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Pharmacy | Formulary | California

2021 California SignatureValue 4-Tier HMO Formulary

Please note: This Formulary is accurate as of August 1, 2021 and is subject to change after this date. All previous versions of this Formulary are no longer in effect. Your estimated coverage and copay/coinsurance may vary based on the benefit plan you choose and the effective date of the plan.

This Formulary can also be accessed online at myuhc.com > Pharmacy Information > Lists > California plans > SignatureValue HMO plans. Plan-specific coverage documents may be accessed online at uhc.com/statedruglists > Small Group Plans > California. If you are a UnitedHealthcare member, please register or log on to myuhc.com, or call the toll-free number on your health plan ID card to find pharmacy information specific to your benefit plan. This Formulary is applicable to the following health insurance products offered by UnitedHealthcare: • SignatureValue • SignatureValue Advantage • SignatureValue Alliance • SignatureValue Flex • SignatureValue Focus • SignatureValue Harmony • SignatureValue Performance

Updated 6/17/2021

6/21 © 2021 United HealthCare Services, Inc. All Rights Reserved. WF3890815-N Contents

At UnitedHealthcare, we want to help you better understand your options...... 3

How do I use my Formulary? ...... 4

What are tiers? ...... 5

When does the Formulary change? ...... 5

Utilization Management Programs ...... 6

Your Right to Request Access to a Non-formulary Drug ...... 6

Requesting a Prior Authorization or Step Therapy Exception ...... 7

How do I locate and fill a prescription through a retail network pharmacy? ...... 7

How do I locate and fill a prescription through the mail order pharmacy? ...... 7

How do I locate and fill a prescription at a specialty pharmacy? ...... 8

How do I get updated information about my pharmacy benefit? ...... 8

Nondiscrimination notice and access to communication services ...... 9

Formulary ...... 13

2 At UnitedHealthcare, 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 used terms and their definitions as well as frequently asked questions: Brand-name drug means a Prescription Drug Product (1) which is manufactured and marketed under a trademark or name by a specific drug manufacturer; or (2) that we identify as a brand-name product, based on available data resources. This includes data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “brand-name” by the manufacturer, pharmacy, or your Physician will be classified as brand-name by us. A brand- name drug is listed in this Formulary in all CAPITAL letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either 1 deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. Your insurance company pays the rest. Drug Tier means a group of Prescription Drug Products that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a Prescription Drug Product is placed determines your portion of the cost for the drug. Enrollee is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this formulary template shall also include subscribers as defined in this section below. Exception request means a request for coverage of a non-formulary drug. If you, your designee, or your prescribing health care provider submits a request for coverage of a non-formulary drug, your insurer must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary means a list that categorizes into tiers or products that have been approved by the U.S. Food and Drug Administration (FDA). This list is subject to our periodic review and modification (generally quarterly, but no more than 6 times per calendar year). means a Prescription Drug Product: (1) that is chemically equivalent to a brand-name drug; or (2) that we identify as a generic product based on available data resources. This includes data sources such as Medi-Span, that classify drugs as either brand or generic based on a number of factors. Not all products identified as a “generic” by the manufacturer, pharmacy or your Physician will be classified as a generic by us. A generic drug is listed in this Formulary in bold and italicized lowercase letters. Non-formulary drug means a Prescription Drug Product that is not listed on this Formulary. Out-of-pocket costs means your expenses for health care benefits that aren’t reimbursed by your health insurance. Out-of- pocket costs include deductibles, copayments and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered. Prescribing provider means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription means an oral, written, or electronic order from a prescribing provider authorizing a Prescription Drug Product to be provided to a specific individual. Prescription Drug Product means a medication or product that has been approved by the U.S. Food and Drug Administration (FDA) and that can, under federal or state law, be dispensed only according to a Prescription Order or Refill. A Prescription Drug Product includes a medication that, due to its characteristics, is appropriate for self-administration or administration by a non-skilled caregiver. We will provide coverage for a Prescription Drug Product which includes a medication that, due to its characteristics, is

3 appropriate for self-administration or administration by a non-skilled caregiver. This definition includes: Inhalers (with spacers); ; the following diabetic supplies: standard insulin with needles; -testing strips - glucose; urine-testing strips - glucose; ketone-testing strips and tablets; lancets and lancet devices; and disposable devices which are medically necessary for the administration of a covered outpatient Prescription Drug Product. Benefits also include FDA-approved contraceptive drugs, devices and products available over-the-counter when prescribed by a Network provider. Prior Authorization means a process by your health insurer to determine that a health care benefit is medically necessary for you. If a Prescription Drug Product is subject to prior authorization in this Formulary, your prescribing provider must request approval from your health insurer to cover the drug. Your health insurer must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy means a specific sequence in which Prescription Drug Products for a particular medical condition must be tried. If a drug is subject to step therapy in this Formulary, you may have to try 1 or more other drugs before your health insurance policy will cover that drug for your medical condition. If your prescribing provider submits a request for an exception to the step therapy requirement, your health insurer must grant the request when it is medically necessary for you to take the drug. Subscriber means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan. How do I use my Formulary? When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if special programs apply. Bring this list with you when you see your doctor. It is organized by therapeutic category and class. The therapeutic category and class are based on the American Hospital Formulary Service (AHFS) Pharmacologic-Therapeutic Classification. You may also find a drug by its brand or generic name in the alphabetical index. If a generic equivalent for a brand-name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name. This is the way Prescription Drug Products appear in the Formulary: 1. A drug is listed alphabetically by its brand and generic names in the therapeutic category and class to which it belongs; 2. The generic name for a brand-name drug is included after the brand-name in parentheses and all lowercase bold and italicized letters; 3. If a generic equivalent for a brand-name drug is both available and covered, the generic drug will be listed separately from the brand-name drug in all bold and lowercase italicized letters; and 4. If a generic drug is marketed under a proprietary, trademark-protected brand-name, the brand-name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. Example:

Prescription Drug Name Drug Tier Coverage Requirements & Limits AVAPRO ORAL 150 MG, 300 MG, 75 MG (irbesartan) 3 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

If your medication is not listed in this document, please visit myuhc.com or call the toll-free member phone number on your health plan ID card. Below is a list of drug tier numbers, abbreviations and designations used in the Formulary as well as an explanation for each. Drug Tier 1 Your lowest cost medications SL Supply Limit Drug Tier 2 Your mid-range cost medications ST Step Therapy Drug Tier 3 Your mid-range cost medications H May be part of health care reform preventive Drug Tier 4 Your highest cost medications H-N May be part of health care reform preventive when used for appropriate AE Age Edit. Prior authorization may be required. preventive purposes PA Prior authorization required CM Orally administered anti-cancer medication

4 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 Tier 2, 3 or 4, look to see if there is a Tier 1 option available. Discuss these options with your doctor. For orally administered anti-cancer medications on any Tier, the total amount of copayments and/or coinsurance shall not exceed $250 for an individual prescription of up to a 30-day supply. For high deductible health plans, the $250 maximum only applies once the deductible has been met. Check your benefit plan documents to find out your specific pharmacy plan costs, including any maximum dollar amount of cost sharing that may apply to a drug. Preferred medications are found in Tier 1, Tier 2 or Tier 3 and may vary depending on the medication and the condition it treats.

$ Drug Tier Includes Helpful Tips Tier 1 Medications that provide the highest overall Use Tier 1 drugs for the lowest $ Your lowest cost value. Mostly generic drugs. Some preferred out-of-pocket costs. brand-name drugs may also be included.

Tier 2 Medications that provide good overall value Use Tier 2 or Tier 3 drugs instead $$ Your mid-range cost of preferred brand-name drugs. of Tier 4 to help reduce your out-of-pocket costs.

Tier 3 Medications that provide good overall value. Use Tier 2 or Tier 3 drugs instead $$$ Your mid-range cost A mix of nonpreferred generic drugs and of Tier 4 to help reduce your nonpreferred brand-name drugs. out-of-pocket costs.

Tier 4 Medications that provide the lowest overall Many Tier 4 drugs have lower-cost $$$$ Your highest cost value. May include biologics, drugs that must options in Tier 1, 2 or 3. Ask your be distributed through a specialty pharmacy, doctor if they could work for you. drugs that require special training or clinical monitoring for self-administration, or drugs that cost the health insurer more than $600 (net of rebates) for a 1-month supply.

Please note: If you have a high deductible plan, the tier cost levels may apply once you reach your deductible. Refer to your enrollment and plan materials on myuhc.com, or call the toll-free number on your health plan ID card for more information.

When does the Formulary change? This Formulary is required to be updated on a monthly basis. • 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 or become non-formulary most often on Jan. 1, May 1, or Sept. 1. • Medications may become subject to new or revised utilization management procedures, such as prior authorization, step therapy or supply limits, at any time but most often upon FDA approval of the medication or its generic, Jan. 1, May 1, or Sept. 1. When a medication changes tiers, you may have to pay a different amount for that medication. The presence of a Prescription Drug Product on the Formulary does not guarantee that you will be prescribed that Prescription Drug Product by your provider for a particular medical condition.

5 Utilization Management Programs

Prior authorization required—Your doctor is required to provide additional information to us to determine coverage. For specific prior authorization requirements, please refer to your Evidence of Coverage.

Supply limit—Amount of medication covered per copayment or in a specific time period.

Step therapy—Requires you to try 1 or more other medications before the medication you are requesting may be covered. For specific step therapy requirements, please refer to your Evidence of Coverage.

Health Care Reform Preventive when used for appropriate preventive purposes—This medication is part of a health care reform preventive benefit and may be available at no cost to you when used for appropriate preventive purposes. For more information, please refer to the California SignatureValue Formulary PPACA $0 Cost-Share Preventive Care Medications list.

To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com or call the toll-free member phone number on your health plan ID card. If you are a pre-enrollee and you would like to learn more about your specific pharmacy benefit, please contact your employer. Drugs administered by a health care professional are generally covered under the medical benefit while drugs that are self- administered are covered under the pharmacy benefit. In order to obtain medical benefits for drugs that are administered by a health care professional, your provider may also be required to obtain a prior authorization. The provider may contact UnitedHealthcare for more information or uhcprovider.com.

Your Right to Request Access to a Non-formulary Drug This plan must cover all Medically Necessary Prescription Drug Products. When a Prescription Drug Product is not on our Formulary, you or your representative may request an exception to gain access to that 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. If approved, we will cover the Prescription Drug Product for the duration of the prescription, including refills.

Urgent Requests If your request requires immediate action and a delay could significantly increase the risk to your health, or the ability to regain maximum function, call us as soon as possible. We will provide a written or electronic determination within 24 hours. If approved, we will cover the Prescription Drug Product for the duration of the exigency.

External Review If you are not satisfied with our determination of your exception request, you may be entitled to request an external review. You or your representative may request an external review by sending a written request to us to the address set out in the determination letter or by calling the toll-free number on your ID card. The Independent Review Organization (IRO) will notify you of its determination within 72 hours.

Expedited External Review If you are not satisfied with our determination of your exception request and it involves an urgent situation, you or your representative may request an expedited external review by calling the toll-free number on your ID card or by sending a written request to the address set out in the determination letter. The IRO will notify you of our determination within 24 hours. If we deny your exception request, you may appeal. Please refer to your Evidence of Coverage for details. The complaint and appeals process, including independent review, is described under Section 6: Questions, Complaints and Appeals. You may also call the telephone number listed on your identification (ID) card.

6 Requesting a Prior Authorization or Step Therapy Exception Before certain Prescription Drug Products are dispensed to you, your prescribing provider or your pharmacist is required to obtain prior authorization or step therapy exception from us. Your prescribing provider can submit a request by phone to OptumRx or electronically by contacting us at uhcprovider.com. The Prior Authorization staff of qualified pharmacists and technicians is available Monday –Friday from 5 a.m.– 10 p.m. PST and Saturday from 6 a.m. – 3 p.m. PST to assist licensed physicians. Most authorizations are completed within 24 hours. The most common reason for delay in the authorization process is insufficient information. Your licensed physician may need to provide information on diagnosis and medication history and/or evidence in the form of documents, records or lab tests which establish that the use of the requested Prescription Drug Product meets plan criteria. You may determine whether a particular Prescription Drug Product is subject to prior authorization or step therapy requirements by going online at myuhc.com or by calling at the toll-free phone number on the back of your health plan ID card. If you are changing policies, we will not require you to repeat step therapy when you are already being treated for a medical condition by a Prescription Drug Product provided the Prescription Drug Product is appropriately prescribed and considered safe and effective for your medical condition. However, we may impose a prior authorization requirement for the continued coverage of a Prescription Drug Product prescribed pursuant to step therapy requirements imposed by the former policy. Your prescribing provider may also prescribe another Prescription Drug Product covered under your policy that is medically appropriate for your medical condition. If you are currently taking a Prescription Drug Product which was approved by UnitedHealthcare for a specific medical condition and that drug is removed from the Formulary and the prescribing provider continues to prescribe the Prescription Drug Product for your medical condition, we will continue to cover the Prescription Drug Product provided that the drug is appropriately prescribed and is considered safe and effective for treating your medical condition. In the case of a standard prior authorization or step therapy exception request, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 72 hours following receipt of the request. In the case of an expedited prior authorization or step therapy exception request based on exigent circumstances, we will notify you, your designee, or your prescribing provider of the Benefit determination no later than 24 hours following receipt of the request. If we fail to respond to you, your designee, or your prescribing provider within the prescribed time limits, the request is deemed approved and we may not deny the request thereafter. If you disagree with a determination, you can request an appeal. The complaint and appeals process, including independent medical review, is described in the Evidence of Coverage. You may also call at the telephone number on your ID card.

How do I locate and fill a prescription through a retail network pharmacy? UnitedHealthcare has a well-established network of pharmacies including most major pharmacy and supermarket chains as well as many independent pharmacies. For a listing of network pharmacies, call the toll-free phone number on your health plan ID card to help locate a network pharmacy near you or visit our website at myuhc.com for an up-to-date list.

How do I locate and fill a prescription through the mail order pharmacy? UnitedHealthcare offers a Mail Order Pharmacy Program through OptumRx®. Here’s how to fill prescriptions through the Mail Order Pharmacy Program. 1. Call your prescribing provider to obtain a new prescription for each medication. When you call, ask the Physician to write the prescription for a 90-day supply which represents 3 prescription units with up to 3 additional refills. The doctor will tell you when to pick up the written prescription. (Note: OptumRx must have a new prescription to process any new Mail Order request.)

7 2. After picking up the prescription, complete the Mail Order Form included in your enrollment materials. (To obtain additional forms or for assistance in completing the form, contact UnitedHealthcare’s Customer Service Department by calling the telephone number on the back of your ID card. You can also find the form atoptumrx.com .) 3. Enclose the prescription and appropriate copayment via check, money order, or credit card. Your Pharmacy Schedule of Benefits will have the applicable copayment for the Mail Order Pharmacy Program. Make the check or money order payable to OptumRx. No cash please. Important Tip: If you are starting a new Prescription Drug Product, please request 2 prescriptions from your physician. Have 1 filled immediately at a network pharmacy while mailing the second prescription to UnitedHealthcare’s Mail Order Pharmacy. Once you receive your medication through the Mail Order Pharmacy Program, you should stop filling the prescription at the network pharmacy.

How do I locate and fill a prescription at a specialty pharmacy? Call the phone number on the back of your health plan ID card or visit specialty.optumrx.com to locate a designated specialty pharmacy for your medication.

How do I get updated information about my pharmacy benefit? Since the Formulary may change during your plan year, we encourage you to visit myuhc.com or call the toll-free member phone number on your health plan ID card for more current information.

Log in to myuhc.com for the following pharmacy information and tools: • Pharmacy benefit and coverage information • Possible lower-cost medication options • Medication interactions and side effects • Participating retail pharmacies by ZIP code • Your prescription history

And, if mail order services are included in your pharmacy benefit, you can also: • Refill prescriptions • Check the status of your order • Set up reminders for refills • Manage your account

Learn more Call the toll-free member phone number on your health plan ID card, or visit myuhc.com.

8 Nondiscrimination notice and access to communication services UnitedHealthcare Services, Inc. on behalf of itself and its affiliates does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. If you think you were treated unfairly for any of these reasons, you can send a complaint to: Online: [email protected] Mail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UT 84130 You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll- free phone number listed on your ID card. If you think you were treated unfairly because of your race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability, you can also send a complaint to the California Department of Managed Health Care: DMHC California Help Center 980 9th Street, Suite 500 Sacramento, CA 95814-2725 1-888-HMO-2219 (1-888-466-2219) 1-800-735-2929 or 1-888-877-5378 (TTY) Internet Website: www.hmohelp.ca.gov If you think you were treated unfairly because of your sex, age, race, color, national origin, or disability, you can also file a complaint with the U.S. Dept. of Health and Human Services: Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201

9 English IMPORTANT LANGUAGE INFORMATION: You may be entitled to the rights and services below. You can get an interpreter or translation services at no charge. Written information may also be available in some languages at no charge. To get help in your language, please call your health plan at: UnitedHealthcare of California 1-800-624-8822 / TTY: 711. If you need more help, call HMO Help Line at 1-888-466-2219.

Spanish INFORMACIÓN IMPORTANTE SOBRE IDIOMAS: Es probable que usted disponga de los derechos y servicios a continuación. Puede pedir un intérprete o servicios de traducción sin cargo. Es posible que tenga disponible documentación impresa en algunos idiomas sin cargo. Para recibir ayuda en su idioma, llame a su plan de salud de UnitedHealthcare of California al 1-800- 624-8822 / TTY: 711. Si necesita más ayuda, llame a la línea de ayuda de la HMO al 1-888-466-2219.

Chinese 重要語言資訊: 您可能有資格享有下列權利並取得下列服務。您可以免費獲取口譯員或翻譯服務。部分語言亦備 有免費書面資訊。如需取得您語言的協助,請撥打下列電話與您的健保計畫聯絡: UnitedHealthcare of California 1-800-624-8822 / 聽力語言殘障服務專線 (TTY):711。若您需要 更多協助,請撥打 HMO 協助專線 1-888-466-2219。

Armenian ԿԱՐԵՎՈՐ ԼԵԶՎԱԿԱՆ ՏԵՂԵԿՈՒԹՅՈՒՆ՝ Հավանական է, որ Ձեզ հասանելի լինեն հետևյալ իրավունքներն ու ծառայությունները: Կարող եք ստանալ բանավոր թարգմանչի կամ թարգմանության անվճար ծառայություններ: Հնարավոր է, որ մի շարք լեզուներով նաև առկա լինի անվճար գրավոր տեղեկություն: Ձեր լեզվով օգնություն ստանալու համար խնդրում ենք զանգահարել Ձեր առողջապահական ծրագիր՝ UnitedHealthcare of California 1-800-624-8822 / TTY 711 համարով: Հավելյալ օգնության կարիքի դեպքում, զանգահարեք HMO-ի Օգնության հեռախոսագիծ 1-888-466-2219 համարով:

10 Hmong COV NTAUB NTAWV LUS TSEEM CEEB: Tej zaum koj yuav muaj cai rau cov cai pab cuam hauv qab no. Koj tuaj yeem tau txais ib tug kws txhais lus los sis txhais ntawv pub dawb. Cov ntaub ntawv sau no muaj sau ua qee yam ntaub ntawv pub dawb rau sawd daws. Yuav tau txais kev cov ntaub ntawv sau ua koj lus, thov hu rau qhov chaw npaj kho mob rau ntawm: UnitedHealthcare of California 1-800-624-8822 / TTY: 711. Yog koj xav tau kev pab ntxiv, hu rau HMO Help Line ntawm tus xov tooj 1-888-466-2219.

Japanese 言語支援サービスについての重要なお知らせ: お客様には、以下権利があり、必要なサービスをご利用いただける可能性があります。お客様 は、通訳または翻訳のサービスを無料でご利用いただけます。言語によっては、文書化された 情報を無料でご利用できる場合もあります。ご希望の言語による援助をご希望の方は、お客様 の医療保険プランにご連絡ください。UnitedHealthcare of California 1-800-624-8822 / TTY: 711。 この他のサポートが必要な場合には、HMO Help Line に 1-888-466-2219 にてお問い合わせください。

Korean 중요 언어 정보: 귀하는 아래와 같은 권리 및 서비스를 누리실 수 있습니다. 귀하는 통역 혹은 번역 서비스를 비용 부담없이 이용하실 수 있습니다. 일부 언어의 경우 서면 번역 서비스 또한 비용 부담없이 제공될 수도 있습니다. 귀하의 언어 지원 서비스가 필요하시면 귀하의 건강보험에 다음 전화번호로 문의하십시오. UnitedHealthcare of California 1-800-624-8822 / TTY: 711. 더 많은 도움이 필요하신 분은 HMO 헬프 라인(안내번호: 1-888-466-2219)으로 문의하십시오.

Punjabi ਮਹੱ ਤਵਪੂਰਨ ਭਾ,ਾ ਦੀ ਜਾਣਕਾਰੀ: ਤੁਸ4 ਹੇਠ7 ਿਦੱ ਤੇ ਅਿਧਕਾਰ ਅਤੇ ਸੇਵਾਵ7 ਦੇ ਹੱ ਕਦਾਰ ਹੋ ਸਕਦੇ ਹੋ। ਤੁਸ4 ਿਬਨਾ ਿਕਸੇ ਲਾਗਤ 'ਤੇ ਦੁਭਾ,ੀਆ ਜ7 ਅਨੁਵਾਦ ਸੇਵਾਵ7 ਪ@ਾਪਤ ਕਰ ਸਕਦੇ ਹੋ। ਿਲਖਤੀ ਜਾਣਕਾਰੀ ਕੁਝ ਭਾ,ਾਵ7 ਿਵਚ ਿਬਨਾ ਿਕਸੇ ਖਰਚੇ ਦੇ ਿਮਲ ਸਕਦੀ ਹੈ। ਆਪਣੀ ਭਾ,ਾ ਿਵਚ ਸਹਾਇਤਾ ਪ@ਾਪਤ ਕਰਨ ਲਈ, ਿਕਰਪਾ ਕਰਕੇ ਆਪਣੀ ਿਸਹਤ ਯੋਜਨਾ ਨੂੰ ਇੱ ਥੇ ਕਾਲ ਕਰੋ: UnitedHealthcare of California 1-800-624-8822 / TTY: 711। ਜੇ ਤੁਹਾ ੰਨੂ ਹੋਰ ਮਦਦ ਚਾਹੀਦੀ ਹੈ, ਤ7 HMO ਹੈਲਪ ਲਾਈਨ 'ਤੇ ਕਾਲ ਕਰੋ 1-888-466-2219।

11 Russian :

12 Table of Contents of Prescription Drug List Informational Section...... 1 DRUGS - Drugs for Allergy...... 13 ANTI-INFECTIVE AGENTS - Drugs for Infections...... 16 ANTINEOPLASTIC AGENTS - Drugs for Cancer ...... 35 ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM...... 43 AUTONOMIC DRUGS - Drugs for the Nervous System ...... 44 BLOOD FORMATION, , THROMBOSIS - Drugs for the Blood ...... 54 CARDIOVASCULAR DRUGS - Drugs for the ...... 59 CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ...... 79 DEVICES - Medical Supplies and Durable Medical Equipment...... 115 DIAGNOSTIC AGENTS...... 118 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants ...... 119 ELECTROLYTIC, CALORIC, AND WATER BALANCE ...... 119 ENZYMES...... 127 EYE, EAR, NOSE AND THROAT (EENT) PREPS...... 128 GASTROINTESTINAL DRUGS ...... 138 GASTROINTESTINAL DRUGS - Drugs for the Stomach ...... 138 GOLD COMPOUNDS...... 146 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron ...... 146 HORMONES AND SYNTHETIC SUBSTITUTES - Hormones ...... 146 LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing ...... 186 MISCELLANEOUS THERAPEUTIC AGENTS ...... 186 NONHORMONAL CONTRACEPTIVES - Drugs for Women ...... 197 OXYTOCICS - Drugs for Women...... 198 PHARMACEUTICAL AIDS...... 198 RESPIRATORY TRACT AGENTS - Drugs for the ...... 198 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ...... 206 SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ...... 229 VITAMINS...... 229

TOC-1 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIHISTAMINE DRUGS - Drugs for Allergy ANTIHISTAMINE DRUGS - Drugs for Allergy hcl oral tablet 25 mg 1 ETHANOLAMINE DERIVATIVES - Drugs for Allergy allergy childrens oral 12.5 mg/5ml 3 aurodryl allergy childrens oral liquid 12.5 mg/5ml 3 banophen oral 25 mg 3 maleate oral 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 fumarate oral tablet 2.68 mg 1 diphen oral 12.5 mg/5ml 3 di-phen oral elixir 12.5 mg/5ml 3 hcl oral capsule 25 mg, 50 mg 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral liquid 12.5 mg/5ml 3 geri-dryl oral liquid 12.5 mg/5ml 3 KARBINAL ER ORAL EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) liquid allergy relief oral liquid 12.5 mg/5ml 3 m-dryl oral liquid 12.5 mg/5ml 3 sleep-aid oral capsule 50 mg 3 FIRST GEN. ANTIHIST. DERIVATIVES, MISC. - Drugs for Allergy hcl oral 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 FIRST GENERATION - Drugs for Allergy allergy childrens oral liquid 12.5 mg/5ml 3 ANTIVERT ORAL TABLET 50 MG ( hcl) 3 aurodryl allergy childrens oral liquid 12.5 mg/5ml 3 banophen oral capsule 25 mg 3 carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cvs motion sickness oral tablet 50 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 13 Coverage Requirements & Prescription Drug Name Drug Tier Limits cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 diphen oral elixir 12.5 mg/5ml 3 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral capsule 25 mg, 50 mg 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral liquid 12.5 mg/5ml 3 geri-dryl oral liquid 12.5 mg/5ml 3 goodsense motion sickness oral tablet 50 mg 3 hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) liquid allergy relief oral liquid 12.5 mg/5ml 3 m-dryl oral liquid 12.5 mg/5ml 3 meclizine hcl oral tablet 12.5 mg, 25 mg 3 motion sickness relief oral tablet 50 mg 3 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 50 mg 1 promethazine hcl rectal 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 sleep-aid oral capsule 50 mg 3 VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) OTHER ANTIHISTAMINES - Drugs for Allergy ALAWAY OPHTHALMIC SOLUTION 0.025 % ( 3 fumarate) hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 cimetidine oral tablet 200 mg 3 cimetidine oral tablet 300 mg, 400 mg, 800 mg 1 eye relief ophthalmic solution 0.025 % 3 famotidine oral suspension reconstituted 40 mg/5ml 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 14 Coverage Requirements & Prescription Drug Name Drug Tier Limits famotidine oral tablet 20 mg, 40 mg 3 hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 SL (0.10 mL per day) nizatidine oral capsule 150 mg, 300 mg 1 nizatidine oral solution 15 mg/ml 1 SL (1.02 gm (0.04 bottles) hcl nasal solution 0.6 % 3 per day) olopatadine hcl ophthalmic solution 0.1 % 3 olopatadine hcl ophthalmic solution 0.2 % 3 PATADAY OPHTHALMIC SOLUTION 0.1 %, 0.2 % 3 (olopatadine hcl) PEPCID ORAL TABLET 20 MG, 40 MG (famotidine) 3 VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) ZADITOR OPHTHALMIC SOLUTION 0.025 % (ketotifen 3 fumarate) DERIVATIVES - Drugs for Allergy promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethazine vc oral syrup 6.25-5 mg/5ml 1 PA; SL (120 mL per promethazine vc/ oral syrup 6.25-5-10 mg/5ml 1 prescription) PA; SL (120 mL per promethazine-codeine oral solution 6.25-10 mg/5ml 1 prescription) PA; SL (120 mL per promethazine-codeine oral syrup 6.25-10 mg/5ml 1 prescription) promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 PA; SL (120 mL per 1 mg/5ml prescription) promethazine- oral syrup 6.25-5 mg/5ml 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 15 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROPYLAMINE DERIVATIVES - Drugs for Allergy polst-chlorphen polst er susp oral PA; SL (120 mL per 3 suspension extended release 10-8 mg/5ml prescription) -bromphen-dm oral syrup 30-2-10 mg/5ml 3 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 SL (30 capsules per month); 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) AE TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR SL (30 tablets per month); 3 54.3-8 MG (chlorpheniramine-codeine) AE SECOND GENERATION ANTIHISTAMINES - Drugs for Allergy ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 3 tromethamine) cetirizine hcl oral solution 1 mg/ml, 5 mg/5ml 3 CLARINEX ORAL TABLET 5 MG (desloratadine) 3 SL (1 tablet per day) CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 SL (2 tablets per day) 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) desloratadine oral tablet 5 mg 3 SL (1 tablet per day) desloratadine oral tablet dispersible 5 mg 3 SL (1 tablet per day) levocetirizine dihydrochloride oral solution 2.5 mg/5ml 3 levocetirizine dihydrochloride oral tablet 5 mg 1 ANTI-INFECTIVE AGENTS - Drugs for Infections 1ST GENERATION CEPHALOSPORIN - Antibiotics SL (45 tablets per cefadroxil oral capsule 500 mg 1 prescription) cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml 1 SL (45 tablets per cefadroxil oral tablet 1 gm 1 prescription) cephalexin oral capsule 250 mg, 500 mg, 750 mg 1 cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cephalexin oral tablet 250 mg, 500 mg 1 KEFLEX ORAL CAPSULE 750 MG (cephalexin) 1 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefaclor er oral tablet extended release 12 hour 500 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 16 Coverage Requirements & Prescription Drug Name Drug Tier Limits cefaclor oral capsule 250 mg, 500 mg 1 cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml 1 cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefprozil oral tablet 250 mg, 500 mg 1 cefuroxime axetil oral tablet 250 mg, 500 mg 1 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS - Antibiotics cefdinir oral capsule 300 mg 1 cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 cefixime oral capsule 400 mg 3 cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml 3 cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml 3 cefpodoxime proxetil oral tablet 100 mg, 200 mg 1 SUPRAX ORAL CAPSULE 400 MG (cefixime) 3 SUPRAX ORAL SUSPENSION RECONSTITUTED 100 3 MG/5ML, 200 MG/5ML, 500 MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 3 (cefixime) ADAMANTANE ANTIVIRALS - Drugs for Viral Infections hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 3 hcl oral tablet 100 mg 1 ALLYLAMINE ANTIFUNGALS - Drugs for Fungus terbinafine hcl oral tablet 250 mg 1 SL (90 tablets per 365 days) AMEBICIDES - Drugs for the Mouth and Throat FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 FLAGYL ORAL TABLET 500 MG (metronidazole) 3 metronidazole oral capsule 375 mg 3 metronidazole oral tablet 250 mg, 500 mg 1 metronidazole vaginal gel 0.75 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 17 Coverage Requirements & Prescription Drug Name Drug Tier Limits paromomycin sulfate oral capsule 250 mg 1 vandazole vaginal gel 0.75 % 1 AMINOGLYCOSIDE ANTIBIOTICS - Antibiotics ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML 3 PA; SL (8.4 mL per day) (amikacin sulfate ) sulfate oral tablet 500 mg 1 paromomycin sulfate oral capsule 250 mg 1 TOBI PODHALER INHALATION CAPSULE 28 MG PA; SL (224 capsules per 8 3 (tobramycin) weeks) tobramycin inhalation nebulization solution 300 mg/4ml 1 PA; SL (224 mL per 8 weeks) AMINOMETHYLCYCLINES - Antibiotics SL (30 tablets per NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) 3 prescription) AMINOPENICILLIN ANTIBIOTICS - Antibiotics SL (112 doses (14 daily amoxicill-clarithro-lansopraz oral 3 administration packs) per 365 days) amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml 1 amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 amoxicillin-potassium clavulanate er oral tablet extended 1 release 12 hour 1000-62.5 mg amoxicillin-potassium clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 1 mg/5ml, 600-42.9 mg/5ml amoxicillin-potassium clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg 1 amoxicillin-potassium clavulanate oral tablet chewable 200- 28.5 mg, 400-57 mg 1 ampicillin oral capsule 500 mg 1 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- SL (80 capsules (1 pack) per 2 clarithro-omeprazole) year) ANTHELMINTICS - Drugs for Parasites PA; SL (124 tablets per albendazole oral tablet 200 mg 3 month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 18 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (124 tablets per ALBENZA ORAL TABLET 200 MG ( albendazole) 3 month) BILTRICIDE ORAL TABLET 600 MG (praziquantel) 3 EGATEN ORAL TABLET 250 MG (triclabendazole) 3 EMVERM ORAL TABLET CHEWABLE 100 MG 3 PA; SL (6 tablets per 3 days) (mebendazole) oral tablet 3 mg 3 praziquantel oral tablet 600 mg 1 STROMECTOL ORAL TABLET 3 MG ( ivermectin) 3 ANTIFUNGALS, MISCELLANEOUS - Drugs for Fungus griseofulvin microsize oral suspension 125 mg/5ml 1 griseofulvin microsize oral tablet 500 mg 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 ANTI-INFECTIVES (SYSTEMIC), MISC. - Drugs for Infections ST; SL (224 doses (1 kit) per HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 365 days) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 365 2 metronid-tetracyc) days) ANTIMALARIALS - Drugs for the Mouth and Throat ARAKODA ORAL TABLET 100 MG (tafenoquine succinate) 3 SL (16 tablets per month) atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg 3 avidoxy oral tablet 100 mg 3 chloroquine phosphate oral tablet 250 mg, 500 mg 1 COARTEM ORAL TABLET 20-120 MG (artemether- 3 lumefantrine) DARAPRIM ORAL TABLET 25 MG (pyrimethamine) 3 PA doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg 1 doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1 doxycycline monohydrate oral suspension reconstituted 25 mg/5ml 3 doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 19 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydroxychloroquine sulfate oral tablet 200 mg 1 SL (2 tablets per KRINTAFEL ORAL TABLET 150 MG ( tafenoquine succinate) 1 prescription) MALARONE ORAL TABLET 250-100 MG, 62.5-25 MG 3 (atovaquone-proguanil hcl) hcl oral tablet 250 mg 1 hcl oral capsule 100 mg, 50 mg 1 minocycline hcl oral capsule 75 mg 3 mondoxyne nl oral capsule 100 mg, 75 mg 1 morgidox oral capsule 100 mg 1 primaquine phosphate oral tablet 26.3 (15 base) mg 1 pyrimethamine oral tablet 25 mg 3 PA QUALAQUIN ORAL CAPSULE 324 MG (quinine sulfate) 3 gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 quinine sulfate oral capsule 324 mg 3 tetracycline hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 3 VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 3 MG/5ML (doxycycline monohydrate) VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline 3 ) ANTIMYCOBACTERIALS, MISCELLANEOUS - Antibiotics dapsone oral tablet 100 mg, 25 mg 1 ANTIPROTOZOALS, MISCELLANEOUS - Drugs for the Mouth and Throat ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 2 SL (60 mL per prescription) (nitazoxanide) SL (6 tablets per ALINIA ORAL TABLET 500 MG (nitazoxanide) 3 prescription) atovaquone oral suspension 750 mg/5ml 3 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) BENZNIDAZOLE ORAL TABLET 100 MG 2 PA; SL (4 tablets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 20 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (720 tablets per 720 BENZNIDAZOLE ORAL TABLET 12.5 MG 2 days) dapsone oral tablet 100 mg, 25 mg 1 FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 FLAGYL ORAL TABLET 500 MG (metronidazole) 3 ST; SL (224 doses (1 kit) per HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 365 days) IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) 2 PA LAMPIT ORAL TABLET 120 MG (nifurtimox) 3 PA; SL (7.5 tablets per day) LAMPIT ORAL TABLET 30 MG (nifurtimox) 3 PA; SL (9 tablets per day) MEPRON ORAL SUSPENSION 750 MG/5ML (atovaquone) 3 metronidazole oral capsule 375 mg 3 metronidazole oral tablet 250 mg, 500 mg 1 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 SL (1 container/inhaler per 3 MG ( isethionate) prescription) SL (6 tablets per nitazoxanide oral tablet 500 mg 1 prescription) pentamidine isethionate inhalation solution reconstituted SL (1 container/inhaler per 1 300 mg prescription) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 365 2 metronid-tetracyc) days) SOLOSEC ORAL PACKET 2 GM (secnidazole) 3 ST; SL (1 packet per month) sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 160 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1 tinidazole oral tablet 250 mg, 500 mg 3 ANTITUBERCULOSIS AGENTS - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) () CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 3 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 er oral tablet extended release 24 hour 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 21 Coverage Requirements & Prescription Drug Name Drug Tier Limits clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 clarithromycin oral tablet 250 mg, 500 mg 1 oral capsule 250 mg 3 ethambutol hcl oral tablet 100 mg, 400 mg 1 isoniazid oral syrup 50 mg/5ml 1 isoniazid oral tablet 100 mg, 300 mg 1 oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl oral tablet 400 mg 3 MYAMBUTOL ORAL TABLET 400 MG ( ethambutol hcl) 3 MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 3 SL (2 capsules per day) PASER ORAL PACKET 4 GM (aminosalicylic acid) 3 PRETOMANID ORAL TABLET 200 MG 3 PRIFTIN ORAL TABLET 150 MG (rifapentine) 3 pyrazinamide oral tablet 500 mg 1 rifabutin oral capsule 150 mg 1 SL (2 capsules per day) rifampin oral capsule 150 mg, 300 mg 1 SIRTURO ORAL TABLET 100 MG ( fumarate) 3 TRECATOR ORAL TABLET 250 MG ( ethionamide) 3 ANTIVIRALS, MISCELLANEOUS - Drugs for Viral Infections PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) 2 PA XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK 2 3 SL (2 tablets per 30 days) X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK 2 3 SL (2 tablets per 30 days) X 40 MG (baloxavir marboxil) AZOLE ANTIFUNGALS - Drugs for Fungus CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium 3 sulfate) DIFLUCAN ORAL SUSPENSION RECONSTITUTED 10 3 MG/ML, 40 MG/ML (fluconazole) DIFLUCAN ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 (fluconazole) fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 22 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 itraconazole oral capsule 100 mg 1 PA itraconazole oral solution 10 mg/ml 3 PA oral tablet 200 mg 1 NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) 3 SL (20 mL per day) posaconazole oral tablet delayed release 100 mg 3 SPORANOX ORAL CAPSULE 100 MG (itraconazole) 3 PA SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) 3 PA SPORANOX PULSEPAK ORAL CAPSULE 100 MG 3 PA (itraconazole) VFEND ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 SL (300 mL per prescription) (voriconazole) VFEND ORAL TABLET 200 MG, 50 MG (voriconazole) 3 SL (4 tablets per day) voriconazole oral suspension reconstituted 40 mg/ml 3 SL (300 mL per prescription) voriconazole oral tablet 200 mg, 50 mg 3 SL (4 tablets per day) ANTIBIOTICS - Antibiotics E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 3 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 3 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 3 MG/5ML (erythromycin ethylsuccinate) ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 3 MG, 500 MG (erythromycin base) ERYTHROCIN STEARATE ORAL TABLET 250 MG 3 (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 mg 1 erythromycin base oral tablet 250 mg, 500 mg 1 erythromycin base oral tablet delayed release 250 mg, 333 mg, 500 mg 3 erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml, 400 mg/5ml 3 erythromycin ethylsuccinate oral tablet 400 mg 1 erythromycin oral tablet delayed release 250 mg, 333 mg, 500 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 23 Coverage Requirements & Prescription Drug Name Drug Tier Limits GLYCOPEPTIDE ANTIBIOTICS - Antibiotics FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML, 50 1 MG/ML (vancomycin hcl) VANCOCIN HCL ORAL CAPSULE 125 MG (vancomycin hcl) 3 VANCOCIN ORAL CAPSULE 250 MG (vancomycin hcl) 3 vancomycin hcl oral capsule 125 mg, 250 mg 3 vancomycin hcl oral solution reconstituted 250 mg/5ml 3 HCV POLYMERASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG 2 PA; SL (1 tablet per day) (sofosbuvir-velpatasvir) HARVONI ORAL TABLET 45-200 MG, 90-400 MG (ledipasvir- 2 PA; SL (1 tablet per day) sofosbuvir) LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 PA; SL (1 tablet per day) SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 PA; SL (1 tablet per day) SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) 4 PA VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 4 PA; SL (4 tablets per day) &250 MG (ombitas-paritapre-ritona-dasab) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- 2 PA; SL (1 tablet per day) velpatasv-voxilaprev) HCV PROTEASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections MAVYRET ORAL TABLET 100-40 MG (glecaprevir- 2 PA; SL (3 tablets per day) pibrentasvir) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 4 PA; SL (4 tablets per day) &250 MG (ombitas-paritapre-ritona-dasab) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- 2 PA; SL (1 tablet per day) velpatasv-voxilaprev) PA; SL (84 tablets per 720 ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 2 days (12 weeks)) HCV REPLICATION COMPLEX INHIBITORS - Drugs for Viral Infections EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG 2 PA; SL (1 tablet per day) (sofosbuvir-velpatasvir) HARVONI ORAL TABLET 45-200 MG, 90-400 MG (ledipasvir- 2 PA; SL (1 tablet per day) sofosbuvir) LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400 MG 2 PA; SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 24 Coverage Requirements & Prescription Drug Name Drug Tier Limits MAVYRET ORAL TABLET 100-40 MG (glecaprevir- 2 PA; SL (3 tablets per day) pibrentasvir) SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100 MG 2 PA; SL (1 tablet per day) VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 4 PA; SL (4 tablets per day) &250 MG (ombitas-paritapre-ritona-dasab) VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- 2 PA; SL (1 tablet per day) velpatasv-voxilaprev) PA; SL (84 tablets per 720 ZEPATIER ORAL TABLET 50-100 MG (elbasvir-grazoprevir) 2 days (12 weeks)) HIV ENTRY AND FUSION INHIBITORS - Drugs for Viral Infections SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) 2 PA SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG 2 PA (maraviroc) TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33ML 2 (ibalizumab-uiyk) HIV INTEGRASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) DOVATO ORAL TABLET 50-300 MG (dolutegravir- 2 lamivudine) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 emtricit-tenofaf) ISENTRESS HD ORAL TABLET 600 MG (raltegravir 2 potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir potassium) 2 ISENTRESS ORAL TABLET 400 MG (raltegravir potassium) 2 ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG 2 (raltegravir potassium) JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 2 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 2 cobic-emtricit-tenofdf) TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG (dolutegravir 2 sodium) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 dolutegravir-lamivud) VOCABRIA ORAL TABLET 30 MG 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 25 Coverage Requirements & Prescription Drug Name Drug Tier Limits HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB. - Drugs for Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- 2 rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 2 lamivudin-tenofov df) EDURANT ORAL TABLET 25 MG (rilpivirine hcl) 2 oral capsule 200 mg, 50 mg 1 efavirenz oral tablet 600 mg 1 efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600-300-300 mg 1 SL (1 tablet per day) etravirine oral tablet 100 mg, 200 mg 1 INTELENCE ORAL TABLET 100 MG, 200 MG ( etravirine) 3 INTELENCE ORAL TABLET 25 MG ( etravirine) 2 JULUCA ORAL TABLET 50-25 MG (dolutegravir-rilpivirine) 2 nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg 1 nevirapine oral suspension 50 mg/5ml 4 nevirapine oral tablet 200 mg 4 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 tenofov af) PIFELTRO ORAL TABLET 100 MG (doravirine) 2 SUSTIVA ORAL TABLET 600 MG (efavirenz) 3 SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 3 SL (1 tablet per day) lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- 3 SL (1 tablet per day) lamivudine-tenofovir) VIRAMUNE ORAL SUSPENSION 50 MG/5ML (nevirapine) 4 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 3 HOUR 400 MG (nevirapine) HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS - Drugs for Viral Infections abacavir sulfate oral solution 20 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 26 Coverage Requirements & Prescription Drug Name Drug Tier Limits abacavir sulfate oral tablet 300 mg 1 abacavir sulfate-lamivudine oral tablet 600-300 mg 1 abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg 1 BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- 2 emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 COMBIVIR ORAL TABLET 150-300 MG (lamivudine- 4 zidovudine) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- 2 rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- 2 lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine- 2 H-N tenofovir af) DOVATO ORAL TABLET 50-300 MG (dolutegravir- 2 lamivudine) efavirenz-emtricitab-tenofovir oral tablet 600-200-300 mg 1 efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600-300-300 mg 1 SL (1 tablet per day) emtricitabine oral capsule 200 mg 1 emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg 1 emtricitabine-tenofovir df oral tablet 200-300 mg 1 H-N EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) 3 EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) 2 EPIVIR HBV ORAL SOLUTION 5 MG/ML (lamivudine) 3 EPIVIR HBV ORAL TABLET 100 MG (lamivudine) 3 EPIVIR ORAL SOLUTION 10 MG/ML (lamivudine) 3 EPIVIR ORAL TABLET 150 MG, 300 MG (lamivudine) 3 EPZICOM ORAL TABLET 600-300 MG (abacavir sulfate- 3 lamivudine) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-cobic- 2 emtricit-tenofaf) lamivudine oral solution 10 mg/ml 1 lamivudine oral tablet 100 mg 3 lamivudine oral tablet 150 mg, 300 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 27 Coverage Requirements & Prescription Drug Name Drug Tier Limits lamivudine-zidovudine oral tablet 150-300 mg 4 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-rilpivir- 2 tenofov af) RETROVIR INTRAVENOUS SOLUTION 10 MG/ML 2 (zidovudine) RETROVIR ORAL CAPSULE 100 MG (zidovudine) 3 RETROVIR ORAL SYRUP 50 MG/5ML (zidovudine) 3 stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg 1 STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 2 cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- 3 SL (1 tablet per day) lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- 3 SL (1 tablet per day) lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine-tenofovir) 2 tenofovir disoproxil fumarate oral tablet 300 mg 1 H-N TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- 2 dolutegravir-lamivud) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 3 MG (emtricitabine-tenofovir df) VIREAD ORAL 40 MG/GM (tenofovir disoproxil 2 fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG (tenofovir 2 disoproxil fumarate) ZIAGEN ORAL SOLUTION 20 MG/ML (abacavir sulfate) 3 ZIAGEN ORAL TABLET 300 MG (abacavir sulfate) 3 zidovudine oral capsule 100 mg 1 zidovudine oral syrup 50 mg/5ml 1 zidovudine oral tablet 300 mg 1 HIV PROTEASE INHIBITOR ANTIRETROVIRALS - Drugs for Viral Infections APTIVUS ORAL CAPSULE 250 MG (tipranavir) 2 atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg 1 CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 28 Coverage Requirements & Prescription Drug Name Drug Tier Limits EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 2 fosamprenavir calcium oral tablet 700 mg 1 INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) 2 KALETRA ORAL SOLUTION 400-100 MG/5ML (lopinavir- 3 ritonavir) KALETRA ORAL TABLET 100-25 MG, 200-50 MG (lopinavir- 3 ritonavir) LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir 2 calcium) lopinavir-ritonavir oral solution 400-100 mg/5ml 1 lopinavir-ritonavir oral tablet 100-25 mg, 200-50 mg 1 NORVIR ORAL PACKET 100 MG (ritonavir) 2 NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) 2 NORVIR ORAL TABLET 100 MG (ritonavir) 3 PREZCOBIX ORAL TABLET 800-150 MG (darunavir- 2 cobicistat) PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir 2 ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 (darunavir ethanolate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) 2 ritonavir oral tablet 100 mg 1 SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 emtricit-tenofaf) VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir 2 mesylate) LINCOMYCIN ANTIBIOTICS - Antibiotics CLEOCIN ORAL CAPSULE 150 MG, 300 MG, 75 MG 3 (clindamycin hcl) CLEOCIN ORAL SOLUTION RECONSTITUTED 75 MG/5ML 3 (clindamycin palmitate hcl) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml 3 MONOBACTAM ANTIBIOTICS - Antibiotics CAYSTON INHALATION SOLUTION RECONSTITUTED 75 PA; SL (84 vials per 8 4 MG (aztreonam ) weeks)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 29 Coverage Requirements & Prescription Drug Name Drug Tier Limits NATURAL ANTIBIOTICS - Antibiotics penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml 1 penicillin v potassium oral tablet 250 mg, 500 mg 1 NEURAMINIDASE INHIBITOR ANTIVIRALS - Drugs for Viral Infections oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg 3 oseltamivir phosphate oral suspension reconstituted 6 mg/ml 3 SL (180 mL per month) RELENZA DISKHALER INHALATION AEROSOL POWDER 3 BREATH ACTIVATED 5 MG/BLISTER (zanamivir) TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG 3 (oseltamivir phosphate) NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS - Drugs for Viral Infections acyclovir oral capsule 200 mg 1 acyclovir oral suspension 200 mg/5ml 1 acyclovir oral tablet 400 mg, 800 mg 1 adefovir dipivoxil oral tablet 10 mg 1 BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) 4 SL (630 mL per 30 days) BARACLUDE ORAL TABLET 0.5 MG, 1 MG (entecavir) 4 SL (1 tablet per day) entecavir oral tablet 0.5 mg, 1 mg 4 SL (1 tablet per day) famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 ribavirin inhalation solution reconstituted 6 gm 3 ribavirin oral capsule 200 mg 3 ribavirin oral tablet 200 mg 1 SITAVIG BUCCAL TABLET 50 MG (acyclovir) 3 valacyclovir hcl oral tablet 1 gm 1 SL (4 tablets per day) valacyclovir hcl oral tablet 500 mg 1 SL (2 tablets per day) valganciclovir hcl oral solution reconstituted 50 mg/ml 1 valganciclovir hcl oral tablet 450 mg 1 SL (4 tablets per day) VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide 3 ST fumarate) VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM 3 (ribavirin) ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 30 Coverage Requirements & Prescription Drug Name Drug Tier Limits OTHER MACROLIDE ANTIBIOTICS - Antibiotics SL (112 doses (14 daily amoxicill-clarithro-lansopraz oral 3 administration packs) per 365 days) azithromycin oral packet 1 gm 1 azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml 1 azithromycin oral tablet 250 mg, 500 mg, 600 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 clarithromycin oral tablet 250 mg, 500 mg 1 DIFICID ORAL SUSPENSION RECONSTITUTED 40 MG/ML 3 SL (136 mL per 10 days) (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) 3 OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- SL (80 capsules (1 pack) per 2 clarithro-omeprazole) year) ZITHROMAX ORAL PACKET 1 GM (azithromycin) 2 ZITHROMAX ORAL SUSPENSION RECONSTITUTED 100 3 MG/5ML, 200 MG/5ML (azithromycin) ZITHROMAX ORAL TABLET 250 MG, 500 MG (azithromycin) 3 ZITHROMAX TRI-PAK ORAL TABLET 500 MG (azithromycin) 3 ZITHROMAX Z-PAK ORAL TABLET 250 MG (azithromycin) 3 OXAZOLIDINONE ANTIBIOTICS - Antibiotics linezolid oral suspension reconstituted 100 mg/5ml 3 SL (900 mL per 11 days) linezolid oral tablet 600 mg 1 SL (28 tablets per 11 days) SL (6 tablets per SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) 3 prescription) ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 3 SL (900 mL per 11 days) (linezolid) PENICILLINASE-RESISTANT - Antibiotics dicloxacillin sodium oral capsule 250 mg, 500 mg 1 PLEUROMUTILINS - Antibiotics XENLETA ORAL TABLET 600 MG ( lefamulin acetate) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 31 Coverage Requirements & Prescription Drug Name Drug Tier Limits POLYENE ANTIFUNGALS - Drugs for Fungus nystatin mouth/throat suspension 100000 unit/ml 1 nystatin oral tablet 500000 unit 1 PYRIMIDINE ANTIFUNGALS - Drugs for Fungus ANCOBON ORAL CAPSULE 250 MG, 500 MG (flucytosine) 3 flucytosine oral capsule 250 mg, 500 mg 3 QUINOLONE ANTIBIOTICS - Antibiotics BAXDELA ORAL TABLET 450 MG (delafloxacin meglumine) 3 CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML 3 (5%), 500 MG/5ML (10%) (ciprofloxacin) CIPRO ORAL TABLET 250 MG, 500 MG (ciprofloxacin hcl) 3 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 1 levofloxacin oral solution 25 mg/ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 moxifloxacin hcl oral tablet 400 mg 3 SL (45 tablets per oral tablet 300 mg, 400 mg 3 prescription) RIFAMYCIN ANTIBIOTICS - Antibiotics AEMCOLO ORAL TABLET DELAYED RELEASE 194 MG SL (12 tablets per 3 (rifamycin sodium) prescription) MYCOBUTIN ORAL CAPSULE 150 MG (rifabutin) 3 SL (2 capsules per day) PRIFTIN ORAL TABLET 150 MG (rifapentine) 3 rifabutin oral capsule 150 mg 1 SL (2 capsules per day) rifampin oral capsule 150 mg, 300 mg 1 XIFAXAN ORAL TABLET 200 MG, 550 MG (rifaximin) 3 PA SULFONAMIDE ANTIBIOTICS (SYSTEMIC) - Antibiotics AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) sulfadiazine oral tablet 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 32 Coverage Requirements & Prescription Drug Name Drug Tier Limits sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 160 mg 1 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1 TETRACYCLINE ANTIBIOTICS - Antibiotics AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) avidoxy oral tablet 100 mg 3 demeclocycline hcl oral tablet 150 mg, 300 mg 1 doxycycline hyclate oral capsule 100 mg, 50 mg 1 doxycycline hyclate oral tablet 100 mg, 20 mg 1 doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg 1 doxycycline monohydrate oral suspension reconstituted 25 mg/5ml 3 doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg 3 ST; SL (224 doses (1 kit) per HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 365 days) minocycline hcl oral capsule 100 mg, 50 mg 1 minocycline hcl oral capsule 75 mg 3 mondoxyne nl oral capsule 100 mg, 75 mg 1 MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG 3 (doxycycline hyclate-cleanser) morgidox oral capsule 100 mg 1 NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3 3-e) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 365 2 metronid-tetracyc) days) tetracycline hcl oral capsule 250 mg, 500 mg 1 VIBRAMYCIN ORAL CAPSULE 100 MG (doxycycline hyclate) 3 VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED 25 3 MG/5ML (doxycycline monohydrate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 33 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline 3 calcium) URINARY ANTI-INFECTIVES - Drugs for the Urinary System BACTRIM DS ORAL TABLET 800-160 MG (sulfamethoxazole- 3 trimethoprim) BACTRIM ORAL TABLET 400-80 MG (sulfamethoxazole- 3 trimethoprim) fosfomycin tromethamine oral packet 3 gm 3 HIPREX ORAL TABLET 1 GM (methenamine hippurate) 3 HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz 3 acd-ph sal) MACROBID ORAL CAPSULE 100 MG (nitrofurantoin 3 monohyd macro) MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 MG 3 (nitrofurantoin macrocrystal) me/naphos/mb/hyo1 oral tablet 81.6 mg 3 methenamine hippurate oral tablet 1 gm 3 methenamine mandelate oral tablet 0.5 gm, 1 gm 1 MONUROL ORAL PACKET 3 GM (fosfomycin tromethamine) 3 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg 1 nitrofurantoin monohydrate macrocrystals oral capsule 100 mg 1 nitrofurantoin oral suspension 25 mg/5ml 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim hcl) 3 sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml 1 sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- 160 mg 1 sulfatrim pediatric oral suspension 200-40 mg/5ml 1 trimethoprim oral tablet 100 mg 1 URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 34 Coverage Requirements & Prescription Drug Name Drug Tier Limits URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 3 meth blue-na phos) uro-mp oral capsule 118 mg 3 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) ANTINEOPLASTIC AGENTS - Drugs for Cancer ANTINEOPLASTIC AGENTS - Drugs for Cancer PA; SL (4 tablets per day); oral tablet 250 mg, 500 mg 1 CM AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 3 PA; CM MG (everolimus) AFINITOR ORAL TABLET 10 MG (everolimus) 3 PA; SL (1 tablet per day); CM PA; SL (8 capsules per day); ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) 3 CM ALKERAN ORAL TABLET 2 MG () 3 CM ALUNBRIG ORAL TABLET 180 MG, 90 MG (brigatinib) 2 PA; SL (1 tablet per day); CM PA; SL (4 tablets per 30 ALUNBRIG ORAL TABLET 30 MG (brigatinib) 2 days); CM ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG PA; SL (1 pack per 365 2 (brigatinib) days); CM anastrozole oral tablet 1 mg 1 CM ARIMIDEX ORAL TABLET 1 MG (anastrozole) 3 CM AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 3 PA; SL (1 tablet per day); CM 50 MG (avapritinib) PA; SL (3 tablets per day); BALVERSA ORAL TABLET 3 MG (erdafitinib) 2 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 35 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (2 tablets per day); BALVERSA ORAL TABLET 4 MG (erdafitinib) 2 CM BALVERSA ORAL TABLET 5 MG (erdafitinib) 2 PA; SL (1 tablet per day); CM oral capsule 75 mg 1 CM oral tablet 50 mg 1 CM PA; SL (4 tablets per day); BOSULIF ORAL TABLET 100 MG (bosutinib) 4 CM BOSULIF ORAL TABLET 400 MG (bosutinib) 2 PA; SL (1 tablet per day); CM BOSULIF ORAL TABLET 500 MG (bosutinib) 4 PA; SL (1 tablet per day); CM PA; SL (6 capsules per day); BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) 3 CM PA; SL (4 tablets per day); BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) 2 CM CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG 2 PA; CM (cabozantinib s-malate) PA; SL (2 capsules per day); CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) 2 CM SL (84 tablets per oral tablet 150 mg 1 prescription); CM SL (140 tablets per capecitabine oral tablet 500 mg 1 prescription); CM PA; SL (2 tablets per day); CAPRELSA ORAL TABLET 100 MG (vandetanib) 2 CM CAPRELSA ORAL TABLET 300 MG (vandetanib) 2 PA; SL (1 tablet per day); CM CASODEX ORAL TABLET 50 MG (bicalutamide) 3 CM PA; SL (3 capsules per day); COMETRIQ ORAL KIT 20 MG (cabozantinib s-malate) 4 CM COMETRIQ ORAL KIT 3 X 20 MG & 80 MG (cabozantinib s- PA; SL (4 capsules per day); 4 malate) CM PA; SL (2 capsules per day); COMETRIQ ORAL KIT 80 & 20 MG (cabozantinib s-malate) 4 CM PA; SL (2 capsules per day); COPIKTRA ORAL CAPSULE 15 MG, 25 MG () 3 CM PA; SL (63 tablets per COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) 2 prescription); CM oral capsule 25 mg, 50 mg 3 CM CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 2 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 36 Coverage Requirements & Prescription Drug Name Drug Tier Limits DAURISMO ORAL TABLET 100 MG (glasdegib maleate) 2 PA; SL (1 tablet per day); CM PA; SL (2 tablets per day); DAURISMO ORAL TABLET 25 MG (glasdegib maleate) 2 CM DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 3 (hydroxyurea) EMCYT ORAL CAPSULE 140 MG ( phosphate 2 CM sodium) PA; SL (1 capsule per day); ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) 2 CM PA; SL (4 tablets per day); ERLEADA ORAL TABLET 60 MG () 2 CM erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg 3 PA; SL (1 tablet per day); CM oral capsule 50 mg 1 CM everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg 3 PA; SL (1 tablet per day); CM oral tablet 25 mg 1 CM FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG PA; SL (6 capsules per 2 ( lactate) month); CM oral capsule 125 mg 1 CM GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG (afatinib 4 PA; SL (1 tablet per day); CM dimaleate) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG 3 CM () PA; SL (182 tablets per HYCAMTIN ORAL CAPSULE 0.25 MG ( hcl) 4 prescription); CM PA; SL (40 tablets per HYCAMTIN ORAL CAPSULE 1 MG (topotecan hcl) 4 prescription); CM HYDREA ORAL CAPSULE 500 MG (hydroxyurea) 3 CM hydroxyurea oral capsule 500 mg 1 CM IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA; SL (0.75 tablets per 2 () day); CM IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PA; SL (0.75 tablets per 2 (palbociclib) day); CM ICLUSIG ORAL TABLET 10 MG, 30 MG, 45 MG (ponatinib 3 PA; SL (1 tablet per day); CM hcl) PA; SL (2 tablets per day); ICLUSIG ORAL TABLET 15 MG (ponatinib hcl) 3 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 37 Coverage Requirements & Prescription Drug Name Drug Tier Limits IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib 2 PA; SL (1 tablet per day); CM mesylate) PA; SL (8 tablets per day); imatinib mesylate oral tablet 100 mg 1 CM PA; SL (2 tablets per day); imatinib mesylate oral tablet 400 mg 1 CM PA; SL (1 capsule per day); IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) 2 CM IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 2 PA; SL (1 tablet per day); CM MG (ibrutinib) PA; SL (4 tablets per day); INLYTA ORAL TABLET 1 MG, 5 MG ( axitinib) 4 CM PA; SL (4 capsules per day); INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) 3 CM IRESSA ORAL TABLET 250 MG (gefitinib) 3 PA; CM JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA; SL (2 tablets per day); 4 (ruxolitinib phosphate) CM JELMYTO SOLUTION RECONSTITUTED 80 (2 X 40) MG 3 (mitomycin) KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 PA; SL (1 pack (91 tablets) 3 MG (-letrozole) per 28 days); CM KISQALI ORAL TABLET THERAPY PACK 200 MG (ribociclib PA; SL (63 tablets per 28 3 succinate) days); CM PA; SL (8 capsules per day); KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) 2 CM PA; SL (4 capsules per day); KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) 2 CM PA; SL (6 tablets per day); lapatinib ditosylate oral tablet 250 mg 4 CM LENVIMA ORAL CAPSULE THERAPY PACK 10 & 4 MG, 2 X PA; SL (2 capsules per day); 3 10 MG (lenvatinib mesylate) CM LENVIMA ORAL CAPSULE THERAPY PACK 10 MG & 2 X 4 3 PA; CM MG, 2 X 4 MG (lenvatinib mesylate) LENVIMA ORAL CAPSULE THERAPY PACK 10 MG, 4 MG PA; SL (1 capsule per day); 3 (lenvatinib mesylate) CM LENVIMA ORAL CAPSULE THERAPY PACK 2 X 10 MG & 4 PA; SL (3 capsules per day); 3 MG, 3 X 4 MG (lenvatinib mesylate) CM letrozole oral tablet 2.5 mg 1 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 38 Coverage Requirements & Prescription Drug Name Drug Tier Limits LEUKERAN ORAL TABLET 2 MG () 2 CM LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG PA; SL (80 tablets per 21 2 (trifluridine-tipiracil) days); CM LORBRENA ORAL TABLET 100 MG, 25 MG ( lorlatinib) 3 PA; CM LUMAKRAS ORAL TABLET 120 MG (sotorasib) 4 PA; CM PA; SL (4 tablets per day); LYNPARZA ORAL TABLET 100 MG, 150 MG () 2 CM LYSODREN ORAL TABLET 500 MG () 2 CM MATULANE ORAL CAPSULE 50 MG ( hcl) 4 CM oral suspension 40 mg/ml 1 CM megestrol acetate oral suspension 625 mg/5ml 3 megestrol acetate oral tablet 20 mg, 40 mg 1 CM MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl PA; SL (4 tablets per day); 4 sulfoxide) CM MEKINIST ORAL TABLET 2 MG (trametinib dimethyl 4 PA; SL (1 tablet per day); CM sulfoxide) PA; SL (6 tablets per day); MEKTOVI ORAL TABLET 15 MG (binimetinib) 3 CM melphalan oral tablet 2 mg 1 CM oral tablet 50 mg 1 CM oral tablet 2.5 mg 1 CM methotrexate sodium oral tablet 2.5 mg 1 CM MYLERAN ORAL TABLET 2 MG () 2 CM PA; SL (6 tablets per day); NERLYNX ORAL TABLET 40 MG ( neratinib maleate) 2 CM PA; SL (4 tablets per day); NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) 4 CM NILANDRON ORAL TABLET 150 MG ( ) 3 CM nilutamide oral tablet 150 mg 1 CM NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ( PA; SL (3 capsules per 2 citrate) month); CM PA; SL (4 tablets per day); NUBEQA ORAL TABLET 300 MG () 2 CM PA; SL (1 capsule per day); ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) 2 CM ONUREG ORAL TABLET 200 MG, 300 MG () 2 SL (1 tablet per day); CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 39 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORGOVYX ORAL TABLET 120 MG (relugolix) 3 PA; SL (1 tablet per day); CM PIQRAY ORAL TABLET THERAPY PACK 2 X 150 MG, 200 & PA; SL (2 tablets per day); 2 50 MG () CM PIQRAY ORAL TABLET THERAPY PACK 200 MG (alpelisib) 2 PA; SL (1 tablet per day); CM POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; SL (1 capsule per day); 4 (pomalidomide) CM PURIXAN ORAL SUSPENSION 2000 MG/100ML 3 PA; CM (mercaptopurine) PA; SL (3 tablets per day); QINLOCK ORAL TABLET 50 MG (ripretinib) 3 CM PA; SL (6 capsules per day); RETEVMO ORAL CAPSULE 40 MG (selpercatinib) 4 CM PA; SL (4 capsules per day); RETEVMO ORAL CAPSULE 80 MG (selpercatinib) 4 CM REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, PA; SL (1 capsule per day); 4 25 MG, 5 MG (lenalidomide) CM PA; SL (1 capsule per day); ROZLYTREK ORAL CAPSULE 100 MG (entrectinib) 3 CM PA; SL (3 capsules per day); ROZLYTREK ORAL CAPSULE 200 MG (entrectinib) 3 CM RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA; SL (4 tablets per day); 3 ( camsylate) CM PA; SL (8 capsules per day); RYDAPT ORAL CAPSULE 25 MG (midostaurin) 2 CM SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) 3 CM SPRYCEL ORAL TABLET 100 MG, 140 MG, 80 MG 4 PA; SL (1 tablet per day); CM (dasatinib) PA; SL (9 tablets per day); SPRYCEL ORAL TABLET 20 MG (dasatinib) 4 CM PA; SL (3 tablets per day); SPRYCEL ORAL TABLET 50 MG (dasatinib) 4 CM PA; SL (2 tablets per day); SPRYCEL ORAL TABLET 70 MG (dasatinib) 4 CM PA; SL (3 tablets per day); STIVARGA ORAL TABLET 40 MG (regorafenib) 4 CM PA; SL (7 capsules per day); SUTENT ORAL CAPSULE 12.5 MG (sunitinib malate) 4 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 40 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (3 capsules per day); SUTENT ORAL CAPSULE 25 MG (sunitinib malate) 4 CM PA; SL (1 capsule per day); SUTENT ORAL CAPSULE 37.5 MG, 50 MG (sunitinib malate) 4 CM TABLOID ORAL TABLET 40 MG (thioguanine) 2 CM PA; SL (4 tablets per day); TABRECTA ORAL TABLET 150 MG, 200 MG ( capmatinib hcl) 4 CM PA; SL (6 capsules per day); TAFINLAR ORAL CAPSULE 50 MG (dabrafenib mesylate) 4 CM PA; SL (4 capsulesf per day); TAFINLAR ORAL CAPSULE 75 MG (dabrafenib mesylate) 4 CM TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib 3 PA; SL (1 tablet per day); CM mesylate) PA; SL (3 capsules per day); TALZENNA ORAL CAPSULE 0.25 MG ( tosylate) 3 CM PA; SL (1 capsule per day); TALZENNA ORAL CAPSULE 1 MG (talazoparib tosylate) 3 CM tamoxifen citrate oral tablet 10 mg 1 CM tamoxifen citrate oral tablet 20 mg 1 H-N; CM TARGRETIN ORAL CAPSULE 75 MG (bexarotene) 2 CM TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG (nilotinib PA; SL (4 capsules per day); 2 hcl) CM TAZVERIK ORAL TABLET 200 MG (tazemetostat hbr) 3 PA; CM oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg 1 PA; CM PA; SL (2 tablets per day); TEPMETKO ORAL TABLET 225 MG ( tepotinib hcl) 4 CM PA; SL (2 tablets per day); TIBSOVO ORAL TABLET 250 MG (ivosidenib) 2 CM toremifene citrate oral tablet 60 mg 1 CM oral capsule 10 mg 1 CM TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 CM (methotrexate sodium) TRUSELTIQ (100MG DAILY DOSE) ORAL CAPSULE 4 CM THERAPY PACK 100 MG (infigratinib phosphate) TRUSELTIQ (125MG DAILY DOSE) ORAL CAPSULE 4 CM THERAPY PACK 100 & 25 MG (infigratinib phosphate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 41 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRUSELTIQ (50MG DAILY DOSE) ORAL CAPSULE 4 CM THERAPY PACK 25 MG (infigratinib phosphate) TRUSELTIQ (75MG DAILY DOSE) ORAL CAPSULE 4 CM THERAPY PACK 25 MG (infigratinib phosphate) PA; SL (4 tablets per day); TUKYSA ORAL TABLET 150 MG (tucatinib) 2 CM PA; SL (10 tablets per day); TUKYSA ORAL TABLET 50 MG (tucatinib) 2 CM PA; SL (4 capsules per day); TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) 3 CM PA; SL (6 tablets per day); TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) 4 CM PA; SL (4 tablets per day); UKONIQ ORAL TABLET 200 MG ( tosylate) 4 CM VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG 3 PA; CM () VENCLEXTA STARTING PACK ORAL TABLET THERAPY 3 PA; CM PACK 10 & 50 & 100 MG (venetoclax) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA; SL (2 tablets per day); 2 () CM PA; SL (2 tablets per day); VITRAKVI ORAL CAPSULE 100 MG (larotrectinib sulfate) 2 CM PA; SL (6 capsules per day); VITRAKVI ORAL CAPSULE 25 MG (larotrectinib sulfate) 2 CM VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib sulfate) 2 PA; SL (10 mL per day); CM VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG 3 PA; SL (1 tablet per day); CM (dacomitinib) PA; SL (4 tablets per day); VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) 4 CM PA; SL (2 capsules per day); XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) 4 CM SL (84 tablets per XELODA ORAL TABLET 150 MG (capecitabine) 4 prescription); CM SL (140 tablets per XELODA ORAL TABLET 500 MG (capecitabine) 4 prescription); CM PA; SL (3 tablets per day); XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) 3 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 42 Coverage Requirements & Prescription Drug Name Drug Tier Limits XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 PA; CM PACK 50 MG (selinexor) XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 PA; CM PACK 40 MG (selinexor) XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET THERAPY 3 PA; CM PACK 40 MG (selinexor) XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 PA; CM PACK 60 MG (selinexor) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (0.86 mg per day); 3 PACK 20 MG (selinexor) CM XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET THERAPY 3 PA; CM PACK 40 MG (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET THERAPY PA; SL (1.15 mg per day); 3 PACK 20 MG (selinexor) CM PA; SL (4 capsules per day); XTANDI ORAL CAPSULE 40 MG () 4 CM PA; SL (4 tablets per day); XTANDI ORAL TABLET 40 MG (enzalutamide) 3 CM PA; SL (2 tablets per day); XTANDI ORAL TABLET 80 MG (enzalutamide) 3 CM PA; SL (3 capsules per day); ZEJULA ORAL CAPSULE 100 MG ( tosylate) 2 CM PA; SL (8 tablets per day); ZELBORAF ORAL TABLET 240 MG (vemurafenib) 2 CM SL (124 capsules per ZOLINZA ORAL CAPSULE 100 MG () 2 prescription); CM; AE PA; SL (2 tablets per day); ZYDELIG ORAL TABLET 100 MG, 150 MG () 3 CM PA; SL (3 tablets per day); ZYKADIA ORAL TABLET 150 MG (ceritinib) 2 CM ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES - DRUGS FOR THE IMMUNE SYSTEM ALLERGENIC EXTRACTS (THERAPEUTIC) - DRUGS FOR THE IMMUNE SYSTEM GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU 3 PA; SL (1 tablet per day) (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 SQ-HDM 3 PA; SL (1 tablet per day) (dust mite mixed allergen ext)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 43 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORALAIR ADULT STARTER PACK SUBLINGUAL TABLET 3 PA; SL (1 tablet per day) SUBLINGUAL 300 IR (grass mix pollens allergen ext) ORALAIR CHILDRENS STARTER PACK SUBLINGUAL PA; SL (3 packs per 365 TABLET SUBLINGUAL 100 IR (grass mix pollens allergen 3 days) ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 IR (grass 3 PA; SL (1 tablet per day) mix pollens allergen ext) PALFORZIA ORAL 0.5 & 1 & 1.5 & 3 & 6 MG (peanut powder- PA; SL (13 capsules per 3 dnfp) year) PALFORZIA ORAL 2 X 1 MG & 10 MG, 3 X 1 MG (peanut PA; SL (45 capsules per 13 3 powder-dnfp) days) PALFORZIA ORAL 2 X 100 MG, 2 X 20 MG, 20 MG & 100 MG PA; SL (30 capsules per 13 3 (peanut powder-dnfp) days) PALFORZIA ORAL 2 X 20 MG & 2 X 100 MG, 3 X 20 MG & 100 PA; SL (60 capsules per 13 3 MG, 4 X 20 MG (peanut powder-dnfp) days) PA; SL (15 capsules per 13 PALFORZIA ORAL 20 MG (peanut powder-dnfp) 3 days) PA; SL (90 capsules per 13 PALFORZIA ORAL 6 X 1 MG (peanut powder-dnfp) 3 days) PALFORZIA ORAL PACKET 300 MG (peanut powder-dnfp) 3 SL (1 capsule per day) RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 AMB A 3 PA; SL (1 tablet per day) 1-U (short ragweed pollen ext) AUTONOMIC DRUGS - Drugs for the Nervous System ALPHA- AND BETA-ADRENERGIC - Drugs for Heart and Lungs SL (2 single units or 1 two ADRENALIN SOLUTION 1 MG/ML (epinephrine) 3 pack per prescription) ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 3 (nasal)) CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 3 SL (2 tablets per day) 12 HOUR 2.5-120 MG (desloratadine-pseudoephedrine) droxidopa oral capsule 100 mg 3 PA; SL (3 capsules per day) droxidopa oral capsule 200 mg, 300 mg 3 PA; SL (6 capsules per day) epinephrine solution auto-injector 0.15 mg/0.3ml injection SL (4 single units or 2 two- 1 0.15 mg/0.3ml pack per prescription) epinephrine solution auto-injector 0.3 mg/0.3ml injection SL (4 single units or 2 two- 1 0.3 mg/0.3ml pack per prescription) pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 44 Coverage Requirements & Prescription Drug Name Drug Tier Limits SYMJEPI INJECTION SOLUTION PREFILLED 0.15 2 SL (2 pens per prescription) MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ALPHA-ADRENERGIC AGONISTS - Drugs for Heart and Lungs hcl er oral tablet extended release 12 hour 0.1 mg 3 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr 3 GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 ) KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 3 ST MG (clonidine hcl) LUCEMYRA ORAL TABLET 0.18 MG ( hcl) 3 PA; SL (192 tablets per year) oral tablet 250 mg, 500 mg 1 hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 promethazine vc oral syrup 6.25-5 mg/5ml 1 PA; SL (120 mL per promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 prescription) promethazine-phenyleph-codeine oral syrup 6.25-5-10 PA; SL (120 mL per 1 mg/5ml prescription) promethazine-phenylephrine oral syrup 6.25-5 mg/5ml 1 ANTIMUSCARINICS/ - Drugs for Parkinson ANASPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 ( sulfate) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 SL (2 blisters per day) ) ATROVENT HFA INHALATION AEROSOL SOLUTION 17 3 SL (0.87 gm per day) MCG/ACT (ipratropium hfa) belladonna - rectal suppository 16.2-30 mg, 16.2-60 mg 3 BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 SL (1 inhaler (10.7g) per 30 2 MCG/ACT (glycopyrrolate-) days) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 SL (1 or 2 inhalers per 3 MCG/ACT (budeson-glycopyrrol-formoterol) month) -clidinium oral capsule 5-2.5 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 45 Coverage Requirements & Prescription Drug Name Drug Tier Limits COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION SL (8 g (2 inhalers) per 2 20-100 MCG/ACT (ipratropium-albuterol) month) CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) 3 dicyclomine hcl oral capsule 10 mg 1 dicyclomine hcl oral solution 10 mg/5ml 1 dicyclomine hcl oral tablet 20 mg 1 diphenoxylate- oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 ED-SPAZ ORAL TABLET DISPERSIBLE 0.125 MG 3 glycopyrrolate oral tablet 1 mg, 2 mg 3 HYCODAN ORAL SYRUP 5-1.5 MG/5ML (hydrocodone- PA; SL (120 mL per 3 ) prescription) PA; SL (120 mL per hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 prescription) hydrocodone-homatropine oral tablet 5-1.5 mg 1 PA PA; SL (120 mL per hydromet oral syrup 5-1.5 mg/5ml 1 prescription) HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz 3 acd-ph sal) hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg 1 hyoscyamine sulfate oral elixir 0.125 mg/5ml 1 hyoscyamine sulfate oral solution 0.125 mg/ml 1 hyoscyamine sulfate oral tablet 0.125 mg 1 hyoscyamine sulfate oral tablet dispersible 0.125 mg 3 hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg 1 hyoscyamine sulfate sublingual tablet sublingual 0.125 mg 1 hyosyne oral elixir 0.125 mg/5ml 1 hyosyne oral solution 0.125 mg/ml 1 inhalation solution 0.02 % 1 ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 LEVBID ORAL TABLET EXTENDED RELEASE 12 HOUR 2 0.375 MG (hyoscyamine sulfate) LEVSIN ORAL TABLET 0.125 MG (hyoscyamine sulfate) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 46 Coverage Requirements & Prescription Drug Name Drug Tier Limits LEVSIN/SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 2 (hyoscyamine sulfate) LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 3 atropine) me/naphos/mb/hyo1 oral tablet 81.6 mg 3 methscopolamine bromide oral tablet 2.5 mg, 5 mg 3 NULEV ORAL TABLET DISPERSIBLE 0.125 MG 3 (hyoscyamine sulfate) oscimin oral tablet 0.125 mg 1 oscimin sr oral tablet extended release 12 hour 0.375 mg 1 oscimin sublingual tablet sublingual 0.125 mg 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) transdermal patch 72 hour 1 mg/3days 3 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 SL (1 capsule per day) ( monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 SL (1 inhaler (4 grams) per 2 MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) month) SYMAX DUOTAB ORAL TABLET EXTENDED RELEASE 0.375 3 MG (hyoscyamine sulfate) SYMAX-SL SUBLINGUAL TABLET SUBLINGUAL 0.125 MG 2 (hyoscyamine sulfate) SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HOUR 2 0.375 MG (hyoscyamine sulfate) TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 3 HOUR 1 MG/3DAYS (scopolamine base) TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 3 HOUR 1 MG/3DAYS (scopolamine base) TRELEGY ELLIPTA INHALATION AEROSOL POWDER SL (60 blisters (1 pack) per BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 2 30 days) umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH (fluticasone- 2 umeclidin-vilant) URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 47 Coverage Requirements & Prescription Drug Name Drug Tier Limits URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 3 meth blue-na phos) uro-mp oral capsule 118 mg 3 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) YUPELRI INHALATION SOLUTION 175 MCG/3ML 3 PA; SL (3 mL per day) () ANTIPARKINSONIAN AGENTS - Drugs for Parkinson allergy childrens oral liquid 12.5 mg/5ml 3 aurodryl allergy childrens oral liquid 12.5 mg/5ml 3 banophen oral capsule 25 mg 3 benztropine mesylate oral tablet 0.5 mg 3 benztropine mesylate oral tablet 1 mg, 2 mg 1 diphen oral elixir 12.5 mg/5ml 3 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral capsule 25 mg, 50 mg 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral liquid 12.5 mg/5ml 3 geri-dryl oral liquid 12.5 mg/5ml 3 liquid allergy relief oral liquid 12.5 mg/5ml 3 m-dryl oral liquid 12.5 mg/5ml 3 sleep-aid oral capsule 50 mg 3 hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 48 Coverage Requirements & Prescription Drug Name Drug Tier Limits AUTONOMIC DRUGS, MISCELLANEOUS - Drugs for the Nervous System CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG 3 H (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline tartrate) 3 H CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 3 H 11 & 1 MG X 42 (varenicline tartrate) goodsense mouth/ 4 mg 3 H habitrol transdermal patch 24 hour 21 mg/24hr 3 H NICORETTE MOUTH/THROAT GUM 2 MG (nicotine 3 H polacrilex) nicotine polacrilex mini mouth/throat lozenge 2 mg 3 H nicotine polacrilex mouth/throat gum 2 mg, 4 mg 3 H nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg 3 H nicotine step 1 transdermal patch 24 hour 21 mg/24hr 3 H nicotine step 2 transdermal patch 24 hour 14 mg/24hr 3 H nicotine step 3 transdermal patch 24 hour 7 mg/24hr 3 H NICOTROL INHALATION INHALER 10 MG (nicotine) 3 H NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) 3 H CENTRALLY ACTING SKELETAL MUSCLE RELAXNT - Drugs for Relaxing Muscles oral tablet 250 mg, 350 mg 1 carisoprodol--codeine oral tablet 200-325-16 mg 3 oral tablet 375 mg, 500 mg, 750 mg 3 hcl oral tablet 10 mg, 5 mg 1 LORZONE ORAL TABLET 375 MG, 750 MG (chlorzoxazone) 3 oral tablet 400 mg, 800 mg 3 oral tablet 500 mg, 750 mg 1 SKELAXIN ORAL TABLET 800 MG (metaxalone) 3 hcl oral capsule 2 mg, 4 mg, 6 mg 3 tizanidine hcl oral tablet 2 mg, 4 mg 1 ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6 MG (tizanidine 3 hcl) ZANAFLEX ORAL TABLET 4 MG (tizanidine hcl) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 49 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIRECT-ACTING SKELETAL MUSCLE RELAXANTS - Drugs for Relaxing Muscles DANTRIUM ORAL CAPSULE 25 MG, 50 MG ( 3 sodium) dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg 1 GABA-DERIVATIVE SKELETAL - Drugs for Relaxing Muscles oral tablet 10 mg, 20 mg, 5 mg 1 OZOBAX ORAL SOLUTION 5 MG/5ML (baclofen) 3 AE NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 ( hcl af) oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG () 3 HEMANGEOL ORAL SOLUTION 4.28 MG/ML ( 3 hcl) hcl oral tablet 100 mg, 200 mg, 300 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 maleate oral tablet 10 mg, 20 mg, 5 mg 1 NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS - Drugs for the Heart CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 ( mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 ST HOUR 4 MG, 8 MG (doxazosin mesylate) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 50 Coverage Requirements & Prescription Drug Name Drug Tier Limits MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG ( 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for the Heart CAFERGOT ORAL TABLET 1-100 MG (-) 3 mesylate nasal solution 4 mg/ml 3 PA; SL (1 kit per month) mesylates oral tablet 1 mg 1 ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 3 PA (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg 3 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) hcl oral capsule 10 mg 1 PARASYMPATHOMIMETIC ( AGENTS) - Drugs for Bladder Incontinence bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 1 hcl oral capsule 30 mg 1 hcl oral tablet 10 mg, 5 mg 1 donepezil hcl oral tablet dispersible 10 mg, 5 mg 1 hydrobromide er oral capsule extended 1 release 24 hour 16 mg, 24 mg, 8 mg SL (2 bottles per galantamine hydrobromide oral solution 4 mg/ml 1 prescription) galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg 1 MESTINON ORAL SOLUTION 60 MG/5ML (pyridostigmine 3 bromide) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 SL (56 capsules per 365 2 & 14 & 21 &28 -10 MG ( hcl-donepezil hcl) days) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 2 SL (1 capsule per day) donepezil hcl) hcl oral tablet 5 mg, 7.5 mg 1 pyridostigmine bromide er oral tablet extended release 180 mg 1 pyridostigmine bromide oral solution 60 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 51 Coverage Requirements & Prescription Drug Name Drug Tier Limits pyridostigmine bromide oral tablet 60 mg 1 RAZADYNE ER ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 16 MG, 24 MG, 8 MG (galantamine hydrobromide) tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 1 SL (2 capsules per day) rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr 3 SALAGEN ORAL TABLET 5 MG, 7.5 MG (pilocarpine hcl) 3 SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT - Drugs for the Heart hcl er oral tablet extended release 24 hour 10 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 FLOMAX ORAL CAPSULE 0.4 MG ( hcl) 3 SL (2 capsules per day) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 oral capsule 4 mg, 8 mg 3 tamsulosin hcl oral capsule 0.4 mg 1 SL (2 capsules per day) SELECTIVE BETA-2-ADRENERGIC AGONISTS - Drugs for Heart and Lungs ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 3 SL (60 blisters per month) MCG/DOSE (fluticasone-) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- SL (12g (1 inhaler) per 3 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) month) albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 SL (6.7 g per prescription) inhalation 108 (90 base) mcg/act albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 SL (8.5 g per prescription) inhalation 108 (90 base) mcg/act albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 3 inhalation 108 (90 base) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml 1 albuterol sulfate inhalation nebulization solution 2.5 mg/0.5ml 3 albuterol sulfate nebulization solution (5 mg/ml) 0.5% 3 inhalation (5 mg/ml) 0.5% albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 52 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- 3 SL (2 blisters per day) vilanterol) tartrate inhalation nebulization solution 15 mcg/2ml 3 SL (4 mL per day) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 SL (1 inhaler (10.7g) per 30 2 MCG/ACT (glycopyrrolate-formoterol) days) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 3 SL (2 blisters per day) ACTIVATED 100-25 MCG/INH (fluticasone furoate-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH SL (1 inhaler (60 blisters) per 3 ACTIVATED 200-25 MCG/INH (fluticasone furoate-vilanterol) month) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 SL (1 or 2 inhalers per 3 MCG/ACT (budeson-glycopyrrol-formoterol) month) BROVANA INHALATION NEBULIZATION SOLUTION 15 3 SL (4 mL per day) MCG/2ML (arformoterol tartrate) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION SL (8 g (2 inhalers) per 2 20-100 MCG/ACT (ipratropium-albuterol) month) FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 2 SL (1 inhaler per 30 days) MCG/ACT, 55-14 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml 3 SL (90 mL per prescription) levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml 3 SL (30 vials per prescription) SL (30 grams (2 inhalers) per LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 month) PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 SL (120 mL (60 vials) per 3 MCG/2ML (formoterol fumarate) prescription) PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 3 BASE) MCG/ACT (albuterol sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 SL (1 device per month) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (1 inhaler per month) 2.5 MCG/ACT (olodaterol hcl) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 SL (0.34 grams per day) 4.5 MCG/ACT (budesonide-formoterol fumarate) sulfate oral tablet 2.5 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 53 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRELEGY ELLIPTA INHALATION AEROSOL POWDER SL (60 blisters (1 pack) per BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 2 30 days) umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH (fluticasone- 2 umeclidin-vilant) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT SL (30 grams (2 inhalers) per 3 (levalbuterol tartrate) month) SELECTIVE BETA-ADRENERGIC BLOCKING AGENT - Drugs for the Heart hcl oral capsule 200 mg, 400 mg 1 oral tablet 100 mg, 25 mg, 50 mg 1 hcl oral tablet 10 mg, 20 mg 1 fumarate oral tablet 10 mg, 5 mg 1 KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG ( 3 succinate) LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS - Drugs for Relaxing Muscles citrate er oral tablet extended release 12 hour 100 mg 1 BLOOD FORMATION, COAGULATION, THROMBOSIS - Drugs for the Blood , MISCELLANEOUS - Drugs to Prevent Blood Clots ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 3 GM/100ML ( cit dext soln a) ANTICOAGULANT SODIUM CITRATE IN VITRO SOLUTION 4 3 %, 4 GM/100ML TRICITRASOL IN VITRO CONCENTRATE 46.7 % 3 (anticoagulant sodium citrate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 54 Coverage Requirements & Prescription Drug Name Drug Tier Limits BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC. - Drugs to Prevent OXBRYTA ORAL TABLET 500 MG (voxelotor) 3 PA; SL (3 tablets per day) TAVALISSE ORAL TABLET 100 MG, 150 MG ( 3 PA; SL (2 tablets per day) disodium) COUMARIN DERIVATIVES - Drugs to Prevent Blood Clots jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1 warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1 DIRECT FACTOR XA INHIBITORS - Drugs to Prevent Blood Clots ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY 2 SL (2.5 tablets per day) PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG (apixaban) 2 SL (2 tablets per day) ELIQUIS ORAL TABLET 5 MG (apixaban) 2 SL (2.5 tablets per day) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG (edoxaban 3 SL (1 tablet per day) tosylate) XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) 2 SL (1 tablet per day) XARELTO ORAL TABLET 15 MG, 2.5 MG (rivaroxaban) 2 SL (2 tablets per day) XARELTO STARTER PACK ORAL TABLET THERAPY PACK SL (one pack (51 tablets) per 2 15 & 20 MG (rivaroxaban) month) DIRECT INHIBITORS - Drugs to Prevent Blood Clots PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 2 SL (2 capsules per day) (dabigatran etexilate mesylate) HEMATOPOIETIC AGENTS - Drugs for Anemia PA; SL (15 tablets per DOPTELET ORAL TABLET 20 MG ( maleate) 4 month) PROMACTA ORAL PACKET 25 MG ( olamine) 4 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG 4 PA (eltrombopag olamine) HEMORRHEOLOGIC AGENTS - Drugs for Blood Flow er oral tablet extended release 400 mg 1 HEMOSTATICS - Drugs to Prevent Bleeding oral solution 0.25 gm/ml 3 aminocaproic acid oral tablet 1000 mg, 500 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 55 Coverage Requirements & Prescription Drug Name Drug Tier Limits ASTRINGYN EXTERNAL SOLUTION 259 MG/GM (ferric 3 subsulfate) desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate spray nasal solution 0.01 % 1 GELFILM OPHTHALMIC FILM (gelatin adsorbable) 3 LYSTEDA ORAL TABLET 650 MG () 3 SL (30 tablets per month) NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 PA; SL (1 tablet per day) 55.3 MCG (desmopressin acetate) RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 3 20000 UNIT, 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION 3 RECONSTITUTED 20000 UNIT (thrombin (recombinant)) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 3 acetate) THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 UNIT 3 (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 UNIT 3 (thrombin) THROMBOGEN EXTERNAL KIT 10000 UNIT (thrombin) 3 THROMBOGEN EXTERNAL SOLUTION RECONSTITUTED 3 1000 UNIT, 10000 UNIT (thrombin) tranexamic acid oral tablet 650 mg 3 SL (30 tablets per month) IRON PREPARATIONS - Vitamins and Minerals ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- 2 fa) CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 2 fecb-fegl-fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 2 MG (prenat w/o a-fecbgl-fa-dha) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 2 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 2 omega) ferrocite plus oral tablet 106-1 mg 3 hematinic plus vit/minerals oral tablet 106-1 mg 3 hematinic/folic acid oral tablet 324-1 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 56 Coverage Requirements & Prescription Drug Name Drug Tier Limits hemocyte-f oral tablet 324-1 mg 1 M-NATAL PLUS ORAL TABLET 27-1 MG 2 MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- 2 succ-c-thre-b12-fa) NEONATAL + DHA ORAL 29-1 & 200 MG 2 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 2 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 2 fumarate-fa) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- 2 methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 2 vit a) ONE VITE WOMENS ORAL TABLET 27-0.8 MG 2 ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 2 PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-0.8 mg, 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 2 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 2 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 2 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 57 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRETAB ORAL TABLET 29-1 MG 2 RELNATE DHA ORAL CAPSULE 28-1-200 MG 2 SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 2 vit-fe psac cmplx-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 2 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 2 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 2 fecbn-meth-fa-dha) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 2 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 2 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 2 fum-fa-dha) VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 2 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTAB PLUS ORAL TABLET 27-1 MG 2 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 PLATELET-AGGREGATION INHIBITORS - Drugs to Prevent Blood Clots aspirin-dipyridamole er oral capsule extended release 12 3 hour 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 MG ( ticagrelor) 2 cilostazol oral tablet 100 mg, 50 mg 1 clopidogrel bisulfate oral tablet 300 mg, 75 mg 1 dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 SL (1 capsule per day) 162.5 MG (aspirin) PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) 3 prasugrel hcl oral tablet 10 mg, 5 mg 1 SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 58 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) 3 SL (1 tablet per day) PLATELET-REDUCING AGENTS - Drugs to Prevent Blood Clots AGRYLIN ORAL CAPSULE 0.5 MG ( hcl) 3 anagrelide hcl oral capsule 0.5 mg, 1 mg 1 CARDIOVASCULAR DRUGS - Drugs for the Heart ALPHA-ADRENERGIC BLOCKING AGENTS - Drugs for High CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 ST HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ALPHA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina CARDURA ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG 3 (doxazosin mesylate) CARDURA XL ORAL TABLET EXTENDED RELEASE 24 3 ST HOUR 4 MG, 8 MG (doxazosin mesylate) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5 MG (prazosin 3 hcl) prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 ANGIOTENSIN II ANTAGON.(HYPOTN) - Drugs for High Blood Pressure & Angina candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 59 Coverage Requirements & Prescription Drug Name Drug Tier Limits losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 SL (1 tablet per day) valsartan oral tablet 160 mg, 40 mg, 80 mg 1 SL (2 tablets per day) valsartan oral tablet 320 mg 1 SL (1 tablet per day) ANGIOTENSIN II RECEPTOR ANTAGONISTS - Drugs for the Heart candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg 3 EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 ST (azilsartan-chlorthalidone) ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 3 PA; SL (2 tablets per day) (sacubitril-valsartan) HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 MG (losartan potassium-hctz) irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 irbesartan- oral tablet 150-12.5 mg, 300- 12.5 mg 1 losartan potassium oral tablet 100 mg, 25 mg, 50 mg 1 losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg 1 olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg 1 SL (1 tablet per day) telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 SL (2 tablets per day) valsartan oral tablet 160 mg, 40 mg, 80 mg 1 SL (2 tablets per day) valsartan oral tablet 320 mg 1 SL (1 tablet per day) valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- 25 mg, 80-12.5 mg 1 SL (2 tablets per day) valsartan-hydrochlorothiazide oral tablet 320-12.5 mg, 320- 25 mg 1 SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 60 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN) - Drugs for High Blood Pressure & Angina ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (quinapril hcl) benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 PA fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG ( benazepril 3 hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 trandolapril oral tablet 1 mg 3 trandolapril oral tablet 2 mg, 4 mg 1 ANGIOTENSIN-CONVERTING ENZYME INHIBITORS - Drugs for the Heart ACCUPRIL ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 3 (quinapril hcl) ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) besylate-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg 1 benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg, 5-6.25 mg 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) 3 PA fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 61 Coverage Requirements & Prescription Drug Name Drug Tier Limits fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1 LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG ( benazepril 3 hcl) moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 1 quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg 1 TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril- hcl) trandolapril oral tablet 1 mg 3 trandolapril oral tablet 2 mg, 4 mg 1 trandolapril-verapamil hcl er oral tablet extended release 1- 240 mg, 2-180 mg, 2-240 mg, 4-240 mg 1 ANTIARRHYTHMICS, MISCELLANEOUS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1 digox oral tablet 125 mcg, 250 mcg 1 oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG 3 (digoxin) ANTILIPEMIC AGENTS, MISCELLANEOUS - Drugs for JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG 4 PA; SL (1 capsule per day) (lomitapide mesylate) NEXLETOL ORAL TABLET 180 MG ( bempedoic acid) 2 PA; SL (1 tablet per day) NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 SL (1 tablet per day) ezetimibe) er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 62 Coverage Requirements & Prescription Drug Name Drug Tier Limits NIASPAN ORAL TABLET EXTENDED RELEASE 1000 MG, 3 500 MG, 750 MG (niacin (antihyperlipidemic)) omega-3-acid ethyl esters oral capsule 1 gm 1 BETA-ADRENERGIC BLOCKING AGENTS - Drugs for Abnormal Heart Rhythms acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- 6.25 mg, 5-6.25 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol 3 hcl) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100- 50 mg, 50-25 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 63 Coverage Requirements & Prescription Drug Name Drug Tier Limits sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) BETA-ADRENERGIC BLOCKING AGT.(HYPOTEN) - Drugs for High Blood Pressure & Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 CORGARD ORAL TABLET 20 MG, 40 MG, 80 MG (nadolol) 3 HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol 3 hcl) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 nadolol oral tablet 20 mg, 40 mg, 80 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 64 Coverage Requirements & Prescription Drug Name Drug Tier Limits sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) BILE ACID SEQUESTRANTS - Drugs for Cholesterol cholestyramine light oral packet 4 gm 1 cholestyramine light oral powder 4 gm/dose 1 cholestyramine oral packet 4 gm 1 cholestyramine oral powder 4 gm/dose 1 COLESTID FLAVORED ORAL GRANULES 5 GM (colestipol 3 hcl) COLESTID FLAVORED ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL GRANULES 5 GM (colestipol hcl) 3 COLESTID ORAL PACKET 5 GM (colestipol hcl) 3 COLESTID ORAL TABLET 1 GM (colestipol hcl) 3 colestipol hcl oral granules 5 gm 1 colestipol hcl oral packet 5 gm 1 colestipol hcl oral tablet 1 gm 1 prevalite oral packet 4 gm 1 prevalite oral powder 4 gm/dose 1 QUESTRAN LIGHT ORAL POWDER 4 GM/DOSE 3 (cholestyramine light) QUESTRAN ORAL PACKET 4 GM (cholestyramine) 3 QUESTRAN ORAL POWDER 4 GM/DOSE (cholestyramine) 3 WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 2 SL (1 pack per day) WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 2 CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN) - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 3 HOUR 120 MG ( hcl coated beads) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 65 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl er coated beads oral capsule extended release 3 24 hour 360 mg diltiazem hcl er coated beads oral tablet extended release 3 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 3 taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1 tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1 verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CALCIUM-CHANNEL BLOCKING AGENTS, MISC. - Drugs for High Blood Pressure & Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 66 Coverage Requirements & Prescription Drug Name Drug Tier Limits CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 3 HOUR 120 MG (diltiazem hcl coated beads) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1 diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl er coated beads oral capsule extended release 3 24 hour 360 mg diltiazem hcl er coated beads oral tablet extended release 3 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 3 TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG, 2- 3 240 MG, 4-240 MG (trandolapril-verapamil hcl) taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1 tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) trandolapril-verapamil hcl er oral tablet extended release 1- 240 mg, 2-180 mg, 2-240 mg, 4-240 mg 1 verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1 verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 67 Coverage Requirements & Prescription Drug Name Drug Tier Limits VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) CARBONIC ANHYDRASE INHIBITORS(HYPOTEN) - Drugs for High Blood Pressure & Angina acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 methazolamide oral tablet 25 mg, 50 mg 1 CARDIAC DRUGS, MISCELLANEOUS - Drugs for Angina CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 PA; SL (20 mL per day) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 3 PA; SL (2 tablets per day) er oral tablet extended release 12 hour 1000 mg, 500 mg 1 VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 2 PA; SL (1 capsule per day) VYNDAQEL ORAL CAPSULE 20 MG (tafamidis meglumine 2 PA; SL (4 capsules per day) (cardiac)) CARDIOTONIC AGENTS - Drugs for Angina digitek oral tablet 125 mcg, 250 mcg 1 digox oral tablet 125 mcg, 250 mcg 1 digoxin oral solution 0.05 mg/ml 1 digoxin oral tablet 125 mcg, 250 mcg 1 LANOXIN ORAL TABLET 125 MCG, 250 MCG, 62.5 MCG 3 (digoxin) CENTRAL ALPHA-AGONISTS - Drugs for High Blood Pressure & Angina clonidine hcl er oral tablet extended release 12 hour 0.1 mg 3 clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr 3 hcl oral tablet 1 mg, 2 mg 1 KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 3 ST MG (clonidine hcl) methyldopa oral tablet 250 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 68 Coverage Requirements & Prescription Drug Name Drug Tier Limits CHOLESTEROL ABSORPTION INHIBITORS - Drugs for Cholesterol ezetimibe oral tablet 10 mg 3 ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg 3 NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- 2 SL (1 tablet per day) ezetimibe) CLASS IA ANTIARRHYTHMICS - Drugs for Angina phosphate oral capsule 100 mg, 150 mg 1 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 2 HOUR 100 MG, 150 MG (disopyramide phosphate) NORPACE ORAL CAPSULE 100 MG, 150 MG (disopyramide 3 phosphate) quinidine gluconate er oral tablet extended release 324 mg 1 quinidine sulfate oral tablet 200 mg, 300 mg 1 CLASS IB ANTIARRHYTHMICS - Drugs for Angina DILANTIN ORAL CAPSULE 30 MG ( sodium 3 extended) mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg 1 PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 3 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1 phenytoin oral suspension 125 mg/5ml 3 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg 1 CLASS IC ANTIARRHYTHMICS - Drugs for Angina acetate oral tablet 100 mg, 150 mg, 50 mg 1 hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg 3 propafenone hcl oral tablet 150 mg, 225 mg, 300 mg 1 CLASS II ANTIARRHYTHMICS - Drugs for Angina acebutolol hcl oral capsule 200 mg, 400 mg 1 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 69 Coverage Requirements & Prescription Drug Name Drug Tier Limits betaxolol hcl oral tablet 10 mg, 20 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg 1 HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol 3 hcl) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG (metoprolol 3 succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 1 LOPRESSOR ORAL TABLET 100 MG, 50 MG (metoprolol 3 tartrate) metoprolol succinate er oral tablet extended release 24 1 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 pindolol oral tablet 10 mg, 5 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 25 MG, 50 MG (metoprolol succinate) CLASS III ANTIARRHYTHMICS - Drugs for Angina hcl oral tablet 100 mg, 200 mg, 400 mg 1 BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG 3 (sotalol hcl af) oral capsule 125 mcg, 250 mcg, 500 mcg 3 MULTAQ ORAL TABLET 400 MG ( hcl) 3 PA PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG 3 (amiodarone hcl) sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg 1 sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 70 Coverage Requirements & Prescription Drug Name Drug Tier Limits SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) 3 TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 3 (dofetilide) CLASS IV ANTIARRHYTHMICS - Drugs for Angina CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 3 HOUR 120 MG (diltiazem hcl coated beads) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1 diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl er coated beads oral capsule extended release 3 24 hour 360 mg diltiazem hcl er coated beads oral tablet extended release 3 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 3 taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1 tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 71 Coverage Requirements & Prescription Drug Name Drug Tier Limits verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl) DIHYDROPYRIDINES - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 amlodipine besylate-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg 1 er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1 oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 PA benzoate) hcl oral capsule 20 mg, 30 mg 1 er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg 1 nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 oral capsule 30 mg 3 er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg 3 SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) DIHYDROPYRIDINES (ANTIHYPERTENSIVE) - Drugs for High Blood Pressure & Angina amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1 isradipine oral capsule 2.5 mg, 5 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 PA benzoate) nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 72 Coverage Requirements & Prescription Drug Name Drug Tier Limits nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 3 nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg 3 SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 3 MG, 34 MG, 8.5 MG (nisoldipine) DIRECT VASODILATORS - Drugs for High Blood Pressure & Angina BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 3 hydralazine) hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 oral tablet 10 mg, 2.5 mg 1 DIURETICS, MISCELLANEOUS (HYPOTENSIVE) - Drugs for High Blood Pressure & Angina ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 FIBRIC ACID DERIVATIVES - Drugs for Cholesterol ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate 3 micronized) fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 67 mg 1 fenofibrate micronized oral capsule 43 mg 3 fenofibrate oral capsule 134 mg, 150 mg, 200 mg, 50 mg, 67 mg 1 fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg 1 fenofibric acid oral tablet 105 mg, 35 mg 3 FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric acid) 3 gemfibrozil oral tablet 600 mg 1 LOPID ORAL TABLET 600 MG (gemfibrozil) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 73 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRICOR ORAL TABLET 48 MG (fenofibrate) 3 HMG-COA REDUCTASE INHIBITORS - Drugs for Cholesterol atorvastatin calcium oral tablet 10 mg, 20 mg 1 SL (1 tablet per day); H-N atorvastatin calcium oral tablet 40 mg, 80 mg 1 SL (1 tablet per day) EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 MG, 20 3 PA MG, 40 MG, 5 MG (rosuvastatin calcium) ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg 3 FLOLIPID ORAL SUSPENSION 20 MG/5ML, 40 MG/5ML 3 PA fluvastatin sodium er oral tablet extended release 24 hour 80 mg 3 fluvastatin sodium oral capsule 20 mg, 40 mg 1 lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 H-N pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg 1 rosuvastatin calcium oral tablet 10 mg 1 SL (3 tablets per day) rosuvastatin calcium oral tablet 20 mg, 40 mg, 5 mg 1 SL (1 tablet per day) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 H-N simvastatin oral tablet 80 mg 1 ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG 3 (simvastatin) HYPOTENSIVE AGENTS, MISCELLANEOUS - Drugs for High Blood Pressure & Angina phenoxybenzamine hcl oral capsule 10 mg 1 VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) 3 PA LOOP DIURETICS (HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 3 ethacrynic acid oral tablet 25 mg 3 oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 74 Coverage Requirements & Prescription Drug Name Drug Tier Limits MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS - Drugs for the Heart ALDACTAZIDE ORAL TABLET 25-25 MG (- 3 hctz) ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone- 2 hctz) ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 PA (spironolactone) eplerenone oral tablet 25 mg, 50 mg 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 MINERALOCORTICOID(ALDOSTER.)ANTAG(HYPOT) - Drugs for High Blood Pressure & Angina ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 PA (spironolactone) eplerenone oral tablet 25 mg, 50 mg 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 NITRATES AND - Drugs for the Heart BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- 3 hydralazine) DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 3 MG (isosorbide dinitrate) ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG 3 (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 er oral tablet extended release 24 1 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 1 minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr 3 NITRO-BID TRANSDERMAL OINTMENT 2 % ( nitroglycerin) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 75 Coverage Requirements & Prescription Drug Name Drug Tier Limits NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.3 MG/HR, 0.4 MG/HR, 0.6 MG/HR, 0.8 MG/HR 3 (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr 3 nitroglycerin translingual solution 0.4 mg/spray 3 NITROLINGUAL TRANSLINGUAL SOLUTION 0.4 MG/SPRAY 3 (nitroglycerin) NITROMIST TRANSLINGUAL AEROSOL SOLUTION 400 3 MCG/SPRAY (nitroglycerin) NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 3 0.4 MG, 0.6 MG (nitroglycerin) NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 2 6.5 MG, 9 MG (nitroglycerin) PHOSPHODIESTERASE TYPE 5 INHIBITORS - Drugs for the Heart ADCIRCA ORAL TABLET 20 MG (tadalafil (pah)) 4 PA; SL (2 tablets per day) alyq oral tablet 20 mg 4 PA; SL (2 tablets per day) cilostazol oral tablet 100 mg, 50 mg 1 REVATIO ORAL TABLET 20 MG (sildenafil citrate) 4 SL (0.5 tablets per day) sildenafil citrate oral suspension reconstituted 10 mg/ml 3 PA; SL (6 mL per day) sildenafil citrate oral tablet 20 mg 1 SL (0.5 tablets per day) tadalafil (pah) oral tablet 20 mg 4 PA; SL (2 tablets per day) tadalafil oral tablet 2.5 mg, 5 mg 3 PA; SL (5 tablets per month) POTASSIUM-SPARING DIURETICS (HYPOTEN) - Drugs for High Blood Pressure & Angina ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) hcl oral tablet 5 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 PA (spironolactone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG () 3 eplerenone oral tablet 25 mg, 50 mg 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 76 Coverage Requirements & Prescription Drug Name Drug Tier Limits RENIN INHIBITORS - Drugs for the Heart aliskiren fumarate oral tablet 150 mg, 300 mg 3 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG ( aliskiren 3 fumarate) RENIN-ANGIOTEN.-ALDOST. SYS. INHIB, MISC - Drugs for the Heart ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG 3 PA; SL (2 tablets per day) (sacubitril-valsartan) DIURETICS(HYPOTENSIVE AGENTS) - Drugs for High Blood Pressure & Angina DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 3 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 THIAZIDE-LIKE DIURETICS(HYPOTENSIVE AGT) - Drugs for High Blood Pressure & Angina chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 VASODILATING AGENTS, MISCELLANEOUS - Drugs for the Heart amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 CALAN SR ORAL TABLET EXTENDED RELEASE 120 MG, 3 180 MG, 240 MG (verapamil hcl) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 3 HOUR 120 MG (diltiazem hcl coated beads) cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg 1 CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine hcl) 3 PA; SL (20 mL per day) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine hcl) 3 PA; SL (2 tablets per day) diltiazem hcl er beads oral capsule extended release 24 1 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 1 24 hour 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl er coated beads oral capsule extended release 3 24 hour 360 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 77 Coverage Requirements & Prescription Drug Name Drug Tier Limits diltiazem hcl er coated beads oral tablet extended release 3 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg 1 diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg 1 dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 hcl oral tablet 10 mg, 20 mg 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine 3 PA benzoate) matzim la oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 3 nicardipine hcl oral capsule 20 mg, 30 mg 1 nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg 1 nifedipine er osmotic release oral tablet extended release 1 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg 1 nimodipine oral capsule 30 mg 3 taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg 1 tiadylt er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg 1 TIAZAC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG 3 (diltiazem hcl er beads) verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg 1 verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 1 verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 VERELAN ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 120 MG, 180 MG, 240 MG, 360 MG (verapamil hcl) VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 3 HOUR 100 MG, 200 MG, 300 MG (verapamil hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 78 Coverage Requirements & Prescription Drug Name Drug Tier Limits CENTRAL NERVOUS SYSTEM AGENTS - Drugs for the Nervous System ADAMANTANES (CNS) - Drugs for Parkinson amantadine hcl oral capsule 100 mg 1 amantadine hcl oral syrup 50 mg/5ml 1 amantadine hcl oral tablet 100 mg 3 - Drugs for the Nervous System ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG 2 SL (1 capsule per day); AE (-dextroamphetamine) amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg 1 SL (3 tablets per day) amphetamine-dextroamphetamine oral tablet 30 mg 1 SL (2 tablets per day) dextroamphetamine sulfate er oral capsule extended 1 SL (4 capsules per day) release 24 hour 10 mg, 15 mg dextroamphetamine sulfate er oral capsule extended 1 SL (10 capsules per day) release 24 hour 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml 3 SL (60 mL per day) dextroamphetamine sulfate oral tablet 10 mg 1 SL (6 tablets per day) dextroamphetamine sulfate oral tablet 5 mg 1 SL (3 tablets per day) hcl oral tablet 5 mg 1 PROCENTRA ORAL SOLUTION 5 MG/5ML 3 ST; SL (60 mL per day) (dextroamphetamine sulfate) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 3 SL (1 capsule per day) MG, 60 MG, 70 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, SL (1 unit (capsule or tablet) 3 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) per day) ZENZEDI ORAL TABLET 10 MG (dextroamphetamine 3 ST; SL (6 tablets per day) sulfate) ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 3 ST; SL (3 tablets per day) MG (dextroamphetamine sulfate) ZENZEDI ORAL TABLET 30 MG (dextroamphetamine 3 ST; SL (2 tablets per day) sulfate) AND ANTIPYRETICS, MISC. - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 79 Coverage Requirements & Prescription Drug Name Drug Tier Limits acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg 1 bac oral tablet 50-325-40 mg 1 SL (6 tablet per day) -ACETAMINOPHEN ORAL TABLET 3 4.08-325 MG, 6.12-325 MG, 8.16-325 MG BUPAP ORAL TABLET 50-300 MG (- 3 acetaminophen) butalbital-acetaminophen oral tablet 50-300 mg 3 butalbital-acetaminophen oral tablet 50-325 mg 1 butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 3 SL (6 capsules per day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325- 40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablet per day) endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 325 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 3 SL (6 tablet per day) caffeine) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 SL (6 capsules per day) (butalbital-apap-caff-cod) oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 ST daily)) GRALISE ORAL TABLET 300 MG (gabapentin (once-daily)) 3 ST; SL (1 tablet per day) GRALISE ORAL TABLET 600 MG (gabapentin (once-daily)) 3 ST; SL (3 tablets per day) hydrocodone-acetaminophen oral solution 10-325 mg/15ml 3 SL (185 mL per day) hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml 3 hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg 3 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 80 Coverage Requirements & Prescription Drug Name Drug Tier Limits HYOPHEN ORAL TABLET 81.6 MG (meth-hyo-m bl-benz 3 acd-ph sal) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 3 acetaminophen) -ACETAMINOPHEN ORAL SOLUTION 10-300 4 MG/5ML oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1 PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) PROLATE ORAL SOLUTION 10-300 MG/5ML (oxycodone- 4 acetaminophen) TENCON ORAL TABLET 50-325 MG ( butalbital- 2 acetaminophen) -acetaminophen oral tablet 37.5-325 mg 1 SL (8 tablets per day) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- 3 SL (8 tablets per day) acetaminophen) URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 uro-mp oral capsule 118 mg 3 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal) UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 3 SL (180 mL per prescription) apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 81 Coverage Requirements & Prescription Drug Name Drug Tier Limits AGENTS (CNS) - Drugs for Parkinson allergy childrens oral liquid 12.5 mg/5ml 3 aurodryl allergy childrens oral liquid 12.5 mg/5ml 3 banophen oral capsule 25 mg 3 benztropine mesylate oral tablet 0.5 mg 3 benztropine mesylate oral tablet 1 mg, 2 mg 1 diphen oral elixir 12.5 mg/5ml 3 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral capsule 25 mg, 50 mg 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral liquid 12.5 mg/5ml 3 geri-dryl oral liquid 12.5 mg/5ml 3 liquid allergy relief oral liquid 12.5 mg/5ml 3 m-dryl oral liquid 12.5 mg/5ml 3 orphenadrine citrate er oral tablet extended release 12 hour 100 mg 1 sleep-aid oral capsule 50 mg 3 trihexyphenidyl hcl oral solution 0.4 mg/ml 1 trihexyphenidyl hcl oral tablet 2 mg, 5 mg 1 , MISCELLANEOUS - Drugs for Seizures acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG 3 PA () BANZEL ORAL SUSPENSION 40 MG/ML () 4 BANZEL ORAL TABLET 200 MG, 400 MG ( rufinamide) 3 PA BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 3 PA MG (brivaracetam) er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg 1 carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg 3 carbamazepine oral suspension 100 mg/5ml 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 82 Coverage Requirements & Prescription Drug Name Drug Tier Limits carbamazepine oral tablet 200 mg 3 carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) DIACOMIT ORAL CAPSULE 250 MG, 500 MG () 3 PA DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) 3 PA divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg 3 divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg 1 EPIDIOLEX ORAL SOLUTION 100 MG/ML () 3 PA epitol oral tablet 200 mg 3 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) oral suspension 600 mg/5ml 3 felbamate oral tablet 400 mg, 600 mg 3 FELBATOL ORAL SUSPENSION 600 MG/5ML (felbamate) 3 FELBATOL ORAL TABLET 400 MG, 600 MG ( felbamate) 3 FINTEPLA ORAL SOLUTION 2.2 MG/ML ( hcl) 3 PA FYCOMPA ORAL SUSPENSION 0.5 MG/ML () 3 PA FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 3 PA 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 gabapentin oral solution 250 mg/5ml 1 gabapentin oral tablet 600 mg, 800 mg 1 GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG 3 ( hcl) GRALISE ORAL 300 (9) & 600(24) MG (gabapentin (once- 3 ST daily)) GRALISE ORAL TABLET 300 MG (gabapentin (once-daily)) 3 ST; SL (1 tablet per day) GRALISE ORAL TABLET 600 MG (gabapentin (once-daily)) 3 ST; SL (3 tablets per day) KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 500 MG, 750 MG ()

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 83 Coverage Requirements & Prescription Drug Name Drug Tier Limits LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG SL (28 tablets (1 box) per 3 () prescription) SL (35 tablets (1 box) per LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG (lamotrigine) 3 prescription) LAMICTAL ODT ORAL KIT 42 X 50 MG & 14X100 MG SL (56 tablets (1 box) per 3 (lamotrigine) prescription) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 3 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 3 X 100 MG (lamotrigine) LAMICTAL STARTER ORAL KIT 84 X 25 MG & 14X100 MG SL (98 tablets (1 kit) per 3 (lamotrigine) year) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 100 MG, 50 & 100 & 200 MG (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg 3 SL (35 tablets (1 box) per lamotrigine oral kit 25 & 50 & 100 mg 3 prescription) lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg 3 lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 SL (98 tablets (1 kit) per 1 mg year) lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg 1 levetiracetam oral solution 100 mg/ml 1 levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 1 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 3 PA; SL (3 capsules per day) 50 MG, 75 MG () LYRICA ORAL CAPSULE 225 MG, 300 MG (pregabalin) 3 PA; SL (2 capsules per day) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 3 PA; SL (30 mL per day) oral suspension 300 mg/5ml 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 84 Coverage Requirements & Prescription Drug Name Drug Tier Limits pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg 1 SL (3 capsules per day) pregabalin oral capsule 225 mg, 300 mg 1 SL (2 capsules per day) pregabalin oral solution 20 mg/ml 3 SL (30 mL per day) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 3 ST MG, 150 MG, 200 MG, 25 MG, 50 MG () roweepra oral tablet 500 mg 1 rufinamide oral suspension 40 mg/ml 3 rufinamide oral tablet 200 mg, 400 mg 3 PA SABRIL ORAL PACKET 500 MG (vigabatrin) 4 PA; SL (6 packets per day) SABRIL ORAL TABLET 500 MG (vigabatrin) 3 PA; SL (6 tablets per day) subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 SL (98 tablets (1 kit) per subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 year) subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG ( carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg 3 topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg 3 ST topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 TRILEPTAL ORAL SUSPENSION 300 MG/5ML 3 PA (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG 3 PA (oxcarbazepine) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 3 ST HOUR 100 MG, 200 MG, 25 MG, 50 MG (topiramate) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 vigabatrin oral packet 500 mg 3 PA; SL (6 packets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 85 Coverage Requirements & Prescription Drug Name Drug Tier Limits vigabatrin oral tablet 500 mg 3 PA; SL (6 tablets per day) vigadrone oral packet 500 mg 3 PA; SL (6 packets per day) VIMPAT ORAL SOLUTION 10 MG/ML () 3 PA VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 PA (lacosamide) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 3 PA () XCOPRI ORAL TABLET THERAPY PACK 100 & 150 MG, 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 3 PA MG & 14 X100 MG, 150 & 200 MG, 50 & 200 MG (cenobamate) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG () 3 PA zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 , MISCELLANEOUS - Drugs for Depression & Psychosis hcl er (smoking det) oral tablet extended release 3 H 12 hour 150 mg bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg 1 bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg 1 SL (3 tablets per day) bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg 1 SL (1 tablet per day) BUPROPION HCL ER (XL) ORAL TABLET EXTENDED 1 SL (1 tablet per day) RELEASE 24 HOUR 450 MG bupropion hcl oral tablet 100 mg, 75 mg 1 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 3 SL (1 tablet per day) 450 MG (bupropion hcl) oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg 1 mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg 1 REMERON ORAL TABLET 15 MG, 30 MG (mirtazapine) 3 REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 3 MG, 45 MG (mirtazapine) SPRAVATO (56 MG DOSE) NASAL SOLUTION THERAPY PA; SL (8 devices (4 kits) per 3 PACK 28 MG/DEVICE ( hcl) month) SPRAVATO (84 MG DOSE) NASAL SOLUTION THERAPY PA; SL (12 devices (4 kits) 3 PACK 28 MG/DEVICE (esketamine hcl) per month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 86 Coverage Requirements & Prescription Drug Name Drug Tier Limits WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 150 MG, 200 MG (bupropion hcl) ANTIMANIC AGENTS - Drugs for Personality Disorder oral solution 1 mg/ml 1 SL (25mL per day) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg 1 SL (1 tablet per day) aripiprazole oral tablet dispersible 10 mg, 15 mg 1 SL (2 tablets per day) carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg 1 carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg 3 carbamazepine oral suspension 100 mg/5ml 3 carbamazepine oral tablet 200 mg 3 carbamazepine oral tablet chewable 100 mg 1 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 300 MG (carbamazepine) divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg 3 divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg 1 epitol oral tablet 200 mg 3 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 3 100 MG, 200 MG, 300 MG (carbamazepine (antipsychotic)) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG SL (28 tablets (1 box) per 3 (lamotrigine) prescription) SL (35 tablets (1 box) per LAMICTAL ODT ORAL KIT 25 & 50 & 100 MG (lamotrigine) 3 prescription) LAMICTAL ODT ORAL KIT 42 X 50 MG & 14X100 MG SL (56 tablets (1 box) per 3 (lamotrigine) prescription) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 MG, 200 3 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 3 X 100 MG (lamotrigine) LAMICTAL STARTER ORAL KIT 84 X 25 MG & 14X100 MG SL (98 tablets (1 kit) per 3 (lamotrigine) year)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 87 Coverage Requirements & Prescription Drug Name Drug Tier Limits LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 & 50 & 3 100 MG, 50 & 100 & 200 MG (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg 3 SL (35 tablets (1 box) per lamotrigine oral kit 25 & 50 & 100 mg 3 prescription) lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 lamotrigine oral tablet chewable 25 mg, 5 mg 1 lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg 3 lamotrigine starter kit-blue oral kit 35 x 25 mg 1 lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 SL (98 tablets (1 kit) per 1 mg year) lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 lithium carbonate er oral tablet extended release 300 mg, 450 mg 1 lithium carbonate oral capsule 150 mg, 300 mg, 600 mg 1 lithium carbonate oral tablet 300 mg 1 LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG 3 (lithium carbonate) oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 5 mg 1 SL (3 tablets per day) fumarate er oral tablet extended release 24 hour 150 mg, 300 mg, 400 mg, 50 mg 1 SL (2 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 200 mg 1 SL (3 tablets per day) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 SL (3 tablets per day) quetiapine fumarate oral tablet 300 mg, 400 mg 1 SL (2 tablets per day) oral solution 1 mg/ml 1 SL (8 mL per day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 SL (2 tablets per day) risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 SL (2 tablets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 88 Coverage Requirements & Prescription Drug Name Drug Tier Limits SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 3 SL (2 tablets per day) MG, 5 MG ( maleate) subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg 1 subvenite starter kit-blue oral kit 35 x 25 mg 1 SL (98 tablets (1 kit) per subvenite starter kit-green oral kit 84 x 25 mg & 14x100 mg 1 year) subvenite starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg 1 TEGRETOL ORAL SUSPENSION 100 MG/5ML 3 (carbamazepine) TEGRETOL ORAL TABLET 200 MG ( carbamazepine) 3 TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 3 HOUR 100 MG, 200 MG, 400 MG (carbamazepine) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 SL (2 tablets per day) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 3 SL (1 tablet per day) MG, 20 MG (olanzapine) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 5 MG 3 SL (3 tablets per day) (olanzapine) ANTIMIGRAINE AGENTS, MISCELLANEOUS - Migraine Treatment SL (7.5 mL (3 bottles) per tartrate nasal solution 10 mg/ml 3 month) CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 3 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 3 dihydroergotamine mesylate nasal solution 4 mg/ml 3 PA; SL (1 kit per month) divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg 3 divalproex sodium oral capsule delayed release sprinkle 125 mg 1 divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg 1 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG () ec-naproxen oral tablet delayed release 375 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 89 Coverage Requirements & Prescription Drug Name Drug Tier Limits ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG 3 PA (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg 3 HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol 3 hcl) oral suspension 100 mg/5ml 3 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 375 MG, 500 MG (naproxen sodium) naproxen oral suspension 125 mg/5ml 1 PA naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg 3 NAPROXEN SODIUM ER ORAL TABLET EXTENDED 3 RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 275 mg, 550 mg 1 propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml 1 propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg 1 timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 topiramate oral capsule sprinkle 15 mg, 25 mg 1 topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 3 ST HOUR 100 MG, 200 MG, 25 MG, 50 MG (topiramate) valproic acid oral capsule 250 mg 1 valproic acid oral solution 250 mg/5ml 1 ANTIPSYCHOTICS, MISCELLANEOUS - Drugs for Depression & Psychosis ADASUVE INHALATION AEROSOL POWDER BREATH 3 ACTIVATED 10 MG () loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 90 Coverage Requirements & Prescription Drug Name Drug Tier Limits oral tablet 1 mg, 2 mg 3 ,,AND ,MISC - Drugs for Anxiety & Sleep Disorder allergy childrens oral liquid 12.5 mg/5ml 3 aurodryl allergy childrens oral liquid 12.5 mg/5ml 3 banophen oral capsule 25 mg 3 BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 3 ST; SL (1 tablet per day) () hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 1 DAYVIGO ORAL TABLET 10 MG, 5 MG () 3 ST; SL (1 tablet per day) diphen oral elixir 12.5 mg/5ml 3 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral capsule 25 mg, 50 mg 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral liquid 12.5 mg/5ml 3 EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG 3 SL (1 tablet per day) ( tartrate) oral tablet 1 mg, 2 mg, 3 mg 1 SL (1 tablet per day) geri-dryl oral liquid 12.5 mg/5ml 3 HETLIOZ ORAL CAPSULE 20 MG () 4 PA; SL (1 capsule per day) hydroxyzine hcl oral syrup 10 mg/5ml 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 1 liquid allergy relief oral liquid 12.5 mg/5ml 3 m-dryl oral liquid 12.5 mg/5ml 3 oral tablet 200 mg 3 meprobamate oral tablet 400 mg 1 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 oral tablet 8 mg 3 SL (1 tablet per day) sleep-aid oral capsule 50 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 91 Coverage Requirements & Prescription Drug Name Drug Tier Limits VISTARIL ORAL CAPSULE 25 MG, 50 MG (hydroxyzine 3 pamoate) oral capsule 10 mg 1 SL (2 capsules per day) zaleplon oral capsule 5 mg 1 SL (1 capsule per day) zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg 3 SL (1 tablet per day) zolpidem tartrate oral tablet 10 mg, 5 mg 1 SL (1 tablet per day) zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg 3 SL (1 tablet per day) ST; SL (7.7 mL (1 bottle) per ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem tartrate) 3 month) ATYPICAL ANTIPSYCHOTICS - Drugs for Depression & Psychosis aripiprazole oral solution 1 mg/ml 1 SL (25mL per day) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg 1 SL (1 tablet per day) aripiprazole oral tablet dispersible 10 mg, 15 mg 1 SL (2 tablets per day) CAPLYTA ORAL CAPSULE 42 MG ( tosylate) 3 PA; SL (1 capsule per day) oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 clozapine oral tablet dispersible 100 mg, 25 mg 3 SL (9 tablets per day) clozapine oral tablet dispersible 12.5 mg 3 SL (3 tablets per day) clozapine oral tablet dispersible 150 mg 3 SL (6 tablets per day) clozapine oral tablet dispersible 200 mg 3 SL (4 tablets per day) CLOZARIL ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG 3 (clozapine) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 3 ST; SL (2 tablets per day) MG, 8 MG () FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG ST; SL (8 titration pack per 3 (iloperidone) 365 days) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG 3 SL (1 tablet per day) ( hcl) LATUDA ORAL TABLET 80 MG (lurasidone hcl) 3 SL (2 tablets per day) NUPLAZID ORAL CAPSULE 34 MG ( tartrate) 3 PA NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) 3 PA; SL (2 tablets per day) olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg 1 SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 92 Coverage Requirements & Prescription Drug Name Drug Tier Limits olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg 1 SL (1 tablet per day) olanzapine oral tablet dispersible 5 mg 1 SL (3 tablets per day) olanzapine- hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg 3 SL (1 capsule per day) olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg 3 SL (3 capsules per day) er oral tablet extended release 24 hour 1.5 mg, 3 mg, 9 mg 3 SL (1 tablet per day) paliperidone er oral tablet extended release 24 hour 6 mg 3 SL (2 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 300 mg, 400 mg, 50 mg 1 SL (2 tablets per day) quetiapine fumarate er oral tablet extended release 24 hour 200 mg 1 SL (3 tablets per day) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 SL (3 tablets per day) quetiapine fumarate oral tablet 300 mg, 400 mg 1 SL (2 tablets per day) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 3 PA; SL (1 tablet per day) MG, 4 MG () risperidone oral solution 1 mg/ml 1 SL (8 mL per day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 SL (2 tablets per day) risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 SL (2 tablets per day) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 3 SL (2 tablets per day) MG, 5 MG (asenapine maleate) SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 3 SL (3 capsules per day) fluoxetine hcl) VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) 3 SL (18 mL per day) VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG 3 ST; SL (1 capsule per day) ( hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG 3 ST; SL (7 capsules per year) (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg 1 SL (2 tablets per day) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 10 MG, 15 3 SL (1 tablet per day) MG, 20 MG (olanzapine) ZYPREXA ZYDIS ORAL TABLET DISPERSIBLE 5 MG 3 SL (3 tablets per day) (olanzapine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 93 Coverage Requirements & Prescription Drug Name Drug Tier Limits (ANTICONVULSANTS) - Drugs for Seizures oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 1 oral tablet 250 mg, 50 mg 1 BARBITURATES (, /HYP) - Drugs for Anxiety & Sleep Disorder ascomp-codeine oral capsule 50-325-40-30 mg 1 bac oral tablet 50-325-40 mg 1 SL (6 tablet per day) BUPAP ORAL TABLET 50-300 MG (butalbital- 3 acetaminophen) butalbital-acetaminophen oral tablet 50-300 mg 3 butalbital-acetaminophen oral tablet 50-325 mg 1 butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 3 SL (6 capsules per day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325- 40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablet per day) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 3 SL (6 tablet per day) caffeine) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 SL (6 capsules per day) (butalbital-apap-caff-cod) phenobarbital oral elixir 20 mg/5ml 1 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 1 TENCON ORAL TABLET 50-325 MG ( butalbital- 2 acetaminophen) VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 3 SL (180 mL per prescription) apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 94 Coverage Requirements & Prescription Drug Name Drug Tier Limits (ANTICONVULSANTS) - Drugs for Seizures oral suspension 2.5 mg/ml 3 clobazam oral tablet 10 mg, 20 mg 3 oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg 1 SL (3 tablets per day) clonazepam oral tablet dispersible 2 mg 1 SL (10 tablets per day) dipotassium oral tablet 15 mg 1 SL (6 tablets per day) clorazepate dipotassium oral tablet 3.75 mg 1 SL (24 tablets per day) clorazepate dipotassium oral tablet 7.5 mg 1 SL (12 tablets per day) SL (2 boxes (2doses/box) DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG () 3 per prescription) SL (2 boxes (2doses/box) DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 3 per prescription) diazepam intensol oral concentrate 5 mg/ml 3 diazepam oral concentrate 5 mg/ml 3 diazepam oral solution 5 mg/5ml 3 diazepam oral tablet 10 mg, 2 mg, 5 mg 1 SL (2 boxes (2doses/box) diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 per prescription) intensol oral concentrate 2 mg/ml 3 SL (5mL per day) lorazepam oral concentrate 2 mg/ml 3 SL (5mL per day) lorazepam oral tablet 0.5 mg, 1 mg 1 SL (3 tablets per day) lorazepam oral tablet 2 mg 1 SL (5 tablets per day) NAYZILAM NASAL SOLUTION 5 MG/0.1ML ( PA; ST; SL (2 doses (1 box) 3 ()) per prescription) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 3 PA ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 3 PA TRANXENE-T ORAL TABLET 7.5 MG ( clorazepate 3 SL (12 tablets per day) dipotassium) VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) 3 VALTOCO NASAL LIQUID 10 MG/0.1ML, 5 MG/0.1ML 3 ST; SL (2 per prescription) (diazepam) VALTOCO NASAL LIQUID THERAPY PACK 10 MG/0.1ML, 7.5 3 ST; SL (2 per prescription) MG/0.1ML (diazepam)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 95 Coverage Requirements & Prescription Drug Name Drug Tier Limits BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) - Drugs for Anxiety & Sleep Disorder er oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg 1 SL (1 tablet per day) alprazolam er oral tablet extended release 24 hour 3 mg 1 SL (3 tablets per day) alprazolam intensol oral concentrate 1 mg/ml 3 SL (10 mL per day) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 1 SL (3 tablets per day) alprazolam oral tablet 2 mg 1 SL (5 tablets per day) alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg 3 SL (4 tablets per day) alprazolam oral tablet dispersible 2 mg 3 SL (5 tablets per day) alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, 2 mg 1 SL (1 tablet per day) alprazolam xr oral tablet extended release 24 hour 3 mg 1 SL (3 tablets per day) chlordiazepoxide hcl oral capsule 10 mg 1 SL (30 capusles per day) chlordiazepoxide hcl oral capsule 25 mg 1 SL (12 capsules per day) chlordiazepoxide hcl oral capsule 5 mg 1 SL (4 capusles per day) chlordiazepoxide- oral tablet 10-25 mg, 5-12.5 mg 1 chlordiazepoxide-clidinium oral capsule 5-2.5 mg 3 clobazam oral suspension 2.5 mg/ml 3 clobazam oral tablet 10 mg, 20 mg 3 clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg 1 SL (3 tablets per day) clonazepam oral tablet dispersible 2 mg 1 SL (10 tablets per day) clorazepate dipotassium oral tablet 15 mg 1 SL (6 tablets per day) clorazepate dipotassium oral tablet 3.75 mg 1 SL (24 tablets per day) clorazepate dipotassium oral tablet 7.5 mg 1 SL (12 tablets per day) SL (2 boxes (2doses/box) DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG (diazepam) 3 per prescription) SL (2 boxes (2doses/box) DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) 3 per prescription) diazepam intensol oral concentrate 5 mg/ml 3 diazepam oral concentrate 5 mg/ml 3 diazepam oral solution 5 mg/5ml 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 96 Coverage Requirements & Prescription Drug Name Drug Tier Limits diazepam oral tablet 10 mg, 2 mg, 5 mg 1 SL (2 boxes (2doses/box) diazepam rectal gel 10 mg, 2.5 mg, 20 mg 1 per prescription) oral tablet 1 mg, 2 mg 3 SL (1 tablet per day) hcl oral capsule 15 mg, 30 mg 1 SL (1 capsule per day) HALCION ORAL TABLET 0.25 MG () 3 SL (2 tablets per day) lorazepam intensol oral concentrate 2 mg/ml 3 SL (5mL per day) lorazepam oral concentrate 2 mg/ml 3 SL (5mL per day) lorazepam oral tablet 0.5 mg, 1 mg 1 SL (3 tablets per day) lorazepam oral tablet 2 mg 1 SL (5 tablets per day) midazolam hcl oral syrup 2 mg/ml 3 ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) 3 PA ONFI ORAL TABLET 10 MG, 20 MG (clobazam) 3 PA oral capsule 10 mg, 15 mg, 30 mg 1 SL (4 capusles per day) RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG 3 SL (1 capusle per day) () temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg 1 SL (1 capusle per day) TRANXENE-T ORAL TABLET 7.5 MG ( clorazepate 3 SL (12 tablets per day) dipotassium) triazolam oral tablet 0.125 mg 1 SL (1 tablet per day) triazolam oral tablet 0.25 mg 1 SL (2 tablets per day) VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) 3 XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG (alprazolam) 3 SL (3 tablets per day) XANAX ORAL TABLET 2 MG (alprazolam) 3 SL (5 tablets per day) XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 SL (1 tablet per day) 0.5 MG, 1 MG, 2 MG (alprazolam) XANAX XR ORAL TABLET EXTENDED RELEASE 24 HOUR 3 3 SL (3 tablets per day) MG (alprazolam) BUTYROPHENONES - Drugs for Depression & Psychosis lactate oral concentrate 2 mg/ml 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 1 CALCITONIN GENE-RELATED PEPTIDE ANTAG. - Migraine Treatment UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) 2 PA; SL (8 tablets per month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 97 Coverage Requirements & Prescription Drug Name Drug Tier Limits CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. - Drugs for Parkinson carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 3 150-200 mg, 50-200-200 mg COMTAN ORAL TABLET 200 MG ( entacapone) 3 entacapone oral tablet 200 mg 1 STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 3 levodopa-entacapone) tolcapone oral tablet 100 mg 3 PA CENTRAL NERVOUS SYSTEM AGENTS, MISC. - Drugs for Attention Deficit Disorder acamprosate calcium oral tablet delayed release 333 mg 3 hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg 3 SL (2 capsules per day) atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg 3 SL (1 capsule per day) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg 1 SL (1 tablet per day) guanfacine hcl oral tablet 1 mg, 2 mg 1 memantine hcl oral solution 2 mg/ml 1 memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg 1 NAMENDA TITRATION PAK ORAL TABLET 28 X 5 MG & 21 X 3 10 MG (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK 7 SL (56 capsules per 365 2 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) days) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine hcl- 2 SL (1 capsule per day) donepezil hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 98 Coverage Requirements & Prescription Drug Name Drug Tier Limits NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) 3 PA; SL (1 tablet per day) NUEDEXTA ORAL CAPSULE 20-10 MG (- 3 PA quinidine) RILUTEK ORAL TABLET 50 MG () 3 riluzole oral tablet 50 mg 3 TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) 3 PA VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) 2 PA; SL (1 capsule per day) PA; SL (540mL (3 bottles) XYREM ORAL SOLUTION 500 MG/ML () 4 per month) XYWAV ORAL SOLUTION 500 MG/ML (ca, mg, k, and na 4 PA; SL (18 mL per day) oxybates) CYCLOOXYGENASE-2 (COX-2) INHIBITORS - Drugs for Pain oral capsule 100 mg, 200 mg, 50 mg 3 SL (2 capsules per day) celecoxib oral capsule 400 mg 3 SL (1 capsule per day) PRECURSORS - Drugs for Parkinson carbidopa oral tablet 25 mg 3 carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg 1 carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25- 250 mg 1 carbidopa-levodopa oral tablet dispersible 10-100 mg, 25- 100 mg, 25-250 mg 3 carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- 3 150-200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML (carbidopa- 3 PA levodopa) INBRIJA INHALATION CAPSULE 42 MG (levodopa) 3 PA; SL (10 capsules per day) SINEMET ORAL TABLET 10-100 MG, 25-100 MG (carbidopa- 3 levodopa) STALEVO 100 ORAL TABLET 25-100-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 125 ORAL TABLET 31.25-125-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 150 ORAL TABLET 37.5-150-200 MG (carbidopa- 3 levodopa-entacapone)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 99 Coverage Requirements & Prescription Drug Name Drug Tier Limits STALEVO 200 ORAL TABLET 50-200-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 50 ORAL TABLET 12.5-50-200 MG (carbidopa- 3 levodopa-entacapone) STALEVO 75 ORAL TABLET 18.75-75-200 MG (carbidopa- 3 levodopa-entacapone) -DERIV. AGONISTS - Drugs for Parkinson mesylate oral capsule 5 mg 1 oral tablet 0.5 mg 3 AGENTS - Drugs for Nerve Pain hcl oral capsule delayed release particles 20 mg, 30 mg 1 SL (2 capsules per day) duloxetine hcl oral capsule delayed release particles 60 mg 1 SL (1 capsule per day) LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 3 PA; SL (3 capsules per day) 50 MG, 75 MG (pregabalin) LYRICA ORAL CAPSULE 225 MG, 300 MG (pregabalin) 3 PA; SL (2 capsules per day) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) 3 PA; SL (30 mL per day) pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg 1 SL (3 capsules per day) pregabalin oral capsule 225 mg, 300 mg 1 SL (2 capsules per day) pregabalin oral solution 20 mg/ml 3 SL (30 mL per day) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 SL (2 tablets per day) ( hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG SL (55 tablets (1 pack) per 3 (milnacipran hcl) 365 days) HYDANTOINS - Drugs for Seizures DILANTIN ORAL CAPSULE 30 MG (phenytoin sodium 3 extended) PHENYTEK ORAL CAPSULE 200 MG, 300 MG (phenytoin 3 sodium extended) phenytoin infatabs oral tablet chewable 50 mg 1 phenytoin oral suspension 125 mg/5ml 3 phenytoin oral tablet chewable 50 mg 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 100 Coverage Requirements & Prescription Drug Name Drug Tier Limits INHALATION ANESTHETICS - Anesthetics FORANE INHALATION SOLUTION () 3 isoflurane inhalation solution 3 inhalation solution 3 terrell inhalation solution 3 ULTANE INHALATION SOLUTION (sevoflurane) 3 B INHIBITORS - Drugs for Parkinson EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 SL (1 patch per day) MG/24HR, 9 MG/24HR () mesylate oral tablet 0.5 mg, 1 mg 3 selegiline hcl oral capsule 5 mg 3 selegiline hcl oral tablet 5 mg 1 ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline SL (60 tablets per 3 hcl) prescription) MONOAMINE OXIDASE INHIBITORS - Drugs for Depression & Psychosis EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 3 SL (1 patch per day) MG/24HR, 9 MG/24HR (selegiline) MARPLAN ORAL TABLET 10 MG ( isocarboxazid) 3 NARDIL ORAL TABLET 15 MG ( sulfate) 3 PARNATE ORAL TABLET 10 MG (tranylcypromine sulfate) 3 phenelzine sulfate oral tablet 15 mg 1 rasagiline mesylate oral tablet 0.5 mg, 1 mg 3 selegiline hcl oral capsule 5 mg 3 selegiline hcl oral tablet 5 mg 1 tranylcypromine sulfate oral tablet 10 mg 1 ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG (selegiline SL (60 tablets per 3 hcl) prescription) NONERGOT-DERIV.DOPAMINE RECEPTOR - Drugs for Parkinson KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 3 PA; SL (5 films per day) 30 MG ( hcl) MIRAPEX ORAL TABLET 0.125 MG, 0.5 MG, 0.75 MG, 1 MG 3 ( dihydrochloride)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 101 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR 3 () pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg 1 hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg 1 AGONISTS - Drugs for Pain acetaminophen-codeine #2 oral tablet 300-15 mg 1 acetaminophen-codeine #3 oral tablet 300-30 mg 1 acetaminophen-codeine #4 oral tablet 300-60 mg 1 acetaminophen-codeine oral solution 120-12 mg/5ml 1 acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg 1 ascomp-codeine oral capsule 50-325-40-30 mg 1 belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2-60 mg 3 BENZHYDROCODONE-ACETAMINOPHEN ORAL TABLET 3 4.08-325 MG, 6.12-325 MG, 8.16-325 MG butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 3 SL (6 capsules per day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 3 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 CONZIP ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 PA; SL (1capsule per day) 100 MG, 200 MG, 300 MG (tramadol hcl) DILAUDID ORAL LIQUID 1 MG/ML ( hcl) 3 DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG 3 (hydromorphone hcl) endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5- 325 mg 1 citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg 1 PA; SL (4 units per day) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, PA; SL (10 patches per 1 25 mcg/hr, 50 mcg/hr, 75 mcg/hr month) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 SL (6 capsules per day) (butalbital-apap-caff-cod)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 102 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocodone bitartrate er oral capsule extended release 12 3 PA; SL (2 capsules per day) hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg hydrocodone bitartrate er oral capsule extended release 12 3 PA; SL (0 per 31 days) hour 50 mg hydrocodone-acetaminophen oral solution 10-325 mg/15ml 3 SL (185 mL per day) hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml 3 hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg 3 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg 1 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg 3 hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 hydromorphone hcl oral liquid 1 mg/ml 3 hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg 1 hydromorphone hcl rectal suppository 3 mg 1 LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT 3 PA; SL (1 bottle per day) (fentanyl citrate) tartrate oral tablet 2 mg, 3 mg 3 SL (4 tablets per day) LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- 3 acetaminophen) meperidine hcl oral solution 50 mg/5ml 1 meperidine hcl oral tablet 50 mg 1 hcl intensol oral concentrate 10 mg/ml 3 SL (6 mL per day) methadone hcl oral concentrate 10 mg/ml 3 SL (6 mL per day) methadone hcl oral solution 10 mg/5ml 1 PA; SL (11.3 mL per day) methadone hcl oral solution 5 mg/5ml 1 PA; SL (22.6 mL per day) methadone hcl oral tablet 10 mg 1 PA; SL (2 tablets per day) methadone hcl oral tablet 5 mg 1 PA; SL (4 tablets per day) methadone hcl oral tablet soluble 40 mg 1 SL (1.5 mL per day) methadose oral concentrate 10 mg/ml 3 SL (6 mL per day) methadose oral tablet soluble 40 mg 1 SL (1.5 mL per day) methadose sugar-free oral concentrate 10 mg/ml 3 SL (6 mL per day) sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml 1 morphine sulfate er beads oral capsule extended release 24 3 PA; SL (0 per 31 days) hour 120 mg

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 103 Coverage Requirements & Prescription Drug Name Drug Tier Limits morphine sulfate er beads oral capsule extended release 24 3 PA; SL (1 capsule per day) hour 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral tablet extended release 100 mg, 200 mg, 60 mg 1 PA; SL (0 per 31 days) morphine sulfate er oral tablet extended release 15 mg, 30 mg 1 PA; SL (3 tablets per day) morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml 1 morphine sulfate oral tablet 15 mg, 30 mg 1 morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg 1 MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MG, 3 PA; SL (0 per 31 days) 200 MG, 60 MG (morphine sulfate) MS CONTIN ORAL TABLET EXTENDED RELEASE 15 MG, 30 3 PA; SL (3 tablets per day) MG (morphine sulfate) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 3 PA; SL (2 tablets per day) HOUR 100 MG, 50 MG ( hcl) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 3 PA; SL (0 per 31 days) HOUR 150 MG, 200 MG, 250 MG (tapentadol hcl) NUCYNTA ORAL TABLET 100 MG ( tapentadol hcl) 3 SL (7 tablets per day) NUCYNTA ORAL TABLET 50 MG, 75 MG ( tapentadol hcl) 3 SL (6 tablets per day) oxycodone hcl oral capsule 5 mg 1 oxycodone hcl oral concentrate 100 mg/5ml 3 oxycodone hcl oral solution 5 mg/5ml 3 oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg 1 OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 10-300 4 MG/5ML oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1 hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg 3 PA; SL (4 tablets per day) oxymorphone hcl oral tablet 10 mg, 5 mg 1 SL (12 tablets per day) PROLATE ORAL SOLUTION 10-300 MG/5ML (oxycodone- 4 acetaminophen) TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 3 PA; SL (1capsule per day) 24 HOUR 100 MG, 200 MG, 300 MG tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg 3 SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 104 Coverage Requirements & Prescription Drug Name Drug Tier Limits tramadol hcl oral tablet 50 mg 1 tramadol-acetaminophen oral tablet 37.5-325 mg 1 SL (8 tablets per day) ULTRACET ORAL TABLET 37.5-325 MG (tramadol- 3 SL (8 tablets per day) acetaminophen) ULTRAM ORAL TABLET 50 MG ( tramadol hcl) 3 XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- 2 PA; SL (2 capsules per day) DETERRENT 13.5 MG, 18 MG, 27 MG, 9 MG (oxycodone) XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- 2 PA; SL (0 per 31 days) DETERRENT 36 MG (oxycodone) OPIATE ANTAGONISTS - Drugs for Overdose or Poisoning BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG 3 PA; SL (2 films per day) ( hcl- hcl) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 4- 1 mg 1 SL (2 films per day) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg 1 PA; SL (3 films per day) buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 SL (3 films per day) buprenorphine hcl-naloxone hcl sublingual tablet 2 SL (3 tablets per day) sublingual 2-0.5 mg, 8-2 mg hcl oral tablet 50 mg 1 NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) 2 -naloxone hcl oral tablet 50-0.5 mg 1 SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG 3 SL (2 films per day) (buprenorphine hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 2-0.5 MG (buprenorphine 3 PA; SL (3 films per day) hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 8-2 MG (buprenorphine hcl- 3 SL (3 films per day) naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1 SL (3 tablets per day) 1.4-0.36 MG, 5.7-1.4 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 1 SL (1 tablet per day) 2.9-0.71 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-2.1 MG 1 SL (2 tablets per day) (buprenorphine hcl-naloxone hcl) OPIATE PARTIAL AGONISTS - Drugs for Pain BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 3 PA; SL (2 films per day) MCG, 75 MCG, 750 MCG, 900 MCG (buprenorphine hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 105 Coverage Requirements & Prescription Drug Name Drug Tier Limits BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG 3 PA; SL (2 films per day) (buprenorphine hcl-naloxone hcl) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg 3 SL (3 tablets per day) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 4- 1 mg 1 SL (2 films per day) buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg 1 PA; SL (3 films per day) buprenorphine hcl-naloxone hcl sublingual film 8-2 mg 1 SL (3 films per day) buprenorphine hcl-naloxone hcl sublingual tablet 2 SL (3 tablets per day) sublingual 2-0.5 mg, 8-2 mg SL (7.5 mL (3 bottles) per butorphanol tartrate nasal solution 10 mg/ml 3 month) pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG 3 SL (2 films per day) (buprenorphine hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 2-0.5 MG (buprenorphine 3 PA; SL (3 films per day) hcl-naloxone hcl) SUBOXONE SUBLINGUAL FILM 8-2 MG (buprenorphine hcl- 3 SL (3 films per day) naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-0.18 MG, 1 SL (3 tablets per day) 1.4-0.36 MG, 5.7-1.4 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-2.9 MG, 1 SL (1 tablet per day) 2.9-0.71 MG (buprenorphine hcl-naloxone hcl) ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-2.1 MG 1 SL (2 tablets per day) (buprenorphine hcl-naloxone hcl) OTHER ANTI-INFLAM. AGENTS - Drugs for Pain DAYPRO ORAL TABLET 600 MG () 3 PATCH EXTERNAL PATCH 1.3 % 3 SL (2 patches per day) diclofenac potassium oral tablet 50 mg 1 diclofenac sodium er oral tablet extended release 24 hour 100 mg 1 diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg 1 diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg 3 oral tablet 500 mg 1 DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-famotidine) 3 ST; SL (3 tablets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 106 Coverage Requirements & Prescription Drug Name Drug Tier Limits EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg 1 etodolac oral capsule 200 mg 1 SL (8 capsules per day) etodolac oral capsule 300 mg 1 SL (4 capsules per day) etodolac oral tablet 500 mg 1 FELDENE ORAL CAPSULE 10 MG, 20 MG () 3 FLECTOR EXTERNAL PATCH 1.3 % (diclofenac epolamine) 3 SL (2 patches per day) oral tablet 100 mg, 50 mg 1 hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg 3 hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 ibuprofen oral suspension 100 mg/5ml 3 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 3 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 2 indomethacin er oral capsule extended release 75 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 TROMETHAMINE NASAL SOLUTION 15.75 ST; SL (5 bottles per 3 MG/SPRAY prescription) ketorolac tromethamine oral tablet 10 mg 1 SL (20 tablets per month) LICART EXTERNAL PATCH 24 HOUR 1.3 % (diclofenac 3 epolamine) meclofenamate sodium oral capsule 100 mg, 50 mg 1 oral capsule 250 mg 3 oral tablet 15 mg, 7.5 mg 1 MOBIC ORAL TABLET 15 MG, 7.5 MG (meloxicam) 3 oral tablet 500 mg, 750 mg 1 NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 375 MG, 500 MG (naproxen sodium) naproxen oral suspension 125 mg/5ml 1 PA naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 107 Coverage Requirements & Prescription Drug Name Drug Tier Limits naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg 3 NAPROXEN SODIUM ER ORAL TABLET EXTENDED 3 RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 275 mg, 550 mg 1 naproxen-esomeprazole oral tablet delayed release 375-20 mg, 500-20 mg 3 PA; SL (2 tablets per day) oxaprozin oral tablet 600 mg 1 piroxicam oral capsule 10 mg, 20 mg 1 PRASTERA ORAL KIT 200 & 400 MG ( & 3 ibuprofen) SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac ST; SL (5 bottles per 3 tromethamine) prescription) oral tablet 150 mg, 200 mg 1 TORONOVA II SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & anesthetic) TORONOVA SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & anesthetic) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 MG, 3 PA; SL (2 tablets per day) 500-20 MG (naproxen-esomeprazole) - Drugs for Depression & Psychosis hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg 1 compro rectal suppository 25 mg 1 hcl oral concentrate 5 mg/ml 1 fluphenazine hcl oral elixir 2.5 mg/5ml 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg 1 oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- 10 mg, 4-25 mg, 4-50 mg 1 maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg 1 hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 108 Coverage Requirements & Prescription Drug Name Drug Tier Limits RESPIRATORY AND CNS STIMULANTS - Drugs for the Nervous System ascomp-codeine oral capsule 50-325-40-30 mg 1 AZSTARYS ORAL CAPSULE 26.1-5.2 MG, 39.2-7.8 MG, 52.3- 3 10.4 MG (serdexmethylphen-dexmethylphen) bac oral tablet 50-325-40 mg 1 SL (6 tablet per day) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg 3 SL (6 capsules per day) butalbital-apap-caff-cod oral capsule 50-325-40-30 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325- 40 mg 1 SL (6 capsules per day) butalbital-apap-caffeine oral tablet 50-325-40 mg 1 SL (6 tablet per day) butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 CAFERGOT ORAL TABLET 1-100 MG (ergotamine-caffeine) 3 caffeine citrate oral solution 20 mg/ml, 60 mg/3ml 3 CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 2 SL (1 tablet per day) MG, 54 MG (methylphenidate hcl) CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG 2 SL (2 tablets per day) (methylphenidate hcl) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 3 ST; SL (one patch per day) MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 1 SL (1 capsule per day) 24 hour 10 mg, 15 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl er oral capsule extended release 1 SL (2 capsules per day) 24 hour 20 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg 1 SL (2 tablets per day) ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 ergotamine-caffeine oral tablet 1-100 mg 3 ESGIC ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap- 3 SL (6 tablet per day) caffeine) FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG 3 SL (6 capsules per day) (butalbital-apap-caff-cod) FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 SL (2 tablets per day) (dexmethylphenidate hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 109 Coverage Requirements & Prescription Drug Name Drug Tier Limits FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG 3 ST; SL (1 capsule per day) (dexmethylphenidate hcl) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 3 ST; SL (2 capsules per day) HOUR 20 MG (dexmethylphenidate hcl) METHYLIN ORAL SOLUTION 10 MG/5ML (methylphenidate 3 ST; SL (30mLs per day) hcl) METHYLIN ORAL SOLUTION 5 MG/5ML (methylphenidate 3 ST; SL (60mL per day) hcl) methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg 1 SL (1 capsule per day) methylphenidate hcl er (la) oral capsule extended release 1 SL (1 capsule per day) 24 hour 10 mg, 20 mg, 30 mg, 40 mg methylphenidate hcl er (la) oral capsule extended release 3 SL (1 capsule per day) 24 hour 60 mg methylphenidate hcl er oral tablet extended release 10 mg 3 SL (2 tablets per day) methylphenidate hcl er oral tablet extended release 20 mg 3 SL (3 tablets per day) methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg 3 ST; SL (1 tablet per day); AE methylphenidate hcl er oral tablet extended release 24 hour ST; SL (2 tablets per day); 3 36 mg AE methylphenidate hcl oral solution 10 mg/5ml 3 SL (30mLs per day) methylphenidate hcl oral solution 5 mg/5ml 3 SL (60mL per day) methylphenidate hcl oral tablet 10 mg 1 SL (5 tablets per day) methylphenidate hcl oral tablet 20 mg, 5 mg 1 SL (3 tablets per day) methylphenidate hcl oral tablet chewable 10 mg 3 SL (6 tablets per day) methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg 3 SL (3 tablets per day) MIGERGOT RECTAL SUPPOSITORY 2-100 MG (ergotamine- 3 caffeine) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER 3 ST; SL (12 mL per day) 25 MG/5ML (methylphenidate hcl) RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 3 ST; SL (1 capsule per day) HOUR 10 MG, 20 MG, 30 MG, 40 MG (methylphenidate hcl) RITALIN ORAL TABLET 10 MG (methylphenidate hcl) 3 SL (5 tablets per day) RITALIN ORAL TABLET 20 MG, 5 MG (methylphenidate hcl) 3 SL (3 tablets per day) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 110 Coverage Requirements & Prescription Drug Name Drug Tier Limits theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 VTOL LQ ORAL SOLUTION 50-325-40 MG/15ML (butalbital- 3 SL (180 mL per prescription) apap-caffeine) ZEBUTAL ORAL CAPSULE 50-325-40 MG (butalbital-apap- 3 SL (6 capsules per day) caffeine) SALICYLATES - Drugs for Pain ascomp-codeine oral capsule 50-325-40-30 mg 1 aspirin-dipyridamole er oral capsule extended release 12 3 hour 25-200 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg 1 butalbital-aspirin-caffeine oral capsule 50-325-40 mg 1 carisoprodol-aspirin-codeine oral tablet 200-325-16 mg 3 DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 SL (1 capsule per day) 162.5 MG (aspirin) oral tablet 500 mg, 750 mg 1 SEL.,NOREPI REUPTAKE INHIBITOR - Drugs for Depression & Psychosis DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 3 24 HOUR 100 MG, 50 MG desvenlafaxine succinate er oral tablet extended release 24 3 SL (4 tablets per day) hour 100 mg desvenlafaxine succinate er oral tablet extended release 24 3 SL (1 tablet per day) hour 25 mg, 50 mg DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 3 SL (2 capsules per day); AE SPRINKLE 20 MG, 30 MG, 60 MG (duloxetine hcl) DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE 3 SL (1 capsule per day); AE SPRINKLE 40 MG (duloxetine hcl) duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg 1 SL (2 capsules per day) duloxetine hcl oral capsule delayed release particles 60 mg 1 SL (1 capsule per day) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 ST; SL (1 capsule per day) 120 MG, 20 MG, 40 MG, 80 MG ( hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 111 Coverage Requirements & Prescription Drug Name Drug Tier Limits FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR ST; SL (28 capsules per 3 THERAPY PACK 20 & 40 MG (levomilnacipran hcl) year) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 SL (2 tablets per day) (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG SL (55 tablets (1 pack) per 3 (milnacipran hcl) 365 days) hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg 1 venlafaxine hcl er oral tablet extended release 24 hour 150 mg 3 SL (2 tablets per day) venlafaxine hcl er oral tablet extended release 24 hour 225 mg 3 SL (1 tablet per day) venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg, 75 mg 3 SL (3 tablets per day) venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 SELECTIVE SEROTONIN AGONISTS - Migraine Treatment SL (4 tablets per malate oral tablet 12.5 mg, 6.25 mg 3 prescription) SL (4 tablets per hydrobromide oral tablet 20 mg, 40 mg 3 prescription) SL (4 tablets per succinate oral tablet 2.5 mg 3 prescription) IMITREX NASAL SOLUTION 20 MG/ACT, 5 MG/ACT SL (12 devices (2 packages) 3 () per month) SL (4 tablets per hcl oral tablet 1 mg, 2.5 mg 1 prescription) PA; SL (8 tablets per REYVOW ORAL TABLET 100 MG ( succinate) 2 prescription) PA; SL (4 tablets per REYVOW ORAL TABLET 50 MG (lasmiditan succinate) 2 prescription) SL (18 tablets per month at benzoate oral tablet 10 mg, 5 mg 1 retail.) rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 1 SL (18 tablets per month) SL (12 devices (2 packages) sumatriptan nasal solution 20 mg/act, 5 mg/act 1 per month) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg 1 SL (9 tablets per month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 112 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (4 tablets per oral tablet 2.5 mg, 5 mg 1 prescription) SL (4 tablets per zolmitriptan oral tablet dispersible 2.5 mg, 5 mg 1 prescription) ST; SL (6 units per ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) 3 prescription) SELECTIVE-SEROTONIN REUPTAKE INHIBITORS - Drugs for Depression & Psychosis CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG ( 3 hydrobromide) citalopram hydrobromide oral solution 10 mg/5ml 1 citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg 1 oxalate oral solution 5 mg/5ml 3 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg 1 fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 SL (4 capsules per fluoxetine hcl oral capsule delayed release 90 mg 3 prescription) fluoxetine hcl oral solution 20 mg/5ml 1 fluoxetine hcl oral tablet 10 mg, 20 mg 3 maleate er oral capsule extended release 24 3 hour 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg 1 olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg 3 SL (1 capsule per day) olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg 3 SL (3 capsules per day) hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg 1 SL (2 tablets per day) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg 1 PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) 2 PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG 3 (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG 3 SL (2 tablets per day) (paroxetine mesylate) hcl oral concentrate 20 mg/ml 1 sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 SYMBYAX ORAL CAPSULE 3-25 MG, 6-25 MG (olanzapine- 3 SL (3 capsules per day) fluoxetine hcl)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 113 Coverage Requirements & Prescription Drug Name Drug Tier Limits SEROTONIN MODULATORS - Drugs for Depression & Psychosis hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg 1 hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg 1 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 3 ST; SL (1 tablet per day) ( hbr) VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG ( 3 SL (1 tablet per day) hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG (vilazodone SL (30 tablets (1 kit) per 3 hcl) month) - Drugs for Seizures CELONTIN ORAL CAPSULE 300 MG (methsuximide) 3 oral capsule 250 mg 1 ethosuximide oral solution 250 mg/5ml 1 ZARONTIN ORAL CAPSULE 250 MG (ethosuximide) 3 ZARONTIN ORAL SOLUTION 250 MG/5ML (ethosuximide) 3 - Drugs for Depression & Psychosis thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 TRICYCLICS, OTHER NOREPI-RU INHIBITORS - Drugs for Depression & Psychosis amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 oral tablet 100 mg, 150 mg, 25 mg, 50 mg 1 chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg 1 hcl oral capsule 25 mg, 50 mg, 75 mg 3 hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 doxepin hcl oral concentrate 10 mg/ml 1 doxepin hcl oral tablet 3 mg, 6 mg 3 SL (1 tablet per day) hcl oral tablet 10 mg, 25 mg, 50 mg 1 imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 114 Coverage Requirements & Prescription Drug Name Drug Tier Limits NORPRAMIN ORAL TABLET 10 MG, 25 MG (desipramine 3 hcl) hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 1 nortriptyline hcl oral solution 10 mg/5ml 1 perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- 10 mg, 4-25 mg, 4-50 mg 1 hcl oral tablet 10 mg, 5 mg 1 SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) 3 SL (1 tablet per day) maleate oral capsule 100 mg, 25 mg, 50 mg 3 VESICULAR MONOAMINE TRANSPORT2 INHIBITOR - Drugs for the Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG 2 PA; SL (4 tablets per day) (deutetrabenazine) tetrabenazine oral tablet 12.5 mg, 25 mg 3 PA XENAZINE ORAL TABLET 12.5 MG, 25 MG (tetrabenazine) 3 PA WAKEFULNESS-PROMOTING AGENTS - Drugs for the Nervous System oral tablet 150 mg, 200 mg, 250 mg 3 PA; SL (1 tablet per day) armodafinil oral tablet 50 mg 3 PA; SL (2 tablets per day) oral tablet 100 mg, 200 mg 3 PA; SL (1 tablet per day) NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG 3 PA; SL (1 tablet per day) (armodafinil) NUVIGIL ORAL TABLET 50 MG (armodafinil) 3 PA; SL (2 tablets per day) PROVIGIL ORAL TABLET 100 MG, 200 MG (modafinil) 3 PA; SL (1 tablet per day) SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) 3 PA; SL (1 tablet per day) WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant hcl) 3 PA; SL (2 tablets per day) DEVICES - Medical Supplies and Durable Medical Equipment DEVICES - Medical Supplies and Durable Medical Equipment ACCU-CHEK AVIVA IN VITRO SOLUTION (blood glucose 1 calibration) ACCU-CHEK COMPACT PLUS CONTROL IN VITRO 1 SOLUTION (blood glucose calibration) ACCU-CHEK FASTCLIX LANCET KIT KIT (lancets misc.) 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 115 Coverage Requirements & Prescription Drug Name Drug Tier Limits ACCU-CHEK GUIDE CONTROL IN VITRO LIQUID (blood 1 glucose calibration) ACCU-CHEK GUIDE KIT W/DEVICE (blood glucose 3 monitoring suppl) ACCU-CHEK SMARTVIEW CONTROL IN VITRO LIQUID 1 (blood glucose calibration) ACCU-CHEK SOFTCLIX LANCET DEVICE KIT KIT (lancets 1 misc.) AUTOLET LANCING DEVICE (lancet devices) 3 CARETOUCH CONTROL SOL LEVEL 2 IN VITRO LIQUID 3 (blood glucose calibration) CARETOUCH LANCING/EJECTOR (lancet devices) 3 CONTOUR CONTROL IN VITRO LIQUID HIGH , LOW , 3 NORMAL (blood glucose calibration) CONTOUR NEXT CONTROL IN VITRO SOLUTION LOW , 3 NORMAL (blood glucose calibration) SL (1 spacer per EASIVENT (spacer/aero-holding chambers) 2 prescription) EASYMAX 15 LEVEL 2-3 CONTROL IN VITRO LIQUID (blood 3 glucose calibration) EASYMAX CONTROL IN VITRO SOLUTION NORMAL (blood 3 glucose calibration) EASYMAX CONTROL NORMAL/HIGH IN VITRO LIQUID 3 (blood glucose calibration) FLEXICHAMBER ADULT MASK/SMALL (spacer/aero-hold SL (1 spacer per 2 chamber mask) prescription) FLEXICHAMBER CHILD MASK/LARGE (spacer/aero-hold SL (1 spacer per 2 chamber mask) prescription) FLEXICHAMBER CHILD MASK/SMALL (spacer/aero-hold SL (1 spacer per 2 chamber mask) prescription) FORTISCARE CONTROL IN VITRO SOLUTION HIGH , LOW , 3 NORMAL (blood glucose calibration) INSPIREASE RESERVOIR BAGS (spacer/aero-hold chamber SL (1 spacer per 2 bags) prescription) INSULIN PEN NEEDLES 29G X 12.7MM , 29G X 5MM , 29G X 8MM , 31G X 5 MM , 32G X 4 MM , 33G X 4 MM , 33G X 5 MM 2 , 33G X 6 MM (insulin pen needle)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 116 Coverage Requirements & Prescription Drug Name Drug Tier Limits INSULIN PEN NEEDLES 29G X 12MM , 31G X 6 MM , 31G X 8 2 MM INSULIN SYRINGES 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 SL (100 syringes per ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 2 prescription) 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MICROLET NEXT LANCING DEVICE (lancet devices) 3 NOVOFINE AUTOCOVER PEN NEEDLE 30G X 8 MM (insulin 2 pen needle) NOVOFINE PEN NEEDLE 32G X 6 MM (insulin pen needle) 2 NOVOFINE PLUS PEN NEEDLE 32G X 4 MM (insulin pen 2 needle) NOVOTWIST PEN NEEDLE 32G X 5 MM (insulin pen needle) 2 ONETOUCH DELICA LANCING DEVICE (lancet devices) 1 ONETOUCH DELICA PLUS LANCING DEVICE (lancet 1 devices) ONETOUCH VERIO IN VITRO SOLUTION HIGH (blood 1 glucose calibration) SURESTEP PRO HIGH GLUCOSE IN VITRO LIQUID (blood 1 glucose calibration) SURESTEP PRO LOW GLUCOSE IN VITRO LIQUID (blood 1 glucose calibration) SURESTEP PRO NORMAL GLUCOSE IN VITRO LIQUID 1 (blood glucose calibration) TRUE METRIX LEVEL 1 IN VITRO SOLUTION LOW (blood 3 glucose calibration) TRUE METRIX LEVEL 2 IN VITRO SOLUTION NORMAL 3 (blood glucose calibration) TRUE METRIX LEVEL 3 IN VITRO SOLUTION HIGH (blood 3 glucose calibration) UNISTRIP CONTROL IN VITRO SOLUTION LOW (blood 3 glucose calibration)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 117 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIAGNOSTIC AGENTS MELLITUS PA; SL (300 test strips per ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose blood) 3 month) ACCU-CHEK COMPACT PLUS TEST STRIPS IN VITRO PA; SL (300 test strips per 3 STRIP (glucose blood) month) SL (300 test strips per ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) 3 month) ACCU-CHEK SMARTVIEW TEST STRIPS IN VITRO STRIP PA; SL (300 test strips per 3 (glucose blood) month) PA; SL (300 test strips per CARETOUCH TEST IN VITRO STRIP (glucose blood) 3 month) SL (300 test strips per CONTOUR NEXT TEST STRIP IN VITRO (glucose blood) 2 month) PA; SL (300 test strips per CONTOUR NEXT TEST STRIP IN VITRO (glucose blood) 3 month) PA; SL (300 test strips per CONTOUR TEST IN VITRO STRIP (glucose blood) 3 month) FREESTYLE PRECISION NEO TEST IN VITRO STRIP PA; SL (300 test strips per 3 (glucose blood) month) PA; SL (300 test strips per MICRODOT TEST IN VITRO STRIP (glucose blood) 3 month) SL (300 test strips per ONETOUCH ULTRA IN VITRO STRIP (glucose blood) 1 month) SL (300 test strips per ONETOUCH VERIO IN VITRO STRIP (glucose blood) 1 month) PRECISION PCX PLUS TEST IN VITRO STRIP (glucose PA; SL (300 test strips per 3 blood) month) PA; SL (300 test strips per PRECISION QID TEST IN VITRO STRIP (glucose blood) 3 month) PRECISION SOF-TACT TEST IN VITRO STRIP (glucose PA; SL (300 test strips per 3 blood) month) PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP PA; SL (300 test strips per 3 (glucose blood) month) RELION BLOOD GLUCOSE TEST IN VITRO STRIP (glucose PA; SL (300 test strips per 3 blood) month) TRUE METRIX BLOOD GLUCOSE TEST IN VITRO STRIP PA; SL (300 test strips per 3 (glucose blood) month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 118 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRUE METRIX PRO BLOOD GLUCOSE IN VITRO STRIP 3 PA; SL (10 strips per day) (glucose blood) PA; SL (300 test strips per TRUETRACK TEST IN VITRO STRIP (glucose blood) 3 month) DIAGNOSTIC AGENTS ACCUCAINE COMBINATION KIT 1 % (lido-pentaf-tetrafl- 3 ultrasound) KETONES KETONE TEST IN VITRO STRIP 3 KETOSTIX IN VITRO STRIP ( (urine) test) 3 OCULAR DISORDERS MEMBRANEBLUE OPHTHALMIC SOLUTION 0.15 % (trypan 3 blue) VISIONBLUE OPHTHALMIC SOLUTION 0.06 % (trypan blue) 3 PANCREATIC FUNCTION oral tablet 500 mg 1 DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants DISINFECTANTS (FOR NON-DERMATOLOGIC USE) - Disinfectants external solution 10 % 3 FORMALDEHYDE EXTERNAL SOLUTION 37 % 3 GLUTARALDEHYDE EXTERNAL SOLUTION 25 % 3 ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AGENTS K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac 3 phosphates) ALKALINIZING AGENTS cytra k crystals oral packet 3300-1002 mg 1 ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- 3 citric acid) potassium citrate er oral tablet extended release 10 meq (1080 mg), 5 meq (540 mg) 1 potassium citrate er oral tablet extended release 15 meq (1620 mg) 3 potassium citrate-citric acid oral solution 1100-334 mg/5ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 119 Coverage Requirements & Prescription Drug Name Drug Tier Limits sod citrate-citric acid oral solution 500-334 mg/5ml 1 tricitrates oral solution 550-500-334 mg/5ml 1 UROCIT-K 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 3 (1080 MG) (potassium citrate) UROCIT-K 15 ORAL TABLET EXTENDED RELEASE 15 MEQ 3 (1620 MG) (potassium citrate) UROCIT-K 5 ORAL TABLET EXTENDED RELEASE 5 MEQ 3 (540 MG) (potassium citrate) DETOXICANTS BUPHENYL ORAL POWDER 3 GM/TSP (sodium 3 PA phenylbutyrate) BUPHENYL ORAL TABLET 500 MG (sodium phenylbutyrate) 3 PA CARBAGLU ORAL TABLET 200 MG (carglumic acid) 3 PA constulose oral solution 10 gm/15ml 1 enulose oral solution 10 gm/15ml 1 generlac oral solution 10 gm/15ml 1 KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) 3 lactulose encephalopathy oral solution 10 gm/15ml 1 lactulose oral solution 10 gm/15ml, 20 gm/30ml 1 LITHOSTAT ORAL TABLET 250 MG ( ) 3 RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol phenylbutyrate) 4 PA sodium phenylbutyrate oral powder 3 gm/tsp 3 PA sodium phenylbutyrate oral tablet 500 mg 3 PA CALORIC AGENTS - Drugs for Nutrition aminoamrms oral capsule 3 aminoreliefrms oral capsule 3 DOJOLVI ORAL LIQUID 100 % (triheptanoin) 3 PA MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- 2 succ-c-thre-b12-fa) n-acetyl-l- oral capsule 600 mg 3 CARBONIC ANHYDRASE INHIBITORS - Drugs for Water Balance acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 120 Coverage Requirements & Prescription Drug Name Drug Tier Limits DIURETICS, MISCELLANEOUS - Drugs for Water Balance ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 IRRIGATING SORBITOL IRRIGATION SOLUTION 3 %, 3.3 % 3 LOOP DIURETICS - Drugs for Water Balance bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 BUMEX ORAL TABLET 0.5 MG (bumetanide) 3 EDECRIN ORAL TABLET 25 MG (ethacrynic acid) 3 ethacrynic acid oral tablet 25 mg 3 furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 20 mg, 40 mg, 80 mg 1 LASIX ORAL TABLET 20 MG, 40 MG, 80 MG (furosemide) 3 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 OTHER -REMOVING AGENTS RADIOGARDASE ORAL CAPSULE 0.5 GM ( 3 insoluble) PHOSPHATE-REMOVING AGENTS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric citrate) 3 calcium acetate (phos binder) oral capsule 667 mg 1 calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 FOSRENOL ORAL PACKET 1000 MG, 750 MG ( 3 carbonate) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg 3 PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 121 Coverage Requirements & Prescription Drug Name Drug Tier Limits RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 3 carbonate) sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 3 VELPHORO ORAL TABLET CHEWABLE 500 MG (sucroferric 2 oxyhydroxide) POTASSIUM-REMOVING AGENTS LOKELMA ORAL PACKET 10 GM (sodium zirconium 3 PA; SL (3 packets per day) cyclosilicate) LOKELMA ORAL PACKET 5 GM (sodium zirconium 3 PA; SL (1 packet per day) cyclosilicate) sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM 3 PA; SL (1 packet per day) (patiromer sorbitex calcium) POTASSIUM-SPARING DIURETICS - Drugs for Water Balance ALDACTONE ORAL TABLET 100 MG, 25 MG, 50 MG 3 (spironolactone) amiloride hcl oral tablet 5 mg 1 amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 CAROSPIR ORAL SUSPENSION 25 MG/5ML 3 PA (spironolactone) DYRENIUM ORAL CAPSULE 100 MG, 50 MG (triamterene) 3 eplerenone oral tablet 25 mg, 50 mg 3 MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 triamterene oral capsule 100 mg, 50 mg 3 triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 REPLACEMENT PREPARATIONS CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium acetate (phos binder) oral capsule 667 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 122 Coverage Requirements & Prescription Drug Name Drug Tier Limits calcium acetate (phos binder) oral tablet 667 mg 1 calcium acetate oral tablet 667 mg 1 calcium-folic acid plus d oral wafer 1342-1 mg 3 CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 2 MG (prenat w/o a-fecbgl-fa-dha) CORVITA ORAL TABLET 1.25 MG (multiple vitamins- 2 minerals-fa) DIALYVITE SUPREME D ORAL TABLET 3 MG (multiple 2 vitamins-minerals-fa) EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ 3 (potassium bicarb-citric acid) effer-k oral tablet effervescent 25 meq 1 ferrocite plus oral tablet 106-1 mg 3 GALZIN ORAL CAPSULE 25 MG, 50 MG ( acetate (oral)) 3 hematinic plus vit/minerals oral tablet 106-1 mg 3 INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-% 3 (calfactant in nacl) klor-con 10 oral tablet extended release 10 meq 1 klor-con m10 oral tablet extended release 10 meq 1 KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 3 MEQ (potassium chloride crys er) klor-con m20 oral tablet extended release 20 meq 1 klor-con oral packet 20 meq 1 klor-con oral tablet extended release 8 meq 1 klor-con/ef oral tablet effervescent 25 meq 1 K-PHOS ORAL TABLET 500 MG (potassium phosphate 3 monobasic) K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG (k phos 2 mono-sod phos di & mono) k-prime oral tablet effervescent 25 meq 1 K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 3 MEQ, 8 MEQ (potassium chloride) MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML- 3 % (insulin regular(human) in nacl) NEONATAL + DHA ORAL 29-1 & 200 MG 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 123 Coverage Requirements & Prescription Drug Name Drug Tier Limits OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- 2 minerals-fa) ONEVITE ORAL TABLET 1 MG 2 PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium acetate 3 (phos binder)) PHOSPHA 250 NEUTRAL ORAL TABLET 155-852-130 MG (k 2 phos mono-sod phos di & mono ) phosphorous oral tablet 155-852-130 mg 1 phospho-trin 250 neutral oral tablet 155-852-130 mg 1 potassium chloride crys er oral tablet extended release 10 meq, 20 meq 1 potassium chloride crys er tablet extended release 15 meq 3 oral 15 meq potassium chloride er oral capsule extended release 10 meq, 8 meq 1 potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq 1 potassium chloride oral packet 20 meq 1 potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) 1 PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 2 ginger) prenatal oral tablet 27-0.8 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 2 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 2 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 124 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENATVITE RX ORAL TABLET 0.8 MG 3 REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- 2 minerals-fa) STROVITE FORTE ORAL SYRUP (multiple vitamins- 2 minerals-fa) TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 2 fecbn-meth-fa-dha) UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- 2 minerals-fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins- 2 minerals-fa) virt-phos 250 neutral oral tablet 155-852-130 mg 1 VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 2 fum-fa-dha) WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 WILZIN ORAL CAPSULE 25 MG (zinc acetate (oral)) 3 THIAZIDE DIURETICS - Drugs for Water Balance ACCURETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 3 MG (quinapril-hydrochlorothiazide) ALDACTAZIDE ORAL TABLET 25-25 MG (spironolactone- 3 hctz) ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone- 2 hctz) amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg, 5-6.25 mg 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- 6.25 mg, 5-6.25 mg 1 candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg 3 DIURIL ORAL SUSPENSION 250 MG/5ML (chlorothiazide) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 125 Coverage Requirements & Prescription Drug Name Drug Tier Limits EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG 3 ST (azilsartan-chlorthalidone) enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg 1 fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg 1 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 3 MG (losartan potassium-hctz) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- 12.5 mg 1 lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1 losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg 1 LOTENSIN HCT ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20- 3 25 MG (benazepril-hydrochlorothiazide) MAXZIDE ORAL TABLET 75-50 MG (triamterene-hctz) 3 MAXZIDE-25 ORAL TABLET 37.5-25 MG (triamterene-hctz) 3 metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100- 50 mg, 50-25 mg 1 olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg 1 quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- 12.5 mg, 20-25 mg 1 spironolactone-hctz oral tablet 25-25 mg 1 TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 MG, 3 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg 1 SL (2 tablets per day) triamterene-hctz oral capsule 37.5-25 mg 1 triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 1 valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- 25 mg, 80-12.5 mg 1 SL (2 tablets per day) valsartan-hydrochlorothiazide oral tablet 320-12.5 mg, 320- 25 mg 1 SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 126 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG 3 (bisoprolol-hydrochlorothiazide) THIAZIDE-LIKE DIURETICS - Drugs for Water Balance atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg 1 chlorthalidone oral tablet 25 mg, 50 mg 1 indapamide oral tablet 1.25 mg, 2.5 mg 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 URICOSURIC AGENTS colchicine-probenecid oral tablet 0.5-500 mg 1 probenecid oral tablet 500 mg 1 VASOPRESSIN ANTAGONISTS - Drugs for Water Balance JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) 2 PA; SL (2 tablets per day) JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 2 PA; SL (2 tablets per day) MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG (tolvaptan) SAMSCA ORAL TABLET 15 MG (tolvaptan) 2 PA; SL (90 tablets per year) SAMSCA ORAL TABLET 30 MG (tolvaptan) 3 PA; SL (60 tablets per year) TOLVAPTAN ORAL TABLET 15 MG 2 SL (1 tablet per day) tolvaptan oral tablet 30 mg 1 PA; SL (2 tablets per day) ENZYMES ENZYMES BRINEURA KIT 2 X 150 MG/5ML (cerliponase alfa) 3 CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip- prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 3 ST 54700 UNIT, 2600-8800 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 3 ST 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase 2 PA; SL (5 mL per day) alfa) SANTYL EXTERNAL OINTMENT 250 UNIT/GM ( collagenase) 3 SL (60g per prescription) SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) 2 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 127 Coverage Requirements & Prescription Drug Name Drug Tier Limits VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 3 ST UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) EYE, EAR, NOSE AND THROAT (EENT) PREPS. ALPHA-ADRENERGIC AGONISTS (EENT) - Drugs for the Eye ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 % 2 SL (10 mL per month) ( tartrate) brimonidine tartrate ophthalmic solution 0.15 % 1 SL (10 mL per month) brimonidine tartrate ophthalmic solution 0.2 % 1 BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 3 0.15-2 % COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 2 SL (10mL per month) (brimonidine tartrate-timolol) SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 2 SL (8 ml (1 bottle) per month) (brinzolamide-brimonidine) ANTIALLERGIC AGENTS - Drugs for Allergy ALAWAY OPHTHALMIC SOLUTION 0.025 % (ketotifen 3 fumarate) ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil 3 sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide 3 tromethamine) azelastine hcl nasal solution 0.1 %, 137 mcg/spray 3 azelastine hcl ophthalmic solution 0.05 % 1 cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 cromolyn sodium ophthalmic solution 4 % 1 eye itch relief ophthalmic solution 0.025 % 3 LASTACAFT OPHTHALMIC SOLUTION 0.25 % (alcaftadine) 3 SL (0.10 mL per day) SL (1.02 gm (0.04 bottles) olopatadine hcl nasal solution 0.6 % 3 per day) olopatadine hcl ophthalmic solution 0.1 % 3 olopatadine hcl ophthalmic solution 0.2 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 128 Coverage Requirements & Prescription Drug Name Drug Tier Limits PATADAY OPHTHALMIC SOLUTION 0.1 %, 0.2 % 3 (olopatadine hcl) ZADITOR OPHTHALMIC SOLUTION 0.025 % (ketotifen 3 fumarate) ANTIBACTERIALS (EENT) - Drugs for Infections ak-poly-bac ophthalmic ointment 500-10000 unit/gm 1 AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) 3 bacitracin ophthalmic ointment 500 unit/gm 1 bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm 1 bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BESIVANCE OPHTHALMIC SUSPENSION 0.6 % 3 (besifloxacin hcl) BLEPH-10 OPHTHALMIC SOLUTION 10 % (sulfacetamide 3 sodium) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 3 (sulfacetamide-prednisolone) CETRAXAL OTIC SOLUTION 0.2 % (ciprofloxacin hcl) 3 CILOXAN OPHTHALMIC OINTMENT 0.3 % (ciprofloxacin 3 hcl) CILOXAN OPHTHALMIC SOLUTION 0.3 % (ciprofloxacin hcl) 3 CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 3 dexamethasone) ciprofloxacin hcl ophthalmic solution 0.3 % 1 ciprofloxacin hcl otic solution 0.2 % 3 CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium ) erythromycin ophthalmic ointment 5 mg/gm 1 H-N gatifloxacin ophthalmic solution 0.5 % 3 gentak ophthalmic ointment 0.3 % 1 gentamicin sulfate ophthalmic solution 0.3 % 1 SL (15 g per prescription) levofloxacin ophthalmic solution 0.5 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 129 Coverage Requirements & Prescription Drug Name Drug Tier Limits MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) 3 MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin hcl) 3 moxifloxacin hcl (2x day) ophthalmic solution 0.5 % 3 moxifloxacin hcl ophthalmic solution 0.5 % 3 MOXIFLOXACIN HCL OPHTHALMIC SOLUTION PREFILLED 3 SYRINGE 0.5 % neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5- 400-10000 , 5-400-10000 1 neomycin-polymyxin-dexameth ophthalmic ointment 3.5- 10000-0.1 1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 10000-0.1 1 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- 10000-.025 1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000- 1 3 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1 neo-polycin hc ophthalmic ointment 1 % 1 neo-polycin ophthalmic ointment 3.5-400-10000 1 OCUFLOX OPHTHALMIC SOLUTION 0.3 % (ofloxacin) 3 ofloxacin ophthalmic solution 0.3 % 1 ofloxacin otic solution 0.3 % 1 OTIPRIO INTRATYMPANIC SUSPENSION 6 % 3 (ciprofloxacin) polycin ophthalmic ointment 500-10000 unit/gm 1 polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% 1 POLYTRIM OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-% 3 (polymyxin b-trimethoprim) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 130 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) PREDNISOLON-GATIFLOX- OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % sulfacetamide sodium ophthalmic ointment 10 % 1 sulfacetamide sodium ophthalmic solution 10 % 1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 3 (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 3 (tobramycin-dexamethasone) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 SL (3.5 grams per TOBREX OPHTHALMIC OINTMENT 0.3 % ( tobramycin) 3 prescription) VANCOMYCIN HCL OPHTHALMIC SOLUTION PREFILLED 3 SYRINGE 10 MG/ML VIGAMOX OPHTHALMIC SOLUTION 0.5 % (moxifloxacin 3 hcl) ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) ZYMAXID OPHTHALMIC SOLUTION 0.5 % (gatifloxacin) 3 ANTIFUNGALS (EENT) - Drugs for Infections NATACYN OPHTHALMIC SUSPENSION 5 % (natamycin) 2 ANTIVIRALS (EENT) - Drugs for Infections trifluridine ophthalmic solution 1 % 1 ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) 3 BETA-ADRENERGIC BLOCKING AGENTS (EENT) - Drugs for the Eye betaxolol hcl ophthalmic solution 0.5 % 1 BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 3 SL (5mL per prescription) hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % (betaxolol 3 hcl) hcl ophthalmic solution 1 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 131 Coverage Requirements & Prescription Drug Name Drug Tier Limits COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % 2 SL (10mL per month) (brimonidine tartrate-timolol) COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 3 (dorzolamide hcl-timolol mal) COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % (dorzolamide 3 hcl-timolol mal) dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 3 ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol maleate) 3 hcl ophthalmic solution 0.5 % 1 timolol maleate ocudose ophthalmic solution 0.5 % 1 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % 1 timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % (daily) 1 timolol maleate pf ophthalmic solution 0.5 % 1 TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % 2 (timolol maleate) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % 3 (timolol maleate) TIMOPTIC OPHTHALMIC SOLUTION 0.25 %, 0.5 % (timolol 3 maleate) TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION 0.25 3 %, 0.5 % (timolol maleate) CARBONIC ANHYDRASE INHIBITORS (EENT) - Drugs for the Eye acetazolamide er oral capsule extended release 12 hour 500 mg 1 acetazolamide oral tablet 125 mg, 250 mg 1 AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) 3 SL (10mL per prescription) BRIMONIDINE-DORZOLAMIDE OPHTHALMIC SOLUTION 3 0.15-2 % brinzolamide ophthalmic suspension 1 % 1 SL (10mL per prescription) COSOPT OPHTHALMIC SOLUTION 22.3-6.8 MG/ML 3 (dorzolamide hcl-timolol mal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 132 Coverage Requirements & Prescription Drug Name Drug Tier Limits COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % (dorzolamide 3 hcl-timolol mal) dorzolamide hcl ophthalmic solution 2 % 1 SL (10mL per prescription) dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml 1 dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % 3 methazolamide oral tablet 25 mg, 50 mg 1 SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % 2 SL (8 ml (1 bottle) per month) (brinzolamide-brimonidine) TRUSOPT OPHTHALMIC SOLUTION 2 % (dorzolamide hcl) 3 SL (10mL per prescription) CORTICOSTEROIDS (EENT) - Drugs for ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol 3 SL (10 mL per prescription) etabonate) bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % 1 BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY SL (50g (2 bottles) per 3 (beclomethasone diprop monohyd) prescription) BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % 3 (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 % 3 (sulfacetamide-prednisolone) CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- 3 hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- 3 dexamethasone) cortic-nd otic solution 10-10-1 mg/ml 1 CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 MG/ML 3 (neomycin-colist-hc-thonzonium ) DERMOTIC OTIC OIL 0.01 % (fluocinolone acetonide) 3 dexamethasone sodium phosphate ophthalmic solution 0.1 % 1 DEXTENZA OPHTHALMIC INSERT 0.4 MG (dexamethasone) 3 DUREZOL OPHTHALMIC 0.05 % (difluprednate) 3 flac otic oil 0.01 % 3 FLAREX OPHTHALMIC SUSPENSION 0.1 % 3 (fluorometholone acetate) SL (75mL (3 bottles) per flunisolide nasal solution 25 mcg/act (0.025%) 1 prescription)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 133 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluocinolone acetonide otic oil 0.01 % 3 fluorometholone ophthalmic suspension 0.1 % 1 SL (16 g (1 bottle) per fluticasone propionate nasal suspension 50 mcg/act 1 prescription) FML FORTE OPHTHALMIC SUSPENSION 0.25 % 3 (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % 3 (fluorometholone) FML OPHTHALMIC OINTMENT 0.1 % ( fluorometholone) 3 hydrocortisone-acetic acid otic solution 1-2 % 1 INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol 3 etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % ( loteprednol 3 etabonate) LOTEMAX OPHTHALMIC SUSPENSION 0.5 % (loteprednol 3 SL (5 mL per prescription) etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol 3 SL (5 grams per prescription) etabonate) loteprednol etabonate ophthalmic suspension 0.5 % 3 SL (5 mL per prescription) MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 3 (dexamethasone) MAXITROL OPHTHALMIC OINTMENT 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) MAXITROL OPHTHALMIC SUSPENSION 3.5-10000-0.1 3 (neomycin-polymyxin-dexameth) SL (34g (2 bottles) per mometasone furoate nasal suspension 50 mcg/act 3 month) NASACORT ALLERGY 24HR NASAL AEROSOL 55 MCG/ACT SL (16.5g (1 bottle) per 3 (triamcinolone acetonide) month) neomycin-polymyxin-dexameth ophthalmic ointment 3.5- 10000-0.1 1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- 10000-0.1 1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000- 1 3 neomycin-polymyxin-hc otic solution 1 %, 3.5-10000-1 1 neomycin-polymyxin-hc otic suspension 3.5-10000-1 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 134 Coverage Requirements & Prescription Drug Name Drug Tier Limits neo-polycin hc ophthalmic ointment 1 % 1 PRED FORTE OPHTHALMIC SUSPENSION 1 % 3 (prednisolone acetate) PRED MILD OPHTHALMIC SUSPENSION 0.12 % 3 (prednisolone acetate) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % (gentamicin- 3 prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % 3 (gentamicin-prednisolone acet) prednisolone acetate ophthalmic suspension 1 % 1 prednisolone sodium phosphate ophthalmic solution 1 % 1 PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 SL (1 canister (6.8 grams) 3 MCG/ACT (beclomethasone diprop (nasal)) per month) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT SL (10.6 (1 inhaler) per 3 (beclomethasone diprop (nasal)) prescription) sulfacetamide-prednisolone ophthalmic solution 10-0.23 % 1 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % 3 (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % 3 (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % 3 (tobramycin-dexamethasone) tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % 1 ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % (loteprednol- 3 tobramycin) EENT ANTI-INFECTIVES, MISCELLANEOUS - Drugs for Infections ARZOL SILVER NIT APPLICATORS EXTERNAL 75-25 % 3 (silver nitrate-pot nitrate) BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION 5 3 % (povidone-iodine) chlorhexidine gluconate mouth/throat solution 0.12 % 3 cortic-nd otic solution 10-10-1 mg/ml 1 PERIDEX MOUTH/THROAT SOLUTION 0.12 % 3 (chlorhexidine gluconate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 135 Coverage Requirements & Prescription Drug Name Drug Tier Limits periogard mouth/throat solution 0.12 % 3 PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 2 silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % 1 EENT ANTI-INFLAMMATORY AGENTS, MISC. - Drugs for Inflammation RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 % 2 PA (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % (cyclosporine) 2 PA XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) 2 PA EENT DRUGS, MISCELLANEOUS acetic acid otic solution 2 % 1 hcl ophthalmic solution 0.5 % 3 cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 CYSTADROPS OPHTHALMIC SOLUTION 0.37 % PA; SL (20 mL bottles per 3 (cysteamine hcl) month) CYSTARAN OPHTHALMIC SOLUTION 0.44 % (cysteamine 3 PA; SL (60 mL per 21 days) hcl) DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % 3 (sulfuric acid-sulf phenolics) hydrocortisone-acetic acid otic solution 1-2 % 1 IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine hcl) 3 LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear 3 insert) MUCOSITISRX MOUTH/THROAT PACKET (artificial saliva) 3 OXERVATE OPHTHALMIC SOLUTION 0.002 % (cenegermin- 3 PA; SL (56 vials per year) bkbj) EENT NONSTEROIDAL ANTI-INFLAM. AGENTS - Drugs for Inflammation ACULAR LS OPHTHALMIC SOLUTION 0.4 % (ketorolac 3 tromethamine) ACULAR OPHTHALMIC SOLUTION 0.5 % (ketorolac 3 tromethamine) ACUVAIL OPHTHALMIC SOLUTION 0.45 % (ketorolac 3 tromethamine) bromfenac sodium (once-daily) ophthalmic solution 0.09 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 136 Coverage Requirements & Prescription Drug Name Drug Tier Limits diclofenac sodium ophthalmic solution 0.1 % 1 flurbiprofen sodium ophthalmic solution 0.03 % 1 ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % 1 NEVANAC OPHTHALMIC SUSPENSION 0.1 % (nepafenac) 3 PREDNISOLON-GATIFLOX-BROMFENAC OPHTHALMIC 3 SOLUTION 1-0.5-0.075 % LOCAL ANESTHETICS (EENT) - Drugs for Numbing AKTEN OPHTHALMIC GEL 3.5 % ( hcl) 3 ALCAINE OPHTHALMIC SOLUTION 0.5 % (proparacaine hcl) 3 ALTACAINE OPHTHALMIC SOLUTION 0.5 % ( hcl) 2 cortic-nd otic solution 10-10-1 mg/ml 1 lidocaine hcl mouth/throat solution 4 % 3 lidocaine viscous hcl mouth/throat solution 2 % 1 PRAMOTIC OTIC LIQUID 1-0.1 % (pramoxine-chloroxylenol) 2 proparacaine hcl ophthalmic solution 0.5 % 1 tetracaine hcl ophthalmic solution 0.5 % 1 MIOTICS - Drugs for the Eye ISOPTO CARPINE OPHTHALMIC SOLUTION 1 %, 2 %, 4 % 3 (pilocarpine hcl) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % 1 MYDRIATICS - Drugs for the Eye altafrin ophthalmic solution 10 % 1 altafrin ophthalmic solution 2.5 % 3 atropine sulfate ophthalmic ointment 1 % 1 atropine sulfate ophthalmic solution 1 % 3 CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 1 %, 2 % 3 ( hcl) CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % 1 homatropaire ophthalmic solution 5 % 1 ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % (atropine 3 sulfate) phenylephrine hcl ophthalmic solution 10 % 1 phenylephrine hcl ophthalmic solution 2.5 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 137 Coverage Requirements & Prescription Drug Name Drug Tier Limits ophthalmic solution 0.5 %, 1 % 1 PROSTAGLANDIN ANALOGS - Drugs for the Eye latanoprost ophthalmic solution 0.005 % 1 SL (2.5mL (1 bottle) per LUMIGAN OPHTHALMIC SOLUTION 0.01 % (bimatoprost) 2 month) travoprost (bak free) ophthalmic solution 0.004 % 1 SL (3 per prescription) XELPROS OPHTHALMIC EMULSION 0.005 % (latanoprost) 3 SL (2.5 mL per prescription) ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % (tafluprost) 3 SL (1 container per day) VASOCONSTRICTORS ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 3 (nasal)) altafrin ophthalmic solution 10 % 1 altafrin ophthalmic solution 2.5 % 3 CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % 3 (cyclopentolate-phenylephrine) phenylephrine hcl ophthalmic solution 10 % 1 phenylephrine hcl ophthalmic solution 2.5 % 3 UPNEEQ OPHTHALMIC SOLUTION 0.1 % ( PA; SL (30 vials per 3 hcl) prescription) GASTROINTESTINAL DRUGS ANTACIDS AND ADSORBENTS omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40-1100 mg 3 ST SODIUM BICARBONATE ORAL POWDER 3 ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG 3 ST (omeprazole-sodium bicarbonate) GASTROINTESTINAL DRUGS - Drugs for the Stomach 5-HT3 RECEPTOR ANTAGONISTS - Drugs for and Nausea AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 3 ) hcl oral tablet 1 mg 3 SL (8 per prescription) hcl oral solution 4 mg/5ml 1 ondansetron hcl oral tablet 24 mg 1 SL (2 tablets per month) ondansetron hcl oral tablet 4 mg, 8 mg 1 ondansetron odt oral tablet dispersible 4 mg, 8 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 138 Coverage Requirements & Prescription Drug Name Drug Tier Limits SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR 3 SL (1 patch per Rx) (granisetron) ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) 3 SL (10 per prescription) ANTIDIARRHEA AGENTS - Drugs for Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg 1 ST; SL (224 doses (1 kit) per HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 365 days) LOMOTIL ORAL TABLET 2.5-0.025 MG (diphenoxylate- 3 atropine) hcl oral capsule 2 mg 3 PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 365 2 metronid-tetracyc) days) XERMELO ORAL TABLET 250 MG (telotristat etiprate) 3 PA; SL (3 tablets per day) ANTIEMETICS, MISCELLANEOUS - Drugs for Vomiting and Nausea oral capsule 10 mg, 2.5 mg, 5 mg 1 MARINOL ORAL CAPSULE 10 MG, 2.5 MG, 5 MG 3 (dronabinol) promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 scopolamine transdermal patch 72 hour 1 mg/3days 3 PA; SL (120 mL (4 bottles) SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) 3 per 28 days) TRANSDERM SCOP (1.5 MG) TRANSDERMAL PATCH 72 3 HOUR 1 MG/3DAYS (scopolamine base) TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 72 3 HOUR 1 MG/3DAYS (scopolamine base) ANTIHISTAMINES (GI DRUGS) - Drugs for Vomiting and Nausea ANTIVERT ORAL TABLET 50 MG ( meclizine hcl) 3 compro rectal suppository 25 mg 1 cvs motion sickness oral tablet 50 mg 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 139 Coverage Requirements & Prescription Drug Name Drug Tier Limits goodsense motion sickness oral tablet 50 mg 3 meclizine hcl oral tablet 12.5 mg, 25 mg 3 motion sickness relief oral tablet 50 mg 3 prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 1 hcl oral capsule 300 mg 1 ANTI-INFLAMMATORY AGENTS (GI DRUGS) - Drugs for Inflammation hcl oral tablet 0.5 mg, 1 mg 3 PA; SL (2 tablets per day) APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 2 0.375 GM (mesalamine) AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 balsalazide disodium oral capsule 750 mg 1 CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) 3 SL (1 suppository per day) DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) 3 LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 2 (mesalamine) LOTRONEX ORAL TABLET 0.5 MG, 1 MG ( alosetron hcl) 3 PA; SL (2 tablets per day) mesalamine rectal 4 gm 1 mesalamine rectal suppository 1000 mg 1 SL (1 suppository per day) mesalamine-cleanser rectal kit 4 gm 3 SL (1 kit per day) ROWASA RECTAL KIT 4 GM (mesalamine-cleanser) 3 SL (1 kit per day) SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) 2 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 ANTIULCER AGENTS AND ACID SUPPRESS.,MISC - Drugs for Ulcers and Stomach Acid ST; SL (224 doses (1 kit) per HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) 3 365 days) PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- SL (120 capsules per 365 2 metronid-tetracyc) days) ANTIULCER AGENTS AND ACID SUPPRESSANTS - Drugs for Ulcers and Stomach Acid amoxicillin oral capsule 250 mg, 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 140 Coverage Requirements & Prescription Drug Name Drug Tier Limits amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml 1 amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 125 mg, 250 mg 1 clarithromycin er oral tablet extended release 24 hour 500 mg 1 clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 1 clarithromycin oral tablet 250 mg, 500 mg 1 FLAGYL ORAL CAPSULE 375 MG (metronidazole) 3 FLAGYL ORAL TABLET 500 MG (metronidazole) 3 metronidazole oral capsule 375 mg 3 metronidazole oral tablet 250 mg, 500 mg 1 SODIUM BICARBONATE ORAL POWDER 3 tetracycline hcl oral capsule 250 mg, 500 mg 1 CATHARTICS AND LAXATIVES - Drugs for Constipation cascara sagrada oral fluid extract 1 gm/ml 3 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 2 fecb-fegl-fa) clearlax oral powder 17 gm/scoop 3 H CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -GM/160ML 3 (sod picosulfate-mag ox-cit acd) gavilax oral powder 17 gm/scoop 3 H gavilyte-c oral solution reconstituted 240 gm 1 H SL (4000 mL per gavilyte-g oral solution reconstituted 236 gm 1 prescription); H gavilyte-n with flavor pack oral solution reconstituted 420 gm 1 H glycolax oral powder 17 gm/scoop 3 H GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM SL (4000 mL per 3 (peg 3350-kcl-nabcb-nacl-nasulf) prescription) mineral oil heavy oral oil 3 mm clearlax oral powder 17 gm/scoop 3 H MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 3 SL (1 box per prescription) (peg-kcl-nacl-nasulf-na asc-c)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 141 Coverage Requirements & Prescription Drug Name Drug Tier Limits NULYTELY LEMON-LIME ORAL SOLUTION 3 RECONSTITUTED 420 GM (peg 3350-kcl-na bicarb-nacl) peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm 1 H SL (4000 mL per peg-3350/electrolytes oral solution reconstituted 236 gm 1 prescription); H peg-3350/electrolytes/ascorbat oral solution reconstituted 100 gm 3 SL (1 box per prescription) peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm 3 SL (1 box per prescription) peg-prep oral kit 5-210 mg-gm 3 PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- SL (3 cartons per 3 kcl-nacl-nasulf-na asc-c) prescription) polyethylene glycol 3350 oral powder 17 gm/scoop 3 H PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-1.6 3 SL (354 mL per prescription) GM/177ML (na sulfate-k sulfate-mg sulf) SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate- 3 mag sulfate-kcl) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 2 MG (prenatal-fefum-fa-dss-fish oil) CHOLELITHOLYTIC AGENTS - Drugs for the Stomach CHENODAL ORAL TABLET 250 MG (chenodiol) 3 URSO 250 ORAL TABLET 250 MG (ursodiol) 3 URSO FORTE ORAL TABLET 500 MG (ursodiol) 3 ursodiol oral capsule 300 mg 1 ursodiol oral tablet 250 mg, 500 mg 1 DIGESTANTS - Drugs for the Stomach CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 2 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip- prot-amyl)) PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- 3 ST 54700 UNIT, 2600-8800 UNIT, 4200-14200 UNIT (pancrelipase (lip-prot-amyl))

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 142 Coverage Requirements & Prescription Drug Name Drug Tier Limits PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-14375 UNIT, 3 ST 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-78300 3 ST UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 2 25000-79000 UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-amyl)) GI DRUGS, MISCELLANEOUS - Drugs for the Stomach alvimopan oral capsule 12 mg 3 AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) 3 PA; SL (2 capsules per day) CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) 3 PA LINZESS ORAL CAPSULE 145 MCG, 290 MCG (linaclotide) 2 PA; SL (1 capsule per day) LINZESS ORAL CAPSULE 72 MCG (linaclotide) 2 PA LUBIPROSTONE ORAL CAPSULE 24 MCG, 8 MCG 3 PA; SL (2 capsules per day) MOTEGRITY ORAL TABLET 1 MG, 2 MG ( 3 PA; SL (1 tablet per day) succinate) OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) 4 PA; SL (1 tablet per day) SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) 2 PA; SL (1 tablet per day) TRULANCE ORAL TABLET 3 MG (plecanatide) 3 PA; SL (1 tablet per day) VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) 3 PA; SL (2 tablets per day) HISTAMINE H2-ANTAGONISTS - Drugs for Ulcers and Stomach Acid cimetidine hcl oral solution 300 mg/5ml, 400 mg/6.67ml 1 cimetidine oral tablet 200 mg 3 cimetidine oral tablet 300 mg, 400 mg, 800 mg 1 DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-famotidine) 3 ST; SL (3 tablets per day) famotidine oral suspension reconstituted 40 mg/5ml 3 famotidine oral tablet 20 mg, 40 mg 3 nizatidine oral capsule 150 mg, 300 mg 1 nizatidine oral solution 15 mg/ml 1 PEPCID ORAL TABLET 20 MG, 40 MG (famotidine) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 143 Coverage Requirements & Prescription Drug Name Drug Tier Limits NEUROKININ-1 RECEPTOR ANTAGONISTS - Drugs for Vomiting and Nausea AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- 3 palonosetron) SL (3 capsules per oral 80 & 125 mg 3 prescription) SL (1 capsule per aprepitant oral capsule 125 mg, 40 mg 3 prescription) SL (3 capsules per aprepitant oral capsule 80 & 125 mg 3 prescription) SL (2 capsules per aprepitant oral capsule 80 mg 3 prescription) SL (2 capsules per EMEND ORAL CAPSULE 80 MG (aprepitant) 3 prescription) EMEND ORAL SUSPENSION RECONSTITUTED 125 MG/5ML SL (3 packets (125 mg/5 mL 3 (aprepitant) per packet) per 30 days) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG SL (3 capsules per 3 (aprepitant) prescription) PROKINETIC AGENTS - Drugs for the Stomach hcl oral solution 10 mg/10ml, 5 mg/5ml 1 metoclopramide hcl oral tablet 10 mg, 5 mg 1 metoclopramide hcl oral tablet dispersible 10 mg, 5 mg 3 REGLAN ORAL TABLET 10 MG, 5 MG (metoclopramide hcl) 3 ZELNORM ORAL TABLET 6 MG ( maleate) 3 PA; SL (2 tablets per day) PROSTAGLANDINS - Drugs for Ulcers and Stomach Acid CYTOTEC ORAL TABLET 100 MCG, 200 MCG (misoprostol) 3 diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-0.2 mg 3 misoprostol oral tablet 100 mcg, 200 mcg 1 PROTECTANTS - Drugs for Ulcers and Stomach Acid sucralfate oral suspension 1 gm/10ml 1 sucralfate oral tablet 1 gm 1 PROTON-PUMP INHIBITORS - Drugs for Ulcers and Stomach Acid SL (112 doses (14 daily amoxicill-clarithro-lansopraz oral 3 administration packs) per 365 days)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 144 Coverage Requirements & Prescription Drug Name Drug Tier Limits DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 2 SL (1 capsule per day) MG (dexlansoprazole) esomeprazole oral capsule delayed release 20 mg, 40 mg 3 SL (1 capsule per day) esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg 3 SL (1 packet per day) ESOMEPRAZOLE ORAL CAPSULE DELAYED 3 ST; SL (2 tablets per day) RELEASE 49.3 MG FIRST-LANSOPRAZOLE ORAL SUSPENSION 3 MG/ML 3 PA; SL (20 mL per day) (lansoprazole) FIRST-OMEPRAZOLE ORAL SUSPENSION 2 MG/ML 3 PA; ST; SL (40 mL per day) (omeprazole) lansoprazole oral capsule delayed release 15 mg, 30 mg 3 SL (1 capsule per day) lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg 3 SL (1 tablet per day) naproxen-esomeprazole oral tablet delayed release 375-20 mg, 500-20 mg 3 PA; SL (2 tablets per day) NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 3 SL (1 capsule per day) MG (esomeprazole magnesium) NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG 3 SL (1 packet per day) (esomeprazole magnesium) OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- SL (80 capsules (1 pack) per 2 clarithro-omeprazole) year) omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg 1 SL (1 capsule per day) OMEPRAZOLE+SYRSPEND SF ALKA ORAL SUSPENSION 2 3 PA; ST; SL (40 mL per day) MG/ML (omeprazole) omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40-1100 mg 3 ST pantoprazole sodium oral tablet delayed release 20 mg, 40 mg 1 SL (1 tablet per day) PREVACID 24HR ORAL CAPSULE DELAYED RELEASE 15 3 SL (1 capsule per day) MG (lansoprazole) PREVACID ORAL CAPSULE DELAYED RELEASE 30 MG 3 SL (1 capsule per day) (lansoprazole) rabeprazole sodium oral tablet delayed release 20 mg 3 ST; SL (1 capsule per day) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 MG, 3 PA; SL (2 tablets per day) 500-20 MG (naproxen-esomeprazole)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 145 Coverage Requirements & Prescription Drug Name Drug Tier Limits ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG 3 ST (omeprazole-sodium bicarbonate) GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron HEAVY METAL ANTAGONISTS - Drugs to Reduce Iron CHEMET ORAL CAPSULE 100 MG (succimer) 3 clovique oral capsule 250 mg 3 PA deferasirox granules oral packet 180 mg, 360 mg, 90 mg 1 PA deferasirox oral packet 180 mg, 360 mg, 90 mg 1 PA deferasirox oral tablet 180 mg, 360 mg, 90 mg 3 PA deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg 3 PA deferiprone oral tablet 500 mg 4 PA DEPEN TITRATABS ORAL TABLET 250 MG ( ) 2 EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG 3 PA (deferasirox) FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) 3 PA FERRIPROX ORAL TABLET 1000 MG (deferiprone) 4 FERRIPROX ORAL TABLET 500 MG (deferiprone) 4 PA penicillamine oral capsule 250 mg 3 PA penicillamine oral tablet 250 mg 1 trientine hcl oral capsule 250 mg 3 PA HORMONES AND SYNTHETIC SUBSTITUTES - Hormones ADRENALS - Hormones ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 3 SL (60 blisters per month) MCG/DOSE (fluticasone-salmeterol) ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230- SL (12g (1 inhaler) per 3 21 MCG/ACT, 45-21 MCG/ACT (fluticasone-salmeterol) month) ARNUITY ELLIPTA INHALATION AEROSOL POWDER SL (1 inhaler (30 blisters) per BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 1 month) MCG/ACT (fluticasone furoate) BETALOAN SUIK COMBINATION KIT 30 MG/5ML (betameth 3 sod phos-ace & anesth)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 146 Coverage Requirements & Prescription Drug Name Drug Tier Limits BREO ELLIPTA INHALATION AEROSOL POWDER BREATH 3 SL (2 blisters per day) ACTIVATED 100-25 MCG/INH (fluticasone furoate-vilanterol) BREO ELLIPTA INHALATION AEROSOL POWDER BREATH SL (1 inhaler (60 blisters) per 3 ACTIVATED 200-25 MCG/INH (fluticasone furoate-vilanterol) month) BREZTRI AEROSPHERE INHALATION AEROSOL 160-9-4.8 SL (1 or 2 inhalers per 3 MCG/ACT (budeson-glycopyrrol-formoterol) month) SL (120 mL (60 respules) per budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 prescription) budesonide inhalation suspension 1 mg/2ml 1 SL (2 mL per day) budesonide oral capsule delayed release particles 3 mg 1 CORTEF ORAL TABLET 10 MG, 20 MG, 5 MG 3 (hydrocortisone) DECADRON ORAL TABLET 0.5 MG, 0.75 MG, 4 MG, 6 MG 3 (dexamethasone) dexamethasone intensol oral concentrate 1 mg/ml 1 dexamethasone oral elixir 0.5 mg/5ml 1 dexamethasone oral solution 0.5 mg/5ml 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 1 dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg (35), 1.5 mg (51) 3 DMT SUIK COMBINATION KIT 10 MG/ML (dexameth sod 3 phos & anesthetic) ENTOCORT EC ORAL CAPSULE DELAYED RELEASE 3 PARTICLES 3 MG (budesonide) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST 1 SL (4 blisters per day) (fluticasone propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone 1 SL (8 blisters per day) propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT SL (12 grams (1 inhaler) per 1 (fluticasone propionate hfa) month) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT SL (24 grams (2 inhalers) 1 (fluticasone propionate hfa) per month) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT SL (11 grams (1 inhaler) per 1 (fluticasone propionate hfa) month) fludrocortisone acetate oral tablet 0.1 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 147 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (75mL (3 bottles) per flunisolide nasal solution 25 mcg/act (0.025%) 1 prescription) SL (16 g (1 bottle) per fluticasone propionate nasal suspension 50 mcg/act 1 prescription) FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 2 SL (1 inhaler per 30 days) MCG/ACT, 55-14 MCG/ACT hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) 3 MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3 (methylprednisolone) MEDROL ORAL TABLET 2 MG (methylprednisolone) 2 MEDROL ORAL TABLET THERAPY PACK 4 MG 3 (methylprednisolone) MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) MEDROLOAN SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg 1 methylprednisolone oral tablet therapy pack 4 mg 1 MILLIPRED ORAL TABLET 5 MG (prednisolone) 2 SL (34g (2 bottles) per mometasone furoate nasal suspension 50 mcg/act 3 month) ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 15 MG, 3 30 MG (prednisolone sodium phosphate) P-CARE K40G COMBINATION KIT 40 MG/ML 3 P-CARE K80G COMBINATION KIT 40 MG/ML 3 PEDIAPRED ORAL SOLUTION 6.7 (5 BASE) MG/5ML 3 (prednisolone sodium phosphate) prednisolone oral solution 15 mg/5ml 1 prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml, 25 mg/5ml 3 prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml 1 prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg 3 prednisone intensol oral concentrate 5 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 148 Coverage Requirements & Prescription Drug Name Drug Tier Limits prednisone oral solution 5 mg/5ml 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg 1 prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48) 1 PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 1 SL (2 inhalers per month) (budesonide) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80- 3 SL (0.34 grams per day) 4.5 MCG/ACT (budesonide-formoterol fumarate) TAPERDEX 12-DAY ORAL TABLET THERAPY PACK 1.5 MG 3 (49) (dexamethasone) TAPERDEX 6-DAY ORAL TABLET THERAPY PACK 1.5 MG, 3 1.5 MG (21) (dexamethasone) TRELEGY ELLIPTA INHALATION AEROSOL POWDER SL (60 blisters (1 pack) per BREATH ACTIVATED 100-62.5-25 MCG/INH (fluticasone- 2 30 days) umeclidin-vilant) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 200-62.5-25 MCG/INH (fluticasone- 2 umeclidin-vilant) TRILOAN II SUIK COMBINATION KIT 40 MG/ML 3 (triamcinolone acet & anesth) TRILOAN SUIK COMBINATION KIT 40 MG/ML (triamcinolone 3 acet & anesth) UCERIS ORAL TABLET EXTENDED RELEASE 24 HOUR 9 3 MG (budesonide) ALPHA-GLUCOSIDASE INHIBITORS - Drugs for Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg 1 miglitol oral tablet 100 mg, 25 mg, 50 mg 3 PRECOSE ORAL TABLET 100 MG, 25 MG, 50 MG (acarbose) 3 AMYLINOMIMETICS - Drugs for Diabetes SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- 3 PA INJECTOR 2700 MCG/2.7ML (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- 3 PA INJECTOR 1500 MCG/1.5ML (pramlintide acetate) - Hormones ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 2 PA; SL (1 patch per day) MG/24HR, 4 MG/24HR ()

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 149 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT 3 PA; SL (5 gm per day) (1.62%) (testosterone) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%) PA; SL (1.25 g (1 packet) per 3 (testosterone) day) ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%) PA; SL (2.5 gms (1 packet) 3 (testosterone) per day) ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (1.62%) PA; SL (5 g (2 packets) per 3 (testosterone) day) ANDROGEL TRANSDERMAL GEL 50 MG/5GM (1%) PA; SL (2 packets (10 3 (testosterone) grams) per day) COVARYX HS ORAL TABLET 0.625-1.25 MG (est estrogens- 2 SL (2 tablets per day) methyltest) COVARYX ORAL TABLET 1.25-2.5 MG (est estrogens- 2 SL (2 tablets per day) methyltest) oral capsule 100 mg, 200 mg, 50 mg 1 EEMT HS ORAL TABLET 0.625-1.25 MG (est estrogens- 2 SL (2 tablets per day) methyltest) EEMT ORAL TABLET 1.25-2.5 MG (est estrogens- 2 SL (2 tablets per day) methyltest) est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 SL (2 tablets per day) est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 SL (2 tablets per day) est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 SL (2 tablets per day) FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) PA; SL (120g (2 bottles) per 3 (testosterone) month) METHITEST ORAL TABLET 10 MG 3 oral capsule 10 mg 3 PA; SL (3 bottles (21.96 NATESTO NASAL GEL 5.5 MG/ACT (testosterone) 3 grams) per month) oral tablet 10 mg, 2.5 mg 3 TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) PA; SL (2 packets (10 3 (testosterone) grams) per day) testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%) 1 PA; SL (5 gm per day) PA; SL (120g (2 bottles) per testosterone transdermal gel 10 mg/act (2%) 3 month) PA; SL (4 bottles (300 testosterone transdermal gel 12.5 mg/act (1%) 1 grams) per month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 150 Coverage Requirements & Prescription Drug Name Drug Tier Limits PA; SL (1.25 g (1 packet) per testosterone transdermal gel 20.25 mg/1.25gm (1.62%) 1 day) PA; SL (2.5 gms (1 packet) testosterone transdermal gel 25 mg/2.5gm (1%) 3 per day) PA; SL (5 g (2 packets) per testosterone transdermal gel 40.5 mg/2.5gm (1.62%) 1 day) PA; SL (2 packets (10 testosterone transdermal gel 50 mg/5gm (1%) 3 grams) per day) PA; SL (180mL (2 bottles) testosterone transdermal solution 30 mg/act 3 per month) VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT (1%) PA; SL (4 bottles (300 3 (testosterone) grams) per month) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) PA; SL (2 packets (10 3 (testosterone) grams) per day) ANTIDIABETIC AGENTS, MISCELLANEOUS - Drugs for Diabetes CYCLOSET ORAL TABLET 0.8 MG (bromocriptine mesylate) 3 ST KORLYM ORAL TABLET 300 MG () 3 PA WELCHOL ORAL PACKET 3.75 GM (colesevelam hcl) 2 SL (1 pack per day) WELCHOL ORAL TABLET 625 MG (colesevelam hcl) 2 ANTIESTROGENS - Drugs for Women anastrozole oral tablet 1 mg 1 CM ARIMIDEX ORAL TABLET 1 MG (anastrozole) 3 CM exemestane oral tablet 25 mg 1 CM KISQALI FEMARA ORAL TABLET THERAPY PACK 200 & 2.5 PA; SL (1 pack (91 tablets) 3 MG (ribociclib-letrozole) per 28 days); CM letrozole oral tablet 2.5 mg 1 CM ANTIGONADTROPINS - Hormones ORGOVYX ORAL TABLET 120 MG (relugolix) 3 PA; SL (1 tablet per day); CM ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA; SL (2 tablets per day) MG (elagolix--norethind) ORILISSA ORAL TABLET 150 MG (elagolix sodium) 3 PA; SL (1 tablet per day) ORILISSA ORAL TABLET 200 MG (elagolix sodium) 3 PA; SL (2 tablets per day) ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS - Hormones oral suspension 50 mg/ml 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 151 Coverage Requirements & Prescription Drug Name Drug Tier Limits ANTIPARATHYROID AGENTS - Drugs for Bones SL (3.8mL (2 bottles) per calcitonin (salmon) nasal solution 200 unit/act 1 month) cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg 3 PA ANTITHYROID AGENTS - Drugs for the Thyroid methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg 1 TAPAZOLE ORAL TABLET 10 MG, 5 MG (methimazole) 3 BIGUANIDES - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 3 SL (3 tablets per day) (pioglitazone hcl-metformin hcl) -metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg 1 GLUMETZA ORAL TABLET EXTENDED RELEASE 24 HOUR 3 PA 1000 MG, 500 MG (metformin hcl) glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5- 500 mg 1 JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 SL (2 tablets per day) 850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablet per day) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 SL (2 tablets per day) (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day) HOUR 2.5-1000 MG (saxagliptin-metformin) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day) HOUR 5-1000 MG, 5-500 MG (saxagliptin-metformin) metformin hcl er (mod) oral tablet extended release 24 hour 1000 mg, 500 mg 3 PA metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg, 500 mg 3 PA metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg 1 metformin hcl oral solution 500 mg/5ml 3 metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 152 Coverage Requirements & Prescription Drug Name Drug Tier Limits pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 1 SL (3 tablets per day) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 SL (2 tablets per day) 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG (empagliflozin-metformin 2 SL (1 tablet per day) hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin 2 SL (2 tablets per day) hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day) linaglip-metform) CONTRACEPTIVES - Drugs for Women afirmelle oral tablet 0.1-20 mg-mcg 1 H altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H SL (90 days supply max per amethia oral tablet 0.15-0.03 &0.01 mg 3 prescription); H amethyst oral tablet 90-20 mcg 3 H ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per year); 3 (segesterone-ethinyl estradiol) H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H SL (90 days supply max per ashlyna oral tablet 0.15-0.03 &0.01 mg 3 prescription); H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 3 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 153 Coverage Requirements & Prescription Drug Name Drug Tier Limits aviane oral tablet 0.1-20 mg-mcg 1 H ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H bekyree oral tablet 0.15-0.02/0.01 mg (21/5) 1 H blisovi 24 fe oral tablet 1-20 mg-mcg(24) 3 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camila oral tablet 0.35 mg 1 H SL (90 days supply max per camrese lo oral tablet 0.1-0.02 & 0.01 mg 3 prescription); H SL (90 days supply max per camrese oral tablet 0.15-0.03 &0.01 mg 3 prescription); H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 3 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H SL (90 days supply max per daysee oral tablet 0.15-0.03 &0.01 mg 3 prescription); H deblitane oral tablet 0.35 mg 1 H delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML 2 SL (3.25 mL per year); H (medroxyprogesterone acetate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 154 Coverage Requirements & Prescription Drug Name Drug Tier Limits -ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg 1 H dolishale oral tablet 90-20 mcg 3 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 3 H -ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H elinest oral tablet 0.3-30 mg-mcg 1 H ELLA ORAL TABLET 30 MG (ulipristal acetate) 1 SL (1 tablet per prescription) emoquette oral tablet 0.15-30 mg-mcg 1 H enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H errin oral tablet 0.35 mg 1 H estarylla oral tablet 0.25-35 mg-mcg 1 H ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1 H ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg 1 H falmina oral tablet 0.1-20 mg-mcg 1 H SL (90 days supply max per fayosim oral tablet 42-21-21-7 days 3 prescription); H femynor oral tablet 0.25-35 mg-mcg 1 H gemmily oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG 3 (norethin-eth estradiol-fe) hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 3 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H heather oral tablet 0.35 mg 1 H SL (90 days supply max per iclevia oral tablet 0.15-0.03 mg 1 prescription); H incassia oral tablet 0.35 mg 1 H SL (90 days supply max per introvale oral tablet 0.15-0.03 mg 1 prescription); H isibloom oral tablet 0.15-30 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 155 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (90 days supply max per jaimiess oral tablet 0.15-0.03 &0.01 mg 3 prescription); H jasmiel oral tablet 3-0.02 mg 1 H jencycla oral tablet 0.35 mg 1 H SL (90 days supply max per jolessa oral tablet 0.15-0.03 mg 1 prescription); H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 3 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 3 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 3 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 3 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H SL (90 days supply max per levonorgest-eth est & eth est oral tablet 42-21-21-7 days 3 prescription); H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 SL (90 days supply max per 3 mg, 0.15-0.03 &0.01 mg prescription); H SL (90 days supply max per levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg 1 prescription); H oral tablet 1.5 mg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 156 Coverage Requirements & Prescription Drug Name Drug Tier Limits levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 H levonorgestrel-ethinyl estrad oral tablet 90-20 mcg 3 H levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg 1 H levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 3 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) SL (90 days supply max per lojaimiess oral tablet 0.1-0.02 & 0.01 mg 3 prescription); H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG SL (90 days supply max per 3 (levonorgest-eth estrad 91-day) prescription) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H lyleq oral tablet 0.35 mg 1 H lyza oral tablet 0.35 mg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H medroxyprogesterone acetate intramuscular suspension 150 mg/ml 1 SL (5 mL per year); H medroxyprogesterone acetate intramuscular suspension 1 H prefilled syringe 150 mg/ml merzee oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 3 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 3 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 157 Coverage Requirements & Prescription Drug Name Drug Tier Limits microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG- 3 MCG(24) (norethin ace-eth estrad-fe) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 1 H ) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 3 H estetrol) nikki oral tablet 3-0.02 mg 1 H nora-be oral tablet 0.35 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg 1 H norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- mcg(24) 3 H norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 H norethindrone oral tablet 0.35 mg 1 H norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- mcg, 0.8-25 mg-mcg 3 H -eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H norlyda oral tablet 0.35 mg 1 H norlyroc oral tablet 0.35 mg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 158 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H PLAN B ONE-STEP ORAL TABLET 1.5 MG ( levonorgestrel) 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H previfem oral tablet 0.25-35 mg-mcg 1 H QUARTETTE ORAL TABLET 42-21-21-7 DAYS (levonorgest- SL (90 days supply max per 3 eth estrad 91-day) prescription) reclipsen oral tablet 0.15-30 mg-mcg 1 H SL (90 days supply max per rivelsa oral tablet 42-21-21-7 days 3 prescription); H SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol) SL (90 days supply max per setlakin oral tablet 0.15-0.03 mg 1 prescription); H sharobel oral tablet 0.35 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H SL (90 days supply max per simpesse oral tablet 0.15-0.03 &0.01 mg 3 prescription); H SLYND ORAL TABLET 4 MG (drospirenone) 3 H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 3 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 3 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 159 Coverage Requirements & Prescription Drug Name Drug Tier Limits tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 3 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tulana oral tablet 0.35 mg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 3 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 3 H SL (3 patches/1 carton per xulane transdermal patch weekly 150-35 mcg/24hr 1 prescription); H SL (3 patches/1 carton per zafemy transdermal patch weekly 150-35 mcg/24hr 1 prescription); H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 160 Coverage Requirements & Prescription Drug Name Drug Tier Limits zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS - Drugs for Diabetes GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 ST; SL (1 tablet per day) linagliptin) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5- 2 SL (2 tablets per day) 850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablet per day) HOUR 2.5-1000 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day) HOUR 5-1000 MG (linagliptin-metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG 2 SL (2 tablets per day) (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (2 tablets per day) HOUR 2.5-1000 MG (saxagliptin-metformin) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 2 SL (1 tablet per day) HOUR 5-1000 MG, 5-500 MG (saxagliptin-metformin) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG (alogliptin 2 SL (1 tablet per day) benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) 2 SL (1 tablet per day) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 SL (1 tablet per day) 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) TRADJENTA ORAL TABLET 5 MG ( linagliptin) 2 SL (1 tablet per day) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day) linaglip-metform) ESTROGEN AGONIST-ANTAGONISTS - Drugs for Women clomiphene citrate oral tablet 50 mg 1 DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 2 SL (1 tablet per day) bazedoxifene) OSPHENA ORAL TABLET 60 MG (ospemifene) 3 PA; SL (1 tablet per day) raloxifene hcl oral tablet 60 mg 1 H-N SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen citrate) 3 CM

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 161 Coverage Requirements & Prescription Drug Name Drug Tier Limits tamoxifen citrate oral tablet 10 mg 1 CM tamoxifen citrate oral tablet 20 mg 1 H-N; CM toremifene citrate oral tablet 60 mg 1 CM ESTROGENS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol- 3 norethindrone acet) afirmelle oral tablet 0.1-20 mg-mcg 1 H ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 3 SL (8 patches per month) (estradiol) altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 SL (90 days supply max per amethia oral tablet 0.15-0.03 &0.01 mg 3 prescription); H amethyst oral tablet 90-20 mcg 3 H ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per year); 3 (segesterone-ethinyl estradiol) H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H SL (90 days supply max per ashlyna oral tablet 0.15-0.03 &0.01 mg 3 prescription); H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 3 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 162 Coverage Requirements & Prescription Drug Name Drug Tier Limits BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H bekyree oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BIJUVA ORAL CAPSULE 1-100 MG (estradiol-) 3 blisovi 24 fe oral tablet 1-20 mg-mcg(24) 3 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H SL (90 days supply max per camrese lo oral tablet 0.1-0.02 & 0.01 mg 3 prescription); H SL (90 days supply max per camrese oral tablet 0.15-0.03 &0.01 mg 3 prescription); H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 3 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- SL (4 patches (1 box) per 2 0.015 MG/DAY (estradiol-levonorgestrel) month) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY SL (8 patches (1 box) per 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol- 3 month) norethindrone acet) COVARYX HS ORAL TABLET 0.625-1.25 MG (est estrogens- 2 SL (2 tablets per day) methyltest) COVARYX ORAL TABLET 1.25-2.5 MG (est estrogens- 2 SL (2 tablets per day) methyltest) cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H SL (90 days supply max per daysee oral tablet 0.15-0.03 &0.01 mg 3 prescription); H delyla oral tablet 0.1-20 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 163 Coverage Requirements & Prescription Drug Name Drug Tier Limits desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg 1 H DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM 3 (estradiol) dolishale oral tablet 90-20 mcg 3 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 3 H drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- 2 SL (1 tablet per day) bazedoxifene) EEMT HS ORAL TABLET 0.625-1.25 MG (est estrogens- 2 SL (2 tablets per day) methyltest) EEMT ORAL TABLET 1.25-2.5 MG (est estrogens- 2 SL (2 tablets per day) methyltest) ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 (estradiol) elinest oral tablet 0.3-30 mg-mcg 1 H emoquette oral tablet 0.15-30 mg-mcg 1 H enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H est estrogens-methyltest ds oral tablet 1.25-2.5 mg 1 SL (2 tablets per day) est estrogens-methyltest hs oral tablet 0.625-1.25 mg 1 SL (2 tablets per day) est estrogens-methyltest oral tablet 0.625-1.25 mg, 1.25-2.5 mg 1 SL (2 tablets per day) estarylla oral tablet 0.25-35 mg-mcg 1 H ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG (estradiol) 3 estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr 1 SL (8 patches per month) estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 SL (4 patches (1 box) per mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 mg/24hr month) estradiol vaginal 0.1 mg/gm 3 estradiol vaginal tablet 10 mcg 1 estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 164 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (1 ring/3 months (90 ESTRING VAGINAL RING 2 MG (estradiol) 3 days) per prescription) ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) SL (50 gm (1 bottle) per 3 (estradiol) month) ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1 H ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg 1 H EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 3 (estradiol) falmina oral tablet 0.1-20 mg-mcg 1 H SL (90 days supply max per fayosim oral tablet 42-21-21-7 days 3 prescription); H FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 SL (1 ring per 3 months) (estradiol acetate) femynor oral tablet 0.25-35 mg-mcg 1 H fyavolv oral tablet 0.5-2.5 mg-mcg 3 fyavolv oral tablet 1-5 mg-mcg 1 gemmily oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG 3 (norethin-eth estradiol-fe) hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 3 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H SL (90 days supply max per iclevia oral tablet 0.15-0.03 mg 1 prescription); H IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG, SL (0.29 vaginal inserts per 3 4 MCG (estradiol) day) IMVEXXY STARTER PACK VAGINAL INSERT 10 MCG, 4 3 SL (18 inserts per year) MCG (estradiol) SL (90 days supply max per introvale oral tablet 0.15-0.03 mg 1 prescription); H isibloom oral tablet 0.15-30 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 165 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (90 days supply max per jaimiess oral tablet 0.15-0.03 &0.01 mg 3 prescription); H jasmiel oral tablet 3-0.02 mg 1 H jinteli oral tablet 1-5 mg-mcg 1 SL (90 days supply max per jolessa oral tablet 0.15-0.03 mg 1 prescription); H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 3 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 3 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 3 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 3 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H SL (90 days supply max per levonorgest-eth est & eth est oral tablet 42-21-21-7 days 3 prescription); H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 SL (90 days supply max per 3 mg, 0.15-0.03 &0.01 mg prescription); H SL (90 days supply max per levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg 1 prescription); H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 166 Coverage Requirements & Prescription Drug Name Drug Tier Limits levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 H levonorgestrel-ethinyl estrad oral tablet 90-20 mcg 3 H levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg 1 H levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 3 H (norethin-eth estrad-fe biphas) LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) SL (90 days supply max per lojaimiess oral tablet 0.1-0.02 & 0.01 mg 3 prescription); H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG SL (90 days supply max per 3 (levonorgest-eth estrad 91-day) prescription) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H lyllana transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr 3 SL (8 patches per month) marlissa oral tablet 0.15-30 mg-mcg 1 H MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 2 (esterified estrogens) merzee oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 3 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 3 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 167 Coverage Requirements & Prescription Drug Name Drug Tier Limits mimvey oral tablet 1-0.5 mg 1 MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG- 3 MCG(24) (norethin ace-eth estrad-fe) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 1 H dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 3 H estetrol) nikki oral tablet 3-0.02 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg 1 H norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- mcg(24) 3 H norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 H norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg 3 norethindrone-eth estradiol oral tablet 1-5 mg-mcg 1 norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- mcg, 0.8-25 mg-mcg 3 H norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 168 Coverage Requirements & Prescription Drug Name Drug Tier Limits ocella oral tablet 3-0.03 mg 1 H ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA; SL (2 tablets per day) MG (elagolix-estradiol-norethind) orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 3 norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 2 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 2 conjugated) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 2 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 2 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) previfem oral tablet 0.25-35 mg-mcg 1 H QUARTETTE ORAL TABLET 42-21-21-7 DAYS (levonorgest- SL (90 days supply max per 3 eth estrad 91-day) prescription) reclipsen oral tablet 0.15-30 mg-mcg 1 H SL (90 days supply max per rivelsa oral tablet 42-21-21-7 days 3 prescription); H SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol) SL (90 days supply max per setlakin oral tablet 0.15-0.03 mg 1 prescription); H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H SL (90 days supply max per simpesse oral tablet 0.15-0.03 &0.01 mg 3 prescription); H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 3 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 169 Coverage Requirements & Prescription Drug Name Drug Tier Limits tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 3 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 3 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 3 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 2 SL (8 patches per month) MG/24HR, 0.1 MG/24HR (estradiol) volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 3 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 170 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (3 patches/1 carton per xulane transdermal patch weekly 150-35 mcg/24hr 1 prescription); H yuvafem vaginal tablet 10 mcg 1 SL (3 patches/1 carton per zafemy transdermal patch weekly 150-35 mcg/24hr 1 prescription); H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H GLYCOGENOLYTIC AGENTS - Hormones BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE SL (2 devices per 2 () prescription) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE SL (2 devices per 2 (glucagon) prescription) GLUCAGEN HYPOKIT INJECTION SOLUTION SL (2 devices per 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) prescription) SL (2 devices per glucagon emergency kit 1 mg injection 1 mg 1 prescription) SL (2 devices per GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 2 prescription) GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 mL per prescription) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon) GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 mL per prescription) AUTO-INJECTOR 1 MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 mL per prescription) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 mL per prescription) AUTO-INJECTOR 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SL (2 syringes per 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) prescription) GONADOTROPINS - Hormones SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin acetate) 2 INCRETIN MIMETICS - Drugs for Diabetes ADLYXIN STARTER PACK SUBCUTANEOUS PEN- 3 PA; SL (6 mL per year) INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 171 Coverage Requirements & Prescription Drug Name Drug Tier Limits ADLYXIN SUBCUTANEOUS SOLUTION PEN-INJECTOR 20 3 PA; SL (6mL per month) MCG/0.2ML (lixisenatide) BYDUREON BCISE AUTOINJECTOR SUBCUTANEOUS 2 PA AUTO-INJECTOR 2 MG/0.85ML (exenatide) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; SL (4 vials per pen-inj 2 INJECTOR 10 MCG/0.04ML (exenatide) per 28 days) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- PA; SL (4 vials per pen-inj 2 INJECTOR 5 MCG/0.02ML (exenatide) per 28 days) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; SL (1.5mL (1 pen) per 28 2 MG/1.5ML (semaglutide) days) OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 PA; SL (3mL (2 pens) per 28 2 MG/1.5ML, 4 MG/3ML (semaglutide) days) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG 2 PA; SL (1 tablet per day) (semaglutide) SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- SL (18 mL (6 pens) per 30 2 33 UNT-MCG/ML (insulin glargine-lixisenatide) days) TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR PA; SL (4 pens (2 mL) per 28 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, 4.5 MG/0.5ML 2 days) (dulaglutide) VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML 2 PA; SL (0.3mL per day) SUBCUTANEOUS 18 MG/3ML (liraglutide) VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML 3 PA; SL (0.3mL per day) SUBCUTANEOUS 18 MG/3ML (liraglutide) INTERMEDIATE-ACTING - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 1 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph human 2 (isophane)) HUMULIN N VIAL SUBCUTANEOUS SUSPENSION 100 1 UNIT/ML (insulin nph human (isophane)) LONG-ACTING INSULINS - Drugs for Diabetes LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 1 SL (75 mL per prescription) INJECTOR 100 UNIT/ML (insulin glargine) LANTUS U-100 VIAL SUBCUTANEOUS SOLUTION 100 1 SL (70 mL per prescription) UNIT/ML (insulin glargine)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 172 Coverage Requirements & Prescription Drug Name Drug Tier Limits SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100- SL (18 mL (6 pens) per 30 2 33 UNT-MCG/ML (insulin glargine-lixisenatide) days) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION 2 SL (37.5 mL per prescription) PEN-INJECTOR 300 UNIT/ML (insulin glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN- 2 SL (37.5 mL per prescription) INJECTOR 300 UNIT/ML (insulin glargine) MEGLITINIDES - Drugs for Diabetes oral tablet 120 mg, 60 mg 1 SL (3 tablets per day) oral tablet 0.5 mg, 1 mg 1 SL (4 tablets per day) repaglinide oral tablet 2 mg 1 SL (8 tablets per day) PITUITARY - Hormones desmopressin ace spray refrig nasal solution 0.01 % 1 desmopressin acetate oral tablet 0.1 mg, 0.2 mg 1 desmopressin acetate spray nasal solution 0.01 % 1 NOCDURNA SUBLINGUAL TABLET SUBLINGUAL 27.7 MCG, 3 PA; SL (1 tablet per day) 55.3 MCG (desmopressin acetate) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin 3 acetate) PROGESTINS - Drugs for Women ACTIVELLA ORAL TABLET 1-0.5 MG (estradiol- 3 norethindrone acet) afirmelle oral tablet 0.1-20 mg-mcg 1 H altavera oral tablet 0.15-30 mg-mcg 1 H alyacen 1/35 oral tablet 1-35 mg-mcg 1 H alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 SL (90 days supply max per amethia oral tablet 0.15-0.03 &0.01 mg 3 prescription); H amethyst oral tablet 90-20 mcg 3 H ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG 3 (drospirenone-estradiol) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR SL (1 vaginal ring per year); 3 (segesterone-ethinyl estradiol) H apri oral tablet 0.15-30 mg-mcg 1 H aranelle oral tablet 0.5/1/0.5-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 173 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (90 days supply max per ashlyna oral tablet 0.15-0.03 &0.01 mg 3 prescription); H aubra eq oral tablet 0.1-20 mg-mcg 1 H aubra oral tablet 0.1-20 mg-mcg 1 H aurovela 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela 1/20 oral tablet 1-20 mg-mcg 1 H aurovela 24 fe oral tablet 1-20 mg-mcg(24) 3 H aurovela fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H aurovela fe 1/20 oral tablet 1-20 mg-mcg 1 H aviane oral tablet 0.1-20 mg-mcg 1 H AYGESTIN ORAL TABLET 5 MG (norethindrone acetate) 3 ayuna oral tablet 0.15-30 mg-mcg 1 H azurette oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) 3 H (levonorgest-eth estrad-fe bisg) balziva oral tablet 0.4-35 mg-mcg 1 H bekyree oral tablet 0.15-0.02/0.01 mg (21/5) 1 H BIJUVA ORAL CAPSULE 1-100 MG (estradiol-progesterone) 3 blisovi 24 fe oral tablet 1-20 mg-mcg(24) 3 H blisovi fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H blisovi fe 1/20 oral tablet 1-20 mg-mcg 1 H briellyn oral tablet 0.4-35 mg-mcg 1 H camila oral tablet 0.35 mg 1 H SL (90 days supply max per camrese lo oral tablet 0.1-0.02 & 0.01 mg 3 prescription); H SL (90 days supply max per camrese oral tablet 0.15-0.03 &0.01 mg 3 prescription); H caziant oral tablet 0.1/0.125/0.15 -0.025 mg 1 H charlotte 24 fe oral tablet chewable 1-20 mg-mcg(24) 3 H chateal eq oral tablet 0.15-30 mg-mcg 1 H chateal oral tablet 0.15-30 mg-mcg 1 H CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- SL (4 patches (1 box) per 2 0.015 MG/DAY (estradiol-levonorgestrel) month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 174 Coverage Requirements & Prescription Drug Name Drug Tier Limits COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY SL (8 patches (1 box) per 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY (estradiol- 3 month) norethindrone acet) CRINONE VAGINAL GEL 4 %, 8 % (progesterone) 3 cryselle-28 oral tablet 0.3-30 mg-mcg 1 H cyclafem 1/35 oral tablet 1-35 mg-mcg 1 H cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H cyred eq oral tablet 0.15-30 mg-mcg 1 H cyred oral tablet 0.15-30 mg-mcg 1 H dasetta 1/35 oral tablet 1-35 mg-mcg 1 H dasetta 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H SL (90 days supply max per daysee oral tablet 0.15-0.03 &0.01 mg 3 prescription); H deblitane oral tablet 0.35 mg 1 H delyla oral tablet 0.1-20 mg-mcg 1 H DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML 2 SL (3.25 mL per year); H (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5), 0.15-30 mg-mcg 1 H dolishale oral tablet 90-20 mcg 3 H drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 3 H drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg 1 H elinest oral tablet 0.3-30 mg-mcg 1 H ELLA ORAL TABLET 30 MG (ulipristal acetate) 1 SL (1 tablet per prescription) emoquette oral tablet 0.15-30 mg-mcg 1 H ENDOMETRIN VAGINAL INSERT 100 MG (progesterone) 2 enpresse-28 oral tablet 50-30/75-40/ 125-30 mcg 1 H enskyce oral tablet 0.15-30 mg-mcg 1 H errin oral tablet 0.35 mg 1 H estarylla oral tablet 0.25-35 mg-mcg 1 H estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg 1 ESTROSTEP FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 3 (norethindron-ethinyl estrad-fe)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 175 Coverage Requirements & Prescription Drug Name Drug Tier Limits ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg 1 H ethynodiol diac-eth estradiol oral tablet 1-50 mg-mcg 1 H falmina oral tablet 0.1-20 mg-mcg 1 H SL (90 days supply max per fayosim oral tablet 42-21-21-7 days 3 prescription); H FEMHRT ORAL TABLET 0.5-2.5 MG-MCG (norethindrone-eth 3 estradiol) femynor oral tablet 0.25-35 mg-mcg 1 H fyavolv oral tablet 0.5-2.5 mg-mcg 3 fyavolv oral tablet 1-5 mg-mcg 1 gemmily oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H GENERESS FE ORAL TABLET CHEWABLE 0.8-25 MG-MCG 3 (norethin-eth estradiol-fe) hailey 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey 24 fe oral tablet 1-20 mg-mcg(24) 3 H hailey fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H hailey fe 1/20 oral tablet 1-20 mg-mcg 1 H heather oral tablet 0.35 mg 1 H SL (90 days supply max per iclevia oral tablet 0.15-0.03 mg 1 prescription); H incassia oral tablet 0.35 mg 1 H SL (90 days supply max per introvale oral tablet 0.15-0.03 mg 1 prescription); H isibloom oral tablet 0.15-30 mg-mcg 1 H SL (90 days supply max per jaimiess oral tablet 0.15-0.03 &0.01 mg 3 prescription); H jasmiel oral tablet 3-0.02 mg 1 H jencycla oral tablet 0.35 mg 1 H jinteli oral tablet 1-5 mg-mcg 1 SL (90 days supply max per jolessa oral tablet 0.15-0.03 mg 1 prescription); H juleber oral tablet 0.15-30 mg-mcg 1 H junel 1.5/30 oral tablet 1.5-30 mg-mcg 1 H junel 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 176 Coverage Requirements & Prescription Drug Name Drug Tier Limits junel fe 1/20 oral tablet 1-20 mg-mcg 1 H junel fe 24 oral tablet 1-20 mg-mcg(24) 3 H kaitlib fe oral tablet chewable 0.8-25 mg-mcg 3 H kalliga oral tablet 0.15-30 mg-mcg 1 H kariva oral tablet 0.15-0.02/0.01 mg (21/5) 1 H kelnor 1/35 oral tablet 1-35 mg-mcg 1 H kelnor 1/50 oral tablet 1-50 mg-mcg 1 H kurvelo oral tablet 0.15-30 mg-mcg 1 H larin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin 1/20 oral tablet 1-20 mg-mcg 1 H larin 24 fe oral tablet 1-20 mg-mcg(24) 3 H larin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H larin fe 1/20 oral tablet 1-20 mg-mcg 1 H larissia oral tablet 0.1-20 mg-mcg 1 H layolis fe oral tablet chewable 0.8-25 mg-mcg 3 H leena oral tablet 0.5/1/0.5-35 mg-mcg 1 H lessina oral tablet 0.1-20 mg-mcg 1 H levonest oral tablet 50-30/75-40/ 125-30 mcg 1 H SL (90 days supply max per levonorgest-eth est & eth est oral tablet 42-21-21-7 days 3 prescription); H levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 SL (90 days supply max per 3 mg, 0.15-0.03 &0.01 mg prescription); H SL (90 days supply max per levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg 1 prescription); H levonorgestrel oral tablet 1.5 mg 1 H levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg 1 H levonorgestrel-ethinyl estrad oral tablet 90-20 mcg 3 H levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 mcg 1 H levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg 1 H lillow oral tablet 0.15-30 mg-mcg 1 H LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG 3 H (norethin-eth estrad-fe biphas)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 177 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN 1/20 (21) ORAL TABLET 1-20 MG-MCG 3 (norethindrone acet-ethinyl est) LOESTRIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3 (norethin ace-eth estrad-fe) SL (90 days supply max per lojaimiess oral tablet 0.1-0.02 & 0.01 mg 3 prescription); H loryna oral tablet 3-0.02 mg 1 H LOSEASONIQUE ORAL TABLET 0.1-0.02 & 0.01 MG SL (90 days supply max per 3 (levonorgest-eth estrad 91-day) prescription) low-ogestrel oral tablet 0.3-30 mg-mcg 1 H lo-zumandimine oral tablet 3-0.02 mg 1 H lutera oral tablet 0.1-20 mg-mcg 1 H lyleq oral tablet 0.35 mg 1 H lyza oral tablet 0.35 mg 1 H marlissa oral tablet 0.15-30 mg-mcg 1 H medroxyprogesterone acetate intramuscular suspension 150 mg/ml 1 SL (5 mL per year); H medroxyprogesterone acetate intramuscular suspension 1 H prefilled syringe 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg 1 megestrol acetate oral suspension 40 mg/ml 1 CM megestrol acetate oral suspension 625 mg/5ml 3 megestrol acetate oral tablet 20 mg, 40 mg 1 CM merzee oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H mibelas 24 fe oral tablet chewable 1-20 mg-mcg(24) 3 H microgestin 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin 1/20 oral tablet 1-20 mg-mcg 1 H microgestin 24 fe oral tablet 1-20 mg-mcg 3 H microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg 1 H microgestin fe 1/20 oral tablet 1-20 mg-mcg 1 H mili oral tablet 0.25-35 mg-mcg 1 H mimvey oral tablet 1-0.5 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 178 Coverage Requirements & Prescription Drug Name Drug Tier Limits MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 MG- 3 MCG(24) (norethin ace-eth estrad-fe) MIRCETTE ORAL TABLET 0.15-0.02/0.01 MG (21/5) 3 (desogestrel-ethinyl estradiol) mono-linyah oral tablet 0.25-35 mg-mcg 1 H NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol valerate- 1 H dienogest) necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H NEXTSTELLIS ORAL TABLET 3-14.2 MG ( drospirenone- 3 H estetrol) nikki oral tablet 3-0.02 mg 1 H nora-be oral tablet 0.35 mg 1 H norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) 3 SL (1 tablet per day); H norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg 1 H norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- mcg(24) 3 H norethindrone acetate oral tablet 5 mg 1 norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg, 1.5- 30 mg-mcg 1 H norethindrone oral tablet 0.35 mg 1 H norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg 3 norethindrone-eth estradiol oral tablet 1-5 mg-mcg 1 norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg- mcg, 0.8-25 mg-mcg 3 H norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg 1 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H norlyda oral tablet 0.35 mg 1 H norlyroc oral tablet 0.35 mg 1 H nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 H nortrel 1/35 (21) oral tablet 1-35 mg-mcg 1 H nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 H nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 179 Coverage Requirements & Prescription Drug Name Drug Tier Limits NUVARING VAGINAL RING 0.12-0.015 MG/24HR 1 H (etonogestrel-ethinyl estradiol) nylia 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H nymyo oral tablet 0.25-35 mg-mcg 1 H ocella oral tablet 3-0.03 mg 1 H ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 & 300 3 PA; SL (2 tablets per day) MG (elagolix-estradiol-norethind) orsythia oral tablet 0.1-20 mg-mcg 1 H philith oral tablet 0.4-35 mg-mcg 1 H pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H pirmella 1/35 oral tablet 1-35 mg-mcg 1 H pirmella 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg 1 H PLAN B ONE-STEP ORAL TABLET 1.5 MG ( levonorgestrel) 1 H portia-28 oral tablet 0.15-30 mg-mcg 1 H PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- 3 norgestimate) PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- 2 medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 2 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) previfem oral tablet 0.25-35 mg-mcg 1 H progesterone oral capsule 100 mg, 200 mg 3 PROVERA ORAL TABLET 10 MG, 2.5 MG, 5 MG 3 (medroxyprogesterone acetate) QUARTETTE ORAL TABLET 42-21-21-7 DAYS (levonorgest- SL (90 days supply max per 3 eth estrad 91-day) prescription) reclipsen oral tablet 0.15-30 mg-mcg 1 H SL (90 days supply max per rivelsa oral tablet 42-21-21-7 days 3 prescription); H SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol) SL (90 days supply max per setlakin oral tablet 0.15-0.03 mg 1 prescription); H sharobel oral tablet 0.35 mg 1 H simliya oral tablet 0.15-0.02/0.01 mg (21/5) 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 180 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (90 days supply max per simpesse oral tablet 0.15-0.03 &0.01 mg 3 prescription); H SLYND ORAL TABLET 4 MG (drospirenone) 3 H sprintec 28 oral tablet 0.25-35 mg-mcg 1 H sronyx oral tablet 0.1-20 mg-mcg 1 H syeda oral tablet 3-0.03 mg 1 H tarina 24 fe oral tablet 1-20 mg-mcg(24) 3 H tarina fe 1/20 eq oral tablet 1-20 mg-mcg 1 H tarina fe 1/20 oral tablet 1-20 mg-mcg 1 H tilia fe oral tablet 1-20/1-30/1-35 mg-mcg 3 H tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg 3 H tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-mili oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-nymyo oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H trivora (28) oral tablet 50-30/75-40/ 125-30 mcg 1 H tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg 3 H tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 1 H tulana oral tablet 0.35 mg 1 H TWIRLA TRANSDERMAL PATCH WEEKLY 120-30 3 H MCG/24HR (levonorgestrel-eth estradiol) tyblume oral tablet chewable 0.1-20 mg-mcg 1 H tydemy oral tablet 3-0.03-0.451 mg 3 H velivet oral tablet 0.1/0.125/0.15 -0.025 mg 1 H vestura oral tablet 3-0.02 mg 1 H vienva oral tablet 0.1-20 mg-mcg 1 H viorele oral tablet 0.15-0.02/0.01 mg (21/5) 1 H

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 181 Coverage Requirements & Prescription Drug Name Drug Tier Limits volnea oral tablet 0.15-0.02/0.01 mg (21/5) 1 H vyfemla oral tablet 0.4-35 mg-mcg 1 H vylibra oral tablet 0.25-35 mg-mcg 1 H wera oral tablet 0.5-35 mg-mcg 1 H wymzya fe oral tablet chewable 0.4-35 mg-mcg 3 H SL (3 patches/1 carton per xulane transdermal patch weekly 150-35 mcg/24hr 1 prescription); H SL (3 patches/1 carton per zafemy transdermal patch weekly 150-35 mcg/24hr 1 prescription); H zarah oral tablet 3-0.03 mg 1 H zovia 1/35 (28) oral tablet 1-35 mg-mcg 1 H zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 H zumandimine oral tablet 3-0.03 mg 1 H RAPID-ACTING INSULINS - Drugs for Diabetes AFREZZA INHALATION POWDER 12 UNIT, 4 UNIT, 8 UNIT PA; SL (900 cartridges per 3 (insulin regular human) prescription) AFREZZA INHALATION POWDER 4 & 8 & 12 UNIT, 90 X 4 PA; SL (1800 cartridges per 3 UNIT & 90X8 UNIT (insulin regular human) prescription) AFREZZA INHALATION POWDER 90 X 8 UNIT & 90X12 UNIT SL (1800 cartridges per 3 (insulin regular human) prescription) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 50/50 VIAL SUBCUTANEOUS SUSPENSION 1 (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML (insulin 2 lispro prot & lispro) HUMALOG MIX 75/25 VIAL SUBCUTANEOUS SUSPENSION 1 (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG U-100 JUNIOR KWIKPEN SUBCUTANEOUS 2 SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro) HUMALOG VIAL SUBCUTANEOUS SOLUTION 100 UNIT/ML 1 (insulin lispro)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 182 Coverage Requirements & Prescription Drug Name Drug Tier Limits HUMALOG VIAL SUBCUTANEOUS SOLUTION CARTRIDGE 2 100 UNIT/ML (insulin lispro) LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN- 2 SL (75 mL per prescription) INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin lispro-aabc) LYUMJEV VIAL INJECTION SOLUTION 100 UNIT/ML (insulin 1 SL (70 mL per prescription) lispro-aabc) SHORT-ACTING INSULINS - Drugs for Diabetes HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML (insulin nph isophane 2 & regular) HUMULIN 70/30 VIAL SUBCUTANEOUS SUSPENSION (70- 1 30) 100 UNIT/ML (insulin nph isophane & regular) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION 2 SL (75mL per prescription) PEN-INJECTOR 500 UNIT/ML (insulin regular human) HUMULIN R U-500 VIAL SUBCUTANEOUS SOLUTION 500 1 UNIT/ML (insulin regular human) HUMULIN R VIAL INJECTION SOLUTION 100 UNIT/ML 1 (insulin regular human) MYXREDLIN INTRAVENOUS SOLUTION 100-0.9 UT/100ML- 3 % (insulin regular(human) in nacl) SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB - Drugs for Diabetes GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG (empagliflozin- 2 ST; SL (1 tablet per day) linagliptin) JARDIANCE ORAL TABLET 10 MG, 25 MG (empagliflozin) 2 ST; SL (1 tablet per day) SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, 5- 2 SL (2 tablets per day) 1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 25-1000 MG (empagliflozin-metformin 2 SL (1 tablet per day) hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-1000 MG, 5-1000 MG (empagliflozin-metformin 2 SL (2 tablets per day) hcl) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 25-5-1000 MG (empagliflozin-linaglip- 2 SL (1 tablet per day) metform) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 12.5-2.5-1000 MG, 5-2.5-1000 MG (empagliflozin- 2 SL (2 tablets per day) linaglip-metform)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 183 Coverage Requirements & Prescription Drug Name Drug Tier Limits SULFONYLUREAS - Drugs for Diabetes AMARYL ORAL TABLET 1 MG, 2 MG, 4 MG () 3 DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone 3 SL (1 tablet per day) hcl-glimepiride) glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1 glipizide oral tablet 10 mg, 5 mg 1 glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg 1 glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg 1 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24 3 HOUR 10 MG, 2.5 MG, 5 MG (glipizide) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 1 glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1 glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5- 500 mg 1 GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6 MG (glyburide 3 micronized) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 SL (1 tablet per day) tolbutamide oral tablet 500 mg 1 THIAZOLIDINEDIONES - Drugs for Diabetes ACTOPLUS MET ORAL TABLET 15-500 MG, 15-850 MG 3 SL (3 tablets per day) (pioglitazone hcl-metformin hcl) DUETACT ORAL TABLET 30-2 MG, 30-4 MG (pioglitazone 3 SL (1 tablet per day) hcl-glimepiride) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 2 SL (1 tablet per day) 25-15 MG, 25-30 MG, 25-45 MG (alogliptin-pioglitazone) pioglitazone hcl oral tablet 15 mg 1 SL (2 tablets per day) pioglitazone hcl oral tablet 30 mg, 45 mg 1 SL (1 tablet per day) pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg 1 SL (1 tablet per day) pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg 1 SL (3 tablets per day) THYROID AGENTS - Drugs for the Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 3 240 MG, 30 MG, 300 MG, 60 MG, 90 MG (thyroid)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 184 Coverage Requirements & Prescription Drug Name Drug Tier Limits euthyrox oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 1 mcg levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 1 88 mcg LEVOTHYROXINE SODIUM ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 3 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 1 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 1 mcg liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg 1 NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 3 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg 3 TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 3 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 2 PA MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) TIROSINT-SOL ORAL SOLUTION 37.5 MCG/ML, 44 MCG/ML, 2 PA 62.5 MCG/ML (levothyroxine sodium) unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 1 mcg, 88 mcg WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, 65 3 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 3 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 185 Coverage Requirements & Prescription Drug Name Drug Tier Limits LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing LOCAL ANESTHETICS (PARENTERAL) - Drugs for Numbing ACCUCAINE COMBINATION KIT 1 % (lido-pentaf-tetrafl- 3 ultrasound) MARVONA SUIK COMBINATION KIT 0.5 % ( hcl 3 & anesthetic) MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA-REDUCTASE INHIBITORS dutasteride oral capsule 0.5 mg 1 finasteride oral tablet 5 mg 1 PROSCAR ORAL TABLET 5 MG (finasteride) 3 DETERRENTS - Drugs for Alcohol Dependence disulfiram oral tablet 250 mg, 500 mg 1 naltrexone hcl oral tablet 50 mg 1 - Drugs for Overdose or Poisoning inhalation solution 10 %, 20 % 1 BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE SL (2 devices per 2 (glucagon) prescription) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE SL (2 devices per 2 (glucagon) prescription) CHEMET ORAL CAPSULE 100 MG (succimer) 3 FOSRENOL ORAL PACKET 1000 MG, 750 MG (lanthanum 3 carbonate) GLUCAGEN HYPOKIT INJECTION SOLUTION SL (2 devices per 2 RECONSTITUTED 1 MG (glucagon hcl (rdna)) prescription) SL (2 devices per glucagon emergency kit 1 mg injection 1 mg 1 prescription) SL (2 devices per GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG 2 prescription) GLUCAGON EMERGENCY KIT INJECTION SOLUTION 2 RECONSTITUTED 1 MG/ML GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 mL per prescription) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon) GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 mL per prescription) AUTO-INJECTOR 1 MG/0.2ML (glucagon)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 186 Coverage Requirements & Prescription Drug Name Drug Tier Limits GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.2 mL per prescription) AUTO-INJECTOR 0.5 MG/0.1ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION 2 SL (0.4 mL per prescription) AUTO-INJECTOR 1 MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SL (2 syringes per 2 SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) prescription) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg 3 leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 CM MEPHYTON ORAL TABLET 5 MG ( phytonadione) 3 SL (5 tablets per day) naltrexone hcl oral tablet 50 mg 1 phytonadione oral tablet 5 mg 3 SL (5 tablets per day) RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue 3 insoluble) RENAGEL ORAL TABLET 800 MG (sevelamer hcl) 3 RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer 3 carbonate) sevelamer carbonate oral packet 0.8 gm, 2.4 gm 1 sevelamer carbonate oral tablet 800 mg 1 sevelamer hcl oral tablet 400 mg, 800 mg 3 sodium polystyrene sulfonate oral powder 1 sps oral suspension 15 gm/60ml 1 VISTOGARD ORAL PACKET 10 GM (uridine triacetate) 2 ANTIGOUT AGENTS - Drugs for Gout allopurinol oral tablet 100 mg, 300 mg 1 colchicine oral tablet 0.6 mg 1 colchicine-probenecid oral tablet 0.5-500 mg 1 COLCRYS ORAL TABLET 0.6 MG (colchicine) 2 EC-NAPROSYN ORAL TABLET DELAYED RELEASE 375 MG, 3 500 MG (naproxen) ec-naproxen oral tablet delayed release 375 mg, 500 mg 1 febuxostat oral tablet 40 mg, 80 mg 1 ST; SL (1 tablet per day) GLOPERBA ORAL SOLUTION 0.6 MG/5ML (colchicine) 3 PA INDOCIN ORAL SUSPENSION 25 MG/5ML (indomethacin) 3 INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 187 Coverage Requirements & Prescription Drug Name Drug Tier Limits indomethacin er oral capsule extended release 75 mg 1 indomethacin oral capsule 25 mg, 50 mg 1 NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 3 375 MG, 500 MG (naproxen sodium) naproxen oral suspension 125 mg/5ml 1 PA naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet delayed release 375 mg, 500 mg 1 naproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg 3 NAPROXEN SODIUM ER ORAL TABLET EXTENDED 3 RELEASE 24 HOUR 750 MG naproxen sodium oral tablet 275 mg, 550 mg 1 probenecid oral tablet 500 mg 1 ZYLOPRIM ORAL TABLET 100 MG, 300 MG (allopurinol) 3 BONE RESORPTION INHIBITORS - Drugs for Bone Loss SL (300mL (4 bottles) per alendronate sodium oral solution 70 mg/75ml 1 month) alendronate sodium oral tablet 10 mg, 5 mg 1 alendronate sodium oral tablet 35 mg, 70 mg 1 SL (4 tablets per 28 days) ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR 3 SL (8 patches per month) (estradiol) BINOSTO ORAL TABLET EFFERVESCENT 70 MG 3 SL (4 tablets per 28 days) (alendronate sodium) BONIVA ORAL TABLET 150 MG (ibandronate sodium) 3 SL (3.8mL (2 bottles) per calcitonin (salmon) nasal solution 200 unit/act 1 month) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 MG/1.25GM 3 (estradiol) ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) 3 (estradiol) ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2 MG (estradiol) 3 estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr 1 SL (8 patches per month)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 188 Coverage Requirements & Prescription Drug Name Drug Tier Limits estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 SL (4 patches (1 box) per mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 1 mg/24hr month) estradiol vaginal cream 0.1 mg/gm 3 estradiol vaginal tablet 10 mcg 1 SL (1 ring/3 months (90 ESTRING VAGINAL RING 2 MG (estradiol) 3 days) per prescription) ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM (0.06%) SL (50 gm (1 bottle) per 3 (estradiol) month) EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY 3 (estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR 3 SL (1 ring per 3 months) (estradiol acetate) FOSAMAX ORAL TABLET 70 MG (alendronate sodium) 3 SL (4 tablets per 28 days) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 SL (4 tablets per 28 days) 5600 MG-UNIT (alendronate-cholecalciferol) ibandronate sodium oral tablet 150 mg 1 lyllana transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr 3 SL (8 patches per month) MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG 2 (esterified estrogens) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 2 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, 2 conjugated) raloxifene hcl oral tablet 60 mg 1 H-N risedronate sodium oral tablet 150 mg 3 SL (1 tablet per month) risedronate sodium oral tablet 30 mg, 5 mg 3 risedronate sodium oral tablet 35 mg 3 SL (4 tablets per month) VIVELLE-DOT TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.075 2 SL (8 patches per month) MG/24HR, 0.1 MG/24HR (estradiol) yuvafem vaginal tablet 10 mcg 1 CARBONIC ANHYDRASE INHIBITORS (MISC.) KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) 3 PA; SL (4 tablets per day) CARIOSTATIC AGENTS - Vitamins and Fluoride easygel dental gel 0.4 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 189 Coverage Requirements & Prescription Drug Name Drug Tier Limits DISEASE-MODIFYING ANTIRHEUMATIC AGENTS - Drugs for Arthritis ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 SL (1 tablet per day) AZASAN ORAL TABLET 100 MG, 75 MG () 3 azathioprine oral tablet 50 mg 1 AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 cyclosporine intravenous solution 50 mg/ml 1 cyclosporine modified oral capsule 100 mg, 50 mg 1 cyclosporine modified oral capsule 25 mg 3 cyclosporine modified oral solution 100 mg/ml 3 cyclosporine oral capsule 100 mg, 25 mg 1 DEPEN TITRATABS ORAL TABLET 250 MG ( penicillamine) 2 gengraf oral capsule 100 mg 1 gengraf oral capsule 25 mg 3 gengraf oral solution 100 mg/ml 3 hydroxychloroquine sulfate oral tablet 200 mg 1 leflunomide oral tablet 10 mg, 20 mg 1 SL (1 tablet per day) methotrexate oral tablet 2.5 mg 1 CM methotrexate sodium oral tablet 2.5 mg 1 CM OLUMIANT ORAL TABLET 1 MG (baricitinib) 2 SL (1 tablet per day) OLUMIANT ORAL TABLET 2 MG (baricitinib) 2 PA; SL (1 tablet per day) OTEZLA ORAL TABLET 30 MG (apremilast) 2 PA; SL (2 tablets per day) OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SL (27 tablets per 1 2 (apremilast) year) penicillamine oral capsule 250 mg 3 PA penicillamine oral tablet 250 mg 1 RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 2 PA; SL (1 tablet per day) MG (upadacitinib) SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 190 Coverage Requirements & Prescription Drug Name Drug Tier Limits TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 CM (methotrexate sodium) XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) 2 PA; SL (8 mL per day) XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib citrate) 2 PA; SL (2 tablets per day) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 PA 11 MG (tofacitinib citrate) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2 PA; SL (1 tablet per day) 22 MG (tofacitinib citrate) IMMUNOMODULATORY AGENTS - DRUGS FOR THE IMMUNE SYSTEM ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 SL (1 tablet per day) AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) 3 PA; SL (1 tablet per day) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 AZULFIDINE EN-TABS ORAL TABLET DELAYED RELEASE 3 500 MG (sulfasalazine) AZULFIDINE ORAL TABLET 500 MG (sulfasalazine) 3 BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95 MG 2 PA; SL (4 capsules per day) (monomethyl fumarate) cyclosporine intravenous solution 50 mg/ml 1 cyclosporine modified oral capsule 100 mg, 50 mg 1 cyclosporine modified oral capsule 25 mg 3 cyclosporine modified oral solution 100 mg/ml 3 cyclosporine oral capsule 100 mg, 25 mg 1 PA; SL (56 capsules per dimethyl fumarate oral capsule delayed release 120 mg 1 year) dimethyl fumarate oral capsule delayed release 240 mg 1 PA; SL (2 tablets per day) dimethyl fumarate starter pack oral 120 & 240 mg 3 PA; SL (1 kit per year) gengraf oral capsule 100 mg 1 gengraf oral capsule 25 mg 3 gengraf oral solution 100 mg/ml 3 GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG (fingolimod hcl) 3 PA; SL (1 capsule per day) hydroxychloroquine sulfate oral tablet 200 mg 1 leflunomide oral tablet 10 mg, 20 mg 1 SL (1 tablet per day) MAYZENT ORAL TABLET 0.25 MG ( siponimod fumarate) 3 PA; SL (4 tablets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 191 Coverage Requirements & Prescription Drug Name Drug Tier Limits MAYZENT ORAL TABLET 2 MG ( siponimod fumarate) 3 PA; SL (1 tablet per day) methotrexate oral tablet 2.5 mg 1 CM methotrexate sodium oral tablet 2.5 mg 1 CM OTEZLA ORAL TABLET 30 MG (apremilast) 2 PA; SL (2 tablets per day) OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SL (27 tablets per 1 2 (apremilast) year) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; SL (1 capsule per day); 4 (pomalidomide) CM REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, PA; SL (1 capsule per day); 4 25 MG, 5 MG (lenalidomide) CM RIDAURA ORAL CAPSULE 3 MG (auranofin) 3 SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2 sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet delayed release 500 mg 1 PA; SL (4 capsules per day); THALOMID ORAL CAPSULE 100 MG, 50 MG () 4 CM PA; SL (8 capsules per day); THALOMID ORAL CAPSULE 150 MG, 200 MG (thalidomide) 4 CM TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 CM (methotrexate sodium) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE PA; SL (1 starter pack per 3 THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod hcl) year) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) 3 PA; SL (1 capsule per day) ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK PA; SL (1 starter kit pack per 3 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) year) IMMUNOSUPPRESSIVE AGENTS - Drugs for Transplant ARAVA ORAL TABLET 10 MG, 20 MG (leflunomide) 3 SL (1 tablet per day) ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 4 HOUR 0.5 MG, 1 MG, 5 MG (tacrolimus) AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) 3 azathioprine oral tablet 50 mg 1 CELLCEPT ORAL CAPSULE 250 MG (mycophenolate 4 mofetil) CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 4 MG/ML (mycophenolate mofetil) CELLCEPT ORAL TABLET 500 MG ( mycophenolate mofetil) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 192 Coverage Requirements & Prescription Drug Name Drug Tier Limits cyclophosphamide oral capsule 25 mg, 50 mg 3 CM CYCLOPHOSPHAMIDE ORAL TABLET 25 MG, 50 MG 2 CM cyclosporine intravenous solution 50 mg/ml 1 cyclosporine modified oral capsule 100 mg, 50 mg 1 cyclosporine modified oral capsule 25 mg 3 cyclosporine modified oral solution 100 mg/ml 3 cyclosporine oral capsule 100 mg, 25 mg 1 everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg 3 gengraf oral capsule 100 mg 1 gengraf oral capsule 25 mg 3 gengraf oral solution 100 mg/ml 3 leflunomide oral tablet 10 mg, 20 mg 1 SL (1 tablet per day) LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) 4 PA; SL (6 capsules per day) MAVENCLAD ORAL TABLET THERAPY PACK 10 MG PA; SL (40 tablets per 720 3 () days) mercaptopurine oral tablet 50 mg 1 CM methotrexate oral tablet 2.5 mg 1 CM methotrexate sodium oral tablet 2.5 mg 1 CM mycophenolate mofetil oral capsule 250 mg 4 mycophenolate mofetil oral suspension reconstituted 200 mg/ml 4 mycophenolate mofetil oral tablet 500 mg 4 mycophenolate sodium oral tablet delayed release 180 mg, 360 mg 3 MYFORTIC ORAL TABLET DELAYED RELEASE 180 MG, 360 4 MG (mycophenolate sodium) pimecrolimus external cream 1 % 3 ST; SL (100g per month) PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG 3 (tacrolimus) PROGRAF ORAL PACKET 0.2 MG, 1 MG (tacrolimus) 3 PA PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % 3 ST; SL (100g per month) (tacrolimus) PURIXAN ORAL SUSPENSION 2000 MG/100ML 3 PA; CM (mercaptopurine) RAPAMUNE ORAL SOLUTION 1 MG/ML (sirolimus) 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 193 Coverage Requirements & Prescription Drug Name Drug Tier Limits RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 MG (sirolimus) 4 SANDIMMUNE ORAL SOLUTION 100 MG/ML (cyclosporine) 2 sirolimus oral solution 1 mg/ml 3 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 3 tacrolimus external ointment 0.03 %, 0.1 % 1 ST; SL (100g per month) tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 3 CM (methotrexate sodium) ZORTRESS ORAL TABLET 1 MG (everolimus) 3 OTHER MISCELLANEOUS THERAPEUTIC AGENTS AZALGIA ORAL CAPSULE 3 CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) 3 PA CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 2 MG (prenat w/o a-fecbgl-fa-dha) CYSTADANE ORAL POWDER (betaine) 3 CYSTAGON ORAL CAPSULE 150 MG, 50 MG (cysteamine 2 bitartrate) dalfampridine er oral tablet extended release 12 hour 10 mg 1 PA; SL (2 tablets per day) DEMSER ORAL CAPSULE 250 MG (metyrosine) 3 ELMIRON ORAL CAPSULE 100 MG ( 3 ST sodium) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 2 omega) ENDARI ORAL PACKET 5 GM ( (sickle cell)) 3 PA; SL (6 packets per day) EVOTAZ ORAL TABLET 300-150 MG (atazanavir-cobicistat) 2 EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 MG/ML PA; SL (1280 mL per 180 2 (risdiplam) days) PA; SL (14 capsules (1 pack) GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) 3 per 21 days) ISTURISA ORAL TABLET 1 MG (osilodrostat phosphate) 3 PA; SL (8 tablets per day) ISTURISA ORAL TABLET 10 MG (osilodrostat phosphate) 3 PA; SL (6 tablets per day.) ISTURISA ORAL TABLET 5 MG (osilodrostat phosphate) 3 PA; SL (2 tablets per day) me/naphos/mb/hyo1 oral tablet 81.6 mg 3 metyrosine oral capsule 250 mg 3 miglustat oral capsule 100 mg 4

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 194 Coverage Requirements & Prescription Drug Name Drug Tier Limits MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- 2 succ-c-thre-b12-fa) NEONATAL + DHA ORAL 29-1 & 200 MG 2 NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- 2 methylfol-dha w/o a) NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3 3-e) ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG (nitisinone) 2 PA ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) 2 PA PHOSPHASAL ORAL TABLET 81.6 MG (meth-hyo-m bl-na 2 phos-ph sal) PRASTERA ORAL KIT 200 & 400 MG (prasterone & 3 ibuprofen) PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 2 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 2 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 2 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PREZCOBIX ORAL TABLET 800-150 MG (darunavir- 2 cobicistat) PROCYSBI ORAL CAPSULE DELAYED RELEASE 25 MG, 75 4 PA MG (cysteamine bitartrate) PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine 4 PA bitartrate) RELNATE DHA ORAL CAPSULE 28-1-200 MG 2 RUZURGI ORAL TABLET 10 MG () 2 PA; SL (10 tablets per day) sapropterin dihydrochloride oral packet 100 mg, 500 mg 1 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 195 Coverage Requirements & Prescription Drug Name Drug Tier Limits sapropterin dihydrochloride oral tablet 100 mg 1 PA; SL (16mL per day) SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3 10 % STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- 2 cobic-emtricit-tenofdf) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-cobic- 2 emtricit-tenofaf) THIOLA EC ORAL TABLET DELAYED RELEASE 100 MG, 300 3 MG () THIOLA ORAL TABLET 100 MG (tiopronin) 3 tiopronin oral tablet 100 mg 3 TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 2 MG (prenatal-fefum-fa-dss-fish oil) TRI-CHLOR EXTERNAL LIQUID 80 % (trichloroacetic acid) 3 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 2 fecbn-meth-fa-dha) TYBOST ORAL TABLET 150 MG ( cobicistat) 2 ULTRA HERS RX ORAL CAPSULE 3 ULTRA HIS ORAL CAPSULE 3 ULTRA PCOS ORAL CAPSULE 3 URELLE ORAL TABLET 81 MG (meth-hyo-m bl-na phos-ph 3 sal) URIBEL ORAL CAPSULE 118 MG (meth-hyo-m bl-na phos- 3 ph sal) URIMAR-T ORAL TABLET 120 MG (meth-hyo-m bl-na phos- 3 ph sal) urin ds oral tablet 81.6 mg 1 URO-458 ORAL TABLET 81 MG 3 UROGESIC-BLUE ORAL TABLET 81.6 MG (methen-hyosc- 3 meth blue-na phos) uro-mp oral capsule 118 mg 3 USTELL ORAL CAPSULE 120 MG (meth-hyo-m bl-na phos- 3 ph sal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 196 Coverage Requirements & Prescription Drug Name Drug Tier Limits UTIRA-C ORAL TABLET 81.6 MG (meth-hyo-m bl-na phos- 2 ph sal) VILAMIT MB ORAL CAPSULE 118 MG (meth-hyo-m bl-na 3 phos-ph sal) VILEVEV MB ORAL TABLET 81 MG (meth-hyo-m bl-na phos- 3 ph sal) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 2 fum-fa-dha) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 PA; SL (30 packets per XURIDEN ORAL PACKET 2 GM (uridine triacetate) 2 prescription) XYZMUNE ORAL CAPSULE 3 ZAVESCA ORAL CAPSULE 100 MG (miglustat) 4 ZOKINVY ORAL CAPSULE 50 MG, 75 MG (lonafarnib) 2 PA; SL (4 capsules per day) PROTECTIVE AGENTS MESNEX ORAL TABLET 400 MG () 4 CM NONHORMONAL CONTRACEPTIVES - Drugs for Women NONHORMONAL CONTRACEPTIVES - Drugs for Women CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) 1 H PARAGARD INTRAUTERINE COPPER INTRAUTERINE 1 H (copper) PHEXXI VAGINAL GEL 1.8-1-0.4 % (lactic ac-citric ac-pot 3 PA; H bitart) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 197 Coverage Requirements & Prescription Drug Name Drug Tier Limits WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 2 % 1 H (diaphragm wide seal) OXYTOCICS - Drugs for Women OXYTOCICS - Drugs for Women CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) 3 methergine oral tablet 0.2 mg 1 SL (28 per 365 days) methylergonovine maleate oral tablet 0.2 mg 1 SL (28 per 365 days) PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) 3 PROSTIN E2 VAGINAL SUPPOSITORY 20 MG 3 (dinoprostone) PHARMACEUTICAL AIDS PHARMACEUTICAL AIDS PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 3 RESPIRATORY TRACT AGENTS - Drugs for the Lungs ALPHA AND BETA ADRENERGIC AGONIST(RESPR) - Drugs for Asthma/COPD SL (2 single units or 1 two ADRENALIN INJECTION SOLUTION 1 MG/ML (epinephrine) 3 pack per prescription) ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl 3 (nasal)) epinephrine solution auto-injector 0.15 mg/0.3ml injection SL (4 single units or 2 two- 1 0.15 mg/0.3ml pack per prescription) epinephrine solution auto-injector 0.3 mg/0.3ml injection SL (4 single units or 2 two- 1 0.3 mg/0.3ml pack per prescription) SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 2 SL (2 pens per prescription) MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ANTICHOLINERGIC AGENTS (RESPIR.TRACT) - Drugs for Asthma/COPD ATROVENT HFA INHALATION AEROSOL SOLUTION 17 3 SL (0.87 gm per day) MCG/ACT (ipratropium bromide hfa) COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION SL (8 g (2 inhalers) per 2 20-100 MCG/ACT (ipratropium-albuterol) month) ipratropium bromide inhalation solution 0.02 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 198 Coverage Requirements & Prescription Drug Name Drug Tier Limits ipratropium bromide nasal solution 0.03 %, 0.06 % 1 ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml 1 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG 2 SL (1 capsule per day) (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 SL (1 inhaler (4 grams) per 2 MCG/ACT, 2.5 MCG/ACT (tiotropium bromide monohydrate) month) ANTIFIBROTIC AGENTS - Drugs for the Lungs ESBRIET ORAL CAPSULE 267 MG (pirfenidone) 3 PA; SL (9 capsules per day) ESBRIET ORAL TABLET 267 MG (pirfenidone) 3 PA; SL (9 capsules per day) ESBRIET ORAL TABLET 801 MG (pirfenidone) 3 PA; SL (3 tablets per day) OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib esylate) 4 PA; SL (2 capsules per day) ANTITUSSIVES - Drugs for Cough and Cold allergy childrens oral liquid 12.5 mg/5ml 3 aurodryl allergy childrens oral liquid 12.5 mg/5ml 3 banophen oral capsule 25 mg 3 oral capsule 100 mg, 200 mg 1 benzonatate oral capsule 150 mg 3 codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 1 diphen oral elixir 12.5 mg/5ml 3 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral capsule 25 mg, 50 mg 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral liquid 12.5 mg/5ml 3 geri-dryl oral liquid 12.5 mg/5ml 3 guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 HYCODAN ORAL SYRUP 5-1.5 MG/5ML (hydrocodone- PA; SL (120 mL per 3 homatropine) prescription) hydrocodone polst-chlorphen polst er susp oral PA; SL (120 mL per 3 suspension extended release 10-8 mg/5ml prescription) PA; SL (120 mL per hydrocodone-homatropine oral syrup 5-1.5 mg/5ml 1 prescription) hydrocodone-homatropine oral tablet 5-1.5 mg 1 PA PA; SL (120 mL per hydromet oral syrup 5-1.5 mg/5ml 1 prescription)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 199 Coverage Requirements & Prescription Drug Name Drug Tier Limits liquid allergy relief oral liquid 12.5 mg/5ml 3 maxi-tuss ac oral solution 100-10 mg/5ml 1 m-dryl oral liquid 12.5 mg/5ml 3 PA; SL (120 mL per promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml 1 prescription) PA; SL (120 mL per promethazine-codeine oral solution 6.25-10 mg/5ml 1 prescription) PA; SL (120 mL per promethazine-codeine oral syrup 6.25-10 mg/5ml 1 prescription) promethazine-dm oral syrup 6.25-15 mg/5ml 1 promethazine-phenyleph-codeine oral syrup 6.25-5-10 PA; SL (120 mL per 1 mg/5ml prescription) pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg/5ml 3 sleep-aid oral capsule 50 mg 3 TESSALON PERLES ORAL CAPSULE 100 MG (benzonatate) 3 TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 SL (30 capsules per month); 3 HOUR 10-8 MG (hydrocod polst-chlorphen polst) AE TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 HOUR SL (30 tablets per month); 3 54.3-8 MG (chlorpheniramine-codeine) AE virtussin ac w/alc oral liquid 100-10 mg/5ml 1 (CFTR) CORRECTORS - Drugs for the Lungs ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG 2 PA; SL (2 packets per day) (lumacaftor-) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG 2 PA; SL (4 tablets per day) (lumacaftor-ivacaftor) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 2 PA; SL (2 tablets per day) MG, 50-75 & 75 MG (tezacaftor-ivacaftor) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 2 PA; SL (3 tablets per day) MG, 50-25-37.5 & 75 MG (elexacaftor-tezacaftor-ivacaft) CYSTIC FIBROSIS (CFTR) POTENTIATORS - Drugs for the Lungs KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG (ivacaftor) 3 PA; SL (2 packets per day) KALYDECO ORAL TABLET 150 MG (ivacaftor) 3 PA; SL (2 tablets per day) ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG 2 PA; SL (2 packets per day) (lumacaftor-ivacaftor)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 200 Coverage Requirements & Prescription Drug Name Drug Tier Limits ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG 2 PA; SL (4 tablets per day) (lumacaftor-ivacaftor) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 2 PA; SL (2 tablets per day) MG, 50-75 & 75 MG (tezacaftor-ivacaftor) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 2 PA; SL (3 tablets per day) MG, 50-25-37.5 & 75 MG (elexacaftor-tezacaftor-ivacaft) EXPECTORANTS - Drugs for the Lungs GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- 3 guaifenesin) guaiatussin ac oral syrup 100-10 mg/5ml 1 guaifenesin ac oral syrup 100-10 mg/5ml 1 IODINE STRONG ORAL SOLUTION 5 % 3 maxi-tuss ac oral solution 100-10 mg/5ml 1 SSKI ORAL SOLUTION 1 GM/ML ( 2 (expectorant)) virtussin ac w/alc oral liquid 100-10 mg/5ml 1 FIRST GENERATION ANTIHIST.(RESPIR TRACT) - Drugs for Allergy allergy childrens oral liquid 12.5 mg/5ml 3 aurodryl allergy childrens oral liquid 12.5 mg/5ml 3 banophen oral capsule 25 mg 3 carbinoxamine maleate oral solution 4 mg/5ml 1 carbinoxamine maleate oral tablet 4 mg 1 clemastine fumarate oral tablet 2.68 mg 1 cyproheptadine hcl oral syrup 2 mg/5ml 1 cyproheptadine hcl oral tablet 4 mg 1 diphen oral elixir 12.5 mg/5ml 3 di-phen oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral capsule 25 mg, 50 mg 3 diphenhydramine hcl oral elixir 12.5 mg/5ml 3 diphenhydramine hcl oral liquid 12.5 mg/5ml 3 geri-dryl oral liquid 12.5 mg/5ml 3 KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE 4 3 MG/5ML (carbinoxamine maleate) liquid allergy relief oral liquid 12.5 mg/5ml 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 201 Coverage Requirements & Prescription Drug Name Drug Tier Limits m-dryl oral liquid 12.5 mg/5ml 3 promethazine hcl oral solution 6.25 mg/5ml 1 promethazine hcl oral syrup 6.25 mg/5ml 1 promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 1 promethazine hcl rectal suppository 12.5 mg, 25 mg 1 promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 1 sleep-aid oral capsule 50 mg 3 LEUKOTRIENE MODIFIERS - Drugs for Inflammation ACCOLATE ORAL TABLET 10 MG, 20 MG (zafirlukast) 3 montelukast sodium oral packet 4 mg 3 SL (1 packet per day) montelukast sodium oral tablet 10 mg 1 SL (1 tablet per day) montelukast sodium oral tablet chewable 4 mg, 5 mg 1 SL (1 tablet per day) zafirlukast oral tablet 10 mg, 20 mg 1 zileuton er oral tablet extended release 12 hour 600 mg 3 ZYFLO ORAL TABLET 600 MG (zileuton) 3 MAST-CELL STABILIZERS - Drugs for Inflammation ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil 3 sodium) cromolyn sodium inhalation nebulization solution 20 mg/2ml 1 cromolyn sodium ophthalmic solution 4 % 1 cromolyn sodium oral concentrate 100 mg/5ml 1 MUCOLYTIC AGENTS - Drugs for the Lungs acetylcysteine inhalation solution 10 %, 20 % 1 HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %, 2 7 % (sodium chloride) PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase 2 PA; SL (5 mL per day) alfa) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 %, 7 % 1 NASAL PREPARATIONS () - Drugs for Inflammation BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY SL (50g (2 bottles) per 3 (beclomethasone diprop monohyd) prescription) SL (75mL (3 bottles) per flunisolide nasal solution 25 mcg/act (0.025%) 1 prescription)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 202 Coverage Requirements & Prescription Drug Name Drug Tier Limits SL (16 g (1 bottle) per fluticasone propionate nasal suspension 50 mcg/act 1 prescription) SL (34g (2 bottles) per mometasone furoate nasal suspension 50 mcg/act 3 month) NASACORT ALLERGY 24HR NASAL AEROSOL 55 MCG/ACT SL (16.5g (1 bottle) per 3 (triamcinolone acetonide) month) QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 SL (1 canister (6.8 grams) 3 MCG/ACT (beclomethasone diprop (nasal)) per month) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT SL (10.6 (1 inhaler) per 3 (beclomethasone diprop (nasal)) prescription) ORALLY INHALED PREPARATIONS (STEROIDS) - Drugs for Inflammation ARNUITY ELLIPTA INHALATION AEROSOL POWDER SL (1 inhaler (30 blisters) per BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT, 50 1 month) MCG/ACT (fluticasone furoate) SL (120 mL (60 respules) per budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml 1 prescription) budesonide inhalation suspension 1 mg/2ml 1 SL (2 mL per day) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST 1 SL (4 blisters per day) (fluticasone propionate (inhal)) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST (fluticasone 1 SL (8 blisters per day) propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT SL (12 grams (1 inhaler) per 1 (fluticasone propionate hfa) month) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT SL (24 grams (2 inhalers) 1 (fluticasone propionate hfa) per month) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT SL (11 grams (1 inhaler) per 1 (fluticasone propionate hfa) month) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 1 SL (2 inhalers per month) (budesonide) PHOSPHODIESTERASE TYPE 4 INHIBITORS - Drugs for the Lungs PA; SL (31 tablets per 365 DALIRESP ORAL TABLET 250 MCG (roflumilast) 3 days) DALIRESP ORAL TABLET 500 MCG (roflumilast) 3 PA; SL (1 tablet per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 203 Coverage Requirements & Prescription Drug Name Drug Tier Limits PULMONARY SURFACTANTS - Drugs for the Lungs CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML 3 (poractant alfa) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 MG/ML-% 3 (calfactant in nacl) SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 MG/ML- 3 % (beractant in nacl) RESPIRATORY TRACT AGENTS, MISCELLANEOUS - Drugs for the Lungs BRONCHITOL INHALATION CAPSULE 40 MG ( 4 PA; SL (20 capsules per day) (cystic fibrosis)) BRONCHITOL TOLERANCE TEST INHALATION CAPSULE 40 4 PA; SL (20 capsules per day) MG (mannitol (cystic fibrosis)) SECOND GENERATION ANTIHIST(RESPIR TRACT) - Drugs for Allergy azelastine hcl nasal solution 0.1 %, 137 mcg/spray 3 azelastine hcl ophthalmic solution 0.05 % 1 cetirizine hcl oral solution 1 mg/ml, 5 mg/5ml 3 CLARINEX ORAL TABLET 5 MG (desloratadine) 3 SL (1 tablet per day) desloratadine oral tablet 5 mg 3 SL (1 tablet per day) desloratadine oral tablet dispersible 5 mg 3 SL (1 tablet per day) SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR) - Drugs for Asthma/COPD albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 SL (6.7 g per prescription) inhalation 108 (90 base) mcg/act albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 1 SL (8.5 g per prescription) inhalation 108 (90 base) mcg/act albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act 3 inhalation 108 (90 base) mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml 1 albuterol sulfate inhalation nebulization solution 2.5 mg/0.5ml 3 albuterol sulfate nebulization solution (5 mg/ml) 0.5% 3 inhalation (5 mg/ml) 0.5% albuterol sulfate oral syrup 2 mg/5ml 1 albuterol sulfate oral tablet 2 mg, 4 mg 3 PA

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 204 Coverage Requirements & Prescription Drug Name Drug Tier Limits levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/3ml 3 SL (90 mL per prescription) levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml 3 SL (30 vials per prescription) SL (30 grams (2 inhalers) per LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT 3 month) PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 SL (120 mL (60 vials) per 3 MCG/2ML (formoterol fumarate) prescription) PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 3 BASE) MCG/ACT (albuterol sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER 2 SL (1 device per month) BREATH ACTIVATED 50 MCG/DOSE (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2 SL (1 inhaler per month) 2.5 MCG/ACT (olodaterol hcl) terbutaline sulfate oral tablet 2.5 mg, 5 mg 1 XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT SL (30 grams (2 inhalers) per 3 (levalbuterol tartrate) month) VASODILATING AGENTS (RESPIRATORY TRACT) - Drugs for the Lungs ADCIRCA ORAL TABLET 20 MG (tadalafil (pah)) 4 PA; SL (2 tablets per day) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 2 PA; SL (3 tablets per day) MG (riociguat) alyq oral tablet 20 mg 4 PA; SL (2 tablets per day) ambrisentan oral tablet 10 mg, 5 mg 1 PA; SL (1 tablet per day) bosentan oral tablet 125 mg, 62.5 mg 1 PA; SL (2 tablets per day) OPSUMIT ORAL TABLET 10 MG (macitentan) 2 PA; SL (one tablet per day) ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 3 PA; SL (6 tablets per day) MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil diolamine) REVATIO ORAL TABLET 20 MG (sildenafil citrate) 4 SL (0.5 tablets per day) sildenafil citrate oral suspension reconstituted 10 mg/ml 3 PA; SL (6 mL per day) sildenafil citrate oral tablet 20 mg 1 SL (0.5 tablets per day) tadalafil (pah) oral tablet 20 mg 4 PA; SL (2 tablets per day) TRACLEER ORAL TABLET 125 MG, 62.5 MG ( bosentan) 3 PA; SL (2 tablets per day) PA; SL (112 tablets per 28 TRACLEER ORAL TABLET SOLUBLE 32 MG ( bosentan) 2 days) PA; SL (2.9 mL (1 ampule) TYVASO INHALATION SOLUTION 0.6 MG/ML (treprostinil) 3 per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 205 Coverage Requirements & Prescription Drug Name Drug Tier Limits TYVASO REFILL INHALATION SOLUTION 0.6 MG/ML PA; SL (2.9 mL (1 ampule) 3 (treprostinil) per day) TYVASO STARTER INHALATION SOLUTION 0.6 MG/ML PA; SL (2.9 mL (1 ampule) 3 (treprostinil) per day) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 3 PA; SL (2 tablets per day) (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG PA; SL (400 tablets (2 boxes) 3 (selexipag) per year) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML 4 PA; SL (9 ampules per day) (iloprost) XANTHINE DERIVATIVES - Drugs for Asthma/COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 SKIN AND MUCOUS MEMBRANE AGENTS - Drugs for the Skin ALLYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin naftifine hcl external cream 1 %, 2 % 3 NAFTIN EXTERNAL GEL 2 % (naftifine hcl) 3 ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 3 SL (15g (1 tube) per ALTABAX EXTERNAL OINTMENT 1 % ( retapamulin) 3 prescription) AMZEEQ EXTERNAL FOAM 4 % (minocycline hcl PA; SL (30 grams per 3 micronized) prescription) AVAR CLEANSER EXTERNAL EMULSION 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % 3 (sulfacetamide sodium-sulfur)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 206 Coverage Requirements & Prescription Drug Name Drug Tier Limits AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR-E GREEN EXTERNAL CREAM 10-5 % (sulfacetamide 3 sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- 3 erythromycin) benzoyl peroxide-erythromycin external gel 5-3 % 1 bp 10-1 external emulsion 10-1 % 3 bp cleansing wash external emulsion 10-4 % 3 CENTANY AT EXTERNAL KIT 2 % ( mupirocin) 3 CENTANY EXTERNAL OINTMENT 2 % ( mupirocin) 3 CLEOCIN VAGINAL CREAM 2 % (clindamycin phosphate) 3 CLEOCIN VAGINAL SUPPOSITORY 100 MG (clindamycin 2 phosphate) CLEOCIN-T EXTERNAL 1 % (clindamycin 3 phosphate) CLINDACIN ETZ EXTERNAL KIT 1 % (clindamycin phos & 3 cleanser) clindacin etz external swab 1 % 1 CLINDACIN PAC EXTERNAL KIT 1 % (clindamycin phos & 3 cleanser) clindacin-p external swab 1 % 1 clindamycin phosphate external foam 1 % 3 clindamycin phosphate external gel 1 % 3 SL (30 g per prescription) clindamycin phosphate external lotion 1 % 3 clindamycin phosphate external solution 1 % 1 SL (30 mL per prescription) clindamycin phosphate external swab 1 % 1 clindamycin phosphate vaginal cream 2 % 1 CLINDESSE VAGINAL CREAM 2 % (clindamycin phosphate 3 (1 dose)) ery external pad 2 % 1 ERYGEL EXTERNAL GEL 2 % (erythromycin) 3 erythromycin external gel 2 % 1 erythromycin external solution 2 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 207 Coverage Requirements & Prescription Drug Name Drug Tier Limits EVOCLIN EXTERNAL FOAM 1 % (clindamycin phosphate) 3 gentamicin sulfate external cream 0.1 % 1 SL (30 g per prescription) gentamicin sulfate external ointment 0.1 % 1 SL (30 g per prescription.) KLARON EXTERNAL LOTION 10 % (sulfacetamide sodium 3 ()) METROCREAM EXTERNAL CREAM 0.75 % (metronidazole) 3 METROLOTION EXTERNAL LOTION 0.75 % ( metronidazole) 3 metronidazole external cream 0.75 % 1 metronidazole external gel 0.75 % 3 metronidazole external lotion 0.75 % 1 metronidazole vaginal gel 0.75 % 1 mupirocin calcium external cream 2 % 1 SL (15g per month) mupirocin external ointment 2 % 1 NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 3 moist) NORITATE EXTERNAL CREAM 1 % (metronidazole) 3 OVACE PLUS EXTERNAL CREAM 10 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL LOTION 9.8 % (sulfacetamide 3 sodium) OVACE PLUS EXTERNAL 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL GEL 10 % (sulfacetamide 3 sodium) OVACE PLUS WASH EXTERNAL LIQUID 10 % 2 (sulfacetamide sodium) OVACE WASH EXTERNAL LIQUID 10 % (sulfacetamide 2 sodium) PLEXION CLEANSER EXTERNAL LIQUID 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) rosadan external cream 0.75 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 208 Coverage Requirements & Prescription Drug Name Drug Tier Limits rosadan external gel 0.75 % 3 ROSADAN EXTERNAL KIT 0.75 % (CREAM), 0.75 % (GEL) 3 (metronidazole-cleanser) sodium sulfacetamide external shampoo 10 % 3 sodium sulfacetamide wash external liquid 10 % 1 SODIUM SULFACETAMIDE-BAKUCHIOL EXTERNAL LIQUID 3 10 % sss 10-5 external cream 10-5 % 3 sss 10-5 external foam 10-5 % 3 sulfacetamide sodium (acne) external lotion 10 % 3 sulfacetamide sodium external gel 10 % (cleans) 3 sulfacetamide sodium external liquid 10 % 1 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 9.8-4.8 % 3 sulfacetamide sodium-sulfur external emulsion 10-5 % 3 sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %, 9.8-4.8 % 3 sulfacetamide sodium-sulfur external lotion 10-5 % 1 sulfacetamide sodium-sulfur external lotion 9.8-4.8 % 3 sulfacetamide sodium-sulfur external pad 10-4 %, 9.8-4.8 % 3 sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 % 3 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 3 sulfacetamide-sulfur in external emulsion 10-5 % 3 SULFACLEANSE 8/4 EXTERNAL SUSPENSION 8-4 % 3 (sulfacetamide sodium-sulfur) sulfamez wash external emulsion 10-1 % 3 SUMADAN EXTERNAL KIT 9-4.5 % (sulfacetamide-sulfur- 3 cleanser) SUMADAN WASH EXTERNAL LIQUID 9-4.5 % 3 (sulfacetamide sodium-sulfur) SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide- 3 sulfur-sunscreen) SUMAXIN CP EXTERNAL KIT 10-4 % (sulfacetamide-sulfur- 3 cleanser)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 209 Coverage Requirements & Prescription Drug Name Drug Tier Limits SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) SUMAXIN WASH EXTERNAL LIQUID 9-4 % (sulfacetamide 3 sodium-sulfur) vandazole vaginal gel 0.75 % 1 XEPI EXTERNAL CREAM 1 % (ozenoxacin) 3 SL (30 gm per prescription) PA; SL (30 grams per ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl micronized) 3 prescription) ANTI-INFLAMMATORY AGENTS, MISC (SKIN) - Drugs for the Skin EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) 3 ST ANTIPRURITICS AND LOCAL ANESTHETICS - Drugs for the Skin ACCUCAINE COMBINATION KIT 1 % (lido-pentaf-tetrafl- 3 ultrasound) ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 2 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 2 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 2 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % 3 (hydrocortisone ace-pramoxine) BETALOAN SUIK COMBINATION KIT 30 MG/5ML (betameth 3 sod phos-ace & anesth) CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 3 pramoxine-chloroxylenol) DMT SUIK COMBINATION KIT 10 MG/ML (dexameth sod 3 phos & anesthetic) PA; SL (45 grams per doxepin hcl external cream 5 % 3 prescription) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 3 glydo external prefilled syringe 2 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 lidocaine external ointment 5 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 210 Coverage Requirements & Prescription Drug Name Drug Tier Limits lidocaine external patch 5 % 3 PA; SL (3 patches per day) lidocaine hcl external solution 4 % 1 lidocaine hcl urethral/mucosal external gel 2 % 1 lidocaine hcl urethral/mucosal external prefilled syringe 2 % 1 lidocaine- external cream 2.5-2.5 % 1 MARVONA SUIK COMBINATION KIT 0.5 % (bupivacaine hcl 3 & anesthetic) MEDROLOAN II SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) MEDROLOAN SUIK COMBINATION KIT 40 MG/ML 3 (methylprednisolone & anesth) P-CARE K40G COMBINATION KIT 40 MG/ML 3 P-CARE K80G COMBINATION KIT 40 MG/ML 3 phenazo oral tablet 200 mg 1 hcl oral tablet 100 mg, 200 mg 1 pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 2 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % 3 (pramoxine-hc) pramox external gel 1 % 3 premium lidocaine external ointment 5 % 1 PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 3 ace-pramoxine) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine) PYRIDIUM ORAL TABLET 100 MG, 200 MG 2 (phenazopyridine hcl) TORONOVA II SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & anesthetic) TORONOVA SUIK COMBINATION KIT 30 MG/ML (ketorolac 3 trometh & anesthetic) TRILOAN II SUIK COMBINATION KIT 40 MG/ML 3 (triamcinolone acet & anesth)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 211 Coverage Requirements & Prescription Drug Name Drug Tier Limits TRILOAN SUIK COMBINATION KIT 40 MG/ML (triamcinolone 3 acet & anesth) ANTIVIRALS (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin acyclovir external cream 5 % 1 acyclovir external ointment 5 % 1 DENAVIR EXTERNAL CREAM 1 % (penciclovir) 3 XERESE EXTERNAL CREAM 5-1 % (acyclovir- 3 hydrocortisone) ASTRINGENTS - Drugs for the Skin DRYSOL EXTERNAL SOLUTION 20 % (aluminum chloride) 3 MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 3 OINTMENT 0.25-15-81.35 % VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 3 (miconazole-zinc oxide-petrolat) AZOLES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin clotrimazole external cream 1 % 3 clotrimazole external solution 1 % 3 clotrimazole mouth/throat troche 10 mg 1 clotrimazole-betamethasone external cream 1-0.05 % 3 clotrimazole-betamethasone external lotion 1-0.05 % 3 econazole nitrate external cream 1 % 3 ECOZA EXTERNAL FOAM 1 % (econazole nitrate) 3 ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) 3 EXELDERM EXTERNAL CREAM 1 % (sulconazole nitrate) 3 EXELDERM EXTERNAL SOLUTION 1 % (sulconazole 3 nitrate) EXTINA EXTERNAL FOAM 2 % (ketoconazole) 3 ST GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole nitrate (1 3 dose)) JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) 3 PA SL (30 grams per ketoconazole external cream 2 % 1 prescription) ketoconazole external foam 2 % 3 ST ketoconazole external shampoo 2 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 212 Coverage Requirements & Prescription Drug Name Drug Tier Limits ketodan external foam 2 % 3 ST miconazole 3 vaginal suppository 200 mg 3 MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 3 OINTMENT 0.25-15-81.35 % ORAVIG BUCCAL TABLET 50 MG (miconazole) 3 oxiconazole nitrate external cream 1 % 3 PA OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) 3 PA OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) 3 SULCONAZOLE NITRATE EXTERNAL CREAM 1 % 3 SULCONAZOLE NITRATE EXTERNAL SOLUTION 1 % 3 terconazole vaginal cream 0.4 % 3 terconazole vaginal cream 0.8 % 1 terconazole vaginal suppository 80 mg 3 VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 3 (miconazole-zinc oxide-petrolat) XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % (ketoconazole- 3 hydrocortisone) XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 3 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % 3 (ketoconazole & pyrithione zinc) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) 3 BASIC AND - Drugs for the Skin ammonium lactate external cream 12 % 3 ammonium lactate external lotion 12 % 3 GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 3 acid-lactic acid) external liquid 3 SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % (- 3 urea in lactac) TURPENTINE EXTERNAL SPIRIT 3 ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % (benzoyl 3 peroxide-hyaluronate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 213 Coverage Requirements & Prescription Drug Name Drug Tier Limits BASIC OINTMENTS AND PROTECTANTS - Drugs for the Skin NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 3 moist) PROSILK EXTERNAL GEL (silicone) 3 BASIC AND DEMULCENTS - Drugs for the Skin benzoin compound external 3 BENZOIN EXTERNAL TINCTURE 3 BENZYLAMINES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin MENTAX EXTERNAL CREAM 1 % (butenafine hcl) 3 CELL STIMULANTS AND PROLIFERANTS - Drugs for the Skin tretinoin external cream 0.025 %, 0.05 %, 0.1 % 3 SL (20 g per prescription) CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) 3 ala-cort external cream 1 % 3 alclometasone dipropionate external cream 0.05 % 1 alclometasone dipropionate external ointment 0.05 % 1 amcinonide external cream 0.1 % 3 amcinonide external lotion 0.1 % 3 amcinonide external ointment 0.1 % 3 ANALPRAM HC EXTERNAL CREAM 2.5-1 % (hydrocortisone 2 ace-pramoxine) ANALPRAM HC SINGLES EXTERNAL CREAM 2.5-1 % 2 (hydrocortisone ace-pramoxine) ANALPRAM-HC EXTERNAL CREAM 1-1 % (hydrocortisone 2 ace-pramoxine) ANALPRAM-HC EXTERNAL LOTION 2.5-1 % 3 (hydrocortisone ace-pramoxine) anucort-hc rectal suppository 25 mg 1 ANUSOL-HC EXTERNAL CREAM 2.5 % (hydrocortisone) 3 ANUSOL-HC RECTAL SUPPOSITORY 25 MG 2 (hydrocortisone acetate)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 214 Coverage Requirements & Prescription Drug Name Drug Tier Limits APEXICON E EXTERNAL CREAM 0.05 % (diflorasone diacet 3 emoll base) beser external lotion 0.05 % 1 betamethasone dipropionate aug external cream 0.05 % 1 betamethasone dipropionate aug external gel 0.05 % 1 betamethasone dipropionate aug external lotion 0.05 % 1 betamethasone dipropionate aug external ointment 0.05 % 1 betamethasone dipropionate external cream 0.05 % 1 betamethasone dipropionate external lotion 0.05 % 1 betamethasone dipropionate external ointment 0.05 % 1 betamethasone valerate external cream 0.1 % 1 betamethasone valerate external foam 0.12 % 3 betamethasone valerate external lotion 0.1 % 1 betamethasone valerate external ointment 0.1 % 1 calcipotriene-betameth diprop external ointment 0.005- 0.064 % 3 SL (1 60g tube per month) calcipotriene-betameth diprop external suspension 0.005- 0.064 % 3 SL (1 60g bottle per month) CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone 3 acetonide) clobetasol prop emollient base external cream 0.05 % 1 clobetasol propionate e external cream 0.05 % 1 clobetasol propionate emulsion external foam 0.05 % 3 clobetasol propionate external cream 0.05 % 1 clobetasol propionate external foam 0.05 % 3 SL (50 g per month) clobetasol propionate external gel 0.05 % 1 clobetasol propionate external liquid 0.05 % 3 SL (59 mL per month) clobetasol propionate external lotion 0.05 % 3 clobetasol propionate external ointment 0.05 % 1 clobetasol propionate external shampoo 0.05 % 3 clobetasol propionate external solution 0.05 % 1 clocortolone pivalate external cream 0.1 % 3 CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & 3 cleanser) clodan external shampoo 0.05 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 215 Coverage Requirements & Prescription Drug Name Drug Tier Limits clotrimazole-betamethasone external cream 1-0.05 % 3 clotrimazole-betamethasone external lotion 1-0.05 % 3 CORDRAN EXTERNAL OINTMENT 0.05 % ( flurandrenolide) 3 CORDRAN EXTERNAL TAPE 4 MCG/SQCM SL (1 package per 3 (flurandrenolide) prescription) CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 3 pramoxine-chloroxylenol) CORTENEMA RECTAL ENEMA 100 MG/60ML 3 (hydrocortisone) CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone 2 acetate) CUTIVATE EXTERNAL LOTION 0.05 % (fluticasone 3 propionate) DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 % 3 (fluocinolone acetonide) DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 % 3 (fluocinolone acetonide) DESONATE EXTERNAL GEL 0.05 % (desonide) 3 desonide external cream 0.05 % 1 desonide external gel 0.05 % 3 desonide external lotion 0.05 % 1 desonide external ointment 0.05 % 1 DESOWEN EXTERNAL CREAM 0.05 % (desonide) 3 desoximetasone external cream 0.05 %, 0.25 % 1 desoximetasone external gel 0.05 % 1 desoximetasone external ointment 0.05 % 3 desoximetasone external ointment 0.25 % 1 desrx external gel 0.05 % 3 diflorasone diacetate external cream 0.05 % 3 SL (30 gm per prescription) DIPROLENE AF EXTERNAL CREAM 0.05 % (betamethasone 3 dipropionate aug) DIPROLENE EXTERNAL OINTMENT 0.05 % ( betamethasone 3 dipropionate aug) ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- SL (7 cans (420 grams) per 3 betameth diprop) month) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 216 Coverage Requirements & Prescription Drug Name Drug Tier Limits fluocinolone acetonide body external oil 0.01 % 1 fluocinolone acetonide external cream 0.01 %, 0.025 % 1 fluocinolone acetonide external ointment 0.025 % 1 fluocinolone acetonide external solution 0.01 % 1 fluocinolone acetonide scalp external oil 0.01 % 1 fluocinonide emulsified base external cream 0.05 % 1 fluocinonide external cream 0.05 % 1 fluocinonide external cream 0.1 % 3 fluocinonide external gel 0.05 % 1 fluocinonide external ointment 0.05 % 1 fluocinonide external solution 0.05 % 1 flurandrenolide external cream 0.05 % 3 SL (60 mL per month) flurandrenolide external lotion 0.05 % 3 SL (120 mL per month) flurandrenolide external ointment 0.05 % 3 fluticasone propionate external cream 0.05 % 1 fluticasone propionate external lotion 0.05 % 1 fluticasone propionate external ointment 0.005 % 1 halcinonide external cream 0.1 % 3 halobetasol propionate external cream 0.05 % 3 halobetasol propionate external ointment 0.05 % 3 HALOG EXTERNAL OINTMENT 0.1 % ( halcinonide) 3 HEMMOREX-HC RECTAL SUPPOSITORY 25 MG 2 (hydrocortisone acetate) hydrocortisone (perianal) external cream 1 % 3 hydrocortisone (perianal) external cream 2.5 % 1 hydrocortisone ace-pramoxine external cream 1-1 %, 2.5-1 % 1 hydrocortisone acetate external ointment 1 % 3 hydrocortisone acetate rectal suppository 25 mg 1 hydrocortisone acetate rectal suppository 30 mg 3 hydrocortisone butyr lipo base external cream 0.1 % 3 hydrocortisone butyrate external cream 0.1 % 1 hydrocortisone butyrate external ointment 0.1 % 1 hydrocortisone butyrate external solution 0.1 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 217 Coverage Requirements & Prescription Drug Name Drug Tier Limits hydrocortisone external cream 1 % 3 hydrocortisone external cream 2.5 % 1 hydrocortisone external lotion 2.5 % 1 hydrocortisone external ointment 1 % 3 hydrocortisone external ointment 2.5 % 1 hydrocortisone rectal enema 100 mg/60ml 1 hydrocortisone valerate external cream 0.2 % 1 hydrocortisone valerate external ointment 0.2 % 1 hydrocortisone-iodoquinol external cream 1-1 % 1 hydrocort-pramoxine (perianal) external cream 2.5-1 % 1 LOCOID LIPOCREAM EXTERNAL CREAM 0.1 % 3 (hydrocortisone butyr lipo base) LUXIQ EXTERNAL FOAM 0.12 % (betamethasone valerate) 3 mometasone furoate external cream 0.1 % 1 mometasone furoate external ointment 0.1 % 1 mometasone furoate external solution 0.1 % 1 nolix external cream 0.05 % 3 SL (60 mL per month) nolix external lotion 0.05 % 3 SL (120 mL per month) NUCORT EXTERNAL LOTION 2 % (hydrocortisone acetate) 3 OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate 3 emulsion) oralone mouth/throat 0.1 % 1 PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone 3 probutate) pramosone external cream 1-1 % 1 PRAMOSONE EXTERNAL CREAM 1-2.5 % (pramoxine-hc) 2 PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % 2 (pramoxine-hc) PRAMOSONE EXTERNAL OINTMENT 1-1 %, 1-2.5 % 3 (pramoxine-hc) prednicarbate external ointment 0.1 % 3 PROCORT EXTERNAL CREAM 1.85-1.15 % (hydrocortisone 3 ace-pramoxine) PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 218 Coverage Requirements & Prescription Drug Name Drug Tier Limits PROCTOCORT RECTAL SUPPOSITORY 30 MG 3 (hydrocortisone acetate) PROCTOFOAM HC EXTERNAL FOAM 1-1 % (hydrocortisone 2 ace-pramoxine) procto-med hc external cream 2.5 % 1 procto-pak external cream 1 % 3 proctozone-hc external cream 2.5 % 1 PSORCON EXTERNAL CREAM 0.05 % 3 SL (30 gm per prescription) SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 sulfur & shampoo) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 SL (1 60g bottle per month) (calcipotriene-betameth diprop) TEMOVATE EXTERNAL CREAM 0.05 % (clobetasol 3 propionate) TEMOVATE EXTERNAL OINTMENT 0.05 % ( clobetasol 3 propionate) TEXACORT EXTERNAL SOLUTION 2.5 % (hydrocortisone) 3 TOPICORT EXTERNAL CREAM 0.05 %, 0.25 % 3 (desoximetasone) TOPICORT EXTERNAL GEL 0.05 % (desoximetasone) 3 TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 % 3 (desoximetasone) tovet external foam 0.05 % 3 triamcinolone acetonide external aerosol solution 0.147 SL (63 grams per 3 mg/gm prescription) triamcinolone acetonide external cream 0.025 %, 0.1 % 1 triamcinolone acetonide external cream 0.5 % 1 SL (15 g per prescription) triamcinolone acetonide external lotion 0.025 %, 0.1 % 1 triamcinolone acetonide external ointment 0.025 %, 0.05 %, 0.1 %, 0.5 % 1 triamcinolone acetonide mouth/throat paste 0.1 % 1 TRIANEX EXTERNAL OINTMENT 0.05 % ( triamcinolone 2 acetonide) triderm external cream 0.1 % 1 triderm external cream 0.5 % 1 SL (15 g per prescription) TRIDESILON EXTERNAL CREAM 0.05 % (desonide) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 219 Coverage Requirements & Prescription Drug Name Drug Tier Limits tritocin external ointment 0.05 % 1 UCERIS RECTAL FOAM 2 MG/ACT (budesonide) 2 VANOS EXTERNAL CREAM 0.1 % (fluocinonide) 3 VANOXIDE-HC EXTERNAL LOTION 5-0.5 % (benzoyl perox- 3 hydrocortisone) VERDESO EXTERNAL FOAM 0.05 % (desonide) 3 XERESE EXTERNAL CREAM 5-1 % (acyclovir- 3 hydrocortisone) XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % (ketoconazole- 3 hydrocortisone) DETERGENTS - Drugs for the Skin CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & 3 cleanser) EMOLLIENTS, DEMULCENTS, AND PROTECTANTS - Drugs for the Skin INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % (benzoyl peroxide- 3 ) MICONAZOLE-ZINC OXIDE-PETROLAT EXTERNAL 3 OINTMENT 0.25-15-81.35 % VUSION EXTERNAL OINTMENT 0.25-15-81.35 % 3 (miconazole-zinc oxide-petrolat) HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE) - Drugs for the Skin ciclodan external solution 8 % 1 ciclopirox external gel 0.77 % 1 ciclopirox external shampoo 1 % 1 ciclopirox external solution 8 % 1 ciclopirox olamine external cream 0.77 % 1 ciclopirox olamine external suspension 0.77 % 1 ciclopirox treatment external kit 8 % 3 LOPROX EXTERNAL KIT 0.77 % (ciclopirox olamine- 3 cleanser)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 220 Coverage Requirements & Prescription Drug Name Drug Tier Limits KERATOLYTIC AGENTS - Drugs for the Skin AVAR CLEANSER EXTERNAL EMULSION 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR LS CLEANSER EXTERNAL LIQUID 10-2 % 3 (sulfacetamide sodium-sulfur) AVAR-E EMOLLIENT EXTERNAL CREAM 10-5 % 3 (sulfacetamide sodium-sulfur) AVAR-E GREEN EXTERNAL CREAM 10-5 % (sulfacetamide 3 sodium-sulfur) AVAR-E LS EXTERNAL CREAM 10-2 % (sulfacetamide 3 sodium-sulfur) AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) bp 10-1 external emulsion 10-1 % 3 bp cleansing wash external emulsion 10-4 % 3 cerovel external lotion 40 % 1 GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % (salicylic 3 acid-lactic acid) HYDRO 40 EXTERNAL FOAM 40 % (urea) 3 INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) KERALAC EXTERNAL CREAM 47 % (urea) 3 KERALYT SCALP EXTERNAL KIT 6 % (salicylic acid) 3 PLEXION CLEANSER EXTERNAL LIQUID 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION CLEANSING CLOTH EXTERNAL PAD 9.8-4.8 % 3 (sulfacetamide sodium-sulfur) PLEXION EXTERNAL CREAM 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PLEXION EXTERNAL LOTION 9.8-4.8 % (sulfacetamide 3 sodium-sulfur) PROMISEB EXTERNAL CREAM (antiseborrheic products, 3 misc.) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 3 salicylic acid er external solution 28.5 % 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 221 Coverage Requirements & Prescription Drug Name Drug Tier Limits salicylic acid external solution 26 % 3 salicylic acid wart remover external liquid 27.5 % 3 SALVAX DUO PLUS EXTERNAL KIT 6 & 35 % (salicylic acid- 3 urea in lactac) SCALACORT DK EXTERNAL KIT 2 & 2-2 % (hc & sal acid- 3 sulfur & shampoo) sulfide external shampoo 2.25 % 3 sss 10-5 external cream 10-5 % 3 sss 10-5 external foam 10-5 % 3 sulfacetamide sodium-sulfur external cream 10-2 %, 10-5 %, 9.8-4.8 % 3 sulfacetamide sodium-sulfur external emulsion 10-5 % 3 sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %, 9.8-4.8 % 3 sulfacetamide sodium-sulfur external lotion 10-5 % 1 sulfacetamide sodium-sulfur external lotion 9.8-4.8 % 3 sulfacetamide sodium-sulfur external pad 10-4 %, 9.8-4.8 % 3 sulfacetamide sodium-sulfur external suspension 10-5 %, 8-4 % 3 sulfacetamide sod-sulfur wash external liquid 9-4 %, 9-4.5 % 3 sulfacetamide-sulfur in urea external emulsion 10-5 % 3 SULFACLEANSE 8/4 EXTERNAL SUSPENSION 8-4 % 3 (sulfacetamide sodium-sulfur) sulfamez wash external emulsion 10-1 % 3 SUMADAN EXTERNAL KIT 9-4.5 % (sulfacetamide-sulfur- 3 cleanser) SUMADAN WASH EXTERNAL LIQUID 9-4.5 % 3 (sulfacetamide sodium-sulfur) SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide- 3 sulfur-sunscreen) SUMAXIN CP EXTERNAL KIT 10-4 % (sulfacetamide-sulfur- 3 cleanser) SUMAXIN EXTERNAL PAD 10-4 % (sulfacetamide sodium- 3 sulfur) SUMAXIN WASH EXTERNAL LIQUID 9-4 % (sulfacetamide 3 sodium-sulfur)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 222 Coverage Requirements & Prescription Drug Name Drug Tier Limits ULTRASAL-ER EXTERNAL SOLUTION 28.5 % (salicylic acid) 3 UMECTA MOUSSE EXTERNAL FOAM 40 % (urea) 3 URAMAXIN EXTERNAL GEL 45 % (urea) 3 urea external cream 40 %, 45 %, 47 % 3 urea external lotion 40 % 1 urea nail external gel 45 % 3 VIRASAL EXTERNAL LIQUID 27.5 % (salicylic acid) 3 xurea external cream 39 % 3 KERATOPLASTIC AGENTS - Drugs for the Skin COAL TAR EXTERNAL SOLUTION 20 % 3 LOCAL ANTI-INFECTIVES, MISCELLANEOUS - Drugs for the Skin BENZAC AC WASH EXTERNAL LIQUID 5 % (benzoyl 3 peroxide) BENZALKONIUM CHLORIDE EXTERNAL SOLUTION 3 benzalkonium chloride external solution 50 % 3 BENZAMYCIN EXTERNAL GEL 5-3 % (benzoyl peroxide- 3 erythromycin) BENZEPRO CREAMY WASH EXTERNAL LIQUID 7 % 3 (benzoyl peroxide) benzepro external foam 5.3 % 3 BENZEPRO FOAMING CLOTHS EXTERNAL 6 % (benzoyl 3 peroxide) BENZEPRO SHORT CONTACT EXTERNAL FOAM 9.8 % 3 (benzoyl peroxide) benzoyl peroxide-erythromycin external gel 5-3 % 1 bp wash external liquid 2.5 %, 7 % 3 chlorhexidine gluconate mouth/throat solution 0.12 % 3 CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML ( hc- 3 pramoxine-chloroxylenol) DEBACTEROL MOUTH/THROAT SOLUTION 30-50 % 3 (sulfuric acid-sulf phenolics) ENZOCLEAR EXTERNAL FOAM 9.8 % (benzoyl peroxide) 3 FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid- 3 oxyquinoline) hydrocortisone-iodoquinol external cream 1-1 % 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 223 Coverage Requirements & Prescription Drug Name Drug Tier Limits INOVA 4/1 ACNE CONTROL THERAPY EXTERNAL KIT 4 & 1 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA 8/2 ACNE CONTROL THERAPY EXTERNAL KIT 8 & 2 3 & 5 % (benzoyl perox-salicyl ac-vit e) INOVA EXTERNAL KIT 4 & 5 %, 8 & 5 % (benzoyl peroxide- 3 vitamin e) iodine tincture external tincture 2 % 3 mafenide acetate external packet 5 % 3 NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- 3 moist) PERIDEX MOUTH/THROAT SOLUTION 0.12 % 3 (chlorhexidine gluconate) periogard mouth/throat solution 0.12 % 3 PR BENZOYL PEROXIDE WASH EXTERNAL LIQUID 7 % 3 (benzoyl peroxide) selenium sulfide external lotion 2.5 % 1 selenium sulfide external shampoo 2.25 % 3 SILVADENE EXTERNAL CREAM 1 % (silver sulfadiazine) 3 silver sulfadiazine external cream 1 % 1 ssd external cream 1 % 1 SULFAMYLON EXTERNAL CREAM 85 MG/GM (mafenide 3 acetate) SULFAMYLON EXTERNAL PACKET 5 % (mafenide acetate) 3 VANOXIDE-HC EXTERNAL LOTION 5-0.5 % (benzoyl perox- 3 hydrocortisone) XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL KIT 2 & 1 3 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % 3 (ketoconazole & pyrithione zinc) ZACARE EXTERNAL KIT 4 & 0.2 %, 8 & 0.2 % (benzoyl 3 peroxide-hyaluronate) zaclir cleansing external lotion 8 % 3 NONSTEROIDAL ANTI-INFLAMMAT.AGENTS(SKIN) - Drugs for the Skin diclofenac sodium external gel 1 % 3 PA; SL (100g per diclofenac sodium external gel 3 % 2 prescription)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 224 Coverage Requirements & Prescription Drug Name Drug Tier Limits diclofenac sodium external solution 1.5 % 3 PENNSAID EXTERNAL SOLUTION 2 % (diclofenac sodium) 3 OXABOROLES - Drugs for the Skin KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) 3 PA; SL (4 mL per month) tavaborole external solution 5 % 3 PA; SL (4 mL per month) PIGMENTING AGENTS - Drugs for the Skin methoxsalen rapid oral capsule 10 mg 3 POLYENES (SKIN AND MUCOUS MEMBRANE) - Drugs for the Skin nyamyc external powder 100000 unit/gm 1 SL (120 g per prescription) nystatin external cream 100000 unit/gm 1 SL (90 g per prescription) nystatin external ointment 100000 unit/gm 1 SL (90 g per prescription) nystatin external powder 100000 unit/gm 1 nystop external powder 100000 unit/gm 1 SL (120 g per prescription) SCABICIDES AND PEDICULICIDES - Drugs for the Skin crotan external lotion 10 % 1 ivermectin external lotion 0.5 % 1 external shampoo 1 % 1 malathion external lotion 0.5 % 3 NATROBA EXTERNAL SUSPENSION 0.9 % (spinosad) 3 OVIDE EXTERNAL LOTION 0.5 % (malathion) 3 permethrin external cream 5 % 1 SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) 2 spinosad external suspension 0.9 % 3 SULFURATED LIME EXTERNAL SOLUTION 3 SKIN AND MUCOUS MEMBRANE AGENTS, MISC. - Drugs for the Skin ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 MG, 3 PA 35 MG, 40 MG (isotretinoin) accutane oral capsule 20 mg, 30 mg, 40 mg 1 acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) 3 ALDARA EXTERNAL CREAM 5 % (imiquimod) 3 SL (48 packets per 112 days) amnesteem oral capsule 10 mg, 20 mg, 40 mg 1

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 225 Coverage Requirements & Prescription Drug Name Drug Tier Limits ARTISS EXTERNAL SOLUTION (fibrin sealant component) 3 external gel 15 % 1 AZELEX EXTERNAL CREAM 20 % (azelaic acid) 3 balsam peru-castor oil external ointment 3 calcipotriene external cream 0.005 % 1 SL (60g per month) calcipotriene external ointment 0.005 % 3 calcipotriene external solution 0.005 % 1 SL (60g per month) calcipotriene-betameth diprop external ointment 0.005- 0.064 % 3 SL (1 60g tube per month) calcipotriene-betameth diprop external suspension 0.005- 0.064 % 3 SL (1 60g bottle per month) CALCITRENE EXTERNAL OINTMENT 0.005 % 3 (calcipotriene) calcitriol external ointment 3 mcg/gm 1 CARAC EXTERNAL CREAM 0.5 % () 3 claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 CONDYLOX EXTERNAL GEL 0.5 % (podofilox) 3 DERMELLE EXTERNAL GEL (scar treatment products) 3 diclofenac sodium external gel 1 % 3 diclofenac sodium external solution 1.5 % 3 DOVONEX EXTERNAL CREAM 0.005 % (calcipotriene) 3 SL (60g per month) EFUDEX EXTERNAL CREAM 5 % (fluorouracil) 3 ENSTILAR EXTERNAL FOAM 0.005-0.064 % (calcipotriene- SL (7 cans (420 grams) per 3 betameth diprop) month) FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid- 3 oxyquinoline) FINACEA EXTERNAL FOAM 15 % (azelaic acid) 3 ST FINACEA EXTERNAL GEL 15 % (azelaic acid) 3 ST FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) 3 FLUOROURACIL EXTERNAL CREAM 0.5 % 3 fluorouracil external cream 5 % 1 fluorouracil external solution 2 %, 5 % 1 HYLATOPIC PLUS EXTERNAL LOTION (dermatological 3 products, misc.) HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 226 Coverage Requirements & Prescription Drug Name Drug Tier Limits imiquimod external cream 3.75 % 3 SL (56 packets per 60 days) imiquimod external cream 5 % 1 SL (48 packets per 112 days) IMIQUIMOD PUMP EXTERNAL CREAM 3.75 % 3 SL (56 packets per 60 days) isotretinoin capsule 10 mg oral 10 mg 3 PA isotretinoin capsule 10 mg oral 10 mg 1 isotretinoin capsule 20 mg oral 20 mg 3 PA isotretinoin capsule 20 mg oral 20 mg 1 isotretinoin capsule 30 mg oral 30 mg 3 PA isotretinoin capsule 30 mg oral 30 mg 1 isotretinoin capsule 40 mg oral 40 mg 1 isotretinoin capsule 40 mg oral 40 mg 3 PA isotretinoin oral capsule 25 mg, 35 mg 3 PA LEVULAN KERASTICK EXTERNAL SOLUTION 3 RECONSTITUTED 20 % (aminolevulinic acid hcl) LOPROX EXTERNAL KIT 0.77 % (ciclopirox olamine- 3 cleanser) MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) 2 SL (30 gm per month) MORGIDOX COMBINATION KIT 1 X 100 MG, 2 X 100 MG 3 (doxycycline hyclate-cleanser) myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 NUVAIL EXTERNAL SOLUTION (dermatological products, 3 misc.) OTEZLA ORAL TABLET 30 MG (apremilast) 2 PA; SL (2 tablets per day) OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG PA; SL (27 tablets per 1 2 (apremilast) year) PANRETIN EXTERNAL GEL 0.1 % () 3 PENNSAID EXTERNAL SOLUTION 2 % (diclofenac sodium) 3 pimecrolimus external cream 1 % 3 ST; SL (100g per month) podocon external solution 25 % 3 podofilox external solution 0.5 % 1 PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % 3 ST; SL (100g per month) (tacrolimus) PYROGALLIC ACID EXTERNAL OINTMENT 25-2 % 3 QUTENZA (2 PATCH) EXTERNAL KIT 8 % (- 4 cleansing gel)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 227 Coverage Requirements & Prescription Drug Name Drug Tier Limits QUTENZA (4 PATCH) EXTERNAL KIT 8 % (capsaicin- 4 cleansing gel) QUTENZA EXTERNAL KIT 8 % (capsaicin-cleansing gel) 4 RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) 3 PA; SL (30 g (2 tubes) per REGRANEX EXTERNAL GEL 0.01 % (becaplermin) 3 month) PA; SL (30 packets per RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) 3 prescription) SANTYL EXTERNAL OINTMENT 250 UNIT/GM ( collagenase) 3 SL (60g per prescription) SCARSILK EXTERNAL GEL 3 STRATA TRIZ EXTERNAL GEL (scar treatment products) 3 TACHOSIL EXTERNAL PATCH 4.8 X 4.8 CM, 9.5 X 4.8 CM 3 (absorbable fibrin sealant) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % 3 SL (1 60g bottle per month) (calcipotriene-betameth diprop) tacrolimus external ointment 0.03 %, 0.1 % 1 ST; SL (100g per month) TARGRETIN EXTERNAL GEL 1 % (bexarotene) 3 tazarotene external cream 0.1 % 3 SL (30g per month); AE TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) 3 SL (30g per month); AE TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) 3 SL (30g per month); AE VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine hcl 3 PA (topical)) VENELEX EXTERNAL OINTMENT ( balsam peru-castor oil) 3 ST; SL (30 grams per VEREGEN EXTERNAL OINTMENT 15 % ( sinecatechins) 3 prescription) zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg 1 ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) 3 SL (15 grams per 45 days) ZYCLARA PUMP EXTERNAL CREAM 3.75 % (imiquimod) 3 SL (15 gm per 45 days) SUNSCREEN AGENTS - Drugs for the Skin AVIDOXY DK COMBINATION KIT 100 MG (doxycycline- 3 suncreen-sal acid) SUMADAN XLT EXTERNAL KIT 9-4.5 % (sulfacetamide- 3 sulfur-sunscreen)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 228 Coverage Requirements & Prescription Drug Name Drug Tier Limits SMOOTH MUSCLE RELAXANTS - Drugs to Relax Muscles ANTIMUSCARINICS - Drugs for the Urinary System chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg 1 oxybutynin chloride oral syrup 5 mg/5ml 1 oxybutynin chloride oral tablet 5 mg 1 succinate oral tablet 10 mg, 5 mg 3 tartrate er oral capsule extended release 24 3 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg 1 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HOUR 4 3 MG, 8 MG ( fumarate) RESPIRATORY SMOOTH MUSCLE RELAXANTS - Drugs for Lungs ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML (theophylline) 2 REVATIO ORAL TABLET 20 MG (sildenafil citrate) 4 SL (0.5 tablets per day) sildenafil citrate oral suspension reconstituted 10 mg/ml 3 PA; SL (6 mL per day) sildenafil citrate oral tablet 20 mg 1 SL (0.5 tablets per day) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 3 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 mg 1 theophylline er oral tablet extended release 24 hour 400 mg, 600 mg 1 theophylline oral solution 80 mg/15ml 1 VITAMINS MULTIVITAMIN PREPARATIONS ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- 2 fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 2 MG (prenat w/o a-fecbgl-fa-dha) CORVITA ORAL TABLET 1.25 MG (multiple vitamins- 2 minerals-fa) DIALYVITE SUPREME D ORAL TABLET 3 MG (multiple 2 vitamins-minerals-fa) ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 2 carbonyl-fa)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 229 Coverage Requirements & Prescription Drug Name Drug Tier Limits ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 2 omega) M-NATAL PLUS ORAL TABLET 27-1 MG 2 NEONATAL + DHA ORAL 29-1 & 200 MG 2 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 2 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 2 fumarate-fa) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- 2 methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 2 vit a) OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- 2 minerals-fa) ONE VITE WOMENS ORAL TABLET 27-0.8 MG 2 ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 2 ONEVITE ORAL TABLET 1 MG 2 PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 2 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-0.8 mg, 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 2 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 2 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 2 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 230 Coverage Requirements & Prescription Drug Name Drug Tier Limits PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 2 RELNATE DHA ORAL CAPSULE 28-1-200 MG 2 REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- 2 minerals-fa) SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 2 vit-fe psac cmplx-fa) STROVITE FORTE ORAL SYRUP (multiple vitamins- 2 minerals-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 2 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 2 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 2 fecbn-meth-fa-dha) UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- 2 minerals-fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins- 2 minerals-fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 2 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3-folic 2 acid) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 2 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 2 fum-fa-dha) VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 2 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTAB PLUS ORAL TABLET 27-1 MG 2

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 231 Coverage Requirements & Prescription Drug Name Drug Tier Limits WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 VITAMIN B COMPLEX ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- 2 fa) CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcium-folic acid plus d oral wafer 1342-1 mg 3 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 2 fecb-fegl-fa) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 & 300 2 MG (prenat w/o a-fecbgl-fa-dha) CORVITA ORAL TABLET 1.25 MG (multiple vitamins- 2 minerals-fa) DIALYVITE SUPREME D ORAL TABLET 3 MG (multiple 2 vitamins-minerals-fa) drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-0.03-0.451 mg 3 H ELITE-OB ORAL TABLET 50-1.25 MG (prenatal vit-iron 2 carbonyl-fa) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- 2 omega) ferrocite plus oral tablet 106-1 mg 3 folic acid oral tablet 1 mg 1 hematinic plus vit/minerals oral tablet 106-1 mg 3 hematinic/folic acid oral tablet 324-1 mg 1 hemocyte-f oral tablet 324-1 mg 1 leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg 1 CM M-NATAL PLUS ORAL TABLET 27-1 MG 2 MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- 2 succ-c-thre-b12-fa) NEONATAL + DHA ORAL 29-1 & 200 MG 2 NEONATAL COMPLETE ORAL TABLET 27-1 MG, 29-1 MG 2 NEONATAL PLUS ORAL TABLET 27-1 MG ( prenatal vit-fe 2 fumarate-fa) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- 2 methylfol-dha w/o a)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 232 Coverage Requirements & Prescription Drug Name Drug Tier Limits NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o 2 vit a) OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- 2 minerals-fa) ONE VITE WOMENS ORAL TABLET 27-0.8 MG 2 ONE VITE WOMENS PLUS ORAL TABLET 27-1 MG 2 ONEVITE ORAL TABLET 1 MG 2 PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12-fa- 2 ginger) PRENAISSANCE ORAL CAPSULE 29-1.25-325 MG 2 prenatal oral tablet 27-0.8 mg, 27-1 mg 1 prenatal plus iron oral tablet 29-1 mg 1 prenatal vitamin plus low iron oral tablet 27-1 mg 1 PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG (prenatal- 2 feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 MG 2 (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG (prenat- 2 fecbn-feasp-meth-fa-dha) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG (prenat- 2 feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 MG 2 (prenat w/o a-fe-methfol-fa-dha) PRENATVITE COMPLETE ORAL TABLET 1 MG 3 PRENATVITE PLUS ORAL TABLET 1 MG 3 PRENATVITE RX ORAL TABLET 0.8 MG 3 preplus oral tablet 27-1 mg 1 PRETAB ORAL TABLET 29-1 MG 2 RELNATE DHA ORAL CAPSULE 28-1-200 MG 2 REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- 2 minerals-fa) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth 3 estrad-levomefol)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 233 Coverage Requirements & Prescription Drug Name Drug Tier Limits SELECT-OB ORAL TABLET CHEWABLE 29-1 MG (prenatal 2 vit-fe psac cmplx-fa) STROVITE FORTE ORAL SYRUP (multiple vitamins- 2 minerals-fa) TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 2 MG (prenatal-fefum-fa-dss-fish oil) TRINATE ORAL TABLET ( prenatal vit-fe fumarate-fa) 2 TRISTART DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o a- 3 fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat w/o a- 2 fecbn-meth-fa-dha) tydemy oral tablet 3-0.03-0.451 mg 3 H UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- 2 minerals-fa) VENTRIXYL ORAL TABLET 1 MG (multiple vitamins- 2 minerals-fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe 2 fumarate-fa) VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG (prenat-fe 3 poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-fe 2 fum-methf-fa w/o a) VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-min-fe 2 fum-fa-dha) VITATHELY WITH GINGER ORAL TABLET 27-1 MG (prenatal 2 vit-fe fumarate-fa) vp-pnv-dha oral capsule 28-1-215.8 mg 1 WESTAB PLUS ORAL TABLET 27-1 MG 2 WESTGEL DHA ORAL CAPSULE 31-0.6-0.4-200 MG 2 CITRANATAL BLOOM ORAL TABLET 90-1 MG ( prenatal-dss- 2 fecb-fegl-fa) ferrocite plus oral tablet 106-1 mg 3 hematinic plus vit/minerals oral tablet 106-1 mg 3 MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 3 SL (1 box per prescription) (peg-kcl-nacl-nasulf-na asc-c)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 234 Coverage Requirements & Prescription Drug Name Drug Tier Limits MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe asp gly- 2 succ-c-thre-b12-fa) peg-3350/electrolytes/ascorbat oral solution reconstituted 100 gm 3 SL (1 box per prescription) peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm 3 SL (1 box per prescription) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM (peg- SL (3 cartons per 3 kcl-nacl-nasulf-na asc-c) prescription) VITAMIN D CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6-b12- 3 boron-mg) calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 calcitriol oral solution 1 mcg/ml 1 calcium-folic acid plus d oral wafer 1342-1 mg 3 DECARA ORAL CAPSULE 1.25 MG (50000 UT) 3 (cholecalciferol) doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg 3 DRISDOL ORAL CAPSULE 1.25 MG (50000 UT) 3 (ergocalciferol) ergocalciferol oral capsule 1.25 mg (50000 ut) 1 FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, 70- 3 SL (4 tablets per 28 days) 5600 MG-UNIT (alendronate-cholecalciferol) paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 ROCALTROL ORAL CAPSULE 0.25 MCG, 0.5 MCG 3 (calcitriol) ROCALTROL ORAL SOLUTION 1 MCG/ML (calcitriol) 3 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) 1 ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG (paricalcitol) 3 VITAMIN E NUTRIDOX ORAL KIT 75 MG (doxycycline monohyd-omega 3 3-e) ACTIVITY MEPHYTON ORAL TABLET 5 MG ( phytonadione) 3 SL (5 tablets per day) phytonadione oral tablet 5 mg 3 SL (5 tablets per day)

Drug Tier 1: Your lowest cost medications; Drug Tier 2: Your mid-range cost medications; Drug Tier 3: Your mid-range cost medications; Drug Tier 4: Your highest cost medications; AE: Age edit - prior authorization may be required; PA: Prior authorization required; SL: Supply Limit; ST: Step Therapy; H: May be part of health care reform preventive; H-N: May be part of health care reform preventive when used for appropriate preventive purposes; CM: Orally administered anticancer medication. 235 Index of Drugs abacavir sulfate...... 26, 27 ADASUVE...... 90 ALTACAINE ...... 137 abacavir sulfate-lamivudine ...27 ADCIRCA...... 76, 205 altafrin...... 137, 138 abacavir-lamivudine- ADDERALL XR...... 79 altavera...... 153, 162, 173 zidovudine ...... 27 adefovir dipivoxil...... 30 ALUNBRIG...... 35 abiraterone acetate...... 35 ADEMPAS...... 205 alvimopan...... 143 ABSORICA...... 225 ADLYXIN...... 172 alyacen 1/35...... 153, 162, 173 acamprosate calcium...... 98 ADLYXIN STARTER PACK.... 171 alyacen 7/7/7...... 153, 162, 173 acarbose...... 149 ADRENALIN...... 44, 138, 198 alyq...... 76, 205 ACCOLATE...... 202 ADVAIR DISKUS...... 52, 146 amabelz...... 162, 173 ACCUCAINE...... 119, 186, 210 ADVAIR HFA...... 52, 146 amantadine hcl...... 17, 79 ACCU-CHEK AVIVA...... 115 AEMCOLO...... 32 AMARYL...... 184 ACCU-CHEK AVIVA PLUS.....118 AFINITOR...... 35 ambrisentan...... 205 ACCU-CHEK COMPACT AFINITOR DISPERZ...... 35 amcinonide ...... 214 PLUS CONTROL...... 115 afirmelle...... 153, 162, 173 amethia...... 153, 162, 173 ACCU-CHEK COMPACT AFREZZA...... 182 amethyst...... 153, 162, 173 PLUS TEST STRIPS...... 118 AGRYLIN...... 59 amiloride hcl...... 76, 122 ACCU-CHEK FASTCLIX ak-poly-bac ...... 129 amiloride- LANCET KIT...... 115 AKTEN...... 137 hydrochlorothiazide ...... 122, 125 ACCU-CHEK GUIDE...... 116, 118 AKYNZEO...... 138, 144 aminoamrms...... 120 ACCU-CHEK GUIDE ALA SCALP...... 214 aminocaproic acid...... 55 CONTROL ...... 116 ala-cort...... 214 aminoreliefrms...... 120 ACCU-CHEK SMARTVIEW ALAWAY...... 14, 128 amiodarone hcl ...... 70 CONTROL ...... 116 albendazole ...... 18 AMITIZA...... 143 ACCU-CHEK SMARTVIEW ALBENZA ...... 19 amitriptyline hcl...... 114 TEST STRIPS ...... 118 albuterol sulfate...... 52, 204 amlodipine besylate...... 72, 77 ACCU-CHEK SOFTCLIX albuterol sulfate hfa ...... 52, 204 amlodipine besylate- LANCET DEVICE KIT...... 116 ALCAINE...... 137 benazepril hcl...... 61, 72 ACCUPRIL...... 61 alclometasone dipropionate 214 ammonium lactate ...... 213 ACCURETIC...... 61, 125 ALDACTAZIDE...... 75, 125 amnesteem...... 225 accutane...... 225 ALDACTONE ...... 75, 76, 122 amoxapine...... 114 ACD-A NOCLOT-50...... 54 ALDARA...... 225 amoxicill-clarithro-lansopraz acebutolol hcl ...... 54, 63, 64, 69 ALECENSA...... 35 ...... 18, 31, 144 acetaminophen-codeine .80, 102 alendronate sodium ...... 188 amoxicillin...... 18, 140, 141 acetaminophen-codeine #2 alfuzosin hcl er ...... 52 amoxicillin-potassium ...... 79, 102 ALINIA...... 20 clavulanate...... 18 acetaminophen-codeine #3 aliskiren fumarate...... 77 amoxicillin-potassium ...... 79, 102 ALKERAN...... 35 clavulanate er...... 18 acetaminophen-codeine #4 allergy childrens amphetamine- ...... 79, 102 ...... 13, 48, 82, 91, 199, 201 dextroamphetamine ...... 79 acetazolamide ... 68, 82, 120, 132 allopurinol...... 187 ampicillin...... 18 acetazolamide er almotriptan malate ...... 112 AMZEEQ...... 206 ...... 68, 82, 120, 132 ALOCRIL...... 128, 202 anagrelide hcl...... 59 acetic acid...... 136 ALOMIDE...... 16, 128 ANALPRAM HC ...... 210, 214 acetylcysteine...... 186, 202 ALORA...... 162, 188 ANALPRAM HC SINGLES acitretin...... 225 alosetron hcl...... 140 ...... 210, 214 ACTIVELLA...... 162, 173 ALPHAGAN P...... 128 ANALPRAM-HC...... 210, 214 ACTOPLUS MET...... 152, 184 alprazolam...... 96 ANASPAZ...... 45 ACULAR...... 136 alprazolam er...... 96 anastrozole ...... 35, 151 ACULAR LS...... 136 alprazolam intensol ...... 96 ANCOBON...... 32 ACUVAIL...... 136 alprazolam xr...... 96 ANDRODERM...... 149 acyclovir...... 30, 212 ALREX...... 133 ANDROGEL...... 150 ACZONE...... 206, 225 ALTABAX ...... 206 ANDROGEL PUMP...... 150

236 ANGELIQ...... 162, 173 aurovela fe 1.5/30.. 153, 162, 174 BELBUCA...... 105 ANNOVERA ...... 153, 162, 173 aurovela fe 1/20..... 153, 162, 174 belladonna alkaloids-opium ANORO ELLIPTA ...... 45, 53 AURYXIA...... 121 ...... 45, 102 ANTARA ...... 73 AUSTEDO...... 115 BELSOMRA ...... 91 ANTICOAGULANT SODIUM AUTOLET LANCING DEVICE 116 benazepril hcl...... 61 CITRATE ...... 54 AVAR CLEANSER...... 206, 221 benazepril- ANTIVERT...... 13, 139 AVAR LS CLEANSER.... 206, 221 hydrochlorothiazide ...... 61, 125 anucort-hc ...... 214 AVAR-E EMOLLIENT..... 207, 221 BENZAC AC WASH...... 223 ANUSOL-HC...... 214 AVAR-E GREEN...... 207, 221 BENZALKONIUM CHLORIDE 223 APEXICON E...... 215 AVAR-E LS...... 207, 221 benzalkonium chloride ...... 223 apraclonidine hcl...... 136 aviane...... 154, 162, 174 BENZAMYCIN...... 207, 223 aprepitant...... 144 avidoxy...... 19, 33 benzepro...... 223 apri...... 153, 162, 173 AVIDOXY DK...... 33, 221, 228 BENZEPRO CREAMY WASH 223 APRISO...... 140 AYGESTIN...... 174 BENZEPRO FOAMING APTIOM...... 82 ayuna...... 154, 162, 174 CLOTHS...... 223 APTIVUS...... 28 AYVAKIT...... 35 BENZEPRO SHORT ARAKODA...... 19 AZALGIA...... 194 CONTACT ...... 223 aranelle...... 153, 162, 173 AZASAN...... 190, 191, 192 BENZHYDROCODONE- ARAVA...... 190, 191, 192 AZASITE...... 129 ACETAMINOPHEN...... 80, 102 arformoterol tartrate ...... 53 azathioprine...... 190, 191, 192 BENZNIDAZOLE ...... 20, 21 ARIKAYCE...... 18 azelaic acid...... 226 BENZOIN...... 214 ARIMIDEX...... 35, 151 azelastine hcl...... 128, 204 benzoin compound ...... 214 aripiprazole...... 87, 92 AZELEX...... 226 benzonatate ...... 199 armodafinil...... 115 azithromycin...... 31 benzoyl peroxide- ARMOUR THYROID...... 184 AZOPT...... 132 erythromycin...... 207, 223 ARNUITY ELLIPTA ...... 146, 203 AZSTARYS...... 109 benztropine mesylate ...... 48, 82 ARTISS...... 226 AZULFIDINE..... 32, 140, 190, 191 beser...... 215 ARZOL SILVER NIT AZULFIDINE EN-TABS BESIVANCE...... 129 APPLICATORS...... 135 ...... 32, 140, 190, 191 BETADINE OPHTHALMIC ascomp-codeine azurette...... 154, 162, 174 PREP...... 135 ...... 94, 102, 109, 111 bac...... 80, 94, 109 BETALOAN SUIK...... 146, 210 ashlyna...... 153, 162, 174 bacitracin...... 129 betamethasone dipropionate aspirin-dipyridamole er .. 58, 111 bacitracin-polymyxin b ...... 129 ...... 215 ASTAGRAF XL...... 192 bacitra-neomycin- betamethasone dipropionate ASTRINGYN...... 56 polymyxin-hc...... 129, 133 aug...... 215 ATABEX OB...... 56, 229, 232 baclofen...... 50 betamethasone valerate ...... 215 atazanavir sulfate ...... 28 BACTRIM...... 20, 32, 34 BETAPACE AF. 50, 63, 64, 69, 70 atenolol...... 54, 63, 64, 69 BACTRIM DS...... 20, 32, 34 betaxolol hcl.. 54, 63, 64, 70, 131 atenolol-chlorthalidone .. 63, 127 BAFIERTAM...... 191 bethanechol chloride ...... 51 atomoxetine hcl ...... 98 BALCOLTRA ...... 154, 163, 174 BETIMOL...... 131 atorvastatin calcium ...... 74 balsalazide disodium ...... 140 BETOPTIC-S...... 131 atovaquone ...... 20 balsam peru-castor oil...... 226 BEVESPI AEROSPHERE...45, 53 atovaquone-proguanil hcl ...... 19 BALVERSA...... 35, 36 bexarotene...... 36 atropine sulfate ...... 137 balziva...... 154, 163, 174 bicalutamide...... 36 ATROVENT HFA ...... 45, 198 banophen BIDIL...... 73, 75 AUBAGIO...... 191 ...... 13, 48, 82, 91, 199, 201 BIJUVA...... 163, 174 aubra...... 153, 162, 174 BANZEL ...... 82 BIKTARVY...... 25, 26, 27 aubra eq...... 153, 162, 174 BAQSIMI ONE PACK..... 171, 186 BILTRICIDE...... 19 aurodryl allergy childrens BAQSIMI TWO PACK.....171, 186 BINOSTO...... 188 ...... 13, 48, 82, 91, 199, 201 BARACLUDE...... 30 bisoprolol fumarate aurovela 1.5/30...... 153, 162, 174 BAXDELA...... 32 ...... 54, 63, 64, 70 aurovela 1/20...... 153, 162, 174 BECONASE AQ...... 133, 202 bisoprolol- aurovela 24 fe...... 153, 162, 174 bekyree...... 154, 163, 174 hydrochlorothiazide ...... 63, 125

237 BLEPH-10...... 129 butalbital-apap-caffeine CARDURA...... 50, 59 BLEPHAMIDE...... 129, 133 ...... 80, 94, 109 CARDURA XL...... 50, 59 BLEPHAMIDE S.O.P...... 129, 133 butalbital-asa-caff-codeine CARETOUCH CONTROL SOL blisovi 24 fe...... 154, 163, 174 ...... 94, 102, 109, 111 LEVEL 2...... 116 blisovi fe 1.5/30..... 154, 163, 174 butalbital-aspirin-caffeine CARETOUCH blisovi fe 1/20...... 154, 163, 174 ...... 94, 109, 111 LANCING/EJECTOR...... 116 BONIVA...... 188 butorphanol tartrate ...... 89, 106 CARETOUCH TEST...... 118 bosentan...... 205 BYDUREON BCISE carisoprodol...... 49 BOSULIF...... 36 AUTOINJECTOR...... 172 carisoprodol-aspirin-codeine bp 10-1...... 207, 221 BYETTA 10 MCG PEN ...... 172 ...... 49, 102, 111 bp cleansing wash...... 207, 221 BYETTA 5 MCG PEN ...... 172 CAROSPIR...... 75, 76, 122 bp wash...... 223 cabergoline...... 100 carteolol hcl...... 131 BRAFTOVI ...... 36 CABOMETYX ...... 36 cartia xt...... 65, 67, 71, 77 BREO ELLIPTA ...... 53, 147 CAFERGOT...... 51, 89, 109 carvedilol... 50, 52, 59, 63, 64, 70 BREZTRI AEROSPHERE caffeine citrate...... 89, 109 cascara sagrada...... 141 ...... 45, 53, 147 CALAN SR...... 65, 66, 71, 77 CASODEX...... 36 briellyn...... 154, 163, 174 CALCIFOL...... 122, 232, 235 CAYA...... 197 BRILINTA ...... 58 calcipotriene...... 226 CAYSTON...... 29 brimonidine tartrate ...... 128 calcipotriene-betameth caziant...... 154, 163, 174 BRIMONIDINE- diprop...... 215, 226 cefaclor...... 17 DORZOLAMIDE...... 128, 132 calcitonin (salmon) ...... 152, 188 cefaclor er...... 16 BRINEURA...... 127 CALCITRENE ...... 226 cefadroxil...... 16 brinzolamide ...... 132 calcitriol...... 226, 235 cefdinir...... 17 BRIVIACT...... 82 calcium acetate...... 121, 123 cefixime...... 17 bromfenac sodium (once- calcium acetate (phos cefpodoxime proxetil ...... 17 daily)...... 136 binder)...... 121, 122, 123 cefprozil...... 17 bromocriptine mesylate ...... 100 calcium-folic acid plus d cefuroxime axetil...... 17 BRONCHITOL ...... 204 ...... 123, 232, 235 celecoxib...... 99 BRONCHITOL TOLERANCE CALQUENCE...... 36 CELEXA...... 113 TEST...... 204 camila...... 154, 174 CELLCEPT...... 192 BROVANA...... 53 camrese...... 154, 163, 174 CELONTIN...... 114 BRUKINSA...... 36 camrese lo...... 154, 163, 174 CENTANY ...... 207 budesonide ...... 147, 203 CANASA...... 140 CENTANY AT ...... 207 bumetanide ...... 74, 121 candesartan cilexetil...... 59, 60 cephalexin...... 16 BUMEX...... 74, 121 candesartan cilexetil-hctz CERDELGA...... 194 BUNAVAIL...... 105, 106 ...... 60, 125 cerovel...... 221 BUPAP...... 80, 94 capecitabine...... 36 CERVIDIL...... 198 BUPHENYL...... 120 CAPEX...... 215 cetirizine hcl...... 16, 204 buprenorphine hcl ...... 106 CAPLYTA...... 92 CETRAXAL...... 129 buprenorphine hcl-naloxone CAPRELSA...... 36 cevimeline hcl...... 51 hcl...... 105, 106 captopril...... 61 CHANTIX...... 49 bupropion hcl ...... 86 CARAC...... 226 CHANTIX CONTINUING bupropion hcl er (smoking CARBAGLU...... 120 MONTH PAK ...... 49 det)...... 86 carbamazepine...... 82, 83, 87 CHANTIX STARTING MONTH bupropion hcl er (sr) ...... 86 carbamazepine er...... 82, 87 PAK...... 49 bupropion hcl er (xl) ...... 86 CARBATROL...... 83, 87 charlotte 24 fe...... 154, 163, 174 BUPROPION HCL ER (XL)...... 86 carbidopa...... 99 chateal...... 154, 163, 174 buspirone hcl ...... 91 carbidopa-levodopa ...... 99 chateal eq...... 154, 163, 174 butalbital-acetaminophen 80, 94 carbidopa-levodopa er ...... 99 CHEMET...... 146, 186 butalbital-apap-caff-cod carbidopa-levodopa- CHENODAL...... 142 ...... 80, 94, 102, 109 entacapone ...... 98, 99 chlordiazepoxide hcl ...... 96 carbinoxamine maleate .. 13, 201 chlordiazepoxide- CARDIZEM LA...... 65, 67, 71, 77 amitriptyline...... 96, 114

238 chlordiazepoxide-clidinium clobetasol propionate e ...... 215 cortic-nd...... 133, 135, 137 ...... 45, 96 clobetasol propionate CORTIFOAM...... 216 chlorhexidine gluconate emulsion...... 215 CORTISPORIN-TC...... 129, 133 ...... 135, 223 clocortolone pivalate ...... 215 CORVITA...... 123, 229, 232 chloroquine phosphate ...... 19 CLODAN...... 215, 220 COSOPT...... 132 chlorpromazine hcl ...... 108 clodan...... 215 COSOPT PF...... 132, 133 chlorthalidone ...... 77, 127 clomiphene citrate...... 161 COTELLIC...... 36 chlorzoxazone ...... 49 clomipramine hcl...... 114 COVARYX...... 150, 163 CHOLBAM...... 143 clonazepam ...... 95, 96 COVARYX HS...... 150, 163 cholestyramine...... 65 clonidine...... 45, 68 CREON...... 127, 142 cholestyramine light...... 65 clonidine hcl...... 45, 68 CRESEMBA...... 22 ciclodan...... 220 clonidine hcl er...... 45, 68 CRINONE...... 175 ciclopirox...... 220 clopidogrel bisulfate ...... 58 CRIXIVAN...... 28 ciclopirox olamine...... 220 clorazepate dipotassium .. 95, 96 cromolyn sodium .. 128, 136, 202 ciclopirox treatment ...... 220 clotrimazole...... 212 crotan...... 225 cilostazol...... 58, 76 clotrimazole-betamethasone cryselle-28...... 154, 163, 175 CILOXAN...... 129 ...... 212, 216 CUROSURF...... 204 CIMDUO...... 27 clovique...... 146 CUTIVATE...... 216 cimetidine...... 14, 143 clozapine...... 92 CUVPOSA...... 46 cimetidine hcl...... 14, 143 CLOZARIL...... 92 cvs motion sickness ...... 13, 139 cinacalcet hcl...... 152 COAL TAR...... 223 cyclafem 1/35...... 154, 163, 175 CIPRO...... 21, 32 COARTEM...... 19 cyclafem 7/7/7...... 154, 163, 175 CIPRO HC...... 129, 133 codeine sulfate ...... 102, 199 cyclobenzaprine hcl...... 49 CIPRODEX...... 129, 133 colchicine...... 187 CYCLOGYL...... 137 ciprofloxacin hcl...... 21, 32, 129 colchicine-probenecid ..127, 187 CYCLOMYDRIL...... 137, 138 citalopram hydrobromide .....113 COLCRYS...... 187 cyclopentolate hcl ...... 137 CITRANATAL BLOOM COLESTID...... 65 cyclophosphamide ...... 36, 193 ...... 56, 141, 232, 234 COLESTID FLAVORED...... 65 CYCLOPHOSPHAMIDE... 36, 193 CITRANATAL ESSENCE colestipol hcl...... 65 cycloserine...... 22 ...... 56, 123, 194, 229, 232 COMBIGAN...... 128, 132 CYCLOSET...... 151 claravis...... 226 COMBIPATCH...... 163, 175 cyclosporine...... 190, 191, 193 CLARINEX...... 16, 204 COMBIVENT RESPIMAT cyclosporine modified CLARINEX-D 12 HOUR...... 16, 44 ...... 46, 53, 198 ...... 190, 191, 193 clarithromycin...... 22, 31, 141 COMBIVIR...... 27 cyproheptadine hcl ... 13, 14, 201 clarithromycin er...... 21, 31, 141 COMETRIQ...... 36 cyred...... 154, 163, 175 clearlax...... 141 COMPLERA...... 26, 27 cyred eq...... 154, 163, 175 clemastine fumarate ...... 13, 201 compro...... 108, 139 CYSTADANE ...... 194 CLENPIQ...... 141 COMTAN...... 98 CYSTADROPS...... 136 CLEOCIN...... 29, 207 CONCERTA ...... 109 CYSTAGON...... 194 CLEOCIN-T...... 207 CONDYLOX...... 226 CYSTARAN...... 136 CLIMARA PRO...... 163, 174 constulose ...... 120 CYTOTEC...... 144 CLINDACIN ETZ ...... 207 CONTOUR CONTROL ...... 116 cytra k crystals...... 119 clindacin etz...... 207 CONTOUR NEXT CONTROL .116 dalfampridine er...... 194 CLINDACIN PAC...... 207 CONTOUR NEXT TEST ...... 118 DALIRESP...... 203 clindacin-p...... 207 CONTOUR TEST...... 118 danazol...... 150 clindamycin hcl...... 29 CONZIP...... 102 DANTRIUM...... 50 clindamycin palmitate hcl ...... 29 COPIKTRA...... 36 dantrolene sodium...... 50 clindamycin phosphate ...... 207 CORDRAN...... 216 dapsone...... 20, 21 CLINDESSE...... 207 CORGARD...... 50, 63, 64 DARAPRIM...... 19 clobazam...... 95, 96 CORLANOR...... 68, 77 dasetta 1/35...... 154, 163, 175 clobetasol prop emollient CORTANE-B...... 210, 216, 223 dasetta 7/7/7...... 154, 163, 175 base...... 215 CORTEF...... 147 DAURISMO...... 37 clobetasol propionate ...... 215 CORTENEMA ...... 216 DAYPRO...... 106

239 daysee...... 154, 163, 175 DIALYVITE SUPREME D DIVIGEL...... 164, 188 DAYTRANA ...... 109 ...... 123, 229, 232 DMT SUIK...... 147, 210 DAYVIGO...... 91 DIASTAT ACUDIAL...... 95, 96 dofetilide...... 70 DEBACTEROL...... 136, 223 DIASTAT PEDIATRIC...... 95, 96 DOJOLVI...... 120 deblitane...... 154, 175 diazepam...... 95, 96, 97 dolishale...... 155, 164, 175 DECADRON...... 147 diazepam intensol ...... 95, 96 donepezil hcl ...... 51 DECARA...... 235 diazoxide...... 151 DOPTELET...... 55 deferasirox...... 146 DICLOFENAC PATCH...... 106 dorzolamide hcl ...... 133 deferasirox granules...... 146 diclofenac potassium ...... 106 dorzolamide hcl-timolol mal deferiprone...... 146 diclofenac sodium ...... 132, 133 DELSTRIGO...... 26, 27 ...... 106, 137, 224, 225, 226 dorzolamide hcl-timolol mal delyla...... 154, 163, 175 diclofenac sodium er ...... 106 pf...... 132, 133 demeclocycline hcl...... 33 diclofenac-misoprostol 106, 144 DOVATO...... 25, 27 DEMSER...... 194 dicloxacillin sodium...... 31 DOVONEX...... 226 DENAVIR...... 212 dicyclomine hcl...... 46 doxazosin mesylate ...... 50, 59 DEPEN TITRATABS ...... 146, 190 DIFICID...... 31 doxepin hcl ...... 114, 210 DEPO-SUBQ PROVERA 104 diflorasone diacetate ...... 216 doxercalciferol...... 235 ...... 154, 175 DIFLUCAN...... 22 doxycycline hyclate...... 19, 33 DERMA-SMOOTHE/FS BODY diflunisal...... 106 doxycycline monohydrate 19, 33 ...... 216 digitek...... 62, 68 DRISDOL...... 235 DERMA-SMOOTHE/FS digox...... 62, 68 DRIZALMA SPRINKLE...... 111 SCALP...... 216 digoxin...... 62, 68 dronabinol...... 139 DERMELLE ...... 226 dihydroergotamine mesylate drospiren-eth estrad- DERMOTIC...... 133 ...... 51, 89 levomefol...... 155, 164, 175, 232 DESCOVY...... 27 DILANTIN...... 69, 100 drospirenone-ethinyl desipramine hcl...... 114 DILATRATE-SR...... 75 estradiol...... 155, 164, 175 desloratadine...... 16, 204 DILAUDID...... 102 DROXIA...... 37 desmopressin ace spray diltiazem hcl ...... 66, 67, 71, 78 droxidopa...... 44 refrig...... 56, 173 diltiazem hcl er...... 66, 67, 71, 78 DRYSOL...... 212 desmopressin acetate .... 56, 173 diltiazem hcl er beads DUAVEE...... 161, 164 desmopressin acetate spray ...... 66, 67, 71, 77 DUETACT...... 184 ...... 56, 173 diltiazem hcl er coated DUEXIS...... 106, 143 desogestrel-ethinyl estradiol beads...... 66, 67, 71, 77, 78 duloxetine hcl...... 100, 111 ...... 155, 164, 175 dilt-xr...... 66, 67, 71, 78 DUOPA...... 99 DESONATE...... 216 dimethyl fumarate ...... 191 DUREZOL...... 133 desonide...... 216 dimethyl fumarate starter DURLAZA...... 58, 111 DESOWEN...... 216 pack...... 191 dutasteride...... 186 desoximetasone ...... 216 DIPENTUM...... 140 DYRENIUM...... 76, 122 desrx...... 216 diphen E.E.S. GRANULES...... 23 DESVENLAFAXINE ER...... 111 ...... 13, 14, 48, 82, 91, 199, 201 EASIVENT...... 116 desvenlafaxine succinate er 111 di-phen easygel...... 189 dexamethasone ...... 147 ...... 13, 14, 48, 82, 91, 199, 201 EASYMAX 15 LEVEL 2-3 dexamethasone intensol ...... 147 diphenhydramine hcl CONTROL...... 116 dexamethasone sodium ...... 13, 14, 48, 82, 91, 199, 201 EASYMAX CONTROL...... 116 phosphate ...... 133 diphenoxylate-atropine .. 46, 139 EASYMAX CONTROL DEXILANT...... 145 DIPROLENE...... 216 NORMAL/HIGH...... 116 dexmethylphenidate hcl ...... 109 DIPROLENE AF...... 216 EC-NAPROSYN...... 89, 107, 187 dexmethylphenidate hcl er ...109 dipyridamole...... 58, 78 ec-naproxen...... 89, 107, 187 DEXTENZA ...... 133 disopyramide phosphate ...... 69 econazole nitrate ...... 212 dextroamphetamine sulfate ... 79 disulfiram...... 186 ECOZA...... 212 dextroamphetamine sulfate DIURIL...... 77, 125 EDARBYCLOR...... 60, 126 er...... 79 divalproex sodium...... 83, 87, 89 EDECRIN...... 74, 121 DIACOMIT...... 83 divalproex sodium er ..83, 87, 89 EDLUAR...... 91

240 ED-SPAZ...... 46 epinephrine...... 44, 198 etodolac er...... 107 EDURANT...... 26 epitol...... 83, 87 etoposide...... 37 EEMT...... 150, 164 EPIVIR...... 27 etravirine...... 26 EEMT HS ...... 150, 164 EPIVIR HBV...... 27 EUCRISA...... 210 efavirenz...... 26 eplerenone...... 75, 76, 122 euthyrox...... 185 efavirenz-emtricitab- EPZICOM...... 27 EVAMIST...... 165, 189 tenofovir ...... 26, 27 EQUETRO...... 83, 87 everolimus...... 37, 193 efavirenz-lamivudine- ergocalciferol...... 235 EVOCLIN...... 208 tenofovir ...... 26, 27 ergoloid mesylates...... 51 EVOTAZ...... 29, 194 EFFER-K...... 123 ERGOMAR...... 51, 90 EVRYSDI...... 194 effer-k...... 123 ergotamine-caffeine ..51, 90, 109 EXELDERM...... 212 EFUDEX...... 226 ERIVEDGE...... 37 exemestane...... 37, 151 EGATEN...... 19 ERLEADA...... 37 EXJADE...... 146 ELESTRIN...... 164, 188 erlotinib hcl...... 37 EXTINA...... 212 eletriptan hydrobromide ...... 112 errin...... 155, 175 eye itch relief...... 14, 128 elinest...... 155, 164, 175 ERTACZO...... 212 EZALLOR SPRINKLE ...... 74 ELIQUIS...... 55 ery...... 207 ezetimibe...... 69 ELIQUIS DVT/PE STARTER ERYGEL...... 207 ezetimibe-simvastatin ...... 69, 74 PACK...... 55 ERYPED 200...... 23 falmina...... 155, 165, 176 ELITE-OB...... 56, 229, 232 ERYPED 400...... 23 famciclovir...... 30 ELIXOPHYLLIN ERY-TAB...... 23 famotidine...... 14, 15, 143 ...... 73, 109, 121, 206, 229 ERYTHROCIN STEARATE ...... 23 FANAPT...... 92 ELLA...... 155, 175 erythromycin...... 23, 129, 207 FANAPT TITRATION PACK ..... 92 ELMIRON...... 194 erythromycin base...... 23 FARYDAK...... 37 EMCYT...... 37 erythromycin ethylsuccinate . 23 fayosim...... 155, 165, 176 EMEND ...... 144 ESBRIET...... 199 febuxostat...... 187 EMEND TRI-PACK...... 144 escitalopram oxalate...... 113 felbamate...... 83 emoquette ...... 155, 164, 175 ESGIC...... 80, 94, 109 FELBATOL ...... 83 EMSAM...... 101 esomeprazole magnesium ... 145 FELDENE...... 107 emtricitabine...... 27 ESOMEPRAZOLE felodipine er...... 72 emtricitabine-tenofovir df ...... 27 STRONTIUM...... 145 FEM PH...... 223, 226 EMTRIVA...... 27 est estrogens-methyltest FEMHRT...... 165, 176 EMVERM...... 19 ...... 150, 164 FEMRING...... 165, 189 enalapril maleate...... 61 est estrogens-methyltest ds femynor...... 155, 165, 176 enalapril- ...... 150, 164 fenofibrate...... 73 hydrochlorothiazide ...... 61, 126 est estrogens-methyltest hs fenofibrate micronized ...... 73 ENBRACE HR .. 56, 194, 230, 232 ...... 150, 164 fenofibric acid...... 73 ENDARI...... 194 estarylla...... 155, 164, 175 fentanyl...... 102 endocet...... 80, 102 estazolam...... 97 fentanyl citrate...... 102 ENDOMETRIN ...... 175 ESTRACE...... 164, 188 FERRIPROX...... 146 enpresse-28...... 155, 164, 175 estradiol...... 164, 188, 189 ferrocite plus... 56, 123, 232, 234 enskyce...... 155, 164, 175 estradiol-norethindrone acet FETZIMA ...... 111 ENSTILAR ...... 216, 226 ...... 164, 175 FETZIMA TITRATION ...... 112 entacapone ...... 98 ESTRING...... 165, 189 FIBRICOR...... 73 entecavir...... 30 ESTROGEL...... 165, 189 FINACEA...... 226 ENTOCORT EC ...... 147 ESTROSTEP FE.....155, 165, 175 finasteride...... 186 ENTRESTO ...... 60, 77 eszopiclone ...... 91 FINTEPLA ...... 83 enulose...... 120 ethacrynic acid...... 74, 121 FIORICET/CODEINE ENZOCLEAR...... 223 ethambutol hcl ...... 22 ...... 80, 94, 102, 109 EPANED...... 61 ethosuximide...... 114 FIRST-LANSOPRAZOLE...... 145 EPCLUSA...... 24 ethynodiol diac-eth estradiol FIRST-OMEPRAZOLE...... 145 EPIDIOLEX...... 83 ...... 155, 165, 176 FIRVANQ...... 24 EPIFOAM...... 210, 216 etodolac...... 107 flac...... 133

241 FLAGYL...... 17, 21, 141 FORMALDEHYDE...... 119 GLUCAGON EMERGENCY FLAREX...... 133 FORTESTA ...... 150 KIT...... 171, 186 flecainide acetate...... 69 FORTISCARE CONTROL ...... 116 GLUCOTROL XL...... 184 FLECTOR ...... 107 FOSAMAX...... 189 GLUMETZA...... 152 FLEXICHAMBER ADULT FOSAMAX PLUS D...... 189, 235 GLUTARALDEHYDE...... 119 MASK/SMALL...... 116 fosamprenavir calcium...... 29 glyburide...... 184 FLEXICHAMBER CHILD fosfomycin tromethamine ...... 34 glyburide micronized...... 184 MASK/LARGE...... 116 fosinopril sodium ...... 61 glyburide-metformin ..... 152, 184 FLEXICHAMBER CHILD fosinopril sodium-hctz ... 62, 126 glycolax...... 141 MASK/SMALL...... 116 FOSRENOL...... 121, 186 glycopyrrolate...... 46 FLOLIPID...... 74 FREESTYLE PRECISION glydo...... 210 FLOMAX...... 52 NEO TEST...... 118 GLYNASE...... 184 FLOVENT DISKUS...... 147, 203 frovatriptan succinate ...... 112 GLYXAMBI...... 161, 183 FLOVENT HFA ...... 147, 203 furosemide...... 74, 121 GOLYTELY ...... 141 fluconazole ...... 22, 23 fyavolv...... 165, 176 goodsense motion sickness flucytosine ...... 32 FYCOMPA...... 83 ...... 14, 140 fludrocortisone acetate ...... 147 gabapentin...... 80, 83 goodsense nicotine ...... 49 flunisolide ...... 133, 148, 202 GABITRIL...... 83 GORDOFILM...... 213, 221 fluocinolone acetonide .134, 217 GALAFOLD...... 194 GRALISE...... 80, 83 fluocinolone acetonide body 217 galantamine hydrobromide ....51 granisetron hcl...... 138 fluocinolone acetonide scalp galantamine hydrobromide GRASTEK...... 43 ...... 217 er...... 51 griseofulvin microsize ...... 19 fluocinonide ...... 217 GALZIN...... 123 griseofulvin ultramicrosize .... 19 fluocinonide emulsified base gatifloxacin...... 129 guaiatussin ac...... 199, 201 ...... 217 gavilax...... 141 guaifenesin ac...... 199, 201 fluorometholone ...... 134 gavilyte-c...... 141 guanfacine hcl...... 68, 98 FLUOROPLEX...... 226 gavilyte-g...... 141 guanfacine hcl er ...... 98 FLUOROURACIL...... 226 gavilyte-n with flavor pack... 141 GVOKE HYPOPEN 1-PACK fluorouracil...... 226 GELFILM...... 56 ...... 171, 186 fluoxetine hcl ...... 113 gemfibrozil...... 73 GVOKE HYPOPEN 2-PACK fluphenazine hcl ...... 108 gemmily...... 155, 165, 176 ...... 171, 187 flurandrenolide ...... 217 GENERESS FE...... 155, 165, 176 GVOKE PFS...... 171, 187 flurazepam hcl ...... 97 generlac...... 120 GYNAZOLE-1...... 212 flurbiprofen ...... 107 gengraf...... 190, 191, 193 habitrol...... 49 flurbiprofen sodium ...... 137 gentak...... 129 hailey 1.5/30...... 155, 165, 176 flutamide ...... 37 gentamicin sulfate ...... 129, 208 hailey 24 fe...... 155, 165, 176 fluticasone propionate GENVOYA...... 25, 27 hailey fe 1.5/30...... 155, 165, 176 ...... 134, 148, 203, 217 geri-dryl hailey fe 1/20...... 155, 165, 176 FLUTICASONE- ...... 13, 14, 48, 82, 91, 199, 201 halcinonide ...... 217 SALMETEROL ...... 53, 148 GILENYA...... 191 HALCION...... 97 fluvastatin sodium ...... 74 GILOTRIF...... 37 halobetasol propionate ...... 217 fluvastatin sodium er ...... 74 GILPHEX TR...... 45, 201 HALOG...... 217 fluvoxamine maleate ...... 113 GLEOSTINE...... 37 haloperidol...... 97 fluvoxamine maleate er ...... 113 glimepiride...... 184 haloperidol lactate...... 97 FML...... 134 glipizide...... 184 HARVONI...... 24 FML FORTE ...... 134 glipizide er...... 184 heather...... 155, 176 FML LIQUIFILM...... 134 glipizide xl...... 184 HELIDAC THERAPY FOCALIN...... 109 glipizide-metformin hcl .152, 184 ...... 19, 21, 33, 139, 140 FOCALIN XR...... 110 GLOPERBA...... 187 HEMANGEOL... 50, 63, 64, 70, 90 folic acid...... 232 GLUCAGEN HYPOKIT... 171, 186 hematinic plus vit/minerals FORANE...... 101 glucagon emergency kit ...... 56, 123, 232, 234 FORFIVO XL...... 86 ...... 171, 186 hematinic/folic acid...... 56, 232 formaldehyde ...... 119 HEMMOREX-HC...... 217

242 hemocyte-f ...... 57, 232 hydroxychloroquine sulfate INVIRASE...... 29 HETLIOZ...... 91 ...... 20, 190, 191 IODINE STRONG...... 201 HIPREX...... 34 hydroxyurea...... 37 iodine tincture ...... 224 homatropaire...... 137 hydroxyzine hcl ...... 14, 15, 91 IOPIDINE...... 136 HUMALOG KWIKPEN...... 182 hydroxyzine pamoate . 14, 15, 91 ipratropium bromide HUMALOG MIX 50/50 HYLATOPIC PLUS...... 226 ...... 46, 198, 199 KWIKPEN...... 182 HYOPHEN...... 34, 46, 81 ipratropium-albuterol 46, 53, 199 HUMALOG MIX 50/50 VIAL....182 hyoscyamine sulfate...... 46 irbesartan...... 59, 60 HUMALOG MIX 75/25 hyoscyamine sulfate er ...... 46 irbesartan- KWIKPEN...... 182 hyoscyamine sulfate sl...... 46 hydrochlorothiazide ...... 60, 126 HUMALOG MIX 75/25 VIAL....182 hyosyne...... 46 IRESSA...... 38 HUMALOG U-100 JUNIOR HYPERSAL...... 202 ISENTRESS...... 25 KWIKPEN...... 182 HYPOCYN...... 226 ISENTRESS HD...... 25 HUMALOG VIAL...... 182, 183 HYZAAR...... 60, 126 isibloom...... 155, 165, 176 HUMULIN 70/30 KWIKPEN ibandronate sodium ...... 189 isoflurane...... 101 ...... 172, 183 IBRANCE...... 37 isoniazid...... 22 HUMULIN 70/30 VIAL.....172, 183 ibuprofen...... 90, 107 ISOPTO ATROPINE...... 137 HUMULIN N KWIKPEN...... 172 iclevia...... 155, 165, 176 ISOPTO CARPINE...... 137 HUMULIN N VIAL...... 172 ICLUSIG...... 37 ISORDIL TITRADOSE...... 75 HUMULIN R U-500 KWIKPEN183 IDHIFA...... 38 isosorbide dinitrate ...... 75 HUMULIN R U-500 VIAL...... 183 imatinib mesylate ...... 38 isosorbide mononitrate ...... 75 HUMULIN R VIAL...... 183 IMBRUVICA...... 38 isosorbide mononitrate er ...... 75 HYCAMTIN...... 37 imipramine hcl...... 114 isotretinoin...... 227 HYCODAN...... 46, 199 imipramine pamoate ...... 114 isoxsuprine hcl...... 78 hydralazine hcl...... 73 imiquimod...... 227 isradipine...... 72 HYDREA...... 37 IMIQUIMOD PUMP...... 227 ISTALOL...... 132 HYDRO 40...... 221 IMITREX...... 112 ISTURISA...... 194 hydrochlorothiazide ...... 77, 126 IMPAVIDO...... 21 itraconazole...... 23 hydrocodone bitartrate er .... 103 IMVEXXY MAINTENANCE ivermectin...... 19, 225 hydrocodone polst- PACK...... 165 jaimiess...... 156, 166, 176 chlorphen polst er susp . 16, 199 IMVEXXY STARTER PACK... 165 JAKAFI...... 38 hydrocodone- INBRIJA...... 99 jantoven...... 55 acetaminophen ...... 80, 103 incassia...... 155, 176 JARDIANCE...... 183 hydrocodone-homatropine indapamide ...... 77, 127 jasmiel...... 156, 166, 176 ...... 46, 199 INDOCIN...... 107, 187 JELMYTO...... 38 hydrocodone-ibuprofen 103, 107 indomethacin ...... 107, 188 jencycla...... 156, 176 hydrocortisone ...... 148, 218 indomethacin er ...... 107, 188 JENTADUETO ...... 152, 161 hydrocortisone (perianal) .....217 INFASURF...... 123, 204 JENTADUETO XR...... 152, 161 hydrocortisone ace- INLYTA...... 38 jinteli...... 166, 176 pramoxine...... 210, 217 INOVA...... 220, 224 jolessa...... 156, 166, 176 hydrocortisone acetate ...... 217 INOVA 4/1 ACNE CONTROL JUBLIA...... 212 hydrocortisone butyr lipo THERAPY...... 220, 221, 224 juleber...... 156, 166, 176 base...... 217 INOVA 8/2 ACNE CONTROL JULUCA...... 25, 26 hydrocortisone butyrate ...... 217 THERAPY...... 220, 221, 224 junel 1.5/30...... 156, 166, 176 hydrocortisone valerate ...... 218 INREBIC...... 38 junel 1/20...... 156, 166, 176 hydrocortisone-acetic acid INSPIREASE RESERVOIR junel fe 1.5/30...... 156, 166, 176 ...... 134, 136 BAGS...... 116 junel fe 1/20...... 156, 166, 177 hydrocortisone-iodoquinol INSULIN PEN NEEDLES 116, 117 junel fe 24...... 156, 166, 177 ...... 218, 223 INSULIN SYRINGES...... 117 JUXTAPID...... 62 hydrocort-pramoxine INTELENCE ...... 26 JYNARQUE...... 127 (perianal)...... 210, 218 INTRAROSA...... 148 kaitlib fe...... 156, 166, 177 hydromet...... 46, 199 introvale...... 155, 165, 176 KALETRA...... 29 hydromorphone hcl ...... 103 INVELTYS...... 134 kalliga...... 156, 166, 177

243 KALYDECO...... 200 lamotrigine...... 84, 88 levonorg-eth estrad triphasic KAPSPARGO SPRINKLE lamotrigine er...... 84, 88 ...... 157, 167, 177 ...... 54, 63, 64, 70 lamotrigine starter kit-blue levora 0.15/30 (28). 157, 167, 177 KAPVAY...... 45, 68 ...... 84, 88 levorphanol tartrate...... 103 KARBINAL ER...... 13, 14, 201 lamotrigine starter kit-green levo-t...... 185 kariva...... 156, 166, 177 ...... 84, 88 LEVOTHYROXINE SODIUM.. 185 KATERZIA...... 72, 78 lamotrigine starter kit- levothyroxine sodium ...... 185 KAZANO...... 152, 161 orange...... 84, 88 levoxyl...... 185 KEFLEX...... 16 LAMPIT...... 21 LEVSIN...... 46 kelnor 1/35...... 156, 166, 177 LANOXIN...... 62, 68 LEVSIN/SL...... 47 kelnor 1/50...... 156, 166, 177 lansoprazole...... 145 LEVULAN KERASTICK...... 227 KEPPRA XR...... 83 lanthanum carbonate ....121, 187 LEXIVA...... 29 KERALAC...... 221 LANTUS SOLOSTAR ...... 172 LIALDA...... 140 KERALYT SCALP ...... 221 LANTUS U-100 VIAL...... 172 LICART...... 107 KERYDIN...... 225 lapatinib ditosylate ...... 38 lidocaine...... 210, 211 ketoconazole ...... 23, 212 larin 1.5/30...... 156, 166, 177 lidocaine hcl...... 137, 211 ketodan...... 213 larin 1/20...... 156, 166, 177 lidocaine hcl KETONE TEST ...... 119 larin 24 fe...... 156, 166, 177 urethral/mucosal...... 211 KETOROLAC larin fe 1.5/30...... 156, 166, 177 lidocaine viscous hcl...... 137 TROMETHAMINE ...... 107 larin fe 1/20...... 156, 166, 177 lidocaine-prilocaine...... 211 ketorolac tromethamine107, 137 larissia...... 156, 166, 177 lillow...... 157, 167, 177 KETOSTIX...... 119 LASIX...... 74, 121 lindane...... 225 KEVEYIS...... 189 LASTACAFT...... 15, 128 linezolid...... 31 KISQALI...... 38 latanoprost ...... 138 LINZESS...... 143 KISQALI FEMARA...... 38, 151 LATUDA...... 92 liothyronine sodium ...... 185 KLARON...... 208 layolis fe...... 156, 166, 177 liquid allergy relief klor-con...... 123 LAZANDA...... 103 ...... 13, 14, 48, 82, 91, 200, 201 klor-con 10...... 123 LEDIPASVIR-SOFOSBUVIR.... 24 lisinopril...... 61, 62 klor-con m10...... 123 leena...... 156, 166, 177 lisinopril- KLOR-CON M15...... 123 leflunomide...... 190, 191, 193 hydrochlorothiazide ...... 62, 126 klor-con m20...... 123 LENVIMA...... 38 lithium carbonate ...... 88 klor-con/ef...... 123 lessina...... 156, 166, 177 lithium carbonate er ...... 88 KOMBIGLYZE XR...... 152, 161 letrozole...... 38, 151 LITHOBID...... 88 KORLYM...... 151 leucovorin calcium...... 187, 232 LITHOSTAT...... 120 KOSELUGO...... 38 LEUKERAN...... 39 LO LOESTRIN FE ...157, 167, 177 K-PHOS...... 123 levalbuterol hcl...... 53, 205 LOCOID LIPOCREAM...... 218 K-PHOS NO 2...... 119 LEVALBUTEROL HFA ...... 53, 205 LOESTRIN 1.5/30 (21) K-PHOS-NEUTRAL...... 123 LEVBID...... 46 ...... 157, 167, 178 k-prime...... 123 levetiracetam...... 84 LOESTRIN 1/20 (21) KRINTAFEL...... 20 levetiracetam er...... 84 ...... 157, 167, 178 KRISTALOSE...... 120 levobunolol hcl ...... 132 LOESTRIN FE 1.5/30 K-TAB...... 123 levocetirizine ...... 157, 167, 178 kurvelo...... 156, 166, 177 dihydrochloride...... 16 lojaimiess...... 157, 167, 178 KYNMOBI ...... 101 levofloxacin...... 22, 32, 129 LOKELMA...... 122 labetalol hcl50, 52, 59, 63, 64, 70 levonest...... 156, 166, 177 LOMOTIL...... 47, 139 LACRISERT...... 136 levonorgest-eth est & eth est LONSURF...... 39 lactulose...... 120 ...... 156, 166, 177 loperamide hcl...... 139 lactulose encephalopathy .... 120 levonorgest-eth estrad 91- LOPID...... 73 LAMICTAL ODT ...... 84, 87 day...... 156, 166, 177 lopinavir-ritonavir ...... 29 LAMICTAL STARTER ...... 84, 87 levonorgestrel...... 156, 177 LOPRESSOR...... 54, 63, 64, 70 LAMICTAL XR ...... 84, 88 levonorgestrel-ethinyl estrad LOPROX...... 220, 227 lamivudine...... 27 ...... 157, 167, 177 lorazepam...... 95, 97 lamivudine-zidovudine ...... 28 lorazepam intensol ...... 95, 97

244 LORBRENA ...... 39 m-dryl methyl salicylate...... 213 LORTAB ...... 81, 103 ...... 13, 14, 48, 82, 91, 200, 202 methyldopa...... 45, 68 loryna...... 157, 167, 178 me/naphos/mb/hyo1 . 34, 47, 194 methylergonovine maleate ...198 LORZONE...... 49 meclizine hcl...... 14, 140 METHYLIN...... 110 losartan potassium ...... 60 meclofenamate sodium ...... 107 methylphenidate hcl ...... 110 losartan potassium-hctz .60, 126 MEDROL...... 148 methylphenidate hcl er ...... 110 LOSEASONIQUE... 157, 167, 178 MEDROLOAN II SUIK.... 148, 211 methylphenidate hcl er (cd) . 110 LOTEMAX ...... 134 MEDROLOAN SUIK...... 148, 211 methylphenidate hcl er (la) .. 110 LOTEMAX SM ...... 134 medroxyprogesterone methylprednisolone ...... 148 LOTENSIN...... 61, 62 acetate...... 157, 178 methyltestosterone ...... 150 LOTENSIN HCT ...... 62, 126 mefenamic acid...... 107 metoclopramide hcl ...... 144 loteprednol etabonate ...... 134 mefloquine hcl ...... 20 metolazone ...... 77, 127 LOTRONEX ...... 140 megestrol acetate...... 39, 178 metoprolol succinate er lovastatin...... 74 MEKINIST...... 39 ...... 54, 63, 64, 70 low-ogestrel...... 157, 167, 178 MEKTOVI...... 39 metoprolol tartrate 54, 63, 64, 70 loxapine succinate ...... 90 meloxicam...... 107 metoprolol- lo-zumandimine .....157, 167, 178 melphalan...... 39 hydrochlorothiazide ...... 63, 126 LUBIPROSTONE...... 143 memantine hcl ...... 98 METROCREAM...... 208 LUCEMYRA...... 45 MEMBRANEBLUE ...... 119 METROLOTION ...... 208 LUMAKRAS...... 39 MENEST...... 167, 189 metronidazole ....17, 21, 141, 208 LUMIGAN...... 138 MENTAX ...... 214 metyrosine...... 194 LUPKYNIS...... 193 meperidine hcl...... 103 mexiletine hcl...... 69 lutera...... 157, 167, 178 MEPHYTON...... 187, 235 mibelas 24 fe...... 157, 167, 178 LUXIQ...... 218 meprobamate ...... 91 miconazole 3...... 213 lyleq...... 157, 178 MEPRON...... 21 MICONAZOLE-ZINC OXIDE- lyllana...... 167, 189 mercaptopurine...... 39, 193 PETROLAT...... 212, 213, 220 LYNPARZA ...... 39 merzee...... 157, 167, 178 MICRODOT TEST...... 118 LYRICA...... 84, 100 mesalamine...... 140 microgestin 1.5/30.157, 167, 178 LYSODREN...... 39 mesalamine-cleanser...... 140 microgestin 1/20....157, 167, 178 LYSTEDA...... 56 MESNEX...... 197 microgestin 24 fe.. 157, 167, 178 LYUMJEV KWIKPEN...... 183 MESTINON...... 51 microgestin fe 1.5/30 LYUMJEV VIAL...... 183 metaxalone...... 49 ...... 157, 167, 178 lyza...... 157, 178 metformin hcl ...... 152 microgestin fe 1/20158, 167, 178 MACROBID...... 34 metformin hcl er ...... 152 MICROLET NEXT LANCING MACRODANTIN...... 34 metformin hcl er (mod) ...... 152 DEVICE...... 117 mafenide acetate ...... 224 metformin hcl er (osm) ...... 152 midazolam hcl...... 97 MALARONE ...... 20 methadone hcl ...... 103 midodrine hcl...... 45 malathion...... 225 methadone hcl intensol ...... 103 MIGERGOT...... 51, 90, 110 MARINOL...... 139 methadose ...... 103 miglitol...... 149 marlissa...... 157, 167, 178 methadose sugar-free ...... 103 miglustat...... 194 MARPLAN...... 101 methamphetamine hcl ...... 79 mili...... 158, 167, 178 MARVONA SUIK...... 186, 211 methazolamide ...... 68, 133 MILLIPRED...... 148 MATULANE ...... 39 methenamine hippurate ...... 34 mimvey...... 168, 178 matzim la...... 66, 67, 71, 78 methenamine mandelate ...... 34 MINASTRIN 24 FE ..158, 168, 179 MAVENCLAD ...... 193 methergine...... 198 mineral oil heavy...... 141 MAVYRET...... 24, 25 methimazole ...... 152 MINIPRESS...... 51, 59 MAXIDEX...... 134 METHITEST ...... 150 minitran...... 75 MAXITROL...... 130, 134 methocarbamol...... 49 minocycline hcl...... 20, 33 maxi-tuss ac...... 200, 201 methotrexate ... 39, 190, 192, 193 minoxidil...... 73 MAXZIDE...... 122, 126 methotrexate sodium MIRAPEX...... 101 MAXZIDE-25...... 122, 126 ...... 39, 190, 192, 193 MIRCETTE ...... 158, 168, 179 MAYZENT...... 191, 192 methoxsalen rapid...... 225 mirtazapine ...... 86 methscopolamine bromide .... 47 MIRVASO...... 227

245 misoprostol ...... 144 naproxen sodium .... 90, 108, 188 NIASPAN...... 63 MITOSOL...... 130 naproxen sodium er 90, 108, 188 nicardipine hcl...... 72, 78 mm clearlax...... 141 NAPROXEN SODIUM ER NICORETTE ...... 49 M-NATAL PLUS ...... 57, 230, 232 ...... 90, 108, 188 nicotine polacrilex...... 49 MOBIC...... 107 naproxen-esomeprazole nicotine polacrilex mini...... 49 modafinil ...... 115 ...... 108, 145 nicotine step 1...... 49 moexipril hcl...... 61, 62 naratriptan hcl...... 112 nicotine step 2...... 49 mometasone furoate NARCAN...... 105 nicotine step 3...... 49 ...... 134, 148, 203, 218 NARDIL...... 101 NICOTROL...... 49 mondoxyne nl ...... 20, 33 NASACORT ALLERGY 24HR NICOTROL NS ...... 49 mono-linyah ...... 158, 168, 179 ...... 134, 203 nifedipine...... 72, 73, 78 montelukast sodium ...... 202 NATACYN...... 131 nifedipine er...... 72, 78 MONUROL...... 34 NATAZIA...... 158, 168, 179 nifedipine er osmotic release morgidox...... 20, 33 nateglinide ...... 173 ...... 72, 73, 78 MORGIDOX...... 33, 227 NATESTO ...... 150 nikki...... 158, 168, 179 morphine sulfate ...... 104 NATROBA ...... 225 NILANDRON...... 39 morphine sulfate NATURE-THROID...... 185 nilutamide...... 39 (concentrate)...... 103 NAYZILAM...... 95 nimodipine...... 72, 73, 78 morphine sulfate er ...... 104 NEBUPENT ...... 21 NINLARO...... 39 morphine sulfate er beads necon 0.5/35 (28)... 158, 168, 179 nisoldipine er...... 72, 73 ...... 103, 104 nefazodone hcl ...... 114 nitazoxanide ...... 21 MOTEGRITY...... 143 neomycin sulfate ...... 18 NITRO-BID...... 75 motion sickness relief.... 14, 140 neomycin-bacitracin zn- NITRO-DUR...... 76 MOVIPREP...... 141, 234 polymyx...... 130 nitrofurantoin ...... 34 MOXEZA...... 130 neomycin-polymyxin- nitrofurantoin macrocrystal ... 34 moxifloxacin hcl ...... 22, 32, 130 dexameth...... 130, 134 nitrofurantoin monohydrate MOXIFLOXACIN HCL...... 130 neomycin-polymyxin- macrocrystals...... 34 moxifloxacin hcl (2x day) ..... 130 gramicidin...... 130 nitroglycerin...... 76 MS CONTIN ...... 104 neomycin-polymyxin-hc NITROLINGUAL...... 76 MUCOSITISRX...... 136 ...... 130, 134 NITROMIST...... 76 MULTAQ ...... 70 NEONATAL + DHA NITROSTAT ...... 76 MULTIGEN FOLIC ...... 57, 123, 195, 230, 232 NITRO-TIME...... 76 ...... 57, 120, 195, 232, 235 NEONATAL COMPLETE nizatidine...... 15, 143 mupirocin...... 208 ...... 57, 230, 232 NOCDURNA...... 56, 173 mupirocin calcium ...... 208 NEONATAL PLUS .... 57, 230, 232 nolix...... 218 MYAMBUTOL ...... 22 neo-polycin...... 130 nora-be...... 158, 179 MYCOBUTIN...... 22, 32 neo-polycin hc ...... 130, 135 norethin ace-eth estrad-fe mycophenolate mofetil ...... 193 NERLYNX ...... 39 ...... 158, 168, 179 mycophenolate sodium ...... 193 NESINA...... 161 norethindrone ...... 158, 179 MYFORTIC...... 193 NESTABS ...... 57, 230, 233 norethindrone acetate ...... 179 MYLERAN...... 39 NESTABS ONE 57, 195, 230, 232 norethindrone acet-ethinyl myorisan...... 227 NEUAC...... 208, 214, 224 est...... 158, 168, 179 MYXREDLIN...... 123, 183 NEUPRO...... 102 norethindrone-eth estradiol nabumetone ...... 107 NEVANAC...... 137 ...... 168, 179 n-acetyl-l-cysteine ...... 120 nevirapine...... 26 norethin-eth estradiol-fe nadolol...... 50, 63, 64 nevirapine er...... 26 ...... 158, 168, 179 naftifine hcl ...... 206 NEXAVAR...... 39 norgestimate-eth estradiol NAFTIN ...... 206 NEXIUM...... 145 ...... 158, 168, 179 naltrexone hcl...... 105, 186, 187 NEXLETOL ...... 62 norgestimate-ethinyl NAMENDA TITRATION PAK ....98 NEXLIZET...... 62, 69 estradiol triphasic. 158, 168, 179 NAMZARIC...... 51, 98 NEXTSTELLIS ...... 158, 168, 179 NORITATE ...... 208 NAPRELAN...... 90, 107, 188 niacin er norlyda...... 158, 179 naproxen...... 90, 107, 188 (antihyperlipidemic) ...... 62 norlyroc...... 158, 179

246 NORPACE...... 69 OLUX-E...... 218 oxaprozin...... 108 NORPACE CR...... 69 OMECLAMOX-PAK.... 18, 31, 145 oxazepam...... 97 NORPRAMIN...... 115 omega-3-acid ethyl esters ...... 63 OXBRYTA...... 55 nortrel 0.5/35 (28).. 158, 168, 179 omeprazole ...... 145 oxcarbazepine...... 84 nortrel 1/35 (21)..... 158, 168, 179 OMEPRAZOLE+SYRSPEND OXERVATE...... 136 nortrel 1/35 (28)..... 158, 168, 179 SF ALKA...... 145 oxiconazole nitrate ...... 213 nortrel 7/7/7...... 158, 168, 179 omeprazole-sodium OXISTAT...... 213 nortriptyline hcl ...... 115 bicarbonate...... 138, 145 oxybutynin chloride ...... 229 NORVIR...... 29 ondansetron hcl ...... 138 oxybutynin chloride er ...... 229 NOURIANZ...... 99 ondansetron odt ...... 138 oxycodone hcl...... 104 NOVOFINE AUTOCOVER ONE VITE WOMENS 57, 230, 233 OXYCODONE- PEN NEEDLE ...... 117 ONE VITE WOMENS PLUS ACETAMINOPHEN...... 81, 104 NOVOFINE PEN NEEDLE ..... 117 ...... 57, 230, 233 oxycodone-acetaminophen NOVOFINE PLUS PEN ONETOUCH DELICA ...... 81, 104 NEEDLE ...... 117 LANCING DEVICE...... 117 oxymorphone hcl ...... 104 NOVOTWIST PEN NEEDLE .. 117 ONETOUCH DELICA PLUS oxymorphone hcl er ...... 104 NOXAFIL...... 23 LANCING DEVICE...... 117 OZEMPIC...... 172 np thyroid ...... 185 ONETOUCH ULTRA ...... 118 OZOBAX...... 50 NUBEQA...... 39 ONETOUCH VERIO...... 117, 118 PACERONE...... 70 NUCORT...... 218 ONEVITE...... 124, 230, 233 PALFORZIA...... 44 NUCYNTA ...... 104 ONFI...... 95, 97 paliperidone er...... 93 NUCYNTA ER ...... 104 ONGLYZA...... 161 PANCREAZE...... 127, 142 NUEDEXTA...... 99 ONUREG...... 39 PANDEL...... 218 NULEV...... 47 OPSUMIT...... 205 PANRETIN...... 227 NULYTELY LEMON-LIME ...... 142 ORACIT...... 119 pantoprazole sodium ...... 145 NUPLAZID...... 92 ORALAIR...... 44 PARAGARD INTRAUTERINE NUTRIDOX...... 33, 195, 235 ORALAIR ADULT STARTER COPPER...... 197 NUVAIL...... 227 PACK...... 44 paricalcitol...... 235 NUVARING...... 159, 168, 180 ORALAIR CHILDRENS PARNATE...... 101 NUVIGIL...... 115 STARTER PACK ...... 44 paromomycin sulfate ...... 18 NUZYRA...... 18 oralone...... 218 paroxetine hcl...... 113 nyamyc...... 225 ORAPRED ODT...... 148 paroxetine hcl er...... 113 nylia 7/7/7...... 159, 168, 180 ORAVIG...... 213 PASER...... 22 nymyo...... 159, 168, 180 ORENITRAM...... 205 PATADAY...... 15, 129 nystatin...... 32, 225 ORFADIN...... 195 PAXIL...... 113 nystop...... 225 ORGOVYX...... 40, 151 P-CARE K40G...... 148, 211 OCALIVA...... 143 ORIAHNN...... 151, 169, 180 P-CARE K80G...... 148, 211 ocella...... 159, 169, 180 ORILISSA...... 151 PEDIAPRED...... 148 OCUFLOX...... 130 ORKAMBI...... 200, 201 peg 3350-kcl-na bicarb-nacl .142 OCUVEL...... 124, 230, 233 orphenadrine citrate er .....54, 82 peg-3350/electrolytes...... 142 ODACTRA...... 43 orsythia...... 159, 169, 180 peg- ODEFSEY...... 26, 28 oscimin...... 47 3350/electrolytes/ascorbat ODOMZO...... 39 oscimin sr...... 47 ...... 142, 235 OFEV...... 199 oseltamivir phosphate ...... 30 peg-kcl-nacl-nasulf-na asc-c ofloxacin...... 32, 130 OSENI...... 161, 184 ...... 142, 235 olanzapine ...... 88, 92, 93 OSPHENA...... 161 peg-prep...... 142 olanzapine-fluoxetine hcl OTEZLA ...... 190, 192, 227 penicillamine...... 146, 190 ...... 93, 113 OTIPRIO...... 130 penicillin v potassium ...... 30 olmesartan medoxomil ...... 60 OVACE PLUS...... 208 PENNSAID...... 225, 227 olmesartan medoxomil-hctz OVACE PLUS WASH...... 208 pentamidine isethionate ...... 21 ...... 60, 126 OVACE WASH...... 208 pentazocine-naloxone hcl olopatadine hcl ...... 15, 128 OVIDE...... 225 ...... 105, 106 OLUMIANT...... 190 oxandrolone ...... 150 pentoxifylline er ...... 55

247 PEPCID...... 15, 143 polycin...... 130 PRENAISSANCE PERFOROMIST...... 53, 205 polyethylene glycol 3350 ...... 142 ...... 57, 142, 195, 230, 233 PERIDEX...... 135, 224 polymyxin b-trimethoprim ....130 prenatal...... 57, 124, 230, 233 perindopril erbumine ...... 61, 62 POLYTRIM...... 130 prenatal plus iron....57, 230, 233 periogard...... 136, 224 POMALYST...... 40, 192 prenatal vitamin plus low permethrin...... 225 portia-28...... 159, 169, 180 iron...... 57, 230, 233 perphenazine ...... 108 posaconazole ...... 23 PRENATE DHA perphenazine-amitriptyline potassium chloride ...... 124 ...... 57, 124, 195, 230, 233 ...... 108, 115 potassium chloride crys er .. 124 PRENATE ELITE ...... 57, 230, 233 PERTZYE...... 127, 143 potassium chloride er...... 124 PRENATE ENHANCE PEXEVA...... 113 potassium citrate er ...... 119 ...... 57, 124, 195, 230, 233 phenazo ...... 211 potassium citrate-citric acid 119 PRENATE ESSENTIAL phenazopyridine hcl ...... 211 PR BENZOYL PEROXIDE ...... 57, 124, 195, 230, 233 phenelzine sulfate ...... 101 WASH...... 224 PRENATE MINI phenobarbital ...... 94 PRADAXA...... 55 ...... 57, 124, 195, 230, 233 phenoxybenzamine hcl .... 51, 74 pramipexole dihydrochloride PRENATE PIXIE phenylephrine hcl ...... 137, 138 ...... 102 ...... 57, 124, 195, 230, 233 PHENYTEK...... 69, 100 pramosone...... 211, 218 PRENATE RESTORE phenytoin...... 69, 100 PRAMOSONE...... 211, 218 ...... 57, 124, 195, 230, 233 phenytoin infatabs ...... 69, 100 PRAMOTIC...... 136, 137 PRENATVITE COMPLETE phenytoin sodium extended pramox...... 211 ...... 57, 124, 230, 233 ...... 69, 100 PRASTERA...... 108, 195 PRENATVITE PLUS PHEXXI...... 197 prasugrel hcl...... 58 ...... 57, 124, 231, 233 philith...... 159, 169, 180 pravastatin sodium ...... 74 PRENATVITE RX PHOSLYRA...... 121, 124 praziquantel...... 19 ...... 57, 125, 231, 233 PHOSPHA 250 NEUTRAL...... 124 prazosin hcl...... 51, 59 PREPIDIL...... 198 PHOSPHASAL...... 34, 47, 81, 195 PRECISION PCX PLUS TEST118 preplus...... 57, 231, 233 phosphorous ...... 124 PRECISION QID TEST...... 118 PRETAB...... 58, 231, 233 phospho-trin 250 neutral ...... 124 PRECISION SOF-TACT TEST PRETOMANID...... 22 phytonadione ...... 187, 235 ...... 118 PREVACID...... 145 PIFELTRO...... 26 PRECISION XTRA BLOOD PREVACID 24HR...... 145 pilocarpine hcl...... 51, 137 GLUCOSE...... 118 prevalite...... 65 pimecrolimus...... 193, 227 PRECOSE...... 149 previfem...... 159, 169, 180 pimozide ...... 91 PRED FORTE...... 135 PREVYMIS...... 22 pimtrea...... 159, 169, 180 PRED MILD...... 135 PREZCOBIX...... 29, 195 pindolol ...... 50, 63, 64, 70 PRED-G...... 130, 135 PREZISTA...... 29 pioglitazone hcl ...... 184 PRED-G S.O.P...... 131, 135 PRIFTIN...... 22, 32 pioglitazone hcl-glimepiride 184 prednicarbate...... 218 primaquine phosphate ...... 20 pioglitazone hcl-metformin prednisolone ...... 148 primidone...... 94 hcl...... 153, 184 prednisolone acetate ...... 135 PRIMSOL...... 34 PIQRAY...... 40 prednisolone sodium probenecid...... 127, 188 pirmella 1/35...... 159, 169, 180 phosphate ...... 135, 148 PROCENTRA...... 79 pirmella 7/7/7...... 159, 169, 180 PREDNISOLON-GATIFLOX- prochlorperazine...... 108, 140 piroxicam...... 108 BROMFENAC ...... 131, 135, 137 prochlorperazine maleate PLAN B ONE-STEP ...... 159, 180 prednisone...... 149 ...... 108, 140 PLAVIX...... 58 prednisone intensol ...... 148 PROCORT...... 211, 218 PLENVU...... 142, 235 PREFEST...... 169, 180 PROCTOCORT...... 218, 219 PLEXION...... 208, 221 pregabalin...... 85, 100 PROCTOFOAM HC...... 211, 219 PLEXION CLEANSER.... 208, 221 PREMARIN...... 169, 189 procto-med hc ...... 219 PLEXION CLEANSING PREMESISRX 124, 195, 230, 233 procto-pak...... 219 CLOTH ...... 208, 221 premium lidocaine...... 211 proctozone-hc ...... 219 podocon...... 227 PREMPHASE...... 169, 180 PROCYSBI...... 195 podofilox ...... 227 PREMPRO...... 169, 180 progesterone ...... 180

248 PROGRAF...... 193 quetiapine fumarate ...... 88, 93 rifampin...... 22, 32 PROLATE...... 81, 104 quetiapine fumarate er ..... 88, 93 RILUTEK...... 99 PROMACTA...... 55 QUILLIVANT XR...... 110 riluzole...... 99 promethazine hcl quinapril hcl...... 61, 62 rimantadine hcl ...... 17 ...... 13, 14, 15, 91, 139, 202 quinapril- RINVOQ...... 190 promethazine vc ...... 15, 45 hydrochlorothiazide ...... 62, 126 risedronate sodium...... 189 promethazine vc/codeine quinidine gluconate er ...... 20, 69 risperidone...... 88, 93 ...... 15, 45, 200 quinidine sulfate ...... 20, 69 RITALIN...... 110 promethazine-codeine ....15, 200 quinine sulfate ...... 20 RITALIN LA...... 110 promethazine-dm ...... 15, 200 QUTENZA...... 228 ritonavir...... 29 promethazine-phenyleph- QUTENZA (2 PATCH) ...... 227 rivastigmine...... 52 codeine...... 15, 45, 200 QUTENZA (4 PATCH) ...... 228 rivastigmine tartrate...... 52 promethazine-phenylephrine rabeprazole sodium ...... 145 rivelsa...... 159, 169, 180 ...... 15, 45 RADIOGARDASE...... 121, 187 rizatriptan benzoate ...... 112 promethegan14, 15, 91, 139, 202 RAGWITEK...... 44 ROCALTROL...... 235 PROMISEB...... 221 raloxifene hcl...... 161, 189 ropinirole hcl...... 102 propafenone hcl ...... 69 ramelteon...... 91 rosadan...... 208, 209 propafenone hcl er ...... 69 ramipril...... 61, 62 ROSADAN...... 209 proparacaine hcl...... 137 ranolazine er...... 68 rosuvastatin calcium...... 74 propranolol hcl 50, 63, 64, 70, 90 RAPAMUNE...... 193, 194 ROWASA...... 140 propranolol hcl er rasagiline mesylate...... 101 roweepra...... 85 ...... 50, 63, 64, 70, 90 RAVICTI...... 120 ROZLYTREK...... 40 propylthiouracil ...... 152 RAZADYNE ER...... 52 RUBRACA...... 40 PROSCAR...... 186 reclipsen...... 159, 169, 180 rufinamide...... 85 PROSILK...... 214 RECOTHROM...... 56 RUZURGI...... 195 PROSTIN E2...... 198 RECOTHROM SPRAY KIT...... 56 RYBELSUS...... 172 PROTOPIC...... 193, 227 RECTIV...... 228 RYDAPT...... 40 protriptyline hcl ...... 115 REGLAN...... 144 SABRIL...... 85 PROVENTIL HFA ...... 53, 205 REGRANEX...... 228 SAFYRAL...... 159, 169, 180, 233 PROVERA...... 180 RELENZA DISKHALER...... 30 SALAGEN...... 52 PROVIGIL...... 115 RELION BLOOD GLUCOSE salicylic acid...... 222 pseudoephedrine- TEST...... 118 salicylic acid er...... 221 bromphen-dm ...... 16, 44, 200 RELNATE DHA .58, 195, 231, 233 salicylic acid wart remover.. 222 PSORCON...... 219 REMEDIENT...... 125, 231, 233 salsalate...... 111 PULMICORT FLEXHALER REMERON...... 86 SALVAX DUO PLUS...... 213, 222 ...... 149, 203 REMERON SOLTAB ...... 86 SAMSCA...... 127 PULMOZYME...... 127, 202 RENAGEL...... 121, 187 SANCUSO...... 139 PURIXAN...... 40, 193 RENVELA...... 122, 187 SANDIMMUNE...... 190, 192, 194 PYLERA...... 19, 21, 33, 139, 140 repaglinide...... 173 SANTYL...... 127, 228 pyrazinamide...... 22 RESTASIS...... 136 SAPHRIS...... 89, 93 PYRIDIUM...... 211 RESTASIS MULTIDOSE...... 136 sapropterin dihydrochloride pyridostigmine bromide ... 51, 52 RESTORIL...... 97 ...... 195, 196 pyridostigmine bromide er .....51 RETEVMO...... 40 SAVAYSA...... 55 pyrimethamine ...... 20 RETROVIR...... 28 SAVELLA...... 100, 112 PYROGALLIC ACID198, 221, 227 REVATIO...... 76, 205, 229 SAVELLA TITRATION PACK QINLOCK...... 40 REVLIMID...... 40, 192 ...... 100, 112 QNASL...... 135, 203 REXULTI...... 93 SCALACORT DK...... 219, 222 QNASL CHILDRENS ...... 135, 203 REYATAZ...... 29 SCARSILK...... 228 QUALAQUIN...... 20 REYVOW...... 112 scopolamine...... 47, 139 QUARTETTE ...... 159, 169, 180 RHOFADE...... 228 SELECT-OB...... 58, 231, 234 QUDEXY XR...... 85 ribavirin...... 30 selegiline hcl...... 101 QUESTRAN...... 65 RIDAURA...... 146, 190, 192 selenium sulfide...... 222, 224 QUESTRAN LIGHT...... 65 rifabutin...... 22, 32 SELZENTRY ...... 25

249 SEREVENT DISKUS...... 53, 205 spironolactone ...... 75, 76, 122 sulfamethoxazole- sertraline hcl...... 113 spironolactone-hctz ...... 75, 126 trimethoprim...... 21, 33, 34 setlakin...... 159, 169, 180 SPORANOX...... 23 sulfamez wash...... 209, 222 sevelamer carbonate.... 122, 187 SPORANOX PULSEPAK...... 23 SULFAMYLON...... 224 sevelamer hcl...... 122, 187 SPRAVATO (56 MG DOSE)..... 86 sulfasalazine....33, 140, 190, 192 sevoflurane...... 101 SPRAVATO (84 MG DOSE)..... 86 sulfatrim pediatric...... 21, 33, 34 SFROWASA...... 140 sprintec 28...... 159, 169, 181 SULFURATED LIME...... 225 sharobel...... 159, 180 SPRIX...... 108 sulindac...... 108 sildenafil citrate...... 76, 205, 229 SPRYCEL...... 40 SUMADAN...... 209, 222 SILENOR...... 115 sps...... 122, 187 SUMADAN WASH...... 209, 222 silodosin...... 52 sronyx...... 159, 169, 181 SUMADAN XLT...... 209, 222, 228 SILVADENE...... 224 ssd...... 224 sumatriptan...... 112 silver nitrate...... 136 SSKI...... 201 sumatriptan succinate ...... 112 silver sulfadiazine...... 224 sss 10-5...... 209, 222 SUMAXIN...... 210, 222 SIMBRINZA...... 128, 133 STALEVO 100...... 98, 99 SUMAXIN CP...... 209, 222 simliya...... 159, 169, 180 STALEVO 125...... 98, 99 SUMAXIN WASH...... 210, 222 simpesse...... 159, 169, 181 STALEVO 150...... 98, 99 SUNOSI...... 115 simvastatin...... 74 STALEVO 200...... 98, 100 SUPRAX...... 17 SINEMET...... 99 STALEVO 50...... 98, 100 SUPREP BOWEL PREP KIT..142 sirolimus...... 194 STALEVO 75...... 98, 100 SURESTEP PRO HIGH SIRTURO...... 22 stavudine...... 28 GLUCOSE...... 117 SITAVIG...... 30 STIMATE...... 56, 173 SURESTEP PRO LOW SIVEXTRO...... 31 STIVARGA...... 40 GLUCOSE...... 117 SKELAXIN...... 49 STRATA TRIZ ...... 228 SURESTEP PRO NORMAL sleep-aid STRIBILD...... 25, 28, 196 GLUCOSE...... 117 ...... 13, 14, 48, 82, 91, 200, 202 STRIVERDI RESPIMAT... 53, 205 SURVANTA...... 204 SLYND ...... 159, 181 STROMECTOL ...... 19 SUSTIVA...... 26 sod citrate-citric acid...... 120 STROVITE FORTE .125, 231, 234 SUTAB...... 142 SODIUM BICARBONATE SUBOXONE...... 105, 106 SUTENT...... 40, 41 ...... 138, 141 subvenite...... 85, 89 syeda...... 159, 169, 181 sodium chloride ...... 202 subvenite starter kit-blue . 85, 89 SYMAX DUOTAB...... 47 sodium phenylbutyrate ...... 120 subvenite starter kit-green SYMAX-SL...... 47 sodium polystyrene ...... 85, 89 SYMAX-SR...... 47 sulfonate ...... 122, 187 subvenite starter kit-orange SYMBICORT...... 53, 149 sodium sulfacetamide ...... 209 ...... 85, 89 SYMBYAX...... 93, 113 sodium sulfacetamide wash 209 SUCRAID...... 127 SYMDEKO...... 200, 201 SODIUM SULFACETAMIDE- sucralfate...... 144 SYMFI...... 26, 28 BAKUCHIOL...... 196, 209 SULAR...... 72, 73 SYMFI LO...... 26, 28 SOFOSBUVIR-VELPATASVIR SULCONAZOLE NITRATE .....213 SYMJEPI...... 45, 198 ...... 24, 25 sulfacetamide sodium .. 131, 209 SYMLINPEN 120...... 149 solifenacin succinate ...... 229 sulfacetamide sodium (acne) SYMLINPEN 60...... 149 SOLIQUA...... 172, 173 ...... 209 SYMPROIC...... 143 SOLOSEC...... 21 sulfacetamide sodium-sulfur SYMTUZA...... 28, 29, 196 SOLTAMOX ...... 40, 161 ...... 209, 222 SYNAREL...... 171 SOOLANTRA ...... 225 sulfacetamide sod-sulfur SYNDROS...... 139 SORBITOL...... 121 wash...... 209, 222 SYNJARDY...... 153, 183 sotalol hcl...... 50, 64, 65, 70 sulfacetamide-prednisolone SYNJARDY XR...... 153, 183 sotalol hcl (af)...... 50, 63, 64, 70 ...... 131, 135 TABLOID...... 41 SOTYLIZE...... 50, 64, 65, 70, 71 sulfacetamide-sulfur in urea TABRECTA ...... 41 SOVALDI...... 24 ...... 209, 222 TACHOSIL...... 228 spinosad...... 225 SULFACLEANSE 8/4...... 209, 222 TACLONEX ...... 219, 228 SPIRIVA HANDIHALER....47, 199 sulfadiazine ...... 32 tacrolimus...... 194, 228 SPIRIVA RESPIMAT...... 47, 199 tadalafil...... 76

250 tadalafil (pah) ...... 76, 205 theophylline er TOVIAZ...... 229 TAFINLAR ...... 41 ...... 73, 111, 121, 206, 229 TRACLEER...... 205 TAGRISSO...... 41 THIOLA...... 196 TRADJENTA ...... 161 TALZENNA ...... 41 THIOLA EC...... 196 tramadol hcl...... 105 TAMIFLU ...... 30 thioridazine hcl ...... 108 TRAMADOL HCL ER ...... 104 tamoxifen citrate ...... 41, 162 thiothixene...... 114 tramadol hcl er...... 104 tamsulosin hcl ...... 52 THROMBIN-JMI ...... 56 tramadol-acetaminophen81, 105 TAPAZOLE...... 152 THROMBIN-JMI EPISTAXIS.... 56 trandolapril...... 61, 62 TAPERDEX 12-DAY...... 149 THROMBOGEN...... 56 trandolapril-verapamil hcl er TAPERDEX 6-DAY...... 149 tiadylt er...... 66, 67, 71, 78 ...... 62, 67 TARGRETIN...... 41, 228 tiagabine hcl...... 85 tranexamic acid...... 56 tarina 24 fe...... 159, 169, 181 TIAZAC...... 66, 67, 71, 78 TRANSDERM SCOP (1.5 MG) tarina fe 1/20...... 159, 170, 181 TIBSOVO...... 41 ...... 47, 139 tarina fe 1/20 eq.....159, 170, 181 TIGLUTIK...... 99 TRANSDERM-SCOP (1.5 MG) TARKA...... 62, 67 TIKOSYN...... 71 ...... 47, 139 TASIGNA...... 41 tilia fe...... 159, 170, 181 TRANXENE-T ...... 95, 97 tavaborole...... 225 timolol maleate tranylcypromine sulfate ...... 101 TAVALISSE...... 55 ...... 50, 64, 65, 70, 90, 132 travoprost (bak free)...... 138 tazarotene ...... 228 timolol maleate ocudose ...... 132 trazodone hcl ...... 114 TAZORAC...... 228 timolol maleate pf ...... 132 TRECATOR ...... 22 taztia xt...... 66, 67, 71, 78 TIMOPTIC...... 132 TRELEGY ELLIPTA ....47, 54, 149 TAZVERIK...... 41 TIMOPTIC OCUDOSE...... 132 tretinoin...... 41, 214 TEGRETOL...... 85, 89 TIMOPTIC-XE...... 132 TREXALL...... 41, 191, 192, 194 TEGRETOL-XR...... 85, 89 tinidazole...... 21 tri femynor...... 159, 170, 181 TEKTURNA ...... 77 tiopronin...... 196 triamcinolone acetonide ...... 219 TEKTURNA HCT ...... 77, 126 TIROSINT...... 185 triamterene...... 76, 122 telmisartan...... 60 TIROSINT-SOL...... 185 triamterene-hctz ...... 122, 126 telmisartan-hctz ...... 60, 126 TIVICAY...... 25 TRIANEX...... 219 temazepam ...... 97 tizanidine hcl ...... 49 triazolam...... 97 TEMIXYS...... 28 TOBI PODHALER...... 18 TRICARE PRENATAL DHA TEMOVATE ...... 219 TOBRADEX...... 131, 135 ONE...... 58, 142, 196, 231, 234 temozolomide ...... 41 TOBRADEX ST...... 131, 135 TRI-CHLOR...... 196 TENCON...... 81, 94 tobramycin...... 18 TRICITRASOL...... 54 tenofovir disoproxil fumarate 28 tobramycin-dexamethasone tricitrates...... 120 TEPMETKO ...... 41 ...... 131, 135 TRICOR...... 74 terazosin hcl...... 51, 59 TOBREX...... 131 triderm...... 219 terbinafine hcl ...... 17 tolbutamide ...... 119, 184 TRIDESILON...... 219 terbutaline sulfate ...... 53, 205 tolcapone ...... 98 trientine hcl...... 146 terconazole ...... 213 tolterodine tartrate ...... 229 tri-estarylla...... 160, 170, 181 terrell...... 101 tolterodine tartrate er ...... 229 trifluoperazine hcl ...... 108 TESSALON PERLES ...... 200 TOLVAPTAN ...... 127 trifluridine...... 131 TESTIM...... 150 tolvaptan...... 127 trihexyphenidyl hcl...... 48, 82 testosterone ...... 150, 151 TOPICORT...... 219 TRIJARDY XR...... 153, 161, 183 tetrabenazine ...... 115 topiramate...... 85, 90 TRIKAFTA...... 200, 201 tetracaine hcl...... 137 topiramate er...... 85 tri-legest fe...... 160, 170, 181 tetracycline hcl...... 20, 33, 141 TOPROL XL...... 54, 64, 65, 70 TRILEPTAL...... 85 TEXACORT...... 219 toremifene citrate ...... 41, 162 tri-linyah...... 160, 170, 181 THALOMID ...... 192 TORONOVA II SUIK...... 108, 211 TRILOAN II SUIK...... 149, 211 THEO-24...73, 110, 121, 206, 229 TORONOVA SUIK...... 108, 211 TRILOAN SUIK...... 149, 212 theophylline torsemide...... 74, 121 tri-lo-estarylla...... 160, 170, 181 ...... 73, 111, 121, 206, 229 TOUJEO MAX SOLOSTAR.... 173 tri-lo-marzia...... 160, 170, 181 TOUJEO SOLOSTAR...... 173 tri-lo-mili...... 160, 170, 181 tovet...... 219 tri-lo-sprintec...... 160, 170, 181

251 trimethobenzamide hcl ...... 140 TYKERB...... 42 VANOXIDE-HC...... 220, 224 trimethoprim ...... 34 TYVASO...... 205 VECAMYL...... 74 tri-mili...... 160, 170, 181 TYVASO REFILL...... 206 velivet...... 160, 170, 181 trimipramine maleate...... 115 TYVASO STARTER...... 206 VELPHORO...... 122 TRINATE ...... 58, 231, 234 UBRELVY...... 97 VELTASSA...... 122 TRINTELLIX ...... 114 UCERIS...... 149, 220 VEMLIDY...... 30 tri-nymyo...... 160, 170, 181 UDAMIN SP...... 125, 231, 234 VENCLEXTA ...... 42 tri-previfem...... 160, 170, 181 UKONIQ...... 42 VENCLEXTA STARTING tri-sprintec...... 160, 170, 181 ULTANE ...... 101 PACK...... 42 TRISTART DHA ULTRA HERS RX...... 196 VENELEX...... 228 ...... 58, 125, 196, 231, 234 ULTRA HIS...... 196 venlafaxine hcl...... 112 TRISTART FREE ULTRA PCOS...... 196 venlafaxine hcl er...... 112 ...... 58, 125, 196, 231, 234 ULTRACET...... 81, 105 VENTAVIS...... 206 TRISTART ONE ULTRAM...... 105 VENTRIXYL...... 125, 231, 234 ...... 58, 125, 196, 231, 234 ULTRASAL-ER...... 223 verapamil hcl...... 66, 67, 72, 78 tritocin...... 220 UMECTA MOUSSE...... 223 verapamil hcl er.....66, 67, 71, 78 TRIUMEQ...... 25, 28 UNISTRIP CONTROL...... 117 VERDESO...... 220 trivora (28)...... 160, 170, 181 unithroid...... 185 VEREGEN...... 228 tri-vylibra...... 160, 170, 181 UPNEEQ...... 138 VERELAN...... 66, 68, 72, 78 tri-vylibra lo...... 160, 170, 181 UPTRAVI...... 206 VERELAN PM...... 66, 68, 72, 78 TROGARZO...... 25 URAMAXIN...... 223 VERSACLOZ...... 93 TROKENDI XR...... 85, 90 urea...... 223 VERZENIO...... 42 tropicamide...... 138 urea nail...... 223 vestura...... 160, 170, 181 TRUE METRIX BLOOD URELLE...... 34, 47, 81, 196 VFEND...... 23 GLUCOSE TEST...... 118 URIBEL...... 34, 47, 81, 196 VIBERZI...... 143 TRUE METRIX LEVEL 1 ...... 117 URIMAR-T...... 35, 48, 81, 196 VIBRAMYCIN...... 20, 33, 34 TRUE METRIX LEVEL 2 ...... 117 urin ds...... 35, 48, 81, 196 VICTOZA...... 172 TRUE METRIX LEVEL 3 ...... 117 URO-458...... 35, 48, 81, 196 VIEKIRA PAK...... 24, 25 TRUE METRIX PRO BLOOD UROCIT-K 10...... 120 vienva...... 160, 170, 181 GLUCOSE...... 119 UROCIT-K 15...... 120 vigabatrin...... 85, 86 TRUETRACK TEST ...... 119 UROCIT-K 5...... 120 vigadrone...... 86 TRULANCE ...... 143 UROGESIC-BLUE...... 35, 48, 196 VIGAMOX...... 131 TRULICITY...... 172 uro-mp...... 35, 48, 81, 196 VIIBRYD...... 114 TRUSELTIQ (100MG DAILY URSO 250...... 142 VIIBRYD STARTER PACK..... 114 DOSE)...... 41 URSO FORTE...... 142 VILAMIT MB...... 35, 48, 81, 197 TRUSELTIQ (125MG DAILY ursodiol...... 142 VILEVEV MB...... 35, 48, 81, 197 DOSE)...... 41 USTELL...... 35, 48, 81, 196 VIMOVO...... 108, 145 TRUSELTIQ (50MG DAILY UTIRA-C...... 35, 48, 81, 197 VIMPAT...... 86 DOSE)...... 42 valacyclovir hcl...... 30 VINATE ONE...... 58, 231, 234 TRUSELTIQ (75MG DAILY VALCHLOR...... 228 VIOKACE...... 128, 143 DOSE)...... 42 valganciclovir hcl...... 30 viorele...... 160, 170, 181 TRUSOPT...... 133 VALIUM...... 95, 97 VIRACEPT...... 29 TRUVADA...... 28 valproic acid...... 85, 89, 90 VIRAMUNE...... 26 TUKYSA...... 42 valsartan...... 60 VIRAMUNE XR...... 26 tulana...... 160, 181 valsartan- VIRASAL...... 223 TURALIO...... 42 hydrochlorothiazide ...... 60, 126 VIRAZOLE...... 30 TURPENTINE ...... 213 VALTOCO...... 95 VIREAD...... 28 TUSSICAPS...... 16, 200 VANCOCIN...... 24 virt-phos 250 neutral...... 125 TUXARIN ER...... 16, 200 VANCOCIN HCL...... 24 virtussin ac w/alc...... 200, 201 TWIRLA...... 160, 170, 181 vancomycin hcl...... 24 VISIONBLUE...... 119 tyblume...... 160, 170, 181 VANCOMYCIN HCL...... 131 VISTARIL...... 14, 15, 92 TYBOST...... 196 vandazole...... 18, 210 VISTOGARD...... 187 tydemy...... 160, 170, 181, 234 VANOS...... 220

252 VITAFOL FE+ XCOPRI...... 86 ZARONTIN...... 114 ...... 58, 125, 197, 231, 234 XELJANZ...... 191 ZAVESCA...... 197 VITAFOL STRIPS...... 231 XELJANZ XR...... 191 ZEBUTAL...... 81, 94, 111 VITAFOL-NANO ...... 58, 231, 234 XELODA...... 42 ZEGERID...... 138, 146 VITAFOL-OB+DHA XELPROS...... 138 ZEJULA...... 43 ...... 58, 125, 197, 231, 234 XENAZINE...... 115 ZELAPAR...... 101 vitamin d (ergocalciferol) ..... 235 XENLETA ...... 31 ZELBORAF...... 43 VITATHELY WITH GINGER XEPI...... 210 ZELNORM...... 144 ...... 58, 231, 234 XERESE...... 212, 220 ZEMPLAR...... 235 VITRAKVI...... 42 XERMELO...... 139 zenatane...... 228 VIVELLE-DOT...... 170, 189 XIFAXAN...... 32 ZENPEP...... 128, 143 VIZIMPRO...... 42 XIIDRA...... 136 ZENZEDI...... 79 VOCABRIA...... 25 XOFLUZA (40 MG DOSE)...... 22 ZEPATIER...... 24, 25 VOGELXO...... 151 XOFLUZA (80 MG DOSE)...... 22 ZEPOSIA...... 192 VOGELXO PUMP...... 151 XOLEGEL...... 213 ZEPOSIA 7-DAY STARTER volnea...... 160, 170, 182 XOLEGEL COREPAK.....213, 220 PACK...... 192 voriconazole...... 23 XOLEGEL DUO/HEAD & ZEPOSIA STARTER KIT...... 192 VOSEVI...... 24, 25 SHOULDERS...... 213, 224 ZIAC...... 64, 127 VOTRIENT...... 42 XOLEGEL DUO/XOLEX. 213, 224 ZIAGEN...... 28 vp-pnv-dha ...... 58, 197, 231, 234 XOPENEX HFA...... 54, 205 zidovudine ...... 28 VRAYLAR...... 93 XOSPATA...... 42 zileuton er...... 202 VTOL LQ ...... 81, 94, 111 XPOVIO (100 MG ONCE ZILXI...... 210 VUSION...... 212, 213, 220 WEEKLY)...... 43 ZIOPTAN...... 138 vyfemla...... 160, 170, 182 XPOVIO (40 MG ONCE ziprasidone hcl...... 89, 93 vylibra...... 160, 170, 182 WEEKLY)...... 43 ZIRGAN...... 131 VYNDAMAX...... 68, 99 XPOVIO (40 MG TWICE ZITHROMAX...... 31 VYNDAQEL...... 68 WEEKLY)...... 43 ZITHROMAX TRI-PAK...... 31 VYVANSE...... 79 XPOVIO (60 MG ONCE ZITHROMAX Z-PAK...... 31 WAKIX...... 115 WEEKLY)...... 43 ZOCOR...... 74 warfarin sodium...... 55 XPOVIO (60 MG TWICE ZOKINVY...... 197 WELCHOL...... 65, 151 WEEKLY)...... 43 ZOLINZA...... 43 WELLBUTRIN SR ...... 87 XPOVIO (80 MG ONCE zolmitriptan ...... 113 wera...... 160, 170, 182 WEEKLY)...... 43 zolpidem tartrate ...... 92 WESTAB PLUS...... 58, 231, 234 XPOVIO (80 MG TWICE zolpidem tartrate er ...... 92 WESTGEL DHA WEEKLY)...... 43 ZOLPIMIST...... 92 ...... 58, 125, 197, 232, 234 XTAMPZA ER...... 105 ZOMIG...... 113 WESTHROID...... 185 XTANDI ...... 43 ZONEGRAN...... 86 WIDE-SEAL DIAPHRAGM 60 197 xulane...... 160, 171, 182 zonisamide...... 86 WIDE-SEAL DIAPHRAGM 65 197 xurea...... 223 ZONTIVITY...... 59 WIDE-SEAL DIAPHRAGM 70 197 XURIDEN...... 197 ZORTRESS...... 194 WIDE-SEAL DIAPHRAGM 75 197 XYREM...... 99 zovia 1/35 (28)...... 160, 171, 182 WIDE-SEAL DIAPHRAGM 80 197 XYWAV...... 99 zovia 1/35e (28)...... 161, 171, 182 WIDE-SEAL DIAPHRAGM 85 198 XYZMUNE...... 197 ZOVIRAX...... 30 WIDE-SEAL DIAPHRAGM 90 198 YUPELRI...... 48 ZUBSOLV...... 105, 106 WIDE-SEAL DIAPHRAGM 95 198 yuvafem...... 171, 189 zumandimine ...... 161, 171, 182 WILZIN...... 125 ZACARE...... 213, 224 ZUPLENZ...... 139 WP THYROID...... 185 zaclir cleansing...... 224 ZYCLARA PUMP...... 228 wymzya fe...... 160, 170, 182 ZADITOR...... 15, 129 ZYDELIG...... 43 XALKORI...... 42 zafemy...... 160, 171, 182 ZYFLO...... 202 XANAX...... 97 zafirlukast...... 202 ZYKADIA...... 43 XANAX XR...... 97 zaleplon...... 92 ZYLET...... 131, 135 XARELTO...... 55 ZANAFLEX...... 49 ZYLOPRIM...... 188 XARELTO STARTER PACK .....55 zarah...... 160, 171, 182 ZYMAXID...... 131

253 ZYPREXA ZYDIS...... 89, 93 ZYVOX...... 31

254