Your 2017 Prescription Drug List Effective January 1, 2017 Oxford Connecticut Traditional Three-Tier Please read: This document contains information about commonly prescribed medications. This Prescription Drug List (PDL) is accurate as of August 1, 2016 and is subject to change after this date. The next anticipated update will be in January 2017. Your estimated coverage and copay/co-insurance may vary based on the benefit plan you choose and the effective date of the plan. For more information: Call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1- 800-303-6719, 1-888-201-4746.

Visit oxfordhealth.com, click on the Pharmacies & Prescriptions tab and then “Online Pharmacy” to log in to the OptumRx1 website and: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

1OptumRx is the administrator of your Oxford pharmacy benefit plan. Note: Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Specialized non-standard infant formulas and nutritional supplements may be subject to prior authorization. Please see your Summary of Benefits and Coverage (SBC) for specifics. 1 Your Prescription Drug List This Prescription Drug List (PDL) outlines covered medications and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you. Go to oxfordhealth.com for drug information. Since the PDL may change, we encourage you to visit our website, oxfordhealth.com. This website is the best source for accessing up-to-date information about the medications your pharmacy benefit covers, possible lower-cost options, and cost comparisons. You may access the prescription drug list by visiting oxfordhealth.comMembers Tools and Resources and choosing Prescription Drug List under the ‘Your Pharmacy Coverage’ section.

2 We want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List (PDL) below.

What is a Prescription Drug List (PDL)? This document is a list of covered medications. They are placed into cost levels known as tiers. The PDL includes both brand-name and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this PDL and your health plan documents, the health plan documents will rule. Please look at your health plan documents to see what medications are covered under your health plan. You may also log on to oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more information. How do I use my PDL? Bring your PDL with you when you see your doctor. When choosing a medication, you and your doctor should consult this guide. It will help you and your doctor choose the most cost-effective prescription drugs. This guide will also help you know if a medication has special programs that apply to it. When a Prescription Drug Product is excluded from coverage, you or your representative may request an exception to gain access to the excluded Prescription Drug Product. To make a request, contact us in writing or call the toll-free number on your ID card. We will notify you of our determination within 72 hours.

3 What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or health plan. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tiers 2 or 3, look to see if there is a Tier 1 option available. You should discuss these options with your doctor. Check your health plan documents to find your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lower-cost drugs. Use Tier 1 drugs for the lowest Lowest Cost Some brand names and out‑of-pocket costs. generics are also included.

Tier 2 Preferred brands. Use Tier 2 drugs, instead of Mid-range Cost Tier 3, to help reduce your out-of-pocket costs.

Tier 3 Higher cost brands. Many Tier 3 drugs have Highest Cost lower‑cost options in Tiers 1 or 2. Ask your doctor if they could work for you.

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible health plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollment and plan materials on oxfordhealth.com, or call us at the toll-free phone number on your health plan ID card for more information about your health plan. Diabetic supplies and prescription medications may be subject to different cost-share arrangements. Please see your Summary of Benefits and Coverage (SBC) for specifics. When does the PDL change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic becomes available. • Medications may move to a higher tier on January 1. • Medications may be excluded from coverage on January 1 or July 1. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call us at the toll-free phone number on your health plan ID card.

4 Programs and Limits Some medications are in one or more of our pharmacy benefit programs. Your health plan determines how these medications are covered and may differ than what is noted in the PDL.

Health Care Reform (HCR) Preventive – This medication is part of a Health Care Reform preventive benefit and may be available at no additional cost to you.

Notification or Precertification (sometimes referred to as Prior Authorization) required1 – Your doctor is required to provide additional information to us to determine coverage.

Supply Limit – Amount of medication covered per copayment or in a specific time period.

Step Therapy – Trial of a lower-cost medication is required before a higher-cost medication is covered.

1Depending on your benefit, you may have notification or precertification requirements for select medications.

To learn more about a pharmacy program or to find out if it applies to you, please visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to an over-the-counter (OTC) medication.2 There may be other medication options available. Should I talk to my doctor about over-the-counter (OTC) medications? An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand- name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes, the same company that makes a brand-name medication also makes the generic version.

2 This is not applicable for Connecticut Public Sector plans. For Connecticut commercial business, a prescription drug product that is therapeutically equivalent to an over-the counter drug may be covered if it is determined to be medically necessary 5 What if my doctor writes a prescription for a brand-name medication? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. For some health plans, if a brand-name medication is prescribed and a generic equivalent is available, your share of the cost may be the copayment PLUS the cost difference between the brand-name medication and its generic equivalent. Visit oxfordhealth.com to make sure. Are you taking a specialty medication? Take advantage of personalized support designed to help you get the most out of your benefit plan. Visit UHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more. If you’re taking a specialty medication that is on Tier 3, call us at the toll-free phone number on your health plan ID card to talk with a pharmacist about finding lower-cost options or a financial assistance program. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit oxfordhealth.com or call us at the toll-free phone number on your health plan ID card for more current information.

For more information

Call us at the toll-free phone number on your health plan ID card. TTY users can dial 711. Si usted necesita ayuda en español llame al número de teléfono en su tarjeta de identificación, 1- 800-303-6719, 1-888-201-4746.

Or, visit oxfordhealth.com.

In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.

All branded medications are trademarks or registered trademarks of their respective owners. Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. ©2016 Oxford Health Plans LLC. All rights reserved.

Created August 1, 2016. January 1, 2017 Prescription Drug List – Oxford Connecticut Traditional Three-Tier CT-16-486 MT993780.4 6 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty 1st Generation/Typical - Mood Disorder Drugs ADASUVE INH 10MG Tier 3 1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ POW HCL Tier 3 1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 100MG Tier 1 1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 200MG Tier 1 1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 25MG Tier 1 1st Generation/Typical - Mood Disorder Drugs CHLORPROMAZ TAB 50MG Tier 1 1st Generation/Typical - Mood Disorder Drugs COMPRO SUP 25MG Tier 1 1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE CON 5MG/ML Tier 1 1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE ELX 2.5/5ML Tier 1 1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 2.5MG Tier 1 1st Generation/Typical - Mood Disorder Drugs FLUPHENAZINE TAB 5MG Tier 1 1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL CON 2MG/ML Tier 1 1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 0.5MG Tier 1 1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 20MG Tier 1 1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 2MG Tier 1 1st Generation/Typical - Mood Disorder Drugs HALOPERIDOL TAB 5MG Tier 1 1st Generation/Typical - Mood Disorder Drugs LOXAPINE CAP 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs LOXAPINE CAP 25MG Tier 1 1st Generation/Typical - Mood Disorder Drugs LOXAPINE CAP 50MG Tier 1 1st Generation/Typical - Mood Disorder Drugs LOXAPINE CAP 5MG Tier 1 1st Generation/Typical - Mood Disorder Drugs ORAP TAB 1MG Tier 3 1st Generation/Typical - Mood Disorder Drugs ORAP TAB 2MG Tier 3 1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 16MG Tier 1

Page 1 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty 1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 2MG Tier 1 1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 4MG Tier 1 1st Generation/Typical - Mood Disorder Drugs PERPHENAZINE TAB 8MG Tier 1 1st Generation/Typical - Mood Disorder Drugs PIMOZIDE TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder Drugs PIMOZIDE TAB 2MG Tier 1 1st Generation/Typical - Mood Disorder Drugs PROCHLORPER SUP 25MG Tier 1 1st Generation/Typical - Mood Disorder Drugs PROCHLORPER TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs PROCHLORPER TAB 5MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 100MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 25MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIORIDAZINE TAB 50MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 1MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 2MG Tier 1 1st Generation/Typical - Mood Disorder Drugs THIOTHIXENE CAP 5MG Tier 1 1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 10MG Tier 1 1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 1MG Tier 1 1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 2MG Tier 1 1st Generation/Typical - Mood Disorder Drugs TRIFLUOPERAZ TAB 5MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY SOL 1MG/ML Tier 3 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY TAB 10MG Tier 3 X X X 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY TAB 15MG Tier 3 X X X 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY TAB 20MG Tier 3 X X X 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY TAB 2MG Tier 3 X X X 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY TAB 30MG Tier 3 X X X 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY TAB 5MG Tier 3 X X X 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY DISC TAB 10MG Tier 3 X

Page 2 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY DISC TAB 15MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE SOL 1MG/ML Tier 1 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 10MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 10MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 15MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 15MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 20MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 2MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 30MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ARIPIPRAZOLE TAB 5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT PAK Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT TAB 10MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT TAB 12MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT TAB 1MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT TAB 2MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT TAB 4MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT TAB 6MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs FANAPT TAB 8MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs GEODON CAP 20MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs GEODON CAP 40MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs GEODON CAP 60MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs GEODON CAP 80MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs INVEGA TAB 1.5MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs INVEGA TAB 3MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs INVEGA TAB 6MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs INVEGA TAB 9MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs LATUDA TAB 120MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs LATUDA TAB 20MG Tier 3 X

Page 3 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty 2nd Generation/Atypical - Mood Disorder Drugs LATUDA TAB 40MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs LATUDA TAB 60MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs LATUDA TAB 80MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 10MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 10MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 15MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 15MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 2.5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 20MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 20MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 5MG ODT Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs OLANZAPINE TAB 7.5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs PALIPERIDONE TAB ER 1.5MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs PALIPERIDONE TAB ER 3MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs PALIPERIDONE TAB ER 6MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs PALIPERIDONE TAB ER 9MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs QUETIAPINE TAB 100MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs QUETIAPINE TAB 200MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs QUETIAPINE TAB 25MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs QUETIAPINE TAB 300MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs QUETIAPINE TAB 400MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs QUETIAPINE TAB 50MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL SOL 1MG/ML Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL TAB 0.25MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL TAB 0.5MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL TAB 1MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL TAB 2MG Tier 3 X

Page 4 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL TAB 3MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL TAB 4MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL M TAB 0.5MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL M TAB 1MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL M TAB 2MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL M TAB 3MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERDAL M TAB 4MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE SOL 1MG/ML Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 0.25 ODT Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 0.25MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 0.5MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 0.5MG OD Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 1MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 1MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 2MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 2MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 3MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 3MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 4MG Tier 1 2nd Generation/Atypical - Mood Disorder Drugs RISPERIDONE TAB 4MG ODT Tier 1 2nd Generation/Atypical - Mood Disorder Drugs SAPHRIS SUB 10MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SAPHRIS SUB 2.5MG Tier 3 2nd Generation/Atypical - Mood Disorder Drugs SAPHRIS SUB 5MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL TAB 100MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL TAB 200MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL TAB 25MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL TAB 300MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL TAB 400MG Tier 3 X

Page 5 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL TAB 50MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL XR TAB 150MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL XR TAB 200MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL XR TAB 300MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL XR TAB 400MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs SEROQUEL XR TAB 50MG Tier 3 X 2nd Generation/Atypical - Mood Disorder Drugs ZIPRASIDONE CAP 20MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ZIPRASIDONE CAP 40MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ZIPRASIDONE CAP 60MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ZIPRASIDONE CAP 80MG Tier 1 X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA TAB 10MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA TAB 15MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA TAB 2.5MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA TAB 20MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA TAB 5MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA TAB 7.5MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA ZYDI TAB 10MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA ZYDI TAB 15MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA ZYDI TAB 20MG Tier 3 X X 2nd Generation/Atypical - Mood Disorder Drugs ZYPREXA ZYDI TAB 5MG Tier 3 X X

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants ACAMPRO CAL TAB 333MG Tier 1

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants ANTABUSE TAB 250MG Tier 3

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants ANTABUSE TAB 500MG Tier 3

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants DISULFIRAM TAB 250MG Tier 1

Page 6 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants DISULFIRAM TAB 500MG Tier 1

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants NALTREXONE TAB 50MG Tier 1

Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants REVIA TAB 50MG Tier 3 Alkylating Agents - Chemotherapy Agents ALKERAN TAB 2MG Tier 2 X Alkylating Agents - Chemotherapy Agents CYCLOPHOSPH CAP 25MG Tier 2 X Alkylating Agents - Chemotherapy Agents CYCLOPHOSPH CAP 50MG Tier 2 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 100MG Tier 3 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 10MG Tier 3 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 40MG Tier 3 X Alkylating Agents - Chemotherapy Agents GLEOSTINE CAP 5MG Tier 3 X Alkylating Agents - Chemotherapy Agents HEXALEN CAP 50MG Tier 2 X Alkylating Agents - Chemotherapy Agents LEUKERAN TAB 2MG Tier 2 X Alkylating Agents - Chemotherapy Agents LOMUSTINE CAP 100MG Tier 1 X Alkylating Agents - Chemotherapy Agents LOMUSTINE CAP 10MG Tier 1 X Alkylating Agents - Chemotherapy Agents LOMUSTINE CAP 40MG Tier 1 X Alkylating Agents - Chemotherapy Agents MATULANE CAP 50MG Tier 2 X Alkylating Agents - Chemotherapy Agents MYLERAN TAB 2MG Tier 2 X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 100MG Tier 3 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 140MG Tier 3 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 180MG Tier 3 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 20MG Tier 3 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 250MG Tier 3 X X Alkylating Agents - Chemotherapy Agents TEMODAR CAP 5MG Tier 3 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 100MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 140MG Tier 1 X X

Page 7 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 180MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 20MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 250MG Tier 1 X X Alkylating Agents - Chemotherapy Agents TEMOZOLOMIDE CAP 5MG Tier 1 X X Alkylating Agents - Chemotherapy Agents VALCHLOR GEL 0.016% Tier 2 X X X Alpha-Adrenergic Agonists - Blood Pressure Drugs CATAPRES TAB 0.1MG Tier 3 Alpha-Adrenergic Agonists - Blood Pressure Drugs CATAPRES TAB 0.2MG Tier 3 Alpha-Adrenergic Agonists - Blood Pressure Drugs CATAPRES TAB 0.3MG Tier 3 Alpha-Adrenergic Agonists - Blood Pressure Drugs CATAPRES-TTS DIS 0.1/24HR Tier 3 Alpha-Adrenergic Agonists - Blood Pressure Drugs CATAPRES-TTS DIS 0.2/24HR Tier 3 Alpha-Adrenergic Agonists - Blood Pressure Drugs CATAPRES-TTS DIS 0.3/24HR Tier 3 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLONIDINE DIS 0.1/24HR Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLONIDINE DIS 0.2/24HR Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLONIDINE DIS 0.3/24HR Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLONIDINE TAB 0.1MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLONIDINE TAB 0.2MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLONIDINE TAB 0.3MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLORPRES TAB 0.1-15MG Tier 2 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLORPRES TAB 0.2-15MG Tier 2 Alpha-Adrenergic Agonists - Blood Pressure Drugs CLORPRES TAB 0.3-15MG Tier 2 Alpha-Adrenergic Agonists - Blood Pressure Drugs GUANFACINE TAB 1MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs GUANFACINE TAB 2MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs METHYLD/HCTZ TAB 250/15 Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs METHYLD/HCTZ TAB 250/25 Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs METHYLDOPA TAB 250MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs METHYLDOPA TAB 500MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs MIDODRINE TAB 10MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs MIDODRINE TAB 2.5MG Tier 1

Page 8 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Alpha-Adrenergic Agonists - Blood Pressure Drugs MIDODRINE TAB 5MG Tier 1 Alpha-Adrenergic Agonists - Blood Pressure Drugs TENEX TAB 1MG Tier 3 Alpha-Adrenergic Agonists - Blood Pressure Drugs TENEX TAB 2MG Tier 3 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs CARDURA XL TAB 4MG Tier 3 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs CARDURA XL TAB 8MG Tier 3 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs DIBENZYLINE CAP 10MG Tier 3 X Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs MINIPRESS CAP 1MG Tier 3 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs MINIPRESS CAP 2MG Tier 3 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs MINIPRESS CAP 5MG Tier 3 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs PHENOXYBENZA CAP 10MG Tier 1 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs PRAZOSIN HCL CAP 1MG Tier 1 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs PRAZOSIN HCL CAP 2MG Tier 1 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs PRAZOSIN HCL CAP 5MG Tier 1 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs RESERPINE TAB 0.1MG Tier 1 Alpha-Adrenergic Blocking Agents - Blood Pressure Drugs RESERPINE TAB 0.25MG Tier 1 Aminoglycosides - Antibiotics BETHKIS NEB 300/4ML Tier 1 X X X Aminoglycosides - Antibiotics GARAMYCIN SOL 0.3% OP Tier 3 Aminoglycosides - Antibiotics GENTAK OIN 0.3% OP Tier 1 Aminoglycosides - Antibiotics GENTAMICIN CRE 0.1% Tier 1 Aminoglycosides - Antibiotics GENTAMICIN OIN 0.1% Tier 1 Aminoglycosides - Antibiotics GENTAMICIN OIN 0.3% OP Tier 1 Aminoglycosides - Antibiotics GENTAMICIN SOL 0.3% OP Tier 1 Aminoglycosides - Antibiotics KITABIS PAK NEB 300/5ML Tier 3 X X X X Aminoglycosides - Antibiotics NEOMYCIN TAB 500MG Tier 1 Aminoglycosides - Antibiotics PAROMOMYCIN CAP 250MG Tier 1 Aminoglycosides - Antibiotics TOBI NEB 300/5ML Tier 3 X X X X Aminoglycosides - Antibiotics TOBI PODHALR CAP 28MG Tier 3 X X X Aminoglycosides - Antibiotics TOBRAMYCIN NEB 300/5ML Tier 1 X X X X Aminoglycosides - Antibiotics TOBRAMYCIN SOL 0.3% OP Tier 1 Aminoglycosides - Antibiotics TOBREX OIN 0.3% OP Tier 3 Aminoglycosides - Antibiotics TOBREX SOL 0.3% OP Tier 3

Aminosalicylates - Inflammatory Bowel Disease Drugs APRISO CAP 0.375GM Tier 2

Aminosalicylates - Inflammatory Bowel Disease Drugs ASACOL HD TAB 800MG Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs BALSALAZIDE CAP 750MG Tier 1

Page 9 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Aminosalicylates - Inflammatory Bowel Disease Drugs CANASA SUP 1000MG Tier 2

Aminosalicylates - Inflammatory Bowel Disease Drugs COLAZAL CAP 750MG Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs DELZICOL CAP 400MG Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs DIPENTUM CAP 250MG Tier 3

Aminosalicylates - Inflammatory Bowel Disease Drugs GIAZO TAB 1.1GM Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs LIALDA TAB 1.2GM Tier 2

Aminosalicylates - Inflammatory Bowel Disease Drugs MESALAMINE ENE 4GM Tier 1

Aminosalicylates - Inflammatory Bowel Disease Drugs MESALAMINE KIT 4GM Tier 1 X

Aminosalicylates - Inflammatory Bowel Disease Drugs MESALAMINE TAB 800MG DR Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs PENTASA CAP 250MG CR Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs PENTASA CAP 500MG CR Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs ROWASA KIT 4GM Tier 3 X

Aminosalicylates - Inflammatory Bowel Disease Drugs SFROWASA ENE 4GM Tier 3 Anabolic Steroids - Hormone Replacement/Modifying Drugs ANADROL-50 TAB 50MG Tier 3 Anabolic Steroids - Hormone Replacement/Modifying Drugs OXANDRIN TAB 10MG Tier 3 Anabolic Steroids - Hormone Replacement/Modifying Drugs OXANDRIN TAB 2.5MG Tier 3 Anabolic Steroids - Hormone Replacement/Modifying Drugs OXANDROLONE TAB 10MG Tier 1 Anabolic Steroids - Hormone Replacement/Modifying Drugs OXANDROLONE TAB 2.5MG Tier 1

Analgesics - Miscellaneous Analgesics ALAGESIC LQ SOL Tier 1 X

Analgesics - Miscellaneous Analgesics ALLZITAL TAB 25-325MG Tier 3 X X

Analgesics - Miscellaneous Analgesics BUPAP TAB 50-300MG Tier 3

Page 10 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Analgesics - Miscellaneous Analgesics BUT/APAP/CAF CAP Tier 1 X

Analgesics - Miscellaneous Analgesics BUT/APAP/CAF CAP Tier 1 X

Analgesics - Miscellaneous Analgesics BUT/APAP/CAF TAB Tier 1 X

Analgesics - Miscellaneous Analgesics BUT/ASA/CAFF CAP Tier 1

Analgesics - Miscellaneous Analgesics BUTAL/APAP TAB 50-325MG Tier 1

Analgesics - Miscellaneous Analgesics CAPACET CAP Tier 1 X

Analgesics - Miscellaneous Analgesics ESGIC CAP Tier 3 X

Analgesics - Miscellaneous Analgesics ESGIC TAB Tier 3 X

Analgesics - Miscellaneous Analgesics FIORICET CAP Tier 3 X

Analgesics - Miscellaneous Analgesics FIORINAL CAP Tier 3

Analgesics - Miscellaneous Analgesics GRALISE TAB 300MG Tier 3 X X

Analgesics - Miscellaneous Analgesics GRALISE TAB 600MG Tier 3 X X

Analgesics - Miscellaneous Analgesics GRALISE STAR MIS 300/600 Tier 3 X X

Analgesics - Miscellaneous Analgesics MARGESIC CAP Tier 1 X

Analgesics - Miscellaneous Analgesics MARTEN-TAB TAB 50-325MG Tier 1

Analgesics - Miscellaneous Analgesics TENCON TAB 50-325MG Tier 1

Analgesics - Miscellaneous Analgesics VANATOL LQ SOL Tier 1 X

Analgesics - Miscellaneous Analgesics ZEBUTAL CAP Tier 1 X Androgens - Hormone Replacement/Modifying Drugs ANDRODERM DIS 2MG/24HR Tier 2 X X Androgens - Hormone Replacement/Modifying Drugs ANDRODERM DIS 4MG/24HR Tier 2 X X Androgens - Hormone Replacement/Modifying Drugs ANDROGEL GEL 1%(25MG) Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs ANDROGEL GEL 1%(50MG) Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs ANDROGEL GEL 1.62% Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs ANDROGEL GEL 1.62% Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs ANDROGEL GEL 1.62% Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs ANDROGEL GEL PUMP 1% Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs ANDROID CAP 10MG Tier 3 Androgens - Hormone Replacement/Modifying Drugs ANDROXY TAB 10MG Tier 1

Page 11 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Androgens - Hormone Replacement/Modifying Drugs AXIRON SOL 30MG/ACT Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs DANAZOL CAP 100MG Tier 1 Androgens - Hormone Replacement/Modifying Drugs DANAZOL CAP 200MG Tier 1 Androgens - Hormone Replacement/Modifying Drugs DANAZOL CAP 50MG Tier 1 Androgens - Hormone Replacement/Modifying Drugs DEPO-TESTOST INJ 100MG/ML Tier 3 Androgens - Hormone Replacement/Modifying Drugs DEPO-TESTOST INJ 200MG/ML Tier 3 Androgens - Hormone Replacement/Modifying Drugs FIRST-TESTOS CRE MC 2% Tier 3 X Androgens - Hormone Replacement/Modifying Drugs FIRST-TESTOS OIN 2% Tier 3 X Androgens - Hormone Replacement/Modifying Drugs FORTESTA GEL 10MG/ACT Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs METHITEST TAB 10MG Tier 2 Androgens - Hormone Replacement/Modifying Drugs METHYLTESTOS CAP 10MG Tier 1 Androgens - Hormone Replacement/Modifying Drugs NATESTO GEL 5.5MG Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs STRIANT MIS 30MG Tier 3 X X Androgens - Hormone Replacement/Modifying Drugs TESTIM GEL 1%(50MG) Tier 2 X X Androgens - Hormone Replacement/Modifying Drugs TESTOST CYP INJ 100MG/ML Tier 1 Androgens - Hormone Replacement/Modifying Drugs TESTOST CYP INJ 200MG/ML Tier 1 Androgens - Hormone Replacement/Modifying Drugs TESTOST ENAN INJ 200MG/ML Tier 1 Androgens - Hormone Replacement/Modifying Drugs TESTOSTERONE GEL 1%(25MG) Tier 1 X X X Androgens - Hormone Replacement/Modifying Drugs TESTOSTERONE GEL 1%(50MG) Tier 1 X X X Androgens - Hormone Replacement/Modifying Drugs TESTOSTERONE GEL 1%(50MG) Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs TESTOSTERONE GEL 10MG/ACT Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs TESTOSTERONE GEL PUMP 1% Tier 1 X X X Androgens - Hormone Replacement/Modifying Drugs TESTOSTERONE GEL PUMP 1% Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs TESTOSTERONE INJ 250MG/ML Tier 3 Androgens - Hormone Replacement/Modifying Drugs TESTRED CAP 10MG Tier 3 Androgens - Hormone Replacement/Modifying Drugs VOGELXO GEL 1%(50MG) Tier 3 X X X Androgens - Hormone Replacement/Modifying Drugs VOGELXO GEL PUMP 1% Tier 3 X X X

Page 12 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin II Receptor Antagonists - Blood Pressure Drugs ATACAND TAB 16MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs ATACAND TAB 32MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs ATACAND TAB 4MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs ATACAND TAB 8MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs ATACAND HCT TAB 16-12.5 Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs ATACAND HCT TAB 32-12.5 Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs ATACAND HCT TAB 32-25MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs AVALIDE TAB 150-12.5 Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs AVALIDE TAB 300-12.5 Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs AVAPRO TAB 150MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs AVAPRO TAB 300MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs AVAPRO TAB 75MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs BENICAR TAB 20MG Tier 2 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs BENICAR TAB 40MG Tier 2 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs BENICAR TAB 5MG Tier 2 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs BENICAR HCT TAB 20-12.5 Tier 2 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs BENICAR HCT TAB 40-12.5 Tier 2 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs BENICAR HCT TAB 40-25MG Tier 2 X

Page 13 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin II Receptor Antagonists - Blood Pressure Drugs CANDESA/HCTZ TAB 16-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs CANDESA/HCTZ TAB 32-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs CANDESA/HCTZ TAB 32-25MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs CANDESARTAN TAB 16MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs CANDESARTAN TAB 32MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs CANDESARTAN TAB 4MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs CANDESARTAN TAB 8MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs COZAAR TAB 100MG Tier 3

Angiotensin II Receptor Antagonists - Blood Pressure Drugs COZAAR TAB 25MG Tier 3

Angiotensin II Receptor Antagonists - Blood Pressure Drugs COZAAR TAB 50MG Tier 3

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN TAB 160MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN TAB 320MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN TAB 40MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN TAB 80MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN HCT TAB 160-12.5 Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN HCT TAB 160-25MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN HCT TAB 320-12.5 Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN HCT TAB 320-25MG Tier 3 X X

Page 14 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin II Receptor Antagonists - Blood Pressure Drugs DIOVAN HCT TAB 80/12.5 Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs EDARBI TAB 40MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs EDARBI TAB 80MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs EDARBYCLOR TAB 40-12.5 Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs EDARBYCLOR TAB 40-25MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs EPROSART MES TAB 600MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs HYZAAR TAB 100-12.5 Tier 3

Angiotensin II Receptor Antagonists - Blood Pressure Drugs HYZAAR TAB 100-25 Tier 3

Angiotensin II Receptor Antagonists - Blood Pressure Drugs HYZAAR TAB 50-12.5 Tier 3

Angiotensin II Receptor Antagonists - Blood Pressure Drugs IRBESAR/HCTZ TAB 150-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs IRBESAR/HCTZ TAB 300-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs IRBESARTAN TAB 150MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs IRBESARTAN TAB 300MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs IRBESARTAN TAB 75MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs LOSARTAN POT TAB 100MG Tier 1

Angiotensin II Receptor Antagonists - Blood Pressure Drugs LOSARTAN POT TAB 25MG Tier 1

Angiotensin II Receptor Antagonists - Blood Pressure Drugs LOSARTAN POT TAB 50MG Tier 1

Angiotensin II Receptor Antagonists - Blood Pressure Drugs LOSARTAN/HCT TAB 100-12.5 Tier 1

Page 15 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin II Receptor Antagonists - Blood Pressure Drugs LOSARTAN/HCT TAB 100-25 Tier 1

Angiotensin II Receptor Antagonists - Blood Pressure Drugs LOSARTAN/HCT TAB 50-12.5 Tier 1

Angiotensin II Receptor Antagonists - Blood Pressure Drugs MICARDIS TAB 20MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs MICARDIS TAB 40MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs MICARDIS TAB 80MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs MICARDIS HCT TAB 40/12.5 Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs MICARDIS HCT TAB 80/12.5 Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs MICARDIS HCT TAB 80-25MG Tier 3 X X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs TELMISA/HCTZ TAB 40-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs TELMISA/HCTZ TAB 80-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs TELMISA/HCTZ TAB 80-25MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs TELMISARTAN TAB 20MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs TELMISARTAN TAB 40MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs TELMISARTAN TAB 80MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs TEVETEN HCT TAB 600-25MG Tier 3 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSART/HCTZ TAB 160-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSART/HCTZ TAB 160-25MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSART/HCTZ TAB 320-12.5 Tier 1 X

Page 16 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSART/HCTZ TAB 320-25MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSART/HCTZ TAB 80-12.5 Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSARTAN TAB 160MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSARTAN TAB 320MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSARTAN TAB 40MG Tier 1 X

Angiotensin II Receptor Antagonists - Blood Pressure Drugs VALSARTAN TAB 80MG Tier 1 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACCUPRIL TAB 10MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACCUPRIL TAB 20MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACCUPRIL TAB 40MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACCUPRIL TAB 5MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACCURETIC TAB 10-12.5 Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACCURETIC TAB 20-12.5 Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACCURETIC TAB 20-25MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACEON TAB 4MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ACEON TAB 8MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ALTACE CAP 1.25MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ALTACE CAP 10MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ALTACE CAP 2.5MG Tier 3

Page 17 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ALTACE CAP 5MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEP/HCTZ TAB 10-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEP/HCTZ TAB 20-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEP/HCTZ TAB 20-25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEP/HCTZ TAB 5-6.25 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEPRIL TAB 10MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEPRIL TAB 20MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEPRIL TAB 40MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs BENAZEPRIL TAB 5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPR/HCTZ TAB 25-15MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPR/HCTZ TAB 25-25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPR/HCTZ TAB 50-15MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPR/HCTZ TAB 50-25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPRIL TAB 100MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPRIL TAB 12.5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPRIL TAB 25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs CAPTOPRIL TAB 50MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ENALAPR/HCTZ TAB 10-25MG Tier 1

Page 18 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ENALAPR/HCTZ TAB 5-12.5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ENALAPRIL TAB 10MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ENALAPRIL TAB 2.5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ENALAPRIL TAB 20MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ENALAPRIL TAB 5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs EPANED SOL 1MG/ML Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs FOSINOP/HCTZ TAB 10/12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs FOSINOP/HCTZ TAB 20/12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs FOSINOPRIL TAB 10MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs FOSINOPRIL TAB 20MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs FOSINOPRIL TAB 40MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOP/HCTZ TAB 10-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOP/HCTZ TAB 20-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOP/HCTZ TAB 20-25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOPRIL TAB 10MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOPRIL TAB 2.5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOPRIL TAB 20MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOPRIL TAB 30MG Tier 1

Page 19 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOPRIL TAB 40MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LISINOPRIL TAB 5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LOTENSIN TAB 10MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LOTENSIN TAB 20MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LOTENSIN TAB 40MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LOTENSIN HCT TAB 10-12.5 Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LOTENSIN HCT TAB 20-12.5 Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs LOTENSIN HCT TAB 20-25MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MAVIK TAB 1MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MAVIK TAB 2MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MAVIK TAB 4MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MOEXIPR/HCTZ TAB 15-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MOEXIPR/HCTZ TAB 15-25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MOEXIPR/HCTZ TAB 7.5-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MOEXIPRIL TAB 15MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs MOEXIPRIL TAB 7.5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs PERINDOPRIL TAB 2MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs PERINDOPRIL TAB 4MG Tier 1

Page 20 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs PERINDOPRIL TAB 8MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs PRINIVIL TAB 10MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs PRINIVIL TAB 20MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs PRINIVIL TAB 5MG Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QBRELIS SOL 1MG/ML Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QNAPRIL/HCTZ TAB 10-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QNAPRIL/HCTZ TAB 20-12.5 Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QNAPRIL/HCTZ TAB 20-25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QUINAPRIL TAB 10MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QUINAPRIL TAB 20MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QUINAPRIL TAB 40MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs QUINAPRIL TAB 5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs RAMIPRIL CAP 1.25MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs RAMIPRIL CAP 10MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs RAMIPRIL CAP 2.5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs RAMIPRIL CAP 5MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TARKA TAB 1-240 CR Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TARKA TAB 2-180 CR Tier 3

Page 21 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TARKA TAB 2-240 CR Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TARKA TAB 4-240 CR Tier 3

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 1-240 CR Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 1-240 ER Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 2-180 CR Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 2-180 ER Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 2-240 CR Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 2-240 ER Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 4-240 CR Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDO/VERAP TAB 4-240 ER Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDOLAPRIL TAB 1MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDOLAPRIL TAB 2MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs TRANDOLAPRIL TAB 4MG Tier 1

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs VASERETIC TAB 10-25MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs VASOTEC TAB 10MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs VASOTEC TAB 2.5MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs VASOTEC TAB 20MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs VASOTEC TAB 5MG Tier 3 X

Page 22 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTORETIC TAB 10-12.5 Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTORETIC TAB 20-12.5 Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTORETIC TAB 20-25MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTRIL TAB 10MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTRIL TAB 2.5MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTRIL TAB 20MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTRIL TAB 30MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTRIL TAB 40MG Tier 3 X

Angiotensin-converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs ZESTRIL TAB 5MG Tier 3 X

Anthelmintics - Worm Infection Drugs ALBENZA TAB 200MG Tier 2

Anthelmintics - Worm Infection Drugs BILTRICIDE TAB 600MG Tier 2

Anthelmintics - Worm Infection Drugs EMVERM CHW 100MG Tier 3 X

Anthelmintics - Worm Infection Drugs IVERMECTIN TAB 3MG Tier 1 Antiandrogens - Hormone Suppressants BICALUTAMIDE TAB 50MG Tier 1 X Antiandrogens - Hormone Suppressants CASODEX TAB 50MG Tier 3 X Antiandrogens - Hormone Suppressants FLUTAMIDE CAP 125MG Tier 1 X Antiandrogens - Hormone Suppressants NILANDRON TAB 150MG Tier 3 X Antiandrogens - Hormone Suppressants NILUTAMIDE TAB 150MG Tier 1 X Antiandrogens - Hormone Suppressants XTANDI CAP 40MG Tier 3 X X X X Antiangiogenic Agents - Chemotherapy Agents CAPRELSA TAB 100MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents CAPRELSA TAB 300MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents REVLIMID CAP 10MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents REVLIMID CAP 15MG Tier 2 X X X

Page 23 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antiangiogenic Agents - Chemotherapy Agents REVLIMID CAP 2.5MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents REVLIMID CAP 20MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents REVLIMID CAP 25MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents REVLIMID CAP 5MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents THALOMID CAP 100MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents THALOMID CAP 150MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents THALOMID CAP 200MG Tier 2 X X X Antiangiogenic Agents - Chemotherapy Agents THALOMID CAP 50MG Tier 2 X X X Antiarrhythmics - Heart Regulation Drugs AMIODARONE TAB 100MG Tier 1 Antiarrhythmics - Heart Regulation Drugs AMIODARONE TAB 200MG Tier 1 Antiarrhythmics - Heart Regulation Drugs AMIODARONE TAB 400MG Tier 1 Antiarrhythmics - Heart Regulation Drugs BETAPACE TAB 120MG Tier 3 X Antiarrhythmics - Heart Regulation Drugs BETAPACE TAB 160MG Tier 3 X Antiarrhythmics - Heart Regulation Drugs BETAPACE TAB 80MG Tier 3 X Antiarrhythmics - Heart Regulation Drugs BETAPACE AF TAB 120MG Tier 3 Antiarrhythmics - Heart Regulation Drugs BETAPACE AF TAB 160MG Tier 3 Antiarrhythmics - Heart Regulation Drugs BETAPACE AF TAB 80MG Tier 3 Antiarrhythmics - Heart Regulation Drugs CORDARONE TAB 200MG Tier 3 Antiarrhythmics - Heart Regulation Drugs DISOPYRAMIDE CAP 100MG Tier 1 Antiarrhythmics - Heart Regulation Drugs DISOPYRAMIDE CAP 150MG Tier 1 Antiarrhythmics - Heart Regulation Drugs DOFETILIDE CAP 125MCG Tier 1 Antiarrhythmics - Heart Regulation Drugs DOFETILIDE CAP 250MCG Tier 1 Antiarrhythmics - Heart Regulation Drugs DOFETILIDE CAP 500MCG Tier 1 Antiarrhythmics - Heart Regulation Drugs FLECAINIDE TAB 100MG Tier 1 Antiarrhythmics - Heart Regulation Drugs FLECAINIDE TAB 150MG Tier 1 Antiarrhythmics - Heart Regulation Drugs FLECAINIDE TAB 50MG Tier 1 Antiarrhythmics - Heart Regulation Drugs MEXILETINE CAP 150MG Tier 1 Antiarrhythmics - Heart Regulation Drugs MEXILETINE CAP 200MG Tier 1

Page 24 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antiarrhythmics - Heart Regulation Drugs MEXILETINE CAP 250MG Tier 1 Antiarrhythmics - Heart Regulation Drugs MULTAQ TAB 400MG Tier 3 X Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 100MG Tier 3 Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 100MG CR Tier 2 Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 150MG Tier 3 Antiarrhythmics - Heart Regulation Drugs NORPACE CAP 150MG CR Tier 2 Antiarrhythmics - Heart Regulation Drugs PACERONE TAB 100MG Tier 3 Antiarrhythmics - Heart Regulation Drugs PACERONE TAB 200MG Tier 1 Antiarrhythmics - Heart Regulation Drugs PACERONE TAB 400MG Tier 3 Antiarrhythmics - Heart Regulation Drugs PROPAFENONE CAP 225MG ER Tier 1 Antiarrhythmics - Heart Regulation Drugs PROPAFENONE CAP 325MG ER Tier 1 Antiarrhythmics - Heart Regulation Drugs PROPAFENONE CAP 425MG SR Tier 1 Antiarrhythmics - Heart Regulation Drugs PROPAFENONE TAB 150MG Tier 1 Antiarrhythmics - Heart Regulation Drugs PROPAFENONE TAB 225MG Tier 1 Antiarrhythmics - Heart Regulation Drugs PROPAFENONE TAB 300MG Tier 1 Antiarrhythmics - Heart Regulation Drugs QUINIDINE GL TAB 324MG CR Tier 1 Antiarrhythmics - Heart Regulation Drugs QUINIDINE GL TAB 324MG ER Tier 1 Antiarrhythmics - Heart Regulation Drugs QUINIDINE SU TAB 200MG Tier 1 Antiarrhythmics - Heart Regulation Drugs QUINIDINE SU TAB 300MG Tier 1 Antiarrhythmics - Heart Regulation Drugs QUINIDINE SU TAB 300MG ER Tier 1 Antiarrhythmics - Heart Regulation Drugs RYTHMOL TAB 150MG Tier 3 Antiarrhythmics - Heart Regulation Drugs RYTHMOL TAB 225MG Tier 3 Antiarrhythmics - Heart Regulation Drugs RYTHMOL SR CAP 225MG Tier 3 Antiarrhythmics - Heart Regulation Drugs RYTHMOL SR CAP 325MG Tier 3 Antiarrhythmics - Heart Regulation Drugs RYTHMOL SR CAP 425MG Tier 3 Antiarrhythmics - Heart Regulation Drugs SOTALOL AF TAB 120MG Tier 1 Antiarrhythmics - Heart Regulation Drugs SOTALOL AF TAB 160MG Tier 1 Antiarrhythmics - Heart Regulation Drugs SOTALOL AF TAB 80MG Tier 1

Page 25 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antiarrhythmics - Heart Regulation Drugs SOTALOL HCL TAB 120MG Tier 1 Antiarrhythmics - Heart Regulation Drugs SOTALOL HCL TAB 160MG Tier 1 Antiarrhythmics - Heart Regulation Drugs SOTALOL HCL TAB 240MG Tier 1 Antiarrhythmics - Heart Regulation Drugs SOTALOL HCL TAB 80MG Tier 1 Antiarrhythmics - Heart Regulation Drugs SOTYLIZE SOL 5MG/ML Tier 3 X Antiarrhythmics - Heart Regulation Drugs TIKOSYN CAP 125MCG Tier 3 Antiarrhythmics - Heart Regulation Drugs TIKOSYN CAP 250MCG Tier 3 Antiarrhythmics - Heart Regulation Drugs TIKOSYN CAP 500MCG Tier 3

Antibacterials, Other - Antibiotics AK-POLY-BAC OIN OP Tier 1

Antibacterials, Other - Antibiotics ALCOH-GLOVE PAD CONTOURE Tier 3

Antibacterials, Other - Antibiotics ALCOHOL PREP PAD Tier 3

Antibacterials, Other - Antibiotics ALCOHOL PREP PAD 70% Tier 1

Antibacterials, Other - Antibiotics ALCOHOL PREP PAD 70% Tier 3

Antibacterials, Other - Antibiotics ALCOHOL PREP PAD MED 70% Tier 3

Antibacterials, Other - Antibiotics ALCOHOL SWAB PAD Tier 3

Antibacterials, Other - Antibiotics ALCOH-WIPE PAD 12"X12" Tier 3

Antibacterials, Other - Antibiotics ALTABAX OIN 1% Tier 3 X

Antibacterials, Other - Antibiotics AZUPHEN MB CAP 120MG Tier 1

Antibacterials, Other - Antibiotics BACIT/POLYMY OIN OP Tier 1

Antibacterials, Other - Antibiotics BACITRACIN OIN OP Tier 1

Antibacterials, Other - Antibiotics BACTROBAN CRE 2% Tier 3 X

Antibacterials, Other - Antibiotics BACTROBAN OIN 2% Tier 3

Antibacterials, Other - Antibiotics BACTROBAN OIN NASAL 2% Tier 2

Antibacterials, Other - Antibiotics CENTANY OIN 2% Tier 3

Antibacterials, Other - Antibiotics CENTANY AT KIT 2% Tier 3 X

Antibacterials, Other - Antibiotics CLEOCIN CAP 150MG Tier 3

Antibacterials, Other - Antibiotics CLEOCIN CAP 300MG Tier 3

Antibacterials, Other - Antibiotics CLEOCIN CAP 75MG Tier 2

Page 26 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antibacterials, Other - Antibiotics CLEOCIN CRE 2% VAG Tier 3

Antibacterials, Other - Antibiotics CLEOCIN SUP 100MG Tier 2

Antibacterials, Other - Antibiotics CLEOCIN PED SOL 75MG/5ML Tier 3

Antibacterials, Other - Antibiotics CLINDAMYCIN CAP 150MG Tier 1

Antibacterials, Other - Antibiotics CLINDAMYCIN CAP 300MG Tier 1

Antibacterials, Other - Antibiotics CLINDAMYCIN CAP 75MG Tier 1

Antibacterials, Other - Antibiotics CLINDAMYCIN CRE 2% VAG Tier 1

Antibacterials, Other - Antibiotics CLINDAMYCIN SOL 75MG/5ML Tier 1

Antibacterials, Other - Antibiotics CLINDESSE CRE 2% Tier 2

Antibacterials, Other - Antibiotics COLISTIMETH INJ 150MG Tier 1

Antibacterials, Other - Antibiotics COLY-MYCIN M INJ 150MG Tier 3

Antibacterials, Other - Antibiotics CORTISPORIN CRE 0.5% Tier 2

Antibacterials, Other - Antibiotics CORTISPORIN OIN 1% Tier 3

Antibacterials, Other - Antibiotics FLAGYL CAP 375MG Tier 3

Antibacterials, Other - Antibiotics FLAGYL TAB 250MG Tier 3

Antibacterials, Other - Antibiotics FLAGYL TAB 500MG Tier 3

Antibacterials, Other - Antibiotics FLAGYL ER TAB 750MG Tier 3

Antibacterials, Other - Antibiotics FURADANTIN SUS 25MG/5ML Tier 3

Antibacterials, Other - Antibiotics GNP ALCOHOL PAD SWABS Tier 3

Antibacterials, Other - Antibiotics HIPREX TAB 1GM Tier 3

Antibacterials, Other - Antibiotics HYOLEV MB TAB 81MG Tier 1

Antibacterials, Other - Antibiotics HYOPHEN TAB Tier 1

Antibacterials, Other - Antibiotics INDIOMIN MB CAP 120MG Tier 3

Antibacterials, Other - Antibiotics IODINE TIN 2% Tier 1

Antibacterials, Other - Antibiotics LANSOPR/AMOX MIS /CLARITH Tier 1 X X

Antibacterials, Other - Antibiotics LINEZOLID SUS 100/5ML Tier 1 X

Antibacterials, Other - Antibiotics LINEZOLID TAB 600MG Tier 1 X

Antibacterials, Other - Antibiotics LUGOLS SOL STRONG Tier 1

Page 27 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antibacterials, Other - Antibiotics MACROBID CAP 100MG Tier 3

Antibacterials, Other - Antibiotics MACRODANTIN CAP 100MG Tier 3

Antibacterials, Other - Antibiotics MACRODANTIN CAP 25MG Tier 3

Antibacterials, Other - Antibiotics MACRODANTIN CAP 50MG Tier 3

Antibacterials, Other - Antibiotics ME/NAPHOS/MB TAB HYO 1 Tier 1

Antibacterials, Other - Antibiotics METHENAM HIP TAB 1GM Tier 1

Antibacterials, Other - Antibiotics METHENAM MAN TAB 1000MG Tier 1

Antibacterials, Other - Antibiotics METHENAM MAN TAB 1GM Tier 1

Antibacterials, Other - Antibiotics METHENAM MAN TAB 500MG Tier 1

Antibacterials, Other - Antibiotics METROCREAM CRE 0.75% Tier 3

Antibacterials, Other - Antibiotics METROGEL GEL 1% Tier 3 X

Antibacterials, Other - Antibiotics METROGEL-VAG GEL 0.75% Tier 3 X

Antibacterials, Other - Antibiotics METROLOTION LOT 0.75% Tier 3

Antibacterials, Other - Antibiotics METRONIDAZOL CAP 375MG Tier 1

Antibacterials, Other - Antibiotics METRONIDAZOL CRE 0.75% Tier 1

Antibacterials, Other - Antibiotics METRONIDAZOL GEL 0.75% Tier 1

Antibacterials, Other - Antibiotics METRONIDAZOL GEL 0.75%VAG Tier 1

Antibacterials, Other - Antibiotics METRONIDAZOL GEL 1% Tier 1 X

Antibacterials, Other - Antibiotics METRONIDAZOL LOT 0.75% Tier 1

Antibacterials, Other - Antibiotics METRONIDAZOL TAB 250MG Tier 1

Antibacterials, Other - Antibiotics METRONIDAZOL TAB 500MG Tier 1

Antibacterials, Other - Antibiotics MITOSOL KIT 0.2MG Tier 3

Antibacterials, Other - Antibiotics MONUROL PAK GRANULES Tier 3

Antibacterials, Other - Antibiotics MUPIROCIN CRE 2% Tier 1 X

Antibacterials, Other - Antibiotics MUPIROCIN OIN 2% Tier 1

Antibacterials, Other - Antibiotics MUPIROCIN CA CRE 2% Tier 1 X

Antibacterials, Other - Antibiotics NEO/BAC/POLY OIN OP Tier 1

Antibacterials, Other - Antibiotics NEO/POLY/GRA SOL OP Tier 1

Page 28 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antibacterials, Other - Antibiotics NEO-POLYCIN OIN OP Tier 1

Antibacterials, Other - Antibiotics NEOSPORIN SOL OP Tier 3

Antibacterials, Other - Antibiotics NITROFUR MAC CAP 100MG Tier 1

Antibacterials, Other - Antibiotics NITROFUR MAC CAP 25MG Tier 1

Antibacterials, Other - Antibiotics NITROFUR MAC CAP 50MG Tier 1

Antibacterials, Other - Antibiotics NITROFURANTN CAP 100MG Tier 1

Antibacterials, Other - Antibiotics NITROFURANTN SUS 25MG/5ML Tier 1

Antibacterials, Other - Antibiotics NORITATE CRE 1% Tier 3 X

Antibacterials, Other - Antibiotics NUVESSA GEL 1.3% Tier 3 X

Antibacterials, Other - Antibiotics OMECLAMOX- MIS PAK Tier 3 X

Antibacterials, Other - Antibiotics PHOSPHASAL TAB Tier 1

Antibacterials, Other - Antibiotics POLYCIN OIN OP Tier 1

Antibacterials, Other - Antibiotics POLYCIN B OIN OP Tier 1

Antibacterials, Other - Antibiotics POLYMYXIN B/ SOL TRIMETHP Tier 1

Antibacterials, Other - Antibiotics POLYTRIM SOL OP Tier 3

Antibacterials, Other - Antibiotics PREP PADS PAD Tier 3

Antibacterials, Other - Antibiotics PREVPAC MIS Tier 3 X X

Antibacterials, Other - Antibiotics PRIMSOL SOL 50MG/5ML Tier 3

Antibacterials, Other - Antibiotics QC ALCOHOL PAD SWABS Tier 3

Antibacterials, Other - Antibiotics RA ALCOHOL PAD SWABS Tier 3

Antibacterials, Other - Antibiotics ROSADAN CRE 0.75% Tier 1

Antibacterials, Other - Antibiotics ROSADAN GEL 0.75% Tier 1

Antibacterials, Other - Antibiotics SILVADENE CRE 1% Tier 3

Antibacterials, Other - Antibiotics SILVER SULFA CRE 1% Tier 1

Antibacterials, Other - Antibiotics SIVEXTRO TAB 200MG Tier 3 X

Antibacterials, Other - Antibiotics SM ALCOHOL PAD PREP Tier 3

Antibacterials, Other - Antibiotics SSD CRE 1% Tier 1

Antibacterials, Other - Antibiotics SULFAMYLON CRE 85MG/GM Tier 3

Page 29 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antibacterials, Other - Antibiotics SULFAMYLON PAK 5% Tier 3

Antibacterials, Other - Antibiotics TRIMETHOPRIM SOL POLYMYXN Tier 1

Antibacterials, Other - Antibiotics TRIMETHOPRIM TAB 100MG Tier 1

Antibacterials, Other - Antibiotics ULTILET ALCH PAD SWAB Tier 1

Antibacterials, Other - Antibiotics UR N-C TAB Tier 1

Antibacterials, Other - Antibiotics URAMIT MB CAP 118MG Tier 1

Antibacterials, Other - Antibiotics URELLE TAB Tier 1

Antibacterials, Other - Antibiotics URETRON D/S TAB Tier 1

Antibacterials, Other - Antibiotics URIBEL CAP 118MG Tier 3

Antibacterials, Other - Antibiotics URIMAR-T TAB Tier 2

Antibacterials, Other - Antibiotics URIN D/S TAB Tier 1

Antibacterials, Other - Antibiotics URO-458 TAB Tier 1

Antibacterials, Other - Antibiotics UROAV-81 TAB Tier 1

Antibacterials, Other - Antibiotics UROAV-B CAP Tier 1

Antibacterials, Other - Antibiotics URO-BLUE TAB 81.6MG Tier 1

Antibacterials, Other - Antibiotics UROGESIC- TAB BLUE Tier 3

Antibacterials, Other - Antibiotics URO-L TAB 81MG Tier 1

Antibacterials, Other - Antibiotics UROLET MB TAB Tier 1

Antibacterials, Other - Antibiotics URO-MP CAP 118MG Tier 1

Antibacterials, Other - Antibiotics UROPHEN MB TAB 81.6MG Tier 1

Antibacterials, Other - Antibiotics URYL TAB Tier 2

Antibacterials, Other - Antibiotics USTELL CAP Tier 1

Antibacterials, Other - Antibiotics UTA CAP 120MG Tier 3

Antibacterials, Other - Antibiotics UTICAP CAP Tier 1

Antibacterials, Other - Antibiotics UTIRA-C TAB Tier 1

Antibacterials, Other - Antibiotics UTRONA-C TAB Tier 1

Antibacterials, Other - Antibiotics VANCOCIN HCL CAP 250MG Tier 3 X

Antibacterials, Other - Antibiotics VANCOMYCIN CAP 125MG Tier 1 X

Page 30 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antibacterials, Other - Antibiotics VANCOMYCIN CAP 250MG Tier 1 X

Antibacterials, Other - Antibiotics VANCOMYCIN SUS +SYRSPEN Tier 3 X

Antibacterials, Other - Antibiotics VANCOMYCN 25 SOL 25MG/ML Tier 3 X

Antibacterials, Other - Antibiotics VANCOMYCN 50 SOL 50MG/ML Tier 3 X

Antibacterials, Other - Antibiotics VANDAZOLE GEL 0.75% Tier 1

Antibacterials, Other - Antibiotics V-R ALC PREP PAD SWABS Tier 1

Antibacterials, Other - Antibiotics XIFAXAN TAB 200MG Tier 3 X X

Antibacterials, Other - Antibiotics XIFAXAN TAB 550MG Tier 3 X X

Antibacterials, Other - Antibiotics ZYVOX SUS 100MG/5M Tier 3 X

Antibacterials, Other - Antibiotics ZYVOX TAB 600MG Tier 3 X X Anticholinergics - Parkinson's Disease Drugs BENZTROPINE TAB 0.5MG Tier 1 Anticholinergics - Parkinson's Disease Drugs BENZTROPINE TAB 1MG Tier 1 Anticholinergics - Parkinson's Disease Drugs BENZTROPINE TAB 2MG Tier 1 Anticholinergics - Parkinson's Disease Drugs TRIHEXYPHEN ELX 0.4MG/ML Tier 1 Anticholinergics - Parkinson's Disease Drugs TRIHEXYPHEN TAB 2MG Tier 1 Anticholinergics - Parkinson's Disease Drugs TRIHEXYPHEN TAB 5MG Tier 1

Anticoagulants - Blood Thinners ARIXTRA INJ 10/0.8ML Tier 3 X

Anticoagulants - Blood Thinners ARIXTRA INJ 2.5/0.5 Tier 3 X

Anticoagulants - Blood Thinners ARIXTRA INJ 5/0.4ML Tier 3 X

Anticoagulants - Blood Thinners ARIXTRA INJ 7.5/0.6 Tier 3 X

Anticoagulants - Blood Thinners COUMADIN TAB 10MG Tier 3

Anticoagulants - Blood Thinners COUMADIN TAB 1MG Tier 3

Anticoagulants - Blood Thinners COUMADIN TAB 2.5MG Tier 3

Anticoagulants - Blood Thinners COUMADIN TAB 2MG Tier 3

Anticoagulants - Blood Thinners COUMADIN TAB 3MG Tier 3

Anticoagulants - Blood Thinners COUMADIN TAB 4MG Tier 3

Anticoagulants - Blood Thinners COUMADIN TAB 5MG Tier 3

Anticoagulants - Blood Thinners COUMADIN TAB 6MG Tier 3

Page 31 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anticoagulants - Blood Thinners COUMADIN TAB 7.5MG Tier 3

Anticoagulants - Blood Thinners ELIQUIS TAB 2.5MG Tier 3 X

Anticoagulants - Blood Thinners ELIQUIS TAB 5MG Tier 3 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 100MG/ML Tier 1 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 120/0.8 Tier 1 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 150MG/ML Tier 1 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 30/0.3ML Tier 1 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 300/3ML Tier 1 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 40/0.4ML Tier 1 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 60/0.6ML Tier 1 X

Anticoagulants - Blood Thinners ENOXAPARIN INJ 80/0.8ML Tier 1 X

Anticoagulants - Blood Thinners FONDAPARINUX INJ 10/0.8ML Tier 1 X

Anticoagulants - Blood Thinners FONDAPARINUX INJ 2.5/0.5 Tier 1 X

Anticoagulants - Blood Thinners FONDAPARINUX INJ 5/0.4ML Tier 1 X

Anticoagulants - Blood Thinners FONDAPARINUX INJ 7.5/0.6 Tier 1 X

Anticoagulants - Blood Thinners FRAGMIN INJ 10000/ML Tier 3 X

Anticoagulants - Blood Thinners FRAGMIN INJ 12500UNT Tier 3 X

Anticoagulants - Blood Thinners FRAGMIN INJ 15000UNT Tier 3 X

Anticoagulants - Blood Thinners FRAGMIN INJ 18000UNT Tier 3 X

Anticoagulants - Blood Thinners FRAGMIN INJ 2500/0.2 Tier 3 X

Anticoagulants - Blood Thinners FRAGMIN INJ 5000/0.2 Tier 3 X

Anticoagulants - Blood Thinners FRAGMIN INJ 7500/0.3 Tier 3 X

Anticoagulants - Blood Thinners FRAGMIN INJ 95000UNT Tier 3

Anticoagulants - Blood Thinners HEPARIN LOCK INJ 100/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN LOCK INJ 10UNT/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 1000/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 10000/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 10000/ML Tier 1

Page 32 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anticoagulants - Blood Thinners HEPARIN SOD INJ 2000/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 20000/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 2500/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 5000/0.5 Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 5000/ML Tier 1

Anticoagulants - Blood Thinners HEPARIN SOD INJ 5000U Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 10MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 1MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 2.5MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 2MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 3MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 4MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 5MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 6MG Tier 1

Anticoagulants - Blood Thinners JANTOVEN TAB 7.5MG Tier 1

Anticoagulants - Blood Thinners LOVENOX INJ 100MG/ML Tier 3 X

Anticoagulants - Blood Thinners LOVENOX INJ 120/0.8 Tier 3 X

Anticoagulants - Blood Thinners LOVENOX INJ 150MG/ML Tier 3 X

Anticoagulants - Blood Thinners LOVENOX INJ 30/0.3ML Tier 3 X

Anticoagulants - Blood Thinners LOVENOX INJ 300/3ML Tier 3 X

Anticoagulants - Blood Thinners LOVENOX INJ 40/0.4ML Tier 3 X

Anticoagulants - Blood Thinners LOVENOX INJ 60/0.6ML Tier 3 X

Anticoagulants - Blood Thinners LOVENOX INJ 80/0.8ML Tier 3 X

Anticoagulants - Blood Thinners PRADAXA CAP 110MG Tier 2 X

Anticoagulants - Blood Thinners PRADAXA CAP 150MG Tier 2 X

Anticoagulants - Blood Thinners PRADAXA CAP 75MG Tier 2 X

Anticoagulants - Blood Thinners WARFARIN TAB 10MG Tier 1

Anticoagulants - Blood Thinners WARFARIN TAB 1MG Tier 1

Page 33 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anticoagulants - Blood Thinners WARFARIN TAB 2.5MG Tier 1

Anticoagulants - Blood Thinners WARFARIN TAB 2MG Tier 1

Anticoagulants - Blood Thinners WARFARIN TAB 3MG Tier 1

Anticoagulants - Blood Thinners WARFARIN TAB 4MG Tier 1

Anticoagulants - Blood Thinners WARFARIN TAB 5MG Tier 1

Anticoagulants - Blood Thinners WARFARIN TAB 6MG Tier 1

Anticoagulants - Blood Thinners WARFARIN TAB 7.5MG Tier 1

Anticoagulants - Blood Thinners WARFARIN SOD TAB 10MG Tier 1

Anticoagulants - Blood Thinners XARELTO TAB 10MG Tier 2 X

Anticoagulants - Blood Thinners XARELTO TAB 15MG Tier 2 X

Anticoagulants - Blood Thinners XARELTO TAB 20MG Tier 2 X

Anticoagulants - Blood Thinners XARELTO STAR TAB 15/20MG Tier 2 Anticonvulsants, Other - Seizure Control Drugs APTIOM TAB 200MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs APTIOM TAB 400MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs APTIOM TAB 600MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs APTIOM TAB 800MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs KEPPRA SOL 100MG/ML Tier 3 X X Anticonvulsants, Other - Seizure Control Drugs KEPPRA TAB 1000MG Tier 3 X X Anticonvulsants, Other - Seizure Control Drugs KEPPRA TAB 250MG Tier 3 X X Anticonvulsants, Other - Seizure Control Drugs KEPPRA TAB 500MG Tier 3 X X Anticonvulsants, Other - Seizure Control Drugs KEPPRA TAB 750MG Tier 3 X X Anticonvulsants, Other - Seizure Control Drugs KEPPRA XR TAB 500MG Tier 3 X X Anticonvulsants, Other - Seizure Control Drugs KEPPRA XR TAB 750MG Tier 3 X X Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA SOL 100MG/ML Tier 1 Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA SOL 500/5ML Tier 1 Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 1000MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 250MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 500MG Tier 1

Page 34 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 500MG ER Tier 1 Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 750MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs LEVETIRACETA TAB 750MG ER Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB ELX 20/5ML Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB ELX 20MG/5ML Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB SOL 20MG/5ML Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 100MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 15MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 16.2MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 30MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 32.4MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 60MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 64.8MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs PHENOBARB TAB 97.2MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs POTIGA TAB 200MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs POTIGA TAB 300MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs POTIGA TAB 400MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs POTIGA TAB 50MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs ROWEEPRA TAB 500MG Tier 1 Anticonvulsants, Other - Seizure Control Drugs SPRITAM TAB 1000MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs SPRITAM TAB 250MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs SPRITAM TAB 500MG Tier 3 X Anticonvulsants, Other - Seizure Control Drugs SPRITAM TAB 750MG Tier 3 X

Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs VALCYTE SOL 50MG/ML Tier 3

Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs VALCYTE TAB 450MG Tier 3 X X

Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs VALGANCICLOV TAB 450MG Tier 1 X

Page 35 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs ZIRGAN GEL 0.15% Tier 3 X

Antidementia Agents, Other ERGOLOID MES TAB 1MG ORAL Tier 1 Antidepressants, Other - Antidepressants APLENZIN TAB 174MG Tier 3 X X X Antidepressants, Other - Antidepressants APLENZIN TAB 348MG Tier 3 X X X Antidepressants, Other - Antidepressants APLENZIN TAB 522MG Tier 3 X X X Antidepressants, Other - Antidepressants BRINTELLIX TAB 10MG Tier 3 X X Antidepressants, Other - Antidepressants BRINTELLIX TAB 20MG Tier 3 X X Antidepressants, Other - Antidepressants BRINTELLIX TAB 5MG Tier 3 X X Antidepressants, Other - Antidepressants BUPROPION TAB 100MG Tier 1 Antidepressants, Other - Antidepressants BUPROPION TAB 100MG ER Tier 1 Antidepressants, Other - Antidepressants BUPROPION TAB 100MG SR Tier 1 Antidepressants, Other - Antidepressants BUPROPION TAB 150MG ER Tier 1 Antidepressants, Other - Antidepressants BUPROPION TAB 150MG SR Tier 1 Antidepressants, Other - Antidepressants BUPROPION TAB 200MG ER Tier 1 Antidepressants, Other - Antidepressants BUPROPION TAB 200MG SR Tier 1 Antidepressants, Other - Antidepressants BUPROPION TAB 75MG Tier 1 Antidepressants, Other - Antidepressants BUPROPN HCL TAB 150MG XL Tier 1 Antidepressants, Other - Antidepressants BUPROPN HCL TAB 300MG XL Tier 1 Antidepressants, Other - Antidepressants FORFIVO XL TAB 450MG Tier 3 X X X Antidepressants, Other - Antidepressants MAPROTILINE TAB 25MG Tier 1 Antidepressants, Other - Antidepressants MAPROTILINE TAB 50MG Tier 1 Antidepressants, Other - Antidepressants MAPROTILINE TAB 75MG Tier 1 Antidepressants, Other - Antidepressants MIRTAZAPINE TAB 15MG Tier 1 Antidepressants, Other - Antidepressants MIRTAZAPINE TAB 15MG ODT Tier 1 Antidepressants, Other - Antidepressants MIRTAZAPINE TAB 30MG Tier 1 Antidepressants, Other - Antidepressants MIRTAZAPINE TAB 30MG ODT Tier 1 Antidepressants, Other - Antidepressants MIRTAZAPINE TAB 45MG Tier 1

Page 36 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antidepressants, Other - Antidepressants MIRTAZAPINE TAB 45MG ODT Tier 1 Antidepressants, Other - Antidepressants MIRTAZAPINE TAB 7.5MG Tier 1 Antidepressants, Other - Antidepressants NEFAZODONE TAB 100MG Tier 1 Antidepressants, Other - Antidepressants NEFAZODONE TAB 150MG Tier 1 Antidepressants, Other - Antidepressants NEFAZODONE TAB 200MG Tier 1 Antidepressants, Other - Antidepressants NEFAZODONE TAB 250MG Tier 1 Antidepressants, Other - Antidepressants NEFAZODONE TAB 50MG Tier 1 Antidepressants, Other - Antidepressants OLEPTRO TAB 24HR150 Tier 3 X X Antidepressants, Other - Antidepressants OLEPTRO TAB 24HR300 Tier 3 X X Antidepressants, Other - Antidepressants REMERON TAB 15MG Tier 3 Antidepressants, Other - Antidepressants REMERON TAB 30MG Tier 3 Antidepressants, Other - Antidepressants REMERON TAB 45MG Tier 3 Antidepressants, Other - Antidepressants REMERON SLTB TAB 15MG Tier 3 Antidepressants, Other - Antidepressants REMERON SLTB TAB 30MG Tier 3 Antidepressants, Other - Antidepressants REMERON SLTB TAB 45MG Tier 3 Antidepressants, Other - Antidepressants TRAZODONE TAB 100MG Tier 1 Antidepressants, Other - Antidepressants TRAZODONE TAB 150MG Tier 1 Antidepressants, Other - Antidepressants TRAZODONE TAB 300MG Tier 1 Antidepressants, Other - Antidepressants TRAZODONE TAB 50MG Tier 1 Antidepressants, Other - Antidepressants TRINTELLIX TAB 10MG Tier 3 X X Antidepressants, Other - Antidepressants TRINTELLIX TAB 20MG Tier 3 X X Antidepressants, Other - Antidepressants TRINTELLIX TAB 5MG Tier 3 X X Antidepressants, Other - Antidepressants WELLBUTRIN TAB 100MG Tier 3 X Antidepressants, Other - Antidepressants WELLBUTRIN TAB 100MG SR Tier 3 X X Antidepressants, Other - Antidepressants WELLBUTRIN TAB 150MG SR Tier 3 X X Antidepressants, Other - Antidepressants WELLBUTRIN TAB 200MG SR Tier 3 X X Antidepressants, Other - Antidepressants WELLBUTRIN TAB 75MG Tier 3 X Antidepressants, Other - Antidepressants WELLBUTRIN TAB XL 150MG Tier 3 X X

Page 37 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antidepressants, Other - Antidepressants WELLBUTRIN TAB XL 300MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ACARBOSE TAB 100MG Tier 1

Antidiabetic Agents - Diabetic Drugs ACARBOSE TAB 25MG Tier 1

Antidiabetic Agents - Diabetic Drugs ACARBOSE TAB 50MG Tier 1

Antidiabetic Agents - Diabetic Drugs ACTOPLUS MET TAB 15-500MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs ACTOPLUS MET TAB 15-850MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs ACTOPLUS MET TAB XR Tier 3 X

Antidiabetic Agents - Diabetic Drugs ACTOPLUS MET TAB XR Tier 3 X

Antidiabetic Agents - Diabetic Drugs ACTOS TAB 15MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ACTOS TAB 30MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ACTOS TAB 45MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOG/PIOGLIP TAB 12.5-15 Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOG/PIOGLIP TAB 12.5-30 Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOG/PIOGLIT TAB 12.5-45 Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOG/PIOGLIT TAB 25-15MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOG/PIOGLIT TAB 25-30MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOG/PIOGLIT TAB 25-45MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOGLIPTIN TAB 12.5MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOGLIPTIN TAB 25MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOGLIPTIN TAB 6.25MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOGLIPTIN/ TAB METFORM Tier 3 X X

Antidiabetic Agents - Diabetic Drugs ALOGLIPTIN/ TAB METFORM Tier 3 X X

Antidiabetic Agents - Diabetic Drugs AMARYL TAB 1MG Tier 3

Antidiabetic Agents - Diabetic Drugs AMARYL TAB 2MG Tier 3

Antidiabetic Agents - Diabetic Drugs AMARYL TAB 4MG Tier 3

Antidiabetic Agents - Diabetic Drugs AVANDAMET TAB 2-1000MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs AVANDAMET TAB 4-500MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs AVANDARYL TAB 4-1MG Tier 3 X

Page 38 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antidiabetic Agents - Diabetic Drugs AVANDARYL TAB 4-2MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs AVANDARYL TAB 8-4MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs AVANDIA TAB 2MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs AVANDIA TAB 4MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs AVANDIA TAB 8MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs BYDUREON INJ Tier 2 X

Antidiabetic Agents - Diabetic Drugs BYDUREON INJ Tier 2 X

Antidiabetic Agents - Diabetic Drugs BYETTA INJ 10MCG Tier 2 X

Antidiabetic Agents - Diabetic Drugs BYETTA INJ 5MCG Tier 2 X

Antidiabetic Agents - Diabetic Drugs CHLORPROPAM TAB 100MG Tier 1

Antidiabetic Agents - Diabetic Drugs CHLORPROPAM TAB 250MG Tier 1

Antidiabetic Agents - Diabetic Drugs CYCLOSET TAB 0.8MG Tier 3

Antidiabetic Agents - Diabetic Drugs DIABETA TAB 1.25MG Tier 3

Antidiabetic Agents - Diabetic Drugs DIABETA TAB 2.5MG Tier 3

Antidiabetic Agents - Diabetic Drugs DIABETA TAB 5MG Tier 3

Antidiabetic Agents - Diabetic Drugs DUETACT TAB 30-2MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs DUETACT TAB 30-4MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs FARXIGA TAB 10MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs FARXIGA TAB 5MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs FORTAMET TAB 1000MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs FORTAMET TAB 500MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs GLIMEPIRIDE TAB 1MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIMEPIRIDE TAB 2MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIMEPIRIDE TAB 4MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIP/METFORM TAB 2.5-250M Tier 1

Antidiabetic Agents - Diabetic Drugs GLIP/METFORM TAB 2.5-500 Tier 1

Antidiabetic Agents - Diabetic Drugs GLIP/METFORM TAB 2.5-500M Tier 1

Antidiabetic Agents - Diabetic Drugs GLIP/METFORM TAB 5-500MG Tier 1

Page 39 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE POW Tier 3

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE TAB 10MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE TAB 5MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE ER TAB 10MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE ER TAB 2.5MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE ER TAB 5MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE XL TAB 10MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE XL TAB 2.5MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLIPIZIDE XL TAB 5MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLUCOPHAGE TAB 1000MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOPHAGE TAB 500MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOPHAGE TAB 500MG XR Tier 3 X

Antidiabetic Agents - Diabetic Drugs GLUCOPHAGE TAB 750MG XR Tier 3 X

Antidiabetic Agents - Diabetic Drugs GLUCOPHAGE TAB 850MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOTROL TAB 10MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOTROL TAB 5MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOTROL XL TAB 10MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOTROL XL TAB 2.5MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOTROL XL TAB 5MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOVANCE TAB 1.25-250 Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOVANCE TAB 2.5-500 Tier 3

Antidiabetic Agents - Diabetic Drugs GLUCOVANCE TAB 5-500MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLUMETZA TAB 1000MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs GLUMETZA TAB 500MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs GLYB/METFORM TAB 1.25-250 Tier 1

Antidiabetic Agents - Diabetic Drugs GLYB/METFORM TAB 2.5-500 Tier 1

Antidiabetic Agents - Diabetic Drugs GLYB/METFORM TAB 5-500MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLYBURID MCR TAB 1.5MG Tier 1

Page 40 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antidiabetic Agents - Diabetic Drugs GLYBURID MCR TAB 3MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLYBURID MCR TAB 6MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLYBURIDE POW Tier 3

Antidiabetic Agents - Diabetic Drugs GLYBURIDE TAB 1.25MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLYBURIDE TAB 2.5MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLYBURIDE TAB 5MG Tier 1

Antidiabetic Agents - Diabetic Drugs GLYNASE TAB 1.5MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLYNASE TAB 3MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLYNASE TAB 6MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLYSET TAB 100MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLYSET TAB 25MG Tier 3

Antidiabetic Agents - Diabetic Drugs GLYSET TAB 50MG Tier 3

Antidiabetic Agents - Diabetic Drugs INVOKAMET TAB 150-1000 Tier 2 X

Antidiabetic Agents - Diabetic Drugs INVOKAMET TAB 150-500 Tier 2 X

Antidiabetic Agents - Diabetic Drugs INVOKAMET TAB 50-1000 Tier 2 X

Antidiabetic Agents - Diabetic Drugs INVOKAMET TAB 50-500MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs INVOKANA TAB 100MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs INVOKANA TAB 300MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs JANUMET TAB 50-1000 Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JANUMET TAB 50-500MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JANUMET XR TAB 100-1000 Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JANUMET XR TAB 50-1000 Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JANUMET XR TAB 50-500MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JANUVIA TAB 100MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JANUVIA TAB 25MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JANUVIA TAB 50MG Tier 3 X X

Antidiabetic Agents - Diabetic Drugs JARDIANCE TAB 10MG Tier 2 X X X

Antidiabetic Agents - Diabetic Drugs JARDIANCE TAB 25MG Tier 2 X X X

Page 41 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antidiabetic Agents - Diabetic Drugs JENTADUETO TAB 2.5-1000 Tier 2 X

Antidiabetic Agents - Diabetic Drugs JENTADUETO TAB 2.5-500 Tier 2 X

Antidiabetic Agents - Diabetic Drugs JENTADUETO TAB 2.5-850 Tier 2 X

Antidiabetic Agents - Diabetic Drugs JENTADUETO TAB XR Tier 3 X

Antidiabetic Agents - Diabetic Drugs JENTADUETO TAB XR Tier 3 X

Antidiabetic Agents - Diabetic Drugs KAZANO 12.5- TAB 1000MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs KAZANO 12.5- TAB 500MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs KOMBIGLYZE TAB 2.5-1000 Tier 2 X

Antidiabetic Agents - Diabetic Drugs KOMBIGLYZE TAB 5-1000MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs KOMBIGLYZE TAB 5-500MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 1000MG Tier 1

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 1000MG Tier 1 X X

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 500MG Tier 1

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 500MG ER Tier 1

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 500MG ER Tier 1 X X

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 500MG ER Tier 1 X X

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 750MG ER Tier 1

Antidiabetic Agents - Diabetic Drugs METFORMIN TAB 850MG Tier 1

Antidiabetic Agents - Diabetic Drugs METFORMIN ER TAB 1000MG Tier 1 X X

Antidiabetic Agents - Diabetic Drugs MIGLITOL TAB 100MG Tier 1

Antidiabetic Agents - Diabetic Drugs MIGLITOL TAB 25MG Tier 1

Antidiabetic Agents - Diabetic Drugs MIGLITOL TAB 50MG Tier 1

Antidiabetic Agents - Diabetic Drugs NATEGLINIDE TAB 120MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs NATEGLINIDE TAB 60MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs NESINA TAB 12.5MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs NESINA TAB 25MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs NESINA TAB 6.25MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs ONGLYZA TAB 2.5MG Tier 2 X

Page 42 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antidiabetic Agents - Diabetic Drugs ONGLYZA TAB 5MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs OSENI TAB 12.5-15 Tier 2 X

Antidiabetic Agents - Diabetic Drugs OSENI TAB 12.5-30 Tier 2 X

Antidiabetic Agents - Diabetic Drugs OSENI TAB 12.5-45 Tier 2 X

Antidiabetic Agents - Diabetic Drugs OSENI TAB 25-15MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs OSENI TAB 25-30MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs OSENI TAB 25-45MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs PIOGLIT/GLIM TAB 30-2MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs PIOGLIT/GLIM TAB 30-4MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs PIOGLITA/MET TAB 15-500MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs PIOGLITA/MET TAB 15-850MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs PIOGLITAZONE TAB 15MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs PIOGLITAZONE TAB 30MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs PIOGLITAZONE TAB 45MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs PRANDIMET TAB 1-500MG Tier 3

Antidiabetic Agents - Diabetic Drugs PRANDIMET TAB 2-500MG Tier 3

Antidiabetic Agents - Diabetic Drugs PRANDIN TAB 0.5MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs PRANDIN TAB 1MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs PRANDIN TAB 2MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs PRECOSE TAB 100MG Tier 3

Antidiabetic Agents - Diabetic Drugs PRECOSE TAB 25MG Tier 3

Antidiabetic Agents - Diabetic Drugs PRECOSE TAB 50MG Tier 3

Antidiabetic Agents - Diabetic Drugs REPAGLINIDE TAB 0.5MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs REPAGLINIDE TAB 1-500MG Tier 1

Antidiabetic Agents - Diabetic Drugs REPAGLINIDE TAB 1MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs REPAGLINIDE TAB 2-500MG Tier 1

Antidiabetic Agents - Diabetic Drugs REPAGLINIDE TAB 2MG Tier 1 X

Antidiabetic Agents - Diabetic Drugs RIOMET SOL Tier 3

Page 43 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antidiabetic Agents - Diabetic Drugs RIOMET SOL 500/5ML Tier 3

Antidiabetic Agents - Diabetic Drugs STARLIX TAB 120MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs STARLIX TAB 60MG Tier 3 X

Antidiabetic Agents - Diabetic Drugs SYMLINPEN 60 INJ 1000MCG Tier 3 X

Antidiabetic Agents - Diabetic Drugs SYMLNPEN 120 INJ 1000MCG Tier 3

Antidiabetic Agents - Diabetic Drugs TANZEUM INJ 30MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs TANZEUM INJ 50MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs TOLAZAMIDE TAB 250MG Tier 1

Antidiabetic Agents - Diabetic Drugs TOLAZAMIDE TAB 500MG Tier 1

Antidiabetic Agents - Diabetic Drugs TOLBUTAMIDE TAB 500MG Tier 1

Antidiabetic Agents - Diabetic Drugs TRADJENTA TAB 5MG Tier 2 X

Antidiabetic Agents - Diabetic Drugs VICTOZA INJ 18MG/3ML Tier 2 X

Antidiabetic Agents - Diabetic Drugs VICTOZA INJ 18MG/3ML Tier 3 X

Antidotes - Antidotes/Protectants CETYLEV TAB 2.5GM Tier 3 X

Antidotes - Antidotes/Protectants CETYLEV TAB 500MG Tier 3 X Antiemetics - Drugs to Treat Nausea and Vomiting DICLEGIS TAB 10-10MG Tier 3 X Antiemetics, Other - Nausea and Vomiting Drugs TIGAN CAP 300MG Tier 3 Antiemetics, Other - Nausea and Vomiting Drugs TRANSDERM-SC DIS 1MG Tier 3 Antiemetics, Other - Nausea and Vomiting Drugs TRIMETHOBENZ CAP 300MG Tier 1 Antiestrogens/Modifiers - Chemotherapy Agents EMCYT CAP 140MG Tier 2 X Antiestrogens/Modifiers - Chemotherapy Agents FARESTON TAB 60MG Tier 2 X Antiestrogens/Modifiers - Chemotherapy Agents SOLTAMOX SOL 10MG/5ML Tier 3 X Antiestrogens/Modifiers - Chemotherapy Agents TAMOXIFEN TAB 10MG Tier 1 Antiestrogens/Modifiers - HCR Chemotherapy Agents TAMOXIFEN TAB 20MG Preventative

Antifungals - Fungal Infection Drugs ANCOBON CAP 250MG Tier 3

Antifungals - Fungal Infection Drugs ANCOBON CAP 500MG Tier 3

Antifungals - Fungal Infection Drugs AVC CRE 15% Tier 2

Antifungals - Fungal Infection Drugs BIO-STATIN CAP 1000000 Tier 3

Page 44 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antifungals - Fungal Infection Drugs BIO-STATIN CAP 500000 Tier 3

Antifungals - Fungal Infection Drugs BIO-STATIN POW Tier 1

Antifungals - Fungal Infection Drugs CICLODAN CRE 0.77% Tier 1

Antifungals - Fungal Infection Drugs CICLODAN SOL 8% Tier 1

Antifungals - Fungal Infection Drugs CICLODAN CRE KIT 0.77% Tier 3 X

Antifungals - Fungal Infection Drugs CICLODAN SOL KIT 8% Tier 3 X

Antifungals - Fungal Infection Drugs CICLOPIROX CRE 0.77% Tier 1

Antifungals - Fungal Infection Drugs CICLOPIROX GEL 0.77% Tier 1

Antifungals - Fungal Infection Drugs CICLOPIROX KIT 8% Tier 1

Antifungals - Fungal Infection Drugs CICLOPIROX KIT 8% Tier 1 X

Antifungals - Fungal Infection Drugs CICLOPIROX SHA 1% Tier 1

Antifungals - Fungal Infection Drugs CICLOPIROX SOL 8% Tier 1

Antifungals - Fungal Infection Drugs CICLOPIROX SUS 0.77% Tier 1

Antifungals - Fungal Infection Drugs CLOTRIM/BETA CRE 1-0.05% Tier 1 X

Antifungals - Fungal Infection Drugs CLOTRIM/BETA CRE DIPROP Tier 1 X

Antifungals - Fungal Infection Drugs CLOTRIM/BETA LOT DIPROP Tier 1

Antifungals - Fungal Infection Drugs CLOTRIMAZOLE LOZ 10MG Tier 1

Antifungals - Fungal Infection Drugs CLOTRIMAZOLE TRO 10MG Tier 1

Antifungals - Fungal Infection Drugs CNL8 NAIL KIT Tier 3

Antifungals - Fungal Infection Drugs DIFLUCAN SUS 10MG/ML Tier 3

Antifungals - Fungal Infection Drugs DIFLUCAN SUS 40MG/ML Tier 3

Antifungals - Fungal Infection Drugs DIFLUCAN TAB 100MG Tier 3

Antifungals - Fungal Infection Drugs DIFLUCAN TAB 150MG Tier 3

Antifungals - Fungal Infection Drugs DIFLUCAN TAB 200MG Tier 3

Antifungals - Fungal Infection Drugs DIFLUCAN TAB 50MG Tier 3

Antifungals - Fungal Infection Drugs ECONAZOLE CRE 1% Tier 1 X

Antifungals - Fungal Infection Drugs ECOZA AER 1% Tier 3 X X

Antifungals - Fungal Infection Drugs ERTACZO CRE 2% Tier 3 X

Page 45 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antifungals - Fungal Infection Drugs EXELDERM CRE 1% Tier 3

Antifungals - Fungal Infection Drugs EXELDERM SOL 1% Tier 3

Antifungals - Fungal Infection Drugs EXTINA AER 2% Tier 3 X

Antifungals - Fungal Infection Drugs FLUCONAZOLE SUS 10MG/ML Tier 1

Antifungals - Fungal Infection Drugs FLUCONAZOLE SUS 40MG/ML Tier 1

Antifungals - Fungal Infection Drugs FLUCONAZOLE TAB 100MG Tier 1

Antifungals - Fungal Infection Drugs FLUCONAZOLE TAB 150MG Tier 1

Antifungals - Fungal Infection Drugs FLUCONAZOLE TAB 200MG Tier 1

Antifungals - Fungal Infection Drugs FLUCONAZOLE TAB 50MG Tier 1

Antifungals - Fungal Infection Drugs FLUCYTOSINE CAP 250MG Tier 1

Antifungals - Fungal Infection Drugs FLUCYTOSINE CAP 500MG Tier 1

Antifungals - Fungal Infection Drugs GRIFULVIN V TAB 500MG Tier 3

Antifungals - Fungal Infection Drugs GRISEOFULVIN SUS 125/5ML Tier 1

Antifungals - Fungal Infection Drugs GRISEOFULVIN TAB MICR 500 Tier 1

Antifungals - Fungal Infection Drugs GRISEOFULVIN TAB ULTR 125 Tier 1

Antifungals - Fungal Infection Drugs GRISEOFULVIN TAB ULTR 250 Tier 1

Antifungals - Fungal Infection Drugs GRIS-PEG TAB 125MG Tier 3

Antifungals - Fungal Infection Drugs GRIS-PEG TAB 250MG Tier 3

Antifungals - Fungal Infection Drugs GYNAZOLE-1 CRE 2% Tier 3

Antifungals - Fungal Infection Drugs ITRACONAZOLE CAP 100MG Tier 1 X

Antifungals - Fungal Infection Drugs JUBLIA SOL 10% Tier 3 X X X

Antifungals - Fungal Infection Drugs KETOCONAZOLE AER 2% Tier 1 X

Antifungals - Fungal Infection Drugs KETOCONAZOLE CRE 2% Tier 1

Antifungals - Fungal Infection Drugs KETOCONAZOLE SHA 2% Tier 1

Antifungals - Fungal Infection Drugs KETOCONAZOLE TAB 200MG Tier 1

Antifungals - Fungal Infection Drugs KETODAN AER 2% Tier 1 X

Antifungals - Fungal Infection Drugs KETODAN KIT 2% Tier 3 X

Antifungals - Fungal Infection Drugs LAMISIL GRA 125MG Tier 3 X

Page 46 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antifungals - Fungal Infection Drugs LAMISIL GRA 187.5MG Tier 3 X

Antifungals - Fungal Infection Drugs LAMISIL SPR 1% Tier 2

Antifungals - Fungal Infection Drugs LAMISIL TAB 250MG Tier 3 X

Antifungals - Fungal Infection Drugs LOPROX CRE 0.77% Tier 3 X

Antifungals - Fungal Infection Drugs LOPROX KIT 0.77% Tier 3 X

Antifungals - Fungal Infection Drugs LOPROX SHA 1% Tier 3 X

Antifungals - Fungal Infection Drugs LOTRISONE CRE Tier 3 X

Antifungals - Fungal Infection Drugs LUZU CRE 1% Tier 3 X X

Antifungals - Fungal Infection Drugs MENTAX CRE 1% Tier 3

Antifungals - Fungal Infection Drugs MICONAZOLE 3 SUP 200MG Tier 1

Antifungals - Fungal Infection Drugs NAFTIFINE CRE HCL 1% Tier 1 X

Antifungals - Fungal Infection Drugs NAFTIFINE CRE HCL 2% Tier 1 X

Antifungals - Fungal Infection Drugs NAFTIN CRE 1% Tier 3 X

Antifungals - Fungal Infection Drugs NAFTIN CRE 2% Tier 3 X

Antifungals - Fungal Infection Drugs NAFTIN GEL 1% Tier 3 X

Antifungals - Fungal Infection Drugs NAFTIN GEL 2% Tier 3 X

Antifungals - Fungal Infection Drugs NATACYN SUS 5% OP Tier 3

Antifungals - Fungal Infection Drugs NIZORAL SHA 2% Tier 3

Antifungals - Fungal Infection Drugs NOXAFIL SUS 40MG/ML Tier 2

Antifungals - Fungal Infection Drugs NOXAFIL TAB 100MG Tier 2

Antifungals - Fungal Infection Drugs NYAMYC POW 100000 Tier 1

Antifungals - Fungal Infection Drugs NYSTAT/TRIAM CRE Tier 1 X

Antifungals - Fungal Infection Drugs NYSTAT/TRIAM OIN Tier 1 X

Antifungals - Fungal Infection Drugs NYSTATIN CRE 100000 Tier 1

Antifungals - Fungal Infection Drugs NYSTATIN OIN 100000 Tier 1

Antifungals - Fungal Infection Drugs NYSTATIN POW Tier 1

Antifungals - Fungal Infection Drugs NYSTATIN POW 100000 Tier 1

Antifungals - Fungal Infection Drugs NYSTATIN SUS 100000 Tier 1

Page 47 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antifungals - Fungal Infection Drugs NYSTATIN TAB 500000 Tier 1

Antifungals - Fungal Infection Drugs NYSTOP POW 100000 Tier 1

Antifungals - Fungal Infection Drugs ONMEL TAB 200MG Tier 3 X X

Antifungals - Fungal Infection Drugs ORAVIG TAB 50MG Tier 3

Antifungals - Fungal Infection Drugs OXICONAZOLE CRE NITR 1% Tier 1 X X X

Antifungals - Fungal Infection Drugs OXICONAZOLE CRE NITRATE Tier 1 X X X

Antifungals - Fungal Infection Drugs OXISTAT CRE 1% Tier 3 X X X

Antifungals - Fungal Infection Drugs OXISTAT LOT 1% Tier 3 X

Antifungals - Fungal Infection Drugs PEDIADERM AF KIT COMPLETE Tier 3 X

Antifungals - Fungal Infection Drugs PENLAC SOL 8% Tier 3 X

Antifungals - Fungal Infection Drugs SPORANOX CAP 100MG Tier 3 X

Antifungals - Fungal Infection Drugs SPORANOX CAP PULSEPAK Tier 3 X

Antifungals - Fungal Infection Drugs SPORANOX SOL 10MG/ML Tier 2 X

Antifungals - Fungal Infection Drugs TERAZOL 3 CRE 0.8% Tier 3

Antifungals - Fungal Infection Drugs TERAZOL 7 CRE 0.4% Tier 3

Antifungals - Fungal Infection Drugs TERBINAFINE TAB 250MG Tier 1 X

Antifungals - Fungal Infection Drugs TERCONAZOLE CRE 0.4% Tier 1

Antifungals - Fungal Infection Drugs TERCONAZOLE CRE 0.8% Tier 1

Antifungals - Fungal Infection Drugs TERCONAZOLE SUP 80MG Tier 1

Antifungals - Fungal Infection Drugs VFEND SUS 40MG/ML Tier 3

Antifungals - Fungal Infection Drugs VFEND TAB 200MG Tier 3 X

Antifungals - Fungal Infection Drugs VFEND TAB 50MG Tier 3 X

Antifungals - Fungal Infection Drugs VORICONAZOLE SUS 40MG/ML Tier 1

Antifungals - Fungal Infection Drugs VORICONAZOLE TAB 200MG Tier 1 X

Antifungals - Fungal Infection Drugs VORICONAZOLE TAB 50MG Tier 1 X

Antifungals - Fungal Infection Drugs XOLEGEL GEL 2% Tier 3

Antifungals - Fungal Infection Drugs ZAZOLE CRE 0.8% Tier 1

Antifungals - Fungal Infection Drugs ZAZOLE SUP 80MG Tier 1

Page 48 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antigout Agents - Gout Drugs ALLOPURINOL TAB 100MG Tier 1 Antigout Agents - Gout Drugs ALLOPURINOL TAB 300MG Tier 1 Antigout Agents - Gout Drugs COLCHICINE CAP 0.6MG Tier 3 X Antigout Agents - Gout Drugs COLCHICINE TAB 0.6MG Tier 3 X Antigout Agents - Gout Drugs COLCRYS TAB 0.6MG Tier 3 X Antigout Agents - Gout Drugs MITIGARE CAP 0.6MG Tier 2 Antigout Agents - Gout Drugs PROBEN/COLCH TAB 500-0.5 Tier 1 Antigout Agents - Gout Drugs PROBENECID TAB 500MG Tier 1 Antigout Agents - Gout Drugs ULORIC TAB 40MG Tier 3 X X Antigout Agents - Gout Drugs ULORIC TAB 80MG Tier 3 X X Antigout Agents - Gout Drugs ZYLOPRIM TAB 100MG Tier 3 Antigout Agents - Gout Drugs ZYLOPRIM TAB 300MG Tier 3

Antihepatitis Agents - Hepatitis Drugs ADEFOV DIPIV TAB 10MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs BARACLUDE SOL .05MG/ML Tier 2 X

Antihepatitis Agents - Hepatitis Drugs BARACLUDE TAB 0.5MG Tier 3 X

Antihepatitis Agents - Hepatitis Drugs BARACLUDE TAB 1MG Tier 3 X

Antihepatitis Agents - Hepatitis Drugs COPEGUS TAB 200MG Tier 3 X

Antihepatitis Agents - Hepatitis Drugs ENTECAVIR TAB 0.5MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs ENTECAVIR TAB 1MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs HEPSERA TAB 10MG Tier 3 X

Antihepatitis Agents - Hepatitis Drugs INTRON A INJ 10MU Tier 3 X X

Antihepatitis Agents - Hepatitis Drugs INTRON A INJ 18MU Tier 3 X X

Antihepatitis Agents - Hepatitis Drugs INTRON A INJ 18MU Tier 3 X X

Antihepatitis Agents - Hepatitis Drugs INTRON A INJ 25MU Tier 3 X X

Antihepatitis Agents - Hepatitis Drugs INTRON A INJ 50MU Tier 3 X X

Antihepatitis Agents - Hepatitis Drugs MODERIBA PAK 1000/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs MODERIBA PAK 1200/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs MODERIBA PAK 600/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs MODERIBA PAK 800/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs MODERIBA TAB 200MG Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs OLYSIO CAP 150MG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEGASYS INJ Tier 2 X X X

Antihepatitis Agents - Hepatitis Drugs PEGASYS INJ 180MCG/M Tier 2 X X X

Antihepatitis Agents - Hepatitis Drugs PEGASYS INJ PROCLICK Tier 2 X X X

Page 49 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antihepatitis Agents - Hepatitis Drugs PEGASYS INJ PROCLICK Tier 2 X X X

Antihepatitis Agents - Hepatitis Drugs PEGINTRON KIT 120MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEGINTRON KIT 150MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEGINTRON KIT 50MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEGINTRON KIT 80MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 120 RP Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 120MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 150 RP Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 150MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 50MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 50MCG RP Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 80MCG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs PEG-INTRON KIT 80MCG RP Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs REBETOL CAP 200MG Tier 3 X

Antihepatitis Agents - Hepatitis Drugs REBETOL SOL 40MG/ML Tier 2 X

Antihepatitis Agents - Hepatitis Drugs RIBAPAK PAK 1000/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs RIBAPAK PAK 1200/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs RIBAPAK PAK 600/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs RIBAPAK PAK 800/DAY Tier 1 X X

Antihepatitis Agents - Hepatitis Drugs RIBASPHERE CAP 200MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBASPHERE TAB 200MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBASPHERE TAB 400MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBASPHERE TAB 600MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBATAB PAK 1000/DAY Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBATAB TAB 1200/DAY Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBATAB TAB 800/DAY Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBAVIRIN CAP 200MG Tier 1 X

Antihepatitis Agents - Hepatitis Drugs RIBAVIRIN TAB 200MG Tier 1 X

Page 50 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antihepatitis Agents - Hepatitis Drugs SOVALDI TAB 400MG Tier 2 X X X X

Antihepatitis Agents - Hepatitis Drugs TYZEKA TAB 600MG Tier 3 X

Antihepatitis Agents - Hepatitis Drugs VICTRELIS CAP 200MG Tier 3 X X X

Antihepatitis Agents - Hepatitis Drugs VIRAZOLE INH 6GM Tier 2

Antiherpetic Agents - Herpes Drugs ACYCLOVIR CAP 200MG Tier 1

Antiherpetic Agents - Herpes Drugs ACYCLOVIR OIN 5% Tier 1 X X X

Antiherpetic Agents - Herpes Drugs ACYCLOVIR SUS 200/5ML Tier 1

Antiherpetic Agents - Herpes Drugs ACYCLOVIR TAB 400MG Tier 1

Antiherpetic Agents - Herpes Drugs ACYCLOVIR TAB 800MG Tier 1

Antiherpetic Agents - Herpes Drugs DENAVIR CRE 1% Tier 3 X

Antiherpetic Agents - Herpes Drugs FAMCICLOVIR TAB 125MG Tier 1 X

Antiherpetic Agents - Herpes Drugs FAMCICLOVIR TAB 250MG Tier 1 X

Antiherpetic Agents - Herpes Drugs FAMCICLOVIR TAB 500MG Tier 1 X

Antiherpetic Agents - Herpes Drugs FAMVIR TAB 125MG Tier 3 X

Antiherpetic Agents - Herpes Drugs FAMVIR TAB 250MG Tier 3 X

Antiherpetic Agents - Herpes Drugs FAMVIR TAB 500MG Tier 3 X

Antiherpetic Agents - Herpes Drugs LIDOVIR OIN 4-4% Tier 3 X

Antiherpetic Agents - Herpes Drugs SITAVIG TAB 50MG Tier 3 X X

Antiherpetic Agents - Herpes Drugs TRIFLURIDINE SOL 1% OP Tier 1

Antiherpetic Agents - Herpes Drugs VALACYCLOVIR TAB 1GM Tier 1 X

Antiherpetic Agents - Herpes Drugs VALACYCLOVIR TAB 500MG Tier 1 X

Antiherpetic Agents - Herpes Drugs VALTREX TAB 1GM Tier 3 X X

Antiherpetic Agents - Herpes Drugs VALTREX TAB 500MG Tier 3 X X

Antiherpetic Agents - Herpes Drugs VIROPTIC SOL 1% OP Tier 3

Antiherpetic Agents - Herpes Drugs XERESE CRE 5-1% Tier 3 X

Antiherpetic Agents - Herpes Drugs ZOVIRAX CAP 200MG Tier 3

Antiherpetic Agents - Herpes Drugs ZOVIRAX CRE 5% Tier 3 X X

Antiherpetic Agents - Herpes Drugs ZOVIRAX OIN 5% Tier 3 X X X

Page 51 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antiherpetic Agents - Herpes Drugs ZOVIRAX SUS 200/5ML Tier 3

Antiherpetic Agents - Herpes Drugs ZOVIRAX TAB 400MG Tier 3

Antiherpetic Agents - Herpes Drugs ZOVIRAX TAB 800MG Tier 3 Antihistamines - Allergy Drugs ANDEHIST SYP 4-60MG/5 Tier 3 Antihistamines - Allergy Drugs ARBINOXA SOL 4MG/5ML Tier 2 Antihistamines - Allergy Drugs ARBINOXA TAB 4MG Tier 1 Antihistamines - Allergy Drugs ASTEPRO SPR 0.15% Tier 3 X Antihistamines - Allergy Drugs AZELASTINE SPR 0.1% Tier 1 X Antihistamines - Allergy Drugs AZELASTINE SPR 0.15% Tier 1 X Antihistamines - Allergy Drugs BROM/PSE/DM SYP Tier 1 Antihistamines - Allergy Drugs BROMFED DM SYP Tier 1

Antihistamines - Allergy Drugs BROMPHENIRAM CHW 12MG Tier 1 Antihistamines - Allergy Drugs CARBAPHEN 12 LIQ Tier 3 Antihistamines - Allergy Drugs CARBAPHEN 12 SUS PED Tier 3

Antihistamines - Allergy Drugs CARBINOXAMIN SOL 4MG/5ML Tier 1 Antihistamines - Allergy Drugs CARBINOXAMIN TAB 4MG Tier 1 Antihistamines - Allergy Drugs CLARINEX SYP 0.5MG/ML Tier 3 X Antihistamines - Allergy Drugs CLARINEX TAB 5MG Tier 3 X X Antihistamines - Allergy Drugs CLARINEX-D TAB 2.5-120 Tier 3 X X Antihistamines - Allergy Drugs CLEMASTINE SYP 0.5/5ML Tier 1 Antihistamines - Allergy Drugs CLEMASTINE TAB 2.68MG Tier 1 Antihistamines - Allergy Drugs CODAR AR LIQ 2-8/5ML Tier 3 Antihistamines - Allergy Drugs CPB WC LIQ Tier 3

Antihistamines - Allergy Drugs CYPROHEPTAD SYP 2MG/5ML Tier 1 Antihistamines - Allergy Drugs CYPROHEPTAD TAB 4MG Tier 1 Antihistamines - Allergy Drugs DECON-A ELX 2-5MG/5M Tier 3 Antihistamines - Allergy Drugs DECON-G DRO 2-1-40MG Tier 2 Antihistamines - Allergy Drugs DESLORATADIN TAB 2.5 ODT Tier 1 X X Antihistamines - Allergy Drugs DESLORATADIN TAB 5MG Tier 1 X X

Antihistamines - Allergy Drugs DESLORATADIN TAB 5MG ODT Tier 1 X X Antihistamines - Allergy Drugs DICOPANOL SUS 5MG/ML Tier 3 X Antihistamines - Allergy Drugs DICOPANOL SUS RAPIDPAQ Tier 3 X Antihistamines - Allergy Drugs DM/CPM/PE DRO Tier 1 Antihistamines - Allergy Drugs DYMISTA SPR 137-50 Tier 3 X X Antihistamines - Allergy Drugs GNP ALLERGY ELX CHILDREN Tier 1 Antihistamines - Allergy Drugs GNP DIPHEDRY CAP 25MG Tier 1 Antihistamines - Allergy Drugs GNP SUPHEDRI TAB PLUS Tier 1 Antihistamines - Allergy Drugs HYD POL/CPM SUS 10-8/5ML Tier 1 X

Antihistamines - Allergy Drugs HYDR/CPM/PSE LIQ 5-4-60MG Tier 1 X

Antihistamines - Allergy Drugs HYDRO/CHLOR/ LIQ 5-4-60MG Tier 1 X

Antihistamines - Allergy Drugs HYDROXYZ HCL SOL 10MG/5ML Tier 1

Antihistamines - Allergy Drugs HYDROXYZ HCL SYP 10MG/5ML Tier 1 Antihistamines - Allergy Drugs HYDROXYZ HCL TAB 10MG Tier 1 Antihistamines - Allergy Drugs HYDROXYZ HCL TAB 25MG Tier 1 Antihistamines - Allergy Drugs HYDROXYZ HCL TAB 50MG Tier 1 Antihistamines - Allergy Drugs HYDROXYZ PAM CAP 100MG Tier 1

Page 52 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antihistamines - Allergy Drugs HYDROXYZ PAM CAP 25MG Tier 1 Antihistamines - Allergy Drugs HYDROXYZ PAM CAP 50MG Tier 1 Antihistamines - Allergy Drugs KARBINAL ER SUS 4MG/5ML Tier 3 X Antihistamines - Allergy Drugs LEVOCETIRIZI SOL 2.5/5ML Tier 1 Antihistamines - Allergy Drugs LEVOCETIRIZI TAB 5MG Tier 1 X Antihistamines - Allergy Drugs LEXUSS 210 LIQ 2-10/5ML Tier 1 Antihistamines - Allergy Drugs MDL ANTIHIST ELX 12.5/5ML Tier 1 Antihistamines - Allergy Drugs MED 12HR REL TAB 6-120 CR Tier 1 Antihistamines - Allergy Drugs NEOTUSS PLUS LIQ Tier 3 Antihistamines - Allergy Drugs OLOPATADINE SPR 0.6% Tier 1 X Antihistamines - Allergy Drugs PATANASE SPR 0.6% Tier 3 X Antihistamines - Allergy Drugs PHENADOZ SUP 12.5MG Tier 1 Antihistamines - Allergy Drugs PHENADOZ SUP 25MG Tier 1 Antihistamines - Allergy Drugs PHENERGAN SUP 12.5MG Tier 1 Antihistamines - Allergy Drugs PHENERGAN SUP 25MG Tier 1 Antihistamines - Allergy Drugs PHENERGAN SUP 50MG Tier 1 Antihistamines - Allergy Drugs PROMETH VC SYP PLAIN Tier 1 Antihistamines - Allergy Drugs PROMETH VC/ SYP CODEINE Tier 1 Antihistamines - Allergy Drugs PROMETH/COD SYP 6.25-10 Tier 1 Antihistamines - Allergy Drugs PROMETH/PE SYP 6.25-5/5 Tier 3 Antihistamines - Allergy Drugs PROMETH/PE SYP 6.25-5/5 Tier 1 Antihistamines - Allergy Drugs PROMETH/PE/ SYP CODEINE Tier 1

Antihistamines - Allergy Drugs PROMETHAZINE SOL 6.25/5ML Tier 1 Antihistamines - Allergy Drugs PROMETHAZINE SUP 12.5MG Tier 1 Antihistamines - Allergy Drugs PROMETHAZINE SUP 25MG Tier 1 Antihistamines - Allergy Drugs PROMETHAZINE SUP 50MG Tier 1

Antihistamines - Allergy Drugs PROMETHAZINE SYP 6.25/5ML Tier 1 Antihistamines - Allergy Drugs PROMETHAZINE SYP DM Tier 1 Antihistamines - Allergy Drugs PROMETHAZINE TAB 12.5MG Tier 1 Antihistamines - Allergy Drugs PROMETHAZINE TAB 25MG Tier 1 Antihistamines - Allergy Drugs PROMETHAZINE TAB 50MG Tier 1 Antihistamines - Allergy Drugs PROMETHEGAN SUP 12.5MG Tier 1 Antihistamines - Allergy Drugs PROMETHEGAN SUP 25MG Tier 1 Antihistamines - Allergy Drugs PROMETHEGAN SUP 50MG Tier 1 Antihistamines - Allergy Drugs RELHIST CHW Tier 2 Antihistamines - Allergy Drugs RESPA-BR TAB 11MG Tier 3 Antihistamines - Allergy Drugs SEMPREX-D CAP 8-60MG Tier 3 Antihistamines - Allergy Drugs TGQ 15DM/5PE SYP H/2CPM Tier 1

Antihistamines - Allergy Drugs TGQ 30/PSE/3 SYP BRM/15DM Tier 1

Antihistamines - Allergy Drugs TGQ 50PSE/3 SYP BRM/30DM Tier 1 Antihistamines - Allergy Drugs TUSNEL CAP Tier 3 Antihistamines - Allergy Drugs TUSSICAPS CAP 10-8MG Tier 3 Antihistamines - Allergy Drugs TUSSICAPS CAP 5-4MG Tier 3 Antihistamines - Allergy Drugs TUSSIONEX SUS 10-8/5ML Tier 3 X Antihistamines - Allergy Drugs VISTARIL CAP 25MG Tier 3 Antihistamines - Allergy Drugs VISTARIL CAP 50MG Tier 3 Antihistamines - Allergy Drugs VITUZ SOL 5-4MG Tier 3 X X Antihistamines - Allergy Drugs XYZAL SOL Tier 3 Antihistamines - Allergy Drugs XYZAL SOL 2.5/5ML Tier 3 Antihistamines - Allergy Drugs XYZAL TAB 5MG Tier 3 X Antihistamines - Allergy Drugs ZUTRIPRO LIQ 60-4-5MG Tier 3 X X

Page 53 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs ATRIPLA TAB Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs COMPLERA TAB Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs EDURANT TAB 25MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs INTELENCE TAB 100MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs INTELENCE TAB 200MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs INTELENCE TAB 25MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs NEVIRAPINE SUS 50MG/5ML Tier 1 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs NEVIRAPINE TAB 100MG Tier 1 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs NEVIRAPINE TAB 200MG Tier 1 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs NEVIRAPINE TAB 400MG ER Tier 1 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs RESCRIPTOR TAB 100 MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs RESCRIPTOR TAB 200MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs STRIBILD TAB Tier 3 X X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs SUSTIVA CAP 200MG Tier 2 X

Page 54 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs SUSTIVA CAP 50MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs SUSTIVA TAB 600MG Tier 2 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs VIRAMUNE SUS 50MG/5ML Tier 3 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs VIRAMUNE TAB 200MG Tier 3 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs VIRAMUNE XR TAB 100MG Tier 3 X

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors - HIV Drugs VIRAMUNE XR TAB 400MG Tier 3 X X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ABACAV/LAMIV TAB /ZIDOVUD Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ABACAVIR TAB 300MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs COMBIVIR TAB 150-300 Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs DIDANOSINE CAP 125MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs DIDANOSINE CAP 200MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs DIDANOSINE CAP 250MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs DIDANOSINE CAP 400MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs EMTRIVA CAP 200MG Tier 2 X

Page 55 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs EMTRIVA SOL 10MG/ML Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs EPIVIR SOL 10MG/ML Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs EPIVIR TAB 150MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs EPIVIR TAB 300MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs EPZICOM TAB 600-300 Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs LAMIVUD/ZIDO TAB 150-300 Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs LAMIVUDINE SOL 10MG/ML Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs LAMIVUDINE TAB 150MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs LAMIVUDINE TAB 300MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs RETROVIR CAP 100MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs RETROVIR SYP 50MG/5ML Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs STAVUDINE CAP 15MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs STAVUDINE CAP 20MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs STAVUDINE CAP 30MG Tier 1 X

Page 56 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs STAVUDINE CAP 40MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs STAVUDINE SOL 1MG/ML Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs TRIZIVIR TAB Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs TRUVADA TAB 100-150 Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs TRUVADA TAB 133-200 Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs TRUVADA TAB 167-250 Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs TRUVADA TAB 200-300 Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIDEX SOL 2GM Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIDEX SOL 4GM Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIDEX EC CAP 125MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIDEX EC CAP 200MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIDEX EC CAP 250MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIDEX EC CAP 400MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIREAD POW 40MG/GM Tier 3 X

Page 57 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIREAD TAB 150MG Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIREAD TAB 200MG Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIREAD TAB 250MG Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs VIREAD TAB 300MG Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZERIT CAP 15MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZERIT CAP 20MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZERIT CAP 30MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZERIT CAP 40MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZERIT SOL 1MG/ML Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZIAGEN SOL 20MG/ML Tier 2 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZIAGEN TAB 300MG Tier 3 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZIDOVUDINE CAP 100MG Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZIDOVUDINE SYP 50MG/5ML Tier 1 X

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors - HIV Drugs ZIDOVUDINE TAB 300MG Tier 1 X

Page 58 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-HIV Agents, Other - HIV Drugs FUZEON INJ 90MG Tier 2 X

Anti-HIV Agents, Other - HIV Drugs ISENTRESS CHW 100MG Tier 2 X

Anti-HIV Agents, Other - HIV Drugs ISENTRESS CHW 25MG Tier 2 X

Anti-HIV Agents, Other - HIV Drugs ISENTRESS POW 100MG Tier 2 X

Anti-HIV Agents, Other - HIV Drugs ISENTRESS TAB 400MG Tier 2 X

Anti-HIV Agents, Other - HIV Drugs SELZENTRY TAB 150MG Tier 2 X X

Anti-HIV Agents, Other - HIV Drugs SELZENTRY TAB 300MG Tier 2 X X

Anti-HIV Agents, Other - HIV Drugs TIVICAY TAB 10MG Tier 3 X

Anti-HIV Agents, Other - HIV Drugs TIVICAY TAB 25MG Tier 3 X

Anti-HIV Agents, Other - HIV Drugs TIVICAY TAB 50MG Tier 3 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs APTIVUS CAP 250MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs APTIVUS SOL Tier 3 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs CRIXIVAN CAP 200MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs CRIXIVAN CAP 400MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs INVIRASE CAP 200MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs INVIRASE TAB 500MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs KALETRA SOL Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs KALETRA TAB 100-25MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs KALETRA TAB 200-50MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs LEXIVA SUS 50MG/ML Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs LEXIVA TAB 700MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs NORVIR CAP 100MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs NORVIR SOL 80MG/ML Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs NORVIR TAB 100MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs PREZISTA SUS 100MG/ML Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs PREZISTA TAB 150MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs PREZISTA TAB 600MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs PREZISTA TAB 75MG Tier 2 X

Page 59 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Anti-HIV Agents, Protease Inhibitors - HIV Drugs PREZISTA TAB 800MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs REYATAZ CAP 150MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs REYATAZ CAP 200MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs REYATAZ CAP 300MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs REYATAZ POW 50MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs VIRACEPT TAB 250MG Tier 2 X Anti-HIV Agents, Protease Inhibitors - HIV Drugs VIRACEPT TAB 625MG Tier 2 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ADVAIR DISKU AER 100/50 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ADVAIR DISKU AER 250/50 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ADVAIR DISKU AER 500/50 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ADVAIR HFA AER 115/21 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ADVAIR HFA AER 230/21 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ADVAIR HFA AER 45/21 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs AEROSPAN AER 80MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ALVESCO AER 160MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ALVESCO AER 80MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX 120 AER 220MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX 14 AER 220MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX 30 AER 110MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX 30 AER 220MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX 60 AER 220MCG Tier 1 X

Page 60 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX 7 AER 110MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX HFA AER 100 MCG Tier 1

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ASMANEX HFA AER 200 MCG Tier 1

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs BECONASE AQ SUS 0.042% Tier 3 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs BREO ELLIPTA INH 100-25 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs BREO ELLIPTA INH 200-25 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs BUDESONIDE SUS 0.25MG/2 Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs BUDESONIDE SUS 0.5MG/2 Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs BUDESONIDE SUS 1MG/2ML Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs BUDESONIDE SUS 32MCG Tier 1 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs DULERA AER 100-5MCG Tier 3 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs DULERA AER 200-5MCG Tier 3 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLOVENT DISK AER 100MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLOVENT DISK AER 250MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLOVENT DISK AER 50MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLOVENT HFA AER 110MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLOVENT HFA AER 220MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLOVENT HFA AER 44MCG Tier 3 X

Page 61 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLUNISOLIDE SPR 0.025% Tier 1

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs FLUTICASONE SPR 50MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs MOMETASONE SPR 50MCG Tier 1 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs NASONEX SPR 50MCG/AC Tier 3 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs OMNARIS SPR Tier 3 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs PULMICORT INH 180MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs PULMICORT INH 90MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs PULMICORT SUS 0.25MG/2 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs PULMICORT SUS 0.5MG/2 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs PULMICORT SUS 1MG/2ML Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs QNASL AER 80MCG Tier 3 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs QNASL CHILD SPR 40MCG Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs QVAR AER 40MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs QVAR AER 80MCG Tier 1 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs RHINOCORT SUS AQUA Tier 3 X X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs SYMBICORT AER 160-4.5 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs SYMBICORT AER 80-4.5 Tier 3 X

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs VERAMYST SPR 27.5MCG Tier 3 X X

Page 62 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs ZETONNA AER 37MCG Tier 3 X

Anti-Influenza Agents - Flu Drugs AMANTADINE CAP 100MG Tier 1

Anti-Influenza Agents - Flu Drugs AMANTADINE SYP 50MG/5ML Tier 1

Anti-Influenza Agents - Flu Drugs AMANTADINE TAB 100MG Tier 1

Anti-Influenza Agents - Flu Drugs FLUMADINE TAB 100MG Tier 3

Anti-Influenza Agents - Flu Drugs RELENZA MIS DISKHALE Tier 3 X

Anti-Influenza Agents - Flu Drugs RIMANTADINE TAB 100MG Tier 1

Anti-Influenza Agents - Flu Drugs TAMIFLU CAP 30MG Tier 3 X

Anti-Influenza Agents - Flu Drugs TAMIFLU CAP 45MG Tier 3 X

Anti-Influenza Agents - Flu Drugs TAMIFLU CAP 75MG Tier 3 X

Anti-Influenza Agents - Flu Drugs TAMIFLU SUS 6MG/ML Tier 3 X

Antileukotrienes - Asthma/Lung Drugs ACCOLATE TAB 10MG Tier 3 X

Antileukotrienes - Asthma/Lung Drugs ACCOLATE TAB 20MG Tier 3 X

Antileukotrienes - Asthma/Lung Drugs MONTELUKAST CHW 4MG Tier 1

Antileukotrienes - Asthma/Lung Drugs MONTELUKAST CHW 5MG Tier 1

Antileukotrienes - Asthma/Lung Drugs MONTELUKAST GRA 4MG Tier 1

Antileukotrienes - Asthma/Lung Drugs MONTELUKAST TAB 10MG Tier 1

Antileukotrienes - Asthma/Lung Drugs SINGULAIR CHW 4MG Tier 3 X

Antileukotrienes - Asthma/Lung Drugs SINGULAIR CHW 5MG Tier 3 X

Antileukotrienes - Asthma/Lung Drugs SINGULAIR GRA 4MG Tier 3

Antileukotrienes - Asthma/Lung Drugs SINGULAIR TAB 10MG Tier 3 X

Antileukotrienes - Asthma/Lung Drugs ZAFIRLUKAST TAB 10MG Tier 1 X

Antileukotrienes - Asthma/Lung Drugs ZAFIRLUKAST TAB 20MG Tier 1 X

Antileukotrienes - Asthma/Lung Drugs ZYFLO TAB 600MG Tier 3 X

Antileukotrienes - Asthma/Lung Drugs ZYFLO CR TAB 600MG Tier 3 X X Antimetabolites - Chemotherapy Agents CAPECITABINE TAB 150MG Tier 3 X X X Antimetabolites - Chemotherapy Agents CAPECITABINE TAB 500MG Tier 3 X X X

Page 63 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antimetabolites - Chemotherapy Agents DROXIA CAP 200MG Tier 2 X Antimetabolites - Chemotherapy Agents DROXIA CAP 300MG Tier 2 X Antimetabolites - Chemotherapy Agents DROXIA CAP 400MG Tier 2 X Antimetabolites - Chemotherapy Agents HYDREA CAP 500MG Tier 3 X Antimetabolites - Chemotherapy Agents HYDROXYUREA CAP 500MG Tier 1 X Antimetabolites - Chemotherapy Agents MERCAPTOPUR TAB 50MG Tier 1 X Antimetabolites - Chemotherapy Agents PURINETHOL TAB 50MG Tier 3 X Antimetabolites - Chemotherapy Agents PURIXAN SUS 20MG/ML Tier 3 X X Antimetabolites - Chemotherapy Agents TABLOID TAB 40MG Tier 2 X Antimetabolites - Chemotherapy Agents XELODA TAB 150MG Tier 1 X X Antimetabolites - Chemotherapy Agents XELODA TAB 500MG Tier 1 X X Antimycobacterials, Other - Miscellaneous Anti-Infectives DAPSONE TAB 100MG Tier 1 Antimycobacterials, Other - Miscellaneous Anti-Infectives DAPSONE TAB 25MG Tier 1 Antimycobacterials, Other - Miscellaneous Anti-Infectives MYCOBUTIN CAP 150MG Tier 3 Antimycobacterials, Other - Miscellaneous Anti-Infectives RIFABUTIN CAP 150MG Tier 1 Antineoplastics - Chemotherapy Agents TAFINLAR CAP 50MG Tier 2 X X X Antineoplastics - Chemotherapy Agents TAFINLAR CAP 75MG Tier 2 X X X Antineoplastics - Chemotherapy Agents ZYKADIA CAP 150MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents CABOMETYX TAB 20MG Tier 3 X X Antineoplastics, Other - Chemotherapy Agents CABOMETYX TAB 40MG Tier 3 X X Antineoplastics, Other - Chemotherapy Agents CABOMETYX TAB 60MG Tier 3 X X Antineoplastics, Other - Chemotherapy Agents COMETRIQ KIT 100MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents COMETRIQ KIT 140MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents COMETRIQ KIT 60MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents ERIVEDGE CAP 150MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents GILOTRIF TAB 20MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents GILOTRIF TAB 30MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents GILOTRIF TAB 40MG Tier 3 X X X

Page 64 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antineoplastics, Other - Chemotherapy Agents ICLUSIG TAB 15MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents ICLUSIG TAB 45MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents JAKAFI TAB 10MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents JAKAFI TAB 15MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents JAKAFI TAB 20MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents JAKAFI TAB 25MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents JAKAFI TAB 5MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents LEUCOVOR CA TAB 10MG Tier 1 Antineoplastics, Other - Chemotherapy Agents LEUCOVOR CA TAB 15MG Tier 1 Antineoplastics, Other - Chemotherapy Agents LEUCOVOR CA TAB 25MG Tier 1 Antineoplastics, Other - Chemotherapy Agents LEUCOVOR CA TAB 5MG Tier 1 Antineoplastics, Other - Chemotherapy Agents MEKINIST TAB 0.5MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents MEKINIST TAB 2MG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents MENEST TAB 0.3MG Tier 3 Antineoplastics, Other - Chemotherapy Agents MENEST TAB 0.625MG Tier 3 Antineoplastics, Other - Chemotherapy Agents MENEST TAB 1.25MG Tier 3 Antineoplastics, Other - Chemotherapy Agents MENEST TAB 2.5MG Tier 3 Antineoplastics, Other - Chemotherapy Agents MESNEX TAB 400MG Tier 3 X Antineoplastics, Other - Chemotherapy Agents PICATO GEL 0.015% Tier 3 X Antineoplastics, Other - Chemotherapy Agents PICATO GEL 0.05% Tier 3 X Antineoplastics, Other - Chemotherapy Agents POMALYST CAP 1MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents POMALYST CAP 2MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents POMALYST CAP 3MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents POMALYST CAP 4MG Tier 3 X X X Antineoplastics, Other - Chemotherapy Agents SYLATRON KIT 200MCG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents SYLATRON KIT 300MCG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents SYLATRON KIT 300MCG Tier 2 X X X Antineoplastics, Other - Chemotherapy Agents SYLATRON KIT 600MCG Tier 2 X X X

Page 65 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antineoplastics, Other - Chemotherapy Agents ZOLINZA CAP 100MG Tier 2 X X Antineoplastics, Other - Chemotherapy Agents ZYTIGA TAB 250MG Tier 2 X X X Antiparkinson Agents, Other - Parkinson's Disease Drugs COMTAN TAB 200MG Tier 3 Antiparkinson Agents, Other - Parkinson's Disease Drugs ENTACAPONE TAB 200MG Tier 1 Antiparkinson Agents, Other - Parkinson's Disease Drugs NEUPRO DIS 1MG/24HR Tier 3 Antiparkinson Agents, Other - Parkinson's Disease Drugs NEUPRO DIS 2MG/24HR Tier 3 Antiparkinson Agents, Other - Parkinson's Disease Drugs NEUPRO DIS 3MG/24HR Tier 3 Antiparkinson Agents, Other - Parkinson's Disease Drugs NEUPRO DIS 4MG/24HR Tier 3 Antiparkinson Agents, Other - Parkinson's Disease Drugs NEUPRO DIS 6MG/24HR Tier 3 Antiparkinson Agents, Other - Parkinson's Disease Drugs NEUPRO DIS 8MG/24HR Tier 3 Antiparkinson Agents, Other - Parkinson's Disease Drugs TASMAR TAB 100MG Tier 3 X Antiparkinson Agents, Other - Parkinson's Disease Drugs TOLCAPONE TAB 100MG Tier 1 Antiprotozoals - Protozoal Infection Drugs ALINIA SUS 100/5ML Tier 2 X Antiprotozoals - Protozoal Infection Drugs ALINIA TAB 500MG Tier 2 X Antiprotozoals - Protozoal Infection Drugs ARALEN TAB 500MG Tier 3 Antiprotozoals - Protozoal Infection Drugs ATOVAQ/PROGU TAB 250-100 Tier 1 Antiprotozoals - Protozoal Infection Drugs ATOVAQ/PROGU TAB 62.5-25 Tier 1 Antiprotozoals - Protozoal Infection Drugs ATOVAQUONE SUS 750/5ML Tier 1 Antiprotozoals - Protozoal Infection Drugs CHLOROQUINE TAB 250MG Tier 1 Antiprotozoals - Protozoal Infection Drugs CHLOROQUINE TAB 500MG Tier 1 Antiprotozoals - Protozoal Infection Drugs COARTEM TAB 20-120MG Tier 2 Antiprotozoals - Protozoal Infection Drugs DARAPRIM TAB 25MG Tier 2 X X Antiprotozoals - Protozoal Infection Drugs HYDROXYCHLOR TAB 200MG Tier 1 Antiprotozoals - Protozoal Infection Drugs MALARONE TAB 250-100 Tier 3 Antiprotozoals - Protozoal Infection Drugs MALARONE TAB 62.5-25 Tier 3 Antiprotozoals - Protozoal Infection Drugs MEFLOQUINE TAB 250MG Tier 1 Antiprotozoals - Protozoal Infection Drugs MEPRON SUS Tier 3 X Antiprotozoals - Protozoal Infection Drugs NEBUPENT INH 300MG Tier 2

Page 66 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antiprotozoals - Protozoal Infection Drugs PLAQUENIL TAB 200MG Tier 3 Antiprotozoals - Protozoal Infection Drugs PRIMAQUINE TAB 26.3MG Tier 1 Antiprotozoals - Protozoal Infection Drugs QUALAQUIN CAP 324MG Tier 3 X Antiprotozoals - Protozoal Infection Drugs QUININE SULF CAP 324MG Tier 1 X Antiprotozoals - Protozoal Infection Drugs TINDAMAX TAB 250MG Tier 3 Antiprotozoals - Protozoal Infection Drugs TINDAMAX TAB 500MG Tier 3 Antiprotozoals - Protozoal Infection Drugs TINIDAZOLE TAB 250MG Tier 1 Antiprotozoals - Protozoal Infection Drugs TINIDAZOLE TAB 500MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs ANASPAZ TAB 0.125MG Tier 2

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs ATROPINE POW SULFATE Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs BELLA/OPIUM SUP 16.2-30 Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs BELLA/OPIUM SUP 16.2-60 Tier 2

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs BENTYL CAP 10MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs BENTYL TAB 20MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs CANTIL TAB 25MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs CHLORD/CLIDI CAP 5-2.5MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs CUVPOSA SOL 1MG/5ML Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs DICYCLOMINE CAP 10MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs DICYCLOMINE SOL 10MG/5ML Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs DICYCLOMINE TAB 20MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs ED-SPAZ TAB 0.125MG Tier 1

Page 67 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs GASTRINEX NF CAP Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs GLYCOPYRROL TAB 1MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs GLYCOPYRROL TAB 2MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSCYAMINE DRO 0.125/ML Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSCYAMINE ELX 0.125/5 Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSCYAMINE SUB 0.125MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSCYAMINE TAB 0.125MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSCYAMINE TAB 0.125MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSCYAMINE TAB 0.375 ER Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSCYAMINE TAB 0.375 SR Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSYNE DRO 0.125/ML Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs HYOSYNE ELX 0.125/5 Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs LEVBID TAB 0.375 ER Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs LEVSIN TAB 0.125MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs LEVSIN/SL SUB 0.125MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs LIBRAX CAP 5-2.5MG Tier 3 X

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs METHSCOPOLAM TAB 2.5MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs METHSCOPOLAM TAB 5MG Tier 1

Page 68 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs NULEV TAB 0.125MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs OSCIMIN SUB 0.125MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs OSCIMIN TAB 0.125MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs OSCIMIN TAB 0.125MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs OSCIMIN SR TAB 0.375MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs PAMINE TAB 2.5MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs PAMINE FQ KIT Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs PROPANTHELIN TAB 15MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs ROBINUL TAB 1MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs ROBINUL FORT TAB 2MG Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs SYMAX DUOTAB TAB Tier 3

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs SYMAX-SL SUB 0.125MG Tier 1

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs SYMAX-SR TAB 0.375MG Tier 1 Antispasmodics, Urinary - Bladder Control Drugs DARIFENACIN TAB 7.5MG ER Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs DARIFENACIN TAB HBR ER Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs DARIFENACIN TAB HBR ER Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs DETROL TAB 1MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs DETROL TAB 2MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs DETROL LA CAP 2MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs DETROL LA CAP 4MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs DITROPAN XL TAB 10MG Tier 3

Page 69 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antispasmodics, Urinary - Bladder Control Drugs DITROPAN XL TAB 15MG Tier 3 Antispasmodics, Urinary - Bladder Control Drugs DITROPAN XL TAB 5MG Tier 3 Antispasmodics, Urinary - Bladder Control Drugs ENABLEX TAB 15MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs ENABLEX TAB 7.5MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs FLAVOXATE TAB 100MG Tier 1 Antispasmodics, Urinary - Bladder Control Drugs GELNIQUE GEL 10% Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs GELNIQUE GEL 3% Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs MYRBETRIQ TAB 25MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs MYRBETRIQ TAB 50MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs OXYBUTYNIN SYP 5MG/5ML Tier 1 Antispasmodics, Urinary - Bladder Control Drugs OXYBUTYNIN TAB 10MG ER Tier 1 Antispasmodics, Urinary - Bladder Control Drugs OXYBUTYNIN TAB 15MG ER Tier 1 Antispasmodics, Urinary - Bladder Control Drugs OXYBUTYNIN TAB 5MG Tier 1 Antispasmodics, Urinary - Bladder Control Drugs OXYBUTYNIN TAB 5MG ER Tier 1 Antispasmodics, Urinary - Bladder Control Drugs OXYTROL DIS 3.9MG/24 Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs OXYTROL DIS 3.9MG/24 Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs TOLTERODINE CAP 2MG ER Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs TOLTERODINE CAP 4MG ER Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs TOLTERODINE TAB 1MG Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs TOLTERODINE TAB 2MG Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs TOVIAZ TAB 4MG Tier 3 Antispasmodics, Urinary - Bladder Control Drugs TOVIAZ TAB 8MG Tier 3 Antispasmodics, Urinary - Bladder Control Drugs TROSPIUM CHL CAP 60MG ER Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs TROSPIUM CL TAB 20MG Tier 1 X Antispasmodics, Urinary - Bladder Control Drugs VESICARE TAB 10MG Tier 3 X Antispasmodics, Urinary - Bladder Control Drugs VESICARE TAB 5MG Tier 3 X Antispasticity Agents GINSENG ROOT POW Tier 3 X Antispasticity Agents - Muscle Spasm Drugs BACLOFEN POW Tier 3 X

Page 70 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Antispasticity Agents - Muscle Spasm Drugs BACLOFEN TAB 10MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs BACLOFEN TAB 20MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs DANTRIUM CAP 25MG Tier 3 Antispasticity Agents - Muscle Spasm Drugs DANTRIUM CAP 50MG Tier 3 Antispasticity Agents - Muscle Spasm Drugs DANTROLENE CAP 100MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs DANTROLENE CAP 25MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs DANTROLENE CAP 50MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs TIZANIDINE CAP 2MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs TIZANIDINE CAP 4MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs TIZANIDINE CAP 6MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs TIZANIDINE TAB 2MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs TIZANIDINE TAB 4MG Tier 1 Antispasticity Agents - Muscle Spasm Drugs ZANAFLEX CAP 2MG Tier 3 Antispasticity Agents - Muscle Spasm Drugs ZANAFLEX CAP 4MG Tier 3 Antispasticity Agents - Muscle Spasm Drugs ZANAFLEX CAP 6MG Tier 3 Antispasticity Agents - Muscle Spasm Drugs ZANAFLEX TAB 4MG Tier 3 Antithyroid Agents - Thyroid Suppressing Drugs METHIMAZOLE TAB 10MG Tier 1 Antithyroid Agents - Thyroid Suppressing Drugs METHIMAZOLE TAB 5MG Tier 1 Antithyroid Agents - Thyroid Suppressing Drugs PROPYLTHIOUR TAB 50MG Tier 1 Antithyroid Agents - Thyroid Suppressing Drugs TAPAZOLE TAB 10MG Tier 3 Antithyroid Agents - Thyroid Suppressing Drugs TAPAZOLE TAB 5MG Tier 3

Antituberculars - Tuberculosis Drugs CYCLOSERINE CAP 250MG Tier 1

Antituberculars - Tuberculosis Drugs ETHAMBUTOL TAB 100MG Tier 1

Antituberculars - Tuberculosis Drugs ETHAMBUTOL TAB 400MG Tier 1

Antituberculars - Tuberculosis Drugs ISONIAZID SYP 50MG/5ML Tier 1

Antituberculars - Tuberculosis Drugs ISONIAZID TAB 100MG Tier 1

Antituberculars - Tuberculosis Drugs ISONIAZID TAB 300MG Tier 1

Antituberculars - Tuberculosis Drugs MYAMBUTOL TAB 100MG Tier 3

Page 71 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Antituberculars - Tuberculosis Drugs MYAMBUTOL TAB 400MG Tier 3

Antituberculars - Tuberculosis Drugs PASER GRA 4GM Tier 3

Antituberculars - Tuberculosis Drugs PRIFTIN TAB 150MG Tier 2

Antituberculars - Tuberculosis Drugs PYRAZINAMIDE TAB 500MG Tier 1

Antituberculars - Tuberculosis Drugs RIFADIN CAP 150MG Tier 3

Antituberculars - Tuberculosis Drugs RIFADIN CAP 300MG Tier 3

Antituberculars - Tuberculosis Drugs RIFAMATE CAP Tier 3

Antituberculars - Tuberculosis Drugs RIFAMPIN CAP 150MG Tier 1

Antituberculars - Tuberculosis Drugs RIFAMPIN CAP 300MG Tier 1

Antituberculars - Tuberculosis Drugs RIFATER TAB Tier 2

Antituberculars - Tuberculosis Drugs SIRTURO TAB 100MG Tier 2 X

Antituberculars - Tuberculosis Drugs TRECATOR TAB 250MG Tier 2

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM CON 1 MG/ML Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 0.25 ODT Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 0.25MG Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 0.5MG Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 0.5MG ER Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 0.5MG OD Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 0.5MG XR Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 1MG Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 1MG ER Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 1MG ODT Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 1MG XR Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 2MG Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 2MG ER Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 2MG ODT Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 2MG XR Tier 1

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 3MG ER Tier 1

Page 72 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anxiolytics, Other - Anxiety Drugs ALPRAZOLAM TAB 3MG XR Tier 1

Anxiolytics, Other - Anxiety Drugs ATIVAN TAB 0.5MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs ATIVAN TAB 1MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs ATIVAN TAB 2MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs BUSPIRONE TAB 10MG Tier 1

Anxiolytics, Other - Anxiety Drugs BUSPIRONE TAB 15MG Tier 1

Anxiolytics, Other - Anxiety Drugs BUSPIRONE TAB 30MG Tier 1

Anxiolytics, Other - Anxiety Drugs BUSPIRONE TAB 5MG Tier 1

Anxiolytics, Other - Anxiety Drugs BUSPIRONE TAB 7.5MG Tier 1

Anxiolytics, Other - Anxiety Drugs CDP/AMITRIP TAB 10-25MG Tier 1

Anxiolytics, Other - Anxiety Drugs CDP/AMITRIP TAB 5-12.5MG Tier 1

Anxiolytics, Other - Anxiety Drugs CHLORDIAZEP CAP 10MG Tier 1

Anxiolytics, Other - Anxiety Drugs CHLORDIAZEP CAP 25MG Tier 1

Anxiolytics, Other - Anxiety Drugs CHLORDIAZEP CAP 5MG Tier 1

Anxiolytics, Other - Anxiety Drugs DIAZEPAM CON 5MG/ML Tier 1

Anxiolytics, Other - Anxiety Drugs DIAZEPAM SOL 1MG/ML Tier 1

Anxiolytics, Other - Anxiety Drugs DIAZEPAM TAB 10MG Tier 1

Anxiolytics, Other - Anxiety Drugs DIAZEPAM TAB 2MG Tier 1

Anxiolytics, Other - Anxiety Drugs DIAZEPAM TAB 5MG Tier 1

Anxiolytics, Other - Anxiety Drugs ESTAZOLAM TAB 1MG Tier 1

Anxiolytics, Other - Anxiety Drugs ESTAZOLAM TAB 2MG Tier 1

Anxiolytics, Other - Anxiety Drugs LORAZEPAM CON 2MG/ML Tier 1

Anxiolytics, Other - Anxiety Drugs LORAZEPAM TAB 0.5MG Tier 1

Anxiolytics, Other - Anxiety Drugs LORAZEPAM TAB 1MG Tier 1

Anxiolytics, Other - Anxiety Drugs LORAZEPAM TAB 2MG Tier 1

Anxiolytics, Other - Anxiety Drugs MEPROBAMATE TAB 200MG Tier 1

Anxiolytics, Other - Anxiety Drugs MEPROBAMATE TAB 400MG Tier 1

Anxiolytics, Other - Anxiety Drugs OXAZEPAM CAP 10MG Tier 1

Page 73 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Anxiolytics, Other - Anxiety Drugs OXAZEPAM CAP 15MG Tier 1

Anxiolytics, Other - Anxiety Drugs OXAZEPAM CAP 30MG Tier 1

Anxiolytics, Other - Anxiety Drugs VALIUM TAB 10MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs VALIUM TAB 2MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs VALIUM TAB 5MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX TAB 0.25MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX TAB 0.5MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX TAB 1MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX TAB 2MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX XR TAB 0.5MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX XR TAB 1MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX XR TAB 2MG Tier 3 X

Anxiolytics, Other - Anxiety Drugs XANAX XR TAB 3MG Tier 3 X Anxiolytics, Sedatives and Hypnotics - Benzodiazepines DORAL TAB 15MG Tier 3 Anxiolytics, Sedatives and Hypnotics - Benzodiazepines MIDAZOLAM SYP 2MG/ML Tier 1 Anxiolytics, Sedatives and Hypnotics - Benzodiazepines QUAZEPAM TAB 15MG Tier 1

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents ANASTROZOLE TAB 1MG Tier 1

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents ARIMIDEX TAB 1MG Tier 3 X

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents AROMASIN TAB 25MG Tier 3

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents EXEMESTANE TAB 25MG Tier 1

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents FEMARA TAB 2.5MG Tier 3 X

Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents LETROZOLE TAB 2.5MG Tier 1 Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs CLONIDINE TAB 0.1MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs GUANFACINE TAB 1MG ER Tier 1 X

Page 74 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs GUANFACINE TAB 2MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs GUANFACINE TAB 3MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs GUANFACINE TAB 4MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs INTUNIV TAB 1MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs INTUNIV TAB 2MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs INTUNIV TAB 3MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs INTUNIV TAB 4MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs KAPVAY TAB 0.1 MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs STRATTERA CAP 100MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs STRATTERA CAP 10MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs STRATTERA CAP 18MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs STRATTERA CAP 25MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs STRATTERA CAP 40MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs STRATTERA CAP 60MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Non-Stimulants - ADHD Drugs STRATTERA CAP 80MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL TAB 10MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL TAB 12.5MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL TAB 15MG Tier 3 X X

Page 75 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL TAB 20MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL TAB 30MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL TAB 5MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL TAB 7.5MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL XR CAP 10MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL XR CAP 15MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL XR CAP 20MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL XR CAP 25MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL XR CAP 30MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ADDERALL XR CAP 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR CAP 10MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR CAP 15MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR CAP 20MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR CAP 25MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR CAP 30MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR CAP 5MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR TAB 10MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR TAB 12.5MG Tier 1 X

Page 76 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR TAB 15MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR TAB 20MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR TAB 30MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR TAB 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHET/DEXTR TAB 7.5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHETAMINE CAP 10MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHETAMINE CAP 15MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHETAMINE CAP 20MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHETAMINE CAP 25MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHETAMINE CAP 30MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs AMPHETAMINE CAP 5MG ER Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs APTENSIO XR CAP 10MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs APTENSIO XR CAP 15MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs APTENSIO XR CAP 20MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs APTENSIO XR CAP 30MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs APTENSIO XR CAP 40MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs APTENSIO XR CAP 50MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs APTENSIO XR CAP 60MG Tier 3 X X X

Page 77 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs CONCERTA TAB 18MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs CONCERTA TAB 27MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs CONCERTA TAB 36MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs CONCERTA TAB 54MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DAYTRANA DIS 10MG/9HR Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DAYTRANA DIS 15MG/9HR Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DAYTRANA DIS 20MG/9HR Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DAYTRANA DIS 30MG/9HR Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DESOXYN TAB 5MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXEDRINE CAP 10MG CR Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXEDRINE CAP 15MG CR Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXEDRINE CAP 5MG CR Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXEDRINE TAB 10MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXEDRINE TAB 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPH CAP 15MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPH CAP 30MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPH CAP 40MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPH TAB 10MG Tier 1 X

Page 78 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPH TAB 2.5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPH TAB 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPHE CAP 10MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPHE CAP 20MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXMETHYLPHE CAP 5MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXTROAMPHET CAP 10MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXTROAMPHET CAP 15MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXTROAMPHET CAP 5MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXTROAMPHET SOL 5MG/5ML Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXTROAMPHET TAB 10MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs DEXTROAMPHET TAB 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN TAB 10MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN TAB 2.5MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN TAB 5MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 10MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 15MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 20MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 25MG Tier 3 X X X

Page 79 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 30MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 35MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 40MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs FOCALIN XR CAP 5MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METADATE TAB 20MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METADATE CD CAP 10MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METADATE CD CAP 20MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METADATE CD CAP 30MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METADATE CD CAP 40MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METADATE CD CAP 50MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METADATE CD CAP 60MG Tier 1 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHAMPHETAM TAB 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHLPHENIDA CHW 2.5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLIN CHW 10MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLIN CHW 2.5MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLIN CHW 5MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLIN SOL 10MG/5ML Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLIN SOL 5MG/5ML Tier 3 X

Page 80 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 10MG Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 20MG Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 20MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 30MG Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 30MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 40MG Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 40MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 50MG Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CAP 60MG Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CHW 10MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID CHW 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID SOL 10MG/5ML Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID SOL 5MG/5ML Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 10MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 10MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 18MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 18MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 20MG Tier 1 X

Page 81 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 20MG ER Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 20MG SR Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 27MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 27MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 36MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 36MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 54MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 54MG ER Tier 1 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs METHYLPHENID TAB 5MG Tier 1 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs PROCENTRA SOL 5MG/5ML Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs QUILLICHEW CHW 20MG ER Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs QUILLICHEW CHW 30MG ER Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs QUILLICHEW CHW 40MG ER Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs QUILLIVANT SUS 25MG/5ML Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN TAB 10MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN TAB 20MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN TAB 5MG Tier 3 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN LA CAP 10MG Tier 3 X X X

Page 82 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN LA CAP 20MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN LA CAP 30MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN LA CAP 40MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs RITALIN LA CAP 60MG Tier 3 X X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs VYVANSE CAP 10MG Tier 2 X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs VYVANSE CAP 20MG Tier 2 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs VYVANSE CAP 30MG Tier 2 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs VYVANSE CAP 40MG Tier 2 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs VYVANSE CAP 50MG Tier 2 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs VYVANSE CAP 60MG Tier 2 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs VYVANSE CAP 70MG Tier 2 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ZENZEDI TAB 10MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ZENZEDI TAB 15MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ZENZEDI TAB 2.5MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ZENZEDI TAB 20MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ZENZEDI TAB 30MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ZENZEDI TAB 5MG Tier 3 X X Attention Deficit Hyperactivity Disorder Agents, Stimulants - ADHD Drugs ZENZEDI TAB 7.5MG Tier 3 X X

Page 83 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

AUTONOMIC DRUGS - CENTRALLY ACTING SKELETAL MUSCLE RELAXNT TIZANIDINE KIT COMFORT Tier 3 X

Benign Prostatic Hypertrophy Agents CIALIS TAB 2.5MG Tier 3 X X X

Benign Prostatic Hypertrophy Agents CIALIS TAB 5MG Tier 3 X X X

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs ALFUZOSIN TAB 10MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs AVODART CAP 0.5MG Tier 3 X X

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs CARDURA TAB 1MG Tier 3

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs CARDURA TAB 2MG Tier 3

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs CARDURA TAB 4MG Tier 3

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs CARDURA TAB 8MG Tier 3

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs DOXAZOSIN TAB 1MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs DOXAZOSIN TAB 2MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs DOXAZOSIN TAB 4MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs DOXAZOSIN TAB 8MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs DUTAST/TAMSU CAP 0.5-0.4 Tier 1 X

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs DUTASTERIDE CAP 0.5MG Tier 1 X

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs FINASTERIDE TAB 5MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs FLOMAX CAP 0.4MG Tier 3 X

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs JALYN CAP Tier 3 X

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs PROSCAR TAB 5MG Tier 3

Page 84 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs RAPAFLO CAP 4MG Tier 3

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs RAPAFLO CAP 8MG Tier 3

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs TAMSULOSIN CAP 0.4MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs TERAZOSIN CAP 10MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs TERAZOSIN CAP 1MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs TERAZOSIN CAP 2MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs TERAZOSIN CAP 5MG Tier 1

Benign Prostatic Hypertrophy Agents - Prostate Enlargement Drugs UROXATRAL TAB 10MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ACEBUTOLOL CAP 200MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ACEBUTOLOL CAP 400MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ATENOL/CHLOR TAB 100-25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ATENOL/CHLOR TAB 50-25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ATENOLOL TAB 100MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ATENOLOL TAB 25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ATENOLOL TAB 50MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BETAXOLOL TAB 10MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BETAXOLOL TAB 20MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BISOPRL/HCTZ TAB 10/6.25 Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BISOPRL/HCTZ TAB 2.5/6.25 Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BISOPRL/HCTZ TAB 5-6.25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BISOPROL FUM TAB 10MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BISOPROL FUM TAB 5MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BYSTOLIC TAB 10MG Tier 2 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BYSTOLIC TAB 2.5MG Tier 2

Page 85 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BYSTOLIC TAB 20MG Tier 2 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs BYSTOLIC TAB 5MG Tier 2 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CARVEDILOL TAB 12.5MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CARVEDILOL TAB 25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CARVEDILOL TAB 3.125MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CARVEDILOL TAB 6.25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG TAB 12.5MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG TAB 25MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG TAB 3.125MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG TAB 6.25MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG CR CAP 10MG Tier 3 X X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG CR CAP 20MG Tier 3 X X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG CR CAP 40MG Tier 3 X X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs COREG CR CAP 80MG Tier 3 X X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CORGARD TAB 20MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CORGARD TAB 40MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CORGARD TAB 80MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CORZIDE TAB 40-5MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs CORZIDE TAB 80-5MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs DUTOPROL TAB 100-12.5 Tier 2 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs DUTOPROL TAB 25-12.5 Tier 2 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs DUTOPROL TAB 50-12.5 Tier 2 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs HEMANGEOL SOL 4.28/ML Tier 3 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INDERAL LA CAP 120MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INDERAL LA CAP 160MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INDERAL LA CAP 60MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INDERAL LA CAP 80MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INDERAL XL CAP 120MG Tier 3

Page 86 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INDERAL XL CAP 80MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INNOPRAN XL CAP 120MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs INNOPRAN XL CAP 80MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs KERLONE TAB 10MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs KERLONE TAB 20MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LABETALOL TAB 100MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LABETALOL TAB 200MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LABETALOL TAB 300MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LEVATOL TAB 20MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LOPRESS HCT TAB 100-25MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LOPRESS HCT TAB 50-25MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LOPRESSOR TAB 100MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs LOPRESSOR TAB 50MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPRL/HCTZ TAB 100-25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPRL/HCTZ TAB 100-50MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPRL/HCTZ TAB 50-25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROL TAR TAB 100MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROL TAR TAB 25MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROL TAR TAB 50MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROLOL TAB 100MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROLOL TAB 200MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROLOL TAB 25MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROLOL TAB 37.5MG Tier 1 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROLOL TAB 50MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs METOPROLOL TAB 75MG Tier 1 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs NADOLOL TAB 20MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs NADOLOL TAB 40MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs NADOLOL TAB 80MG Tier 1

Page 87 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Beta-Adrenergic Blocking Agents - Blood Pressure Drugs NADOLOL/BEND TAB 40-5MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs NADOLOL/BEND TAB 80-5MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PINDOLOL TAB 10MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PINDOLOL TAB 5MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRAN/HCTZ TAB 40/25 Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRAN/HCTZ TAB 80/25 Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL CAP 120MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL CAP 160MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL CAP 60MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL CAP 80MG ER Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL SOL 20MG/5ML Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL SOL 40MG/5ML Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL TAB 10MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL TAB 20MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL TAB 40MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL TAB 60MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs PROPRANOLOL TAB 80MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs SECTRAL CAP 200MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs SECTRAL CAP 400MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TENORETIC TAB 100 Tier 3 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TENORETIC TAB 50 Tier 3 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TENORMIN TAB 100MG Tier 3 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TENORMIN TAB 25MG Tier 3 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TENORMIN TAB 50MG Tier 3 X Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TIMOLOL MAL TAB 10MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TIMOLOL MAL TAB 20MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TIMOLOL MAL TAB 5MG Tier 1 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TOPROL XL TAB 100MG Tier 3

Page 88 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TOPROL XL TAB 200MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TOPROL XL TAB 25MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs TOPROL XL TAB 50MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ZEBETA TAB 10MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ZEBETA TAB 5MG Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ZIAC TAB 10/6.25 Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ZIAC TAB 2.5/6.25 Tier 3 Beta-Adrenergic Blocking Agents - Blood Pressure Drugs ZIAC TAB 5-6.25MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEDAX CAP 400MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEDAX SUS 180/5ML Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEFACLOR CAP 250MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFACLOR CAP 500MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFACLOR SUS 125/5ML Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEFACLOR SUS 250/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFACLOR SUS 375/5ML Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEFACLOR ER TAB 500MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFADROXIL CAP 500MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFADROXIL SUS 250/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFADROXIL SUS 500/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFADROXIL TAB 1GM Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFDINIR CAP 300MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFDINIR SUS 125/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFDINIR SUS 250/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFDITOREN TAB 200MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFDITOREN TAB 400MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFIXIME SUS 100/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFIXIME SUS 200/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFPODO PROX SUS 100/5ML Tier 1

Page 89 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Beta-Lactam, Cephalosporins - Antibiotics CEFPODO PROX SUS 50MG/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFPODOXIME TAB 100MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFPODOXIME TAB 200MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFPROZIL SUS 125/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFPROZIL SUS 250/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFPROZIL TAB 250MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFPROZIL TAB 500MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFTIBUTEN CAP 400MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFTIBUTEN SUS 180/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFTIN SUS 125/5ML Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEFTIN SUS 250/5ML Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEFTIN TAB 250MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEFTIN TAB 500MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics CEFUROXIME TAB 250MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEFUROXIME TAB 500MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEPHALEXIN CAP 250MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEPHALEXIN CAP 500MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEPHALEXIN CAP 750MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEPHALEXIN SUS 125/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEPHALEXIN SUS 250/5ML Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEPHALEXIN TAB 250MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics CEPHALEXIN TAB 500MG Tier 1 Beta-Lactam, Cephalosporins - Antibiotics KEFLEX CAP 250MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics KEFLEX CAP 500MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics KEFLEX CAP 750MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics SPECTRACEF TAB 200MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics SPECTRACEF TAB 400MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics SUPRAX CAP 400MG Tier 3

Page 90 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Beta-Lactam, Cephalosporins - Antibiotics SUPRAX CHW 100MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics SUPRAX CHW 200MG Tier 3 Beta-Lactam, Cephalosporins - Antibiotics SUPRAX SUS 100/5ML Tier 3 Beta-Lactam, Cephalosporins - Antibiotics SUPRAX SUS 200/5ML Tier 3 Beta-Lactam, Cephalosporins - Antibiotics SUPRAX SUS 500/5ML Tier 3

Beta-Lactam, Other - Antibiotics CAYSTON INH 75MG Tier 2 X X X

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV CHW 200MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV CHW 400MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV SUS 200/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV SUS 250/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV SUS 400/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV SUS 600/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV TAB 250-125 Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV TAB 500-125 Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX/K CLAV TAB 875MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN CAP 250MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN CAP 500MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN CHW 125MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN CHW 250MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN SUS 125/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN SUS 200/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN SUS 250/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN SUS 250MG/5M Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN SUS 400/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN TAB 500MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN TAB 775MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOXICILLIN TAB 875MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMOX-POT CLA TAB ER Tier 1 X

Page 91 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Beta-Lactam, Penicillins - Antibiotics AMPICILLIN CAP 250MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMPICILLIN CAP 500MG Tier 1

Beta-Lactam, Penicillins - Antibiotics AMPICILLIN SUS 125/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AMPICILLIN SUS 250/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics AUGMENTIN SUS 125/5ML Tier 2 X

Beta-Lactam, Penicillins - Antibiotics AUGMENTIN SUS 250/5ML Tier 2 X

Beta-Lactam, Penicillins - Antibiotics AUGMENTIN SUS ES-600 Tier 2 X

Beta-Lactam, Penicillins - Antibiotics AUGMENTIN TAB 500MG Tier 2 X

Beta-Lactam, Penicillins - Antibiotics AUGMENTIN TAB 875MG Tier 2 X

Beta-Lactam, Penicillins - Antibiotics AUGMENTIN XR TAB 12HR Tier 3 X

Beta-Lactam, Penicillins - Antibiotics DICLOXACILL CAP 250MG Tier 1

Beta-Lactam, Penicillins - Antibiotics DICLOXACILL CAP 500MG Tier 1

Beta-Lactam, Penicillins - Antibiotics MOXATAG TAB 775MG Tier 3

Beta-Lactam, Penicillins - Antibiotics PENICILLN VK SOL 125/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics PENICILLN VK SOL 250/5ML Tier 1

Beta-Lactam, Penicillins - Antibiotics PENICILLN VK TAB 250MG Tier 1

Beta-Lactam, Penicillins - Antibiotics PENICILLN VK TAB 500MG Tier 1 Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 12-25MG Tier 1 X Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 12-50MG Tier 1 X Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 3-25MG Tier 1 X Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 6-25MG Tier 1 X Bipolar Agents, Other - Mood Disorder Drugs OLANZA/FLUOX CAP 6-50MG Tier 1 X Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX CAP 12-25MG Tier 3 X Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX CAP 12-50MG Tier 3 X Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX CAP 3-25MG Tier 3 X Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX CAP 6-25MG Tier 3 X Bipolar Agents, Other - Mood Disorder Drugs SYMBYAX CAP 6-50MG Tier 3 X Blood Formation Modifiers - Blood Formation Drugs AGRYLIN CAP 0.5MG Tier 3

Page 92 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Blood Formation Modifiers - Blood Formation Drugs ANAGRELIDE CAP 0.5MG Tier 1 Blood Formation Modifiers - Blood Formation Drugs ANAGRELIDE CAP 1MG Tier 1 Blood Formation Modifiers - Blood Formation Drugs EPOGEN INJ 10000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs EPOGEN INJ 2000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs EPOGEN INJ 20000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs EPOGEN INJ 3000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs EPOGEN INJ 4000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs GRANIX INJ 300/0.5 Tier 3 X X Blood Formation Modifiers - Blood Formation Drugs GRANIX INJ 480/0.8 Tier 3 X X Blood Formation Modifiers - Blood Formation Drugs LEUKINE INJ 250MCG Tier 2 X Blood Formation Modifiers - Blood Formation Drugs MOZOBIL INJ Tier 2 X Blood Formation Modifiers - Blood Formation Drugs NEULASTA INJ 6MG/0.6M Tier 3 X Blood Formation Modifiers - Blood Formation Drugs NEULASTA KIT 6MG/0.6M Tier 3 X Blood Formation Modifiers - Blood Formation Drugs NEUMEGA INJ 5MG Tier 2 X Blood Formation Modifiers - Blood Formation Drugs NEUPOGEN INJ 300/0.5 Tier 2 X Blood Formation Modifiers - Blood Formation Drugs NEUPOGEN INJ 300MCG Tier 2 X Blood Formation Modifiers - Blood Formation Drugs NEUPOGEN INJ 480/0.8 Tier 2 X Blood Formation Modifiers - Blood Formation Drugs NEUPOGEN INJ 480MCG Tier 2 X Blood Formation Modifiers - Blood Formation Drugs PROCRIT INJ 10000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs PROCRIT INJ 2000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs PROCRIT INJ 20000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs PROCRIT INJ 3000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs PROCRIT INJ 4000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs PROCRIT INJ 40000/ML Tier 2 X X Blood Formation Modifiers - Blood Formation Drugs PROMACTA TAB 12.5MG Tier 3 X X Blood Formation Modifiers - Blood Formation Drugs PROMACTA TAB 25MG Tier 3 X X Blood Formation Modifiers - Blood Formation Drugs PROMACTA TAB 50MG Tier 3 X X Blood Formation Modifiers - Blood Formation Drugs PROMACTA TAB 75MG Tier 3 X X

Page 93 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - ANTICOAGULANTS ANTICOAG CIT SOL DEX SOL Tier 1

BLOOD FORMATION,COAGULATION & THROMBOSIS - ANTICOAGULANTS NOCLOT-50 SOL ACD-A Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - ANTICOAGULANTS TRICITRASOL CON Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ADVATE INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ADVATE INJ 1500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ADVATE INJ 2000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ADVATE INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ADVATE INJ 3000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ADVATE INJ 4000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ADVATE INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANATE INJ VWF/HUM Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANATE INJ VWF/HUM Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANATE INJ VWF/HUM Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANATE INJ VWF/HUM Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANATE INJ VWF/HUM Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANINE SD INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANINE SD INJ 1500UNIT Tier 2 X

Page 94 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ALPHANINE SD INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS AMICAR SOL 0.25/ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS AMICAR TAB 1000MG Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS AMICAR TAB 500MG Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS AMINOCAPR AC SYP 25% Tier 1

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS AMINOCAPR AC TAB 1000MG Tier 1

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS AMINOCAPR AC TAB 500MG Tier 1

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ARTISS SOL 10ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ARTISS SOL 2ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ARTISS SOL 4ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS ASTRINGYN SOL 259MG/GM Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BEBULIN INJ 200-1200 Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BENEFIX INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BENEFIX INJ 2000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BENEFIX INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BENEFIX INJ 3000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS BENEFIX INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS CORIFACT KIT Tier 2 X

Page 95 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS EVICEL KIT 2ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS EVICEL KIT 5ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS EVITHROM SOL 800-1200 Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS FEIBA INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS FEIBA NF INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HELIXATE FS INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HELIXATE FS INJ 2000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HELIXATE FS INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HELIXATE FS INJ 3000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HELIXATE FS INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HEMOFIL M INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HEMOFIL M INJ 1700UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HEMOFIL M INJ 220-400 Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HEMOFIL M INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HEMOFIL M INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HEMOFIL M SOL Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HEMOFIL M SOL 801-1500 Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HUMATE-P SOL 2400UNIT Tier 2 X

Page 96 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HUMATE-P SOL 250-600 Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS HUMATE-P SOL 500-1200 Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS IXINITY INJ 1000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS IXINITY INJ 1500UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS IXINITY INJ 500UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOATE-DVI INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOATE-DVI INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOATE-DVI INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 1000/BS Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 2000/BS Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 2000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 250/BS Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 3000/BS Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 3000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 500/BS Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOGENATE FS INJ 500UNIT Tier 2 X

Page 97 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOVALTRY INJ 1000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOVALTRY INJ 2000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOVALTRY INJ 250UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOVALTRY INJ 3000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS KOVALTRY INJ 500UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS MONOCLATE-P INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS MONOCLATE-P INJ 1500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS MONOCLATE-P INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS MONONINE INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS MONONINE INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS MONSELS FERR SOL SUBSULF Tier 1

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOEIGHT INJ 1000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOEIGHT INJ 1500UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOEIGHT INJ 2000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOEIGHT INJ 250UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOEIGHT INJ 3000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOEIGHT INJ 500UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOSEVEN RT INJ 1MG Tier 2 X

Page 98 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOSEVEN RT INJ 2MG Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOSEVEN RT INJ 5MG Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NOVOSEVEN RT INJ 8MG Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ INJ 1000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ INJ 2000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ INJ 250UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ INJ 500UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ KIT 1000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ KIT 2000UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ KIT 250UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS NUWIQ KIT 500UNIT Tier 3 X X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS PROFILNINE INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS PROFILNINE INJ 1500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS PROFILNINE INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RECOMBINATE INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RECOMBINATE INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RECOMBINATE INJ 220-400 Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RECOMBINATE INJ 401-800 Tier 2 X

Page 99 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RECOMBINATE INJ 801-1240 Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RECOTHROM SOL 20000UNT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RECOTHROM SOL 5000UNIT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RIASTAP SOL 1GM Tier 3 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RIXUBIS INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RIXUBIS INJ 2000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RIXUBIS INJ 250 UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RIXUBIS INJ 3000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS RIXUBIS INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS THROMBIN KIT 5000UNIT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS THROMBIN-JMI KIT 20000UNT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS THROMBIN-JMI KIT 5000UNIT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS THROMBOGEN KIT 10000UNT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS THROMBOGEN SOL 10000UNT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS THROMBOGEN SOL 1000UNIT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS TISSEEL KIT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS TISSEEL KIT Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS TISSEEL KIT Tier 3

Page 100 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS TISSEEL SOL Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS TISSEEL VH KIT 10ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS TISSEEL VH KIT 2ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS TISSEEL VH KIT 4ML Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS WILATE INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS WILATE INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS WILATE INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS WILATE INJ Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA INJ 2000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA INJ 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA SOLOF INJ 1000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA SOLOF INJ 2000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA SOLOF INJ 3000UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA SOLOF INJ 500UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - HEMOSTATICS XYNTHA SOLOF KIT 250UNIT Tier 2 X

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS ED CYTE F TAB Tier 3

Page 101 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS FER-IN-SOL DRO 15MG/ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS FER-IRON DRO 15MG/ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS FEROSUL ELX 220/5ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS FERROUS DRO 15MG/ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS FERROUS SULF DRO 15MG/ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS FERROUS SULF ELX 220/5ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS FERROUS SULF SYP 300/5ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS HEMATINIC/FA TAB Tier 1

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS HEMOCYTE-F TAB Tier 1

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS IRON SUPPLMT DRO 15MG/ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON HCR PREPARATIONS PEDIA IRON DRO 15MG/ML Preventative

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS PROFERRIN- TAB FORTE Tier 3

BLOOD FORMATION,COAGULATION & THROMBOSIS - IRON PREPARATIONS TANDEM F CAP Tier 3

Blood Products/Modifiers/Volume Expanders BERINERT INJ 500UNIT Tier 2 X X X

Page 102 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Blood Products/Modifiers/Volume Expanders CINRYZE SOL 500 UNIT Tier 3 X X

Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT HFA AER 17MCG Tier 3 X

Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT NAS SOL 0.03% Tier 3

Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT NAS SOL 0.06% Tier 3

Bronchodilators, Anticholinergic - Asthma/Lung Drugs COMBIVENT AER 20-100 Tier 3 X

Bronchodilators, Anticholinergic - Asthma/Lung Drugs IPRATROPIUM SOL 0.02%INH Tier 1

Bronchodilators, Anticholinergic - Asthma/Lung Drugs IPRATROPIUM SPR 0.03% Tier 1

Bronchodilators, Anticholinergic - Asthma/Lung Drugs IPRATROPIUM SPR 0.06% Tier 1

Bronchodilators, Anticholinergic - Asthma/Lung Drugs IPRATROPIUM/ SOL ALBUTER Tier 1

Bronchodilators, Anticholinergic - Asthma/Lung Drugs IPRATROPIUM/ SOL SULFATE Tier 1

Bronchodilators, Anticholinergic - Asthma/Lung Drugs SPIRIVA AER 1.25MCG Tier 3 X X

Bronchodilators, Anticholinergic - Asthma/Lung Drugs SPIRIVA CAP HANDIHLR Tier 3 X

Bronchodilators, Anticholinergic - Asthma/Lung Drugs SPIRIVA SPR 2.5MCG Tier 3 X

Bronchodilators, Anticholinergic - Asthma/Lung Drugs TUDORZA PRES AER 400/ACT Tier 2 X

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs DIFIL-G FORT LIQ 100-100 Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs ELIXOPHYLLIN ELX 80/15ML Tier 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs LUFYLLIN TAB 200MG Tier 3

Page 103 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs LUFYLLIN TAB 400MG Tier 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEO-24 CAP 100MG CR Tier 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEO-24 CAP 200MG CR Tier 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEO-24 CAP 300MG CR Tier 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEO-24 CAP 400MG ER Tier 3

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOCHRON TAB 100MG CR Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOCHRON TAB 200MG CR Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOCHRON TAB 300MG CR Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE SOL 80/15ML Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 100MG CR Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 100MG ER Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 200MG CR Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 200MG ER Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 300MG ER Tier 1

Page 104 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 400MG ER Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 450MG ER Tier 1

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) - Asthma/Lung Drugs THEOPHYLLINE TAB 600MG ER Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ADRENACLICK INJ 0.15MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ADRENACLICK INJ 0.3MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ADRENALIN SOL 1:1000 Tier 2

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL NEB 0.083% Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL NEB 0.5% Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL NEB 0.63MG/3 Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL NEB 1.25MG/3 Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL SYP 2MG/5ML Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL TAB 2MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL TAB 4MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL TAB 4MG ER Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ALBUTEROL TAB 8MG ER Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ANORO ELLIPT AER 62.5-25 Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs ARCAPTA CAP 75MCG Tier 3 X

Page 105 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs AUVI-Q INJ 0.15MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs AUVI-Q INJ 0.3MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs BL DIXAPHEDR TAB 60MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs BROVANA NEB 15MCG Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs EPINEPHRINE INJ 0.15MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs EPINEPHRINE INJ 0.3MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs EPIPEN 2-PAK INJ 0.3MG Tier 2 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs EPIPEN-JR INJ 2-PAK Tier 2 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs FORADIL CAP AEROLIZE Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs GNP DIPHEDRY TAB 60MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs GNP DIXAPHED TAB 12 HR Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs LEVALBUTEROL NEB 0.31MG Tier 1 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs LEVALBUTEROL NEB 0.63MG Tier 1 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs LEVALBUTEROL NEB 1.25/0.5 Tier 1 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs LEVALBUTEROL NEB 1.25MG Tier 1 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs METAPROTEREN SYP 10MG/5ML Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs METAPROTEREN TAB 10MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs METAPROTEREN TAB 20MG Tier 1

Page 106 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs PERFOROMIST NEB 20MCG Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs PROAIR HFA AER Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs PROAIR RESPI AER Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs PROVENTIL AER HFA Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs SEREVENT DIS AER 50MCG Tier 3 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs STRIVERDI AER 2.5MCG Tier 2 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs TERBUTALINE POW SULFATE Tier 3

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs TERBUTALINE TAB 2.5MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs TERBUTALINE TAB 5MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs VENTOLIN HFA AER Tier 1 X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs VOSPIRE ER TAB 4MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs VOSPIRE ER TAB 8MG Tier 1

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs XOPENEX NEB 0.31MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs XOPENEX NEB 0.63MG Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs XOPENEX NEB 1.25/3ML Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs XOPENEX CONC NEB 1.25/0.5 Tier 3 X X

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs XOPENEX HFA AER Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs ADALAT CC TAB 30MG ER Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs ADALAT CC TAB 60MG ER Tier 3

Page 107 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs ADALAT CC TAB 90MG ER Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs AFEDITAB TAB 30MG CR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs AFEDITAB TAB 60MG CR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 10-10MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 10-20MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 10-40MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 10-80MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 2.5-10MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 2.5-20MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 2.5-40MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 5-10MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 5-20MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 5-40MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/ATORVA TAB 5-80MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/BENAZP CAP 10-20MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/BENAZP CAP 10-40MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/BENAZP CAP 2.5-10MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/BENAZP CAP 5-10MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/BENAZP CAP 5-20MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/BENAZP CAP 5-40MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB /HCTZ Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB /HCTZ Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB /HCTZ Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB /HCTZ Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB /HCTZ Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB 10-160MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB 10-320MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB 5-160MG Tier 1 X

Page 108 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs AMLOD/VALSAR TAB 5-320MG Tier 1 X Calcium Channel Blocking Agents - Blood Pressure Drugs AMLODIPINE TAB 10MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs AMLODIPINE TAB 2.5MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs AMLODIPINE TAB 5MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs AZOR TAB 10-20MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AZOR TAB 10-40MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AZOR TAB 5-20MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs AZOR TAB 5-40MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 10-10MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 10-20MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 10-40MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 10-80MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 2.5-10MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 2.5-20MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 2.5-40MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 5-10MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 5-20MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 5-40MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CADUET TAB 5-80MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs CALAN TAB 120MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs CALAN TAB 80MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs CALAN SR TAB 120MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs CALAN SR TAB 180MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs CALAN SR TAB 240MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM TAB 120MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM TAB 30MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM TAB 60MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM CD CAP 120MG/24 Tier 3 X

Page 109 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM CD CAP 180MG/24 Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM CD CAP 240MG/24 Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM CD CAP 300MG/24 Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM CD CAP 360MG/24 Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM LA TAB 120MG Tier 2 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM LA TAB 180MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM LA TAB 240MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM LA TAB 300MG/24 Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM LA TAB 360MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARDIZEM LA TAB 420MG/24 Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs CARTIA XT CAP 120/24HR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs CARTIA XT CAP 180/24HR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs CARTIA XT CAP 240/24HR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs CARTIA XT CAP 300/24HR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 120MG CD Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 120MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 120MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 120MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 120MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 180MG CD Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 180MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 180MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 180MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 240MG CD Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 240MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 240MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 240MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 300MG CD Tier 1

Page 110 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 300MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 300MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 360MG CD Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 360MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 360MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 360MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 420MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 60MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM CAP 90MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM TAB 120MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM TAB 30MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM TAB 60MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM TAB 90MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM ER TAB 180MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM ER TAB 240MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM ER TAB 300MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM ER TAB 360MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILTIAZEM ER TAB 420MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILT-XR CAP 120MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILT-XR CAP 180MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs DILT-XR CAP 240MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGE TAB 10-160MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGE TAB 10-320MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGE TAB 5-160MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGE TAB 5-320MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGEH/10- TAB 160-12.5 Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGEH/10- TAB 160-25 Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGEH/10- TAB 320-25 Tier 3 X X

Page 111 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGEH/5- TAB 160-12.5 Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs EXFORGEH/5- TAB 160-25 Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs FELODIPINE TAB 10MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs FELODIPINE TAB 2.5MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs FELODIPINE TAB 5MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs ISRADIPINE CAP 2.5MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs ISRADIPINE CAP 5MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs LOTREL CAP 10-20MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs LOTREL CAP 10-40MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs LOTREL CAP 2.5-10MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs LOTREL CAP 5-10MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs LOTREL CAP 5-20MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs LOTREL CAP 5-40MG Tier 3 X Calcium Channel Blocking Agents - Blood Pressure Drugs MATZIM LA TAB 180MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs MATZIM LA TAB 240MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs MATZIM LA TAB 300MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs MATZIM LA TAB 360MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs MATZIM LA TAB 420MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NICARDIPINE CAP 20MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NICARDIPINE CAP 30MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDICAL XL TAB 30MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDICAL XL TAB 60MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE CAP 10MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE CAP 20MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE TAB 30MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE TAB 30MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE TAB 60MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE TAB 60MG ER Tier 1

Page 112 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE TAB 90MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIFEDIPINE TAB 90MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NIMODIPINE CAP 30MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NISOLDIPINE TAB 17MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NISOLDIPINE TAB 20MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NISOLDIPINE TAB 25.5MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NISOLDIPINE TAB 30MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NISOLDIPINE TAB 34MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NISOLDIPINE TAB 40MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NISOLDIPINE TAB 8.5MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs NORVASC TAB 10MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs NORVASC TAB 2.5MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs NORVASC TAB 5MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs NYMALIZE SOL 60/20ML Tier 2 Calcium Channel Blocking Agents - Blood Pressure Drugs PROCARDIA CAP 10MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs PROCARDIA XL TAB 30MG CR Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs PROCARDIA XL TAB 60MG CR Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs PROCARDIA XL TAB 90MG CR Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs SULAR TAB 17MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs SULAR TAB 34MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs SULAR TAB 8.5MG Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs TAZTIA XT CAP 120MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs TAZTIA XT CAP 180MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs TAZTIA XT CAP 240MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs TAZTIA XT CAP 300MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs TAZTIA XT CAP 360MG/24 Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs TELMIS/AMLOD TAB 40-10MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TELMIS/AMLOD TAB 40-5MG Tier 1 X X

Page 113 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs TELMIS/AMLOD TAB 80-10MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TELMIS/AMLOD TAB 80-5MG Tier 1 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TIAZAC CAP 120MG/24 Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs TIAZAC CAP 180MG/24 Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs TIAZAC CAP 240MG/24 Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs TIAZAC CAP 300MG/24 Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs TIAZAC CAP 360MG/24 Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs TIAZAC CAP 420MG/24 Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs TRIBENZOR20- TAB 5-12.5MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TRIBENZOR40- TAB 10-12.5 Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TRIBENZOR40- TAB 10-25MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TRIBENZOR40- TAB 5-12.5MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TRIBENZOR40- TAB 5-25MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TWYNSTA TAB 40-10MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TWYNSTA TAB 40-5MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TWYNSTA TAB 80-10MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs TWYNSTA TAB 80-5MG Tier 3 X X Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 100MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 120MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 120MG SR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 180MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 180MG SR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 200MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 240MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 240MG SR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 300MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL CAP 360MG SR Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL TAB 120MG Tier 1

Page 114 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL TAB 120MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL TAB 180MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL TAB 240MG ER Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL TAB 40MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERAPAMIL TAB 80MG Tier 1 Calcium Channel Blocking Agents - Blood Pressure Drugs VERELAN CAP 120MG SR Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs VERELAN CAP 180MG SR Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs VERELAN CAP 240MG SR Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs VERELAN CAP 360MG SR Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs VERELAN PM CAP 100MG ER Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs VERELAN PM CAP 200MG ER Tier 3 Calcium Channel Blocking Agents - Blood Pressure Drugs VERELAN PM CAP 300MG ER Tier 3 Calcium Channel Modifying Agents - Seizure Control Drugs CELONTIN CAP 300MG Tier 2 Calcium Channel Modifying Agents - Seizure Control Drugs ETHOSUXIMIDE CAP 250MG Tier 1 Calcium Channel Modifying Agents - Seizure Control Drugs ETHOSUXIMIDE SOL 250/5ML Tier 1 Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 100MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 150MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 200MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 225MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 25MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 300MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 50MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA CAP 75MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs LYRICA SOL 20MG/ML Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs ZARONTIN CAP 250MG Tier 3 Calcium Channel Modifying Agents - Seizure Control Drugs ZARONTIN SOL 250/5ML Tier 3 Calcium Channel Modifying Agents - Seizure Control Drugs ZONEGRAN CAP 100MG Tier 3 X X Calcium Channel Modifying Agents - Seizure Control Drugs ZONEGRAN CAP 25MG Tier 3 X X

Page 115 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Calcium Channel Modifying Agents - Seizure Control Drugs ZONISAMIDE CAP 100MG Tier 1 Calcium Channel Modifying Agents - Seizure Control Drugs ZONISAMIDE CAP 25MG Tier 1 Calcium Channel Modifying Agents - Seizure Control Drugs ZONISAMIDE CAP 50MG Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs AMTURNIDE150 TAB -5-12.5 Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs AMTURNIDE300 TAB -10-12.5 Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs AMTURNIDE300 TAB -10-25MG Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs AMTURNIDE300 TAB -5-12.5 Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs AMTURNIDE300 TAB -5-25MG Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DEMSER CAP 250MG Tier 3 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DIGITEK TAB 0.125MG Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DIGITEK TAB 0.25MG Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DIGOX TAB 0.125MG Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DIGOX TAB 0.25MG Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DIGOXIN SOL 50MCG/ML Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DIGOXIN TAB 0.125MG Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs DIGOXIN TAB 0.25MG Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs LANOXIN TAB 0.0625MG Tier 3 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs LANOXIN TAB 0.125MG Tier 3 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs LANOXIN TAB 0.1875MG Tier 3 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs LANOXIN TAB 0.25MG Tier 3 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs PENTOXIFYLLI TAB 400MG ER Tier 1 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs RANEXA TAB 1000MG Tier 2 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs RANEXA TAB 500MG Tier 2 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKAMLO TAB 150-10MG Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKAMLO TAB 150-5MG Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKAMLO TAB 300-10MG Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKAMLO TAB 300-5MG Tier 3 X X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKTURNA TAB 150MG Tier 3 X

Page 116 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKTURNA TAB 300MG Tier 3 X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKTURNA HCT TAB 150-12.5 Tier 3 X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKTURNA HCT TAB 150-25MG Tier 3 X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKTURNA HCT TAB 300-12.5 Tier 3 X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TEKTURNA HCT TAB 300-25MG Tier 3 X Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs TRENTAL TAB 400MG Tier 3 Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs VECAMYL TAB 2.5MG Tier 3 X X

CARDIOVASCULAR DRUGS - CALCIUM- CHANNEL BLOCKING AGENTS KRISGEL 100 GEL Tier 3 CENTRAL NERVOUS SYSTEM AGENTS - ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS ISOMETH/APAP CAP DICHLOR Tier 1 CENTRAL NERVOUS SYSTEM AGENTS - ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS ISOMETH/CAFF TAB /APAP Tier 1 CENTRAL NERVOUS SYSTEM AGENTS - ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS NODOLOR CAP Tier 1 CENTRAL NERVOUS SYSTEM AGENTS - ANALGESICS AND ANTIPYRETICS, MISCELLANEOUS PRODRIN TAB Tier 3 X CENTRAL NERVOUS SYSTEM AGENTS - ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC TRYPTOPHAN CAP 500MG Tier 3

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS FORANE SOL Tier 2

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS ISOFLURANE SOL Tier 1

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS SEVOFLURANE SOL Tier 1

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS SOJOURN SOL Tier 1

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS SUPRANE INH Tier 2

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS SUPRANE SOL Tier 2

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS TERRELL SOL Tier 1

CENTRAL NERVOUS SYSTEM AGENTS - INHALATION ANESTHETICS ULTANE SOL Tier 3

Page 117 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Central Nervous System, Other - Miscellaneous Central Nervous System Drugs BUT/APAP/CAF CAP CODEINE Tier 1 X X Central Nervous System, Other - Miscellaneous Central Nervous System Drugs BUT/APAP/CAF CAP CODEINE Tier 1 X Central Nervous System, Other - Miscellaneous Central Nervous System Drugs FIORICET CAP CODEINE Tier 3 X X Central Nervous System, Other - Miscellaneous Central Nervous System Drugs HETLIOZ CAP 20MG Tier 3 X X X Central Nervous System, Other - Miscellaneous Central Nervous System Drugs NUEDEXTA CAP 20-10MG Tier 2 Central Nervous System, Other - Miscellaneous Central Nervous System Drugs RILUTEK TAB 50MG Tier 3 Central Nervous System, Other - Miscellaneous Central Nervous System Drugs RILUZOLE TAB 50MG Tier 1 Central Nervous System, Other - Miscellaneous Central Nervous System Drugs TETRABENAZIN TAB 12.5MG Tier 1 X Central Nervous System, Other - Miscellaneous Central Nervous System Drugs TETRABENAZIN TAB 25MG Tier 1 X Central Nervous System, Other - Miscellaneous Central Nervous System Drugs XENAZINE TAB 12.5MG Tier 3 X X Central Nervous System, Other - Miscellaneous Central Nervous System Drugs XENAZINE TAB 25MG Tier 3 X X Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs ARICEPT TAB 10MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs ARICEPT TAB 23MG Tier 3 X Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs ARICEPT TAB 5MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs DONEPEZIL TAB 10MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs DONEPEZIL TAB 10MG ODT Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs DONEPEZIL TAB 5MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs DONEPEZIL TAB 5MG ODT Tier 1

Page 118 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs DONEPEZIL TAB HCL 23MG Tier 1 X Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs EXELON CAP 1.5MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs EXELON CAP 3MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs EXELON CAP 4.5MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs EXELON CAP 6MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs EXELON DIS 13.3/24 Tier 3 X Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs EXELON DIS 4.6MG/24 Tier 3 X Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs EXELON DIS 9.5MG/24 Tier 3 X Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs GALANTAMINE CAP 16MG ER Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs GALANTAMINE CAP 24MG ER Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs GALANTAMINE CAP 8MG ER Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs GALANTAMINE SOL 4MG/ML Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs GALANTAMINE TAB 12MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs GALANTAMINE TAB 4MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs GALANTAMINE TAB 8MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RAZADYNE TAB 12MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RAZADYNE TAB 4MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RAZADYNE TAB 8MG Tier 3

Page 119 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RAZADYNE ER CAP 16MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RAZADYNE ER CAP 24MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RAZADYNE ER CAP 8MG Tier 3 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RIVASTIGMINE CAP 1.5MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RIVASTIGMINE CAP 3MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RIVASTIGMINE CAP 4.5MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RIVASTIGMINE CAP 6MG Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RIVASTIGMINE DIS 13.3/24 Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RIVASTIGMINE DIS 4.6MG/24 Tier 1 Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs RIVASTIGMINE DIS 9.5MG/24 Tier 1

Coagulants - Blood Clotting Drugs BRILINTA TAB 60MG Tier 3 X X

Coagulants - Blood Clotting Drugs BRILINTA TAB 90MG Tier 3 X X

Coagulants - Blood Clotting Drugs LYSTEDA TAB 650MG Tier 3 X

Coagulants - Blood Clotting Drugs TRANEX ACID TAB 650MG Tier 1 X CONTRACEPTIVES (E.G. FOAMS, DEVICES) CAYA DPR Tier 3 CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) FC FEMALE MIS CONDOM Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) OMNIFLEX DPR Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 60 Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 65 Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 70 Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 75 Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 80 Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 85 Preventative

Page 120 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 90 Preventative CONTRACEPTIVES (E.G. FOAMS, HCR DEVICES) WIDE-SEAL DPR KIT 95 Preventative

Conventional - Mood Disorder Drugs MOLINDONE TAB HCL 10MG Tier 1

Conventional - Mood Disorder Drugs MOLINDONE TAB HCL 25MG Tier 1

Conventional - Mood Disorder Drugs MOLINDONE TAB HCL 5MG Tier 1 DENTAL AGENTS HURRISEAL SOL Tier 3 Dental and Oral Agents CEVIMELINE CAP 30MG Tier 1 Dental and Oral Agents CHLORHEX GLU SOL 0.12% Tier 1 Dental and Oral Agents EVOXAC CAP 30MG Tier 3 Dental and Oral Agents ORALONE PST 0.1% Tier 1 Dental and Oral Agents PAROEX SOL 0.12% Tier 1 Dental and Oral Agents PERIDEX SOL 0.12% Tier 3 Dental and Oral Agents PERIOGARD SOL 0.12% Tier 1 Dental and Oral Agents PILOCARPINE TAB 5MG Tier 1 Dental and Oral Agents PILOCARPINE TAB 7.5MG Tier 1 Dental and Oral Agents SALAGEN TAB 5MG Tier 3 Dental and Oral Agents SALAGEN TAB 7.5MG Tier 3 Dental and Oral Agents TRIAMCIN/ORA PST 0.1% Tier 1 Dental and Oral Agents TRIAMCINOLON PST 0.1% Tier 1 Dermatological Agents - Drugs to Treat Skin Conditions MIRVASO GEL 0.33% Tier 3 X

Dermatological Agents - Skin Agents 8-MOP CAP 10MG Tier 2

Dermatological Agents - Skin Agents ABSORICA CAP 10MG Tier 3 X X

Dermatological Agents - Skin Agents ABSORICA CAP 20MG Tier 3 X X

Dermatological Agents - Skin Agents ABSORICA CAP 25MG Tier 3 X X

Dermatological Agents - Skin Agents ABSORICA CAP 30MG Tier 3 X X

Dermatological Agents - Skin Agents ABSORICA CAP 35MG Tier 3 X X

Dermatological Agents - Skin Agents ABSORICA CAP 40MG Tier 3 X X

Dermatological Agents - Skin Agents ACANYA GEL 1.2-2.5% Tier 3 X X

Dermatological Agents - Skin Agents ACITRETIN CAP 10MG Tier 1

Dermatological Agents - Skin Agents ACITRETIN CAP 17.5MG Tier 1

Dermatological Agents - Skin Agents ACITRETIN CAP 25MG Tier 1

Dermatological Agents - Skin Agents ACZONE GEL 5% Tier 3 X

Dermatological Agents - Skin Agents ACZONE GEL 7.5% Tier 3 X

Dermatological Agents - Skin Agents ADAPALENE CRE 0.1% Tier 1 X X

Dermatological Agents - Skin Agents ADAPALENE GEL 0.1% Tier 1 X X

Page 121 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dermatological Agents - Skin Agents ADAPALENE GEL 0.3% Tier 1 X X

Dermatological Agents - Skin Agents ADAPALENE GEL PMP 0.3% Tier 1 X X

Dermatological Agents - Skin Agents ADAPALENE LOT 0.1% Tier 3 X X

Dermatological Agents - Skin Agents ALDARA CRE 5% Tier 3 X

Dermatological Agents - Skin Agents AMNESTEEM CAP 10MG Tier 1 X

Dermatological Agents - Skin Agents AMNESTEEM CAP 20MG Tier 1 X

Dermatological Agents - Skin Agents AMNESTEEM CAP 40MG Tier 1 X

Dermatological Agents - Skin Agents ATRALIN GEL 0.05% Tier 3 X X X

Dermatological Agents - Skin Agents ATRAPRO DERM SPR Tier 3

Dermatological Agents - Skin Agents AVITA CRE 0.025% Tier 1 X X

Dermatological Agents - Skin Agents AVITA GEL 0.025% Tier 1 X X

Dermatological Agents - Skin Agents AZELEX CRE 20% Tier 3 X

Dermatological Agents - Skin Agents BEAU RX GEL Tier 3 X

Dermatological Agents - Skin Agents BENZACLIN GEL 1-5% Tier 3 X X

Dermatological Agents - Skin Agents BENZACLIN GEL 1-5%PUMP Tier 3 X X

Dermatological Agents - Skin Agents BENZAMYCIN GEL 5-3% Tier 2 X

Dermatological Agents - Skin Agents BENZAMYCIN GEL PAK Tier 3

Dermatological Agents - Skin Agents CALCIPOTRIEN CRE 0.005% Tier 1 X

Dermatological Agents - Skin Agents CALCIPOTRIEN OIN 0.005% Tier 1

Dermatological Agents - Skin Agents CALCIPOTRIEN OIN BETAMETH Tier 1 X

Dermatological Agents - Skin Agents CALCIPOTRIEN SOL 0.005% Tier 1 X

Dermatological Agents - Skin Agents CALCITRENE OIN 0.005% Tier 3

Dermatological Agents - Skin Agents CALCITRIOL OIN 3MCG/GM Tier 1 X

Dermatological Agents - Skin Agents CARAC CRE 0.5% Tier 2

Dermatological Agents - Skin Agents CLARAVIS CAP 10MG Tier 1 X

Dermatological Agents - Skin Agents CLARAVIS CAP 20MG Tier 1 X

Dermatological Agents - Skin Agents CLARAVIS CAP 30MG Tier 1 X

Dermatological Agents - Skin Agents CLARAVIS CAP 40MG Tier 1 X

Page 122 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dermatological Agents - Skin Agents CLEOCIN-T GEL 1% Tier 3 X

Dermatological Agents - Skin Agents CLEOCIN-T LOT 1% Tier 3

Dermatological Agents - Skin Agents CLEOCIN-T PAD 1% Tier 3

Dermatological Agents - Skin Agents CLEOCIN-T SOL 1% Tier 3

Dermatological Agents - Skin Agents CLINDACIN KIT ETZ 1% Tier 3 X

Dermatological Agents - Skin Agents CLINDACIN KIT PAC 1% Tier 3 X

Dermatological Agents - Skin Agents CLINDACIN MIS ETZ 1% Tier 1

Dermatological Agents - Skin Agents CLINDACIN-P PAD 1% Tier 1

Dermatological Agents - Skin Agents CLINDAGEL GEL 1% Tier 3 X X

Dermatological Agents - Skin Agents CLINDAMAX GEL 1% Tier 3

Dermatological Agents - Skin Agents CLINDAMY/BEN GEL 1.2-5% Tier 1 X

Dermatological Agents - Skin Agents CLINDAMY/BEN GEL 1-5% Tier 1 X X

Dermatological Agents - Skin Agents CLINDAMYCIN AER 1% Tier 1

Dermatological Agents - Skin Agents CLINDAMYCIN GEL 1% Tier 1 X

Dermatological Agents - Skin Agents CLINDAMYCIN GEL TRETINOI Tier 1 X X

Dermatological Agents - Skin Agents CLINDAMYCIN LOT 1% Tier 1

Dermatological Agents - Skin Agents CLINDAMYCIN LOT 10MG/ML Tier 1

Dermatological Agents - Skin Agents CLINDAMYCIN PAD 1% Tier 1

Dermatological Agents - Skin Agents CLINDAMYCIN SOL 1% Tier 1

Dermatological Agents - Skin Agents CONDYLOX GEL 0.5% Tier 3

Dermatological Agents - Skin Agents CONDYLOX SOL 0.5% Tier 3

Dermatological Agents - Skin Agents CVS SCAR GEL Tier 1 X

Dermatological Agents - Skin Agents DERMASORB HC KIT 2% Tier 3 X

Dermatological Agents - Skin Agents DICLOFENAC GEL 3% Tier 1 X

Dermatological Agents - Skin Agents DIFFERIN CRE 0.1% Tier 3 X X

Dermatological Agents - Skin Agents DIFFERIN GEL 0.1% Tier 3 X X

Dermatological Agents - Skin Agents DIFFERIN GEL 0.3% Tier 3 X X X

Dermatological Agents - Skin Agents DIFFERIN LOT 0.1% Tier 3 X X

Page 123 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dermatological Agents - Skin Agents DOVONEX CRE 0.005% Tier 3 X

Dermatological Agents - Skin Agents DOXEPIN HCL CRE 5% Tier 1

Dermatological Agents - Skin Agents DUAC GEL 1.2-5% Tier 3 X X

Dermatological Agents - Skin Agents EFUDEX CRE 5% Tier 3

Dermatological Agents - Skin Agents ELIDEL CRE 1% Tier 3 X X

Dermatological Agents - Skin Agents ENSTILAR AER Tier 3 X X

Dermatological Agents - Skin Agents EPIDUO GEL 0.1-2.5% Tier 3 X

Dermatological Agents - Skin Agents EPIDUO FORTE GEL 0.3-2.5% Tier 3 X X

Dermatological Agents - Skin Agents EQL SCAR GEL Tier 1 X

Dermatological Agents - Skin Agents ERYTHROMYCIN GEL /BENZOYL Tier 1 X

Dermatological Agents - Skin Agents EVOCLIN AER 1% Tier 3

Dermatological Agents - Skin Agents FABIOR AER 0.1% Tier 3 X X X

Dermatological Agents - Skin Agents FINACEA AER 15% Tier 3

Dermatological Agents - Skin Agents FINACEA GEL 15% Tier 3

Dermatological Agents - Skin Agents FLUOROPLEX CRE 1% Tier 2

Dermatological Agents - Skin Agents FLUOROURACIL CRE 0.5% Tier 3 X

Dermatological Agents - Skin Agents FLUOROURACIL CRE 5% Tier 1

Dermatological Agents - Skin Agents FLUOROURACIL DRO 2% Tier 1 X

Dermatological Agents - Skin Agents FLUOROURACIL DRO 5% Tier 1 X

Dermatological Agents - Skin Agents FLUOROURACIL SOL 2% Tier 1 X

Dermatological Agents - Skin Agents FLUOROURACIL SOL 5% Tier 1 X

Dermatological Agents - Skin Agents GLYCERIN LIQ Tier 2

Dermatological Agents - Skin Agents GLYCERIN LIQ Tier 3

Dermatological Agents - Skin Agents GLYCERINE LIQ Tier 3

Dermatological Agents - Skin Agents GLYCEROL LIQ FORMAL Tier 3

Dermatological Agents - Skin Agents IMIQUIMOD CRE 5% Tier 1 X

Dermatological Agents - Skin Agents KLARON LOT 10% Tier 3

Dermatological Agents - Skin Agents LACTIC ACID LOT 10% Tier 1

Page 124 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dermatological Agents - Skin Agents LAVARE WOUND GEL WASH Tier 1

Dermatological Agents - Skin Agents LEVULAN KERA SOL 20% Tier 3

Dermatological Agents - Skin Agents MEDERMA CRE SPF 30 Tier 3 X

Dermatological Agents - Skin Agents MEDERMA GEL Tier 3 X

Dermatological Agents - Skin Agents MEDERMA FOR GEL KIDS Tier 3 X

Dermatological Agents - Skin Agents MENCAPS PAD Tier 3 X

Dermatological Agents - Skin Agents METHOXSALEN CAP 10MG Tier 1

Dermatological Agents - Skin Agents MYORISAN CAP 10MG Tier 1 X

Dermatological Agents - Skin Agents MYORISAN CAP 20MG Tier 1 X

Dermatological Agents - Skin Agents MYORISAN CAP 30MG Tier 1 X

Dermatological Agents - Skin Agents MYORISAN CAP 40MG Tier 1 X

Dermatological Agents - Skin Agents NEO-SYNALAR CRE Tier 3 X X

Dermatological Agents - Skin Agents NEUAC GEL 1.2-5% Tier 1 X

Dermatological Agents - Skin Agents ONEXTON GEL 1.2-3.75 Tier 3 X X

Dermatological Agents - Skin Agents OXSORALEN LOT 1% Tier 3

Dermatological Agents - Skin Agents OXSORALEN-UL CAP 10MG Tier 2

Dermatological Agents - Skin Agents PODOCON SOL 25% Tier 1

Dermatological Agents - Skin Agents PODOFILOX SOL 0.5% Tier 1

Dermatological Agents - Skin Agents PROTOPIC OIN 0.03% Tier 3 X X X

Dermatological Agents - Skin Agents PROTOPIC OIN 0.1% Tier 3 X X X

Dermatological Agents - Skin Agents PRUDOXIN CRE 5% Tier 1

Dermatological Agents - Skin Agents RA SCAR GEL Tier 1 X

Dermatological Agents - Skin Agents RECEDO GEL Tier 3 X

Dermatological Agents - Skin Agents REGRANEX GEL 0.01% Tier 2 X X

Dermatological Agents - Skin Agents RETIN-A CRE 0.025% Tier 3 X X

Dermatological Agents - Skin Agents RETIN-A CRE 0.05% Tier 3 X X

Dermatological Agents - Skin Agents RETIN-A CRE 0.1% Tier 3 X X

Dermatological Agents - Skin Agents RETIN-A GEL 0.01% Tier 3 X X

Page 125 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dermatological Agents - Skin Agents RETIN-A GEL 0.025% Tier 3 X X

Dermatological Agents - Skin Agents RETIN-A MICR GEL 0.04% Tier 3 X X X

Dermatological Agents - Skin Agents RETIN-A MICR GEL 0.04%PMP Tier 3 X X X

Dermatological Agents - Skin Agents RETIN-A MICR GEL 0.08% Tier 3 X X X

Dermatological Agents - Skin Agents RETIN-A MICR GEL 0.1% Tier 3 X X X

Dermatological Agents - Skin Agents RETIN-A MICR GEL 0.1%PUMP Tier 3 X X X

Dermatological Agents - Skin Agents RETINOIC ACD POW Tier 3 X X

Dermatological Agents - Skin Agents RETINOIC ACD POW ALL TRAN Tier 3 X X

Dermatological Agents - Skin Agents SANTYL OIN 250/GM Tier 3

Dermatological Agents - Skin Agents SCAR GEL Tier 1 X

Dermatological Agents - Skin Agents SCARCIN CRE Tier 3 X

Dermatological Agents - Skin Agents SELENIUM SUL LOT 2.5% Tier 1

Dermatological Agents - Skin Agents SKARJEL GEL Tier 1 X

Dermatological Agents - Skin Agents SOLARAZE GEL 3% W/W Tier 3 X

Dermatological Agents - Skin Agents SORIATANE CAP 10MG Tier 3

Dermatological Agents - Skin Agents SORIATANE CAP 17.5MG Tier 3

Dermatological Agents - Skin Agents SORIATANE CAP 25MG Tier 3

Dermatological Agents - Skin Agents SORILUX AER 0.005% Tier 3 X X

Dermatological Agents - Skin Agents STELARA INJ 45MG/0.5 Tier 2 X X X

Dermatological Agents - Skin Agents STELARA INJ 90MG/ML Tier 2 X X X

Dermatological Agents - Skin Agents SULFACETAMID LOT 10% Tier 1

Dermatological Agents - Skin Agents SULFACETAMID SUS 10% Tier 1

Dermatological Agents - Skin Agents SYNALAR KIT 0.025% Tier 3 X

Dermatological Agents - Skin Agents SYNALAR KIT 0.025% Tier 3 X

Dermatological Agents - Skin Agents TACLONEX OIN Tier 3 X X

Dermatological Agents - Skin Agents TACLONEX SUS Tier 3 X

Dermatological Agents - Skin Agents TACROLIMUS OIN 0.03% Tier 1 X X

Dermatological Agents - Skin Agents TACROLIMUS OIN 0.1% Tier 1 X X

Page 126 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dermatological Agents - Skin Agents TAZORAC CRE 0.05% Tier 3 X X

Dermatological Agents - Skin Agents TAZORAC CRE 0.1% Tier 3 X X

Dermatological Agents - Skin Agents TAZORAC GEL 0.05% Tier 3 X X

Dermatological Agents - Skin Agents TAZORAC GEL 0.1% Tier 3 X X

Dermatological Agents - Skin Agents TERSI FOAM AER 2.25% Tier 3

Dermatological Agents - Skin Agents TOLAK CRE 4% Tier 3 X

Dermatological Agents - Skin Agents TRAMADOL CRE 5% Tier 1 X

Dermatological Agents - Skin Agents TRAMADOL CRE 8% KIT Tier 1 X

Dermatological Agents - Skin Agents TRETINOIN CRE 0.025% Tier 1 X X

Dermatological Agents - Skin Agents TRETINOIN CRE 0.05% Tier 1 X X

Dermatological Agents - Skin Agents TRETINOIN CRE 0.1% Tier 1 X X

Dermatological Agents - Skin Agents TRETINOIN GEL 0.01% Tier 1 X X

Dermatological Agents - Skin Agents TRETINOIN GEL 0.025% Tier 1 X X

Dermatological Agents - Skin Agents TRETINOIN GEL 0.04% Tier 1 X X X

Dermatological Agents - Skin Agents TRETINOIN GEL 0.04%PMP Tier 1 X X X

Dermatological Agents - Skin Agents TRETINOIN GEL 0.05% Tier 3 X X X

Dermatological Agents - Skin Agents TRETINOIN GEL 0.1% Tier 1 X X X

Dermatological Agents - Skin Agents TRETINOIN GEL 0.1%PUMP Tier 1 X X X

Dermatological Agents - Skin Agents TRETINOIN POW Tier 3 X X

Dermatological Agents - Skin Agents TRETIN-X CRE 0.0375% Tier 3 X X X

Dermatological Agents - Skin Agents TRETIN-X CRE 0.075% Tier 3 X X

Dermatological Agents - Skin Agents TRETIN-X CRE KIT 0.05% Tier 3 X X X

Dermatological Agents - Skin Agents VECTICAL OIN 3MCG/GM Tier 3 X

Dermatological Agents - Skin Agents VELTIN GEL Tier 3 X X

Dermatological Agents - Skin Agents VEREGEN OIN 15% Tier 3 X

Dermatological Agents - Skin Agents ZENATANE CAP 10MG Tier 1 X

Dermatological Agents - Skin Agents ZENATANE CAP 20MG Tier 1 X

Dermatological Agents - Skin Agents ZENATANE CAP 30MG Tier 1 X

Page 127 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dermatological Agents - Skin Agents ZENATANE CAP 40MG Tier 1 X

Dermatological Agents - Skin Agents ZIANA GEL Tier 3 X X

Dermatological Agents - Skin Agents ZONALON CRE 5% Tier 3

Dermatological Agents - Skin Agents ZYCLARA CRE 3.75% Tier 3 X X

Dermatological Agents - Skin Agents ZYCLARA PUMP CRE 2.5% Tier 3 X X

Dermatological Agents - Skin Agents ZYCLARA PUMP CRE 3.75% Tier 3 X X

DEVICES AERCHMBR PLS MIS FLOW-VU Tier 2

DEVICES AERCHMBR PLS MIS LRG MASK Tier 2

DEVICES AERCHMBR PLS MIS SM MASK Tier 2 DEVICES AEROCHAMBER MIS PLUS Tier 2 DEVICES EASIVENT MIS Tier 2 DEVICES EASIVENT MIS MASK LG Tier 2 DEVICES EASIVENT MIS MASK SM Tier 2 DEVICES EASIVENT MIS MASK MED Tier 2 DEVICES E-Z SPACER MIS Tier 2 DEVICES E-Z SPACER MIS BODY GRD Tier 2 DEVICES FLEXICHAMBER MIS Tier 2

DEVICES FLEXICHAMBER MIS MASK LRG Tier 2

DEVICES FLEXICHAMBER MIS MASK SM Tier 2 DEVICES INSPIRACHAMB MIS LARGE Tier 2

DEVICES INSPIRACHAMB MIS MEDIUM Tier 2

DEVICES INSPIRACHAMB MIS MOUTHPCE Tier 2 DEVICES INSPIRACHAMB MIS SMALL Tier 2 DEVICES INSPIREASE MIS BAGS Tier 2 DEVICES INSPIREASE MIS DD SYST Tier 2

DEVICES INSPIREASE MIS MOUTHPCE Tier 2 DEVICES INSPIREASE MIS RES BAG Tier 2

DEVICES MASK VORTEX/ MIS BABY DUC Tier 2 DEVICES MASK VORTEX/ MIS DUCK Tier 2 DEVICES MASK VORTEX/ MIS FROG Tier 2

DEVICES MASK VORTEX/ MIS LADY BUG Tier 2 DEVICES OPTIHALER MIS Tier 2

DEVICES VORTEX VALVE MIS CHAMBER Tier 2 DEVICES WATCHHALER MIS Tier 2 DIABETIC DEVICES AUTOJECT 2 MIS Tier 3 X DIABETIC DEVICES CGMS SYSTEM MIS GOLD Tier 3 X X DIABETIC DEVICES GUARDIAN RT KIT Tier 3 X X DIABETIC DEVICES GUARDIAN RT KIT STARTER Tier 3 X X DIABETIC DEVICES GUARDIAN RT KIT SYST PED Tier 3 X X DIABETIC DEVICES GUARDIAN RT KIT SYSTEM Tier 3 X X

Page 128 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

DIABETIC DEVICES GUARDIAN RT MIS REPL PED Tier 3 X X DIABETIC DEVICES GUARDIAN RT MIS REPLACE Tier 3 X X DIABETIC DEVICES GUARDIAN RT MIS SYSTEM Tier 3 X X

DIABETIC DEVICES HUMATROPEN MIS FOR 12MG Tier 3 X

DIABETIC DEVICES HUMATROPEN MIS FOR 24MG Tier 3 X

DIABETIC DEVICES HUMATROPEN MIS FOR 6MG Tier 3 X DIABETIC DEVICES NORDIPEN 5 MIS DEVICE Tier 3 X DIABETIC DEVICES NORDIPEN DEL MIS SYSTEM Tier 3 X DIABETIC DEVICES OMNITROPE 5 MIS DEVICE Tier 3 X DIABETIC DEVICES PCA INJECTOR MIS Tier 3 X DIABETIC DEVICES REAL-TIME KIT Tier 3 X DIABETIC SUPPLIES ACCU-CHEK KIT AVA CONN Tier 1 X X X DIABETIC SUPPLIES ACCU-CHEK KIT AVIVA PL Tier 1 X X X DIABETIC SUPPLIES ACCU-CHEK KIT COMPACT Tier 1 X X DIABETIC SUPPLIES ACCU-CHEK KIT FASTCLIX Tier 1 X DIABETIC SUPPLIES ACCU-CHEK KIT MLTICLIX Tier 1 X DIABETIC SUPPLIES ACCU-CHEK KIT NANO Tier 1 X X X DIABETIC SUPPLIES ACCU-CHEK KIT SOFTCLIX Tier 1 X DIABETIC SUPPLIES ACCU-CHEK KIT VOICEMAT Tier 1 X X X DIABETIC SUPPLIES ACCU-CHEK LIQ ACT/GLUC Tier 1 DIABETIC SUPPLIES ACCU-CHEK LIQ COMPACT Tier 1 DIABETIC SUPPLIES ACCU-CHEK LIQ SMART Tier 1 DIABETIC SUPPLIES ACCU-CHEK MIS ADAPTER Tier 3 DIABETIC SUPPLIES ACCU-CHEK MIS AVIVA Tier 3 X X DIABETIC SUPPLIES ACCU-CHEK MIS BATTERY Tier 3 DIABETIC SUPPLIES ACCU-CHEK MIS CLIP Tier 3 DIABETIC SUPPLIES ACCU-CHEK MIS MLTICLIX Tier 1 X DIABETIC SUPPLIES ACCU-CHEK MIS SPRT COM Tier 3 DIABETIC SUPPLIES ACCU-CHEK SOL Tier 1 DIABETIC SUPPLIES ACCU-CHEK SOL COMFORT Tier 1 DIABETIC SUPPLIES ACCU-CHEK SOL COMPACT Tier 1 DIABETIC SUPPLIES ACCU-CHEK IN LIQ CONTROL Tier 1 DIABETIC SUPPLIES ACCUTREND SOL GLUCOSE Tier 1 DIABETIC SUPPLIES ADV LANCING MIS DEVICE Tier 3 X DIABETIC SUPPLIES ASCENSIA LIQ NORM CON Tier 2 DIABETIC SUPPLIES ASSURE CMFRT MIS 28G Tier 3 X DIABETIC SUPPLIES ASSURE CMFRT MIS 30G Tier 3 X DIABETIC SUPPLIES AT LAST KIT GLUCOSE Tier 3 X DIABETIC SUPPLIES AT LAST MIS LANCETS Tier 3 X DIABETIC SUPPLIES AURORA LANCE MIS 30G Tier 3 X

DIABETIC SUPPLIES AURORA LANCE MIS THIN 23G Tier 3 X DIABETIC SUPPLIES AUTODISC LIQ LOW/HIGH Tier 2 DIABETIC SUPPLIES AUTOLET II KIT CLINISAF Tier 3 X DIABETIC SUPPLIES AUTOLET LANC MIS DEVICE Tier 3 X DIABETIC SUPPLIES AUTOLET LITE KIT STARTER Tier 3 X DIABETIC SUPPLIES AUTOLET MINI MIS Tier 3 X DIABETIC SUPPLIES AUTOPEN MIS 1-21UNIT Tier 3 DIABETIC SUPPLIES AUTOPEN MIS 2-42UNIT Tier 3 DIABETIC SUPPLIES BAYER BREEZE KIT 2 SYSTEM Tier 3 X X X DIABETIC SUPPLIES BAYER BREEZE LIQ HIGH CNT Tier 2

DIABETIC SUPPLIES BAYER BREEZE LIQ LOW CNTL Tier 2

Page 129 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

DIABETIC SUPPLIES BAYER BREEZE LIQ NORM CNT Tier 2

DIABETIC SUPPLIES BAYER MICRLT MIS LANC DVC Tier 3 X DIABETIC SUPPLIES BAYER MICRLT MIS LANCETS Tier 3 X

DIABETIC SUPPLIES BLOOD GLUC MIS MONITOR Tier 3 X DIABETIC SUPPLIES BREEZE 2 MIS SYSTEM Tier 3 X X X DIABETIC SUPPLIES CAREONE ADV MIS LANCING Tier 3 X DIABETIC SUPPLIES CAREONE LANC MIS 28G Tier 3 X

DIABETIC SUPPLIES CAREONE LANC MIS THIN 23G Tier 3 X DIABETIC SUPPLIES CARTRIDGE MIS 3.15ML Tier 2 DIABETIC SUPPLIES CARTRIDGE MIS IR 1000 Tier 2 DIABETIC SUPPLIES CARTRIDGE MIS IR 1200 Tier 2 DIABETIC SUPPLIES CARTRIDGE MIS PUMP Tier 2 DIABETIC SUPPLIES CGMS MIS SOFTWARE Tier 3 X DIABETIC SUPPLIES CGMS CABLE MIS Tier 3 X DIABETIC SUPPLIES CHEMSTRIP BG MIS LOG Tier 1 DIABETIC SUPPLIES CHOICE DM KIT RISK TST Tier 3 X DIABETIC SUPPLIES COAGUCHEK MIS LANCETS Tier 3 X DIABETIC SUPPLIES COMFORT MIS LANCETS Tier 3 X

DIABETIC SUPPLIES COMFORT SET MIS 23"/17MM Tier 2

DIABETIC SUPPLIES COMFORT SET MIS 31"/17MM Tier 2

DIABETIC SUPPLIES COMFORT SET MIS 32"/17MM Tier 2

DIABETIC SUPPLIES COMFORT SET MIS 43"/17MM Tier 2

DIABETIC SUPPLIES COMFORT SHRT MIS 23"/13MM Tier 2

DIABETIC SUPPLIES COMFORT SHRT MIS 31"/13MM Tier 2

DIABETIC SUPPLIES COMFORT SHRT MIS 32"/13MM Tier 2

DIABETIC SUPPLIES COMFORT SHRT MIS 43"/13MM Tier 2 DIABETIC SUPPLIES COMFORTOUCH MIS LANCET Tier 3 X DIABETIC SUPPLIES CONTOUR KIT LINK Tier 3 X X X DIABETIC SUPPLIES CONTOUR KIT MONITOR Tier 3 X X X DIABETIC SUPPLIES CONTOUR KIT NEXT Tier 3 X X X DIABETIC SUPPLIES CONTOUR KIT NEXT EZ Tier 3 X X X DIABETIC SUPPLIES CONTOUR KIT NEXT LNK Tier 3 X X X DIABETIC SUPPLIES CONTOUR KIT NEXT USB Tier 3 X X X DIABETIC SUPPLIES CONTOUR LIQ HIGH CNT Tier 2 DIABETIC SUPPLIES CONTOUR LIQ LOW CNTL Tier 2 DIABETIC SUPPLIES CONTOUR LIQ NORM CNT Tier 2 DIABETIC SUPPLIES CONTOUR MIS MONITOR Tier 3 X X X DIABETIC SUPPLIES CONTOUR MIS MONITOR Tier 3 X X DIABETIC SUPPLIES CONTOUR SOL NEXT Tier 2 DIABETIC SUPPLIES CONTOUR SOL NEXT Tier 2

DIABETIC SUPPLIES CONTROL HIGH SOL UNISTRIP Tier 2

DIABETIC SUPPLIES CONTROL LOW SOL UNISTRIP Tier 2 DIABETIC SUPPLIES CONTROL SOL LIQ HI/MID/L Tier 2

Page 130 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

DIABETIC SUPPLIES CONTROL SOL LIQ HIGH/LOW Tier 2 DIABETIC SUPPLIES CONTROL SOL LIQ MID Tier 2 DIABETIC SUPPLIES CVS LANCETS MIS ORIGINAL Tier 3 X DIABETIC SUPPLIES CVS LANCETS MIS THIN 26G Tier 3 X DIABETIC SUPPLIES CVS LANCETS MIS THIN 33G Tier 3 X DIABETIC SUPPLIES DIDGET KIT Tier 3 X X DIABETIC SUPPLIES EASYMAX SOL HIGH Tier 2 DIABETIC SUPPLIES EASYMAX SOL LOW Tier 2 DIABETIC SUPPLIES EASYMAX SOL NORMAL Tier 2 DIABETIC SUPPLIES EASYMAX 15 SOL LEVEL 1 Tier 2 DIABETIC SUPPLIES EASYMAX 15 SOL LEVEL 2 Tier 2 DIABETIC SUPPLIES EASYMAX L KIT SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX L MIS SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX N KIT SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX N MIS SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX NG KIT SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX NG MIS SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX V KIT SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX V MIS SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX V2 KIT SYSTEM Tier 3 X DIABETIC SUPPLIES EASYMAX V2 MIS SYSTEM Tier 3 X DIABETIC SUPPLIES EASYPLS R13N KIT SYSTEM Tier 3 X DIABETIC SUPPLIES EASYPLUS V KIT SYSTEM Tier 3 X DIABETIC SUPPLIES EMBRACE MIS Tier 3 X DIABETIC SUPPLIES EMBRACE SOL LOW Tier 2 DIABETIC SUPPLIES ENLITE MIS SERTER Tier 2 DIABETIC SUPPLIES ENLITE GLUCO MIS SENSOR Tier 3 X X DIABETIC SUPPLIES FASTCLIX MIS LANCETS Tier 1 X DIABETIC SUPPLIES FINGERSTIX MIS LANCETS Tier 3 X DIABETIC SUPPLIES FLEXLINK MIS PLS/10MM Tier 2 DIABETIC SUPPLIES FLEXLINK MIS PLUS/6MM Tier 2 DIABETIC SUPPLIES FLEXLINK MIS PLUS/8MM Tier 2 DIABETIC SUPPLIES FORA GD50 MIS MONITOR Tier 3 X DIABETIC SUPPLIES FORA TEST N' MIS GO Tier 3 X DIABETIC SUPPLIES FORTISCARE KIT SYSTEM Tier 3 X DIABETIC SUPPLIES FORTISCARE SOL CNTL HI Tier 2 DIABETIC SUPPLIES FORTISCARE SOL CNTL LOW Tier 2 DIABETIC SUPPLIES FORTISCARE SOL CNTL NML Tier 2 DIABETIC SUPPLIES FREESTYLE MIS UNISTICK Tier 3 X DIABETIC SUPPLIES GENTLE-LET MIS 26G Tier 3 X DIABETIC SUPPLIES GENTLE-LET MIS 28G Tier 3 X DIABETIC SUPPLIES GENTLE-LET MIS LANCETS Tier 3 X DIABETIC SUPPLIES GENTLE-LET MIS PLATFORM Tier 3 X DIABETIC SUPPLIES GLUC CONTROL SOL LEVEL 1 Tier 2 DIABETIC SUPPLIES GLUC CONTROL SOL LEVEL 2 Tier 2 DIABETIC SUPPLIES GLUCOLET 2 MIS LANCING Tier 3 X

DIABETIC SUPPLIES GLUCOSE CONT LIQ HIGH/LOW Tier 2

DIABETIC SUPPLIES GLUCOSE CONT SOL PRECISIO Tier 2 DIABETIC SUPPLIES GMATE CONTRO SOL LEVEL 2 Tier 2 DIABETIC SUPPLIES GMATE LANCET MIS 30G Tier 3 X DIABETIC SUPPLIES GMATE LANCIN MIS DEVICE Tier 3 X

DIABETIC SUPPLIES GMATE ORIGIN MIS GLUC SYS Tier 3 X X DIABETIC SUPPLIES GMATE SMART KIT METER Tier 3 X X

Page 131 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty DIABETIC SUPPLIES GMATE SMART KIT STARTER Tier 3 X X DIABETIC SUPPLIES GMATE VOICE MIS GLUC SYS Tier 3 X X

DIABETIC SUPPLIES GUARDIAN MIS TRANSMTR Tier 3 X X

DIABETIC SUPPLIES GUARDIAN RT MIS CHARGER Tier 3 X

DIABETIC SUPPLIES GUARDIAN RT MIS SOFTWARE Tier 3 X

DIABETIC SUPPLIES GUARDIAN RT MIS TST PLUG Tier 3 X

DIABETIC SUPPLIES HAEMOLANCE MIS LOW FLOW Tier 3 X DIABETIC SUPPLIES HAEMOLANCE MIS RETRACT Tier 3 X DIABETIC SUPPLIES HUMAPEN MIS LUXURA Tier 3 DIABETIC SUPPLIES IN TOUCH MIS Tier 3 DIABETIC SUPPLIES INFUSION SET MIS 23" Tier 2

DIABETIC SUPPLIES INFUSION SET MIS 23" 13MM Tier 2

DIABETIC SUPPLIES INFUSION SET MIS 23" 17MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 23" 6MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 23" 8MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 23" 9MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 23"/6MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 23"/9MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 24" Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 24" 6MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 24" 9MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 31" Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 31" 6MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 31" 9MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 32" 8MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 42" 6MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 42" 9MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 43" Tier 2

DIABETIC SUPPLIES INFUSION SET MIS 43" 13MM Tier 2

DIABETIC SUPPLIES INFUSION SET MIS 43" 17MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 43" 6MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 43" 8MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 43" 9MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 43"/6MM Tier 2 DIABETIC SUPPLIES INFUSION SET MIS 43"/9MM Tier 2 DIABETIC SUPPLIES KROGER BGM KIT Tier 3 X X DIABETIC SUPPLIES LANCET ALTER MIS SITE 26G Tier 3 X DIABETIC SUPPLIES LANCET CARRY MIS CASE Tier 3 X

DIABETIC SUPPLIES LANCET SUPER MIS THIN 30G Tier 3 X DIABETIC SUPPLIES LANCET ULTRA MIS 28G Tier 3 X

DIABETIC SUPPLIES LANCET ULTRA MIS THIN 28G Tier 3 X DIABETIC SUPPLIES LANCETS MIS 23G Tier 3 X DIABETIC SUPPLIES LANCETS MIS 28G Tier 3 X

DIABETIC SUPPLIES LANCETS MICR MIS THIN 33G Tier 3 X DIABETIC SUPPLIES LANCETS THIN MIS Tier 3 X

Page 132 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty DIABETIC SUPPLIES LANCETS ULTR MIS THIN 28G Tier 3 X DIABETIC SUPPLIES LANCETS ULTR MIS THIN 30G Tier 3 X DIABETIC SUPPLIES LANCING DEVI MIS Tier 3 X DIABETIC SUPPLIES LB LANCET MIS 28G Tier 3 X DIABETIC SUPPLIES LB LANCING MIS DEVICE Tier 3 X DIABETIC SUPPLIES LIFESCAN MIS UNISTIK2 Tier 1 X DIABETIC SUPPLIES LINK ASSIST MIS ACCU-CHK Tier 3 DIABETIC SUPPLIES MEDISENSE LIQ GLUC/KET Tier 2 DIABETIC SUPPLIES MEDISENSE LIQ GLUC-KET Tier 2 DIABETIC SUPPLIES MEIJER MIS LANCETS Tier 3 X DIABETIC SUPPLIES MICROLET MIS LANCETS Tier 3 X DIABETIC SUPPLIES MINI LANCING MIS DEVICE Tier 3 X DIABETIC SUPPLIES MINILINK RT KIT REPLACE Tier 3 DIABETIC SUPPLIES MINILINK RT KIT STARTER Tier 3 DIABETIC SUPPLIES MINILINK RT MIS TRANSMIT Tier 3

DIABETIC SUPPLIES MINIMED PUMP MIS RES 3ML Tier 2 DIABETIC SUPPLIES MIO INF SET MIS 18"/6MM Tier 2 DIABETIC SUPPLIES MIO INF SET MIS 23"/6MM Tier 2 DIABETIC SUPPLIES MIO INF SET MIS 32"/6MM Tier 2 DIABETIC SUPPLIES MIO INF SET MIS 32"/9MM Tier 2 DIABETIC SUPPLIES NEUTEK 2TEK SOL CONTROL Tier 2 DIABETIC SUPPLIES NOVOPEN ECHO MIS Tier 3 DIABETIC SUPPLIES ON CALL MIS LANCETS Tier 3 X DIABETIC SUPPLIES ON CALL EXPR KIT SYSTEM Tier 3 X DIABETIC SUPPLIES ON CALL EXPR MIS METER Tier 3 X DIABETIC SUPPLIES ON CALL EXPR SOL GLUCOSE Tier 2 DIABETIC SUPPLIES ON CALL LANC MIS DEVICE Tier 3 X DIABETIC SUPPLIES ON CALL PLUS KIT METER Tier 3 X DIABETIC SUPPLIES ON CALL PLUS KIT MONITOR Tier 3 X DIABETIC SUPPLIES ON CALL PLUS MIS LANC DEV Tier 3 X DIABETIC SUPPLIES ON CALL PLUS MIS LANCETS Tier 3 X DIABETIC SUPPLIES ON CALL PLUS MIS METER Tier 3 X DIABETIC SUPPLIES ON CALL PLUS SOL CONTROL Tier 2 DIABETIC SUPPLIES ON CALL VIVD KIT METER Tier 3 X DIABETIC SUPPLIES ON CALL VIVD KIT MONITOR Tier 3 X DIABETIC SUPPLIES ON CALL VIVD MIS METER Tier 3 X DIABETIC SUPPLIES ON CALL VIVD SOL CONTROL Tier 2 DIABETIC SUPPLIES ONETOUCH KIT ULT MINI Tier 1 X DIABETIC SUPPLIES ONETOUCH KIT ULTRA 2 Tier 1 X DIABETIC SUPPLIES ONETOUCH KIT ULTRALNK Tier 1 X DIABETIC SUPPLIES ONETOUCH KIT VERIO Tier 1 X DIABETIC SUPPLIES ONETOUCH KIT VERIO IQ Tier 1 X DIABETIC SUPPLIES ONETOUCH MIS 30G Tier 1 X DIABETIC SUPPLIES ONETOUCH MIS COMBO Tier 1 X DIABETIC SUPPLIES ONETOUCH MIS LANC DEV Tier 1 X DIABETIC SUPPLIES ONETOUCH MIS LANC DEV Tier 1 X DIABETIC SUPPLIES ONETOUCH MIS LANCETS Tier 1 X DIABETIC SUPPLIES ONETOUCH MIS REMOTE Tier 3 DIABETIC SUPPLIES ONETOUCH SOL ULT CONT Tier 1 DIABETIC SUPPLIES ONETOUCH SOL VERIO Tier 1 DIABETIC SUPPLIES ONETOUCH SOL VERIO-HI Tier 1 DIABETIC SUPPLIES ONETOUCH FP MIS LANCETS Tier 1 X DIABETIC SUPPLIES ONETOUCH US MIS LANCETS Tier 1 X DIABETIC SUPPLIES ONETOUCH VER KIT SYNC Tier 1 X DIABETIC SUPPLIES OPTIUM KIT BL GLUC Tier 3 X X DIABETIC SUPPLIES OPTIUM MIS SYSTEM Tier 3 X X

Page 133 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty DIABETIC SUPPLIES OPTUMRX KIT METER Tier 3 X DIABETIC SUPPLIES OPTUMRX KIT SYSTEM Tier 3 X

DIABETIC SUPPLIES OPTUMRX CONT SOL LEVEL1/2 Tier 2 DIABETIC SUPPLIES PARADIGM MIS UPGRADE Tier 3

DIABETIC SUPPLIES PARADIGM QR MIS POLY 24" Tier 2

DIABETIC SUPPLIES PARADIGM QR MIS POLY 42" Tier 2

DIABETIC SUPPLIES PARADIGM REA MIS TRANSMIT Tier 3 DIABETIC SUPPLIES PARADIGM RES MIS 1.8ML Tier 2 DIABETIC SUPPLIES PARADIGM RES MIS 3ML Tier 2 DIABETIC SUPPLIES PARADIGM SOF MIS -SET 24" Tier 2 DIABETIC SUPPLIES PARADIGM SOF MIS -SET 42" Tier 2 DIABETIC SUPPLIES PENLET II KIT BLOOD Tier 1 X DIABETIC SUPPLIES PENLET II MIS REPL CAP Tier 1 X DIABETIC SUPPLIES POLYFIN 24" MIS INFUSION Tier 2 DIABETIC SUPPLIES POLYFIN 42" MIS INFUSION Tier 2 DIABETIC SUPPLIES POLYFIN 42" MIS QR INFUS Tier 2 DIABETIC SUPPLIES POLYFIN 60" MIS TUBING Tier 2 DIABETIC SUPPLIES PREC NEO SYS KIT FREESTYL Tier 3 X X DIABETIC SUPPLIES PRECISION KIT LINK Tier 3 X X DIABETIC SUPPLIES PRECISION KIT XTRA Tier 3 X X DIABETIC SUPPLIES PRECISION LIQ CONTROL Tier 2 DIABETIC SUPPLIES PRECISION LIQ GLUC/KET Tier 2 DIABETIC SUPPLIES PRECISION LIQ NRML/MID Tier 2 DIABETIC SUPPLIES PRECISION MIS QID Tier 3 X X DIABETIC SUPPLIES PRECISION MIS SOF-TACT Tier 3 X X DIABETIC SUPPLIES PRECISION MIS XTRA Tier 3 X X X DIABETIC SUPPLIES PSS SAFE LAN MIS Tier 3 X DIABETIC SUPPLIES PSS SEL LANC MIS Tier 3 X DIABETIC SUPPLIES PSS SEL PLAT MIS Tier 3 X

DIABETIC SUPPLIES PUMP REMOTE MIS PROGRAM Tier 3 DIABETIC SUPPLIES PX LANCETS MIS ULT THIN Tier 3 X DIABETIC SUPPLIES QC LANCETS MIS 28G Tier 3 X DIABETIC SUPPLIES QC LANCETS MIS 30G Tier 3 X DIABETIC SUPPLIES QC LANCING MIS DEVICE Tier 3 X DIABETIC SUPPLIES QUICK-SERTER MIS INS DEV Tier 2 DIABETIC SUPPLIES QUICK-SET MIS 18"/6MM Tier 2 DIABETIC SUPPLIES QUICK-SET MIS 23"/6MM Tier 2 DIABETIC SUPPLIES QUICK-SET MIS 23"/9MM Tier 2 DIABETIC SUPPLIES QUICK-SET MIS 32"/6MM Tier 2 DIABETIC SUPPLIES QUICK-SET MIS 32"/9MM Tier 2 DIABETIC SUPPLIES QUICK-SET MIS 43"/6MM Tier 2 DIABETIC SUPPLIES QUICK-SET MIS 43"/9MM Tier 2 DIABETIC SUPPLIES QUINTET MIS SYSTEM Tier 3 X DIABETIC SUPPLIES QUINTET AC MIS SYSTEM Tier 3 X

DIABETIC SUPPLIES QUINTET CONT SOL HGH/NORM Tier 2 DIABETIC SUPPLIES RA E-ZJECT MIS 28G Tier 3 X DIABETIC SUPPLIES RA E-ZJECT MIS 33G Tier 3 X DIABETIC SUPPLIES RA E-ZJECT MIS THIN 26G Tier 3 X DIABETIC SUPPLIES RA E-ZJECT MIS THIN 28G Tier 3 X DIABETIC SUPPLIES RA E-ZJECT MIS ULT THIN Tier 3 X DIABETIC SUPPLIES RA GLUCOSE MIS MONITOR Tier 3 X

Page 134 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty DIABETIC SUPPLIES RA TRUE2GO KIT Tier 3 X DIABETIC SUPPLIES RAPID-D INF MIS 24"/10MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 24"/6MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 24"/8MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 31"/10MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 31"/6MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 31"/8MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 43"/10MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 43"/6MM Tier 2 DIABETIC SUPPLIES RAPID-D INF MIS 43"/8MM Tier 2

DIABETIC SUPPLIES RAPID-D LINK MIS TRANSFER Tier 2 DIABETIC SUPPLIES RELION LANCE MIS THIN 26G Tier 3 X DIABETIC SUPPLIES RELION ULTIM KIT SYSTEM Tier 3 X DIABETIC SUPPLIES REVEAL KIT MONITOR Tier 3 X DIABETIC SUPPLIES RIGHTSOURCE MIS METER Tier 3 X DIABETIC SUPPLIES SAFE-T-LANCE MIS 21G Tier 3 X DIABETIC SUPPLIES SAFE-T-LANCE MIS 25G Tier 3 X DIABETIC SUPPLIES SAFE-T-LANCE MIS HI FLOW Tier 3 X

DIABETIC SUPPLIES SAFE-T-LANCE MIS LOW FLOW Tier 3 X

DIABETIC SUPPLIES SAFE-T-LANCE MIS NOR FLOW Tier 3 X DIABETIC SUPPLIES SAFE-T-PRO MIS LANCETS Tier 1 X DIABETIC SUPPLIES SAFE-T-PRO MIS PLUS Tier 1 X DIABETIC SUPPLIES SELECT-LITE KIT DEV/LANC Tier 3 X DIABETIC SUPPLIES SEN-SERTER MIS Tier 2 DIABETIC SUPPLIES SILHOUETTE MIS 13MM Tier 2 DIABETIC SUPPLIES SILHOUETTE MIS 17MM Tier 2

DIABETIC SUPPLIES SILHOUETTE MIS 18"/13MM Tier 2 DIABETIC SUPPLIES SILHOUETTE MIS 23" SET Tier 2

DIABETIC SUPPLIES SILHOUETTE MIS 32"/13MM Tier 2

DIABETIC SUPPLIES SILHOUETTE MIS 32"/17MM Tier 2 DIABETIC SUPPLIES SILHOUETTE MIS 43" SET Tier 2 DIABETIC SUPPLIES SILHOUETTE MIS COMBO Tier 2 DIABETIC SUPPLIES SILHOUETTE MIS FULL SET Tier 2 DIABETIC SUPPLIES SIL-SERTER MIS INS DEV Tier 2 DIABETIC SUPPLIES SINGLE-LET MIS 23G Tier 3 X DIABETIC SUPPLIES SNAP PUMP MIS CONTROLL Tier 3 DIABETIC SUPPLIES SOF-SENSOR MIS Tier 3 X X DIABETIC SUPPLIES SOF-SERTER MIS INS DEV Tier 2 DIABETIC SUPPLIES SOF-SET 24" KIT INFUSION Tier 2 DIABETIC SUPPLIES SOF-SET 24" KIT MICRO QR Tier 2 DIABETIC SUPPLIES SOF-SET 24" KIT ULTIM QR Tier 2 DIABETIC SUPPLIES SOF-SET 42" KIT INFUSION Tier 2 DIABETIC SUPPLIES SOF-SET 42" KIT MICRO QR Tier 2 DIABETIC SUPPLIES SOF-SET 42" KIT ULTIM QR Tier 2 DIABETIC SUPPLIES SOFT TOUCH MIS LANCETS Tier 1 X DIABETIC SUPPLIES SOFTCLIX MIS LANCETS Tier 1 X DIABETIC SUPPLIES SOFTCLIX LAN MIS DEVICE Tier 1 X DIABETIC SUPPLIES SUPER THIN MIS LANCETS Tier 3 X DIABETIC SUPPLIES SUPREME II LIQ HIGH/LOW Tier 2 DIABETIC SUPPLIES SURESTEP SOL CONTROL Tier 1 DIABETIC SUPPLIES SURESTEP GLU SOL Tier 1

Page 135 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

DIABETIC SUPPLIES SURESTEP GLU SOL HIGH/LOW Tier 1 DIABETIC SUPPLIES SURESTEP PRO KIT LINEARIT Tier 1

DIABETIC SUPPLIES SURESTEP PRO TES HIGH CON Tier 1 DIABETIC SUPPLIES SURESTEP PRO TES LOW CON Tier 1

DIABETIC SUPPLIES SURESTEP PRO TES NORM CON Tier 1 DIABETIC SUPPLIES SURE-T MIS 23"/6MM Tier 2 DIABETIC SUPPLIES SURE-T MIS 23"/8MM Tier 2 DIABETIC SUPPLIES T:30 INFUSIO MIS SET Tier 2 DIABETIC SUPPLIES T:FLEX 4.8ML MIS CARTRDGE Tier 2 DIABETIC SUPPLIES T:SLIM 3ML MIS CARTRDGE Tier 2 DIABETIC SUPPLIES T:SLIM G4 MIS CARTRDGE Tier 2 DIABETIC SUPPLIES TECHLITE MIS LANCETS Tier 3 X DIABETIC SUPPLIES TEST PLUG MIS Tier 3 X DIABETIC SUPPLIES TGT LANCET MIS 23G Tier 3 X DIABETIC SUPPLIES TGT LANCET MIS 28G Tier 3 X DIABETIC SUPPLIES TGT LANCET MIS 30G Tier 3 X DIABETIC SUPPLIES TGT LANCET MIS ALTERNAT Tier 3 X DIABETIC SUPPLIES TGT LANCING MIS ADV DEV Tier 3 X DIABETIC SUPPLIES TGT LANCING MIS DEVICE Tier 3 X DIABETIC SUPPLIES THIN LANCETS MIS Tier 3 X DIABETIC SUPPLIES THINLETS GP MIS 26G Tier 3 X DIABETIC SUPPLIES TRANSMITTER MIS TAPE Tier 3 X DIABETIC SUPPLIES TRUE METRIX KIT AIR Tier 3 X DIABETIC SUPPLIES TRUE METRIX KIT METER Tier 3 X DIABETIC SUPPLIES TRUE METRIX MIS AIR Tier 3 X DIABETIC SUPPLIES TRUE METRIX SOL LEVEL 1 Tier 2 DIABETIC SUPPLIES TRUE METRIX SOL LEVEL 2 Tier 2 DIABETIC SUPPLIES TRUE METRIX SOL LEVEL 3 Tier 2 DIABETIC SUPPLIES TRUE2GO KIT Tier 3 X DIABETIC SUPPLIES TRUECONTROL LIQ LEVEL 0 Tier 2 DIABETIC SUPPLIES TRUECONTROL LIQ LEVEL 1 Tier 2 DIABETIC SUPPLIES TRUEDRAW MIS LANC DEV Tier 3 X DIABETIC SUPPLIES TRUERESULT KIT Tier 3 X DIABETIC SUPPLIES TRUERESULT KIT MONITOR Tier 3 X DIABETIC SUPPLIES TRUETEST LIQ LEVEL 1 Tier 2 DIABETIC SUPPLIES TRUETEST LIQ LEVEL 2 Tier 2 DIABETIC SUPPLIES TRUETEST LIQ LEVEL 3 Tier 2 DIABETIC SUPPLIES TRUETRACK KIT SYSTEM Tier 3 X DIABETIC SUPPLIES TRUETRACK MIS BLD GLC Tier 3 X DIABETIC SUPPLIES TRUPLUS LANC MIS 26G Tier 3 X DIABETIC SUPPLIES TRUPLUS LANC MIS 28G Tier 3 X DIABETIC SUPPLIES TRUPLUS LANC MIS 30G Tier 3 X DIABETIC SUPPLIES TRUPLUS LANC MIS 33G Tier 3 X DIABETIC SUPPLIES ULTILET OPER MIS DEVICE Tier 3 DIABETIC SUPPLIES ULTIMA KIT MONITOR Tier 3 X X DIABETIC SUPPLIES ULTRA THIN MIS LANC 26G Tier 3 X DIABETIC SUPPLIES ULTRA THIN MIS LANC 28G Tier 3 X DIABETIC SUPPLIES ULTRA THIN MIS LANC 30G Tier 3 X DIABETIC SUPPLIES ULTRA THIN MIS LANCETS Tier 3 X DIABETIC SUPPLIES ULTRAFLEX MIS 12"/6MM Tier 2 DIABETIC SUPPLIES ULTRAFLEX MIS 24"/10MM Tier 2 DIABETIC SUPPLIES ULTRAFLEX MIS 24"/6MM Tier 2 DIABETIC SUPPLIES ULTRAFLEX MIS 24"/8MM Tier 2 DIABETIC SUPPLIES ULTRAFLEX MIS 31"/10MM Tier 2

Page 136 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty DIABETIC SUPPLIES ULTRAFLEX MIS 31"/6MM Tier 2 DIABETIC SUPPLIES ULTRAFLEX MIS 31"/8MM Tier 2 DIABETIC SUPPLIES ULTRAFLEX MIS 43"/10MM Tier 2 DIABETIC SUPPLIES ULTRAFLEX MIS 43"/8MM Tier 2 DIABETIC SUPPLIES UNILET EX II MIS 28G Tier 3 X DIABETIC SUPPLIES UNILET EXCEL MIS 23G Tier 3 X DIABETIC SUPPLIES UNILET G.P MIS SUPR 23G Tier 3 X DIABETIC SUPPLIES UNILET G.P. MIS 21G Tier 3 X DIABETIC SUPPLIES UNILET LANCT MIS 33G Tier 3 X DIABETIC SUPPLIES UNILET SUPER MIS 23G Tier 3 X DIABETIC SUPPLIES UNISTIK 1 MIS 2.4MM Tier 3 X DIABETIC SUPPLIES UNISTIK 1 MIS 3.0MM Tier 3 X DIABETIC SUPPLIES UNISTIK 2 MIS 1.8MM Tier 3 X DIABETIC SUPPLIES UNISTIK 2 MIS 2.4MM Tier 3 X DIABETIC SUPPLIES UNISTIK 2 MIS EXTRA Tier 3 X DIABETIC SUPPLIES UNISTIK 2 MIS SUPER Tier 3 X DIABETIC SUPPLIES UNISTIK 3 MIS 1.8MM Tier 3 X DIABETIC SUPPLIES UNISTIK II MIS LANCETS Tier 1 X DIABETIC SUPPLIES VERIO FLEX KIT ONETOUCH Tier 1 X DIABETIC SUPPLIES VIVID PAL KIT METER Tier 3 X DIABETIC SUPPLIES VIVID PAL MIS METER Tier 3 X

DIAGNOSTIC AGENTS ADVANCED DNA KIT COLLECTI Tier 1 DIAGNOSTIC AGENTS ARIDOL KIT Tier 3 DIAGNOSTIC AGENTS CHEMSTRIP TES UGK Tier 3 DIAGNOSTIC AGENTS CHEMSTRIP K TES Tier 2 X DIAGNOSTIC AGENTS CVS KETONE TES CARE Tier 2 DIAGNOSTIC AGENTS DNA COLLECT KIT Tier 3 DIAGNOSTIC AGENTS DNA COLLECT KIT MEDICATE Tier 3 DIAGNOSTIC AGENTS DYNAMIC KIT Tier 1 DIAGNOSTIC AGENTS DYNAMIC PLUS KIT PAK Tier 3 DIAGNOSTIC AGENTS FLURA-SAFE SOL Tier 3 DIAGNOSTIC AGENTS KETOCARE TES Tier 2 X DIAGNOSTIC AGENTS KETO-DIASTIX TES Tier 3 DIAGNOSTIC AGENTS KETOSTIX TES Tier 2 X DIAGNOSTIC AGENTS KETOSTIX TES STRIP Tier 2 X DIAGNOSTIC AGENTS MEDCATED DNA KIT COLLECT Tier 3 DIAGNOSTIC AGENTS MULTI-DRUG KIT DIUSCREE Tier 3 DIAGNOSTIC AGENTS PRECISN XTRA TES KETONE Tier 3 X DIAGNOSTIC AGENTS PRO DNA KIT KIT Tier 3 DIAGNOSTIC AGENTS RELION KETON TES Tier 2 X DIAGNOSTIC AGENTS T.R.U.E. TES Tier 3

DIAGNOSTIC AGENTS - ADRENOCORTICAL INSUFFICIENCY CORTROSYN INJ 0.25MG Tier 3

DIAGNOSTIC AGENTS - ADRENOCORTICAL INSUFFICIENCY COSYNTROPIN INJ 0.25MG Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS ALTAFLUOR SOL 0.25-0.4 Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS BIO GLO TES 1MG OP Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS FLUCAINE SOL 0.25-0.5 Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS FLUORACAINE SOL OP Tier 3

Page 137 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty DIAGNOSTIC AGENTS - OCULAR DISORDERS FLUORE-BENOX SOL 0.25-0.4 Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS FLUORESCEIN/ SOL PROPARAC Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS FLUOR-I-STRI TES 1MG OP Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS FLUROX SOL OP Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS FUL-GLO TES 0.6MG OP Tier 2 DIAGNOSTIC AGENTS - OCULAR DISORDERS FUL-GLO TES 1MG OP Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS GREEN GLO MIS 1.5MG Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS LISSAMINE GR TES 1.5MG Tier 1 DIAGNOSTIC AGENTS - OCULAR DISORDERS ROSE GLO TES 1.5MG Tier 3 DIAGNOSTIC AGENTS - PITUITARY FUNCTION METOPIRONE CAP 250MG Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY ENTERO VU SUS 24% Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY E-Z-CAT DRY PAK Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY E-Z-DISK TAB 700MG Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY E-Z-DOSE ENE Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY E-Z-HD SUS 98% Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY E-Z-PAQUE SUS 60% Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY E-Z-PAQUE SUS 96% Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY E-Z-PASTE CRE 60% Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY GASTROGRAFIN SOL 66-10% Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY MD-GASTROVIE SOL 66-10% Tier 1 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY POLIBAR ACB KIT 96% Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY POLIBAR PLUS SUS 105% Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY READI-CAT 2 SUS 2.1% Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY READI-CAT 2 SUS BANANA Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY READI-CAT 2 SUS BERRY Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY READI-CAT 2 SUS MOCHACCI Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY TAGITOL V SUS 40% Tier 2 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY VARIBAR PST PUDDING Tier 3

Page 138 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty DIAGNOSTIC AGENTS - ROENTGENOGRAPHY VARIBAR HONE SUS 40% Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY VARIBAR NECT SUS 40% Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY VARIBAR THIN SUS HONEY Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY VARIBAR THIN SUS LIQUID Tier 3 DIAGNOSTIC AGENTS - ROENTGENOGRAPHY VOLUMEN SUS 0.1% Tier 2 DISINFECTANTS (FOR NON- DERMATOLOGIC USE) GLUTARALDEHY SOL 25% Tier 3 Diuretics, Loop - Cardiac Drugs BUMETANIDE TAB 0.5MG Tier 1 Diuretics, Loop - Cardiac Drugs BUMETANIDE TAB 1MG Tier 1 Diuretics, Loop - Cardiac Drugs BUMETANIDE TAB 2MG Tier 1 Diuretics, Loop - Cardiac Drugs BUMEX TAB 0.5MG Tier 3 Diuretics, Loop - Cardiac Drugs BUMEX TAB 1MG Tier 3 Diuretics, Loop - Cardiac Drugs BUMEX TAB 2MG Tier 3 Diuretics, Loop - Cardiac Drugs DEMADEX TAB 100MG Tier 3 Diuretics, Loop - Cardiac Drugs DEMADEX TAB 10MG Tier 3 Diuretics, Loop - Cardiac Drugs DEMADEX TAB 20MG Tier 3 Diuretics, Loop - Cardiac Drugs DEMADEX TAB 5MG Tier 3 Diuretics, Loop - Cardiac Drugs EDECRIN TAB 25MG Tier 3

Diuretics, Loop - Cardiac Drugs ETHACRYNIC TAB ACD 25MG Tier 1

Diuretics, Loop - Cardiac Drugs FUROSEMIDE SOL 10MG/ML Tier 1 Diuretics, Loop - Cardiac Drugs FUROSEMIDE SOL 8MG/ML Tier 1 Diuretics, Loop - Cardiac Drugs FUROSEMIDE TAB 20MG Tier 1 Diuretics, Loop - Cardiac Drugs FUROSEMIDE TAB 40MG Tier 1 Diuretics, Loop - Cardiac Drugs FUROSEMIDE TAB 80MG Tier 1 Diuretics, Loop - Cardiac Drugs LASIX TAB 20MG Tier 3 Diuretics, Loop - Cardiac Drugs LASIX TAB 40MG Tier 3 Diuretics, Loop - Cardiac Drugs LASIX TAB 80MG Tier 3 Diuretics, Loop - Cardiac Drugs TORSEMIDE TAB 100MG Tier 1 Diuretics, Loop - Cardiac Drugs TORSEMIDE TAB 10MG Tier 1 Diuretics, Loop - Cardiac Drugs TORSEMIDE TAB 20MG Tier 1 Diuretics, Loop - Cardiac Drugs TORSEMIDE TAB 5MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs ALDACTAZIDE TAB 25/25 Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs ALDACTAZIDE TAB 50/50 Tier 2 Diuretics, Potassium-sparing - Cardiac Drugs ALDACTONE TAB 100MG Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs ALDACTONE TAB 25MG Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs ALDACTONE TAB 50MG Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs AMILOR/HCTZ TAB 5-50 Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs AMILORIDE TAB 5MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs DYAZIDE CAP 37.5-25 Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs DYRENIUM CAP 100MG Tier 3

Page 139 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Diuretics, Potassium-sparing - Cardiac Drugs DYRENIUM CAP 50MG Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs EPLERENONE TAB 25MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs EPLERENONE TAB 50MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs INSPRA TAB 25MG Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs INSPRA TAB 50MG Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs MAXZIDE TAB 75-50 Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs MAXZIDE-25 TAB Tier 3 Diuretics, Potassium-sparing - Cardiac Drugs SPIRONO/HCTZ TAB 25/25 Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs SPIRONOLACT POW Tier 3 X Diuretics, Potassium-sparing - Cardiac Drugs SPIRONOLACT TAB 100MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs SPIRONOLACT TAB 25MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs SPIRONOLACT TAB 50MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs TRIAMT/HCTZ CAP 37.5-25 Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs TRIAMT/HCTZ CAP 50/25 Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs TRIAMT/HCTZ CAP 50-25MG Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs TRIAMT/HCTZ TAB 37.5-25 Tier 1 Diuretics, Potassium-sparing - Cardiac Drugs TRIAMT/HCTZ TAB 75-50MG Tier 1

Diuretics, Thiazide - Cardiac Drugs CHLOROTHIAZ TAB 250MG Tier 1

Diuretics, Thiazide - Cardiac Drugs CHLOROTHIAZ TAB 500MG Tier 1

Diuretics, Thiazide - Cardiac Drugs CHLORTHALID TAB 100MG Tier 1

Diuretics, Thiazide - Cardiac Drugs CHLORTHALID TAB 25MG Tier 1

Diuretics, Thiazide - Cardiac Drugs CHLORTHALID TAB 50MG Tier 1

Diuretics, Thiazide - Cardiac Drugs DIURIL SUS 250/5ML Tier 2

Diuretics, Thiazide - Cardiac Drugs EZIDE TAB 50MG Tier 1

Diuretics, Thiazide - Cardiac Drugs HYDROCHLOROT CAP 12.5MG Tier 1

Diuretics, Thiazide - Cardiac Drugs HYDROCHLOROT TAB 12.5MG Tier 1

Diuretics, Thiazide - Cardiac Drugs HYDROCHLOROT TAB 25MG Tier 1

Diuretics, Thiazide - Cardiac Drugs HYDROCHLOROT TAB 50MG Tier 1

Page 140 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Diuretics, Thiazide - Cardiac Drugs INDAPAMIDE TAB 1.25MG Tier 1

Diuretics, Thiazide - Cardiac Drugs INDAPAMIDE TAB 2.5MG Tier 1

Diuretics, Thiazide - Cardiac Drugs METHYCLOTHIA TAB 5MG Tier 1

Diuretics, Thiazide - Cardiac Drugs METOLAZONE TAB 10MG Tier 1

Diuretics, Thiazide - Cardiac Drugs METOLAZONE TAB 2.5MG Tier 1

Diuretics, Thiazide - Cardiac Drugs METOLAZONE TAB 5MG Tier 1

Diuretics, Thiazide - Cardiac Drugs MICROZIDE CAP 12.5MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs APOKYN INJ 10MG/ML Tier 2 X Dopamine Agonists - Parkinson's Disease Drugs BROMOCRIPTIN CAP 5MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs BROMOCRIPTIN TAB 2.5MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX TAB 0.125MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX TAB 0.25MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX TAB 0.5MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX TAB 0.75MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX TAB 1.5MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX TAB 1MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX ER TAB 0.375MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX ER TAB 0.75MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX ER TAB 1.5MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX ER TAB 2.25MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX ER TAB 3.75MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX ER TAB 3MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs MIRAPEX ER TAB 4.5MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs PARLODEL CAP 5MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 0.125MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 0.25MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 0.375MG Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 0.5MG Tier 1

Page 141 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 0.75 ER Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 0.75MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 1.5MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 1.5MG ER Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 1MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 2.25MG Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 3.75MG Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 3MG Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs PRAMIPEXOLE TAB 4.5MG Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs REQUIP TAB 0.25MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs REQUIP TAB 0.5MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs REQUIP TAB 1MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs REQUIP TAB 2MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs REQUIP TAB 3MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs REQUIP TAB 4MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs REQUIP TAB 5MG Tier 3 Dopamine Agonists - Parkinson's Disease Drugs REQUIP XL TAB 12MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs REQUIP XL TAB 2MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs REQUIP XL TAB 4MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs REQUIP XL TAB 6MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs REQUIP XL TAB 8MG Tier 3 X Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 0.25MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 0.5MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 12MG ER Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 1MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 2MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 2MG ER Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 3MG Tier 1

Page 142 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 4MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 4MG ER Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 5MG Tier 1 Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 6MG ER Tier 1 X Dopamine Agonists - Parkinson's Disease Drugs ROPINIROLE TAB 8MG ER Tier 1 X

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO TAB 10-100MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO TAB 10-100MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO TAB 25-100MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO TAB 25-100MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO TAB 25-250MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO TAB 25-250MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO 50 TAB /ENTACAP Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO 75 TAB /ENTACAP Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO ER TAB 25-100MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO ER TAB 50-200MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO100 TAB /ENTACAP Tier 1

Page 143 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO125 TAB /ENTACAP Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO150 TAB /ENTACAP Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARB/LEVO200 TAB /ENTACAP Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs CARBIDOPA TAB 25MG Tier 1

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs DUOPA SUS 4.63-20 Tier 3 X

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs LODOSYN TAB 25MG Tier 3 X

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs RYTARY CAP Tier 3 X

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs RYTARY CAP Tier 3 X

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs RYTARY CAP Tier 3 X

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs RYTARY CAP 23.75-95 Tier 3 X

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs SINEMET TAB 10-100MG Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs SINEMET TAB 25-100MG Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs SINEMET TAB 25-250MG Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs SINEMET CR TAB 25-100MG Tier 3

Page 144 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs SINEMET CR TAB 50-200MG Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs STALEVO 100 TAB Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs STALEVO 125 TAB Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs STALEVO 150 TAB Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs STALEVO 200 TAB Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs STALEVO 50 TAB Tier 3

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs STALEVO 75 TAB Tier 3 Dyslipidemics - Cholesterol Control Drugs NIACIN POW USP/NF Tier 3

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs ANTARA CAP 30MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs ANTARA CAP 90MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE CAP 130MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE CAP 134MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE CAP 150MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE CAP 200MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE CAP 43MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE CAP 50MG Tier 1 X

Page 145 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE CAP 67MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE TAB 120MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE TAB 145MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE TAB 160MG Tier 1

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE TAB 40MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE TAB 48MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRATE TAB 54MG Tier 1

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRIC CAP 135MG DR Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRIC CAP 45MG DR Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRIC TAB 105MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOFIBRIC TAB 35MG Tier 1 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOGLIDE TAB 120MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FENOGLIDE TAB 40MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FIBRICOR TAB 105MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs FIBRICOR TAB 35MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs GEMFIBROZIL TAB 600MG Tier 1

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LIPOFEN CAP 150MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LIPOFEN CAP 50MG Tier 3 X

Page 146 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LOFIBRA CAP 134MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LOFIBRA CAP 200MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LOFIBRA CAP 67MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LOFIBRA TAB 160MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LOFIBRA TAB 54MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs LOPID TAB 600MG Tier 3

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs TRICOR TAB 145MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs TRICOR TAB 48MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs TRIGLIDE TAB 160MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs TRILIPIX CAP 135MG Tier 3 X

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs TRILIPIX CAP 45MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ADVICOR TAB 1000-20 Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ADVICOR TAB 1000-40 Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ADVICOR TAB 500-20MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ADVICOR TAB 750-20MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ALTOPREV TAB 20MG ER Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ALTOPREV TAB 40MG ER Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ALTOPREV TAB 60MG ER Tier 3 X X

Page 147 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ATORVASTATIN TAB 10MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ATORVASTATIN TAB 20MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ATORVASTATIN TAB 40MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ATORVASTATIN TAB 80MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs CRESTOR TAB 10MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs CRESTOR TAB 20MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs CRESTOR TAB 40MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs CRESTOR TAB 5MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs FLUVASTATIN CAP 20MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs FLUVASTATIN CAP 40MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs FLUVASTATIN TAB 80MG ER Tier 1 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LESCOL CAP 20MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LESCOL CAP 40MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LESCOL XL TAB 80MG Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LIPITOR TAB 10MG Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LIPITOR TAB 20MG Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LIPITOR TAB 40MG Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LIPITOR TAB 80MG Tier 3 X X

Page 148 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LIVALO TAB 1MG Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LIVALO TAB 2MG Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LIVALO TAB 4MG Tier 3 X X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LOVASTATIN TAB 10MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LOVASTATIN TAB 20MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs LOVASTATIN TAB 40MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs MEVACOR TAB 40MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs PRAVACHOL TAB 20MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs PRAVACHOL TAB 40MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs PRAVACHOL TAB 80MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs PRAVASTATIN TAB 10MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs PRAVASTATIN TAB 20MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs PRAVASTATIN TAB 40MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs PRAVASTATIN TAB 80MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ROSUVASTATIN TAB 10MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ROSUVASTATIN TAB 20MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ROSUVASTATIN TAB 40MG Tier 1 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ROSUVASTATIN TAB 5MG Tier 1 X

Page 149 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMCOR TAB 1000-20 Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMCOR TAB 1000-40 Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMCOR TAB 500-20MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMCOR TAB 500-40MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMCOR TAB 750-20MG Tier 3 X

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMVASTATIN TAB 10MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMVASTATIN TAB 20MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMVASTATIN TAB 40MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMVASTATIN TAB 5MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs SIMVASTATIN TAB 80MG Tier 1

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ZOCOR TAB 10MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ZOCOR TAB 20MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ZOCOR TAB 40MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ZOCOR TAB 5MG Tier 3

Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs ZOCOR TAB 80MG Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs CHOLESTYRAM POW 4GM Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs CHOLESTYRAM POW 4GM Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs CHOLESTYRAM POW 4GM LITE Tier 1

Page 150 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs CHOLESTYRAM POW 4GM LITE Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTID GRA 5GM Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTID POW 5GM Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTID TAB 1GM Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTID FLA GRA 5/7.5GM Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTID FLA GRA 5GM Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTIPOL GRA 5GM Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTIPOL GRA 5GM Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs COLESTIPOL TAB 1GM Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs JUXTAPID CAP 10MG Tier 3 X X X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs JUXTAPID CAP 20MG Tier 3 X X X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs JUXTAPID CAP 30MG Tier 3 X X X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs JUXTAPID CAP 40MG Tier 3 X X X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs JUXTAPID CAP 5MG Tier 3 X X X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs JUXTAPID CAP 60MG Tier 3 X X X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs KYNAMRO INJ 200MG/ML Tier 3 X X X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs LOVAZA CAP 1GM Tier 3 X X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs NIACIN ER TAB 1000MG Tier 1

Page 151 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs NIACIN ER TAB 500MG Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs NIACIN ER TAB 750MG Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs NIACOR TAB 500MG Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs NIASPAN TAB 1000 ER Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs NIASPAN TAB 500MG ER Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs NIASPAN TAB 750MG ER Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs OMEGA-3-ACID CAP 1GM Tier 1 X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs PREVALITE POW 4GM Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs PREVALITE POW 4GM PK Tier 1

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs QUESTRAN POW 4GM Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs QUESTRAN POW 4GM Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs QUESTRAN POW 4GM LITE Tier 3

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs VASCEPA CAP 1GM Tier 3 X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs VYTORIN TAB 10-10MG Tier 3 X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs VYTORIN TAB 10-20MG Tier 3 X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs VYTORIN TAB 10-40MG Tier 3 X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs VYTORIN TAB 10-80MG Tier 3 X

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs WELCHOL PAK 3.75GM Tier 2

Page 152 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs WELCHOL TAB 625MG Tier 2

Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs ZETIA TAB 10MG Tier 3 X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs CHEMET CAP 100MG Tier 2 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs CUPRIMINE CAP 250MG Tier 3 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs DEPEN TITRA TAB 250MG Tier 2 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs EXJADE TAB 125MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs EXJADE TAB 250MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs EXJADE TAB 500MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs JADENU TAB 180MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs JADENU TAB 360MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs JADENU TAB 90MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs KAYEXALATE POW Tier 3 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs KIONEX POW Tier 1 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs KIONEX SUS 15GM/60 Tier 1 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SAMSCA TAB 15MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SAMSCA TAB 30MG Tier 2 X X Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SOD POLY SUL POW Tier 1 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SOD POLY SUL SUS 15GM/60 Tier 1

Page 153 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SOD POLY SUL SUS 30/120ML Tier 1 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SOD POLY SUL SUS 50/200ML Tier 1 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SPS SUS 15GM/60 Tier 1 Electrolyte/Mineral Modifiers - Vitamin, Mineral and Body Fluid Deficiency Drugs SYPRINE CAP 250MG Tier 3 X X

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs CALC ACETATE CAP 667MG Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs CALC ACETATE TAB 667MG Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs ELIPHOS TAB 667MG Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON POW 20MEQ Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON 10 TAB 10MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON 8 TAB 8MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON M10 TAB 10MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON M15 TAB 15MEQ ER Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON M20 TAB 20MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON SPR CAP 10MEQ Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON SPR CAP 8MEQ Tier 1

Page 154 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON/25 POW 25MEQ Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs KLOR-CON-25 POW 25MEQ Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs K-SOL SOL 10% Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs K-SOL SOL 20% Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs K-TAB TAB 10MEQ CR Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs K-TAB TAB 20MEQ Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs K-TAB TAB 8MEQ CR Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs MICRO-K CAP 10MEQ CR Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs MICRO-K CAP 8MEQ CR Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs PHOSLO CAP 667MG Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs PHOSLYRA SOL Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE CAP 10MEQ CR Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE CAP 10MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE CAP 8MEQ ER Tier 1

Page 155 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE POW 20MEQ Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE SOL 10% Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE SOL 10% SF Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE SOL 20% Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE SOL 20% SF Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE TAB 10MEQ CR Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE TAB 10MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE TAB 20MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE TAB 8MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CHLORIDE TAB 8MEQ SR Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CITRATE TAB 1080MG Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CITRATE TAB 1620MG Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CITRATE TAB 540MG ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CL MICRO TAB 10MEQ CR Tier 1

Page 156 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CL MICRO TAB 10MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs POT CL MICRO TAB 20MEQ ER Tier 1

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs SOD CHLORIDE GRA Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs SODIUM POW CHLORIDE Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs UROCIT-K 10 TAB Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs UROCIT-K 15 TAB Tier 3

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs UROCIT-K 5 TAB Tier 3 Electrolytes/Minerals - Electrolytes and Minerals CITRIC ACID/ SOL SOD CITR Tier 1 Electrolytes/Minerals - Electrolytes HCR and Minerals CITROMA SOL CHERRY Preventative Electrolytes/Minerals - Electrolytes HCR and Minerals CITROMA SOL LEMON Preventative Electrolytes/Minerals - Electrolytes and Minerals CYTRA K GRA CRYSTALS Tier 1 Electrolytes/Minerals - Electrolytes and Minerals CYTRA-2 SOL Tier 1 Electrolytes/Minerals - Electrolytes and Minerals CYTRA-3 SYP Tier 1 Electrolytes/Minerals - Electrolytes and Minerals CYTRA-K SOL Tier 1 Electrolytes/Minerals - Electrolytes and Minerals K CITRATE SOL CITR ACD Tier 1 Electrolytes/Minerals - Electrolytes and Minerals K/NA CITRATE SOL CITR ACD Tier 1 Electrolytes/Minerals - Electrolytes HCR and Minerals MAG CITRATE SOL CHERRY Preventative Electrolytes/Minerals - Electrolytes HCR and Minerals MAG CITRATE SOL GRAPE Preventative Electrolytes/Minerals - Electrolytes HCR and Minerals MAG CITRATE SOL LEMON Preventative Electrolytes/Minerals - Electrolytes and Minerals MED CIT MAGN SOL Tier 1 Electrolytes/Minerals - Electrolytes and Minerals ORACIT SOL Tier 2

Page 157 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Electrolytes/Minerals - Electrolytes and Minerals POT CITRATE- PAK CIT ACID Tier 1 Electrolytes/Minerals - Electrolytes and Minerals SHOHLS SOL MODIFIED Tier 2 Electrolytes/Minerals - Electrolytes and Minerals SOD CITRATE SOL CITR ACD Tier 1 Electrolytes/Minerals - Electrolytes and Minerals TARON GRA CRYSTALS Tier 1 Electrolytes/Minerals - Electrolytes and Minerals TAURINE CAP 500MG Tier 1 Electrolytes/Minerals - Electrolytes and Minerals TRICITRATES SOL Tier 1 Electrolytes/Minerals - Electrolytes and Minerals VIRTRATE-2 SOL Tier 1 Electrolytes/Minerals - Electrolytes and Minerals VIRTRATE-2 SOL 500-334 Tier 1 Electrolytes/Minerals - Electrolytes and Minerals VIRTRATE-3 SOL Tier 1 Electrolytes/Minerals - Electrolytes and Minerals VIRTRATE-K SOL Tier 1 Electrolytes/Minerals - Electrolytes and Minerals VIRTRATE-K SOL 1100-334 Tier 1 Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORABON DRO Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUOR-A-DAY DRO 0.125MG Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORIDE CHW 0.25MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORIDE CHW 0.5MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORIDE CHW 1MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORITAB CHW 0.25MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORITAB CHW 0.5MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORITAB CHW 1MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORITAB CHW 2.2MG Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLUORITAB DRO 0.125MG Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLURA-DROPS DRO 0.125MG Preventative

Page 158 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs FLURA-DROPS DRO 0.25MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs KARIDIUM DRO 0.125MG Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs LOZI-FLUR LOZ 1MG F Tier 2 Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs LUDENT CHW 0.25MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs LUDENT CHW 0.5MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs LUDENT CHW 1MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs LURIDE CHW 0.25MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs LURIDE CHW 0.5MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs LURIDE CHW 1MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs LURIDE DRO 0.5MG/ML Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs NAFRINSE CHW 1MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs NAFRINSE DRO 0.125MG Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs SOD FLUORIDE CHW 0.25MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs SOD FLUORIDE CHW 0.5MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs SOD FLUORIDE CHW 1.1MG Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs SOD FLUORIDE CHW 1MG F Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs SOD FLUORIDE CHW 2.2MG Preventative Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency HCR Drugs SOD FLUORIDE DRO 0.5MG/ML Preventative

Page 159 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs SOD FLUORIDE TAB 0.5MG F Tier 1 Electrolytes/Minerals - Vitamin, Mineral and Body Fluid Deficiency Drugs SOD FLUORIDE TAB 1MG F Tier 1

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CHEK TES ACTIVE Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CHEK TES AVIVA Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CHEK TES AVIVA PL Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CHEK TES COMFORT Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CHEK TES COMPACT Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CHEK TES DRUM Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CHEK TES SMART Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCU-CK COMF TES CURVE Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ACCUTREND TES GLUCOSE Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ASCENSIA MIS AUTODISC Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS AT LAST TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS BAYER BREEZE MIS 2 TEST Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS BAYER BREEZE MIS 2 TEST Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS BLOOD GLUCOS TES PREMIUM Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS BLOOD GLUCOS TES STRIPS Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS CLINISTIX TES STRIPS Tier 3

Page 160 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS CONTOUR TES BLD GLUC Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS CONTOUR TES NEXT Tier 3 X X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS CVS ADVANCED TES GLUCOSE Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS DIASTIX TES STRIPS Tier 3

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS EASYMAX TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS EASYMAX 15 TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS EASYPLUS TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS EMBRACE TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS EXACTECH TES Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS EXACTECH TES R-S-G Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS FORA GD50 TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS FORTISCARE TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS FREESTYLE TES PREC NEO Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS GENSTRIP 50 TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS GLUTAMINE POW Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS GLUTATHIONE POW Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS GLUTATHIONE POW REDUCED Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS GMATE BLOOD TES GLUCOSE Tier 3 X

Page 161 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS KROGER TES Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS L-GLUTAMINE POW Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS L-GLUTATHION CRY Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS LIBERTY TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS NEUTEK 2TEK TES STRIPS Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ON CALL TES EXPRESS Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ON CALL PLUS TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ON CALL VIVD TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ONETOUCH TES ULTRA BL Tier 1 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ONETOUCH TES VERIO Tier 1 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS OPTIUM TES Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS OPTIUMEZ TES Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS OPTUMRX TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS PRECISION TES PCX Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS PRECISION TES PCX PLUS Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS PRECISION TES QID Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS PRECISION TES SOF-TACT Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS PRECISION TES XTRA Tier 3 X X X

Page 162 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS PRECISION PT TES OF CARE Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS PROTEIN TAB 975MG Tier 3

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS QUINTET TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS QUINTET AC TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS RA TRUETEST TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS RELION TES ULTIMA Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS RELION BLOOD TES GLUCOSE Tier 3 X X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS REVEAL TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS SUPREME TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS TRUE METRIX TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS TRUE METRIX TES GLUCOSE Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS TRUETEST TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS TRUETEST TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS TRUETRACK TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS TRUETRACK TES BLD GLUC Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS ULTIMA TES Tier 3 X

ELECTROLYTIC, CALORIC, AND WATER BALANCE - CALORIC AGENTS UNISTRIP1 TES GENERIC Tier 3 X X ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS AV-PHOS 250 TAB NEUTRAL Tier 1

Page 163 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS CALCIFOL WAF Tier 3 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS CALCIUM-FA WAF PLUS D Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS EFFER-K TAB 10MEQ Tier 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS EFFER-K TAB 20MEQ Tier 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS EFFER-K TAB 25MEQ EF Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS K-EFFERVESCE TAB 25MEQ EF Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS KLOR-CON/EF TAB 25MEQ EF Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS KLOR-CON/EF TAB 25MEQ FR Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS K-PHOS TAB Tier 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS K-PHOS TAB NEUTRAL Tier 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS K-PRIME TAB 25MEQ EF Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS K-VESCENT TAB 25MEQ EF Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS LEG-GESIC SUS Tier 3 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS MAGNEBIND TAB 400 Tier 2 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS OSTIGEN MIS 350MG Tier 3 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS PHOSPHA 250 TAB NEUTRAL Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS POT CHLORIDE TAB 25MEQ EF Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS POT/CHLORIDE TAB 25MEQ EF Tier 1

Page 164 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS POTASSIUM TAB 25MEQ EF Tier 1 ELECTROLYTIC, CALORIC, AND WATER BALANCE - REPLACEMENT PREPARATIONS VIRT-PHOS TAB 250 NEUT Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ANZEMET TAB 100MG Tier 3 X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ANZEMET TAB 50MG Tier 3 X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs CESAMET CAP 1MG Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs DRONABINOL CAP 10MG Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs DRONABINOL CAP 2.5MG Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs DRONABINOL CAP 5MG Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs EMEND CAP 125MG Tier 2 X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs EMEND CAP 40MG Tier 2 X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs EMEND CAP 80MG Tier 2 X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs EMEND PAK 80 & 125 Tier 2 X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs EMEND SUS 125MG Tier 2 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs GRANISETRON TAB 1MG Tier 1 X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs MARINOL CAP 10MG Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs MARINOL CAP 2.5MG Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs MARINOL CAP 5MG Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ONDANSETRON SOL 4MG/5ML Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ONDANSETRON TAB 24MG Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ONDANSETRON TAB 4MG Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ONDANSETRON TAB 4MG ODT Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ONDANSETRON TAB 8MG Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ONDANSETRON TAB 8MG ODT Tier 1 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs SANCUSO DIS 3.1MG Tier 3 X X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ZOFRAN SOL 4MG/5ML Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ZOFRAN TAB 4MG Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ZOFRAN TAB 4MG ODT Tier 3

Page 165 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ZOFRAN TAB 8MG Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ZOFRAN TAB 8MG ODT Tier 3 Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ZUPLENZ MIS 4MG Tier 3 X X Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs ZUPLENZ MIS 8MG Tier 3 X X Enzyme Inhibitors - Chemotherapy Agents ETOPOSIDE CAP 50MG Tier 1 X Enzyme Inhibitors - Chemotherapy Agents HYCAMTIN CAP 0.25MG Tier 2 X X X Enzyme Inhibitors - Chemotherapy Agents HYCAMTIN CAP 1MG Tier 2 X X X Enzyme Inhibitors - Chemotherapy Agents ZYDELIG TAB 100MG Tier 3 X X X Enzyme Inhibitors - Chemotherapy Agents ZYDELIG TAB 150MG Tier 3 X X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs BUPHENYL POW Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs BUPHENYL TAB 500MG Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CARBAGLU TAB 200MG Tier 2 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CREON CAP 12000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CREON CAP 24000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CREON CAP 3000UNIT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CREON CAP 36000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CREON CAP 6000UNIT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CYSTADANE POW Tier 2 X

Page 166 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CYSTAGON CAP 150MG Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs CYSTAGON CAP 50MG Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs KUVAN POW 100MG Tier 2 X X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs KUVAN POW 500MG Tier 2 X X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs KUVAN TAB 100MG Tier 2 X X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ORFADIN CAP 10MG Tier 3 X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ORFADIN CAP 20MG Tier 3 X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ORFADIN CAP 2MG Tier 3 X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ORFADIN CAP 5MG Tier 3 X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ORFADIN SUS 4MG/ML Tier 3 X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PANCREAZE CAP 10500UNT Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PANCREAZE CAP 16800UNT Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PANCREAZE CAP 21000UNT Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PANCREAZE CAP 4200UNIT Tier 3 X

Page 167 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PANCRELIPASE CAP 5000UNIT Tier 1

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PERTZYE CAP Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PERTZYE CAP Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PHENYLBUTYRA POW SODIUM Tier 1 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PROCYSBI CAP 25MG Tier 3 X X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs PROCYSBI CAP 75MG Tier 3 X X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs RAVICTI LIQ 1.1GM/ML Tier 3 X X X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs SUCRAID SOL 8500/ML Tier 2 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ULTRESA CAP 13800UNT Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ULTRESA CAP 20700UNT Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ULTRESA CAP 23000UNT Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs VIOKACE TAB Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs VIOKACE TAB 20880 Tier 3 X

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZAVESCA CAP 100MG Tier 3 X

Page 168 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZENPEP CAP 10000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZENPEP CAP 15000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZENPEP CAP 20000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZENPEP CAP 25000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZENPEP CAP 3000UNIT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZENPEP CAP 40000UNT Tier 2

Enzyme Replacement/Modifiers - Enzyme Replacement/Modifying Drugs ZENPEP CAP 5000UNIT Tier 2

Ergot Alkaloids - Migraine Drugs CAFERGOT TAB 1-100MG Tier 3

Ergot Alkaloids - Migraine Drugs D.H.E. 45 INJ 1MG/ML Tier 3 X

Ergot Alkaloids - Migraine Drugs DIHYDROERGOT INJ 1MG/ML Tier 1

Ergot Alkaloids - Migraine Drugs DIHYDROERGOT POW MESYLATE Tier 3

Ergot Alkaloids - Migraine Drugs DIHYDROERGOT SPR 4MG/ML Tier 1

Ergot Alkaloids - Migraine Drugs ERGOMAR SUB 2MG Tier 2

Ergot Alkaloids - Migraine Drugs MIGERGOT SUP 2/100 Tier 3

Ergot Alkaloids - Migraine Drugs MIGRANAL SPR 4MG/ML Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs ACTIVELLA TAB 0.5-0.1 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ACTIVELLA TAB 1-0.5MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ALORA DIS 0.025MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs ALORA DIS 0.05MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs ALORA DIS 0.075MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs ALORA DIS 0.1MG Tier 3 X

Page 169 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone HCR Replacement/Modifying Drugs ALTAVERA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ALYACEN TAB 1/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ALYACEN TAB 7/7/7 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs AMETHIA TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs AMETHIA LO TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs AMETHYST TAB 90-20MCG Preventative Estrogens - Hormone Replacement/Modifying Drugs ANGELIQ TAB 0.25-0.5 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ANGELIQ TAB 0.5-1MG Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs APRI TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ARANELLE TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ASHLYNA TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs AUBRA TAB 0.1-0.02 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs AVIANE TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs AZURETTE TAB 28 DAY Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs BALZIVA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs BEKYREE TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs BEYAZ TAB Tier 3 X Estrogens - Hormone HCR Replacement/Modifying Drugs BLISOVI 24 TAB FE 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs BLISOVI FE TAB 1.5/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs BLISOVI FE TAB 1/20 Preventative Estrogens - Hormone Replacement/Modifying Drugs BREVICON TAB 0.5/35 Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs BRIELLYN TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs CAMRESE TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs CAMRESE LO TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs CAZIANT PAK Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs CHATEAL TAB 0.15/30 Preventative Estrogens - Hormone Replacement/Modifying Drugs CLIMARA DIS 0.025MG Tier 2 X Estrogens - Hormone Replacement/Modifying Drugs CLIMARA DIS 0.0375MG Tier 2 X

Page 170 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone Replacement/Modifying Drugs CLIMARA DIS 0.05MG Tier 2 X Estrogens - Hormone Replacement/Modifying Drugs CLIMARA DIS 0.06MG Tier 2 X Estrogens - Hormone Replacement/Modifying Drugs CLIMARA DIS 0.075MG Tier 2 X Estrogens - Hormone Replacement/Modifying Drugs CLIMARA DIS 0.1MG Tier 2 X Estrogens - Hormone Replacement/Modifying Drugs CLIMARA PRO DIS WEEKLY Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs COMBIPATCH DIS .05/.14 Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs COMBIPATCH DIS .05/.25 Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs COVARYX TAB 1.25-2.5 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs COVARYX HS TAB Tier 1 Estrogens - Hormone HCR Replacement/Modifying Drugs CRYSELLE-28 TAB 28 TABS Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs CYCLAFEM TAB 1/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs CYCLAFEM TAB 7/7/7 Preventative Estrogens - Hormone Replacement/Modifying Drugs CYCLESSA PAK Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs CYRED TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs DASETTA TAB 1/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs DASETTA TAB 7/7/7 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs DAYSEE TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs DELYLA TAB 0.1-0.02 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs DESO/ETHINYL TAB ESTRADIO Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs DESO/ETHINYL TAB ESTRADIO Preventative Estrogens - Hormone Replacement/Modifying Drugs DESOGEN-28 TAB Tier 3 Estrogens - Hormone Replacement/Modifying Drugs DIVIGEL GEL 0.25MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs DIVIGEL GEL 0.5MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs DIVIGEL GEL 1MG/GM Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs DROSPIR/ETHI TAB 3-0.03MG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs DROSPIRENONE TAB ETHY EST Preventative Estrogens - Hormone Replacement/Modifying Drugs DUAVEE TAB 0.45-20 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs EEMT TAB 1.25-2.5 Tier 1

Page 171 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone Replacement/Modifying Drugs EEMT HS TAB Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ELESTRIN GEL 0.06% Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs ELINEST TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs EMOQUETTE TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs ENJUVIA TAB 0.3MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ENJUVIA TAB 0.45MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ENJUVIA TAB 0.625MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ENJUVIA TAB 0.9MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ENJUVIA TAB 1.25MG Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs ENPRESSE-28 TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ENSKYCE TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs EST ESTROGEN TAB MTEST Tier 1 Estrogens - Hormone Replacement/Modifying Drugs EST ESTROGEN TAB MTEST HS Tier 1 Estrogens - Hormone HCR Replacement/Modifying Drugs ESTARYLLA TAB 0.25-35 Preventative Estrogens - Hormone Replacement/Modifying Drugs ESTRA/NORETH TAB 0.5-0.1 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTRA/NORETH TAB 1-0.5MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTRACE TAB 0.5MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ESTRACE TAB 1MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ESTRACE TAB 2MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ESTRACE VAG CRE 0.1MG/GM Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.025MG Tier 3 X X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.025MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.0375MG Tier 3 X X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.0375MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.05MG Tier 3 X X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.05MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.06MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.075MG Tier 3 X X

Page 172 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.075MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.1MG Tier 3 X X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL DIS 0.1MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL TAB 0.5MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL TAB 1MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTRADIOL TAB 2MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTRING MIS 2MG Tier 2 X Estrogens - Hormone Replacement/Modifying Drugs ESTROG/MTEST TAB 1.25-2.5 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTROGEL GEL Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs ESTROPIPATE TAB 0.75MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTROPIPATE TAB 1.5MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTROPIPATE TAB 3MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ESTROSTEP FE TAB Tier 3 Estrogens - Hormone Replacement/Modifying Drugs EVAMIST SPR 1.53MG Tier 2 Estrogens - Hormone Replacement/Modifying Drugs FALESSA KIT Tier 3 X Estrogens - Hormone HCR Replacement/Modifying Drugs FALMINA TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs FEMCON FE CHW Tier 3 Estrogens - Hormone Replacement/Modifying Drugs FEMHRT TAB 0.5-2.5 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs FEMRING MIS 0.05/24H Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs FEMRING MIS 0.1MG/24 Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs FYAVOLV TAB 0.5-2.5 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs FYAVOLV TAB 1-5 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs GENERESS FE CHW Tier 3 X Estrogens - Hormone HCR Replacement/Modifying Drugs GIANVI TAB 3-0.02MG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs GILDAGIA TAB 0.4-35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs GILDESS TAB 1.5/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs GILDESS TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs GILDESS 24 TAB FE 1/20 Preventative

Page 173 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone HCR Replacement/Modifying Drugs GILDESS FE TAB 1.5/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs GILDESS FE TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs INTROVALE TAB Preventative X Estrogens - Hormone Replacement/Modifying Drugs JEVANTIQUE L TAB 0.5-2.5 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs JINTELI TAB 1MG-5MCG Tier 1 Estrogens - Hormone HCR Replacement/Modifying Drugs JOLESSA TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs JULEBER TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs JUNEL 1.5/30 TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs JUNEL 1/20 TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs JUNEL FE TAB 1.5/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs JUNEL FE TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs JUNEL FE 24 TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs KAITLIB FE CHW Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs KARIVA TAB 28 DAY Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs KELNOR TAB 1/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs KIMIDESS TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs KURVELO TAB 0.15/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LARIN TAB 1.5/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LARIN TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LARIN 24 TAB FE 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LARIN FE TAB 1.5/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LARIN FE TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LARISSIA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LAYOLIS FE CHW Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs LEENA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LESSINA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LEVO-ETH EST TAB 90-20MCG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LEVONEST TAB Preventative

Page 174 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone HCR Replacement/Modifying Drugs LEVONOR/ETHI TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LEVONOR/ETHI TAB 0.1-0.02 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LEVONOR/ETHI TAB ESTRADIO Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs LEVONOR/ETHI TAB ESTRADIO Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LEVONOR/ETHI TAB ESTRADIO Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs LEVONOR/ETHI TAB ESTRADIO Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs LEVORA-28 TAB 0.15/30 Preventative Estrogens - Hormone Replacement/Modifying Drugs LO LOESTRIN TAB Tier 3 Estrogens - Hormone Replacement/Modifying Drugs LOESTRIN TAB 1/20-21 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs LOESTRIN 21 TAB 1.5/30 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs LOESTRIN FE TAB 1.5/30 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs LOESTRIN FE TAB 1/20 Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs LOMEDIA 24 TAB FE Preventative Estrogens - Hormone Replacement/Modifying Drugs LOPREEZA TAB 0.5-0.1 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs LOPREEZA TAB 1-0.5MG Tier 1 Estrogens - Hormone HCR Replacement/Modifying Drugs LORYNA TAB 3-0.02MG Preventative Estrogens - Hormone Replacement/Modifying Drugs LOSEASONIQUE TAB Tier 3 X Estrogens - Hormone HCR Replacement/Modifying Drugs LOW-OGESTREL TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs LUTERA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs MARLISSA TAB 0.15/30 Preventative Estrogens - Hormone Replacement/Modifying Drugs MENOSTAR DIS 14MCG Tier 3 X Estrogens - Hormone HCR Replacement/Modifying Drugs MICRGSTIN 24 TAB FE 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs MICROGESTIN TAB 1.5/30 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs MICROGESTIN TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs MICROGESTIN TAB FE 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs MICROGESTIN TAB FE1.5/30 Preventative Estrogens - Hormone Replacement/Modifying Drugs MIMVEY TAB 1-0.5MG Tier 1 Estrogens - Hormone Replacement/Modifying Drugs MIMVEY LO TAB 0.5-0.1 Tier 1

Page 175 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone Replacement/Modifying Drugs MINASTRIN 24 CHW FE Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs MINIVELLE DIS 0.025 MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs MINIVELLE DIS 0.0375MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs MINIVELLE DIS 0.05MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs MINIVELLE DIS 0.075MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs MINIVELLE DIS 0.1MG Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs MIRCETTE TAB 28 DAY Tier 3 Estrogens - Hormone Replacement/Modifying Drugs MODICON TAB 0.5/35 Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs MONO-LINYAH TAB 0.25-35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs MONONESSA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs MYZILRA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NATAZIA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NECON TAB 0.5/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NECON TAB 1/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NECON TAB 10/11-28 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NECON TAB 7/7/7 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NIKKI TAB 3-0.02MG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NORETH/ETHIN CHW FE Preventative X Estrogens - Hormone Replacement/Modifying Drugs NORETH/ETHIN TAB 0.5-2.5 Tier 1 Estrogens - Hormone HCR Replacement/Modifying Drugs NORETH/ETHIN TAB 1/20 Preventative Estrogens - Hormone Replacement/Modifying Drugs NORETH/ETHIN TAB 1MG-5MCG Tier 1 Estrogens - Hormone HCR Replacement/Modifying Drugs NORETH/ETHIN TAB FE 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NORETH/ETHIN TAB FE 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NORGEST/ETHI TAB 0.25/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NORGEST/ETHI TAB ESTRADIO Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NORGEST/ETHI TAB ESTRADIO Preventative Estrogens - Hormone Replacement/Modifying Drugs NORINYL TAB 1/35 Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs NORTREL TAB 0.5/35 Preventative

Page 176 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone HCR Replacement/Modifying Drugs NORTREL TAB 1/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NORTREL TAB 7/7/7 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs NUVARING MIS Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs OCELLA TAB 3-0.03MG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs OGESTREL TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ORSYTHIA TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs ORTHO EVRA DIS WEEK Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs ORTHO TRI- TAB CYCLEN Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ORTHO TRI- TAB CYCLN LO Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ORTHO-CEPT TAB 28 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ORTHO-CYCLEN TAB 0.25/35 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ORTHO-EST TAB 0.625 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ORTHO-EST TAB 1.25 Tier 1 Estrogens - Hormone Replacement/Modifying Drugs ORTHO-NOVUM TAB 1/35 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs ORTHO-NOVUM TAB 7/7/7 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs OVCON-35 TAB Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs PHILITH TAB 0.4-35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs PIMTREA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs PIRMELLA TAB 1/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs PIRMELLA TAB 7/7/7 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs PORTIA-28 TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs PREFEST TAB Tier 2 Estrogens - Hormone Replacement/Modifying Drugs PREMARIN TAB 0.3MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMARIN TAB 0.45MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMARIN TAB 0.625MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMARIN TAB 0.9MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMARIN TAB 1.25MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMARIN VAG CRE 0.625MG Tier 3

Page 177 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone Replacement/Modifying Drugs PREMPHASE TAB Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMPRO TAB .625-2.5 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMPRO TAB 0.3-1.5 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMPRO TAB 0.45-1.5 Tier 3 Estrogens - Hormone Replacement/Modifying Drugs PREMPRO TAB 0.625-5 Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs PREVIFEM TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs QUARTETTE TAB Tier 3 X X Estrogens - Hormone HCR Replacement/Modifying Drugs QUASENSE TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs RECLIPSEN TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs SAFYRAL TAB Tier 3 X Estrogens - Hormone Replacement/Modifying Drugs SEASONIQUE TAB Tier 3 X Estrogens - Hormone HCR Replacement/Modifying Drugs SETLAKIN TAB Preventative X Estrogens - Hormone HCR Replacement/Modifying Drugs SPRINTEC 28 TAB 28 DAY Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs SRONYX TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs SYEDA TAB 3-0.03MG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TARINA FE TAB 1/20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TILIA FE TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-ESTARYLL TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-LEGEST TAB FE Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-LINYAH TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-LO TAB ESTARYLL Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-LO- TAB MARZIA Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-LO- TAB SPRINTEC Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRINESSA TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRINESSA LO TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs TRI-NORINYL TAB 28 Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-PREVIFEM TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs TRI-SPRINTEC TAB Preventative

Page 178 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Estrogens - Hormone HCR Replacement/Modifying Drugs TRIVORA-28 TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs VAGIFEM TAB 10MCG Tier 2 Estrogens - Hormone HCR Replacement/Modifying Drugs VELIVET PAK Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs VESTURA TAB 3-0.02MG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs VIENVA TAB 0.1-20 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs VIORELE TAB Preventative Estrogens - Hormone Replacement/Modifying Drugs VIVELLE-DOT DIS 0.025MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs VIVELLE-DOT DIS 0.0375MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs VIVELLE-DOT DIS 0.05MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs VIVELLE-DOT DIS 0.075MG Tier 1 X Estrogens - Hormone Replacement/Modifying Drugs VIVELLE-DOT DIS 0.1MG Tier 1 X Estrogens - Hormone HCR Replacement/Modifying Drugs VYFEMLA TAB 0.4-35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs WERA TAB 0.5/35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs WYMZYA FE CHW 0.4MG-35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs XULANE DIS 150-35 Preventative Estrogens - Hormone Replacement/Modifying Drugs YASMIN 28 TAB 3-0.03MG Tier 3 Estrogens - Hormone Replacement/Modifying Drugs YAZ TAB 3-0.02MG Tier 3 Estrogens - Hormone HCR Replacement/Modifying Drugs ZARAH TAB 3-0.03MG Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ZENCHENT TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ZENCHENT FE CHW 0.4MG-35 Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ZOVIA 1/35E TAB Preventative Estrogens - Hormone HCR Replacement/Modifying Drugs ZOVIA 1/50E TAB Preventative

EYE, EAR, NOSE AND THROAT (EENT) PREPS - LOCAL ANESTHETICS (EENT) BXN MOUTHWSH SUS Tier 3

EYE, EAR, NOSE AND THROAT (EENT) PREPS - LOCAL ANESTHETICS (EENT) COCAINE HCL SOL 4% Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS - LOCAL ANESTHETICS (EENT) FIRST-MOUTHW SUS BLM Tier 3 X EYE, EAR, NOSE AND THROAT (EENT) PREPS - MISCELLANEOUS GELFILM MIS OP Tier 2

Page 179 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS CYCLOGYL SOL 0.5% OP Tier 3 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS CYCLOGYL SOL 1% OP Tier 3 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS CYCLOGYL SOL 2% OP Tier 3 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS CYCLOMYDRIL SOL OP Tier 3 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS CYCLOPENTOL SOL 1% OP Tier 1 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS CYCLOPENTOL SOL 2% OP Tier 1 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS CYCLOPENTOLA SOL 0.5% Tier 1 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS HOMATROPAIRE SOL 5% OP Tier 1 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS HOMATROPINE SOL 5% OP Tier 1 EYE, EAR, NOSE AND THROAT (EENT) PREPS - MYDRIATICS PAREMYD SOL 1-0.25% Tier 3

EYE, EAR, NOSE AND THROAT (EENT) PREPS - VASOCONSTRICTORS ALTAFRIN SOL 10% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS - VASOCONSTRICTORS ALTAFRIN SOL 2.5% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS - VASOCONSTRICTORS NEOFRIN SOL 10% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS - VASOCONSTRICTORS NEOFRIN SOL 2.5% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS - VASOCONSTRICTORS PHENYLEPHRIN SOL 10% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS - VASOCONSTRICTORS PHENYLEPHRIN SOL 2.5% OP Tier 1 EYE, EAR, NOSE AND THROAT (EENT) PREPS. - ANTI-INFECTIVES, MISCELLANEOUS BETADINE SOL 5% OP Tier 3

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) AERO OTIC HC SOL Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) CORTANE-B DRO AQ OTIC Tier 2

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) CORTANE-B DRO OTIC Tier 2

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) CORTIC-ND DRO Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) CYOTIC DRO Tier 1

Page 180 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) EXOTIC-HC DRO OTIC Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) OTIC CARE DRO Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) OTICIN HC DRO Tier 2

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) OTO-END 10 SOL Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - CORTICOSTEROIDS (EENT) OTOMAX-HC DRO Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) AKTEN GEL 3.5% Tier 3

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) ALTACAINE SOL 0.5% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) ANTIPY/BENZO SOL OTIC Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) ANTIPY/BENZO SOL OTIC Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) OTOZIN DRO Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) PINNACAINE DRO 20% OTIC Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) TETCAINE SOL 0.5% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) TETRACAINE SOL 0.5% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) TETRAVISC SOL 0.5% OP Tier 1

EYE, EAR, NOSE AND THROAT (EENT) PREPS. - LOCAL ANESTHETICS (EENT) TETRAVISC SOL FORTE Tier 1 Fibromyalgia Agents - Fibromyalgia Drugs SAVELLA MIS TITR PAK Tier 3 X Fibromyalgia Agents - Fibromyalgia Drugs SAVELLA TAB 100MG Tier 3 X Fibromyalgia Agents - Fibromyalgia Drugs SAVELLA TAB 12.5MG Tier 3 X Fibromyalgia Agents - Fibromyalgia Drugs SAVELLA TAB 25MG Tier 3 X Fibromyalgia Agents - Fibromyalgia Drugs SAVELLA TAB 50MG Tier 3 X

Page 181 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty GABA Receptor Modulators - Sedation and Sleep Drugs AMBIEN TAB 10MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs AMBIEN TAB 5MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs AMBIEN CR TAB 12.5MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs AMBIEN CR TAB 6.25MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs EDLUAR SUB 10MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs EDLUAR SUB 5MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs ESZOPICLONE TAB 1MG Tier 1 X GABA Receptor Modulators - Sedation and Sleep Drugs ESZOPICLONE TAB 2MG Tier 1 X GABA Receptor Modulators - Sedation and Sleep Drugs ESZOPICLONE TAB 3MG Tier 1 X GABA Receptor Modulators - Sedation and Sleep Drugs FLURAZEPAM CAP 15MG Tier 1 GABA Receptor Modulators - Sedation and Sleep Drugs FLURAZEPAM CAP 30MG Tier 1 GABA Receptor Modulators - Sedation and Sleep Drugs HALCION TAB 0.25MG Tier 3 GABA Receptor Modulators - Sedation and Sleep Drugs INTERMEZZO SUB 1.75MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs INTERMEZZO SUB 3.5MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs LUNESTA TAB 1MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs LUNESTA TAB 2MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs LUNESTA TAB 3MG Tier 3 X X GABA Receptor Modulators - Sedation and Sleep Drugs RESTORIL CAP 15MG Tier 3 GABA Receptor Modulators - Sedation and Sleep Drugs RESTORIL CAP 22.5MG Tier 3 GABA Receptor Modulators - Sedation and Sleep Drugs RESTORIL CAP 30MG Tier 3 GABA Receptor Modulators - Sedation and Sleep Drugs RESTORIL CAP 7.5MG Tier 3 GABA Receptor Modulators - Sedation and Sleep Drugs SONATA CAP 10MG Tier 3 X GABA Receptor Modulators - Sedation and Sleep Drugs SONATA CAP 5MG Tier 3 X GABA Receptor Modulators - Sedation and Sleep Drugs TEMAZEPAM CAP 15MG Tier 1 GABA Receptor Modulators - Sedation and Sleep Drugs TEMAZEPAM CAP 22.5MG Tier 1 GABA Receptor Modulators - Sedation and Sleep Drugs TEMAZEPAM CAP 30MG Tier 1 GABA Receptor Modulators - Sedation and Sleep Drugs TEMAZEPAM CAP 7.5MG Tier 1 GABA Receptor Modulators - Sedation and Sleep Drugs TRIAZOLAM TAB 0.125MG Tier 1

Page 182 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty GABA Receptor Modulators - Sedation and Sleep Drugs TRIAZOLAM TAB 0.25MG Tier 1 GABA Receptor Modulators - Sedation and Sleep Drugs ZALEPLON CAP 10MG Tier 1 X GABA Receptor Modulators - Sedation and Sleep Drugs ZALEPLON CAP 5MG Tier 1 X GABA Receptor Modulators - Sedation and Sleep Drugs ZOLPIDEM TAB 10MG Tier 1 X GABA Receptor Modulators - Sedation and Sleep Drugs ZOLPIDEM TAB 5MG Tier 1 X GABA Receptor Modulators - Sedation and Sleep Drugs ZOLPIDEM ER TAB 12.5MG Tier 1 X X GABA Receptor Modulators - Sedation and Sleep Drugs ZOLPIDEM ER TAB 6.25MG Tier 1 X X GABA Receptor Modulators - Sedation and Sleep Drugs ZOLPIDEM TAR SUB 1.75MG Tier 1 X X GABA Receptor Modulators - Sedation and Sleep Drugs ZOLPIDEM TAR SUB 3.5MG Tier 1 X X GABA Receptor Modulators - Sedation and Sleep Drugs ZOLPIMIST SPR 5MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEP ODT TAB 0.125MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEP ODT TAB 0.25MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEP ODT TAB 0.5MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEP ODT TAB 1MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEP ODT TAB 2MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEPAM TAB 0.5MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEPAM TAB 1MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLONAZEPAM TAB 2MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLORAZ DIPOT TAB 15MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLORAZ DIPOT TAB 3.75MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs CLORAZ DIPOT TAB 7.5MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKENE CAP 250MG Tier 3

Page 183 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKENE SYP 250/5ML Tier 3 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKOTE TAB 125MG DR Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKOTE TAB 250MG DR Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKOTE TAB 500MG DR Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKOTE ER TAB 250MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKOTE ER TAB 500MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DEPAKOTE SPR CAP 125MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIASTAT ACDL GEL 12.5-20 Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIASTAT ACDL GEL 5-10MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIASTAT PED GEL 2.5M GEL Tier 2 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIAZEPAM GEL 10MG Tier 1 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIAZEPAM GEL 2.5MG Tier 1 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIAZEPAM GEL 20MG Tier 1 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIVALPROEX CAP 125MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIVALPROEX TAB 125MG DR Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIVALPROEX TAB 250MG DR Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIVALPROEX TAB 250MG ER Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIVALPROEX TAB 500MG DR Tier 1

Page 184 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs DIVALPROEX TAB 500MG ER Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FANATREX SUS 25MG/ML Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FYCOMPA SUS 0.5MG/ML Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FYCOMPA TAB 10MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FYCOMPA TAB 12MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FYCOMPA TAB 2MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FYCOMPA TAB 4MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FYCOMPA TAB 6MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs FYCOMPA TAB 8MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABAPENTIN CAP 100MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABAPENTIN CAP 300MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABAPENTIN CAP 400MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABAPENTIN SOL 250/5ML Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABAPENTIN TAB 600MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABAPENTIN TAB 800MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABITRIL TAB 12MG Tier 2 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABITRIL TAB 16MG Tier 2 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABITRIL TAB 2MG Tier 3

Page 185 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GABITRIL TAB 4MG Tier 3 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GENE-XENE TAB 15MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GENE-XENE TAB 3.75MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs GENE-XENE TAB 7.5MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs HORIZANT TAB 300MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs HORIZANT TAB 600MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs KLONOPIN TAB 0.5MG Tier 3 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs KLONOPIN TAB 1MG Tier 3 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs KLONOPIN TAB 2MG Tier 3 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs MYSOLINE TAB 250MG Tier 2 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs MYSOLINE TAB 50MG Tier 2 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs NEURONTIN CAP 100MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs NEURONTIN CAP 300MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs NEURONTIN CAP 400MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs NEURONTIN SOL 250/5ML Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs NEURONTIN TAB 600MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs NEURONTIN TAB 800MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs ONFI SUS 2.5MG/ML Tier 3 X

Page 186 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs ONFI TAB 10MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs ONFI TAB 20MG Tier 3 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs PRIMIDONE TAB 250MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs PRIMIDONE TAB 50MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs SABRIL POW 500MG Tier 2 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs SABRIL TAB 500MG Tier 2 X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs STAVZOR CAP 125MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs STAVZOR CAP 250MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs STAVZOR CAP 500MG Tier 3 X X Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs TIAGABINE TAB 2MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs TIAGABINE TAB 4MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs TRANXENE T TAB 3.75MG Tier 3 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs TRANXENE T TAB 7.5MG Tier 3 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs VALPROIC ACD CAP 250MG Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs VALPROIC ACD SOL 250/5ML Tier 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs VALPROIC ACD SYP 250/5ML Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs ACTIGALL CAP 300MG Tier 3

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs BISACODYL TAB 5MG EC Preventative

Page 187 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs CASCARA EXT SAGRADA Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs CHENODAL TAB 250MG Tier 3 X

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs CORRECT TAB 5MG EC Preventative

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs CROMOLYN SOD CON 100/5ML Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs DIPHEN/ATROP LIQ 2.5/5 Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs DIPHEN/ATROP TAB 2.5MG Tier 1

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs DUCODYL TAB 5MG EC Preventative

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs ENTEREG CAP 12MG Tier 3

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs EQL LAXATIVE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs EX-LAX ULTRA TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs FEMININE LAX TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs FLEET LAXATI TAB 5MG EC Preventative

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs FULYZAQ TAB 125MG Tier 3 X X X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs GASTROCROM CON 100/5ML Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs GATTEX KIT 5MG Tier 2 X X X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs GAVILYTE-H KIT Tier 1

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs GENTLE LAXAT TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs GNP BISA-LAX TAB 5MG EC Preventative

Page 188 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs GNP LAXATIVE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs HM LAXATIVE TAB 5MG Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs HM LAXATIVE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs KP BISACODYL TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs LAXATIVE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs LOFENE TAB 2.5MG Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs LOMOTIL TAB 2.5MG Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs METOCLOPRAM SOL 5MG/5ML Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs METOCLOPRAM TAB 10MG Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs METOCLOPRAM TAB 5MG Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs METOCLOPRAM TAB 5MG ODT Tier 1 X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs METOCLOPRAMI TAB 10MG ODT Tier 1 X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs METOZOLV ODT TAB 5MG Tier 3 X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs MINERAL OIL HEAVY Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs MOTOFEN TAB 1-0.025 Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs NICOTINAMIDE POW ADENINE Tier 3 X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs OSMOPREP TAB 1.5GM Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs PAREGORIC TIN 2MG/5ML Tier 1

Page 189 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs PEG-PREP KIT Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs PYLERA CAP Tier 3 X

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs QC LAXATIVE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs RA LAXATIVE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs REGLAN TAB 10MG Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs REGLAN TAB 5MG Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs RELISTOR INJ 12/0.6ML Tier 2 X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs RELISTOR INJ 8/0.4ML Tier 2 X

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs REZYST IM CHW Tier 3

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs SM GENTLE TAB LAXATIVE Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs SM LAXATIVE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs SODIUM POW BICARBON Tier 3

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs STIM LAXAT TAB 5MG EC Preventative

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs SUCLEAR KIT Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs URSO 250 TAB 250MG Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs URSO FORTE TAB 500MG Tier 3

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs URSODIOL CAP 300MG Tier 1

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs URSODIOL TAB 250MG Tier 1

Page 190 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs URSODIOL TAB 500MG Tier 1

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs VERCOLATE TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs WOMANS LAXAT TAB 5MG EC Preventative

Gastrointestinal Agents, Other - HCR Miscellaneous Gastrointestinal Drugs WOMENS LAXAT TAB 5MG EC Preventative GASTROINTESTINAL DRUGS - LIPOTROPIC AGENTS LECITHIN GRA Tier 1 Genitourinary Agents, Other CIALIS TAB 10MG Tier 3 X X Genitourinary Agents, Other CIALIS TAB 20MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents CAVERJECT INJ 20MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents CAVERJECT INJ 40MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents CAVERJECT KIT 10MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents CAVERJECT KIT 20MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents EDEX KIT 10MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents EDEX KIT 20MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents EDEX KIT 40MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents LEVITRA TAB 10MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents LEVITRA TAB 2.5MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents LEVITRA TAB 20MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents LEVITRA TAB 5MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents MUSE SUP 1000MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents MUSE SUP 125MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents MUSE SUP 250MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents MUSE SUP 500MCG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents STAXYN TAB 10MG Tier 3 X X X Genitourinary Agents, Other - Erectile Dysfunction Agents STENDRA TAB 100MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents STENDRA TAB 200MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents STENDRA TAB 50MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents VIAGRA TAB 100MG Tier 3 X X

Page 191 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Genitourinary Agents, Other - Erectile Dysfunction Agents VIAGRA TAB 25MG Tier 3 X X Genitourinary Agents, Other - Erectile Dysfunction Agents VIAGRA TAB 50MG Tier 3 X X

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs BETHANECHOL TAB 10MG Tier 1

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs BETHANECHOL TAB 25MG Tier 1

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs BETHANECHOL TAB 50MG Tier 1

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs BETHANECHOL TAB 5MG Tier 1

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs ELMIRON CAP 100MG Tier 2

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs LITHOSTAT TAB 250MG Tier 3

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs PHENAZO TAB 200MG Tier 1

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs PHENAZOPYRID TAB 100MG Tier 1

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs PHENAZOPYRID TAB 200MG Tier 1

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs PYRIDIUM TAB 100MG Tier 3

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs PYRIDIUM TAB 200MG Tier 3

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs THIOLA TAB 100MG Tier 3 X

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs URECHOLINE TAB 10MG Tier 3

Page 192 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs URECHOLINE TAB 25MG Tier 3

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs URECHOLINE TAB 50MG Tier 3

Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs URECHOLINE TAB 5MG Tier 3 Glucocorticoids - Inflammatory Bowel Disease Drugs BUDESONIDE CAP 3MG/24HR Tier 1 Glucocorticoids - Inflammatory Bowel Disease Drugs COLOCORT ENE 100MG Tier 1 Glucocorticoids - Inflammatory Bowel Disease Drugs CORTENEMA ENE 100MG Tier 3 Glucocorticoids - Inflammatory Bowel Disease Drugs ENTOCORT EC CAP 3MG/24HR Tier 3 X Glucocorticoids - Inflammatory Bowel Disease Drugs HYDROCORT ENE 100MG Tier 1 Glucocorticoids - Inflammatory Bowel Disease Drugs MILLIPRED TAB 5MG Tier 2 Glucocorticoids - Inflammatory Bowel Disease Drugs MILLIPRED DP PAK 5MG Tier 2 Glucocorticoids - Inflammatory Bowel Disease Drugs MILLIPRED DP PAK 5MG Tier 2 Glucocorticoids - Inflammatory Bowel Disease Drugs PREDNISOLONE SOL 15MG/5ML Tier 1 Glucocorticoids - Inflammatory Bowel Disease Drugs PREDNISOLONE SYP 15MG/5ML Tier 1 Glucocorticoids - Inflammatory Bowel Disease Drugs UCERIS TAB 9MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ACLOVATE CRE 0.05% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ALA SCALP LOT 2% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ALCLOMETASON CRE 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ALCLOMETASON OIN 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ALPHATREX GEL 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs AMCINONIDE CRE 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs AMCINONIDE LOT 0.1% Tier 1

Page 193 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs AMCINONIDE OIN 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ANUSOL-HC CRE 2.5% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs APEXICON E CRE 0.05% Tier 2 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs AUG BETAMET CRE 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs AUG BETAMET GEL 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs AUG BETAMET LOT 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs AUG BETAMET OIN 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH DIP CRE 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH DIP LOT 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH DIP OIN 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH DIP POW Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH DIP POW MICRONIZ Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH DIP POW USP NF Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH VAL AER 0.12% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH VAL CRE 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH VAL LOT 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETH VAL OIN 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs BETAMETHASON POW VALERATE Tier 3 X

Page 194 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CAPEX SHA 0.01% Tier 2

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL AER 0.05% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL AER 0.05% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL CRE 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL GEL 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL LOT 0.05% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL OIN 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL POW PROPIONA Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL SHA 0.05% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL SOL 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL SPR 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBETASOL E CRE 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBEX LOT 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBEX SHA 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOBEX SPR 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLOCORTOLONE CRE PIV 0.1% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLODAN SHA 0.05% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLODERM CRE 0.1% Tier 3 X X

Page 195 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CLODERM CRE 0.1% PMP Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORDRAN CRE 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORDRAN LOT 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORDRAN OIN 0.05% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORDRAN 24X3 TAP 4MCG/CM Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORDRAN 24X3 TAP SML 24IN Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORDRAN 80X3 TAP 4MCG/CM Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORMAX SCALP SOL 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORTEF TAB 10MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORTEF TAB 20MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORTEF TAB 5MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORTIFOAM AER 90MG Tier 2

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CORTISONE AC TAB 25MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CUTIVATE CRE 0.05% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs CUTIVATE LOT 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DELTASONE TAB 20MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DERMA-SMOOTH OIL /FS BODY Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DERMA-SMOOTH OIL /FS SCLP Tier 3

Page 196 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DERMATOP CRE 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DERMATOP OIN 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESONATE GEL 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESONIDE CRE 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESONIDE LOT 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESONIDE OIN 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESOWEN CRE 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESOWEN LOT 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESOXIMETAS CRE 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESOXIMETAS CRE 0.25% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESOXIMETAS GEL 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESOXIMETAS OIN 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DESOXIMETAS OIN 0.25% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETH SOD POW PHOSPHAT Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON CON 1MG/ML Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON ELX 0.5/5ML Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON POW Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON POW MICRONIZ Tier 3 X

Page 197 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON SOL 0.5/5ML Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON TAB 0.5MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON TAB 0.75MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON TAB 1.5MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON TAB 1MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON TAB 2MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON TAB 4MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXAMETHASON TAB 6MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXPAK PAK 10 DAY Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXPAK PAK 13 DAY Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DEXPAK PAK 6 DAY Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DIFLORASONE CRE 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DIFLORASONE OIN 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DIPROLENE LOT 0.05% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DIPROLENE OIN 0.05% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs DIPROLENE AF CRE 0.05% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ELOCON CRE 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ELOCON LOT 0.1% Tier 3

Page 198 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ELOCON OIN 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUDROCORT TAB 0.1MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET CRE 0.01% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET CRE 0.025% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET OIL 0.01% SC Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET OIL 0.01%BDY Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET OIL BODY Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET OIL SCALP Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET OIN 0.025% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCIN ACET SOL 0.01% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCINONIDE CRE 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCINONIDE CRE 0.1% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCINONIDE CRE -E 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCINONIDE GEL 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCINONIDE OIN 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUOCINONIDE SOL 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLURANDRENOL CRE 0.05% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUTICASONE CRE 0.05% Tier 1

Page 199 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUTICASONE LOT 0.05% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FLUTICASONE OIN 0.005% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs FRST-HYDRCRT GEL 10% Tier 2 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs GNP HYDROCOR OIN 1% W/ALO Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HALOBETASOL CRE 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HALOBETASOL OIN 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HALOG CRE 0.1% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HALOG OIN 0.1% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HC BUTYRATE CRE 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HC BUTYRATE CRE 0.1% Tier 1 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HC BUTYRATE OIN 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HC BUTYRATE SOL 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HC VALERATE CRE 0.2% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HC VALERATE OIN 0.2% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT CRE 1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT CRE 2.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT LOT 2.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT OIN 1% Tier 1

Page 200 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT OIN 2.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT TAB 10MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT TAB 20MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT TAB 5MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORT/AB OIN 1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs HYDROCORTISO CRE 2.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs KENALOG AER SPRAY Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs LOCOID CRE 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs LOCOID LOT 0.1% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs LOCOID OIN 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs LOCOID SOL 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs LOCOID LIPO CRE 0.1% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs LOKARA LOT 0.05% Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs LUXIQ AER 0.12% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MEDROL TAB 16MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MEDROL TAB 2MG Tier 2

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MEDROL TAB 32MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MEDROL TAB 4MG Tier 3

Page 201 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MEDROL TAB 4MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MEDROL TAB 8MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs METHYLPRED POW ACETATE Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs METHYLPRED TAB 16MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs METHYLPRED TAB 32MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs METHYLPRED TAB 4MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs METHYLPRED TAB 4MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs METHYLPRED TAB 8MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MILLIPRED SOL 10MG/5ML Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MOMETASONE CRE 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MOMETASONE OIN 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MOMETASONE POW Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs MOMETASONE SOL 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs OLUX AER 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs OLUX-E AER 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ORAPRED ODT TAB 10MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ORAPRED ODT TAB 15MG Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ORAPRED ODT TAB 30MG Tier 3

Page 202 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PANDEL CRE 0.1% Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PEDIAPRED SOL 6.7/5ML Tier 2

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PRED SOD PHO SOL 5MG/5ML Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNICARBAT CRE 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNICARBAT OIN 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISOLONE SOL 15MG/5ML Tier 1 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISOLONE SOL 25MG/5ML Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISOLONE TAB 10MG ODT Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISOLONE TAB 15MG ODT Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISOLONE TAB 30MG ODT Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE CON 5MG/ML Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE PAK 10MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE PAK 10MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE PAK 5MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE PAK 5MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE SOL 5MG/5ML Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE TAB 10MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE TAB 1MG Tier 1

Page 203 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE TAB 2.5MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE TAB 20MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE TAB 50MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PREDNISONE TAB 5MG Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PROCTOCORT CRE 1% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PROCTO-MED CRE HC 2.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PROCTO-PAK CRE 1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PROCTOSOL HC CRE 2.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PROCTOZONE CRE -HC 2.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs PSORCON CRE 0.05% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs RAYOS TAB 1MG Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs RAYOS TAB 2MG Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs RAYOS TAB 5MG Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs SCALACORT LOT 2% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs SERNIVO SPR Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs SYNALAR CRE 0.025% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs SYNALAR OIN 0.025% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs SYNALAR SOL 0.01% Tier 3 X X

Page 204 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TEMOVATE CRE 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TEMOVATE GEL 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TEMOVATE OIN 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TEMOVATE SOL 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TEMOVATE E CRE 0.05%EML Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TEXACORT SOL 2.5% Tier 2

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TOPICORT CRE 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TOPICORT CRE 0.25% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TOPICORT GEL 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TOPICORT OIN 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TOPICORT OIN 0.25% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TOPICORT SPR 0.25% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON AER SPRAY Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON CRE 0.025% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON CRE 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON CRE 0.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON LOT 0.025% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON LOT 0.1% Tier 1

Page 205 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON OIN 0.025% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON OIN 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON OIN 0.5% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIAMCINOLON POW ACETONID Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIANEX OIN 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs TRIDERM CRE 0.1% Tier 1

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ULTRAVATE CRE 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ULTRAVATE LOT 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs ULTRAVATE OIN 0.05% Tier 3 X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs VANOS CRE 0.1% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs VERDESO AER 0.05% Tier 3 X X

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs VERIPRED 20 SOL 20MG/5ML Tier 3

Glucocorticoids/Mineralocorticoids - Anti-Inflammatory Drugs WESTCORT OIN 0.2% Tier 3 X Glutamate Reducing Agents - Seizure Control Drugs FELBAMATE SUS 600/5ML Tier 1 Glutamate Reducing Agents - Seizure Control Drugs FELBAMATE TAB 400MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs FELBAMATE TAB 600MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs FELBATOL SUS 600/5ML Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs FELBATOL TAB 400MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs FELBATOL TAB 600MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL CHW 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL CHW 5MG Tier 3 X X

Page 206 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL KIT START 35 Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL KIT START 49 Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL KIT START 98 Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL TAB 100MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL TAB 150MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL TAB 200MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL TAB 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL ODT KIT Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL ODT KIT Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL ODT KIT Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL ODT TAB 100MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL ODT TAB 200MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL ODT TAB 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL ODT TAB 50MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR KIT Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR KIT Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR KIT Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR TAB 100MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR TAB 200MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR TAB 250MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR TAB 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR TAB 300MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMICTAL XR TAB 50MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIG ODT KIT 25/50MG Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIG ODT KIT 50/100MG Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE CHW 25MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE CHW 5MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE KIT ODT Tier 1 X X

Page 207 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 100MG Tier 1 X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 100MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 100MG ER Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 150MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 200MG Tier 1 X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 200MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 200MG ER Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 250MG ER Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 25MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 25MG ER Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 25MG ODT Tier 1 X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 300MG ER Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 50MG ER Tier 1 X X Glutamate Reducing Agents - Seizure Control Drugs LAMOTRIGINE TAB 50MG ODT Tier 1 X Glutamate Reducing Agents - Seizure Control Drugs QUDEXY XR CAP 100/24HR Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs QUDEXY XR CAP 150/24HR Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs QUDEXY XR CAP 200/24HR Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs QUDEXY XR CAP 25/24HR Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs QUDEXY XR CAP 50/24HR Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPAMAX TAB 100MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPAMAX TAB 200MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPAMAX TAB 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPAMAX TAB 50MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPAMAX SPR CAP 15MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPAMAX SPR CAP 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPIRAGEN TAB 100MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAGEN TAB 200MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAGEN TAB 25MG Tier 1

Page 208 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Glutamate Reducing Agents - Seizure Control Drugs TOPIRAGEN TAB 50MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE CAP 15MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE CAP 25MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE CAP ER 100MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE CAP ER 150MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE CAP ER 200MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE CAP ER 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE CAP ER 50MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE TAB 100MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE TAB 200MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE TAB 25MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TOPIRAMATE TAB 50MG Tier 1 Glutamate Reducing Agents - Seizure Control Drugs TROKENDI XR CAP 100MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TROKENDI XR CAP 200MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TROKENDI XR CAP 25MG Tier 3 X X Glutamate Reducing Agents - Seizure Control Drugs TROKENDI XR CAP 50MG Tier 3 X X

Glycemic Agents - Diabetic Drugs GLUCAGEN INJ HYPOKIT Tier 2 X

Glycemic Agents - Diabetic Drugs GLUCAGON KIT 1MG Tier 2 X

Glycemic Agents - Diabetic Drugs PROGLYCEM SUS 50MG/ML Tier 3 HEAVY METAL ANTAGONISTS GALZIN CAP 25MG Tier 3 HEAVY METAL ANTAGONISTS GALZIN CAP 50MG Tier 3

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs AXID SOL 15MG/ML Tier 3

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs CIMETIDINE SOL 300/5ML Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs CIMETIDINE TAB 200MG Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs CIMETIDINE TAB 300MG Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs CIMETIDINE TAB 400MG Tier 1

Page 209 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs CIMETIDINE TAB 800MG Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs CIMETIDINE TAB 400MG Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs DEPRIZINE SUS 22.4/ML Tier 3 X

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs DEPRIZINE SUS RAPIDPAQ Tier 3 X

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs FAMOTIDINE SUS 40MG/5ML Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs NIZATIDINE SOL 15MG/ML Tier 3

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs NIZATIDINE SOL 15MG/ML Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs PEPCID SUS 40MG/5ML Tier 3

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs RANITIDINE SYP 150/10ML Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs RANITIDINE SYP 15MG/ML Tier 1

Histamine2 (H2) receptor Antagonists - Ulcer and Stomach Acid Drugs RANITIDINE SYP 75MG/5ML Tier 1 Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs CERVIDIL VAG MIS 10MG INS Tier 3 Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs PREPIDIL GEL 0.5MG/3G Tier 3 Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs PROSTIN E2 SUP 20MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) BRAVELLE INJ 75UNIT Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) CLOMIPHENE TAB 50MG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) FOLLISTIM AQ INJ 150UNIT Tier 3 X X X

Page 210 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) FOLLISTIM AQ INJ 300UNIT Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) FOLLISTIM AQ INJ 600UNIT Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) FOLLISTIM AQ INJ 75UNIT Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) FOLLISTIM AQ INJ 900UNIT Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) GONAL-F INJ 1050UNIT Tier 2 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) GONAL-F INJ 450UNIT Tier 2 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) GONAL-F RFF INJ 300/0.5 Tier 2 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) GONAL-F RFF INJ 450/0.75 Tier 2 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) GONAL-F RFF INJ 75UNIT Tier 2 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) GONAL-F RFF INJ 900/1.5 Tier 2 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) MENOPUR INJ 75UNIT Tier 3 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs CHOR GONADOT INJ 10000UNT Tier 1 X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP INJ 4MCG/ML Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP SOL 0.01% Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP SPR 0.01% Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP TAB 0.1MG Tier 3

Page 211 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DDAVP TAB 0.2MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DESMOPRESSIN INJ 4MCG/ML Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DESMOPRESSIN SOL 0.01% Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DESMOPRESSIN SPR 0.01% Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DESMOPRESSIN SPR 0.01% Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DESMOPRESSIN TAB 0.1MG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs DESMOPRESSIN TAB 0.2MG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs EGRIFTA SOL 1MG Tier 3 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs EGRIFTA SOL 2MG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 0.2MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 0.4MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 0.6MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 0.8MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 1.2MG Tier 3 X X X X

Page 212 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 1.4MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 1.6MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 1.8MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 12MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 1MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 2MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs GENOTROPIN INJ 5MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs H.P. ACTHAR INJ 80UNIT Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs HUMATROPE INJ 12MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs HUMATROPE INJ 24MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs HUMATROPE INJ 5MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs HUMATROPE INJ 6MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs INCRELEX INJ 40MG/4ML Tier 2 X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NORDITROPIN INJ 10/1.5ML Tier 3 X X X X

Page 213 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NORDITROPIN INJ 15/1.5ML Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NORDITROPIN INJ 30/3ML Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NORDITROPIN INJ 5/1.5ML Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NOVAREL INJ 10000UNT Tier 1 X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NUTROPIN AQ INJ 10MG/2ML Tier 2 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NUTROPIN AQ INJ 20MG/2ML Tier 2 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs NUTROPIN AQ INJ NUSPIN 5 Tier 2 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs OMNITROPE INJ 10/1.5ML Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs OMNITROPE INJ 5.8MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs OMNITROPE INJ 5/1.5ML Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs OVIDREL INJ Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs PREGNYL INJ 10000UNT Tier 1 X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs SAIZEN INJ 5MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs SAIZEN INJ 8.8MG Tier 3 X X X X

Page 214 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs SEROSTIM INJ 4MG Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs SEROSTIM INJ 5MG Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs SEROSTIM INJ 6MG Tier 3 X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs STIMATE SOL 1.5MG/ML Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs TEV-TROPIN INJ 5MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs ZOMACTON INJ 10MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs ZOMACTON INJ 5MG Tier 3 X X X X Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs ZORBTIVE INJ 8.8MG Tier 3 X X X

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM TAB 300MG Tier 3 X X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 120MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 15MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 180MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 240MG Tier 3

Page 215 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 300MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 30MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 60MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs ARMOUR THYRO TAB 90MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs CYTOMEL TAB 25MCG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs CYTOMEL TAB 50MCG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs CYTOMEL TAB 5MCG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 100MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 112MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 125MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 137MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 150MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 175MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 200 MCG Tier 1

Page 216 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 25MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 300 MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 50MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 75MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVO-T TAB 88MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 100MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 112MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 125MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 137MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 150MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 175MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 200MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 25MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 300MCG Tier 1

Page 217 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 50MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 75MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOTHYROXIN TAB 88MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 100MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 112MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 125MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 137MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 150MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 175MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 200MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 25MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 50MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 75MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LEVOXYL TAB 88MCG Tier 1

Page 218 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LIOTHYRONINE TAB 25MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LIOTHYRONINE TAB 50MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs LIOTHYRONINE TAB 5MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE THROI TAB 162.5MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 113.75MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 130MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 146.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 16.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 195MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 260MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 32.5MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 325MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 48.75MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 65MG Tier 3

Page 219 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 81.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NATURE-THROI TAB 97.5MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NP THYROID TAB 30MG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NP THYROID TAB 60MG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs NP THYROID TAB 90MG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 100MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 112MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 125MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 137MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 150MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 175MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 200MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 25MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 300MCG Tier 2

Page 220 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 50MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 75MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs SYNTHROID TAB 88MCG Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs THYROLAR-1 TAB 60MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs THYROLAR-1/2 TAB 30MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs THYROLAR-1/4 TAB 15MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs THYROLAR-2 TAB 120MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs THYROLAR-3 TAB 180MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 100MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 112MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 125MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 137MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 13MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 150MCG Tier 3 X

Page 221 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 25MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 50MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 75MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs TIROSINT CAP 88MCG Tier 3 X Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 100MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 112MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 125MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 150MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 175MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 200MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 25MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 300MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 50MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 75MCG Tier 1

Page 222 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITH DIRECT TAB 88MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 100MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 112MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 125MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 137MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 150MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 175MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 200MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 25MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 300MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 50MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 75MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs UNITHROID TAB 88MCG Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 113.75MG Tier 3

Page 223 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 130MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 146.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 16.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 162.50MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 195MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 260MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 32.5MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 325MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 48.75MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 65MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 81.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WESTHROID TAB 97.5MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 113.75MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 130MG Tier 3

Page 224 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 16.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 32.5MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 48.75MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 65MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 81.25MG Tier 3 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs WP THYROID TAB 97.5MG Tier 3

Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN TAB 500MG Tier 2 X Hormonal Agents, Suppressant (Parathyroid) - Hormone Suppressants SENSIPAR TAB 30MG Tier 3 Hormonal Agents, Suppressant (Parathyroid) - Hormone Suppressants SENSIPAR TAB 60MG Tier 3 Hormonal Agents, Suppressant (Parathyroid) - Hormone Suppressants SENSIPAR TAB 90MG Tier 3 Hormonal Agents, Suppressant (Pituitary) CETROTIDE KIT 0.25MG Tier 2 X Hormonal Agents, Suppressant (Pituitary) GANIRELIX AC INJ Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants CABERGOLINE TAB 0.5MG Tier 1

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants ELIGARD INJ 22.5MG Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants ELIGARD INJ 30MG Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants ELIGARD INJ 45MG Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants ELIGARD INJ 7.5MG Tier 3 X X

Page 225 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants FIRMAGON INJ 120MG Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants FIRMAGON INJ 80MG Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants LEUPROLIDE INJ 1MG/0.2 Tier 1 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants OCTREOTIDE INJ 1000MCG Tier 1 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants OCTREOTIDE INJ 100MCG Tier 1 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants OCTREOTIDE INJ 200MCG Tier 1 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants OCTREOTIDE INJ 500MCG Tier 1 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants OCTREOTIDE INJ 50MCG/ML Tier 1 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SANDOSTATIN INJ 1000MCG Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SANDOSTATIN INJ 100MCG Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SANDOSTATIN INJ 200MCG Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SANDOSTATIN INJ 500MCG Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SANDOSTATIN INJ 50MCG/ML Tier 3 X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SIGNIFOR INJ 0.3MG/ML Tier 2 X X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SIGNIFOR INJ 0.6MG/ML Tier 2 X X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SIGNIFOR INJ 0.9MG/ML Tier 2 X X X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMATULINE INJ 120/.5ML Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMATULINE INJ 60/0.2ML Tier 3 X

Page 226 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMATULINE INJ 90/0.3ML Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMAVERT INJ 10MG Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMAVERT INJ 15MG Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMAVERT INJ 20MG Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMAVERT INJ 25MG Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SOMAVERT INJ 30MG Tier 3 X

Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants SYNAREL SOL 2MG/ML Tier 2

HORMONES AND SYNTHETIC SUBSTITUTES - ANTITHYROID AGENTS IODINE SOL STRONG Tier 2

HORMONES AND SYNTHETIC SUBSTITUTES - ANTITHYROID AGENTS SSKI SOL 1GM/ML Tier 3 Immune Suppressants - Immune System Drugs ASTAGRAF XL CAP 0.5MG Tier 3 X X Immune Suppressants - Immune System Drugs ASTAGRAF XL CAP 1MG Tier 3 X X Immune Suppressants - Immune System Drugs ASTAGRAF XL CAP 5MG Tier 3 X X Immune Suppressants - Immune System Drugs AZASAN TAB 100MG Tier 3 Immune Suppressants - Immune System Drugs AZASAN TAB 75 MG Tier 3 Immune Suppressants - Immune System Drugs AZATHIOPRINE TAB 50MG Tier 1 Immune Suppressants - Immune System Drugs CELLCEPT CAP 250MG Tier 3 X Immune Suppressants - Immune System Drugs CELLCEPT SUS 200MG/ML Tier 3 X Immune Suppressants - Immune System Drugs CELLCEPT TAB 500MG Tier 3 X Immune Suppressants - Immune System Drugs CIMZIA KIT Tier 2 X X X Immune Suppressants - Immune System Drugs CIMZIA KIT STARTER Tier 2 X X X Immune Suppressants - Immune System Drugs CIMZIA PREFL KIT 200MG/ML Tier 2 X X X Immune Suppressants - Immune System Drugs CYCLOSPORINE CAP 100MG Tier 1 X Immune Suppressants - Immune System Drugs CYCLOSPORINE CAP 100MG MD Tier 1 X

Page 227 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Immune Suppressants - Immune System Drugs CYCLOSPORINE CAP 25MG Tier 1 X Immune Suppressants - Immune System Drugs CYCLOSPORINE CAP 25MG MOD Tier 1 X Immune Suppressants - Immune System Drugs CYCLOSPORINE CAP 50MG MOD Tier 1 X Immune Suppressants - Immune System Drugs CYCLOSPORINE SOL MODIFIED Tier 1 X Immune Suppressants - Immune System Drugs ENBREL INJ 25/0.5ML Tier 3 X X X Immune Suppressants - Immune System Drugs ENBREL INJ 25MG Tier 3 X X X Immune Suppressants - Immune System Drugs ENBREL INJ 50MG/ML Tier 3 X X X Immune Suppressants - Immune System Drugs ENBREL SRCLK INJ 50MG/ML Tier 3 X X X Immune Suppressants - Immune System Drugs ENVARSUS XR TAB 0.75MG Tier 3 X X Immune Suppressants - Immune System Drugs ENVARSUS XR TAB 1MG Tier 3 X X Immune Suppressants - Immune System Drugs ENVARSUS XR TAB 4MG Tier 3 X X Immune Suppressants - Immune System Drugs GENGRAF CAP 100MG Tier 1 X Immune Suppressants - Immune System Drugs GENGRAF CAP 25MG Tier 1 X Immune Suppressants - Immune System Drugs GENGRAF CAP 50MG Tier 1 X Immune Suppressants - Immune System Drugs GENGRAF SOL 100MG/ML Tier 1 X Immune Suppressants - Immune System Drugs HUMIRA INJ 10MG/0.2 Tier 2 X X X Immune Suppressants - Immune System Drugs HUMIRA KIT 20MG/0.4 Tier 2 X X X Immune Suppressants - Immune System Drugs HUMIRA KIT 40MG/0.8 Tier 2 X X X Immune Suppressants - Immune System Drugs HUMIRA PEDIA INJ CROHNS Tier 2 X X X Immune Suppressants - Immune System Drugs HUMIRA PEN INJ 40MG/0.8 Tier 2 X X X Immune Suppressants - Immune System Drugs HUMIRA PEN INJ CROHNS Tier 2 X X X Immune Suppressants - Immune System Drugs HUMIRA PEN INJ PSORIASI Tier 2 X X X Immune Suppressants - Immune System Drugs IMURAN TAB 50MG Tier 3 Immune Suppressants - Immune System Drugs KINERET INJ Tier 3 X X X Immune Suppressants - Immune System Drugs METHOTREXATE TAB 2.5MG Tier 1 Immune Suppressants - Immune System Drugs MYCOPHENOLAT CAP 250MG Tier 1 X Immune Suppressants - Immune System Drugs MYCOPHENOLAT SUS 200MG/ML Tier 1 X Immune Suppressants - Immune System Drugs MYCOPHENOLAT TAB 500MG Tier 1 X

Page 228 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Immune Suppressants - Immune System Drugs MYCOPHENOLIC TAB 180MG DR Tier 1 X Immune Suppressants - Immune System Drugs MYCOPHENOLIC TAB 360MG DR Tier 1 X Immune Suppressants - Immune System Drugs MYFORTIC TAB 180MG Tier 3 X Immune Suppressants - Immune System Drugs MYFORTIC TAB 360MG Tier 3 X Immune Suppressants - Immune System Drugs NEORAL CAP 100MG Tier 3 X Immune Suppressants - Immune System Drugs NEORAL CAP 25MG Tier 3 X Immune Suppressants - Immune System Drugs NEORAL SOL 100MG/ML Tier 3 X Immune Suppressants - Immune System Drugs ORENCIA INJ 125MG/ML Tier 3 X X X Immune Suppressants - Immune System Drugs ORENCIA CLCK INJ 125MG/ML Tier 3 X Immune Suppressants - Immune System Drugs OTREXUP INJ 10MG Tier 3 X X Immune Suppressants - Immune System Drugs OTREXUP INJ 12.5/0.4 Tier 3 X X Immune Suppressants - Immune System Drugs OTREXUP INJ 15MG Tier 3 X X Immune Suppressants - Immune System Drugs OTREXUP INJ 17.5/0.4 Tier 3 X Immune Suppressants - Immune System Drugs OTREXUP INJ 20MG Tier 3 X X Immune Suppressants - Immune System Drugs OTREXUP INJ 22.5/0.4 Tier 3 X Immune Suppressants - Immune System Drugs OTREXUP INJ 25MG Tier 3 X X Immune Suppressants - Immune System Drugs OTREXUP INJ 7.5/0.4 Tier 3 X X Immune Suppressants - Immune System Drugs PROGRAF CAP 0.5MG Tier 3 X Immune Suppressants - Immune System Drugs PROGRAF CAP 1MG Tier 3 X Immune Suppressants - Immune System Drugs PROGRAF CAP 5MG Tier 3 X Immune Suppressants - Immune System Drugs RAPAMUNE SOL 1MG/ML Tier 2 X Immune Suppressants - Immune System Drugs RAPAMUNE TAB 0.5MG Tier 3 X Immune Suppressants - Immune System Drugs RAPAMUNE TAB 1MG Tier 3 X Immune Suppressants - Immune System Drugs RAPAMUNE TAB 2MG Tier 3 X Immune Suppressants - Immune System Drugs RASUVO INJ 10MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 12.5MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 15MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 17.5MG Tier 3 X X

Page 229 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Immune Suppressants - Immune System Drugs RASUVO INJ 20MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 22.5MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 25MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 27.5MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 30MG Tier 3 X X Immune Suppressants - Immune System Drugs RASUVO INJ 7.5MG Tier 3 X X Immune Suppressants - Immune System Drugs RHEUMATREX TAB 2.5MG Tier 2 Immune Suppressants - Immune System Drugs SANDIMMUNE CAP 100MG Tier 3 X Immune Suppressants - Immune System Drugs SANDIMMUNE CAP 25MG Tier 3 X Immune Suppressants - Immune System Drugs SANDIMMUNE SOL 100MG/ML Tier 3 X Immune Suppressants - Immune System Drugs SIMPONI INJ 100MG/ML Tier 2 X X X Immune Suppressants - Immune System Drugs SIMPONI INJ 100MG/ML Tier 2 X X X Immune Suppressants - Immune System Drugs SIMPONI INJ 50/0.5ML Tier 2 X X X Immune Suppressants - Immune System Drugs SIMPONI INJ 50/0.5ML Tier 2 X X X Immune Suppressants - Immune System Drugs SIROLIMUS TAB 0.5MG Tier 1 X Immune Suppressants - Immune System Drugs SIROLIMUS TAB 1MG Tier 1 X Immune Suppressants - Immune System Drugs SIROLIMUS TAB 2MG Tier 1 X Immune Suppressants - Immune System Drugs TACROLIMUS CAP 0.5MG Tier 1 X Immune Suppressants - Immune System Drugs TACROLIMUS CAP 1MG Tier 1 X Immune Suppressants - Immune System Drugs TACROLIMUS CAP 5MG Tier 1 X Immune Suppressants - Immune System Drugs TREXALL TAB 10MG Tier 2 Immune Suppressants - Immune System Drugs TREXALL TAB 15MG Tier 2 Immune Suppressants - Immune System Drugs TREXALL TAB 5MG Tier 2 Immune Suppressants - Immune System Drugs TREXALL TAB 7.5MG Tier 2 Immune Suppressants - Immune System Drugs ZORTRESS TAB 0.25MG Tier 3 X Immune Suppressants - Immune System Drugs ZORTRESS TAB 0.5MG Tier 3 X Immune Suppressants - Immune System Drugs ZORTRESS TAB 0.75MG Tier 3 X Immunomodulators - Immune System Drugs ACTEMRA INJ 162/0.9 Tier 3 X X X

Page 230 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Immunomodulators - Immune System Drugs ACTIMMUNE INJ 2MU/0.5 Tier 2 X X X Immunomodulators - Immune System Drugs ALFERON N INJ 5MU/ML Tier 2 X Immunomodulators - Immune System Drugs ARAVA TAB 10MG Tier 3 Immunomodulators - Immune System Drugs ARAVA TAB 20MG Tier 3 Immunomodulators - Immune System Drugs ARCALYST INJ 220MG Tier 2 X X X Immunomodulators - Immune System Drugs AVONEX KIT 30MCG Tier 2 X X X Immunomodulators - Immune System Drugs AVONEX PEN KIT 30MCG Tier 2 X X X Immunomodulators - Immune System Drugs AVONEX PREFL KIT 30MCG Tier 2 X X X Immunomodulators - Immune System Drugs BETASERON INJ 0.3MG Tier 2 X X X Immunomodulators - Immune System Drugs EXTAVIA INJ 0.3MG Tier 3 X X X X Immunomodulators - Immune System Drugs LEFLUNOMIDE TAB 10MG Tier 1 Immunomodulators - Immune System Drugs LEFLUNOMIDE TAB 20MG Tier 1 Immunomodulators - Immune System Drugs OTEZLA TAB 10/20/30 Tier 3 X X X Immunomodulators - Immune System Drugs OTEZLA TAB 30MG Tier 3 X X X Immunomodulators - Immune System Drugs REBIF INJ 22/0.5 Tier 3 X X X X Immunomodulators - Immune System Drugs REBIF INJ 44/0.5 Tier 3 X X X X Immunomodulators - Immune System Drugs REBIF REBIDO INJ 22/0.5 Tier 3 X X X X Immunomodulators - Immune System Drugs REBIF REBIDO INJ 44/0.5 Tier 3 X X X X Immunomodulators - Immune System Drugs REBIF REBIDO INJ TITRATN Tier 3 X X X X Immunomodulators - Immune System Drugs REBIF TITRTN INJ PACK Tier 3 X X X X Immunomodulators - Immune System Drugs RIDAURA CAP 3MG Tier 3 Immunomodulators - Immune System Drugs TECFIDERA CAP 120MG Tier 2 X X X Immunomodulators - Immune System Drugs TECFIDERA CAP 240MG Tier 2 X X X Immunomodulators - Immune System Drugs TECFIDERA MIS STARTER Tier 2 X X X Immunomodulators - Immune System Drugs XELJANZ TAB 5MG Tier 3 X X X X Immunomodulators - Immune System Drugs XELJANZ XR TAB 11MG Tier 3 X X X X Insulins - Diabetic Drugs AFREZZA POW Tier 3 X X Insulins - Diabetic Drugs AFREZZA POW 4& 8UNIT Tier 3 X X Insulins - Diabetic Drugs AFREZZA POW 4& 8UNIT Tier 3 X X Insulins - Diabetic Drugs AFREZZA POW 4UNIT Tier 3 X X X Insulins - Diabetic Drugs AFREZZA POW 8&12UNIT Tier 3 X X X

Page 231 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Insulins - Diabetic Drugs APIDRA INJ SOLOSTAR Tier 3 X X Insulins - Diabetic Drugs APIDRA INJ U-100 Tier 3 X X Insulins - Diabetic Drugs HUMALOG INJ 100/ML Tier 1 X Insulins - Diabetic Drugs HUMALOG INJ 100/ML Tier 2 X Insulins - Diabetic Drugs HUMALOG KWIK INJ 100/ML Tier 2 X Insulins - Diabetic Drugs HUMALOG KWIK INJ 200/ML Tier 2 X Insulins - Diabetic Drugs HUMALOG MIX INJ 50/50 Tier 1 X

Insulins - Diabetic Drugs HUMALOG MIX INJ 50/50KWP Tier 2 X

Insulins - Diabetic Drugs HUMALOG MIX INJ 75/25KWP Tier 2 X Insulins - Diabetic Drugs HUMALOG MIX SUS 75/25 Tier 1 X Insulins - Diabetic Drugs HUMULIN INJ 70/30 Tier 1 X Insulins - Diabetic Drugs HUMULIN INJ 70/30KWP Tier 2 X Insulins - Diabetic Drugs HUMULIN N INJ U-100 Tier 1 X Insulins - Diabetic Drugs HUMULIN N INJ U-100KWP Tier 2 X Insulins - Diabetic Drugs HUMULIN R INJ U-100 Tier 1 X Insulins - Diabetic Drugs HUMULIN R INJ U-500 Tier 1 X Insulins - Diabetic Drugs HUMULIN R INJ U-500 Tier 2 Insulins - Diabetic Drugs LANTUS INJ 100/ML Tier 3 X Insulins - Diabetic Drugs LANTUS INJ SOLOSTAR Tier 3 X Insulins - Diabetic Drugs LEVEMIR INJ Tier 1 X Insulins - Diabetic Drugs LEVEMIR INJ FLEXTOUC Tier 1 X Insulins - Diabetic Drugs NOVOLIN INJ 70/30 Tier 3 X X Insulins - Diabetic Drugs NOVOLIN N INJ RELION Tier 3 X X Insulins - Diabetic Drugs NOVOLIN N INJ U-100 Tier 3 X X Insulins - Diabetic Drugs NOVOLIN R INJ RELION Tier 3 X X Insulins - Diabetic Drugs NOVOLIN R INJ U-100 Tier 3 X X Insulins - Diabetic Drugs NOVOLIN70/30 INJ RELION Tier 3 X X Insulins - Diabetic Drugs NOVOLOG INJ 100/ML Tier 3 X X Insulins - Diabetic Drugs NOVOLOG INJ FLEXPEN Tier 3 X X Insulins - Diabetic Drugs NOVOLOG INJ PENFILL Tier 3 X X Insulins - Diabetic Drugs NOVOLOG MIX INJ 70/30 Tier 3 X X Insulins - Diabetic Drugs NOVOLOG MIX INJ FLEXPEN Tier 3 X X Insulins - Diabetic Drugs TOUJEO SOLO INJ 300IU/ML Tier 3 X X

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs ALOSETRON TAB 0.5MG Tier 1 X X

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs ALOSETRON TAB 1MG Tier 1 X X

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs AMITIZA CAP 24MCG Tier 3 X X X

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs AMITIZA CAP 8MCG Tier 3 X X X

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LINZESS CAP 145MCG Tier 2 X X

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LINZESS CAP 290MCG Tier 2 X X

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LOTRONEX TAB 0.5MG Tier 3 X X X

Page 232 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LOTRONEX TAB 1MG Tier 3 X X X

Laxatives - Bowel Treatment Drugs CHOLAC SYP 10GM/15 Tier 1 HCR Laxatives - Bowel Treatment Drugs CLEARLAX POW Preventative

Laxatives - Bowel Treatment Drugs COLYTE/FLAVR SOL PACKS Tier 2

Laxatives - Bowel Treatment Drugs COLYTE/FLAVR SOL PACKS Tier 3

Laxatives - Bowel Treatment Drugs CONSTULOSE SOL 10GM/15 Tier 1 HCR Laxatives - Bowel Treatment Drugs CVS PURELAX POW Preventative

Laxatives - Bowel Treatment Drugs ENULOSE SOL 10GM/15 Tier 1 HCR Laxatives - Bowel Treatment Drugs EQ CLEARLAX POW Preventative HCR Laxatives - Bowel Treatment Drugs EQL CLEARLAX POW Preventative HCR Laxatives - Bowel Treatment Drugs GAVILAX POW Preventative HCR Laxatives - Bowel Treatment Drugs GAVILYTE-C SOL Preventative HCR Laxatives - Bowel Treatment Drugs GAVILYTE-G SOL Preventative HCR Laxatives - Bowel Treatment Drugs GAVILYTE-N SOL FLAV PK Preventative

Laxatives - Bowel Treatment Drugs GENERLAC SOL 10GM/15 Tier 1 HCR Laxatives - Bowel Treatment Drugs GENTLELAX POW Preventative

Laxatives - Bowel Treatment Drugs GIALAX KIT Tier 3 X HCR Laxatives - Bowel Treatment Drugs GLYCOLAX POW 3350 NF Preventative HCR Laxatives - Bowel Treatment Drugs GNP CLEARLAX POW Preventative

Laxatives - Bowel Treatment Drugs GOLYTELY SOL Tier 3

Laxatives - Bowel Treatment Drugs GOLYTELY SOL Tier 2

Laxatives - Bowel Treatment Drugs GOLYTELY SOL PINEAPPL Tier 3 HCR Laxatives - Bowel Treatment Drugs HM CLEARLAX POW Preventative

Laxatives - Bowel Treatment Drugs KRISTALOSE PAK 10GM Tier 3

Laxatives - Bowel Treatment Drugs KRISTALOSE PAK 20GM Tier 3

Laxatives - Bowel Treatment Drugs LACTULOSE SOL 10GM/15 Tier 1

Laxatives - Bowel Treatment Drugs LACTULOSE SOL 10GM/15 Tier 1

Page 233 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Laxatives - Bowel Treatment Drugs LACTULOSE SOL 20GM/30 Tier 1

Laxatives - Bowel Treatment Drugs LACTULOSE SYP 10GM/15 Tier 1 HCR Laxatives - Bowel Treatment Drugs LAXACLEAR POW Preventative HCR Laxatives - Bowel Treatment Drugs LAXATIVE POL POW GLYCOL Preventative

Laxatives - Bowel Treatment Drugs MOVIPREP SOL Tier 3 X HCR Laxatives - Bowel Treatment Drugs NATURA-LAX POW 3350 NF Preventative

Laxatives - Bowel Treatment Drugs NULYTELY SOL FLAV PKS Tier 3 HCR Laxatives - Bowel Treatment Drugs PEG 3350 POW Preventative

Laxatives - Bowel Treatment Drugs PEG 3350 POW Tier 1

Laxatives - Bowel Treatment Drugs PEG 3350 POW Tier 3 HCR Laxatives - Bowel Treatment Drugs PEG 3350 SOL ELECTROL Preventative HCR Laxatives - Bowel Treatment Drugs PEG3350 POW Preventative HCR Laxatives - Bowel Treatment Drugs PEG-3350 SOL ELECTROL Preventative HCR Laxatives - Bowel Treatment Drugs PEG-3350/KCL SOL /SODIUM Preventative

Laxatives - Bowel Treatment Drugs PEGYLAX POW Tier 1

Laxatives - Bowel Treatment Drugs POLYETH GLYC POW 3350 NF Tier 1

Laxatives - Bowel Treatment Drugs POLYETH GLYC POW 3350 NF Tier 1 HCR Laxatives - Bowel Treatment Drugs POLYETH GLYC POW 3350 NF Preventative HCR Laxatives - Bowel Treatment Drugs POLYETH GLYC POW 3350-GRX Preventative HCR Laxatives - Bowel Treatment Drugs POWDERLAX POW Preventative

Laxatives - Bowel Treatment Drugs PREPOPIK PAK Tier 3 HCR Laxatives - Bowel Treatment Drugs RA LAXATIVE POW Preventative HCR Laxatives - Bowel Treatment Drugs SM CLEARLAX POW Preventative HCR Laxatives - Bowel Treatment Drugs SMOOTH LAX POW Preventative

Laxatives - Bowel Treatment Drugs SUPREP BOWEL SOL PREP Tier 3 HCR Laxatives - Bowel Treatment Drugs SW CLEARLAX POW Preventative HCR Laxatives - Bowel Treatment Drugs TRILYTE SOL Preventative Local Anesthetics ATENDIA PAD 4-3% Tier 3 Local Anesthetics BUPIVACAINE POW HCL Tier 3 Local Anesthetics DERMACINRX KIT PRIZOPAK Tier 1 X

Page 234 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Local Anesthetics EMLA CRE 2.5-2.5% Tier 3 Local Anesthetics LETS KIT Tier 1 X Local Anesthetics LEVA SET KIT Tier 1 X Local Anesthetics LIDO/PRILOCN CRE 2.5-2.5% Tier 1 Local Anesthetics LIDO/PRILOCN KIT 2.5-2.5% Tier 1 X Local Anesthetics LIDOCAINE CRE 10% Tier 1 X Local Anesthetics LIDOCAINE CRE 5% Tier 1 X Local Anesthetics LIDOCAINE CRE TETRACAI Tier 3 Local Anesthetics LIDOCAINE GEL 2% JELLY Tier 1 Local Anesthetics LIDOCAINE OIN 5% Tier 1 X Local Anesthetics LIDOCAINE OIN PAK 5% Tier 1 X Local Anesthetics LIDOCAINE PAD 5% Tier 1 X Local Anesthetics LIDOCAINE SOL 2% VISC Tier 1 Local Anesthetics LIDOCAINE SOL 4% Tier 1 Local Anesthetics LIDOCAINE SOL 4% Tier 1 Local Anesthetics LIDOCAINE-PR CRE Tier 1 X Local Anesthetics LIDODERM DIS 5% Tier 3 X X Local Anesthetics LIDOPIN CRE 3.25% Tier 3 Local Anesthetics LIDOPRIL KIT 2.5-2.5% Tier 1 X Local Anesthetics LIDOVEX CRE 3.75% Tier 3 Local Anesthetics LP LITE PAK KIT 2.5-2.5% Tier 1 X Local Anesthetics PAIN RELIEF PAD PATCH Tier 3 Local Anesthetics PLIAGLIS CRE 7-7% Tier 3 Local Anesthetics PROZENA PAD 4% Tier 3 Local Anesthetics RELADOR PAK KIT 2.5-2.5% Tier 1 X Local Anesthetics RELADOR PAK KIT PLUS Tier 1 X Local Anesthetics SYNERA DIS 70-70MG Tier 3 Local Anesthetics SYNVEXIA TC CRE 4-1% Tier 3

Local Anesthetics TOPEX TOPCAL SPR ANESTHET Tier 3 Local Anesthetics VELTRIX CRE 4-1% Tier 3 Local Anesthetics XYLOCAINE SOL 4% Tier 3 Macrolides - Antibiotics AZASITE SOL 1% Tier 3 X

Macrolides - Antibiotics AZITHROMYCIN POW 1GM PAK Tier 1

Macrolides - Antibiotics AZITHROMYCIN SUS 100/5ML Tier 1

Macrolides - Antibiotics AZITHROMYCIN SUS 200/5ML Tier 1 Macrolides - Antibiotics AZITHROMYCIN TAB 250MG Tier 1 Macrolides - Antibiotics AZITHROMYCIN TAB 500MG Tier 1 Macrolides - Antibiotics AZITHROMYCIN TAB 600MG Tier 1 Macrolides - Antibiotics BIAXIN SUS 250/5ML Tier 3 Macrolides - Antibiotics BIAXIN TAB 250MG Tier 3 Macrolides - Antibiotics BIAXIN TAB 500MG Tier 3

Macrolides - Antibiotics CLARITHROMYC SUS 125/5ML Tier 1

Macrolides - Antibiotics CLARITHROMYC SUS 250/5ML Tier 1 Macrolides - Antibiotics CLARITHROMYC TAB 250MG Tier 1 Macrolides - Antibiotics CLARITHROMYC TAB 500MG Tier 1

Macrolides - Antibiotics CLARITHROMYC TAB 500MG ER Tier 1 Macrolides - Antibiotics DIFICID TAB 200MG Tier 3 X Macrolides - Antibiotics E.E.S. 400 TAB 400MG Tier 3 X Macrolides - Antibiotics E.E.S. GRAN SUS 200/5ML Tier 3 Macrolides - Antibiotics ERY PAD 2% Tier 1

Page 235 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Macrolides - Antibiotics ERYGEL GEL 2% Tier 3 Macrolides - Antibiotics ERYPED SUS 200/5ML Tier 3 Macrolides - Antibiotics ERYPED SUS 400/5ML Tier 3 Macrolides - Antibiotics ERY-TAB TAB 250MG EC Tier 2 Macrolides - Antibiotics ERY-TAB TAB 333MG EC Tier 2 Macrolides - Antibiotics ERY-TAB TAB 500MG EC Tier 2 Macrolides - Antibiotics ERYTHROCIN TAB 250MG Tier 2 Macrolides - Antibiotics ERYTHROM ETH TAB 400MG Tier 1

Macrolides - Antibiotics ERYTHROMYCIN CAP 250MG EC Tier 1 Macrolides - Antibiotics ERYTHROMYCIN GEL 2% Tier 1

Macrolides - Antibiotics ERYTHROMYCIN OIN 5MG/GM Tier 1 Macrolides - Antibiotics ERYTHROMYCIN OIN OP Tier 1 Macrolides - Antibiotics ERYTHROMYCIN PAD 2% Tier 1 Macrolides - Antibiotics ERYTHROMYCIN SOL 2% Tier 1

Macrolides - Antibiotics ERYTHROMYCIN TAB 250MG BS Tier 1

Macrolides - Antibiotics ERYTHROMYCIN TAB 500MG BS Tier 1 Macrolides - Antibiotics ILOTYCIN OIN OP Tier 1 Macrolides - Antibiotics KETEK TAB 300MG Tier 3 Macrolides - Antibiotics KETEK TAB 400MG Tier 3 Macrolides - Antibiotics PCE TAB 333MG EC Tier 3 Macrolides - Antibiotics PCE TAB 500MG EC Tier 3 Macrolides - Antibiotics ROMYCIN OIN OP Tier 1 Macrolides - Antibiotics ZITHROMAX POW 1GM PAK Tier 3 Macrolides - Antibiotics ZITHROMAX SUS 100/5ML Tier 3 Macrolides - Antibiotics ZITHROMAX SUS 200/5ML Tier 3 Macrolides - Antibiotics ZITHROMAX TAB 250MG Tier 3 Macrolides - Antibiotics ZITHROMAX TAB 500MG Tier 3 Macrolides - Antibiotics ZITHROMAX TAB 600MG Tier 3 Macrolides - Antibiotics ZITHROMAX TAB TRI-PAK Tier 3 Macrolides - Antibiotics ZITHROMAX TAB Z-PAK Tier 3 Macrolides - Antibiotics ZMAX SUS 2GM Tier 3 Mast Cell Stabilizers - Asthma/Lung Drugs CROMOLYN SOD NEB 20MG/2ML Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ACTONEL TAB 150MG Tier 3 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ACTONEL TAB 30MG Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ACTONEL TAB 35MG Tier 3 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ACTONEL TAB 5MG Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ALENDRONATE SOL 70/75ML Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ALENDRONATE TAB 10MG Tier 1 X

Page 236 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ALENDRONATE TAB 35MG Tier 1 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ALENDRONATE TAB 40MG Tier 1 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ALENDRONATE TAB 5MG Tier 1 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ALENDRONATE TAB 70MG Tier 1 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ATELVIA TAB Tier 3 X X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs BINOSTO TAB 70MG Tier 3 X X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs BONIVA TAB 150MG Tier 3 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs CALCITONIN SPR 200/ACT Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs CALCITRIOL CAP 0.25MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs CALCITRIOL CAP 0.5MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs CALCITRIOL SOL 1MCG/ML Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs DOXERCALCIF CAP 0.5MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs DOXERCALCIF CAP 1MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs DOXERCALCIF CAP 2.5MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ETIDRON DISD TAB 200MG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ETIDRON DISD TAB 400MG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs FORTEO SOL 600/2.4 Tier 2 X X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs FORTICAL SPR 200/ACT Tier 3

Page 237 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs FOSAMAX TAB 70MG Tier 3 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs FOSAMAX + D TAB 70-2800 Tier 3 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs FOSAMAX + D TAB 70-5600 Tier 3 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs HECTOROL CAP 0.5MCG Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs HECTOROL CAP 1MCG Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs HECTOROL CAP 2.5MCG Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs IBANDRONATE TAB 150MG Tier 1 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs MIACALCIN INJ 200/ML Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs MIACALCIN SPR 200/ACT Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs PARICALCITOL CAP 1 MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs PARICALCITOL CAP 2 MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs PARICALCITOL CAP 4 MCG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs RISEDRON SOD TAB 35MG DR Tier 1 X X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs RISEDRONATE TAB 150MG Tier 1 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs RISEDRONATE TAB 30MG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs RISEDRONATE TAB 35MG Tier 1 X

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs RISEDRONATE TAB 5MG Tier 1

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ROCALTROL CAP 0.25MCG Tier 3

Page 238 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ROCALTROL CAP 0.5MCG Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ROCALTROL SOL 1MCG/ML Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ZEMPLAR CAP 1MCG Tier 3

Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs ZEMPLAR CAP 2MCG Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS A/G PRO TAB Tier 3

Miscellaneous Therapeutic Agents ACTIVE MEDIC KIT SPECIMEN Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS ACUNOL TAB 600MG Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ADVERA LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ADVERA LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS AMINOBEZ POT POW Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS APPTRIM CAP Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS APPTRIM-D CAP Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS ASILNASAL CAP RMS Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS AURUM LIQ 12X Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS BCAD 1 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BCAD 2 POW Tier 3

Miscellaneous Therapeutic Agents B-D UF SYRG MIS .3CC/30G Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS BHI URI- TAB CONTROL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BIO-IMMUNEX CAP Tier 1

Miscellaneous Therapeutic Agents BISMUTH SUBC POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST LIQ BUT PECN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST LIQ CHOC/MLT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST LIQ MOCHA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST LIQ STRWBRRY Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST LIQ VANILLA Tier 3

Page 239 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS BOOST HIGH LIQ PROTEIN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST PLUS LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST PLUS LIQ STRAWBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST PLUS LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST PUDDIN MIS BUTTSCTH Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST PUDDIN MIS CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS BOOST PUDDIN MIS VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CARDIOVID CAP PLUS Tier 3

Miscellaneous Therapeutic Agents CAREFINE MIS 31GX8MM Tier 2

Miscellaneous Therapeutic Agents CAREFINE MIS 32GX4MM Tier 2

Miscellaneous Therapeutic Agents CAREFINE MIS 32GX5MM Tier 2

Miscellaneous Therapeutic Agents CAREFINE MIS 32GX6MM Tier 2

Miscellaneous Therapeutic Agents CARNITOR SOL 1GM/10ML Tier 3

Miscellaneous Therapeutic Agents CARNITOR TAB 330MG Tier 3

Miscellaneous Therapeutic Agents CARNITOR SF SOL 1GM/10ML Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CATALYTIC TAB FORMULA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CAVAREST GEL 1.1% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS CAVIRINSE SOL 0.2% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS CHELIDONIUM LIQ COMPOUND Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CHOICE DM LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CHOICE DM TF LIQ UNSWEET Tier 3

Miscellaneous Therapeutic Agents CHOLECALCIF POW Tier 3 X

Miscellaneous Therapeutic Agents CHOLECALCIFE CRY USP/NF Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS CLINPRO 5000 PST 1.1% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS COENZYME Q10 CHW 60MG Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS COENZYME Q10 TAB 200MG Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS COLCIGEL GEL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS COMPLEAT LIQ CLS SYS Tier 3

Page 240 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS COMPLEAT PED LIQ Tier 3 HCR Miscellaneous Therapeutic Agents CONCEPTROL GEL 4% Preventative MISCELLANEOUS THERAPEUTIC AGENTS CONTROLRX CRE 1.1% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS CRITICARE HN LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CRUCIAL LIQ ULTRAPAK Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CRUCIAL LIQ UNFLAVOR Tier 3

Miscellaneous Therapeutic Agents CRYOSERV SOL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CVS NUTRITIO LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CVS NUTRITIO LIQ STRABERY Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS CVS NUTRITIO LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS DENTA 5000 CRE PLUS Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS DENTA 5000 CRE PLUS 2PK Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS DENTAGEL GEL 1.1% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS DERMATODORON LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS DIABETIC TF LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS DIABETISOURC LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS DIABETISOURC LIQ AC Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS DIGESTODORON LIQ Tier 3

Miscellaneous Therapeutic Agents DIMETHYL SOL SULFOXID Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS DISCUS LIQ COMPOSIT Tier 3

Miscellaneous Therapeutic Agents DIUSCREEN ME KIT COLLECTI Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS DIVISTA CAP Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS EASYGEL GEL 0.4% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS EASYGEL GEL 0.4%CHRY Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS EASYGEL GEL 0.4%CITR Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS EASYGEL GEL 0.4%MINT Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS ECZEMOL TAB Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ERYSIDORON LIQ #1 Tier 3

Page 241 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS ESTRO VITAL TAB NUTRIENT Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS F.A.A. LIQ Tier 3

Miscellaneous Therapeutic Agents FEM PH GEL Tier 3

Miscellaneous Therapeutic Agents FERRIPROX SOL 100MG/ML Tier 2 X X

Miscellaneous Therapeutic Agents FERRIPROX TAB 500MG Tier 3 X X MISCELLANEOUS THERAPEUTIC AGENTS FIBERSOUR HN LIQ CLS SYS Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS FIBERSOUR HN LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS FIBERSOURCE LIQ CLS SYS Tier 3

Miscellaneous Therapeutic Agents FIRAZYR INJ 30MG/3ML Tier 3 X X X MISCELLANEOUS THERAPEUTIC AGENTS FIRST DUKES SUS MOUTHWSH Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS FIRST-MARYS SUS MOUTHWSH Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS FLUOR-A-DAY CHW 0.25MG F Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS FLUOR-A-DAY CHW 0.5MG F Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS FLUOR-A-DAY CHW 1MG F Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS FLUORIDEX GEL 1.1% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS FLUORIDEX GEL SENSITIV Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS FLUORIDEX GEL WHITENIN Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS FLUORIDEX DD PST SENSITIV Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS GA POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS GA DIET POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS GEL-KAM CON 0.63% Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS GLONOIN DRO HOMACCOR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS GLYTROL LIQ ULTRAPAK Tier 3

Miscellaneous Therapeutic Agents GRASTEK SUB 2800BAU Tier 3 X X HCR Miscellaneous Therapeutic Agents GYNOL II GEL 3% Preventative MISCELLANEOUS THERAPEUTIC AGENTS H2Q POW 200MG/GM Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS HCU COOLER LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS HCY 1 DIET POW Tier 3

Page 242 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS HCY 2 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS HEXAPEPTIDE POW ACETYL Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS HEXAPEPTIDE SOL ACETYL Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS IMPACT LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS IMPACT LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS IMPACT 1.5 LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS IMPACT GLUTA LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS IMPACT/FIBER LIQ Tier 3

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/29G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/30G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/30G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.3/31G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/28G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/29G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/30G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/30G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/30G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 0.5/31G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/28G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/29G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/30G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/30G Tier 2

Miscellaneous Therapeutic Agents INSULIN SYRG MIS 1ML/31G Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS ISOCAL LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ISOCAL HN LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ISOCAL HN LIQ PLUS Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ISOSOURCE LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ISOSOURCE LIQ 1.5 CAL Tier 3

Page 243 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS ISOSOURCE LIQ CLS SYS Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ISOSOURCE LIQ VHN VANL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ISOSOURCE HN LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS KARIGEL GEL 0.5% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS KARIGEL-N GEL 1.1% Tier 1

Miscellaneous Therapeutic Agents K-PHOS TAB NO 2 Tier 2

Miscellaneous Therapeutic Agents LEVOCARNITIN SOL 1GM/10ML Tier 1

Miscellaneous Therapeutic Agents LEVOCARNITIN TAB 330MG Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS L-GLUT/CHOL/ TAB INOSITOL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS LITHATE CAP Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS LMD POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS LMD DIET POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS MCT PROCAL POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS MERITENE POW CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS MERITENE POW VANILLA Tier 3

Miscellaneous Therapeutic Agents METHERGINE TAB 0.2MG Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS METHIONINE CAP 200MG Tier 3

Miscellaneous Therapeutic Agents METHYLERGON TAB 0.2MG Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS MODULEN IBD POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS MORCIN CRE Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS MSUD COOLER LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS MSUD COOLER LIQ 20 Tier 3

Miscellaneous Therapeutic Agents MYALEPT INJ 11.3MG Tier 3 X X X MISCELLANEOUS THERAPEUTIC AGENTS NAFRINSE SOL DAILY Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS NAFRINSE DLY SOL /NEUTRAL Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS NAFRINSE WK SOL 0.2% Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NESTLE FLAVO PAK EX-STR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NEUTRAGARD GEL 1.1% Tier 1

Page 244 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS NITRIC ACID LIQ Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS NOVASOURCE LIQ PULMONAR Tier 3

Miscellaneous Therapeutic Agents NOVOFINE MIS 30GX8MM Tier 2

Miscellaneous Therapeutic Agents NOVOFINE MIS 32GX6MM Tier 2

Miscellaneous Therapeutic Agents NOVOFINE AUT MIS 30GX8MM Tier 2

Miscellaneous Therapeutic Agents NOVOFINE PLS MIS 32GX4MM Tier 2

Miscellaneous Therapeutic Agents NOVOTWIST MIS 30GX8MM Tier 2

Miscellaneous Therapeutic Agents NOVOTWIST MIS 32GX5MM Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN LIQ JR/FIBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN LIQ JUNIOR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN LIQ PULMONAR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN 1.0 LIQ /FIB UNF Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN 1.0 LIQ /FIBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN 1.0 LIQ ULTRAPAK Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN 1.0 LIQ UNFLAVOR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTREN 1.5 LIQ ULTRAPAK Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI DRINK LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI DRINK LIQ PLUS Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI DRINK LIQ STRWBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI DRINK LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI-DRINK LIQ + CHOCOL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI-DRINK LIQ + VANILA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI-DRINK LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRI-DRINK LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRIHEAL LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRIRENAL LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRITIONAL LIQ SUPPLEME Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS NUTRIVENT LIQ Tier 3

Page 245 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS NUTRIVENT LIQ 1.5 VAN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS OA 1 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS OA 1 DIET POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS OA 2 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS OA 2 DIET POW Tier 3

Miscellaneous Therapeutic Agents ORALAIR SUB 300 IR Tier 3 X X

Miscellaneous Therapeutic Agents ORALAIR ADLT SUB 300 IR Tier 3 X X

Miscellaneous Therapeutic Agents ORALAIR CHLD PAK SAMPLE Tier 3

Miscellaneous Therapeutic Agents ORALAIR CHLD SUB 100 IR Tier 3 X X

Miscellaneous Therapeutic Agents PEN NEEDLE MIS 29GX1/2" Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 29GX1/2" Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 29GX12MM Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 30GX5/16 Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX1/4" Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX3/16 Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX5/16 Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX6MM Tier 2

Miscellaneous Therapeutic Agents PEN NEEDLES MIS 31GX8MM Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN LIQ PREBIO1 Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN LIQ UNFLAVOR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN 1.5 LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN AF LIQ UNFLAVOR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN JR LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN JR LIQ UNFLAVRD Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN JUN POW VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN OS LIQ 1.5/VAN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN OS LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN OS LIQ VANILLA Tier 3

Page 246 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN VHP LIQ ULTRAPAK Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN VHP LIQ UNFLAVOR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTAMEN VHP LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTINEX 1.5 LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTINEX DT LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTINEX DT LIQ /FIBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTINEX DT LIQ PREBIOTC Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PEPTINEX DT LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PFD 1 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PFD 2 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PHOS-FLUR GEL 1.1% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS PNEUMODORON LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS POLYOX POW WSR-301 Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS PORTAGEN POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS POTABA CAP 500MG Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVDNT 5000 PST 1.1% Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT CRE 5000 PLS Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT GEL 1.1% Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT GEL 1.1% BER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT GEL 1.1% CHR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT GEL 1.1% MIN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT PST 5000 BST Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT PST 5000 SEN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT SOL 0.2% Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PREVIDENT SOL RINSE Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PROBALANCE LIQ ULTRAPAK Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PROBALANCE LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PRO-CAL POW Tier 3

Page 247 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS PRODUCT3232A POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PROS-TECH CAP PLUS Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS PROT COOKIE MIS OATRAISN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PROTEOLYTIC TAB FORMULA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PRVDNT 5000 PST ENAML PR Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS PSORIZIDE TAB FORTE Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS PSORIZIDE TAB ULTRA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS Q2 ORAL CLEA KIT SYSTEM Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS Q4 ORAL CLEA KIT SYSTEM Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS QUINZYME TAB 90MG Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RA NUTRITION LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RA NUTRITION LIQ VANILLA Tier 3

Miscellaneous Therapeutic Agents RA PEN NEEDL MIS 31GX3/16 Tier 2

Miscellaneous Therapeutic Agents RADIOGARDASE CAP 0.5GM Tier 3

Miscellaneous Therapeutic Agents RAGWITEK SUB Tier 3 X X MISCELLANEOUS THERAPEUTIC AGENTS RAPID GEL RX GEL Tier 3

Miscellaneous Therapeutic Agents RELAGARD GEL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RENASTART POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS REPLETE LIQ /FIBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS REPLETE LIQ ULTRAPAK Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESOURCE KID LIQ CR STRAW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESOURCE KID LIQ FR VAN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESOURCE KID LIQ SW CHOC Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESOURCE KID LIQ W/FIBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESOURCE SUP LIQ CHOCOLAT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESOURCE SUP LIQ STRAWBER Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESOURCE SUP LIQ VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS RESPALOR LIQ Tier 3

Page 248 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS RHEUMADORON LIQ 102A Tier 3

Miscellaneous Therapeutic Agents RX-SPECIMEN KIT COLLECTI Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SCANDICAL POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SCANDISHAKE POW VANILLA Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SF GEL 1.1% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS SF 5000 PLUS CRE 1.1% Tier 1 HCR Miscellaneous Therapeutic Agents SHUR-SEAL GEL 2% Preventative

Miscellaneous Therapeutic Agents SM INSULIN SYRINGE Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS SOD FLUORIDE SOL 0.2% Tier 1 MISCELLANEOUS THERAPEUTIC AGENTS SOD FLUORIDE SOL 0.2%MINT Tier 1

Miscellaneous Therapeutic Agents SPECIMEN KIT COLLECTI Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SPEEDGEL RX GEL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS STERYMINE GEL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SUBDUE LIQ CHOC/ALM Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SUBDUE LIQ ORNG/VAN Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SUBDUE LIQ REDI-FED Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SUBDUE LIQ UNFLAVRD Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SUBDUE PLUS LIQ UNFLAVRD Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS SULFZIX POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS THALAMUS SUB COMPOSIT Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS THERA-FLUR-N DRO 1.1% Tier 3 HCR Miscellaneous Therapeutic Agents TODAY SPONGE MIS Preventative MISCELLANEOUS THERAPEUTIC AGENTS TRANZGEL GEL Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS TYR COOLER LIQ 20 Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS TYR COOLER LIQ RED Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS TYROS 1 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS TYROS 2 POW Tier 3

Miscellaneous Therapeutic Agents UBIQUINOL POW Tier 3 X

Page 249 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Miscellaneous Therapeutic Agents UBIQUINOL POW 30% Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS UCD TRIO POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ULTRA ENERGY TAB Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ULTRACAL LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS ULTRACAL HN LIQ PLUS Tier 3

Miscellaneous Therapeutic Agents UNFINE PNTP MIS 32GX4MM Tier 2

Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 29GX1/2" Tier 2

Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 29GX12MM Tier 2

Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 31GX3/16 Tier 2

Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 31GX5/16 Tier 2

Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 31GX5MM Tier 2

Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 31GX6MM Tier 2

Miscellaneous Therapeutic Agents UNIFINE PNTP MIS 31GX8MM Tier 2 MISCELLANEOUS THERAPEUTIC AGENTS URI-CONTROL TAB RX Tier 3

Miscellaneous Therapeutic Agents URINX MEDIC KIT SPECIMEN Tier 3 HCR Miscellaneous Therapeutic Agents VCF VAGINAL AER CONTRACP Preventative HCR Miscellaneous Therapeutic Agents VCF VAGINAL GEL CONTRACE Preventative HCR Miscellaneous Therapeutic Agents VCF VAGINAL MIS CONTRACP Preventative MISCELLANEOUS THERAPEUTIC AGENTS VERTIGOHEEL SUB Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS VITAJOULE POW Tier 3

Miscellaneous Therapeutic Agents VITAMIN D3 LIQ Tier 3 X

Miscellaneous Therapeutic Agents VITAMIN D3 POW Tier 3 X

Miscellaneous Therapeutic Agents VITAMIN D3 POW Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS VITAMIN E LIQ ACETATE Tier 3 X MISCELLANEOUS THERAPEUTIC AGENTS VITAPRO POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS VIVONEX RTF LIQ Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS WELLMIND TAB VERTIGO Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS WND POW Tier 3

Page 250 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty MISCELLANEOUS THERAPEUTIC AGENTS WND 1 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS WND 2 POW Tier 3 MISCELLANEOUS THERAPEUTIC AGENTS XIZFLUS POW Tier 3 Molecular Target Inhibitors - Chemotherapy Agents AFINITOR TAB 10MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents AFINITOR TAB 2.5MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents AFINITOR TAB 5MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents AFINITOR TAB 7.5MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DIS TAB 2MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DIS TAB 3MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DIS TAB 5MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents BOSULIF TAB 100MG Tier 2 X X X X Molecular Target Inhibitors - Chemotherapy Agents BOSULIF TAB 500MG Tier 2 X X X X Molecular Target Inhibitors - Chemotherapy Agents GLEEVEC TAB 100MG Tier 1 X X X Molecular Target Inhibitors - Chemotherapy Agents GLEEVEC TAB 400MG Tier 1 X X X Molecular Target Inhibitors - Chemotherapy Agents IMATINIB MES TAB 100MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents IMATINIB MES TAB 400MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents IMBRUVICA CAP 140MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents INLYTA TAB 1MG Tier 3 X X X Molecular Target Inhibitors - Chemotherapy Agents INLYTA TAB 5MG Tier 3 X X X Molecular Target Inhibitors - Chemotherapy Agents IRESSA TAB 250MG Tier 3 X X Molecular Target Inhibitors - Chemotherapy Agents NEXAVAR TAB 200MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents SPRYCEL TAB 100MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents SPRYCEL TAB 140MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents SPRYCEL TAB 20MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents SPRYCEL TAB 50MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents SPRYCEL TAB 70MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents SPRYCEL TAB 80MG Tier 3 X X X X Molecular Target Inhibitors - Chemotherapy Agents STIVARGA TAB 40MG Tier 2 X X X

Page 251 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Molecular Target Inhibitors - Chemotherapy Agents SUTENT CAP 12.5MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents SUTENT CAP 25MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents SUTENT CAP 37.5MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents SUTENT CAP 50MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents TARCEVA TAB 100MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents TARCEVA TAB 150MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents TARCEVA TAB 25MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents TASIGNA CAP 150MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents TASIGNA CAP 200MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents TYKERB TAB 250MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents VOTRIENT TAB 200MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents XALKORI CAP 200MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents XALKORI CAP 250MG Tier 2 X X X Molecular Target Inhibitors - Chemotherapy Agents ZELBORAF TAB 240MG Tier 2 X X X

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs AZILECT TAB 0.5MG Tier 3

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs AZILECT TAB 1MG Tier 3

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs ELDEPRYL CAP 5MG Tier 3

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs SELEGILINE CAP 5MG Tier 1

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs SELEGILINE TAB 5MG Tier 1

Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs ZELAPAR TAB 1.25MG Tier 3 Monoamine Oxidase Inhibitors - Antidepressants EMSAM DIS 12MG/24H Tier 3 Monoamine Oxidase Inhibitors - Antidepressants EMSAM DIS 6MG/24HR Tier 3 Monoamine Oxidase Inhibitors - Antidepressants EMSAM DIS 9MG/24HR Tier 3 Monoamine Oxidase Inhibitors - Antidepressants MARPLAN TAB 10MG Tier 3 Monoamine Oxidase Inhibitors - Antidepressants NARDIL TAB 15MG Tier 3

Page 252 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Monoamine Oxidase Inhibitors - Antidepressants PARNATE TAB 10MG Tier 3 Monoamine Oxidase Inhibitors - Antidepressants PHENELZINE TAB 15MG Tier 1 Monoamine Oxidase Inhibitors - Antidepressants TRANYLCYPROM TAB 10MG Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHIUM SOL 8MEQ/5ML Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHIUM CARB CAP 150MG Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHIUM CARB CAP 300MG Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHIUM CARB CAP 600MG Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHIUM CARB TAB 300MG Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHIUM CARB TAB 300MG ER Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHIUM CARB TAB 450MG ER Tier 1 Mood Stabilizers - Mood Disorder Drugs LITHOBID TAB 300MG CR Tier 3 Multiple Sclerosis Agents - Multiple Sclerosis Drugs AMPYRA TAB 10MG Tier 2 X X X Multiple Sclerosis Agents - Multiple Sclerosis Drugs AUBAGIO TAB 14MG Tier 3 X X X X Multiple Sclerosis Agents - Multiple Sclerosis Drugs AUBAGIO TAB 7MG Tier 3 X X X X Multiple Sclerosis Agents - Multiple Sclerosis Drugs COPAXONE INJ 20MG/ML Tier 1 X X X Multiple Sclerosis Agents - Multiple Sclerosis Drugs COPAXONE INJ 40MG/ML Tier 2 X X X Multiple Sclerosis Agents - Multiple Sclerosis Drugs GILENYA CAP 0.5MG Tier 3 X X X X Multiple Sclerosis Agents - Multiple Sclerosis Drugs GLATOPA INJ 20MG/ML Tier 3 X X X X

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs MEMANT TITRA PAK 5-10MG Tier 1

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs MEMANTINE TAB HCL 10MG Tier 1

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs MEMANTINE TAB HCL 5MG Tier 1

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs MEMANTINE HC SOL 2MG/ML Tier 1

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA SOL 10MG/5ML Tier 3

Page 253 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA TAB 10MG Tier 3

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA TAB 5-10MG Tier 3

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA TAB 5MG Tier 3

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA XR CAP 14MG Tier 3 X

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA XR CAP 21MG Tier 3 X

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA XR CAP 28MG Tier 3 X

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA XR CAP 7MG Tier 3 X

N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs NAMENDA XR CAP TITRATIO Tier 3 X

Non-Amphetamines, Other - Miscellaneous Nervous System Drugs CAFFEINE CIT SOL 20MG/ML Tier 1

Non-Amphetamines, Other - Miscellaneous Nervous System Drugs CAFFEINE CIT SOL 60MG/3ML Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ACTIVE-PREP CRE KIT III Tier 3 X

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ADLT ASA LOW TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs AIF #2 DRUG CRE PREP KIT Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ANAPROX DS TAB 550MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ARTHROTEC 50 TAB Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ARTHROTEC 75 TAB Tier 3

Page 254 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIR-81 TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN TAB 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN 81 TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN CHIL CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN CHLD CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN LOW CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN LOW TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRIN-81 CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIR-LOW TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ASPIRTAB TAB 324MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs BAYER ASA TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs BL ASPIRIN TAB 300MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs BL ASPIRIN TAB 325MG Preventative

Page 255 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs BL ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CAMBIA POW 50MG Tier 3 X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELEBREX CAP 100MG Tier 3 X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELEBREX CAP 200MG Tier 3 X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELEBREX CAP 400MG Tier 3 X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELEBREX CAP 50MG Tier 3 X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELECOXIB CAP 100MG Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELECOXIB CAP 200MG Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELECOXIB CAP 400MG Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CELECOXIB CAP 50MG Tier 1 X

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs CHILD ASA CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs CHILD ASA LS CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CHO MAG TRIS LIQ 500/5ML Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs CHO MAG TRIS TAB 1000MG Tier 1

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs CVS ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs CVS ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs CVS ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs CVS CHLD ASA CHW 81MG Preventative

Page 256 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DAYPRO TAB 600MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLO/MISOPR TAB 50-0.2MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLO/MISOPR TAB 75-0.2MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLOFEN POT TAB 50MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLOFENAC GEL 1% Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLOFENAC SOL 1.5% Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLOFENAC TAB 100MG ER Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLOFENAC TAB 25MG DR Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLOFENAC TAB 50MG DR Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DICLOFENAC TAB 75MG DR Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DIFLUNISAL TAB 500MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DISALCID TAB 500MG Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DISALCID TAB 750MG Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs DURAXIN CAP Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs EC-NAPROSYN TAB 375MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs EC-NAPROSYN TAB 500MG Tier 3

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ECOTRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ECOTRIN LOW TAB 81MG EC Preventative

Page 257 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ECPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ED-FLEX CAP Tier 1

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs EQ ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs EQ ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs EQ CHILD ASA CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs EQL ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs EQL ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs EQL ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs EQL CHLD ASA CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ETODOLAC CAP 200MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ETODOLAC CAP 300MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ETODOLAC TAB 400MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ETODOLAC TAB 500MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ETODOLAC ER TAB 400MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ETODOLAC ER TAB 500MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ETODOLAC ER TAB 600MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FELDENE CAP 10MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FELDENE CAP 20MG Tier 3

Page 258 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FENOPROFEN CAP 200MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FENOPROFEN CAP 400MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FENOPROFEN TAB 600MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FENORTHO CAP 200MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FENORTHO CAP 400MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FLECTOR DIS 1.3% Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FLURBIPROFEN POW Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FLURBIPROFEN TAB 100MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs FLURBIPROFEN TAB 50MG Tier 1

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs GNP ASPIRIN CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs GNP ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs GNP ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs GNP ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs GNP ASPIRIN TAB LT.COAT Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs HM ASPIRIN CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs HM ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs IBUPROFEN CRE 10% Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs IBUPROFEN KIT COMFORT Tier 3

Page 259 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs IBUPROFEN POW Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs IBUPROFEN TAB 400MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs IBUPROFEN TAB 600MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs IBUPROFEN TAB 800MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs INDOCIN SUP 50MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs INDOCIN SUS 25MG/5ML Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs INDOMETHACIN CAP 25MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs INDOMETHACIN CAP 50MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs INDOMETHACIN CAP 75MG ER Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPHENE CRE RAPIDPAQ Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPROFEN CAP 200MG ER Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPROFEN CAP 50MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPROFEN CAP 75MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPROFEN CRE 5% KIT Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPROFEN POW Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPROFEN POW MICRONIZ Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOPROFEN POW ULT MICR Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KETOROLAC TAB 10MG Tier 1

Page 260 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs KLOFENSAID SOL II Tier 1 X

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs KLS ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs KLS ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs KP ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs LEVACET TAB Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs LIDOPROFEN CRE 5-5-2% Tier 3 X

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs LO-DOSE ASA TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MECLOFEN SOD CAP 100MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MECLOFEN SOD CAP 50MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MEFENAM ACID CAP 250MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MEFENAMIC POW ACID Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MELOXICAM KIT COMFORT Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MELOXICAM SUS 7.5/5ML Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MELOXICAM TAB 15MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MELOXICAM TAB 7.5MG Tier 1

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs MINIPRIN LOW TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MOBIC SUS 7.5/5ML Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MOBIC TAB 15MG Tier 3

Page 261 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs MOBIC TAB 7.5MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NABUMETONE TAB 500MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NABUMETONE TAB 750MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NALFON CAP 400MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPRELAN TAB 375MG CR Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPRELAN TAB 500MG CR Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPRELAN TAB 750MG CR Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROSYN SUS 125/5ML Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROSYN TAB 500MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN CRE Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN CRE 10% Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN SUS 125/5ML Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN TAB 250MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN TAB 375MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN TAB 500MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN DR TAB 375MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN DR TAB 500MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN SOD TAB 275MG Tier 1

Page 262 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN SOD TAB 375MG Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN SOD TAB 375MG CR Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN SOD TAB 500MG CR Tier 1 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs NAPROXEN SOD TAB 550MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs OXAPROZIN TAB 600MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs OXYCOD/IBU TAB 5-400MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs PENNSAID SOL 1.5% Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs PENNSAID SOL 2% Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs PIROXICAM CAP 10MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs PIROXICAM CAP 20MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs PIROXICAM POW Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs PONSTEL CAP 250MG Tier 3

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs PX ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs PX ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs QC ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs QC ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs QC CHILD ASA CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs RA ASPIRIN CHW 81MG Preventative

Page 263 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs RA ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs RA ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs RA ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs RA CHILD ASA CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs SALSALATE TAB 500MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs SALSALATE TAB 750MG Tier 1

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs SM ASPIRIN CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs SM ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs SM ASPIRIN TAB 325MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs SM ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs SM CHILD ASA CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs SPRIX SPR 15.75MG Tier 3

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ST JOSEPH CHW LOW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs ST JOSEPH AS CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs SULINDAC TAB 150MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs SULINDAC TAB 200MG Tier 1

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs TGT ASPIRIN CHW 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs TGT ASPIRIN CHW CHILD Preventative

Page 264 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs TGT ASPIRIN TAB 325MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs TGT ASPIRIN TAB 81MG Preventative

Nonsteroidal Anti-Inflammatory HCR Drugs - Pain/Anti-Inflammatory Drugs TGT ASPIRIN TAB 81MG EC Preventative

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs TIVORBEX CAP 20MG Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs TIVORBEX CAP 40MG Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs TOLMETIN SOD CAP 400MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs TOLMETIN SOD TAB 200MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs TOLMETIN SOD TAB 600MG Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs TREXIMET TAB 85-500MG Tier 3 X X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VIVLODEX CAP 10MG Tier 3 X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VIVLODEX CAP 5MG Tier 3 X X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VOLTAREN GEL 1% Tier 1

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VOLTAREN-XR TAB 100MG Tier 3

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VOPAC CRE 10-2% Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VOPAC 5 CRE 5% Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VOPAC GB CRE 5-2-5% Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs VOPAC KT CRE 5-5-2% Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ZIPSOR CAP 25MG Tier 3 X

Page 265 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ZORVOLEX CAP 18MG Tier 3 X

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs ZORVOLEX CAP 35MG Tier 3 X Not Specified 2-DEOXY-D POW -GLUCOSE Tier 3 Not Specified 5-METHYLTETR POW Tier 3 X

Not Specified 5-METHYLTETR POW CALCIUM Tier 3 X Not Specified A.A.G.C KIT CRE TERODERM Tier 3 X

Not Specified ACIDO LACTOB POW 10BU/GM Tier 3 X

Not Specified ACIDO LACTOB POW 1BU/GM Tier 3 X

Not Specified ACIDOPHILUS POW LACTOBAC Tier 3 X Not Specified ACTIVE-PREP CRE KIT I Tier 3 X Not Specified ACTIVE-PREP CRE KIT II Tier 3 X Not Specified ACTIVE-PREP CRE KIT IV Tier 3 X Not Specified ACTIVE-PREP CRE KIT V Tier 3 X Not Specified ADAPTADERM GEL Tier 3 Not Specified ADDYI TAB 100MG Tier 3 X X

Not Specified ADEMETIONINE POW DISULFAT Tier 3 X Not Specified ADENOSINE POW Tier 3 X Not Specified ADYNOVATE INJ 1000UNIT Tier 3 X X Not Specified ADYNOVATE INJ 2000UNIT Tier 3 X X Not Specified ADYNOVATE INJ 250UNIT Tier 3 X X Not Specified ADYNOVATE INJ 500UNIT Tier 3 X X Not Specified ADZENYS XR TAB 12.5MG Tier 3 X X Not Specified ADZENYS XR TAB 15.7 MG Tier 3 X X Not Specified ADZENYS XR TAB 18.8MG Tier 3 X X Not Specified ADZENYS XR TAB 3.1MG Tier 3 X X Not Specified ADZENYS XR TAB 6.3MG Tier 3 X X Not Specified ADZENYS XR TAB 9.4MG Tier 3 X X Not Specified AFSTYLA KIT 1000UNIT Tier 3 X X Not Specified AFSTYLA KIT 2000UNIT Tier 3 X X Not Specified AFSTYLA KIT 250UNIT Tier 3 X X Not Specified AFSTYLA KIT 3000UNIT Tier 3 X X Not Specified AFSTYLA KIT 500UNIT Tier 3 X X Not Specified AIF #3 DRUG CRE PREP KIT Tier 3 X Not Specified AKYNZEO CAP Tier 3 X Not Specified ALASKAN RED POW ALGAE Tier 3 X Not Specified ALECENSA CAP 150MG Tier 3 X X Not Specified A-LIPOIC POW ACID Tier 3 X Not Specified ALLO-PAX CRE 5-5% Tier 3 X Not Specified ALOE VERA OIL Tier 3 X Not Specified ALOE VERA POW Tier 3 X Not Specified ALOE VERA POW 200:1 Tier 3 X Not Specified ALOE VERA POW FRZE DRD Tier 3 X Not Specified ALOE VERA POW LEAF Tier 3 X Not Specified ALPHA LIPOIC POW ACID Tier 3 X Not Specified ALPROLIX INJ 1000UNIT Tier 3 X Not Specified ALPROLIX INJ 2000UNIT Tier 3 X Not Specified ALPROLIX INJ 250UNIT Tier 3 X Not Specified ALPROLIX INJ 3000UNIT Tier 3 X

Page 266 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified ALPROLIX INJ 500UNIT Tier 3 X Not Specified ALPROSTADIL POW Tier 3 X Not Specified AMITRIPTYLIN CRE Tier 3 X Not Specified ANASTROZOLE POW Tier 3 Not Specified ANHYDROUS GEL BASE Tier 3 Not Specified APOMORPHINE POW HCL Tier 3 X Not Specified ARANESP INJ 100MCG Tier 2 X X Not Specified ARANESP INJ 100MCG Tier 2 X X Not Specified ARANESP INJ 10MCG Tier 2 X Not Specified ARANESP INJ 150MCG Tier 2 X X Not Specified ARANESP INJ 200MCG Tier 2 X X Not Specified ARANESP INJ 200MCG Tier 2 X X Not Specified ARANESP INJ 25MCG Tier 2 X X Not Specified ARANESP INJ 25MCG Tier 2 X X Not Specified ARANESP INJ 300MCG Tier 2 X X Not Specified ARANESP INJ 300MCG Tier 2 X X Not Specified ARANESP INJ 40MCG Tier 2 X X Not Specified ARANESP INJ 40MCG Tier 2 X X Not Specified ARANESP INJ 500MCG Tier 2 X X Not Specified ARANESP INJ 60MCG Tier 2 X X Not Specified ARANESP INJ 60MCG Tier 2 X X Not Specified ARNUITY ELPT INH 100MCG Tier 3 X Not Specified ARNUITY ELPT INH 200MCG Tier 3 X Not Specified ASCORBIC ACD GRA Tier 3 X Not Specified ASCORBIC ACD POW Tier 3 X

Not Specified ASCORBIC ACD POW CASSAVE Tier 3 X Not Specified ASCORBIC ACD POW FINE Tier 3 X Not Specified ATROHIST LA TAB CR Tier 3 Not Specified ATROHIST SR CAP SPRINKLE Tier 3 Not Specified AURYXIA TAB 210MG Tier 3 Not Specified AVIPTADIL POW ACETATE Tier 3 X Not Specified BASE FOR GEL SALTS Tier 3 Not Specified BASE FOR GEL WOUNDS Tier 3 Not Specified BEE POLLEN CAP 580MG Tier 1 Not Specified BELSOMRA TAB 10MG Tier 3 X X Not Specified BELSOMRA TAB 15MG Tier 3 X X Not Specified BELSOMRA TAB 20MG Tier 3 X X Not Specified BELSOMRA TAB 5MG Tier 3 X X Not Specified BETA GLUCAN POW Tier 3 X Not Specified BETAMETH ACE POW Tier 3 X

Not Specified BETAMETH ACE POW MICRONIZ Tier 3 X

Not Specified BETAMETHASON POW SOD PHOS Tier 3 X Not Specified BEVESPI AER Tier 3 X Not Specified BHT POW Tier 3 X Not Specified BIEST/PROGES CRE Tier 3 X Not Specified BL DECONGEST TAB CR Tier 1 Not Specified BORAGE CAP Tier 3 Not Specified BRIVIACT INJ 50MG/5ML Tier 3 X Not Specified BRIVIACT SOL 10MG/ML Tier 3 X Not Specified BRIVIACT TAB 100MG Tier 3 X Not Specified BRIVIACT TAB 10MG Tier 3 X Not Specified BRIVIACT TAB 25MG Tier 3 X Not Specified BRIVIACT TAB 50MG Tier 3 X Not Specified BRIVIACT TAB 75MG Tier 3 X

Page 267 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Not Specified BROMFENAC POW SOD 98+% Tier 3 X Not Specified BUPRENORPHIN POW HCL Tier 3 X Not Specified BYVALSON TAB 5-80MG Tier 3 X Not Specified CALCIUM POW FOLINATE Tier 3 Not Specified CALCIUM AA GRA CHELATE Tier 3 X Not Specified CAPSAICIN POW PALMITAT Tier 3 X Not Specified CARBIN/PSE/ SYP DM Tier 1 Not Specified CENOVIA CRE Tier 3 X Not Specified CERDELGA CAP 84MG Tier 2 X X Not Specified CHEMSIL K-51 GEL Tier 3 Not Specified CHLOROFORM SOL Tier 3 X Not Specified CHOLBAM CAP 250MG Tier 2 X X X Not Specified CHOLBAM CAP 50MG Tier 2 X X X Not Specified CHOLESTYRAMI POW Tier 3 X Not Specified CHOLESTYRAMI POW RESIN Tier 3 X Not Specified CHRYSIN POW Tier 3 X Not Specified CLARYS CRE Tier 3 X Not Specified CLINDAP-T CRE Tier 3 X Not Specified CLINOIN CRE Tier 3 X Not Specified CLODAN KIT 0.05% Tier 3 X Not Specified CLOMIPRAMINE POW HCL Tier 3 X Not Specified CLOVAGEL GEL Tier 3 Not Specified COAGADEX INJ 250UNIT Tier 2 X Not Specified COAGADEX INJ 500UNIT Tier 2 X Not Specified COENZYME Q10 POW Tier 3 X Not Specified COLLIGINIX MIS Tier 3 Not Specified CONGESTANT TAB Tier 1 Not Specified CORLANOR TAB 5MG Tier 3 X X Not Specified CORLANOR TAB 7.5MG Tier 3 X X Not Specified COSENTYX INJ 150MG/ML Tier 3 X X X X

Not Specified COSENTYX PEN INJ 150MG/ML Tier 3 X X X X Not Specified COTELLIC TAB 20MG Tier 3 X X X Not Specified CRESEMBA CAP 186 MG Tier 3 Not Specified CUST LIPOTHN GEL 110 Tier 3 Not Specified CUST LIPOTHN GEL 133 Tier 3 Not Specified CYCLACILLIN TAB 500MG Tier 1 Not Specified CYCLOBENZAPR POW Tier 3 X Not Specified CYCLOBENZAPR POW HCL Tier 3 X Not Specified CYCLOPHOSPHA POW Tier 3 X Not Specified CYCLOSERINE POW Tier 3 X Not Specified CYCLOSPORINE POW Tier 3 X Not Specified CYCLOSPORINE POW A Tier 3 X Not Specified DAKLINZA TAB 30MG Tier 2 X X X X Not Specified DAKLINZA TAB 60MG Tier 2 X X X X Not Specified DAKLINZA TAB 90MG Tier 2 X X X Not Specified DEHYDROEPIAN POW MICRO Tier 3 X Not Specified DERMACINRX PAK Tier 3

Not Specified DERMACINRX PAK DUOPATCH Tier 3 Not Specified DERMACINRX SOL BASE Tier 3 Not Specified DESCOVY TAB 200/25 Tier 3 X

Not Specified DEXAMETHASON POW ACETATE Tier 3 X Not Specified DEXCOM G4 PLATINUM Tier 3 X X Not Specified DEXCOM SENSOR Tier 3 X X

Page 268 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified DEXCOM TRANSMITTER Tier 3 X X Not Specified DEXTROMETH POW Tier 3 X Not Specified DHEA POW Tier 3 X Not Specified DIMERCAPT-1- POW SULF NA Tier 3 X Not Specified DIMERCAPTOSU POW ACID Tier 3 X Not Specified DIPENTOCAINE CRE 5-5-2% Tier 3 X

Not Specified DL-3-HYDROXY POW ACID NA Tier 3 X Not Specified DMPS POW Tier 3 X Not Specified DMR ANTIGEN THERAPY Tier 3 Not Specified DOUBLE PM SOL Tier 3 X Not Specified DURACHOL CAP 1-3775IU Tier 3 Not Specified DURLAZA CAP 162.5MG Tier 3 X X

Not Specified D-VITAMIN E POW SUCCINAT Tier 3 X

Not Specified DYANAVEL XR SUS 2.5MG/ML Tier 3 X X Not Specified ELOCTATE INJ 1000UNIT Tier 3 X X Not Specified ELOCTATE INJ 1500UNIT Tier 3 X X Not Specified ELOCTATE INJ 2000UNIT Tier 3 X X Not Specified ELOCTATE INJ 250UNIT Tier 3 X X Not Specified ELOCTATE INJ 3000UNIT Tier 3 X X Not Specified ELOCTATE INJ 500UNIT Tier 3 X X Not Specified ELOCTATE INJ 750UNIT Tier 3 X X Not Specified EMVOREN CRE Tier 3 X Not Specified ENBRACE HR CAP Tier 3 Not Specified ENTRESTO TAB 24-26MG Tier 3 X X Not Specified ENTRESTO TAB 49-51MG Tier 3 X X Not Specified ENTRESTO TAB 97-103MG Tier 3 X X Not Specified EPCLUSA TAB 400-100 Tier 3 X X X Not Specified EPINEPHR HCL SOL 2% OP Tier 1 Not Specified EPIVIR HBV SOL 5MG/ML Tier 2 X Not Specified EPIVIR HBV TAB 100MG Tier 3 X Not Specified ESBRIET CAP 267MG Tier 2 X X X Not Specified ESTRIOL POW Tier 3 Not Specified ESTRIOL POW MICRONIZ Tier 3

Not Specified ESTRIOL ULT POW MICRONIZ Tier 3 Not Specified ETHOSUXIMIDE POW Tier 3 Not Specified ETOPOSIDE POW Tier 3 X Not Specified EVEKEO TAB 10MG Tier 3 X X Not Specified EVEKEO TAB 5MG Tier 3 X X Not Specified EVOTAZ TAB 300-150 Tier 2 X Not Specified EXTARDOL CRE Tier 3 X Not Specified FARYDAK CAP 10MG Tier 3 X X X Not Specified FARYDAK CAP 15MG Tier 3 X X X Not Specified FARYDAK CAP 20MG Tier 3 X X X Not Specified FBL KIT CRE 15-4-5% Tier 3 X HCR Not Specified FEMCAP MIS 22MM Preventative Not Specified FLORIVA DRO 0.25MG Tier 3 Not Specified FLOWTUSS SOL 2.5-200 Tier 3 X X Not Specified FLUOROURACIL POW Tier 3 X

Not Specified FLUOROURACIL POW USP/NF Tier 3 X

Not Specified FLUTICASONE POW PROPIONA Tier 3 X X

Page 269 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified FOLET DHA PAK Tier 3 Not Specified FOLET ONE CAP 38-1-225 Tier 3 Not Specified FORTIGAN CAP Tier 1 Not Specified FP CEPA GEL Tier 3 Not Specified FP DERM GEL Tier 3 Not Specified FP SILO GEL Tier 3 Not Specified FREEDOM GEL CEPAPRO Tier 3 X Not Specified FREEDOM GEL SET Tier 3 Not Specified FREEDOM GEL SILOMAC Tier 3 Not Specified GABAPENTIN POW Tier 3 X Not Specified GAPEAUM CRE BUDIBAC Tier 3 X Not Specified GENVOYA TAB Tier 3 X X

Not Specified GINSENG POW AMERICAN Tier 3 X Not Specified GLUCOCARD 01 TES SENSOR Tier 3 X Not Specified GLUCOCARD 01 TEST STRIPS Tier 3 X Not Specified GLUCOCARD TES VITAL Tier 3 X Not Specified GLYXAMBI TAB 10-5 MG Tier 3 X X X Not Specified GLYXAMBI TAB 25-5 MG Tier 3 X X X

Not Specified GNP DECONGES TAB ADV.FORM Tier 1 Not Specified H20 GEL BASE GEL Tier 3 Not Specified HARVONI TAB 90-400MG Tier 2 X X X Not Specified HYALUCIL-0.5 CRE Tier 3 X X Not Specified HYALUCIL-4 CRE Tier 3 X X

Not Specified HYALURONATE POW SODIUM Tier 3 X Not Specified HYALURONIC POW SODIUM Tier 3 X Not Specified HYALURONIDAS POW Tier 3 X Not Specified HYCOFENIX SOL Tier 3 X X

Not Specified HYDROCODONE CRY BITARTRA Tier 3 X

Not Specified HYDROCODONE POW BITARTRA Tier 3 X Not Specified HYDROPHEN SYP Tier 1 Not Specified HYDROXYUREA POW Tier 3 X Not Specified IBRANCE CAP 100MG Tier 3 X X X Not Specified IBRANCE CAP 125MG Tier 3 X X X Not Specified IBRANCE CAP 75MG Tier 3 X X X Not Specified IDELVION SOL 1000UNIT Tier 3 X Not Specified IDELVION SOL 2000UNIT Tier 3 X Not Specified IDELVION SOL 250UNIT Tier 3 X Not Specified IDELVION SOL 500UNIT Tier 3 X Not Specified IMPAVIDO CAP 50MG Tier 3 X X Not Specified INCRUSE ELPT INH 62.5MCG Tier 2 X Not Specified INNOPRAX-5 CRE Tier 3 X Not Specified K.B.G.L IN CRE TERODERM Tier 3 X Not Specified KERYDIN SOL 5% Tier 3 X X X Not Specified KETAMINE HCL POW Tier 3 X Not Specified KETOPROFEN CRE 10% Tier 3 X Not Specified KETOROLAC GEL 2% Tier 3 X

Not Specified KETOROLAC POW TROMETHA Tier 3 X Not Specified KEVEYIS TAB 50MG Tier 2 X X X Not Specified KUDZU ROOT POW Tier 3 X Not Specified LAMIVUDINE TAB 100MG Tier 1 X Not Specified L-CARNITINE TAB 250MG Tier 3

Page 270 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified L-CYSTINE POW Tier 3 Not Specified LENVIMA CAP 10 MG Tier 3 X X X Not Specified LENVIMA CAP 14 MG Tier 3 X X X Not Specified LENVIMA CAP 18 MG Tier 3 X X Not Specified LENVIMA CAP 20 MG Tier 3 X X X Not Specified LENVIMA CAP 24 MG Tier 3 X X X Not Specified LENVIMA CAP 8 MG Tier 3 X X

Not Specified LEUCOVORIN POW CALCIUM Tier 3 Not Specified LEUPROLIDE POW ACETATE Tier 3 X X LEVOMEFOLATE POW Not Specified GLUCOSAM Tier 3 X Not Specified LIDOCAINE-PR CRE Tier 3 X Not Specified LIDOCAINE-PR CRE Tier 3 X Not Specified LIPODERM HMW GEL PCCA Tier 3 Not Specified LIPOGEL CR GEL BASE Tier 3 Not Specified LIPOIC ACID POW Tier 3 X Not Specified L-ISOLEUCINE POW Tier 3 X Not Specified LONSURF TAB 15-6.14 Tier 3 X X X Not Specified LONSURF TAB 20-8.19 Tier 3 X X X Not Specified LUBRAJEL NP GEL Tier 3 Not Specified LYNPARZA CAP 50MG Tier 3 X X X

Not Specified MAGNESIUM POW GLYCINAT Tier 3

Not Specified MAGNESIUM AA POW CHELATE Tier 3 X Not Specified MELATONIN POW Tier 3 X Not Specified MELOXICAM POW Tier 3 X

Not Specified MEPER/PROMET CAP 50-25MG Tier 3 Not Specified MERCAPTOPURI POW Tier 3 X Not Specified MERCAPTOPURI POW Tier 3 X MERCAPTOPURI POW Not Specified MONOHYDR Tier 3 X Not Specified METHOTREXATE POW Tier 3 Not Specified METHYL POW FOLATE Tier 3 Not Specified METHYLCOBALA POW Tier 3 X

Not Specified METHYLCOBALA POW PREMIUM Tier 3 X Not Specified MIDAZOLAM POW Tier 3 Not Specified MINOXIDIL POW Tier 3 X Not Specified MITOMYCIN POW Tier 3 X Not Specified MITOMYCIN C POW Tier 3 X Not Specified MONOBENZONE POW Tier 3 X Not Specified MORCOMINE SYP Tier 1 Not Specified MOUTH WASH LIQ GP Tier 3 Not Specified MOUTHWASH LIQ AF Tier 3 Not Specified MOUTHWASH LIQ OM Tier 3 Not Specified MOVANTIK TAB 12.5MG Tier 2 X X Not Specified MOVANTIK TAB 25MG Tier 2 X X Not Specified NABUMETONE POW Tier 3 X Not Specified NAMZARIC CAP 14-10MG Tier 3 X Not Specified NAMZARIC CAP 28-10MG Tier 3 X Not Specified NATPARA INJ 100MCG Tier 3 X X X Not Specified NATPARA INJ 25MCG Tier 3 X X X Not Specified NATPARA INJ 50MCG Tier 3 X X X Not Specified NATPARA INJ 75MCG Tier 3 X X X

Page 271 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified NAZIREX CRE Tier 3 X Not Specified NEO-SYNALAR KIT Tier 3 X Not Specified NEUAC KIT 1.2-5% Tier 3 X Not Specified NICOMIDE TAB Tier 3 Not Specified NINLARO CAP 2.3MG Tier 3 X X X Not Specified NINLARO CAP 3MG Tier 3 X X X Not Specified NINLARO CAP 4MG Tier 3 X X X Not Specified NITEBITE BAR CHOCFUDG Tier 3 Not Specified NITEBITE BAR PBUTTER Tier 3 Not Specified NITROFURANZO OIN 0.2% Tier 1 Not Specified NORTHERA CAP 100MG Tier 3 X X X Not Specified NORTHERA CAP 200MG Tier 3 X X X Not Specified NORTHERA CAP 300MG Tier 3 X X X Not Specified NOVOCLAIR CRE Tier 3 X Not Specified NP #2 DRUG CRE PREP KIT Tier 3 X Not Specified NUPLAZID TAB 17MG Tier 3 X X Not Specified NUVYA CRE Tier 3 X Not Specified OBIZUR INJ 500 UNIT Tier 3 X Not Specified OBREDON SOL 2.5-200 Tier 3 X X Not Specified OCALIVA TAB 10MG Tier 3 X X X X Not Specified OCALIVA TAB 5MG Tier 3 X X X X Not Specified OCCLUSADERM GEL PCCA Tier 3 Not Specified ODEFSEY TAB Tier 3 X Not Specified ODOMZO CAP 200MG Tier 3 X X X Not Specified OFEV CAP 100MG Tier 3 X X X Not Specified OFEV CAP 150MG Tier 3 X X X Not Specified ORKAMBI TAB 200-125 Tier 3 X X X Not Specified OTOVEL DRO Tier 3 X Not Specified PCP 100 KIT Tier 3 X Not Specified PEDIPAK PAK Tier 3 Not Specified PEMOLINE POW Tier 3 X Not Specified PENTOXIFYL POW Tier 3 X

Not Specified PERGOLIDE POW MESYLATE Tier 3 X Not Specified PETN TAB 80MG Tier 1 Not Specified PHENYLPROPAN POW HCL Tier 3 X Not Specified PHOSPHATIDYL POW 20% Tier 3 X Not Specified PINE BARK EX POW 95% Tier 3 X Not Specified PLEGRIDY INJ Tier 3 X X X X Not Specified PLEGRIDY INJ PEN Tier 3 X X X X Not Specified PLEGRIDY INJ STARTER Tier 3 X X X X Not Specified PLEGRIDY PEN INJ STARTER Tier 3 X X X X Not Specified POLYSORBATE LIQ 80 Tier 3 Not Specified POLYSORBATE LIQ 80 Tier 2 Not Specified POT PHOSPHAT GRA DIBASIC Tier 3 Not Specified PRALUENT INJ 150MG/ML Tier 2 X X X X Not Specified PRALUENT INJ 150MG/ML Tier 2 X X X X Not Specified PRALUENT INJ 75MG/ML Tier 2 X X X X Not Specified PRALUENT INJ 75MG/ML Tier 2 X X X X Not Specified PREGNENOLONE POW Tier 3 X

Not Specified PREGNENOLONE POW MICRONIZ Tier 3 X Not Specified PRENA 1 TRUE MIS Tier 3 Not Specified PRENATE CAP ESSENT Tier 3 Not Specified PRENATE CAP PIXIE Tier 3 Not Specified PRENATE TAB ELITE Tier 3 Not Specified PRENATE DHA CAP Tier 3

Page 272 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified PRENATE MINI CAP Tier 3 Not Specified PRENATE STAR TAB 20-1MG Tier 3 Not Specified PRESTALIA TAB 14-10MG Tier 3 X X Not Specified PRESTALIA TAB 3.5-2.5 Tier 3 X X Not Specified PRESTALIA TAB 7-5MG Tier 3 X X Not Specified PREZCOBIX TAB 800-150 Tier 2 X Not Specified PROMETHAZINE CRY HCL Tier 3 X Not Specified PROMETHAZINE POW HCL Tier 3 X Not Specified PROSTAGLAND POW E1 Tier 3 X Not Specified PROVIDA DHA CAP Tier 3 Not Specified RA BEE POLLE CHW 500MG Tier 1 Not Specified REGENECARE GEL Tier 3 Not Specified REMAXAZON PAD Tier 3 Not Specified REPATHA INJ 140MG/ML Tier 3 X X X X Not Specified REPATHA PUSH INJ 420/3.5 Tier 3 X X X

Not Specified REPATHA SURE INJ 140MG/ML Tier 3 X X X X Not Specified RESTORA RX CAP 60-1.25 Tier 3 Not Specified RESVERATROL POW Tier 3 X Not Specified RESVERATROL POW +98% Tier 3 X Not Specified RESVERATROL POW 98% Tier 3 X Not Specified RETINALDEHYD POW Tier 3 X Not Specified REXULTI TAB 0.25MG Tier 3 X X Not Specified REXULTI TAB 0.5MG Tier 3 X X Not Specified REXULTI TAB 1MG Tier 3 X X Not Specified REXULTI TAB 2MG Tier 3 X X Not Specified REXULTI TAB 3MG Tier 3 X X Not Specified REXULTI TAB 4MG Tier 3 X X Not Specified RIBAVIRIN POW Tier 3 X Not Specified RUCONEST INJ 2100UNIT Tier 3 X X X Not Specified SAVAYSA TAB 15MG Tier 3 X Not Specified SAVAYSA TAB 30MG Tier 3 X Not Specified SAVAYSA TAB 60MG Tier 3 X Not Specified SEEBRI NEOHA CAP 15.6MCG Tier 2 X Not Specified SERAQUA LIQ Tier 3 Not Specified SERMORELIN POW ACETATE Tier 3 X Not Specified SEROTONIN POW HCL Tier 3 X Not Specified SILOMAC GEL ULTRA Tier 3 Not Specified SIMPLGEL 30 GEL Tier 3 Not Specified SIROLIMUS POW Tier 3 X Not Specified SODIUM BUTYR POW Tier 3 X Not Specified SOLU-K GEL Tier 3 Not Specified SOLUPAK PAK Tier 3 X Not Specified SOOLANTRA CRE 1% Tier 3 X X Not Specified SPIRA-WASH GEL BASE Tier 3 X Not Specified STIOLTO AER 2.5-2.5 Tier 3 X X Not Specified STRENSIQ INJ 18/0.45 Tier 2 X X X Not Specified STRENSIQ INJ 28/0.7ML Tier 2 X X X Not Specified STRENSIQ INJ 40MG/ML Tier 2 X X X Not Specified STRENSIQ INJ 80/0.8ML Tier 2 X X X Not Specified SUCCIMER DMS POW Tier 3 X Not Specified SULFADIMETHO POW Tier 3 X Not Specified SUPRACIL CRE Tier 3 X Not Specified SYNJARDY TAB Tier 2 X Not Specified SYNJARDY TAB 12.5-500 Tier 2 X Not Specified SYNJARDY TAB 5-1000MG Tier 2 X Not Specified SYNJARDY TAB 5-500MG Tier 2 X

Page 273 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified T Tier 1 Not Specified TABRADOL SUS 1MG/ML Tier 3 X Not Specified TABRADOL SUS RAPIDPAQ Tier 3 X Not Specified TACROLIMUS POW Tier 3 X

Not Specified TACROLIMUS POW MONOHYD Tier 3 X Not Specified TAGRISSO TAB 40MG Tier 3 X X X Not Specified TAGRISSO TAB 80MG Tier 3 X X X Not Specified TALTZ INJ 80MG/ML Tier 3 X X X X Not Specified TALTZ INJ 80MG/ML Tier 3 X X X X Not Specified TAMOXIFEN POW CITRATE Tier 2 X Not Specified TDM SOLUTION SOL Tier 3 Not Specified TECHNIVIE TAB Tier 3 X X Not Specified TESTOSTERONE CRY YAM Tier 3 Not Specified TESTOSTERONE POW Tier 3

Not Specified TESTOSTERONE POW CYPIONAT Tier 3

Not Specified TESTOSTERONE POW ENANTHAT Tier 3 Not Specified TESTOSTERONE POW SOY Tier 3 Not Specified TETRAMEX SPR 2-1-3% Tier 3 Not Specified THERATEARS CAP NUTR Tier 3 Not Specified THIOGUANINE POW Tier 3 X Not Specified THIOTEPA POW Tier 3 X Not Specified TIZANIDINE POW HCL Tier 3 X Not Specified TOCOPHEROL LIQ ALPHA Tier 3 X Not Specified TOCOPHEROLS POW 30% Tier 3 X

Not Specified TOCOPHERYL POW SUCCINAT Tier 3 X Not Specified TOMMY GEL GEL Tier 3 Not Specified TOXICOL SALV KIT COLLECT Tier 3 Not Specified TRAMADOL HCL POW Tier 3 X Not Specified TRESIBA FLEX INJ 100UNIT Tier 3 X Not Specified TRESIBA FLEX INJ 200UNIT Tier 3 X Not Specified TRETTEN INJ Tier 3 X Not Specified TRIAMCINOLON POW Tier 3 X

Not Specified TRIAMCINOLON POW DIACETAT Tier 3 X

Not Specified TRIAMCINOLON POW HEXACETO Tier 3 X Not Specified TRICARE PAK PRENATAL Tier 3 Not Specified TRIDERMA CRE FORTE Tier 3 X Not Specified TRIFERIC SOL Tier 3 Not Specified TRIPLE PMB SOL Tier 3 X Not Specified TRIPLE PMK SOL Tier 3 X Not Specified TRISEON CRE Tier 3 X Not Specified TRIUMEQ TAB Tier 2 X Not Specified TRULICITY INJ 0.75/0.5 Tier 3 X X Not Specified TRULICITY INJ 1.5/0.5 Tier 3 X X Not Specified TUZISTRA XR SUS Tier 3 X X Not Specified TYBOST TAB 150MG Tier 2 X Not Specified UBIDECARENON POW Tier 3 X Not Specified UCERIS AER 2MG/ACT Tier 3 X Not Specified UPTRAVI TAB 1000MCG Tier 3 X X X Not Specified UPTRAVI TAB 1200MCG Tier 3 X X X Not Specified UPTRAVI TAB 1400MCG Tier 3 X X X Not Specified UPTRAVI TAB 1600MCG Tier 3 X X X

Page 274 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Not Specified UPTRAVI TAB 200/800 Tier 3 X X X Not Specified UPTRAVI TAB 200MCG Tier 3 X X X Not Specified UPTRAVI TAB 400MCG Tier 3 X X X Not Specified UPTRAVI TAB 600MCG Tier 3 X X X Not Specified UPTRAVI TAB 800MCG Tier 3 X X X Not Specified UREA POW Tier 3 Not Specified UTIBRON CAP NEOHALER Tier 2 X Not Specified VALIDERM CRE Tier 3 X Not Specified VANACHOL CAP Tier 3 Not Specified VARUBI TAB 90MG Tier 2 X Not Specified VELTASSA POW 16.8GM Tier 3 X X Not Specified VELTASSA POW 25.2GM Tier 3 X X Not Specified VELTASSA POW 8.4GM Tier 3 X X Not Specified VENCLEXTA TAB 100MG Tier 3 X X X Not Specified VENCLEXTA TAB 10MG Tier 3 X X X Not Specified VENCLEXTA TAB 50MG Tier 3 X X X Not Specified VENCLEXTA TAB START PK Tier 3 X X X Not Specified VERRUNEX CRE Tier 3 X Not Specified VERSAPRO GEL Tier 3 Not Specified VIBERZI TAB 100MG Tier 3 X X Not Specified VIBERZI TAB 75MG Tier 3 X X Not Specified VIEKIRA PAK TAB Tier 3 X X X X Not Specified VIEKIRA XR TAB Tier 3 X X Not Specified VISTOGARD PAK 10GM Tier 2 X X Not Specified VITAFOL CHW GUMMIES Tier 3 Not Specified VITAFOL FE+ CAP Tier 3 Not Specified VITAMIN E LIQ Tier 3 X Not Specified VITAMIN E POW SUCCINAT Tier 3 X Not Specified VITAMIN K2 POW 0.2% Tier 3 X Not Specified VITATRUE MIS Tier 3 Not Specified VITEKTA TAB 150MG Tier 2 X Not Specified VITEKTA TAB 85MG Tier 2 X Not Specified VONVENDI INJ 1300UNIT Tier 3 X Not Specified VONVENDI INJ 650UNIT Tier 3 X Not Specified VRAYLAR CAP 1.5-3MG Tier 3 X X Not Specified VRAYLAR CAP 1.5MG Tier 3 X X Not Specified VRAYLAR CAP 3MG Tier 3 X X Not Specified VRAYLAR CAP 4.5MG Tier 3 X X Not Specified VRAYLAR CAP 6MG Tier 3 X X Not Specified WOUND WASH GEL BASE Tier 3 Not Specified XIGDUO XR TAB 10-1000 Tier 3 X X X Not Specified XIGDUO XR TAB 10-500MG Tier 3 X X X Not Specified XIGDUO XR TAB 5-1000MG Tier 3 X X X Not Specified XIGDUO XR TAB 5-500MG Tier 3 X X X Not Specified XIIDRA DRO 5% Tier 3 X X Not Specified XTAMPZA ER CAP 13.5MG Tier 3 X Not Specified XTAMPZA ER CAP 18MG Tier 3 X Not Specified XTAMPZA ER CAP 27MG Tier 3 X Not Specified XTAMPZA ER CAP 36MG Tier 3 X Not Specified XTAMPZA ER CAP 9MG Tier 3 X Not Specified XURIDEN POW 2GM Tier 2 X X X Not Specified ZARXIO INJ 300/0.5 Tier 3 X X Not Specified ZARXIO INJ 480/0.8 Tier 3 X X Not Specified ZEPATIER TAB 50-100MG Tier 3 X X X X Not Specified ZINBRYTA INJ 150MG/ML Tier 3 X X Not Specified ZOLATE CAP Tier 3 Not Specified ZYVODOL CRE Tier 3 X

Page 275 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Ophthalmic Agents, Other - Miscellaneous Eye Drugs ALCAINE SOL 0.5% OP Tier 3 Ophthalmic Agents, Other - Miscellaneous Eye Drugs ATROPINE SUL OIN 1% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs ATROPINE SUL SOL 1% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs CYSTARAN SOL 0.44% Tier 2 X X X Ophthalmic Agents, Other - Miscellaneous Eye Drugs ISO ATROPINE SOL 1% OP Tier 3 Ophthalmic Agents, Other - Miscellaneous Eye Drugs LACRISERT MIS 5MG OP Tier 2 Ophthalmic Agents, Other - Miscellaneous Eye Drugs MYDRAL SOL 0.5% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs MYDRAL SOL 1% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs MYDRIACYL SOL 1% OP Tier 3 Ophthalmic Agents, Other - Miscellaneous Eye Drugs NAPHAZOLINE SOL 0.1% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs PARCAINE SOL 0.5% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs PROPARACAINE SOL 0.5% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs RESTASIS EMU 0.05% Tier 3 X X Ophthalmic Agents, Other - Miscellaneous Eye Drugs TROPICAMIDE SOL 0.5% OP Tier 1 Ophthalmic Agents, Other - Miscellaneous Eye Drugs TROPICAMIDE SOL 1% OP Tier 1 Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs ALOCRIL SOL 2% Tier 3 Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs ALOMIDE SOL 0.1% OP Tier 3 Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs AZELASTINE DRO 0.05% Tier 1 X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs BEPREVE DRO 1.5% Tier 3 X X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs CROMOLYN SOD SOL 4% OP Tier 1 Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs ELESTAT DRO 0.05% Tier 3 X X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs EMADINE SOL 0.05% OP Tier 3 X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs EPINASTINE DRO 0.05% Tier 1 X X

Page 276 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs LASTACAFT SOL 0.25% Tier 3 X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs OLOPATADINE DRO 0.1% Tier 1 X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs OPTIVAR DRO 0.05% Tier 3 X X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs PATADAY SOL 0.2% Tier 3 X X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs PATANOL SOL 0.1% OP Tier 3 X X Ophthalmic Anti-Allergy Agents - Allergy, Infection and Inflammation Drugs PAZEO DRO 0.7% Tier 3 X X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ACETAZOLAMID CAP 500MG ER Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ACETAZOLAMID TAB 125MG Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ACETAZOLAMID TAB 250MG Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ALPHAGAN P SOL 0.1% Tier 2 X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ALPHAGAN P SOL 0.15% Tier 3 X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs APRACLONIDIN SOL 0.5% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs AZOPT SUS 1% OP Tier 2 X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs BETAGAN SOL 0.5% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs BETAXOLOL SOL 0.5% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs BETIMOL SOL 0.25% Tier 2 X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs BETIMOL SOL 0.5% Tier 2 X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs BETOPTIC-S SUS 0.25% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs BRIMONIDINE SOL 0.15% Tier 1 X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs BRIMONIDINE SOL 0.2% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs CARTEOLOL SOL 1% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs COMBIGAN SOL 0.2/0.5% Tier 2 X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs COSOPT SOL 22.3-6.8 Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs COSOPT PF SOL Tier 3 X X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs DIAMOX SEQUE CAP 500MG CR Tier 3

Page 277 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Ophthalmic Antiglaucoma Agents - Glaucoma Drugs DORZOL/TIMOL SOL 22.3-6.8 Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs DORZOLAMIDE SOL 2% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs IOPIDINE SOL 0.5% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs IOPIDINE SOL 1% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ISOPTO CARP SOL 1% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ISOPTO CARP SOL 2% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ISOPTO CARP SOL 4% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs ISTALOL SOL 0.5% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs LEVOBUNOLOL SOL 0.5% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs METHAZOLAMID TAB 25MG Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs METHAZOLAMID TAB 50MG Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs METIPRANOLOL SOL 0.3% OPH Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs NEPTAZANE TAB 25MG Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs NEPTAZANE TAB 50MG Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs PHOSPHOLINE SOL 0.125%OP Tier 2 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs PILOCARPINE SOL 1% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs PILOCARPINE SOL 2% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs PILOCARPINE SOL 4% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs SIMBRINZA SUS 1-0.2% Tier 3 X X Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOLOL GEL SOL 0.25% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOLOL GEL SOL 0.5% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOLOL MAL SOL 0.25% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOLOL MAL SOL 0.5% OP Tier 1 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOPTIC SOL 0.25% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOPTIC SOL 0.5% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOPTIC OCU SOL 0.25% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOPTIC OCU SOL 0.25% OP Tier 2 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOPTIC OCU SOL 0.5% OP Tier 2

Page 278 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOPTIC-XE SOL 0.25% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TIMOPTIC-XE SOL 0.5% OP Tier 3 Ophthalmic Antiglaucoma Agents - Glaucoma Drugs TRUSOPT SOL 2% OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ACULAR SOL 0.5% OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ACULAR LS SOL 0.4% Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ACUVAIL SOL 0.45% Tier 3 X X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ALREX SUS 0.2% Tier 3 X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs BLEPHAMIDE OIN S.O.P. Tier 2

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs BLEPHAMIDE SUS OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs BROMFENAC SOL 0.09% OP Tier 1 X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs BROMFENAC SOL 0.09% OP Tier 1 X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs DEXAMETH PHO SOL 0.1% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs DICLOFENAC SOL 0.1% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs DUREZOL EMU 0.05% Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs FLAREX SUS 0.1% OP Tier 2

Page 279 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs FLUOROMETHOL SUS 0.1% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs FLURBIPROFEN SOL 0.03% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs FML OIN 0.1% OP Tier 2

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs FML FORTE SUS 0.25% OP Tier 2

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs FML LIQUIFLM SUS 0.1% OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ILEVRO DRO 0.3% OP Tier 3 X X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs KETOROLAC SOL 0.4% Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs KETOROLAC SOL 0.5% Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs LOTEMAX GEL 0.5% Tier 3 X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs LOTEMAX OIN 0.5% Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs LOTEMAX SUS 0.5% Tier 3 X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs MAXIDEX SUS 0.1% OP Tier 2

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs MAXITROL OIN 0.1% OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs MAXITROL SUS 0.1% OP Tier 3

Page 280 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs NEO/POLY/BAC OIN /HC 1%OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs NEO/POLY/DEX OIN 0.1% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs NEO/POLY/DEX SUS 0.1% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs NEO-POLYCIN OIN HC 1%OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs NEVANAC SUS 0.1% Tier 3 X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs OCUFEN SOL 0.03% OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs OMNIPRED SUS 1% OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs POLY-DEX OIN 0.1% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs PRED FORTE SUS 1% OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs PRED MILD SUS 0.12% OP Tier 2

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs PRED SOD PHO SOL 1% OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs PRED-G SUS OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs PRED-G S.O.P OIN OP Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs PREDNISOLONE SUS 1% OP Tier 1

Page 281 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs PROLENSA SOL 0.07% Tier 3 X X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs SULF/PRED NA SOL OP Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs TOBRA/DEXAME SUS 0.3-0.1% Tier 1

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs TOBRADEX OIN 0.3-0.1% Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs TOBRADEX SUS 0.3-0.1% Tier 3

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs TOBRADEX ST SUS 0.3-0.05 Tier 3 X X

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs VEXOL SUS 1% OP Tier 2

Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ZYLET SUS 0.5-0.3% Tier 3

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs BIMATOPROST SOL 0.03% Tier 1 X X

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs LATANOPROST SOL 0.005% Tier 1

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs LUMIGAN SOL 0.01% Tier 2

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs RESCULA SOL 0.15% Tier 3 X X

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs TRAVATAN Z DRO 0.004% Tier 2 X

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs TRAVOPROST DRO 0.004% Tier 1 X

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs XALATAN SOL 0.005% Tier 3

Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs ZIOPTAN DRO 0.0015% Tier 3 X X

Page 282 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics - Opioid Pain Relievers EMBEDA CAP 100-4MG Tier 3 X X X Opioid Analgesics - Opioid Pain Relievers EMBEDA CAP 20-0.8MG Tier 3 X X X Opioid Analgesics - Opioid Pain Relievers EMBEDA CAP 30-1.2MG Tier 3 X X X Opioid Analgesics - Opioid Pain Relievers EMBEDA CAP 50-2MG Tier 3 X X X Opioid Analgesics - Opioid Pain Relievers EMBEDA CAP 60-2.4MG Tier 3 X X X Opioid Analgesics - Opioid Pain Relievers EMBEDA CAP 80-3.2MG Tier 3 X X X Opioid Analgesics - Opioid Pain Relievers OPIUM TIN 1% Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers AVINZA CAP 120MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers AVINZA CAP 30MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers AVINZA CAP 45MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers AVINZA CAP 60MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers AVINZA CAP 75MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers AVINZA CAP 90MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers BUTRANS DIS 10MCG/HR Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers BUTRANS DIS 15MCG/HR Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers BUTRANS DIS 20MCG/HR Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers BUTRANS DIS 5MCG/HR Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers BUTRANS DIS 7.5/HR Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers CONZIP CAP 100MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers CONZIP CAP 200MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers CONZIP CAP 300MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers DOLOPHINE TAB 10MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers DOLOPHINE TAB 5MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers DURAGESIC DIS 100MCG/H Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers DURAGESIC DIS 12MCG/HR Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers DURAGESIC DIS 25MCG/HR Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers DURAGESIC DIS 50MCG/HR Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers DURAGESIC DIS 75MCG/HR Tier 3 X X

Page 283 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 100MCG/H Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 12MCG/HR Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 25MCG/HR Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 37.5MCG Tier 1 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 50MCG/HR Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 62.5MCG Tier 1 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 75MCG/HR Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers FENTANYL DIS 87.5MCG Tier 1 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers HYSINGLA ER TAB 100 MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers HYSINGLA ER TAB 120 MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers HYSINGLA ER TAB 20 MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers HYSINGLA ER TAB 30 MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers HYSINGLA ER TAB 40 MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers HYSINGLA ER TAB 60 MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers HYSINGLA ER TAB 80 MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 100MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 10MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 200MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 20MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 30MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 40MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 50MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 60MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers KADIAN CAP 80MG ER Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers LEVORPHANOL TAB 2MG Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADONE CON 10MG/ML Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADONE POW Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADONE SOL 10MG/5ML Tier 1 X

Page 284 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADONE SOL 5MG/5ML Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADONE TAB 10MG Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADONE TAB 40MG Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADONE TAB 5MG Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADOSE CON 10MG/ML Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADOSE TAB 40MG Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers METHADOSE SF CON 10MG/ML Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE POW SULFATE Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 100MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 10MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 120MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 20MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 30MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 30MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 45MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 50MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 60MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 60MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 75MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 80MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL CAP 90MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL SOL 100/5ML Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL SOL 10MG/5ML Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL SOL 20MG/5ML Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL SUP 10MG Tier 3 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL SUP 20MG Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL SUP 30MG Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL SUP 5MG Tier 1

Page 285 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL TAB 100MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL TAB 15MG Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL TAB 15MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL TAB 200MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL TAB 30MG Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL TAB 30MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers MORPHINE SUL TAB 60MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers MS CONTIN TAB 100MG CR Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MS CONTIN TAB 15MG CR Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MS CONTIN TAB 200MG CR Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MS CONTIN TAB 30MG CR Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers MS CONTIN TAB 60MG CR Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA TAB 100MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA TAB 50MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA TAB 75MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA ER TAB 100MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA ER TAB 150MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA ER TAB 200MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA ER TAB 250MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers NUCYNTA ER TAB 50MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA TAB 10MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA TAB 5MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA ER TAB 10MG Tier 2 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA ER TAB 15MG Tier 2 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA ER TAB 20MG Tier 2 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA ER TAB 30MG Tier 2 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA ER TAB 40MG Tier 2 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA ER TAB 5MG Tier 2 X X

Page 286 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Long-acting - Opioid Pain Relievers OPANA ER TAB 7.5MG Tier 2 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB 10MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB 15MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB 20MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB 30MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB 40MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB 5MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB 7.5MG ER Tier 1 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB HCL 10MG Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers OXYMORPHONE TAB HCL 5MG Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers SUBSYS SPR 100MCG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers SUBSYS SPR 1200MCG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers SUBSYS SPR 1600MCG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers SUBSYS SPR 200MCG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers SUBSYS SPR 400MCG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers SUBSYS SPR 600MCG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers SUBSYS SPR 800MCG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers SYNAPRYN SUS 10MG/ML Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL CAP 150MG ER Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL CAP ER 100MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL CAP ER 200MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL CAP ER 300MG Tier 3 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL TAB 100MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL TAB 100MG ER Tier 1 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL TAB 200MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL TAB 200MG ER Tier 1 X X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL TAB 300MG ER Tier 1 X Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL TAB 300MG ER Tier 1 X X

Page 287 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Long-acting - Opioid Pain Relievers TRAMADOL HCL TAB 50MG Tier 1 Opioid Analgesics, Long-acting - Opioid Pain Relievers ULTRAM TAB 50MG Tier 3 Opioid Analgesics, Long-acting - Opioid Pain Relievers ULTRAM ER TAB 100MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers ULTRAM ER TAB 200MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers ULTRAM ER TAB 300MG Tier 3 X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 10MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 10MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 15MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 15MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 20MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 20MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 30MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 30MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 40MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 40MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 50MG Tier 3 X X X Opioid Analgesics, Long-acting - Opioid Pain Relievers ZOHYDRO ER CAP 50MG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ABSTRAL SUB 100MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ABSTRAL SUB 200MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ABSTRAL SUB 300MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ABSTRAL SUB 400MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ABSTRAL SUB 600MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ABSTRAL SUB 800MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ACTIQ LOZ 1200MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ACTIQ LOZ 1600MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ACTIQ LOZ 200MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ACTIQ LOZ 400MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers ACTIQ LOZ 600MCG Tier 3 X X X

Page 288 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Short-acting - Opioid Pain Relievers ACTIQ LOZ 800MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers APAP/CODEINE SOL 120-12/5 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers APAP/CODEINE TAB 300-15MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers APAP/CODEINE TAB 300-30MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers APAP/CODEINE TAB 300-60MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers APAP-CAFFEIN CAP DIHYDROC Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ASCOMP/COD CAP 30MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers BUT/ASA/CAF/ CAP COD 30MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers BUTORPHANOL SOL 10MG/ML Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers CAPITAL/COD SUS 120-12/5 Tier 2 X Opioid Analgesics, Short-acting - Opioid Pain Relievers CARISOPRODOL TAB ASA/COD Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers CODEINE SULF SOL 30MG/5ML Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers CODEINE SULF TAB 15MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers CODEINE SULF TAB 30MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers CODEINE SULF TAB 60MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers DEMEROL TAB 100MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers DEMEROL TAB 50MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers DIHYDROCOD/ CAP ASA/CAFF Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers DILAUDID LIQ 1MG/ML Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers DILAUDID TAB 2MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers DILAUDID TAB 4MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers DILAUDID TAB 8MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers ENDOCET TAB 10-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ENDOCET TAB 2.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ENDOCET TAB 5-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ENDOCET TAB 7.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ENDODAN TAB Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers EXALGO TAB 12MG Tier 3 X X X

Page 289 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Short-acting - Opioid Pain Relievers EXALGO TAB 16MG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers EXALGO TAB 32MG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers EXALGO TAB 8MG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTANYL POW CITRATE Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTANYL OT LOZ 1200MCG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTANYL OT LOZ 1600MCG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTANYL OT LOZ 200MCG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTANYL OT LOZ 400MCG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTANYL OT LOZ 600MCG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTANYL OT LOZ 800MCG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTORA TAB 100MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTORA TAB 200MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTORA TAB 400MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTORA TAB 600MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FENTORA TAB 800MCG Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers FIORINAL/COD CAP 30MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYCET SOL 7.5-325 Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP SOL 7.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP TAB 10-300MG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP TAB 10-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP TAB 2.5-325 Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP TAB 5-300MG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP TAB 5-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP TAB 7.5-300 Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCO/APAP TAB 7.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCOD/IBU TAB 10-200MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCOD/IBU TAB 2.5-200 Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCOD/IBU TAB 5-200MG Tier 1

Page 290 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCOD/IBU TAB 7.5-200 Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROCODONE SOL 10-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON LIQ 1MG/ML Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON POW HCL Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON SUP 3MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON TAB 12MG ER Tier 1 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON TAB 16MG ER Tier 1 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON TAB 2MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON TAB 32MG ER Tier 1 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON TAB 4MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON TAB 8MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers HYDROMORPHON TAB 8MG ER Tier 1 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers IBUDONE TAB 10-200MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers IBUDONE TAB 5-200MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers LAZANDA SPR 100MCG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers LAZANDA SPR 300MCG Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers LAZANDA SPR 400MCG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers LORCET TAB 5-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers LORCET HD TAB 10-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers LORCET PLUS TAB 7.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers LORTAB ELX 10-300MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers LORTAB TAB 10-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers LORTAB TAB 5-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers LORTAB TAB 7.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers MEPERIDINE SOL 50MG/5ML Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers MEPERIDINE TAB 100MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers MEPERIDINE TAB 50MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers NORCO TAB 10-325MG Tier 3 X

Page 291 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Short-acting - Opioid Pain Relievers NORCO TAB 5-325MG Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers NORCO TAB 7.5-325 Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXAYDO TAB 5MG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXAYDO TAB 7.5MG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCOD/APAP TAB 10-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCOD/APAP TAB 2.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCOD/APAP TAB 5-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCOD/APAP TAB 7.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCOD/ASA TAB Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE CAP 5MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE CON 100/5ML Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE CON 20MG/ML Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE POW HCL Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE SOL 5MG/5ML Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 10MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 10MG ER Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 15MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 15MG ER Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 20MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 20MG ER Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 30MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 30MG ER Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 40MG ER Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 5MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 60MG ER Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE TAB 80MG ER Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCODONE/ SOL APAP Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCONTIN TAB 10MG CR Tier 3 X X X

Page 292 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCONTIN TAB 15MG CR Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCONTIN TAB 20MG CR Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCONTIN TAB 30MG CR Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCONTIN TAB 40MG CR Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCONTIN TAB 60MG CR Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers OXYCONTIN TAB 80MG CR Tier 3 X X X Opioid Analgesics, Short-acting - Opioid Pain Relievers PENTAZ/NALOX TAB 50-0.5MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers PERCOCET TAB 10-325MG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers PERCOCET TAB 2.5-325 Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers PERCOCET TAB 5-325MG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers PERCOCET TAB 7.5-325 Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers PRIMLEV TAB 10-300MG Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers PRIMLEV TAB 5-300MG Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers PRIMLEV TAB 7.5-300 Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers REPREXAIN TAB 10-200MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers REPREXAIN TAB 5-200MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers ROXICET SOL 5-325/5 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ROXICET TAB 5-325MG Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ROXICODONE TAB 15MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers ROXICODONE TAB 30MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers ROXICODONE TAB 5MG Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers SYNALGOS-DC CAP Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers TRAMADL/APAP TAB 37.5-325 Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers TREZIX CAP Tier 1 X Opioid Analgesics, Short-acting - Opioid Pain Relievers TYLENOL/COD TAB #3 Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers TYLENOL/COD TAB #4 Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers ULTRACET TAB 37.5-325 Tier 3 X Opioid Analgesics, Short-acting - Opioid Pain Relievers VERDROCET TAB 2.5-325 Tier 1

Page 293 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Opioid Analgesics, Short-acting - Opioid Pain Relievers VICODIN TAB 5-300MG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers VICODIN ES TAB 7.5-300 Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers VICODIN HP TAB 10-300MG Tier 1 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers VICOPROFEN TAB 7.5-200 Tier 3 Opioid Analgesics, Short-acting - Opioid Pain Relievers XARTEMIS XR TAB 7.5-325 Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers XODOL TAB 10-300MG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers XODOL TAB 5-300MG Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers XODOL TAB 7.5-300 Tier 3 X X Opioid Analgesics, Short-acting - Opioid Pain Relievers XYLON TAB 10-200MG Tier 1 Opioid Analgesics, Short-acting - Opioid Pain Relievers ZAMICET SOL 10-325MG Tier 1 X

Opioid Antagonists - Antidotes/Deterrents/Protectants BELBUCA MIS 150MCG Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BELBUCA MIS 300MCG Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BELBUCA MIS 450MCG Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BELBUCA MIS 600MCG Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BELBUCA MIS 750MCG Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BELBUCA MIS 75MCG Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BELBUCA MIS 900MCG Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BUNAVAIL MIS 2.1-0.3 Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BUNAVAIL MIS 4.2-0.7 Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BUNAVAIL MIS 6.3-1MG Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BUPREN/NALOX SUB 2-0.5MG Tier 1 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BUPREN/NALOX SUB 8-2MG Tier 1 X X X

Page 294 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Opioid Antagonists - Antidotes/Deterrents/Protectants BUPRENORPHIN SUB 2MG Tier 1 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants BUPRENORPHIN SUB 8MG Tier 1 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants EVZIO INJ Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants NALOXONE INJ 0.4MG/ML Tier 1

Opioid Antagonists - Antidotes/Deterrents/Protectants NALOXONE INJ 1MG/ML Tier 1

Opioid Antagonists - Antidotes/Deterrents/Protectants NARCAN SPR Tier 3 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants SUBOXONE MIS 12-3MG Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants SUBOXONE MIS 2-0.5MG Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants SUBOXONE MIS 4-1MG Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants SUBOXONE MIS 8-2MG Tier 3 X X X

Opioid Antagonists - Antidotes/Deterrents/Protectants ZUBSOLV SUB 1.4-0.36 Tier 1 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants ZUBSOLV SUB 11.4-2.9 Tier 1 X

Opioid Antagonists - Antidotes/Deterrents/Protectants ZUBSOLV SUB 2.9-0.71 Tier 1 X

Opioid Antagonists - Antidotes/Deterrents/Protectants ZUBSOLV SUB 5.7-1.4 Tier 1 X X

Opioid Antagonists - Antidotes/Deterrents/Protectants ZUBSOLV SUB 8.6-2.1 Tier 1 X X Otic Agents - Ear Drugs ACE ACD/ALUM SOL 2% OTIC Tier 1 Otic Agents - Ear Drugs ACETASOL HC SOL OTIC Tier 2 Otic Agents - Ear Drugs ACETIC ACID SOL 2% OTIC Tier 1 Otic Agents - Ear Drugs COLY-MYCIN S SUS OTIC Tier 3 Otic Agents - Ear Drugs CORTISPORIN SUS -TC OTIC Tier 3 Otic Agents - Ear Drugs DERMOTIC OIL 0.01% Tier 3 Otic Agents - Ear Drugs FLUOCIN ACET OIL 0.01% Tier 1 Otic Agents - Ear Drugs FLUOCIN ACET OIL EAR0.01% Tier 1 Otic Agents - Ear Drugs HC/ACET ACID SOL OTIC Tier 1 Otic Agents - Ear Drugs NEO/POLY/HC SOL 1% OTIC Tier 1 Otic Agents - Ear Drugs NEO/POLY/HC SUS 1% OTIC Tier 1

Page 295 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Otic Agents - Ear Drugs NEO/POLY/HC SUS OP Tier 1 Otic Agents - Ear Drugs PRAMOTIC DRO 1-0.1% Tier 3 Parasympathomimetics - Myasthenia Gravis Drugs GUANIDINE TAB 125MG Tier 3 Parasympathomimetics - Myasthenia Gravis Drugs MESTINON SYP 60MG/5ML Tier 2 Parasympathomimetics - Myasthenia Gravis Drugs MESTINON TAB 60MG Tier 3 Parasympathomimetics - Myasthenia Gravis Drugs MESTINON TAB TIMESPAN Tier 3 Parasympathomimetics - Myasthenia Gravis Drugs PYRIDOSTIGM TAB 60MG Tier 1 Parasympathomimetics - Myasthenia Gravis Drugs PYRIDOSTIGMI TAB 180MG Tier 1 Pediculicides/Scabicides - Scabies and Lice Drugs ELIMITE CRE 5% Tier 3 Pediculicides/Scabicides - Scabies and Lice Drugs EURAX CRE 10% Tier 2 Pediculicides/Scabicides - Scabies and Lice Drugs EURAX LOT 10% Tier 3 Pediculicides/Scabicides - Scabies and Lice Drugs LINDANE LOT 1% Tier 1 X Pediculicides/Scabicides - Scabies and Lice Drugs LINDANE SHA 1% Tier 1 X Pediculicides/Scabicides - Scabies and Lice Drugs LYCELLE GEL Tier 3 Pediculicides/Scabicides - Scabies and Lice Drugs MALATHION LOT 0.5% Tier 1 Pediculicides/Scabicides - Scabies and Lice Drugs NATROBA SUS 0.9% Tier 3 X Pediculicides/Scabicides - Scabies and Lice Drugs OVIDE LOT 0.5% Tier 3 Pediculicides/Scabicides - Scabies and Lice Drugs PERMETHRIN CRE 5% Tier 1 Pediculicides/Scabicides - Scabies and Lice Drugs SKLICE LOT 0.5% Tier 3 X Pediculicides/Scabicides - Scabies and Lice Drugs SPINOSAD SUS 0.9% Tier 1 Pediculicides/Scabicides - Scabies and Lice Drugs ULESFIA LOT 5% Tier 3 PHARMACEUTICAL AIDS 1ST BASE CRE Tier 3 X PHARMACEUTICAL AIDS ADAPTADERM CRE Tier 3 X

PHARMACEUTICAL AIDS ADENOSINE-5 POW MONOPHOS Tier 3 X

PHARMACEUTICAL AIDS ADENOSINE-5 POW TRIPHOSP Tier 3 X PHARMACEUTICAL AIDS ADVANCED BAS CRE PLUS Tier 3 X PHARMACEUTICAL AIDS ALBA-DERM CRE Tier 3 X PHARMACEUTICAL AIDS ALMONDERM CRE Tier 3 X PHARMACEUTICAL AIDS ALPAWASH OIN Tier 3 PHARMACEUTICAL AIDS ALTADERM CRE BASE Tier 3 X PHARMACEUTICAL AIDS APOTHEDERM CRE Tier 3

PHARMACEUTICAL AIDS APOTHESAR CRE TRANSDER Tier 3 PHARMACEUTICAL AIDS APOTHESIL CRE Tier 3 X PHARMACEUTICAL AIDS AQUORAL AER Tier 3 PHARMACEUTICAL AIDS ATRAPRO GEL HYDROGEL Tier 3

Page 296 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty PHARMACEUTICAL AIDS ATRAPRO CP KIT Tier 3 PHARMACEUTICAL AIDS AUXIPRO CRE EMOLLIEN Tier 3 X PHARMACEUTICAL AIDS AUXIPRO CRE VANISHIN Tier 3 X PHARMACEUTICAL AIDS AZ CREAM CRE Tier 3 X PHARMACEUTICAL AIDS BACOCALMINE LIQ Tier 3 PHARMACEUTICAL AIDS BASE CRE LIPOSOME Tier 3 PHARMACEUTICAL AIDS BASE FOR CRE SCARS Tier 3 X PHARMACEUTICAL AIDS BASE W301 CRE Tier 3 X PHARMACEUTICAL AIDS B-CREAM CRE Tier 3 X PHARMACEUTICAL AIDS BIOPEPTIDE CRE BASE Tier 3 X PHARMACEUTICAL AIDS CARBOGEL GEL 940 Tier 3 PHARMACEUTICAL AIDS CARBOHOL GEL 940 Tier 2 PHARMACEUTICAL AIDS CARBOMER GEL AQUEOUS Tier 3

PHARMACEUTICAL AIDS CARBOMER GEL HYDROALC Tier 3 PHARMACEUTICAL AIDS CELA BASE CRE Tier 3 X PHARMACEUTICAL AIDS CHERRY SYP Tier 3 PHARMACEUTICAL AIDS CHRYSADERM CRE DAY Tier 3 X PHARMACEUTICAL AIDS CHRYSADERM CRE NIGHT Tier 3 X PHARMACEUTICAL AIDS COLLODION LIQ FLEXIBLE Tier 3 PHARMACEUTICAL AIDS CONCENTRATE CRE Tier 3 X PHARMACEUTICAL AIDS CREAM BASE CRE Tier 3 X PHARMACEUTICAL AIDS CUTIS PLUS CRE Tier 3 X PHARMACEUTICAL AIDS DELBASE OIN COMPOUND Tier 1 X PHARMACEUTICAL AIDS DELIVRA CRE SR Tier 3

PHARMACEUTICAL AIDS DERMA SERUM CRE FREEDOM Tier 3 X PHARMACEUTICAL AIDS DIAB GEL Tier 3 PHARMACEUTICAL AIDS DIAB F.D.G. GEL Tier 3 PHARMACEUTICAL AIDS EMOLIVAN CRE Tier 3 X PHARMACEUTICAL AIDS EMOLLIENT CRE Tier 3 X PHARMACEUTICAL AIDS EMOLLIENT CRE BASE Tier 3 X PHARMACEUTICAL AIDS FAGRON LS CRE PLUS Tier 3 X PHARMACEUTICAL AIDS FAGRON LS CRE ULTRA Tier 3 X PHARMACEUTICAL AIDS FITALITE CRE BASE Tier 3 X PHARMACEUTICAL AIDS FLAVOR BLEND SUS Tier 3 PHARMACEUTICAL AIDS FLAVOR PLUS LIQ Tier 3 PHARMACEUTICAL AIDS FLAVOR SWEET LIQ S/F Tier 3 PHARMACEUTICAL AIDS FLAVOR SWEET SYP Tier 3 PHARMACEUTICAL AIDS FLOW-EZE MIS VENTED Tier 1 PHARMACEUTICAL AIDS FOOD COLOR LIQ BLUE Tier 3 PHARMACEUTICAL AIDS FP DERM CRE Tier 3 X PHARMACEUTICAL AIDS FP ENHANCING CRE Tier 3 X PHARMACEUTICAL AIDS FP NATURAL CRE Tier 3 X PHARMACEUTICAL AIDS FP PLUS CRE Tier 3 X PHARMACEUTICAL AIDS FP SUPREME CRE Tier 3 X PHARMACEUTICAL AIDS FP ULTRA CRE Tier 3 X PHARMACEUTICAL AIDS FREEDOM CRE DERMA-D Tier 3 X PHARMACEUTICAL AIDS FREEDOM CRE DERMA-N Tier 3 X PHARMACEUTICAL AIDS FREEDOM CRE ULTRAPEN Tier 3 X PHARMACEUTICAL AIDS FREEDOM HRT CRE ULTRA Tier 3 X PHARMACEUTICAL AIDS HYDROGEL GEL Tier 1 PHARMACEUTICAL AIDS HYDROPHILIC OIN Tier 3 X PHARMACEUTICAL AIDS HYDROUS CRE EMULSIFI Tier 3 X PHARMACEUTICAL AIDS HYPO NEEDLE MIS 18GX1" Tier 2 PHARMACEUTICAL AIDS LANOLIN OIN Tier 1 PHARMACEUTICAL AIDS LANOLIN ANHY OIN Tier 3

Page 297 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty PHARMACEUTICAL AIDS LECITHIN GEL Tier 3 PHARMACEUTICAL AIDS LIPO CREAM CRE BASE Tier 3 X PHARMACEUTICAL AIDS LIPOBASE CRE HEAVY Tier 3 X PHARMACEUTICAL AIDS LIPOBASE CRE REGULAR Tier 3 X PHARMACEUTICAL AIDS LIPOPEN CRE Tier 2 X PHARMACEUTICAL AIDS LIPOPEN CRE ANHYDRO Tier 3 X PHARMACEUTICAL AIDS LIPOPEN CRE PLUS Tier 3 X PHARMACEUTICAL AIDS LIPOPEN CRE ULTRA Tier 3 X PHARMACEUTICAL AIDS LIPOZYME CRE Tier 3 PHARMACEUTICAL AIDS LUXAMEND CRE Tier 3 PHARMACEUTICAL AIDS MEDIDERM CRE Tier 3 X PHARMACEUTICAL AIDS MICRODERM CRE BASE Tier 3 X PHARMACEUTICAL AIDS MUCOLOX LIQ Tier 3 PHARMACEUTICAL AIDS MULTIUSE CRE BASE Tier 3 X PHARMACEUTICAL AIDS NATACREAM CRE Tier 3 X PHARMACEUTICAL AIDS NATURAL CRE Tier 3 X PHARMACEUTICAL AIDS NEEDLES 22G X 1 1/2" Tier 2 PHARMACEUTICAL AIDS NEUTRASAL POW Tier 3 PHARMACEUTICAL AIDS NOURILITE CRE Tier 3 X PHARMACEUTICAL AIDS NOURIVAN CRE ANTIOX Tier 3 X PHARMACEUTICAL AIDS NOXI-K CRE Tier 3 X PHARMACEUTICAL AIDS OCCLUVAN OIN Tier 3 X PHARMACEUTICAL AIDS ORA-BLEND SUS Tier 3 PHARMACEUTICAL AIDS ORA-BLEND SF SUS Tier 3 PHARMACEUTICAL AIDS ORAL MIX LIQ SUSPENDI Tier 3 PHARMACEUTICAL AIDS ORAL MIX SF LIQ Tier 3 PHARMACEUTICAL AIDS ORAL SUSPEND LIQ Tier 3 PHARMACEUTICAL AIDS ORAL SYRUP LIQ FLAVORED Tier 3 PHARMACEUTICAL AIDS ORAL SYRUP LIQ SF Tier 3 PHARMACEUTICAL AIDS ORA-PLUS LIQ Tier 3 PHARMACEUTICAL AIDS ORA-SWEET SYP Tier 2 PHARMACEUTICAL AIDS ORA-SWEET SF SYP Tier 3 PHARMACEUTICAL AIDS PCCA ACACIA SYP BASE Tier 3 PHARMACEUTICAL AIDS PCCA ALADERM CRE BASE Tier 3 X PHARMACEUTICAL AIDS PCCA BASE CRE 7542 Tier 3 X PHARMACEUTICAL AIDS PCCA COBASE OIN #1 Tier 3

PHARMACEUTICAL AIDS PCCA COSMETI CRE HRT BASE Tier 2 X

PHARMACEUTICAL AIDS PCCA CUSTOM CRE LIPO-MAX Tier 3 PHARMACEUTICAL AIDS PCCA EMOLLIE CRE BASE Tier 3 X PHARMACEUTICAL AIDS PCCA LIPODER CRE BASE Tier 2 X PHARMACEUTICAL AIDS PCCA LIPODER CRE BASE Tier 3 X PHARMACEUTICAL AIDS PCCA LIPOSOM CRE DRY Tier 3 PHARMACEUTICAL AIDS PCCA LIPOSOM CRE NORMAL Tier 3 PHARMACEUTICAL AIDS PCCA LIPOSOM CRE OILY Tier 3 PHARMACEUTICAL AIDS PCCA LIPOSOM CRE SENSITIV Tier 3 PHARMACEUTICAL AIDS PCCA MVC CRE BASE Tier 3 X PHARMACEUTICAL AIDS PCCA SWEET SYP -SF Tier 3 PHARMACEUTICAL AIDS PCCA SYRUP SYP VEHICLE Tier 3 PHARMACEUTICAL AIDS PCCA VANISH CRE BASE Tier 3 X PHARMACEUTICAL AIDS PCCA VANISHI CRE LIGHT Tier 3 X PHARMACEUTICAL AIDS PCCA VANPEN CRE BASE Tier 3 X PHARMACEUTICAL AIDS PCCA-PLUS SUS Tier 3 PHARMACEUTICAL AIDS PENCREAM CRE Tier 3 X PHARMACEUTICAL AIDS PENDERM CRE Tier 3 X PHARMACEUTICAL AIDS PENTAPHENE CRE Tier 3 X

Page 298 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty PHARMACEUTICAL AIDS PETROLATUM OIN YELLOW Tier 3 PHARMACEUTICAL AIDS PFCB CRE Tier 3 X

PHARMACEUTICAL AIDS PHARMABASE CRE ANTIOXID Tier 3 X

PHARMACEUTICAL AIDS PHARMABASE CRE COSMETIC Tier 3 X PHARMACEUTICAL AIDS PHARMABASE CRE HEAVY Tier 3 X PHARMACEUTICAL AIDS PHARMABASE CRE LIGHT Tier 3 X PHARMACEUTICAL AIDS PHARMABASE CRE VAGINAL Tier 3 X PHARMACEUTICAL AIDS PHYTOBASE CRE Tier 2 X PHARMACEUTICAL AIDS PHYTOBASE CRE Tier 3 X PHARMACEUTICAL AIDS PICODERM CRE Tier 3 X PHARMACEUTICAL AIDS PLACEBO #00 CAP Tier 2 PHARMACEUTICAL AIDS PLO GEL MEDIFLO Tier 3 PHARMACEUTICAL AIDS PLO MEDIFLO KIT KIT Tier 3 PHARMACEUTICAL AIDS PLO TRANSDER CRE Tier 3 PHARMACEUTICAL AIDS PLO20 BASE GEL Tier 3 PHARMACEUTICAL AIDS PNA-HRT BASE CRE Tier 3 X PHARMACEUTICAL AIDS POLYETH GLYC OIN 8000 Tier 3 PHARMACEUTICAL AIDS POLYPEG OIN BASE Tier 3 PHARMACEUTICAL AIDS PRACASIL TM- CRE PLUS Tier 3 X PHARMACEUTICAL AIDS PROPYLENE GL SOL Tier 3 PHARMACEUTICAL AIDS P-SILOXAN DS CRE Tier 3 X PHARMACEUTICAL AIDS PURIFIED LIQ WATER Tier 3 PHARMACEUTICAL AIDS Q-DERM CRE Tier 3 X PHARMACEUTICAL AIDS RADIAGEL GEL Tier 2 PHARMACEUTICAL AIDS RADIAPLEXRX GEL Tier 3 PHARMACEUTICAL AIDS RASPBERRY SYP Tier 1 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 18GX1" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 18GX1.5" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 19GX1" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 19GX1.5" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 20GX1" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 20GX1.5" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 21GX1" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 21GX1.5" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 22GX1" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 22GX1.5" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 23GX1" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 25GX1" Tier 2 PHARMACEUTICAL AIDS SAFTY NEEDLE MIS 25GX5/8" Tier 2 PHARMACEUTICAL AIDS SALIVAMAX POW Tier 3 PHARMACEUTICAL AIDS SALIVATE RX POW Tier 3 PHARMACEUTICAL AIDS SALT DURABLE CRE Tier 3 X PHARMACEUTICAL AIDS SALT STABLE CRE Tier 3 X PHARMACEUTICAL AIDS SALT STABLE CRE LS ADV Tier 3 X PHARMACEUTICAL AIDS SANARE CRE ADVANCED Tier 3 X PHARMACEUTICAL AIDS SANARE SCAR CRE THERAPY Tier 3 X PHARMACEUTICAL AIDS SCAR CARE CRE Tier 3 X PHARMACEUTICAL AIDS SEDANARE CRE Tier 3 X PHARMACEUTICAL AIDS SILOSOME CRE TRANSDER Tier 3 PHARMACEUTICAL AIDS SILPROTEX CRE PLUS Tier 3 X PHARMACEUTICAL AIDS SIMPLE SYP Tier 1 PHARMACEUTICAL AIDS SKYY DERM CRE Tier 3 X PHARMACEUTICAL AIDS SOLYDRA LIQ Tier 3 PHARMACEUTICAL AIDS STERA BASE CRE Tier 3 X PHARMACEUTICAL AIDS SUPREME CRE Tier 3 X

Page 299 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty PHARMACEUTICAL AIDS SUSPENSION SUS VEHICLE Tier 3 PHARMACEUTICAL AIDS SYRPALTA SYP Tier 3 PHARMACEUTICAL AIDS SYRPALTA SYP Tier 1 PHARMACEUTICAL AIDS SYRPALTA SYP CLEAR Tier 1 PHARMACEUTICAL AIDS SYRSPEND SF LIQ Tier 3 PHARMACEUTICAL AIDS SYRSPEND SF SUS PH4 Tier 3 PHARMACEUTICAL AIDS SYRUP SYP VEHICLE Tier 3 PHARMACEUTICAL AIDS SYRUP SF SYP VEHICLE Tier 3 PHARMACEUTICAL AIDS TDC MAX CRE Tier 3 PHARMACEUTICAL AIDS TEGADERM AG PAD 2"X2" Tier 3 PHARMACEUTICAL AIDS TEGADERM AG PAD 4"X5" Tier 3 PHARMACEUTICAL AIDS TEGADERM AG PAD 4"X8" Tier 3 PHARMACEUTICAL AIDS TEGADERM AG PAD 8"X8" Tier 3 PHARMACEUTICAL AIDS TERODERM CRE Tier 3 X PHARMACEUTICAL AIDS TIGHTENING CRE BASE Tier 3 X

PHARMACEUTICAL AIDS TRANSDERMAL CRE PAIN BAS Tier 3 PHARMACEUTICAL AIDS TRANS-PEN CRE Tier 3 PHARMACEUTICAL AIDS U-BASE CRE Tier 3 X PHARMACEUTICAL AIDS ULTRADERM CRE Tier 3 X PHARMACEUTICAL AIDS VANIBASE CRE Tier 3 X PHARMACEUTICAL AIDS VANISHING CRE Tier 3 X PHARMACEUTICAL AIDS VANISHING CRE BOTANCAL Tier 3 X PHARMACEUTICAL AIDS VANISH-PEN CRE Tier 3 X

PHARMACEUTICAL AIDS VASCUDERM GEL HYDROGEL Tier 3 PHARMACEUTICAL AIDS VASCUDERM KIT STASIS Tier 3 PHARMACEUTICAL AIDS VERSAFREE SYP Tier 3 PHARMACEUTICAL AIDS VERSAPLUS SYP Tier 3 PHARMACEUTICAL AIDS VERSAPRO CRE Tier 3 X PHARMACEUTICAL AIDS VERSATILE CRE BASE Tier 3 X PHARMACEUTICAL AIDS VERSATILE CRE RICH BSE Tier 3 X PHARMACEUTICAL AIDS VERSIGEL CRE Tier 3 X PHARMACEUTICAL AIDS V-MAX CRE Tier 3 X PHARMACEUTICAL AIDS WOUND CARE CRE Tier 3 X PHARMACEUTICAL AIDS XCEL 100 CRE Tier 3 X PHARMACEUTICAL AIDS XEMATOP CRE BASE Tier 3 X PHARMACEUTICAL AIDS ZOE SCRIPTS CRE IDEALBAS Tier 3 X Phosphate Binders - Phosphate- Removing Agents FOSRENOL CHW 1000MG Tier 3 Phosphate Binders - Phosphate- Removing Agents FOSRENOL CHW 500MG Tier 3 Phosphate Binders - Phosphate- Removing Agents FOSRENOL CHW 750MG Tier 3 Phosphate Binders - Phosphate- Removing Agents FOSRENOL POW 1000MG Tier 3 Phosphate Binders - Phosphate- Removing Agents FOSRENOL POW 750MG Tier 3 Phosphate Binders - Phosphate- Removing Agents RENAGEL TAB 400MG Tier 3 Phosphate Binders - Phosphate- Removing Agents RENAGEL TAB 800MG Tier 3 Phosphate Binders - Phosphate- Removing Agents RENVELA PAK 0.8GM Tier 2 Phosphate Binders - Phosphate- Removing Agents RENVELA PAK 2.4GM Tier 2

Page 300 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Phosphate Binders - Phosphate- Removing Agents RENVELA TAB 800MG Tier 2 Phosphate Binders - Phosphate- Removing Agents VELPHORO CHW 500MG Tier 2 Platelet Modifying Agents - Platelet Modifying Drugs AGGRENOX CAP 25-200MG Tier 3 Platelet Modifying Agents - Platelet Modifying Drugs ASA/DIPYRIDA CAP 25-200MG Tier 3 Platelet Modifying Agents - Platelet Modifying Drugs CILOSTAZOL TAB 100MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs CILOSTAZOL TAB 50MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs CLOPIDOGREL TAB 300MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs CLOPIDOGREL TAB 75MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs DIPYRIDAMOLE TAB 25MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs DIPYRIDAMOLE TAB 50MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs DIPYRIDAMOLE TAB 75MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs EFFIENT TAB 10MG Tier 3 X Platelet Modifying Agents - Platelet Modifying Drugs EFFIENT TAB 5MG Tier 3 X Platelet Modifying Agents - Platelet Modifying Drugs PERSANTINE TAB 25MG Tier 3 Platelet Modifying Agents - Platelet Modifying Drugs PERSANTINE TAB 50MG Tier 3 Platelet Modifying Agents - Platelet Modifying Drugs PERSANTINE TAB 75MG Tier 3 Platelet Modifying Agents - Platelet Modifying Drugs PLAVIX TAB 300MG Tier 3 X Platelet Modifying Agents - Platelet Modifying Drugs PLAVIX TAB 75MG Tier 3 X Platelet Modifying Agents - Platelet Modifying Drugs PLETAL TAB 100MG Tier 3 Platelet Modifying Agents - Platelet Modifying Drugs PLETAL TAB 50MG Tier 3 Platelet Modifying Agents - Platelet Modifying Drugs TICLOPIDINE TAB 250MG Tier 1 Platelet Modifying Agents - Platelet Modifying Drugs ZONTIVITY TAB 2.08MG Tier 3 X X

Progesterone Agonists/Antagonists - Hormone Replacement/Modifying HCR Drugs ELLA TAB 30MG Preventative X Progestins - Hormone HCR Replacement/Modifying Drugs AFTERA TAB 1.5MG Preventative Progestins - Hormone Replacement/Modifying Drugs AYGESTIN TAB 5MG Tier 3 Progestins - Hormone HCR Replacement/Modifying Drugs CAMILA TAB 0.35MG Preventative Progestins - Hormone Replacement/Modifying Drugs CRINONE GEL 4% VAG Tier 2

Page 301 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Progestins - Hormone Replacement/Modifying Drugs CRINONE GEL 8% VAG Tier 2 Progestins - Hormone HCR Replacement/Modifying Drugs DEBLITANE TAB 0.35MG Preventative Progestins - Hormone Replacement/Modifying Drugs DEPO-PROVERA INJ 150MG/ML Tier 3 X Progestins - Hormone Replacement/Modifying Drugs DEPO-SQ PROV INJ 104 Tier 2 X Progestins - Hormone HCR Replacement/Modifying Drugs ECONTRA EZ TAB 1.5MG Preventative Progestins - Hormone Replacement/Modifying Drugs ENDOMETRIN SUP 100MG Tier 3 Progestins - Hormone HCR Replacement/Modifying Drugs ERRIN TAB 0.35MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs FALLBACK TAB 1.5MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs HEATHER TAB 0.35MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs JENCYCLA TAB 0.35MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs JOLIVETTE TAB 0.35MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs LEVONORGESTR TAB 0.75MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs LEVONORGESTR TAB 1.5MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs LYZA TAB 0.35MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs MEDROXYPR AC INJ 150MG/ML Preventative X Progestins - Hormone Replacement/Modifying Drugs MEDROXYPR AC TAB 10MG Tier 1 Progestins - Hormone Replacement/Modifying Drugs MEDROXYPR AC TAB 2.5MG Tier 1 Progestins - Hormone Replacement/Modifying Drugs MEDROXYPR AC TAB 5MG Tier 1 Progestins - Hormone Replacement/Modifying Drugs MEGACE ES SUS 625/5ML Tier 3 Progestins - Hormone Replacement/Modifying Drugs MEGACE ORAL SUS 40MG/ML Tier 3 Progestins - Hormone Replacement/Modifying Drugs MEGESTROL SUS 625MG/5M Tier 1 Progestins - Hormone Replacement/Modifying Drugs MEGESTROL AC SUS 40MG/ML Tier 1 Progestins - Hormone Replacement/Modifying Drugs MEGESTROL AC TAB 20MG Tier 1 Progestins - Hormone Replacement/Modifying Drugs MEGESTROL AC TAB 40MG Tier 1 Progestins - Hormone HCR Replacement/Modifying Drugs MY WAY TAB 1.5MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs NECON TAB 1/50-28 Preventative Progestins - Hormone HCR Replacement/Modifying Drugs NEXT CHOICE TAB 1.5MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs NORA-BE TAB 0.35MG Preventative

Page 302 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Progestins - Hormone Replacement/Modifying Drugs NORETHIN ACE TAB 5MG Tier 1 Progestins - Hormone HCR Replacement/Modifying Drugs NORETHINDRON TAB 0.35MG Preventative Progestins - Hormone Replacement/Modifying Drugs NORINYL TAB 1+50-28 Tier 3 Progestins - Hormone HCR Replacement/Modifying Drugs NORLYROC TAB 0.35MG Preventative Progestins - Hormone Replacement/Modifying Drugs NOR-QD TAB 0.35MG Tier 3 Progestins - Hormone HCR Replacement/Modifying Drugs OPCICON TAB 1.5MG Preventative Progestins - Hormone Replacement/Modifying Drugs ORTHO MICRON TAB 0.35MG Tier 3 Progestins - Hormone HCR Replacement/Modifying Drugs PLAN B TAB 1.5MG Preventative Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE CAP 100MG Tier 1 Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE CAP 200MG Tier 1 Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE CRE 10% KIT Tier 3 X Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE INJ 50MG/ML Tier 1 Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE POW MICRONIZ Tier 3 Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE SUP VGS 100 Tier 3 X Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE SUP VGS 200 Tier 3 X Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE SUP VGS 25 Tier 3 X Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE SUP VGS 400 Tier 3 X Progestins - Hormone Replacement/Modifying Drugs PROGESTERONE SUP VGS 50 Tier 3 X Progestins - Hormone Replacement/Modifying Drugs PROMETRIUM CAP 100MG Tier 3 Progestins - Hormone Replacement/Modifying Drugs PROMETRIUM CAP 200MG Tier 3 Progestins - Hormone Replacement/Modifying Drugs PROVERA TAB 10MG Tier 3 Progestins - Hormone Replacement/Modifying Drugs PROVERA TAB 2.5MG Tier 3 Progestins - Hormone Replacement/Modifying Drugs PROVERA TAB 5MG Tier 3 Progestins - Hormone HCR Replacement/Modifying Drugs REACT TAB 1.5MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs SHAROBEL TAB 0.35MG Preventative Progestins - Hormone HCR Replacement/Modifying Drugs TAKE ACTION TAB 1.5MG Preventative Protectants - Ulcer and Stomach Acid Drugs CARAFATE SUS 1GM/10ML Tier 3 Protectants - Ulcer and Stomach Acid Drugs CARAFATE TAB 1GM Tier 3

Page 303 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Protectants - Ulcer and Stomach Acid Drugs CYTOTEC TAB 100MCG Tier 3 Protectants - Ulcer and Stomach Acid Drugs CYTOTEC TAB 200MCG Tier 3 Protectants - Ulcer and Stomach Acid Drugs MISOPROSTOL TAB 100MCG Tier 1 Protectants - Ulcer and Stomach Acid Drugs MISOPROSTOL TAB 200MCG Tier 1 Protectants - Ulcer and Stomach Acid Drugs SUCRALFATE TAB 1GM Tier 1 Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs ACIPHEX TAB 20MG Tier 3 X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs ACIPHEX SPR CAP 10MG Tier 3 X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs ACIPHEX SPR CAP 5MG Tier 3 X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs DEXILANT CAP 30MG DR Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs DEXILANT CAP 60MG DR Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs FIRST-OMEPRA SUS 2MG/ML Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs LANSOPRAZOLE SUS 3MG/ML Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs NEXIUM GRA 10MG DR Tier 3 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs NEXIUM GRA 2.5MG DR Tier 3 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs NEXIUM GRA 20MG DR Tier 3 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs NEXIUM GRA 40MG DR Tier 3 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs NEXIUM GRA 5MG DR Tier 3 X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs OMEPRA/BICAR POW 20-1680 Tier 1 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs OMEPRA/BICAR POW 40-1680 Tier 1 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs OMEPRAZOLE CAP 10MG Tier 1 Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs OMEPRAZOLE CAP 20MG Tier 1 Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs OMEPRAZOLE CAP 40MG Tier 1 Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs OMEPRAZOLE + SUS SYRSPEND Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PANTOPRAZOLE TAB 20MG Tier 1 Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PANTOPRAZOLE TAB 40MG Tier 1 Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PREVACID TAB 15MG STB Tier 3 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PREVACID TAB 30MG STB Tier 3 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PRILOSEC POW 10MG Tier 3 X

Page 304 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PRILOSEC POW 2.5MG Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PROTONIX PAK Tier 3 X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PROTONIX TAB 20MG Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs PROTONIX TAB 40MG Tier 3 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs RABEPRAZOLE TAB 20MG Tier 1 X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs ZEGERID POW 20-1680 Tier 3 X X X Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs ZEGERID POW 40-1680 Tier 3 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ADCIRCA TAB 20MG Tier 3 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS TAB 0.5MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS TAB 1.5MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS TAB 1MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS TAB 2.5MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS TAB 2MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs LETAIRIS TAB 10MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs LETAIRIS TAB 5MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs OPSUMIT TAB 10MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ORENITRAM TAB 0.125MG Tier 3 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ORENITRAM TAB 0.25MG Tier 3 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ORENITRAM TAB 1MG Tier 3 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs ORENITRAM TAB 2.5MG Tier 3 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs REVATIO SUS 10MG/ML Tier 3 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs REVATIO TAB 20MG Tier 3 X X X X Pulmonary Antihypertensives - Asthma/Lung Drugs SILDENAFIL TAB 20MG Tier 1 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs TRACLEER TAB 125MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs TRACLEER TAB 62.5MG Tier 2 X X X Pulmonary Antihypertensives - Asthma/Lung Drugs TYVASO SOL 0.6MG/ML Tier 2 X X Pulmonary Antihypertensives - Asthma/Lung Drugs TYVASO REFIL SOL 0.6MG/ML Tier 2 X X Pulmonary Antihypertensives - Asthma/Lung Drugs TYVASO START SOL 0.6MG/ML Tier 2 X X

Page 305 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Pulmonary Antihypertensives - Asthma/Lung Drugs VENTAVIS SOL 10MCG/ML Tier 2 X X Pulmonary Antihypertensives - Asthma/Lung Drugs VENTAVIS SOL 20MCG/ML Tier 2 X X Quinolones - Antibiotics AVELOX TAB 400MG Tier 3 X Quinolones - Antibiotics AVELOX ABC TAB 400MG Tier 3 X Quinolones - Antibiotics BESIVANCE SUS 0.6% Tier 3 Quinolones - Antibiotics CETRAXAL SOL 0.2% Tier 3 Quinolones - Antibiotics CILOXAN OIN 0.3% OP Tier 3 Quinolones - Antibiotics CILOXAN SOL 0.3% OP Tier 3 Quinolones - Antibiotics CIPRO TAB 250MG Tier 3 Quinolones - Antibiotics CIPRO TAB 500MG Tier 3 Quinolones - Antibiotics CIPRO (10%) SUS 500MG/5 Tier 3 Quinolones - Antibiotics CIPRO (5%) SUS 250MG/5 Tier 3 Quinolones - Antibiotics CIPRO HC SUS OTIC Tier 3 Quinolones - Antibiotics CIPRO XR TAB 1000MG Tier 3 Quinolones - Antibiotics CIPRO XR TAB 500MG Tier 3 Quinolones - Antibiotics CIPRODEX SUS 0.3-0.1% Tier 2 Quinolones - Antibiotics CIPROFLOXACN SOL 0.2% Tier 1 Quinolones - Antibiotics CIPROFLOXACN SOL 0.3% OP Tier 1

Quinolones - Antibiotics CIPROFLOXACN SUS 250MG/5 Tier 1

Quinolones - Antibiotics CIPROFLOXACN SUS 500MG/5 Tier 1 Quinolones - Antibiotics CIPROFLOXACN TAB 1000MG Tier 1 Quinolones - Antibiotics CIPROFLOXACN TAB 100MG Tier 1 Quinolones - Antibiotics CIPROFLOXACN TAB 250MG Tier 1 Quinolones - Antibiotics CIPROFLOXACN TAB 500MG Tier 1

Quinolones - Antibiotics CIPROFLOXACN TAB 500MG ER Tier 1 Quinolones - Antibiotics CIPROFLOXACN TAB 750MG Tier 1 Quinolones - Antibiotics FACTIVE TAB 320MG Tier 3 Quinolones - Antibiotics FLOXIN SOL 0.3% Tier 3 X Quinolones - Antibiotics GATIFLOXACIN SOL 0.5% Tier 1 X Quinolones - Antibiotics LEVAQUIN SOL 25MG/ML Tier 3 Quinolones - Antibiotics LEVAQUIN TAB 250MG Tier 3 Quinolones - Antibiotics LEVAQUIN TAB 500MG Tier 3 Quinolones - Antibiotics LEVAQUIN TAB 750MG Tier 3 Quinolones - Antibiotics LEVOFLOXACIN SOL 0.5% Tier 1

Quinolones - Antibiotics LEVOFLOXACIN SOL 25MG/ML Tier 1 Quinolones - Antibiotics LEVOFLOXACIN TAB 250MG Tier 1 Quinolones - Antibiotics LEVOFLOXACIN TAB 500MG Tier 1 Quinolones - Antibiotics LEVOFLOXACIN TAB 750MG Tier 1 Quinolones - Antibiotics MOXEZA SOL 0.5% Tier 3 Quinolones - Antibiotics MOXIFLOXACIN TAB 400MG Tier 1 Quinolones - Antibiotics OCUFLOX DRO 0.3% OP Tier 3 Quinolones - Antibiotics OFLOXACIN DRO 0.3% OP Tier 1 Quinolones - Antibiotics OFLOXACIN DRO 0.3%OTIC Tier 1 Quinolones - Antibiotics OFLOXACIN TAB 400MG Tier 1 Quinolones - Antibiotics VIGAMOX DRO 0.5% Tier 3 Quinolones - Antibiotics ZYMAXID SOL 0.5% Tier 3 X Respiratory Tract Agents, Other - Asthma/Lung Drugs ACETYLCYST SOL 10% Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs ACETYLCYST SOL 20% Tier 1

Page 306 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Respiratory Tract Agents, Other - Asthma/Lung Drugs AMBITUSSIN SOL 100-10/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs BENZONATATE CAP 100MG Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs BENZONATATE CAP 150MG Tier 1 X Respiratory Tract Agents, Other - Asthma/Lung Drugs BENZONATATE CAP 200MG Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs BIOTUSS LIQ Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs BIOTUSS LIQ PEDIATRC Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs CHERATUSSIN SYP 100-10/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs CODEINE/GG SOL 10-100/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs DALIRESP TAB 500MCG Tier 3 X X Respiratory Tract Agents, Other - Asthma/Lung Drugs DECONSAL TAB L.A. Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs DECONSAL SR CAP SPRINKLE Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs DECONSAL-II TAB Tier 3 Respiratory Tract Agents, Other - DEXTROMETHOR CRY Asthma/Lung Drugs MONOHYDR Tier 3 X Respiratory Tract Agents, Other - Asthma/Lung Drugs DEXTROMETHOR POW HBR Tier 3 X Respiratory Tract Agents, Other - DEXTROMETHOR POW HBR Asthma/Lung Drugs MONO Tier 3 X Respiratory Tract Agents, Other - Asthma/Lung Drugs EXACTUSS LIQ Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs GG/CODEINE SOL 100-10/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs GILPHEX TR TAB 10-388MG Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs GILTUSS LIQ Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs GILTUSS PED LIQ Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs GILTUSS TR TAB Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs GUAIATUSSIN SYP 100-10/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs GUAIFENESIN SYP 100-10/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs HUMIBID L.A. TAB 600MG Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs HUMIBID SPRI CAP 300MG Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs HUMIBID-DM TAB Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs HYDROC/HOMAT TAB 5-1.5MG Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs HYDROCOD/HOM SYP 5-1.5/5 Tier 1

Page 307 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Respiratory Tract Agents, Other - Asthma/Lung Drugs HYDROMET SYP 5-1.5/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs HYPERSAL NEB 3.5% Tier 2 Respiratory Tract Agents, Other - Asthma/Lung Drugs HYPERSAL NEB 7% Tier 2 Respiratory Tract Agents, Other - Asthma/Lung Drugs HYPER-SAL NEB 7% Tier 2 Respiratory Tract Agents, Other - Asthma/Lung Drugs IOPHEN C-NR LIQ 100-10/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs KALYDECO PAK 50MG Tier 2 X X X Respiratory Tract Agents, Other - Asthma/Lung Drugs KALYDECO PAK 75MG Tier 2 X X X Respiratory Tract Agents, Other - Asthma/Lung Drugs KALYDECO TAB 150MG Tier 2 X X X Respiratory Tract Agents, Other - Asthma/Lung Drugs NEBUSAL NEB 3% Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs NEBUSAL NEB 6% Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs NORTUSS-DE DRO Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs NORTUSS-EX LIQ 200-20/5 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs PE/GUAIFENES DRO 1.5-20MG Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs PULMOSAL NEB 7% Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs PULMOZYME SOL 1MG/ML Tier 2 X X X Respiratory Tract Agents, Other - Asthma/Lung Drugs Q-BID-LA TAB 600MG Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs REZIRA SOL 60-5/5ML Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs SOD CHLORIDE NEB 0.9% Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs SODIUM CHLOR NEB 10% Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs SODIUM CHLOR NEB 3% Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs SODIUM CHLOR NEB 7% Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs SURVANTA INH Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs TESSALON PER CAP 100MG Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs TGQ 30/ SYP 150/15 Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs TUSSIGON TAB 5-1.5MG Tier 1 Respiratory Tract Agents, Other - Asthma/Lung Drugs TYZINE SOL 0.1% Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs TYZINE PED DRO 0.05% Tier 3 Respiratory Tract Agents, Other - Asthma/Lung Drugs VIRTUSSIN AC SOL 100-10/5 Tier 1

Page 308 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Respiratory Tract Agents, Other - Asthma/Lung Drugs ZONATUSS CAP 150MG Tier 1 X

Retinoids - Chemotherapy Agents BEXAROTENE CAP 75MG Tier 3 X X

Retinoids - Chemotherapy Agents PANRETIN GEL 0.1% Tier 3

Retinoids - Chemotherapy Agents TARGRETIN CAP 75MG Tier 1 X

Retinoids - Chemotherapy Agents TARGRETIN GEL 1% Tier 3 X X

Retinoids - Chemotherapy Agents TRETINOIN CAP 10MG Tier 1 X X Selective Estrogen Receptor Modifying Agents - Hormone HCR Replacement/Modifying Drugs EVISTA TAB 60MG Preventative X Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs OSPHENA TAB 60MG Tier 3 Selective Estrogen Receptor Modifying Agents - Hormone HCR Replacement/Modifying Drugs RALOXIFENE TAB 60MG Preventative

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ALMOTRIP MAL TAB 12.5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ALMOTRIP MAL TAB 6.25MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ALMOTRIPTAN TAB 12.5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ALSUMA INJ 6MG/0.5 Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs AMERGE TAB 1MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs AMERGE TAB 2.5MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs AXERT TAB 12.5MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs AXERT TAB 6.25MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs FROVA TAB 2.5MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs FROVATRIPTAN TAB 2.5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX INJ 4MG/0.5 Tier 3 X X

Page 309 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX INJ 4MG/0.5 Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX INJ 6MG/0.5 Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX INJ 6MG/0.5 Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX INJ 6MG/0.5 Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX SPR 20MG/ACT Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX SPR 5MG/ACT Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX TAB 100MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX TAB 25MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs IMITREX TAB 50MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs MAXALT TAB 10MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs MAXALT TAB 5MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs MAXALT-MLT TAB 10MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs MAXALT-MLT TAB 5MG Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs NARATRIPTAN TAB 1MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs NARATRIPTAN TAB 2.5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ONZETRA XSAI MIS 11MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs RELPAX TAB 20MG Tier 2 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs RELPAX TAB 40MG Tier 2 X

Page 310 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs RIZATRIPTAN TAB 10MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs RIZATRIPTAN TAB 10MG ODT Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs RIZATRIPTAN TAB 5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs RIZATRIPTAN TAB 5MG ODT Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN INJ 4MG/0.5 Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN INJ 4MG/0.5 Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN INJ 6MG/0.5 Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN INJ 6MG/0.5 Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN INJ 6MG/0.5 Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN INJ 6MG/0.5 Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN SPR 20MG/ACT Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN SPR 5MG/ACT Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN TAB 100MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN TAB 25MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMATRIPTAN TAB 50MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMAVEL DOSE INJ 4MG/0.5 Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs SUMAVEL DOSE INJ 6MG/0.5 Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZECUITY PAD 6.5MG/4H Tier 3 X X

Page 311 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZEMBRACE SYM INJ 3/0.5ML Tier 3 X X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOLMITRIPTAN TAB 2.5 MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOLMITRIPTAN TAB 2.5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOLMITRIPTAN TAB 5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOLMITRIPTAN TAB 5MG Tier 1 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOMIG SPR 2.5MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOMIG TAB 2.5MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOMIG TAB 5MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOMIG NASAL SPR 5MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOMIG ZMT TAB 2.5 MG Tier 3 X

Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs ZOMIG ZMT TAB 5MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants BRISDELLE CAP 7.5MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CELEXA TAB 10MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CELEXA TAB 20MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CELEXA TAB 40MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CITALOPRAM SOL 10MG/5ML Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CITALOPRAM TAB 10MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CITALOPRAM TAB 20MG Tier 1

Page 312 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CITALOPRAM TAB 40MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CYMBALTA CAP 20MG Tier 3 X X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CYMBALTA CAP 30MG Tier 3 X X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants CYMBALTA CAP 60MG Tier 3 X X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DESVENLAFAX TAB 100MG ER Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DESVENLAFAX TAB 100MG ER Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DESVENLAFAX TAB 50MG ER Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DESVENLAFAX TAB 50MG ER Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DULOXETINE CAP 20MG Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DULOXETINE CAP 30MG Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DULOXETINE CAP 40MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants DULOXETINE CAP 60MG Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants EFFEXOR XR CAP 150MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants EFFEXOR XR CAP 37.5MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants EFFEXOR XR CAP 75MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ESCITALOPRAM SOL 5MG/5ML Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ESCITALOPRAM TAB 10MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ESCITALOPRAM TAB 20MG Tier 1

Page 313 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ESCITALOPRAM TAB 5MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FETZIMA CAP 120MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FETZIMA CAP 20MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FETZIMA CAP 40MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FETZIMA CAP 80MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FETZIMA CAP TITRATIO Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE CAP 10MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE CAP 10MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE CAP 20MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE CAP 20MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE CAP 40MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE CAP 90MG DR Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE SOL 20MG/5ML Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE TAB 10MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE TAB 20MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUOXETINE TAB 60MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUVOXAMINE CAP 100MG ER Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUVOXAMINE CAP 150MG ER Tier 1 X

Page 314 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUVOXAMINE TAB 100MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUVOXAMINE TAB 25MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants FLUVOXAMINE TAB 50MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants IRENKA CAP 40MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants KHEDEZLA TAB 100MG ER Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants KHEDEZLA TAB 50MG ER Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants LEXAPRO SOL 5MG/5ML Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants LEXAPRO TAB 10MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants LEXAPRO TAB 20MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants LEXAPRO TAB 5MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAROXETIN ER TAB 12.5MG Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAROXETIN ER TAB 37.5MG Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAROXETINE TAB 10MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAROXETINE TAB 20MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAROXETINE TAB 25MG ER Tier 1 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAROXETINE TAB 30MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAROXETINE TAB 40MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL SUS 10MG/5ML Tier 3

Page 315 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL TAB 10MG Tier 3

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL TAB 20MG Tier 3

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL TAB 30MG Tier 3

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL TAB 40MG Tier 3

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL CR TAB 12.5MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL CR TAB 25MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PAXIL CR TAB 37.5MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PEXEVA TAB 10MG Tier 3 X X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PEXEVA TAB 20MG Tier 3 X X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PEXEVA TAB 30MG Tier 3 X X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PEXEVA TAB 40MG Tier 3 X X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PRISTIQ TAB 100MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PRISTIQ TAB 25MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PRISTIQ TAB 50MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PROZAC CAP 10MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PROZAC CAP 20MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PROZAC CAP 40MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants PROZAC WEEKL CAP 90MG Tier 3 X X

Page 316 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants SARAFEM TAB 10MG Tier 3

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants SARAFEM TAB 20MG Tier 3

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants SERTRALINE CON 20MG/ML Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants SERTRALINE TAB 100MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants SERTRALINE TAB 25MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants SERTRALINE TAB 50MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE CAP 150MG ER Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE CAP 37.5 ER Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE CAP 75MG ER Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 100MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 150MG ER Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 225MG ER Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 25MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 37.5 ER Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 37.5MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 50MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 75MG Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VENLAFAXINE TAB 75MG ER Tier 3 X X

Page 317 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VIIBRYD KIT Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VIIBRYD KIT STARTER Tier 3

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VIIBRYD TAB 10MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VIIBRYD TAB 20MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants VIIBRYD TAB 40MG Tier 3 X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ZOLOFT CON 20MG/ML Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ZOLOFT TAB 100MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ZOLOFT TAB 25MG Tier 3 X X

Serotonin/Norepinephrine Reuptake Inhibitors - Antidepressants ZOLOFT TAB 50MG Tier 3 X X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs AMRIX CAP 15MG Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs AMRIX CAP 30MG Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs BACLOFEN CRE Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs BACLOFEN CRE 1% Tier 1 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs BACLOFEN CRE 2% Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CARISOPR/ASA TAB 200-325 Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CARISOPRODOL TAB 250MG Tier 1 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CARISOPRODOL TAB 350MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CHLORZOXAZON TAB 250MG Tier 1

Page 318 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CHLORZOXAZON TAB 500MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CYCLOBENZAPR CRE 20MG/GM Tier 1 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CYCLOBENZAPR CRE 5% KIT Tier 1 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CYCLOBENZAPR KIT COMFORT Tier 3

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CYCLOBENZAPR TAB 10MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CYCLOBENZAPR TAB 5MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CYCLOBENZAPR TAB 7.5MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs CYCLOPHENE CRE RAPIDPAQ Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs FEXMID TAB 7.5MG Tier 3

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs LORZONE TAB 375MG Tier 3 X X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs LORZONE TAB 750MG Tier 3 X X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs METAXALL TAB 800MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs METAXALONE TAB 400MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs METAXALONE TAB 800MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs METHOCARBAM TAB 500MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs METHOCARBAM TAB 750MG Tier 1

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs ORPHENADRINE POW CITRATE Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs ORPHENADRINE TAB 100MG ER Tier 1

Page 319 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs PARAFON FORT TAB 500MG Tier 3

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs ROBAXIN TAB 500MG Tier 3

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs ROBAXIN-750 TAB 750MG Tier 3

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs SKELAXIN TAB 800MG Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs SOMA TAB 250MG Tier 3 X

Skeletal Muscle Relaxants - Pain/Swelling Management Drugs SOMA TAB 350MG Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS PETROLATUM OIN WHITE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS VERSABASE GEL Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIBACTERIALS ANTI- INFECTIVES BL TRIP ANTI OIN W/LID 4% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIBACTERIALS ANTI- INFECTIVES ROSADAN KIT 0.75% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTIBACTERIALS ANTI- INFECTIVES ROSADAN KIT 0.75% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES EXODERM LOT 25-1% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES HALOTIN CRE 1% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES KERR TRIPLE MIS DYE SWAB Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES MICONAZOLE POW NITRATE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES VUSION OIN Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES XOLEGEL KIT COREPAK Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES XOLEGEL DUO/ KIT HEAD&SHD Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIFUNGALS ANTI- INFECTIVES XOLEGEL DUO/ KIT XOLEX Tier 3

Page 320 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM KIT ADVANCED Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM E KIT Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM HC CRE 2.5-1% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM-HC CRE 1-1% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM-HC CRE 1-2.5% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM-HC CRE SINGLES Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM-HC CRE SINGLES Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRAM-HC LOT 2.5% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANALPRM SNGL CRE HC 2.5-1 Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANUCORT-HC SUP 25MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ANUSOL-HC SUP 25MG Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) CORTANE-B LOT Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) EPIFOAM AER 1% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) GRX HICORT SUP 25MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HALAC KIT Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HC PRAMOXINE CRE 1-1% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HC PRAMOXINE CRE 2.5-1% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HC PRAMOXINE CRE 2.5-1% Tier 1

Page 321 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HEMMOREX-HC SUP 25MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HEMMOREX-HC SUP 30MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HEMORRHOIDAL SUP -HC 25MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HYDROCORT AC SUP 25MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HYDROCORT AC SUP 30MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) HYDROCORT/ KIT PRAMOXIN Tier 1 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) NUCORT LOT 2% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PEDIADERM HC KIT Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMCORT CRE 1-1% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE CRE 1% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE CRE 1-1% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE CRE 1-2.5% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE LOT 1% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE LOT 2.5% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE OIN 1% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE OIN 2.5% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOSONE E CRE 1-2.5% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PRAMOX GEL 1% Tier 1

Page 322 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PROCORT CRE Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PROCTOCORT SUP 30MG Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) PROCTOFOAM AER HC 1% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) RECTACORT-HC SUP 25MG Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SCALACORT DK KIT Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) SYNALAR TS KIT 0.01% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ULTRAVATE X KIT 0.05-10% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) ULTRAVATE X KIT 0.05-10% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) VANOXIDE-HC LOT 5-0.5% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS ANACAINE OIN Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS CETACAINE AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS DERMASORB TA KIT 0.1% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS ETHYL CHLOR AER FINE PIN Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS ETHYL CHLOR AER FN STRM Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS ETHYL CHLOR AER MED JET Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS ETHYL CHLOR AER MED STRM Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS ETHYL CHLOR AER MIST Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS ETHYL CHLOR AER SPRAY Tier 1

Page 323 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS GEBAUERS SPR AER /STRETCH Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS PAIN EASE AER MD STRM Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS PAIN EASE AER MIST Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS PEDIADERM TA KIT Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS QUTENZA KIT 8% 1-PCH Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ANTIPRURITICS AND LOCAL ANESTHETICS QUTENZA KIT 8% 2-PCH Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - ASTRINGENTS VENELEX OIN Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - ASTRINGENTS XERAC-AC SOL 6.25% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS COPASIL GEL Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS HPR PLUS MB KIT HYDROGEL Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS HYALURONATE GEL 0.2% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS HYLIRA GEL 0.2% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS HYLIRA LOT 0.1% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS LACTIC ACID CRE /VIT E Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS LACTIC ACID CRE E Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS NEOSALUS LOT Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - BASIC OINTMENTS AND PROTECTANTS TROPAZONE LOT Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - DEPIGMENTING AND PIGMENTING AGENTS HYDROQUINONE POW Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS ALUVEA CRE 39% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS BENSAL HP OIN Tier 2

Page 324 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS CARB-O-PHILC CRE /40 Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS CARB-O-PHILC GEL 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS CEM-UREA SOL 45% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS CEROVEL GEL 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS CEROVEL LOT 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS DERMASORB XM KIT 39% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS GORDOFILM SOL Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS GORDONS UREA OIN 40% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS HYDRO 35 AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS HYDRO 40 AER FOAM Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS KERALAC CRE 47% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS KERALYT GEL 6% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS KERALYT KIT SCALP 6% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS LATRIX SUS 50% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS LATRIX XM EMU 45% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS NA HYDROXIDE SOL 10% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS POT HYDROXID SOL 5% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS REA LO 39 CRE 39% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS REA LO 40 CRE 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS REA LO 40 LOT 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS REMEVEN CRE 50% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALACYN CRE 6% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALACYN LOT 6% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALICYLIC AER 6% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALICYLIC AC CRE 6% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALICYLIC AC GEL 6% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALICYLIC AC LIQ 26% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALICYLIC AC LOT 6% Tier 1

Page 325 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS SALVAX AER 6% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UMECTA EMU Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UMECTA MOUSS AER 40% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UMECTA NAIL SUS FILM Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UMECTA PD EMU 40-0.3% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UMECTA PD SUS 40-0.3% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS URAMAXIN AER 20% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS URAMAXIN CRE 45% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS URAMAXIN GEL 45% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS URAMAXIN LOT 45% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS URAMAXIN GT GEL 45% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS URAMAXIN GT KIT 45% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA CRE 39% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA CRE 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA CRE 45% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA CRE 47% Tier 1 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA CRE 50% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA EMU 50% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA GEL 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA LOT 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA LOT 45% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA SUS 50% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA 40% SUS NAIL Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA HYDRATI AER 35% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA NAIL GEL 45% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA NAIL KIT Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA NAIL MIS 50% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA TOPICAL SUS 40% Tier 1

Page 326 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UREA-C40 LOT 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS URE-K CRE 50% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS UTOPIC CRE 41% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS X-VIATE CRE 40% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS X-VIATE GEL 40% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - KERATOLYTIC AGENTS X-VIATE LOT 40% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS AVAR PAD 9.5-5% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS AVAR CLEANSE EMU 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS AVAR LS LIQ 10-2% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS AVAR LS PAD 10-2% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS AVAR-E EMOLL CRE 10-5% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS AVAR-E GREEN CRE 10-5% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS AVAR-E LS CRE 10-2% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS BENZIQ GEL 5.25% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS BENZIQ LS GEL 2.75% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS BENZIQ WASH LIQ 5.25% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS BP 10-1 EMU Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS BP CLEANSING EMU 10-4% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS CERISA WASH EMU 10-1% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS CLARIFOAM EF AER 10-5% Tier 3 X

Page 327 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS CLARIS WASH EMU 10-4% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS COAL TAR SOL 20% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS DRITHO-CREME CRE HP 1% Tier 2

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS INOVA KIT 4% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS INOVA KIT 8% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS INOVA 4/1 KIT ACNE CON Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS INOVA 8/2 KIT ACNE CON Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS NUOX GEL 6-3% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS OSCION CLNSR LOT 6% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS PLEXION CRE 9.8-4.8% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS PLEXION LIQ 9.8-4.8% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS PLEXION LOT 9.8-4.8% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS PLEXION CLTH PAD 9.8-4.8% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS PRASCION EMU Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS PRASCION RA CRE 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS ROSANIL EMU CLEANSER Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF CRE 10-2% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF CRE 10-5% Tier 1

Page 328 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF CRE 9.8-4.8% Tier 1 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF EMU 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF EMU 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF GEL 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF KIT Tier 1 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF LIQ 10-2% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF LIQ 9.8-4.8% Tier 1 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF LIQ 9-4.5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF LIQ WASH Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF LOT 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF LOT 9.8-4.8% Tier 1 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF PAD 10-4% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF SUS 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SOD SUL/SULF SUS 8-4% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SS 10-2 SOL 10-2% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SSS CRE 10%-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SSS 10-5 AER 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUL SOD/SULF LIQ 10-2% Tier 1

Page 329 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUL SOD/SULF PAD 10-4% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SULF/SUNSCRN KIT 9-4.5% Tier 1 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SULFACLEANSE SUS 8-4% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SULFOAM SHA 2% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUMADAN KIT Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUMADAN WASH LIQ 9-4.5% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUMADAN XLT KIT 9-4.5% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUMAXIN PAD 10-4% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUMAXIN CP KIT Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUMAXIN TS SUS 8-4% Tier 3 X

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS SUMAXIN WASH LIQ 9-4% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS VIRTI-SULF CRE 10-5% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS ZACARE KIT KIT 4% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS ZACARE KIT KIT 8% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS ZACLIR LOT 8% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS ZENCIA LIQ 9-4% Tier 1

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS ZITHRANOL SHA 1% Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - KERATOPLASTIC AGENTS ZITHRANOL-RR CRE 1.2% Tier 3

Page 330 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) ARZOL SILVER MIS NITR APP Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) DERMAZENE CRE 1% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) GRAFCO SILVR MIS NIT APPL Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) HYDROCORT/ CRE IODOQUIN Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) LOUTREX CRE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) OVACE PLUS CRE 10% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) OVACE PLUS GEL 10% WASH Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) OVACE PLUS LIQ 10% WASH Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) OVACE PLUS LOT 9.8% Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) OVACE PLUS SHA 10% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) OVACE WASH LIQ 10% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) PROMISEB CRE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) PROMISEB KIT COMPLETE Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SEB-PREV LIQ WASH Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SELENIUM SUL SHA 2.25% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SILVER NITRA OIN 10% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SILVER NITRA SOL 0.5% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SILVER NITRA SOL 10% Tier 1

Page 331 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SILVER NITRA SOL 25% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SILVER NITRA SOL 50% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SOD SULFACET GEL 10% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SOD SULFACET SHA 10% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SODIUM SULFA LIQ 10% WASH Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) TL TRISEB CRE Tier 3

SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES (SKIN & MUCOUS) SODIUM SULFA LIQ 10% WASH Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS ANASEPT SPR Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS BENZALKONIUM SOL 50% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS BENZALKONIUM SOL NF Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS BORIC ACID GRA Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS BUCALSEP SOL Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - LOCAL ANTI-INFECTIVES, MISCELLANEOUS BUCALSEP SPR Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS ATOPICLAIR CRE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS AURSTAT KIT HYDROGEL Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS AURSTAT ANTI GEL -ITCH Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS BENZOIN TIN NF Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS BENZOIN CMPD TIN Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS CERACADE EMU Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS DEBACTEROL SOL 30-50% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS DRYSOL SOL 20% Tier 3

Page 332 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS ELETONE CRE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS ELETONE CRE TWINPACK Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS EMULSION SB EMU Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS EPICERAM EMU Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS EPISONE CRE Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS ESSENTRA MIS 9X9" Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS FORMADON SOL Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS FORMALDEHYDE SOL 10% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS FORMALDEHYDE SOL 37% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS FORMA-RAY SOL 20% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS GENADUR KIT Tier 3 X SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS GENADUR LIQ Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS GRANULEX AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HPR AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HPR PLUS AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HPR PLUS CRE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HPR PLUS KIT Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HYLATOPIC AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HYLATOPIC AER PLUS Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HYLATOPIC CRE PLUS Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS HYPERCARE SOL 20% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS MB HYDROGEL KIT Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS MEDI-DERM CRE -RX Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS MEDROX-RX OIN Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS METHYL SALIC LIQ Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS NEOSALUS AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS NEOSALUS CRE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS NEOSALUS CP CRE Tier 3

Page 333 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS NIVATOPIC CRE PLUS Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS NUVAIL SOL 16% Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS PR CREAM KIT Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS PRESERA AER Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS PRUCLAIR CRE Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS PRUMYX CRE Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS PYROGALL ACD OIN Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS SALICYLIC AC AER 6% Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS SALVAX DUO KIT PLUS Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS TBC AER Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS TRI-CHLOR LIQ 80% Tier 2 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS TURPENTINE SOL SPIRITS Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS VASOLEX OIN Tier 1 SKIN AND MUCOUS MEMBRANE AGENTS - MISCELLANEOUS XERALUX CRE Tier 3 SKIN AND MUCOUS MEMBRANE AGENTS - SCABICIDES SULF LIME SOL Tier 3 Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs ARMODAFINIL TAB 150MG Tier 1 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs ARMODAFINIL TAB 200MG Tier 1 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs ARMODAFINIL TAB 250MG Tier 1 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs ARMODAFINIL TAB 50MG Tier 1 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs BUTISOL SOD TAB 30MG Tier 3 Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs BUTISOL SOD TAB 50MG Tier 3 Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs MODAFINIL TAB 100MG Tier 1 X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs MODAFINIL TAB 200MG Tier 1 X X

Page 334 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs NUVIGIL TAB 150MG Tier 3 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs NUVIGIL TAB 200MG Tier 3 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs NUVIGIL TAB 250MG Tier 3 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs NUVIGIL TAB 50MG Tier 3 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs PROVIGIL TAB 100MG Tier 3 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs PROVIGIL TAB 200MG Tier 3 X X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs ROZEREM TAB 8MG Tier 3 X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs SECONAL CAP 100MG Tier 3 Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs SECONAL SOD CAP 100MG Tier 3 Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs SILENOR TAB 3MG Tier 3 X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs SILENOR TAB 6MG Tier 3 X X Sleep Disorders, Other - Miscellaneous Sedation and Sleep Drugs XYREM SOL 500MG/ML Tier 3 X X X Smoking Cessation Agents - HCR Deterrents BUPROBAN TAB 150MG Preventative X Smoking Cessation Agents - HCR Deterrents BUPROPION TAB 150MG Preventative X Smoking Cessation Agents - HCR Deterrents CHANTIX PAK 0.5& 1MG Preventative X Smoking Cessation Agents - HCR Deterrents CHANTIX PAK 1MG Preventative X Smoking Cessation Agents - HCR Deterrents CHANTIX TAB 0.5MG Preventative X Smoking Cessation Agents - HCR Deterrents CHANTIX TAB 1MG Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 2MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 2MG MINT Preventative X

Page 335 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 2MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 4MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE GUM 4MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE LOZ 2MG Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents CVS NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents CVS NTS DIS STEP 1 Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 2MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 2MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 4MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 4MG REF Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 4MG STRT Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE GUM 4MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE LOZ 2MG CHER Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE LOZ 4MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents EQ NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents EQL NICOTINE GUM 2MG Preventative X

Page 336 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Smoking Cessation Agents - HCR Deterrents EQL NICOTINE GUM 2MG REF Preventative X Smoking Cessation Agents - HCR Deterrents EQL NICOTINE GUM 2MG STRT Preventative X Smoking Cessation Agents - HCR Deterrents EQL NICOTINE GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents EQL NICOTINE GUM 4MG REF Preventative X Smoking Cessation Agents - HCR Deterrents EQL NICOTINE GUM 4MG STRT Preventative X Smoking Cessation Agents - HCR Deterrents EQL NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents EQL NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents GNP NICOTINE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents GNP NICOTINE GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents GNP NICOTINE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents GNP NICOTINE GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents GNP NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents GNP NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents GNP NICOTINE LOZ MINI 2MG Preventative X Smoking Cessation Agents - HCR Deterrents HM NICOTINE DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents HM NICOTINE DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents HM NICOTINE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents HM NICOTINE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents HM NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents HM NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents KLS QUIT2 GUM 2MG Preventative X Smoking Cessation Agents - HCR Deterrents KLS QUIT2 LOZ 2MG Preventative X Smoking Cessation Agents - HCR Deterrents KLS QUIT4 GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents KLS QUIT4 LOZ 4MG Preventative X Smoking Cessation Agents - HCR Deterrents NICODERM CQ DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents NICODERM CQ DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents NICODERM CQ DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents NICORELIEF GUM 2MG MINT Preventative X

Page 337 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Smoking Cessation Agents - HCR Deterrents NICORELIEF GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICORELIEF GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICORELIEF GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 2MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 2MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 4MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE GUM 4MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE LOZ 2MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE LOZ 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE LOZ 4MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE LOZ 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE ST GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE ST GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICORETTE ST GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE GUM 2MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE LOZ 2MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE LOZ 4MG CHRY Preventative X

Page 338 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Smoking Cessation Agents - HCR Deterrents NICOTINE LOZ 4MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE LOZ MINI 2MG Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 2MG Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 2MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 2MG REF Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 2MG STRT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 2MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 4MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 4MG REF Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 4MG STRT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL GUM 4MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL LOZ 2MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL LOZ 2MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL LOZ 4MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL LOZ 4MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE POL LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE SYS KIT TRANSDER Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE TD DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE TD DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents NICOTINE TD DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents NICOTROL INH Preventative X

Page 339 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Smoking Cessation Agents - HCR Deterrents NICOTROL NS SPR 10MG/ML Preventative X Smoking Cessation Agents - HCR Deterrents QC NICOTINE GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE GUM 2MG Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE GUM 2MG CINN Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE GUM 2MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE GUM 4MG FRUT Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents RA NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE DIS 21MG Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE GUM 2MG Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents SM NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents STOP SMOKING GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents STOP SMOKING GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents STOP SMOKING GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents STOP SMOKING LOZ 2MG Preventative X

Page 340 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Smoking Cessation Agents - HCR Deterrents STOP SMOKING LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents STOP SMOKING LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents SW NICOTINE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents SW NICOTINE GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents SW NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents SW NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE DIS 14MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE DIS 21MG/24H Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE DIS 7MG/24HR Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE GUM 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE GUM 2MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE GUM 2MGFRUIT Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE GUM 4MG Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE GUM 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE GUM 4MG ORIG Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE LOZ 2MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE LOZ 2MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE LOZ 4MG CHRY Preventative X Smoking Cessation Agents - HCR Deterrents TGT NICOTINE LOZ 4MG MINT Preventative X Smoking Cessation Agents - HCR Deterrents THRIVE GUM 2MG MINT Preventative X Sodium Channel Agents - Seizure Control Drugs BANZEL SUS 40MG/ML Tier 3 Sodium Channel Agents - Seizure Control Drugs BANZEL TAB 200MG Tier 3 X Sodium Channel Agents - Seizure Control Drugs BANZEL TAB 400MG Tier 3 X Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN CAP 100MG ER Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN CAP 200MG ER Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN CAP 300MG ER Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN CHW 100MG Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN POW Tier 3 X

Page 341 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN SUS 100/5ML Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN TAB 100MGER Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN TAB 200MG Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN TAB 200MG ER Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBAMAZEPIN TAB 400MG ER Tier 1 Sodium Channel Agents - Seizure Control Drugs CARBATROL CAP 100MG Tier 3 Sodium Channel Agents - Seizure Control Drugs CARBATROL CAP 200MG Tier 3 Sodium Channel Agents - Seizure Control Drugs CARBATROL CAP 300MG Tier 3 Sodium Channel Agents - Seizure Control Drugs DILANTIN CAP 100MG Tier 3 Sodium Channel Agents - Seizure Control Drugs DILANTIN CAP 30MG Tier 3 Sodium Channel Agents - Seizure Control Drugs DILANTIN CHW 50MG Tier 3 Sodium Channel Agents - Seizure Control Drugs DILANTIN-125 SUS 125/5ML Tier 3 Sodium Channel Agents - Seizure Control Drugs EPITOL TAB 200MG Tier 1 Sodium Channel Agents - Seizure Control Drugs EQUETRO CAP 100MG Tier 3 Sodium Channel Agents - Seizure Control Drugs EQUETRO CAP 200MG Tier 3 Sodium Channel Agents - Seizure Control Drugs EQUETRO CAP 300MG Tier 3 Sodium Channel Agents - Seizure Control Drugs OXCARBAZEPIN SUS 300MG/5M Tier 1 Sodium Channel Agents - Seizure Control Drugs OXCARBAZEPIN TAB 150MG Tier 1 Sodium Channel Agents - Seizure Control Drugs OXCARBAZEPIN TAB 300MG Tier 1 Sodium Channel Agents - Seizure Control Drugs OXCARBAZEPIN TAB 600MG Tier 1 Sodium Channel Agents - Seizure Control Drugs OXTELLAR XR TAB 150MG Tier 3 X X Sodium Channel Agents - Seizure Control Drugs OXTELLAR XR TAB 300MG Tier 3 X X Sodium Channel Agents - Seizure Control Drugs OXTELLAR XR TAB 600MG Tier 3 X X Sodium Channel Agents - Seizure Control Drugs PEGANONE TAB 250MG Tier 2 Sodium Channel Agents - Seizure Control Drugs PHENYTEK CAP 200MG Tier 3 Sodium Channel Agents - Seizure Control Drugs PHENYTEK CAP 300MG Tier 3 Sodium Channel Agents - Seizure Control Drugs PHENYTOIN CHW 50MG Tier 1 Sodium Channel Agents - Seizure Control Drugs PHENYTOIN SUS 125/5ML Tier 1

Page 342 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Sodium Channel Agents - Seizure Control Drugs PHENYTOIN EX CAP 100MG Tier 1 Sodium Channel Agents - Seizure Control Drugs PHENYTOIN EX CAP 200MG Tier 1 Sodium Channel Agents - Seizure Control Drugs PHENYTOIN EX CAP 300MG Tier 1 Sodium Channel Agents - Seizure Control Drugs TEGRETOL SUS 100/5ML Tier 3 Sodium Channel Agents - Seizure Control Drugs TEGRETOL TAB 200MG Tier 3 Sodium Channel Agents - Seizure Control Drugs TEGRETOL-XR TAB 100MG Tier 3 Sodium Channel Agents - Seizure Control Drugs TEGRETOL-XR TAB 200MG Tier 3 Sodium Channel Agents - Seizure Control Drugs TEGRETOL-XR TAB 400MG Tier 3 Sodium Channel Agents - Seizure Control Drugs TRILEPTAL SUS 300MG/5M Tier 3 X X Sodium Channel Agents - Seizure Control Drugs TRILEPTAL TAB 150MG Tier 3 X X Sodium Channel Agents - Seizure Control Drugs TRILEPTAL TAB 300MG Tier 3 X X Sodium Channel Agents - Seizure Control Drugs TRILEPTAL TAB 600MG Tier 3 X X Sodium Channel Agents - Seizure Control Drugs VIMPAT SOL 10MG/ML Tier 3 X Sodium Channel Agents - Seizure Control Drugs VIMPAT TAB 100MG Tier 3 X Sodium Channel Agents - Seizure Control Drugs VIMPAT TAB 150MG Tier 3 X Sodium Channel Agents - Seizure Control Drugs VIMPAT TAB 200MG Tier 3 X Sodium Channel Agents - Seizure Control Drugs VIMPAT TAB 50MG Tier 3 X Sulfonamides - Antibiotics BACTRIM TAB 400-80MG Tier 3 Sulfonamides - Antibiotics BACTRIM DS TAB 800-160 Tier 3 Sulfonamides - Antibiotics BLEPH-10 SOL 10% OP Tier 3 Sulfonamides - Antibiotics SMZ/TMP DS TAB 800-160 Tier 1 Sulfonamides - Antibiotics SMZ-TMP SUS 200-40/5 Tier 1 Sulfonamides - Antibiotics SMZ-TMP TAB 400-80MG Tier 1 Sulfonamides - Antibiotics SMZ-TMP DS TAB 800-160 Tier 1 Sulfonamides - Antibiotics SOD SULFACET SOL 10% OP Tier 1 Sulfonamides - Antibiotics SULFACET SOD OIN 10% OP Tier 1 Sulfonamides - Antibiotics SULFACET SOD SOL 10% OP Tier 1 Sulfonamides - Antibiotics SULFADIAZINE TAB 500MG Tier 1 Sulfonamides - Antibiotics SULFATRIM PD SUS 200-40/5 Tier 1 Sulfonamides - Inflammatory Bowel Disease Drugs AZULFIDINE TAB 500MG Tier 3 Sulfonamides - Inflammatory Bowel Disease Drugs AZULFIDINE TAB 500MG EN Tier 3 Sulfonamides - Inflammatory Bowel Disease Drugs SULFASALAZIN TAB 500MG Tier 1 Sulfonamides - Inflammatory Bowel Disease Drugs SULFASALAZIN TAB 500MG DR Tier 1 Tetracyclines - Antibiotics ACTICLATE TAB 150MG Tier 3 X Tetracyclines - Antibiotics ACTICLATE TAB 75MG Tier 3 X Tetracyclines - Antibiotics ADOXA CAP 150MG Tier 3 X

Page 343 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Tetracyclines - Antibiotics ADOXA TAB 100MG Tier 3 X Tetracyclines - Antibiotics ADOXA TAB 50MG Tier 3 X Tetracyclines - Antibiotics ADOXA TAB 75MG Tier 3 X Tetracyclines - Antibiotics ADOXA PAK 1/ TAB 100MG Tier 3 X Tetracyclines - Antibiotics ADOXA PAK 1/ TAB 150MG Tier 3 X Tetracyclines - Antibiotics ADOXA PAK 2/ TAB 100MG Tier 3 X Tetracyclines - Antibiotics ALODOX KIT 20MG Tier 3 Tetracyclines - Antibiotics AVIDOXY TAB 100MG Tier 1 Tetracyclines - Antibiotics AVIDOXY DK KIT Tier 3 Tetracyclines - Antibiotics DEMECLOCYCL TAB 150MG Tier 1 Tetracyclines - Antibiotics DEMECLOCYCL TAB 300MG Tier 1 Tetracyclines - Antibiotics DORYX TAB 200MG Tier 3 X Tetracyclines - Antibiotics DORYX TAB 50MG Tier 3 X Tetracyclines - Antibiotics DORYX MPC TAB 120MG Tier 3 X Tetracyclines - Antibiotics DOXYCYC CAP 100MG Tier 1 Tetracyclines - Antibiotics DOXYCYC CAP 50MG Tier 1 Tetracyclines - Antibiotics DOXYCYC MONO CAP 100MG Tier 1 Tetracyclines - Antibiotics DOXYCYC MONO CAP 50MG Tier 1 Tetracyclines - Antibiotics DOXYCYC MONO TAB 100MG Tier 1 Tetracyclines - Antibiotics DOXYCYC MONO TAB 150MG Tier 1 Tetracyclines - Antibiotics DOXYCYC MONO TAB 50MG Tier 1 Tetracyclines - Antibiotics DOXYCYC MONO TAB 75MG Tier 1 Tetracyclines - Antibiotics DOXYCYCL HYC CAP 100MG Tier 1 Tetracyclines - Antibiotics DOXYCYCL HYC CAP 50MG Tier 1 Tetracyclines - Antibiotics DOXYCYCL HYC TAB 100MG Tier 1

Tetracyclines - Antibiotics DOXYCYCL HYC TAB 100MG DR Tier 1 X

Tetracyclines - Antibiotics DOXYCYCL HYC TAB 150MG DR Tier 1 X

Tetracyclines - Antibiotics DOXYCYCL HYC TAB 200MG DR Tier 1 X Tetracyclines - Antibiotics DOXYCYCL HYC TAB 50MG DR Tier 1 X Tetracyclines - Antibiotics DOXYCYCL HYC TAB 75MG DR Tier 1 X Tetracyclines - Antibiotics DOXYCYCLINE CAP 150MG Tier 1 X Tetracyclines - Antibiotics DOXYCYCLINE CAP 40MG Tier 3 X Tetracyclines - Antibiotics DOXYCYCLINE CAP 75MG Tier 1 X Tetracyclines - Antibiotics DOXYCYCLINE POW HYCLATE Tier 3

Tetracyclines - Antibiotics DOXYCYCLINE SUS 25MG/5ML Tier 1 Tetracyclines - Antibiotics DOXYCYCLINE TAB 20MG Tier 1 Tetracyclines - Antibiotics MINOCIN CAP 100MG Tier 3 X Tetracyclines - Antibiotics MINOCIN CAP 50MG Tier 3 X Tetracyclines - Antibiotics MINOCIN CAP 75MG Tier 3 X Tetracyclines - Antibiotics MINOCIN KIT 100MG Tier 3 X Tetracyclines - Antibiotics MINOCIN KIT 50MG Tier 3 X Tetracyclines - Antibiotics MINOCYCLINE CAP 100MG Tier 1 Tetracyclines - Antibiotics MINOCYCLINE CAP 50MG Tier 1 Tetracyclines - Antibiotics MINOCYCLINE CAP 75MG Tier 1 Tetracyclines - Antibiotics MINOCYCLINE TAB 100MG Tier 1

Tetracyclines - Antibiotics MINOCYCLINE TAB 135MG ER Tier 1 Tetracyclines - Antibiotics MINOCYCLINE TAB 45MG ER Tier 1 Tetracyclines - Antibiotics MINOCYCLINE TAB 50MG Tier 1 Tetracyclines - Antibiotics MINOCYCLINE TAB 75MG Tier 1 Tetracyclines - Antibiotics MINOCYCLINE TAB 90MG ER Tier 1 Tetracyclines - Antibiotics MONDOXYNE NL CAP 100MG Tier 1 Tetracyclines - Antibiotics MONDOXYNE NL CAP 50MG Tier 1

Page 344 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Tetracyclines - Antibiotics MONDOXYNE NL CAP 75MG Tier 1 X Tetracyclines - Antibiotics MONODOX CAP 100MG Tier 3 X Tetracyclines - Antibiotics MONODOX CAP 75MG Tier 3 X Tetracyclines - Antibiotics MORGIDOX CAP 1X100MG Tier 1 Tetracyclines - Antibiotics MORGIDOX CAP 1X50MG Tier 1 Tetracyclines - Antibiotics MORGIDOX CAP 2X100MG Tier 1 Tetracyclines - Antibiotics MORGIDOX KIT 1X100MG Tier 3 X Tetracyclines - Antibiotics MORGIDOX KIT 1X50MG Tier 3 X Tetracyclines - Antibiotics MORGIDOX KIT 2X100MG Tier 3 X Tetracyclines - Antibiotics NICAZELDOXY KIT 30 Tier 3 X Tetracyclines - Antibiotics NICAZELDOXY KIT 60 Tier 3 X Tetracyclines - Antibiotics NUTRIDOX KIT Tier 3 Tetracyclines - Antibiotics OCUDOX KIT Tier 2 Tetracyclines - Antibiotics ORACEA CAP 40MG Tier 3 Tetracyclines - Antibiotics SOLODYN TAB 105MG Tier 3 Tetracyclines - Antibiotics SOLODYN TAB 115MG Tier 3 Tetracyclines - Antibiotics SOLODYN TAB 55MG Tier 3 Tetracyclines - Antibiotics SOLODYN TAB 65MG Tier 3 Tetracyclines - Antibiotics SOLODYN TAB 80MG Tier 3 Tetracyclines - Antibiotics TETRACYCLINE CAP 250MG Tier 1 Tetracyclines - Antibiotics TETRACYCLINE CAP 500MG Tier 1 Tetracyclines - Antibiotics VIBRAMYCIN CAP 100MG Tier 3

Tetracyclines - Antibiotics VIBRAMYCIN SUS 25MG/5ML Tier 3

Tetracyclines - Antibiotics VIBRAMYCIN SYP 50MG/5ML Tier 3 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 100/ODT Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 100MG Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 12.5/ODT Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 150/ODT Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 200/ODT Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 200MG Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 25MG Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 25MG ODT Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZAPINE TAB 50MG Tier 1 Treatment-Resistant - Mood Disorder Drugs CLOZARIL TAB 100MG Tier 3 Treatment-Resistant - Mood Disorder Drugs CLOZARIL TAB 25MG Tier 3 Treatment-Resistant - Mood Disorder Drugs FAZACLO TAB 100 ODT Tier 3 Treatment-Resistant - Mood Disorder Drugs FAZACLO TAB 12.5 ODT Tier 3 Treatment-Resistant - Mood Disorder Drugs FAZACLO TAB 150 ODT Tier 3 Treatment-Resistant - Mood Disorder Drugs FAZACLO TAB 200 ODT Tier 3

Page 345 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Treatment-Resistant - Mood Disorder Drugs FAZACLO TAB 25MG ODT Tier 3 Treatment-Resistant - Mood Disorder Drugs VERSACLOZ SUS 50MG/ML Tier 3 X Tricyclics - Antidepressants AMITRIPTYLIN KIT 2% Tier 1 X Tricyclics - Antidepressants AMITRIPTYLIN POW HCL Tier 3 X Tricyclics - Antidepressants AMITRIPTYLIN TAB 100MG Tier 1 Tricyclics - Antidepressants AMITRIPTYLIN TAB 10MG Tier 1 Tricyclics - Antidepressants AMITRIPTYLIN TAB 150MG Tier 1 Tricyclics - Antidepressants AMITRIPTYLIN TAB 25MG Tier 1 Tricyclics - Antidepressants AMITRIPTYLIN TAB 50MG Tier 1 Tricyclics - Antidepressants AMITRIPTYLIN TAB 75MG Tier 1 Tricyclics - Antidepressants AMOXAPINE TAB 100MG Tier 1 Tricyclics - Antidepressants AMOXAPINE TAB 150MG Tier 1 Tricyclics - Antidepressants AMOXAPINE TAB 25MG Tier 1 Tricyclics - Antidepressants AMOXAPINE TAB 50MG Tier 1 Tricyclics - Antidepressants ANAFRANIL CAP 25MG Tier 3 X Tricyclics - Antidepressants ANAFRANIL CAP 50MG Tier 3 X Tricyclics - Antidepressants ANAFRANIL CAP 75MG Tier 3 X Tricyclics - Antidepressants CETYL MYRIST MIS OLEATE Tier 3 X Tricyclics - Antidepressants CETYL MYRIST OIL OLEATE Tier 3 X Tricyclics - Antidepressants CETYL MYRIST POW 20% Tier 3 X Tricyclics - Antidepressants CETYL MYRIST POW OLEATE Tier 3 X Tricyclics - Antidepressants CETYL MYRIST POW OLEATE Tier 3 X Tricyclics - Antidepressants CITRULLINE POW (L) Tier 3 Tricyclics - Antidepressants CLOMIPRAMINE CAP 25MG Tier 1 Tricyclics - Antidepressants CLOMIPRAMINE CAP 50MG Tier 1 Tricyclics - Antidepressants CLOMIPRAMINE CAP 75MG Tier 1 Tricyclics - Antidepressants DESIPRAMINE TAB 100MG Tier 1 Tricyclics - Antidepressants DESIPRAMINE TAB 10MG Tier 1 Tricyclics - Antidepressants DESIPRAMINE TAB 150MG Tier 1 Tricyclics - Antidepressants DESIPRAMINE TAB 25MG Tier 1 Tricyclics - Antidepressants DESIPRAMINE TAB 50MG Tier 1 Tricyclics - Antidepressants DESIPRAMINE TAB 75MG Tier 1 Tricyclics - Antidepressants DOXEPIN HCL CAP 100MG Tier 1 Tricyclics - Antidepressants DOXEPIN HCL CAP 10MG Tier 1 Tricyclics - Antidepressants DOXEPIN HCL CAP 150MG Tier 1 Tricyclics - Antidepressants DOXEPIN HCL CAP 25MG Tier 1 Tricyclics - Antidepressants DOXEPIN HCL CAP 50MG Tier 1 Tricyclics - Antidepressants DOXEPIN HCL CAP 75MG Tier 1

Tricyclics - Antidepressants DOXEPIN HCL CON 10MG/ML Tier 1 Tricyclics - Antidepressants ELAVIL TAB 25MG Tier 3 Tricyclics - Antidepressants IMIPRAM HCL TAB 10MG Tier 1 Tricyclics - Antidepressants IMIPRAM HCL TAB 25MG Tier 1 Tricyclics - Antidepressants IMIPRAM HCL TAB 50MG Tier 1 Tricyclics - Antidepressants IMIPRAM PAM CAP 100MG Tier 1 Tricyclics - Antidepressants IMIPRAM PAM CAP 125MG Tier 1 Tricyclics - Antidepressants IMIPRAM PAM CAP 150MG Tier 1 Tricyclics - Antidepressants IMIPRAM PAM CAP 75MG Tier 1 Tricyclics - Antidepressants IMIPRAMINE POW HCL Tier 3 X Tricyclics - Antidepressants L-CITRULLINE POW Tier 3 Tricyclics - Antidepressants NORPRAMIN TAB 100MG Tier 3 Tricyclics - Antidepressants NORPRAMIN TAB 10MG Tier 3 Tricyclics - Antidepressants NORPRAMIN TAB 150MG Tier 3 Tricyclics - Antidepressants NORPRAMIN TAB 25MG Tier 3 Tricyclics - Antidepressants NORPRAMIN TAB 50MG Tier 3

Page 346 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty Tricyclics - Antidepressants NORPRAMIN TAB 75MG Tier 3 Tricyclics - Antidepressants NORTRIPTYLIN CAP 10MG Tier 1 Tricyclics - Antidepressants NORTRIPTYLIN CAP 25MG Tier 1 Tricyclics - Antidepressants NORTRIPTYLIN CAP 50MG Tier 1 Tricyclics - Antidepressants NORTRIPTYLIN CAP 75MG Tier 1

Tricyclics - Antidepressants NORTRIPTYLIN SOL 10MG/5ML Tier 1 Tricyclics - Antidepressants PAMELOR CAP 10MG Tier 3 Tricyclics - Antidepressants PAMELOR CAP 25MG Tier 3 Tricyclics - Antidepressants PAMELOR CAP 50MG Tier 3 Tricyclics - Antidepressants PAMELOR CAP 75MG Tier 3 Tricyclics - Antidepressants PERPHEN/AMIT TAB 2-10MG Tier 1 Tricyclics - Antidepressants PERPHEN/AMIT TAB 2-25MG Tier 1 Tricyclics - Antidepressants PERPHEN/AMIT TAB 4-10MG Tier 1 Tricyclics - Antidepressants PERPHEN/AMIT TAB 4-25MG Tier 1 Tricyclics - Antidepressants PERPHEN/AMIT TAB 4-50MG Tier 1 Tricyclics - Antidepressants PROTRIPTYLIN TAB 10MG Tier 1 Tricyclics - Antidepressants PROTRIPTYLIN TAB 5MG Tier 1 Tricyclics - Antidepressants SURMONTIL CAP 100MG Tier 3 Tricyclics - Antidepressants SURMONTIL CAP 25MG Tier 3 Tricyclics - Antidepressants SURMONTIL CAP 50MG Tier 3 Tricyclics - Antidepressants TOFRANIL TAB 10MG Tier 3 Tricyclics - Antidepressants TOFRANIL TAB 25MG Tier 3 Tricyclics - Antidepressants TOFRANIL TAB 50MG Tier 3 Tricyclics - Antidepressants TOFRANIL-PM CAP 100MG Tier 3 Tricyclics - Antidepressants TOFRANIL-PM CAP 125MG Tier 3 Tricyclics - Antidepressants TOFRANIL-PM CAP 150MG Tier 3 Tricyclics - Antidepressants TOFRANIL-PM CAP 75MG Tier 3 Tricyclics - Antidepressants TRIMIPRAMINE CAP 100MG Tier 1 Tricyclics - Antidepressants TRIMIPRAMINE CAP 25MG Tier 1 Tricyclics - Antidepressants TRIMIPRAMINE CAP 50MG Tier 1

Vasodilators - Chest Pain Drugs ISOPROTEREN AER 131MCG Tier 1

Vasodilators - Chest Pain Drugs ISOXSUPRINE TAB 10MG Tier 1

Vasodilators - Chest Pain Drugs ISOXSUPRINE TAB HCL 20MG Tier 1

Vasodilators - Chest Pain Drugs PAPAVERINE POW HCL Tier 3 X Vasodilators, Direct-acting Arterial - Chest Pain Drugs HYDRALAZINE TAB 100MG Tier 1 Vasodilators, Direct-acting Arterial - Chest Pain Drugs HYDRALAZINE TAB 10MG Tier 1 Vasodilators, Direct-acting Arterial - Chest Pain Drugs HYDRALAZINE TAB 25MG Tier 1 Vasodilators, Direct-acting Arterial - Chest Pain Drugs HYDRALAZINE TAB 50MG Tier 1 Vasodilators, Direct-acting Arterial - Chest Pain Drugs MINOXIDIL TAB 10MG Tier 1 Vasodilators, Direct-acting Arterial - Chest Pain Drugs MINOXIDIL TAB 2.5MG Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs BIDIL TAB Tier 2

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs DILATRATE SR CAP 40MG Tier 3

Page 347 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISORDIL TAB 40MG Tier 2

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISORDIL TAB 5MG Tier 3

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB DIN TAB 10MG Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB DIN TAB 20MG Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB DIN TAB 30MG Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB DIN TAB 40MG ER Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB DIN TAB 5MG Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB MONO TAB 10MG Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB MONO TAB 120MG ER Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB MONO TAB 20MG Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB MONO TAB 30MG ER Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs ISOSORB MONO TAB 60MG ER Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs MINITRAN DIS 0.1MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs MINITRAN DIS 0.2MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs MINITRAN DIS 0.4MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs MINITRAN DIS 0.6MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-BID OIN 2% Tier 2

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-DUR DIS 0.1MG/HR Tier 3

Page 348 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-DUR DIS 0.2MG/HR Tier 3

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-DUR DIS 0.3MG/HR Tier 3

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-DUR DIS 0.4MG/HR Tier 3

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-DUR DIS 0.6MG/HR Tier 3

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-DUR DIS 0.8MG/HR Tier 3

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER AER 400MCG Tier 1 X

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER CAP 2.5MG ER Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER CAP 6.5MG ER Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER CAP 9MG ER Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER DIS 0.1MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER DIS 0.2MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER DIS 0.4MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER DIS 0.4MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCER DIS 0.6MG/HR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCRN SPR 0.4MG Tier 1 X X

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROGLYCRN SPR LINGUAL Tier 1 X X

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROLINGUAL SPR PUMPSPRA Tier 3 X X

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROMIST AER 400MCG Tier 3 X

Page 349 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROSTAT SUB 0.3MG Tier 2

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROSTAT SUB 0.4MG Tier 2

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITROSTAT SUB 0.6MG Tier 2

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-TIME CAP 2.5MG CR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-TIME CAP 6.5MG CR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs NITRO-TIME CAP 9MG CR Tier 1

Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs RECTIV OIN 0.4% Tier 3 X X VITAMINS - MULTIVITAMIN PREPARATIONS ACTIVE OB CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS AIRSHIELD TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS AP-ZEL TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS ATABEX EC TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS BAL-CARE MIS DHA Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS BP FOLINATAL TAB PLUS B Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS BP MULTINATL CHW PLUS Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS BP MULTINATL TAB PLUS Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS CALCIUM PNV CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS CHLORELLA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS CITRANATAL MIS 90 DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS CITRANATAL MIS B-CALM Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS CITRANATAL PAK ASSURE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS CITRANATAL PAK DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS CITRANATAL TAB RX Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS C-NATE DHA CAP 28-1-200 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS COMPLETE NAT PAK DHA Tier 1

Page 350 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS COMPLETENATE CHW Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS CO-NATAL FA TAB 29-1MG Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS CONCEPT DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS CONCEPT OB CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS DOTHELLE DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS DUET DHA MIS BALANCED Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS DUET DHA 400 MIS 25-1-400 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS ELITE-OB TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS ESCAVITE CHW Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS EXTRA-VIRT CAP PLUS DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS FLORIVA DRO PLUS Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS FOCALGIN 90 MIS DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS FOCALGIN CA MIS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS FOLCAL DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS FOLCAPS CAP OMEGA 3 Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS FOLIVANE-OB CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS FOLIVANE-PRX CAP DHA NF Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS GERM DEFENSE TAB LEM-LIME Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS GERM DEFENSE TAB ORANGE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS GERM DEFENSE TAB PM Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS GESTICARE PAK DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS HEMENATAL OB MIS + DHA Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS HEMENATAL OB TAB 28-6-1MG Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS INATAL ADV TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS INATAL ADV TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS INATAL GT TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS INATAL ULTRA TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS INATAL ULTRA TAB Tier 1

Page 351 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS INFANATE CAP BALANCE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS LEVOMEFOLATE CAP DHA Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS LYSIPLEX TAB PLUS Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MACNATAL CN CAP DHA Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS MARNATAL-F CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS MILTAB #1 TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS MULTI-VIT/FE DRO /FL 0.25 Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MULTIVIT/FL CHW 0.25MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MULTIVIT/FL CHW 0.5MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MULTIVIT/FL CHW 1MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MULTI-VIT/FL DRO /FE 0.25 Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MULTI-VIT/FL DRO 0.25MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MULTI-VIT/FL DRO 0.5MG/ML Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MULT-VIT/FL CHW 0.5MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MVC-FLUORIDE CHW 0.25MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MVC-FLUORIDE CHW 0.5MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MVC-FLUORIDE CHW 1MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS M-VIT TAB 27-1MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MYKIDZ IRON SUS FL Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS MYNATAL CAP Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS MYNATAL TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS MYNATAL TAB ADVANCE Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS MYNATAL PLUS TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS MYNATAL-Z TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS MYNATE 90 TAB PLUS Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS NATACHEW CHW Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NATALVIT TAB 75-1MG Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS NATELLE ONE CAP Tier 3

Page 352 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS NEEVO DHA CAP 27-1.13 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NESTABS TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NESTABS ABC MIS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NESTABS DHA PAK Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NEWGEN TAB 32-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NEXA PLUS CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NICAZEL TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NICAZEL TAB FORTE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS NIVA-PLUS TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS OB COMPLETE CAP GOLD Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS OB COMPLETE CAP ONE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS OB COMPLETE CAP PETITE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS OB COMPLETE TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS OB COMPLETE TAB PREMIER Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS OB COMPLETE/ CAP DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS OBSTETRIX PAK DHA Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS OBSTETRIX EC TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS O-CAL TAB PRENATAL Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS O-CAL FA TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS PAIRE OB MIS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PNV FE FUM TAB DOC/FA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PNV FOLIC AC TAB + IRON Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PNV OB+DHA PAK Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PNV PRENATAL TAB PLUS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PNV TABS TAB 29-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PNV-DHA CAP Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PNV-DHA CAP DOCUSATE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PNV-OMEGA CAP Tier 3

Page 353 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS PNV-SELECT TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PNV-TOTAL CAP Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS PNV-VP-U CAP 106.5-1 Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS POLY-VI-FLOR CHW 0.25MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS POLY-VI-FLOR CHW 0.5MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS POLY-VI-FLOR CHW 1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS POLY-VI-FLOR CHW W/IRON Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS POLY-VI-FLOR SUS /IRON Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS POLY-VI-FLOR SUS 0.25/ML Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PR NATAL 400 PAK Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PR NATAL 400 PAK EC Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PR NATAL 430 PAK Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PR NATAL 430 PAK EC Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PREFERA OB MIS + DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PREFERA OB TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PREFERA OB TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PREFERAOB CAP ONE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PREFERAOB MIS +DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE CAP Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE CAP BALANCE Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE CAP PLUS Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE MIS HARMONY Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE PAK 90 DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE PAK DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE PAK PROMISE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE TAB NEXT Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAISSANCE TAB NEXT-B Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENAT PLUS TAB 27-1MG Tier 3

Page 354 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS PRENATA CHW 29-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATABS FA TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATABS RX TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL MIS COMPLEAT Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL TAB 27-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL TAB PLUS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL TAB PLUS Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL 19 CHW 29-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL 19 CHW TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL 19 TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL 19 TAB 29-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL VIT TAB LOW IRON Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL+FE TAB 29-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATAL-U CAP 106.5-1 Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATE CAP ENHANCE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATE CAP RESTORE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATE CHW 0.6-0.4 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATE TAB ELITE Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATE AM TAB 1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATE DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRENATE MINI CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PREPLUS TAB 27-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PREQUE 10 TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PRETAB TAB 29-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PROVIDA OB CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS PUREFE OB CAP PLUS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS QUFLORA PED CHW 0.25MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS QUFLORA PED CHW 0.5MG Tier 3

Page 355 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS QUFLORA PED CHW 1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS QUFLORA PED DRO 0.25MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS QUFLORA PED DRO 0.5MG/ML Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS RA EFFERVESC TAB FORMULA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS RELNATE DHA CAP Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS R-NATAL OB CAP 20-1-320 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS RULAVITE DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS SELECT-OB CHW Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS SELECT-OB CHW Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS SELECT-OB+ PAK DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS SE-NATAL 19 CHW Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS SE-NATAL 19 TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS SE-TAN DHA CAP Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TARON-BC MIS Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS TARON-C DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TARON-PREX CAP Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS THRIVITE 19 TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS THRIVITE RX TAB 29-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TL FOLATE TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TL-CARE DHA CAP 27-1-500 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TL-FLUORIVIT CHW Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TL-SELECT CAP Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS TRIADVANCE TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TRICARE TAB PRENATAL Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRICARE PRE CAP 27-1-500 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRINATAL GT TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS TRINATAL RX TAB 1 Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TRINATE TAB Tier 1

Page 356 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS TRISTART DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-TABS DHA MIS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRIVEEN-DUO PAK DHA Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS TRIVEEN-PRX CAP RNF Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VI-FLOR SUS 0.25/ML Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VI-FLOR SUS 0.5MG/ML Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VI-FLORO SUS 0.25/ML Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VI-FLORO SUS 0.5MG/ML Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VIT/FE DRO /FL 0.25 Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VIT/FL DRO 0.25MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VIT/FL DRO 0.5MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VIT/FLUO DRO 0.25MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VIT/FLUO DRO 0.5MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS TRI-VITA/FL DRO 0.25MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS ULTIMATECARE CAP ONE Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS ULTIMATECARE CAP ONE NF Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VEMAVITE- CAP PRX 2 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VENA-BAL MIS DHA Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS VENATAL-FA TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VINACAL B MIS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE AZ EX TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE C TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE CAL TAB Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE CARE CHW Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE DHA CAP 27-1.13 Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE IC CAP Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE II TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VINATE M TAB Tier 1

Page 357 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS VINATE ONE TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT NATE TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT NATE TAB 28-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-ADVANCE TAB 90-1MG Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-C DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-CARE CAP ONE Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-NATE CAP DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-PN TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-PN DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-PN PLUS CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRTPREX CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-SELECT CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIRT-VITE GT TAB 90-1MG Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS VIT A/C/D/FL DRO 0.25MG Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS VITAFOL CAP ULTRA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VITAFOL-OB PAK +DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VITAFOL-OB TAB 65-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VITAFOL-ONE CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VITAMEDMD CAP ONE RX Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VITAMEDMD MIS PLUS RX Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VITA-PREN TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VIVA DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VOL-NATE TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VOL-PLUS TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VOL-TAB RX TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-CH PLUS CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-CH-PNV CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-CH-PNV CAP Tier 2

Page 358 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - MULTIVITAMIN PREPARATIONS VP-GGR-B6 TAB PRENATAL Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS VP-HEME OB MIS + DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-HEME OB TAB Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-HEME ONE CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-HEME-OB TAB 28-6-1MG Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-PNV-DHA CAP Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS VP-ZEL TAB Tier 1 VITAMINS - MULTIVITAMIN PREPARATIONS ZATEAN-CH CAP Tier 2 VITAMINS - MULTIVITAMIN PREPARATIONS ZATEAN-PN CAP DHA Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS ZATEAN-PN CAP PLUS Tier 3 VITAMINS - MULTIVITAMIN PREPARATIONS ZATEAN-PN TAB Tier 3

VITAMINS - VITAMIN B COMPLEX BIOTIN POW Tier 3 X

VITAMINS - VITAMIN B COMPLEX BIOTIN-D POW Tier 3 X

VITAMINS - VITAMIN B COMPLEX BL FOLIC ACD TAB 400MCG Tier 1

VITAMINS - VITAMIN B COMPLEX CYANOCOBAL POW Tier 3

VITAMINS - VITAMIN B COMPLEX CYANOCOBALAM CRY Tier 3 HCR VITAMINS - VITAMIN B COMPLEX FA-8 CAP 800MCG Preventative HCR VITAMINS - VITAMIN B COMPLEX FA-8 TAB 0.8MG Preventative

VITAMINS - VITAMIN B COMPLEX FOLIC ACID INJ 5MG/ML Tier 1

VITAMINS - VITAMIN B COMPLEX FOLIC ACID POW Tier 3

VITAMINS - VITAMIN B COMPLEX FOLIC ACID TAB 1000MCG Tier 1

VITAMINS - VITAMIN B COMPLEX FOLIC ACID TAB 1MG Tier 1 HCR VITAMINS - VITAMIN B COMPLEX FOLIC ACID TAB 400MCG Preventative HCR VITAMINS - VITAMIN B COMPLEX FOLIC ACID TAB 800MCG Preventative

VITAMINS - VITAMIN B COMPLEX NASCOBAL SPR 500MCG Tier 3

VITAMINS - VITAMIN B COMPLEX NIACINAMIDE POW Tier 3 X

VITAMINS - VITAMIN B COMPLEX NICOTINAMIDE POW Tier 3 X HCR VITAMINS - VITAMIN B COMPLEX SM FOLIC ACD TAB 400MCG Preventative

Page 359 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty VITAMINS - VITAMIN C ASCOCID POW Tier 3 X VITAMINS - VITAMIN C ASCORBIC ACD POW Tier 3 X VITAMINS - VITAMIN C VITAMIN C POW Tier 3 X HCR VITAMINS - VITAMIN D CVD D3 CHW 1000UNIT Preventative HCR VITAMINS - VITAMIN D CVS D3 CAP 1000UNIT Preventative HCR VITAMINS - VITAMIN D CVS D3 CAP 400UNIT Preventative HCR VITAMINS - VITAMIN D D 1000 CHW 1000UNIT Preventative HCR VITAMINS - VITAMIN D D 400 CHW 400UNIT Preventative HCR VITAMINS - VITAMIN D D 400 TAB 400UNIT Preventative HCR VITAMINS - VITAMIN D D3 CAP 1000UNIT Preventative HCR VITAMINS - VITAMIN D D-3 GUMMY CHW 400UNIT Preventative HCR VITAMINS - VITAMIN D D-400 TAB 400UNIT Preventative HCR VITAMINS - VITAMIN D DELTA D3 TAB 400UNIT Preventative VITAMINS - VITAMIN D DRISDOL CAP 50000UNT Tier 3 HCR VITAMINS - VITAMIN D D-VI-SOL LIQ 400UNIT Preventative HCR VITAMINS - VITAMIN D D-VITA LIQ 400UNIT Preventative

VITAMINS - VITAMIN D ERGOCALCIFER CAP 50000UNT Tier 1 HCR VITAMINS - VITAMIN D GNP VIT D TAB 1000UNIT Preventative HCR VITAMINS - VITAMIN D PEDIA D-VITE DRO 400UNIT Preventative HCR VITAMINS - VITAMIN D VIT D CHILD CHW 1000UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D CAP 1000UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D CAP 400UNIT Preventative VITAMINS - VITAMIN D VITAMIN D CAP 50000UNT Tier 1 HCR VITAMINS - VITAMIN D VITAMIN D CHW 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D DRO 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D TAB 1000UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D TAB 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D2 TAB 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D3 CAP 1000UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D3 CAP 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D3 CHW 1000UNIT Preventative

Page 360 of 361 Prior Supply Step Therapeutic Class Product Name Tier Value Authorization Limit Therapy Specialty HCR VITAMINS - VITAMIN D VITAMIN D3 CHW 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D3 DRO 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D3 TAB 1000UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D3 TAB 400UNIT Preventative HCR VITAMINS - VITAMIN D VITAMIN D-3 TAB 1000UNIT Preventative VITAMINS - VITAMIN E VITAMIN E POW ACETATE Tier 3 X VITAMINS - VITAMIN E WHEAT GERM OIL Tier 3 VITAMINS - VITAMIN K ACTIVITY MEPHYTON TAB 5MG Tier 2 X

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs CITRANATAL CAP HARMONY Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs INFANATE CAP PLUS Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs PRENA1 CHW Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs PRENA1 PEARL CAP Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs PRENATE CAP ESSENTIA Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs REDICHEW RX CHW Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs VITAFOL-NANO TAB Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs VITAPEARL CAP Tier 3

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs VP CH ULTRA CAP Tier 3

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