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Oregon Essential Rx Drug List

The Essential Rx Drug List includes a list of drugs covered by Health Net. This drug list is for Oregon. The drug list is updated often and may change. To get the most up-to-date information, you may view the latest drug list on our website at www.healthnet.com/ordruglistpdf or call us at the toll-free telephone number on your Health Net ID card.

OR Essential Drug List Updated: July 1, 2020

Welcome to Health Net

What is the Essential Rx Drug List? The Essential Rx Drug List or formulary is a list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: • Safety; • Effectiveness; • Side effects; and • Value (If two drugs are equally effective, the less costly drug will be preferred)

How much will I pay for my drugs? To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan documents.

Abbreviation Copayment/Coinsurance Description 1 Tier 1 copayment or Generic drugs coinsurance 2 Tier 2 copayment or Preferred brand drugs coinsurance 3 Tier 3 copayment or Non-preferred brand drugs coinsurance SP Specialty copayment or Specialty drugs. This category includes self- coinsurance injectable and some oral high cost drugs. You may be required to get these drugs from a Specialty pharmacy. AC Anticancer drug copayment Oral anticancer drugs. You may be required to or coinsurance get these drugs from a Specialty pharmacy. GP Generic Preferred This includes most brand name drugs with a generic equivalent. Depending on your plan, these drugs are either not covered (non- formulary), covered at Tier 3 or covered at a copayment plus the difference in cost between the brand and generic drug. Refer to your Summary of Benefits or other plan documents.

How do I use the drug list? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.

ii What if my drug is not on the drug list? If your drug is not on the drug list, call us at the telephone number on your Health Net ID card and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. Your doctor can ask us to make an exception if he or she feels you need the drug that is not covered. If we approve an exception request for a drug not on the drug list, the non-preferred brand tier (Tier 3) copayment will apply.

What are generic drugs? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective, and generally cost less.

Generic drugs are available on the drug list at Tier 1. Brand name drugs with a generic equivalent are either non-formulary or non-preferred, depending on your plan benefits. If your doctor determines that you need a brand name drug instead of its generic equivalent, your doctor can submit a prior authorization request for a formulary exception with documentation of medical necessity.

Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list: Abbreviation Definition Description AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA or clinical recommendations. PA Prior Authorization These drugs require prior authorization for coverage, effectiveness or safety reasons. This means that your doctor must request approval from Health Net before the drug will be covered. PV Preventive Benefit If your plan has a preventive benefit, these drugs are covered at no cost. QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval from Health Net for a higher quantity of the drug. RX/OTC Prescription & Certain drugs are available both in a prescription Over-the-Counter form and in an OTC form. Only prescription (OTC) drugs are covered by your plan with the exception of some , supplies and some covered preventive drugs. ST Step Therapy You must first try another specific drug(s) before these drugs will be covered.

How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug coverage. • Your doctor can ask us to cover your drug even if it is not on the drug list. • Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more. To request an exception, your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-255-9198.

iii Are injectable drugs covered? Injectable drugs are not covered, except for those listed on the drug list. Some injectable drugs are considered “specialty drugs” and, in most cases, must be obtained from one of Health Net’s approved Specialty Pharmacies.

Are compounded prescriptions covered? Compounded prescriptions require prior authorization for coverage. If prior authorization is granted, your Tier 3 copayment or coinsurance applies.

Can I go to any pharmacy? To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at www.healthnet.com or call us at the telephone number on your Health Net ID card.

If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill Health Net online, so you may have to pay the full cost of your drug. If you do pay out-of-pocket for your drug, you may be able to send us your pharmacy receipt and ask for reimbursement of our share of the cost. Please refer to your plan documents for more information.

Some injectable and high cost drugs (including anticancer drugs) may be considered “specialty drugs”. These drugs must be obtained from one of Health Net’s approved Specialty pharmacies.

Can I use a mail order pharmacy? You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those needed for a long term condition.

To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug. Mail order forms are available on our website at www.healthnet.com or you may call us at the telephone number on your Health Net ID card to request a form.

How often can I refill my prescription? • For prescriptions written for 10-days or less, you may refill after 50 percent of the supply has been used as directed. • For prescriptions written for more than 10-days, you may refill after 74 percent of the supply has been used as directed.

If your physician has increased your dose, your pharmacy must be notified of the change. If this change will result in an early refill request, your pharmacy can contact Health Net for an override.

How can I save money on my prescription drugs? You can save time and money with these simple steps: • Ask your doctor about generic drugs that may work for you. • Fill prescriptions at Health Net participating pharmacies. • Be sure your doctor prescribes drugs on the drug list • Fill your maintenance drugs through our mail order pharmacy program.

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Nondiscrimination Notice Health Net Health Plan of Oregon, Inc. (Health Net) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently

because of race, color, national origin, age, disability, or sex. Health Net: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net’s Customer Contact Center at 1-888-802-7001 (TTY: 711). If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Nondiscrimination Notice FLY029224ER00 (1/20)

OR WA Commercial Notice of Language Assistance

Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Notice of Language Assistance FLY029225ER00 (1/20) Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(1 ea daily) OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine ADHD, Sleep and Eating Disorders cp24 5 mg-5 mg-5 mg- Amphetamines 5 mg, 2.5 mg-2.5 mg- (Dextroamphetamine 2.5 mg-2.5 mg, 7.5 mg- Sulfate) PROCENTRA 1 7.5 mg-7.5 mg-7.5 mg, 1 SOLN 1.25 mg-1.25 mg-1.25 (Dextroamphetamine 1 bal on hand, mg-1.25 mg, 3.75 mg- Sulfate) ZENZEDI TABS 1 3.75 mg-3.75 mg-3.75 2.5 MG, 7.5 MG mg, 6.25 mg-6.25 mg- (Dextroamphetamine 6.25 mg-6.25 mg Sulfate) ZENZEDI TABS 5 1 MG, 10 MG, 7.5 MG amphetamine- ADDERALL TABS 2.5 MG- dextroamphetamine 2.5 MG-2.5 MG-2.5 MG, tabs 5 mg-5 mg-5 mg-5 1.25 MG-1.25 MG-1.25 mg, 2.5 mg-2.5 mg-2.5 MG-1.25 MG, 3.75 MG- mg-2.5 mg, 7.5 mg-7.5 3.75 MG-3.75 MG-3.75 mg-7.5 mg-7.5 mg, MG, 1.875 MG-1.875 MG- GP 1.25 mg-1.25 mg-1.25 1 1.875 MG-1.875 MG, 3.125 MG-3.125 MG-3.125 MG- mg-1.25 mg, 3.75 mg- 3.125 MG 3.75 mg-3.75 mg-3.75 (amphetamine- mg, 1.875 mg-1.875 dextroamphetamine) mg-1.875 mg-1.875 ADDERALL TABS 5 MG-5 mg, 3.125 mg-3.125 MG-5 MG-5 MG, 7.5 MG- mg-3.125 mg-3.125 mg 7.5 MG-7.5 MG-7.5 MG DESOXYN TABS PA NF GP (amphetamine- (methamphetamine hcl) dextroamphetamine) DEXEDRINE CP24 ADDERALL XR CP24 2.5 QL(1 ea daily) (dextroamphetamine GP MG-2.5 MG-2.5 MG-2.5 sulfate) MG, 1.25 MG-1.25 MG- dextroamphetamine 1.25 MG-1.25 MG, 3.75 GP 1 MG-3.75 MG-3.75 MG-3.75 sulfate cp24 MG (amphetamine- dextroamphetamine 1 dextroamphetamine) sulfate soln ADDERALL XR CP24 5 QL(1 ea daily) dextroamphetamine 1 MG-5 MG-5 MG-5 MG, 7.5 sulfate tabs MG-7.5 MG-7.5 MG-7.5 PA MG, 6.25 MG-6.25 MG- NF methamphetamine hcl 1 6.25 MG-6.25 MG tabs (amphetamine- VYVANSE CAPS QL(1 ea daily) dextroamphetamine) (lisdexamfetamine 2 ADZENYS ER SUER 1 bal on hand, dimesylate) NF (amphetamine) VYVANSE CHEW QL(1 ea daily) (lisdexamfetamine 2 dimesylate) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Analeptics dexmethylphenidate hcl cp24 25 mg, 30 mg, 35 1 caffeine citrate soln 1 mg, 40 mg Attention-Deficit/Hyperactivity Disorder (ADHD) dexmethylphenidate hcl QL(1 ea daily) QL(2 ea daily) atomoxetine hcl caps cp24 5 mg, 10 mg, 15 1 10 mg, 18 mg, 25 mg, 1 mg, 20 mg, 30 mg, 35 40 mg, 80 mg, 100 mg mg, 40 mg QL(1 ea daily) dexmethylphenidate hcl QL(2 ea daily) atomoxetine hcl caps 1 60 mg, 80 mg, 100 mg tabs 5 mg, 10 mg, 2.5 1 QL(4 ea daily) mg clonidine hcl (adhd) 1 tb12 FOCALIN TABS QL(2 ea daily) QL(1 ea daily) (dexmethylphenidate GP guanfacine hcl (adhd) 1 tb24 hcl) FOCALIN XR CP24 15 MG QL(1 ea daily) INTUNIV TB24 QL(1 ea daily) GP (dexmethylphenidate NF (guanfacine hcl (adhd)) hcl) KAPVAY TB12 ( QL(4 ea daily) clonidine GP FOCALIN XR CP24 25 MG ) hcl (adhd) (dexmethylphenidate NF STRATTERA CAPS 10 QL(2 ea daily) hcl) MG, 25 MG, 40 MG NF ( ) FOCALIN XR CP24 35 atomoxetine hcl MG, 40 MG STRATTERA CAPS 18 QL(2 ea daily) (dexmethylphenidate GP MG, 80 MG, 100 MG GP hcl) (atomoxetine hcl) FOCALIN XR CP24 5 MG, QL(1 ea daily) STRATTERA CAPS 60 QL(1 ea daily) 10 MG, 20 MG, 30 MG, 40 MG, 80 MG, 100 MG GP MG GP (atomoxetine hcl) (dexmethylphenidate Stimulants - Misc. hcl) (Methylphenidate Hcl) QL(1 ea daily) METHYLIN SOLN 1 GP METADATE ER TBCR (methylphenidate hcl) armodafinil tabs 1 PA methylphenidate hcl chew 5 mg, 10 mg, 2.5 1 CONCERTA TBCR 18 MG, QL(1 ea daily) mg 27 MG (methylphenidate GP hcl) methylphenidate hcl QL(1 ea daily) CONCERTA TBCR 36 MG QL(2 ea daily) cp24 10 mg, 20 mg, 30 1 GP (methylphenidate hcl) mg, 40 mg CONCERTA TBCR 54 MG QL(1 ea daily) methylphenidate hcl NF (methylphenidate hcl) cpcr 10 mg, 30 mg, 40 1 DAYTRANA PTCH QL(1 ea daily) mg, 50 mg, 60 mg 3 (methylphenidate) methylphenidate hcl QL(2 ea daily) cpcr 20 mg, 30 mg, 40 1 mg, 50 mg, 60 mg

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methylphenidate hcl ODACTRA SUBL (dust PA soln 5 mg/5ml, 10 1 mite mixed allergen 3 mg/5ml extract) methylphenidate hcl ORALAIR ADULT SAMPLE PA 1 KIT SUBL (grass mixed tabs 5 mg, 10 mg, 20 3 mg pollens allergen QL(1 ea daily)1 extract) methylphenidate hcl 1 tb24 18 mg, 54 mg bal on hand, ORALAIR ADULT PA STARTER PACK SUBL QL(1 ea daily) 3 methylphenidate hcl 1 (grass mixed pollens tb24 27 mg, 54 mg allergen extract) QL(2 ea daily) methylphenidate hcl 1 ORALAIR SUBL (grass PA tb24 36 mg, 54 mg mixed pollens allergen 3 methylphenidate hcl QL(1 ea daily) extract) 1 tbcr 18 mg, 20 mg, 27 RAGWITEK SUBL (short PA mg, 54 mg ragweed pollen 3 QL(2 ea daily) methylphenidate hcl 1 allergen extract) tbcr 36 mg, 54 mg Biologicals Misc METHYLPHENIDATE QL(1 ea daily) ADAGEN SOLN PA HYDROCHLORIDE ER SP TBCR 72 MG 3 (pegademase bovine) (methylphenidate hcl) AMINOGLYCOSIDES - Drugs to Treat Bacterial modafinil tabs 1 ST; QL(1 ea daily) Aminoglycosides NUVIGIL TABS PA GP (Tobramycin) (armodafinil) TOBRAMYCIN SP PROVIGIL TABS ST; QL(1 ea INHALATION SOLUTION GP (modafinil) daily) PAK NEBU QUILLIVANT XR SRER PA; QL(12 ml SP PA 3 amikacin sulfate soln (methylphenidate hcl) daily) ARIKAYCE SUSP PA RELEXXII TBCR QL(1 ea daily) 3 (amikacin sulfate SP (methylphenidate hcl) liposome) RITALIN LA CP24 QL(1 ea daily) BETHKIS NEBU PA GP SP (methylphenidate hcl) (tobramycin) RITALIN TABS GP gentamicin in saline PA; 1 bal on (methylphenidate hcl) hand, soln 0.9 %-0.8 mg/ml, SP ALLERGENIC EXTRACTS/BIOLOGICALS MISC 0.9 %-1.6 mg/ml, 0.9 %-1 mg/ml Allergenic Extracts gentamicin in saline PA GRASTEK SUBL PA soln 0.9 %-1.2 mg/ml, SP (timothy grass pollen 3 0.9 %-1.6 mg/ml, 0.9 allergen extract) %-1 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA SIMPONI SOAJ PA gentamicin sulfate soln SP SP (golimumab) KITABIS PAK NEBU 1 bal on hand, SIMPONI SOSY PA SP SP (tobramycin) (golimumab) neomycin sulfate tabs 1 Antirheumatic - Enzyme Inhibitors 1 bal on hand, RINVOQ TB24 PA paromomycin sulfate 1 SP caps (upadacitinib) XELJANZ TABS PA paromomycin sulfate 1 SP caps (tofacitinib citrate) PA; 1 bal on XELJANZ XR TB24 11 MG PA streptomycin sulfate SP SP solr hand, (tofacitinib citrate) Antirheumatic Antimetabolites TOBI NEBU ( ) SP tobramycin TABS TOBI PODHALER CAPS PA (methotrexate sodium 2 SP (tobramycin) (antirheumatic)) tobramycin nebu SP 1 bal on hand, OTREXUP SOAJ PA (methotrexate SP tobramycin nebu SP (antirheumatic)) RASUVO SOAJ PA tobramycin sulfate soln PA; 1 bal on SP (methotrexate SP 10 mg/ml hand, (antirheumatic)) PA tobramycin sulfate soln SP 80 mg/2ml Gold Compounds RIDAURA CAPS 2 - ANTI-INFLAMMATORY - Drugs (auranofin) to Treat , Swelling, Muscle and Joint Conditions -1 Blockers ARCALYST SOLR PA Anti-TNF-alpha - Monoclonal Antibodies SP HUMIRA PEDIATRIC PA (rilonacept) CROHNS DISEASE 3 Interleukin-1 Antagonist (IL-1Ra) STARTER PACK PSKT KINERET SOSY PA SP (adalimumab) (anakinra) HUMIRA PEN PNKT PA 3 Interleukin-6 Receptor Inhibitors (adalimumab) ACTEMRA SOLN PA HUMIRA PEN-CD/UC/HS PA SP ( ) STARTER PNKT 3 tocilizumab ACTEMRA SOSY PA (adalimumab) SP HUMIRA PEN-PS/UV PA (tocilizumab) STARTER PNKT 3 KEVZARA SOAJ 150 PA; SP (adalimumab) MG/1.14ML, 200 SP HUMIRA PSKT PA MG/1.14ML (sarilumab) 3 (adalimumab) KEVZARA SOSY 150 PA MG/1.14ML, 200 SP SIMPONI ARIA SOLN PA SP MG/1.14ML (sarilumab) (golimumab) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EC-NAPROXEN TBEC Nonsteroidal Anti-inflammatory Agents (NSAIDs) GP (naproxen) (Fenoprofen ) 1 PROFENO TABS etodolac caps 200 mg, 1 (Ibuprofen) IBU TABS 1 300 mg etodolac tabs 400 mg, 1 (Naproxen) NAPROXEN 1 DR TBEC 500 mg ANAPROX DS TABS etodolac tb24 400 mg, QL(2 ea daily) GP 1 (naproxen sodium) 500 mg, 600 mg FELDENE CAPS ARTHROTEC 50 TBEC GP (diclofenac w/ GP (piroxicam) misoprostol) FENOPROFEN CALCIUM CAPS 200 MG ARTHROTEC 75 TBEC 3 ( ) (diclofenac w/ GP fenoprofen calcium 1 bal on hand, misoprostol) fenoprofen calcium 1 ST; QL(2 ea caps 200 mg, 400 mg CELEBREX CAPS 400 MG daily); AL(At GP fenoprofen calcium 1 (celecoxib) least 60 yrs tabs 600 mg old) FENORTHO CAPS 3 CELEBREX CAPS 50 MG, ST; QL(2 ea (fenoprofen calcium) 100 MG, 200 MG GP daily) (celecoxib) flurbiprofen tabs 1 ST; QL(2 ea ibuprofen tabs 1 celecoxib caps 400 mg 1 daily); AL(At least 60 yrs INDOCIN SUPP RE 50 MG old) 3 (indomethacin) ST; QL(2 ea celecoxib caps 50 mg, 1 INDOCIN SUSP OR 25 daily) 2 100 mg, 200 mg MG/5ML (indomethacin) DAYPRO TABS GP indomethacin caps 20 ST; QL(3 ea (oxaprozin) 1 daily)1 bal on mg, 50 mg hand, diclofenac potassium 1 tabs indomethacin caps 25 1 mg, 50 mg diclofenac sodium tb24 1 or 100 mg indomethacin cpcr 75 1 diclofenac sodium tbec mg or 25 mg, 50 mg, 75 1 ketoprofen caps 1 1 bal on hand, mg ketoprofen cp24 1 1 bal on hand, diclofenac w/ 1 misoprostol tbec KETOROLAC QL(1 ea daily,5 DUEXIS TABS PA 3 TROMETHAMINE SOLN day(s) limit) (ibuprofen-famotidine) NA 15.75 MG/SPRAY 3 EC-NAPROSYN TBEC (ketorolac GP (naproxen) tromethamine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ketorolac tromethamine Limit 20 per oxaprozin tabs 1 1 month;QL(0.67 tabs or 10 mg ea daily) piroxicam caps 1 LODINE TABS (etodolac) GP SPRIX SOLN ( QL(1 ea daily,5 ketorolac 3 1 bal on hand, tromethamine) day(s) limit) meclofenamate sodium 1 caps sulindac tabs 1 1 caps TIVORBEX CAPS 20 MG, ST; QL(3 ea 3 daily) meloxicam tabs 15 mg 1 QL(1 ea daily) 40 MG (indomethacin) TIVORBEX CAPS 20 MG, ST; QL(3 ea meloxicam tabs 7.5 mg 1 QL(2 ea daily) 3 daily)1 bal on 40 MG (indomethacin) hand, MOBIC TABS 15 MG QL(1 ea daily) GP 1 bal on hand, (meloxicam) tolmetin sodium caps 1 MOBIC TABS 7.5 MG QL(2 ea daily) 1 bal on hand, GP tolmetin sodium tabs 1 (meloxicam) QL(4 ea daily) VIMOVO TBEC PA nabumetone tabs 500 1 mg (naproxen- esomeprazole GP QL(3 ea daily) nabumetone tabs 750 1 magnesium) mg ZIPSOR CAPS ST NALFON CAPS 400 MG 3 3 (diclofenac potassium) (fenoprofen calcium) ZORVOLEX CAPS ST; QL(3 ea NALFON TABS 600 MG 3 GP (diclofenac) daily) (fenoprofen calcium) Phosphodiesterase 4 (PDE4) Inhibitors NAPRELAN TB24 375 MG, OTEZLA TABS PA 500 MG (naproxen GP 3 sodium) (apremilast) NAPRELAN TB24 750 MG OTEZLA TBPK PA 3 3 (naproxen sodium) (apremilast) NAPROSYN SUSP Pyrimidine Synthesis Inhibitors GP ARAVA TABS 10 MG QL(2 ea daily) (naproxen) GP NAPROSYN TABS (leflunomide) GP ARAVA TABS 20 MG QL(1 ea daily) (naproxen) GP (leflunomide) naproxen sodium tabs 1 leflunomide tabs 10 mg 1 QL(2 ea daily) naproxen sodium tb24 1 leflunomide tabs 20 mg 1 QL(1 ea daily) naproxen susp 1 Selective Costimulation Modulators naproxen tabs 1 ORENCIA CLICKJECT PA SP naproxen- PA SOAJ (abatacept) ORENCIA SOLR PA esomeprazole 1 SP magnesium tbec (abatacept) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORENCIA SOSY PA BUTALBITAL/ACETAMINO SP (abatacept) PHEN CAPS (butalbital- NF Soluble Tumor Necrosis Factor Receptor Agents acetaminophen) ENBREL MINI SOCT PA BUTALBITAL/ASPIRIN/CA 3 FFEINE TABS (etanercept) (butalbital-aspirin- 2 ENBREL SOLR PA 3 caffeine) (etanercept) ESGIC TABS ( ENBREL SOSY PA butalbital- 3 acetaminophen- GP (etanercept) caffeine) ENBREL SURECLICK PA 3 FIORICET CAPS SOAJ (etanercept) (butalbital- ANALGESICS - NonNarcotic - Drugs to Treat acetaminophen- GP Pain, Muscle and Joint Conditions caffeine) Combinations FIORINAL CAPS (Acetaminophen- 1 bal on hand, (butalbital-aspirin- GP Salicylamide- 1 caffeine) Phenyltoloxamine) DURAXIN CAPS Salicylates (Butalbital-Acetaminophen) 1 BUPAP, TENCON TABS (Butalbital-Acetaminophen) 1 1 bal on hand, BUPAP, TENCON TABS (Butalbital-Acetaminophen- Caffeine) ESGIC, 1 ZEBUTAL, PHRENILIN FORTE CAPS (Butalbital-Acetaminophen- Caffeine) VANATOL LQ, 1 VTOL LQ, VANATOL S SOLN butalbital- acetaminophen tabs 1 300 mg-50 mg, 325 mg-50 mg butalbital- acetaminophen- 1 caffeine caps butalbital- acetaminophen- 1 caffeine tabs butalbital-aspirin- 1 caffeine caps

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ADULT ASPIRIN PV DOSE, BAYER ASPIRIN EC LOW STRENGTH, TGT REGIMEN, BAYER ENTERIC-COATED ASPIRIN EC LOW DOSE, ASPIRIN, TGT ASPIRIN BAYER ASPIRIN, LOW DOSE, TGT ASPIRTAB, ASPIRIN ASPIRIN, ST JOSEPH REGIMEN LOW ASPIRIN, SM ASPIRIN DOSE/ADULT, ASPIRIN ENTERIC COATED, SM LOW DOSE, ASPIRIN ASPIRIN EC LOW ENTERIC COATED STRENGTH, H-E-B ADULT LOW STRENGTH, ASPIRIN, SM ASPIRIN ASPIRIN EC LOW DOSE, ADULT LOW STRENGTH, ASPIRIN ADULT LOW SB LOW DOSE ASA EC, STRENGTH, ASPIRIN SB ASPIRIN EC, SB ADULT LOW DOSE, ASPIRIN ADULT LOW ASPIRIN 81, ASPIR-LOW, STRENGTH, SB ASPIRIN, ADULT ASPIRIN RA ASPIRIN EC ADULT REGIMEN TBEC LOW STRENGTH, RA ASPIRIN EC, QC ENTERIC ASPIRIN, QC ASPIRIN LOW DOSE, QC ASPIRIN, PX ENTERIC ASPIRIN, MINIPRIN LOW DOSE, MEIJER ASPIRIN EC, KP ASPIRIN, KLS ASPIRIN LOW DOSE, KLS PV ASPIRIN EC, HM ASPIRIN EC LOW DOSE, HM ASPIRIN EC, HM ASPIRIN, GOODSENSE ASPIRIN LOW DOSE, GOODSENSE ASPIRIN, GNP ASPIRIN LOW DOSE, GNP ASPIRIN, EQL ASPIRIN LOW DOSE, EQL ASPIRIN EC, EQ ASPIRIN LOW DOSE, EQ ASPIRIN EC, EQ ASPIRIN ADULT LOW DOSE, EQ ASPIRIN, EQ ADULT ASPIRIN LOW STRENGTH, ECPIRIN, ECOTRIN LOW STRENGTH, ECOTRIN, EC-81 ASPIRIN, CVS ASPIRIN LOW STRENGTH, CVS ASPIRIN LOW DOSE, CVS ASPIRIN EC, CVS ASPIRIN ADULT LOW STRENGTH, CVS ASPIRIN, BAYER LOW You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN ADULT PV (Aspirin) BAYER PV LOW DOSE, TGT ADVANCED ASPIRIN CHILDRENS ASPIRIN, REGULAR STRENGTH, TGT ASPIRIN, ST TGT ASPIRIN, SM JOSEPH LOW DOSE ASPIRIN, SB ASPIRIN, RA ASPIRIN, SM CHILDRENS PAIN RELIEF ASPIRIN, ASPIRIN, SM ASPIRIN RA ASPIRIN, QC ASPIRIN, LOW DOSE, HM ASPIRIN, PX ASPIRIN, NORWICH PV SM ASPIRIN ADULT LOW ASPIRIN, MM ASPIRIN, STRENGTH, SB MEDIQUE ASPIRIN, HM CHILDRENS ASPIRIN, RA ASPIRIN, GOODSENSE CHILDRENS ASPIRIN, RA ASPIRIN, GNP ASPIRIN, ASPIRIN CHILDRENS, RA EQL ASPIRIN, ASPIRIN ASPIRIN ADULT LOW ADULT, EQ ASPIRIN, CVS STRENGTH, RA ASPIRIN ASPIRIN, BAYER ASPIRIN ADULT LOW DOSE, QC TABS CHILDRENS ASPIRIN, QC ASCRIPTIN TABS PV CHEWABLE ASPIRIN (aspirin buffered (al LOW DOSE, QC ASPIRIN PV LOW DOSE, PX ASPIRIN, hydrox-mg hydrox-ca GOODSENSE ASPIRIN PV carb)) ADULT LOW STRENGTH, PV PV GOODSENSE ASPIRIN, aspirin chew GNP ADULT ASPIRIN PV LOW STRENGTH, EQL aspirin tabs PV ASPIRIN LOW DOSE, EQ PV CHILDRENS ASPIRIN, EQ aspirin tbec PV ASPIRIN LOW DOSE, MAGNESIUM ASPIRIN 81 LOW DOSE, TRISALICYLATE LIQD CVS ASPIRIN ADULT ( 2 LOW DOSE, CHILDRENS choline & mag ASPIRIN LOW salicylate) STRENGTH, CHILDRENS diflunisal tabs 1 ASPIRIN, BAYER CHEWABLE LOW DOSE, ECOTRIN REGULAR PV ASPIRIN LOW STRENGTH TBEC GP STRENGTH, ASPIRIN (aspirin) LOW DOSE, ASPIRIN CHILDRENS, ASPIRIN salsalate tabs 1 ADULT LOW STRENGTH CHEW ST JOSEPH ADULT PV ANALGESICLOW DOSE BITE SIZE CHEW GP (aspirin) ST JOSEPH ADULT PV GP CHEW (aspirin) ANALGESICS - - Drugs to Treat Pain, Muscle and Joint Conditions Opioid Agonists

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9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Methadone Hcl) pt72 12 Limit 15 per METHADONE HCL 1 month;QL(0.5 mcg/hr, 25 mcg/hr, 50 1 INTENSOL CONC mcg/hr, 75 mcg/hr, 100 ea daily) (Methadone Hcl) 1 mcg/hr METHADOSE TBSO FENTORA TABS PA; QL(3 ea (Morphine Sulfate) SP PA 3 daily)1 bal on DURAMORPH SOLN (fentanyl citrate) hand, ABSTRAL SUBL PA 3 hydromorphone hcl liqd 1 (fentanyl citrate) 1 mg/ml ACTIQ LPOP (fentanyl PA GP hydromorphone hcl QL(4 ea daily) citrate) t24a 8 mg, 12 mg, 16 1 codeine sulfate tabs 1 mg CONZIP CP24 ( 1 bal on hand, hydromorphone hcl 3 1 hcl) tabs 2 mg, 4 mg, 8 mg DILAUDID LIQD OR 1 KADIAN CP24 10 MG, 30 QL(1 ea daily) MG, 40 MG, 50 MG, 60 MG/ML (hydromorphone GP MG, 80 MG, 100 MG GP hcl) (morphine sulfate) DILAUDID TABS OR 2 KADIAN CP24 20 MG, 30 QL(2 ea daily) MG, 4 MG, 8 MG GP MG, 40 MG, 50 MG, 60 (hydromorphone hcl) MG, 80 MG, 100 MG GP DOLOPHINE TABS QL(12 ea daily) GP (morphine sulfate) (methadone hcl) KADIAN CP24 200 MG QL(1 ea daily) 3 DURAGESIC PT72 12 Limit 15 per (morphine sulfate) MCG/HR, 25 MCG/HR, 50 month;QL(0.5 LAZANDA SOLN 100 PA MCG/HR, 100 MCG/HR GP ea daily) MCG/ACT, 400 MCG/ACT 3 (fentanyl) (fentanyl citrate) DURAGESIC PT72 75 Limit 15 per 1 bal on hand, NF month;QL(0.5 meperidine hcl soln 50 1 MCG/HR (fentanyl) ea daily) mg/5ml EMBEDA CPCR PA meperidine hcl tabs 50 1 bal on hand, 3 1 (morphine-naltrexone) mg, 100 mg, 100 mg EXALGO T24A QL(4 ea daily) meperidine hcl tabs 50 GP 1 (hydromorphone hcl) mg, 100 mg, 100 mg PA fentanyl citrate lpop bu methadone hcl conc or 1 10 mg/ml 200 mcg, 400 mcg, 600 1 mcg, 800 mcg, 1200 PA methadone hcl soln ij SP mcg, 1600 mcg 10 mg/ml fentanyl citrate tabs bu PA; QL(3 ea METHADONE HCL SOLN PA 100 mcg, 200 mcg, 400 daily)1 bal on IJ 10 MG/ML (methadone SP 1 hand, mcg, 600 mcg, 800 hcl) mcg methadone hcl soln or 5 mg/5ml, 10 mg/5ml, 1 10 mg/5ml You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, methadone hcl soln or oxycodone hcl caps 5 1 5 mg/5ml, 10 mg/5ml, 1 mg 10 mg/5ml oxycodone hcl conc 1 QL(12 ea daily) methadone hcl tabs or 1 100 mg/5ml 5 mg, 10 mg oxycodone hcl tabs 5 1 methadone hcl tbso or 1 mg, 10 mg, 15 mg, 20 40 mg mg, 30 mg QL(1 ea daily)1 morphine sulfate beads 1 oxymorphone hcl tabs 1 cp24 bal on hand, 5 mg, 10 mg morphine sulfate cp24 QL(1 ea daily) oxymorphone hcl tb12 QL(2 ea daily)1 bal on hand, or 10 mg, 30 mg, 40 1 5 mg, 10 mg, 15 mg, 20 1 mg, 50 mg, 60 mg, 80 mg, 30 mg, 40 mg, 7.5 mg, 100 mg mg QL(2 ea daily) ROXICODONE TABS morphine sulfate cp24 GP (oxycodone hcl) or 20 mg, 30 mg, 40 1 mg, 50 mg, 60 mg, 80 ROXYBOND TABA 5 MG QL(4 ea daily) 3 mg, 100 mg (oxycodone hcl) PA PA morphine sulfate soln ij SP SUBSYS LIQD (fentanyl) 3 0.5 mg/ml, 1 mg/ml morphine sulfate soln tramadol hcl cp24 100 1 bal on hand, mg, 150 mg, 200 mg, 1 or 20 mg/ml, 10 1 mg/5ml, 20 mg/5ml, 300 mg 1 bal on hand, 100 mg/5ml tramadol hcl tabs 100 1 morphine sulfate supp 1 bal on hand, mg QL(8 ea daily) re 5 mg, 10 mg, 20 mg, 1 tramadol hcl tabs 50 1 30 mg mg 1 bal on hand, tramadol hcl tb24 100 morphine sulfate tabs 1 1 or 15 mg, 30 mg mg, 200 mg, 300 mg ULTRAM TABS ( QL(8 ea daily) morphine sulfate tbcr or QL(3 ea daily) tramadol GP 15 mg, 30 mg, 60 mg, 1 hcl) 100 mg, 200 mg Opioid Combinations MS CONTIN TBCR QL(3 ea daily) GP (Butalbital-Aspirin-Caffeine (morphine sulfate) W/Cod) 1 NUCYNTA ER TB12 QL(2 ea daily) ASCOMP/CODEINE CAPS 2 (tapentadol hcl) (Hydrocodone- Acetaminophen) LORCET, NUCYNTA TABS 1 2 LORCET PLUS, LORCET (tapentadol hcl) HD TABS OPANA TABS GP (Hydrocodone-Ibuprofen) 1 bal on hand, (oxymorphone hcl) IBUDONE TABS 200 MG- 1 OXAYDO TABA QL(4 ea daily) 10 MG 3 (oxycodone hcl)

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11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocodone-Ibuprofen) oxycodone w/ 1 bal on hand, IBUDONE TABS 200 MG-5 1 acetaminophen soln 5 1 MG mg/5ml-325 mg/5ml (Oxycodone W/ oxycodone w/ Acetaminophen) 1 ENDOCET, NALOCET acetaminophen tabs 5 TABS mg-325 mg, 10 mg-325 1 mg, 2.5 mg-300 mg, acetaminophen w/ 1 codeine soln 2.5 mg-325 mg, 7.5 mg-325 mg acetaminophen w/ 1 codeine tabs oxycodone-aspirin tabs 1 1 bal on hand, butalbital- oxycodone-aspirin tabs 1 acetaminophen- 1 caffeine w/ codeine QL(4 ea daily)1 oxycodone-ibuprofen 1 caps tabs bal on hand, PERCOCET TABS 10 MG- butalbital-aspirin- 1 caffeine w/cod caps 325 MG (oxycodone w/ NF FIORICET/CODEINE acetaminophen) CAPS (butalbital- PERCOCET TABS 5 MG- acetaminophen- GP 325 MG, 2.5 MG-325 MG, caffeine w/ codeine) 7.5 MG-325 MG GP FIORINAL/CODEINE #3 (oxycodone w/ CAPS (butalbital-aspirin- GP acetaminophen) caffeine w/cod) PRIMLEV TABS HYDROCODONE (oxycodone w/ 3 BITARTRATE/ACETAMIN acetaminophen) OPHEN SOLN 2 PROLATE TABS (hydrocodone- (oxycodone w/ 3 acetaminophen) acetaminophen) ROXICET SOLN hydrocodone- 1 acetaminophen soln (oxycodone w/ 2 acetaminophen) hydrocodone- 1 acetaminophen tabs tramadol- 1 acetaminophen tabs hydrocodone-ibuprofen 1 tabs TYLENOL/CODEINE #3 LORTAB ELIX TABS (acetaminophen GP (hydrocodone- 3 w/ codeine) acetaminophen) TYLENOL/CODEINE #4 NORCO TABS TABS (acetaminophen GP (hydrocodone- GP w/ codeine) acetaminophen) ULTRACET TABS (tramadol- GP acetaminophen)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Opioid Partial Agonists BUTRANS PTWK Limit 4 per GP month;QL(0.15 BELBUCA FILM QL(2 ea daily) ( ) 3 buprenorphine ea daily) (buprenorphine hcl) pentazocine w/ 1 BUNAVAIL FILM PA required for naloxone tabs ( 3 more than 30 buprenorphine hcl- day supply per PA required for naloxone hcl dihydrate) SUBOXONE FILM year; (buprenorphine hcl- GP more than 30 BUPRENEX SOLN PA day supply per SP naloxone hcl dihydrate) year; (buprenorphine hcl) PA required for buprenorphine hcl soln PA ZUBSOLV SUBL SP ( 3 more than 30 ij 0.3 mg/ml buprenorphine hcl- day supply per ) PA required for naloxone hcl dihydrate year; buprenorphine hcl subl more than 30 ANDROGENS-ANABOLIC - Drugs to Regulate 1 day supply per Hormones sl 2 mg year;QL(3 ea daily) Anabolic Steroids ANADROL-50 TABS PA required for 3 buprenorphine hcl subl more than 30 (oxymetholone) 1 day supply per sl 8 mg year;QL(4 ea oxandrolone tabs 1 daily) Androgens PA required for buprenorphine hcl- ANDRODERM PT24 ST; QL(1 ea more than 30 3 naloxone hcl dihydrate () daily) film 4 mg-1 mg, 8 mg-2 1 day supply per year; ANDROGEL GEL 40.5 QL(10 gm mg, 12 mg-3 mg, 2 mg- MG/2.5GM, 20.25 daily) 0.5 mg MG/1.25GM GP PA required for (testosterone) buprenorphine hcl- more than 30 ANDROGEL GEL 50 QL(10 gm naloxone hcl dihydrate 1 day supply per MG/5GM, 25 MG/2.5GM 2 daily) subl 2 mg-0.5 mg year;QL(3 ea daily) (testosterone) ANDROGEL PUMP GEL QL(10 gm PA required for GP buprenorphine hcl- more than 30 (testosterone) daily) naloxone hcl dihydrate 1 day supply per danazol caps 1 subl 8 mg-2 mg year;QL(4 ea daily) DEPO-TESTOSTERONE buprenorphine ptwk td Limit 4 per SOLN 100 MG/ML month;QL(0.15 (testosterone SP 5 mcg/hr, 10 mcg/hr, 1 15 mcg/hr, 20 mcg/hr, ea daily) cypionate) 7.5 mcg/hr DEPO-TESTOSTERONE Limit 7.5mls SOLN 200 MG/ML (testosterone GP butorphanol tartrate 1 per soln month;QL(0.25 cypionate) ml daily) FORTESTA GEL QL(4 gm daily) GP (testosterone)

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13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHITEST TABS (Hydrocortisone 2 (methyltestosterone) (Intrarectal)) COLOCORT 1 1 bal on hand, ENEM methyltestosterone 1 caps CORTENEMA ENEM (hydrocortisone GP STRIANT MISC QL(2 ea daily) 3 (intrarectal)) (testosterone) CORTIFOAM FOAM TESTIM GEL PA; QL(10 gm 3 (hydrocortisone acetate 2 (testosterone) daily) (intrarectal)) testosterone cypionate SP hydrocortisone 1 soln im 100 mg/ml (intrarectal) enem testosterone cypionate 1 UCERIS FOAM RE 2 PA soln im 200 mg/ml MG/ACT (budesonide 3 testosterone enanthate SP (intrarectal)) soln im Rectal Combinations 1 bal on hand, testosterone enanthate SP ANALPRAM HC CREA soln im (hydrocortisone acetate NF testosterone gel td 1 %, QL(10 gm w/ pramoxine) 1.62 %, 50 mg/5gm, 25 daily)1 bal on hand, ANALPRAM HC SINGLES mg/2.5gm, 40.5 1 CREA (hydrocortisone NF mg/2.5gm, 20.25 acetate w/ pramoxine) mg/1.25gm ANALPRAM-HC CREA 1 testosterone gel td 1 %, QL(10 gm %-1 % (hydrocortisone GP 1.62 %, 50 mg/5gm, 25 daily) acetate w/ pramoxine) mg/2.5gm, 40.5 1 ANALPRAM-HC LOTN 1 mg/2.5gm, 20.25 %-2.5 % (hydrocortisone 3 mg/1.25gm acetate w/ pramoxine) testosterone gel td 10 QL(4 gm daily) hydrocortisone acetate 1 mg/act, 50 mg/5gm, 25 w/ pramoxine crea mg/2.5gm, 40.5 1 lidocaine- mg/2.5gm, 20.25 hydrocortisone acetate 1 mg/1.25gm (rectal) QL(6 ml daily) testosterone soln td 30 1 PROCORT CREA mg/act (hydrocortisone acetate 3 VOGELXO GEL QL(10 gm w/ pramoxine) NF daily)1 bal on (testosterone) hand, PROCTOFOAM HC FOAM (hydrocortisone acetate 2 VOGELXO PUMP GEL QL(10 gm NF daily)1 bal on w/ pramoxine) (testosterone) hand, Rectal Steroids ANORECTAL AND RELATED PRODUCTS - (Hydrocortisone (Rectal)) Rectal Drugs to Treat Pain, Swelling and Itching PROCTO-MED HC, 1 PROCTOZONE-HC, Intrarectal Steroids PROCTOSOL HC CREA You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone Acetate (Bacitracin) BACIIM SOLR SP PA (Rectal)) ANUCORT-HC, 1 HEMMOREX-HC SUPP bacitracin solr SP PA (Hydrocortisone Acetate FLAGYL CAPS (Rectal)) ANUSOL-HC 1 GP SUPP RE 25 MG (metronidazole) ANUSOL-HC CREA EX 2.5 FLAGYL TABS GP % (hydrocortisone GP (metronidazole) (rectal)) IMPAVIDO CAPS SP () hydrocortisone (rectal) 1 crea metronidazole caps 1 hydrocortisone acetate 1 PA (rectal) supp metronidazole in nacl SP PROCTOCORT SUPP soln (hydrocortisone acetate GP metronidazole tabs 1 (rectal)) NEBUPENT SOLR Vasodilating Agents ( GP RECTIV OINT isethionate) (nitroglycerin (intra- 3 pentamidine isethionate 1 anal)) solr ANTHELMINTICS - Drugs to Treat Worm PRIMSOL SOLN 3 Infections (trimethoprim hcl) Anthelmintics TINDAMAX TABS GP albendazole tabs 1 (tinidazole) ALBENZA TABS tinidazole tabs 1 GP (albendazole) trimethoprim tabs 1 BENZNIDAZOLE TABS AL(At least 2 3 yrs old - Up to TRIMPEX SOLN (benznidazole) 3 12 yrs old) (trimethoprim hcl) BILTRICIDE TABS GP XIFAXAN TABS 200 MG PA; QL(9 ea (praziquantel) 3 per fill retail,9 () ea per fill mail) EMVERM CHEW QL(6 ea per fill 3 retail,6 ea per XIFAXAN TABS 550 MG PA; QL(2 ea (mebendazole) 3 fill mail) (rifaximin) daily) ivermectin tabs 1 Anti-infective Misc. - Combinations (Sulfamethoxazole- praziquantel tabs 1 Trimethoprim) SULFATRIM 1 PEDIATRIC SUSP STROMECTOL TABS GP (ivermectin) BACTRIM DS TABS (sulfamethoxazole- GP ANTI-INFECTIVE AGENTS - MISC. - Drugs to trimethoprim) Treat Bacterial Infections Anti-infective Agents - Misc. You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BACTRIM TABS CUBICIN SOLR PA SP (sulfamethoxazole- GP (daptomycin) trimethoprim) daptomycin solr SP PA sulfamethoxazole- 1 trimethoprim susp Glycopeptides FIRVANQ SOLR PA sulfamethoxazole- 1 3 trimethoprim tabs (vancomycin hcl) VANCOCIN CAPS PA Antiprotozoal Agents GP (vancomycin hcl) ALINIA SUSR 3 VANCOCIN HCL CAPS PA (nitazoxanide) GP (vancomycin hcl) ALINIA TABS 3 (nitazoxanide) vancomycin hcl caps 1 PA susp 1 Leprostatics MEPRON SUSP GP tabs 1 (atovaquone) Lincosamides Carbapenems CLEOCIN CAPS OR 75 doripenem solr SP PA; 1 bal on MG, 150 MG, 300 MG GP hand, ( hcl) PA ertapenem sodium solr SP CLEOCIN IN D5W SOLN PA imipenem-cilastatin solr PA (clindamycin phosphate SP 250 mg-250 mg, 500 SP in d5w) mg-500 mg CLEOCIN PEDIATRIC GRANULES SOLR imipenem-cilastatin solr PA; 1 bal on ( GP hand, clindamycin palmitate 250 mg-250 mg, 500 SP hydrochloride) mg-500 mg CLEOCIN PHOSPHATE PA INVANZ SOLR PA SP SOLN IJ 900 MG/6ML (ertapenem sodium) (clindamycin SP meropenem solr SP PA phosphate) CLEOCIN PHOSPHATE PA MERREM SOLR PA SP SOLN IV 300 MG/50ML-5 (meropenem) %, 600 MG/50ML-5 % SP PRIMAXIN IV SOLR PA (clindamycin phosphate SP (imipenem-cilastatin) in d5w) Chloramphenicols CLEOCIN PHOSPHATE PA SOLN IV 600 MG/4ML chloramphenicol PA; 1 bal on SP SP hand, (clindamycin sodium succinate solr phosphate) Cyclic Lipopeptides clindamycin hcl caps 1 CUBICIN RF SOLR PA SP (daptomycin) clindamycin palmitate 1 hydrochloride solr

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16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA DILATRATE SR CPCR clindamycin phosphate SP 3 in d5w soln (isosorbide dinitrate) PA GONITRO PACK PA clindamycin phosphate SP 3 soln (nitroglycerin) LINCOCIN SOLN PA ISORDIL TITRADOSE SP (lincomycin hcl) TABS (isosorbide GP dinitrate) lincomycin hcl soln SP PA isosorbide dinitrate tabs Oxazolidinones 5 mg, 10 mg, 20 mg, 30 1 linezolid susr 100 mg, 40 mg 1 1 bal on hand, mg/5ml isosorbide dinitrate tbcr 1 QL(20 ea per 40 mg 90 days linezolid tabs 600 mg 1 isosorbide mononitrate 1 retail,20 ea per tabs 90 days mail) SIVEXTRO TABS QL(6 ea per 90 isosorbide mononitrate 1 2 (tedizolid phosphate) days retail) tb24 ZYVOX SUSR 100 NITRO-BID OINT GP 2 MG/5ML (linezolid) (nitroglycerin) QL(20 ea per NITRO-DUR PT24 0.1 QL(1 ea daily) ZYVOX TABS 600 MG 90 days MG/HR, 0.2 MG/HR, 0.4 GP MG/HR, 0.6 MG/HR GP (linezolid) retail,20 ea per 90 days mail) (nitroglycerin) NITRO-DUR PT24 0.3 QL(1 ea daily) Polymyxins MG/HR, 0.8 MG/HR 2 polymyxin b sulfate solr SP PA (nitroglycerin) ANTIANGINAL AGENTS - Drugs to Treat Chest nitroglycerin cpcr or 9 1 Pain mg, 2.5 mg QL(1 ea daily) Antianginals-Other nitroglycerin pt24 td 0.1 1 RANEXA TB12 1000 MG mg/hr, 0.2 mg/hr, 0.4 GP (ranolazine) mg/hr, 0.6 mg/hr RANEXA TB12 500 MG QL(4 ea daily) nitroglycerin soln tl 0.4 GP 1 (ranolazine) mg/spray nitroglycerin subl sl 0.3 ranolazine tb12 1000 1 1 mg mg, 0.4 mg, 0.6 mg QL(4 ea daily) NITROLINGUAL ranolazine tb12 500 mg 1 PUMPSPRAY SOLN GP (nitroglycerin) Nitrates NITROMIST AERS (Nitroglycerin) MINITRAN 1 QL(1 ea daily) 3 PT24 (nitroglycerin) NITROSTAT SUBL (Nitroglycerin) NITRO- 1 1 bal on hand, GP TIME CPCR (nitroglycerin)

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17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIANXIETY AGENTS - Drugs to Treat diazepam conc 5 mg/ml 1 1 bal on hand, Antianxiety Agents - Misc. diazepam soln 5 1 mg/5ml buspirone hcl tabs 1 diazepam tabs 2 mg, 5 PA; 1 bal on 1 hydroxyzine hcl soln im SP mg, 10 mg 25 mg/ml, 50 mg/ml hand, lorazepam conc 1 hydroxyzine hcl syrp or 1 10 mg/5ml lorazepam tabs 1 hydroxyzine hcl tabs or 1 oxazepam caps 10 mg, 10 mg, 25 mg, 50 mg 1 15 mg, 15 mg, 30 mg hydroxyzine pamoate 1 bal on hand, 1 oxazepam caps 10 mg, 1 bal on hand, caps 100 mg 1 15 mg, 15 mg, 30 mg hydroxyzine pamoate 1 TRANXENE T TABS caps 25 mg, 50 mg (clorazepate GP meprobamate tabs 1 dipotassium) VISTARIL CAPS VALIUM TABS 2 MG, 10 GP GP (hydroxyzine pamoate) MG (diazepam) VALIUM TABS 5 MG NF Benzodiazepines (diazepam) (Alprazolam) 1 XANAX TABS ALPRAZOLAM XR TB24 GP (alprazolam) (Diazepam) DIAZEPAM 1 XANAX XR TB24 INTENSOL CONC GP (alprazolam) (Lorazepam) LORAZEPAM 1 INTENSOL CONC ANTIARRHYTHMICS - Drugs to treat abnormal ALPRAZOLAM INTENSOL heart rhythms 3 CONC (alprazolam) Antiarrhythmics Type I-A alprazolam tabs 1 disopyramide 1 phosphate caps alprazolam tb24 1 NORPACE CAPS (disopyramide GP 1 alprazolam tbdp phosphate) ATIVAN TABS 0.5 MG, 2 GP NORPACE CR CP12 100 MG (lorazepam) MG (disopyramide 2 ATIVAN TABS 1 MG phosphate) NF (lorazepam) NORPACE CR CP12 150 MG (disopyramide 3 chlordiazepoxide hcl 1 caps phosphate) PA clorazepate 1 procainamide hcl soln SP dipotassium tabs quinidine gluconate tbcr 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, XOLAIR SOLR PA quinidine sulfate tabs 1 SP (omalizumab) Antiarrhythmics Type I-B XOLAIR SOSY PA SP mexiletine hcl caps 150 1 bal on hand, (omalizumab) mg, 200 mg, 250 mg, 1 Bronchodilators - Anticholinergics 250 mg ATROVENT HFA AERS Limit 2 inhalers per mexiletine hcl caps 200 1 (ipratropium bromide 2 mg, 250 mg, 250 mg month;QL(0.86 hfa) gm daily) Antiarrhythmics Type I-C INCRUSE ELLIPTA AEPB Limit 1 inhaler flecainide acetate tabs 1 2 per month;QL(1 (umeclidinium bromide) ea daily) propafenone hcl cp12 ipratropium bromide 1 225 mg, 325 mg, 425 1 soln mg SEEBRI NEOHALER ST; QL(2 ea QL(6 ea daily) propafenone hcl tabs 1 CAPS (glycopyrrolate 3 daily) 150 mg, 300 mg (inhalation)) QL(3 ea daily) propafenone hcl tabs 1 SPIRIVA HANDIHALER QL(1 ea daily) 225 mg, 300 mg CAPS (tiotropium 2 RYTHMOL SR CP12 ) GP bromide monohydrate (propafenone hcl) SPIRIVA RESPIMAT Limit 1 inhaler Antiarrhythmics Type III AERS ( 2 per tiotropium month;QL(0.14 ( Hcl) 1 bromide monohydrate) gm daily) PACERONE TABS TUDORZA PRESSAIR ST; Limit 1 1 amiodarone hcl tabs AEPB ( 3 inhaler per aclidinium month;QL(0.04 CORDARONE TABS bromide) GP ea daily) (amiodarone hcl) Leukotriene Modulators dofetilide caps 1 ACCOLATE TABS GP MULTAQ TABS () 2 ( ) QL(1 ea daily) dronedarone hcl montelukast sodium 1 TIKOSYN CAPS chew GP (dofetilide) QL(1 ea daily) montelukast sodium 1 ANTIASTHMATIC AND BRONCHODILATOR pack AGENTS - Drugs to Treat Lung Conditions QL(1 ea daily) montelukast sodium 1 Anti-Inflammatory Agents tabs SINGULAIR CHEW 4 MG, QL(1 ea daily) cromolyn sodium nebu 1 5 MG (montelukast GP CROMOLYN SODIUM sodium) NEBU (cromolyn 2 SINGULAIR PACK 4 MG QL(1 ea daily) GP sodium) (montelukast sodium) Antiasthmatic - Monoclonal Antibodies

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SINGULAIR TABS 10 MG QL(1 ea daily) ASMANEX TWISTHALER Limit 1 inhaler NF (montelukast sodium) 14 METERED DOSES per AEPB (mometasone 2 month;QL(0.04 zafirlukast tabs 1 furoate (inhalation)) ea daily) zileuton tb12 1 ST ASMANEX TWISTHALER Limit 1 inhaler 30 METERED DOSES per ZYFLO CR TB12 ST 2 month;QL(0.04 NF AEPB (mometasone (zileuton) furoate (inhalation)) ea daily) ZYFLO TABS (zileuton) 3 ST ASMANEX TWISTHALER Limit 1 inhaler 60 METERED DOSES per Selective Phosphodiesterase 4 (PDE4) Inhibitors AEPB (mometasone 2 month;QL(0.04 DALIRESP TABS QL(1 ea daily) furoate (inhalation)) ea daily) 3 (roflumilast) ASMANEX TWISTHALER Limit 1 inhaler 7 METERED DOSES per Steroid Inhalants AEPB (mometasone 2 month;QL(0.04 Limit 2 inhalers ea daily) ALVESCO AERS furoate (inhalation)) 3 per month;QL(0.41 QL(8 ml daily) (ciclesonide) budesonide (inhalation) 1 gm daily) susp 0.25 mg/2ml ARMONAIR RESPICLICK QL(0.04 ea QL(4 ml daily) budesonide (inhalation) 1 113 AEPB (fluticasone 3 daily) susp 0.5 mg/2ml propionate (inhalation)) QL(2 ml daily) budesonide (inhalation) 1 ARMONAIR RESPICLICK QL(0.04 ea susp 1 mg/2ml 232 AEPB (fluticasone 3 daily) FLOVENT DISKUS AEPB QL(20 ea daily) propionate (inhalation)) 100 MCG/BLIST ARMONAIR RESPICLICK QL(0.04 ea (fluticasone propionate 2 55 AEPB (fluticasone 3 daily) (inhalation)) propionate (inhalation)) FLOVENT DISKUS AEPB QL(8 ea daily) ARNUITY ELLIPTA AEPB QL(1 ea daily) 250 MCG/BLIST (fluticasone furoate 2 (fluticasone propionate 2 (inhalation)) (inhalation)) ASMANEX HFA AERO 100 Limit 1 inhaler FLOVENT DISKUS AEPB QL(40 ea daily) MCG/ACT, 200 MCG/ACT per 50 MCG/BLIST 2 (mometasone furoate month;QL(0.44 (fluticasone propionate 2 (inhalation)) gm daily) (inhalation)) ASMANEX HFA AERO 50 Limit 1 Inhaler FLOVENT HFA AERO 110 Limit 2 inhalers MCG/ACT, 200 MCG/ACT per MCG/ACT, 220 MCG/ACT per 2 (mometasone furoate month;QL(0.44 (fluticasone propionate 2 month;QL(0.8 (inhalation)) gm daily) hfa) gm daily) ASMANEX TWISTHALER Limit 1 inhaler FLOVENT HFA AERO 44 Limit 1 inhaler 120 METERED DOSES per MCG/ACT, 220 MCG/ACT per 2 AEPB (mometasone month;QL(0.04 (fluticasone propionate 2 month;QL(0.36 furoate (inhalation)) ea daily) hfa) gm daily)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PULMICORT FLEXHALER Limit 2 inhalers albuterol sulfate aers in QL(1.2 gm AEPB 180 MCG/ACT per 1 daily)1 bal on 108 mcg/act (budesonide 2 month;QL(0.07 hand, (inhalation)) ea daily) QL(1.2 gm albuterol sulfate aers in 1 PULMICORT FLEXHALER Limit 2 inhalers 108 mcg/act daily) AEPB 90 MCG/ACT per Limit 2 inhalers (budesonide 2 month;QL(0.27 albuterol sulfate aers in 1 per (inhalation)) ea daily) 108 mcg/act month;QL(0.57 PULMICORT SUSP 0.25 QL(8 ml daily) gm daily) QL(0.45 gm MG/2ML (budesonide NF albuterol sulfate aers in 1 (inhalation)) 108 mcg/act daily) PULMICORT SUSP 0.5 QL(4 ml daily) albuterol sulfate nebu MG/2ML (budesonide GP in 0.63 mg/3ml, 0.083 1 (inhalation)) %, 0.5 %, 1.25 mg/3ml, PULMICORT SUSP 1 QL(2 ml daily) 2.5 mg/0.5ml MG/2ML (budesonide GP albuterol sulfate syrp or 1 (inhalation)) 2 mg/5ml QVAR REDIHALER AERB Limit 1 inhaler albuterol sulfate tabs or 1 40 MCG/ACT per 2 mg, 4 mg (beclomethasone 2 month;QL(0.36 albuterol sulfate tb12 or QL(2 ea daily)1 dipropionate hfa) gm daily) 1 4 mg, 8 mg bal on hand, QVAR REDIHALER AERB Limit 2 Inhalers 80 MCG/ACT per ANORO ELLIPTA AEPB QL(2 ea daily) (beclomethasone 2 month;QL(0.72 (umeclidinium- 2 dipropionate hfa) gm daily) vilanterol) ARCAPTA NEOHALER QL(1 ea daily) Sympathomimetics CAPS (indacaterol 3 (Fluticasone-Salmeterol) 1 QL(2 ea daily) maleate) WIXELA INHUB AEPB Limit 1 inhaler ADVAIR DISKUS AEPB QL(2 ea daily) BEVESPI AEROSPHERE GP AERO ( 3 per (fluticasone-salmeterol) glycopyrrolate- month;QL(0.36 Limit 1 inhaler formoterol fumarate) gm daily) ADVAIR HFA AERO 2 per BREO ELLIPTA AEPB QL(2 ea daily) (fluticasone-salmeterol) month;QL(0.4 (fluticasone furoate- 2 gm daily) vilanterol) AIRDUO RESPICLICK QL(0.04 ea BROVANA NEBU 113/14 AEPB NF daily)1 bal on 3 (fluticasone-salmeterol) hand, (arformoterol tartrate) Limit 1 inhaler AIRDUO RESPICLICK QL(0.04 ea budesonide-formoterol 232/14 AEPB NF daily)1 bal on per 1 month;QL(0.34 (fluticasone-salmeterol) hand, fumarate dihydrate aero gm daily)1 bal AIRDUO RESPICLICK QL(0.04 ea on hand, 55/14 AEPB (fluticasone- NF daily)1 bal on salmeterol) hand,

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMBIVENT RESPIMAT Limit 1 inhaler STIOLTO RESPIMAT Limit 1 inhaler AERS ( 3 per AERS ( 2 per ipratropium- month;QL(0.2 tiotropium month;QL(0.14 albuterol) gm daily) bromide-olodaterol hcl) gm daily) SP PA Limit 1 inhaler epinephrine hcl soln STRIVERDI RESPIMAT 2 per fluticasone-salmeterol QL(2 ea daily) AERS (olodaterol hcl) month;QL(0.14 aepb 50 mcg/dose-100 gm daily) mcg/dose, 50 Limit 1 inhaler SYMBICORT AERO mcg/dose-250 1 per (budesonide-formoterol GP month;QL(0.34 mcg/dose, 50 fumarate dihydrate) gm daily)1 bal mcg/dose-500 on hand, mcg/dose terbutaline sulfate tabs 1 ipratropium-albuterol 1 soln TRELEGY ELLIPTA AEPB QL(2 ea daily) (fluticasone- 2 levalbuterol hcl nebu 1 umeclidinium-vilanterol) Limit 2 inhalers UTIBRON NEOHALER QL(2 ea daily) levalbuterol tartrate 1 per month;QL(1 CAPS (indacaterol 3 aero gm daily)1 bal maleate-glycopyrrolate) on hand, Limit 2 inhalers metaproterenol sulfate 1 bal on hand, 1 VENTOLIN HFA AERS per syrp 1 month;QL(1.2 (albuterol sulfate) 1 bal on hand, gm daily)1 bal metaproterenol sulfate 1 tabs on hand, PERFOROMIST NEBU QL(4 ml daily) Limit 2 inhalers 3 VENTOLIN HFA AERS per (formoterol fumarate) 1 month;QL(0.54 Limit 2 inhalers (albuterol sulfate) gm daily)1 bal PROAIR HFA AERS 1 per on hand, (albuterol sulfate) month;QL(0.57 XOPENEX gm daily) CONCENTRATE NEBU GP Limit 2 inhalers (levalbuterol hcl) PROAIR RESPICLICK per 3 Limit 2 inhalers AEPB (albuterol sulfate) month;QL(0.07 XOPENEX HFA AERO ea daily) 1 per month;QL(1 (levalbuterol tartrate) gm daily)1 bal Limit 2 inhalers on hand, PROVENTIL HFA AERS per 1 XOPENEX NEBU (albuterol sulfate) month;QL(0.45 GP gm daily) (levalbuterol hcl) Limit 2 inhalers Xanthines PROVENTIL HFA AERS NF per PA (albuterol sulfate) month;QL(0.45 aminophylline soln SP gm daily) ELIXOPHYLLIN ELIX 3 SEREVENT DISKUS QL(2 ea daily) (theophylline) AEPB (salmeterol 2 THEO-24 CP24 2 xinafoate) (theophylline) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ml per 10 theophylline soln 80 1 enoxaparin sodium mg/15ml soln sc 30 mg/0.3ml, SP days retail) theophylline tb12 100 120 mg/0.8ml mg, 200 mg, 300 mg, 1 enoxaparin sodium QL(8 ml per 10 450 mg, 450 mg soln sc 40 mg/0.4ml, SP days retail) theophylline tb12 300 1 bal on hand, 120 mg/0.8ml mg, 300 mg, 450 mg, 1 enoxaparin sodium QL(12 ml per 450 mg soln sc 60 mg/0.6ml, SP 10 days retail) 120 mg/0.8ml theophylline tb24 400 1 mg, 600 mg enoxaparin sodium QL(16 ml per soln sc 80 mg/0.8ml, SP 10 days retail) ANTICOAGULANTS - Blood Thinners 120 mg/0.8ml Coumarin Anticoagulants PA; fondaparinux sodium SP (Warfarin Sodium) 1 soln JANTOVEN TABS FRAGMIN SOLN 10000 QL(20 ml per COUMADIN TABS UNIT/ML, 5000 365 days retail) GP (warfarin sodium) UNIT/0.2ML (dalteparin SP warfarin sodium tabs 1 sodium) FRAGMIN SOLN 12500 QL(10 ml per Direct Factor Xa Inhibitors UNIT/0.5ML (dalteparin SP 365 days retail) BEVYXXA CAPS QL(42 ea per sodium) 3 (betrixaban maleate) 42 days retail) FRAGMIN SOLN 15000 QL(12 ml per ELIQUIS STARTER PACK UNIT/0.6ML (dalteparin SP 365 days retail) 2 TABS (apixaban) sodium) ELIQUIS TABS FRAGMIN SOLN 18000 QL(14 ml per 2 (apixaban) UNT/0.72ML (dalteparin SP 365 days retail) SAVAYSA TABS sodium) 3 (edoxaban tosylate) FRAGMIN SOLN 2500 QL(4 ml per UNIT/0.2ML, 5000 365 days retail) XARELTO STARTER SP PACK TBPK 2 UNIT/0.2ML (dalteparin (rivaroxaban) sodium) XARELTO TABS 10 MG, FRAGMIN SOLN 7500 QL(6 ml per 15 MG, 20 MG 2 UNIT/0.3ML (dalteparin SP 365 days retail) (rivaroxaban) sodium) Heparins And Heparinoid-Like Agents FRAGMIN SOLN 95000 PA ARIXTRA SOLN PA; UNIT/3.8ML (dalteparin SP SP (fondaparinux sodium) sodium) QL(3 ml per 10 heparin (porcine) in enoxaparin sodium SP soln ij 300 mg/3ml days retail) sodium chloride soln SP enoxaparin sodium QL(20 ml per 2000 unit/l-0.9 %, 1000 unit/500ml-0.9 %, 1000 soln sc 100 mg/ml, 150 SP 10 days retail) unit/500ml-0.9 % mg/ml, 120 mg/0.8ml

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits heparin (porcine) in 1 bal on hand, LOVENOX SOLN SC 80 QL(16 ml per sodium chloride soln MG/0.8ML, 120 MG/0.8ML SP 10 days retail) 2000 unit/l-0.9 %, 1000 SP (enoxaparin sodium) unit/500ml-0.9 %, 1000 Thrombin Inhibitors unit/500ml-0.9 % PRADAXA CAPS 1 bal on hand, (dabigatran etexilate 3 heparin sod (porcine) in SP d5w soln mesylate) heparin sodium SP ANTICONVULSANTS - Drugs to Treat Seizures (porcine) soln HEPARIN SODIUM/NACL AMPA Glutamate Receptor Antagonists FYCOMPA SUSP 0.45% SOLN (heparin SP 3 (porcine) in sodium (perampanel) chloride) FYCOMPA TABS 3 HEPARIN (perampanel) SODIUM/SODIUM Anticonvulsants - Benzodiazepines CHLORIDE 0.9% SOLN SP (heparin (porcine) in clobazam susp 1 sodium chloride) HEPARIN clobazam tabs 1 SODIUM/SODIUM CHLORIDE SOLN 2000 clonazepam tabs 1 UNIT/L-0.9 %, 1000 UNIT/500ML-0.9 %, 25000 SP clonazepam tbdp 1 UNIT/250ML-0.45 %, 25000 UNIT/500ML-0.45 % DIASTAT ACUDIAL GEL Limit 4 per ( 3 month;QL(0.14 (heparin (porcine) in diazepam ea daily)1 bal sodium chloride) (anticonvulsant)) on hand, LOVENOX SOLN IJ 300 QL(3 ml per 10 Limit 4 per MG/3ML (enoxaparin SP days retail) DIASTAT PEDIATRIC GEL ( 3 month;QL(0.14 sodium) diazepam ea daily)1 bal ) LOVENOX SOLN SC 100 QL(20 ml per (anticonvulsant) on hand, MG/ML, 150 MG/ML, 120 10 days retail) Limit 4 per SP diazepam MG/0.8ML (enoxaparin (anticonvulsant) gel 10 3 month;QL(0.14 sodium) ea daily)1 bal mg on hand, LOVENOX SOLN SC 30 QL(6 ml per 10 MG/0.3ML, 120 MG/0.8ML SP days retail) diazepam Limit 4 per (enoxaparin sodium) 1 month;QL(0.14 (anticonvulsant) gel 20 ea daily)1 bal LOVENOX SOLN SC 40 QL(8 ml per 10 mg, 2.5 mg on hand, MG/0.4ML, 120 MG/0.8ML days retail) SP KLONOPIN TABS (enoxaparin sodium) GP (clonazepam) LOVENOX SOLN SC 60 QL(12 ml per MG/0.6ML, 120 MG/0.8ML 10 days retail) NAYZILAM SOLN PA; QL(10 ea SP per 30 days (enoxaparin sodium) (midazolam SP (anticonvulsant)) retail) ONFI SUSP (clobazam) GP

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIACOMIT CAPS 250 MG PA; QL(12 ea ONFI TABS (clobazam) GP SP (stiripentol) daily) VALTOCO LIQD PA; QL(10 ea DIACOMIT CAPS 500 MG PA; QL(6 ea per 30 days SP (diazepam SP (stiripentol) daily) (anticonvulsant)) retail) DIACOMIT PACK 250 MG PA; QL(12 ea SP VALTOCO LQPK PA; QL(10 ea (stiripentol) daily) (diazepam SP per 30 days DIACOMIT PACK 500 MG PA; QL(6 ea (anticonvulsant)) retail) SP (stiripentol) daily) Anticonvulsants - Misc. EPIDIOLEX SOLN PA SP () EPITOL 1 () TABS (Lamotrigine) SUBVENITE gabapentin caps 1 STARTER KIT/BLUE, gabapentin soln 1 SUBVENITE STARTER 1 KIT/ORANGE, SUBVENITE STARTER gabapentin tabs 1 KIT/GREEN KIT KEPPRA SOLN IV 500 PA SP (Lamotrigine) SUBVENITE 1 MG/5ML (levetiracetam) TABS KEPPRA SOLN OR 100 (Levetiracetam) 1 3 ROWEEPRA TABS MG/ML (levetiracetam) KEPPRA TABS OR 250 (Levetiracetam) 1 ROWEEPRA XR TB24 MG, 500 MG, 750 MG, 3 ) APTIOM TABS 200 MG, QL(2 ea daily) 1000 MG (levetiracetam KEPPRA XR TB24 400 MG, 600 MG 3 (eslicarbazepine 3 (levetiracetam) acetate) LAMICTAL CHEWABLE APTIOM TABS 800 MG QL(1 ea daily) DISPERSIBLE CHEW 3 (eslicarbazepine 3 (lamotrigine) LAMICTAL ODT KIT PA acetate) 3 BANZEL SUSP (lamotrigine) 2 (rufinamide) LAMICTAL ODT TBDP 25 PA MG, 50 MG, 100 MG, 200 BANZEL TABS 3 2 MG (lamotrigine) (rufinamide) LAMICTAL STARTER/NOT carbamazepine chew 1 TAKING CARBAMAZEPINE KIT GP carbamazepine cp12 1 (lamotrigine) LAMICTAL carbamazepine susp 1 STARTER/TAKING CARBAMAZEPINE/NOT GP carbamazepine tabs 1 TAKING KIT (lamotrigine) carbamazepine tb12 1 CARBATROL CP12 3 (carbamazepine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL levetiracetam tb24 or 1 STARTER/TAKING 500 mg, 750 mg VALPROATE KIT GP LYRICA CAPS 150 MG, PA; QL(2 ea ( ) lamotrigine 200 MG, 225 MG, 300 MG 3 daily) LAMICTAL TABS 3 (pregabalin) (lamotrigine) LYRICA CAPS 25 MG, 50 PA; QL(3 ea LAMICTAL XR KIT PA 3 MG, 75 MG, 100 MG, 200 daily) (lamotrigine) MG, 225 MG, 300 MG 3 LAMICTAL XR TB24 25 PA; QL(1 ea (pregabalin) MG, 50 MG, 100 MG, 200 3 daily) LYRICA SOLN 20 MG/ML PA 3 MG (lamotrigine) (pregabalin) LAMICTAL XR TB24 250 PA MYSOLINE TABS 3 3 MG (lamotrigine) (primidone) LAMICTAL XR TB24 300 NEURONTIN CAPS 3 3 MG (lamotrigine) (gabapentin) lamotrigine chew 5 mg, NEURONTIN SOLN 1 3 25 mg (gabapentin) PA NEURONTIN TABS lamotrigine kit 1 3 (gabapentin) lamotrigine kit 25 mg, 1 oxcarbazepine susp 1 lamotrigine tabs 25 mg, 100 mg, 150 mg, 200 1 oxcarbazepine tabs 1 mg OXTELLAR XR TB24 3 lamotrigine tb24 25 mg, PA; QL(1 ea (oxcarbazepine) 50 mg, 100 mg, 200 1 daily) pregabalin caps 150 PA; QL(2 ea mg mg, 200 mg, 225 mg, 1 daily) PA 300 mg lamotrigine tb24 250 1 mg pregabalin caps 25 mg, PA; QL(3 ea 50 mg, 75 mg, 100 mg, daily) lamotrigine tb24 300 1 1 mg 200 mg, 225 mg, 300 lamotrigine tbdp 25 mg, PA mg PA 50 mg, 100 mg, 200 1 pregabalin soln 20 1 mg mg/ml PA levetiracetam soln iv SP primidone tabs 1 500 mg/5ml QUDEXY XR CS24 PA; 1 bal on 3 levetiracetam soln or 1 (topiramate) hand, 100 mg/ml, 500 mg/5ml TEGRETOL SUSP 3 levetiracetam tabs or (carbamazepine) 250 mg, 500 mg, 750 1 TEGRETOL TABS 3 mg, 1000 mg (carbamazepine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGRETOL-XR TB12 100 GABITRIL TABS GP 3 MG (carbamazepine) (tiagabine hcl) TEGRETOL-XR TB12 200 SABRIL PACK GP MG, 400 MG 3 (vigabatrin) (carbamazepine) SABRIL TABS TOPAMAX SPRINKLE GP 3 (vigabatrin) CPSP (topiramate) tiagabine hcl tabs 1 TOPAMAX TABS 3 (topiramate) vigabatrin pack 1 topiramate cpsp 15 mg, 1 25 mg vigabatrin tabs 1 topiramate cs24 25 mg, PA; 1 bal on Hydantoins 50 mg, 100 mg, 150 1 hand, () PHENYTOIN 1 mg, 200 mg INFATABS CHEW topiramate tabs 25 mg, CEREBYX SOLN PA SP 50 mg, 100 mg, 200 1 (fosphenytoin sodium) mg DILANTIN CAPS 100 MG TRILEPTAL SUSP ( 3 3 phenytoin sodium (oxcarbazepine) extended) TRILEPTAL TABS DILANTIN CAPS 30 MG 3 (oxcarbazepine) (phenytoin sodium 2 TROKENDI XR CP24 PA extended) 3 (topiramate) DILANTIN INFATABS 3 VIMPAT SOLN CHEW (phenytoin) 2 (lacosamide) DILANTIN-125 SUSP 3 VIMPAT TABS (phenytoin) 2 (lacosamide) PA fosphenytoin sodium SP ZONEGRAN CAPS soln 3 (zonisamide) PEGANONE TABS 3 zonisamide caps 1 (ethotoin) PHENYTEK CAPS Carbamates (phenytoin sodium 3 felbamate susp 1 extended) phenytoin chew 1 felbamate tabs 1 phenytoin sodium FELBATOL SUSP 1 3 extended caps (felbamate) PA FELBATOL TABS phenytoin sodium soln SP 3 (felbamate) phenytoin susp 1 GABA Modulators Succinimides (Vigabatrin) VIGADRONE 1 PACK You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELONTIN CAPS 2 bupropion hcl tabs 75 1 (methsuximide) mg, 100 mg ethosuximide caps 1 bupropion hcl tb12 100 1 mg, 150 mg, 200 mg ethosuximide soln 1 QL(1 ea daily) bupropion hcl tb24 150 1 ZARONTIN CAPS mg, 300 mg 3 (ethosuximide) bupropion hcl tb24 450 ST; QL(1 ea ZARONTIN SOLN 1 daily)1 bal on 3 mg (ethosuximide) hand, FORFIVO XL TB24 ST; QL(1 ea Valproic Acid 3 daily)1 bal on DEPAKENE CAPS 250 MG (bupropion hcl) hand, 3 (valproic acid) maprotiline hcl tabs 1 1 bal on hand, DEPAKOTE ER TB24 3 WELLBUTRIN SR TB12 (divalproex sodium) GP DEPAKOTE SPRINKLES 100 MG (bupropion hcl) CSDR (divalproex 3 WELLBUTRIN SR TB12 sodium) 150 MG, 200 MG NF (bupropion hcl) DEPAKOTE TBEC 3 WELLBUTRIN XL TB24 QL(1 ea daily) (divalproex sodium) NF 150 MG (bupropion hcl) divalproex sodium csdr 1 WELLBUTRIN XL TB24 QL(1 ea daily) GP 300 MG (bupropion hcl) divalproex sodium tb24 1 Monoamine Oxidase Inhibitors (MAOIs) divalproex sodium tbec 1 EMSAM PT24 QL(1 ea daily) 3 () valproic acid caps or 1 MARPLAN TABS 3 ANTIDEPRESSANTS - Drugs to Treat (isocarboxazid) Depression NARDIL TABS GP Alpha-2 Receptor Antagonists (Tetracyclics) (phenelzine sulfate) PARNATE TABS 1 mirtazapine tabs (tranylcypromine GP mirtazapine tbdp 1 sulfate) REMERON SOLTAB TBDP phenelzine sulfate tabs 1 GP (mirtazapine) tranylcypromine sulfate 1 REMERON TABS GP tabs (mirtazapine) Selective Reuptake Inhibitors (SSRIs) Antidepressants - Misc. CELEXA TABS 10 MG QL(4 ea daily) APLENZIN TB24 ST; QL(1 ea (citalopram GP (bupropion 3 daily) hydrobromide) hydrobromide)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELEXA TABS 20 MG QL(2 ea daily) LEXAPRO TABS 10 MG, (citalopram GP 20 MG (escitalopram NF hydrobromide) oxalate) CELEXA TABS 40 MG QL(1 ea daily) LEXAPRO TABS 5 MG GP (citalopram GP (escitalopram oxalate) hydrobromide) paroxetine hcl tabs 1 citalopram QL(20 ml daily) hydrobromide soln 10 1 paroxetine hcl tb24 1 mg/5ml PAXIL CR TB24 25 MG, GP citalopram QL(4 ea daily) 12.5 MG (paroxetine hcl) hydrobromide tabs 10 1 PAXIL CR TB24 37.5 MG NF mg (paroxetine hcl) citalopram QL(2 ea daily) PAXIL TABS 10 MG, 30 hydrobromide tabs 20 1 MG, 40 MG (paroxetine GP mg hcl) citalopram QL(1 ea daily) PAXIL TABS 20 MG NF hydrobromide tabs 40 1 (paroxetine hcl) mg PEXEVA TABS 3 escitalopram oxalate 1 (paroxetine mesylate) soln PROZAC CAPS GP (fluoxetine hcl) escitalopram oxalate 1 tabs sertraline hcl conc 1 fluoxetine hcl caps 10 1 mg, 20 mg, 40 mg sertraline hcl tabs 1 fluoxetine hcl cpdr 90 1 bal on hand, ZOLOFT CONC 20 MG/ML 1 GP mg (sertraline hcl) fluoxetine hcl soln 20 ZOLOFT TABS 100 MG 1 NF mg/5ml (sertraline hcl) fluoxetine hcl tabs 10 ZOLOFT TABS 25 MG, 50 1 GP mg, 20 mg MG (sertraline hcl) fluoxetine hcl tabs 60 ST; QL(1 ea Serotonin Modulators 1 daily)1 bal on 1 bal on hand, mg hand, hcl tabs 50 mg, 100 mg, 150 mg, fluoxetine hcl tabs 60 ST; QL(1 ea 1 1 daily) 200 mg, 250 mg, 250 mg mg FLUOXETINE ST; QL(1 ea HYDROCHLORIDE TABS 3 daily) nefazodone hcl tabs 50 (fluoxetine hcl) mg, 100 mg, 150 mg, 1 200 mg, 250 mg, 250 fluvoxamine maleate 1 mg cp24 trazodone hcl tabs 1 fluvoxamine maleate 1 tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRINTELLIX TABS ST; QL(1 ea QL(1 ea daily) 3 venlafaxine hcl cp24 75 1 (vortioxetine hbr) daily) mg, 37.5 mg VIIBRYD STARTER PACK ST 3 venlafaxine hcl tabs 25 KIT (vilazodone hcl) mg, 50 mg, 75 mg, 100 1 VIIBRYD TABS ST 3 mg, 37.5 mg (vilazodone hcl) venlafaxine hcl tb24 75 Serotonin-Norepinephrine Reuptake Inhibitors mg, 150 mg, 225 mg, 1 CYMBALTA CPEP 20 MG QL(2 ea daily) 37.5 mg GP (duloxetine hcl) Tricyclic Agents CYMBALTA CPEP 30 MG, QL(2 ea daily) NF 1 60 MG (duloxetine hcl) hcl tabs DESVENLAFAXINE ER ST; QL(1 ea 1 bal on hand, 3 amoxapine tabs 1 TB24 (desvenlafaxine) daily) ANAFRANIL CAPS GP desvenlafaxine 1 (clomipramine hcl) succinate tb24 ST; QL(1 ea clomipramine hcl caps 1 desvenlafaxine tb24 1 daily)1 bal on hand, desipramine hcl tabs 1 QL(2 ea daily) duloxetine hcl cpep 20 1 doxepin hcl caps 10 mg, 30 mg, 60 mg mg, 25 mg, 50 mg, 75 1 EFFEXOR XR CP24 150 QL(2 ea daily) NF mg, 100 mg, 150 mg MG (venlafaxine hcl) 1 bal on hand, doxepin hcl caps 150 1 EFFEXOR XR CP24 75 QL(1 ea daily) mg, 150 mg MG, 37.5 MG GP doxepin hcl conc 10 (venlafaxine hcl) 1 mg/ml FETZIMA CP24 20 MG, 80 ST; QL(2 ea MG, 120 MG 3 daily) imipramine hcl tabs 1 (levomilnacipran hcl) imipramine pamoate 1 FETZIMA CP24 40 MG, 80 ST; QL(1 ea caps MG, 120 MG 3 daily) NORPRAMIN TABS (levomilnacipran hcl) GP FETZIMA TITRATION ST (desipramine hcl) PACK C4PK 3 nortriptyline hcl caps 10 (levomilnacipran hcl) mg, 25 mg, 50 mg, 75 1 mg KHEDEZLA TB24 ST; QL(1 ea 3 daily)1 bal on PAMELOR CAPS (desvenlafaxine) GP hand, (nortriptyline hcl) PRISTIQ TB24 (desvenlafaxine NF protriptyline hcl tabs 1 succinate) SURMONTIL CAPS GP QL(2 ea daily) (trimipramine maleate) venlafaxine hcl cp24 1 150 mg, 37.5 mg TOFRANIL TABS GP (imipramine hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INVOKAMET XR TB24 trimipramine maleate 1 caps (canagliflozin- 2 ) ANTIDIABETICS - Drugs to Regulate Blood metformin hcl Sugar JANUMET TABS (sitagliptin-metformin 2 Alpha-Glucosidase Inhibitors hcl) acarbose tabs 1 JANUMET XR TB24 (sitagliptin-metformin 2 GP GLYSET TABS (miglitol) hcl) miglitol tabs 1 KAZANO TABS 1 bal on hand, (alogliptin-metformin NF PRECOSE TABS GP hcl) (acarbose) OSENI TABS ( 1 bal on hand, alogliptin- NF Antidiabetic - Amylin Analogs pioglitazone) SYMLINPEN 120 SOPN PA SP pioglitazone hcl- 1 (pramlintide acetate) glimepiride tabs SYMLINPEN 60 SOPN PA SP pioglitazone hcl- 1 (pramlintide acetate) metformin hcl tabs Antidiabetic Combinations 1 bal on hand, repaglinide-metformin 1 ACTOPLUS MET TABS hcl tabs (pioglitazone hcl- GP SEGLUROMET TABS metformin hcl) (ertugliflozin-metformin 3 ACTOPLUS MET XR TB24 hcl) (pioglitazone hcl- 3 SOLIQUA 100/33 SOPN PA ) metformin hcl (insulin glargine- SP DUETACT TABS lixisenatide) (pioglitazone hcl- GP SYNJARDY TABS ) glimepiride (empagliflozin- 2 glipizide-metformin hcl 1 metformin hcl) tabs SYNJARDY XR TB24 GLUCOVANCE TABS GP (empagliflozin- 2 (glyburide-metformin) metformin hcl) glyburide-metformin 1 XULTOPHY 100/3.6 SOPN PA tabs (insulin degludec- SP GLYXAMBI TABS liraglutide) (empagliflozin- 2 Biguanides linagliptin) GLUCOPHAGE TABS GP INVOKAMET TABS (metformin hcl) (canagliflozin- 2 GLUCOPHAGE XR TB24 GP metformin hcl) (metformin hcl) GLUMETZA TB24 PA SP (metformin hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metformin hcl soln 500 1 Receptor Agonists - Antidiabetic mg/5ml CYCLOSET TABS (bromocriptine 3 metformin hcl tabs 500 1 mg, 850 mg, 1000 mg mesylate (diabetes)) PA metformin hcl tb24 500 SP Incretin Mimetic Agents (GLP-1 Receptor mg, 1000 mg ADLYXIN SOPN PA SP (lixisenatide) metformin hcl tb24 500 1 mg, 750 mg ADLYXIN STARTER PACK PA SP METFORMIN 1 bal on hand, PNKT (lixisenatide) HYDROCHLORIDE SOLN 1 BYDUREON BCISE AUIJ PA SP (metformin hcl) (exenatide) RIOMET SOLN 1 bal on hand, BYDUREON PEN PEN PA 3 SP (metformin hcl) (exenatide) Diabetic Other BYDUREON SRER PA SP BAQSIMI ONE PACK QL(0.069 ea (exenatide) 2 POWD (glucagon) daily) BYETTA SOPN PA SP BAQSIMI TWO PACK QL(0.069 ea (exenatide) 2 POWD (glucagon) daily) OZEMPIC SOPN PA SP (semaglutide) diazoxide susp 1 TANZEUM PEN PA SP GLUCAGEN HYPOKIT (albiglutide) SOLR (glucagon hcl 2 TRULICITY SOPN PA SP (rdna)) (dulaglutide) GLUCAGON VICTOZA SOPN PA EMERGENCY KIT FOR SP LOW BLOOD SUGAR 2 (liraglutide) SOLR (glucagon hcl) Insulin Sensitizing Agents ACTOS TABS GLUCAGON GP EMERGENCY KIT KIT 2 (pioglitazone hcl) (glucagon (rdna)) AVANDIA TABS 2 GVOKE PFS SOSY QL(0.02 ml ( ) 2 rosiglitazone maleate (glucagon) daily) pioglitazone hcl tabs 1 KORLYM TABS PA ( SP Insulin (hyperglycemia)) HUMALOG JUNIOR Limit 45mls per PROGLYCEM SUSP KWIKPEN SOPN (insulin 2 month;QL(1.5 GP (diazoxide) lispro) ml daily) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors HUMALOG KWIKPEN Limit 45mls per JANUVIA TABS SOPN 100 UNIT/ML 2 month;QL(1.5 2 ml daily) (sitagliptin phosphate) (insulin lispro) HUMALOG KWIKPEN Limit 4mls per NESINA TABS ( 1 bal on hand, alogliptin NF SOPN 100 UNIT/ML 2 month;QL(1.5 benzoate) (insulin lispro) ml daily)

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32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMALOG KWIKPEN Limit 24mls per HUMULIN R U-500 Limit 2 vials per SOPN 200 UNIT/ML 2 month;QL(0.8 KWIKPEN SOPN (insulin 2 month;QL(1.5 (insulin lispro) ml daily) regular (human)) ml daily) HUMALOG MIX 50/50 Limit 45mls per INSULIN LISPRO Limit 45mls per KWIKPEN SUPN (insulin month;QL(1.5 PROTAMINE/INSULIN month;QL(1.5 2 lispro protamine & ml daily) LISPRO KWIKPEN SUPN 2 ml daily) lispro) (insulin lispro protamine HUMALOG MIX 50/50 Limit 4 vials per & lispro) SUSP (insulin lispro 2 month;QL(1.5 LANTUS SOLN (insulin Limit 45mls per protamine & lispro) ml daily) 2 month;QL(1.5 glargine) ml daily) HUMALOG MIX 75/25 Limit 45mls per Limit 45mls per KWIKPEN SUPN (insulin month;QL(1.5 LANTUS SOLOSTAR 2 ml daily) 2 month;QL(1.5 lispro protamine & SOPN (insulin glargine) ml daily) lispro) LEVEMIR FLEXTOUCH Limit 45mls per HUMALOG MIX 75/25 Limit 45mls per 2 month;QL(1.5 SOPN ( ) SUSP (insulin lispro 2 month;QL(1.5 insulin detemir ml daily) ml daily) protamine & lispro) LEVEMIR SOLN (insulin Limit 45mls per 2 month;QL(1.5 HUMALOG SOCT Limit 45mls per detemir) 2 month;QL(1.5 ml daily) (insulin lispro) ml daily) NOVOLIN N FLEXPEN Limit 45mls per RELION SUPN (insulin 2 month;QL(1.5 HUMALOG SOLN (insulin Limit 45mls per 2 month;QL(1.5 nph (human) (isophane)) ml daily) lispro) ml daily) NOVOLIN N FLEXPEN Limit 45mls per HUMULIN 70/30 KWIKPEN Limit 45mls per SUPN (insulin nph 2 month;QL(1.5 SUPN (insulin nph month;QL(1.5 (human) (isophane)) ml daily) 2 ml daily) isophane & reg Limit 3 boxes (human)) TOUJEO MAX SOLOSTAR 2 per HUMULIN 70/30 SUSP Limit 45mls per SOPN (insulin glargine) month;QL(0.6 (insulin nph isophane & 2 month;QL(1.5 ml daily) reg (human)) ml daily) Limit 3 boxes TOUJEO SOLOSTAR HUMULIN N KWIKPEN Limit 45mls per 2 per month;QL(1.5 SOPN (insulin glargine) month;QL(0.6 SUPN (insulin nph 2 ml daily) (isophane)) ml daily) (human) Limit 3 boxes HUMULIN N SUSP Limit 45mls per TRESIBA FLEXTOUCH SOPN 100 UNIT/ML 2 per (insulin nph (human) 2 month;QL(1.5 month;QL(1.5 (isophane)) ml daily) (insulin degludec) ml daily) HUMULIN R SOLN Limit 45mls per TRESIBA FLEXTOUCH Limit 3 boxes month;QL(1.5 (insulin regular 2 SOPN 200 UNIT/ML 2 per (human)) ml daily) month;QL(0.9 (insulin degludec) ml daily) HUMULIN R U-500 Limit 2 vials per month;QL(1.5 TRESIBA SOLN (insulin (CONCENTRATED) 2 2 SOLN (insulin regular ml daily) degludec) (human)) Meglitinide Analogues

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nateglinide tabs 1 ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat PRANDIN TABS GP (repaglinide) Antidiarrheal - Chloride Channel Antagonists MYTESI TBEC PA; QL(2 ea 3 repaglinide tabs 1 (crofelemer) daily) STARLIX TABS GP Antiperistaltic Agents (nateglinide) (Loperamide Hcl) ANTI- RX/OTC Sodium- Co-Transporter 2 (SGLT2) DIARRHEAL, TGT LOPERAMIDE HCL, SM INVOKANA TABS 2 ANTI-DIARRHEAL, RA (canagliflozin) ANTI-DIARRHEAL, QC JARDIANCE TABS ANTI-DIARRHEAL, HM 1 2 (empagliflozin) LOPERAMIDE HCL, HM ANTI-DIARRHEAL, GNP STEGLATRO TABS ANTI-DIARRHEAL, EQ (ertugliflozin l- 3 ANTI-DIARRHEAL, CVS pyroglutamic acid) ANTI-DIARRHEAL CAPS Sulfonylureas diphenoxylate w/ 1 bal on hand, atropine liqd 2.5 1 (Glipizide) GLIPIZIDE XL 1 TB24 mg/5ml-0.025 mg/5ml AMARYL TABS GP diphenoxylate w/ (glimepiride) atropine tabs 2.5 mg- 1 glimepiride tabs 1 0.025 mg IMODIUM A-D CAPS RX/OTC GP glipizide tabs 1 (loperamide hcl) LOMOTIL TABS glipizide tb24 1 (diphenoxylate w/ GP GLUCOTROL TABS atropine) GP (glipizide) loperamide hcl caps 1 RX/OTC GLUCOTROL XL TB24 10 NF MOTOFEN TABS MG (glipizide) 2 GLUCOTROL XL TB24 5 (difenoxin w/ atropine) GP MG, 2.5 MG (glipizide) opium tincture tinc 1 glyburide micronized 1 1 bal on hand, tabs paregoric tinc 1 glyburide tabs 1 ANTIDOTES AND SPECIFIC ANTAGONISTS GLYNASE TABS GP Antidotes - Chelating Agents (glyburide micronized) CHEMET CAPS 3 tolazamide tabs 1 1 bal on hand, (succimer) deferasirox tabs SP PA tolbutamide tabs 1 1 bal on hand, deferasirox tbso SP PA

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXJADE TBSO PA ANZEMET TABS PA; Limit 2 per SP 3 month;QL(0.07 (deferasirox) (dolasetron mesylate) FERRIPROX TABS 500 PA ea daily) SP MG (deferiprone) granisetron hcl tabs 1 QL(2 ea daily) JADENU SPRINKLE PACK PA SP PA; Limit 50mls (deferasirox) ondansetron hcl soln 4 1 per JADENU TABS PA month;QL(1.67 SP mg/5ml (deferasirox) ml daily) ondansetron hcl tabs 4 QL(20 ea per Antidotes and Specific Antagonists 1 fill retail,60 ea RADIOGARDASE CAPS mg, 8 mg per fill mail) (prussian blue insoluble 3 QL(20 ea per (ferric ondansetron tbdp 1 fill retail,60 ea hexacyanoferrate ii)) per fill mail) VISTOGARD PACK palonosetron hcl soln SP PA (uridine triacetate SP (emergency treatment)) PALONOSETRON PA HYDROCHLORIDE SOLN SP Opioid Antagonists (palonosetron hcl) PA required for SANCUSO PTCH PA EVZIO SOAJ 0.4 more than 30 3 SP ( ) MG/0.4ML (naloxone hcl) day supply per granisetron year; ZOFRAN ODT TBDP QL(20 ea per PA required for GP fill retail,60 ea (ondansetron) per fill mail) EVZIO SOAJ 2 MG/0.4ML more than 30 SP day supply per PA; Limit 50mls (naloxone hcl) ZOFRAN SOLN 4 MG/5ML year;1 bal on GP per hand, (ondansetron hcl) month;QL(1.67 PA required for ml daily) more than 30 ZOFRAN TABS 4 MG, 8 QL(20 ea per naloxone hcl soaj 2 GP fill retail,60 ea SP day supply per MG (ondansetron hcl) mg/0.4ml year;1 bal on per fill mail) hand, ZUPLENZ FILM QL(20 ea per 3 fill retail,60 ea naloxone hcl sosy 2 SP (ondansetron) mg/2ml per fill mail) Antiemetics - Anticholinergic naltrexone hcl tabs 1 Limit 2 boxes NARCAN LIQD 3 per month;QL(4 (naloxone hcl) ea per 30 days retail) ANTIEMETICS - Drugs to Treat and 5-HT3 Receptor Antagonists ALOXI SOLN PA SP (palonosetron hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ( Hcl) CVS RX/OTC MARINOL CAPS GP MOTION SICKNESS II, (dronabinol) WAL-DRAM II, TRAVEL- EASE, SM MOTION Substance P/Neurokinin 1 (NK1) Receptor SICKNESS, RA MOTION QL(3 ea per fill SICKNESS RELIEF, HM caps 1 retail,9 ea per MOTION SICKNESS fill mail) RELIEF, HM MOTION 1 aprepitant caps 40 mg, QL(2 ea per fill RELIEF, GNP MOTION 1 retail,6 ea per SICKNESS RELIEF, EQL 125 mg fill mail) MOTION SICKNESS RELIEF, EQ MOTION aprepitant caps 80 mg, QL(1 ea per fill 1 retail,3 ea per SICKNESS RELIEF, 125 mg DRAMAMINE LESS fill mail) DROWSY TABS EMEND CAPS 40 MG, 125 QL(2 ea per fill RX/OTC GP retail,6 ea per meclizine hcl tabs 1 MG (aprepitant) fill mail) EMEND CAPS 80 MG, 125 QL(1 ea per fill scopolamine pt72 1 GP retail,3 ea per MG (aprepitant) TIGAN CAPS fill mail) (trimethobenzamide GP EMEND TRIPACK CAPS QL(3 ea per fill hcl) GP retail,9 ea per (aprepitant) fill mail) TRANSDERM SCOP PT72 NF VARUBI TBPK ( QL(4 ea per fill (scopolamine) 3 hcl) retail) TRANSDERM-SCOP PT72 NF (scopolamine) - Drugs to Treat Fungal Infections trimethobenzamide hcl 1 - Glucan Synthesis Inhibitors caps CANCIDAS SOLR PA SP Antiemetics - Miscellaneous ( acetate) AKYNZEO CAPS OR 300 QL(2 ea per 28 PA caspofungin acetate SP MG-0.5 MG (- 3 days retail) solr 50 mg, 70 mg palonosetron) CASPOFUNGIN ACETATE PA BONJESTA TBCR QL(2 ea daily) SOLR 50 MG, 70 MG SP (doxylamine- 3 (caspofungin acetate) pyridoxine) ERAXIS SOLR PA SP CESAMET CAPS PA; QL(2 ea ( ) 3 (nabilone) daily) sodium solr SP PA DICLEGIS TBEC QL(4 ea daily) MYCAMINE SOLR PA; 1 bal on (doxylamine- GP SP pyridoxine) (micafungin sodium) hand, QL(4 ea daily) Antifungals doxylamine-pyridoxine 1 tbec () BIO-STATIN 1 POWD dronabinol caps 1 ABELCET SUSP PA SP ( lipid)

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36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMBISOME SUSR PA NOXAFIL SUSP 40 MG/ML 3 (amphotericin b SP () liposome) NOXAFIL TBEC 100 MG GP SP PA; 1 bal on (posaconazole) amphotericin b solr hand, 1 ANCOBON CAPS posaconazole tbec GP () SPORANOX CAPS PA GP BIO-STATIN CAPS 500000 () UNIT, 1000000 UNIT 3 SPORANOX PULSEPAK PA GP (nystatin) CAPS (itraconazole) SPORANOX SOLN PA flucytosine caps 1 GP (itraconazole) microsize TOLSURA CAPS PA 1 SP susp (itraconazole) griseofulvin microsize VFEND SUSR 1 GP tabs () griseofulvin VFEND TABS 1 GP ultramicrosize tabs (voriconazole) nystatin tabs 1 voriconazole susr or 40 1 mg/ml QL(90 ea per voriconazole tabs or 50 1 365 days 1 hcl tabs retail,90 ea per mg, 200 mg 365 days mail) ANTIHISTAMINES - Drugs to Treat Allergies -Related Antifungals CRESEMBA CAPS Antihistamines - Alkylamines ( 3 (Dexchlorpheniramine 1 1 bal on hand, sulfate) Maleate) RYCLORA SOLN DIFLUCAN SUSR brompheniramine 1 bal on hand, GP 1 () tannate chew DIFLUCAN TABS dexchlorpheniramine 1 bal on hand, GP 1 (fluconazole) maleate soln PA fluconazole in dextrose SP Antihistamines - Ethanolamines soln (Diphenhydramine Hcl) BANOPHEN, fluconazole susr 1 PHARBEDRYL, KP 1 DIPHENHYDRAMINE HCL fluconazole tabs 1 CAPS 1 PA (Diphenhydramine Hcl) RX/OTC itraconazole caps DIPHEN, EQ ALLERGY 1 RELIEF CHILDRENS ELIX itraconazole soln 1 PA 1 bal on hand, carbinoxamine maleate 1 tabs 1 soln 4 mg/5ml

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cetirizine Hcl) ALL DAY RX/OTC carbinoxamine maleate 1 soln 4 mg/5ml ALLERGY CHILDRENS, CETIRIZINE HCL 1 bal on hand, carbinoxamine maleate 1 CHILDRENS, CETIRIZINE tabs 4 mg HCL ALLERGY carbinoxamine maleate CHILDRENS, WAL-ZYR 1 CHILDRENS, WAL-ZYR tabs 4 mg ALL DAY 1 bal on hand, clemastine fumarate 1 ALLERGYCHILDRENS, tabs WAL-ZYR ALL DAY ALLERGY CHILDRENS, diphenhydramine hcl 1 WAL-ZYR, TGT ALL DAY caps or 50 mg ALLERGY RELIEF RX/OTC CHILDRENS, SM ALL DAY diphenhydramine hcl 1 elix or 12.5 mg/5ml ALLERGY CHILDRENS, SB CETIRIZINE HCL PA diphenhydramine hcl SP CHILDRENS, RA soln ij 50 mg/ml CETIRIZINE HCL Antihistamines - Non-Sedating CHILDRENS ALLERGY, RA ALLERGY RELIEF CHILDRENS, QC CHILDRENS ALLERGY, PX CHILDRENS ALLERGY, KLS ALLER- 1 TEC CHILDRENS, HM CETIRIZINE HCL CHILDRENS, HM ALL DAY ALLERGY CHILDRENS, GOODSENSE ALL DAY ALLERGYCHILDRENS, GNP ALL DAY ALLERGY CHILDRENS, EQL ALL DAY ALLERGY CHILDRENS, EQ ALLERGY RELIEF CHILDRENS, CVS ALLERGY RELIEF CHILDRENS, CETIRIZINE HYDROCHLORIDECHILD RENS ALLERGY, CETIRIZINE HCL HIVES RELIEF CHILDRENS, CETIRIZINE HCL CHILDRENSALLERGY, ALLERGY RELIEF CHILDRENS, ALL-DAY ALLERGY CHILDRENS SOLN (Cetirizine Hcl) EQ RX/OTC ALLERGY RELIEF SOLN 1 OR 1 MG/ML

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38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cetirizine Hcl) QC RX/OTC cyproheptadine hcl syrp 1 ALLERGY RELIEF CHILDRENS, RA 1 1 ALLERGY RELIEF cyproheptadine hcl tabs CHILDRENS SYRP ANTIHYPERLIPIDEMICS - Drugs to Treat High cetirizine hcl soln 1 RX/OTC Cholesterol CLARINEX SYRP 0.5 Antihyperlipidemics - Combinations 3 QL(1 ea daily) MG/ML (desloratadine) ezetimibe- 1 CLARINEX TABS 5 MG PA; QL(1 ea tabs GP (desloratadine) daily) VYTORIN TABS 10 MG-10 QL(1 ea daily) PA; QL(1 ea MG (ezetimibe- NF desloratadine tabs 5 1 mg daily) simvastatin) 1 bal on hand, VYTORIN TABS 10 MG-20 QL(1 ea daily) desloratadine tbdp 5 1 MG, 40 MG-10 MG, 80 mg, 2.5 mg MG-10 MG (ezetimibe- GP ZYRTEC CHILDRENS RX/OTC simvastatin) ALLERGY SOLN GP (cetirizine hcl) Antihyperlipidemics - Misc. (Omega-3-Acid Ethyl 1 Antihistamines - Phenothiazines Esters) TRIKLO CAPS (Promethazine Hcl) 1 LOVAZA CAPS ( PHENADOZ SUPP omega- GP 3-acid ethyl esters) (Promethazine Hcl) PROMETHEGAN SUPP 25 1 omega-3-acid ethyl 1 MG, 12.5 MG esters caps (Promethazine Hcl) 1 bal on hand, VASCEPA CAPS ST 3 PROMETHEGAN SUPP 50 1 (icosapent ethyl) MG, 12.5 MG Sequestrants PHENERGAN SOLN PA SP (promethazine hcl) (Cholestyramine Light) 1 PREVALITE PACK promethazine hcl soln ij PA SP (Cholestyramine Light) 1 25 mg/ml, 50 mg/ml PREVALITE POWD promethazine hcl soln 1 cholestyramine light 1 or 6.25 mg/5ml pack promethazine hcl supp cholestyramine light 1 re 25 mg, 50 mg, 12.5 1 powd mg cholestyramine pack 1 promethazine hcl syrp 1 or 6.25 mg/5ml cholestyramine powd 1 promethazine hcl tabs or 25 mg, 50 mg, 12.5 1 colesevelam hcl pack 1 mg colesevelam hcl tabs 1 Antihistamines - Piperidines

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39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COLESTID FLAVORED FENOFIBRIC ACID TABS GP 3 GRAN (colestipol hcl) 105 MG (fenofibric acid) COLESTID FLAVORED 1 bal on hand, GP fenofibric acid tabs 35 1 PACK (colestipol hcl) mg, 105 mg COLESTID GRAN FIBRICOR TABS 35 MG, 1 bal on hand, GP 3 (colestipol hcl) 105 MG (fenofibric acid) COLESTID PACK FIBRICOR TABS 35 MG, GP 3 (colestipol hcl) 105 MG (fenofibric acid) COLESTID TABS GP gemfibrozil tabs 1 (colestipol hcl) LIPOFEN CAPS 1 bal on hand, 3 colestipol hcl gran 1 (fenofibrate) LOPID TABS colestipol hcl pack 1 GP (gemfibrozil) colestipol hcl tabs 1 TRICOR TABS GP QUESTRAN LIGHT POWD (fenofibrate) GP TRIGLIDE TABS (cholestyramine light) 3 QUESTRAN PACK (fenofibrate) GP TRILIPIX CPDR ( (cholestyramine) choline GP QUESTRAN POWD fenofibrate) GP (cholestyramine) HMG CoA Reductase Inhibitors WELCHOL PACK ADVICOR TB24 20 MG- GP (colesevelam hcl) 1000 MG (niacin- 2 WELCHOL TABS ) GP (colesevelam hcl) ADVICOR TB24 40 MG- QL(1 ea daily) Fibric Acid Derivatives 1000 MG (niacin- 2 ANTARA CAPS lovastatin) 3 ALTOPREV TB24 (fenofibrate micronized) 3 (lovastatin) choline fenofibrate cpdr 1 QL(1 ea daily) atorvastatin calcium 1 1 bal on hand, tabs fenofibrate caps 50 mg, 1 150 mg CRESTOR TABS QL(1 ea daily) NF (rosuvastatin calcium) fenofibrate micronized 1 caps fluvastatin sodium caps 1 QL(1 ea daily) FENOFIBRATE TABS 160 1 bal on hand, 3 MG (fenofibrate) fluvastatin sodium tb24 1 QL(1 ea daily) fenofibrate tabs 160 1 bal on hand, LESCOL XL TB24 QL(1 ea daily) 1 GP mg, 160 mg (fluvastatin sodium) fenofibrate tabs 48 mg, LIPITOR TABS QL(1 ea daily) NF 54 mg, 145 mg, 160 1 (atorvastatin calcium) mg

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40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIVALO TABS ST; QL(1 ea REPATHA PUSHTRONEX PA 3 (pitavastatin calcium) daily) SYSTEM SOCT SP (evolocumab) 1 $0 copay, age lovastatin tabs 40 to 76;PV REPATHA SOSY PA SP PRAVACHOL TABS 20 QL(1 ea daily) (evolocumab) MG, 80 MG (pravastatin GP REPATHA SURECLICK PA SP sodium) SOAJ (evolocumab) PRAVACHOL TABS 40 QL(2 ea daily) ANTIHYPERTENSIVES - Drugs to Treat High MG, 80 MG (pravastatin GP Blood Pressure sodium) ACE Inhibitors pravastatin sodium QL(1 ea daily) ACCUPRIL TABS 10 MG NF tabs 10 mg, 20 mg, 80 1 (quinapril hcl) mg ACCUPRIL TABS 5 MG, QL(2 ea daily) pravastatin sodium 1 20 MG, 40 MG (quinapril GP tabs 40 mg, 80 mg hcl) rosuvastatin calcium QL(1 ea daily) ALTACE CAPS 10 MG, QL(2 ea daily) 1 GP tabs 1.25 MG (ramipril) SIMCOR TB24 ( ALTACE CAPS 2.5 MG QL(1 ea daily) niacin- 2 NF simvastatin) (ramipril) QL(1 ea daily) ALTACE CAPS 5 MG, 1.25 QL(1 ea daily) simvastatin tabs 5 mg, GP 10 mg, 20 mg, 40 mg, 1 MG (ramipril) 80 mg benazepril hcl tabs 1 ZOCOR TABS QL(1 ea daily) GP (simvastatin) captopril tabs 1 Intestinal Cholesterol Absorption Inhibitors enalapril maleate tabs 1 QL(2 ea daily) 1 ezetimibe tabs EPANED SOLN QL(5 ml daily) 3 ZETIA TABS (ezetimibe) GP (enalapril maleate) fosinopril sodium tabs 1 Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS PA SP lisinopril tabs 1 (lomitapide mesylate) LOTENSIN TABS GP Nicotinic Acid Derivatives (benazepril hcl) niacin (antihyperlipidemic) 1 moexipril hcl tabs 1 tbcr perindopril erbumine 1 NIASPAN TBCR ( tabs niacin GP (antihyperlipidemic)) PRINIVIL TABS (lisinopril) GP Proprotein Convertase Subtilisin/Kexin Type 9 Limited to 1 PRALUENT SOAJ PA QBRELIS SOLN SP 3 bottle per (alirocumab) (lisinopril) month.;QL(5 ml daily) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MICARDIS TABS quinapril hcl tabs 1 GP () ramipril caps 10 mg, QL(2 ea daily) 1 olmesartan medoxomil 1 2.5 mg, 1.25 mg tabs QL(1 ea daily) ramipril caps 5 mg, 2.5 1 mg, 1.25 mg telmisartan tabs 1 trandolapril tabs 1 valsartan tabs 1 VASOTEC TABS QL(2 ea daily) GP Antiadrenergic Antihypertensives (enalapril maleate) CARDURA TABS GP ZESTRIL TABS (lisinopril) GP (doxazosin mesylate) CATAPRES TABS GP Agents for Pheochromocytoma (clonidine hcl) DEMSER CAPS CATAPRES-TTS-1 PTWK 3 GP (metyrosine) (clonidine) DIBENZYLINE CAPS CATAPRES-TTS-2 PTWK GP (phenoxybenzamine GP (clonidine) hcl) CATAPRES-TTS-3 PTWK GP phenoxybenzamine hcl 1 (clonidine) caps clonidine hcl tabs 1 II Receptor Antagonists ATACAND TABS clonidine ptwk 1 GP (candesartan cilexetil) doxazosin mesylate AVAPRO TABS 1 GP tabs (irbesartan) BENICAR TABS guanfacine hcl tabs 1 (olmesartan NF 1 medoxomil) methyldopa tabs PA; 1 bal on candesartan cilexetil 1 methyldopate hcl soln SP tabs hand, MINIPRESS CAPS COZAAR TABS (losartan GP GP (prazosin hcl) potassium) DIOVAN TABS prazosin hcl caps 1 GP (valsartan) terazosin hcl caps 1 EDARBI TABS 3 (azilsartan medoxomil) Antihypertensive Combinations 1 bal on hand, ACCURETIC TABS eprosartan mesylate 1 tabs (quinapril- GP hydrochlorothiazide) irbesartan tabs 1 besylate- 1 losartan potassium 1 benazepril hcl caps tabs

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42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amlodipine besylate- candesartan cilexetil- olmesartan medoxomil 1 hydrochlorothiazide 1 tabs tabs 1 bal on hand, amlodipine besylate- 1 captopril & valsartan tabs hydrochlorothiazide 1 amlodipine-valsartan- tabs hydrochlorothiazide 1 CORZIDE TABS 40 MG-5 tabs MG (nadolol & 3 ATACAND HCT TABS bendroflumethiazide) (candesartan cilexetil- GP CORZIDE TABS 80 MG-5 hydrochlorothiazide) MG (nadolol & 2 bendroflumethiazide) atenolol & 1 chlorthalidone tabs DIOVAN HCT TABS 160 MG-25 MG, 80 MG-12.5 AVALIDE TABS MG, 160 MG-12.5 MG, 320 GP (irbesartan- GP MG-12.5 MG (valsartan- hydrochlorothiazide) hydrochlorothiazide) AZOR TABS 20 MG-5 MG, DIOVAN HCT TABS 320 40 MG-5 MG, 20 MG-10 MG-25 MG (valsartan- NF MG (amlodipine GP besylate-olmesartan hydrochlorothiazide) medoxomil) DUTOPROL TB24 (metoprolol & 3 AZOR TABS 40 MG-10 MG hydrochlorothiazide) (amlodipine besylate- NF olmesartan medoxomil) EDARBYCLOR TABS (azilsartan medoxomil- 3 benazepril & chlorthalidone) hydrochlorothiazide 1 tabs enalapril maleate & hydrochlorothiazide 1 BENICAR HCT TABS 20 tabs MG-12.5 MG (olmesartan medoxomil- GP EXFORGE HCT TABS hydrochlorothiazide) (amlodipine-valsartan- GP hydrochlorothiazide) BENICAR HCT TABS 40 MG-25 MG, 40 MG-12.5 EXFORGE TABS MG (olmesartan NF (amlodipine besylate- GP medoxomil- valsartan) hydrochlorothiazide) fosinopril sodium & bisoprolol & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs HYZAAR TABS (losartan BYVALSON TABS potassium & GP 3 (nebivolol-valsartan) hydrochlorothiazide)

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43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits irbesartan- olmesartan medoxomil- 1 hydrochlorothiazide amlodipine- 1 tabs hydrochlorothiazide lisinopril & tabs hydrochlorothiazide 1 olmesartan medoxomil- tabs hydrochlorothiazide 1 LOPRESSOR HCT TABS tabs (metoprolol & GP propranolol & 1 bal on hand, hydrochlorothiazide) hydrochlorothiazide 1 losartan potassium & tabs hydrochlorothiazide 1 quinapril- tabs hydrochlorothiazide 1 LOTENSIN HCT TABS tabs (benazepril & GP TARKA TBCR hydrochlorothiazide) (trandolapril-verapamil GP LOTREL CAPS hcl) (amlodipine besylate- GP TEKTURNA HCT TABS benazepril hcl) (aliskiren- 3 methyldopa & 1 bal on hand, hydrochlorothiazide) hydrochlorothiazide 1 telmisartan-amlodipine 1 tabs tabs metoprolol & 1 bal on hand, telmisartan- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs 100 mg-50 mg tabs metoprolol & TENORETIC 100 TABS ( GP hydrochlorothiazide 1 atenolol & tabs 50 mg-25 mg, 100 chlorthalidone) mg-25 mg TENORETIC 50 TABS METOPROLOL (atenolol & GP SUCCINATE chlorthalidone) ER/HYDROCHLOROTHIA 3 trandolapril-verapamil 1 bal on hand, ZIDE TB24 (metoprolol hcl tbcr 1 mg-240 mg, 2 & hydrochlorothiazide) 1 mg-240 mg, 4 mg-240 MICARDIS HCT TABS mg (telmisartan- GP hydrochlorothiazide) trandolapril-verapamil hcl tbcr 2 mg-180 mg, 2 1 moexipril- mg-240 mg, 4 mg-240 hydrochlorothiazide 1 mg tabs TRIBENZOR TABS nadolol & 1 bal on hand, (olmesartan bendroflumethiazide 1 medoxomil-amlodipine- GP tabs hydrochlorothiazide)

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44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TWYNSTA TABS atovaquone-proguanil 1 (telmisartan- GP hcl tabs amlodipine) COARTEM TABS Limit 24 per valsartan- (artemether- 2 month;QL(0.8 hydrochlorothiazide 1 lumefantrine) ea daily) tabs MALARONE TABS VASERETIC TABS (atovaquone-proguanil GP (enalapril maleate & GP hcl) hydrochlorothiazide) Antimalarials ZESTORETIC TABS chloroquine phosphate 1 (lisinopril & GP tabs 250 mg, 500 mg hydrochlorothiazide) chloroquine phosphate 1 bal on hand, ZIAC TABS ( 1 bisoprolol & GP tabs 500 mg hydrochlorothiazide) DARAPRIM TABS PA; 1 bal on 3 Antihypertensives - Misc. (pyrimethamine) hand, VECAMYL TABS PA SP hydroxychloroquine 1 (mecamylamine hcl) sulfate tabs Direct Renin Inhibitors KRINTAFEL TABS QL(2 ea per 30 2 days retail) aliskiren fumarate tabs 1 (tafenoquine succinate) QL(6 ea per fill TEKTURNA TABS 150 mefloquine hcl tabs 1 retail)1 bal on MG, 300 MG, 300 MG 3 hand, (aliskiren fumarate) PLAQUENIL TABS TEKTURNA TABS 150 1 bal on hand, (hydroxychloroquine 1 MG, 300 MG, 300 MG 3 sulfate) (aliskiren fumarate) primaquine phosphate 1 Selective Aldosterone Receptor Antagonists tabs eplerenone tabs 1 PRIMAQUINE PHOSPHATE TABS GP INSPRA TABS GP (primaquine phosphate) (eplerenone) pyrimethamine tabs 1 PA Vasodilators PA PA; QL(42 ea hydralazine hcl soln ij SP QUALAQUIN CAPS 20 mg/ml GP per 7 days (quinine sulfate) retail) hydralazine hcl tabs or PA; QL(42 ea 10 mg, 25 mg, 50 mg, 1 quinine sulfate caps 1 per 7 days 100 mg retail) minoxidil tabs 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMALARIALS - Drugs to Treat Malaria Antimyasthenic/Cholinergic Agents (Parasitic Infections) Antimalarial Combinations

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45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIRDAPSE TABS PA ISONIAZID TABS OR 100 2 (amifampridine SP MG (isoniazid) phosphate) isoniazid tabs or 100 1 GUANIDINE HCL TABS 2 mg, 300 mg (guanidine hcl) MYAMBUTOL TABS GP MESTINON SOLN 60 PA (ethambutol hcl) MG/5ML (pyridostigmine GP MYCOBUTIN CAPS GP bromide) (rifabutin) MESTINON TABS 60 MG PASER PACK 3 (pyridostigmine GP (aminosalicylic acid) bromide) PRIFTIN TABS 3 MESTINON TIMESPAN (rifapentine) TBCR (pyridostigmine GP bromide) pyrazinamide tabs 1 PA pyridostigmine bromide 1 rifabutin caps 1 soln 60 mg/5ml RIFADIN CAPS OR 150 pyridostigmine bromide GP 1 MG, 300 MG (rifampin) tabs 60 mg RIFADIN SOLR IV 600 MG PA SP pyridostigmine bromide 1 (rifampin) tbcr 180 mg rifampin caps or 150 RUZURGI TABS PA; QL(10 ea 1 SP mg, 300 mg (amifampridine) daily) PA ANTIMYCOBACTERIAL AGENTS - Drugs to rifampin solr iv 600 mg SP Treat Tuberculosis (Bacterial Infections) SIRTURO TABS SP Anti TB Combinations (bedaquiline fumarate) RIFAMATE CAPS TRECATOR TABS 2 2 (isoniazid & rifampin) (ethionamide) RIFATER TABS ANTINEOPLASTICS AND ADJUNCTIVE (isoniazid-rifampin w/ 3 THERAPIES - Drugs to Treat Cancer pyrazinamide) Alkylating Agents Antimycobacterial Agents ALKERAN SOLR IV 50 MG PA AC CAPASTAT SULFATE PA (melphalan hcl) SOLR (capreomycin SP ALKERAN TABS OR 2 MG AC sulfate) (melphalan) cycloserine caps 1 busulfan soln AC PA BUSULFEX SOLN PA ethambutol hcl tabs 1 AC (busulfan) isoniazid soln ij 100 PA; 1 bal on SP hand, mg/ml caps 25 mg, 50 mg, 50 AC 1 bal on hand, isoniazid syrp or 50 1 mg mg/5ml

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46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyclophosphamide 1 bal on hand, decitabine solr AC PA caps 25 mg, 50 mg, 50 AC mg floxuridine solr AC PA GLEOSTINE CAPS PA PA AC fludarabine phosphate AC (lomustine) soln HEXALEN CAPS AC fludarabine phosphate PA (altretamine) AC solr LEUKERAN TABS AC PA (chlorambucil) fluorouracil soln AC melphalan hcl solr AC PA gemcitabine hcl soln 1 PA; 1 bal on gm/10ml, 2 gm/20ml, hand, melphalan tabs AC 200 mg/2ml, 2 AC MYLERAN TABS gm/52.6ml, 200 AC (busulfan) mg/5.26ml TEMODAR CAPS gemcitabine hcl soln 1 PA AC (temozolomide) gm/26.3ml, 2 AC gm/52.6ml, 200 temozolomide caps AC mg/5.26ml ZANOSAR SOLR PA PA AC gemcitabine hcl solr 1 AC (streptozocin) gm, 2 gm, 200 mg Antimetabolites GEMCITABINE PA; 1 bal on HYDROCHLORIDE SOLN hand, (Fluorouracil) ADRUCIL AC PA SOLN 1 GM/10ML, 2 GM/20ML, AC 200 MG/2ML ALIMTA SOLR AC (gemcitabine hcl) (pemetrexed disodium) GEMCITABINE PA ARRANON SOLN PA AC HYDROCHLORIDE SOLN (nelarabine) 1.5 GM/15ML AC azacitidine susr AC PA (gemcitabine hcl) GEMCITABINE SOLN PA AC capecitabine tabs AC (gemcitabine hcl) GEMZAR SOLR PA AC PA AC cladribine soln (gemcitabine hcl) PA clofarabine soln AC mercaptopurine tabs AC CLOLAR SOLN PA AC methotrexate sodium (clofarabine) soln ij 25 mg/ml, 1 SP PA gm/40ml, 50 mg/2ml, cytarabine soln 20 AC mg/ml, 100 mg/ml 250 mg/10ml PA; 1 bal on methotrexate sodium 1 bal on hand, cytarabine soln 20 AC mg/ml, 100 mg/ml hand, soln ij 250 mg/10ml, SP DACOGEN SOLR PA 250 mg/10ml AC (decitabine)

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47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA methotrexate sodium SP abiraterone acetate AC solr ij 1 gm tabs methotrexate sodium 1 anastrozole tabs AC tabs or 2.5 mg ARIMIDEX TABS PURIXAN SUSP PA; AL(Up to AC AC ( ) (mercaptopurine) 13 yrs old ) anastrozole AROMASIN TABS TABLOID TABS AC AC ( ) (thioguanine) exemestane TREXALL TABS bicalutamide tabs AC 3 (methotrexate sodium) CASODEX TABS VIDAZA SUSR PA AC AC (bicalutamide) (azacitidine) DEPO-PROVERA SUSP PA XATMEP SOLN PA AC (medroxyprogesterone (methotrexate) acetate SP XELODA TABS AC (antineoplastic)) (capecitabine) ELIGARD KIT ( PA leuprolide AC Antineoplastic - Antibodies acetate (3 month)) ARZERRA CONC PA ELIGARD KIT ( PA AC leuprolide AC (ofatumumab) acetate (4 month)) CAMPATH SOLN PA ELIGARD KIT ( PA AC leuprolide AC (alemtuzumab) acetate (6 month)) ERBITUX SOLN PA ELIGARD KIT ( PA AC leuprolide AC () acetate) RITUXAN SOLN PA AC EMCYT CAPS (rituximab) (estramustine AC YERVOY SOLN PA AC phosphate sodium) (ipilimumab) ERLEADA TABS PA AC Antineoplastic - BCL-2 Inhibitors (apalutamide) VENCLEXTA STARTING PA exemestane tabs AC PACK TBPK AC (venetoclax) FARESTON TABS AC VENCLEXTA TABS PA (toremifene citrate) AC (venetoclax) FEMARA TABS AC Antineoplastic - Hedgehog Pathway Inhibitors (letrozole) DAURISMO TABS PA FENSOLVI KIT PA AC (glasdegib maleate) (leuprolide acetate (6 AC ERIVEDGE CAPS month)) AC FIRMAGON SOLR PA (vismodegib) AC ODOMZO CAPS PA (degarelix acetate) AC (sonidegib phosphate) flutamide caps AC Antineoplastic - Hormonal and Related Agents

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48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits letrozole tabs AC toremifene citrate tabs AC leuprolide acetate kit AC PA TRELSTAR MIXJECT PA SUSR (triptorelin AC LEUPROLIDE PA pamoate) ACETATE/BUPIVACAINE XTANDI CAPS PA HYDROCHLORIDE SOLN AC AC (leuprolide acetate- (enzalutamide) YONSA TABS PA bupivacaine hcl) AC (abiraterone acetate) LUPRON DEPOT (1- PA ZYTIGA TABS 250 MG PA MONTH) KIT 3.75 MG SP AC (leuprolide acetate) (abiraterone acetate) ZYTIGA TABS 500 MG PA LUPRON DEPOT (1- PA AC MONTH) KIT 7.5 MG AC (abiraterone acetate) (leuprolide acetate) Antineoplastic - Immunomodulators LUPRON DEPOT (3- PA POMALYST CAPS PA AC MONTH) KIT 11.25 MG SP (pomalidomide) (leuprolide acetate (3 month)) Antineoplastic - XPO1 Inhibitors XPOVIO 100 MG ONCE PA LUPRON DEPOT (3- PA WEEKLY TBPK AC MONTH) KIT 22.5 MG AC ( ) (leuprolide acetate (3 selinexor month)) XPOVIO 60 MG ONCE PA WEEKLY TBPK LUPRON DEPOT (4- PA AC (selinexor) MONTH) KIT (leuprolide AC acetate (4 month)) XPOVIO 80 MG ONCE PA WEEKLY TBPK PA AC LUPRON DEPOT (6- (selinexor) MONTH) KIT (leuprolide AC acetate (6 month)) XPOVIO 80 MG TWICE PA WEEKLY TBPK AC LYSODREN TABS AC (selinexor) (mitotane) Antineoplastic Antibiotics megestrol acetate susp 1 40 mg/ml, 400 mg/10ml mitoxantrone hcl conc SP PA megestrol acetate tabs AC Antineoplastic Combinations 20 mg, 40 mg KISQALI FEMARA 200 PA NILANDRON TABS AC DOSE TBPK (ribociclib AC (nilutamide) succinate-letrozole) nilutamide tabs AC KISQALI FEMARA 400 PA NUBEQA TABS PA DOSE TBPK (ribociclib AC AC (darolutamide) succinate-letrozole) SOLTAMOX SOLN KISQALI FEMARA 600 PA AC (tamoxifen citrate) DOSE TBPK (ribociclib AC succinate-letrozole) tamoxifen citrate tabs AC PV

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49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LONSURF TABS PA PA; QL(1 ea AC everolimus tabs AC (trifluridine-tipiracil) daily) FARYDAK CAPS PA RITUXAN HYCELA SOLN PA AC (rituximab- AC (panobinostat lactate) hyaluronidase human) GILOTRIF TABS ( PA AC Antineoplastic Enzyme Inhibitors dimaleate) AFINITOR DISPERZ TBSO PA; QL(1 ea GLEEVEC TABS ( PA AC AC (everolimus) daily) mesylate) AFINITOR TABS 10 MG PA; QL(1 ea IBRANCE CAPS 75 MG, PA AC (everolimus) daily) 100 MG, 125 MG AC AFINITOR TABS 5 MG, 2.5 PA; QL(1 ea (palbociclib) AC ICLUSIG TABS MG, 7.5 MG (everolimus) daily) AC ALECENSA CAPS PA ( hcl) AC IDHIFA TABS PA ( hcl) AC ALUNBRIG TABS PA ( mesylate) AC () imatinib mesylate tabs AC PA ALUNBRIG TBPK PA IMBRUVICA CAPS PA AC AC (brigatinib) (ibrutinib) AYVAKIT TABS PA; QL(1 ea IMBRUVICA TABS PA AC daily) AC () (ibrutinib) BALVERSA TABS PA AC PA (erdafitinib) INLYTA TABS () AC BOSULIF TABS PA INREBIC CAPS PA AC AC () (fedratinib hcl) BRAFTOVI CAPS PA PA AC IRESSA TABS () AC () BRUKINSA CAPS PA ISTODAX (OVERFILL) PA AC AC (zanubrutinib) SOLR (romidepsin) CABOMETYX TABS PA JAKAFI TABS (ruxolitinib PA AC AC ( s-malate) phosphate) CALQUENCE CAPS PA KISQALI TBPK (ribociclib PA AC AC (acalabrutinib) succinate) CAPRELSA TABS LENVIMA 10 MG DAILY PA AC () DOSE CPPK ( AC COMETRIQ KIT mesylate) AC (cabozantinib s-malate) LENVIMA 12MG DAILY PA COPIKTRA CAPS PA DOSE CPPK (lenvatinib AC AC (duvelisib) mesylate) COTELLIC TABS PA LENVIMA 14 MG DAILY PA AC ( fumarate) DOSE CPPK (lenvatinib AC mesylate) hcl tabs AC PA

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50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LENVIMA 18 MG DAILY PA RUBRACA TABS PA AC DOSE CPPK (lenvatinib AC (rucaparib camsylate) mesylate) RYDAPT CAPS PA AC LENVIMA 20 MG DAILY PA (midostaurin) DOSE CPPK (lenvatinib AC SPRYCEL TABS PA AC mesylate) () LENVIMA 24 MG DAILY PA STIVARGA TABS PA; SP AC DOSE CPPK (lenvatinib AC () mesylate) SUTENT CAPS ( PA AC LENVIMA 4 MG DAILY PA malate) DOSE CPPK (lenvatinib AC TAFINLAR CAPS PA AC mesylate) ( mesylate) LENVIMA 8 MG DAILY PA TAGRISSO TABS PA AC DOSE CPPK (lenvatinib AC ( mesylate) mesylate) TALZENNA CAPS PA LORBRENA TABS PA AC AC (talazoparib tosylate) () TARCEVA TABS (erlotinib PA LYNPARZA CAPS PA AC AC hcl) (olaparib) TASIGNA CAPS ( PA LYNPARZA TABS PA AC AC hcl) (olaparib) TAZVERIK TABS PA MEKINIST TABS PA AC (tazemetostat hbr) ( dimethyl AC sulfoxide) temsirolimus soln AC PA MEKTOVI TABS PA TIBSOVO TABS PA AC AC () (ivosidenib) NERLYNX TABS PA TORISEL SOLN PA AC AC ( maleate) (temsirolimus) NEXAVAR TABS PA TURALIO CAPS PA AC AC ( tosylate) (pexidartinib hcl) NINLARO CAPS PA AC TYKERB TABS ( PA ( ) AC ixazomib citrate ditosylate) PIQRAY 200MG DAILY PA AC VELCADE SOLR PA DOSE TBPK ( ) AC alpelisib (bortezomib) PIQRAY 250MG DAILY PA AC VERZENIO TABS PA DOSE TBPK ( ) AC alpelisib (abemaciclib) PIQRAY 300MG DAILY PA AC VITRAKVI CAPS PA DOSE TBPK ( ) AC alpelisib ( sulfate) ROMIDEPSIN SOLR PA AC VITRAKVI SOLN PA ( ) AC romidepsin (larotrectinib sulfate) ROZLYTREK CAPS PA AC VIZIMPRO TABS PA ( ) AC ()

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51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VOTRIENT TABS PA AC Adjuncts ( hcl) KEPIVANCE SOLR PA XALKORI CAPS PA SP AC (palifermin) () Chemotherapy Rescue/Antidote Agents XOSPATA TABS PA AC ETHYOL SOLR PA (gilteritinib fumarate) SP ( crystalline) ZEJULA CAPS ( PA niraparib AC PA leucovorin calcium soln AC tosylate) ij 500 mg/50ml ZELBORAF TABS PA AC leucovorin calcium solr PA () AC ij 100 mg, 350 mg ZOLINZA CAPS PA AC 1 bal on hand, (vorinostat) leucovorin calcium tabs or 10 mg, 15 mg, 25 AC ZYDELIG TABS PA AC mg (idelalisib) ZYKADIA CAPS PA leucovorin calcium tabs AC AC () or 5 mg, 15 mg, 25 mg ZYKADIA TABS PA MESNEX TABS () AC AC (ceritinib) Mitotic Inhibitors Antineoplastics Misc. (Etoposide) TOPOSAR PA ACTIMMUNE SOLN PA AC SP SOLN (interferon gamma-1b) ETOPOPHOS SOLR PA ALFERON N SOLN PA AC AC (etoposide phosphate) (interferon alfa-n3) 1 bal on hand, etoposide caps or 50 AC bexarotene caps AC PA mg PA HYDREA CAPS etoposide soln iv 1 AC (hydroxyurea) gm/50ml, 100 mg/5ml, AC 500 mg/25ml hydroxyurea caps AC Topoisomerase I Inhibitors INTRON A SOLN PA AC HYCAMTIN CAPS OR 0.25 PA (interferon alfa-2b) MG, 1 MG (topotecan AC INTRON A SOLR PA ) AC hcl (interferon alfa-2b) HYCAMTIN SOLR IV 4 MG PA AC MATULANE CAPS ( ) AC topotecan hcl (procarbazine hcl) PA topotecan hcl soln 4 AC SYLATRON KIT PA mg/4ml (peginterferon alfa-2b AC TOPOTECAN HCL SOLN PA (antineoplastic)) 4 MG/4ML (topotecan AC TARGRETIN CAPS OR 75 PA AC hcl) MG (bexarotene) TOPOTECAN HCL SOLN PA tretinoin AC 4 MG/4ML (topotecan AC (chemotherapy) caps hcl)

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52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA topotecan hcl solr 4 mg AC carbidopa-levodopa 1 tbcr ANTIPARKINSON AND RELATED THERAPY carbidopa-levodopa 1 AGENTS - Drugs to Treat Parkinson's Disease tbdp Antiparkinson Adjunctive Therapy 1 bal on hand, carbidopa-levodopa- 1 carbidopa tabs 1 entacapone tabs LODOSYN TABS DUOPA SUSP GP SP (carbidopa) (carbidopa-levodopa) GOCOVRI CP24 PA Antiparkinson Anticholinergics 3 (amantadine hcl) PA benztropine mesylate SP MIRAPEX ER TB24 soln ij 1 mg/ml (pramipexole GP benztropine mesylate dihydrochloride) tabs or 0.5 mg, 1 mg, 2 1 MIRAPEX TABS mg (pramipexole GP COGENTIN SOLN PA SP dihydrochloride) (benztropine mesylate) NEUPRO PT24 1 trihexyphenidyl hcl soln 1 MG/24HR, 3 MG/24HR, 6 MG/24HR, 8 MG/24HR 3 trihexyphenidyl hcl tabs 1 (rotigotine) NEUPRO PT24 2 QL(3 ea daily) Antiparkinson COMT Inhibitors MG/24HR, 3 MG/24HR, 6 3 COMTAN TABS MG/24HR, 8 MG/24HR GP (entacapone) (rotigotine) NEUPRO PT24 4 QL(1 ea daily) 1 entacapone tabs MG/24HR, 6 MG/24HR, 8 3 TASMAR TABS MG/24HR (rotigotine) GP (tolcapone) OSMOLEX ER T4PK PA 3 (amantadine hcl) tolcapone tabs 1 OSMOLEX ER TB24 PA 3 Antiparkinson Dopaminergics (amantadine hcl) amantadine hcl caps 1 PARLODEL CAPS (bromocriptine GP amantadine hcl syrp 1 mesylate) PARLODEL TABS amantadine hcl tabs 1 (bromocriptine GP mesylate) bromocriptine mesylate 1 caps pramipexole 1 dihydrochloride tabs bromocriptine mesylate 1 tabs pramipexole 1 dihydrochloride tb24 carbidopa-levodopa 1 REQUIP TABS ( tabs ropinirole GP hydrochloride) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REQUIP XL TB24 selegiline hcl tabs 1 (ropinirole GP ZELAPAR TBDP hydrochloride) 3 (selegiline hcl) ropinirole hydrochloride 1 tabs ANTIPSYCHOTICS/ANTIMANIC AGENTS - Drugs to Treat Mood Disorders ropinirole hydrochloride 1 tb24 Antimanic Agents RYTARY CPCR PA lithium carbonate caps 1 bal on hand, 3 (carbidopa-levodopa) 150 mg, 300 mg, 600 1 SINEMET CR TBCR mg, 600 mg GP (carbidopa-levodopa) lithium carbonate caps SINEMET TABS 150 mg, 300 mg, 600 1 GP (carbidopa-levodopa) mg, 600 mg STALEVO 100 TABS 1 bal on hand, lithium carbonate tabs 1 (carbidopa-levodopa- GP 300 mg entacapone) lithium carbonate tbcr 1 STALEVO 125 TABS 1 bal on hand, 300 mg, 450 mg (carbidopa-levodopa- GP 3 entacapone) LITHIUM SOLN (lithium) STALEVO 150 TABS 1 bal on hand, LITHOBID TBCR ( lithium 3 (carbidopa-levodopa- GP carbonate) entacapone) Antipsychotics - Misc. STALEVO 200 TABS 1 bal on hand, CAPLYTA CAPS PA; QL(1 ea 3 (carbidopa-levodopa- GP (lumateperone tosylate) daily) entacapone) EQUETRO CP12 STALEVO 50 TABS 1 bal on hand, (carbamazepine 3 (carbidopa-levodopa- GP (antipsychotic)) entacapone) GEODON CAPS OR 20 STALEVO 75 TABS 1 bal on hand, MG, 40 MG, 60 MG, 80 MG GP (carbidopa-levodopa- GP (ziprasidone hcl) entacapone) GEODON SOLR IM 20 MG PA SP Antiparkinson Monoamine Oxidase Inhibitors (ziprasidone mesylate) AZILECT TABS LATUDA TABS PA GP 3 (rasagiline mesylate) (lurasidone hcl) ELDEPRYL CAPS NUPLAZID CAPS 34 MG PA; QL(1 ea GP SP (selegiline hcl) (pimavanserin tartrate) daily) NUPLAZID TABS 10 MG PA; QL(1 ea rasagiline mesylate 1 SP tabs (pimavanserin tartrate) daily) NUPLAZID TABS 17 MG PA selegiline hcl caps 1 SP (pimavanserin tartrate) 1 bal on hand, VRAYLAR CAPS PA selegiline hcl tabs 1 3 (cariprazine hcl)

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54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VRAYLAR CPPK PA 3 risperidone tbdp 0.5 (cariprazine hcl) mg, 1 mg, 2 mg, 3 mg, 1 ziprasidone hcl caps 1 4 mg Butyrophenones PA ziprasidone mesylate SP solr haloperidol lactate conc 1 Benzisoxazoles haloperidol tabs 1 (Risperidone) RISPERIDONE M-TAB 1 Dibenzapines TBDP clozapine tabs 25 mg, FANAPT TABS PA 1 3 50 mg, 100 mg, 200 mg (iloperidone) 1 bal on hand, clozapine tbdp 150 mg, 1 FANAPT TITRATION PA 200 mg, 12.5 mg PACK TABS 3 (iloperidone) clozapine tbdp 25 mg, 1 INVEGA SUSTENNA PA 100 mg, 200 mg, 12.5 SUSY (paliperidone SP mg CLOZARIL TABS palmitate) GP INVEGA TB24 (clozapine) GP FAZACLO TBDP 12.5 MG (paliperidone) 3 INVEGA TRINZA SUSY PA (clozapine) SP FAZACLO TBDP 150 MG, 1 bal on hand, (paliperidone palmitate) 3 200 MG (clozapine) paliperidone tb24 1 FAZACLO TBDP 25 MG, GP PERSERIS PRSY PA 100 MG (clozapine) SP (risperidone) loxapine succinate 1 RISPERDAL CONSTA PA caps SRER (risperidone SP PA olanzapine solr im 10 SP microspheres) mg RISPERDAL SOLN GP olanzapine tabs or 5 (risperidone) mg, 10 mg, 15 mg, 20 1 RISPERDAL TABS GP mg, 2.5 mg, 7.5 mg (risperidone) olanzapine tbdp or 5 risperidone soln 1 1 mg, 10 mg, 15 mg, 20 1 mg/ml mg risperidone tabs 0.25 quetiapine fumarate mg, 0.5 mg, 1 mg, 2 1 tabs 25 mg, 50 mg, 100 1 mg, 3 mg, 4 mg mg, 200 mg, 300 mg, risperidone tbdp 0.25 1 bal on hand, 400 mg mg, 1 mg, 2 mg, 3 mg, 1 quetiapine fumarate PA 4 mg tb24 50 mg, 150 mg, 1 200 mg, 300 mg, 400 mg You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAPHRIS SUBL PA 1 bal on hand, 3 fluphenazine hcl tabs 1 (asenapine maleate) mg, 5 mg, 5 mg, 10 mg, 1 SECUADO PT24 PA; QL(1 ea 10 mg, 2.5 mg, 2.5 mg 3 (asenapine) daily) perphenazine tabs 1 SEROQUEL TABS GP (quetiapine fumarate) prochlorperazine 1 SEROQUEL XR TB24 300 PA maleate tabs MG (quetiapine NF prochlorperazine supp 1 fumarate) SEROQUEL XR TB24 50 PA thioridazine hcl tabs 1 MG, 150 MG, 200 MG, 400 MG (quetiapine GP trifluoperazine hcl tabs 1 fumarate) Quinolinone Derivatives VERSACLOZ SUSP QL(18 ml daily) ABILIFY TABS 2 MG, 10 3 GP (clozapine) MG, 30 MG (aripiprazole) ZYPREXA SOLR IM 10 PA ABILIFY TABS 5 MG, 15 SP NF MG (olanzapine) MG, 20 MG (aripiprazole) ZYPREXA TABS OR 5 MG, 10 MG, 15 MG, 20 aripiprazole soln 1 1 MG, 2.5 MG, 7.5 MG GP mg/ml (olanzapine) aripiprazole tabs 2 mg, ZYPREXA ZYDIS TBDP 5 mg, 10 mg, 15 mg, 20 1 GP (olanzapine) mg, 30 mg PA Dihydroindolones aripiprazole tbdp 10 1 mg, 15 mg molindone hcl tabs 1 1 bal on hand, REXULTI TABS PA 3 Phenothiazines (brexpiprazole) (Prochlorperazine) 1 Thioxanthenes COMPRO SUPP thiothixene caps 1 hcl 1 tabs ANTISEPTICS & DISINFECTANTS 1 bal on hand, fluphenazine hcl conc 5 1 mg/ml Antiseptics & Disinfectants 1 bal on hand, () 1 fluphenazine hcl elix 1 FORMADON SOLN 2.5 mg/5ml fluphenazine hcl tabs 1 formaldehyde soln 1 mg, 5 mg, 5 mg, 10 1 formaldehyde soln 1 1 bal on hand, mg, 10 mg, 2.5 mg, 2.5 mg ANTIVIRALS - Drugs to Treat Viral Infections Antiretrovirals abacavir sulfate soln 1

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56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMTRIVA CAPS abacavir sulfate tabs 1 2 (emtricitabine) abacavir sulfate- EMTRIVA SOLN 1 2 lamivudine tabs (emtricitabine) abacavir sulfate- EPIVIR SOLN GP lamivudine-zidovudine 1 (lamivudine) tabs EPIVIR TABS APTIVUS CAPS GP 2 (lamivudine) (tipranavir) EPZICOM TABS APTIVUS SOLN 2 (abacavir sulfate- GP (tipranavir) lamivudine) atazanavir sulfate caps 1 EVOTAZ TABS (atazanavir sulfate- 2 ATRIPLA TABS ST cobicistat) (- 2 fosamprenavir calcium emtricitabine-tenofovir 1 disoproxil fumarate) tabs FUZEON SOLR PA COMBIVIR TABS SP GP ( ) (lamivudine-zidovudine) enfuvirtide GENVOYA TABS COMPLERA TABS ST (elvitegravir-cobicistat- (emtricitabine- 2 rilpivirine-tenofovir 2 emtricitabine-tenofovir ) disoproxil fumarate) alafenamide INTELENCE TABS CRIXIVAN CAPS 2 2 ( ) ( sulfate) etravirine INVIRASE CAPS DELSTRIGO TABS ST 2 ( ) (doravirine-lamivudine- saquinavir mesylate 3 INVIRASE TABS tenofovir disoproxil 2 fumarate) (saquinavir mesylate) ISENTRESS CHEW DESCOVY TABS PA 2 (emtricitabine-tenofovir 2 (raltegravir potassium) ISENTRESS HD TABS alafenamide fumarate) 2 (raltegravir potassium) 1 1 bal on hand, didanosine cpdr ISENTRESS PACK 2 DOVATO TABS (raltegravir potassium) (dolutegravir sodium- 2 ISENTRESS TABS 2 lamivudine) (raltegravir potassium) EDURANT TABS 2 JULUCA TABS (rilpivirine hcl) (dolutegravir sodium- 2 efavirenz caps 1 rilpivirine hcl) KALETRA SOLN 400 efavirenz tabs 1 MG/5ML-100 MG/5ML GP (lopinavir-)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KALETRA TABS 100 MG- RETROVIR SYRP GP 25 MG, 200 MG-50 MG 2 (zidovudine) (lopinavir-ritonavir) REYATAZ CAPS 150 MG, lamivudine soln 1 200 MG (atazanavir GP sulfate) lamivudine tabs 1 REYATAZ CAPS 300 MG NF lamivudine-zidovudine (atazanavir sulfate) 1 REYATAZ PACK 50 MG tabs 2 LEXIVA SUSP 50 MG/ML (atazanavir sulfate) (fosamprenavir 2 ritonavir tabs 1 calcium) SELZENTRY SOLN 2 LEXIVA TABS 700 MG (maraviroc) (fosamprenavir GP SELZENTRY TABS calcium) 2 (maraviroc) lopinavir-ritonavir soln 1 stavudine caps 1 susp 50 1 STRIBILD TABS mg/5ml (elvitegravir-cobicistat- 2 nevirapine tabs 200 mg 1 emtricitabine-tenofovir df) nevirapine tb24 100 1 SUSTIVA CAPS mg, 400 mg GP (efavirenz) 1 bal on hand, nevirapine tb24 100 1 SUSTIVA TABS GP mg, 400 mg (efavirenz) NORVIR CAPS 100 MG 2 SYMTUZA TABS ST (ritonavir) (darunavir-cobicistat- NORVIR SOLN 80 MG/ML 3 2 emtricitabine-tenofovir (ritonavir) alafenamide) NORVIR TABS 100 MG GP tenofovir disoproxil 1 (ritonavir) fumarate tabs PIFELTRO TABS TIVICAY TABS 50 MG 2 2 (doravirine) (dolutegravir sodium) PREZCOBIX TABS 2 TRIUMEQ TABS (darunavir-cobicistat) (abacavir-dolutegravir- 2 PREZISTA SUSP 2 lamivudine) (darunavir ethanolate) TRIZIVIR TABS (abacavir PREZISTA TABS 2 sulfate-lamivudine- GP (darunavir ethanolate) zidovudine) RESCRIPTOR TABS 2 TRUVADA TABS (delavirdine mesylate) (emtricitabine-tenofovir 2 RETROVIR CAPS GP disoproxil fumarate) (zidovudine)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYBOST TABS 2 zidovudine tabs 1 (cobicistat) VIDEX EC CPDR 125 MG CMV Agents 2 (didanosine) cidofovir soln SP PA VIDEX EC CPDR 200 MG, FOSCAVIR SOLN PA 250 MG, 400 MG 3 SP (didanosine) (foscarnet sodium) VIDEXPEDIATRIC SOLR PREVYMIS TABS PA; SP 2 SP (didanosine) (letermovir) VIRACEPT TABS VALCYTE SOLR 50 QL(21 ml daily) 2 (nelfinavir mesylate) MG/ML (valganciclovir GP VIRAMUNE SUSP hcl) GP VALCYTE TABS 450 MG (nevirapine) GP VIRAMUNE TABS (valganciclovir hcl) GP QL(21 ml daily) (nevirapine) valganciclovir hcl solr 1 VIRAMUNE XR TB24 100 50 mg/ml 3 MG (nevirapine) valganciclovir hcl tabs 1 VIRAMUNE XR TB24 400 450 mg GP MG (nevirapine) Hepatitis Agents VIREAD POWD 40 MG/GM (Ribavirin (Hepatitis C)) 1 PA (tenofovir disoproxil 2 MODERIBA TABS fumarate) (Ribavirin (Hepatitis C)) PA VIREAD TABS 150 MG, RIBASPHERE CAPS 200 1 200 MG, 250 MG MG (tenofovir disoproxil 2 (Ribavirin (Hepatitis C)) PA fumarate) RIBASPHERE RIBAPAK 1 TBPK 400 MG, 600 MG VIREAD TABS 300 MG ( NF (Ribavirin (Hepatitis C)) PA tenofovir disoproxil RIBASPHERE TABS 200 1 fumarate) MG, 400 MG ZERIT CAPS 15 MG, 20 (Ribavirin (Hepatitis C)) PA; 1 bal on MG, 30 MG, 40 MG GP RIBASPHERE TABS 600 1 hand, (stavudine) MG ZERIT SOLR 1 MG/ML 2 adefovir dipivoxil tabs 1 (stavudine) ZIAGEN SOLN ( BARACLUDE SOLN 0.05 abacavir GP 2 sulfate) MG/ML (entecavir) BARACLUDE TABS 0.5 ZIAGEN TABS (abacavir GP GP MG, 1 MG ( ) sulfate) entecavir DAKLINZA TABS PA zidovudine caps 1 (daclatasvir SP dihydrochloride) zidovudine syrp 1 entecavir tabs 1

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPCLUSA TABS PA SOFOSBUVIR/VELPATAS PA 3 (sofosbuvir-velpatasvir) VIR TABS (sofosbuvir- 3 EPIVIR HBV SOLN 5 velpatasvir) MG/ML (lamivudine 3 SOVALDI TABS 200 MG, PA 3 (hbv)) 400 MG (sofosbuvir) EPIVIR HBV TABS 100 TECHNIVIE TABS PA GP MG (lamivudine (hbv)) (ombitasvir-paritaprevir- SP HARVONI TABS 200 MG- PA ritonavir) 45 MG, 400 MG-90 MG 3 VEMLIDY TABS PA (ledipasvir-sofosbuvir) (tenofovir alafenamide SP HEPSERA TABS fumarate) NF (adefovir dipivoxil) VIEKIRA PAK TBPK PA lamivudine (hbv) tabs 1 (ombitasvir-paritaprevir- SP ritonavir-dasabuvir) LEDIPASVIR/SOFOSBUVI PA VOSEVI TABS PA R TABS (ledipasvir- 3 (sofosbuvir-velpatasvir- 3 sofosbuvir) voxilaprevir) MAVYRET TABS PA ZEPATIER TABS PA SP (glecaprevir- 3 (elbasvir-grazoprevir) pibrentasvir) Herpes Agents MODERIBA 1200 DOSE PA PACK TBPK (ribavirin 3 acyclovir caps 1 (hepatitis c)) PEGASYS PROCLICK PA acyclovir susp 1 SOLN (peginterferon SP acyclovir tabs 1 alfa-2a) PEGASYS SOLN PA SP famciclovir tabs 1 (peginterferon alfa-2a) PEGINTRON KIT PA valacyclovir hcl tabs 1 SP (peginterferon alfa-2b) VALTREX TABS 1 GM REBETOL CAPS 200 MG PA GP GP (valacyclovir hcl) (ribavirin (hepatitis c)) VALTREX TABS 500 MG NF REBETOL SOLN 40 PA (valacyclovir hcl) MG/ML (ribavirin 2 ZOVIRAX CAPS OR 200 GP (hepatitis c)) MG (acyclovir) RIBASPHERE RIBAPAK PA ZOVIRAX SUSP OR 200 GP TBPK (ribavirin 3 MG/5ML (acyclovir) (hepatitis c)) ZOVIRAX TABS OR 400 PA GP ribavirin (hepatitis c) 1 MG, 800 MG (acyclovir) caps Influenza Agents PA ribavirin (hepatitis c) 1 tabs

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUMADINE TABS COREG TABS 3.125 MG QL(2 ea daily) GP (rimantadine 3 () hydrochloride) COREG TABS 6.25 MG NF oseltamivir phosphate QL(10 ea per (carvedilol) 1 180 days retail) caps or 30 mg, 45 mg labetalol hcl tabs 1 oseltamivir phosphate 1 caps or 75 mg Beta Blockers Cardio-Selective QL(180 ml per acebutolol hcl caps 1 oseltamivir phosphate 1 180 days susr or 6 mg/ml retail); AL(At atenolol tabs 1 least 1 yrs old) RELENZA DISKHALER Limit 20 per betaxolol hcl tabs 1 3 month;QL(0.67 AEPB (zanamivir) QL(1 ea daily) ea daily) bisoprolol fumarate 1 rimantadine 1 bal on hand, tabs 1 BYSTOLIC TABS hydrochloride tabs 3 TAMIFLU CAPS 30 MG, 45 QL(10 ea per (nebivolol hcl) LOPRESSOR TABS MG (oseltamivir GP 180 days retail) GP phosphate) (metoprolol tartrate) TAMIFLU CAPS 75 MG metoprolol succinate NF 1 (oseltamivir phosphate) tb24 QL(180 ml per metoprolol tartrate tabs 1 TAMIFLU SUSR 6 MG/ML GP 180 days retail); AL(At TENORMIN TABS (oseltamivir phosphate) GP least 1 yrs old) (atenolol) Respiratory Syncytial Virus (RSV) Agents TOPROL XL TB24 25 MG, 100 MG, 200 MG GP ribavirin solr 1 (metoprolol succinate) VIRAZOLE SOLR TOPROL XL TB24 50 MG GP NF (ribavirin) (metoprolol succinate) BETA BLOCKERS - Drugs to Treat High Blood Beta Blockers Non-Selective Pressure (Sotalol Hcl) SORINE 1 Alpha-Beta Blockers TABS BETAPACE AF TABS carvedilol phosphate 1 GP cp24 (sotalol hcl (afib/afl)) BETAPACE TABS (sotalol carvedilol tabs 25 mg, 1 GP 12.5 mg, 6.25 mg hcl) QL(2 ea daily) CORGARD TABS carvedilol tabs 3.125 1 GP mg (nadolol) COREG CR CP24 HEMANGEOL SOLN AL(Up to 1 yrs GP 3 old ) (carvedilol phosphate) (propranolol hcl) COREG TABS 25 MG, INDERAL LA CP24 GP GP 12.5 MG (carvedilol) (propranolol hcl) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INDERAL XL CP24 80 MG, 1 bal on hand, (Diltiazem Hcl Coated 120 MG, 120 MG Beads) CARTIA XT, 1 (propranolol hcl 3 DILTIAZEM CD CP24 sustained-release (Diltiazem Hcl Coated 1 beads) Beads) MATZIM LA TB24 INDERAL XL CP24 80 MG, (Diltiazem Hcl Extended 120 MG, 120 MG Release Beads) TAZTIA 1 XT, TIADYLT ER CP24 (propranolol hcl 3 sustained-release (Diltiazem Hcl) DILT-XR 1 1 bal on hand, beads) CP24 () AFEDITAB CR 1 INNOPRAN XL CP24 80 1 bal on hand, TB24 MG, 120 MG, 120 MG ADALAT CC TB24 30 MG, (propranolol hcl 3 GP sustained-release 60 MG (nifedipine) ADALAT CC TB24 90 MG QL(1 ea daily) beads) GP INNOPRAN XL CP24 80 (nifedipine) MG, 120 MG, 120 MG QL(2 ea daily) amlodipine besylate 1 (propranolol hcl 3 tabs sustained-release CALAN SR TBCR GP beads) (verapamil hcl) CALAN TABS ( nadolol tabs 1 verapamil GP hcl) pindolol tabs 1 CARDIZEM CD CP24 propranolol hcl cp24 60 (diltiazem hcl coated GP mg, 80 mg, 120 mg, 1 beads) 160 mg CARDIZEM LA TB24 120 1 bal on hand, MG (diltiazem hcl 2 propranolol hcl soln 20 1 mg/5ml, 40 mg/5ml coated beads) CARDIZEM LA TB24 180 propranolol hcl tabs 10 MG, 240 MG, 300 MG, 360 mg, 20 mg, 40 mg, 60 1 MG, 420 MG (diltiazem GP mg, 80 mg hcl coated beads) 1 CARDIZEM TABS sotalol hcl (afib/afl) tabs GP (diltiazem hcl) sotalol hcl tabs 1 diltiazem hcl coated 1 SOTYLIZE SOLN ( beads cp24 sotalol 3 hcl) diltiazem hcl coated 1 QL(2 ea daily) beads tb24 timolol maleate tabs 5 1 mg, 10 mg, 20 mg diltiazem hcl cp12 1 CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure diltiazem hcl cp24 1 Calcium Channel Blockers diltiazem hcl extended 1 release beads cp24 You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diltiazem hcl tabs 1 verapamil hcl cp24 100 mg, 120 mg, 180 mg, tb24 1 200 mg, 200 mg, 240 1 mg, 300 mg, 300 mg, isradipine caps 1 360 mg hcl caps 1 verapamil hcl tabs 40 1 mg, 80 mg, 120 mg nifedipine caps 10 mg, 1 verapamil hcl tbcr 120 1 20 mg mg, 180 mg, 240 mg nifedipine tb24 30 mg, 1 VERELAN CP24 120 MG, 60 mg, 60 mg, 90 mg 180 MG, 240 MG GP QL(1 ea daily) (verapamil hcl) nifedipine tb24 30 mg, 1 60 mg, 60 mg, 90 mg VERELAN CP24 360 MG 1 bal on hand, GP (verapamil hcl) nimodipine caps 1 VERELAN PM CP24 1 bal on hand, 3 tb24 17 mg, (verapamil hcl) 1 30 mg, 34 mg, 40 mg, CARDIOTONICS - Drugs to Treat Heart Failure 8.5 mg, 25.5 mg and Abnormal Heart Rhythm 1 bal on hand, nisoldipine tb24 20 mg, Cardiac Glycosides 30 mg, 34 mg, 40 mg, 1 (Digoxin) DIGITEK, DIGOX 1 8.5 mg, 25.5 mg TABS NORVASC TABS QL(2 ea daily) GP (amlodipine besylate) digoxin soln 0.05 mg/ml 1 NYMALIZE SOLN 30 digoxin soln 0.05 mg/ml 1 1 bal on hand, MG/10ML, 60 MG/20ML 3 (nimodipine) digoxin tabs 0.125 mg, 1 PROCARDIA CAPS 125 mcg, 250 mcg GP ( ) LANOXIN TABS 125 MCG, nifedipine 3 PROCARDIA XL TB24 QL(1 ea daily) 250 MCG (digoxin) GP (nifedipine) LANOXIN TABS 62.5 SULAR TB24 MCG, 187.5 MCG 3 GP (nisoldipine) (digoxin) TIAZAC CP24 (diltiazem CARDIOVASCULAR AGENTS - MISC. - Drugs to hcl extended release GP Treat Heart and Circulation Conditions beads) Cardiovascular Agents Misc. - Combinations verapamil hcl cp24 100 1 bal on hand, amlodipine besylate- mg, 120 mg, 180 mg, atorvastatin calcium 1 200 mg, 200 mg, 240 1 tabs mg, 300 mg, 300 mg, BIDIL TABS (isosorbide 360 mg dinitrate-hydralazine 3 hcl)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CADUET TABS REVATIO SOLN PA (amlodipine besylate- GP (sildenafil citrate SP atorvastatin calcium) (pulmonary ENTRESTO TABS PA hypertension)) 3 (sacubitril-valsartan) REVATIO SUSR PA Impotence Agents (sildenafil citrate (pulmonary SP GP PA; QL(1 ea CIALIS TABS (tadalafil) daily) hypertension)) PA; QL(1 ea REVATIO TABS PA tadalafil tabs 1 (sildenafil citrate daily) SP Peripheral Vasodilators (pulmonary hypertension)) isoxsuprine hcl tabs 1 sildenafil citrate PA Prostaglandin Vasodilators (pulmonary SP ORENITRAM TBCR PA hypertension) soln iv 10 SP (treprostinil diolamine) mg/12.5ml REMODULIN SOLN PA; 1 bal on sildenafil citrate PA SP (treprostinil) hand, (pulmonary SP PA hypertension) susr or treprostinil soln SP 10 mg/ml VENTAVIS SOLN PA SILDENAFIL CITRATE PA SP (iloprost) TABS (sildenafil citrate 2 Pulmonary Hypertension - Endothelin Receptor (pulmonary PA hypertension)) tabs SP PA tadalafil (pulmonary SP tabs SP PA hypertension) tabs LETAIRIS TABS PA Pulmonary Hypertension - Prostacyclin Receptor SP UPTRAVI TABS PA (ambrisentan) SP (selexipag) OPSUMIT TABS PA SP UPTRAVI TBPK PA (macitentan) SP (selexipag) TRACLEER TABS 125 PA SP MG, 62.5 MG (bosentan) Pulmonary Hypertension - Sol Guanylate Cyclase TRACLEER TBSO 32 MG PA; SP ADEMPAS TABS PA SP SP (bosentan) (riociguat) Pulmonary Hypertension - Phosphodiesterase Sinus Node Inhibitors CORLANOR SOLN 5 ST; QL(15 ml (Tadalafil (Pulmonary PA 3 Hypertension)) ALYQ SP MG/5ML (ivabradine hcl) daily) TABS CORLANOR TABS 5 MG, ST 3 ADCIRCA TABS (tadalafil PA 7.5 MG (ivabradine hcl) (pulmonary SP Transthyretin Stabilizers hypertension))

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VYNDAMAX CAPS PA; QL(1 ea CEFOXITIN SODIUM PA SP ( ) daily) SOLR IV 1 GM-4 %, 2 GM- tafamidis SP VYNDAQEL CAPS PA; QL(4 ea 2.2 % (cefoxitin sodium (tafamidis meglumine SP daily) and dextrose) (cardiac)) cefprozil susr 1 CEPHALOSPORINS - Drugs to Treat Bacterial Infections cefprozil tabs 1 Cephalosporins - 1st Generation cefuroxime axetil tabs 1 cefadroxil caps 1 cefuroxime sodium solr SP PA cefadroxil susr 1 Cephalosporins - 3rd Generation cefadroxil tabs 1 (Ceftazidime) TAZICEF PA SOLR IJ 1 GM, 2 GM, 6 SP cefazolin sodium solr SP PA GM (Ceftazidime) TAZICEF SP PA; 1 bal on cephalexin caps 250 1 SOLR IV 1 GM, 2 GM hand, mg, 500 mg, 750 mg cefdinir caps 1 cephalexin susr 125 1 mg/5ml, 250 mg/5ml cefdinir susr 1 1 bal on hand, cephalexin tabs 250 1 1 bal on hand, mg, 500 mg cefditoren pivoxil tabs 1 KEFLEX CAPS GP cefixime caps 1 (cephalexin) Cephalosporins - 2nd Generation cefixime susr 1 cefaclor caps 250 mg, 1 cefotaxime sodium solr PA 500 mg 1 gm, 2 gm, 10 gm, 500 SP CEFACLOR ER TB12 3 mg, 500 mg (cefaclor monohydrate) cefotaxime sodium solr PA; 1 bal on cefaclor susr 125 1 bal on hand, 2 gm, 10 gm, 500 mg, SP hand, mg/5ml, 250 mg/5ml, 1 500 mg 375 mg/5ml cefpodoxime proxetil CEFOTAN SOLR PA 1 SP susr (cefotetan disodium) cefpodoxime proxetil PA 1 cefotetan disodium solr SP tabs 1 gm, 2 gm ceftazidime solr SP PA cefotetan disodium solr PA; 1 bal on SP hand, 10 gm ceftriaxone sodium solr SP PA PA cefoxitin sodium solr ij SP CLAFORAN SOLR PA SP 10 gm (cefotaxime sodium) cefoxitin sodium solr iv PA SPECTRACEF TABS 1 bal on hand, SP 3 1 gm, 2 gm (cefditoren pivoxil) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPRAX CAPS 400 MG (Drospirenone-Ethinyl PV GP (cefixime) ) GIANVI, SUPRAX CHEW 100 MG, ZUMANDIMINE, ZARAH, 3 SYEDA, OCELLA, NIKKI, 1 200 MG (cefixime) LORYNA, LO- SUPRAX SUSR 100 ZUMANDIMINE, JASMIEL MG/5ML, 200 MG/5ML GP TABS (cefixime) (Drospirenone-Ethinyl PV SUPRAX SUSR 500 Estradiol-Levomefolate 3 1 MG/5ML (cefixime) Calcium) RAJANI, TYDEMY TABS Cephalosporins - 4th Generation (Ethynodiol Diacet & Eth PV PA cefepime hcl solr SP Estrad) KELNOR 1/35, 1 ZOVIA 1/35E, KELNOR CEFEPIME SOLN PA 1/50 TABS SP (cefepime hcl) (Ethynodiol Diacet & Eth PV CEFEPIME/DEXTROSE PA Estrad) KELNOR 1/35, PV SOLR (cefepime hcl- SP ZOVIA 1/35E, KELNOR dextrose) 1/50 TABS (Levonorgestrel & Eth PV MAXIPIME SOLR PA SP Estradiol) AFIRMELLE, (cefepime hcl) VIENVA, SRONYX, Cephalosporins - 5th Generation PORTIA-28, ORSYTHIA, TEFLARO SOLR PA MARLISSA, LUTERA, SP LILLOW, LEVORA 0.15/30- PV (ceftaroline fosamil) 28, LESSINA, LARISSIA, CONTRACEPTIVES - Drugs to Prevent KURVELO, FALMINA, Pregnancy DELYLA, CHATEAL EQ, CHATEAL, AYUNA, Combination Contraceptives - Oral AVIANE, AUBRA EQ, (Desogestrel & Ethinyl PV AUBRA, ALTAVERA TABS Estradiol) APRI, (Levonorgestrel-Eth PV RECLIPSEN, KALLIGA, 1 Estradiol (Triphasic)) JULEBER, ISIBLOOM, ENPRESSE-28, TRIVORA- PV ENSKYCE, EMOQUETTE, 28, MYZILRA, LEVONEST CYRED EQ, CYRED TABS TABS (Desogestrel-Ethinyl PV (Levonorgestrel-Ethinyl PV Estradiol (Biphasic)) Estradiol (91-Day)) KARIVA, BEKYREE, AMETHIA, SIMPESSE, AZURETTE, VOLNEA, 1 SETLAKIN, RIVELSA, VIORELE, SIMLIYA, QUASENSE, LOJAIMIESS, PV PIMTREA, KIMIDESS JOLESSA, JAIMIESS, TABS INTROVALE, FAYOSIM, (Desogestrel-Ethinyl PV DAYSEE, CAMRESE LO, Estradiol (Triphasic)) 1 CAMRESE, ASHLYNA, CAZIANT, VELIVET TABS AMETHIA LO TABS (Levonorgestrel-Ethinyl PV Estradiol (Continuous)) PV AMETHYST TABS

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethin Acet & Estrad- PV (Norethindrone-Eth PV Fe) AUROVELA 24 FE, Estradiol (Triphasic)) TARINA FE 1/20 EQ, ALYACEN 7/7/7, TARINA FE 1/20, TARINA PIRMELLA 7/7/7, 1 24 FE, MICROGESTIN FE NORTREL 7/7/7, NECON 1.5/30, MICROGESTIN FE, 7/7/7, LEENA, DASETTA LARIN FE 1/20, LARIN FE 7/7/7, CYCLAFEM 7/7/7, 1.5/30, LARIN 24 FE, ARANELLE TABS JUNEL FE 24, JUNEL FE 1 (Norgestimate-Ethinyl PV 1/20, JUNEL FE 1.5/30, Estradiol (Triphasic)) TRI HAILEY FE 1/20, HAILEY FEMYNOR, TRINESSA FE 1.5/30, HAILEY 24 FE, LO, TRINESSA, TRI- BLISOVI FE 1/20, BLISOVI VYLIBRA LO, TRI- FE 1.5/30, BLISOVI 24 FE, VYLIBRA, TRI-SPRINTEC, 1 AUROVELA FE 1/20, TRI-PREVIFEM, TRI-MILI, AUROVELA FE 1.5/30 TRI-LO-SPRINTEC, TRI- TABS LO-MILI, TRI-LO-MARZIA, (Norethin Acet & Estrad- PV TRI-LO-ESTARYLLA, TRI- Fe) MELODETTA 24 FE, 1 LINYAH, TRI-ESTARYLLA MIBELAS 24 FE CHEW TABS (Norethindrone & Eth PV (Norgestimate-Ethinyl PV Estradiol) ALYACEN 1/35, Estradiol) ESTARYLLA, ZENCHENT, WERA, VYLIBRA, SPRINTEC 28, VYFEMLA, PIRMELLA PREVIFEM, 1 1/35, PHILITH, NORTREL MONONESSA, MONO- 1/35, NORTREL 0.5/35 1 LINYAH, MILI, FEMYNOR (28), NECON 0.5/35-28, TABS DASETTA 1/35, (Norgestrel & Ethinyl PV CYCLAFEM 1/35, Estradiol) CRYSELLE-28, BRIELLYN, BALZIVA OGESTREL, LOW- 1 TABS OGESTREL, ELINEST (Norethindrone & Ethinyl PV TABS Estradiol-Fe) KAITLIB FE, 1 (Norgestrel & Ethinyl 1 bal on hand,; WYMZYA FE, LAYOLIS FE Estradiol) CRYSELLE-28, PV CHEW OGESTREL, LOW- 1 (Norethindrone Acet & Eth PV OGESTREL, ELINEST Estra) AUROVELA 1.5/30, TABS MICROGESTIN 1/20, BALCOLTRA TABS QL(1 ea daily); MICROGESTIN 1.5/30, 1 (levonorgestrel-ethinyl PV LARIN 1/20, LARIN 1.5/30, 3 JUNEL 1/20, JUNEL estradiol-ferrous 1.5/30, HAILEY 1.5/30, bisglycinate) AUROVELA 1/20 TABS BEYAZ TABS PV (Norethindrone Acetate- PV (drospirenone-ethinyl Ethinyl Estradiol-Fe) TILIA 1 estradiol-levomefolate GP FE, TRI-LEGEST FE TABS calcium) DESOGEN TABS PV (desogestrel & ethinyl GP estradiol)

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PV LOESTRIN FE 1.5/30 PV desogestrel & ethinyl 1 estradiol tabs TABS (norethin acet & GP desogestrel-ethinyl PV estrad-fe) estradiol (biphasic) 1 LOESTRIN FE 1/20 TABS PV tabs (norethin acet & estrad- GP PV fe) drospirenone-ethinyl 1 estradiol tabs LOSEASONIQUE TABS PV (levonorgestrel-ethinyl GP drospirenone-ethinyl PV estradiol (91-day)) estradiol-levomefolate 1 calcium tabs MINASTRIN 24 FE CHEW PV (norethin acet & estrad- 3 ESTROSTEP FE TABS PV fe) (norethindrone acetate- GP ethinyl estradiol-fe) MINASTRIN 24 FE CHEW PV (norethin acet & estrad- GP PV ethynodiol diacet & eth fe) estrad tabs 1 mg-35 1 mcg, 1 mg-50 mcg MIRCETTE TABS PV (desogestrel-ethinyl GP FALESSA KIT PA; PV estradiol (biphasic)) (levonorgestrel-ethinyl 3 NATAZIA TABS PV estradiol & folic acid) (estradiol valerate- 2 GENERESS FE CHEW PV dienogest) (norethindrone & GP PV ethinyl estradiol-fe) norethin acet & estrad- 1 fe chew levonorgestrel & eth PV PV PV estradiol tabs norethin acet & estrad- 1 fe tabs levonorgestrel-eth PV PV estradiol (triphasic) PV norethindrone & ethinyl 1 tabs estradiol-fe chew PV norethindrone acet & PV levonorgestrel-ethinyl PV 1 estradiol (91-day) tabs eth estra tabs levonorgestrel-ethinyl PV norgestimate-ethinyl PV estradiol (continuous) PV estradiol (triphasic) 1 tabs tabs PV LO LOESTRIN FE TABS PV norgestimate-ethinyl 1 (norethindrone acetate- estradiol tabs ethinyl estradiol-fe fum 3 ORTHO TRI-CYCLEN LO PV TABS (norgestimate- (biphasic)) GP LOESTRIN 1.5/30-21 PV ethinyl estradiol TABS (norethindrone GP (triphasic)) acet & eth estra) ORTHO TRI-CYCLEN PV TABS (norgestimate- LOESTRIN 1/20-21 TABS PV GP (norethindrone acet & GP ethinyl estradiol eth estra) (triphasic)) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORTHO-CYCLEN TABS PV NUVARING RING PV (norgestimate-ethinyl GP (etonogestrel-ethinyl GP estradiol) estradiol) ORTHO-NOVUM 1/35 PV Copper Contraceptives - IUD TABS (norethindrone & GP PARAGARD PV eth estradiol) INTRAUTERINE COPPER 3 ORTHO-NOVUM 7/7/7 PV CONTRACEPTIVE T380A TABS (norethindrone- GP IUD (copper (iud)) eth estradiol (triphasic)) Emergency Contraceptives QUARTETTE TABS PV (Levonorgestrel PV (levonorgestrel-ethinyl GP (Emergency Oc)) AFTERA, estradiol (91-day)) TAKE ACTION, REACT, SAFYRAL TABS PV PREVENTEZA, OPTION 2, OPCICON ONE-STEP, PV (drospirenone-ethinyl GP NEW DAY, MY WAY, MY estradiol-levomefolate CHOICE, ECONTRA ONE- calcium) STEP, ECONTRA EZ SEASONIQUE TABS PV TABS ( ELLA TABS ( PV levonorgestrel-ethinyl GP ulipristal PV estradiol (91-day)) acetate) TAYTULLA CAPS PA; QL(1 ea PV levonorgestrel PV (norethin acet & estrad- 3 daily); PV (emergency oc) tabs fe) PLAN B ONE-STEP TABS PV TRI-NORINYL 28 TABS PV (levonorgestrel GP (norethindrone-eth GP (emergency oc)) estradiol (triphasic)) Progestin Contraceptives - IUD YASMIN 28 TABS PV KYLEENA IUD PV 3 (drospirenone-ethinyl GP (levonorgestrel (iud)) estradiol) LILETTA IUD PV 3 YAZ TABS PV (levonorgestrel (iud)) (drospirenone-ethinyl GP MIRENA IUD PV estradiol) 3 (levonorgestrel (iud)) Combination Contraceptives - Transdermal SKYLA IUD PV 3 (-Ethinyl PV 1 bal on hand,; (levonorgestrel (iud)) Estradiol) XULANE PTWK PV Progestin Contraceptives - Implants Combination Contraceptives - Vaginal NEXPLANON IMPL PV 3 (Etonogestrel-Ethinyl PV PV (etonogestrel) Estradiol) ELURYNG RING ANNOVERA RING PV Progestin Contraceptives - Injectable (segesterone acetate- PV DEPO-PROVERA PV ethinyl estradiol) CONTRACEPTIVE SUSP (medroxyprogesterone GP etonogestrel-ethinyl PV PV acetate (contraceptive)) estradiol ring

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPO-PROVERA PV budesonide cpep 3 mg 1 CONTRACEPTIVE SUSY GP (medroxyprogesterone budesonide tb24 9 mg 1 PA acetate (contraceptive)) CORTEF TABS DEPO-SUBQ PROVERA PV GP 104 SUSY (hydrocortisone) 3 (medroxyprogesterone cortisone acetate tabs 1 1 bal on hand, acetate (contraceptive)) elix 0.5 medroxyprogesterone PV 1 mg/5ml acetate (contraceptive) 1 susp DEXAMETHASONE INTENSOL CONC 2 medroxyprogesterone PV (dexamethasone) acetate (contraceptive) 1 dexamethasone PA; 1 bal on susy sodium phosphate soln hand, Progestin Contraceptives - Oral 10 mg/ml, 10 mg/ml, 20 SP (Norethindrone PV mg/5ml, 100 mg/10ml, (Contraceptive)) CAMILA, 120 mg/30ml TULANA, SHAROBEL, dexamethasone PA NORLYROC, NORLYDA, 1 NORA-BE, LYZA, sodium phosphate soln JOLIVETTE, JENCYCLA, 4 mg/ml, 10 mg/ml, 20 SP INCASSIA, HEATHER, mg/5ml, 100 mg/10ml, ERRIN, DEBLITANE TABS 120 mg/30ml norethindrone PV 1 bal on hand, 1 dexamethasone soln 1 (contraceptive) tabs 0.5 mg/5ml ORTHO MICRONOR PV dexamethasone tabs TABS (norethindrone GP 0.75 mg, 0.5 mg, 2 mg, 1 (contraceptive)) 4 mg, 6 mg, 1.5 mg SLYND TABS PV PV 1 bal on hand, (drospirenone) dexamethasone tabs 1 mg, 2 mg, 4 mg, 6 mg, 1 CORTICOSTEROIDS - Steroid Hormone Drugs to 1.5 mg Treat Systemic Swelling Conditions dexamethasone tbpk 1 Glucocorticosteroids 1.5 mg (Dexamethasone) 1 ENTOCORT EC CPEP DECADRON ELIX GP (budesonide) (Dexamethasone) 1 DECADRON TABS hydrocortisone tabs 1 (Dexamethasone) MEDROL DOSEPAK TBPK DEXPAK 10 DAY, GP TAPERDEX 6-DAY, () MEDROL TABS 2 MG TAPERDEX 12-DAY, 1 2 HIDEX 6-DAY, DEXPAK 6 (methylprednisolone) DAY, DEXPAK 13 DAY TBPK

You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDROL TABS 4 MG, 8 VERIPRED 20 SOLN MG, 16 MG, 32 MG GP ( sodium GP (methylprednisolone) phosphate) methylprednisolone 1 Mineralocorticoids tabs fludrocortisone acetate 1 methylprednisolone 1 tabs tbpk COUGH/COLD/ALLERGY - Drugs to Treat MILLIPRED DP TBPK 3 Cough, Cold and Allergy Symptoms (prednisolone) Antitussives MILLIPRED SOLN 10 (Hydrocodone W/ MG/5ML (prednisolone GP Homatropine) HYDROMET 1 sodium phosphate) SYRP MILLIPRED TABS 5 MG 2 (Hydrocodone W/ (prednisolone) Homatropine) TUSSIGON 1 ORAPRED ODT TBDP TABS (prednisolone sodium GP benzonatate caps 1 phosphate) hydrocodone w/ prednisolone sodium 1 homatropine syrp phosphate soln or 10 1 mg/5ml, 15 mg/5ml, 20 hydrocodone w/ 1 mg/5ml homatropine tabs TESSALON PERLES prednisolone sodium 1 bal on hand, GP phosphate soln or 25 1 CAPS (benzonatate) mg/5ml Cough/Cold/Allergy Combinations prednisolone sodium (Guaifenesin-Codeine) phosphate tbdp or 10 1 CHERATUSSIN AC, 1 GUAIFENESIN AC, mg, 15 mg, 30 mg GUAIATUSSIN AC SYRP prednisolone soln 1 1 bal on hand, (Guaifenesin-Codeine) G TUSSIN AC, VIRTUSSIN PREDNISONE INTENSOL 1 2 A/C, ROBAFEN AC, MAXI- CONC (prednisone) TUSS AC SOLN prednisone soln 5 1 bal on hand, 1 (Guaifenesin-Codeine) 1 mg/5ml VIRTUSSIN AC/ALC LIQD prednisone tabs 1 mg, (Phenylephrine W/ Dm-Gg) RX/OTC 5 mg, 10 mg, 20 mg, 1 BIOGTUSS, GILTUSS 1 50 mg, 2.5 mg PEDIATRIC LIQD (Promethazine & prednisone tbpk 5 mg, 1 Phenylephrine) 1 10 mg PROMETHAZINE VC RAYOS TBEC PA PLAIN SOLN 3 (prednisone) (Promethazine- UCERIS TB24 OR 9 MG PA Phenylephrine-Codeine) 1 GP PROMETHAZINE (budesonide) VC/CODEINE SYRP You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pseudoephedrine W/ EXAPHEX TR TABS RX/OTC Codeine-Gg) 1 (phenylephrine- 3 GUAIFENESIN DAC, guaifenesin) VIRTUSSIN DAC SOLN GILPHEX TR TABS RX/OTC ACTIDOM DMX LIQD (phenylephrine- 3 (phenylephrine w/ dm- 3 guaifenesin) gg) GILTUSS COUGH & COLD RX/OTC BIO-DTUSS DMX LIQD TABS (phenylephrine w/ 3 (pseudoephed- 3 dm-gg) bromphen-dm) GILTUSS LIQD RX/OTC CARBAPHEN 12 LIQD (phenylephrine w/ dm- GP (phenylephrine- gg) chlorpheniramine- 3 ) GILTUSS SINUS & RX/OTC carbetapentane CONGESTION TABS CARBAPHEN 12 PED (phenylephrine- 3 SUSP (phenylephrine- 3 guaifenesin) chlorpheniramine- GILTUSS TR TABS RX/OTC ) carbetapentane (phenylephrine w/ dm- 3 CLARINEX-D 12 HOUR PA gg) TB12 (desloratadine- 3 guaifenesin-codeine pseudoephedrine) 1 soln CODITUSSIN AC LIQD 3 HISTEX-PE SYRP (guaifenesin-codeine) (triprolidine- GP DECON-G LIQD phenylephrine) (phenylephrine- brompheniramine- 3 hydrocodone polistirex- guaifenesin) chlorpheniramine 1 polistirex lqcr DOCTOR MANZANILLA PE SYRUP hydrocodone polistirex- ANTIHISTAMINE/DECON chlorpheniramine 1 GESTANT LIQD 3 polistirex suer (triprolidine- NEOTUSS PLUS LIQD phenylephrine) (phenylephrine- 3 DOMETUSS-DMX LIQD chlorphen-dm) (phenylephrine w/ dm- 3 promethazine & 1 gg) phenylephrine syrp EXACTUSS LIQD RX/OTC promethazine & 1 bal on hand, (phenylephrine w/ dm- GP 1 phenylephrine syrp gg) EXACTUSS TR TABS RX/OTC promethazine 1 (phenylephrine w/ dm- 3 w/codeine soln gg) promethazine 1 w/codeine syrp

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72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine-dm soln 1 1 bal on hand, HYPERSAL NEBU 3.5 % (sodium chloride 3 promethazine-dm syrp 1 (inhalant)) HYPERSAL NEBU 7 % promethazine- 1 bal on hand, (sodium chloride GP phenylephrine-codeine 1 (inhalant)) syrp NEBUSAL NEBU 6 % promethazine- (sodium chloride 3 phenylephrine-codeine 1 (inhalant)) syrp sodium chloride 1 bal on hand, 1 pseudoephed-cpm w/ 1 (inhalant) nebu hydrocod soln Mucolytics SEMPREX-D CAPS (acrivastine & 3 acetylcysteine soln 1 pseudoephedrine) DERMATOLOGICALS - Drugs to Treat Skin TUSSICAPS CP12 Conditions (hydrocodone polistirex- 3 Acne Products chlorpheniramine (Benzoyl Peroxide) polistirex) BENZEPRO CREAMY WASH, PR BENZOYL 1 TUSSIONEX PEROXIDE WASH, BP PENNKINETIC WASH LIQD EXTENDED RELEASE (Clindamycin Phosphate SUER (hydrocodone GP (Topical)) CLINDACIN ETZ 1 polistirex- PLEDGETS, CLINDACIN-P chlorpheniramine SWAB polistirex) (Clindamycin Phosphate- TUSSLIN LIQD RX/OTC Benzoyl Peroxide 1 (phenylephrine w/ dm- 3 (Refrigerate)) NEUAC GEL gg) ( (Acne Aid)) 1 1 bal on hand, ERY PADS TUSSLIN PEDIATRIC RX/OTC LIQD (phenylephrine w/ 3 (Isotretinoin) Greater than 5 months dm-gg) AMNESTEEM, 1 requires ZENATANE, MYORISAN PA;QL(2 ea Misc. Respiratory Inhalants CAPS (Sodium Chloride daily) (Inhalant)) NEBUSAL 1 Greater than 5 NEBU 3 % (Isotretinoin) CLARAVIS months (Sodium Chloride CAPS 10 MG, 20 MG, 30 1 requires (Inhalant)) PULMOSAL 1 MG, 40 MG PA;QL(2 ea NEBU daily) HYPER-SAL NEBU (Sulfacetamide Sodium W/ Sulfur) AVAR CLEANSER, (sodium chloride GP SULFAMEZ WASH, 1 (inhalant)) ROSANIL CLEANSER, BP 10-1 EMUL

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73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Sulfacetamide Sodium W/ AVAR LS CLEANSER Sulfur) AVAR-E LIQD (sulfacetamide GP EMOLLIENT, SSS 10%- 1 sodium w/ sulfur) 5%, AVAR-E GREEN CREA AVAR LS PADS (sulfacetamide sodium 3 (Sulfacetamide Sodium W/ 1 1 bal on hand, Sulfur) SSS 10-5 FOAM w/ sulfur) (Sulfacetamide Sodium W/ AVAR PADS Sulfur) SULFACLEANSE 1 (sulfacetamide sodium 3 8/4 SUSP w/ sulfur) (Sulfacetamide Sodium- 1 bal on hand, AVAR-E LS CREA Sulfur In Urea Vehicle) BP 1 (sulfacetamide sodium GP CLEANSING WASH EMUL w/ sulfur) (Tretinoin) AVITA CREA 1 AZELEX CREA ( azelaic 3 acid (acne)) (Tretinoin) AVITA GEL 1 BENZACLIN GEL PA; Limited to (clindamycin ABSORICA CAPS GP 3 5 months of phosphate-benzoyl (isotretinoin) treatment;QL(2 peroxide) ea daily) BENZACLIN WITH PUMP PA; Limited to ABSORICA LD CAPS GEL (clindamycin 3 5 months of GP (isotretinoin micronized) treatment;QL(2 phosphate-benzoyl ea daily) peroxide) ACZONE GEL 5 % PA BENZAMYCIN GEL GP (dapsone (topical)) (benzoyl peroxide- GP ACZONE GEL 7.5 % PA; QL(2 gm erythromycin) GP (dapsone (topical)) daily) benzoyl peroxide- 1 Limit 45gms erythromycin gel adapalene crea 0.1 % 1 per CLEOCIN-T GEL month;QL(1.5 (clindamycin phosphate 3 gm daily) (topical)) Limit 45gms per CLEOCIN-T LOTN adapalene gel 0.1 % 1 month;QL(1.5 (clindamycin phosphate GP gm daily); (topical)) RX/OTC CLEOCIN-T SOLN Limit 45gms (clindamycin phosphate GP 1 per (topical)) adapalene gel 0.3 % month;QL(1.5 gm daily) CLEOCIN-T SWAB 1 bal on hand, (clindamycin phosphate GP adapalene lotn 0.1 % 1 (topical)) CLINDACIN ETZ KIT adapalene-benzoyl 1 peroxide gel (clindamycin phosphate 3 & cleanser) ATRALIN GEL (tretinoin) GP

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74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLINDACIN PAC KIT DIFFERIN LOTN 0.1 % 3 (clindamycin phosphate 3 (adapalene) & cleanser) DUAC GEL (clindamycin CLINDAGEL GEL 1 bal on hand, phosphate-benzoyl GP (clindamycin phosphate GP peroxide (refrigerate)) (topical)) EPIDUO GEL ( NF clindamycin phosphate 1 adapalene-benzoyl (topical) foam peroxide) ERYGEL GEL clindamycin phosphate 1 (topical) gel (erythromycin (acne GP 1 bal on hand, aid)) clindamycin phosphate 1 (topical) gel erythromycin (acne aid) 1 gel clindamycin phosphate 1 (topical) lotn erythromycin (acne aid) 1 pads clindamycin phosphate 1 (topical) soln erythromycin (acne aid) 1 soln clindamycin phosphate 1 (topical) swab EVOCLIN FOAM clindamycin phosphate- (clindamycin phosphate GP benzoyl peroxide 1 (topical)) (refrigerate) gel Limit 50gms FABIOR FOAM 3 per clindamycin phosphate- (tazarotene (acne)) month;QL(1.67 benzoyl peroxide gel 1 1 gm daily) %-5 % Greater than 5 months clindamycin phosphate- 1 tretinoin gel requires PA;QL(2 ea PA isotretinoin caps 1 dapsone (topical) gel 5 1 daily)150 rtl % MAX day(s) PA; QL(2 gm supply,365 rtl dapsone (topical) gel 1 lmt day(s), 7.5 % daily) KLARON LOTN Limit 45gms DIFFERIN CREA 0.1 % (sulfacetamide sodium GP GP per (adapalene) month;QL(1.5 (acne)) gm daily) NEUTROGENA CLEAR Limit 45gms PORE CLEANSER/MASK LIQD (benzoyl 3 DIFFERIN GEL 0.1 % per GP month;QL(1.5 peroxide) (adapalene) gm daily); PLEXION CLEANSER RX/OTC LIQD (sulfacetamide GP Limit 45gms ) DIFFERIN GEL 0.3 % sodium w/ sulfur GP per (adapalene) month;QL(1.5 gm daily)

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75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEXION CLEANSING sulfacetamide sodium CLOTHS PADS 3 w/ sulfur liqd 4 %-9 %, 1 (sulfacetamide sodium 2 %-10 %, 4.5 %-9 %, w/ sulfur) 4.8 %-9.8 % PLEXION CREA sulfacetamide sodium (sulfacetamide sodium GP w/ sulfur lotn 4.8 %-9.8 1 w/ sulfur) % PLEXION LOTN sulfacetamide sodium QL(1 gm (sulfacetamide sodium GP 1 daily)1 bal on w/ sulfur) w/ sulfur lotn 5 %-10 % hand, RETIN-A CREA (tretinoin) GP sulfacetamide sodium w/ sulfur pads 4 %-10 1 RETIN-A GEL (tretinoin) GP %, 4 %-4 %-10 %-10 % RETIN-A MICRO GEL 0.04 sulfacetamide sodium 1 %, 0.1 % (tretinoin GP w/ sulfur susp 4 %-8 % microsphere) SUMADAN WASH LIQD RETIN-A MICRO PUMP (sulfacetamide sodium GP GEL 0.04 %, 0.1 % GP w/ sulfur) (tretinoin microsphere) SUMAXIN PADS RIAX FOAM ( (sulfacetamide sodium GP benzoyl 3 peroxide) w/ sulfur) SODIUM SUMAXIN TS SUSP SULFACETAMIDE/SULFU (sulfacetamide sodium GP R CLEANSER IN UREA w/ sulfur) 3 EMUL (sulfacetamide SUMAXIN WASH LIQD sodium-sulfur in urea (sulfacetamide sodium GP vehicle) w/ sulfur) SODIUM Limit 35gms SULFACETAMIDE/SULFU TRETIN-X CREA 3 3 per R SUSP (sulfacetamide (tretinoin) month;QL(1.2 sodium w/ sulfur) gm daily) sulfacetamide sodium 1 tretinoin crea 1 (acne) lotn sulfacetamide sodium tretinoin gel 1 w/ sulfur crea 2 %-10 1 tretinoin microsphere 1 %, 5 %-10 %, 4.8 %- gel 9.8 % VELTIN GEL sulfacetamide sodium (clindamycin 3 w/ sulfur emul 5 %-10 1 phosphate-tretinoin) % ZIANA GEL ( clindamycin GP phosphate-tretinoin) Agents for External Genital and Perianal Warts

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76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VEREGEN OINT Limit 30gms NEO-SYNALAR CREA 3 per month;QL(1 (sinecatechins) (neomycin sulfate- 3 gm daily) fluocinolone acetonide) Anti-inflammatory Agents - Topical Antifungals - Topical (Diclofenac Sodium QL(5 ml daily) ( Olamine) 1 (Topical)) KLOFENSAID II 1 CICLODAN CREA SOLN ( (Topical)) RX/OTC 1 bal on hand, diclofenac epolamine 1 CVS CLOTRIMAZOLE ptch MAXIMUMSTRENGTH, 1 RX/OTC FUNGICURE INTENSIVE diclofenac sodium 1 (topical) gel 1 % WITHNAILGUARD SOLN (Iodoquinol-Hc) QL(5 ml daily) 1 diclofenac sodium 1 DERMAZENE CREA (topical) soln 1.5 % (Iodoquinol-Hydrocortisone FLECTOR PTCH 3 In Aloe Vehicle) 1 (diclofenac epolamine) IODOQUIMEZ-HC CREA FLECTOR PTCH 1 bal on hand, (Ketoconazole (Topical)) 3 1 (diclofenac epolamine) KETODAN FOAM ALA-QUIN CREA PENNSAID SOLN PA; Limit 1 3 (clioquinol-hc) ( 3 bottle per diclofenac sodium month;QL(4 gm (topical)) ALCORTIN A GEL daily) (iodoquinol- VOLTAREN GEL RX/OTC hydrocortisone-aloe GP (diclofenac sodium NF polysaccharide) (topical)) ciclopirox gel 1 Antibiotics - Topical ALTABAX OINT 1 3 ciclopirox olamine crea (retapamulin) CENTANY AT KIT ciclopirox olamine susp 1 3 (mupirocin) ciclopirox sham 1 CENTANY OINT 2 RX/OTC (mupirocin) clotrimazole (topical) 1 CORTISPORIN CREA soln (neomycin-polymyxin- 3 clotrimazole w/ Limit 1 tube per hc) 1 month;QL(1.5 betamethasone crea gm daily) CORTISPORIN OINT QL(2 ml daily) (bacitracin-polymyxin- 3 clotrimazole w/ 1 neomycin hc) betamethasone lotn 1 gentamicin sulfate 1 nitrate crea (topical) crea ERTACZO CREA PA 3 gentamicin sulfate 1 ( nitrate) (topical) oint EXELDERM CREA 1 bal on hand, 3 mupirocin oint 1 ( nitrate)

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77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXELDERM SOLN 1 bal on hand, 2 hcl crea 1 %, 2 1 (sulconazole nitrate) % EXELDERM SOLN 1 bal on hand, 2 naftifine hcl gel 1 % 1 (sulconazole nitrate) NAFTIN CREA 2 % EXODERM LOTN GP (- 3 (naftifine hcl) NAFTIN GEL 1 % ) GP EXTINA FOAM (naftifine hcl) GP NAFTIN GEL 1 % (ketoconazole (topical)) 3 HALOTIN CREA (naftifine hcl) 3 NAFTIN GEL 2 % (haloprogin) 2 (naftifine hcl) iodoquinol-hc crea 1 NIZORAL SHAM GP iodoquinol- (ketoconazole (topical)) hydrocortisone in aloe 1 nystatin (topical) crea 1 vehicle crea iodoquinol- nystatin (topical) oint 1 hydrocortisone-aloe 1 nystatin-triamcinolone polysaccharide gel 1 crea ketoconazole (topical) QL(2 gm daily) 1 nystatin-triamcinolone crea 1 oint ketoconazole (topical) 1 foam nitrate crea 1 ketoconazole (topical) OXISTAT CREA 1 NF sham (oxiconazole nitrate) LOPROX CREA OXISTAT LOTN GP 3 (ciclopirox olamine) (oxiconazole nitrate) LOPROX SHAMPOO QUINJA GEL GP SHAM (ciclopirox) (iodoquinol-aloe 3 LOPROX SUSP polysaccharides) GP (ciclopirox olamine) sulconazole nitrate crea 1 1 bal on hand, LOTRISONE CREA Limit 1 tube per (clotrimazole w/ GP month;QL(1.5 sulconazole nitrate soln 1 1 bal on hand, betamethasone) gm daily) VUSION OINT 1 bal on hand, crea 1 1 bal on hand, (-zinc oxide- 3 ) LUZU CREA 1 bal on hand, white petrolatum 3 (luliconazole) VYTONE CREA (iodoquinol- miconazole-zinc oxide- 1 bal on hand, GP 1 hydrocortisone in aloe white petrolatum oint vehicle) naftifine hcl crea 1 %, 2 XOLEGEL GEL 1 3 % (ketoconazole (topical)) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antineoplastic or Premalignant Lesion Agents - calcipotriene crea 1 QL(5 gm daily) CARAC CREA 1 bal on hand, GP CALCIPOTRIENE FOAM PA (fluorouracil (topical)) 3 (calcipotriene) PA diclofenac sodium 1 QL(5 gm daily) (actinic keratoses) gel calcipotriene oint 1 EFUDEX CREA GP calcipotriene soln 1 (fluorouracil (topical)) FLUOROPLEX CREA Limited 100 2 (fluorouracil (topical)) gms per calcitriol (topical) oint 1 month;QL(3.4 1 bal on hand, fluorouracil (topical) 1 gm daily)1 bal crea 0.5 % on hand, COSENTYX PA fluorouracil (topical) 1 crea 5 % SENSOREADY PEN SOAJ 3 (secukinumab) fluorouracil (topical) 1 bal on hand, 1 COSENTYX SOSY PA soln 2 %, 5 % 3 (secukinumab) PANRETIN GEL PA 3 DOVONEX CREA QL(5 gm daily) (alitretinoin) GP (calcipotriene) PICATO GEL ( ingenol 3 ILUMYA SOSY PA mebutate) SP (tildrakizumab-asmn) TARGRETIN GEL EX 1 % PA SP (bexarotene (topical)) methoxsalen rapid caps 1 VALCHLOR GEL PA OXSORALEN ULTRA (mechlorethamine hcl SP CAPS (methoxsalen GP (topical)) rapid) SILIQ SOSY PA Antipruritics - Topical SP doxepin hcl 1 bal on hand, (brodalumab) 3 SKYRIZI PSKT PA (antipruritic) crea 3 PRUDOXIN CREA 1 bal on hand, (risankizumab-rzaa) SORIATANE CAPS (doxepin hcl 3 GP (antipruritic)) (acitretin) SORILUX FOAM PA ZONALON CREA 1 bal on hand, 3 (doxepin hcl 3 (calcipotriene) (antipruritic)) STELARA SOLN PA SP ZONALON CREA 1 bal on hand, (ustekinumab) (doxepin hcl NF STELARA SOSY PA SP (antipruritic)) (ustekinumab) TALTZ SOAJ PA Antipsoriatics SP (ixekizumab) (Calcipotriene) 1 QL(5 gm daily) CALCITRENE OINT TALTZ SOSY PA SP (ixekizumab) acitretin caps 1

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79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tazarotene crea 1 acyclovir topical crea 1 TAZORAC CREA 0.05 % QL(1 gm daily) 2 acyclovir topical oint 1 (tazarotene) TAZORAC CREA 0.1 % DENAVIR CREA Limit 5gms per NF 3 month;QL(0.17 (tazarotene) (penciclovir) gm daily) TAZORAC GEL 0.05 %, 2 XERESE CREA Limit 5gms per 0.1 % (tazarotene) (acyclovir- 3 month;QL(0.17 TREMFYA SOPN PA gm daily) SP hydrocortisone) (guselkumab) ZOVIRAX CREA EX 5 % TREMFYA SOSY PA GP SP (acyclovir topical) (guselkumab) ZOVIRAX OINT EX 5 % QL(1 gm daily) GP Limited 100 (acyclovir topical) VECTICAL OINT gms per 3 month;QL(3.4 Burn Products (calcitriol (topical)) gm daily)1 bal (Silver Sulfadiazine) SSD 1 on hand, CREA Antiseborrheic Products mafenide acetate pack 1 (Sulfacetamide Sodium) 1 SILVADENE CREA ( SEB-PREV WASH LIQD silver GP (Sulfacetamide Sodium) sulfadiazine) SODIUM 1 silver sulfadiazine crea 1 SULFACETAMIDE WASH LIQD 10 % SULFAMYLON CREA 85 OVACE PLUS SHAM 10 % MG/GM (mafenide 3 GP (sulfacetamide sodium) acetate) OVACE PLUS WASH LIQD SULFAMYLON PACK 5 % GP GP (sulfacetamide sodium) (mafenide acetate) OVACE WASH LIQD GP Corticosteroids - Topical (sulfacetamide sodium) (Clobetasol Propionate selenium sulfide lotn 1 Emollient Base) CLOBETASOL 1 1 PROPIONATE E, selenium sulfide sham CLOBETASOL SODIUM PROPIONATE SULFACETAMIDE WASH EMOLLIENT CREA LIQD 0.5 %-10 % 3 (Clobetasol Propionate 1 (sulfacetamide sodium Emulsion) TOVET FOAM ) in bakuchiol vehicle (Clobetasol Propionate) 1 CLODAN SHAM sulfacetamide sodium 1 liqd (Flurandrenolide) NOLIX 1 CREA sulfacetamide sodium 1 (Hydrocortisone (Topical)) 1 sham ALA-CORT CREA Antivirals - Topical

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80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) RX/OTC betamethasone CORTIZONE-10, SM dipropionate (topical) 1 HYDROCORTISONE lotn MAXIMUM STRENGTH, SB HYDROCORTISONE betamethasone MAXIMUM STRENGTH, dipropionate (topical) 1 RA ANTI-/MAXIMUM oint STRENGTH, KP HYDROCORTISONE betamethasone MAXIMUM STRENGTH, dipropionate 1 HYDROCORTISONE IN 1 augmented crea ABSORBASE, betamethasone HYDROCORTISONE 1% IN ABSORBASE, GNP dipropionate 1 HYDROCORTISONE augmented gel MAXIMUM STRENGTH, betamethasone 1 bal on hand, EQL ANTI-ITCH dipropionate 1 MAXIMUM STRENGTH, CVS CORTISONE augmented gel MAXIMUM STRENGTH betamethasone OINT dipropionate 1 (Pramoxine-Hc) 1 augmented lotn MEZPAROX-HC CREA betamethasone (Triamcinolone Acetonide dipropionate 1 (Topical)) TRIANEX, 1 TRIANEX OINT augmented oint betamethasone (Triamcinolone Acetonide 1 1 (Topical)) TRIDERM CREA valerate crea ALA SCALP LOTN betamethasone 1 (hydrocortisone 3 valerate foam (topical)) betamethasone 1 valerate lotn alclometasone 1 dipropionate crea betamethasone 1 valerate oint alclometasone 1 dipropionate oint calcipotriene- ST amcinonide crea 1 1 bal on hand, betamethasone 1 dipropionate oint amcinonide lotn 1 1 bal on hand, calcipotriene- ST; QL(2 gm daily) AMCINONIDE OINT betamethasone 1 3 (amcinonide) dipropionate susp APEXICON E CREA calcipotriene- ST; QL(2 gm daily)1 bal on ( 2 betamethasone 1 diflorasone diacetate hand, emollient base) dipropionate susp CAPEX SHAM betamethasone 2 dipropionate (topical) 1 (fluocinolone acetonide) crea

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81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTANE-B LOTN clobetasol propionate 1 crea (hydrocortisone- pramoxine- 3 clobetasol propionate 1 emollient base crea chloroxylenol) CUTIVATE LOTN clobetasol propionate 1 3 emulsion foam (fluticasone propionate) clobetasol propionate DERMA-SMOOTHE/FS 1 BODY OIL (fluocinolone GP foam acetonide) clobetasol propionate 1 DERMA-SMOOTHE/FS gel SCALP OIL (fluocinolone GP clobetasol propionate 1 acetonide) liqd DERMASORB TA KIT clobetasol propionate 1 (triamcinolone 3 lotn acetonide & emollient) DESONATE GEL clobetasol propionate 1 3 oint (desonide) DESONATE GEL clobetasol propionate 1 GP sham (desonide) clobetasol propionate 1 desonide crea 1 soln CLOBEX LIQD desonide gel 1 GP (clobetasol propionate) desonide lotn 1 CLOBEX LOTN GP (clobetasol propionate) desonide oint 1 CLOBEX SHAM GP DESOWEN CREA (clobetasol propionate) GP (desonide) 1 bal on hand, clocortolone pivalate 1 DESOWEN LOTN GP crea (desonide) CLODERM CREA 3 DESOXIMETASONE (clocortolone pivalate) CREA 0.05 % 2 CLODERM CREA 1 bal on hand, 3 (desoximetasone) (clocortolone pivalate) desoximetasone crea CLODERM PUMP CREA 1 3 0.05 %, 0.25 % (clocortolone pivalate) desoximetasone gel CORDRAN CREA 0.05 % 1 GP 0.05 % (flurandrenolide) desoximetasone liqd 1 CORDRAN TAPE 4 0.25 % MCG/SQCM 3 (flurandrenolide) desoximetasone oint 1 0.05 %, 0.25 %

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82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, diflorasone diacetate 1 fluticasone propionate 1 crea oint HALAC KIT ( diflorasone diacetate 1 halobetasol oint propionate & 3 DIPROLENE AF CREA ammonium lactate) (betamethasone halcinonide crea 1 dipropionate GP augmented) halobetasol propionate 1 DIPROLENE OINT crea ( betamethasone halobetasol propionate 1 dipropionate GP oint augmented) HALOG CREA GP ELOCON CREA (halcinonide) GP (mometasone furoate) HALOG OINT 3 ELOCON OINT (halcinonide) GP (mometasone furoate) HALOG SOLN 3 EPIFOAM FOAM (halcinonide) 3 (pramoxine-hc) hydrocortisone (topical) 1 crea 2.5 % fluocinolone acetonide 1 crea hydrocortisone (topical) 1 lotn 2.5 % fluocinolone acetonide 1 oil RX/OTC hydrocortisone (topical) 1 oint 1 % fluocinolone acetonide 1 oint hydrocortisone (topical) 1 oint 2.5 % fluocinolone acetonide 1 soln hydrocortisone butyrate 1 fluocinonide crea 1 crea hydrocortisone butyrate fluocinonide emulsified 1 hydrophilic lipo base 1 base crea crea fluocinonide gel 1 hydrocortisone butyrate 1 lotn fluocinonide oint 1 hydrocortisone butyrate 1 fluocinonide soln 1 oint hydrocortisone butyrate 1 flurandrenolide crea 1 soln hydrocortisone valerate fluticasone propionate 1 1 crea crea hydrocortisone valerate fluticasone propionate 1 1 lotn oint

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83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KENALOG AERS PRAMOSONE CREA 1 %- GP (triamcinolone GP 2.5 % (pramoxine-hc) acetonide (topical)) PRAMOSONE E CREA LOCOID CREA (pramoxine-hc 3 (hydrocortisone GP emollient base) butyrate) PRAMOSONE LOTN 1 %- LOCOID LIPOCREAM 1 %, 1 %-2.5 % 3 CREA (hydrocortisone (pramoxine-hc) GP butyrate hydrophilic lipo PRAMOSONE OINT 1 %-1 base) %, 1 %-2.5 % 3 LOCOID LOTN (pramoxine-hc) (hydrocortisone GP pramoxine-hc crea 1 butyrate) 1 bal on hand, LOCOID OINT prednicarbate crea 1 (hydrocortisone GP 1 bal on hand, butyrate) prednicarbate oint 1 LOCOID SOLN PSORCON CREA 3 (hydrocortisone GP (diflorasone diacetate) butyrate) SYNALAR CREA GP LUXIQ FOAM (fluocinolone acetonide) (betamethasone GP SYNALAR OINT GP valerate) (fluocinolone acetonide) mometasone furoate SYNALAR SOLN 1 GP crea (fluocinolone acetonide) TACLONEX OINT ST mometasone furoate 1 oint (calcipotriene- betamethasone GP mometasone furoate 1 soln dipropionate) NUCORT LOTN TACLONEX SUSP ST; QL(2 gm (calcipotriene- daily)1 bal on (hydrocortisone acetate 3 3 hand, (topical)) betamethasone dipropionate) OLUX FOAM (clobetasol GP TEMOVATE CREA propionate) GP (clobetasol propionate) OLUX-E FOAM TEMOVATE OINT (clobetasol propionate GP GP (clobetasol propionate) emulsion) TEXACORT SOLN PANDEL CREA (hydrocortisone 3 (hydrocortisone 3 (topical)) probutate) TOPICORT CREA PRAMOSONE CREA 1 %- GP 3 (desoximetasone) 1 % (pramoxine-hc) TOPICORT GEL GP (desoximetasone) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPICORT LIQD (Urea) GORDONS UREA, GP (desoximetasone) XUREA, UREMEZ-40, 1 TOPICORT OINT UREDEB, REA LO 40, GP METOPIC CREA (desoximetasone) (Urea) UMECTA MOUSSE 1 triamcinolone FOAM acetonide (topical) aers 1 (Urea) UREA NAIL GEL 45 1 0.147 mg/gm % triamcinolone CEM-UREA SOLN (urea) 3 acetonide (topical) crea 1 GORDONS UREA OINT 0.025 %, 0.1 %, 0.5 % 3 triamcinolone (urea) HYDRO 35 FOAM ( acetonide (topical) lotn 1 urea 3 0.025 %, 0.1 % in lactic acid vehicle) HYDRO 40 FOAM FOAM triamcinolone GP acetonide (topical) oint 1 (urea) 0.025 %, 0.1 %, 0.5 % KERALAC CREA (urea) GP TRIDESILON CREA GP (desonide) URAMAXIN GEL (urea) GP ULTRAVATE CREA URE-K CREA (urea) 3 (halobetasol GP propionate) urea crea 39 %, 41 %, 1 ULTRAVATE OINT 47 %, 50 % (halobetasol GP RX/OTC urea crea 40 %, 41 %, 1 propionate) 47 %, 50 % VANOS CREA 1 bal on hand, GP urea crea 45 %, 47 %, 1 (fluocinonide) 50 % VERDESO FOAM 3 1 (desonide) urea lotn 40 % Eczema Agents UREA NAIL STCK 50 % DUPIXENT SOSY PA (urea in zinc SP 3 (dupilumab) undecylenate-lactic acid vehicle) Emollient/Keratolytic Agents 1 bal on hand, (Urea In Lactic Acid 1 bal on hand, urea susp 40 % 1 Vehicle) UREA 1 HYDRATING FOAM UTOPIC CREA (urea) GP (Urea) CEROVEL, UREA- 1 Emollients C40, REA LO 40 LOTN (Urea) GORDONS UREA, RX/OTC XUREA, UREMEZ-40, 1 UREDEB, REA LO 40, METOPIC CREA

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85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lactic Acid (Ammonium RX/OTC Limit 2 bottles ZYCLARA PUMP CREA Lactate)) AL12, GERI- 3 per 28 HYDROLAC 12, CVS SKIN 2.5 % (imiquimod) days;QL(0.6 TREATMENT BODY gm daily) LOTION, CVS SKIN 1 ZYCLARA PUMP CREA QL(1 gm TREATMENT, CVS 3 daily)1 bal on HYDRATING SKIN 3.75 % (imiquimod) hand, TREATMENT, AMLACTIN DAILY, AMLACTIN LOTN Immunosuppressive Agents - Topical ELIDEL CREA QL(2 gm daily) (Lactic Acid (Ammonium RX/OTC GP Lactate)) GERI- 1 (pimecrolimus) HYDROLAC 12 CREA pimecrolimus crea 1 QL(2 gm daily) hyaluronate sodium 1 bal on hand, 1 PROTOPIC OINT (emollient) gel GP HYLINATE LOTN ( (topical)) (hyaluronate sodium 3 tacrolimus (topical) oint 1 (emollient)) LAC-HYDRIN CREA RX/OTC Keratolytic/Antimitotic Agents (lactic acid (ammonium GP (Salicylic Acid) SALICYLIC lactate)) ACID WART REMOVER 1 LIQD LAC-HYDRIN TWELVE RX/OTC (Salicylic Acid) SALIMEZ 1 LOTN (lactic acid GP CREA (ammonium lactate)) (Salicylic Acid) SALISOL 1 RX/OTC FORTE SOLN lactic acid (ammonium 1 lactate) crea 12 % (Salicylic Acid) SALITECH 1 FORTE LOTN lactic acid (ammonium 1 lactate) lotn 10 % BENSAL HP OINT RX/OTC (salicylic acid & benzoic 3 lactic acid (ammonium 1 lactate) lotn 12 % acid) CONDYLOX GEL 2 Enzymes - Topical (podofilox) SANTYL OINT 3 PODOCON 25 IN (collagenase) BENZOIN TINCTURE 3 Immunomodulating Agents - Topical SOLN (podophyllum ALDARA CREA resin) GP (imiquimod) podofilox soln 1 QL(1 gm imiquimod crea 3.75 % 1 daily)1 bal on SALEX LOTION KIT hand, (salicylic acid w/ GP cleanser) imiquimod crea 5 % 1 SALEX SHAM (salicylic ZYCLARA CREA QL(1 ea daily) GP 3 acid) (imiquimod) salicylic acid crea 6 % 1

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86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits salicylic acid foam 6 % 1 (Lidocaine Hcl) LIDO-K, ZIONODIL 100, ZIONODIL, 1 salicylic acid in LIDOZION, LIDO-SORB ammonium lactate 1 LOTN vehicle foam (Lidocaine Hcl) LIDOPIN 1 RX/OTC CREA 3 % salicylic acid liqd 27.5 1 (Lidocaine) LIDOCAINE % PAK, PREMIUM 1 salicylic acid lotn 6 % 1 1 bal on hand, LIDOCAINE OINT (Pramoxine Hcl) RX/OTC salicylic acid lotn 6 % 1 PRAMEGEL HCL, 1 PRAMOX GEL GEL salicylic acid sham 6 % 1 ethyl chloride aero 1 1 bal on hand, salicylic acid soln 26 % 1 1 bal on hand, ETHYL CHLORIDE/FINE STREAM AERO (ethyl 3 salicylic acid soln 28.5 1 % chloride) ETHYL salicylic acid w/ 1 CHLORIDE/MEDIUM cleanser kit STREAM AERO (ethyl 3 SALISOL SOLN ( salicylic 3 chloride) acid) GEBAUERS INSTANT ICE RX/OTC SALITECH LOTN AERO 3 3 (salicylic acid) (pentafluoropropane- SALVAX FOAM ( tetrafluoroethane) salicylic GP acid) GEBAUERS PAIN EASE RX/OTC AERO ULTRASAL-ER SOLN GP (pentafluoropropane- 3 (salicylic acid) tetrafluoroethane) VIRASAL LIQD ( salicylic GP GEBAUERS SPRAY AND RX/OTC acid) STRETCH AERO 3 Liniments (pentafluoropropane- MEDROX-RX OINT PA tetrafluoroethane) (-- 3 lidocaine crea 3 % 1 1 bal on hand, ) RX/OTC Local Anesthetics - Topical lidocaine hcl crea 3 % 1 (Cocaine Hcl) C-TOPICAL 1 1 bal on hand, SOLN lidocaine hcl gel 2 % 1 (Lidocaine Hcl) 7T LIDO RX/OTC lidocaine hcl gel 2 % 1 1 bal on hand, GEL, REGENECARE HA 1 GEL lidocaine hcl lotn 3 % 1 (Lidocaine Hcl) GLYDO 1 PRSY lidocaine hcl prsy 2 % 1 lidocaine hcl soln 4 % 1

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87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lidocaine oint 5 % 1 PENLEN EMUL (dermatological 3 lidocaine ptch 5 % 1 QL(3 ea daily) products, misc.) PHLAG SPRAY EMUL lidocaine-prilocaine 1 (dermatological 3 crea products, misc.) LIDODERM PTCH QL(3 ea daily) GP SUVICORT EMUL (lidocaine) (dermatological 3 LIDODOSE GEL RX/OTC 3 products, misc.) ( ) lidocaine hcl SYNERDERM EMUL LIDODOSE PEDIATRIC RX/OTC (dermatological 3 BULK PACK GEL 3 products, misc.) (lidocaine hcl) LIDORX GEL (lidocaine RX/OTC Misc. Topical 3 DRYSOL SOLN hcl) 2 (aluminum chloride) SYNERA PTCH 3 (lidocaine-tetracaine) XERAC AC SOLN (aluminum chloride in 3 Misc. Dermatological Products alcohol) 7TOPIC EMUL Phosphodiesterase 4 (PDE4) Inhibitors - Topical (dermatological 3 EUCRISA OINT PA products, misc.) 3 (crisaborole) CERACADE EMUL (dermatological 3 Rosacea Agents products, misc.) (Metronidazole (Topical)) 1 EMULSION SB EMUL ROSADAN CREA (dermatological 3 Limit 45gms products, misc.) (Metronidazole (Topical)) 1 per ROSADAN GEL month;QL(1.5 ENTTY SPRAY gm daily) EMULSION EMUL (dermatological 3 azelaic acid gel 1 products, misc.) PA; 1 bal on doxycycline (rosacea) 1 EPICERAM EMUL cpdr hand, ( 3 dermatological FINACEA FOAM (azelaic ) 3 products, misc. acid) ILIDERM EMUL FINACEA GEL (azelaic (dermatological 3 GP acid) products, misc.) ivermectin (rosacea) PA; QL(1 gm KAMDOY EMUL 1 daily) (dermatological 3 crea products, misc.) ivermectin (rosacea) PA; QL(1 gm 1 daily)1 bal on KIVIK EMUL crea hand, (dermatological 3 products, misc.)

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88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METROCREAM CREA EURAX LOTN 3 (metronidazole GP (crotamiton) (topical)) lindane sham 1 1 bal on hand, METROGEL GEL (metronidazole NF malathion lotn 1 (topical)) NATROBA SUSP 1 bal on METROLOTION LOTN QL(2 ml daily) 3 hand,AL(At (metronidazole GP (spinosad) least 4 yrs old) (topical)) OVIDE LOTN (malathion) GP metronidazole (topical) 1 crea 0.75 % Limit 2 per 1 month;QL(60 Limit 45gms crea gm per 14 days metronidazole (topical) 1 per retail) gel 0.75 % month;QL(1.5 gm daily) SKLICE LOTN (ivermectin 3 metronidazole (topical) 1 gel 1 % (pediculicide)) QL(2 ml daily) 1 bal on metronidazole (topical) 1 spinosad susp 1 hand,AL(At lotn 0.75 % least 4 yrs old) MIRVASO GEL PA ULESFIA LOTN ( benzyl 3 (brimonidine tartrate 3 alcohol (pediculicide)) (topical)) Wound Care Products NORITATE CREA PA Limit 15gms (metronidazole 3 REGRANEX GEL 3 per (topical)) () month;QL(0.5 ORACEA CPDR PA; 1 bal on gm daily) 3 (doxycycline (rosacea)) hand, DIAGNOSTIC PRODUCTS RHOFADE CREA PA (oxymetazoline hcl 3 Diagnostic Drugs (topical)) GLUCAGEN DIAGNOSTIC SOOLANTRA CREA PA; QL(1 gm SOLR (glucagon hcl 2 3 daily)1 bal on (ivermectin (rosacea)) rdna (diagnostic)) hand, METOPIRONE CAPS 3 Scabicides & Pediculicides () (Crotamiton) CROTAN 1 1 bal on hand, Diagnostic Tests LOTN FREESTYLE INSULINX Limit 200 per Limit 2 per BLOODGLUCOSE TEST month;QL(6.67 ELIMITE CREA GP month;QL(60 STRIPS STRP (glucose 2 ea daily); (permethrin) gm per 14 days RX/OTC retail) blood) EURAX CREA Limit 200 per 2 FREESTYLE INSULINX ( ) BLOODGLUCOSE TEST 2 month;QL(6.67 crotamiton ea daily); STRP (glucose blood) RX/OTC

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89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE LITE TEST Limit 200 per FOLBIC RF TABS (l- STRIPS STRP (glucose 2 month;QL(6.67 methylfolate w/ vitamin 3 ea daily); b6-vitamin b12) blood) RX/OTC Limit 200 per FOLTX TABS (l- FREESTYLE TEST methylfolate w/ vitamin 3 STRIPS STRP ( 2 month;QL(6.67 glucose ea daily); b6-vitamin b12) blood) RX/OTC L-METHYLFOLATE CA/S- PA; Limit 200 ALGAL CAPS (l- 3 MICRODOT TEST STRIPS per methylfolate-algae) 3 month;QL(6.67 STRP (glucose blood) ea daily); L-METHYLFOLATE RX/OTC FORTE CAPS (l- 3 methylfolate-algae) NON PREFERRED TEST 3 PA STRIPS l-methylfolate tabs 1 1 bal on hand, Limit 200 per ONETOUCH ULTRA STRP month;QL(6.67 LEVOMEFOLATE 2 CALCIUM ALGAL (glucose blood) ea daily); 3 RX/OTC POWDER CAPS (l- ONETOUCH VERIO TEST Limit 200 per methylfolate-algae) STRIPS STRP (glucose 2 month;QL(6.67 DIGESTIVE AIDS - Drugs to Treat Low Digestive ea daily); Enzymes blood) RX/OTC Digestive Enzymes PRECISION XTRA BLOOD Limit 200 per CREON CPEP GLUCOSE TEST STRIPS 2 month;QL(6.67 ea daily); STRP (glucose blood) (pancrelipase (lipase- 2 RX/OTC protease-amylase)) DIETARY PRODUCTS/DIETARY MANAGEMENT PANCREAZE CPEP PRODUCTS (pancrelipase (lipase- 3 Dietary Management Products protease-amylase)) (Folic Acid-Pyridoxine- PERTZYE CPEP Cyanocobalamin) AV-VITE (pancrelipase (lipase- 3 FB FORTE, WESTAB 1 protease-amylase)) MAX, NIVA-FOL, FOLBIC SUCRAID SOLN PA TABS 3 (sacrosidase) (Folic Acid-Pyridoxine- 1 bal on hand, Cyanocobalamin) AV-VITE VIOKACE TABS FB FORTE, WESTAB 1 (pancrelipase (lipase- 3 MAX, NIVA-FOL, FOLBIC protease-amylase)) TABS ZENPEP CPEP DEPLIN 15 CAPS ( l- 3 (pancrelipase (lipase- 2 methylfolate-algae) protease-amylase)) DEPLIN 7.5 CAPS ( l- 3 DIURETICS - Drugs to Treat Heart, Circulation methylfolate-algae) Conditions and Blood Pressure ELFOLATE TABS ( l- 3 Carbonic Anhydrase Inhibitors methylfolate) acetazolamide cp12 1

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90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEMADEX TABS acetazolamide tabs 1 GP (torsemide) KEVEYIS TABS PA EDECRIN TABS ST SP GP (dichlorphenamide) (ethacrynic acid) methazolamide tabs 1 ethacrynic acid tabs 1 ST NEPTAZANE TABS GP furosemide soln 10 1 (methazolamide) mg/ml Diuretic Combinations 1 bal on hand, furosemide soln 8 1 ALDACTAZIDE TABS 25 mg/ml MG-25 MG GP ( & furosemide tabs 20 mg, 1 hydrochlorothiazide) 40 mg, 80 mg LASIX TABS ALDACTAZIDE TABS 50 GP MG-50 MG (furosemide) 2 (spironolactone & torsemide tabs 1 hydrochlorothiazide) amiloride & Potassium Sparing Diuretics ALDACTONE TABS hydrochlorothiazide 1 GP tabs (spironolactone) DYAZIDE CAPS amiloride hcl tabs 1 (triamterene & GP DYRENIUM CAPS hydrochlorothiazide) GP (triamterene) MAXZIDE TABS (triamterene & GP spironolactone tabs 1 hydrochlorothiazide) 1 MAXZIDE-25 TABS triamterene caps (triamterene & GP Thiazides and Thiazide-Like Diuretics hydrochlorothiazide) 1 bal on hand, chlorothiazide tabs 250 1 spironolactone & mg, 500 mg hydrochlorothiazide 1 chlorothiazide tabs 500 1 tabs mg, 500 mg triamterene & hydrochlorothiazide 1 chlorthalidone tabs 1 caps DIURIL SUSP 3 triamterene & (chlorothiazide) hydrochlorothiazide 1 hydrochlorothiazide 1 tabs caps Loop Diuretics hydrochlorothiazide 1 tabs bumetanide tabs 1 1 BUMEX TABS indapamide tabs GP (bumetanide)

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91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, 1 bal on hand, methyclothiazide tabs 1 etidronate disodium 1 tabs metolazone tabs 1 FORTEO SOPN PA MICROZIDE CAPS (teriparatide SP GP (hydrochlorothiazide) (recombinant)) FOSAMAX PLUS D TABS PA; Limit 4 per ENDOCRINE AND METABOLIC AGENTS - (alendronate sodium- 3 month;QL(0.15 MISC. - Drugs to Treat Bone Disease and ea daily) Regulate Hormones cholecalciferol) FOSAMAX TABS Limit 4 per Bone Density Regulators GP month;QL(0.15 (alendronate sodium) ACTONEL TABS 150 MG ST; Limit 1 per ea daily) GP month;QL(0.04 (risedronate sodium) PA ea daily) ibandronate sodium SP soln iv 3 mg/3ml ACTONEL TABS 35 MG ST; Limit 4 per GP month;QL(0.15 ibandronate sodium Limit 1 tab per (risedronate sodium) 1 month;QL(0.04 ea daily) tabs or 150 mg ACTONEL TABS 5 MG, 30 ST; QL(1 ea ea daily) MIACALCIN SOLN PA MG (risedronate GP daily) SP sodium) ( (salmon)) 1 bal on hand, NATPARA CART PA alendronate sodium 1 soln 70 mg/75ml (parathyroid hormone SP (recombinant)) alendronate sodium Limit 4 per PA tabs 35 mg, 40 mg, 70 1 month;QL(0.15 pamidronate disodium mg ea daily) soln 30 mg/10ml, 90 SP mg/10ml alendronate sodium PAMIDRONATE PA tabs 5 mg, 10 mg, 40 1 DISODIUM SOLN 6 mg, 70 mg MG/ML (pamidronate SP alendronate sodium 1 bal on hand, disodium) tabs 5 mg, 10 mg, 40 1 PROLIA SOSY PA SP mg, 70 mg (denosumab) Limit 4 per RECLAST SOLN PA ATELVIA TBEC SP GP month;QL(0.15 (zoledronic acid) (risedronate sodium) ea daily) risedronate sodium ST; Limit 1 per BINOSTO TBEF Limit 4 tabs per 1 month;QL(0.04 3 month;QL(0.15 tabs 150 mg ea daily) (alendronate sodium) ea daily) risedronate sodium ST; Limit 4 per BONIVA SOLN IV 3 PA 1 month;QL(0.15 MG/3ML (ibandronate SP tabs 35 mg ea daily) sodium) ST; QL(1 ea risedronate sodium 1 BONIVA TABS OR 150 MG Limit 1 tab per tabs 5 mg, 30 mg daily) GP month;QL(0.04 (ibandronate sodium) ea daily) risedronate sodium Limit 4 per 1 month;QL(0.15 calcitonin (salmon) soln 1 tbec 35 mg ea daily)

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92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYMLOS SOPN PA NORDITROPIN FLEXPRO PA SP SOLN 30 MG/3ML, 10 (abaloparatide) SP XGEVA SOLN PA MG/1.5ML, 15 MG/1.5ML SP (denosumab) (somatropin) PA NORDITROPIN FLEXPRO PA; Use zoledronic acid conc 4 SP SOLN 5 MG/1.5ML, 10 preferred mg/5ml MG/1.5ML, 15 MG/1.5ML SP Humatrope or PA; 1 bal on (somatropin) Norditropin zoledronic acid soln 4 SP mg/100ml hand, PA; Use NUTROPIN AQ NUSPIN ZOLEDRONIC ACID SOLN PA SP preferred 4 MG/100ML (zoledronic SP 10 SOLN (somatropin) Humatrope or Norditropin acid) PA; Use zoledronic acid soln 5 PA NUTROPIN AQ NUSPIN SP SP preferred mg/100ml 20 SOLN (somatropin) Humatrope or ZOMETA CONC 4 PA Norditropin MG/5ML (zoledronic SP PA; Use NUTROPIN AQ NUSPIN 5 acid) SP preferred SOLN (somatropin) Humatrope or ZOMETA SOLN 4 PA Norditropin MG/100ML (zoledronic SP PA; Use acid) OMNITROPE SOLN SP preferred Fertility Regulators (somatropin) Humatrope or Limit 15 per Norditropin month;QL(0.5 PA; Use clomiphene citrate tabs 1 OMNITROPE SOLR ea daily)1 bal SP preferred on hand, (somatropin) Humatrope or Norditropin Growth Hormone Receptor Antagonists SEROSTIM SOLR PA SOMAVERT SOLR PA SP (somatropin (non- SP (pegvisomant) refrigerated)) Growth Hormones PA; Use PA; Use ZOMACTON SOLR preferred GENOTROPIN MINIQUICK SP SP preferred (somatropin) Humatrope or SOLR (somatropin) Humatrope or Norditropin Norditropin ZORBTIVE SOLR PA PA; Use (somatropin (non- SP GENOTROPIN SOLR SP preferred refrigerated)) (somatropin) Humatrope or Norditropin Hormone Receptor Modulators HUMATROPE COMBO PA EVISTA TABS ( QL(1 ea daily); raloxifene GP PACK SOLR SP hcl) PV (somatropin) OSPHENA TABS HUMATROPE SOLR PA 3 SP (ospemifene) (somatropin) 1 QL(1 ea daily); raloxifene hcl tabs PV Insulin-Like Growth Factors (Somatomedins) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INCRELEX SOLN PA CYSTADANE POWD PA SP SP () (betaine) LHRH/GnRH Agonist Analog Pituitary doxercalciferol caps or LUPRON DEPOT-PED (1- PA 0.5 mcg, 1 mcg, 2.5 1 MONTH) KIT (leuprolide SP mcg acetate (cpp)) PA doxercalciferol soln iv 4 SP LUPRON DEPOT-PED (3- PA mcg/2ml MONTH) KIT (leuprolide SP ELAPRASE SOLN PA SP acetate (cpp) (3 month)) (idursulfase) SYNAREL SOLN FABRAZYME SOLR PA 2 SP (nafarelin acetate) (agalsidase beta) Metabolic Modifiers GALAFOLD CAPS PA; QL(0.5 ea SP (Levocarnitine (Metabolic RX/OTC (migalastat hcl) daily) Modifiers)) MCCARNITINE 1 HECTOROL SOLN 2 PA TABS MCG/ML SP ALDURAZYME SOLN PA ( ) SP doxercalciferol (laronidase) HECTOROL SOLN 4 PA BUPHENYL POWD PA MCG/2ML SP (sodium SP (doxercalciferol) phenylbutyrate) KUVAN PACK PA BUPHENYL TABS PA (sapropterin SP (sodium SP dihydrochloride) phenylbutyrate) KUVAN TBSO PA (sapropterin SP calcitriol caps or 0.25 1 mcg, 0.5 mcg dihydrochloride) PA; 1 bal on levocarnitine (metabolic calcitriol soln iv 1 SP mcg/ml hand, modifiers) soln 1 1 calcitriol soln or 1 gm/10ml 1 RX/OTC mcg/ml levocarnitine (metabolic 1 CARBAGLU TABS PA modifiers) tabs 330 mg SP LUMIZYME SOLR PA (carglumic acid) SP CARNITOR SF SOLN (alglucosidase alfa) MYALEPT SOLR PA (levocarnitine GP SP (metabolic modifiers)) (metreleptin) NAGLAZYME SOLN PA CARNITOR SOLN 1 SP GM/10ML (levocarnitine GP (galsulfase) (metabolic modifiers)) nitisinone caps SP PA CARNITOR TABS 330 MG RX/OTC (levocarnitine GP NITYR TABS (nitisinone) SP PA (metabolic modifiers)) ORFADIN CAPS 2 MG, 5 PA SP cinacalcet hcl tabs 1 MG, 10 MG (nitisinone)

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94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORFADIN CAPS 20 MG PA DDAVP TABS OR 0.1 MG, SP (nitisinone) 0.2 MG (desmopressin GP ORFADIN SUSP 4 MG/ML PA acetate) SP (nitisinone) desmopressin acetate 1 PALYNZIQ SOSY PA spray refrigerated soln SP (pegvaliase-pqpz) desmopressin acetate 1 spray soln paricalcitol caps or 1 1 mcg, 2 mcg, 4 mcg desmopressin acetate 1 PA tabs paricalcitol soln iv 2 SP mcg/ml, 5 mcg/ml NOCTIVA EMUL PA 3 RAVICTI LIQD ( PA (desmopressin acetate) glycerol SP phenylbutyrate) STIMATE SOLN PA 3 RAYALDEE CPCR PA (desmopressin acetate) SP (calcifediol) Prolactin Inhibitors ROCALTROL CAPS GP cabergoline tabs 1 (calcitriol) ROCALTROL SOLN Somatostatic Agents GP (calcitriol) octreotide acetate soln PA; 1 bal on SENSIPAR TABS hand, GP 200 mcg/ml, 200 (cinacalcet hcl) mcg/ml, 500 mcg/ml, SP PA 1000 mcg/ml, 1000 sodium phenylbutyrate SP powd mcg/ml, 1000 mcg/5ml PA octreotide acetate soln PA sodium phenylbutyrate SP tabs 50 mcg/ml, 100 STRENSIQ SOLN PA mcg/ml, 200 mcg/ml, SP SP (asfotase alfa) 500 mcg/ml, 1000 mcg/ml, 1000 mcg/ml, XURIDEN PACK (uridine SP 1000 mcg/5ml triacetate) SANDOSTATIN LAR PA ZEMPLAR CAPS OR 1 MCG, 2 MCG GP DEPOT KIT (octreotide SP (paricalcitol) acetate) SANDOSTATIN SOLN PA ZEMPLAR SOLN IV 2 PA SP MCG/ML, 5 MCG/ML SP (octreotide acetate) (paricalcitol) SIGNIFOR SOLN PA Posterior Pituitary Hormones (pasireotide SP diaspartate) DDAVP SOLN NA 0.01 % (desmopressin acetate 2 SOMATULINE DEPOT PA refrigerated) SOLN (lanreotide SP acetate) DDAVP SOLN NA 0.01 % (desmopressin acetate GP Receptor Antagonists ) JYNARQUE TABS 15 MG, PA; QL(1 ea spray SP 30 MG (tolvaptan) daily) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JYNARQUE TBPK PA; SP QL(1 ea daily) SP esterified estrogens & (tolvaptan) methyltestosterone 1 SAMSCA TABS 15 MG PA; QL(1 ea tabs SP (tolvaptan) daily) estradiol & SAMSCA TABS 30 MG PA; QL(1 ea 1 SP norethindrone acetate (tolvaptan) daily) tabs tolvaptan tabs SP PA; QL(1 ea FEMHRT LOW DOSE daily) TABS (norethindrone NF ESTROGENS - Hormone Replacement/Modifying acetate-ethinyl Drugs estradiol) Estrogen Combinations norethindrone acetate- 1 (Esterified Estrogens & QL(1 ea daily) ethinyl estradiol tabs Methyltestosterone) PREFEST TABS 3 COVARYX, ESTERIFIED (estradiol-norgestimate) ESTROGENS/METHYLTE STOSTERONE HS, PREMPHASE TABS 1 (conjugated estrogens- ESTERIFIED 2 ESTROGENS/METHYLTE medroxyprogesterone STOSTERONE DS, EEMT acetate) HS, EEMT, COVARYX HS PREMPRO TABS TABS (conjugated estrogens- (Estradiol & Norethindrone medroxyprogesterone 2 Acetate) AMABELZ, 1 MIMVEY LO, MIMVEY, acetate) LOPREEZA TABS Estrogens (Norethindrone Acetate- Limit 8 per Ethinyl Estradiol) 1 (Estradiol) DOTTI PTTW 1 month;QL(0.29 FYAVOLV, JINTELI, ea daily) JEVANTIQUE LO TABS ALORA PTTW 0.025 Limit 8 per ACTIVELLA TABS MG/24HR, 0.075 month;QL(0.29 (estradiol & GP MG/24HR, 0.1 MG/24HR 3 ea daily) norethindrone acetate) (estradiol) ANGELIQ TABS ALORA PTTW 0.05 Limit 8 per GP month;QL(0.29 (drospirenone- 3 MG/24HR (estradiol) estradiol) ea daily) CLIMARA PRO PTWK CLIMARA PTWK 0.025 Limit 4 per (estradiol- 2 MG/24HR, 0.075 month;QL(0.15 MG/24HR, 0.06 MG/24HR, GP ea daily) levonorgestrel) 0.1 MG/24HR, 37.5 COMBIPATCH PTTW MCG/24HR (estradiol) (estradiol & 3 CLIMARA PTWK 0.05 Limit 4 per 28 norethindrone acetate) NF days;QL(0.15 MG/24HR ( ) DUAVEE TABS estradiol ea daily) (conjugated estrogens- 3 DELESTROGEN OIL 10 PA bazedoxifene) MG/ML (estradiol SP valerate)

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96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DELESTROGEN OIL 20 PA MINIVELLE PTTW 0.025 Limit 8 per MG/ML, 40 MG/ML MG/24HR, 0.075 month;QL(0.29 SP NF (estradiol valerate) MG/24HR, 0.1 MG/24HR ea daily) DEPO-ESTRADIOL OIL PA (estradiol) SP (estradiol cypionate) MINIVELLE PTTW 0.0375 Limit 8 per DIVIGEL GEL 0.25 MG/24HR, 0.05 MG/24HR GP month;QL(0.29 MG/0.25GM, 0.5 (estradiol) ea daily) MG/0.5GM, 1 MG/GM, 1.25 3 PREMARIN SOLR IJ 25 PA MG/1.25GM (estradiol) MG (estrogens, SP ELESTRIN GEL conjugated) 3 (estradiol) PREMARIN TABS OR ESTRACE TABS 0.625 MG, 0.45 MG, 0.3 GP 2 (estradiol) MG, 0.9 MG, 1.25 MG (estrogens, conjugated) estradiol pttw td 0.0375 Limit 8 per mg/24hr, 0.025 month;QL(0.29 VIVELLE-DOT PTTW Limit 8 per ea daily) 0.025 MG/24HR, 0.075 month;QL(0.29 mg/24hr, 0.075 1 MG/24HR, 0.1 MG/24HR NF ea daily) mg/24hr, 0.05 mg/24hr, (estradiol) 0.1 mg/24hr VIVELLE-DOT PTTW Limit 8 per estradiol ptwk td 0.025 Limit 4 per 0.0375 MG/24HR, 0.05 GP month;QL(0.29 mg/24hr, 0.075 month;QL(0.15 MG/24HR (estradiol) ea daily) ea daily) mg/24hr, 0.06 mg/24hr, 1 FLUOROQUINOLONES - Drugs to Treat Bacterial 0.1 mg/24hr, 37.5 Infections mcg/24hr Fluoroquinolones estradiol ptwk td 0.05 Limit 4 per 28 AVELOX TABS mg/24hr, 0.06 mg/24hr, days;QL(0.15 GP 1 ea daily) (moxifloxacin hcl) 0.1 mg/24hr, 37.5 BAXDELA TABS ST mcg/24hr (delafloxacin 3 estradiol tabs or 0.5 1 meglumine) mg, 1 mg, 2 mg CIPRO SUSR 5 estradiol valerate oil SP PA GM/100ML, 500 MG/5ML 2 (ciprofloxacin) Limit 50gms ESTROGEL GEL CIPRO TABS 250 MG, 500 3 per GP (estradiol) month;QL(1.67 MG (ciprofloxacin hcl) gm daily) ciprofloxacin hcl tabs 1 bal on hand, EVAMIST SOLN 100 mg, 500 mg, 750 1 3 (estradiol) mg MENEST TABS 2 ciprofloxacin hcl tabs (esterified estrogens) 250 mg, 500 mg, 750 1 MENOSTAR PTWK Limit 4 per mg 3 month;QL(0.14 (estradiol) ea daily) ciprofloxacin susr 1

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97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ciprofloxacin- QL(14 ea per GASTROCROM CONC 1 fill retail)1 bal ciprofloxacin hcl tb24 (cromolyn sodium GP on hand, (mastocytosis)) LEVAQUIN TABS QL(14 ea per GP Gastrointestinal Chloride Channel Activators (levofloxacin) fill retail) AMITIZA CAPS 2 levofloxacin soln 25 1 (lubiprostone) mg/ml QL(14 ea per Gastrointestinal Stimulants levofloxacin tabs 250 1 mg, 500 mg, 750 mg fill retail) metoclopramide hcl soln 5 mg/5ml, 10 1 moxifloxacin hcl tabs 1 mg/10ml 1 bal on hand, ofloxacin tabs 1 metoclopramide hcl 1 tabs 5 mg, 10 mg GASTROINTESTINAL AGENTS - MISC. - 1 bal on hand, metoclopramide hcl 1 Miscellaneous Gastrointestinal Drugs tbdp 5 mg Agents for Chronic Idiopathic (CIC) METOCLOPRAMIDE ODT TRULANCE TABS PA 3 TBDP (metoclopramide 3 (plecanatide) hcl) REGLAN TABS Bile Acid Synthesis Disorder Agents GP CHOLBAM CAPS ( PA (metoclopramide hcl) cholic SP acid) Inflammatory Bowel Agents APRISO CP24 Farnesoid X Receptor (FXR) Agonists NF OCALIVA TABS PA (mesalamine) SP ASACOL HD TBEC PA (obeticholic acid) 3 (mesalamine) Gallstone Solubilizing Agents AZULFIDINE EN-TABS ACTIGALL CAPS GP GP TBEC (sulfasalazine) (ursodiol) AZULFIDINE TABS CHENODAL TABS PA GP 3 (sulfasalazine) (chenodiol) Limit 282 caps URSO 250 TABS GP balsalazide disodium 1 per (ursodiol) caps month;QL(9.4 URSO FORTE TABS ea daily) GP (ursodiol) CANASA SUPP GP ursodiol caps 1 (mesalamine) CIMZIA KIT PA SP ursodiol tabs 1 (certolizumab pegol) CIMZIA STARTER KIT KIT PA SP Gastrointestinal Antiallergy Agents (certolizumab pegol) cromolyn sodium 1 Limit 282 caps (mastocytosis) conc COLAZAL CAPS GP per (balsalazide disodium) month;QL(9.4 ea daily)

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98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DELZICOL CPDR QL(12 ea daily) NF lactulose 1 (mesalamine) (encephalopathy) soln DIPENTUM CAPS 3 Irritable Bowel Syndrome (IBS) Agents (olsalazine sodium) PA GIAZO TABS ST; QL(6 ea alosetron hcl tabs 1 3 (balsalazide disodium) daily) LINZESS CAPS 2 INFLECTRA SOLR PA (linaclotide) SP (infliximab-dyyb) LOTRONEX TABS PA GP LIALDA TBEC (alosetron hcl) NF (mesalamine) VIBERZI TABS PA 3 (eluxadoline) mesalamine cp24 or 1 0.375 gm Peripheral Antagonists mesalamine cpdr or QL(12 ea daily) ENTEREG CAPS 1 3 400 mg (alvimopan) MOVANTIK TABS mesalamine enem re 4 1 3 gm (naloxegol oxalate) RELISTOR SOLN PA mesalamine supp re 1 1000 mg (methylnaltrexone SP bromide) mesalamine tbec or 1.2 1 gm RELISTOR TABS PA (methylnaltrexone SP mesalamine w/ 1 bromide) cleanser kit SYMPROIC TABS PA; 1 bal on PENTASA CPCR PA 3 3 (naldemedine tosylate) hand, (mesalamine) SYMPROIC TABS PA REMICADE SOLR PA 3 SP (naldemedine tosylate) (infliximab) ROWASA KIT Phosphate Binder Agents (mesalamine w/ GP calcium acetate cleanser) (phosphate binder) 1 SFROWASA ENEM caps 2 (mesalamine) FOSRENOL CHEW 500 STELARA SOLN PA MG, 750 MG, 1000 MG GP SP (ustekinumab (iv)) (lanthanum carbonate) lanthanum carbonate 1 sulfasalazine tabs 1 chew sulfasalazine tbec 1 PHOSLYRA SOLN (calcium acetate 3 Intestinal Acidifiers (phosphate binder)) (Lactulose RENAGEL TABS PA GP (Encephalopathy)) 1 (sevelamer hcl) ENULOSE, GENERLAC RENVELA PACK SOLN GP (sevelamer carbonate) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RENVELA TABS GP potassium citrate 1 (sevelamer carbonate) (alkalinizer) tbcr sevelamer carbonate RX/OTC 1 potassium citrate-citric 1 pack acid soln sevelamer carbonate RX/OTC 1 sodium citrate & citric 1 tabs acid soln PA; 1 bal on UROCIT-K 10 TBCR sevelamer hcl tabs 400 1 mg hand, (potassium citrate GP PA (alkalinizer)) sevelamer hcl tabs 800 1 mg UROCIT-K 15 TBCR VELPHORO CHEW PA (potassium citrate GP (sucroferric 3 (alkalinizer)) oxyhydroxide) UROCIT-K 5 TBCR ( GP Short Bowel Syndrome (SBS) Agents potassium citrate (alkalinizer)) GATTEX KIT PA SP (teduglutide (rdna)) Cystinosis Agents CYSTAGON CAPS Tryptophan Hydroxylase Inhibitors 3 (cysteamine bitartrate) XERMELO TABS PA SP (telotristat etiprate) PROCYSBI CPDR 25 MG, 75 MG (cysteamine 3 GENITOURINARY AGENTS - MISCELLANEOUS bitartrate) - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System Genitourinary Irrigants Acidifiers (Sodium Chloride (Gu PA Irrigant)) ARGYLE K-PHOS NO 2 TABS STERILE SALINE 100ML, SP (potassium & sodium 2 CURITY STERILE SALINE acid phosphates) SOLN Alkalinizers neomycin/polymyxin b 1 (Pot & Sod Citrates gu soln W/Citric Ac) CYTRA-3 1 1 bal on hand, neomycin/polymyxin b 1 SYRP gu soln (Potassium Citrate-Citric sodium chloride (gu PA Acid) CYTRA K 1 SP CRYSTALS, TARON- irrigant) soln CRYSTALS PACK Interstitial Cystitis Agents (Potassium Citrate-Citric 1 RX/OTC ELMIRON CAPS QL(3 ea daily) Acid) CYTRA-K SOLN (pentosan polysulfate 3 (Sodium Citrate & Citric 1 RX/OTC sodium) Acid) CYTRA-2 SOLN Prostatic Hypertrophy Agents ORACIT SOLN ( sodium 3 citrate & citric acid) alfuzosin hcl tb24 1 pot & sod citrates AVODART CAPS AL(At least 40 1 GP w/citric ac soln (dutasteride) yrs old)

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100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDURA XL TB24 THIOLA TABS (tiopronin) SP (doxazosin mesylate 3 (bph)) GOUT AGENTS - Drugs to Treat Gout 1 AL(At least 40 dutasteride caps yrs old) Gout Agent Combinations colchicine w/ dutasteride-tamsulosin 1 1 hcl caps tabs DUZALLO TABS PA QL(1 ea daily); 3 finasteride tabs 1 AL(At least 40 (lesinurad-allopurinol) yrs old) Gout Agents FLOMAX CAPS QL(2 ea daily) GP (tamsulosin hcl) allopurinol tabs 1 JALYN CAPS colchicine caps 1 1 bal on hand, (dutasteride-tamsulosin GP hcl) colchicine tabs 1 QL(1 ea daily); PROSCAR TABS COLCRYS TABS GP AL(At least 40 GP (finasteride) yrs old) (colchicine) RAPAFLO CAPS 4 MG 3 febuxostat tabs 1 (silodosin) MITIGARE CAPS 1 bal on hand, RAPAFLO CAPS 4 MG 1 bal on hand, 3 3 (colchicine) (silodosin) ULORIC TABS RAPAFLO CAPS 8 MG GP GP (febuxostat) (silodosin) ZURAMPIC TABS PA 3 silodosin caps 1 (lesinurad) ZYLOPRIM TABS 1 QL(2 ea daily) GP tamsulosin hcl caps (allopurinol) UROXATRAL TB24 GP Uricosurics (alfuzosin hcl) probenecid tabs 1 Urinary Analgesics (Phenazopyridine Hcl) 1 HEMATOLOGICAL AGENTS - MISC. - Drugs to PHENAZO TABS Treat Blood Disorders phenazopyridine hcl 1 B2 Receptor Antagonists tabs FIRAZYR SOLN (icatibant PA PYRIDIUM TABS SP GP acetate) (phenazopyridine hcl) icatibant acetate soln SP PA Urinary Stone Agents LITHOSTAT TABS Complement Inhibitors 3 (acetohydroxamic acid) BERINERT KIT (c1 PA; SP THIOLA EC TBEC esterase inhibitor SP SP (tiopronin) (human))

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101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA ZONTIVITY TABS HAEGARDA SOLR (c1 2 esterase inhibitor SP (vorapaxar sulfate) (human)) HEMATOPOIETIC AGENTS - Drugs to Treat RUCONEST SOLR (c1 PA Blood Disorders esterase inhibitor SP Agents for Gaucher Disease (recombinant)) CERDELGA CAPS PA SP Hemataologic - Inhibitors (eliglustat tartrate) TAVALISSE TABS PA; SP ELELYSO SOLR PA SP SP (fostamatinib disodium) (taliglucerase alfa) Hematorheologic Agents miglustat caps SP PA pentoxifylline tbcr 1 VPRIV SOLR PA SP (velaglucerase alfa) Plasma Kallikrein Inhibitors ZAVESCA CAPS PA TAKHZYRO SOLN PA SP SP (miglustat) (lanadelumab-flyo) Agents for Sickle Cell Disease Platelet Aggregation Inhibitors DROXIA CAPS AGGRENOX CP12 GP (hydroxyurea (sickle 3 (aspirin-dipyridamole) cell anemia)) AGRYLIN CAPS GP ENDARI PACK PA (anagrelide hcl) SP ( (sickle cell)) anagrelide hcl caps 1 SIKLOS TABS PA (hydroxyurea (sickle SP aspirin-dipyridamole 1 cp12 cell anemia)) BRILINTA TABS Folic Acid/ 2 (ticagrelor) (Folic Acid) CVS FOLIC PV CABLIVI KIT PA ACID, YL FOLIC ACID, SM SP FOLIC ACID, RA FOLIC (caplacizumab-yhdp) ACID, QC FOLIC ACID, PX PV cilostazol tabs 1 QL(2 ea daily) FOLIC ACID, HM FOLIC ACID, GNP FOLIC ACID, QL(2 ea daily) , FA-8 TABS clopidogrel bisulfate 1 tabs (Folic Acid) KP FOLIC 1 RX/OTC ACID TABS 1 MG dipyridamole tabs 1 (Folic Acid) KP FOLIC PV PV EFFIENT TABS 10 MG ACID TABS 800 MCG NF (prasugrel hcl) folic acid soln ij 5 mg/ml 1 EFFIENT TABS 5 MG GP (prasugrel hcl) folic acid tabs or 1 mg 1 RX/OTC PLAVIX TABS QL(2 ea daily) PV GP folic acid tabs or 400 PV (clopidogrel bisulfate) mcg, 800 mcg prasugrel hcl tabs 1 Hematopoietic Growth Factors

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102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARANESP ALBUMIN PA PROMACTA TABS 25 MG, PA FREE SOLN SP 50 MG, 12.5 MG SP (darbepoetin alfa) (eltrombopag olamine) ARANESP ALBUMIN PA PROMACTA TABS 75 MG, PA; QL(1 ea FREE SOSY SP 12.5 MG (eltrombopag SP daily) (darbepoetin alfa) olamine) DOPTELET TABS PA RETACRIT SOLN 2000 PA (avatrombopag SP UNIT/ML, 3000 UNIT/ML, maleate) 4000 UNIT/ML, 10000 SP UNIT/ML, 40000 UNIT/ML EPOGEN SOLN (epoetin PA SP (epoetin alfa-epbx) alfa) ZARXIO SOSY PA GRANIX SOSY 300 PA SP MCG/0.5ML, 480 (-sndz) SP ZIEXTENZO SOSY PA MCG/0.8ML (tbo- SP filgrastim) (-bmez) LEUKINE SOLR PA Hematopoietic Mixtures SP () FOLIVANE-F CAPS PA (ferrous fumarate-iron MIRCERA SOSY 2 (methoxy polyethylene SP polysaccharide glycol-epoetin beta) complex-folic acid-c-b3) MULPLETA TABS PA FUSION PLUS CAPS (fe SP (lusutrombopag) fum-iron polysacch 3 NEULASTA ONPRO KIT PA complex-fa-b cmplx-c- SP PSKT (pegfilgrastim) biotin-probiotic) NEULASTA SOSY PA INTEGRA F CAPS SP (ferrous fumarate-iron (pegfilgrastim) 2 NEUPOGEN SOLN PA polysaccharide SP (filgrastim) complex-folic acid-c-b3) NEUPOGEN SOSY PA Iron SP (filgrastim) (Carbonyl Iron) WEE CARE PV PV NIVESTYM SOSY 300 PA SUSP MCG/0.5ML, 480 (Ferrous Sulfate) PV MCG/0.8ML (filgrastim- SP BPROTECTED PEDIA aafi) IRON, IRON PV SUPPLEMENT PROCRIT SOLN 2000 PA CHILDRENS SOLN UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 10000 (Ferrous Sulfate) PV UNIT/ML, 20000 UNIT/ML, SP FEROSUL, IRON PV 40000 UNIT/ML (epoetin SUPPLEMENT ELIX FER-IN-SOL SOLN PV alfa) GP ( ) PROMACTA PACK 25 MG, PA ferrous sulfate PV 12.5 MG (eltrombopag SP ferrous sulfate elix 220 PV olamine) mg/5ml

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103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PV (Diphenhydramine Hcl ferrous sulfate soln 15 PV mg/ml (Sleep)) COMPOZ, WAL- SOM MAXIMUM FERROUS SULFATE PV STRENGTH, TGT SLEEP SYRP 300 MG/5ML PV AID MAXIMUM (ferrous sulfate) STRENGTH, SM SLEEP ICAR PEDIATRIC SUSP PV AID MAXIMUM GP (carbonyl iron) STRENGTH, SLEEP-AID MAXIMUM STRENGTH, MYKIDZ IRON 10 SUSP PV PV SLEEP-AID, SLEEP AID, (iron) RA SLEEP AID MAXIMUM Stem Cell Mobilizers STRENGTH, RA NIGHTTIME SLEEP AID, MOZOBIL SOLN PA SP QC SLEEP-AID MAXIMUM (plerixafor) STRENGTH, QC SLEEP 1 HEMOSTATICS - Drugs to Stop Bleeding/Treat AID MAXIMUM Blood Disorders STRENGTH, ORMIR, GOODSENSE SLEEP AID, Hemostatics - Systemic EQL SLEEP AID AMICAR TABS 500 MG, MAXIMUM STRENGTH, 1000 MG (aminocaproic GP EQ NIGHTTIME SLEEP acid) AID MAXIMUM STRENGTH, CVS SLEEP- aminocaproic acid tabs 1 AID NIGHTTIME, CVS 500 mg, 1000 mg SLEEP AID CYKLOKAPRON SOLN PA NIGHTTIME/MAXIMUM SP (tranexamic acid) STRENGTH, CVS NIGHTTIME SLEEP AID LYSTEDA TABS QL(6 ea daily,5 GP MAXIMUM STRENGTH (tranexamic acid) day(s) limit) CAPS PA UNISOM SLEEPGELS tranexamic acid soln iv SP 1000 mg/10ml CAPS (diphenhydramine GP QL(6 ea daily,5 hcl (sleep)) tranexamic acid tabs or 1 650 mg day(s) limit) Barbiturate Hypnotics BUTISOL SODIUM TABS HYPNOTICS/SEDATIVES/SLEEP DISORDER 3 AGENTS (butabarbital sodium) Antihistamine Hypnotics elix 20 1 mg/5ml phenobarbital soln 20 1 mg/5ml phenobarbital tabs 15 mg, 30 mg, 60 mg, 100 1 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg SECONAL SODIUM CAPS 3 (secobarbital sodium) Hypnotics - Tricyclic Agents

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104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; QL(1 ea PA doxepin hcl (sleep) 1 zolpidem tartrate subl sl 1 tabs daily) 3.5 mg, 1.75 mg SILENOR TABS ( ST; QL(1 ea QL(1 ea daily) doxepin GP zolpidem tartrate tabs 1 hcl (sleep)) daily) or 5 mg, 10 mg QL(1 ea daily) Non-Barbiturate Hypnotics zolpidem tartrate tbcr or 1 AMBIEN CR TBCR QL(1 ea daily) 12.5 mg, 6.25 mg GP (zolpidem tartrate) ST; Limit ZOLPIMIST SOLN AMBIEN TABS 10 MG QL(1 ea daily) 3 7.7mls per GP (zolpidem tartrate) month;QL(0.26 (zolpidem tartrate) ml daily) AMBIEN TABS 5 MG QL(1 ea daily) NF (zolpidem tartrate) Receptor Antagonists BELSOMRA TABS ST; QL(1 ea DORAL TABS 1 bal on hand, 2 3 (suvorexant) daily) (quazepam) EDLUAR SUBL ST; QL(1 ea Selective Melatonin Receptor Agonists 3 daily) HETLIOZ CAPS PA (zolpidem tartrate) SP (tasimelteon) estazolam tabs 1 1 ST; QL(1 ea ramelteon tabs daily) eszopiclone tabs 1 QL(1 ea daily) ROZEREM TABS ST; QL(1 ea GP flurazepam hcl caps 1 1 bal on hand, (ramelteon) daily) HALCION TABS LAXATIVES - Bowel Treatment Drugs GP (triazolam) Laxative Combinations INTERMEZZO SUBL PA GP (Bisacodyl-Peg 3350-Pot PV (zolpidem tartrate) Chloride-Sod Bicarb-Sod 1 LUNESTA TABS 1 MG, 2 QL(1 ea daily) Chloride) GAVILYTE-H, NF MG (eszopiclone) PEG-PREP KIT LUNESTA TABS 3 MG QL(1 ea daily) (Peg 3350-Kcl-Sod Bicarb- 1 bal on GP (eszopiclone) Sod Chloride-Sod Sulfate) 1 hand,PV GAVILYTE-C, GAVILYTE- midazolam hcl syrp 1 G SOLR (Peg 3350-Kcl-Sod Bicarb- PV quazepam tabs 1 1 bal on hand, Sod Chloride-Sod Sulfate) 1 RESTORIL CAPS GAVILYTE-C, GAVILYTE- GP G SOLR (temazepam) (Peg 3350-Potassium PV SONATA CAPS QL(1 ea daily) GP Chloride-Sod Bicarbonate- (zaleplon) Sod Chloride) GAVILYTE- 1 N/FLAVOR PACK, temazepam caps 1 TRILYTE SOLR triazolam tabs 1 CLENPIQ SOLN (sodium PV picosulfate-magnesium 3 zaleplon caps 1 QL(1 ea daily) oxide-anhydrous citric acid)

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105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COLYTE-FLAVOR PACKS PV SUPREP BOWEL PREP PV SOLR (peg 3350-kcl- KIT SOLN (sodium 3 sod bicarb-sod sulfate-potassium 3 chloride-sod sulfate) sulfate-magnesium GOLYTELY SOLR 227.1 PA; PV sulfate) GM-21.5 GM-5.53 GM-2.82 Laxatives - Miscellaneous GM-6.36 GM (peg 3350- 2 (Lactulose) CONSTULOSE 1 kcl-sod bicarb-sod SOLN chloride-sod sulfate) (Polyethylene Glycol 3350) Limit 528gms GOLYTELY SOLR 236 PV CLEARLAX, TGT per GM-22.74 GM-5.86 GM- POWDERLAX, SMOOTH month;QL(17.6 2.97 GM-6.74 GM (peg LAX, SM CLEARLAX, SB gm daily); 3350-kcl-sod bicarb- GP POLYETHYLENE GLYCOL RX/OTC sod chloride-sod 3350, RA LAXATIVE, QC NATURA-LAX, PEGYLAX, sulfate) KLS LAXACLEAR, HM 1 MOVIPREP SOLR (peg PA; PV CLEARLAX, GOODSENSE CLEARLAX, GNP 3350-kcl-nacl-na 3 sulfate-na ascorbate- CLEARLAX, GLYCOLAX, ascorbic acid) GENTLELAX, GAVILAX, EQL CLEARLAX, EQ NULYTELY/FLAVOR PV CLEARLAX, CVS PACKS SOLR (peg 3350- PURELAX POWD potassium chloride-sod GP KRISTALOSE PACK 10 3 bicarbonate-sod GM, 20 GM (lactulose) chloride) LACTULOSE PACK 10 GM 3 peg 3350-kcl-sod PV (lactulose) bicarb-sod chloride-sod 1 lactulose soln 10 1 sulfate solr gm/15ml, 20 gm/30ml peg 3350-potassium PV Limit 528gms MIRALAX POWD per chloride-sod 1 bicarbonate-sod (polyethylene glycol GP month;QL(17.6 chloride solr 3350) gm daily); RX/OTC PLENVU SOLR (peg PA; PV Limit 528gms 3350-kcl-nacl-na PV polyethylene glycol per sulfate-na ascorbate- 1 month;QL(17.6 ascorbic acid) 3350 powd gm daily); PREPOPIK PACK PA; PV RX/OTC (sodium picosulfate- Saline Laxatives 3 magnesium oxide- OSMOPREP TABS PA anhydrous citric acid) (sodium phosphate monobasic-sodium 3 phosphate dibasic) MACROLIDES - Drugs to Treat Bacterial Infections

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106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Azithromycin (Erythromycin Stearate) 1 bal on hand, ERYTHROCIN 1 bal on hand, azithromycin pack 1 gm 1 STEARATE, 1 ERYTHROCIN STEARATE azithromycin susr 100 1 TABS mg/5ml, 200 mg/5ml E.E.S. GRANULES SUSR QL(6 ea per fill azithromycin tabs 250 1 (erythromycin GP mg retail) ethylsuccinate) QL(3 ea per fill ERYPED 200 SUSR azithromycin tabs 500 1 mg retail) (erythromycin GP QL(10 ea per ethylsuccinate) azithromycin tabs 600 1 mg fill retail) ERYPED 400 SUSR ZITHROMAX PACK 1 GM 1 bal on hand, (erythromycin GP GP (azithromycin) ethylsuccinate) 1 bal on hand, ZITHROMAX SUSR 100 erythromycin base 1 MG/5ML, 200 MG/5ML GP cpep 250 mg (azithromycin) erythromycin base ZITHROMAX TABS 250 QL(6 ea per fill 1 GP cpep 250 mg MG (azithromycin) retail) erythromycin base tabs 1 ZITHROMAX TABS 500 QL(3 ea per fill 250 mg, 500 mg GP retail) MG (azithromycin) erythromycin base tbec ZITHROMAX TABS 600 QL(10 ea per GP 250 mg, 333 mg, 500 1 MG (azithromycin) fill retail) mg ZITHROMAX TRI-PAK QL(3 ea per fill GP retail) erythromycin TABS (azithromycin) ethylsuccinate susr 200 1 ZITHROMAX Z-PAK TABS QL(6 ea per fill GP mg/5ml, 400 mg/5ml (azithromycin) retail) erythromycin 1 bal on hand, Clarithromycin ethylsuccinate tabs 400 1 1 bal on hand, clarithromycin susr 125 1 mg mg/5ml, 250 mg/5ml Fidaxomicin clarithromycin tabs 250 DIFICID TABS 1 3 mg, 500 mg (fidaxomicin) QL(14 ea per clarithromycin tb24 500 1 mg fill retail) MEDICAL DEVICES AND SUPPLIES Contraceptives AIMSCO LUBRICATED PV (Erythromycin Base) ERY- 1 TAB TBEC MISC (condoms latex PV (Erythromycin 1 bal on hand, lubricated - male) Ethylsuccinate) E.E.S. 400 1 TABS DIAPHRAGMS PV

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107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DUREX EXTRA PV KIMONO PLUS PV SENSITIVE DEVI SPERMICIDE/LUBRICATE (condoms latex PV D MISC (condoms latex PV lubricated - male) lubricated - male) FANTASY LUBRICATED PV KIMONO PS LUBRICATED PV MISC (condoms latex PV MISC (condoms latex PV lubricated - male) lubricated - male) FANTASY PV KIMONO PS PLUS PV LUBRICATED/SPERMICID SPERMICIDE/LUBRICATE E MISC (condoms latex PV D MISC (condoms latex PV lubricated - male) lubricated - male) FC FEMALE CONDOM PV KIMONO SENSATION PV MISC ( LUBRICATED MISC condoms - PV PV female) (condoms latex FC2 FEMALE CONDOM PV lubricated - male) MISC (condoms - PV KIMONO SENSATION PV female) PLUS SPERMICIDE LUBRICATED MISC PV FEMCAP DEVI ( PV cervical 3 (condoms latex caps) lubricated - male) KAMELEON LUBRICATED PV KIMONO SPECIAL DEVI PV MISC (condoms latex PV (condoms latex PV lubricated - male) lubricated - male) KIMONO COLORS DEVI PV MAXX LUBRICATED MISC PV (condoms latex PV (condoms latex PV lubricated - male) lubricated - male) KIMONO LUBRICATED PV MAXX PLUS SPERMICIDE PV MISC (condoms latex PV LUBRICATED MISC lubricated - male) (condoms latex PV KIMONO MICRO THIN PV lubricated - male) MISC (condoms latex PV PREMIUM CONDOMS PV non-lubricated - male) LUBRICATED MISC PV KIMONO MICRO THIN PV (condoms latex PLUS SPERMICIDE lubricated - male) LUBRICATED MISC PV REALITY LATEX PV (condoms latex CONDOMS/LUBRICATED lubricated - male) MISC (condoms latex PV KIMONO PLUS PV lubricated - male) SPERMICIDE REALITY LATEX/ULTRA PV LUBRICATED MISC PV TEXTURED DEVI (condoms latex (condoms latex PV lubricated - male) lubricated - male)

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108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REALITY LATEX/ULTRA PV TRUSTEX WITH PV THIN DEVI (condoms PV NONOXYNOL- latex lubricated - male) 9/RIBBED/STUDDED PV TRUSTEX COLOR PV MISC (condoms latex CONDOMS + LUBE MISC lubricated - male) (condoms latex PV TRUSTEX/RIA PV LUBRICATED MISC lubricated - male) PV TRUSTEX LUBRICATED PV (condoms latex EXTRALARGE MISC lubricated - male) (condoms latex PV TRUSTEX/RIA PV lubricated - male) LUBRICATED SPERMICIDE MISC TRUSTEX LUBRICATED PV PV EXTRASTRENGTH MISC (condoms latex (condoms latex PV lubricated - male) lubricated - male) TRUSTEX/RIA PV LUBRICATED/SPERMICID TRUSTEX LUBRICATED PV E MISC (condoms latex PV MISC (condoms latex PV lubricated - male) lubricated - male) TRUSTEX/RIA NON- PV TRUSTEX PV LUBRICATED MISC LUBRICATED/RIBBED/ST (condoms latex non- PV UDDED MISC (condoms PV lubricated - male) latex lubricated - male) TRUSTEX PV Diabetic Supplies LUBRICATED/SPERMICID FREESTYLE FREEDOM QL(1 ea per E EXTRA LARGE MISC PV LITE KIT (blood glucose 2 365 days (condoms latex monitoring supplies) retail); RX/OTC lubricated - male) FREESTYLE INSULINX QL(1 ea per TRUSTEX PV BLOODGLUCOSE 365 days LUBRICATED/SPERMICID MONITORING SYSTEM 2 retail); RX/OTC E EXTRA STRENGTH PV KIT (blood glucose MISC (condoms latex monitoring supplies) lubricated - male) FREESTYLE LITE BLOOD QL(1 ea per TRUSTEX PV GLUCOSE MONITORING 365 days retail) LUBRICATED/SPERMICID SYSTEM DEVI (blood 2 E MISC (condoms latex PV glucose monitoring lubricated - male) supplies) TRUSTEX NATURAL PV LANCETS 2 CONDOMS +LUBE/LUBRICATED PV ONETOUCH ULTRA 2 KIT QL(1 ea per MISC (condoms latex (blood glucose 2 365 days lubricated - male) monitoring supplies) retail); RX/OTC TRUSTEX NON- PV ONETOUCH ULTRA MINI QL(1 ea per LUBRICATED MISC 365 days PV KIT (blood glucose 2 (condoms latex non- monitoring supplies) retail); RX/OTC lubricated - male)

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109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONETOUCH VERIO FLEX Limit 1 per EASY TOUCH SAFETY RX/OTC BLOOD GLUCOSE year;QL(1 ea PEN NEEDLES/30G X MONITORING SYSTEM 2 per 365 days 5/16" MISC (insulin pen 2 KIT (blood glucose retail); RX/OTC needle) monitoring supplies) INSULIN SYRINGES AND 2 MO ONETOUCH VERIO IQ QL(1 ea per PEN NEEDLES BLOOD GLUCOSE 365 days INSUPEN ULTRAFIN RX/OTC MONITORING SYSTEM 2 retail); RX/OTC 30GX8MM MISC (insulin 2 KIT (blood glucose pen needle) monitoring supplies) NOVOFINE AUTOCOVER RX/OTC ONETOUCH VERIO KIT Limited to 1 per 30GX8MM MISC (insulin 2 ( 2 year;QL(1 ea blood glucose per 365 days pen needle) monitoring supplies) retail); RX/OTC PEN NEEDLES 30GX5/16" RX/OTC ONETOUCH VERIO SYNC QL(1 ea per MISC (insulin pen 2 BLOODGLUCOSE 365 days needle) MONITORING SYSTEM 2 retail); RX/OTC PEN NEEDLES 30GX8MM RX/OTC KIT (blood glucose MISC (insulin pen 2 monitoring supplies) needle) PRECISION XTRA DEVI QL(1 ea per SURE COMFORT PEN RX/OTC (blood glucose 2 365 days retail) NEEDLES30GX5/16" monitoring supplies) SHORT MISC (insulin 2 Parenteral Therapy Supplies pen needle) ABOUTTIME PEN RX/OTC UNIFINE SAFECONTROL RX/OTC PEN NEEDLE/30G X 5/16" NEEDLES 30GX 5/16" 2 MISC (insulin pen 2 MISC (insulin pen needle) needle) ASSURE ID SAFETY PEN RX/OTC Respiratory Therapy Supplies NEEDLES 30G X 5/16" MO MISC (insulin pen 2 INHALER SPACERS 2 needle) MIGRAINE PRODUCTS - Drugs to Treat Migraine CAREFINE PEN RX/OTC NEEDLES 30GX5/16" Calcitonin Gene-Related (CGRP) MISC (insulin pen 2 AIMOVIG SOAJ 140 PA needle) MG/ML (erenumab- SP DROPLET PEN NEEDLES RX/OTC aooe) 30G X 5/16" MISC 2 AIMOVIG SOAJ 70 MG/ML PA; SP (insulin pen needle) SP (erenumab-aooe) EASY TOUCH PEN RX/OTC AJOVY SOSY PA NEEDLE 30G X 5/16" SP MISC (insulin pen 2 (fremanezumab-vfrm) needle) EMGALITY SOAJ 120 PA MG/ML (galcanezumab- SP gnlm)

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110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMGALITY SOSY 120 PA dihydroergotamine QL(8 ml per fill MG/ML (galcanezumab- SP mesylate soln na 4 3 retail,24 ml per gnlm) mg/ml fill mail) ERGOMAR SUBL Migraine Combinations 2 (ergotamine tartrate) (Ergotamine W/ Caffeine) 1 1 bal on hand, MIGERGOT SUPP MIGRANAL SOLN QL(8 ml per fill CAFERGOT TABS (dihydroergotamine 3 retail,24 ml per (ergotamine w/ GP mesylate) fill mail) caffeine) Serotonin Agonists ergotamine w/ caffeine 1 1 QL(6 ea per 30 tabs almotriptan malate tabs days retail) isometheptene- 1 bal on hand, QL(27 ea per AMERGE TABS dichloralphenazone- 1 GP 90 days acetaminophen caps (naratriptan hcl) retail,27 ea per 90 days mail) isometheptene- AXERT TABS QL(6 ea per 30 GP dichloralphenazone- 1 (almotriptan malate) days retail) acetaminophen caps eletriptan hydrobromide Limit 6 tabs per sumatriptan-naproxen PA; Limit 9 per 1 month;QL(0.2 1 month;QL(0.3 tabs ea daily) sodium tabs ea daily) FROVA TABS Limit 9 per TREXIMET TABS 10 MG- PA; Limit 9 per GP month;QL(0.3 60 MG (sumatriptan- 3 month;QL(0.3 (frovatriptan succinate) ea daily) naproxen sodium) ea daily) frovatriptan succinate Limit 9 per 1 month;QL(0.3 TREXIMET TABS 85 MG- PA; Limit 9 per tabs 500 MG (sumatriptan- GP month;QL(0.3 ea daily) naproxen sodium) ea daily) IMITREX SOLN NA 5 Limit 6 per MG/ACT, 20 MG/ACT GP month;QL(0.2 Migraine Products - NSAIDs (sumatriptan) ea daily) CAMBIA PACK PA; Limit 9 per QL(2 ml per fill (diclofenac potassium 3 month;QL(0.3 IMITREX SOLN SC 6 retail,6 ml per (migraine)) ea daily) MG/0.5ML (sumatriptan GP fill mail,4 ml per Migraine Products 30 days succinate) retail,12 ml per QL(10 ml per 90 days mail) fill retail,30 ml D.H.E. 45 SOLN QL(2 ml per fill ( GP per fill mail,20 dihydroergotamine ml per 30 days IMITREX STATDOSE retail,6 ml per mesylate) retail,60 ml per REFILL SOCT GP fill mail,4 ml per 90 days mail) 30 days (sumatriptan succinate) retail,12 ml per QL(10 ml per 90 days mail) dihydroergotamine fill retail,30 ml 1 per fill mail,20 mesylate soln ij 1 ml per 30 days mg/ml retail,60 ml per 90 days mail)

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111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ml per fill Limit 6 per IMITREX STATDOSE retail,6 ml per sumatriptan soln 1 month;QL(0.2 SYSTEM SOAJ GP fill mail,4 ml per ea daily) 30 days (sumatriptan succinate) QL(2 ml per fill retail,12 ml per retail,6 ml per 90 days mail) sumatriptan succinate 1 fill mail,4 ml per QL(9 ea per fill soaj sc 4 mg/0.5ml, 6 30 days retail,27 ea per mg/0.5ml retail,12 ml per IMITREX TABS OR 25 MG GP fill mail,18 ea 90 days mail) (sumatriptan succinate) per 30 days QL(2 ml per fill retail,54 ea per retail,6 ml per 90 days mail) sumatriptan succinate 1 fill mail,4 ml per QL(9 ea per fill soct sc 4 mg/0.5ml, 6 30 days mg/0.5ml IMITREX TABS OR 50 MG, retail,27 ea per retail,12 ml per 100 MG ( NF fill mail,18 ea 90 days mail) sumatriptan per 30 days succinate) QL(2 ml per fill retail,54 ea per retail,6 ml per 90 days mail) sumatriptan succinate 1 fill mail,4 ml per QL(12 ea per soln sc 6 mg/0.5ml 30 days MAXALT TABS NF 30 days retail,12 ml per (rizatriptan benzoate) retail,36 ea per 90 days mail) 90 days mail) QL(9 ea per fill MAXALT-MLT TBDP 10 QL(12 ea per sumatriptan succinate retail,27 ea per MG ( NF 30 days 1 fill mail,18 ea rizatriptan retail,36 ea per tabs or 25 mg, 50 mg, per 30 days benzoate) 90 days mail) 100 mg retail,54 ea per QL(12 ea per 90 days mail) MAXALT-MLT TBDP 5 MG GP 30 days ZEMBRACE SYMTOUCH PA (rizatriptan benzoate) retail,36 ea per SOAJ (sumatriptan 3 90 days mail) succinate) QL(27 ea per QL(9 ea per fill 1 90 days retail,27 ea per naratriptan hcl tabs retail,27 ea per 1 fill mail,18 ea 90 days mail) zolmitriptan tabs per 30 days RELPAX TABS 20 MG Limit 6 tabs per retail,54 ea per (eletriptan GP month;QL(0.2 90 days mail) hydrobromide) ea daily) QL(9 ea per fill RELPAX TABS 40 MG Limit 6 tabs per retail,27 ea per (eletriptan NF month;QL(0.2 zolmitriptan tbdp 1 fill mail,18 ea ea daily) per 30 days hydrobromide) retail,54 ea per QL(12 ea per 90 days mail) rizatriptan benzoate 1 30 days QL(9 ea per fill tabs retail,36 ea per retail,27 ea per 90 days mail) ZOMIG SOLN NA 2.5 MG 3 fill mail,18 ea QL(12 ea per (zolmitriptan) per 30 days rizatriptan benzoate 1 30 days retail,54 ea per tbdp retail,36 ea per 90 days mail) 90 days mail)

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112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ea per 30 potassium chloride in PA; 1 bal on ZOMIG SOLN NA 5 MG 3 days retail,18 nacl soln 0.45 %-20 hand, (zolmitriptan) ea per 90 days meq/l, 0.9 %-20 meq/l, SP mail) 0.9 %-40 meq/l, 0.9 %- QL(9 ea per fill retail,27 ea per 40 meq/l, 0.9 %-0.15 % ZOMIG TABS OR 5 MG, GP fill mail,18 ea Fluoride 2.5 MG (zolmitriptan) per 30 days (Sodium Fluoride) PV retail,54 ea per FLUORITAB, NAFRINSE 1 90 days mail) DROPS, FLURA-DROPS QL(9 ea per fill SOLN retail,27 ea per (Sodium Fluoride) 1 bal on ZOMIG ZMT TBDP fill mail,18 ea GP FLUORITAB, NAFRINSE 1 hand,PV (zolmitriptan) per 30 days DROPS, FLURA-DROPS retail,54 ea per SOLN 90 days mail) (Sodium Fluoride) PV MINERALS & ELECTROLYTES FLUORITAB, NAFRINSE, 1 LUDENT CHEW Calcium FLUORABON SOLN PV 2 CALCIFOL WAFR (sodium fluoride) (calcium carbonate-folic 3 sodium fluoride chew PV acid-vit d-b6-b12- 0.25 mg, 0.5 mg, 1 mg, 1 boron-magnesium) 2.2 mg CALCIUM-FOLIC ACID PV sodium fluoride soln 0.5 1 PLUS D WAFR (calcium mg/ml carbonate-folic acid-vit 3 d-b6-b12-boron- sodium fluoride tabs 1 bal on 1 hand,PV magnesium) 0.5 mg, 1 mg Electrolyte Mixtures Magnesium ISOLYTE-S SOLN PA MAGNEBIND 400 TABS SP (electrolyte-s) (magnesium-calcium- 3 NORMOSOL-R SOLN PA folic acid) SP PA (electrolyte-r ( 7.4)) magnesium sulfate soln SP PLASMA-LYTE A SOLN PA ij 50 % SP (electrolyte-a) magnesium sulfate soln PA; 1 bal on SP hand, PLASMA-LYTE-148 SOLN PA ij 50 % SP (electrolyte-148) magnesium sulfate soln PA potassium chloride in PA iv 2 gm/50ml, 4 nacl soln 0.45 %-20 gm/50ml, 4 gm/100ml, SP meq/l, 0.9 %-20 meq/l, SP 20 gm/500ml, 40 0.9 %-40 meq/l, 0.9 %- gm/1000ml 40 meq/l, 0.9 %-0.15 %

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113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGNESIUM SULFATE PA (Potassium Chloride 1 bal on hand, SOLN IV 2 GM/50ML, 4 Microencapsulated Crystals GM/50ML, 4 GM/100ML, Er) KLOR-CON M10, 1 20 GM/500ML, 40 SP KLOR-CON M20, KLOR- GM/1000ML (magnesium CON M15 TBCR sulfate) (Potassium Chloride) K- SOL, POTASSIUM 1 Phosphate CHLORIDE PROAMP (Pot Phosphate Monobasic SOLN W/ Sod Phosphate Dibasic (Potassium Chloride) K- PA & Monobasic) AV-PHOS SOL, POTASSIUM SP 250 NEUTRAL, VIRT- 1 CHLORIDE PROAMP PHOS 250 NEUTRAL, SOLN PHOSPHO-TRIN 250 NEUTRAL, PHOSPHA 250 (Potassium Chloride) NEUTRAL TABS KLOR-CON 10, KLOR- 1 CON 8 TBCR K-PHOS NEUTRAL TABS ( (Potassium Chloride) 1 pot phosphate KLOR-CON PACK monobasic w/ sod GP (Potassium Chloride) phosphate dibasic & KLOR-CON SPRINKLE 1 monobasic) CPCR K-PHOS TABS EFFER-K TBEF 1 GM-0.84 (potassium phosphate 2 GM, 2 GM-1.68 GM monobasic) (potassium 3 pot phosphate bicarbonate-citric acid) K-TAB TBCR 10 MEQ, 20 monobasic w/ sod 1 phosphate dibasic & MEQ (potassium GP monobasic tabs chloride) Potassium K-TAB TBCR 8 MEQ, 20 1 bal on hand, (Potassium Bicarb & MEQ (potassium GP chloride) Chloride) 1 EFFERVESCENT POT 1 bal on hand, potassium bicarb & 1 CHLORIDE TBEF chloride tbef (Potassium Bicarbonate) 1 EFFER-K TBEF 25 MEQ potassium bicarbonate 1 tbef (Potassium Bicarbonate) K- potassium chloride cpcr EFFERVESCENT, KLOR- 1 1 CON/EF, K-VESCENT, K- or 8 meq, 10 meq PRIME TBEF potassium chloride (Potassium Chloride microencapsulated 1 Microencapsulated Crystals Er) KLOR-CON 1 crystals er tbcr M10, KLOR-CON M20, potassium chloride 1 KLOR-CON M15 TBCR pack or 20 meq

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114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POTASSIUM CHLORIDE PA CUPRIMINE CAPS PA GP SOLN IV 0.4 MEQ/ML, 10 (penicillamine) MEQ/50ML, 20 DEPEN TITRATABS TABS MEQ/50ML, 10 SP GP (penicillamine) MEQ/100ML (potassium chloride) penicillamine caps 1 PA POTASSIUM CHLORIDE PA; 1 bal on SOLN IV 10 MEQ/100ML, hand, penicillamine tabs 1 10 MEQ/100ML SP SYPRINE CAPS (trientine PA (potassium chloride) SP hcl) PA potassium chloride soln SP PA iv 2 meq/ml trientine hcl caps SP potassium chloride soln PA; 1 bal on Enzymes SP hand, iv 2 meq/ml XIAFLEX SOLR PA ( potassium chloride soln 1 collagenase or 10 %, 20 % clostridium SP potassium chloride tbcr histolyticum) or 8 meq, 10 meq, 20 1 Immunomodulators meq REVLIMID CAPS PA AC potassium chloride tbcr 1 bal on hand, (lenalidomide) or 8 meq, 10 meq, 20 1 THALOMID CAPS AC meq (thalidomide) Sodium Immunosuppressive Agents PA (Cyclosporine Modified (For sodium chloride soln ij SP 2.5 meq/ml Microemulsion)) 1 sodium chloride soln iv PA GENGRAF CAPS SP (Cyclosporine Modified (For 0.45 %, 0.9 %, 3 %, 5 Microemulsion)) 1 % GENGRAF SOLN sodium chloride soln iv PA; 1 bal on ASTAGRAF XL CP24 ST SP 3 0.9 %, 0.9 %, 3 %, 5 % hand, (tacrolimus) Zinc ATGAM INJ (lymphocyte PA (Zinc Sulfate) ORAZINC, 1 immune globulin,anti- SP ZINC-220 CAPS thymocyte globulin GALZIN CAPS ( (equine)) zinc 3 acetate (oral)) AZASAN TABS 3 zinc sulfate caps 1 (azathioprine) AZATHIOPRINE SOLR IJ PA MISCELLANEOUS THERAPEUTIC CLASSES 100 MG (azathioprine SP sodium) Chelating Agents azathioprine tabs or 50 1 (Trientine Hcl) CLOVIQUE SP PA CAPS mg

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115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELLCEPT CAPS MYFORTIC TBEC (mycophenolate GP (mycophenolate GP mofetil) sodium) CELLCEPT PA NEORAL CAPS INTRAVENOUS SOLR ( SP cyclosporine modified GP (mycophenolate mofetil (for microemulsion)) hcl) NEORAL SOLN CELLCEPT SUSR (cyclosporine modified GP (mycophenolate GP (for microemulsion)) mofetil) NULOJIX SOLR PA SP CELLCEPT TABS (belatacept) (mycophenolate GP PROGRAF CAPS OR 0.5 mofetil) MG, 1 MG, 5 MG GP (tacrolimus) cyclosporine caps or 25 1 mg, 100 mg PROGRAF PACK OR 0.2 PA SP cyclosporine modified MG, 1 MG (tacrolimus) PROGRAF SOLN IV 5 PA (for microemulsion) 1 SP caps 25 mg, 50 mg, MG/ML (tacrolimus) 100 mg RAPAMUNE SOLN GP cyclosporine modified () 1 RAPAMUNE TABS (for microemulsion) GP soln 100 mg/ml (sirolimus) PA SANDIMMUNE CAPS OR cyclosporine soln iv 50 SP mg/ml 25 MG, 100 MG GP ( ) ENVARSUS XR TB24 ST cyclosporine 3 SANDIMMUNE SOLN IV PA (tacrolimus) SP 50 MG/ML (cyclosporine) everolimus SIMULECT SOLR PA (immunosuppressant) 1 SP tabs (basiliximab) IMURAN TABS sirolimus soln 1 GP (azathioprine) sirolimus tabs 1 mycophenolate mofetil 1 caps tacrolimus caps 1 PA mycophenolate mofetil SP hcl solr THYMOGLOBULIN SOLR PA (anti-thymocyte globulin SP mycophenolate mofetil 1 (rabbit), lymphocyte susr immune globulin) ZORTRESS TABS 0.25 mycophenolate mofetil 1 tabs MG, 0.75 MG, 0.5 MG (everolimus GP mycophenolate sodium 1 tbec (immunosuppressant)) Irrigation Solutions You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Irrigation Solutions, FIRST-MOUTHWASH BLM Physiological) SUSP PHYSIOLYTE, 1 (diphenhydramine- PHYSIOSOL IRRIGATION lidocaine-alum 3 SOLN hydroxide-mg (Ringer'S Irrigation) TIS-U- 1 hydroxide-simeth) SOL SOLN (Water For Irrigation, lidocaine hcl (mouth- 1 Sterile) ARGYLE STERILE 1 throat) soln 2 % WATER 100ML SOLN 1 bal on hand, lidocaine hcl (mouth- 1 throat) soln 4 % lactated ringer's 1 (irrigation) soln Anti-infectives - Throat ringer's irrigation soln 1 clotrimazole lozg 1 water for irrigation, 1 clotrimazole troc 1 sterile soln Potassium Removing Agents nystatin (mouth-throat) 1 susp (Sodium Polystyrene 1 Sulfonate) KIONEX POWD ORAVIG TABS (Sodium Polystyrene (miconazole (mouth- 3 Sulfonate) KIONEX, SPS 1 throat)) SUSP Antiseptics - Mouth/Throat LOKELMA PACK ST (Chlorhexidine Gluconate (sodium zirconium 3 (Mouth-Throat)) PAROEX, 1 cyclosilicate) PERIOGARD SOLN sodium polystyrene 1 chlorhexidine gluconate 1 sulfonate powd (mouth-throat) soln DEBACTEROL SOLN sodium polystyrene 1 sulfonate susp (sulfuric acid-sulfonated 3 VELTASSA PACK ST; Try/Fail on phenolics) (patiromer sorbitex 3 generic PERIDEX SOLN calcium) Kayexalate (chlorhexidine GP Systemic Lupus Erythematosus Agents gluconate (mouth- throat)) BENLYSTA SOAJ PA SP (belimumab) Steroids - Mouth/Throat/Dental BENLYSTA SOLR PA (Triamcinolone Acetonide SP (belimumab) (Mouth)) ORALONE 1 DENTAL PASTE PSTE BENLYSTA SOSY PA SP (belimumab) triamcinolone acetonide 1 (mouth) pste MOUTH/THROAT/DENTAL AGENTS Throat Products - Misc. Anesthetics Topical Oral cevimeline hcl caps 1

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117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EVOXAC CAPS UDAMIN SP TABS GP (cevimeline hcl) (multiple vitamins w/ 3 GELCLAIR GEL minerals & folic acid) (povidone-sodium 3 Ped MV w/ Fluoride hyaluronate- (Pediatric Multivitamins AL(Up to 6 yrs glycyrrhetinic acid) W/Fl) MULTI- 1 old ) MUCOTROL WAFR ( VITAMIN/FLUORIDE oral 3 wound care products) DROPS SOLN ORAFATE PSTE (Pediatric Multivitamins AL(Up to 6 yrs 3 W/Fl) MULTIVITAMIN old ) (sucralfate-malate) WITH FLUORIDE CHEW 0.25 MG-15 UNIT-400 pilocarpine hcl (oral) 1 tabs UNIT-2500 UNIT-1.2 MG- 4.5 MCG-13.5 MG-1.05 PROTHELIAL PSTE 3 MG-0.3 MG-1.05 MG-60 (sucralfate-malate) MG, 0.5 MG-15 UNIT-400 1 SALAGEN TABS UNIT-2500 UNIT-1.2 MG- GP (pilocarpine hcl (oral)) 4.5 MCG-13.5 MG-1.05 MG-0.3 MG-1.05 MG-60 MULTIVITAMINS MG, 1 MG-15 UNIT-400 UNIT-2500 UNIT-1.2 MG- Multiple Vitamins & Fluoride-Folic Acid 4.5 MCG-13.5 MG-1.05 MULTIVITAMIN WITH AL(Up to 6 yrs MG-0.3 MG-1.05 MG-60 FLUORIDE CHEW 0.25 old ) MG MG-15 UNIT-400 UNIT- (Pediatric Multivitamins AL(Up to 6 yrs 2500 UNIT-1.2 MG-4.5 W/Fl) MULTIVITAMIN old ) MCG-1.05 MG-13.5 MG- WITH FLUORIDE SOLN 1.05 MG-0.3 MG-60 MG, 0.25 MG/ML-0.6 MG/ML-8 0.5 MG-15 UNIT-400 MG/ML-1500 UNIT/ML-2 UNIT-2500 UNIT-1.2 MG- 2 MCG/ML-400 UNIT/ML-0.5 4.5 MCG-1.05 MG-13.5 MG/ML-5 UNIT/ML-0.4 MG-1.05 MG-0.3 MG-60 MG/ML-35 MG/ML, 0.5 MG, 1 MG-15 UNIT-400 MG/ML-0.6 MG/ML-8 UNIT-2500 UNIT-1.2 MG- MG/ML-1500 UNIT/ML-2 4.5 MCG-1.05 MG-13.5 MCG/ML-400 UNIT/ML-0.5 MG-1.05 MG-0.3 MG-60 MG/ML-5 UNIT/ML-0.4 1 MG (multiple vitamins & MG/ML-35 MG/ML, 5 fluoride-folic acid) UNIT/ML-0.5 MG/ML-0.6 MG/ML-8 MG/ML-1500 Multiple Vitamins w/ Minerals UNIT/ML-2 MCG/ML-400 ONEVITE TABS (multiple UNIT/ML-0.5 MG/ML-0.4 vitamins w/ minerals & 3 MG/ML-35 MG/ML, 5 folic acid) UNIT/ML-0.25 MG/ML-0.6 MG/ML-8 MG/ML-1500 THRIVITE 19 TABS UNIT/ML-2 MCG/ML-400 (multiple vitamins w/ 3 UNIT/ML-0.5 MG/ML-0.4 minerals & folic acid) MG/ML-35 MG/ML

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118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Multivitamins 1 bal on (Pediatric Multivitamins AL(Up to 6 yrs W/Fl) hand,AL(Up to W/Fl) old ) MULTIVITAMIN/FLUORID 6 yrs old ) MULTIVITAMIN/FLUORID E CHEW 0.25 MG-2500 E CHEW 15 UNIT-1 MG- UNIT-13.5 MG-1.2 MG-4.5 2500 UNIT-13.5 MG-1.2 MCG-400 UNIT-1.05 MG- MG-4.5 MCG-400 UNIT- 0.3 MG-15 UNIT-1.05 MG- 1.05 MG-0.3 MG-1.05 MG- 60 MG, 0.5 MG-2500 60 MG, 2500 UNIT-1 MG- UNIT-13.5 MG-1.2 MG-4.5 15 UNIT-400 UNIT-1.2 MG- MCG-400 UNIT-1.05 MG- 4.5 MCG-1.05 MG-13.5 0.3 MG-15 UNIT-1.05 MG- MG-1.05 MG-300 MCG-60 60 MG, 1 MG-2500 UNIT- MG, 15 UNIT-0.5 MG-2500 13.5 MG-1.2 MG-4.5 MCG- UNIT-13.5 MG-1.2 MG-4.5 400 UNIT-1.05 MG-0.3 MCG-400 UNIT-1.05 MG- 1 MG-15 UNIT-1.05 MG-60 0.3 MG-1.05 MG-60 MG, MG, 2500 UNIT-1 MG-15 15 UNIT-0.25 MG-2500 UNIT-400 UNIT-1.2 MG- UNIT-13.5 MG-1.2 MG-4.5 4.5 MCG-1.05 MG-13.5 1 MCG-400 UNIT-1.05 MG- MG-1.05 MG-300 MCG-60 0.3 MG-1.05 MG-60 MG, MG, 15 UNIT-0.5 MG-2500 2500 UNIT-0.5 MG-15 UNIT-13.5 MG-1.2 MG-4.5 UNIT-400 UNIT-1.2 MG-4.5 MCG-400 UNIT-1.05 MG- MCG-1.05 MG-13.5 MG- 0.3 MG-1.05 MG-60 MG, 1.05 MG-300 MCG-60 MG, 15 UNIT-0.25 MG-2500 2500 UNIT-0.25 MG-15 UNIT-13.5 MG-1.2 MG-4.5 UNIT-400 UNIT-1.2 MG-4.5 MCG-400 UNIT-1.05 MG- MCG-1.05 MG-13.5 MG- 0.3 MG-1.05 MG-60 MG, 1.05 MG-300 MCG-60 MG 2500 UNIT-0.5 MG-15 (Pediatric Multivitamins AL(Up to 6 yrs UNIT-400 UNIT-1.2 MG- W/Fl) old ) 4.5 MCG-1.05 MG-13.5 MULTIVITAMIN/FLUORID MG-1.05 MG-300 MCG-60 E SOLN 0.25 MG/ML-5 MG, 2500 UNIT-0.25 MG- UNIT/ML-0.6 MG/ML-8 15 UNIT-400 UNIT-1.2 MG/ML-1500 UNIT/ML-2 MG-4.5 MCG-1.05 MG- MCG/ML-400 UNIT/ML-0.5 1 13.5 MG-1.05 MG-300 MG/ML-0.4 MG/ML-35 MCG-60 MG MG/ML, 0.5 MG/ML-5 UNIT/ML-0.6 MG/ML-8 MG/ML-1500 UNIT/ML-2 MCG/ML-400 UNIT/ML-0.5 MG/ML-0.4 MG/ML-35 MG/ML (Pediatric Multivitamins AL(Up to 6 yrs W/Fl) old ) MULTIVITAMINS/FLUORI 1 DE, MVC-FLUORIDE CHEW (Pediatric Vitamins Acd W/ AL(Up to 6 yrs Fluoride) TRI- 1 old ) VITAMIN/FLUORIDE, TRI- VITE/FLUORIDE SOLN

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119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLORIVA PLUS SOLN AL(Up to 6 yrs POLY-VI-FLOR/IRON AL(Up to 6 yrs (pediatric multivitamins 2 old ) CHEW 200 MCG-0.5 MG- old ) w/fl) 10 MG-15 UNIT-400 UNIT 3 (ped multivitamins w/fl pediatric vitamins acd AL(Up to 6 yrs 1 & iron) w/ fluoride soln old ) POLY-VI-FLOR/IRON POLY-VI-FLOR CHEW 200 AL(Up to 6 yrs SUSP 200 MCG/ML-7 MCG-1 MG-15 UNIT-400 old ) UNIT, 200 MCG-0.5 MG-15 MG/ML-0.25 MG/ML (ped 3 UNIT-400 UNIT, 200 MCG- 3 multivitamins w/fl & 0.25 MG-15 UNIT-400 iron) UNIT (pediatric Prenatal Vitamins multivitamins w/fl) (Prenatal Vit W/ - 1 bal on hand, POLY-VI-FLOR SUSP 200 Fe Fumarate-Folic Acid) MCG/ML-0.25 MG/ML PRENATAL 19 TABS 1000 3 (pediatric multivitamins UNIT-30 UNIT-20 MG-25 1 w/fl) MG-3 MG-200 MG-29 MG- 15 MG-3 MG-7 MG-12 QUFLORA GUMMIES AL(Up to 6 yrs MCG-400 UNIT-20 MG-1 CHEW (pediatric 2 old ) MG-100 MG multivitamins w/fl) (Prenatal Vit W/ Docusate- 1 bal on hand, QUFLORA PEDIATRIC AL(Up to 6 yrs Iron Carbonyl-Folic Acid) 1 CHEW (pediatric 2 old ) INATAL GT TABS multivitamins w/fl) (Prenatal Vit W/ Ferrous 1 bal on hand, QUFLORA PEDIATRIC AL(Up to 6 yrs Fumarate-Folic Acid) SOLN (pediatric 2 old ) PRENATAL 19 CHEW 1000 UNIT-400 UNIT-20 1 multivitamins w/fl) MG-25 MG-3 MG-200 MG- TRI-VI-FLOR SUSP 29 MG-7 MG-6 MG-3 MG- (pediatric vitamins acd 12 MCG-1 MG-30 UNIT-20 & l-methylfolate w/ 3 MG-100 MG fluoride) (Prenatal Vit W/ Ferrous 1 bal on hand, TRI-VI-FLORO SUSP Fumarate-L Methylfolate- 1 Folic Acid) PNV-SELECT (pediatric vitamins acd 3 TABS & l-methylfolate w/ (Prenatal Vit W/ Iron 1 bal on hand, fluoride) Carbonyl-Folic Acid) 1 Ped Multi Vitamins w/Fl & FE PRENATABS RX TABS (Ped Multivitamins W/Fl & (Prenatal Without A W/ Fe 1 bal on hand, Iron) MULTI- Fumarate-L Methylfolate- 1 VIT/IRON/FLUORIDE, Fa-Dha) PNV-DHA CAPS MULTIVITAMIN/FLUORID 1 ATABEX EC TBEC E/IRON, MULTI- (prenatal vit w/ VITAMIN/FLUORIDE/IRON docusate-iron carbonyl- 2 SOLN folic acid)

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120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATABEX OB TABS CITRANATAL MEDLEY (prenatal vit w/ fe CAPS (prenatal w/o vit bisglycinate chelate- 2 a w/ fe fumarate-fe 3 folic acid) carbonyl-fa-dha) BAL-CARE DHA MISC CITRANATAL RX TABS (prenatal w/fe (prenatal without vit a polysacch cmplx-sod 2 w/ fe carbonyl-fe gluc- 3 feredetate-fa-omega 3) docusate-fa) C-NATE DHA CAPS COMPLETENATE CHEW (prenatal vit w/ ferrous (prenatal vit w/ ferrous 2 3 fumarate-fa-omega 3 fumarate-folic acid) fatty acids) CONCEPT DHA CAPS CITRANATAL 90 DHA (prenatal vit w/ fe fum- 2 MISC (prenatal w/o vit a iron polysacch complex 2 w/ fe carbonyl-fe -fa-omega 3) gluconate-dss-fa-dha) CONCEPT OB CAPS CITRANATAL ASSURE (prenatal without a vit 2 MISC (prenatal w/o vit a w/ fe fum-iron 2 w/ fe carbonyl-fe polysacch complex -fa) gluconate-dss-fa-dha) CVS PRENATAL TABS CITRANATAL B-CALM (prenatal vit w/ ferrous 2 MISC (prenatal w/o vit a fumarate-folic acid) 3 w/ fe carbonyl-fe DOTHELLE DHA CAPS gluconate-fa & vit b6) (prenatal vit w/ fe fum- 2 CITRANATAL BLOOM iron polysacch complex DHA MISC (prenatal w/o -fa-omega 3) 2 vit a w/ fe carbonyl-fe DUET DHA 400 MISC gluconate-dss-fa-dha) (prenatal w/fe 3 CITRANATAL BLOOM polysacch cmplx-sod TABS (prenatal vit w/ feredetate-fa-omega 3) 3 docusate-fe carbonyl-fe DUET DHA BALANCED gluconate-folic acid) MISC (prenatal w/fe 3 CITRANATAL DHA MISC polysacch cmplx-sod (prenatal w/o vit a w/ fe feredetate-fa-omega 3) 2 carbonyl-fe gluconate- ENBRACE HR CAPS dss-fa-dha) (prenatal vit w/ fe 3 CITRANATAL HARMONY cysteinate-fa- CAPS (prenatal w/o vit omega 3 fatty acids) 3 a w/ fe fumarate-fe FOLET DHA THPK carbonyl-dss-fa-dha) (prenatal vit w/fe carbonyl-fe bisglyc- 3 methylfol-dss & dha)

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121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOLET ONE CAPS MYNATAL ULTRACAPLET (prenatal w/o a w/fe TABS (prenatal vit w/ carbonyl-fe bisglyc-l 3 docusate-iron carbonyl- 2 methylfol-dss-dha) folic acid) FOLIVANE-OB CAPS MYNATE 90 PLUS TBCR (prenatal without a vit (prenatal vit w/ w/ fe fum-iron 2 docusate-fe fumarate- 2 polysacch complex -fa) folic acid) HEMENATAL OB + DHA NATACHEW CHEW MISC (prenatal vit w/ fe (prenatal vit w/ fe fum- poly cmplx-fe heme 2 fe bisglycinate chelate- 3 polypept-fa & omega 3) folic acid) HEMENATAL OB TABS NATELLE ONE CAPS (prenatal vit w/ fe (prenatal without vit a polysacch complex-fe 3 w/ fe fum-fa-omega 3 heme polypeptide-fa) fatty acids) INFANATE BALANCE NEEVO DHA CAPS CAPS (prenatal w/o vit (prenatal without vit a a w/ fe carbonyl-dss-fa- 3 w/ fe fumarate-l 3 dha) methylfolate-omegas) KOSHER PRENATAL NEONATAL COMPLETE RX/OTC PLUS IRON TABS TABS ( 3 prenatal vit w/ (prenatal vit w/ iron ferrous fumarate-folic 2 carbonyl-folic acid) acid) M-NATAL PLUS TABS RX/OTC NEONATAL PLUS TABS RX/OTC (prenatal vit w/ ferrous 2 (prenatal vit w/ ferrous 2 fumarate-folic acid) fumarate-folic acid) M-VIT TABS (prenatal vit RX/OTC NEONATAL VITAMIN w/ ferrous fumarate- 2 TABS (prenatal vit w/ 2 folic acid) ferrous fumarate-folic MARNATAL-F CAPS acid) (prenatal without vit a NESTABS DHA MISC 2 w/ iron polysaccharide (prenatal vit without vit 2 complex-fa) a w/ fe bisglycinate-fa- MULTI PRENATAL TABS omeg 3) (prenatal vit w/ ferrous 2 NESTABS ONE CAPS fumarate-folic acid) (prenatal w/o a w/fe 3 MYNATAL ADVANCE carbonyl-fe bisglyc-l TABS (prenatal vit w/ methylfol-dha) 2 docusate-iron carbonyl- NESTABS TABS folic acid) (prenatal vit without vit a w/ fe bisglycinate-folic 3 acid)

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122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEXA PLUS CAPS PNV TABS 29-1 TABS (prenatal w/o vit a w/fe (prenatal vit w/ iron 3 3 fumarate-docusate ca- carbonyl-folic acid) folic acid-dha) PNV-DHA+DOCUSATE NIVA-PLUS TABS RX/OTC CAPS (prenatal w/o vit 3 (prenatal vit w/ ferrous 2 a w/ fe fumarate-dss-fa- fumarate-folic acid) dha) O-CAL FA TABS RX/OTC PNV-OMEGA CAPS (prenatal vit w/ ferrous 2 (prenatal without a w/ fumarate-folic acid) fe fumarate-l 3 OB COMPLETE ONE methylfolate-fa-omega CAPS (prenatal w/o vit 3) 3 a w/ fe carbonyl-fe PNV-TOTAL CAPS aspart glyc-fa-fish oil) (prenatal vit w/ fe 3 OB COMPLETE PETITE carbonyl-fe CAPS (prenatal w/o vit bisglycinate-fa-fish oil) 3 a w/ fe carbonyl-fe PR NATAL 400 EC MISC aspart glyc-fa-omega 3) (prenatal mv & min w/fe 2 OB COMPLETE PREMIER bisglyc-fe prot succ-fa- TABS (prenatal vit w/ ca-omega 3) 3 iron carbonyl-fe aspart PR NATAL 430 EC MISC glycinate-fa) (prenatal mv & min w/fe 3 OB COMPLETE/DHA bisglyc-fe prot succ-fa- CAPS (prenat vit w/ iron ca-omega 3) 3 carbonyl-fe asp glyc-fa- PR NATAL 430 MISC omega fatty acid) (prenatal mv & min w/fe 3 OBSTETRIX ONE CAPS bisglyc-fe prot succ-fa- (prenatal w/o a w/fe ca-omega 3) 3 carbonyl-fe bisglyc-l PREFERAOB +DHA MISC methylfol-dss-dha) (prenatal vit w/ fe PNV FOLIC ACID + IRON RX/OTC polysacch cmplx-fe 3 MULTIVITAMIN TABS heme polypept-fa & 2 (prenatal vit w/ ferrous dha) fumarate-folic acid) PRENA 1 TRUE MISC PNV OB+DHA MISC (prenatal without a w/ 3 (prenatal w/o vit a w/ fe fe chelate- 2 carbonyl-fe gluconate- fa-dha) dss-fa-dha) PRENA1 PEARL CPCR PNV PRENATAL PLUS RX/OTC (prenatal without a w/ MULTIVITAMIN TABS 3 2 fe fumarate-sod (prenatal vit w/ ferrous feredetate-fa-dha) fumarate-folic acid)

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123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENAISSANCE PRENATAL LOW IRON BALANCE CAPS TABS ( 3 prenatal vit w/ (prenatal w/o vit a w/ fe ferrous fumarate-folic 2 carbonyl-dss-fa-dha) acid) PRENAISSANCE CAPS PRENATAL ONE DAILY (prenatal w/o vit a w/ fe 3 TABS (prenatal vit w/ fumarate-dss-fa-dha) ferrous fumarate-folic 2 PRENAISSANCE acid) HARMONY DHA MISC PRENATAL PLUS IRON (prenatal w/fe 3 TABS (prenatal vit w/ 3 polysacch cmplx-sod iron carbonyl-folic acid) feredetate-fa-omega 3) PRENATAL PLUS TABS RX/OTC PRENAISSANCE NEXT (prenatal vit w/ ferrous 2 TABS (prenatal w/ 3 fumarate-folic acid) calcium-vit b6-folic PRENATAL TABS 11 acid-) UNIT-263 MG-25 MG-1.5 PRENAISSANCE NEXT-B MG-27 MG-4000 UNIT-18 TABS (prenatal w/ MG-1.7 MG-4 MCG-400 calcium-vit b6-folic 3 UNIT-0.8 MG-2.6 MG-100 ) MG, 160 MG-11 UNIT-200 acid-ginger MG-25 MG-1.84 MG-27 2 PRENAISSANCE PLUS MG-4000 UNIT-18 MG-1.7 CAPS (prenatal w/o vit MG-4 MCG-400 UNIT-800 a w/ fe carbonyl-dss-fa- 3 MCG-2.6 MG-100 MG dha) (prenatal vit w/ ferrous PRENATA CHEW fumarate-folic acid) (prenatal without a vit PRENATAL TABS 22 MG- RX/OTC w/ fe fumarate-folic 2 2 MG-25 MG-1.84 MG-200 ) MG-27 MG-4000 UNIT-20 acid MG-3 MG-12 MCG-400 PRENATAL 19 CHEW 30 UNIT-1 MG-10 MG-120 UNIT-1000 UNIT-20 MG-3 MG, 160 MG-11 UNIT-200 MG-200 MG-29 MG-7 MG- MG-25 MG-1.84 MG-27 2 15 MG-3 MG-12 MCG-400 MG-4000 UNIT-18 MG-1.7 UNIT-1 MG-20 MG-100 2 MG-4 MCG-400 UNIT-800 MG (prenatal vit w/ MCG-2.6 MG-100 MG ferrous fumarate-folic (prenatal vit w/ ferrous acid) fumarate-folic acid) PRENATAL 19 TABS 30 PRENATAL VITAMIN UNIT-1000 UNIT-20 MG- TABS (prenatal vit w/ 25 MG-3 MG-200 MG-29 ferrous fumarate-folic 2 MG-7 MG-15 MG-3 MG-12 MCG-400 UNIT-1 MG-20 3 acid) MG-100 MG (prenatal vit PRENATAL VITAMINS RX/OTC PLUS LOW IRON TABS w/ docusate-fe 2 fumarate-folic acid) (prenatal vit w/ ferrous fumarate-folic acid)

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124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL-U CAPS PRIMACARE CAPS (prenatal without a vit (prenatal without a w/ 2 w/ fe fumarate-folic fe asp glyc-l 3 acid) methylfolate-fa-omega PRENATE CHEW 3) (prenatal multivitamins PROVIDA DHA CAPS 3 & minerals w/ l- (prenatal without a w/fe 3 methylfolate-fa) fum-fe polysacch PRENATE DHA CAPS complex-fa-dha) (prenatal w/o a w/ fe RELNATE DHA CAPS 3 asparto glyc-l (prenatal vit w/ ferrous 3 methylfolate-fa-dha) fumarate-fa-omega 3 PRENATE ELITE TABS fatty acids) (prenatal w/ fe asparto RIGHT STEP PRENATAL 3 glycinate-l methylfolate- TABS (prenatal vit w/ 2 folic acid) ferrous fumarate-folic PRENATE ENHANCE acid) CAPS (prenatal without SE-NATAL 19 CHEW 30 a w/ fe fumarate-l 3 UNIT-1000 UNIT-100 MG- methylfolate-fa-dha) 20 MG-3 MG-200 MG-29 MG-7 MG-15 MG-3 MG-12 PRENATE ESSENTIAL MCG-400 UNIT-1 MG-20 2 CAPS (prenatal w/o a 3 MG (prenatal vit w/ w/ fe asparto glyc-l ferrous fumarate-folic methylfolate-fa-dha) acid) PRENATE MINI CAPS SE-NATAL 19 TABS 30 (prenatal w/o vit a w/ fe 3 UNIT-1000 UNIT-20 MG-25 carbonyl-fe asp glyc- MG-200 MG-29 MG-7 MG- methfol-fa-dha) 15 MG-3 MG-12 MCG-400 3 PRENATE PIXIE CAPS UNIT-3 MG-20 MG-1 MG- (prenatal w/o a w/ fe 100 MG (prenatal vit w/ asparto glyc-l 3 docusate-fe fumarate- methylfolate-fa-dha) folic acid) PRENATE RESTORE SELECT-OB CHEW 1700 UNIT-29 MG-30 UNIT-15 CAPS (prenatal without 3 MG-25 MG-1.6 MG-15 MG- a w/ fe fumarate-l 1.8 MG-5 MCG-400 UNIT-1 methylfolate-fa-dha) MG-2.5 MG-60 MG 3 PREPLUS TABS RX/OTC (prenatal vit w/ iron (prenatal vit w/ ferrous 2 polysaccharide fumarate-folic acid) complex-folic acid) SELECT-OB+DHA MISC (prenatal mv & min w/fe polysaccharide 3 complex-fa-dha)

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125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TARON-BC MISC TRISTART DHA CAPS (prenatal without vit a (prenatal without a w/ w/ iron carbonyl-folic 3 fe carbonyl-l 3 acid & vit b6) methylfolate-fa-dha) TARON-C DHA CAPS TRISTART ONE CAPS (prenatal vit w/ fe fum- (prenatal without a w/ iron polysacch complex 2 fe carbonyl-l 3 -fa-omega 3) methylfolate-fa-dha) TARON-PREX CAPS ULTIMATECARE ONE (prenatal w/o vit a w/ fe 3 CAPS (prenatal vit w/ 3 fumarate-dss-fa-dha) iron carbonyl-fe aspart THERANATAL CORE RX/OTC glyc-fa-omega 3) NUTRITION TABS VENA-BAL DHA MISC 2 (prenatal vit w/ ferrous (prenatal w/fe fumarate-folic acid) polysacch cmplx-sod 2 THRIVITE RX TABS feredetate-fa-omega 3) (prenatal vit w/ iron 3 VIL-RX TABS (prenatal carbonyl-folic acid) vit w/ iron carbonyl-folic 3 TL FOLATE TABS acid) (prenatal vit w/ ferrous 2 VINATE DHA RF CAPS fumarate-l methylfolate- (prenatal without vit a folic acid) w/ fe fumarate-l 3 TL-CARE DHA CAPS methylfolate-omegas) (prenatal w/fe 3 VINATE II TABS fumarate-fa-dss-fish oil) (prenatal vit w/ fe TL-SELECT CAPS bisglycinate chelate- 2 (prenatal w/o vit a w/ fe 3 folic acid) fumarate-dss-fa-dha) VIRT-C DHA CAPS TRI-TABS DHA MISC (prenatal vit w/ fe fum- (prenatal vit without vit 2 2 iron polysacch complex a w/ fe bisglycinate-fa- -fa-omega 3) omeg 3) VIRT-NATE DHA CAPS TRICARE PRENATAL (prenatal vit w/ ferrous DHA ONE CAPS 3 3 fumarate-fa-omega 3 (prenatal w/fe fatty acids) fumarate-fa-dss-fish oil) VIRT-PN DHA CAPS TRICARE PRENATAL (prenatal without a w/ DHA ONE/FOLATE CAPS 3 2 fe fumarate-l (prenatal multivit-min methylfolate-fa-dha) w/fe-fa) TRICARE TABS RX/OTC (prenatal vit w/ ferrous 2 fumarate-folic acid)

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126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIRT-PN PLUS CAPS VITATHELY/GINGER RX/OTC (prenatal without a w/ TABS (prenatal vit w/ 2 fe fumarate-l 3 ferrous fumarate-folic methylfolate-fa-omega acid) 3) VITATRUE MISC (prenatal without a w/ VIRT-PN TABS (prenatal 3 vit w/ ferrous fumarate-l 3 fe amino acid chelate- methylfolate-folic acid) fa-dha) VITAFOL FE+ CPPK 415 VIVA DHA CAPS MG-0.6 MG-90 MG-20 (prenatal vit w/ ferrous UNIT-150 MCG-1100 fumarate-fa-omega 3 3 UNIT-200 MG-2 MG-25 fatty acids) MG-20 MG-50 MG-15 MG- VOL-PLUS TABS RX/OTC 1.8 MG-25 MCG-1000 3 UNIT-1.6 MG-0.4 MG-2.5 (prenatal vit w/ ferrous 2 MG-60 MG (prenatal vit fumarate-folic acid) w/ fe polysacch VOL-TAB RX TABS complex-l methylfol-fa- (prenatal vit w/ iron 3 dha-dss) carbonyl-folic acid) VITAFOL GUMMIES VP-GGR-B6 PRENATAL CHEW (prenatal vit w/ TABS (prenatal w/ ferric phosphate-fa- 3 calcium-vit b6-folic 3 omega 3 fatty acids) acid-ginger) VITAFOL ULTRA CAPS VP-HEME OB + DHA MISC (prenatal vit w/ fe (prenatal vit w/ fe poly polysacch complex-l 2 cmplx-fe heme 2 methylfolate-fa-dha) polypept-fa & omega 3) VITAFOL-NANO TABS VP-HEME OB TABS (prenatal w/o a vit w/ fe (prenatal vit w/ fe fumarate-l methylfolate- 3 polysacch complex-fe 3 folic acid) heme polypeptide-fa) VITAFOL-ONE CAPS VP-PNV-DHA CAPS (prenatal mv & min w/fe (prenatal vit w/ ferrous polysaccharide 3 fumarate-fa-omega 3 3 complex-fa-dha) fatty acids) VITAMEDMD ONE ZATEAN-PN DHA CAPS RX/QUATREFOLIC CAPS (prenatal without a w/ 3 (prenatal without a w/ 3 fe fumarate-l fe fumarate-l methylfolate-fa-dha) methylfolate-fa-dha) ZATEAN-PN PLUS CAPS VITAPEARL CPCR (prenatal without a w/ (prenatal without a w/ 3 fe fumarate-l 3 fe fumarate-sod methylfolate-fa-omega feredetate-fa-dha) 3)

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127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MUSCULOSKELETAL THERAPY AGENTS - orphenadrine citrate 1 Drugs to Treat Spasms tb12 ROBAXIN TABS Central Muscle Relaxants GP (methocarbamol) (Carisoprodol) VANADOM 1 TABS ROBAXIN-750 TABS GP (methocarbamol) (Chlorzoxazone) 1 LORZONE TABS SKELAXIN TABS GP (Cyclobenzaprine Hcl) 1 1 bal on hand, (metaxalone) FEXMID TABS SOMA TABS GP (Metaxalone) METAXALL 1 (carisoprodol) TABS AMRIX CP24 ST; QL(1 ea tizanidine hcl caps 1 GP (cyclobenzaprine hcl) daily) tizanidine hcl tabs 1 baclofen soln it 500 PA SP ZANAFLEX CAPS mcg/ml GP baclofen tabs or 10 mg, (tizanidine hcl) 1 ZANAFLEX TABS 20 mg GP 1 bal on hand, (tizanidine hcl) baclofen tabs or 5 mg, 1 20 mg Direct Muscle Relaxants DANTRIUM CAPS 1 GP carisoprodol tabs (dantrolene sodium) CHLORZOXAZONE TABS 3 dantrolene sodium 1 250 MG (chlorzoxazone) caps chlorzoxazone tabs Combinations 375 mg, 500 mg, 750 1 carisoprodol w/ aspirin mg 1 & codeine tabs cyclobenzaprine hcl ST; QL(1 ea 1 carisoprodol w/ aspirin 1 bal on hand, cp24 15 mg, 30 mg daily) 1 & codeine tabs cyclobenzaprine hcl carisoprodol w/ aspirin tabs 5 mg, 10 mg, 7.5 1 1 tabs mg 1 bal on hand, GABLOFEN SOLN PA carisoprodol w/ aspirin 1 SP (baclofen) tabs LIORESAL INTRATHECAL PA NORGESIC FORTE TABS 1 bal on hand, SOLN 0.05 MG/ML, 10 SP (orphenadrine w/ NF MG/5ML (baclofen) aspirin & caff) LIORESAL INTRATHECAL PA orphenadrine w/ aspirin SOLN 10 MG/20ML SP & caff tabs 25 mg-30 1 (baclofen) mg-385 mg metaxalone tabs 1 NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus methocarbamol tabs 1 Nasal Agent Combinations

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128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azelastine hcl- Limit 1 inhaler (Fluticasone Propionate Limit 2 inhalers 1 per (Nasal)) ALLERGY NASAL per fluticasone propionate month;QL(0.77 SPRAY 24 HOUR, SM month;QL(1.1 susp gm daily) ALLERGY RELIEF NASAL ml daily); Limit 1 inhaler SPRAY, QC RX/OTC DYMISTA SUSP FLUTICASONE ( GP per azelastine hcl- month;QL(0.77 PROPIONATE, QC fluticasone propionate) gm daily) ALLERGY RELIEF, KP FLUTICASONE Nasal Anti-infectives PROPIONATE, KLS BACTROBAN NASAL ALLER-FLO, HM OINT (mupirocin 2 ALLERGY RELIEF NASAL calcium) SPRAY 24HR, GNP FLUTICASONE 1 Nasal Antiallergy PROPIONATE ASTEPRO SOLN QL(1 ml daily) CHILDRENS, GNP NF (azelastine hcl) FLUTICASONE PROPIONATE, EQL Limit 1 inhaler FLUTICASONE azelastine hcl soln 0.1 1 per PROPIONATE %, 137 mcg/spray month;QL(1.2 CHILDRENS, EQL ml daily) FLUTICASONE QL(1 ml daily) PROPIONATE, CVS azelastine hcl soln 0.15 1 %, 137 mcg/spray FLUTICASONE PROPRIONATE NASAL olopatadine hcl (nasal) 1 SPRAY, CLARISPRAY, soln ALLERGY RELIEF SUSP PATANASE SOLN (Fluticasone Propionate Limit 2 inhalers (olopatadine hcl GP per (Nasal)) EQ ALLERGY 1 month;QL(1.1 (nasal)) RELIEF SUSP NA 50 MCG/ACT ml daily); Nasal Anticholinergics RX/OTC ipratropium bromide 1 BECONASE AQ SUSP Limit 2 inhalers (nasal) soln ( 3 per beclomethasone month;QL(1.67 Nasal Steroids diprop monohyd) gm daily) (Budesonide (Nasal)) CVS Limit 2 inhalers Limit 2 inhalers BUDESONIDE NASAL per budesonide (nasal) 1 per SPRAY, RHINOCORT month;QL(0.6 susp month;QL(0.6 ALLERGY, RA ml daily) ml daily) BUDESONIDE NASAL 1 SPRAY, GNP FLONASE ALLERGY Limit 2 inhalers BUDESONIDE NASAL RELIEF CHILDRENS per SPRAY, EQ BUDESONIDE SUSP (fluticasone GP month;QL(1.1 NASAL SPRAY SUSP ml daily); propionate (nasal)) RX/OTC FLONASE ALLERGY Limit 2 inhalers RELIEF SUSP per ( GP month;QL(1.1 fluticasone propionate ml daily); (nasal)) RX/OTC

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129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLONASE SENSIMIST Limit 1 inhaler Artificial Tears and Lubricants per SUSP (fluticasone 3 LACRISERT INST month;QL(0.34 3 furoate) ml daily) (artificial tear insert) flunisolide (nasal) soln 1 1 bal on hand, Beta-blockers - Ophthalmic BETAGAN SOLN 3 Limit 2 inhalers (levobunolol hcl) fluticasone propionate per 1 month;QL(1.1 betaxolol hcl (ophth) 1 (nasal) susp ml daily); soln RX/OTC BETIMOL SOLN (timolol) 2 Limit 2 inhalers mometasone furoate per BETOPTIC-S SUSP 1 2 (nasal) susp month;QL(1.14 (betaxolol hcl (ophth)) gm daily) 1 bal on hand, carteolol hcl (ophth) 1 NASONEX SUSP Limit 2 inhalers soln ( GP per mometasone furoate month;QL(1.14 COMBIGAN SOLN (nasal)) gm daily) (brimonidine tartrate- 3 Limit 1 inhaler timolol maleate) OMNARIS SUSP 3 per COSOPT PF SOLN (ciclesonide (nasal)) month;QL(0.42 (dorzolamide hcl-timolol GP gm daily) maleate) Limit 1 inhaler QNASL AERS COSOPT SOLN ( 3 per beclomethasone month;QL(0.29 (dorzolamide hcl-timolol 3 dipropionate (nasal)) gm daily) maleate) QNASL CHILDRENS Limit 1 inhaler dorzolamide hcl-timolol AERS ( 3 per maleate soln 2 %-0.5 beclomethasone month;QL(0.17 1 dipropionate (nasal)) %, 20 mg/ml-5 mg/ml, gm daily) 22.3 mg/ml-6.8 mg/ml Limit 1 inhaler ZETONNA AERS dorzolamide hcl-timolol 1 bal on hand, 3 per (ciclesonide (nasal)) month;QL(0.3 maleate soln 2 %-0.5 1 gm daily) %, 20 mg/ml-5 mg/ml, NEUROMUSCULAR AGENTS - Drugs to 22.3 mg/ml-6.8 mg/ml Relax/Paralyze Muscles ISTALOL SOLN ( timolol GP ALS Agents maleate (ophth)) RILUTEK TABS (riluzole) GP levobunolol hcl soln 1 1 bal on hand, riluzole tabs 1 levobunolol hcl soln 1 Neuromuscular Blocking Agent - Neurotoxins metipranolol soln 1 1 bal on hand, BOTOX SOLR PA 1 bal on hand, SP timolol maleate (ophth) 1 (onabotulinumtoxina) solg 0.25 %, 0.5 % OPHTHALMIC AGENTS - Drugs to Treat the Eye

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130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PHOSPHOLINE IODIDE timolol maleate (ophth) 1 soln 0.25 %, 0.5 % SOLR (echothiophate 2 TIMOPTIC OCUDOSE iodide) SOLN 0.25 % (timolol 2 pilocarpine hcl soln 1 maleate (ophth)) TIMOPTIC OCUDOSE Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % SOLN 0.5 % (timolol 3 2 maleate (ophth)) (brimonidine tartrate) TIMOPTIC SOLN ( ALPHAGAN P SOLN 0.15 timolol GP GP maleate (ophth)) % (brimonidine tartrate) TIMOPTIC-XE SOLG 1 bal on hand, apraclonidine hcl soln 1 (timolol maleate GP (ophth)) brimonidine tartrate 1 soln Cycloplegic Mydriatics IOPIDINE SOLN 0.5 % GP (Homatropine Hbr) 1 1 bal on hand, (apraclonidine hcl) HOMATROPAIRE SOLN IOPIDINE SOLN 1 % (Phenylephrine Hcl 3 (Mydriatic)) ALTAFRIN 1 (apraclonidine hcl) SOLN SIMBRINZA SUSP ATROPINE SULFATE (brinzolamide- 3 SOLN OP 1 % (atropine 2 brimonidine tartrate) sulfate (ophthalmic)) Ophthalmic Anti-infectives CYCLOGYL SOLN GP (Bacitracin-Polymyxin B (cyclopentolate hcl) (Ophth)) AK-POLY-BAC, 1 CYCLOMYDRIL SOLN POLYCIN OINT (cyclopentolate w/ 3 (Erythromycin (Ophth)) 1 phenylephrine) ILOTYCIN OINT (Gentamicin Sulfate 1 1 bal on hand, cyclopentolate hcl soln 1 (Ophth)) GENTAK OINT (Neomycin-Bacitracin Zn- homatropine hbr soln 1 Polymyxin) NEO-POLYCIN 1 ISOPTO ATROPINE SOLN OINT (atropine sulfate 2 AZASITE SOLN Limit 5mls per (ophthalmic)) 3 month;QL(0.17 (azithromycin (ophth)) ml daily) MYDRIACYL SOLN GP 1 bal on hand, (tropicamide) bacitracin (ophthalmic) 2 oint phenylephrine hcl 1 (mydriatic) soln bacitracin-polymyxin b 1 (ophth) oint tropicamide soln 1 BESIVANCE SUSP 3 Miotics (besifloxacin hcl) ISOPTO CARPINE SOLN GP (pilocarpine hcl)

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131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BETADINE OPHTHALMIC ofloxacin (ophth) soln 1 PREP SOLN (povidone- 3 iodine (ophth)) polymyxin b- 1 BLEPH-10 SOLN trimethoprim soln (sulfacetamide sodium GP POLYTRIM SOLN (ophth)) (polymyxin b- GP CILOXAN OINT trimethoprim) (ciprofloxacin hcl 2 POVIDONE IODINE SOLN (ophth)) (povidone-iodine 3 CILOXAN SOLN (ophth)) ( GP 1 bal on hand, ciprofloxacin hcl sulfacetamide sodium 1 (ophth)) (ophth) oint sulfacetamide sodium ciprofloxacin hcl 1 1 (ophth) soln (ophth) soln erythromycin (ophth) 1 tobramycin (ophth) soln 1 oint TOBREX OINT gatifloxacin (ophth) 2 1 (tobramycin (ophth)) soln TOBREX SOLN GP gentamicin sulfate 1 (tobramycin (ophth)) (ophth) soln trifluridine soln 1 1 bal on hand, KLARITY-A SOLN Limit 5mls per 3 month;QL(0.17 VIGAMOX SOLN (azithromycin (ophth)) ml daily) (moxifloxacin hcl NF levofloxacin (ophth) 1 (ophth)) soln VIROPTIC SOLN 3 MOXEZA SOLN (trifluridine) (moxifloxacin hcl GP ZIRGAN GEL 3 (ophth)) (ganciclovir ophthalmic) moxifloxacin hcl (ophth) ZYMAXID SOLN 1 GP soln (gatifloxacin (ophth)) NATACYN SUSP 2 Ophthalmic Immunomodulators () RESTASIS EMUL QL(2.14 ml 3 neomycin-bacitracin 1 (cyclosporine (ophth)) daily) zn-polymyxin oint RESTASIS MULTIDOSE QL(2.14 ml 1 bal on hand, neomycin-polymyxin- 1 EMUL (cyclosporine 3 daily) gramicidin soln (ophth)) NEOSPORIN SOLN Ophthalmic Antagonists (neomycin-polymyxin- 3 PA gramicidin) XIIDRA SOLN (lifitegrast) 3 OCUFLOX SOLN GP Ophthalmic Local Anesthetics (ofloxacin (ophth))

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132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tetracaine Hcl (Ophth)) FML LIQUIFILM SUSP ALTACAINE, TETRAVISC 1 ( GP FORTE, TETRAVISC, (ophth)) TETCAINE SOLN FML OINT AKTEN GEL ( lidocaine 3 (fluorometholone 2 hcl (ophth)) (ophth)) ALCAINE SOLN LOTEMAX GEL GP 3 (proparacaine hcl) (loteprednol etabonate) proparacaine hcl soln 1 LOTEMAX OINT 3 (loteprednol etabonate) tetracaine hcl (ophth) 1 LOTEMAX SUSP soln GP (loteprednol etabonate) Ophthalmic Nerve Growth Factors loteprednol etabonate OXERVATE SOLN PA 1 SP susp (-bkbj) MAXIDEX SUSP Ophthalmic Steroids (dexamethasone 2 (Bacitracin-Poly-Neomycin- QL(4 gm per fill (ophth)) Hc) NEO-POLYCIN HC 1 retail) MAXITROL OINT OINT (neomycin-polymy- GP ALREX SUSP 3 dexameth) (loteprednol etabonate) MAXITROL SUSP QL(4 gm per fill bacitracin-poly- ( 1 retail) neomycin-polymy- GP neomycin-hc oint dexameth) BLEPHAMIDE S.O.P. neomycin-polymy- 1 OINT (sulfacetamide 2 dexameth oint sod-prednisolone) neomycin-polymy- BLEPHAMIDE SUSP 1 dexameth susp (sulfacetamide sod- 2 1 bal on hand, prednisolone) neomycin-polymyxin-hc 1 dexamethasone 1 bal on hand, (ophth) susp sodium phosphate 1 OMNIPRED SUSP (ophth) soln (prednisolone acetate GP (ophth)) DUREZOL EMUL 3 (difluprednate) PRED FORTE SUSP (prednisolone acetate 2 FLAREX SUSP (ophth)) (fluorometholone 2 acetate) PRED FORTE SUSP 1 bal on hand, (prednisolone acetate NF fluorometholone 1 (ophth)) (ophth) susp PRED MILD SUSP FML FORTE SUSP (prednisolone acetate 2 ( fluorometholone 2 (ophth)) (ophth))

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133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRED-G S.O.P. OINT ACULAR SOLN (gentamicin- 3 (ketorolac GP prednisolone acetate) tromethamine (ophth)) PRED-G SUSP ACUVAIL SOLN (gentamicin- 3 (ketorolac 3 prednisolone acetate) tromethamine (ophth)) 1 bal on hand, ALOCRIL SOLN prednisolone acetate 1 (ophth) susp (nedocromil sodium 3 PREDNISOLONE (ophth)) ACETATE P-F SUSP ALOMIDE SOLN 2 (prednisolone acetate (lodoxamide 2 (ophth)) tromethamine) PREDNISOLONE SODIUM azelastine hcl (ophth) 1 PHOSPHATE SOLN OP 1 soln % (prednisolone sodium 2 AZOPT SUSP Limit 10mls per phosphate (ophth)) 2 month;QL(0.4 (brinzolamide) ml daily) sulfacetamide sod- 1 prednisolone soln ST; Limit 10mls BEPREVE SOLN sulfacetamide sod- 1 bal on hand, 3 per 1 (bepotastine besilate) month;QL(0.34 prednisolone soln ml daily) TOBRADEX OINT bromfenac sodium 1 (tobramycin- 3 (ophth) soln dexamethasone) BROMSITE SOLN TOBRADEX ST SUSP (bromfenac sodium 3 (tobramycin- 3 (ophth)) dexamethasone) cromolyn sodium 1 TOBRADEX SUSP QL(5 ml per fill (ophth) soln (tobramycin- GP retail) CYSTARAN SOLN dexamethasone) SP (cysteamine hcl) QL(5 ml per fill tobramycin- 1 dexamethasone susp retail) diclofenac sodium 1 (ophth) soln ZYLET SUSP Limit 5mls per (loteprednol etabonate- 3 fill;QL(5 ml per Limit 10mls per fill retail) dorzolamide hcl soln 1 month;QL(0.34 tobramycin) ml daily) Ophthalmic Surgical Aids DORZOLAMIDE HCL Limit 10mls per 2 month;QL(0.34 GELFILM OP FILM SOLN (dorzolamide hcl) (gelatin adsorbable 3 ml daily) ELESTAT SOLN (ophth)) GP (epinastine hcl (ophth)) Ophthalmics - Misc. EMADINE SOLN ACULAR LS SOLN (emedastine 3 (ketorolac GP difumarate) tromethamine (ophth))

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134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits epinastine hcl (ophth) 1 latanoprost soln 1 soln 1 bal on hand, 1 bal on hand, latanoprost soln 1 flurbiprofen sodium 1 soln LUMIGAN SOLN 2 ( ) flurbiprofen sodium 1 bimatoprost soln Limit 2.5mls ILEVRO SUSP TRAVATAN Z SOLN per 3 GP (nepafenac) (travoprost) month;QL(0.09 ml daily) ketorolac tromethamine 1 Limit 2.5mls (ophth) soln 1 per LASTACAFT SOLN ST travoprost soln month;QL(0.09 3 (alcaftadine) ml daily) NEVANAC SUSP XALATAN SOLN 3 3 (nepafenac) (latanoprost) ZIOPTAN SOLN Limit 10mls per 3 olopatadine hcl soln 0.1 1 month;QL(0.34 (tafluprost) % ml daily); RX/OTC OTIC AGENTS - Drugs to Treat the Ear QL(0.09 ml olopatadine hcl soln 0.2 1 Otic Agents - Miscellaneous % daily); RX/OTC 1 PAREMYD SOLN acetic acid (otic) soln (hydroxyamphetamine- 3 Otic Anti-infectives tropicamide) CETRAXAL SOLN 1 bal on hand, 3 Limit 10mls per (ciprofloxacin hcl (otic)) PATADAY SOLN 0.1 % NF month;QL(0.34 1 bal on hand, (olopatadine hcl) ml daily); ciprofloxacin hcl (otic) 1 RX/OTC soln PATADAY SOLN 0.2 % QL(0.09 ml FLOXIN OTIC SOLN GP GP (olopatadine hcl) daily); RX/OTC (ofloxacin (otic)) Limit 10mls per ofloxacin (otic) soln 1 PATANOL SOLN NF month;QL(0.34 (olopatadine hcl) ml daily); Otic Combinations RX/OTC (Pramoxine-Hc- PROLENSA SOLN Chloroxylenol) CORTIC- 1 (bromfenac sodium 3 ND, EXOTIC-HC SOLN (ophth)) CIPRO HC SUSP ( TRUSOPT SOLN Limit 10mls per ciprofloxacin- 3 GP month;QL(0.34 ) (dorzolamide hcl) hydrocortisone ml daily) CIPRODEX SUSP Prostaglandins - Ophthalmic (ciprofloxacin- 2 Limit 2.5mls dexamethasone) 1 per bimatoprost soln month;QL(0.09 ml daily)

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135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 bottle OXYTOCICS - Drugs to Prevent/Control Uterine ciprofloxacin- per Bleeding fluocinolone acetonide 1 month;QL(0.5 soln ea daily)1 bal Oxytocics on hand, (Methylergonovine COLY-MYCIN S SUSP Maleate) METHERGINE 1 (neomycin-colistin-hc- 3 TABS thonzonium) methylergonovine 1 CORTANE-B AQUEOUS maleate tabs SOLN (pramoxine-hc- 3 PASSIVE IMMUNIZING AND TREATMENT chloroxylenol aqueous) AGENTS - Antibody Drugs to Treat Low Immune CORTANE-B-OTIC SOLN System (pramoxine-hc- GP Immune Serums chloroxylenol) BIVIGAM SOLN ( PA immune SP CORTISPORIN-TC SUSP globulin (human) iv) (neomycin-colistin-hc- 3 CUVITRU SOLN PA thonzonium) (immune globulin SP (human) subcutaneous) neomycin-polymyxin-hc 1 (otic) soln FLEBOGAMMA DIF SOLN PA (immune globulin SP neomycin-polymyxin-hc 1 (otic) susp (human) iv) OTICIN HC NR SOLN GAMASTAN INJ PA (pramoxine-hc- GP (immune globulin SP chloroxylenol) (human) im) Limit 1 bottle GAMASTAN S/D INJ PA OTOVEL SOLN per (immune globulin SP (ciprofloxacin- 3 month;QL(0.5 (human) im) fluocinolone acetonide) ea daily)1 bal GAMMAGARD LIQUID PA on hand, SOLN (immune globulin SP PRAMOTIC LIQD (human) iv or (pramoxine- 3 subcutaneous) chloroxylenol) GAMMAKED SOLN PA Otic Steroids (immune globulin SP (human) iv or (Fluocinolone Acetonide 1 (Otic)) FLAC OIL subcutaneous) DERMOTIC OIL GAMMAPLEX SOLN PA (fluocinolone acetonide GP (immune globulin SP (otic)) (human) iv) GAMUNEX-C SOLN PA fluocinolone acetonide 1 (otic) oil (immune globulin SP (human) iv or hydrocortisone w/acetic QL(10 ml per 1 fill retail,30 ml subcutaneous) acid soln per fill mail)

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136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HIZENTRA SOLN PA BICILLIN L-A SUSP PA SP (immune globulin SP (penicillin g benzathine) (human) subcutaneous) PENICILLIN G PA OCTAGAM SOLN 1 PA POTASSIUM IN ISO- GM/20ML, 2 GM/20ML, 5 OSMOTIC DEXTROSE SP GM/50ML, 10 GM/200ML, SP SOLN (penicillin g pot in 20 GM/200ML (immune dextrose) globulin (human) iv) PA penicillin g potassium SP PRIVIGEN SOLN PA solr (immune globulin SP PENICILLIN G PROCAINE PA (human) iv) SUSP (penicillin g SP Passive Immunizing Agents - Combinations procaine) HYQVIA KIT (immune PA SP PA; 1 bal on penicillin g sodium solr hand, globulin (human)- SP hyaluronidase (human penicillin v potassium 1 bal on hand, recombinant)) solr 125 mg/5ml, 250 1 PENICILLINS - Drugs to Treat Bacterial Infections mg/5ml penicillin v potassium 1 Aminopenicillins tabs 250 mg, 500 mg amoxicillin caps 250 1 mg, 500 mg Penicillin Combinations amoxicillin & pot 1 bal on hand, amoxicillin chew 125 1 bal on hand, 1 clavulanate chew 400 1 mg, 250 mg mg-57 mg, 200 mg- amoxicillin susr 125 28.5 mg mg/5ml, 200 mg/5ml, 1 amoxicillin & pot 250 mg/5ml, 400 clavulanate susr 400 mg/5ml mg/5ml-57 mg/5ml, 200 amoxicillin tabs 500 1 mg/5ml-28.5 mg/5ml, 1 mg, 875 mg 250 mg/5ml-62.5 ampicillin caps 1 1 bal on hand, mg/5ml, 600 mg/5ml- 42.9 mg/5ml PA ampicillin sodium solr ij SP amoxicillin & pot 1 gm clavulanate tabs 250 PA; 1 bal on ampicillin sodium solr ij SP mg-125 mg, 500 mg- 1 125 mg hand, 125 mg, 875 mg-125 mg ampicillin sodium solr iv 1 10 gm amoxicillin & pot 1 bal on hand, MOXATAG TB24 PA; QL(1 ea clavulanate tb12 1000 1 3 daily,10 ea per mg-62.5 mg (amoxicillin) fill retail) amoxicillin & pot Natural Penicillins clavulanate tb12 1000 1 (Penicillin G Potassium) SP PA; 1 bal on mg-62.5 mg PFIZERPEN SOLR hand, You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ampicillin & sulbactam PA ZOSYN SOLN 0.375 PA sodium solr ij 1 gm-2 SP GM/50ML-3 GM/50ML-5 %, gm 0.25 GM/50ML-2 GM/50ML-5 % SP ampicillin & sulbactam PA; 1 bal on (piperacillin sodium- sodium solr iv 0.5 gm-1 SP hand, tazobactam sodium in gm dextrose) ampicillin & sulbactam PA ZOSYN SOLR 0.375 GM-3 PA sodium solr iv 5 gm-10 SP GM, 0.25 GM-2 GM, 0.5 gm GM-4 GM (piperacillin SP AUGMENTIN ES-600 sodium-tazobactam SUSR (amoxicillin & pot GP sodium) clavulanate) Penicillinase-Resistant Penicillins AUGMENTIN SUSR 125 sodium 1 MG/5ML-31.25 MG/5ML caps (amoxicillin & pot 2 PA clavulanate) sodium solr ij 1 SP gm AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML NAFCILLIN SODIUM PA (amoxicillin & pot GP SOLR IJ 10 GM (nafcillin SP clavulanate) sodium) PA; 1 bal on AUGMENTIN TABS 500 nafcillin sodium solr iv 2 SP MG-125 MG, 875 MG-125 gm hand, GP MG (amoxicillin & pot NAFCILLIN SOLN PA clavulanate) (nafcillin sodium in SP AUGMENTIN XR TB12 dextrose) (amoxicillin & pot 3 OXACILLIN SODIUM PA clavulanate) SOLN IV 1.5 GM/50ML-1 BICILLIN C-R SUSP PA GM/50ML, 300 MG/50ML-2 SP (penicillin g benzathine SP GM/50ML (oxacillin & procaine) sodium in dextrose) PA piperacillin sodium- PA oxacillin sodium solr ij 1 SP tazobactam sodium SP gm PA solr oxacillin sodium solr iv SP UNASYN BULK PACK PA 10 gm SOLR (ampicillin & SP PROGESTINS - Hormone Replacement/Modifying sulbactam sodium) Drugs UNASYN SOLR PA Progestins (ampicillin & sulbactam SP AYGESTIN TABS GP sodium) (norethindrone acetate) PA hydroxyprogesterone SP caproate oil

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138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAKENA OIL IM 250 PA Anti-Cataplectic Agents MG/ML XYREM SOLN (sodium PA (hydroxyprogesterone SP SP oxybate) caproate) MAKENA SOAJ SC 275 PA Antidementia Agents MG/1.1ML ARICEPT TABS QL(1 ea daily) (hydroxyprogesterone SP (donepezil GP caproate) hydrochloride) donepezil QL(1 ea daily) medroxyprogesterone 1 1 acetate tabs hydrochloride tabs MEGACE ES SUSP QL(1 ea daily) donepezil 1 (megestrol acetate GP hydrochloride tbdp (appetite)) EXELON PT24 GP (rivastigmine) megestrol acetate 1 (appetite) susp galantamine QL(1 ea daily) hydrobromide cp24 8 1 norethindrone acetate 1 tabs mg, 16 mg, 24 mg QL(2 ea daily) galantamine 1 bal on hand, 1 micronized caps hydrobromide soln 4 1 mg/ml progesterone oil 1 galantamine PROMETRIUM CAPS QL(2 ea daily) hydrobromide tabs 4 1 (progesterone GP mg, 8 mg, 12 mg micronized) memantine hcl cp24 7 PA PROVERA TABS mg, 14 mg, 21 mg, 28 1 (medroxyprogesterone GP mg acetate) memantine hcl soln 2 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL mg/ml, 10 mg/5ml AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions memantine hcl tabs 5 1 mg, 10 mg, Agents for Chemical Dependency NAMENDA TABS GP acamprosate calcium 1 (memantine hcl) tbec NAMENDA TITRATION ANTABUSE TABS GP PAK TABS (memantine GP (disulfiram) hcl) disulfiram tabs 1 NAMENDA XR CP24 PA GP PA required for (memantine hcl) more than 30 NAMENDA XR TITRATION PA LUCEMYRA TABS 3 day supply per PACK CP24 (memantine 3 (lofexidine hcl) year;QL(224 ea hcl) per 14 days retail)

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139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RAZADYNE ER CP24 QL(1 ea daily) (Glatiramer Acetate) PA (galantamine GP GLATOPA SOSY 40 SP hydrobromide) MG/ML AMPYRA TB12 PA RAZADYNE TABS GP (galantamine GP (dalfampridine) AUBAGIO TABS PA hydrobromide) 3 (teriflunomide) rivastigmine pt24 1 AVONEX KIT ( PA interferon SP ) rivastigmine tartrate 1 beta-1a caps AVONEX PEN AJKT PA SP Combination Psychotherapeutics (interferon beta-1a) 1 bal on hand, AVONEX PSKT PA chlordiazepoxide- 1 SP amitriptyline tabs (interferon beta-1a) BETASERON KIT PA olanzapine-fluoxetine 1 SP hcl caps (interferon beta-1b) 1 bal on hand, COPAXONE SOSY PA perphenazine- 1 SP amitriptyline tabs (glatiramer acetate) PA SYMBYAX CAPS dalfampridine tb12 1 ( olanzapine-fluoxetine GP EXTAVIA KIT (interferon PA ) SP hcl beta-1b) Fibromyalgia Agents GILENYA CAPS PA SAVELLA TABS PA; QL(2 ea 3 3 (fingolimod hcl) (milnacipran hcl) daily) PA glatiramer acetate sosy 1 SAVELLA TITRATION PA; QL(2 ea 20 mg/ml PACK MISC 3 daily) PA (milnacipran hcl) glatiramer acetate sosy SP 40 mg/ml Movement Disorder Drug Therapy MAVENCLAD TBPK PA AUSTEDO TABS PA 3 (cladribine (multiple SP (deutetrabenazine) sclerosis)) INGREZZA CAPS PA 3 MAYZENT STARTER PA (valbenazine tosylate) PACK TBPK (siponimod 3 INGREZZA CPPK PA 3 fumarate) (valbenazine tosylate) MAYZENT TABS PA 3 tetrabenazine tabs SP (siponimod fumarate) PLEGRIDY SOPN PA XENAZINE TABS SP SP (peginterferon beta-1a) (tetrabenazine) PLEGRIDY SOSY PA SP Multiple Sclerosis Agents (peginterferon beta-1a) (Glatiramer Acetate) PA PLEGRIDY STARTER PA GLATOPA SOSY 20 1 PACK SOPN MG/ML SP (peginterferon beta-1a)

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140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEGRIDY STARTER PA ORAP TABS (pimozide) 3 PACK SOSY SP (peginterferon beta-1a) pimozide tabs 1 1 bal on hand, REBIF REBIDOSE SOAJ PA SP (interferon beta-1a) Restless Leg Syndrome (RLS) Agents HORIZANT TBCR QL(1 ea daily) REBIF REBIDOSE PA 3 TITRATIONPACK SOAJ SP (gabapentin enacarbil) (interferon beta-1a) Smoking Deterrents REBIF SOSY ( PA interferon SP ( Polacrilex) CVS PV beta-1a) NICOTINE LOZENGE, REBIF TITRATION PACK PA TGT NICOTINE POLACRILEX, SM SOSY (interferon beta- SP NICOTINE POLACRILEX, 1a) SM NICOTINE, RA TECFIDERA CPDR PA NICOTINE POLACRILEX, 3 (dimethyl fumarate) RA MINI NICOTINE, PX TECFIDERA STARTER PA STOP SMOKING AID, NICOTINE MINI PACK MISC (dimethyl 3 LOZENGE, KLS QUIT4, fumarate) KLS QUIT2, HM NICOTINE TYSABRI CONC PA POLACRILEX, SP (natalizumab) GOODSENSE NICOTINE PV POLACRILEX, Postherpetic (PHN)/Neuropathic Pain GOODSENSE NICOTINE, GRALISE STARTER MISC PA GNP NICOTINE (gabapentin (once- 3 POLACRILEX MINI, GNP daily)) NICOTINE POLACRILEX, GNP NICOTINE MINI GRALISE TABS PA LOZENGE, EQL (gabapentin (once- 3 NICOTINE POLACRILEX, daily)) EQ NICOTINE POLACRILEX, EQ Premenstrual Dysphoric Disorder (PMDD) Agents NICOTINE LOZENGES, 1 bal on hand, EQ NICOTINE, CVS fluoxetine hcl (pmdd) 1 caps 10 mg, 20 mg NICOTINE POLACRILEX LOZG fluoxetine hcl (pmdd) 1 tabs 10 mg, 20 mg SARAFEM TABS GP (fluoxetine hcl (pmdd)) Pseudobulbar Affect (PBA) Agents NUEDEXTA CAPS PA (dextromethorphan hbr- 3 quinidine sulfate) Psychotherapeutic and Neurological Agents - ergoloid mesylates tabs 1 1 bal on hand,

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141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS PV (Nicotine) CVS NICOTINE PV NICOTINE, THRIVE, TGT TRANSDERMALSYSTEM, NICOTINE POLACRILEX, TGT NICOTINE STEP TGT NICOTINE GUM, SR TWO, TGT NICOTINE NICOTINE GUM, SM STEP THREE, TGT NICOTINE POLACRILEX, NICOTINE STEP ONE, SM SM NICOTINE, RA NICOTINE NICOTINE POLACRILEX, TRANSDERMAL RA NICOTINE GUM, RA SYSTEM/STEP 3/CLEAR, NICOTINE, PX STOP SM NICOTINE SMOKING AID, TRANSDERMAL NICORELIEF, KLS QUIT4, SYSTEM/STEP 2/CLEAR, KLS QUIT2, HM NICOTINE SM NICOTINE POLACRILEX, TRANSDERMAL GOODSENSE NICOTINE SYSTEM/STEP 1/CLEAR, POLACRILEX GUM, SM NICOTINE GOODSENSE NICOTINE PV TRANSDERMAL SYSTEM, GUM, GNP NICOTINE RA NICOTINE POLACRILEX, GNP TRANSDERMAL SYSTEM NICOTINE GUM, EQL STEP 3, RA NICOTINE NICOTINE POLACRILEX TRANSDERMAL SYSTEM, STARTER, EQL NICOTINE RA NICOTINE, NICOTINE POLACRILEX REFILL, TRANSDERMAL SYSTEM EQL NICOTINE STEP 3, NICOTINE POLACRILEX, EQ TRANSDERMAL SYSTEM NICOTINE POLACRILEX, STEP 2, NICOTINE PV EQ NICOTINE GUM TRANSDERMAL SYSTEM STARTER, EQ NICOTINE STEP 1, NICOTINE STEP GUM REFILL, CVS 3, NICOTINE STEP 2, NICOTINE POLACRILEX NICOTINE STEP 1, HM STARTER, CVS NICOTINE NICOTINE POLACRILEX TRANSDERMALSYSTEM, GUM HM NICOTINE TRANSDERMAL SYSTEM STEP 3, HM NICOTINE TRANSDERMAL SYSTEM STEP 2, HM NICOTINE TRANSDERMAL SYSTEM STEP 1, HM NICOTINE TRANSDERMAL SYSTEM, GNP NICOTINE TRANSDERMALSYSTEM STEP 2, GNP NICOTINE TRANSDERMALSYSTEM, EQ NICOTINE STEP 3, EQ NICOTINE, CVS NICOTINE TRANSDERMALSYSTEM/ STEP 3, CVS NICOTINE TRANSDERMALSYSTEM STEP 2, CVS NICOTINE TRANSDERMALSYSTEM You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STEP 1 PT24 BRISDELLE CAPS (paroxetine mesylate GP PV bupropion hcl (smoking PV (vasomotor)) deterrent) tb12 paroxetine mesylate 1 CHANTIX CONTINUING PV (vasomotor) caps MONTHPAK TABS PV (varenicline tartrate) RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions CHANTIX STARTING PV MONTH PAK TABS PV Alpha-Proteinase Inhibitor (Human) (varenicline tartrate) ARALAST NP SOLR PA CHANTIX TABS PV (alpha1-proteinase SP PV (varenicline tartrate) inhibitor (human)) NICODERM CQ PT24 PV GLASSIA SOLN (alpha1- PA GP (nicotine) proteinase inhibitor SP NICORETTE GUM PV (human)) GP (nicotine polacrilex) PROLASTIN-C SOLN PA NICORETTE LOZG PV (alpha1-proteinase SP GP (nicotine polacrilex) inhibitor (human)) NICORETTE MINI LOZG PV PROLASTIN-C SOLR PA GP (nicotine polacrilex) (alpha1-proteinase SP NICORETTE STARTER PV inhibitor (human)) KIT GUM (nicotine GP ZEMAIRA SOLR (alpha1- PA polacrilex) proteinase inhibitor SP (human)) nicotine polacrilex gum PV PV Cystic Fibrosis Agents nicotine polacrilex lozg PV PV KALYDECO PACK PA SP PV (ivacaftor) nicotine pt24 PV KALYDECO TABS PA SP NICOTINE PV (ivacaftor) TRANSDERMAL SYSTEM PV ORKAMBI PACK PA SP KIT (nicotine) (lumacaftor-ivacaftor) NICOTROL INHALER PV ORKAMBI TABS PA 3 SP INHA (nicotine) (lumacaftor-ivacaftor) NICOTROL NS SOLN PV 3 PA; Limited to (nicotine) PULMOZYME SOLN 2 75mls per ZYBAN TB12 ( PV (dornase alfa) month;QL(2.5 bupropion GP hcl (smoking deterrent)) ml daily) SYMDEKO TBPK PA SP Transthyretin Amyloidosis Agents (tezacaftor-ivacaftor) TEGSEDI SOSY PA SP TRIKAFTA TBPK PA; QL(3 ea (inotersen sodium) (elexacaftor-tezacaftor- SP daily) Vasomotor Symptom Agents ivacaftor) Pulmonary Fibrosis Agents

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143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESBRIET CAPS PA SP doxycycline (pirfenidone) (monohydrate) susr 25 1 ESBRIET TABS PA mg/5ml SP (pirfenidone) doxycycline OFEV CAPS ( PA (monohydrate) tabs 50 1 SP esylate) mg, 100 mg, 150 mg SULFONAMIDES - Drugs to Treat Bacterial doxycycline ST Infections (monohydrate) tabs 75 1 Sulfonamides mg, 100 mg, 150 mg SULFADIAZINE TABS doxycycline hyclate 3 1 (sulfadiazine) caps 50 mg, 100 mg - Drugs to Treat Bacterial doxycycline hyclate 1 Infections tabs 20 mg, 100 mg Glycylcyclines doxycycline hyclate ST PA tbec 75 mg, 100 mg, 1 tigecycline solr SP 150 mg TIGECYCLINE SOLR PA MINOCIN CAPS SP GP (tigecycline) (minocycline hcl) TYGACIL SOLR PA SP minocycline hcl caps 50 1 (tigecycline) mg, 75 mg, 100 mg Tetracyclines minocycline hcl tabs 50 1 (Doxycycline mg, 75 mg, 100 mg (Monohydrate)) AVIDOXY 1 minocycline hcl tb24 45 ST TABS mg, 55 mg, 65 mg, 80 1 (Doxycycline mg, 90 mg, 105 mg, (Monohydrate)) 1 MONDOXYNE NL, OKEBO 115 mg, 135 mg CAPS SOLODYN TB24 ST GP (Doxycycline Hyclate) (minocycline hcl) MORGIDOX 1X100MG, TARGADOX TABS 1 bal on hand, NF MORGIDOX 2X100MG, 1 (doxycycline hyclate) MORGIDOX 1X50MG CAPS hcl caps 1 250 mg, 500 mg (Minocycline Hcl) 1 ST COREMINO TB24 VIBRAMYCIN CAPS 100 MG (doxycycline GP demeclocycline hcl 1 tabs hyclate) doxycycline VIBRAMYCIN SUSR 25 MG/5ML (doxycycline GP (monohydrate) caps 50 1 mg, 75 mg, 100 mg, (monohydrate)) 150 mg VIBRAMYCIN SYRP 50 MG/5ML (doxycycline 2 calcium)

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144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THYROLAR-1 TABS THYROID AGENTS - Drugs to Regulate Thyroid 3 Hormones (liotrix (t3-t4)) THYROLAR-1/2 TABS Antithyroid Agents 3 (liotrix (t3-t4)) 1 methimazole tabs THYROLAR-1/4 TABS 3 propylthiouracil tabs 1 (liotrix (t3-t4)) THYROLAR-2 TABS TAPAZOLE TABS 3 GP (liotrix (t3-t4)) (methimazole) THYROLAR-3 TABS 3 Thyroid Hormones (liotrix (t3-t4)) ( Sodium) TIROSINT CAPS 13 MCG, EUTHYROX, UNITHROID, 1 25 MCG, 50 MCG, 75 LEVOXYL, LEVO-T TABS MCG, 88 MCG, 100 MCG, (Thyroid) NP THYROID 112 MCG, 125 MCG, 137 3 120, NP THYROID 90, NP MCG, 150 MCG THYROID 60, NP 1 (levothyroxine sodium) THYROID 30, NP TIROSINT-SOL SOLN 13 THYROID 15 TABS MCG/ML, 25 MCG/ML, 50 ARMOUR THYROID TABS GP MCG/ML, 75 MCG/ML, 88 15 MG, 120 MG (thyroid) MCG/ML, 100 MCG/ML, ARMOUR THYROID TABS 112 MCG/ML, 125 3 30 MG, 60 MG, 90 MG, MCG/ML, 137 MCG/ML, 180 MG, 240 MG, 300 MG 2 150 MCG/ML, 200 (thyroid) MCG/ML (levothyroxine CYTOMEL TABS sodium) 3 WESTHROID TABS (liothyronine sodium) 2 (thyroid) levothyroxine sodium WP THYROID TABS tabs or 25 mcg, 50 2 mcg, 75 mcg, 88 mcg, (thyroid) 100 mcg, 112 mcg, 125 1 ULCER DRUGS - Drugs to Treat Bowel, Intestine mcg, 137 mcg, 150 and Stomach Conditions mcg, 175 mcg, 200 Antispasmodics mcg, 300 mcg (Hyoscyamine Sulfate) ED- SPAZ, OSCIMIN, NULEV 1 liothyronine sodium 1 tabs TBDP NATURE-THROID NT-2.5 (Hyoscyamine Sulfate) 2 OSCIMIN SR, SYMAX-SR 1 TABS (thyroid) TB12 NATURE-THROID TABS 2 (Hyoscyamine Sulfate) 1 (thyroid) OSCIMIN TABS SYNTHROID TABS 3 (Hyoscyamine Sulfate) (levothyroxine sodium) OSCIMIN, SYMAX-SL 1 SUBL 1 thyroid tabs ANASPAZ TBDP GP (hyoscyamine sulfate)

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145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIBRAX CAPS atropine sulfate soln ij SP 0.1 mg/ml, 1 mg/ml (chlordiazepoxide hcl- GP 1 bal on hand, clidinium bromide) atropine sulfate soln ij SP 0.4 mg/ml, 1 mg/ml methscopolamine 1 bal on hand, BELLADONNA/OPIUM bromide tabs 5 mg, 2.5 1 SUPP (belladonna 3 mg, 2.5 mg alkaloids & opium) methscopolamine BENTYL CAPS bromide tabs 5 mg, 2.5 1 GP (dicyclomine hcl) mg, 2.5 mg propantheline bromide 1 bal on hand, chlordiazepoxide hcl- 1 1 clidinium bromide caps tabs CUVPOSA SOLN ROBINUL FORTE TABS 2 GP (glycopyrrolate) (glycopyrrolate) ROBINUL TABS dicyclomine hcl caps 1 GP (glycopyrrolate) dicyclomine hcl soln 1 H-2 Antagonists (Cimetidine) CIMETIDINE RX/OTC dicyclomine hcl tabs 1 200, SM ACID REDUCER, GLYCATE TABS SB CIMETIDINE, RA ACID 3 REDUCER, PX ACID (glycopyrrolate) REDUCER, HEARTBURN RELIEF, GNP glycopyrrolate tabs or 1 1 mg, 2 mg HEARTBURN RELIEF 200, GLYCOPYRROLATE GNP HEARTBURN 1 TABS OR 1.5 MG RELIEF, EQ HEARTBURN 3 RELIEF, EQ CIMETIDINE (glycopyrrolate) ACID REDUCER, EQ ACID REDUCER, CVS hyoscyamine sulfate 1 subl HEARTBURN RELIEF, CIMETIDINE ACID hyoscyamine sulfate 1 REDUCER TABS tabs hyoscyamine sulfate 1 tb12 hyoscyamine sulfate 1 tbdp LEVBID TB12 GP (hyoscyamine sulfate) LEVSIN TABS GP (hyoscyamine sulfate) LEVSIN/SL SUBL GP (hyoscyamine sulfate)

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146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID RX/OTC (Ranitidine Hcl) SB ACID RX/OTC CONTROL MAXIMUM REDUCER, RANITIDINE STRENGTH, SM ACID 150 MAXIMUM REDUCER MAXIMUM STRENGTH, RA ACID STRENGTH, SB ACID REDUCER MAXIMUM CONTROLLER MAXIMUM STRENGTH, PX ACID STRENGTH, RA ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, KLS ACID STRENGTH, QC ACID REDUCER CONTROLLER MAXIMUM MAXIMUMSTRENGTH, STRENGTH, PX ACID HM ACID REDUCER REDUCER MAXIMUM MAXIMUM STRENGTH, STRENGTH, MM HM ACID REDUCER, FAMOTIDINE, KLS ACID HEARTBURN RELIEF 150 CONTROLLER MAXIMUM MAXIMUM STRENGTH, STRENGTH, HM 1 GOODSENSE ACID FAMOTIDINE, REDUCER, GNP ACID HEARTBURN RELIEF CONTROL 150 MAXIMUM 1 MAXIMUMSTRENGTH, STRENGTH, EQL GNP ACID REDUCER HEARTBURN RELIEF MAXIMUMSTRENGTH, MAXIMUM STRENGTH, EQL HEARTBURN EQL ACID REDUCER PREVENTION/MAXIMUM MAXIMUMSTRENGTH, STRENGTH, EQ ACID EQ ACID REDUCER, CVS REDUCER MAXIMUM ACID REDUCER STRENGTH, CVS ACID MAXIMUMSTRENGTH, CONTROLLER MAXIMUM ACID REDUCER STRENGTH, ACID MAXIMUM STRENGTH, REDUCER MAXIMUM ACID REDUCER, ACID STRENGTH, ACID CONTROL MAXIMUM CONTROLLER MAXIMUM STRENGTH, WAL-ZAN STRENGTH TABS 150 MAXIMUM STRENGTH, SM ACID REDUCER MAXIMUM STRENGTH TABS cimetidine hcl soln 1 1 bal on hand, RX/OTC cimetidine tabs 200 mg, 1 400 mg, 800 mg cimetidine tabs 300 mg, 1 400 mg, 800 mg famotidine tabs 20 mg 1 RX/OTC famotidine tabs 40 mg 1 QL(2 ea daily) NIZATIDINE CAPS 150 2 MG (nizatidine) nizatidine caps 150 mg, 1 300 mg

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147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 bal on hand, (Esomeprazole PA; QL(1 ea nizatidine soln 15 1 mg/ml Magnesium) CVS daily); RX/OTC ESOMEPRAZOLE PEPCID AC MAXIMUM RX/OTC MAGNESIUM, SM STRENGTH TABS GP ESOMEPRAZOLE (famotidine) MAGNESIUM, RA PEPCID TABS 20 MG RX/OTC ESOMEPRAZOLE GP (famotidine) MAGNESIUM, QC ESOMEPRAZOLE PEPCID TABS 40 MG QL(2 ea daily) GP MAGNESIUM, KLS 1 (famotidine) ESOMEPRAZOLE MAGNESIUM, HM ranitidine hcl caps 150 1 mg, 300 mg ESOMEPRAZOLE MAGNESIUM DELAYED ranitidine hcl syrp 15 RELEASE, GOODSENSE mg/ml, 75 mg/5ml, 150 1 ESOMEPRAZOLE mg/10ml MAGNESIUM, GNP RX/OTC ESOMEPRAZOLE ranitidine hcl tabs 150 1 MAGNESIUM CPDR mg (Esomeprazole PA; QL(1 ea ranitidine hcl tabs 300 1 Magnesium) HEARTBURN 1 daily); RX/OTC mg TREATMENT 24 HOUR TAGAMET HB TABS RX/OTC CPDR 20 MG GP (cimetidine) (Lansoprazole) CVS RX/OTC ZANTAC 150 MAXIMUM RX/OTC LANSOPRAZOLE, SM STRENGTH TABS LANSOPRAZOLE, RA GP LANSOPRAZOLE, QC (ranitidine hcl) LANSOPRAZOLE, KLS ZANTAC TABS ( LANSOPRAZOLE, HM 1 ranitidine GP hcl) LANSOPRAZOLE, GOODSENSE Misc. Anti-Ulcer LANSOPRAZOLE, GNP CARAFATE SUSP LANSOPRAZOLE, EQ GP (sucralfate) LANSOPRAZOLE CPDR CARAFATE TABS (Lansoprazole) RX/OTC GP (sucralfate) HEARTBURN 1 TREATMENT 24 HOUR sucralfate susp 1 CPDR 15 MG ACIPHEX SPRINKLE PA sucralfate tabs 1 CPSP 5 MG, 10 MG 3 (rabeprazole sodium) Proton Pump Inhibitors ACIPHEX TBEC PA; QL(2 ea NF (rabeprazole sodium) daily) DEXILANT CPDR PA; QL(1 ea 3 (dexlansoprazole) daily) PA; QL(1 ea esomeprazole 1 magnesium cpdr 20 mg daily); RX/OTC

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148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea + esomeprazole 1 magnesium cpdr 40 mg daily) SYRSPEND SFALKA 3 esomeprazole PA SUSP (omeprazole) magnesium pack 10 1 omeprazole cpdr 10 1 mg, 20 mg, 40 mg mg, 40 mg RX/OTC ESOMEPRAZOLE PA; QL(1 ea omeprazole cpdr 20 1 STRONTIUM CPDR daily) mg, 40 mg (esomeprazole 3 pantoprazole sodium 1 strontium) tbec FIRST-LANSOPRAZOLE PA PREVACID 24HR CPDR RX/OTC 3 NF SUSP (lansoprazole) (lansoprazole) FIRST-OMEPRAZOLE PREVACID CPDR 15 MG RX/OTC 3 NF SUSP (omeprazole) (lansoprazole) lansoprazole cpdr 15 RX/OTC PREVACID CPDR 30 MG 1 GP mg (lansoprazole) PREVACID SOLUTAB QL(1 ea daily); lansoprazole cpdr 30 1 mg TBDD 15 MG GP AL(Up to 12 yrs (lansoprazole) old ); RX/OTC lansoprazole tbdd 15 QL(1 ea daily); 1 AL(Up to 12 yrs PREVACID SOLUTAB QL(1 ea daily); mg old ); RX/OTC TBDD 30 MG GP AL(Up to 12 yrs old ) lansoprazole tbdd 30 QL(1 ea daily); (lansoprazole) 1 AL(Up to 12 yrs mg PRILOSEC PACK PA old ) (omeprazole 3 NEXIUM 24HR CLEAR PA; QL(1 ea magnesium) MINIS CPDR daily); RX/OTC GP PROTONIX PACK 40 MG (esomeprazole 3 (pantoprazole sodium) magnesium) PROTONIX TBEC 20 MG NEXIUM 24HR CPDR PA; QL(1 ea GP (pantoprazole sodium) (esomeprazole GP daily); RX/OTC PROTONIX TBEC 40 MG magnesium) NF (pantoprazole sodium) NEXIUM CPDR 20 MG PA; QL(1 ea (esomeprazole GP daily); RX/OTC RABEPRAZOLE SODIUM PA DR SPRINKLE CPSP 3 magnesium) (rabeprazole sodium) NEXIUM CPDR 40 MG PA; QL(1 ea daily) rabeprazole sodium PA; QL(2 ea (esomeprazole GP 1 daily) magnesium) tbec NEXIUM PACK 10 MG, 20 PA Ulcer Drugs - Prostaglandins MG, 40 MG CYTOTEC TABS GP GP (esomeprazole (misoprostol) magnesium) misoprostol tabs 1 NEXIUM PACK 5 MG, 2.5 PA MG (esomeprazole 3 Ulcer Therapy Combinations magnesium)

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149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Omeprazole-Sodium PA (Methenamine-Hyosc- 1 bal on hand, Bicarbonate) OMEPPI 1 Methylene Blue-Sod Phos- CAPS Phenyl Sal) amoxicillin- PHOSPHASAL, VILEVEV MB, UTRONA-C, UTIRA-C, 1 clarithromycin w/ 1 UROAV-81, URO-458, lansoprazole misc URIN D/S, URIMAR-T, OMECLAMOX-PAK MISC URETRON D/S, URELLE (amoxicillin- TABS clarithromycin w/ 3 (Methenamine-Hyosc- omeprazole) Methylene Blue-Sod Phos- Phenyl Sal) URIBEL, 1 omeprazole-sodium PA VILAMIT MB, UTICAP, bicarbonate caps 40 1 USTELL, UROAV-B, URO- mg-1100 mg MP CAPS omeprazole-sodium Urinary Anti-infectives bicarbonate pack 20 FURADANTIN SUSP 1 GP mg-1680 mg, 40 mg- (nitrofurantoin) 1680 mg HIPREX TABS PYLERA CAPS (bismuth (methenamine GP ) subcitrate potassium- 3 hippurate metronidazole- MACROBID CAPS tetracycline) (nitrofurantoin monohyd GP ZEGERID CAPS 40 MG- PA macro) 1100 MG (omeprazole- GP MACRODANTIN CAPS sodium bicarbonate) (nitrofurantoin GP ZEGERID PACK 20 MG- macrocrystal) 1680 MG, 40 MG-1680 MG GP methenamine hippurate 1 (omeprazole-sodium tabs bicarbonate) methenamine URINARY ANTI-INFECTIVES - Drugs to Treat mandelate tabs 0.5 gm, 1 Bladder/Kidney Infections 1 gm Urinary Anti-infective Combinations MONUROL PACK (Methenamine-Hyosc- 1 bal on hand, (fosfomycin 3 Methylene Blue-Benzoic 1 tromethamine) Acid-Phenyl Sal) HYOPHEN TABS nitrofurantoin 1 (Methenamine-Hyosc- macrocrystal caps Methylene Blue-Sod Phos- nitrofurantoin monohyd 1 Phenyl Sal) macro caps PHOSPHASAL, VILEVEV MB, UTRONA-C, UTIRA-C, 1 nitrofurantoin susp 1 UROAV-81, URO-458, URIN D/S, URIMAR-T, URINARY ANTISPASMODICS - Drugs to Treat URETRON D/S, URELLE Miscellaneous Bladder Spasms TABS Urinary Antispasmodic - Antimuscarinics

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150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOVIAZ TB24 QL(1 ea daily) darifenacin 1 2 hydrobromide tb24 (fesoterodine fumarate) DETROL LA CP24 2 MG QL(1 ea daily) GP trospium chloride cp24 1 (tolterodine tartrate) DETROL LA CP24 4 MG QL(1 ea daily) trospium chloride tabs 1 NF (tolterodine tartrate) VESICARE TABS DETROL TABS 1 MG QL(2 ea daily) GP GP (solifenacin succinate) (tolterodine tartrate) Urinary Antispasmodics - Beta-3 Adrenergic DETROL TABS 2 MG GP MYRBETRIQ TB24 QL(1 ea daily) (tolterodine tartrate) 3 (mirabegron) DITROPAN XL TB24 GP (oxybutynin chloride) Urinary Antispasmodics - Cholinergic Agonists ENABLEX TB24 15 MG bethanechol chloride 1 (darifenacin NF tabs URECHOLINE TABS hydrobromide) GP ENABLEX TB24 7.5 MG (bethanechol chloride) (darifenacin GP Urinary Antispasmodics - Direct Muscle Relaxants hydrobromide) flavoxate hcl tabs 1 GELNIQUE GEL 3 (oxybutynin chloride) VACCINES GELNIQUE PUMP GEL 3 (oxybutynin chloride) Bacterial Vaccines PEDVAX HIB SUSP PV oxybutynin chloride 1 syrp (haemophilus b polysac PV conj vac) oxybutynin chloride 1 VIVOTIF BERNA CPDR QL(4 ea per fill tabs 3 retail,4 ea per (typhoid vaccine) fill mail) oxybutynin chloride 1 tb24 VIVOTIF CPDR (typhoid QL(4 ea per fill OXYTROL FOR WOMEN RX/OTC 3 retail,4 ea per 3 vaccine) PTTW (oxybutynin) fill mail) OXYTROL PTTW RX/OTC Viral Vaccines 3 (oxybutynin) FLUCELVAX PV QUADRIVALENT 2017- solifenacin succinate 1 tabs 2018 SUSY (influenza virus vaccine tissue- PV QL(1 ea daily) tolterodine tartrate 1 cultured subunit cp24 2 mg, 4 mg quadrivalent) QL(2 ea daily) tolterodine tartrate tabs 1 FLUCELVAX PV 1 mg QUADRIVALENT 2018- 2019 SUSY (influenza tolterodine tartrate tabs 1 PV 2 mg virus vaccine tissue- cultured subunit quadrivalent) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUCELVAX PV SHUR-SEAL GEL PV PV QUADRIVALENT 2019- (nonoxynol-9) 2020 SUSY (influenza TODAY SPONGE MISC PV PV PV virus vaccine tissue- (nonoxynol-9) cultured subunit VCF VAGINAL PV quadrivalent) CONTRACEPTIVE FILM PV GARDASIL 9 SUSP PV FILM (nonoxynol-9) (human papillomavirus PV VCF VAGINAL PV (hpv) 9-valent recombinant CONTRACEPTIVE FOAM PV vaccine) FOAM (nonoxynol-9) GARDASIL 9 SUSY PV Vaginal Anti-infectives (human papillomavirus PV (Metronidazole Vaginal) 1 (hpv) 9-valent recombinant VANDAZOLE GEL vaccine) (Miconazole Nitrate 1 bal on hand, RECOMBIVAX HB SUSP Vaginal) MICONAZOLE 3 1 (hepatitis b vaccine 3 SUPP (recomb)) AVC CREA 3 ROTATEQ SOLN (sulfanilamide vaginal) (rotavirus vaccine, live 3 CLEOCIN CREA VA 2 % oral pentavalent) (clindamycin phosphate GP VAGINAL AND RELATED PRODUCTS vaginal) CLEOCIN SUPP VA 100 Miscellaneous Vaginal Products MG (clindamycin 3 (Acetic Acid-Oxyquinoline 3 1 bal on hand, phosphate vaginal) Vaginal) RELAGARD GEL clindamycin phosphate 1 FEM PH GEL (acetic vaginal crea acid-oxyquinoline 3 vaginal) CLINDESSE CREA (clindamycin phosphate 3 INTRAROSA INST 3 (one dose)) ( vaginal) GYNAZOLE-1 CREA Spermicides ( nitrate 3 (Nonoxynol-9) VCF PV (one dose)) VAGINAL PV CONTRACEPTIVEGEL METROGEL-VAGINAL GEL GEL (metronidazole GP ENCARE SUPP PV vaginal) PV (nonoxynol-9) metronidazole vaginal 1 OPTIONS CONCEPTROL PV gel VAGINAL TERAZOL 7 CREA GP GP CONTRACEPTIVE GEL ( vaginal) (nonoxynol-9) terconazole vaginal 1 OPTIONS GYNOL II PV crea 0.4 % VAGINALCONTRACEPTIV PV 1 bal on hand, E GEL (nonoxynol-9) terconazole vaginal 1 crea 0.8 % You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii. OR Essential Drug List Updated: July 1, 2020

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits terconazole vaginal epinephrine QL(4 ea per fill 1 retail) supp 80 mg (anaphylaxis) soaj 0.15 2 Vaginal Estrogens mg/0.3ml, 0.3 mg/0.3ml, 0.3 mg/0.3ml (Estradiol Vaginal) 1 YUVAFEM TABS EPINEPHRINE SOAJ 0.3 QL(4 ea per fill ESTRACE CREA MG/0.3ML (epinephrine 2 retail) GP (estradiol vaginal) (anaphylaxis)) EPIPEN 2-PAK SOAJ PA; QL(4 ea 1 estradiol vaginal crea (epinephrine GP per fill retail) estradiol vaginal tabs 1 (anaphylaxis)) EPIPEN-JR 2-PAK SOAJ PA; QL(4 ea ESTRING RING 3 (epinephrine GP per fill retail) (estradiol vaginal) (anaphylaxis)) FEMRING RING QL(1 ea per 90 Neurogenic Orthostatic Hypotension (NOH) - (estradiol acetate 3 days retail) NORTHERA CAPS PA vaginal) SP () PREMARIN CREA VA 0.625 MG/GM Vasopressors 2 (estrogens, conjugated EPINEPHRINE HCL SOLN PA SP vaginal) (epinephrine) VAGIFEM TABS PA NF epinephrine soln 1 SP (estradiol vaginal) mg/ml Vaginal Progestins midodrine hcl tabs 1 CRINONE GEL 4 % (progesterone 3 VITAMINS (vaginal)) Oil Soluble Vitamins CRINONE GEL 8 % PA ( 3 (Cholecalciferol) AL(At least 65 progesterone AQUEOUS VITAMIN D yrs old); PV (vaginal)) INFANTS, VITAMIN D ENDOMETRIN INST PA INFANT, JUST D, D3 PV (progesterone 3 VITAMIN, D-VITE (vaginal)) PEDIATRIC, BPROTECTED PEDIA D- VASOPRESSORS - Drugs to Treat Heart and VITE LIQD Circulation Conditions (Cholecalciferol) CVS D3, AL(At least 65 Anaphylaxis Therapy Agents WEEKLY-D, OPTIMAL-D yrs old); PV QL(4 ea per fill PACK, OPTIMAL-D, EQL PV epinephrine VITAMIN D3, DECARA, (anaphylaxis) soaj 0.15 retail)1 bal on 2 hand, D3-50 CAPS mg/0.15ml, 0.3 (Cholecalciferol) CVS D3, mg/0.3ml, 0.3 mg/0.3ml WEEKLY-D, OPTIMAL-D PACK, OPTIMAL-D, EQL 1 VITAMIN D3, DECARA, D3-50 CAPS

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153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cholecalciferol) D 400, PA AL(At least 65 POTABA CAPS VITAMIN D-3 GUMMY, KP yrs old); PV (potassium 3 VITAMIN D, HEALTHY PV aminobenzoate) KIDS VITAMIN D3, GNP 1 bal on hand, VITAMIN D, D3 KIDS potassium 1 CHEW aminobenzoate pack (Cholecalciferol) D 400, AL(At least 65 VITAMIN D-400, SM yrs old); PV VITAMIN D, QC VITAMIN D3, HM VITAMIN D, GNP PV VITAMIN D-400, DELTA D3, D3 HIGH POTENCY, D-400 TABS BABY DDROPS LIQD AL(At least 65 PV (cholecalciferol) yrs old); PV AL(At least 65 cholecalciferol caps PV 400 unit yrs old); PV cholecalciferol caps 1 50000 unit AL(At least 65 cholecalciferol chew PV 400 unit yrs old); PV AL(At least 65 cholecalciferol liqd 400 PV unit/ml yrs old); PV AL(At least 65 cholecalciferol tabs 400 PV unit yrs old); PV D-VI-SOL LIQD AL(At least 65 GP (cholecalciferol) yrs old); PV DRISDOL CAPS GP (ergocalciferol) ergocalciferol caps 1 MEPHYTON TABS GP (phytonadione) phytonadione tabs 1 VITAMIN D2 TABS AL(At least 65 PV (ergocalciferol) yrs old); PV VITAMIN D3 IMMUNE AL(At least 65 HEALTH LIQD PV yrs old); PV (cholecalciferol) VITAMIN D3 LIQD AL(At least 65 PV (cholecalciferol) yrs old); PV Water Soluble Vitamins

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154 Index 7t lido gel 87 adapalene 74 ALDARA 86 7TOPIC 88 adapalene-benzoyl ALDURAZYME 94 abacavir sulfate 56 peroxide 74 ALECENSA 50 ADCIRCA 64 abacavir sulfate-lamivudine 57 alendronate sodium 92 ADDERALL 1 abacavir sulfate-lamivudine- ALFERON N 52 ADDERALL XR 1 zidovudine 57 alfuzosin hcl 100 ABELCET 36 adefovir dipivoxil 59 ALIMTA 47 ABILIFY 56 ADEMPAS 64 ALINIA 16 abiraterone acetate 48 ADLYXIN 32 aliskiren fumarate 45 ABOUTTIME PEN NEEDLES ADLYXIN STARTER 30GX 5/16" 110 PACK 32 ALKERAN 46 ABSORICA 74 adrucil 47 all day allergy childrens 38 ABSORICA LD 74 adult aspirin ec low strength 8 allergy nasal spray 24 hour 129 ABSTRAL 10 ADVAIR DISKUS 21 allopurinol 101 acamprosate calcium 139 ADVAIR HFA 21 almotriptan malate 111 acarbose 31 ADVICOR 40 ALOCRIL 134 ACCOLATE 19 ADZENYS ER 1 ALOMIDE 134 ACCUPRIL 41 afeditab cr 62 ALORA 96 ACCURETIC 42 AFINITOR 50 alosetron hcl 99 acebutolol hcl 61 AFINITOR DISPERZ 50 ALOXI 35 acetaminophen w/ codeine 12 afirmelle 66 ALPHAGAN P 131 acetazolamide 90 aftera 69 alprazolam 18 acetic acid (otic) 135 AGGRENOX 102 ALPRAZOLAM INTENSOL 18 acetylcysteine 73 AGRYLIN 102 alprazolam xr 18 acid control maximum AIMOVIG 110 ALREX 133 strength 147 AIMSCO LUBRICATED 107 ALTABAX 77 ACIPHEX 148 AIRDUO RESPICLICK altacaine 133 ACIPHEX SPRINKLE 148 113/14 21 ALTACE 41 AIRDUO RESPICLICK acitretin 79 altafrin 131 ACTEMRA 4 232/14 21 AIRDUO RESPICLICK ALTOPREV 40 ACTIDOM DMX 72 55/14 21 ALUNBRIG 50 ACTIGALL 98 AJOVY 110 ALVESCO 20 ACTIMMUNE 52 ak-poly-bac 131 alyacen 1/35 67 ACTIQ 10 AKTEN 133 alyacen 7/7/7 67 ACTIVELLA 96 AKYNZEO 36 alyq 64 ACTONEL 92 al12 86 amabelz 96 ACTOPLUS MET 31 ALA SCALP 81 amantadine hcl 53 ACTOPLUS MET XR 31 ala-cort 80 AMARYL 34 ACTOS 32 ALA-QUIN 77 AMBIEN 105 ACULAR 134 albendazole 15 AMBIEN CR 105 ACULAR LS 134 ALBENZA 15 AMBISOME 37 ACUVAIL 134 albuterol sulfate 21 ambrisentan 64 acyclovir 60 ALCAINE 133 amcinonide 81 acyclovir topical 80 alclometasone AMCINONIDE 81 ACZONE 74 dipropionate 81 ALCORTIN A 77 AMERGE 111 ADAGEN 3 amethia 66 ADALAT CC 62 ALDACTAZIDE 91 ALDACTONE 91 amethyst 66

Index 1 AMICAR 104 ANGELIQ 96 ascomp/codeine 11 amikacin sulfate 3 ANNOVERA 69 ASCRIPTIN 9 amiloride & ANORO ELLIPTA 21 ASMANEX HFA 20 hydrochlorothiazide 91 ANTABUSE 139 ASMANEX TWISTHALER 120 amiloride hcl 91 ANTARA 40 METERED DOSES 20 aminocaproic acid 104 ASMANEX TWISTHALER 14 anti-diarrheal 34 aminophylline 22 METERED DOSES 20 anucort-hc 15 ASMANEX TWISTHALER 30 amiodarone hcl 19 anusol-hc 15 METERED DOSES 20 AMITIZA 98 ASMANEX TWISTHALER 60 ANUSOL-HC 15 amitriptyline hcl 30 METERED DOSES 20 ANZEMET 35 ASMANEX TWISTHALER 7 amlodipine besylate 62 APEXICON E 81 METERED DOSES 20 amlodipine besylate-atorvastatin aspirin 9 calcium 63 APLENZIN 28 amlodipine besylate-benazepril apraclonidine hcl 131 aspirin adult low dose 9 hcl 42 aprepitant 36 aspirin-dipyridamole 102 amlodipine besylate-olmesartan apri 66 ASSURE ID SAFETY PEN medoxomil 43 NEEDLES 30G X 5/16" 110 amlodipine besylate- APRISO 98 ASTAGRAF XL 115 valsartan 43 APTIOM 25 ASTEPRO 129 amlodipine-valsartan- APTIVUS 57 hydrochlorothiazide 43 ATABEX EC 120 amnesteem 73 aqueous vitamin d infants 153 ATABEX OB 121 amoxapine 30 ARALAST NP 143 ATACAND 42 ARANESP ALBUMIN amoxicillin 137 FREE 103 ATACAND HCT 43 amoxicillin & pot ARAVA 6 atazanavir sulfate 57 clavulanate 137 ATELVIA 92 amoxicillin-clarithromycin w/ ARCALYST 4 lansoprazole 150 ARCAPTA NEOHALER 21 atenolol 61 amphetamine- argyle sterile saline atenolol & chlorthalidone 43 dextroamphetamine 1 100ml 100 ATGAM 115 amphotericin b 37 argyle sterile water 100ml117 ATIVAN 18 ampicillin 137 ARICEPT 139 atomoxetine hcl 2 ampicillin & sulbactam ARIKAYCE 3 sodium 138 atorvastatin calcium 40 ARIMIDEX 48 ampicillin sodium 137 atovaquone 16 aripiprazole 56 AMPYRA 140 atovaquone-proguanil hcl 45 ARIXTRA 23 AMRIX 128 ATRALIN 74 armodafinil 2 ANADROL-50 13 ATRIPLA 57 ARMONAIR RESPICLICK ATROPINE SULFATE 131 ANAFRANIL 30 113 20 anagrelide hcl 102 ARMONAIR RESPICLICK atropine sulfate 146 ANALPRAM HC 14 232 20 ATROVENT HFA 19 ARMONAIR RESPICLICK AUBAGIO 140 ANALPRAM HC SINGLES 14 55 20 AUGMENTIN 138 ANALPRAM-HC 14 ARMOUR THYROID 145 AUGMENTIN ES-600 138 ANAPROX DS 5 ARNUITY ELLIPTA 20 AUGMENTIN XR 138 ANASPAZ 145 AROMASIN 48 aurovela 1.5/30 67 anastrozole 48 ARRANON 47 aurovela 24 fe 67 ANCOBON 37 ARTHROTEC 50 5 AUSTEDO 140 ANDRODERM 13 ARTHROTEC 75 5 av-phos 250 neutral 114 ANDROGEL 13 ARZERRA 48 av-vite fb forte 90 ANDROGEL PUMP 13 ASACOL HD 98 AVALIDE 43

Index 2 AVANDIA 32 BAL-CARE DHA 121 bethanechol chloride 151 AVAPRO 42 BALCOLTRA 67 BETHKIS 3 AVAR 74 balsalazide disodium 98 BETIMOL 130 avar cleanser 73 BALVERSA 50 BETOPTIC-S 130 AVAR LS 74 banophen 37 BEVESPI AEROSPHERE 21 AVAR LS CLEANSER 74 BANZEL 25 BEVYXXA 23 avar-e emollient 74 BAQSIMI ONE PACK 32 bexarotene 52 AVAR-E LS 74 BAQSIMI TWO PACK 32 BEYAZ 67 AVC 152 BARACLUDE 59 bicalutamide 48 AVELOX 97 BAXDELA 97 BICILLIN C-R 138 avidoxy 144 bayer advanced aspirin regular BICILLIN L-A 137 avita 74 strength 9 BIDIL 63 BECONASE AQ 129 AVODART 100 BILTRICIDE 15 BELBUCA 13 AVONEX 140 bimatoprost 135 BELLADONNA/OPIUM 146 AVONEX PEN 140 BINOSTO 92 BELSOMRA 105 AXERT 111 BIO-DTUSS DMX 72 benazepril & AYGESTIN 138 hydrochlorothiazide 43 bio-statin 36 AYVAKIT 50 benazepril hcl 41 BIO-STATIN 37 azacitidine 47 BENICAR 42 biogtuss 71 AZASAN 115 BENICAR HCT 43 bisoprolol & hydrochlorothiazide 43 AZASITE 131 BENLYSTA 117 bisoprolol fumarate 61 AZATHIOPRINE 115 BENSAL HP 86 BIVIGAM 136 azathioprine 115 BENTYL 146 BLEPH-10 132 azelaic acid 88 BENZACLIN 74 BLEPHAMIDE 133 azelastine hcl 129 BENZACLIN WITH PUMP 74 BLEPHAMIDE S.O.P. 133 azelastine hcl (ophth) 134 BENZAMYCIN 74 BONIVA 92 azelastine hcl-fluticasone benzepro creamy wash 73 propionate 129 BONJESTA 36 BENZNIDAZOLE 15 AZELEX 74 bosentan 64 benzonatate 71 AZILECT 54 BOSULIF 50 benzoyl peroxide- azithromycin 107 erythromycin 74 BOTOX 130 AZOPT 134 benztropine mesylate 53 bp cleansing wash 74 AZOR 43 BEPREVE 134 bprotected pedia iron 103 AZULFIDINE 98 BERINERT 101 BRAFTOVI 50 AZULFIDINE EN-TABS 98 BESIVANCE 131 BREO ELLIPTA 21 BABY DDROPS 154 BETADINE OPHTHALMIC BRILINTA 102 baciim 15 PREP 132 brimonidine tartrate 131 bacitracin 15 BETAGAN 130 BRISDELLE 143 betamethasone dipropionate bacitracin (ophthalmic) 131 (topical) 81 bromfenac sodium (ophth) 134 bacitracin-poly-neomycin-hc betamethasone dipropionate bromocriptine mesylate 53 133 augmented 81 brompheniramine tannate 37 bacitracin-polymyxin b betamethasone valerate 81 (ophth) 131 BROMSITE 134 baclofen 128 BETAPACE 61 BROVANA 21 BACTRIM 16 BETAPACE AF 61 BRUKINSA 50 BACTRIM DS 15 BETASERON 140 budesonide 70 BACTROBAN NASAL 129 betaxolol hcl 61 budesonide (inhalation) 20 betaxolol hcl (ophth) 130

Index 3 budesonide (nasal) 129 CALCIFOL 113 carisoprodol 128 budesonide-formoterol fumarate calcipotriene 79 carisoprodol w/ aspirin 128 dihydrate 21 CALCIPOTRIENE 79 carisoprodol w/ aspirin & bumetanide 91 calcipotriene-betamethasone codeine 128 BUMEX 91 dipropionate 81 CARNITOR 94 BUNAVAIL 13 calcitonin (salmon) 92 CARNITOR SF 94 bupap 7 calcitrene 79 carteolol hcl (ophth) 130 BUPHENYL 94 calcitriol 94 cartia xt 62 BUPRENEX 13 calcitriol (topical) 79 carvedilol 61 buprenorphine 13 calcium acetate (phosphate carvedilol phosphate 61 buprenorphine hcl 13 binder) 99 CASODEX 48 CALCIUM-FOLIC ACID PLUS buprenorphine hcl-naloxone hcl D 113 caspofungin acetate 36 dihydrate 13 CALQUENCE 50 CASPOFUNGIN ACETATE 36 bupropion hcl 28 CATAPRES 42 bupropion hcl (smoking CAMBIA 111 deterrent) 143 camila 70 CATAPRES-TTS-1 42 buspirone hcl 18 CAMPATH 48 CATAPRES-TTS-2 42 busulfan 46 CANASA 98 CATAPRES-TTS-3 42 BUSULFEX 46 CANCIDAS 36 caziant 66 butalbital-acetaminophen 7 candesartan cilexetil 42 cefaclor 65 butalbital-acetaminophen- candesartan cilexetil- CEFACLOR ER 65 caffeine 7 hydrochlorothiazide 43 cefadroxil 65 butalbital-acetaminophen- CAPASTAT SULFATE 46 cefazolin sodium 65 caffeine w/ codeine 12 capecitabine 47 butalbital-aspirin-caffeine 7 cefdinir 65 CAPEX 81 butalbital-aspirin-caffeine cefditoren pivoxil 65 w/cod 12 CAPLYTA 54 CEFEPIME 66 BUTALBITAL/ACETAMINOPHEN CAPRELSA 50 cefepime hcl 66 7 captopril 41 CEFEPIME/DEXTROSE 66 BUTALBITAL/ASPIRIN/CAFFEIN captopril & E 7 hydrochlorothiazide 43 cefixime 65 BUTISOL SODIUM 104 CARAC 79 CEFOTAN 65 butorphanol tartrate 13 CARAFATE 148 cefotaxime sodium 65 BUTRANS 13 CARBAGLU 94 cefotetan disodium 65 BYDUREON 32 carbamazepine 25 cefoxitin sodium 65 BYDUREON BCISE 32 CARBAPHEN 12 72 CEFOXITIN SODIUM 65 BYDUREON PEN 32 CARBAPHEN 12 PED 72 cefpodoxime proxetil 65 BYETTA 32 CARBATROL 25 cefprozil 65 BYSTOLIC 61 carbidopa 53 ceftazidime 65 BYVALSON 43 carbidopa-levodopa 53 ceftriaxone sodium 65 C-NATE DHA 121 carbidopa-levodopa- cefuroxime axetil 65 c-topical 87 entacapone 53 cefuroxime sodium 65 cabergoline 95 carbinoxamine maleate 37,38 CELEBREX 5 CABLIVI 102 CARDIZEM 62 celecoxib 5 CABOMETYX 50 CARDIZEM CD 62 CELEXA 28,29 CADUET 64 CARDIZEM LA 62 CELLCEPT 116 CAFERGOT 111 CARDURA 42 CELLCEPT caffeine citrate 2 CARDURA XL 101 INTRAVENOUS 116 CALAN 62 CAREFINE PEN NEEDLES CELONTIN 28 30GX5/16" 110 CALAN SR 62 CEM-UREA 85

Index 4 CENTANY 77 cimetidine 200 146 CLINDAGEL 75 CENTANY AT 77 cimetidine hcl 147 clindamycin hcl 16 cephalexin 65 CIMZIA 98 clindamycin palmitate CERACADE 88 CIMZIA STARTER KIT 98 hydrochloride 16 clindamycin phosphate 17 CERDELGA 102 cinacalcet hcl 94 clindamycin phosphate CEREBYX 27 CIPRO 97 (topical) 75 cerovel 85 CIPRO HC 135 clindamycin phosphate in CESAMET 36 CIPRODEX 135 d5w 17 clindamycin phosphate cetirizine hcl 39 ciprofloxacin 97 vaginal 152 CETRAXAL 135 ciprofloxacin hcl 97 clindamycin phosphate-benzoyl cevimeline hcl 117 ciprofloxacin hcl (ophth) 132 peroxide 75 CHANTIX 143 ciprofloxacin hcl (otic) 135 clindamycin phosphate-benzoyl peroxide (refrigerate) 75 CHANTIX CONTINUING ciprofloxacin-ciprofloxacin clindamycin phosphate- MONTHPAK 143 hcl 98 tretinoin 75 CHANTIX STARTING MONTH ciprofloxacin-fluocinolone PAK 143 acetonide 136 CLINDESSE 152 CHEMET 34 citalopram hydrobromide 29 clobazam 24 CHENODAL 98 CITRANATAL 90 DHA 121 clobetasol propionate 82 cheratussin ac 71 CITRANATAL ASSURE 121 clobetasol propionate e 80 chloramphenicol sodium CITRANATAL B-CALM 121 clobetasol propionate emollient base 82 succinate 16 CITRANATAL BLOOM 121 chlordiazepoxide hcl 18 clobetasol propionate CITRANATAL BLOOM emulsion 82 chlordiazepoxide hcl-clidinium DHA 121 CLOBEX 82 bromide 146 CITRANATAL DHA 121 chlordiazepoxide-amitriptyline clocortolone pivalate 82 140 CITRANATAL HARMONY 121 clodan 80 chlorhexidine gluconate (mouth- CLODERM 82 throat) 117 CITRANATAL MEDLEY 121 chloroquine phosphate 45 CITRANATAL RX 121 CLODERM PUMP 82 chlorothiazide 91 cladribine 47 clofarabine 47 chlorpromazine hcl 56 CLAFORAN 65 CLOLAR 47 chlorthalidone 91 claravis 73 clomiphene citrate 93 CHLORZOXAZONE 128 CLARINEX 39 clomipramine hcl 30 chlorzoxazone 128 CLARINEX-D 12 HOUR 72 clonazepam 24 CHOLBAM 98 clarithromycin 107 clonidine 42 cholecalciferol 154 clearlax 106 clonidine hcl 42 cholestyramine 39 clemastine fumarate 38 clonidine hcl (adhd) 2 cholestyramine light 39 CLENPIQ 105 clopidogrel bisulfate 102 choline fenofibrate 40 CLEOCIN 16,152 clorazepate dipotassium 18 CHOLINE MAGNESIUM CLEOCIN IN D5W 16 clotrimazole 117 TRISALICYLATE 9 CLEOCIN PEDIATRIC clotrimazole (topical) 77 CIALIS 64 GRANULES 16 clotrimazole w/ ciclodan 77 CLEOCIN PHOSPHATE 16 betamethasone 77 ciclopirox 77 CLEOCIN-T 74 clovique 115 ciclopirox olamine 77 CLIMARA 96 clozapine 55 cidofovir 59 CLIMARA PRO 96 CLOZARIL 55 cilostazol 102 CLINDACIN ETZ 74 COARTEM 45 CILOXAN 132 clindacin etz pledgets 73 codeine sulfate 10 cimetidine 147 CLINDACIN PAC 75 CODITUSSIN AC 72

Index 5 COGENTIN 53 CORTISPORIN-TC 136 cyclophosphamide 46 COLAZAL 98 cortizone-10 81 cycloserine 46 colchicine 101 CORZIDE 43 CYCLOSET 32 colchicine w/ probenecid 101 COSENTYX 79 cyclosporine 116 COLCRYS 101 COSENTYX SENSOREADY cyclosporine modified (for colesevelam hcl 39 PEN 79 microemulsion) 116 COSOPT 130 CYKLOKAPRON 104 COLESTID 40 COSOPT PF 130 CYMBALTA 30 COLESTID FLAVORED 40 COTELLIC 50 cyproheptadine hcl 39 colestipol hcl 40 COUMADIN 23 CYSTADANE 94 colocort 14 covaryx 96 CYSTAGON 100 COLY-MYCIN S 136 COZAAR 42 CYSTARAN 134 COLYTE-FLAVOR PACKS 106 CREON 90 cytarabine 47 COMBIGAN 130 CRESEMBA 37 CYTOMEL 145 COMBIPATCH 96 CRESTOR 40 CYTOTEC 149 COMBIVENT RESPIMAT 22 CRINONE 153 cytra k crystals 100 COMBIVIR 57 CRIXIVAN 57 cytra-2 100 COMETRIQ 50 cromolyn sodium 19 cytra-3 100 COMPLERA 57 CROMOLYN SODIUM 19 cytra-k 100 COMPLETENATE 121 cromolyn sodium d 400 154 compoz 104 (mastocytosis) 98 D-VI-SOL 154 compro 56 cromolyn sodium (ophth) 134 D.H.E. 45 111 COMTAN 53 crotan 89 d3-50 153 CONCEPT DHA 121 cryselle-28 67 DACOGEN 47 CONCEPT OB 121 CUBICIN 16 DAKLINZA 59 CONCERTA 2 CUBICIN RF 16 dalfampridine 140 CONDYLOX 86 CUPRIMINE 115 DALIRESP 20 constulose 106 CUTIVATE 82 danazol 13 CONZIP 10 CUVITRU 136 DANTRIUM 128 COPAXONE 140 CUVPOSA 146 dantrolene sodium 128 COPIKTRA 50 cvs budesonide nasal dapsone 16 CORDARONE 19 spray 129 cvs clotrimazole dapsone (topical) 75 CORDRAN 82 maximumstrength 77 daptomycin 16 COREG 61 cvs d3 153 DARAPRIM 45 COREG CR 61 cvs esomeprazole darifenacin hydrobromide 151 coremino 144 magnesium 148 DAURISMO 48 CORGARD 61 cvs folic acid 102 DAYPRO 5 CORLANOR 64 cvs lansoprazole 148 DAYTRANA 2 CORTANE-B 82 cvs motion sickness ii 36 DDAVP 95 CORTANE-B AQUEOUS 136 cvs nicotine 142 DEBACTEROL 117 CORTANE-B-OTIC 136 cvs nicotine lozenge 141 decadron 70 CORTEF 70 cvs nicotine transdermalsystem 142 decitabine 47 CORTENEMA 14 CVS PRENATAL 121 DECON-G 72 cortic-nd 135 cyclobenzaprine hcl 128 deferasirox 34 CORTIFOAM 14 CYCLOGYL 131 DELESTROGEN 96,97 cortisone acetate 70 CYCLOMYDRIL 131 DELSTRIGO 57 CORTISPORIN 77 cyclopentolate hcl 131

Index 6 DELZICOL 99 dexamethasone 70 dilt-xr 62 DEMADEX 91 DEXAMETHASONE diltiazem hcl 62 demeclocycline hcl 144 INTENSOL 70 diltiazem hcl coated beads 62 dexamethasone sodium DEMSER 42 phosphate 70 diltiazem hcl extended release DENAVIR 80 dexamethasone sodium beads 62 DIOVAN 42 DEPAKENE 28 phosphate (ophth) 133 dexchlorpheniramine DIOVAN HCT 43 DEPAKOTE 28 maleate 37 DIPENTUM 99 DEPAKOTE ER 28 DEXEDRINE 1 diphen 37 DEPAKOTE SPRINKLES 28 DEXILANT 148 diphenhydramine hcl 38 DEPEN TITRATABS 115 dexmethylphenidate hcl 2 diphenoxylate w/ atropine 34 DEPLIN 15 90 dexpak 10 day 70 DIPROLENE 83 DEPLIN 7.5 90 dextroamphetamine sulfate 1 DIPROLENE AF 83 DEPO-ESTRADIOL 97 DIACOMIT 25 dipyridamole 102 DEPO-PROVERA 48 DIAPHRAGMS 107 disopyramide phosphate 18 DEPO-PROVERA DIASTAT ACUDIAL 24 CONTRACEPTIVE 69 disulfiram 139 DEPO-SUBQ PROVERA DIASTAT PEDIATRIC 24 DITROPAN XL 151 104 70 diazepam 18 DIURIL 91 DEPO-TESTOSTERONE 13 diazepam (anticonvulsant) 24 divalproex sodium 28 DERMA-SMOOTHE/FS diazepam intensol 18 BODY 82 DIVIGEL 97 DERMA-SMOOTHE/FS diazoxide 32 DOCTOR MANZANILLA PE SCALP 82 DIBENZYLINE 42 SYRUP DERMASORB TA 82 DICLEGIS 36 ANTIHISTAMINE/DECONGESTA dermazene 77 diclofenac epolamine 77 NT 72 dofetilide 19 DERMOTIC 136 diclofenac potassium 5 DOLOPHINE 10 DESCOVY 57 diclofenac sodium 5 DOMETUSS-DMX 72 desipramine hcl 30 diclofenac sodium (actinic donepezil hydrochloride 139 desloratadine 39 keratoses) 79 diclofenac sodium (ophth)134 DOPTELET 103 desmopressin acetate 95 diclofenac sodium (topical) 77 DORAL 105 desmopressin acetate spray 95 desmopressin acetate spray diclofenac w/ misoprostol 5 doripenem 16 refrigerated 95 dicloxacillin sodium 138 dorzolamide hcl 134 DESOGEN 67 dicyclomine hcl 146 DORZOLAMIDE HCL 134 desogestrel & ethinyl didanosine 57 dorzolamide hcl-timolol estradiol 68 DIFFERIN 75 maleate 130 desogestrel-ethinyl estradiol DOTHELLE DHA 121 DIFICID 107 (biphasic) 68 dotti 96 DESONATE 82 diflorasone diacetate 83 DOVATO 57 desonide 82 DIFLUCAN 37 DOVONEX 79 DESOWEN 82 diflunisal 9 doxazosin mesylate 42 DESOXIMETASONE 82 digitek 63 doxepin hcl 30 desoximetasone 82 digoxin 63 doxepin hcl (antipruritic) 79 DESOXYN 1 dihydroergotamine mesylate 111 doxepin hcl (sleep) 105 desvenlafaxine 30 DILANTIN 27 doxercalciferol 94 DESVENLAFAXINE ER 30 DILANTIN INFATABS 27 doxycycline (monohydrate) 144 desvenlafaxine succinate 30 DILANTIN-125 27 doxycycline (rosacea) 88 DETROL 151 DILATRATE SR 17 doxycycline hyclate 144 DETROL LA 151 DILAUDID 10 doxylamine-pyridoxine 36

Index 7 DRISDOL 154 efavirenz 57 enoxaparin sodium 23 dronabinol 36 effer-k 114 enpresse-28 66 DROPLET PEN NEEDLES 30G EFFER-K 114 entacapone 53 X 5/16" 110 effervescent pot chloride 114 entecavir 59 drospirenone-ethinyl estradiol 68 EFFEXOR XR 30 ENTEREG 99 drospirenone-ethinyl estradiol- EFFIENT 102 ENTOCORT EC 70 levomefolate calcium 68 EFUDEX 79 ENTRESTO 64 DROXIA 102 ELAPRASE 94 ENTTY SPRAY EMULSION 88 DRYSOL 88 ELDEPRYL 54 enulose 99 DUAC 75 ELELYSO 102 ENVARSUS XR 116 DUAVEE 96 ELESTAT 134 EPANED 41 DUET DHA 400 121 ELESTRIN 97 EPCLUSA 60 DUET DHA BALANCED 121 eletriptan hydrobromide 111 EPICERAM 88 DUETACT 31 ELFOLATE 90 EPIDIOLEX 25 DUEXIS 5 ELIDEL 86 EPIDUO 75 duloxetine hcl 30 ELIGARD 48 EPIFOAM 83 DUOPA 53 ELIMITE 89 epinastine hcl (ophth) 135 DUPIXENT 85 ELIQUIS 23 EPINEPHRINE 153 DURAGESIC 10 ELIQUIS STARTER PACK 23 epinephrine 153 duramorph 10 ELIXOPHYLLIN 22 epinephrine (anaphylaxis) 153 duraxin 7 ELLA 69 epinephrine hcl 22 DUREX EXTRA SENSITIVE 108 ELMIRON 100 EPINEPHRINE HCL 153 DUREZOL 133 ELOCON 83 EPIPEN 2-PAK 153 dutasteride 101 eluryng 69 EPIPEN-JR 2-PAK 153 dutasteride-tamsulosin hcl 101 EMADINE 134 epitol 25 DUTOPROL 43 EMBEDA 10 EPIVIR 57 DUZALLO 101 EMCYT 48 EPIVIR HBV 60 DYAZIDE 91 EMEND 36 eplerenone 45 DYMISTA 129 EMEND TRIPACK 36 EPOGEN 103 DYRENIUM 91 EMGALITY 110 eprosartan mesylate 42 e.e.s. 400 107 EMSAM 28 EPZICOM 57 E.E.S. GRANULES 107 EMTRIVA 57 eq allergy relief 38,129 EASY TOUCH PEN NEEDLE EMULSION SB 88 EQUETRO 54 30G X 5/16" 110 EMVERM 15 ERAXIS 36 EASY TOUCH SAFETY PEN ENABLEX 151 ERBITUX 48 NEEDLES/30G X 5/16" 110 EC-NAPROSYN 5 enalapril maleate 41 ergocalciferol 154 enalapril maleate & EC-NAPROXEN 5 ergoloid mesylates 141 hydrochlorothiazide 43 ERGOMAR 111 econazole nitrate 77 ENBRACE HR 121 ergotamine w/ caffeine 111 ECOTRIN REGULAR ENBREL 7 STRENGTH 9 ERIVEDGE 48 ENBREL MINI 7 ed-spaz 145 ERLEADA 48 ENBREL SURECLICK 7 EDARBI 42 erlotinib hcl 50 ENCARE 152 EDARBYCLOR 43 ERTACZO 77 ENDARI 102 EDECRIN 91 ertapenem sodium 16 endocet 12 EDLUAR 105 ery 73 ENDOMETRIN 153 EDURANT 57 ery-tab 107

Index 8 ERYGEL 75 EVAMIST 97 FEMCAP 108 ERYPED 200 107 everolimus 50 FEMHRT LOW DOSE 96 ERYPED 400 107 everolimus FEMRING 153 erythrocin stearate 107 (immunosuppressant) 116 fenofibrate 40 EVISTA 93 erythromycin (acne aid) 75 FENOFIBRATE 40 EVOCLIN 75 erythromycin (ophth) 132 fenofibrate 40 EVOTAZ 57 erythromycin base 107 fenofibrate micronized 40 EVOXAC 118 erythromycin FENOFIBRIC ACID 40 EVZIO 35 ethylsuccinate 107 fenofibric acid 40 ESBRIET 144 EXACTUSS 72 FENOPROFEN CALCIUM 5 escitalopram oxalate 29 EXACTUSS TR 72 fenoprofen calcium 5 esgic 7 EXALGO 10 FENORTHO 5 ESGIC 7 EXAPHEX TR 72 FENSOLVI 48 esomeprazole EXELDERM 77 fentanyl 10 magnesium 148,149 EXELON 139 ESOMEPRAZOLE fentanyl citrate 10 exemestane 48 STRONTIUM 149 FENTORA 10 EXFORGE 43 estarylla 67 FER-IN-SOL 103 EXFORGE HCT 43 estazolam 105 ferosul 103 esterified estrogens & EXJADE 35 FERRIPROX 35 methyltestosterone 96 EXODERM 78 ferrous sulfate 103,104 ESTRACE 97 EXTAVIA 140 FERROUS SULFATE 104 estradiol 97 EXTINA 78 estradiol & norethindrone FETZIMA 30 ezetimibe 41 acetate 96 FETZIMA TITRATION PACK30 ezetimibe-simvastatin 39 estradiol vaginal 153 fexmid 128 FABIOR 75 estradiol valerate 97 FIBRICOR 40 FABRAZYME 94 ESTRING 153 FINACEA 88 FALESSA 68 ESTROGEL 97 finasteride 101 famciclovir 60 ESTROSTEP FE 68 FIORICET 7 famotidine 147 eszopiclone 105 FIORICET/CODEINE 12 FANAPT 55 ethacrynic acid 91 FIORINAL 7 ethambutol hcl 46 FANAPT TITRATION PACK 55 FIORINAL/CODEINE #3 12 ethosuximide 28 FANTASY LUBRICATED 108 FIRAZYR 101 ethyl chloride 87 FANTASY FIRDAPSE 46 ETHYL CHLORIDE/FINE LUBRICATED/SPERMICIDE FIRMAGON 48 STREAM 87 108 FIRST-LANSOPRAZOLE 149 ETHYL CHLORIDE/MEDIUM FARESTON 48 STREAM 87 FIRST-MOUTHWASH BLM 117 FARYDAK 50 ethynodiol diacet & eth FIRST-OMEPRAZOLE 149 estrad 68 FAZACLO 55 FIRVANQ 16 ETHYOL 52 FC FEMALE CONDOM 108 flac 136 etidronate disodium 92 FC2 FEMALE CONDOM 108 FLAGYL 15 etodolac 5 febuxostat 101 FLAREX 133 etonogestrel-ethinyl estradiol69 felbamate 27 flavoxate hcl 151 ETOPOPHOS 52 FELBATOL 27 FLEBOGAMMA DIF 136 etoposide 52 FELDENE 5 flecainide acetate 19 EUCRISA 88 felodipine 63 FLECTOR 77 EURAX 89 FEM PH 152 FLOMAX 101 euthyrox 145 FEMARA 48

Index 9 FLONASE ALLERGY fluvoxamine maleate 29 furosemide 91 RELIEF 129 FML 133 FUSION PLUS 103 FLONASE ALLERGY RELIEF CHILDRENS 129 FML FORTE 133 FUZEON 57 FLONASE SENSIMIST 130 FML LIQUIFILM 133 fyavolv 96 FLORIVA PLUS 120 FOCALIN 2 FYCOMPA 24 FLOVENT DISKUS 20 FOCALIN XR 2 g tussin ac 71 FLOVENT HFA 20 folbic 90 gabapentin 25 FLOXIN OTIC 135 FOLBIC RF 90 GABITRIL 27 floxuridine 47 FOLET DHA 121 GABLOFEN 128 FLUCELVAX QUADRIVALENT FOLET ONE 122 GALAFOLD 94 2017-2018 151 folic acid 102 galantamine hydrobromide 139 FLUCELVAX QUADRIVALENT 2018-2019 151 FOLIVANE-F 103 GALZIN 115 FLUCELVAX QUADRIVALENT FOLIVANE-OB 122 GAMASTAN 136 2019-2020 152 FOLTX 90 GAMASTAN S/D 136 fluconazole 37 fondaparinux sodium 23 GAMMAGARD LIQUID 136 fluconazole in dextrose 37 FORFIVO XL 28 GAMMAKED 136 flucytosine 37 formadon 56 GAMMAPLEX 136 fludarabine phosphate 47 formaldehyde 56 GAMUNEX-C 136 fludrocortisone acetate 71 FORTEO 92 GARDASIL 9 152 FLUMADINE 61 FORTESTA 13 GASTROCROM 98 flunisolide (nasal) 130 FOSAMAX 92 gatifloxacin (ophth) 132 fluocinolone acetonide 83 FOSAMAX PLUS D 92 GATTEX 100 fluocinolone acetonide fosamprenavir calcium 57 gavilyte-c 105 (otic) 136 fluocinonide 83 FOSCAVIR 59 gavilyte-g 105 fluocinonide emulsified base 83 fosinopril sodium 41 gavilyte-h 105 fosinopril sodium & FLUORABON 113 gavilyte-n/flavor pack 105 hydrochlorothiazide 43 GEBAUERS INSTANT ICE 87 fluoritab 113 fosphenytoin sodium 27 fluorometholone (ophth) 133 GEBAUERS PAIN EASE 87 FOSRENOL 99 GEBAUERS SPRAY AND FLUOROPLEX 79 FRAGMIN 23 STRETCH 87 fluorouracil 47 FREESTYLE FREEDOM GELCLAIR 118 fluorouracil (topical) 79 LITE 109 GELFILM OP 134 fluoxetine hcl 29 FREESTYLE INSULINX BLOODGLUCOSE GELNIQUE 151 fluoxetine hcl (pmdd) 141 MONITORING SYSTEM 109 GELNIQUE PUMP 151 FLUOXETINE FREESTYLE INSULINX GEMCITABINE 47 HYDROCHLORIDE 29 BLOODGLUCOSE TEST 89 fluphenazine hcl 56 FREESTYLE INSULINX gemcitabine hcl 47 GEMCITABINE flura-drops 113 BLOODGLUCOSE TEST STRIPS 89 HYDROCHLORIDE 47 flurandrenolide 83 FREESTYLE LITE BLOOD gemfibrozil 40 flurazepam hcl 105 GLUCOSE MONITORING GEMZAR 47 flurbiprofen 5 SYSTEM 109 GENERESS FE 68 flurbiprofen sodium 135 FREESTYLE LITE TEST STRIPS 90 gengraf 115 flutamide 48 FREESTYLE TEST GENOTROPIN 93 fluticasone propionate 83 STRIPS 90 GENOTROPIN MINIQUICK 93 fluticasone propionate FROVA 111 gentak 131 (nasal) 130 frovatriptan succinate 111 fluticasone-salmeterol 22 gentamicin in saline 3 FURADANTIN 150 fluvastatin sodium 40 gentamicin sulfate 4

Index 10 gentamicin sulfate (ophth) 132 GOLYTELY 106 HISTEX-PE 72 gentamicin sulfate (topical) 77 GONITRO 17 HIZENTRA 137 GENVOYA 57 gordons urea 85 homatropaire 131 GEODON 54 GORDONS UREA 85 homatropine hbr 131 geri-hydrolac 12 86 GRALISE 141 HORIZANT 141 gianvi 66 GRALISE STARTER 141 HUMALOG 33 GIAZO 99 granisetron hcl 35 HUMALOG JUNIOR GILENYA 140 GRANIX 103 KWIKPEN 32 HUMALOG KWIKPEN 32,33 GILOTRIF 50 GRASTEK 3 HUMALOG MIX 50/50 33 GILPHEX TR 72 griseofulvin microsize 37 HUMALOG MIX 50/50 GILTUSS 72 griseofulvin ultramicrosize 37 KWIKPEN 33 GILTUSS COUGH & COLD 72 guaifenesin dac 72 HUMALOG MIX 75/25 33 GILTUSS SINUS & guaifenesin-codeine 72 HUMALOG MIX 75/25 CONGESTION 72 guanfacine hcl 42 KWIKPEN 33 GILTUSS TR 72 guanfacine hcl (adhd) 2 HUMATROPE 93 GLASSIA 143 HUMATROPE COMBO GUANIDINE HCL 46 glatiramer acetate 140 PACK 93 GVOKE PFS 32 glatopa 140 HUMIRA 4 GYNAZOLE-1 152 HUMIRA PEDIATRIC CROHNS GLEEVEC 50 HAEGARDA 102 DISEASE STARTER PACK 4 GLEOSTINE 47 HALAC 83 HUMIRA PEN 4 glimepiride 34 halcinonide 83 HUMIRA PEN-CD/UC/HS glipizide 34 STARTER 4 HALCION 105 glipizide xl 34 HUMIRA PEN-PS/UV halobetasol propionate 83 STARTER 4 glipizide-metformin hcl 31 HALOG 83 HUMULIN 70/30 33 GLUCAGEN DIAGNOSTIC 89 haloperidol 55 HUMULIN 70/30 KWIKPEN 33 GLUCAGEN HYPOKIT 32 haloperidol lactate 55 HUMULIN N 33 GLUCAGON EMERGENCY KIT 32 HALOTIN 78 HUMULIN N KWIKPEN 33 GLUCAGON EMERGENCY KIT HARVONI 60 HUMULIN R 33 FOR LOW BLOOD SUGAR 32 heartburn treatment 24 HUMULIN R U-500 GLUCOPHAGE 31 hour 148 (CONCENTRATED) 33 GLUCOPHAGE XR 31 HECTOROL 94 HUMULIN R U-500 KWIKPEN 33 GLUCOTROL 34 HEMANGEOL 61 hyaluronate sodium GLUCOTROL XL 34 HEMENATAL OB 122 (emollient) 86 GLUCOVANCE 31 HEMENATAL OB + DHA 122 HYCAMTIN 52 GLUMETZA 31 heparin (porcine) in sodium hydralazine hcl 45 chloride 23 HYDREA 52 glyburide 34 heparin sod (porcine) in glyburide micronized 34 d5w 24 HYDRO 35 85 glyburide-metformin 31 heparin sodium (porcine) 24 HYDRO 40 FOAM 85 GLYCATE 146 HEPARIN SODIUM/NACL hydrochlorothiazide 91 glycopyrrolate 146 0.45% 24 HYDROCODONE HEPARIN SODIUM/SODIUM BITARTRATE/ACETAMINOPHE GLYCOPYRROLATE 146 CHLORIDE 24 N 12 glydo 87 HEPARIN SODIUM/SODIUM hydrocodone polistirex- GLYNASE 34 CHLORIDE 0.9% 24 chlorpheniramine polistirex 72 GLYSET 31 HEPSERA 60 hydrocodone w/ HETLIOZ 105 homatropine 71 GLYXAMBI 31 hydrocodone- GOCOVRI 53 HEXALEN 47 acetaminophen 12 HIPREX 150

Index 11 hydrocodone-ibuprofen 12 imiquimod 86 iodoquinol-hydrocortisone in aloe hydrocortisone 70 IMITREX 111,112 vehicle 78 iodoquinol-hydrocortisone-aloe hydrocortisone (intrarectal) 14 IMITREX STATDOSE polysaccharide 78 hydrocortisone (rectal) 15 REFILL 111 IMITREX STATDOSE IOPIDINE 131 hydrocortisone (topical) 83 SYSTEM 112 ipratropium bromide 19 hydrocortisone acetate IMODIUM A-D 34 ipratropium bromide (nasal)129 (rectal) 15 hydrocortisone acetate w/ IMPAVIDO 15 ipratropium-albuterol 22 pramoxine 14 IMURAN 116 irbesartan 42 hydrocortisone butyrate 83 inatal gt 120 irbesartan-hydrochlorothiazide hydrocortisone butyrate INCRELEX 94 44 IRESSA 50 hydrophilic lipo base 83 INCRUSE ELLIPTA 19 hydrocortisone valerate 83 ISENTRESS 57 indapamide 91 hydrocortisone w/acetic ISENTRESS HD 57 INDERAL LA 61 acid 136 ISOLYTE-S 113 INDERAL XL 62 hydromet 71 isometheptene- hydromorphone hcl 10 INDOCIN 5 dichloralphenazone- hydroxychloroquine sulfate 45 indomethacin 5 acetaminophen 111 hydroxyprogesterone INFANATE BALANCE 122 isoniazid 46 caproate 138 INFLECTRA 99 ISONIAZID 46 hydroxyurea 52 INGREZZA 140 isoniazid 46 hydroxyzine hcl 18 INHALER SPACERS 110 ISOPTO ATROPINE 131 hydroxyzine pamoate 18 INLYTA 50 ISOPTO CARPINE 131 HYLINATE 86 INNOPRAN XL 62 ISORDIL TITRADOSE 17 hyophen 150 INREBIC 50 isosorbide dinitrate 17 hyoscyamine sulfate 146 INSPRA 45 isosorbide mononitrate 17 HYPER-SAL 73 INSULIN LISPRO isotretinoin 75 HYPERSAL 73 PROTAMINE/INSULIN LISPRO isoxsuprine hcl 64 HYQVIA 137 KWIKPEN 33 INSULIN SYRINGES AND PEN isradipine 63 HYZAAR 43 NEEDLES 110 ISTALOL 130 ibandronate sodium 92 INSUPEN ULTRAFIN ISTODAX (OVERFILL) 50 IBRANCE 50 30GX8MM 110 itraconazole 37 INTEGRA F 103 ibu 5 ivermectin 15 INTELENCE 57 ibudone 11,12 ivermectin (rosacea) 88 INTERMEZZO 105 ibuprofen 5 JADENU 35 INTRAROSA 152 ICAR PEDIATRIC 104 JADENU SPRINKLE 35 INTRON A 52 icatibant acetate 101 JAKAFI 50 INTUNIV 2 ICLUSIG 50 JALYN 101 INVANZ 16 IDHIFA 50 jantoven 23 INVEGA 55 ILEVRO 135 JANUMET 31 INVEGA SUSTENNA 55 ILIDERM 88 JANUMET XR 31 INVEGA TRINZA 55 ilotycin 131 JANUVIA 32 INVIRASE 57 ILUMYA 79 JARDIANCE 34 INVOKAMET 31 imatinib mesylate 50 JULUCA 57 INVOKAMET XR 31 IMBRUVICA 50 JUXTAPID 41 INVOKANA 34 imipenem-cilastatin 16 JYNARQUE 95,96 iodoquimez-hc 77 imipramine hcl 30 k-effervescent 114 iodoquinol-hc 78 imipramine pamoate 30 K-PHOS 114

Index 12 K-PHOS NEUTRAL 114 KIMONO SENSATION PLUS LAMICTAL ODT 25 K-PHOS NO 2 100 SPERMICIDE LAMICTAL STARTER/NOT LUBRICATED 108 k-sol 114 TAKING CARBAMAZEPINE 25 KIMONO SPECIAL 108 LAMICTAL STARTER/TAKING K-TAB 114 KINERET 4 CARBAMAZEPINE/NOT TAKING KADIAN 10 kionex 117 VALPROATE 25 kaitlib fe 67 LAMICTAL STARTER/TAKING KISQALI 50 VALPROATE 26 KALETRA 57,58 KISQALI FEMARA 200 LAMICTAL XR 26 KALYDECO 143 DOSE 49 lamivudine 58 KAMDOY 88 KISQALI FEMARA 400 DOSE 49 lamivudine (hbv) 60 KAMELEON LUBRICATED 108 KISQALI FEMARA 600 lamivudine-zidovudine 58 KAPVAY 2 DOSE 49 lamotrigine 26 kariva 66 KITABIS PAK 4 LANCETS 109 KAZANO 31 KIVIK 88 LANOXIN 63 KEFLEX 65 KLARITY-A 132 lansoprazole 149 kelnor 1/35 66 KLARON 75 lanthanum carbonate 99 kelnor 1/50 66 klofensaid ii 77 LANTUS 33 KENALOG 84 KLONOPIN 24 LANTUS SOLOSTAR 33 KEPIVANCE 52 klor-con 114 LASIX 91 KEPPRA 25 klor-con 10 114 LASTACAFT 135 KEPPRA XR 25 klor-con m10 114 latanoprost 135 KERALAC 85 klor-con m15 114 LATUDA 54 ketoconazole 37 klor-con sprinkle 114 LAZANDA 10 ketoconazole (topical) 78 KORLYM 32 LEDIPASVIR/SOFOSBUVIR ketodan 77 KOSHER PRENATAL PLUS 60 ketoprofen 5 IRON 122 leflunomide 6 KETOROLAC kp folic acid 102 LENVIMA 10 MG DAILY TROMETHAMINE 5 KRINTAFEL 45 DOSE 50 ketorolac tromethamine 6 KRISTALOSE 106 LENVIMA 12MG DAILY ketorolac tromethamine KUVAN 94 DOSE 50 LENVIMA 14 MG DAILY (ophth) 135 KYLEENA 69 KEVEYIS 91 DOSE 50 l-methylfolate 90 LENVIMA 18 MG DAILY KEVZARA 4 L-METHYLFOLATE CA/S- DOSE 51 KHEDEZLA 30 ALGAL 90 LENVIMA 20 MG DAILY KIMONO COLORS 108 L-METHYLFOLATE DOSE 51 LENVIMA 24 MG DAILY KIMONO LUBRICATED 108 FORTE 90 labetalol hcl 61 DOSE 51 KIMONO MICRO THIN 108 LENVIMA 4 MG DAILY KIMONO MICRO THIN PLUS LAC-HYDRIN 86 DOSE 51 SPERMICIDE LAC-HYDRIN TWELVE 86 LENVIMA 8 MG DAILY LUBRICATED 108 LACRISERT 130 DOSE 51 KIMONO PLUS SPERMICIDE lactated ringer's LESCOL XL 40 LUBRICATED 108 (irrigation) 117 LETAIRIS 64 KIMONO PLUS lactic acid (ammonium letrozole 49 SPERMICIDE/LUBRICATED lactate) 86 108 LACTULOSE 106 leucovorin calcium 52 KIMONO PS LUBRICATED108 lactulose 106 LEUKERAN 47 KIMONO PS PLUS lactulose (encephalopathy)99 LEUKINE 103 SPERMICIDE/LUBRICATED leuprolide acetate 49 108 LAMICTAL 26 KIMONO SENSATION LAMICTAL CHEWABLE LUBRICATED 108 DISPERSIBLE 25

Index 13 LEUPROLIDE lindane 89 LOTENSIN HCT 44 ACETATE/BUPIVACAINE linezolid 17 loteprednol etabonate 133 HYDROCHLORIDE 49 levalbuterol hcl 22 LINZESS 99 LOTREL 44 LIORESAL levalbuterol tartrate 22 LOTRISONE 78 INTRATHECAL 128 LOTRONEX 99 LEVAQUIN 98 liothyronine sodium 145 lovastatin 41 LEVBID 146 LIPITOR 40 LOVAZA 39 LEVEMIR 33 LIPOFEN 40 LOVENOX 24 LEVEMIR FLEXTOUCH 33 lisinopril 41 loxapine succinate 55 levetiracetam 26 lisinopril & levobunolol hcl 130 hydrochlorothiazide 44 LUCEMYRA 139 levocarnitine (metabolic LITHIUM 54 luliconazole 78 modifiers) 94 lithium carbonate 54 LUMIGAN 135 levofloxacin 98 LITHOBID 54 LUMIZYME 94 levofloxacin (ophth) 132 LITHOSTAT 101 LUNESTA 105 LEVOMEFOLATE CALCIUM LIVALO 41 LUPRON DEPOT (1- ALGAL POWDER 90 MONTH) 49 levonorgestrel & eth LO LOESTRIN FE 68 LUPRON DEPOT (3- estradiol 68 LOCOID 84 MONTH) 49 levonorgestrel (emergency LOCOID LIPOCREAM 84 LUPRON DEPOT (4- oc) 69 LODINE 6 MONTH) 49 levonorgestrel-eth estradiol LUPRON DEPOT (6- (triphasic) 68 LODOSYN 53 MONTH) 49 levonorgestrel-ethinyl estradiol LOESTRIN 1.5/30-21 68 LUPRON DEPOT-PED (1- (91-day) 68 LOESTRIN 1/20-21 68 MONTH) 94 levonorgestrel-ethinyl estradiol LUPRON DEPOT-PED (3- (continuous) 68 LOESTRIN FE 1.5/30 68 MONTH) 94 levothyroxine sodium 145 LOESTRIN FE 1/20 68 LUXIQ 84 LEVSIN 146 LOKELMA 117 LUZU 78 LEVSIN/SL 146 LOMOTIL 34 LYNPARZA 51 LEXAPRO 29 LONSURF 50 LYRICA 26 LEXIVA 58 loperamide hcl 34 LYSODREN 49 LIALDA 99 LOPID 40 LYSTEDA 104 LIBRAX 146 lopinavir-ritonavir 58 M-NATAL PLUS 122 lido-k 87 LOPRESSOR 61 M-VIT 122 lidocaine 87,88 LOPRESSOR HCT 44 MACROBID 150 lidocaine hcl 87 LOPROX 78 MACRODANTIN 150 lidocaine hcl (mouth-throat) 117 LOPROX SHAMPOO 78 mafenide acetate 80 lidocaine pak 87 lorazepam 18 MAGNEBIND 400 113 lidocaine-hydrocortisone acetate lorazepam intensol 18 magnesium sulfate 113 (rectal) 14 LORBRENA 51 MAGNESIUM SULFATE 114 lidocaine-prilocaine 88 lorcet 11 MAKENA 139 LIDODERM 88 LORTAB 12 MALARONE 45 LIDODOSE 88 lorzone 128 LIDODOSE PEDIATRIC BULK malathion 89 PACK 88 losartan potassium 42 maprotiline hcl 28 lidopin 87 losartan potassium & MARINOL 36 hydrochlorothiazide 44 LIDORX 88 LOSEASONIQUE 68 MARNATAL-F 122 LILETTA 69 LOTEMAX 133 MARPLAN 28 LINCOCIN 17 LOTENSIN 41 MATULANE 52 lincomycin hcl 17 matzim la 62

Index 14 MAVENCLAD 140 mesalamine w/ cleanser 99 metoprolol & MAVYRET 60 MESNEX 52 hydrochlorothiazide 44 metoprolol succinate 61 MAXALT 112 MESTINON 46 METOPROLOL SUCCINATE MAXALT-MLT 112 MESTINON TIMESPAN 46 ER/HYDROCHLOROTHIAZIDE MAXIDEX 133 metadate er 2 44 MAXIPIME 66 metaproterenol sulfate 22 metoprolol tartrate 61 MAXITROL 133 metaxall 128 METROCREAM 89 MAXX LUBRICATED 108 metaxalone 128 METROGEL 89 MAXX PLUS SPERMICIDE metformin hcl 32 METROGEL-VAGINAL 152 LUBRICATED 108 METFORMIN METROLOTION 89 MAXZIDE 91 HYDROCHLORIDE 32 metronidazole 15 MAXZIDE-25 91 methadone hcl 10 metronidazole (topical) 89 MAYZENT 140 METHADONE HCL 10 metronidazole in nacl 15 MAYZENT STARTER methadone hcl 10,11 metronidazole vaginal 152 PACK 140 methadone hcl intensol 10 mccarnitine 94 mexiletine hcl 19 methadose 10 meclizine hcl 36 mezparox-hc 81 methamphetamine hcl 1 meclofenamate sodium 6 MIACALCIN 92 methazolamide 91 MEDROL 70,71 micafungin sodium 36 methenamine hippurate 150 MEDROL DOSEPAK 70 MICARDIS 42 methenamine mandelate 150 MEDROX-RX 87 MICARDIS HCT 44 methergine 136 medroxyprogesterone miconazole 3 152 acetate 139 methimazole 145 miconazole-zinc oxide-white medroxyprogesterone acetate METHITEST 14 petrolatum 78 (contraceptive) 70 methocarbamol 128 MICRODOT TEST STRIPS 90 mefenamic acid 6 METHOTREXATE 4 MICROZIDE 92 mefloquine hcl 45 methotrexate sodium 47,48 midazolam hcl 105 MEGACE ES 139 methoxsalen rapid 79 midodrine hcl 153 megestrol acetate 49 methscopolamine migergot 111 megestrol acetate bromide 146 miglitol 31 (appetite) 139 methyclothiazide 92 MEKINIST 51 miglustat 102 methyldopa 42 MIGRANAL 111 MEKTOVI 51 methyldopa & melodetta 24 fe 67 hydrochlorothiazide 44 MILLIPRED 71 meloxicam 6 methyldopate hcl 42 MILLIPRED DP 71 melphalan 47 methylergonovine MINASTRIN 24 FE 68 maleate 136 melphalan hcl 47 MINIPRESS 42 METHYLIN 2 memantine hcl 139 minitran 17 methylphenidate hcl 2,3 MENEST 97 MINIVELLE 97 METHYLPHENIDATE MINOCIN 144 MENOSTAR 97 HYDROCHLORIDE ER 3 meperidine hcl 10 methylprednisolone 71 minocycline hcl 144 MEPHYTON 154 methyltestosterone 14 minoxidil 45 meprobamate 18 metipranolol 130 MIRALAX 106 MEPRON 16 metoclopramide hcl 98 MIRAPEX 53 mercaptopurine 47 METOCLOPRAMIDE ODT 98 MIRAPEX ER 53 meropenem 16 metolazone 92 MIRCERA 103 MERREM 16 metopic 85 MIRCETTE 68 mesalamine 99 METOPIRONE 89 MIRENA 69 mirtazapine 28

Index 15 MIRVASO 89 mycophenolate mofetil NATELLE ONE 122 misoprostol 149 hcl 116 NATPARA 92 mycophenolate sodium 116 MITIGARE 101 NATROBA 89 MYDRIACYL 131 mitoxantrone hcl 49 NATURE-THROID 145 MYFORTIC 116 MOBIC 6 NATURE-THROID NT-2.5 145 MYKIDZ IRON 10 104 modafinil 3 NAYZILAM 24 MYLERAN 47 moderiba 59 NEBUPENT 15 MYNATAL ADVANCE 122 MODERIBA 1200 DOSE nebusal 73 MYNATAL PACK 60 NEBUSAL 73 moexipril hcl 41 ULTRACAPLET 122 NEEVO DHA 122 moexipril-hydrochlorothiazide MYNATE 90 PLUS 122 44 MYRBETRIQ 151 nefazodone hcl 29 molindone hcl 56 MYSOLINE 26 neo-polycin 131 mometasone furoate 84 MYTESI 34 neo-polycin hc 133 mometasone furoate nabumetone 6 NEO-SYNALAR 77 (nasal) 130 nadolol 62 neomycin sulfate 4 mondoxyne nl 144 nadolol & neomycin-bacitracin zn- montelukast sodium 19 bendroflumethiazide 44 polymyxin 132 MONUROL 150 NAFCILLIN 138 neomycin-polymy- dexameth 133 morgidox 1x100mg 144 nafcillin sodium 138 neomycin-polymyxin-gramicidin morphine sulfate 11 NAFCILLIN SODIUM 138 132 morphine sulfate beads 11 nafcillin sodium 138 neomycin-polymyxin-hc MOTOFEN 34 naftifine hcl 78 (ophth) 133 neomycin-polymyxin-hc MOVANTIK 99 NAFTIN 78 (otic) 136 MOVIPREP 106 NAGLAZYME 94 neomycin/polymyxin b gu 100 MOXATAG 137 NALFON 6 NEONATAL COMPLETE 122 MOXEZA 132 naloxone hcl 35 NEONATAL PLUS 122 moxifloxacin hcl 98 naltrexone hcl 35 NEONATAL VITAMIN 122 moxifloxacin hcl (ophth) 132 NAMENDA 139 NEORAL 116 MOZOBIL 104 NAMENDA TITRATION NEOSPORIN 132 PAK 139 MS CONTIN 11 NEOTUSS PLUS 72 NAMENDA XR 139 MUCOTROL 118 NAMENDA XR TITRATION NEPTAZANE 91 MULPLETA 103 PACK 139 NERLYNX 51 MULTAQ 19 NAPRELAN 6 NESINA 32 MULTI PRENATAL 122 NAPROSYN 6 NESTABS 122 multi-vit/iron/fluoride 120 naproxen 6 NESTABS DHA 122 multi-vitamin/fluoride drops 118 naproxen dr 5 NESTABS ONE 122 MULTIVITAMIN WITH naproxen sodium 6 neuac 73 FLUORIDE 118 naproxen-esomeprazole NEULASTA 103 multivitamin with fluoride 118 magnesium 6 NEULASTA ONPRO KIT 103 multivitamin/fluoride 119 naratriptan hcl 112 NEUPOGEN 103 multivitamins/fluoride 119 NARCAN 35 NEUPRO 53 mupirocin 77 NARDIL 28 NEURONTIN 26 MYALEPT 94 NASONEX 130 NEUTROGENA CLEAR PORE MYAMBUTOL 46 NATACHEW 122 CLEANSER/MASK 75 MYCAMINE 36 NATACYN 132 NEVANAC 135 MYCOBUTIN 46 NATAZIA 68 nevirapine 58 mycophenolate mofetil 116 nateglinide 34 NEXA PLUS 123

Index 16 NEXAVAR 51 NORCO 12 nystatin (mouth-throat) 117 NEXIUM 149 NORDITROPIN FLEXPRO 93 nystatin (topical) 78 NEXIUM 24HR 149 norethin acet & estrad-fe 68 nystatin-triamcinolone 78 NEXIUM 24HR CLEAR norethindrone & ethinyl O-CAL FA 123 MINIS 149 estradiol-fe 68 OB COMPLETE ONE 123 NEXPLANON 69 norethindrone OB COMPLETE PETITE 123 niacin (antihyperlipidemic) 41 (contraceptive) 70 norethindrone acet & eth OB COMPLETE PREMIER 123 NIASPAN 41 estra 68 OB COMPLETE/DHA 123 nicardipine hcl 63 norethindrone acetate 139 OBSTETRIX ONE 123 NICODERM CQ 143 norethindrone acetate-ethinyl OCALIVA 98 NICORETTE 143 estradiol 96 OCTAGAM 137 NICORETTE MINI 143 NORGESIC FORTE 128 octreotide acetate 95 NICORETTE STARTER norgestimate-ethinyl KIT 143 estradiol 68 OCUFLOX 132 norgestimate-ethinyl estradiol ODACTRA 3 nicotine 143 (triphasic) 68 nicotine polacrilex 143 NORITATE 89 ODOMZO 48 NICOTINE TRANSDERMAL NORMOSOL-R 113 OFEV 144 SYSTEM 143 ofloxacin 98 NICOTROL INHALER 143 NORPACE 18 NORPACE CR 18 ofloxacin (ophth) 132 NICOTROL NS 143 ofloxacin (otic) 135 nifedipine 63 NORPRAMIN 30 NORTHERA 153 ogestrel 67 NILANDRON 49 olanzapine 55 nilutamide 49 nortriptyline hcl 30 NORVASC 63 olanzapine-fluoxetine hcl 140 nimodipine 63 olmesartan medoxomil 42 NINLARO 51 NORVIR 58 NOVOFINE AUTOCOVER olmesartan medoxomil- nisoldipine 63 30GX8MM 110 amlodipine-hydrochlorothiazide nitisinone 94 44 NOVOLIN N FLEXPEN 33 olmesartan medoxomil- NITRO-BID 17 NOVOLIN N FLEXPEN hydrochlorothiazide 44 NITRO-DUR 17 RELION 33 olopatadine hcl 135 NOXAFIL 37 nitro-time 17 olopatadine hcl (nasal) 129 np thyroid 120 145 nitrofurantoin 150 OLUX 84 NUBEQA 49 nitrofurantoin macrocrystal 150 OLUX-E 84 NUCORT 84 nitrofurantoin monohyd OMECLAMOX-PAK 150 macro 150 NUCYNTA 11 omega-3-acid ethyl esters 39 nitroglycerin 17 NUCYNTA ER 11 omeppi 150 NITROLINGUAL NUEDEXTA 141 PUMPSPRAY 17 omeprazole 149 NITROMIST 17 NULOJIX 116 OMEPRAZOLE + SYRSPEND NULYTELY/FLAVOR NITROSTAT 17 SFALKA 149 PACKS 106 omeprazole-sodium NITYR 94 NUPLAZID 54 bicarbonate 150 NIVA-PLUS 123 NUTROPIN AQ NUSPIN OMNARIS 130 NIVESTYM 103 10 93 OMNIPRED 133 NIZATIDINE 147 NUTROPIN AQ NUSPIN 20 93 OMNITROPE 93 nizatidine 147,148 NUTROPIN AQ NUSPIN 5 93 ondansetron 35 NIZORAL 78 NUVARING 69 ondansetron hcl 35 NOCTIVA 95 NUVIGIL 3 ONETOUCH ULTRA 90 nolix 80 NYMALIZE 63 ONETOUCH ULTRA 2 109 NON PREFERRED TEST ONETOUCH ULTRA MINI 109 STRIPS 90 nystatin 37

Index 17 ONETOUCH VERIO 110 oscimin sr 145 PANDEL 84 ONETOUCH VERIO FLEX oseltamivir phosphate 61 PANRETIN 79 BLOOD GLUCOSE OSENI 31 pantoprazole sodium 149 MONITORING SYSTEM 110 ONETOUCH VERIO IQ BLOOD OSMOLEX ER 53 PARAGARD INTRAUTERINE GLUCOSE MONITORING OSMOPREP 106 COPPER CONTRACEPTIVE T380A 69 SYSTEM 110 OSPHENA 93 ONETOUCH VERIO SYNC paregoric 34 BLOODGLUCOSE OTEZLA 6 PAREMYD 135 MONITORING SYSTEM 110 OTICIN HC NR 136 paricalcitol 95 ONETOUCH VERIO TEST OTOVEL 136 PARLODEL 53 STRIPS 90 OTREXUP 4 ONEVITE 118 PARNATE 28 OVACE PLUS 80 ONFI 24 paroex 117 OVACE PLUS WASH 80 OPANA 11 paromomycin sulfate 4 OVACE WASH 80 opium tincture 34 paroxetine hcl 29 OVIDE 89 OPSUMIT 64 paroxetine mesylate OXACILLIN SODIUM 138 (vasomotor) 143 OPTIONS CONCEPTROL VAGINAL oxacillin sodium 138 PASER 46 CONTRACEPTIVE 152 oxandrolone 13 PATADAY 135 OPTIONS GYNOL II oxaprozin 6 PATANASE 129 VAGINALCONTRACEPTIVE OXAYDO 11 PATANOL 135 152 PAXIL 29 ORACEA 89 oxazepam 18 PAXIL CR 29 ORACIT 100 oxcarbazepine 26 OXERVATE 133 pediatric vitamins acd w/ ORAFATE 118 fluoride 120 oxiconazole nitrate 78 ORALAIR 3 PEDVAX HIB 151 ORALAIR ADULT SAMPLE OXISTAT 78 peg 3350-kcl-sod bicarb-sod KIT 3 OXSORALEN ULTRA 79 chloride-sod sulfate 106 ORALAIR ADULT STARTER OXTELLAR XR 26 peg 3350-potassium chloride-sod PACK 3 oxybutynin chloride 151 bicarbonate-sod chloride 106 oralone dental paste 117 PEGANONE 27 oxycodone hcl 11 ORAP 141 oxycodone w/ PEGASYS 60 ORAPRED ODT 71 acetaminophen 12 PEGASYS PROCLICK 60 ORAVIG 117 oxycodone-aspirin 12 PEGINTRON 60 orazinc 115 oxycodone-ibuprofen 12 PEN NEEDLES 30GX5/16" 110 ORENCIA 6 oxymorphone hcl 11 PEN NEEDLES 30GX8MM 110 ORENCIA CLICKJECT 6 OXYTROL 151 penicillamine 115 ORENITRAM 64 OXYTROL FOR WOMEN 151 penicillin g potassium 137 ORFADIN 94,95 OZEMPIC 32 PENICILLIN G POTASSIUM IN ORKAMBI 143 pacerone 19 ISO-OSMOTIC DEXTROSE 137 orphenadrine citrate 128 paliperidone 55 orphenadrine w/ aspirin & PENICILLIN G PROCAINE 137 palonosetron hcl 35 penicillin g sodium 137 caff 128 PALONOSETRON ORTHO MICRONOR 70 HYDROCHLORIDE 35 penicillin v potassium 137 ORTHO TRI-CYCLEN 68 PALYNZIQ 95 PENLEN 88 ORTHO TRI-CYCLEN LO 68 PAMELOR 30 PENNSAID 77 ORTHO-CYCLEN 69 pamidronate disodium 92 pentamidine isethionate 15 ORTHO-NOVUM 1/35 69 PAMIDRONATE PENTASA 99 ORTHO-NOVUM 7/7/7 69 DISODIUM 92 pentazocine w/ naloxone 13 oscimin 145 PANCREAZE 90 pentoxifylline 102

Index 18 PEPCID 148 PIQRAY 200MG DAILY potassium bicarbonate 114 PEPCID AC MAXIMUM DOSE 51 potassium chloride 114 PIQRAY 250MG DAILY STRENGTH 148 POTASSIUM CHLORIDE 115 PERCOCET 12 DOSE 51 PIQRAY 300MG DAILY potassium chloride 115 PERFOROMIST 22 DOSE 51 potassium chloride in nacl 113 PERIDEX 117 piroxicam 6 potassium chloride perindopril erbumine 41 PLAN B ONE-STEP 69 microencapsulated crystals permethrin 89 PLAQUENIL 45 er 114 perphenazine 56 PLASMA-LYTE A 113 potassium chloride proamp 114 perphenazine-amitriptyline 140 potassium citrate PLASMA-LYTE-148 113 (alkalinizer) 100 PERSERIS 55 PLAVIX 102 potassium citrate-citric acid 100 PERTZYE 90 PLEGRIDY 140 POVIDONE IODINE 132 PEXEVA 29 PLEGRIDY STARTER PR NATAL 400 EC 123 PACK 140 pfizerpen 137 PR NATAL 430 123 phenadoz 39 PLENVU 106 PLEXION 76 PR NATAL 430 EC 123 phenazo 101 PRADAXA 24 phenazopyridine hcl 101 PLEXION CLEANSER 75 PLEXION CLEANSING PRALUENT 41 phenelzine sulfate 28 CLOTHS 76 pramegel hcl 87 PHENERGAN 39 PNV FOLIC ACID + IRON pramipexole dihydrochloride 53 MULTIVITAMIN 123 phenobarbital 104 PRAMOSONE 84 PNV OB+DHA 123 phenoxybenzamine hcl 42 PRAMOSONE E 84 phenylephrine hcl PNV PRENATAL PLUS (mydriatic) 131 MULTIVITAMIN 123 PRAMOTIC 136 PHENYTEK 27 PNV TABS 29-1 123 pramoxine-hc 84 phenytoin 27 pnv-dha 120 PRANDIN 34 phenytoin infatabs 27 PNV-DHA+DOCUSATE 123 prasugrel hcl 102 phenytoin sodium 27 PNV-OMEGA 123 PRAVACHOL 41 phenytoin sodium extended 27 pnv-select 120 pravastatin sodium 41 PHLAG SPRAY 88 PNV-TOTAL 123 praziquantel 15 PHOSLYRA 99 PODOCON 25 IN BENZOIN prazosin hcl 42 TINCTURE 86 PRECISION XTRA 110 phosphasal 150 podofilox 86 PHOSPHOLINE IODIDE 131 PRECISION XTRA BLOOD POLY-VI-FLOR 120 GLUCOSE TEST STRIPS 90 physiolyte 117 POLY-VI-FLOR/IRON 120 PRECOSE 31 phytonadione 154 polyethylene glycol 3350 106 PRED FORTE 133 PICATO 79 polymyxin b sulfate 17 PRED MILD 133 PIFELTRO 58 polymyxin b-trimethoprim 132 PRED-G 134 pilocarpine hcl 131 POLYTRIM 132 PRED-G S.O.P. 134 pilocarpine hcl (oral) 118 POMALYST 49 prednicarbate 84 pimecrolimus 86 posaconazole 37 prednisolone 71 pimozide 141 pot & sod citrates w/citric prednisolone acetate pindolol 62 ac 100 (ophth) 134 pioglitazone hcl 32 pot phosphate monobasic w/ PREDNISOLONE ACETATE P- sod phosphate dibasic & F 134 pioglitazone hcl-glimepiride 31 monobasic 114 prednisolone sodium pioglitazone hcl-metformin POTABA 154 phosphate 71 hcl 31 potassium PREDNISOLONE SODIUM piperacillin sodium-tazobactam PHOSPHATE 134 sodium 138 aminobenzoate 154 potassium bicarb & prednisone 71 chloride 114

Index 19 PREDNISONE INTENSOL 71 PREZISTA 58 promethazine-phenylephrine- PREFERAOB +DHA 123 PRIFTIN 46 codeine 73 promethegan 39 PREFEST 96 PRILOSEC 149 PROMETRIUM 139 pregabalin 26 PRIMACARE 125 propafenone hcl 19 PREMARIN 97,153 primaquine phosphate 45 PREMIUM CONDOMS PRIMAQUINE propantheline bromide 146 LUBRICATED 108 PHOSPHATE 45 proparacaine hcl 133 PREMPHASE 96 PRIMAXIN IV 16 propranolol & PREMPRO 96 primidone 26 hydrochlorothiazide 44 propranolol hcl 62 PRENA 1 TRUE 123 PRIMLEV 12 propylthiouracil 145 PRENA1 PEARL 123 PRIMSOL 15 PROSCAR 101 PRENAISSANCE 124 PRINIVIL 41 PROTHELIAL 118 PRENAISSANCE PRISTIQ 30 PROTONIX 149 BALANCE 124 PRIVIGEN 137 PRENAISSANCE HARMONY PROTOPIC 86 PROAIR HFA 22 DHA 124 protriptyline hcl 30 PRENAISSANCE NEXT 124 PROAIR RESPICLICK 22 PROVENTIL HFA 22 PRENAISSANCE NEXT-B 124 probenecid 101 PROVERA 139 PRENAISSANCE PLUS 124 procainamide hcl 18 PROVIDA DHA 125 PRENATA 124 PROCARDIA 63 PROVIGIL 3 prenatabs rx 120 PROCARDIA XL 63 PROZAC 29 PRENATAL 124 procentra 1 PRUDOXIN 79 prochlorperazine 56 prenatal 19 120 pseudoephed-cpm w/ PRENATAL 19 124 prochlorperazine maleate 56 hydrocod 73 PRENATAL LOW IRON 124 PROCORT 14 PSORCON 84 PRENATAL ONE DAILY 124 PROCRIT 103 PULMICORT 21 PRENATAL PLUS 124 procto-med hc 14 PULMICORT FLEXHALER 21 PRENATAL PLUS IRON 124 PROCTOCORT 15 pulmosal 73 PRENATAL VITAMIN 124 PROCTOFOAM HC 14 PULMOZYME 143 PRENATAL VITAMINS PLUS PROCYSBI 100 PURIXAN 48 LOW IRON 124 profeno 5 PYLERA 150 PRENATAL-U 125 progesterone 139 pyrazinamide 46 PRENATE 125 progesterone micronized 139 PYRIDIUM 101 PRENATE DHA 125 PROGLYCEM 32 pyridostigmine bromide 46 PRENATE ELITE 125 PROGRAF 116 pyrimethamine 45 PRENATE ENHANCE 125 PROLASTIN-C 143 QBRELIS 41 PRENATE ESSENTIAL 125 PROLATE 12 qc allergy relief childrens 39 PRENATE MINI 125 PROLENSA 135 QNASL 130 PRENATE PIXIE 125 PROLIA 92 QNASL CHILDRENS 130 PRENATE RESTORE 125 PROMACTA 103 QUALAQUIN 45 PREPLUS 125 promethazine & QUARTETTE 69 PREPOPIK 106 phenylephrine 72 quazepam 105 PREVACID 149 promethazine hcl 39 QUDEXY XR 26 PREVACID 24HR 149 promethazine vc plain 71 QUESTRAN 40 PREVACID SOLUTAB 149 promethazine vc/codeine 71 QUESTRAN LIGHT 40 prevalite 39 promethazine w/codeine 72 quetiapine fumarate 55 PREVYMIS 59 promethazine-dm 73 QUFLORA GUMMIES 120 PREZCOBIX 58

Index 20 QUFLORA PEDIATRIC 120 RELENZA DISKHALER 61 RILUTEK 130 QUILLIVANT XR 3 RELEXXII 3 riluzole 130 quinapril hcl 42 RELISTOR 99 rimantadine hydrochloride 61 quinapril-hydrochlorothiazide RELNATE DHA 125 ringer's irrigation 117 44 RELPAX 112 RINVOQ 4 quinidine gluconate 18 REMERON 28 RIOMET 32 quinidine sulfate 19 REMERON SOLTAB 28 risedronate sodium 92 quinine sulfate 45 REMICADE 99 RISPERDAL 55 QUINJA 78 REMODULIN 64 RISPERDAL CONSTA 55 QVAR REDIHALER 21 RENAGEL 99 risperidone 55 rabeprazole sodium 149 RENVELA 99 risperidone m-tab 55 RABEPRAZOLE SODIUM DR SPRINKLE 149 repaglinide 34 RITALIN 3 RADIOGARDASE 35 repaglinide-metformin hcl 31 RITALIN LA 3 RAGWITEK 3 REPATHA 41 ritonavir 58 rajani 66 REPATHA PUSHTRONEX RITUXAN 48 SYSTEM 41 raloxifene hcl 93 RITUXAN HYCELA 50 REPATHA SURECLICK 41 ramelteon 105 rivastigmine 140 REQUIP 53 ramipril 42 rivastigmine tartrate 140 REQUIP XL 54 RANEXA 17 rizatriptan benzoate 112 RESCRIPTOR 58 ranitidine hcl 148 ROBAXIN 128 RESTASIS 132 ranolazine 17 ROBAXIN-750 128 RESTASIS MULTIDOSE 132 RAPAFLO 101 ROBINUL 146 RESTORIL 105 RAPAMUNE 116 ROBINUL FORTE 146 RETACRIT 103 rasagiline mesylate 54 ROCALTROL 95 RETIN-A 76 RASUVO 4 ROMIDEPSIN 51 RETIN-A MICRO 76 RAVICTI 95 ropinirole hydrochloride 54 RETIN-A MICRO PUMP 76 RAYALDEE 95 rosadan 88 RETROVIR 58 RAYOS 71 rosuvastatin calcium 41 REVATIO 64 RAZADYNE 140 ROTATEQ 152 REVLIMID 115 RAZADYNE ER 140 ROWASA 99 REXULTI 56 REALITY LATEX roweepra 25 REYATAZ 58 CONDOMS/LUBRICATED 108 roweepra xr 25 REALITY LATEX/ULTRA RHOFADE 89 ROXICET 12 TEXTURED 108 RIAX 76 REALITY LATEX/ULTRA ROXICODONE 11 ribasphere 59 THIN 109 ROXYBOND 11 ribasphere ribapak 59 REBETOL 60 ROZEREM 105 RIBASPHERE RIBAPAK 60 REBIF 141 ROZLYTREK 51 ribavirin 61 REBIF REBIDOSE 141 RUBRACA 51 ribavirin (hepatitis c) 60 REBIF REBIDOSE RUCONEST 102 TITRATIONPACK 141 RIDAURA 4 RUZURGI 46 REBIF TITRATION PACK 141 rifabutin 46 ryclora 37 RECLAST 92 RIFADIN 46 RYDAPT 51 RECOMBIVAX HB 152 RIFAMATE 46 RYTARY 54 RECTIV 15 rifampin 46 RYTHMOL SR 19 REGLAN 98 RIFATER 46 SABRIL 27 REGRANEX 89 RIGHT STEP relagard 152 PRENATAL 125 SAFYRAL 69

Index 21 SALAGEN 118 SEROSTIM 93 SODIUM SALEX 86 sertraline hcl 29 SULFACETAMIDE/SULFUR 76 SALEX LOTION 86 sevelamer carbonate 100 SODIUM salicylic acid 86,87 sevelamer hcl 100 SULFACETAMIDE/SULFUR salicylic acid in ammonium SFROWASA 99 CLEANSER IN UREA 76 SOFOSBUVIR/VELPATASVIR lactate vehicle 87 SHUR-SEAL 152 salicylic acid w/ cleanser 87 60 SIGNIFOR 95 salicylic acid wart remover 86 solifenacin succinate 151 SIKLOS 102 salimez 86 SOLIQUA 100/33 31 SILDENAFIL CITRATE 64 SALISOL 87 SOLODYN 144 sildenafil citrate (pulmonary SOLTAMOX 49 salisol forte 86 hypertension) 64 SALITECH 87 SILENOR 105 SOMA 128 salitech forte 86 SILIQ 79 SOMATULINE DEPOT 95 salsalate 9 silodosin 101 SOMAVERT 93 SALVAX 87 SILVADENE 80 SONATA 105 SAMSCA 96 silver sulfadiazine 80 SOOLANTRA 89 SANCUSO 35 SIMBRINZA 131 SORIATANE 79 SANDIMMUNE 116 SIMCOR 41 SORILUX 79 SANDOSTATIN 95 SIMPONI 4 sorine 61 SANDOSTATIN LAR SIMPONI ARIA 4 sotalol hcl 62 DEPOT 95 SIMULECT 116 sotalol hcl (afib/afl) 62 SANTYL 86 simvastatin 41 SOTYLIZE 62 SAPHRIS 56 SINEMET 54 SOVALDI 60 SARAFEM 141 SINEMET CR 54 SPECTRACEF 65 SAVAYSA 23 SINGULAIR 19,20 spinosad 89 SAVELLA 140 sirolimus 116 SPIRIVA HANDIHALER 19 SAVELLA TITRATION SPIRIVA RESPIMAT 19 PACK 140 SIRTURO 46 spironolactone 91 sb acid reducer 147 SIVEXTRO 17 spironolactone & scopolamine 36 SKELAXIN 128 hydrochlorothiazide 91 SE-NATAL 19 125 SKLICE 89 SPORANOX 37 SEASONIQUE 69 SKYLA 69 SPORANOX PULSEPAK 37 seb-prev wash 80 SKYRIZI 79 SPRIX 6 SECONAL SODIUM 104 SLYND 70 SPRYCEL 51 SECUADO 56 sodium chloride 115 ssd 80 SEEBRI NEOHALER 19 sodium chloride (gu sss 10-5 74 irrigant) 100 SEGLUROMET 31 sodium chloride (inhalant) 73 ST JOSEPH ADULT 9 SELECT-OB 125 sodium citrate & citric ST JOSEPH ADULT SELECT-OB+DHA 125 acid 100 ANALGESICLOW DOSE BITE selegiline hcl 54 sodium fluoride 113 SIZE 9 STALEVO 100 54 selenium sulfide 80 sodium phenylbutyrate 95 STALEVO 125 54 SELZENTRY 58 sodium polystyrene STALEVO 150 54 SEMPREX-D 73 sulfonate 117 sodium sulfacetamide STALEVO 200 54 SENSIPAR 95 wash 80 STALEVO 50 54 SEREVENT DISKUS 22 SODIUM SULFACETAMIDE STALEVO 75 54 SEROQUEL 56 WASH 80 STARLIX 34 SEROQUEL XR 56 stavudine 58

Index 22 STEGLATRO 34 SURE COMFORT PEN TARON-PREX 126 STELARA 79 NEEDLES30GX5/16" TASIGNA 51 SHORT 110 STIMATE 95 SURMONTIL 30 TASMAR 53 STIOLTO RESPIMAT 22 SUSTIVA 58 TAVALISSE 102 STIVARGA 51 SUTENT 51 TAYTULLA 69 STRATTERA 2 SUVICORT 88 tazarotene 80 STRENSIQ 95 SYLATRON 52 tazicef 65 streptomycin sulfate 4 SYMBICORT 22 TAZORAC 80 STRIANT 14 SYMBYAX 140 taztia xt 62 STRIBILD 58 SYMDEKO 143 TAZVERIK 51 STRIVERDI RESPIMAT 22 SYMLINPEN 120 31 TECFIDERA 141 TECFIDERA STARTER STROMECTOL 15 SYMLINPEN 60 31 SUBOXONE 13 PACK 141 SYMPROIC 99 TECHNIVIE 60 SUBSYS 11 SYMTUZA 58 TEFLARO 66 subvenite 25 SYNALAR 84 TEGRETOL 26 subvenite starter kit/blue 25 SYNAREL 94 TEGRETOL-XR 27 SUCRAID 90 SYNERA 88 TEGSEDI 143 sucralfate 148 SYNERDERM 88 TEKTURNA 45 SULAR 63 SYNJARDY 31 TEKTURNA HCT 44 sulconazole nitrate 78 SYNJARDY XR 31 sulfacetamide sod- telmisartan 42 prednisolone 134 SYNTHROID 145 telmisartan-amlodipine 44 sulfacetamide sodium 80 SYPRINE 115 telmisartan-hydrochlorothiazide sulfacetamide sodium (acne)76 TABLOID 48 44 sulfacetamide sodium TACLONEX 84 temazepam 105 (ophth) 132 tacrolimus 116 TEMODAR 47 sulfacetamide sodium w/ tacrolimus (topical) 86 TEMOVATE 84 sulfur 76 temozolomide 47 sulfacleanse 8/4 74 tadalafil 64 tadalafil (pulmonary temsirolimus 51 SULFADIAZINE 144 hypertension) 64 tencon 7 sulfamethoxazole-trimethoprim TAFINLAR 51 16 tenofovir disoproxil fumarate 58 SULFAMYLON 80 TAGAMET HB 148 TENORETIC 100 44 sulfasalazine 99 TAGRISSO 51 TENORETIC 50 44 sulfatrim pediatric 15 TAKHZYRO 102 TENORMIN 61 sulindac 6 TALTZ 79 TERAZOL 7 152 SUMADAN WASH 76 TALZENNA 51 terazosin hcl 42 sumatriptan 112 TAMIFLU 61 terbinafine hcl 37 sumatriptan succinate 112 tamoxifen citrate 49 terbutaline sulfate 22 sumatriptan-naproxen tamsulosin hcl 101 terconazole vaginal 152,153 sodium 111 TANZEUM 32 TESSALON PERLES 71 SUMAXIN 76 TAPAZOLE 145 TESTIM 14 SUMAXIN TS 76 TARCEVA 51 testosterone 14 SUMAXIN WASH 76 TARGADOX 144 testosterone cypionate 14 SUPRAX 66 TARGRETIN 52,79 testosterone enanthate 14 SUPREP BOWEL PREP TARKA 44 KIT 106 tetrabenazine 140 TARON-BC 126 tetracaine hcl (ophth) 133 TARON-C DHA 126 tetracycline hcl 144

Index 23 TEXACORT 84 TOBRADEX ST 134 trazodone hcl 29 THALOMID 115 tobramycin 4 TRECATOR 46 THEO-24 22 tobramycin (ophth) 132 TRELEGY ELLIPTA 22 theophylline 23 tobramycin inhalation solution TRELSTAR MIXJECT 49 THERANATAL CORE pak 3 TREMFYA 80 tobramycin sulfate 4 NUTRITION 126 treprostinil 64 THIOLA 101 tobramycin- TRESIBA 33 THIOLA EC 101 dexamethasone 134 TOBREX 132 TRESIBA FLEXTOUCH 33 thioridazine hcl 56 TODAY SPONGE 152 TRETIN-X 76 thiothixene 56 TOFRANIL 30 tretinoin 76 THRIVITE 19 118 tolazamide 34 tretinoin (chemotherapy) 52 THRIVITE RX 126 tolbutamide 34 tretinoin microsphere 76 THYMOGLOBULIN 116 tolcapone 53 TREXALL 48 thyroid 145 tolmetin sodium 6 TREXIMET 111 THYROLAR-1 145 TOLSURA 37 tri femynor 67 THYROLAR-1/2 145 tolterodine tartrate 151 TRI-NORINYL 28 69 THYROLAR-1/4 145 tolvaptan 96 TRI-TABS DHA 126 THYROLAR-2 145 TOPAMAX 27 TRI-VI-FLOR 120 THYROLAR-3 145 TOPAMAX SPRINKLE 27 TRI-VI-FLORO 120 tiagabine hcl 27 TOPICORT 84 tri-vitamin/fluoride 119 TIAZAC 63 topiramate 27 triamcinolone acetonide TIBSOVO 51 (mouth) 117 toposar 52 TIGAN 36 triamcinolone acetonide topotecan hcl 52 tigecycline 144 (topical) 85 TOPOTECAN HCL 52 triamterene 91 TIGECYCLINE 144 topotecan hcl 53 triamterene & TIKOSYN 19 TOPROL XL 61 hydrochlorothiazide 91 tilia fe 67 trianex 81 toremifene citrate 49 timolol maleate 62 triazolam 105 TORISEL 51 timolol maleate (ophth) 130 TRIBENZOR 44 torsemide 91 TIMOPTIC 131 TOUJEO MAX TRICARE 126 TIMOPTIC OCUDOSE 131 SOLOSTAR 33 TRICARE PRENATAL DHA TIMOPTIC-XE 131 TOUJEO SOLOSTAR 33 ONE 126 TRICARE PRENATAL DHA TINDAMAX 15 tovet 80 ONE/FOLATE 126 tinidazole 15 TOVIAZ 151 TRICOR 40 TIROSINT 145 TRACLEER 64 triderm 81 TIROSINT-SOL 145 tramadol hcl 11 TRIDESILON 85 tis-u-sol 117 tramadol-acetaminophen 12 trientine hcl 115 TIVICAY 58 trandolapril 42 trifluoperazine hcl 56 TIVORBEX 6 trandolapril-verapamil hcl 44 trifluridine 132 tizanidine hcl 128 tranexamic acid 104 TRIGLIDE 40 TL FOLATE 126 TRANSDERM SCOP 36 trihexyphenidyl hcl 53 TL-CARE DHA 126 TRANSDERM-SCOP 36 TRIKAFTA 143 TL-SELECT 126 TRANXENE T 18 triklo 39 TOBI 4 tranylcypromine sulfate 28 TRILEPTAL 27 TOBI PODHALER 4 TRAVATAN Z 135 TRILIPIX 40 TOBRADEX 134 travoprost 135 trimethobenzamide hcl 36

Index 24 trimethoprim 15 tussigon 71 VAGIFEM 153 trimipramine maleate 31 TUSSIONEX PENNKINETIC valacyclovir hcl 60 TRIMPEX 15 EXTENDED RELEASE 73 VALCHLOR 79 TUSSLIN 73 TRINTELLIX 30 VALCYTE 59 TUSSLIN PEDIATRIC 73 TRISTART DHA 126 valganciclovir hcl 59 TWYNSTA 45 TRISTART ONE 126 VALIUM 18 TYBOST 59 TRIUMEQ 58 valproic acid 28 TYGACIL 144 TRIZIVIR 58 valsartan 42 TYKERB 51 TROKENDI XR 27 valsartan-hydrochlorothiazide TYLENOL/CODEINE #3 12 tropicamide 131 45 TYLENOL/CODEINE #4 12 VALTOCO 25 trospium chloride 151 TYMLOS 93 VALTREX 60 TRULANCE 98 TYSABRI 141 vanadom 128 TRULICITY 32 UCERIS 14,71 vanatol lq 7 TRUSOPT 135 TRUSTEX COLOR CONDOMS + UDAMIN SP 118 VANCOCIN 16 LUBE 109 ULESFIA 89 VANCOCIN HCL 16 TRUSTEX LUBRICATED 109 ULORIC 101 vancomycin hcl 16 TRUSTEX LUBRICATED ULTIMATECARE ONE 126 vandazole 152 EXTRALARGE 109 ULTRACET 12 VANOS 85 TRUSTEX LUBRICATED EXTRASTRENGTH 109 ULTRAM 11 VARUBI 36 TRUSTEX ULTRASAL-ER 87 VASCEPA 39 LUBRICATED/RIBBED/STUDDE ULTRAVATE 85 VASERETIC 45 D 109 TRUSTEX umecta mousse 85 VASOTEC 42 LUBRICATED/SPERMICIDE UNASYN 138 VCF VAGINAL 109 UNASYN BULK PACK 138 CONTRACEPTIVE FILM 152 TRUSTEX VCF VAGINAL UNIFINE SAFECONTROL PEN CONTRACEPTIVE FOAM 152 LUBRICATED/SPERMICIDE NEEDLE/30G X 5/16" 110 vcf vaginal contraceptivegel152 EXTRA LARGE 109 UNISOM SLEEPGELS 104 TRUSTEX VECAMYL 45 UPTRAVI 64 LUBRICATED/SPERMICIDE VECTICAL 80 EXTRA STRENGTH 109 URAMAXIN 85 VELCADE 51 TRUSTEX NATURAL URE-K 85 VELPHORO 100 CONDOMS urea 85 +LUBE/LUBRICATED 109 VELTASSA 117 urea hydrating 85 TRUSTEX NON- VELTIN 76 LUBRICATED 109 urea nail 85 VEMLIDY 60 TRUSTEX WITH NONOXYNOL- UREA NAIL 85 9/RIBBED/STUDDED 109 VENA-BAL DHA 126 URECHOLINE 151 TRUSTEX/RIA VENCLEXTA 48 uribel 150 LUBRICATED 109 VENCLEXTA STARTING TRUSTEX/RIA LUBRICATED urimar-t 150 PACK 48 SPERMICIDE 109 TRUSTEX/RIA UROCIT-K 10 100 venlafaxine hcl 30 LUBRICATED/SPERMICIDE UROCIT-K 15 100 VENTAVIS 64 109 UROCIT-K 5 100 VENTOLIN HFA 22 TRUSTEX/RIA NON- UROXATRAL 101 verapamil hcl 63 LUBRICATED 109 URSO 250 98 TRUVADA 58 VERDESO 85 URSO FORTE 98 TUDORZA PRESSAIR 19 VEREGEN 77 ursodiol 98 TURALIO 51 VERELAN 63 UTIBRON NEOHALER 22 TUSSICAPS 73 VERELAN PM 63 UTOPIC 85 VERIPRED 20 71

Index 25 VERSACLOZ 56 VITAMIN D3 IMMUNE XATMEP 48 VERZENIO 51 HEALTH 154 XELJANZ 4 VITAPEARL 127 VESICARE 151 XELJANZ XR 4 VITATHELY/GINGER 127 VFEND 37 XELODA 48 VITATRUE 127 VIBERZI 99 XENAZINE 140 VITRAKVI 51 VIBRAMYCIN 144 XERAC AC 88 VIVA DHA 127 VICTOZA 32 XERESE 80 VIVELLE-DOT 97 VIDAZA 48 XERMELO 100 VIVOTIF 151 VIDEX EC 59 XGEVA 93 VIVOTIF BERNA 151 VIDEXPEDIATRIC 59 XIAFLEX 115 VIZIMPRO 51 VIEKIRA PAK 60 XIFAXAN 15 VOGELXO 14 vigabatrin 27 XIIDRA 132 VOGELXO PUMP 14 vigadrone 27 XOLAIR 19 VOL-PLUS 127 VIGAMOX 132 XOLEGEL 78 VOL-TAB RX 127 VIIBRYD 30 XOPENEX 22 VOLTAREN 77 VIIBRYD STARTER PACK 30 XOPENEX CONCENTRATE 22 voriconazole 37 VIL-RX 126 XOPENEX HFA 22 VOSEVI 60 VIMOVO 6 XOSPATA 52 VOTRIENT 52 VIMPAT 27 XPOVIO 100 MG ONCE VP-GGR-B6 PRENATAL 127 VINATE DHA RF 126 WEEKLY 49 VP-HEME OB 127 XPOVIO 60 MG ONCE VINATE II 126 VP-HEME OB + DHA 127 WEEKLY 49 VIOKACE 90 XPOVIO 80 MG ONCE VP-PNV-DHA 127 VIRACEPT 59 WEEKLY 49 VPRIV 102 XPOVIO 80 MG TWICE VIRAMUNE 59 VRAYLAR 54 WEEKLY 49 VIRAMUNE XR 59 VUSION 78 XTANDI 49 VIRASAL 87 VYNDAMAX 65 xulane 69 VIRAZOLE 61 VYNDAQEL 65 XULTOPHY 100/3.6 31 VIREAD 59 VYTONE 78 XURIDEN 95 VIROPTIC 132 VYTORIN 39 XYREM 139 VIRT-C DHA 126 VYVANSE 1 YASMIN 28 69 VIRT-NATE DHA 126 warfarin sodium 23 YAZ 69 VIRT-PN 127 water for irrigation, sterile 117 YERVOY 48 VIRT-PN DHA 126 wee care 103 YONSA 49 VIRT-PN PLUS 127 WELCHOL 40 yuvafem 153 virtussin ac/alc 71 WELLBUTRIN SR 28 zafirlukast 20 VISTARIL 18 WELLBUTRIN XL 28 zaleplon 105 VISTOGARD 35 WESTHROID 145 ZANAFLEX 128 VITAFOL FE+ 127 wixela inhub 21 ZANOSAR 47 VITAFOL GUMMIES 127 WP THYROID 145 ZANTAC 148 VITAFOL ULTRA 127 ZANTAC 150 MAXIMUM XALATAN 135 VITAFOL-NANO 127 STRENGTH 148 XALKORI 52 VITAFOL-ONE 127 ZARONTIN 28 VITAMEDMD ONE XANAX 18 ZARXIO 103 RX/QUATREFOLIC 127 XANAX XR 18 ZATEAN-PN DHA 127 VITAMIN D2 154 XARELTO 23 ZATEAN-PN PLUS 127 VITAMIN D3 154 XARELTO STARTER ZAVESCA 102 PACK 23

Index 26 ZEGERID 150 ZONEGRAN 27 ZEJULA 52 zonisamide 27 ZELAPAR 54 ZONTIVITY 102 ZELBORAF 52 ZORBTIVE 93 ZEMAIRA 143 ZORTRESS 116 ZEMBRACE SYMTOUCH 112 ZORVOLEX 6 ZEMPLAR 95 ZOSYN 138 ZENPEP 90 ZOVIRAX 60,80 zenzedi 1 ZUBSOLV 13 ZEPATIER 60 ZUPLENZ 35 ZERIT 59 ZURAMPIC 101 ZESTORETIC 45 ZYBAN 143 ZESTRIL 42 ZYCLARA 86 ZETIA 41 ZYCLARA PUMP 86 ZETONNA 130 ZYDELIG 52 ZIAC 45 ZYFLO 20 ZIAGEN 59 ZYFLO CR 20 ZIANA 76 ZYKADIA 52 zidovudine 59 ZYLET 134 ZIEXTENZO 103 ZYLOPRIM 101 zileuton 20 ZYMAXID 132 zinc sulfate 115 ZYPREXA 56 ZIOPTAN 135 ZYPREXA ZYDIS 56 ziprasidone hcl 55 ZYRTEC CHILDRENS ziprasidone mesylate 55 ALLERGY 39 ZYTIGA 49 ZIPSOR 6 ZYVOX 17 ZIRGAN 132 ZITHROMAX 107 ZITHROMAX TRI-PAK 107 ZITHROMAX Z-PAK 107 ZOCOR 41 ZOFRAN 35 ZOFRAN ODT 35 zoledronic acid 93 ZOLEDRONIC ACID 93 zoledronic acid 93 ZOLINZA 52 zolmitriptan 112 ZOLOFT 29 zolpidem tartrate 105 ZOLPIMIST 105 ZOMACTON 93 ZOMETA 93 ZOMIG 112,113 ZOMIG ZMT 113 ZONALON 79

Index 27