114 Oralone...... 113 149 Ora-Plus...... 127 Palynziq...... 91 phenytoin sodium extended...... 26 Ora-Sweet...... 127 Pancreaze...... 86 Phesgo...... 51 Ora-Sweet SF...... 127 Pandel...... 81 Phoslyra...... 95 Oravig...... 113 PanOxyl Creamy Wash...... 76 Phospha 250 Neutral...... 110 Orencia...... 12 Panretin...... 77 Phosphasal...... 41 Orenitram...... 68 pantoprazole sodium...... 136 phosphorous...... 110 Orfadin...... 89 Panzyga...... 125 Phospho-Trin 250 Neutral...... 110 organic coconut oil...... 70 Paraplatin...... 42 Photofrin...... 51 Orgovyx...... 52 paricalcitol...... 89 Photrexa Viscous...... 122 Oriahnn...... 93 Paroex...... 113 Photrexa-Photrexa Viscous Kit.. 122 Orilissa...... 88 paromomycin sulfate...... 10 phytonadione...... 139 Orkambi...... 132 paroxetine hcl...... 28 Pifeltro...... 63 Orladeyo...... 98 paroxetine hcl er...... 28 Piko 1...... 107 orphenadrine citrate er...... 116 paroxetine mesylate...... 132 pilocarpine hcl...... 113, 120 OrthoVisc...... 117 Paser...... 41 pimecrolimus...... 83 oscimin...... 136 Paxil...... 28 pimozide...... 131 oscimin sr...... 136 PCCA Sweet-SF...... 127 Pimtrea...... 70 oseltamivir phosphate...... 65 PCCA Syrup Vehicle...... 127 pindolol...... 65 Osmolex ER...... 57 PCCA-Plus...... 127 pioglitazone hcl...... 32 OsmoPrep...... 102 Peak Air Peak Flow Meter...... 107 pioglitazone hcl-glimepiride...... 32 Osphena...... 91 peak flow meter universal rang...... 107 pioglitazone hcl-metformin hcl...... 32 Otezla...... 12 peanut oil...... 70 Piqray (200 MG Daily Dose)...... 54 Otovel...... 124 Pediarix...... 135 Piqray (250 MG Daily Dose)...... 55 Ovace Plus...... 78 Pedvax HIB...... 137 Piqray (300 MG Daily Dose)...... 55 oxaliplatin...... 42 peg-3350/electrolytes...... 101 piroxicam...... 12 oxaprozin...... 12 Pegasys...... 64 Plegridy...... 130 oxazepam...... 18 peg-kcl-nacl-nasulf-na asc-c...... 101 Plegridy Starter Pack...... 130 Oxbryta...... 100 PEG-Prep...... 101 Plenvu...... 101 oxcarbazepine...... 25 Pemazyre...... 47 Plexion Cleansing Cloth...... 75 oxiconazole nitrate...... 82 penicillamine...... 111 Pneumovax 23...... 137 Oxistat...... 82 penicillin v potassium...... 126 pnv prenatal plus multivitamin...... 114 Oxlumo...... 97 Pentacel...... 135 pnv tabs 29-1...... 114 Oxtellar XR...... 25 Pentasa...... 95 pnv-dha...... 115 oxybutynin chloride...... 137 pentazocine-naloxone hcl...... 16 pnv-dha+docusate...... 115 oxybutynin chloride er...... 137 pentetate calcium trisodium...... 33 pnv-omega...... 114 oxycodone hcl...... 15 pentetate zinc trisodium...... 33 pnv-select...... 114 oxycodone hcl er...... 15 pentoxifylline er...... 98 Pocket Chamber...... 108 oxycodone-acetaminophen...... 15, 16 Pepaxto...... 54 Pocket Peak Flow Meter...... 107 OxyCONTIN...... 15 perindopril erbumine...... 37 Pocket Spacer...... 108 oxymorphone hcl...... 15 Periogard...... 113 PocketChem EZ Control...... 106 Ozempic (0.25 or 0.5 MG/DOSE)... 31 Perjeta...... 45 Pocketpeak Peak Flow Meter...... 107 Ozempic (1 MG/DOSE)...... 31 permethrin...... 85 podocon...... 82 Ozobax...... 116 perphenazine...... 59 podofilox...... 82 Pacerone...... 19 perphenazine-amitriptyline...... 131 Polivy...... 45 paclitaxel...... 54 Personal Best Full Range...... 107 Polycin...... 121 Padcev...... 46 Pertzye...... 86 polymyxin b-trimethoprim...... 121 Palforzia (12 MG Daily Dose)...... 9 Pexeva...... 28 polypeg...... 127 Palforzia (120 MG Daily Dose)...... 9 Pharmacist Choice Alcohol...... 103 Pomalyst...... 48 Palforzia (160 MG Daily Dose)...... 9 Phenazo...... 97 Ponvory...... 132 Palforzia (20 MG Daily Dose)...... 9 phenazopyridine hcl...... 97 Ponvory Starter Pack...... 132 Palforzia (200 MG Daily Dose)...... 9 phenelzine sulfate...... 27 Portrazza...... 47 Palforzia (240 MG Daily Dose)...... 9 phenobarbital...... 100, 101 potassium chloride...... 111 Palforzia (3 MG Daily Dose)...... 9 phenobarbital-belladonna alk...... 135 potassium chloride crys er...... 110 Palforzia (300 MG Maintenance)... 10 Phenohytro...... 135 potassium chloride er...... 111 Palforzia (300 MG Titration)...... 10 phenol...... 60 potassium citrate er...... 96 Palforzia (40 MG Daily Dose)...... 10 phenoxybenzamine hcl...... 37 potassium citrate-citric acid...... 96 Palforzia (6 MG Daily Dose)...... 10 phenylephrine hcl...... 120 Poteligeo...... 44 Palforzia (80 MG Daily Dose)...... 10 Phenytek...... 26 pr benzoyl peroxide...... 76 Palforzia Initial Escalation...... 10 phenytoin...... 26 PR Benzoyl Peroxide Wash...... 76 paliperidone er...... 58 Phenytoin Infatabs...... 26 PR Cream...... 84 150 Praluent...... 36 PrimaCare...... 114 qc glycerin...... 82 pramipexole dihydrochloride...... 57 primaquine phosphate...... 41 qc mineral oil heavy...... 102 pramipexole dihydrochloride er...... 57 primidone...... 25 qc sweet oil...... 70 Pramosone...... 85 Primsol...... 39 Qinlock...... 48 prasugrel hcl...... 99 Privigen...... 125 Qnasl...... 117 pravastatin sodium...... 36 pro comfort alcohol...... 103 Qnasl Childrens...... 117 praziquantel...... 17 pro comfort spacer adult...... 108 Qtern...... 31 prazosin hcl...... 39 pro comfort spacer child...... 108 Quadracel...... 135 Precision Glucose Control...... 106 ProAir Digihaler...... 20 quazepam...... 101 Precision Glucose Control Soln. 106 ProAir HFA...... 20 Qudexy XR...... 25 Precision Glucose Ketone Contr 106 ProAir RespiClick...... 20 quetiapine fumarate...... 59 Precision Glucose/Ketone Contr 106 probenecid...... 97 quetiapine fumarate er...... 59 Pred Mild...... 123 prochlorperazine...... 59 QuickTek Control Solution...... 106 Pred-G...... 122 prochlorperazine maleate...... 59 QuilliChew ER...... 9 Pred-G S.O.P...... 122 Procysbi...... 96 quinapril hcl...... 37 prednicarbate...... 81 Prodigy Control Solution...... 106 quinapril-hydrochlorothiazide...... 37 prednisolone...... 72 progesterone...... 128 quinidine gluconate er...... 18 prednisolone acetate...... 123 Prograf...... 112 quinidine sulfate...... 18 prednisolone acetate p-f...... 123 Prolastin-C...... 132 quinine sulfate...... 41 prednisolone sodium phosphate Prolensa...... 122 Quintet Control High/Normal...... 106 ...... 72, 123 Proleukin...... 51 Qvar RediHaler...... 22 prednisone...... 72 Prolia...... 91 ra alcohol swabs...... 103 PredniSONE Intensol...... 72 Promacta...... 100 ra glycerin...... 82 Prefest...... 92 promethazine hcl...... 35 ra isopropyl alcohol wipes...... 85 pregabalin...... 25 promethazine-codeine...... 74 ra mineral oil...... 102 pregabalin er...... 131 promethazine-dm...... 73 rabeprazole sodium...... 136 Premarin...... 93, 139 promethazine-phenyleph-codeine....74 Ragwitek...... 10 premium lidocaine...... 83 promethazine-phenylephrine...... 73 raloxifene hcl...... 91 Premphase...... 92 Promethegan...... 35 ramelteon...... 101 Prempro...... 92 Promiseb...... 78 ramipril...... 37 prena 1 true...... 115 propafenone hcl...... 19 ranolazine er...... 17 prena1...... 116 propafenone hcl er...... 19 Rapamune...... 112 prena1 pearl...... 114 proparacaine hcl...... 121 rasagiline mesylate...... 57 prenaissance...... 115 Propel...... 117 Ravicti...... 92 prenaissance plus...... 115 Propel Mini...... 117 Rayaldee...... 89 prenatal...... 114 propranolol hcl...... 65, 66 Rayos...... 72 prenatal 19...... 114 propranolol hcl er...... 65 reality swabs...... 103 prenatal plus iron...... 114 propylthiouracil...... 133 Rebif...... 130 prenatal vitamin plus low iron...... 114 ProQuad...... 137 Rebif Rebidose...... 130 Prenatal-U...... 114 Pro-Red AC...... 74 Rebif Rebidose Titration Pack.... 130 Prenate...... 116 ProThelial...... 113 Rebif Titration Pack...... 130 Prenate DHA...... 115 protriptyline hcl...... 29 Reblozyl...... 99 Prenate Elite...... 114 Provenge...... 46 Reclast...... 87 Prenate Enhance...... 115 Proventil HFA...... 20 Recombivax HB...... 138 Prenate Essential...... 115 Provida OB...... 114 Rectiv...... 17 Prenate Mini...... 115 pseudoeph-bromphen-dm...... 74 RefuAH Plus Glucose Control.... 107 Prenate Pixie...... 115 psorcon...... 81 Regranex...... 85 Prenate Restore...... 115 Pulmicort Flexhaler...... 22 Relenza Diskhaler...... 65 Prepidil...... 124 Pulmozyme...... 133 ReliOn Alcohol Swabs...... 103 preplus...... 114 purified water...... 127 ReliOn Ketone Test...... 86 Presera...... 84 Purixan...... 44 Relistor...... 95 Prestalia...... 37 px purified water...... 127 relnate dha...... 114 pretab...... 114 pyrazinamide...... 41 Relpax...... 109 Pretomanid...... 41 pyridostigmine bromide...... 41 Remicade...... 96 Prevalite...... 35 pyridostigmine bromide er...... 41 remigen...... 84 Prevnar 13...... 137 pyrogallic acid...... 82 Remodulin...... 68 Prevymis...... 63 Qbrelis...... 37 Renflexis...... 96 Prezcobix...... 61 Qbrexza...... 84 repaglinide...... 31 Prezista...... 62 qc alcohol swabs...... 103 Repatha...... 37 Priftin...... 41 qc castor oil...... 70 Repatha Pushtronex System...... 36 151 Repatha SureClick...... 37 Samsca...... 91 sodium chloride...... 73 Restasis...... 121 Sancuso...... 33 sodium phenylbutyrate...... 92 Restora RX...... 32 SandIMMUNE...... 111 sodium polystyrene sulfonate...... 112 Retevmo...... 49 SandoSTATIN...... 91 sodium sulfacetamide...... 78 Retin-A Micro Pump...... 76 SandoSTATIN LAR Depot...... 91 sodium sulfacetamide wash...... 78 Retrovir...... 63 Santyl...... 82 Solartek Glucose Control...... 107 Revatio...... 68 Saphnelo...... 113 solifenacin succinate...... 137 Revcovi...... 87 sapropterin dihydrochloride...... 91 Soliqua...... 31 Revlimid...... 112 saps care alcohol prep...... 103 Soliris...... 98 Rexulti...... 60 saps health alcohol prep...... 103 Soltamox...... 43 Reyataz...... 62 saps health care alcohol prep...... 104 Solus V2 Control...... 107 Reyvow...... 110 Sarclisa...... 45 Somatuline Depot...... 91 Rhofade...... 84 Savella...... 129 Somavert...... 88 Riabni...... 44 Savella Titration Pack...... 129 sorbitol...... 102, 127 ribavirin...... 64 sb alcohol prep...... 104 Soriatane...... 78 Ridaura...... 11 Scenesse...... 83 Sorine...... 66 rifabutin...... 41 scopolamine...... 34 sotalol hcl...... 66 rifampin...... 42 Sebuderm...... 84 sotalol hcl (af)...... 66 Rightest GC300 Control...... 107 Select-OB...... 115 Sotylize...... 66 riluzole...... 118 Select-OB+DHA...... 115 soybean oil...... 70 rimantadine hcl...... 64 selegiline hcl...... 57 spg supposi-base...... 127 Rinvoq...... 10 selenium sulfide...... 78 spinosad...... 85 risedronate sodium...... 87 Selzentry...... 62 Spinraza...... 118 RisperDAL Consta...... 58 Sensipar...... 88 Spiriva HandiHaler...... 21 risperidone...... 59 Serevent Diskus...... 20 Spiriva Respimat...... 21 RiteFlo...... 108 Sernivo...... 81 spironolactone...... 87 ritonavir...... 62 Serostim...... 89 spironolactone-hctz...... 86 Rituxan...... 44 sertraline hcl...... 28 Spravato (56 MG Dose)...... 27 Rituxan Hycela...... 51 sesame oil...... 70 Spravato (84 MG Dose)...... 27 rivastigmine...... 129 sevelamer carbonate...... 95 Sprix...... 12 rivastigmine tartrate...... 129 sevelamer hcl...... 95 Sprycel...... 46 rizatriptan benzoate...... 109 SfRowasa...... 95 SPS...... 112 romidepsin...... 48 Signifor...... 91 SSD...... 79 ropinirole hcl...... 57 Signifor LAR...... 91 SSKI...... 73 ropinirole hcl er...... 57 Siklos...... 99 sss 10-5...... 75 Rosadan...... 84 sildenafil citrate...... 68, 69 stavudine...... 63 rosuvastatin calcium...... 36 Silenor...... 101 Stelara...... 78, 95 Rotarix...... 138 silodosin...... 96 Stendra...... 69 RotaTeq...... 138 silver nitrate...... 79 Stimate...... 92 Rozlytrek...... 49 silver sulfadiazine...... 79 Stiolto Respimat...... 19 Rubraca...... 55 Simbrinza...... 119 Stivarga...... 49 Ruconest...... 98 simple syrup...... 127 Strensiq...... 89 rufinamide...... 25 Simponi Aria...... 11 Stribild...... 61 Rukobia...... 62 simvastatin...... 36 Striverdi Respimat...... 20 Ruxience...... 44 Sinuva...... 117 Suboxone...... 16 Ruzurgi...... 41 sirolimus...... 112 Subsys...... 15 Rybelsus...... 31 Sirturo...... 42 Subvenite...... 25 Rybrevant...... 49 Sitavig...... 64 Subvenite Starter Kit-Blue...... 25 RyClora...... 34 Sivextro...... 40 Subvenite Starter Kit-Green...... 25 Rydapt...... 48 Skyrizi...... 78 Subvenite Starter Kit-Orange...... 25 Rylaze...... 51 Skyrizi (150 MG Dose)...... 78 Sucraid...... 86 Rytary...... 57 Skyrizi Pen...... 78 sucralfate...... 136 Sabril...... 26 Slynd...... 71 sulconazole nitrate...... 82 safflower oil...... 70 sm alcohol prep...... 104 sulfacetamide sodium...... 78, 123 Saizen...... 89 sm benzoin tincture...... 85 sulfacetamide sodium (acne)...... 74 Saizenprep...... 89 sm glycerin...... 82 sulfacetamide sodium-sulfur...... 75 salicylic acid...... 83 sm mineral oil...... 102 sulfacetamide-prednisolone...... 122 salicylic acid er...... 82 sm sweet oil...... 70 SulfaCleanse 8/4...... 75 salicylic acid wart remover...... 83 Smartest Control Medium...... 107 sulfadiazine...... 133 salsalate...... 13 sod citrate-citric acid...... 96 sulfamethoxazole-trimethoprim...... 40 152 sulfamez wash...... 75 syrup vehicle sf...... 127 Tetrix...... 84 Sulfamylon...... 79 Tabloid...... 44 Texacort...... 81 sulfasalazine...... 95 Tabrecta...... 48 Thalomid...... 111 Sulfatrim Pediatric...... 40 Taclonex...... 85 Theo-24...... 22 sulindac...... 12 tacrolimus...... 83, 112 theophylline...... 22 sumatriptan...... 109 tadalafil...... 69 theophylline er...... 22 sumatriptan succinate...... 109, 110 tadalafil (pah)...... 68 Thiola EC...... 97 sumatriptan succinate refill...... 109 Tafinlar...... 47 thioridazine hcl...... 59 sunitinib malate...... 49 Tagrisso...... 47 thiotepa...... 42 Sunosi...... 8 Tai Doc Control...... 107 thiothixene...... 60 Supartz FX...... 117 Takhzyro...... 98 thrivite rx...... 115 Supposiblend...... 127 Talzenna...... 55 Thyquidity...... 134 Supposi-Plex R36...... 127 Tamiflu...... 65 tiagabine hcl...... 26 Supposi-Plex V33...... 128 tamoxifen citrate...... 43 Tibsovo...... 53 Supprelin LA...... 90 tamsulosin hcl...... 96 Tice BCG...... 52 Suprax...... 70 Tarceva...... 47 Tiglutik...... 118 supreme ii high/low control...... 107 Targretin...... 55, 85 timolol maleate...... 66, 119, 120 Suprep Bowel Prep Kit...... 102 Taron-Prex...... 115 Timoptic Ocudose...... 120 sure comfort alcohol prep...... 104 Tasigna...... 46 tinidazole...... 39 Sure-Prep Alcohol Prep...... 104 tavaborole...... 84 tiopronin...... 97 SureStep Glucose Control...... 107 Tavalisse...... 98 Tirosint...... 134 SureStep Pro High Glucose...... 107 tazarotene...... 78 Tirosint-SOL...... 134 SureStep Pro Low Glucose...... 107 Tazorac...... 78 Tivicay...... 62 SureStep Pro Normal Glucose....107 Taztia XT...... 67 Tivicay PD...... 62 SuspendRx w/BitterBloc Sweet..127 Tazverik...... 48 tizanidine hcl...... 116 SuspendRx w/BitterBloc TDVAX...... 135 Tobi...... 10 Unsweet...... 127 Tecartus...... 46 Tobi Podhaler...... 10 suspension vehicle...... 127 Tecentriq...... 46 TobraDex...... 122 Sustiva...... 63 Tecfidera...... 130 TobraDex ST...... 123 Sutab...... 102 TEGretol...... 25 tobramycin...... 10, 121 Sutent...... 49 TEGretol-XR...... 25 tobramycin-dexamethasone...... 123 sweet oil...... 70 Tegsedi...... 128 Tobrex...... 121 Sylvant...... 112 Tekturna HCT...... 39 tolbutamide...... 32 Symax Duotab...... 136 telmisartan...... 38 tolcapone...... 57 Symax-SL...... 136 telmisartan-amlodipine...... 38 tolterodine tartrate...... 137 Symax-SR...... 136 telmisartan-hctz...... 38 tolvaptan...... 91 Symbicort...... 19 temazepam...... 101 Topamax...... 25 Symdeko...... 132 Temodar...... 52 Topamax Sprinkle...... 25 Symfi...... 61 temozolomide...... 53 topiramate...... 25 Symfi Lo...... 61 temsirolimus...... 48 topiramate er...... 25 SymlinPen 120...... 29 Tencon...... 13 Toposar...... 54 SymlinPen 60...... 29 Tenivac...... 135 topotecan hcl...... 55 Sympazan...... 23 tenofovir disoproxil fumarate...... 63 toremifene citrate...... 43 Symproic...... 95 Tenoretic 100...... 39 Torisel...... 48 Symtuza...... 61 Tenoretic 50...... 39 torsemide...... 87 Synagis...... 125 Tenormin...... 65 Toujeo Max SoloStar...... 31 Syndros...... 34 Tepadina...... 42 Toujeo SoloStar...... 31 Synera...... 85 Tepezza...... 89 Toviaz...... 137 Synjardy...... 32 Tepmetko...... 49 Tracleer...... 68 Synjardy XR...... 32 terazosin hcl...... 39 tramadol hcl...... 15 Synribo...... 52 terbinafine hcl...... 34 tramadol hcl er...... 15 Synthroid...... 134 terbutaline sulfate...... 20 tramadol hcl er (biphasic)...... 15 Synvisc...... 117 terconazole...... 138 tramadol-acetaminophen...... 16 Synvisc One...... 117 Teriparatide (Recombinant)...... 90 trandolapril...... 37 Syprine...... 111 testosterone...... 16 trandolapril-verapamil hcl er...... 37 syrpalta...... 127 testosterone cypionate...... 16 tranexamic acid...... 100 Syrpalta (Red)...... 127 testosterone enanthate...... 16 tranylcypromine sulfate...... 27 SyrSpend SF...... 127 tetrabenazine...... 129 Travatan Z...... 124 syrup nf...... 127 tetracaine hcl...... 121 Trazimera...... 45 syrup vehicle...... 127 tetracycline hcl...... 133 trazodone hcl...... 28 153 Treanda...... 42 Turalio...... 49 Veletri...... 68 Trecator...... 42 Tusnel Pediatric...... 73 Velphoro...... 95 Trelegy Ellipta...... 19 TussiCaps...... 74 Veltassa...... 112 Trelstar Mixject...... 53 Tuzistra XR...... 74 Veltin...... 75 Tremfya...... 78 Twinrix...... 138 Vemlidy...... 64 treprostinil...... 68 Twirla...... 71 Venclexta...... 46 tretinoin...... 55, 76 Tybost...... 63 Venclexta Starting Pack...... 46 tretinoin microsphere...... 76 Tykerb...... 49 Venelex...... 86 Trexall...... 44 Tymlos...... 90 venlafaxine hcl...... 28 Trezix...... 14 Tysabri...... 130 venlafaxine hcl er...... 28 triamcinolone acetonide...... 81, 113 Tyvaso...... 68 Ventavis...... 68 triamterene...... 87 Tyvaso Refill...... 68 Ventolin HFA...... 20 triamterene-hctz...... 86, 87 Tyvaso Starter...... 68 verapamil hcl...... 67 Trianex...... 81 Ubrelvy...... 109 verapamil hcl er...... 67 triazolam...... 101 Uceris...... 17 verasens glucose control...... 107 TriCare...... 115 Udenyca...... 100 Verdeso...... 81 TriCare Prenatal DHA ONE...... 115 Ukoniq...... 49 Veregen...... 76 Tri-Chlor...... 79 UltiCare Alcohol Swabs...... 104 Verquvo...... 69 tricitrates...... 96 ultilet alcohol swabs...... 104 Versacloz...... 59 Triderm...... 81 ultra-care alcohol prep pads...... 104 VersaFree...... 127 trientine hcl...... 111 Ultravate...... 81 VersaPlus...... 127 trifluoperazine hcl...... 60 Unistrip Control...... 107 Verzenio...... 52 trifluridine...... 121 Unithroid...... 134 VESIcare LS...... 137 trihexyphenidyl hcl...... 56 Unituxin...... 45 Viberzi...... 94 Trijardy XR...... 31 Uplizna...... 112 Vibramycin...... 133 Trikafta...... 132 Upneeq...... 123 Victoza...... 31 Trileptal...... 25 Uptravi...... 68, 69 Vidaza...... 44 Tri-Lo-Estarylla...... 72 urea...... 82 vigabatrin...... 26 Tri-Lo-Marzia...... 72 Uredeb...... 82 Vigadrone...... 26 Tri-Lo-Sprintec...... 72 Urelle...... 41 Viibryd...... 28 Triluron...... 117 Uribel...... 41 Viibryd Starter Pack...... 28 trimethobenzamide hcl...... 34 uro-mp...... 41 Vilamit MB...... 41 trimethoprim...... 40 ursodiol...... 94 Viltepso...... 118 trimipramine maleate...... 29 Ustell...... 41 Vimizim...... 90 Trintellix...... 28 Utira-C...... 41 Vimpat...... 25 Triptodur...... 90 valacyclovir hcl...... 64 Vinate Care...... 115 Trisenox...... 52 Valchlor...... 77 Vinate II...... 115 tristart dha...... 115 Valcyte...... 63, 64 Vinate One...... 115 Triumeq...... 61 valganciclovir hcl...... 64 vinblastine sulfate...... 54 TriVisc...... 117 valproic acid...... 27 vincristine sulfate...... 54 Tri-VyLibra Lo...... 72 valrubicin...... 50 vinorelbine tartrate...... 54 Trizivir...... 61 valsartan...... 38 Viokace...... 86 Trodelvy...... 55 valsartan-hydrochlorothiazide...... 38 viorele...... 70 Trokendi XR...... 25 Valstar...... 50 Viracept...... 62 tropicamide...... 120 Valtoco 10 MG Dose...... 23 Viramune...... 63 trospium chloride...... 137 Valtoco 15 MG Dose...... 23 Viramune XR...... 63 trospium chloride er...... 137 Valtoco 20 MG Dose...... 23 Viread...... 63 true comfort alcohol prep pads...... 104 Valtoco 5 MG Dose...... 23 virt-c dha...... 115 Trulance...... 94 vancomycin hcl...... 40 virt-nate dha...... 115 Trulicity...... 31 Vandazole...... 138 virt-phos 250 neutral...... 110 Trumenba...... 137 Vanoxide-HC...... 75 virt-pn dha...... 115 Truseltiq (100MG Daily Dose)...... 47 Vantas...... 53 virt-pn plus...... 115 Truseltiq (125MG Daily Dose)...... 47 Vaqta...... 138 virtussin a/c...... 73 Truseltiq (50MG Daily Dose)...... 47 vardenafil hcl...... 69 virtussin dac...... 73 Truseltiq (75MG Daily Dose)...... 47 Varivax...... 138 Visco-3...... 117 Truvada...... 61 Vascepa...... 35 Vistogard...... 33 Truxima...... 44 Vecamyl...... 39 Vitafol Ultra...... 115 TruZone Peak Flow Meter...... 107 Vectibix...... 47 Vitafol-OB...... 115 Tudorza Pressair...... 21 Veklury...... 64 Vitafol-OB+DHA...... 115 Tukysa...... 46 Velcade...... 49 Vitafol-One...... 115 154 VitaMedMD RediChew Rx...... 116 Xospata...... 49 Zolgensma 12.1-12.5 kg...... 118 vitamin d (ergocalciferol)...... 139 Xpovio (100 MG Once Weekly)..... 49 Zolgensma 12.6-13.0 kg...... 118 VitaPearl...... 115 Xpovio (40 MG Once Weekly)...... 49 Zolgensma 13.1-13.5 kg...... 118 VitaTrue...... 116 Xpovio (40 MG Twice Weekly)...... 49 Zolgensma 2.6-3.0 kg...... 118 Vitrakvi...... 49 Xpovio (60 MG Once Weekly)...... 49 Zolgensma 3.1-3.5 kg...... 118 Viva DHA...... 115 Xpovio (60 MG Twice Weekly)...... 50 Zolgensma 3.6-4.0 kg...... 118 Vivitrol...... 33 Xpovio (80 MG Once Weekly)...... 50 Zolgensma 4.1-4.5 kg...... 118 Vizimpro...... 47 Xpovio (80 MG Twice Weekly)...... 50 Zolgensma 4.6-5.0 kg...... 119 Vocabria...... 62 Xtampza ER...... 15 Zolgensma 5.1-5.5 kg...... 119 voriconazole...... 34 Xtandi...... 42 Zolgensma 5.6-6.0 kg...... 119 Vortex Valved Holding Chamber 108 xulane...... 71 Zolgensma 6.1-6.5 kg...... 119 Vosevi...... 64 Xultophy...... 31 Zolgensma 6.6-7.0 kg...... 119 Votrient...... 49 Xuriden...... 89 Zolgensma 7.1-7.5 kg...... 119 Vpriv...... 99 Xyrem...... 128 Zolgensma 7.6-8.0 kg...... 119 Vraylar...... 58 Yervoy...... 45 Zolgensma 8.1-8.5 kg...... 119 Vumerity...... 130 Yescarta...... 46 Zolgensma 8.6-9.0 kg...... 119 Vyepti...... 109 Yondelis...... 55 Zolgensma 9.1-9.5 kg...... 119 Vyleesi...... 129 Yonsa...... 42 Zolgensma 9.6-10.0 kg...... 119 Vyndamax...... 69 Yosprala...... 98 Zolinza...... 48 Vyndaqel...... 69 Yuvafem...... 139 zolmitriptan...... 110 Vyondys 53...... 118 zafirlukast...... 21 zolpidem tartrate...... 101 Vyvanse...... 8 zaleplon...... 101 zolpidem tartrate er...... 101 Vyxeos...... 51 Zaltrap...... 56 Zomacton...... 89 Wakix...... 8 Zanosar...... 54 Zonegran...... 25 warfarin sodium...... 22 Zarontin...... 26 zonisamide...... 25 Webcol Alcohol Prep Large...... 104 Zarxio...... 100 Zontivity...... 98 Webcol Alcohol Prep Medium.... 104 Zavesca...... 99 Zorbtive...... 89 Westhroid...... 134 Zebutal...... 13 Zortress...... 112 wheat germ oil...... 139 Zejula...... 55 Zubsolv...... 16 Winlevi...... 76 Zelapar...... 57 Zyclara Pump...... 82 Witepsol...... 128 Zelboraf...... 47 Zydelig...... 55 Wixela Inhub...... 20 Zemaira...... 132 Zyflo...... 19 WP Thyroid...... 134 Zembrace SymTouch...... 110 Zykadia...... 44 Xadago...... 57 Zenatane...... 76 Zylet...... 123 Xalkori...... 44 Zenpep...... 86 Zynlonta...... 44 Xarelto...... 22 Zenzedi...... 8 ZyPREXA...... 60 Xarelto Starter Pack...... 22 Zeposia...... 132 ZyPREXA Relprevv...... 60 Xatmep...... 44 Zeposia 7-Day Starter Pack...... 132 Zytiga...... 42 Xcopri...... 26 Zeposia Starter Kit...... 132 Xcopri (250 MG Daily Dose)...... 26 Zepzelca...... 42 Xcopri (350 MG Daily Dose)...... 26 Zerviate...... 120 Xeljanz...... 10 Zetonna...... 117 Xeljanz XR...... 10 zidovudine...... 63 Xeloda...... 44 Ziextenzo...... 100 Xembify...... 125 zileuton er...... 19 Xenazine...... 129 Zilxi...... 84 Xenleta...... 40 Zinplava...... 125 Xeomin...... 118 Zioptan...... 124 Xepi...... 76 ziprasidone hcl...... 58 Xeralux...... 84 Zipsor...... 12 Xerese...... 79 Zirabev...... 56 Xermelo...... 96 Zirgan...... 121 Xgeva...... 91 Zithranol...... 78 Xifaxan...... 40 Zokinvy...... 111 Xigduo XR...... 32 Zoladex...... 53 Xiidra...... 120 zoledronic acid...... 87 Xofluza (40 MG Dose)...... 65 Zolgensma 10.1-10.5 kg...... 118 Xofluza (80 MG Dose)...... 65 Zolgensma 10.6-11.0 kg...... 118 Xolair...... 20 Zolgensma 11.1-11.5 kg...... 118 Xolegel...... 82 Zolgensma 11.6-12.0 kg...... 118 155