2020 Preferredrx

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HealthPartners® PreferredRx

2020 Formulary

(List of covered drugs)

For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy.

Effective: October 1, 2020

©2020 HealthPartners What’s the PreferredRx drug list? This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates.

Who decides what’s on the drug list? The HealthPartners Pharmacy and Therapeutics Committee manage the list. This team of experts focuses on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.

How do you use the drug list? The medicines are listed in alphabetical order by type of medicine starting on page 4.

Generic medicines are in lowercase italics (e.g., cephalexin). These medicines are safe and effective but cost less than brand medicines.

Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.

The Tier is used to determine how much a medicine will cost you. For exact cost information,  Find the tier status for your medicine.  Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or,  Log on to your myHealthPartners account to check your pharmacy benefits.

Formulary Low Cost Generics - Depending on your plan, these medicines might be covered at the lowest copay or coinsurance.

Formulary High Cost Generics - Depending on your plan, these medicines may cost more than the Formulary Low Cost Generics, but less than Formulary Brands.

Formulary Brands - Brand medicines are more expensive than generic medicines. Depending on your plan, these medicines might be covered at a higher copay or coinsurance than generic medicines.

What’s a Specialty Medicine? Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines. What do the abbreviations under Limits & Restrictions mean? Special information about the medicine you’re searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list:

 PA - Prior Authorization Required  SC - Smoking Cessation Benefit  ST - Step Therapy Required  WL - Weight Loss Benefit  AL1 - Age Limit  ONC - Oncology Benefit  AQ1 – Age Quantity Limit  TD - Trial Drug Program  QL - Quantity Limit  S – Specialty

Why do you need prior authorization (PA) What’s a Quantity Limit (QL)? for some medicines? This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. Even though some medicines are on the drug list, they The quantity limit may be less than the day supply listed need to meet the HealthPartners prior authorization in your contract or Summary Plan Description. criteria in order for the medicine to be covered by your pharmacy benefits. What’s the Trial Drug Program (TD)? What’s Step Therapy (ST)? The trial drug program is for new prescriptions for certain medicines due to: Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners  Side effects covers a medicine with step therapy, if you've already  High cost tried the other medicine(s). If you haven't, you or your  High potential for waste doctor will need to get approval from HealthPartners Your first 6 fills of a trial drug may be limited to less before the medicine will be covered by your lowest than a month supply. If the medicine works well, you’ll brand, generic or specialty copay or coinsurance. get the rest of your month supply. If a copay applies to the medicine, you’ll pay no more than one copay for What’s an Age Limit (AL1)? each one month supply. An age edit means some medicines are only covered if you’re within a specific age range. If you're not in the What’s the Weight Loss Benefit (WL)? approved age range, you or your doctor will need to This type of medicine may have limits on the amount request approval from HealthPartners for your you get or may not be covered under all plans. Log on to medicine to be covered. your myHealthPartners account and click on My plan benefits on the Medical Plan tab to check your benefits What’s an Age Quantity Limit (AQ1)? for weight loss. Weight Loss medicines are listed on the An age quantity limit means some medicines have a drug list under the Weight Loss medicine category. quantity limit that only applies to a specific age range. If you're not in the approved age range, you or your What’s the Oncology Benefit (ONC)? doctor will need to request approval from These are oncology (cancer) medicines that must be HealthPartners for your medicine to be covered. filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.

The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (1/20) ©2020 HealthPartners LEGEND TIER DESCRIPTION

1 Formulary Low Cost Generics

2 Formulary High Cost Generics

3 Formulary Brands

4 Covered

5 NOT COVERED

TYPE DESCRIPTION

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

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

In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before we will cover another drug for that condition.

This prescription drug may only be covered if you meet the minimum AL1 Age Limit or maximum age limit.

Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.

There is a limit on the amount of drug covered per prescription, or AQ1 Age Quantity Limit within a specific time frame. Must also fall into the specified age range.

ACA Affordable Care Act This product is covered under the Affordable Care Act.

Medicines marked with this symbol are used for weight loss. Certain WL Weight Loss plans dont cover these medicines. Log on to your secure account to check your benefits for weight loss.

SC Smoking Cessation Medicines marked with this symbol are used for smoking cessation.

PAGE 1 LAST UPDATED 12/2020 Oncology (cancer) medicines must be filled at a specialty pharmacy, ONC Oncology but are not subject to the specialty benefit. Your regular generic or brand pharmacy copay or coinsurance will apply.

DS Diabetic Supply

GH Growth Hormone

INF Infertility

TD Trial Drug

New users will be limited to a 7 days supply for their first fill, and a total of 14 days supply for each episode within a 60 day period. Longer therapy requires prior authorization: Provider attestation, that OP Opioid Program therapy for this patient is being managed per standard opioid prescribing guidelines, including assessment and documentation of risk factors for chronic opioid use.

PAGE 2 LAST UPDATED 12/2020 LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

ERGOMAR Formulary Brands QL 20 TABS / 30 DAYS

phenoxybenzamine hcl Formulary High Cost Generics PA

SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT

alfuzosin hcl Formulary High Cost Generics tamsulosin hcl Formulary Low Cost Generics ANALGESICS AND ANTIPYRETICS

ANALGESICS AND ANTIPYRETICS, MISC.

butalb/acetaminophen/caffeine 50-325- Formulary High Cost Generics QL 6 CAPS / 1 DAY 40 capsule butalb/acetaminophen/caffeine 50-325- Formulary High Cost Generics QL 6 TABS / 1 DAY 40 tablet butalbital/acetaminophen 50mg-325mg Formulary High Cost Generics QL 6 TABS / 1 DAY tablet

TENCON Formulary High Cost Generics QL 6 TABS / 1 DAY

ZEBUTAL Formulary High Cost Generics QL 6 CAPS / 1 DAY

OPIATE AGONISTS

At least 12 yrs old; 60 / acetaminophen with codeine 120- AQ1 Formulary Low Cost Generics 1 day(s) 12mg/5 solution OP Opioid Program

At least 12 yrs old; 60 / acetaminophen with codeine AQ1 Formulary High Cost Generics 1 DAY 300mg/12.5 solution OP Opioid Program

acetaminophen with codeine phosphate AQ1 At least 12 yrs old; 8 / (300mg-15mg tablet, 300mg-30mg Formulary High Cost Generics 1 DAY tablet, 300mg-60mg tablet) OP Opioid Program

AQ1 At least 12 yrs old; 8 / codeine sulfate Formulary High Cost Generics 1 DAY OP Opioid Program

QL 5 TABS / 1 DAY ENDOCET 10-325 MG TABLET Formulary High Cost Generics OP Opioid Program

PAGE 3 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 8 TABS / 1 DAY ENDOCET 5-325 TABLET Formulary High Cost Generics OP Opioid Program

QL 7 TABS / 1 DAY ENDOCET 7.5-325 MG TABLET Formulary High Cost Generics OP Opioid Program

10 PATCHES / 30 fentanyl (12 mcg/hr patch td72, 25 QL Formulary High Cost Generics DAYS mcg/hr patch td72, 50mcg/hr patch td72) PA

fentanyl (75mcg/hr patch td72, 100 Formulary High Cost Generics PA mcg/hr patch td72) hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5 solution, hydrocodone/acetaminophen 5- QL 120 ML / 1 DAY Formulary High Cost Generics 217mg/10 solution, OP Opioid Program hydrocodone/acetaminophen 7.5-325/15 solution) hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg- 325mg tablet, QL 8 TABS / 1 DAY Formulary High Cost Generics hydrocodone/acetaminophen 7.5-325 OP Opioid Program mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet)

hydrocodone/ibuprofen 7.5-200 mg QL 8 TABS / 1 DAY Formulary High Cost Generics tablet OP Opioid Program

QL 20 ML / 1 DAY hydromorphone hcl 1 mg/ml liquid Formulary High Cost Generics OP Opioid Program

QL 8 TABS / 1 DAY hydromorphone hcl 2 mg tablet Formulary High Cost Generics OP Opioid Program

QL 8 SUPP / 1 DAY hydromorphone hcl 3 mg supp.rect Formulary High Cost Generics OP Opioid Program

QL 5 TABS / 1 DAY hydromorphone hcl 4 mg tablet Formulary High Cost Generics OP Opioid Program

QL 2 TABS / 1 DAY hydromorphone hcl 8 mg tablet Formulary High Cost Generics OP Opioid Program

QL 8 TABS / 1 DAY LORCET Formulary High Cost Generics OP Opioid Program

PAGE 4 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 8 TABS / 1 DAY LORCET HD Formulary High Cost Generics OP Opioid Program

QL 8 TABS / 1 DAY LORCET PLUS Formulary High Cost Generics OP Opioid Program

QL 2 TABS / 1 DAY methadone hcl 10 mg tablet Formulary High Cost Generics PA

QL 10 ML / 1 DAY methadone hcl 10 mg/5 ml solution Formulary High Cost Generics PA

QL 2 ML / 1 DAY methadone hcl 10 mg/ml oral conc Formulary High Cost Generics PA

methadone hcl 40 mg tablet sol Formulary High Cost Generics PA

QL 4 TABS / 1 DAY methadone hcl 5 mg tablet Formulary High Cost Generics PA

QL 20 ML / 1 DAY methadone hcl 5 mg/5 ml solution Formulary High Cost Generics PA

QL 2 ML / 1 DAY METHADONE INTENSOL Formulary High Cost Generics PA

METHADOSE 40 MG TABLET DISPR Formulary High Cost Generics PA

morphine sulfate (5 mg supp.rect, 10 mg QL 8 SUPP / 1 DAY supp.rect, 20 mg supp.rect, 30 mg Formulary High Cost Generics supp.rect) OP Opioid Program morphine sulfate (60 mg tablet er, 100 Formulary High Cost Generics PA mg tablet er, 200 mg tablet er)

QL 30 ML / 1 DAY morphine sulfate 10 mg/5 ml solution Formulary High Cost Generics OP Opioid Program

QL 4 ML / 1 DAY morphine sulfate 100 mg/5ml solution Formulary High Cost Generics OP Opioid Program

QL 5 TABS / 1 DAY morphine sulfate 15 mg tablet Formulary Brands OP Opioid Program

QL 4 TABS / 1 DAY morphine sulfate 15 mg tablet er Formulary High Cost Generics PA

PAGE 5 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 20 ML / 1 DAY morphine sulfate 20 mg/5 ml solution Formulary High Cost Generics OP Opioid Program

QL 2 TABS / 1 DAY morphine sulfate 30 mg tablet Formulary Brands OP Opioid Program

QL 2 TABS / 1 DAY morphine sulfate 30 mg tablet er Formulary High Cost Generics PA

oxycodone hcl (30 mg tab er 12h, 40 mg tab er 12h, 60 mg tab er 12h, 80 mg tab Formulary Low Cost Generics PA er 12h)

QL 4 TABS / 1 DAY oxycodone hcl 10 mg tab er 12h Formulary Low Cost Generics PA

QL 5 TABS / 1 DAY oxycodone hcl 10 mg tablet Formulary High Cost Generics OP Opioid Program

QL 3 TABS / 1 DAY oxycodone hcl 15 mg tab er 12h Formulary Low Cost Generics PA

QL 3 TABS / 1 DAY oxycodone hcl 15 mg tablet Formulary High Cost Generics OP Opioid Program

QL 2 TABS / 1 DAY oxycodone hcl 20 mg tab er 12h Formulary Low Cost Generics PA

QL 2 TABS / 1 DAY oxycodone hcl 20 mg tablet Formulary High Cost Generics OP Opioid Program

QL 2 ML / 1 DAY oxycodone hcl 20 mg/ml oral conc Formulary High Cost Generics OP Opioid Program

PA oxycodone hcl 30 mg tablet Formulary High Cost Generics OP Opioid Program

QL 8 CAPS / 1 DAY oxycodone hcl 5 mg capsule Formulary High Cost Generics OP Opioid Program

QL 8 TABS / 1 DAY oxycodone hcl 5 mg tablet Formulary High Cost Generics OP Opioid Program

QL 40 ML / 1 DAY oxycodone hcl 5 mg/5 ml solution Formulary Low Cost Generics OP Opioid Program

PAGE 6 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

oxycodone hcl/acetaminophen 10mg- QL 5 TABS / 1 DAY Formulary High Cost Generics 325mg tablet OP Opioid Program

oxycodone hcl/acetaminophen 5 mg- QL 8 TABS / 1 DAY Formulary High Cost Generics 325mg tablet OP Opioid Program

oxycodone hcl/acetaminophen 7.5-325 QL 7 TABS / 1 DAY Formulary High Cost Generics mg tablet OP Opioid Program

QL 8 TABS / 1 DAY oxycodone hcl/aspirin Formulary High Cost Generics OP Opioid Program

OXYCONTIN (ER 30 MG TABLET, ER 40 MG TABLET, ER 60 MG TABLET, Formulary Brands PA ER 80 MG TABLET)

QL 4 TABS / 1 DAY OXYCONTIN ER 10 MG TABLET Formulary Brands PA

QL 3 TABS / 1 DAY OXYCONTIN ER 15 MG TABLET Formulary Brands PA

QL 2 TABS / 1 DAY OXYCONTIN ER 20 MG TABLET Formulary Brands PA

AQ1 At least 12 yrs old; 8 / tramadol hcl 50 mg tablet Formulary Low Cost Generics 1 DAY OP Opioid Program

OPIATE PARTIAL AGONISTS

QL 4 PATCHES / 28 buprenorphine Formulary High Cost Generics DAYS PA

buprenorphine hcl/naloxone hcl 12 mg-3 Formulary High Cost Generics QL 60 FILMS / 30 DAY(S) mg film buprenorphine hcl/naloxone hcl 2 mg- Formulary High Cost Generics QL 360 FILMS / 30 0.5mg film DAY(S) buprenorphine hcl/naloxone hcl 2 mg- Formulary High Cost Generics QL 360 TABS / 30 DAYS 0.5mg tab subl buprenorphine hcl/naloxone hcl 4mg- Formulary High Cost Generics QL 180 FILMS / 30 1mg film DAY(S) buprenorphine hcl/naloxone hcl 8 mg-2 Formulary High Cost Generics QL 90 FILMS / 30 DAY(S) mg film

PAGE 7 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS buprenorphine hcl/naloxone hcl 8 mg-2 Formulary High Cost Generics QL 90 TABS / 30 DAYS mg tab subl ANOREXIGENIC AGENTS

AMPHETAMINE DERIVATIVES

QL 3 TABS / 1 DAY LOMAIRA Formulary High Cost Generics WL Weight Loss

phentermine hcl (30 mg capsule, 37.5 QL 1 CAP / 1 DAY Formulary High Cost Generics mg capsule) WL Weight Loss

QL 2 CAPS / 1 DAY phentermine hcl 15 mg capsule Formulary High Cost Generics WL Weight Loss

QL 1 TAB / 1 DAY phentermine hcl 37.5 mg tablet Formulary High Cost Generics WL Weight Loss

ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS

AMPHETAMINES

ADDERALL XR Formulary High Cost Generics QL 2 CAPS / 1 DAY

dextroamphetamine sulf- saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 15 Formulary High Cost Generics QL 3 Tabs / 1 day(s) mg tablet, dextroamphetamine/amphetamine 20 mg tablet) dextroamphetamine sulf- saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 Formulary High Cost Generics QL 3 TABS / 1 DAY mg tablet, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 12.5 mg tablet) dextroamphetamine sulfate (5 mg capsule er, 10 mg capsule er, 15 mg Formulary High Cost Generics QL 4 CAPS / 1 DAY capsule er) dextroamphetamine sulfate (5 mg tablet, Formulary High Cost Generics QL 4 TABS / 1 DAY 10 mg tablet) dextroamphetamine/amphetamine 30 Formulary High Cost Generics QL 2 Tabs / 1 day(s) mg tablet

PAGE 8 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VYVANSE (10 MG CAPSULE, 20 MG Formulary Brands QL 2 CAPS / 1 DAY CAPSULE, 30 MG CAPSULE) VYVANSE (10 MG TABLET, 20 MG Formulary Brands QL 2 CHEW TABS / 1 TABLET, 30 MG TABLET) DAY VYVANSE (40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MG Formulary Brands QL 1 CAP / 1 DAY CAPSULE) VYVANSE (40 MG TABLET, 50 MG Formulary Brands QL 1 CHEW TABS / 1 TABLET, 60 MG TABLET) DAY RESPIRATORY AND CNS STIMULANTS

CONCERTA (ER 18 MG TABLET, ER Formulary High Cost Generics QL 2 TABS / 1 DAY 27 MG TABLET, ER 36 MG TABLET)

CONCERTA ER 54 MG TABLET Formulary High Cost Generics QL 1 TAB / 1 DAY

dexmethylphenidate hcl (2.5 mg tablet, 5 Formulary High Cost Generics QL 2 TABS / 1 DAY mg tablet, 10 mg tablet) dexmethylphenidate hcl (25 mg cpbp 50- 50, 30 mg cpbp 50-50, 35 mg cpbp 50- Formulary High Cost Generics QL 1 CAP / 1 DAY 50, 40 mg cpbp 50-50) dexmethylphenidate hcl (5 mg cpbp 50- 50, 10 mg cpbp 50-50, 15 mg cpbp 50- Formulary High Cost Generics QL 2 CAPS / 1 DAY 50, 20 mg cpbp 50-50)

METADATE ER Formulary High Cost Generics QL 3 TABS / 1 DAY

methylphenidate hcl (10 mg cpbp 30-70, 10 mg cpbp 50-50, 20 mg cpbp 30-70, Formulary High Cost Generics QL 2 CAPS / 1 DAY 20 mg cpbp 50-50, 30 mg cpbp 30-70, 30 mg cpbp 50-50) methylphenidate hcl (40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mg cpbp 30-70, Formulary High Cost Generics QL 1 CAP / 1 DAY 60 mg cpbp 30-70, 60 mg cpbp 50-50) methylphenidate hcl (5 mg tablet, 10 mg Formulary High Cost Generics QL 3 TABS / 1 DAY tablet, 20 mg tablet, 20 mg tablet er)

methylphenidate hcl 10 mg tablet er Formulary High Cost Generics QL 4 TABS / 1 DAY

QUILLICHEW ER 20 MG CHEW TAB Formulary Brands QL 3 CHEW TABS / 1 DAY

QUILLICHEW ER 30 MG CHEW TAB Formulary Brands QL 2 CHEW TABS / 1 DAY

QUILLICHEW ER 40 MG CHEW TAB Formulary Brands QL 1 CHEW TABS / 1 DAY

PAGE 9 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QUILLIVANT XR Formulary Brands QL 180 ML / 30 day(s)

WAKEFULNESS-PROMOTING AGENTS

armodafinil (150 mg tablet, 200 mg Formulary High Cost Generics QL 1 TAB / 1 DAY tablet, 250 mg tablet)

armodafinil 50 mg tablet Formulary High Cost Generics QL 2 TABS / 1 DAY

modafinil Formulary High Cost Generics QL 2 TABS / 1 DAY

QL 1 TAB / 1 DAY SUNOSI Formulary Brands PA

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

albendazole Formulary High Cost Generics PA

ivermectin 3 mg tablet Formulary High Cost Generics praziquantel Formulary High Cost Generics URINARY ANTI-INFECTIVES

fosfomycin tromethamine Formulary High Cost Generics QL 1 packet / rx

nitrofurantoin Formulary High Cost Generics AL1 Up to 12 yrs old

nitrofurantoin macrocrystal (50 mg Formulary High Cost Generics capsule, 100 mg capsule) nitrofurantoin macrocrystal 25 mg Formulary High Cost Generics AL1 Up to 12 yrs old capsule nitrofurantoin Formulary High Cost Generics monohydrate/macrocrystals trimethoprim Formulary Low Cost Generics ANTI-INFECTIVES (EENT)

ANTIBACTERIALS (EENT)

bacitracin 500 unit/g oint. (g) Formulary High Cost Generics bacitracin/polymyxin b sulfate Formulary High Cost Generics

BESIVANCE Formulary Brands PA

BLEPHAMIDE S.O.P. Formulary Brands CILOXAN 0.3% OINTMENT Formulary Brands

PAGE 10 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CIPRO HC Formulary Brands CIPRODEX Formulary Brands ciprofloxacin hcl 0.3 % drops Formulary Low Cost Generics ciprofloxacin hcl/dexamethasone Formulary High Cost Generics doxycycline hyclate 20 mg tablet Formulary Low Cost Generics erythromycin base 5 mg/gram oint. (g) Formulary High Cost Generics gatifloxacin Formulary High Cost Generics moxifloxacin hcl 0.5 % drops Formulary Low Cost Generics neomycin sulfate/bacitracin/polymyxin b Formulary High Cost Generics neomycin sulfate/polymyxin b Formulary Low Cost Generics sulfate/gramicidin d neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxin b/hydrocort drops Formulary High Cost Generics susp, neomycin/polymyxin b/hydrocort solution) neomycin/polymyxin b sulfate/dexamethasone (neomycin/polymyxin b/dexametha 0.1 Formulary High Cost Generics % drops susp, neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. (g)) ofloxacin 0.3 % drops Formulary High Cost Generics polymyxin b sulfate/trimethoprim Formulary High Cost Generics sulfacetamide sodium (10 % drops, 10 Formulary High Cost Generics % oint. (g)) sulfacetamide sodium/prednisolone Formulary High Cost Generics sodium phosphate TOBRADEX EYE OINTMENT Formulary Brands tobramycin 0.3 % drops Formulary High Cost Generics tobramycin/dexamethasone Formulary High Cost Generics TOBREX 0.3% EYE OINTMENT Formulary Brands ANTIVIRALS (EENT)

trifluridine Formulary High Cost Generics ZIRGAN Formulary Brands

PAGE 11 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EENT ANTI-INFECTIVES, MISCELLANEOUS

acetic acid 2 % solution Formulary High Cost Generics chlorhexidine gluconate Formulary Low Cost Generics PAROEX Formulary High Cost Generics PERIOGARD Formulary High Cost Generics ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)

ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)

ALTABAX Formulary Brands ST

CLEOCIN 100 MG VAGINAL OVULE Formulary Brands

CLEOCIN T 1% SOLUTION Formulary Brands QL 60 ML / 30 day(s)

clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 % med. swab, 2 % Formulary High Cost Generics cream/appl)

clindamycin phosphate 1 % solution Formulary High Cost Generics QL 60 ML / 30 day(s)

clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 %-5 % gel (gram), Formulary High Cost Generics phos/benzoyl 1.2(1)%-5% gel (gram)) erythromycin base in ethanol 2 % gel Formulary High Cost Generics (gram) erythromycin base in ethanol 2 % Formulary Low Cost Generics QL 60 ML / 30 day(s) solution

gentamicin sulfate 0.1 % cream (g) Formulary High Cost Generics QL 30 GM / 30 day(s)

gentamicin sulfate 0.1 % oint. (g) Formulary Low Cost Generics metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel Formulary High Cost Generics (gram)) metronidazole 0.75 % gel w/appl Formulary Low Cost Generics

mupirocin Formulary Low Cost Generics QL 44 grams / rx

QL 30 GM / 30 day(s) mupirocin calcium Formulary High Cost Generics PA

ROSADAN 0.75% CREAM Formulary High Cost Generics

PAGE 12 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS LOCAL ANTI-INFECTIVES, MISCELLANEOUS

hydrocortisone/iodoquinol Formulary High Cost Generics selenium sulfide 2.5 % lotion Formulary High Cost Generics silver sulfadiazine Formulary High Cost Generics SSD Formulary High Cost Generics sulfacetamide sod/sulfur/urea 10%-5%- Formulary High Cost Generics 10% cleanser sulfacetamide sodium 10 % suspension Formulary High Cost Generics SCABICIDES AND PEDICULICIDES

EURAX 10% CREAM Formulary Brands malathion Formulary High Cost Generics permethrin Formulary High Cost Generics ANTI-INFLAMMATORY AGENTS (EENT)

CORTICOSTEROIDS (EENT)

dexamethasone sodium phosphate 0.1 Formulary High Cost Generics % drops flunisolide Formulary High Cost Generics fluocinolone acetonide oil Formulary High Cost Generics fluorometholone Formulary High Cost Generics fluticasone propionate 50 mcg spray Formulary Low Cost Generics susp FML S.O.P. Formulary Brands LOTEMAX (EYE OINTMENT, Formulary Brands OPHTHALMIC GEL) LOTEMAX SM Formulary Brands loteprednol etabonate Formulary High Cost Generics prednisolone acetate Formulary High Cost Generics prednisolone sodium phosphate 1 % Formulary Low Cost Generics drops QNASL Formulary Brands QNASL CHILDREN Formulary Brands

PAGE 13 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EENT ANTI-INFLAMMATORY AGENTS, MISC.

RESTASIS Formulary Brands RESTASIS MULTIDOSE Formulary Brands EENT NONSTEROIDAL ANTI-INFLAM. AGENTS

ACUVAIL Formulary Brands PA

bromfenac sodium Formulary High Cost Generics diclofenac sodium 0.1 % drops Formulary Low Cost Generics flurbiprofen sodium Formulary Low Cost Generics ketorolac tromethamine (0.4 % drops, Formulary High Cost Generics 0.5 % drops) ANTI-INFLAMMATORY AGENTS (RESPIRATORY)

INTERLEUKIN ANTAGONISTS

QL 2.28 ML / 28 DAY(S)

DUPIXENT 200 MG/1.14 ML SYRING Formulary Brands PA

PA FASENRA PEN Formulary Brands S

NUCALA (100 MG/ML AUTO- PA Formulary Brands INJECTOR, 100 MG/ML SYRINGE) S

LEUKOTRIENE MODIFIERS

montelukast sodium (4 mg gran pack, 4 Formulary High Cost Generics mg tab chew, 5 mg tab chew) montelukast sodium 10 mg tablet Formulary Low Cost Generics MAST-CELL STABILIZERS

cromolyn sodium 4 % drops Formulary High Cost Generics ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)

ANTI-INFLAMMATORY AGENTS, MISC (SKIN)

QL 60 GM / 30 DAYS EUCRISA Formulary Brands ST

PAGE 14 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)

alclometasone dipropionate Formulary High Cost Generics betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % Formulary High Cost Generics lotion, 0.05 % oint. (g)) betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05 Formulary High Cost Generics % lotion, betamethasone/propylene 0.05 % oint. (g)) betamethasone valerate (0.1 % cream Formulary High Cost Generics (g), 0.1 % lotion, 0.1 % oint. (g)) betamethasone/propylene glyc 0.05 % Formulary Low Cost Generics cream (g) clobetasol propionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 Formulary High Cost Generics % solution) clobetasol propionate/emoll 0.05 % Formulary High Cost Generics cream (g) CORDRAN 4 MCG/SQ CM TAPE Formulary Brands PA LARGE desonide (0.05 % cream (g), 0.05 % Formulary High Cost Generics lotion, 0.05 % oint. (g)) desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.25 % cream (g), 0.25 % Formulary High Cost Generics oint. (g)) fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.025 % cream (g), 0.025 Formulary High Cost Generics % oint. (g)) fluocinolone acetonide/shower cap Formulary High Cost Generics fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 % Formulary High Cost Generics solution) fluocinonide/emollient base Formulary High Cost Generics fluticasone propionate (0.005 % oint. (g), Formulary High Cost Generics 0.05 % cream (g)) hydrocortisone (2.5 % cream (g), 2.5 % crm/pe app, 2.5 % lotion, 100mg/60ml Formulary High Cost Generics enema) hydrocortisone 2.5 % oint. (g) Formulary Low Cost Generics

PAGE 15 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS hydrocortisone acetate 25 mg supp.rect Formulary High Cost Generics hydrocortisone acetate/pramoxine hcl (hydrocortisone/pramoxine 1 % cream/appl, hydrocortisone/pramoxine Formulary High Cost Generics 2.5 % cream (g), hydrocortisone/pramoxine 2.5 % cream/appl) hydrocortisone valerate Formulary High Cost Generics mometasone furoate (0.1 % cream (g), Formulary High Cost Generics 0.1 % oint. (g), 0.1 % solution) PROCTO-MED HC Formulary High Cost Generics PROCTOFOAM-HC Formulary Brands PROCTOSOL-HC Formulary High Cost Generics PROCTOZONE-HC Formulary High Cost Generics triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g), 0.1 Formulary High Cost Generics % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint. (g)) triamcinolone acetonide 0.1 % paste (g) Formulary Low Cost Generics TRIDERM Formulary High Cost Generics ANTIARRHYTHMIC AGENTS

CLASS IA ANTIARRHYTHMICS

disopyramide phosphate Formulary High Cost Generics NORPACE CR Formulary Brands quinidine sulfate Formulary High Cost Generics CLASS IB ANTIARRHYTHMICS

mexiletine hcl Formulary High Cost Generics CLASS IC ANTIARRHYTHMICS

flecainide acetate Formulary High Cost Generics propafenone hcl (150 mg tablet, 225 mg Formulary High Cost Generics tablet, 300 mg tablet) CLASS III ANTIARRHYTHMICS

amiodarone hcl (100 mg tablet, 200 mg Formulary High Cost Generics tablet, 400 mg tablet)

PAGE 16 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dofetilide Formulary High Cost Generics

MULTAQ Formulary Brands PA

PACERONE (100 MG TABLET, 400 MG Formulary High Cost Generics TABLET) ANTIBACTERIALS

AMINOGLYCOSIDE ANTIBIOTICS

neomycin sulfate Formulary High Cost Generics

PA tobramycin in 0.225 % sodium chloride Formulary High Cost Generics S

QUINOLONE ANTIBIOTICS

CIPRO (5% SUSPENSION, 10% Formulary Brands AL1 Up to 12 yrs old SUSPENSION)

ciprofloxacin Formulary High Cost Generics AL1 Up to 12 yrs old

ciprofloxacin hcl (100 mg tablet, 250 mg Formulary Low Cost Generics tablet, 500 mg tablet, 750 mg tablet) levofloxacin (250 mg tablet, 500 mg Formulary Low Cost Generics tablet, 750 mg tablet)

levofloxacin 250mg/10ml solution Formulary High Cost Generics AL1 Up to 12 yrs old

moxifloxacin hcl 400 mg tablet Formulary High Cost Generics SULFONAMIDE ANTIBIOTICS (SYSTEMIC)

sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200- 40mg/5 oral susp, Formulary High Cost Generics sulfamethoxazole/trimethoprim 800- 160/20 oral susp) sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 400mg- 80mg tablet, Formulary Low Cost Generics sulfamethoxazole/trimethoprim 800-160 mg tablet) sulfasalazine (500 mg tablet, 500 mg Formulary High Cost Generics tablet dr) SULFATRIM Formulary High Cost Generics

PAGE 17 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TETRACYCLINE ANTIBIOTICS

demeclocycline hcl Formulary High Cost Generics doxycycline hyclate (50 mg capsule, 100 Formulary Low Cost Generics mg capsule, 100 mg tablet) doxycycline monohydrate (50 mg capsule, 50 mg tablet, 100 mg capsule, Formulary High Cost Generics 100 mg tablet) doxycycline monohydrate 25 mg/5 ml Formulary High Cost Generics AL1 Up to 12 yrs old susp recon minocycline hcl (50 mg capsule, 75 mg Formulary High Cost Generics capsule, 100 mg capsule) MONDOXYNE NL 100 MG CAPSULE Formulary High Cost Generics ANTIBACTERIALS, MISCELLANEOUS

GLYCOPEPTIDE ANTIBIOTICS

vancomycin hcl 125 mg capsule Formulary High Cost Generics vancomycin hcl 250 mg capsule Formulary Low Cost Generics LINCOMYCIN ANTIBIOTICS

clindamycin hcl (150 mg capsule, 300 Formulary Low Cost Generics mg capsule) clindamycin hcl 75 mg capsule Formulary High Cost Generics

clindamycin palmitate hcl Formulary High Cost Generics AL1 Up to 12 yrs old

OXAZOLIDINONE ANTIBIOTICS

linezolid 100 mg/5ml susp recon Formulary High Cost Generics PA

linezolid 600 mg tablet Formulary High Cost Generics QL 28 tablets / rx

SIVEXTRO 200 MG TABLET Formulary Brands PA

PLEUROMUTILINS

QL 10 TABS / rx XENLETA 600 MG TABLET Formulary Brands PA

RIFAMYCIN ANTIBIOTICS

XIFAXAN Formulary Brands PA

PAGE 18 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTICHOLINERGIC AGENTS

ANTIMUSCARINICS/ANTISPASMODICS

ANORO ELLIPTA Formulary Brands

ATROVENT HFA Formulary Brands QL 1 INHALER / 25 day(s)

COMBIVENT RESPIMAT Formulary Brands QL 1 INHALER / 30 day(s)

CUVPOSA Formulary Brands PA

dicyclomine hcl (10 mg/5 ml solution, 20 Formulary Low Cost Generics mg tablet) dicyclomine hcl 10 mg capsule Formulary High Cost Generics glycopyrrolate (1 mg tablet, 2 mg tablet) Formulary High Cost Generics hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg Formulary High Cost Generics tablet, 0.125mg/ml drops, 0.375 mg tab er 12h, 125mcg/5ml elixir) INCRUSE ELLIPTA Formulary Brands ipratropium bromide 0.2 mg/ml solution Formulary High Cost Generics ipratropium bromide/albuterol sulfate Formulary High Cost Generics propantheline bromide Formulary High Cost Generics ANTICOAGULANTS

ANTICOAGULANTS, MISCELLANEOUS

fondaparinux sodium (2.5 mg/0.5 QL 1 syringe / 1 day(s) syringe, 5mg/0.4ml syringe, 10mg/0.8ml Formulary High Cost Generics syringe) PA

QL 1 syringe / 1 day(s) fondaparinux sodium 7.5mg/0.6 syringe Formulary High Cost Generics PA

COUMARIN DERIVATIVES

warfarin sodium Formulary Low Cost Generics DIRECT FACTOR XA INHIBITORS

ELIQUIS (2.5 MG TABLET, 5 MG Formulary Brands QL 60 TABS / 30 DAY(S) TABLET)

ELIQUIS DVT-PE TREAT START 5MG Formulary Brands QL 1 RX / 30 day(s)

XARELTO (10 MG TABLET, 20 MG Formulary Brands QL 30 TABS / 30 DAY(S) TABLET)

PAGE 19 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS XARELTO (2.5 MG TABLET, 15 MG Formulary Brands QL 60 TABS / 30 DAY(S) TABLET)

XARELTO DVT-PE TREAT START 30D Formulary Brands QL 51 TABS / 30 DAY(S)

DIRECT THROMBIN INHIBITORS

PRADAXA Formulary Brands PA

HEPARINS

enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe, 60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 mg/ml Formulary High Cost Generics QL 2 syringes / 1 day(s) syringe, 120mg/.8ml syringe, 150 mg/ml syringe)

enoxaparin sodium 300mg/3ml vial Formulary High Cost Generics QL 2 vials / 1 day(s)

heparin sodium,porcine (1000/ml vial, 5000/ml syringe, 5000/ml vial, Formulary High Cost Generics 5000/ml(1) cartridge, 10000/ml vial, 20000/ml vial) heparin sodium,porcine/pf 5000/0.5ml Formulary High Cost Generics cartridge ANTICONVULSANTS

ANTICONVULSANTS, MISCELLANEOUS

APTIOM Formulary Brands PA

QL 16 TABS / 1 DAY BANZEL 200 MG TABLET Formulary Brands PA

QL 8 TABS / 1 DAY BANZEL 400 MG TABLET Formulary Brands PA

BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MG TABLET, 50 MG Formulary Brands PA TABLET, 75 MG TABLET, 100 MG TABLET) carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100 mg/5ml oral susp, 200 mg cpmp 12hr, Formulary High Cost Generics 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp 12hr, 400 mg tab er 12h)

QL 360 CAPS / 30 day(s)

DIACOMIT 250 MG CAPSULE Formulary Brands PA

PAGE 20 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 360 PACKETS / 30 day(s) DIACOMIT 250 MG POWDER PACKET Formulary Brands PA

PA DIACOMIT 500 MG CAPSULE Formulary Brands S

QL 180 PACKETS / 30 day(s) DIACOMIT 500 MG POWDER PACKET Formulary Brands PA

divalproex sodium (125 mg cap dr spr, Formulary Low Cost Generics 250 mg tab er 24h, 500 mg tab er 24h) divalproex sodium (125 mg tablet dr, Formulary High Cost Generics 250 mg tablet dr, 500 mg tablet dr)

QL 20 ML / 1 DAY

EPIDIOLEX Formulary Brands PA

felbamate (400 mg tablet, 600 mg tablet, Formulary High Cost Generics 600 mg/5ml oral susp) FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG Formulary Brands PA TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) gabapentin (100 mg capsule, 300 mg Formulary High Cost Generics QL 12 CAPS / 1 DAY capsule) gabapentin (250 mg/5ml solution, 300 Formulary High Cost Generics QL 72 ML / 1 DAY mg/6ml solution)

gabapentin 400 mg capsule Formulary High Cost Generics QL 9 CAPS / 1 DAY

gabapentin 600 mg tablet Formulary High Cost Generics QL 6 TABS / 1 DAY

gabapentin 800 mg tablet Formulary High Cost Generics QL 4 TABS / 1 DAY

lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25 mg tb chw dsp, 100 mg tablet, Formulary High Cost Generics 150 mg tablet, 200 mg tablet) levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tablet, 750 mg tablet, Formulary High Cost Generics 1000 mg tablet)

PAGE 21 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levetiracetam (500 mg tab er 24h, 750 Formulary Low Cost Generics mg tab er 24h) oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg Formulary High Cost Generics tablet) pregabalin (225 mg capsule, 300 mg Formulary High Cost Generics QL 2 CAPS / 1 DAY capsule) pregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg Formulary High Cost Generics QL 3 CAPS / 1 DAY capsule, 150 mg capsule, 200 mg capsule)

pregabalin 20 mg/ml solution Formulary High Cost Generics QL 30 ML / 1 DAY

QL 80 ML / 1 day(s) rufinamide Formulary High Cost Generics PA

SUBVENITE Formulary High Cost Generics tiagabine hcl Formulary High Cost Generics topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, Formulary Low Cost Generics 100 mg tablet, 200 mg tablet) valproic acid Formulary High Cost Generics valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, Formulary High Cost Generics 500mg/10ml solution)

PA vigabatrin Formulary High Cost Generics S

PA VIGADRONE Formulary High Cost Generics S

VIMPAT (150 MG TABLET, 200 MG Formulary Brands QL 2 TABS / 1 DAY TABLET)

VIMPAT 10 MG/ML SOLUTION Formulary Brands QL 40 ML / 1 DAY

VIMPAT 100 MG TABLET Formulary Brands QL 4 TABS / 1 DAY

VIMPAT 50 MG TABLET Formulary Brands QL 8 TABS / 1 DAY

zonisamide Formulary Low Cost Generics

PAGE 22 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BARBITURATES (ANTICONVULSANTS)

primidone Formulary High Cost Generics BENZODIAZEPINES (ANTICONVULSANTS)

clobazam 10 mg tablet Formulary High Cost Generics QL 4 TABS / 1 DAY

clobazam 2.5 mg/ml oral susp Formulary High Cost Generics QL 16 ML / 1 DAY

clobazam 20 mg tablet Formulary High Cost Generics QL 2 TABS / 1 DAY

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg Formulary Low Cost Generics QL 6 TABS / 1 DAY tablet) clonazepam (1 mg tab rapdis, 1 mg Formulary Low Cost Generics QL 4 TABS / 1 DAY tablet) clonazepam (2 mg tab rapdis, 2 mg Formulary Low Cost Generics QL 2 TABS / 1 DAY tablet)

QL 2 bottles / rx NAYZILAM Formulary Brands PA

HYDANTOINS

DILANTIN 30 MG CAPSULE Formulary Brands phenytoin (50 mg tab chew, 125 mg/5ml Formulary High Cost Generics oral susp) phenytoin sodium extended Formulary High Cost Generics SUCCINIMIDES

ethosuximide (250 mg capsule, 250 Formulary High Cost Generics mg/5ml solution) ANTIDEPRESSANTS

ANTIDEPRESSANTS, MISCELLANEOUS

bupropion hcl (75 mg tablet, 100 mg tab sr 12h, 100 mg tablet, 150 mg tab er 12h, 150 mg tab er 24h, 150 mg tab sr Formulary High Cost Generics 12h, 200 mg tab sr 12h, 300 mg tab er 24h) mirtazapine (7.5 mg tablet, 15 mg tablet, Formulary High Cost Generics 30 mg tablet, 45 mg tablet)

PAGE 23 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MONOAMINE OXIDASE INHIBITORS

phenelzine sulfate Formulary High Cost Generics tranylcypromine sulfate Formulary High Cost Generics SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR

desvenlafaxine succinate Formulary Low Cost Generics duloxetine hcl (20 mg capsule dr, 30 mg Formulary High Cost Generics capsule dr, 60 mg capsule dr)

FETZIMA Formulary Brands PA

venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tablet, 50 mg tablet, Formulary High Cost Generics 75 mg cap er 24h, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h) SELECTIVE-SEROTONIN REUPTAKE INHIBITORS

citalopram hydrobromide (10 mg tablet, Formulary Low Cost Generics 20 mg tablet, 40 mg tablet) citalopram hydrobromide (10 mg/5 ml Formulary High Cost Generics solution, 20 mg/10ml solution) escitalopram oxalate (5 mg tablet, 10 mg Formulary Low Cost Generics tablet, 20 mg tablet) escitalopram oxalate 5 mg/5 ml solution Formulary High Cost Generics fluoxetine hcl (10 mg capsule, 20 mg Formulary Low Cost Generics capsule, 40 mg capsule) fluoxetine hcl 20 mg/5 ml solution Formulary High Cost Generics fluvoxamine maleate (25 mg tablet, 50 Formulary High Cost Generics mg tablet, 100 mg tablet) paroxetine hcl (10 mg tablet, 20 mg Formulary Low Cost Generics tablet, 30 mg tablet, 40 mg tablet) PAXIL 10 MG/5 ML SUSPENSION Formulary Brands sertraline hcl (20 mg/ml oral conc, 25 mg Formulary Low Cost Generics tablet, 50 mg tablet, 100 mg tablet) SEROTONIN MODULATORS

nefazodone hcl Formulary High Cost Generics trazodone hcl Formulary Low Cost Generics

TRINTELLIX Formulary Brands PA

PAGE 24 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

VIIBRYD Formulary Brands PA

TRICYCLICS, OTHER NOREPI-RU INHIBITORS

amitriptyline hcl Formulary High Cost Generics

clomipramine hcl Formulary High Cost Generics AL1 Up to 64 yrs old

desipramine hcl Formulary High Cost Generics doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, Formulary High Cost Generics 100 mg capsule, 150 mg capsule)

doxepin hcl 10 mg/ml oral conc Formulary High Cost Generics AL1 Up to 64 yrs old

imipramine hcl Formulary High Cost Generics nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25 mg capsule, 50 mg Formulary High Cost Generics capsule, 75 mg capsule) ANTIDIABETIC AGENTS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose Formulary Low Cost Generics miglitol Formulary High Cost Generics BIGUANIDES

metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 850 mg Formulary Low Cost Generics tablet, 1000 mg tablet) DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS

JENTADUETO Formulary Brands QL 60 TABS / 30 DAY(S)

JENTADUETO XR Formulary Brands QL 60 TABS / 30 DAY(S)

TRADJENTA Formulary Brands QL 30 TABS / 30 DAY(S)

INCRETIN MIMETICS

BYDUREON Formulary Brands QL 4 ML / 28 DAYS

BYDUREON BCISE Formulary Brands QL 3.4 ML / 28 day(s)

BYDUREON PEN Formulary Brands QL 4 PEN / 28 DAYS

BYETTA 10 MCG DOSE PEN INJ Formulary Brands QL 2.4 ML / 30 DAYS

PAGE 25 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BYETTA 5 MCG DOSE PEN INJ Formulary Brands QL 1.2 ML / 30 DAYS

OZEMPIC 0.25-0.5 MG DOSE PEN Formulary Brands QL 1.5 ML / 28 DAYS

OZEMPIC 1 MG DOSE PEN Formulary Brands QL 3 ML / 28 DAYSS

RYBELSUS Formulary Brands QL 1 tab / 1 day(s)

TRULICITY (0.75 MG/0.5 ML PEN, 1.5 Formulary Brands QL 2 ML / 28 DAYS MG/0.5 ML PEN) TRULICITY (3 MG/0.5 ML PEN, 4.5 Formulary Brands QL 2 ML / 28 DAY(S) MG/0.5 ML PEN)

VICTOZA 2-PAK Formulary Brands QL 9 ML / 30 DAYS

VICTOZA 3-PAK Formulary Brands QL 9 ML / 30 DAYS

MEGLITINIDES

nateglinide Formulary High Cost Generics repaglinide Formulary High Cost Generics SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB

INVOKAMET Formulary Brands QL 60 TABS / 30 DAY(S)

INVOKAMET XR Formulary Brands QL 60 TABS / 30 DAY(S)

INVOKANA Formulary Brands QL 30 TABS / 30 DAY(S)

JARDIANCE Formulary Brands QL 30 TABS / 30 DAY(S)

SYNJARDY Formulary Brands QL 60 TABS / 30 DAY(S)

SYNJARDY XR (10-1,000 MG TABLET, Formulary Brands QL 1 TABS / 1 DAY 25-1,000 MG TABLET) SYNJARDY XR (5-1,000 MG TABLET, Formulary Brands QL 60 TABS / 30 DAY(S) 12.5-1,000 MG TAB) TRIJARDY XR (10-5-1,000 MG TAB, Formulary Brands QL 1 TABLET / 1 day(s) 25-5-1,000 MG TAB) TRIJARDY XR (5-2.5-1,000 MG TAB, Formulary Brands QL 2 TABLETS / 1 day(s) 12.5-2.5-1,000 MG) SULFONYLUREAS

glimepiride Formulary Low Cost Generics glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mg Formulary Low Cost Generics tablet)

PAGE 26 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS glipizide/metformin hcl Formulary Low Cost Generics

glyburide Formulary High Cost Generics PA

glyburide,micronized Formulary High Cost Generics PA

THIAZOLIDINEDIONES

pioglitazone hcl Formulary Low Cost Generics pioglitazone hcl/glimepiride Formulary High Cost Generics pioglitazone hcl/metformin hcl Formulary High Cost Generics ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

ondansetron Formulary High Cost Generics ondansetron hcl (4 mg tablet, 8 mg Formulary High Cost Generics tablet, 24 mg tablet) ondansetron hcl 4 mg/5 ml solution Formulary Low Cost Generics ANTIEMETICS, MISCELLANEOUS

dronabinol (2.5 mg capsule, 5 mg Formulary High Cost Generics QL 6 CAPS / 1 DAY capsule)

dronabinol 10 mg capsule Formulary Low Cost Generics QL 4 CAPS / 1 DAY

scopolamine Formulary High Cost Generics ANTIHISTAMINES (GI DRUGS)

prochlorperazine Formulary High Cost Generics prochlorperazine maleate Formulary Low Cost Generics trimethobenzamide hcl Formulary High Cost Generics NEUROKININ-1 RECEPTOR ANTAGONISTS

aprepitant Formulary High Cost Generics EMEND 125 MG POWDER PACKET Formulary Brands ANTIFUNGAL (SYSTEMIC)

ALLYLAMINE ANTIFUNGALS

terbinafine hcl Formulary Low Cost Generics

PAGE 27 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIFUNGALS, MISCELLANEOUS

griseofulvin ultramicrosize Formulary High Cost Generics griseofulvin, microsize (125 mg/5ml oral Formulary High Cost Generics susp, 500 mg tablet) AZOLE ANTIFUNGALS

CRESEMBA 186 MG CAPSULE Formulary Brands PA

fluconazole (10 mg/ml susp recon, 40 Formulary High Cost Generics mg/ml susp recon) fluconazole (50 mg tablet, 100 mg tablet, Formulary Low Cost Generics 150 mg tablet, 200 mg tablet)

itraconazole 100 mg capsule Formulary High Cost Generics ST

ketoconazole 200 mg tablet Formulary Low Cost Generics posaconazole (100 mg tablet dr, 200 Formulary High Cost Generics PA mg/5ml oral susp) voriconazole (50 mg tablet, 200 mg Formulary High Cost Generics PA tablet, 200 mg/5ml susp recon) POLYENE ANTIFUNGALS

nystatin 100000/ml oral susp Formulary High Cost Generics QL 480 ml / rx

nystatin 500k unit tablet Formulary Low Cost Generics ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)

AZOLES (SKIN AND MUCOUS MEMBRANE)

clotrimazole 10 mg troche Formulary High Cost Generics

econazole nitrate Formulary High Cost Generics QL 85 GM / 30 day(s)

ketoconazole 2 % cream (g) Formulary Low Cost Generics QL 60 GM / 30 day(s)

ketoconazole 2 % shampoo Formulary High Cost Generics terconazole (0.4 % cream/appl, 0.8 % Formulary High Cost Generics cream/appl, 80 mg supp.vag) HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)

ciclopirox (0.77 % gel (gram), 8 % Formulary High Cost Generics solution) ciclopirox olamine 0.77 % cream (g) Formulary High Cost Generics

ciclopirox olamine 0.77 % suspension Formulary High Cost Generics QL 60 ML / 30 day(s)

PAGE 28 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS POLYENES (SKIN AND MUCOUS MEMBRANE)

nystatin (100000/g cream (g), 100000/g Formulary High Cost Generics oint. (g))

nystatin 100000/g powder Formulary High Cost Generics QL 240 grams / rx

ANTIGLAUCOMA AGENTS

ALPHA-ADRENERGIC AGONISTS (EENT)

ALPHAGAN P 0.1% DROPS Formulary Brands brimonidine tartrate Formulary High Cost Generics COMBIGAN Formulary Brands BETA-ADRENERGIC BLOCKING AGENTS (EENT)

betaxolol hcl 0.5 % drops Formulary High Cost Generics carteolol hcl Formulary Low Cost Generics levobunolol hcl Formulary Low Cost Generics timolol maleate (0.25 % drops, 0.5 % Formulary Low Cost Generics drops) timolol maleate (0.25 % sol-gel, 0.5 % Formulary High Cost Generics sol-gel) CARBONIC ANHYDRASE INHIBITORS (EENT)

acetazolamide (125 mg tablet, 250 mg Formulary Low Cost Generics tablet) acetazolamide 500 mg capsule er Formulary High Cost Generics AZOPT Formulary Brands dorzolamide hcl Formulary High Cost Generics dorzolamide hcl/timolol maleate Formulary High Cost Generics dorzolamide/timolol/pf 2 %-0.5 % Formulary High Cost Generics droperette methazolamide Formulary High Cost Generics SIMBRINZA Formulary Brands MIOTICS

PHOSPHOLINE IODIDE Formulary Brands pilocarpine hcl (1 % drops, 2 % drops, 4 Formulary High Cost Generics % drops)

PAGE 29 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROSTAGLANDIN ANALOGS

bimatoprost 0.03 % drops Formulary High Cost Generics latanoprost Formulary High Cost Generics LUMIGAN Formulary Brands travoprost Formulary High Cost Generics

ZIOPTAN Formulary Brands PA

RHO KINASE INHIBITORS

RHOPRESSA Formulary Brands ROCKLATAN Formulary Brands ANTIHEMORRHAGIC AGENTS

HEMOSTATICS

PA ADVATE Formulary Brands S

PA ADYNOVATE Formulary Brands S

PA AFSTYLA Formulary Brands S

PA ALPHANATE Formulary Brands S

PA ALPHANINE SD Formulary Brands S

PA ALPROLIX Formulary Brands S

PA BENEFIX Formulary Brands S

PA COAGADEX Formulary Brands S

PA CORIFACT Formulary Brands S

PAGE 30 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA ELOCTATE Formulary Brands S

ESPEROCT (500 UNIT VIAL, 1,000 PA UNIT VIAL, 1,500 UNIT VIAL, 2,000 Formulary Brands UNIT VIAL, 3,000 UNIT VIAL) S

PA FEIBA NF Formulary Brands S

PA HELIXATE FS Formulary Brands S

PA HEMLIBRA Formulary Brands S

PA HEMOFIL M Formulary Brands S

PA HUMATE-P Formulary Brands S

PA IDELVION Formulary Brands S

PA IXINITY Formulary Brands S

PA JIVI Formulary Brands S

PA KOATE Formulary Brands S

PA KOGENATE FS Formulary Brands S

PA KOVALTRY Formulary Brands S

MONONINE Formulary Brands S

PA NOVOEIGHT Formulary Brands S

PAGE 31 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA NOVOSEVEN RT Formulary Brands S

PA NUWIQ Formulary Brands S

PA OBIZUR Formulary Brands S

PA PROFILNINE Formulary Brands S

PA REBINYN Formulary Brands S

PA RECOMBINATE Formulary Brands S

PA RIXUBIS Formulary Brands S

PA SEVENFACT Formulary Brands S

tranexamic acid 650 mg tablet Formulary High Cost Generics QL 30 TABS / RX

PA TRETTEN Formulary Brands S

PA VONVENDI Formulary Brands S

PA WILATE Formulary Brands S

PA XYNTHA Formulary Brands S

PA XYNTHA SOLOFUSE Formulary Brands S

PAGE 32 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIHYPOGLYCEMIC AGENTS

GLYCOGENOLYTIC AGENTS

BAQSIMI Formulary Brands GLUCAGEN 1 MG HYPOKIT Formulary Brands GLUCAGON EMERGENCY KIT Formulary Brands GVOKE HYPOPEN 1-PACK Formulary Brands GVOKE HYPOPEN 2-PACK Formulary Brands GVOKE PFS 1-PACK SYRINGE Formulary Brands GVOKE PFS 2-PACK SYRINGE Formulary Brands ANTILIPEMIC AGENTS

ANTILIPEMIC AGENTS, MISCELLANEOUS

icosapent ethyl Formulary High Cost Generics PA

PA JUXTAPID Formulary Brands S

omega-3 acid ethyl esters Formulary Low Cost Generics TRIKLO Formulary Low Cost Generics

VASCEPA 0.5 GM CAPSULE Formulary Brands PA

BILE ACID SEQUESTRANTS

cholestyramine (with sugar) (4 g powd Formulary High Cost Generics pack, 4 g powder) cholestyramine/aspartame (cholestyramine/aspartame 4 g powd Formulary High Cost Generics pack, cholestyramine/aspartame 4 g powder) colestipol hcl 1 g tablet Formulary High Cost Generics PREVALITE (PACKET, POWDER) Formulary High Cost Generics CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe Formulary Low Cost Generics FIBRIC ACID DERIVATIVES

fenofibrate (54 mg tablet, 160 mg tablet) Formulary High Cost Generics fenofibrate nanocrystallized (48 mg Formulary Low Cost Generics tablet, 145 mg tablet)

PAGE 33 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS fenofibrate,micronized (67 mg capsule, Formulary Low Cost Generics 134 mg capsule, 200 mg capsule) gemfibrozil Formulary Low Cost Generics HMG-COA REDUCTASE INHIBITORS

atorvastatin calcium (10 mg tablet, 20 Formulary Low Cost Generics ACA mg tablet) atorvastatin calcium (40 mg tablet, 80 Formulary Low Cost Generics mg tablet)

lovastatin (20 mg tablet, 40 mg tablet) Formulary Low Cost Generics ACA

lovastatin 10 mg tablet Formulary Low Cost Generics

pravastatin sodium Formulary Low Cost Generics ACA

rosuvastatin calcium (20 mg tablet, 40 Formulary Low Cost Generics mg tablet) rosuvastatin calcium (5 mg tablet, 10 mg Formulary Low Cost Generics ACA tablet) simvastatin (10 mg tablet, 20 mg tablet, Formulary Low Cost Generics ACA 40 mg tablet) simvastatin (5 mg tablet, 80 mg tablet) Formulary Low Cost Generics PCSK9 INHIBITORS

QL 1 pen / 28 day(s) REPATHA PUSHTRONEX Formulary Brands PA

QL 2 pens / 28 day(s) REPATHA SURECLICK Formulary Brands PA

QL 2 pens / 28 day(s) REPATHA SYRINGE Formulary Brands PA

ANTIMIGRAINE AGENTS

CALCITONIN GENE-RELATED PEPTIDE ANTAG.

QL 1.5 ML / 30 day(s)

AJOVY AUTOINJECTOR Formulary Brands PA

QL 1.5 ML / 30 DAY(S)

AJOVY SYRINGE Formulary Brands PA

PAGE 34 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 ML / 30 DAY(S)

EMGALITY 120 MG/ML SYRINGE Formulary Brands PA

QL 1 ML / 30 DAYS

EMGALITY PEN Formulary Brands PA

QL 3 ML / 30 day(s) EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG (100 MG Formulary Brands PA X3SYR)) S

QL 8 TABS / 30 day(s) NURTEC ODT Formulary Brands PA

SELECTIVE SEROTONIN AGONISTS

naratriptan hcl Formulary Low Cost Generics QL 12 TABS / 30 DAYS

QL 8 tabs / 30 day(s) REYVOW Formulary Brands PA

rizatriptan benzoate Formulary High Cost Generics QL 12 TABS / 28 DAYS

sumatriptan Formulary High Cost Generics QL 12 ML / 30 DAYS

sumatriptan succinate (25 mg tablet, 50 Formulary High Cost Generics QL 12 TABS / 28 DAYS mg tablet, 100 mg tablet) sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 Formulary High Cost Generics QL 5 ML / 30 DAYS mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml vial) sumatriptan succinate 6 mg/0.5ml Formulary High Cost Generics QL 5 ML / 30 DAYSS syringe ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, MISCELLANEOUS

dapsone (25 mg tablet, 100 mg tablet) Formulary High Cost Generics ANTITUBERCULOSIS AGENTS

cycloserine Formulary High Cost Generics PA

ethambutol hcl Formulary Low Cost Generics

PAGE 35 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS isoniazid (100 mg tablet, 300 mg tablet) Formulary Low Cost Generics isoniazid 50 mg/5 ml solution Formulary High Cost Generics

pretomanid Formulary High Cost Generics PA

PRIFTIN Formulary Brands pyrazinamide Formulary High Cost Generics rifabutin Formulary High Cost Generics rifampin (150 mg capsule, 300 mg Formulary Low Cost Generics capsule)

SIRTURO Formulary Brands PA

TRECATOR Formulary Brands PA

ANTINEOPLASTIC AGENTS

QL 4 TABS / 1 DAY

abiraterone acetate Formulary High Cost Generics S

ONC Oncology

TD Trial Drug

QL 30 TABS / 30 DAY(S)

AFINITOR 10 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 60 TABS / 30 DAY(S)

PA AFINITOR DISPERZ (2 MG TABLET, 5 Formulary Brands S MG TABLET) ONC Oncology

TD Trial Drug

QL 90 TABS / 30 day(s)

AFINITOR DISPERZ 3 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

PAGE 36 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 240 CAPS / 30 day(s)

PA ALECENSA Formulary Brands S

ONC Oncology

anastrozole Formulary Low Cost Generics ACA

QL 1 tab / 1 day(s)

PA AYVAKIT Formulary Brands S

ONC Oncology

BALVERSA Formulary Brands S

ONC Oncology

bicalutamide Formulary Low Cost Generics

QL 1 tab / 1 day(s)

PA BOSULIF (400 MG TABLET, 500 MG Formulary Brands S TABLET) ONC Oncology

TD Trial Drug

QL 4 tabs / 1 day(s)

BOSULIF 100 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 60 CAPS / 30 DAY(S)

PA BRAFTOVI 50 MG CAPSULE Formulary Brands S

ONC Oncology

QL 180 CAPS / 30 DAY(S)

PA BRAFTOVI 75 MG CAPSULE Formulary Brands S

ONC Oncology

PAGE 37 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

BRUKINSA Formulary Brands S

ONC Oncology

QL 30 TABS / 30 DAY(S)

CABOMETYX Formulary Brands S

ONC Oncology

TD Trial Drug

S capecitabine Formulary High Cost Generics ONC Oncology

QL 60 TABS / 30 DAY(S)

PA CAPRELSA 100 MG TABLET Formulary Brands S

ONC Oncology

QL 30 TABS / 30 DAY(S)

PA CAPRELSA 300 MG TABLET Formulary Brands S

ONC Oncology

QL 60 TABS / 30 DAY(S)

COMETRIQ 100 MG DAILY-DOSE PK Formulary Brands S

ONC Oncology

TD Trial Drug

QL 120 TABS / 30 day(s)

COMETRIQ 140 MG DAILY-DOSE PK Formulary Brands S

ONC Oncology

TD Trial Drug

QL 90 TABS / 30 day(s)

COMETRIQ 60 MG DAILY-DOSE PACK Formulary Brands S

ONC Oncology

TD Trial Drug

PAGE 38 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 CAPS / 30 DAY(S)

COPIKTRA Formulary Brands S

ONC Oncology

TD Trial Drug

QL 90 TABS / 30 day(s)

PA COTELLIC Formulary Brands S

ONC Oncology

cyclophosphamide (25 mg capsule, 50 Formulary High Cost Generics mg capsule)

QL 30 TABS / 30 DAY(S)

DAURISMO 100 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 90 TABS / 30 day(s)

DAURISMO 25 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

EMCYT Formulary Brands

QL 30 CAPS / 30 DAY(S)

ERIVEDGE Formulary Brands S

ONC Oncology

TD Trial Drug

ERLEADA Formulary Brands S

ONC Oncology

PAGE 39 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 90 TABS / 30 day(s)

erlotinib hcl 25 mg tablet Formulary High Cost Generics S

ONC Oncology

TD Trial Drug

etoposide 50 mg capsule Formulary High Cost Generics

QL 30 TABS / 30 DAY(S)

everolimus (5 mg tablet, 7.5 mg tablet) Formulary High Cost Generics S

ONC Oncology

TD Trial Drug

QL 1 TAB / 1 day(s)

everolimus 2.5 mg tablet Formulary High Cost Generics S

ONC Oncology

TD Trial Drug

exemestane Formulary High Cost Generics ACA

FLUOROPLEX Formulary Brands fluorouracil (2 % solution, 5 % cream (g), Formulary High Cost Generics 5 % solution) flutamide Formulary High Cost Generics

QL 30 TABS / 30 DAY(S)

PA GILOTRIF Formulary Brands S

ONC Oncology

GLEOSTINE Formulary Brands

S HYCAMTIN Formulary Brands ONC Oncology

hydroxyurea Formulary High Cost Generics

QL 21 CAPS / 28 DAYS

IBRANCE (75 MG CAPSULE, 100 MG PA Formulary Brands CAPSULE, 125 MG CAPSULE) S

ONC Oncology

PAGE 40 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 21 TABS / 28 DAYS

IBRANCE (75 MG TABLET, 100 MG PA Formulary Brands TABLET, 125 MG TABLET) S

ONC Oncology

QL 60 TABS / 30 DAY(S)

ICLUSIG 15 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 30 TABS / 30 DAY(S)

ICLUSIG 45 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 30 TABS / 30 DAY(S)

PA IDHIFA Formulary Brands S

ONC Oncology

imatinib mesylate Formulary High Cost Generics ONC Oncology

TD Trial Drug

QL 1 tablet / 1 day(s)

IMBRUVICA (420 MG TABLET, 560 MG PA Formulary Brands TABLET) S

ONC Oncology

QL 4 CAPS / 1 day(s)

PA IMBRUVICA 140 MG CAPSULE Formulary Brands S

ONC Oncology

QL 1 CAPSULE / 1 day(s)

PA IMBRUVICA 70 MG CAPSULE Formulary Brands S

ONC Oncology

PAGE 41 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 180 TABS / 30 day(s)

INLYTA 1 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 120 TABS / 30 day(s)

INLYTA 5 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

INREBIC Formulary Brands S

ONC Oncology

QL 30 TABS / 30 DAY(S)

PA IRESSA Formulary Brands S

ONC Oncology

QL 60 TABS / 30 DAY(S)

JAKAFI Formulary Brands S

ONC Oncology

TD Trial Drug

QL 21 TABS / 28 DAYS

PA KISQALI 200 MG DAILY DOSE Formulary Brands S

ONC Oncology

QL 42 TABS / 28 DAYS

PA KISQALI 400 MG DAILY DOSE Formulary Brands S

ONC Oncology

QL 63 TABS / 28 DAYS

PA KISQALI 600 MG DAILY DOSE Formulary Brands S

ONC Oncology

PAGE 42 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 49 TABS / 28 DAYS

PA KISQALI FEMARA 200 MG CO-PACK Formulary Brands S

ONC Oncology

QL 70 TABS / 28 DAYS

PA KISQALI FEMARA 400 MG CO-PACK Formulary Brands S

ONC Oncology

QL 91 TABS / 28 DAYS

PA KISQALI FEMARA 600 MG CO-PACK Formulary Brands S

ONC Oncology

QL 8 capsules / 1 day(s)

PA KOSELUGO 10 MG CAPSULE Formulary Brands S

ONC Oncology

QL 4 capsules / 1 day(s)

PA KOSELUGO 25 MG CAPSULE Formulary Brands S

ONC Oncology

QL 6 TABS / DAY

PA lapatinib ditosylate Formulary High Cost Generics S

ONC Oncology

QL 30 TABS / 30 DAY(S)

LENVIMA 10 MG DAILY DOSE Formulary Brands S

ONC Oncology

TD Trial Drug

letrozole Formulary High Cost Generics ACA

LEUKERAN Formulary Brands

PAGE 43 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 60 TABS / 30 DAY(S)

PA LONSURF 15 MG-6.14 MG TABLET Formulary Brands S

ONC Oncology

QL 90 TABS / 30 day(s)

PA LONSURF 20 MG-8.19 MG TABLET Formulary Brands S

ONC Oncology

QL 30 TABS / 30 DAY(S)

LORBRENA 100 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 90 TABS / 30 day(s)

LORBRENA 25 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

QL 4 TABS / 1 DAY

LYNPARZA Formulary Brands S

ONC Oncology

TD Trial Drug

QL 60 CAPS / 30 DAY(S)

PA MATULANE Formulary Brands S

ONC Oncology

QL 90 TABS / 30 day(s)

PA MEKINIST 0.5 MG TABLET Formulary Brands S

ONC Oncology

PAGE 44 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 TABS / 30 DAY(S)

PA MEKINIST 2 MG TABLET Formulary Brands S

ONC Oncology

QL 180 TABS / 30 day(s)

PA MEKTOVI Formulary Brands S

ONC Oncology

melphalan Formulary High Cost Generics mercaptopurine Formulary High Cost Generics methotrexate sodium (2.5 mg tablet, 25 Formulary High Cost Generics mg/ml vial) methotrexate sodium/pf 25 mg/ml vial Formulary High Cost Generics MYLERAN Formulary Brands

QL 180 TABS / 30 day(s)

NERLYNX Formulary Brands S

ONC Oncology

TD Trial Drug

QL 120 TABS / 30 day(s)

NEXAVAR Formulary Brands S

ONC Oncology

TD Trial Drug

QL 30 CAPS / 30 DAY(S)

PA NINLARO Formulary Brands S

ONC Oncology

NUBEQA Formulary Brands S

ONC Oncology

PAGE 45 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 14 tablets / 21 day(s)

PEMAZYRE (9 MG TABLET, 13.5 MG PA Formulary Brands TABLET) S

ONC Oncology

QL 14 tablets / 21 day(s)

PEMAZYRE 4.5 MG TABLET Formulary Brands S

ONC Oncology

PICATO Formulary Brands PA

QL 30 CAPS / 30 DAY(S)

PA POMALYST Formulary Brands S

ONC Oncology

QL 3 tablets / 1 day(s)

PA QINLOCK Formulary Brands S

ONC Oncology

RASUVO Formulary Brands PA

QL 6 capsules / 1 day(s)

PA RETEVMO 40 MG CAPSULE Formulary Brands S

ONC Oncology

QL 4 capsules / 1 day(s)

PA RETEVMO 80 MG CAPSULE Formulary Brands S

ONC Oncology

QL 30 CAPS / 30 DAY(S)

REVLIMID Formulary Brands S

ONC Oncology

ROZLYTREK Formulary Brands S

ONC Oncology

PAGE 46 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

RYDAPT Formulary Brands S

ONC Oncology

S SPRYCEL Formulary Brands ONC Oncology

TD Trial Drug

STIVARGA Formulary Brands S

ONC Oncology

QL 30 CAPS / 30 DAY(S)

SUTENT Formulary Brands S

ONC Oncology

TD Trial Drug

TABLOID Formulary Brands

QL 4 tablets / 1 day(s)

PA TABRECTA Formulary Brands S

ONC Oncology

QL 120 CAPS / 30 DAY(S)

PA TAFINLAR Formulary Brands S

ONC Oncology

QL 30 TABS / 30 DAY(S)

TAGRISSO Formulary Brands S

ONC Oncology

TD Trial Drug

S TASIGNA Formulary Brands ONC Oncology

TD Trial Drug

PAGE 47 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 8 tabs / 1 day(s)

PA TAZVERIK Formulary Brands S

ONC Oncology

S temozolomide Formulary High Cost Generics ONC Oncology

QL 60 TABS / 30 DAY(S)

PA TIBSOVO Formulary Brands S

ONC Oncology

S tretinoin 10 mg capsule Formulary High Cost Generics ONC Oncology

TURALIO Formulary Brands S

ONC Oncology

QL 6 TABS / DAY

PA TYKERB Formulary Brands S

ONC Oncology

QL 120 GM / 30 DAYS

PA VALCHLOR Formulary Brands S

ONC Oncology

QL 56 TABS / 28 DAYS

PA VERZENIO Formulary Brands S

ONC Oncology

QL 60 CAPS / 30 DAY(S)

VITRAKVI 100 MG CAPSULE Formulary Brands S

ONC Oncology

TD Trial Drug

PAGE 48 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 300 ML / 30 DAY(S)

VITRAKVI 20 MG/ML SOLUTION Formulary Brands S

ONC Oncology

TD Trial Drug

QL 180 CAPS / 30 DAY(S)

VITRAKVI 25 MG CAPSULE Formulary Brands S

ONC Oncology

TD Trial Drug

QL 30 TABS / 30 DAY(S)

VIZIMPRO Formulary Brands S

ONC Oncology

TD Trial Drug

QL 120 TABS / 30 day(s)

VOTRIENT Formulary Brands S

ONC Oncology

TD Trial Drug

QL 60 CAPS / 30 DAY(S)

XALKORI Formulary Brands S

ONC Oncology

TD Trial Drug

QL 90 TABS / 30 day(s)

PA XOSPATA Formulary Brands S

ONC Oncology

XPOVIO Formulary Brands S

ONC Oncology

PAGE 49 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

S XTANDI Formulary Brands ONC Oncology

TD Trial Drug

QL 90 CAPS / 30 DAY(S)

ZEJULA Formulary Brands S

ONC Oncology

TD Trial Drug

QL 240 TABS / 30 DAY(S)

PA ZELBORAF Formulary Brands S

ONC Oncology

QL 120 CAPS / 30 DAY(S)

ZOLINZA Formulary Brands S

ONC Oncology

TD Trial Drug

QL 90 caps / 30 day(s)

ZYKADIA 150 MG CAPSULE Formulary Brands S

ONC Oncology

TD Trial Drug

QL 3 TABS / 1 DAY

ZYKADIA 150 MG TABLET Formulary Brands S

ONC Oncology

TD Trial Drug

PAGE 50 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIPARKINSONIAN AGENTS (CNS)

ADAMANTANES (CNS)

amantadine hcl (50 mg/5 ml solution, Formulary High Cost Generics 100 mg tablet) amantadine hcl 100 mg capsule Formulary Low Cost Generics ANTICHOLINERGIC AGENTS (CNS)

benztropine mesylate (0.5 mg tablet, 1 Formulary High Cost Generics mg tablet, 2 mg tablet) trihexyphenidyl hcl (2 mg tablet, 5 mg Formulary Low Cost Generics tablet) trihexyphenidyl hcl 2 mg/5 ml elixir Formulary High Cost Generics CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.

entacapone Formulary High Cost Generics DOPAMINE PRECURSORS

carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tab rapdis, carbidopa/levodopa 10mg-100mg tablet, carbidopa/levodopa 25mg-100mg tab rapdis, carbidopa/levodopa 25mg- 100mg tablet, carbidopa/levodopa Formulary High Cost Generics 25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tab rapdis, carbidopa/levodopa 25mg- 250mg tablet, carbidopa/levodopa 50mg-200mg tablet er) carbidopa/levodopa/entacapone Formulary High Cost Generics

PA INBRIJA Formulary Brands S

RYTARY Formulary Brands ST

MONOAMINE OXIDASE B INHIBITORS

EMSAM Formulary Brands PA

rasagiline mesylate Formulary High Cost Generics PA

selegiline hcl Formulary High Cost Generics

PAGE 51 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANTIPROTOZOALS

ANTIMALARIALS

atovaquone/proguanil hcl Formulary High Cost Generics chloroquine phosphate Formulary High Cost Generics hydroxychloroquine sulfate Formulary High Cost Generics mefloquine hcl Formulary Low Cost Generics ANTIPROTOZOALS, MISCELLANEOUS

ALINIA (100 MG/5 ML SUSPENSION, Formulary Brands PA 500 MG TABLET) atovaquone Formulary High Cost Generics metronidazole (250 mg tablet, 500 mg Formulary High Cost Generics tablet) ANTIPSYCHOTIC AGENTS

ANTIPSYCHOTICS, MISCELLANEOUS

loxapine succinate Formulary High Cost Generics AL1 At least 13 yrs old

ATYPICAL ANTIPSYCHOTICS

aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg Formulary High Cost Generics AL1 At least 13 yrs old tablet, 20 mg tablet, 30 mg tablet)

aripiprazole (10 mg tab rapdis, 15 mg PA Formulary High Cost Generics tab rapdis) AL1 At least 13 yrs old

QL 1 cap / 1 day(s) CAPLYTA Formulary Brands PA

clozapine (12.5 mg tab rapdis, 25 mg PA tab rapdis, 100 mg tab rapdis, 150 mg Formulary High Cost Generics tab rapdis) AL1 At least 13 yrs old clozapine (25 mg tablet, 50 mg tablet, Formulary High Cost Generics AL1 At least 13 yrs old 100 mg tablet, 200 mg tablet)

PA clozapine 200 mg tab rapdis Formulary Low Cost Generics AL1 At least 13 yrs old

FANAPT Formulary Brands PA

QL 1 TAB / 1 DAY LATUDA Formulary Brands PA

PAGE 52 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

NUPLAZID Formulary Brands S

TD Trial Drug

olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg Formulary High Cost Generics AL1 At least 13 yrs old tablet, 20 mg tablet)

olanzapine (5 mg tab rapdis, 10 mg tab PA rapdis, 15 mg tab rapdis, 20 mg tab Formulary High Cost Generics rapdis) AL1 At least 13 yrs old

paliperidone Formulary Low Cost Generics PA

quetiapine fumarate (25 mg tablet, 50 mg tab er 24h, 50 mg tablet, 100 mg tablet, 150 mg tab er 24h, 200 mg tab er Formulary High Cost Generics AL1 At least 13 yrs old 24h, 200 mg tablet, 300 mg tab er 24h, 300 mg tablet, 400 mg tab er 24h, 400 mg tablet)

REXULTI Formulary Brands PA

risperidone (0.25 mg tab rapdis, 0.5 mg PA tab rapdis, 1 mg tab rapdis, 2 mg tab Formulary High Cost Generics rapdis, 3 mg tab rapdis, 4 mg tab rapdis) AL1 At least 13 yrs old risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg Formulary Low Cost Generics AL1 At least 13 yrs old tablet, 4 mg tablet)

risperidone 1 mg/ml solution Formulary High Cost Generics AL1 At least 13 yrs old

SAPHRIS Formulary Brands PA

SECUADO Formulary Brands PA

PA VERSACLOZ Formulary Brands AL1 At least 13 yrs old

2 CAPSULES / 1 VRAYLAR (1.5 MG CAPSULE, 1.5 MG- QL Formulary Brands day(s) 3 MG PACK) PA

VRAYLAR (3 MG CAPSULE, 4.5 MG QL 1 CAPSULE / 1 day(s) Formulary Brands CAPSULE, 6 MG CAPSULE) PA

ziprasidone hcl Formulary High Cost Generics AL1 At least 13 yrs old

PAGE 53 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BUTYROPHENONES

haloperidol Formulary High Cost Generics AL1 At least 13 yrs old

haloperidol lactate 2 mg/ml oral conc Formulary High Cost Generics AL1 At least 13 yrs old

PHENOTHIAZINES

fluphenazine hcl (1 mg tablet, 2.5 mg Formulary High Cost Generics AL1 At least 13 yrs old tablet, 5 mg tablet, 10 mg tablet) fluphenazine hcl (2.5 mg/5ml elixir, 5 Formulary Low Cost Generics AL1 At least 13 yrs old mg/ml oral conc)

perphenazine Formulary Low Cost Generics AL1 At least 13 yrs old

thioridazine hcl Formulary Low Cost Generics AL1 At least 13 yrs old

trifluoperazine hcl Formulary High Cost Generics AL1 At least 13 yrs old

THIOXANTHENES

thiothixene Formulary Low Cost Generics AL1 At least 13 yrs old

ANTIRETROVIRALS

HIV ENTRY AND FUSION INHIBITORS

FUZEON Formulary Brands S

SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MG TABLET, 150 Formulary Brands MG TABLET, 300 MG TABLET) HIV INTEGRASE INHIBITOR ANTIRETROVIRALS

ISENTRESS Formulary Brands ISENTRESS HD Formulary Brands JULUCA Formulary Brands TIVICAY Formulary Brands TIVICAY PD Formulary Brands HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.

EDURANT Formulary Brands efavirenz (50 mg capsule, 600 mg Formulary High Cost Generics tablet) efavirenz 200 mg capsule Formulary Low Cost Generics

PAGE 54 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS INTELENCE Formulary Brands nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg Formulary High Cost Generics tab er 24h) HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS

abacavir sulfate (20 mg/ml solution, 300 Formulary High Cost Generics mg tablet) abacavir sulfate/lamivudine Formulary Low Cost Generics abacavir sulfate/lamivudine/zidovudine Formulary High Cost Generics BIKTARVY Formulary Brands COMPLERA Formulary Brands

DESCOVY Formulary Brands ACA

efavirenz/emtricitabine/tenofovir Formulary High Cost Generics disoproxil fumarate

emtricitabine Formulary High Cost Generics ACA

emtricitabine/tenofovir disoproxil Formulary High Cost Generics ACA fumarate

EMTRIVA 10 MG/ML SOLUTION Formulary Brands ACA

EPIVIR HBV 25 MG/5 ML SOLN Formulary Brands GENVOYA Formulary Brands lamivudine (10 mg/ml solution, 100 mg Formulary High Cost Generics tablet, 150 mg tablet, 300 mg tablet) lamivudine/zidovudine Formulary High Cost Generics ODEFSEY Formulary Brands STRIBILD Formulary Brands

tenofovir disoproxil fumarate Formulary Low Cost Generics ACA

TRIUMEQ Formulary Brands TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MG TABLET, 167 MG-250 Formulary Brands ACA MG TABLET) VIREAD (150 MG TABLET, 200 MG Formulary Brands TABLET, 250 MG TABLET, POWDER) zidovudine (10 mg/ml syrup, 300 mg Formulary High Cost Generics tablet)

PAGE 55 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS zidovudine 100 mg capsule Formulary Low Cost Generics HIV PROTEASE INHIBITOR ANTIRETROVIRALS

APTIVUS (100 MG/ML SOLUTION, 250 Formulary Brands MG CAPSULE) atazanavir sulfate Formulary High Cost Generics EVOTAZ Formulary Brands fosamprenavir calcium Formulary High Cost Generics INVIRASE Formulary Brands KALETRA (100-25 MG TABLET, 200-50 Formulary Brands MG TABLET) LEXIVA 50 MG/ML SUSPENSION Formulary Brands lopinavir/ritonavir Formulary High Cost Generics NORVIR 80 MG/ML SOLUTION Formulary Brands PREZCOBIX Formulary Brands PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG Formulary Brands TABLET, 600 MG TABLET, 800 MG TABLET) REYATAZ 50 MG POWDER PACKET Formulary Brands ritonavir Formulary High Cost Generics SYMTUZA Formulary Brands ANTITHROMBOTIC AGENTS

ANTITHROMBOTIC AGENTS, MISCELLANEOUS

PA CABLIVI 11 MG KIT Formulary Brands S

PLATELET-AGGREGATION INHIBITORS

BRILINTA Formulary Brands cilostazol Formulary High Cost Generics clopidogrel bisulfate 75 mg tablet Formulary Low Cost Generics prasugrel hcl Formulary High Cost Generics

ZONTIVITY Formulary Brands PA

PAGE 56 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PLATELET-REDUCING AGENTS

anagrelide hcl Formulary High Cost Generics ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES

ALLERGENIC EXTRACTS (THERAPEUTIC)

GRASTEK Formulary Brands PA

ODACTRA Formulary Brands PA

PA PALFORZIA Formulary Brands S

RAGWITEK Formulary Brands PA

ANTITOXINS AND IMMUNE GLOBULINS

PA PANZYGA Formulary Brands S

TOXOIDS

ADACEL TDAP Formulary Brands BOOSTRIX TDAP Formulary Brands DAPTACEL DTAP Formulary Brands INFANRIX DTAP Formulary Brands TENIVAC SYRINGE Formulary Brands tetanus and diphtheria toxoids, adult Formulary Brands tetanus,diphtheria toxoid ped/pf Formulary Brands VACCINES

ACTHIB Formulary Brands adenovirus live type-4 and adenovirus Formulary Brands live type-7 vaccine adenovirus vaccine live type-4 Formulary Brands adenovirus vaccine live type-7 Formulary Brands AFLURIA 2018-2019 (SYRINGE, VIAL) Formulary Brands AFLURIA QUAD 2018-2019 (SYRINGE, Formulary Brands VIAL) AFLURIA QUAD 2019-20 (3YR UP) Formulary Brands

PAGE 57 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS AFLURIA QUAD 2019-20 (6-35MO) Formulary Brands AFLURIA QUAD 2019-2020 Formulary Brands AFLURIA QUAD 2020-2021 Formulary Brands AFLURIA QUAD 2020-21 (3YR UP) Formulary Brands AFLURIA QUAD 2020-21 (6-35MO) Formulary Brands BEXSERO Formulary Brands ENGERIX-B ADULT Formulary Brands ENGERIX-B PEDIATRIC- Formulary Brands ADOLESCENT EZ FLU 2018-2019 (FLUCELVAX) Formulary Brands FLUAD 2018-2019 Formulary Brands FLUAD 2019-2020 Formulary Brands FLUAD 2020-2021 Formulary Brands FLUAD QUAD 2020-2021 Formulary Brands FLUARIX QUAD 2018-2019 Formulary Brands FLUARIX QUAD 2019-2020 Formulary Brands FLUARIX QUAD 2020-2021 Formulary Brands FLUBLOK QUAD 2018-2019 Formulary Brands FLUBLOK QUAD 2019-2020 Formulary Brands FLUBLOK QUAD 2020-2021 Formulary Brands FLUCELVAX QUAD 2018-2019 (SYR, Formulary Brands VIAL) FLUCELVAX QUAD 2019-2020 (SYR, Formulary Brands VIAL) FLUCELVAX QUAD 2020-2021 (SYR, Formulary Brands VIAL) FLULAVAL QUAD 2018-2019 (SYR, Formulary Brands VIAL) FLULAVAL QUAD 2019-2020 (SYR, Formulary Brands VIAL) FLULAVAL QUAD 2020-2021 Formulary Brands FLUMIST QUAD 2018-2019 Formulary Brands FLUMIST QUAD 2019-2020 Formulary Brands

PAGE 58 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FLUMIST QUAD 2020-2021 Formulary Brands FLUZONE HIGH-DOSE 2018-2019 Formulary Brands FLUZONE HIGH-DOSE 2019-2020 Formulary Brands FLUZONE HIGH-DOSE QUAD 2020-21 Formulary Brands FLUZONE QUAD 2018-2019 Formulary Brands FLUZONE QUAD 2019-2020 Formulary Brands FLUZONE QUAD 2020-2021 Formulary Brands FLUZONE QUAD PEDI 2018-2019 Formulary Brands FLUZONE QUAD PEDI 2019-2020 Formulary Brands GARDASIL 9 Formulary Brands HAVRIX Formulary Brands HEPLISAV-B 20 MCG/0.5 ML SYRNG Formulary Brands HIBERIX Formulary Brands KINRIX Formulary Brands MENACTRA Formulary Brands MENQUADFI Formulary Brands MENVEO A-C-Y-W-135-DIP Formulary Brands MODERNA COVID19 Formulary Brands VACC(UNAPPROV) PEDIARIX Formulary Brands PEDVAXHIB Formulary Brands PENTACEL Formulary Brands PENTACEL ACTHIB COMPONENT Formulary Brands PENTACEL DTAP-IPV COMPONENT Formulary Brands PFIZER COVID19 VACC (UNAPPROV) Formulary Brands PNEUMOVAX 23 Formulary Brands PREVNAR 13 Formulary Brands PROQUAD Formulary Brands RECOMBIVAX HB (5 MCG/0.5 ML SYR, Formulary Brands 10 MCG/ML SYR, 40 MCG/ML VIAL)

SHINGRIX Formulary Brands QL 1 KIT / rx

PAGE 59 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

SHINGRIX GE ANTIGEN COMPONENT Formulary Brands QL 1 KIT / rx

TRUMENBA Formulary Brands TWINRIX Formulary Brands VAQTA (25 UNITS/0.5 ML SYRINGE, 50 UNITS/ML SYRINGE, 50 UNITS/ML Formulary Brands VIAL) VARIVAX VACCINE Formulary Brands VAXCHORA ACTIVE COMPONENT Formulary Brands VAXCHORA VACCINE Formulary Brands VIVOTIF Formulary Brands ZOSTAVAX Formulary Brands ANTIULCER AGENTS AND ACID SUPPRESSANTS

ANTIULCER AGENTS AND ACID SUPPRESS.,MISC

TALICIA Formulary Brands PA

HISTAMINE H2-ANTAGONISTS

cimetidine (300 mg tablet, 400 mg tablet, Formulary High Cost Generics 800 mg tablet) cimetidine hcl Formulary High Cost Generics famotidine (20 mg tablet, 40 mg tablet) Formulary Low Cost Generics PROSTAGLANDINS

misoprostol Formulary High Cost Generics PROTECTANTS

sucralfate 1 g tablet Formulary High Cost Generics PROTON-PUMP INHIBITORS

esomeprazole magnesium (20 mg Formulary High Cost Generics capsule dr, 40 mg capsule dr) lansoprazole (15 mg capsule dr, 30 mg Formulary High Cost Generics capsule dr) lansoprazole (15 mg tab rap dr, 30 mg Formulary High Cost Generics AL1 Up to 9 yrs old tab rap dr) omeprazole Formulary High Cost Generics pantoprazole sodium (20 mg tablet dr, Formulary Low Cost Generics 40 mg tablet dr)

PAGE 60 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS rabeprazole sodium 20 mg tablet dr Formulary High Cost Generics ANTIVIRALS (SYSTEMIC)

ADAMANTANE ANTIVIRALS

rimantadine hcl Formulary High Cost Generics ANTIVIRALS, MISCELLANEOUS

PREVYMIS (240 MG TABLET, 480 MG Formulary Brands TABLET) INTERFERON ANTIVIRALS

ALFERON N Formulary Brands S

INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLION Formulary Brands S UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)

PA PEGASYS Formulary Brands S

PA PEGASYS PROCLICK Formulary Brands S

PA PEGINTRON Formulary Brands S

S SYLATRON Formulary Brands ONC Oncology

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir phosphate (45 mg capsule, Formulary High Cost Generics QL 10 CAPS / 1 FILL 75 mg capsule)

oseltamivir phosphate 30 mg capsule Formulary High Cost Generics QL 20 CAPS / 1 FILL

oseltamivir phosphate 6 mg/ml susp Formulary High Cost Generics QL 180 ML / 1 FILL recon

RELENZA Formulary Brands QL 20 CAPS / 1 FILL

NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALS

acyclovir (200 mg capsule, 400 mg Formulary High Cost Generics tablet, 800 mg tablet)

acyclovir 200 mg/5ml oral susp Formulary High Cost Generics AL1 Up to 12 yrs old

PAGE 61 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS adefovir dipivoxil Formulary High Cost Generics BARACLUDE 0.05 MG/ML SOLUTION Formulary Brands entecavir Formulary Low Cost Generics famciclovir Formulary High Cost Generics

REBETOL Formulary Brands S

ribavirin (200 mg capsule, 200 mg Formulary High Cost Generics S tablet) valacyclovir hcl Formulary High Cost Generics valganciclovir hcl (50 mg/ml soln recon, Formulary High Cost Generics 450 mg tablet) VEMLIDY Formulary Brands ANXIOLYTICS, SEDATIVES AND HYPNOTICS

ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC

buspirone hcl Formulary High Cost Generics eszopiclone Formulary High Cost Generics hydroxyzine hcl (10 mg tablet, 25 mg Formulary Low Cost Generics tablet, 50 mg tablet) hydroxyzine hcl (10 mg/5 ml solution, 50 Formulary High Cost Generics mg/25ml solution) hydroxyzine pamoate Formulary High Cost Generics zaleplon Formulary High Cost Generics zolpidem tartrate (5 mg tablet, 10 mg Formulary Low Cost Generics tablet) zolpidem tartrate (6.25 mg tab mphase, Formulary High Cost Generics ST 12.5 mg tab mphase) BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 60 Formulary High Cost Generics mg tablet, 100 mg tablet) BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)

alprazolam (0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tablet, 1 mg tab er 24h, 1 Formulary Low Cost Generics QL 6 TABS / 1 DAY mg tablet) alprazolam (2 mg tab er 24h, 2 mg Formulary Low Cost Generics QL 3 TABS / 1 DAY tablet)

PAGE 62 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

alprazolam 3 mg tab er 24h Formulary Low Cost Generics QL 2 TABS / 1 DAY

chlordiazepoxide hcl 10 mg capsule Formulary Low Cost Generics QL 6 CAPS / 1 DAY

chlordiazepoxide hcl 25 mg capsule Formulary Low Cost Generics QL 4 CAPS / 1 DAY

chlordiazepoxide hcl 5 mg capsule Formulary High Cost Generics QL 6 CAPS / 1 DAY

diazepam (2 mg tablet, 5 mg tablet) Formulary Low Cost Generics QL 6 TABS / 1 DAY

diazepam (2.5 mg kit, 5-7.5-10mg kit, Formulary High Cost Generics QL 4 KIT / 30 DAYS 12.5-15-20 kit)

diazepam 10 mg tablet Formulary Low Cost Generics QL 4 TABS / 1 DAY

diazepam 5 mg/5 ml solution Formulary High Cost Generics QL 40 ML / 1 DAY

diazepam 5 mg/ml oral conc Formulary High Cost Generics QL 8 ML / 1 DAY

lorazepam (0.5 mg tablet, 1 mg tablet) Formulary Low Cost Generics QL 6 TABS / 1 DAY

lorazepam 2 mg tablet Formulary Low Cost Generics QL 5 TABS / 1 DAY

lorazepam 2 mg/ml oral conc Formulary High Cost Generics QL 5 ML / 1 DAY

LORAZEPAM INTENSOL Formulary High Cost Generics QL 5 ML / 1 DAY

temazepam 15 mg capsule Formulary Low Cost Generics QL 2 CAPS / 1 DAY

temazepam 30 mg capsule Formulary Low Cost Generics QL 1 CAP / 1 DAY

QL 1 carton / rx VALTOCO Formulary Brands PA

AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

QL 2 TABS / 1 DAY CHANTIX Formulary Brands SC Smoking Cessation

NICOTROL Formulary Brands SC Smoking Cessation

NICOTROL NS Formulary Brands SC Smoking Cessation

PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)

bethanechol chloride Formulary High Cost Generics cevimeline hcl Formulary High Cost Generics

PAGE 63 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS donepezil hcl (5 mg tab rapdis, 5 mg Formulary High Cost Generics tablet, 10 mg tab rapdis, 10 mg tablet) galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, Formulary High Cost Generics 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel) pilocarpine hcl (5 mg tablet, 7.5 mg Formulary High Cost Generics tablet)

pyridostigmine bromide 180 mg tablet er Formulary High Cost Generics PA

pyridostigmine bromide 30 mg tablet Formulary High Cost Generics QL 30 TABS / 30 DAY(S)

pyridostigmine bromide 60 mg tablet Formulary High Cost Generics rivastigmine Formulary High Cost Generics rivastigmine tartrate Formulary High Cost Generics BETA-3-ADRENERGIC AGONISTS

SELECTIVE BETA-3-ADRENERGIC AGONISTS

MYRBETRIQ Formulary Brands BETA-ADRENERGIC AGONISTS

SELECTIVE BETA-2-ADRENERGIC AGONISTS

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg/5 ml syrup, Formulary High Cost Generics 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 5 mg/ml solution) levalbuterol tartrate Formulary High Cost Generics SEREVENT DISKUS Formulary Brands STRIVERDI RESPIMAT Formulary Brands VENTOLIN HFA Formulary High Cost Generics BLOOD FORMATION, COAGULATION, THROMBOSIS

BLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.

QL 3 tablets / 1 day(s)

OXBRYTA Formulary Brands PA

PAGE 64 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS HEMATOPOIETIC AGENTS

ARANESP Formulary Brands S

FULPHILA Formulary Brands

GRANIX Formulary Brands S

PROMACTA (12.5 MG TABLET, 25 MG PA TABLET, 50 MG TABLET, 75 MG Formulary Brands TABLET) S

QL 1 PACKETS / 1 day(s) PROMACTA 12.5 MG SUSPEN Formulary Brands PA PACKET S

QL 3 PACKETS / 1 day(s) PROMACTA 25 MG SUSPENSION Formulary Brands PA PCKT S

RETACRIT (2,000 UNIT/ML VIAL, 3,000 UNIT/ML VIAL, 4,000 UNIT/ML VIAL, Formulary Brands S 10,000 UNIT/ML VIAL, 20,000 UNIT/2 ML VIAL, 40,000 UNIT/ML VIAL) UDENYCA Formulary Brands ZIEXTENZO Formulary Brands HEMORRHEOLOGIC AGENTS

pentoxifylline Formulary High Cost Generics CALCIUM-CHANNEL BLOCKING AGENTS

CALCIUM-CHANNEL BLOCKING AGENTS, MISC.

CARTIA XT Formulary High Cost Generics DILT-XR Formulary Low Cost Generics diltiazem hcl (120 mg cap er deg, 180 mg cap er deg, 240 mg cap er deg, 360 Formulary Low Cost Generics mg cap sa 24h) diltiazem hcl (30 mg tablet, 60 mg tablet, 90 mg tablet, 120 mg cap er 24h, 120 mg cap sa 24h, 120 mg tablet, 180 mg cap er 24h, 180 mg cap sa 24h, 240 mg Formulary High Cost Generics cap er 24h, 240 mg cap sa 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 420 mg cap sa 24h)

PAGE 65 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MATZIM LA 240 MG TABLET Formulary Low Cost Generics TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MG CAPSULE, 300 Formulary High Cost Generics MG CAPSULE) TAZTIA XT 360 MG CAPSULE Formulary Low Cost Generics TIADYLT ER (ER 180 MG CAPSULE, Formulary High Cost Generics ER 420 MG CAPSULE) verapamil hcl (120 mg tablet er, 180 mg tablet er, 240 mg tablet er, 360 mg Formulary High Cost Generics cap24h pel) verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg cap24h pel, 120 mg Formulary Low Cost Generics tablet, 180 mg cap24h pel, 240 mg cap24h pel) DIHYDROPYRIDINES

AFEDITAB CR Formulary High Cost Generics amlodipine besylate Formulary Low Cost Generics amlodipine besylate/benazepril hcl Formulary High Cost Generics amlodipine besylate/valsartan Formulary Low Cost Generics amlodipine Formulary High Cost Generics besylate/valsartan/hydrochlorothiazide felodipine Formulary High Cost Generics nifedipine (10 mg capsule, 20 mg Formulary High Cost Generics AL1 Up to 45 yrs old capsule) nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tab er 24, 60 mg tablet er, 90 Formulary High Cost Generics mg tab er 24, 90 mg tablet er) nimodipine Formulary High Cost Generics CARDIAC DRUGS

CARDIAC DRUGS, MISCELLANEOUS

CORLANOR (5 MG TABLET, 5 MG/5 Formulary Brands PA ML ORAL SOLN, 7.5 MG TABLET)

PA VYNDAMAX Formulary Brands S

PA VYNDAQEL Formulary Brands S

PAGE 66 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CARDIOTONIC AGENTS

DIGITEK 125 MCG TABLET Formulary High Cost Generics

DIGITEK 250 MCG TABLET Formulary High Cost Generics AL1 Up to 64 yrs old

DIGOX 125 MCG TABLET Formulary High Cost Generics

DIGOX 250 MCG TABLET Formulary High Cost Generics AL1 Up to 64 yrs old

digoxin 125 mcg tablet Formulary High Cost Generics

digoxin 250 mcg tablet Formulary High Cost Generics AL1 Up to 64 yrs old

digoxin 50 mcg/ml solution Formulary Brands CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate Formulary High Cost Generics prazosin hcl Formulary High Cost Generics terazosin hcl Formulary Low Cost Generics BETA-ADRENERGIC BLOCKING AGENTS

atenolol Formulary Low Cost Generics atenolol/chlorthalidone Formulary High Cost Generics bisoprolol fumarate Formulary High Cost Generics bisoprolol fumarate/hydrochlorothiazide Formulary Low Cost Generics carvedilol Formulary Low Cost Generics labetalol hcl (100 mg tablet, 200 mg Formulary High Cost Generics tablet, 300 mg tablet) metoprolol succinate Formulary High Cost Generics metoprolol tartrate (25 mg tablet, 50 mg Formulary Low Cost Generics tablet, 100 mg tablet) metoprolol tartrate/hydrochlorothiazide Formulary High Cost Generics nadolol Formulary Low Cost Generics propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet, Formulary High Cost Generics 40mg/5ml solution, 60 mg tablet, 80 mg tablet) propranolol hcl (60 mg cap sa 24h, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 Formulary Low Cost Generics mg cap sa 24h)

PAGE 67 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS propranolol hcl/hydrochlorothiazide Formulary High Cost Generics sotalol hcl (80 mg tablet, 120 mg tablet, Formulary High Cost Generics 160 mg tablet, 240 mg tablet) CENTRAL NERVOUS SYSTEM AGENTS

ANTIMANIC AGENTS

lithium carbonate (150 mg capsule, 300 mg capsule, 300 mg tablet, 300 mg Formulary High Cost Generics tablet er, 450 mg tablet er, 600 mg capsule) lithium citrate Formulary High Cost Generics CENTRAL NERVOUS SYSTEM AGENTS, MISC.

acamprosate calcium Formulary High Cost Generics atomoxetine hcl (10 mg capsule, 18 mg Formulary High Cost Generics QL 2 CAPS / 1 DAY capsule, 25 mg capsule, 40 mg capsule) atomoxetine hcl (60 mg capsule, 80 mg Formulary High Cost Generics QL 1 CAP / 1 DAY capsule, 100 mg capsule) carbidopa Formulary Low Cost Generics guanfacine hcl (3 mg tab er 24h, 4 mg Formulary High Cost Generics QL 1 TAB / 1 DAY tab er 24h)

guanfacine hcl 1 mg tab er 24h Formulary High Cost Generics QL 3 TABS / 1 DAY

guanfacine hcl 2 mg tab er 24h Formulary High Cost Generics QL 2 TABS / 1 DAY

memantine hcl (2 mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk, 10 mg Formulary High Cost Generics tablet)

PA NOURIANZ Formulary Brands S

riluzole Formulary High Cost Generics

QL 18 ML / 1 DAY

XYREM Formulary Brands PA

QL 18 ML / DAY

XYWAV Formulary Brands PA

PAGE 68 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS FIBROMYALGIA AGENTS

SAVELLA (12.5 MG TABLET, 25 MG QL 2 tabs / 1 day(s) TABLET, 50 MG TABLET, 100 MG Formulary Brands TABLET) PA

QL 55 tabs / 28 day(s) SAVELLA TITRATION PACK Formulary Brands PA

OPIATE ANTAGONISTS

naloxone hcl 1 mg/ml syringe Formulary High Cost Generics naltrexone hcl Formulary High Cost Generics NARCAN Formulary Brands VESICULAR MONOAMINE TRANSPORT2 INHIBITOR

PA AUSTEDO Formulary Brands S

PA INGREZZA Formulary Brands S

PA INGREZZA INITIATION PACK Formulary Brands S

PA tetrabenazine Formulary High Cost Generics S

CEPHALOSPORIN ANTIBIOTICS

1ST GENERATION CEPHALOSPORIN ANTIBIOTICS

cefadroxil (1 g tablet, 250 mg/5ml susp Formulary Low Cost Generics recon, 500 mg/5ml susp recon) cefadroxil 500 mg capsule Formulary High Cost Generics cephalexin (125 mg/5ml susp recon, 250 Formulary High Cost Generics mg/5ml susp recon) cephalexin (250 mg capsule, 500 mg Formulary Low Cost Generics capsule) 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS

cefprozil (125 mg/5ml susp recon, 250 Formulary Low Cost Generics mg/5ml susp recon) cefprozil (250 mg tablet, 500 mg tablet) Formulary High Cost Generics

PAGE 69 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cefuroxime axetil Formulary High Cost Generics 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS

cefdinir (125 mg/5ml susp recon, 250 Formulary High Cost Generics mg/5ml susp recon) cefdinir 300 mg capsule Formulary Low Cost Generics

cefixime 400 mg capsule Formulary High Cost Generics QL 1 CAP / 30 DAY(S)

CORTICOSTEROIDS (RESPIRATORY TRACT)

ORALLY INHALED PREPARATIONS (STEROIDS)

ADVAIR DISKUS Formulary High Cost Generics ADVAIR HFA Formulary Brands ARNUITY ELLIPTA Formulary Brands ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #30, Formulary Brands TWISTHALER 220 MCG #60, TWISTHALR 220 MCG #120) ASMANEX HFA Formulary Brands BREO ELLIPTA Formulary Brands budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul- Formulary High Cost Generics neb)

budesonide/formoterol fumarate Formulary High Cost Generics PA

DULERA Formulary Brands PA

FLOVENT DISKUS Formulary Brands FLOVENT HFA Formulary Brands fluticasone propionate/salmeterol xinafoate (propion/salmeterol 55-14 mcg aer pow ba, propion/salmeterol 113-14 Formulary High Cost Generics mcg aer pow ba, propion/salmeterol 232-14 mcg aer pow ba) PULMICORT FLEXHALER Formulary Brands QVAR REDIHALER Formulary Brands TRELEGY ELLIPTA Formulary Brands

PAGE 70 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CYSTIC FIBROSIS (CFTR) MODULATORS

CYSTIC FIBROSIS (CFTR) CORRECTORS

PA SYMDEKO Formulary Brands S

PA TRIKAFTA Formulary Brands S

CYSTIC FIBROSIS (CFTR) POTENTIATORS

PA KALYDECO Formulary Brands S

PA ORKAMBI Formulary Brands S

DEVICES

ACE AEROSOL CLOUD ENHANCER Covered AEROCHAMBER MINI Covered AEROCHAMBER MV Covered AEROCHAMBER PLUS FLOW-VU (, Covered LARGE, MED, SMALL) AEROCHAMBER WITH FLOWSIGNAL Covered AEROCHAMBER Z-STAT PLUS (PLUS LARGE, PLUS W-FLOW, PLUS-MED, Covered PLUS-SMALL) AEROTRACH PLUS Covered BREATHERITE Covered BREATHRITE Covered

QL 1 receiver / 365 day(s)

DEXCOM Covered PA

DS Diabetic Supply

QL 1 receiver / 365 day(s) DEXCOM G4 ((PED) RECEIVER KIT, RECEIVER KIT, RECEIVER-SHARE Covered PA (PED), RECEIVER-SHARE KIT) DS Diabetic Supply

QL 1 transmitter / 180 day(s) DEXCOM G4 TRANSMITTER KIT Covered PA

DS Diabetic Supply

PAGE 71 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 1 receiver / 365 day(s)

DEXCOM G5 RECEIVER KIT Covered PA

DS Diabetic Supply

QL 1 transmitter / 90 day(s) DEXCOM G5 TRANSMITTER KIT Covered PA

DS Diabetic Supply

QL 1 kit (a 4 pack) / 28 day(s) DEXCOM G5-G4 SENSOR Covered PA

DS Diabetic Supply

QL 1 receiver / 365 day(s)

DEXCOM G6 RECEIVER Covered PA

DS Diabetic Supply

QL 3 sensors / 30 day(s)

DEXCOM G6 SENSOR Covered PA

DS Diabetic Supply

QL 1 transmitter / 84 day(s) DEXCOM G6 TRANSMITTER Covered PA

DS Diabetic Supply

EASIVENT (HOLDING CHAMBER, MASK-LARGE, MASK-MEDIUM, MASK- Covered SMALL)

QL 1 reader / 365 day(s)

FREESTYLE LIBRE 10 DAY READER Covered PA

DS Diabetic Supply

QL 3 sensors / 30 day(s)

FREESTYLE LIBRE 10 DAY SENSOR Covered PA

DS Diabetic Supply

QL 1 reader / 365 day(s)

FREESTYLE LIBRE 14 DAY READER Covered PA

DS Diabetic Supply

PAGE 72 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 sensors / 28 day(s)

FREESTYLE LIBRE 14 DAY SENSOR Covered PA

DS Diabetic Supply

QL 1 reader / 365 day(s)

FREESTYLE LIBRE 2 READER Covered PA

DS Diabetic Supply

QL 2 sensors / 28 day(s)

FREESTYLE LIBRE 2 SENSOR Covered PA

DS Diabetic Supply

INPEN (FOR HUMALOG) Covered INPEN (FOR NOVOLOG OR FIASP) Covered LITETOUCH Covered MICROCHAMBER Covered MICROSPACER Covered NOVOPEN ECHO Covered OMNIPOD (5 PACK POD, STARTER Covered KIT) OMNIPOD DASH 5 PACK POD Covered OMNIPOD DASH PDM KIT Covered OPTICHAMBER Covered OPTICHAMBER DIAMOND (VHC, W- Covered LRG MASK) POCKET CHAMBER Covered PROCHAMBER Covered SILICONE MASK-INFANT Covered V-GO 20 Covered V-GO 30 Covered V-GO 40 Covered VGO 20 Covered VGO 30 Covered VGO 40 Covered

PAGE 73 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VORTEX Covered DIAGNOSTIC AGENTS

ADRENOCORTICAL INSUFFICIENCY

PA ACTHAR Formulary Brands S

DIURETICS

LOOP DIURETICS

bumetanide (0.5 mg tablet, 1 mg tablet, Formulary High Cost Generics 2 mg tablet) furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, Formulary Low Cost Generics 80 mg tablet) torsemide Formulary High Cost Generics POTASSIUM-SPARING DIURETICS

amiloride hcl Formulary High Cost Generics amiloride hcl/hydrochlorothiazide Formulary High Cost Generics triamterene/hydrochlorothiazide Formulary Low Cost Generics THIAZIDE DIURETICS

chlorothiazide Formulary High Cost Generics DIURIL Formulary Brands hydrochlorothiazide Formulary Low Cost Generics THIAZIDE-LIKE DIURETICS

chlorthalidone Formulary High Cost Generics indapamide Formulary High Cost Generics metolazone Formulary High Cost Generics DOPAMINE RECEPTOR AGONISTS

ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS

bromocriptine mesylate Formulary High Cost Generics cabergoline Formulary High Cost Generics

CYCLOSET Formulary Brands PA

PAGE 74 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST

NEUPRO Formulary Brands PA

pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg Formulary High Cost Generics tablet, 1 mg tablet, 1.5 mg tablet) pramipexole di-hcl (0.375 mg tab er 24h, 0.75 mg tab er 24h, 1.5 mg tab er 24h, Formulary High Cost Generics PA 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mg tab er 24h, 4.5 mg tab er 24h) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg Formulary High Cost Generics tablet, 4 mg tablet, 5 mg tablet) ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 24h, 8 mg tab er Formulary High Cost Generics PA 24h, 12 mg tab er 24h) ELECTROLYTIC, CALORIC, AND WATER BALANCE

ALKALINIZING AGENTS

potassium citrate Formulary High Cost Generics AMMONIA DETOXICANTS

PA CARBAGLU Formulary Brands S

ENULOSE Formulary High Cost Generics GENERLAC Formulary High Cost Generics lactulose 10 g/15 ml solution Formulary High Cost Generics

sodium phenylbutyrate 0.94 g/g powder Formulary High Cost Generics PA

CALORIC AGENTS

PA DOJOLVI Formulary Brands S

REPLACEMENT PREPARATIONS

KLOR-CON M10 Formulary High Cost Generics KLOR-CON M15 Formulary High Cost Generics KLOR-CON M20 Formulary High Cost Generics

PAGE 75 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10 meq tab er prt, 10 meq tablet er, 20 meq Formulary High Cost Generics packet, 20 meq tab er prt, 20 meq tablet er, 20meq/15ml liquid, 40meq/15ml liquid) URICOSURIC AGENTS

probenecid Formulary High Cost Generics probenecid/colchicine Formulary High Cost Generics EMOLLIENTS, DEMULCENTS, AND PROTECTANTS

BASIC LOTIONS AND LINIMENTS

ammonium lactate 12 % lotion Formulary High Cost Generics BASIC OINTMENTS AND PROTECTANTS

ammonium lactate 12 % cream (g) Formulary High Cost Generics ENZYMES

PA REVCOVI Formulary Brands S

PA STRENSIQ Formulary Brands S

PA SUCRAID Formulary Brands S

ESTROGENS AND ANTIESTROGENS

ESTROGEN AGONIST-ANTAGONISTS

clomiphene citrate Covered INF Infertility

raloxifene hcl Formulary High Cost Generics ACA

SEROPHENE Covered INF Infertility

SOLTAMOX Formulary Brands

tamoxifen citrate Formulary High Cost Generics ACA

ESTROGENS

AMABELZ 0.5 MG-0.1 MG TABLET Formulary High Cost Generics CLIMARA PRO Formulary Brands

PAGE 76 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS COMBIPATCH Formulary Brands DOTTI Formulary High Cost Generics estradiol (0.01 % cream/appl, .025mg/24h patch tdsw, .025mg/24h patch tdwk, .0375mg/24 patch tdsw, .0375mg/24 patch tdwk, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk, Formulary High Cost Generics 0.06mg/24h patch tdwk, .075mg/24h patch tdsw, .075mg/24h patch tdwk, 0.1mg/24hr patch tdsw, 0.1mg/24hr patch tdwk, 10 mcg tablet) estradiol (0.5 mg tablet, 1 mg tablet, 2 Formulary Low Cost Generics mg tablet) estradiol/norethindrone acet 0.5-0.1 mg Formulary High Cost Generics tablet ESTRING Formulary Brands FYAVOLV 1 MG-5 MCG TABLET Formulary High Cost Generics JINTELI Formulary High Cost Generics LOPREEZA 0.5 MG-0.1 MG TABLET Formulary High Cost Generics MIMVEY LO Formulary High Cost Generics norethindrone acetate-ethinyl estradiol Formulary High Cost Generics (0.5mg-2.5 tablet, 1mg-5mcg tablet) PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG Formulary Brands TABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL) PREMPHASE Formulary Brands PREMPRO Formulary Brands YUVAFEM Formulary High Cost Generics EYE, EAR, NOSE AND THROAT (EENT) PREPS.

ANTIALLERGIC AGENTS

azelastine hcl (0.05 % drops, 137 mcg Formulary High Cost Generics spray/pump) epinastine hcl Formulary High Cost Generics olopatadine hcl 0.1 % drops Formulary High Cost Generics

PAGE 77 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS EENT DRUGS, MISCELLANEOUS

PA CYSTADROPS Formulary Brands S

PA CYSTARAN Formulary Brands S

ipratropium bromide (21 mcg spray, 42 Formulary High Cost Generics mcg spray)

LACRISERT Formulary Brands PA

QL 1 ML / 1 DAY

OXERVATE Formulary Brands PA

LOCAL ANESTHETICS (EENT)

lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 40 mg/ml Formulary High Cost Generics solution) MYDRIATICS

atropine sulfate (1 % drops, 1 % oint. Formulary High Cost Generics (g)) cyclopentolate hcl Formulary High Cost Generics homatropine hbr Formulary High Cost Generics VASOCONSTRICTORS

phenylephrine hcl (2.5 % drops, 10 % Formulary High Cost Generics drops) FIRST GENERATION ANTIHISTAMINES

FIRST GEN. ANTIHIST. DERIVATIVES, MISC.

cyproheptadine hcl Formulary High Cost Generics PHENOTHIAZINE DERIVATIVES

PHENADOZ Formulary High Cost Generics phenylephrine hcl/promethazine hcl Formulary Low Cost Generics promethazine hcl (12.5 mg supp.rect, 25 Formulary High Cost Generics mg supp.rect, 50 mg supp.rect) promethazine hcl (12.5 mg tablet, 25 mg Formulary High Cost Generics AQ1 Up to 64 yrs old; 30 / 1 tablet, 50 mg tablet) FILL

PAGE 78 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

promethazine hcl 6.25mg/5ml syrup Formulary Low Cost Generics AQ1 Up to 64 yrs old; 300 / 1 FILL PROMETHEGAN Formulary High Cost Generics GASTROINTESTINAL DRUGS

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron hcl Formulary High Cost Generics PA

balsalazide disodium Formulary High Cost Generics mesalamine (0.375g cap er 24h, 1.2 g tablet dr, 4 g/60 ml enema, 400 mg Formulary High Cost Generics cap(drtab), 800 mg tablet dr, 1000 mg supp.rect) ANTIDIARRHEA AGENTS

diphenoxylate hcl/atropine 2.5-.025/5 Formulary High Cost Generics QL 40 ML / 1 DAY liquid diphenoxylate hcl/atropine 2.5-.025mg Formulary High Cost Generics QL 8 TABS / 1 DAY tablet

paregoric Formulary High Cost Generics QL 40 ML / 1 DAY

PA XERMELO Formulary Brands S

CATHARTICS AND LAXATIVES

AMITIZA Formulary Brands QL 2 CAPS / 1 DAY

GAVILYTE-C Formulary High Cost Generics

GAVILYTE-G Formulary High Cost Generics ACA

GAVILYTE-N Formulary High Cost Generics sodium chloride/sodium Formulary High Cost Generics bicarbonate/potassium chloride/peg

SUPREP Formulary Brands ACA

TRILYTE WITH FLAVOR PACKETS Formulary High Cost Generics CHOLELITHOLYTIC AGENTS

ursodiol Formulary High Cost Generics

PAGE 79 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DIGESTANTS

CREON Formulary Brands GI DRUGS, MISCELLANEOUS

PA CHOLBAM Formulary Brands S

PA ENDARI Formulary Brands S

QL 2 ML / 28 day(s)

HUMIRA(CF) PEDI CROHN 80-40 MG Formulary Brands PA

LINZESS Formulary Brands QL 1 CAP / 1 DAY

QL 1 TAB / 1 DAY MOVANTIK Formulary Brands PA

SYMPROIC Formulary Brands PA

PA XENICAL Formulary Brands WL Weight Loss

PROKINETIC AGENTS

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10ml Formulary Low Cost Generics solution) GENITOURINARY SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

oxybutynin chloride (5 mg tab er 24, 5 mg/5 ml syrup, 10 mg tab er 24, 15 mg Formulary High Cost Generics tab er 24) oxybutynin chloride 5 mg tablet Formulary Low Cost Generics solifenacin succinate Formulary High Cost Generics tolterodine tartrate (1 mg tablet, 2 mg cap er 24h, 2 mg tablet, 4 mg cap er Formulary High Cost Generics 24h) trospium chloride 20 mg tablet Formulary Low Cost Generics

PAGE 80 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS GOLD COMPOUNDS

RIDAURA Formulary Brands GONADOTROPINS AND ANTIGONADOTROPINS

ANTIGONADTROPINS

CETROTIDE Covered INF Infertility

ganirelix acetate Covered INF Infertility

QL 28 TABS / 28 DAYS

ORILISSA 150 MG TABLET Formulary Brands PA

QL 56 TABS / 28 DAYS

ORILISSA 200 MG TABLET Formulary Brands PA

GONADOTROPINS

chorionic gonadotropin, human (6000 Covered INF Infertility unit vial, 10000 unit vial, 12000 unit vial)

FOLLISTIM AQ Covered INF Infertility

leuprolide acetate Covered INF Infertility

MENOPUR Covered INF Infertility

NOVAREL Covered INF Infertility

OVIDREL Covered INF Infertility

PREGNYL Covered INF Infertility

HCV ANTIVIRALS

HCV POLYMERASE INHIBITOR ANTIVIRALS

PA EPCLUSA 200 MG-50 MG TABLET Formulary Brands S

HARVONI (33.75-150 MG PELLET PK, PA 45-200 MG PELLET PACKT, 45-200 Formulary Brands MG TABLET) S

PA ledipasvir/sofosbuvir Formulary High Cost Generics S

PAGE 81 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA sofosbuvir/velpatasvir Formulary High Cost Generics S

SOVALDI (150 MG PELLET PACKET, PA 200 MG PELLET PACKET, 200 MG Formulary Brands TABLET) S

PA VOSEVI Formulary Brands S

HCV PROTEASE INHIBITOR ANTIVIRALS

PA MAVYRET Formulary Brands S

HEAVY METAL ANTAGONISTS

CHEMET Formulary Brands

D-PENAMINE Formulary High Cost Generics PA

deferasirox (90 mg tablet, 125 mg tab PA disper, 180 mg tablet, 250 mg tab Formulary High Cost Generics S disper, 360 mg tablet, 500 mg tab disper) TD Trial Drug

PA deferiprone Formulary High Cost Generics S

FERRIPROX (100 MG/ML SOLUTION, PA Formulary Brands 500 MG TABLET, 1,000 MG TABLET) S

PA penicillamine 250 mg tablet Formulary High Cost Generics S

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

budesonide 3 mg capdr - er Formulary High Cost Generics dexamethasone (0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 4 mg Formulary Low Cost Generics tablet, 6 mg tablet) dexamethasone (0.5 mg/5ml elixir, 0.5 Formulary High Cost Generics mg/5ml solution, 2 mg tablet) DEXAMETHASONE INTENSOL Formulary Brands

PAGE 82 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS dexamethasone sodium phosphate 10 Formulary High Cost Generics mg/ml vial dexamethasone sodium phosphate 4 Formulary Low Cost Generics mg/ml vial dexamethasone sodium phosphate/pf Formulary High Cost Generics fludrocortisone acetate Formulary High Cost Generics hydrocortisone (5 mg tablet, 10 mg Formulary High Cost Generics tablet, 20 mg tablet) MEDROL 2 MG TABLET Formulary Brands methylprednisolone Formulary High Cost Generics MILLIPRED Formulary Brands prednisolone Formulary Low Cost Generics prednisolone sodium phosphate (5 mg/5 ml solution, 15 mg/5 ml solution, 25 Formulary Low Cost Generics mg/5 ml solution) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 10 mg tab ds Formulary Low Cost Generics pk, 10 mg tablet, 20 mg tablet, 50 mg tablet) prednisone 5 mg/5 ml solution Formulary High Cost Generics PREDNISONE INTENSOL Formulary Brands SOLU-CORTEF 100 MG ACT-O-VIAL Formulary Brands ANDROGENS

danazol Formulary High Cost Generics testosterone (1.25g-1.62 gel packet, 2.5g-1.62% gel packet, 10 mg (2%) gel md pmp, 12.5/1.25g gel md pmp, Formulary High Cost Generics PA 20.25/1.25 gel md pmp, 25mg(1%) gel packet, 50 mg (1%) gel (gram), 50 mg (1%) gel packet) testosterone cypionate (100 mg/ml vial, Formulary High Cost Generics PA 200 mg/ml vial)

testosterone enanthate 200 mg/ml vial Formulary High Cost Generics PA

testosterone propionate Formulary High Cost Generics PA

PAGE 83 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CONTRACEPTIVES

ALTAVERA Formulary High Cost Generics ALYACEN Formulary High Cost Generics AMETHIA Formulary High Cost Generics AMETHIA LO Formulary High Cost Generics APRI Formulary High Cost Generics ARANELLE Formulary High Cost Generics ASHLYNA Formulary High Cost Generics AUBRA Formulary High Cost Generics AUBRA EQ Formulary High Cost Generics AVIANE Formulary High Cost Generics AZURETTE Formulary High Cost Generics BALZIVA Formulary High Cost Generics BEKYREE Formulary High Cost Generics BLISOVI 24 FE Formulary Brands BLISOVI FE Formulary High Cost Generics BRIELLYN Formulary High Cost Generics CAMILA Formulary High Cost Generics CAMRESE Formulary High Cost Generics CAMRESE LO Formulary High Cost Generics CAZIANT Formulary High Cost Generics CHATEAL Formulary High Cost Generics CHATEAL EQ Formulary High Cost Generics CRYSELLE Formulary High Cost Generics CYCLAFEM Formulary High Cost Generics CYRED Formulary High Cost Generics CYRED EQ Formulary High Cost Generics DASETTA Formulary High Cost Generics DAYSEE Formulary High Cost Generics DEBLITANE Formulary High Cost Generics

PAGE 84 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS DELYLA Formulary High Cost Generics desogestrel-ethinyl estradiol Formulary High Cost Generics desogestrel-ethinyl estradiol/ethinyl Formulary High Cost Generics estradiol ELINEST Formulary High Cost Generics ELLA Formulary Brands ELURYNG Formulary High Cost Generics EMOQUETTE Formulary High Cost Generics ENPRESSE Formulary High Cost Generics ENSKYCE Formulary High Cost Generics ERRIN Formulary High Cost Generics ESTARYLLA Formulary High Cost Generics ethinyl estradiol/drospirenone Formulary High Cost Generics ethynodiol d-ethinyl estradiol 1 mg- Formulary High Cost Generics 50mcg tablet etonogestrel/ethinyl estradiol Formulary High Cost Generics FALMINA Formulary High Cost Generics FEMYNOR Formulary High Cost Generics GIANVI Formulary High Cost Generics HEATHER Formulary High Cost Generics INCASSIA Formulary High Cost Generics INTROVALE Formulary High Cost Generics ISIBLOOM Formulary High Cost Generics JASMIEL Formulary High Cost Generics JENCYCLA Formulary High Cost Generics JOLESSA Formulary High Cost Generics JOLIVETTE Formulary High Cost Generics JULEBER Formulary High Cost Generics JUNEL Formulary High Cost Generics JUNEL FE Formulary High Cost Generics KARIVA Formulary High Cost Generics

PAGE 85 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS KELNOR 1-35 Formulary High Cost Generics KELNOR 1-50 Formulary High Cost Generics KURVELO Formulary High Cost Generics LARIN Formulary High Cost Generics LARIN FE Formulary High Cost Generics LARISSIA Formulary High Cost Generics LEENA Formulary High Cost Generics LESSINA Formulary High Cost Generics LEVONEST Formulary High Cost Generics levonorgestrel/ethinyl estradiol (levonorgestrel/ethin.estradiol 0.1- 0.02mg tablet, Formulary High Cost Generics levonorgestrel/ethin.estradiol 0.15-0.03 tablet, levonorgestrel/ethin.estradiol 0.15-0.03 tbdspk 3mo) levonorgestrel/ethinyl estradiol and Formulary High Cost Generics ethinyl estradiol LEVORA-28 Formulary High Cost Generics LILLOW Formulary High Cost Generics LORYNA Formulary High Cost Generics LOW-OGESTREL Formulary High Cost Generics LUTERA Formulary High Cost Generics LYZA Formulary High Cost Generics MARLISSA Formulary High Cost Generics MICROGESTIN Formulary High Cost Generics MICROGESTIN FE Formulary High Cost Generics MILI Formulary High Cost Generics MONO-LINYAH Formulary High Cost Generics MONONESSA Formulary High Cost Generics MYZILRA Formulary High Cost Generics NECON Formulary High Cost Generics NIKKI Formulary High Cost Generics NORA-BE Formulary High Cost Generics

PAGE 86 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS norethindrone Formulary High Cost Generics norethindrone ac-eth estradiol 1mg- Formulary High Cost Generics 20mcg tablet norethindrone acetate-ethinyl estradiol/ferrous fumarate (1mg-20(21) Formulary High Cost Generics tablet, 1.5-30(21) tablet) norgestimate-ethinyl estradiol (0.25- 0.035 tablet, 7daysx3 28 tablet, 7daysx3 Formulary High Cost Generics lo tablet) NORLYDA Formulary High Cost Generics NORLYROC Formulary High Cost Generics NORTREL Formulary High Cost Generics OCELLA Formulary High Cost Generics OGESTREL Formulary High Cost Generics ORSYTHIA Formulary High Cost Generics PHILITH Formulary High Cost Generics PIMTREA Formulary High Cost Generics PIRMELLA Formulary High Cost Generics PORTIA Formulary High Cost Generics PREVIFEM Formulary High Cost Generics QUASENSE Formulary High Cost Generics RECLIPSEN Formulary High Cost Generics SETLAKIN Formulary High Cost Generics SHAROBEL Formulary High Cost Generics SIMPESSE Formulary High Cost Generics SPRINTEC Formulary High Cost Generics SRONYX Formulary High Cost Generics SYEDA Formulary High Cost Generics TARINA FE Formulary High Cost Generics TARINA FE 1-20 EQ Formulary High Cost Generics TILIA FE Formulary High Cost Generics TRI FEMYNOR Formulary High Cost Generics

PAGE 87 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS TRI-ESTARYLLA Formulary High Cost Generics TRI-LEGEST FE Formulary High Cost Generics TRI-LINYAH Formulary High Cost Generics TRI-LO-ESTARYLLA Formulary High Cost Generics TRI-LO-MARZIA Formulary High Cost Generics TRI-LO-SPRINTEC Formulary High Cost Generics TRI-MILI Formulary High Cost Generics TRI-PREVIFEM Formulary High Cost Generics TRI-SPRINTEC Formulary High Cost Generics TRI-VYLIBRA Formulary High Cost Generics TRI-VYLIBRA LO Formulary High Cost Generics TRIVORA-28 Formulary High Cost Generics TULANA Formulary High Cost Generics VELIVET Formulary High Cost Generics VIENVA Formulary High Cost Generics VIORELE Formulary High Cost Generics VYFEMLA Formulary High Cost Generics VYLIBRA Formulary High Cost Generics WERA Formulary High Cost Generics XULANE Formulary High Cost Generics ZARAH Formulary High Cost Generics ZOVIA 1-35E Formulary High Cost Generics PITUITARY

desmopressin acetate (0.1 mg tablet, Formulary High Cost Generics AL1 At least 8 yrs old 0.2 mg tablet)

desmopressin acetate (non-refrigerated) Formulary High Cost Generics PA

desmopressin acetate 10/spray Formulary High Cost Generics PA spray/pump

PA NORDITROPIN FLEXPRO Covered GH Growth Hormone

STIMATE Formulary Brands PA

PAGE 88 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PROGESTINS

QL 2 ML / 1 FILL hydroxyprogesterone caproate/pf Formulary High Cost Generics S

QL 2 ML / 1 FILL MAKENA 250 MG/ML VIAL Formulary Brands S

QL 2.2 ML / FILL(S) MAKENA 275 MG/1.1 ML AUTOINJCT Formulary Brands S

medroxyprogesterone acetate (2.5 mg Formulary Low Cost Generics tablet, 5 mg tablet, 10 mg tablet) megestrol acetate (20 mg tablet, 40 mg Formulary High Cost Generics tablet, 400mg/10ml oral susp) norethindrone acetate Formulary High Cost Generics progesterone, micronized Formulary High Cost Generics HYPOTENSIVE AGENTS

CENTRAL ALPHA-AGONISTS

clonidine Formulary High Cost Generics clonidine hcl (0.1 mg tablet, 0.2 mg Formulary Low Cost Generics tablet, 0.3 mg tablet)

QL 4 TABS / 1 DAY clonidine hcl 0.1 mg tab er 12h Formulary High Cost Generics PA

guanfacine hcl (1 mg tablet, 2 mg tablet) Formulary Low Cost Generics methyldopa Formulary High Cost Generics DIRECT VASODILATORS

hydralazine hcl (10 mg tablet, 25 mg Formulary High Cost Generics tablet, 50 mg tablet, 100 mg tablet) minoxidil Formulary High Cost Generics INSULINS

LONG-ACTING INSULINS

LANTUS Formulary Brands LANTUS SOLOSTAR Formulary Brands

LEVEMIR Formulary Brands PA

PAGE 89 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

LEVEMIR FLEXTOUCH Formulary Brands PA

SOLIQUA 100-33 Formulary Brands QL 18 ml / 30 day(s)

TOUJEO MAX SOLOSTAR Formulary Brands TOUJEO SOLOSTAR Formulary Brands

XULTOPHY 100-3.6 Formulary Brands QL 15 ml / 30 day(s)

RAPID-ACTING INSULINS

HUMALOG Formulary Brands HUMALOG JUNIOR KWIKPEN Formulary Brands HUMALOG KWIKPEN U-100 Formulary Brands HUMALOG KWIKPEN U-200 Formulary Brands HUMALOG MIX 50-50 Formulary Brands HUMALOG MIX 50-50 KWIKPEN Formulary Brands HUMALOG MIX 75-25 Formulary Brands HUMALOG MIX 75-25 KWIKPEN Formulary Brands insulin lispro (100/ml ins pen hf, 100/ml Formulary High Cost Generics insuln pen, 100/ml vial) insulin lispro protamine and insulin lispro Formulary High Cost Generics SHORT-ACTING INSULINS

HUMULIN R U-500 Formulary Brands HUMULIN R U-500 KWIKPEN Formulary Brands ION-REMOVING AGENTS

PHOSPHATE-REMOVING AGENTS

calcium acetate Formulary High Cost Generics PHOSLYRA Formulary Brands sevelamer carbonate Formulary High Cost Generics POTASSIUM-REMOVING AGENTS

sodium polystyrene sulfonate (15 g/60 Formulary High Cost Generics ml oral susp, powder)

PAGE 90 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS MACROLIDE ANTIBIOTICS

OTHER MACROLIDE ANTIBIOTICS

azithromycin (100 mg/5ml susp recon, Formulary High Cost Generics 200 mg/5ml susp recon) azithromycin (250 mg tablet, 500 mg Formulary Low Cost Generics tablet, 600 mg tablet) clarithromycin (125 mg/5ml susp recon, Formulary High Cost Generics AL1 Up to 12 yrs old 250 mg/5ml susp recon) clarithromycin (250 mg tablet, 500 mg Formulary High Cost Generics tablet)

DIFICID 200 MG TABLET Formulary Brands PA

MISC. BETA-LACTAM ANTIBIOTICS

MONOBACTAM ANTIBIOTICS

PA CAYSTON Formulary Brands S

MISCELLANEOUS THERAPEUTIC AGENTS

5-ALPHA-REDUCTASE INHIBITORS

dutasteride Formulary High Cost Generics dutasteride/tamsulosin hcl Formulary High Cost Generics finasteride 5 mg tablet Formulary Low Cost Generics ALCOHOL DETERRENTS

disulfiram Formulary High Cost Generics ANTIDOTES

leucovorin calcium (5 mg tablet, 10 mg Formulary High Cost Generics tablet, 15 mg tablet, 25 mg tablet)

PA VISTOGARD Formulary Brands S

ANTIGOUT AGENTS

allopurinol Formulary Low Cost Generics colchicine Formulary High Cost Generics

febuxostat Formulary High Cost Generics ST

PAGE 91 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS BONE RESORPTION INHIBITORS

alendronate sodium (5 mg tablet, 10 mg Formulary Low Cost Generics tablet, 35 mg tablet, 70 mg tablet) alendronate sodium 40 mg tablet Formulary High Cost Generics

alendronate sodium 70 mg/75ml solution Formulary High Cost Generics PA

etidronate disodium Formulary High Cost Generics ibandronate sodium 150 mg tablet Formulary High Cost Generics risedronate sodium (5 mg tablet, 30 mg Formulary High Cost Generics tablet, 35 mg tablet, 150 mg tablet) CARIOSTATIC AGENTS

AL1 Up to 5 yrs old FLUORABON Formulary Low Cost Generics ACA

fluoride (sodium) (0.25(0.55) tab chew, 0.25mg/drp drops, 0.5 mg/ml drops, AL1 Up to 5 yrs old Formulary Low Cost Generics 0.5(1.1)mg tab chew, 1mg(2.2mg) tab ACA chew) fluoride (sodium) (1.1 % cream (g), 1.1 Formulary Low Cost Generics % gel (gram))

AL1 Up to 5 yrs old FLUORITAB Formulary Low Cost Generics ACA

COMPLEMENT INHIBITORS

PA BERINERT Formulary Brands S

PA CINRYZE Formulary Brands S

QL 9 ML / fill(s)

FIRAZYR Formulary Brands PA

PA HAEGARDA Formulary Brands S

PA KALBITOR Formulary Brands S

PAGE 92 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

PA RUCONEST Formulary Brands S

QL 4 ML / 28 DAY(S)

TAKHZYRO Formulary Brands PA

DISEASE-MODIFYING ANTIRHEUMATIC AGENTS

QL 4 SYRINGES / 28 DAYS ACTEMRA 162 MG/0.9 ML SYRINGE Formulary Brands PA

PA ACTEMRA ACTPEN Formulary Brands S

QL 2 SYRINGES / 28 CIMZIA (MG/ML SYRINGE KIT, day(s) Formulary Brands MG/ML(X3)START KT) PA S

QL 4 ML / 28 DAY(S) ENBREL (25 MG/0.5 ML SYRINGE, 50 Formulary Brands PA MG/ML SYRINGE) S

QL 4 Vials / 28 day(s)

ENBREL 25 MG KIT Formulary Brands PA

QL 8 VIALS / 28 DAYS

ENBREL 25 MG/0.5 ML VIAL Formulary Brands PA

QL 4 Cartridges / 28 day(s) ENBREL MINI Formulary Brands PA

QL 4 ml / 28 day(s)

ENBREL SURECLICK Formulary Brands PA

PAGE 93 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 ML / 28 day(s)

HUMIRA 10 MG/0.2 ML SYRINGE Formulary Brands PA

QL 2 sryinges / 28 day(s)

HUMIRA 20 MG/0.4 ML SYRINGE Formulary Brands PA

QL 2 SYRINGES / 28 day(s) HUMIRA 40 MG/0.8 ML SYRINGE Formulary Brands PA

QL 2 SYRINGES / 28 day(s) HUMIRA PEDIATRIC CROHN'S Formulary Brands PA

QL 2 PENS / 28 day(s)

HUMIRA PEN Formulary Brands PA

QL 2 PENS / 28 day(s)

HUMIRA PEN CROHN'S-UC-HS Formulary Brands PA

QL 2 PENS / 28 day(s)

HUMIRA PEN PSOR-UVEITS-ADOL HS Formulary Brands PA

QL 2 SYRINGES / 28 HUMIRA(CF) (10 MG/0.1 ML SYRING, DAYS Formulary Brands 20 MG/0.2 ML SYRING) PA S

QL 2 syringes / 28 day(s)

HUMIRA(CF) 40 MG/0.4 ML SYRING Formulary Brands PA

QL 3 ML / 28 DAY(S)

HUMIRA(CF) PEDI CROHN 80MG/0.8 Formulary Brands PA

PAGE 94 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 pens / 28 day(s)

HUMIRA(CF) PEN 40 MG/0.4 ML Formulary Brands PA

QL 3 ML / 28 DAY(S)

HUMIRA(CF) PEN 80 MG/0.8 ML Formulary Brands PA

QL 3 ML / 28 DAY(S)

HUMIRA(CF) PEN CROHN'S-UC-HS Formulary Brands PA

QL 2 ML / 28 day(s)

HUMIRA(CF) PEN PSOR-UV-ADOL HS Formulary Brands PA

QL 28 SYRINGES / 28 DAYS KINERET Formulary Brands PA

leflunomide Formulary High Cost Generics

QL 1 TAB / 1 day(s)

OLUMIANT 1 MG TABLET Formulary Brands PA

QL 1 TAB / 1 DAY

OLUMIANT 2 MG TABLET Formulary Brands PA

QL 4 SYRINGES / 28 ORENCIA (50 MG/0.4 ML SYRINGE, DAYS 87.5 MG/0.7 ML SYRINGE, 125 MG/ML Formulary Brands PA SYRINGE) S

QL 4 ML / 28 DAY(S)

ORENCIA CLICKJECT Formulary Brands PA

QL 55 TABS / 28 day(s)

OTEZLA 28 DAY STARTER PACK Formulary Brands PA

PAGE 95 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 2 TABS / 1 DAY

OTEZLA 30 MG TABLET Formulary Brands PA

QL 2 PACKS / 28 DAYS

OTEZLA STARTER PACK Formulary Brands PA

QL 1 TAB / 1 day(s)

RINVOQ Formulary Brands PA

IMMUNOMODULATORY AGENTS

QL 1 TAB / 1 DAY AUBAGIO Formulary Brands S

AVONEX (30 MCG VIAL KIT, QL 1 KIT / 28 DAYS Formulary Brands PREFILLED SYR 30 MCG KT) S

QL 1 KIT / 28 DAYS AVONEX PEN Formulary Brands S

QL 15 ML / 28 DAYS BETASERON 0.3 MG KIT Formulary Brands S

QL 15 ML / 30 day(s) BETASERON 0.3 MG VIAL Formulary Brands S

dimethyl fumarate (120 mg capsule dr, QL 2 caps / 1 day(s) Formulary High Cost Generics 240 mg capsule dr) S

dimethyl fumarate 120-240 mg capsule QL 2 CAPS / DAY Formulary High Cost Generics dr S

QL 1 CAP / 1 DAY GILENYA Formulary Brands S

QL 30 ML / 30 DAYS glatiramer acetate 20 mg/ml syringe Formulary High Cost Generics S

QL 12 ML / 28 DAYS glatiramer acetate 40 mg/ml syringe Formulary High Cost Generics S

PAGE 96 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 30 ML / 30 DAYS GLATOPA 20 MG/ML SYRINGE Formulary High Cost Generics S

QL 12 ML / 28 DAYS GLATOPA 40 MG/ML SYRINGE Formulary High Cost Generics S

QL 12 TABS / 4 day(s) MAYZENT 0.25 MG STARTER PACK Formulary Brands S

QL 120 TABS / 30 day(s) MAYZENT 0.25 MG TABLET Formulary Brands S

QL 30 TABS / 30 DAY(S) MAYZENT 2 MG TABLET Formulary Brands S

QL 1 ML / 28 DAYS PLEGRIDY Formulary Brands S

QL 1 ML / 28 DAYS PLEGRIDY PEN Formulary Brands S

REBIF (22 MCG/0.5 ML SYRINGE, 44 QL 6 ML / 28 DAYS Formulary Brands MCG/0.5 ML SYRINGE) S

REBIF REBIDOSE (22 MCG/0.5 ML, 44 QL 6 ML / 28 DAYS Formulary Brands MCG/0.5 ML) S

QL 4.2 ML / 28 DAYS REBIF REBIDOSE TITRATION PACK Formulary Brands S

QL 4.2 ML / 28 DAYS REBIF TITRATION PACK Formulary Brands S

S THALOMID Formulary Brands ONC Oncology

QL 4 CAPS / 1 day(s) VUMERITY Formulary Brands S

IMMUNOSUPPRESSIVE AGENTS

azathioprine Formulary High Cost Generics cyclosporine (25 mg capsule, 100 mg Formulary High Cost Generics capsule)

PAGE 97 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100 Formulary High Cost Generics mg/ml solution) GENGRAF (25 MG CAPSULE, 100 MG Formulary High Cost Generics CAPSULE, 100 MG/ML SOLUTION)

PA MAVENCLAD Formulary Brands S

mycophenolate mofetil (200 mg/ml susp Formulary High Cost Generics recon, 250 mg capsule, 500 mg tablet) sirolimus (0.5 mg tablet, 1 mg tablet, 1 Formulary High Cost Generics mg/ml solution, 2 mg tablet) tacrolimus (0.5 mg capsule, 1 mg Formulary High Cost Generics capsule, 5 mg capsule) OTHER MISCELLANEOUS THERAPEUTIC AGENTS

PA ARCALYST Formulary Brands S

PA CERDELGA Formulary Brands S

CYSTAGON Formulary Brands

QL 60 TABS / 30 DAY(S)

dalfampridine Formulary High Cost Generics PA

QL 14 CAPS / 28 DAYS

GALAFOLD Formulary Brands PA

QL 2 ML / 28 day(s)

ILARIS Formulary Brands PA

PA ISTURISA Formulary Brands S

levocarnitine (with sugar) Formulary High Cost Generics levocarnitine 100 mg/ml solution Formulary High Cost Generics

PAGE 98 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levocarnitine 330 mg tablet Formulary Low Cost Generics

PA miglustat Formulary High Cost Generics S

QL 300 TABS / 30 day(s)

RUZURGI Formulary Brands PA

PA sapropterin dihydrochloride Formulary High Cost Generics S

PA THIOLA Formulary Brands S

PA THIOLA EC Formulary Brands S

TYBOST Formulary Brands PROTECTIVE AGENTS

ELMIRON Formulary Brands NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

celecoxib Formulary High Cost Generics OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS

diclofenac potassium Formulary High Cost Generics diclofenac sodium (1 % gel (gram), 25 mg tablet dr, 50 mg tablet dr, 75 mg Formulary High Cost Generics tablet dr, 100 mg tab er 24h) etodolac (200 mg capsule, 300 mg Formulary Low Cost Generics capsule) etodolac (400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, Formulary High Cost Generics 600 mg tab er 24h) flurbiprofen Formulary High Cost Generics ibuprofen (400 mg tablet, 600 mg tablet, Formulary Low Cost Generics 800 mg tablet) indomethacin (25 mg capsule, 50 mg Formulary Low Cost Generics AQ1 Up to 64 yrs old; 20 / 1 capsule) FILL

PAGE 99 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

ketorolac tromethamine 10 mg tablet Formulary Low Cost Generics QL 20 TABS / 30 DAYS

meloxicam Formulary Low Cost Generics nabumetone Formulary High Cost Generics naproxen (250 mg tablet, 375 mg tablet, Formulary Low Cost Generics 500 mg tablet) naproxen (375 mg tablet dr, 500 mg Formulary High Cost Generics tablet dr) piroxicam Formulary Low Cost Generics sulindac Formulary High Cost Generics SALICYLATES

butalbital/aspirin/caffeine 50-325-40 Formulary Low Cost Generics QL 6 CAPS / 1 DAY capsule salsalate Formulary High Cost Generics OXYTOCICS

methylergonovine maleate 0.2 mg tablet Formulary High Cost Generics PARATHYROID AND ANTIPARATHYROID AGENTS

ANTIPARATHYROID AGENTS

calcitonin,salmon,synthetic Formulary High Cost Generics cinacalcet hcl Formulary High Cost Generics SENSIPAR Formulary Brands PARATHYROID AGENTS

PA FORTEO Formulary Brands S

PA TYMLOS Formulary Brands S

PAGE 100 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS PENICILLIN ANTIBIOTICS

AMINOPENICILLIN ANTIBIOTICS

amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab Formulary Low Cost Generics chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet) amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon, amoxicillin/potassium 200- 28.5mg tab chew, amoxicillin/potassium 250-125 mg tablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab Formulary High Cost Generics chew, amoxicillin/potassium 400-57mg/5 susp recon, amoxicillin/potassium 500- 125 mg tablet, amoxicillin/potassium 600-42.9/5 susp recon, amoxicillin/potassium 875-125 mg tablet) ampicillin trihydrate Formulary Low Cost Generics NATURAL PENICILLIN ANTIBIOTICS

penicillin v potassium (125 mg/5ml soln Formulary High Cost Generics recon, 250 mg/5ml soln recon) penicillin v potassium (250 mg tablet, Formulary Low Cost Generics 500 mg tablet) PENICILLINASE-RESISTANT PENICILLINS

dicloxacillin sodium Formulary High Cost Generics PHARMACEUTICAL AIDS

SHINGRIX ADJUVANT COMPONENT Formulary Brands QL 1 KIT / rx

VAXCHORA BUFFER COMPONENT Formulary Brands RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB

ANGIOTENSIN II RECEPTOR ANTAGONISTS

ENTRESTO Formulary Brands irbesartan Formulary Low Cost Generics irbesartan/hydrochlorothiazide Formulary High Cost Generics

PAGE 101 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS losartan potassium Formulary Low Cost Generics losartan potassium/hydrochlorothiazide Formulary Low Cost Generics olmesartan medoxomil Formulary High Cost Generics olmesartan Formulary High Cost Generics medoxomil/hydrochlorothiazide telmisartan Formulary High Cost Generics valsartan Formulary High Cost Generics valsartan/hydrochlorothiazide Formulary High Cost Generics ANGIOTENSIN-CONVERTING ENZYME INHIBITORS

benazepril hcl Formulary Low Cost Generics benazepril hcl/hydrochlorothiazide Formulary High Cost Generics captopril Formulary High Cost Generics captopril/hydrochlorothiazide Formulary High Cost Generics enalapril maleate Formulary High Cost Generics enalapril maleate/hydrochlorothiazide Formulary Low Cost Generics fosinopril sodium Formulary Low Cost Generics fosinopril sodium/hydrochlorothiazide Formulary High Cost Generics lisinopril Formulary Low Cost Generics lisinopril/hydrochlorothiazide Formulary Low Cost Generics moexipril hcl Formulary High Cost Generics perindopril erbumine Formulary High Cost Generics quinapril hcl Formulary Low Cost Generics quinapril hcl/hydrochlorothiazide Formulary High Cost Generics ramipril Formulary Low Cost Generics trandolapril Formulary High Cost Generics MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS

ALDACTAZIDE 50-50 TABLET Formulary Brands eplerenone Formulary High Cost Generics spironolactone Formulary High Cost Generics spironolactone/hydrochlorothiazide Formulary High Cost Generics

PAGE 102 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS RESPIRATORY TRACT AGENTS

ANTIFIBROTIC AGENTS

PA ESBRIET Formulary Brands S

PA OFEV Formulary Brands S

ANTITUSSIVES

benzonatate Formulary High Cost Generics

QL 60 ML / 1 DAY codeine phosphate/guaifenesin 10- Formulary High Cost Generics AL1 At least 18 yrs old 100mg/5 liquid AQ1 At least 18 yrs old; 60 / 1 day(s) codeine phosphate/guaifenesin 20- Formulary High Cost Generics AQ1 At least 18 yrs old; 60 / 200/10 liquid 1 day(s) promethazine hcl/dextromethorphan hbr Formulary Low Cost Generics MUCOLYTIC AGENTS

acetylcysteine Formulary High Cost Generics

QL 150 ML / 30 DAYS

PULMOZYME Formulary Brands PA

PHOSPHODIESTERASE TYPE 4 INHIBITORS

DALIRESP Formulary Brands PA

RESPIRATORY TRACT AGENTS, MISCELLANEOUS

PA ARALAST NP Formulary Brands S

PA GLASSIA Formulary Brands S

PA PROLASTIN C Formulary Brands S

PA ZEMAIRA Formulary Brands S

PAGE 103 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VASODILATING AGENTS (RESPIRATORY TRACT)

PA ADEMPAS Formulary Brands S

PA ambrisentan Formulary High Cost Generics S

PA bosentan Formulary High Cost Generics S

epoprostenol sodium (glycine) 1.5 mg PA Formulary High Cost Generics vial S

PA FLOLAN 1.5 MG VIAL Formulary Brands S

PA OPSUMIT Formulary Brands S

PA TRACLEER 32 MG TABLET FOR SUSP Formulary Brands S

PA treprostinil sodium Formulary High Cost Generics S

PA TYVASO Formulary Brands S

PA TYVASO REFILL KIT Formulary Brands S

PA TYVASO STARTER KIT Formulary Brands S

PA UPTRAVI Formulary Brands S

PA VELETRI Formulary Brands S

PA VENTAVIS Formulary Brands S

PAGE 104 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS SKELETAL MUSCLE RELAXANTS

CENTRALLY ACTING SKELETAL MUSCLE RELAXNT

chlorzoxazone 500 mg tablet Formulary High Cost Generics AL1 Up to 64 yrs old

cyclobenzaprine hcl (5 mg tablet, 10 mg Formulary Low Cost Generics AL1 Up to 64 yrs old tablet) methocarbamol (500 mg tablet, 750 mg Formulary High Cost Generics AL1 Up to 64 yrs old tablet) tizanidine hcl (2 mg tablet, 4 mg tablet) Formulary High Cost Generics DIRECT-ACTING SKELETAL MUSCLE RELAXANTS

dantrolene sodium (25 mg capsule, 50 Formulary High Cost Generics mg capsule, 100 mg capsule) GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT

baclofen (5 mg tablet, 10 mg tablet, 20 Formulary High Cost Generics mg tablet) SKIN AND MUCOUS MEMBRANE AGENTS

ANTIPRURITICS AND LOCAL ANESTHETICS

QL 30 PATCHES / 30 lidocaine 5 % adh. patch Formulary High Cost Generics DAYS PA

lidocaine/prilocaine 2.5 %-2.5% cream Formulary High Cost Generics QL 60 GM / fill(s) (g) phenazopyridine hcl Formulary Low Cost Generics ASTRINGENTS

DRYSOL Formulary Brands CELL STIMULANTS AND PROLIFERANTS

AVITA Formulary High Cost Generics tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 % Formulary High Cost Generics cream (g), 0.1 % cream (g)) KERATOLYTIC AGENTS

sulfacetamide sodium/sulfur (sodium/sulfur 10-5%(w/v) lotion, Formulary High Cost Generics sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion)

PAGE 105 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS sulfacetamide sodium/sulfur 10-5%(w/w) Formulary High Cost Generics QL 12 ML / 1 day(s) cleanser urea (40 % cream (g), 40 % lotion) Formulary High Cost Generics KERATOPLASTIC AGENTS

DRITHOCREME HP Formulary Brands SKIN AND MUCOUS MEMBRANE AGENTS, MISC.

acitretin Formulary High Cost Generics adapalene (0.1 % cream (g), 0.3 % gel Formulary High Cost Generics (gram), 0.3 % gel w/pump) AMNESTEEM Formulary High Cost Generics azelaic acid Formulary High Cost Generics calcipotriene (0.005 % cream (g), 0.005 Formulary High Cost Generics QL 120 gm / 30 day(s) % oint. (g))

calcitriol 3 mcg/g oint. (g) Formulary High Cost Generics PA

CLARAVIS Formulary High Cost Generics

PA COSENTYX (2 SYRINGES) Formulary Brands S

PA COSENTYX PEN Formulary Brands S

PA COSENTYX PEN (2 PENS) Formulary Brands S

PA COSENTYX SYRINGE Formulary Brands S

dapsone 5 % gel (gram) Formulary High Cost Generics PA

QL 4 ML / 28 DAY(S)

DUPIXENT 300 MG/2 ML SYRINGE Formulary Brands PA

QL 2 pens / 28 day(s)

DUPIXENT PEN Formulary Brands PA

imiquimod 5 % cream pack Formulary High Cost Generics

PAGE 106 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS isotretinoin Formulary High Cost Generics MYORISAN Formulary High Cost Generics pimecrolimus Formulary High Cost Generics podofilox Formulary High Cost Generics

PA SKYRIZI Formulary Brands S

PA SKYRIZI (2 SYRINGES) KIT Formulary Brands S

tacrolimus (0.03 % oint. (g), 0.1 % oint. Formulary High Cost Generics (g))

tazarotene Formulary High Cost Generics QL 30 GM / 30 DAYS

TAZORAC (0.05% CREAM, 0.05% GEL, Formulary Brands QL 30 GM / 30 DAYS 0.1% GEL) ZENATANE Formulary High Cost Generics SMOOTH MUSCLE RELAXANTS

RESPIRATORY SMOOTH MUSCLE RELAXANTS

theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er Formulary High Cost Generics 12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h) SOMATOSTATIN AGONISTS AND ANTAGONISTS

SOMATOSTATIN AGONISTS

octreotide acetate (100 mcg/ml ampul, QL 5 ML / 1 DAY Formulary High Cost Generics 100 mcg/ml vial) S

octreotide acetate (50 mcg/ml ampul, 50 QL 3 ML / 1 DAY Formulary High Cost Generics mcg/ml vial) S

octreotide acetate (50 mcg/ml syringe, 100 mcg/ml syringe, 500 mcg/ml Formulary High Cost Generics S syringe)

octreotide acetate (500 mcg/ml ampul, QL 7 ML / DAY Formulary High Cost Generics 500 mcg/ml vial) S

QL 9 VIALS / 30 DAYS octreotide acetate 1000mcg/ml vial Formulary High Cost Generics S

PAGE 107 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS

QL 7.5 ML / DAY octreotide acetate 200 mcg/ml vial Formulary High Cost Generics S

SANDOSTATIN LAR DEPOT (10 MG QL 1 KIT / 28 DAYS Formulary Brands KT, 10 MG VL) S

SANDOSTATIN LAR DEPOT (20 MG QL 2 KITS / 28 DAYS Formulary Brands KT, 20 MG VL) S

SANDOSTATIN LAR DEPOT (30 MG QL 3 KITS / 28 DAYS Formulary Brands KT, 30 MG VL) S

PA SIGNIFOR Formulary Brands S

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ALPHA- AND BETA-ADRENERGIC AGONISTS

epinephrine (0.15mg/0.3 auto injct, Formulary High Cost Generics 0.3mg/0.3 auto injct) SYMJEPI Formulary Brands ALPHA-ADRENERGIC AGONISTS

midodrine hcl Formulary High Cost Generics TETRACYCLINE ANTIBIOTICS

AMINOMETHYLCYCLINES

NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150 MG-7 DAY WITH Formulary Brands PA LOAD) THYROID AND ANTITHYROID AGENTS

ANTITHYROID AGENTS

methimazole Formulary Low Cost Generics propylthiouracil Formulary High Cost Generics THYROID AGENTS

EUTHYROX Formulary High Cost Generics

PAGE 108 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg Formulary High Cost Generics tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet) liothyronine sodium (5 mcg tablet, 25 Formulary High Cost Generics mcg tablet, 50 mcg tablet) SYNTHROID Formulary Brands VASODILATING AGENTS

NITRATES AND NITRITES

isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg Formulary High Cost Generics tablet er) isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg tab er 24h, 60 mg tab Formulary High Cost Generics er 24h, 120 mg tab er 24h) NITRO-BID Formulary Brands nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.3 mg tab subl, Formulary High Cost Generics 0.4 mg tab subl, 0.4mg/hr patch td24, 0.6 mg tab subl, 0.6mg/hr patch td24) PHOSPHODIESTERASE TYPE 5 INHIBITORS

sildenafil citrate (25 mg tablet, 50 mg Formulary High Cost Generics tablet, 100 mg tablet)

sildenafil citrate 20 mg tablet Formulary High Cost Generics QL 1 TAB / DAY

tadalafil 10 mg tablet Formulary High Cost Generics

tadalafil 2.5 mg tablet Formulary High Cost Generics QL 1 tab / 1 day(s)

QL 2 TABS / 1 day(s) tadalafil 20 mg tablet Formulary High Cost Generics PA

tadalafil 5 mg tablet Formulary High Cost Generics QL 1 TAB / DAY

VASODILATING AGENTS, MISCELLANEOUS

aspirin/dipyridamole Formulary High Cost Generics dipyridamole Formulary High Cost Generics

PAGE 109 LAST UPDATED 12/2020 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VITAMINS

MULTIVITAMIN PREPARATIONS

multivitamin combination no.51/ferrous Formulary High Cost Generics PA fumarate/folic acid O-CAL PRENATAL Formulary Low Cost Generics PRENATA Formulary Brands PRENATABS FA Formulary Low Cost Generics PRENATABS RX Formulary High Cost Generics prenatal vitamin with calcium Formulary High Cost Generics no.76/iron,carbonyl/folic acid prenatal vitamins with calcium/ferrous Formulary Low Cost Generics fumarate/folic acid prenatal vits with calcium 118/ferrous Formulary Low Cost Generics fumarate/folic acid prenatal vits with calcium no.72/ferrous Formulary Low Cost Generics fumarate/folic acid prenatal vits with calcium Formulary Low Cost Generics no.72/iron,carbonyl/folic acid

PRENATE ELITE Formulary Brands PA

PUREFE OB PLUS Formulary Low Cost Generics TRINATE Formulary High Cost Generics VITAMIN B COMPLEX

cyanocobalamin (vitamin b-12) Formulary Low Cost Generics 1000mcg/ml vial folic acid 1 mg tablet Formulary Low Cost Generics VITAMIN D

calcitriol (0.25 mcg capsule, 0.5 mcg Formulary High Cost Generics capsule, 1 mcg/ml solution) ergocalciferol (vitamin d2) Formulary Low Cost Generics VITAMIN K ACTIVITY

phytonadione (vit k1) 5 mg tablet Formulary High Cost Generics QL 3 TABS / 1 FILL

PAGE 110 LAST UPDATED 12/2020 Index of covered drugs AFINITOR DISPERZ 36 A AFLURIA 2018-2019 57 abacavir sulfate 55 AFLURIA QUAD 2018-2019 57 abacavir sulfate/lamivudine 55 AFLURIA QUAD 2019-20 (3YR UP) 57 abacavir sulfate/lamivudine/zidovudine 55 AFLURIA QUAD 2019-20 (6-35MO) 58 abiraterone acetate 36 AFLURIA QUAD 2019-2020 58 acamprosate calcium 68 AFLURIA QUAD 2020-2021 58 acarbose 25 AFLURIA QUAD 2020-21 (3YR UP) 58 ACE AEROSOL CLOUD ENHANCER 71 AFLURIA QUAD 2020-21 (6-35MO) 58 acetaminophen with codeine phosphate 3 AFSTYLA 30 acetazolamide 29 AJOVY AUTOINJECTOR 34 acetic acid 12 AJOVY SYRINGE 34 acetylcysteine 103 albendazole 10 acitretin 106 albuterol sulfate 64 ACTEMRA 93 alclometasone dipropionate 15 ACTEMRA ACTPEN 93 ALDACTAZIDE 102 ACTHAR 74 ALECENSA 37 ACTHIB 57 alendronate sodium 92 ACUVAIL 14 ALFERON N 61 acyclovir 61 alfuzosin hcl 3 ADACEL TDAP 57 ALINIA 52 adapalene 106 allopurinol 91 ADDERALL XR 8 alosetron hcl 79 adefovir dipivoxil 62 ALPHAGAN P 29 ADEMPAS 104 ALPHANATE 30 adenovirus live type-4 and adenovirus live type-7 ALPHANINE SD 30 vaccine 57 alprazolam 62,63 adenovirus vaccine live type-4 57 ALPROLIX 30 adenovirus vaccine live type-7 57 ALTABAX 12 ADVAIR DISKUS 70 ALTAVERA 84 ADVAIR HFA 70 ALYACEN 84 ADVATE 30 AMABELZ 76 ADYNOVATE 30 amantadine hcl 51 AEROCHAMBER MINI 71 ambrisentan 104 AEROCHAMBER MV 71 AMETHIA 84 AEROCHAMBER PLUS FLOW-VU 71 AMETHIA LO 84 AEROCHAMBER WITH FLOWSIGNAL 71 amiloride hcl 74 AEROCHAMBER Z-STAT PLUS 71 amiloride hcl/hydrochlorothiazide 74 AEROTRACH PLUS 71 amiodarone hcl 16 AFEDITAB CR 66 AMITIZA 79 AFINITOR 36 amitriptyline hcl 25

PAGE 111 LAST UPDATED 12/2020 amlodipine besylate 66 AVITA 105 amlodipine besylate/benazepril hcl 66 AVONEX 96 amlodipine besylate/valsartan 66 AVONEX PEN 96 amlodipine besylate/valsartan/hydrochlorothiazide 66 AYVAKIT 37 ammonium lactate 76 azathioprine 97 AMNESTEEM 106 azelaic acid 106 amoxicillin 101 azelastine hcl 77 amoxicillin/potassium clavulanate 101 azithromycin 91 ampicillin trihydrate 101 AZOPT 29 anagrelide hcl 57 AZURETTE 84 anastrozole 37 ANORO ELLIPTA 19 B aprepitant 27 bacitracin 10 APRI 84 bacitracin/polymyxin b sulfate 10 APTIOM 20 baclofen 105 APTIVUS 56 balsalazide disodium 79 ARALAST NP 103 BALVERSA 37 ARANELLE 84 BALZIVA 84 ARANESP 65 BANZEL 20 ARCALYST 98 BAQSIMI 33 aripiprazole 52 BARACLUDE 62 armodafinil 10 BEKYREE 84 ARNUITY ELLIPTA 70 benazepril hcl 102 ASHLYNA 84 benazepril hcl/hydrochlorothiazide 102 ASMANEX 70 BENEFIX 30 ASMANEX HFA 70 benzonatate 103 aspirin/dipyridamole 109 benztropine mesylate 51 atazanavir sulfate 56 BERINERT 92 atenolol 67 BESIVANCE 10 atenolol/chlorthalidone 67 betamethasone dipropionate 15 atomoxetine hcl 68 betamethasone dipropionate/propylene glycol 15 atorvastatin calcium 34 betamethasone valerate 15 atovaquone 52 BETASERON 96 atovaquone/proguanil hcl 52 betaxolol hcl 29 atropine sulfate 78 bethanechol chloride 63 ATROVENT HFA 19 BEXSERO 58 AUBAGIO 96 bicalutamide 37 AUBRA 84 BIKTARVY 55 AUBRA EQ 84 bimatoprost 30 AUSTEDO 69 bisoprolol fumarate 67 AVIANE 84 bisoprolol fumarate/hydrochlorothiazide 67

PAGE 112 LAST UPDATED 12/2020 BLEPHAMIDE S.O.P. 10 CAMRESE 84 BLISOVI 24 FE 84 CAMRESE LO 84 BLISOVI FE 84 capecitabine 38 BOOSTRIX TDAP 57 CAPLYTA 52 bosentan 104 CAPRELSA 38 BOSULIF 37 captopril 102 BRAFTOVI 37 captopril/hydrochlorothiazide 102 BREATHERITE 71 CARBAGLU 75 BREATHRITE 71 carbamazepine 20 BREO ELLIPTA 70 carbidopa 68 BRIELLYN 84 carbidopa/levodopa 51 BRILINTA 56 carbidopa/levodopa/entacapone 51 brimonidine tartrate 29 carteolol hcl 29 BRIVIACT 20 CARTIA XT 65 bromfenac sodium 14 carvedilol 67 bromocriptine mesylate 74 CAYSTON 91 BRUKINSA 38 CAZIANT 84 budesonide 70,82 cefadroxil 69 budesonide/formoterol fumarate 70 cefdinir 70 bumetanide 74 cefixime 70 buprenorphine 7 cefprozil 69 buprenorphine hcl/naloxone hcl 7,8 cefuroxime axetil 70 bupropion hcl 23 celecoxib 99 buspirone hcl 62 cephalexin 69 butalbital/acetaminophen 3 CERDELGA 98 butalbital/acetaminophen/caffeine 3 CETROTIDE 81 butalbital/aspirin/caffeine 100 cevimeline hcl 63 BYDUREON 25 CHANTIX 63 BYDUREON BCISE 25 CHATEAL 84 BYDUREON PEN 25 CHATEAL EQ 84 BYETTA 25,26 CHEMET 82 chlordiazepoxide hcl 63 C chlorhexidine gluconate 12 cabergoline 74 chloroquine phosphate 52 CABLIVI 56 chlorothiazide 74 CABOMETYX 38 chlorthalidone 74 calcipotriene 106 chlorzoxazone 105 calcitonin,salmon,synthetic 100 CHOLBAM 80 calcitriol 106,110 cholestyramine (with sugar) 33 calcium acetate 90 cholestyramine/aspartame 33 CAMILA 84 chorionic gonadotropin, human 81

PAGE 113 LAST UPDATED 12/2020 ciclopirox 28 COMBIGAN 29 ciclopirox olamine 28 COMBIPATCH 77 cilostazol 56 COMBIVENT RESPIMAT 19 CILOXAN 10 COMETRIQ 38 cimetidine 60 COMPLERA 55 cimetidine hcl 60 CONCERTA 9 CIMZIA 93 COPIKTRA 39 cinacalcet hcl 100 CORDRAN 15 CINRYZE 92 CORIFACT 30 CIPRO 17 CORLANOR 66 CIPRO HC 11 COSENTYX (2 SYRINGES) 106 CIPRODEX 11 COSENTYX PEN 106 ciprofloxacin 17 COSENTYX PEN (2 PENS) 106 ciprofloxacin hcl 11,17 COSENTYX SYRINGE 106 ciprofloxacin hcl/dexamethasone 11 COTELLIC 39 citalopram hydrobromide 24 CREON 80 CLARAVIS 106 CRESEMBA 28 clarithromycin 91 cromolyn sodium 14 CLEOCIN 12 CRYSELLE 84 CLEOCIN T 12 CUVPOSA 19 CLIMARA PRO 76 cyanocobalamin (vitamin b-12) 110 clindamycin hcl 18 CYCLAFEM 84 clindamycin palmitate hcl 18 cyclobenzaprine hcl 105 clindamycin phosphate 12 cyclopentolate hcl 78 clindamycin phosphate/benzoyl peroxide 12 cyclophosphamide 39 clobazam 23 cycloserine 35 clobetasol propionate 15 CYCLOSET 74 clobetasol propionate/emollient base 15 cyclosporine 97 clomiphene citrate 76 cyclosporine, modified 98 clomipramine hcl 25 cyproheptadine hcl 78 clonazepam 23 CYRED 84 clonidine 89 CYRED EQ 84 clonidine hcl 89 CYSTADROPS 78 clopidogrel bisulfate 56 CYSTAGON 98 clotrimazole 28 CYSTARAN 78 clozapine 52 COAGADEX 30 D codeine phosphate/guaifenesin 103 D-PENAMINE 82 codeine sulfate 3 dalfampridine 98 colchicine 91 DALIRESP 103 colestipol hcl 33 danazol 83

PAGE 114 LAST UPDATED 12/2020 dantrolene sodium 105 DIGOX 67 dapsone 35,106 digoxin 67 DAPTACEL DTAP 57 DILANTIN 23 DASETTA 84 DILT-XR 65 DAURISMO 39 diltiazem hcl 65 DAYSEE 84 dimethyl fumarate 96 DEBLITANE 84 diphenoxylate hcl/atropine sulfate 79 deferasirox 82 dipyridamole 109 deferiprone 82 disopyramide phosphate 16 DELYLA 85 disulfiram 91 demeclocycline hcl 18 DIURIL 74 DESCOVY 55 divalproex sodium 21 desipramine hcl 25 dofetilide 17 desmopressin acetate 88 DOJOLVI 75 desmopressin acetate (non-refrigerated) 88 donepezil hcl 64 desogestrel-ethinyl estradiol 85 dorzolamide hcl 29 desogestrel-ethinyl estradiol/ethinyl estradiol 85 dorzolamide hcl/timolol maleate 29 desonide 15 dorzolamide hcl/timolol maleate/pf 29 desoximetasone 15 DOTTI 77 desvenlafaxine succinate 24 doxazosin mesylate 67 dexamethasone 82 doxepin hcl 25 DEXAMETHASONE INTENSOL 82 doxycycline hyclate 11,18 dexamethasone sodium phosphate 13,83 doxycycline monohydrate 18 dexamethasone sodium phosphate/pf 83 DRITHOCREME HP 106 DEXCOM 71 dronabinol 27 DEXCOM G4 71 DRYSOL 105 DEXCOM G5 72 DULERA 70 DEXCOM G5-G4 SENSOR 72 duloxetine hcl 24 DEXCOM G6 72 DUPIXENT PEN 106 dexmethylphenidate hcl 9 DUPIXENT SYRINGE 14,106 dextroamphetamine sulf-saccharate/amphetamine sulf- dutasteride 91 aspartate 8 dutasteride/tamsulosin hcl 91 dextroamphetamine sulfate 8 DIACOMIT 20,21 E diazepam 63 EASIVENT 72 diclofenac potassium 99 econazole nitrate 28 diclofenac sodium 14,99 EDURANT 54 dicloxacillin sodium 101 efavirenz 54 dicyclomine hcl 19 efavirenz/emtricitabine/tenofovir disoproxil fumarate 55 DIFICID 91 ELINEST 85 DIGITEK 67 ELIQUIS 19

PAGE 115 LAST UPDATED 12/2020 ELLA 85 ERRIN 85 ELMIRON 99 erythromycin base 11 ELOCTATE 31 erythromycin base in ethanol 12 ELURYNG 85 ESBRIET 103 EMCYT 39 escitalopram oxalate 24 EMEND 27 esomeprazole magnesium 60 EMGALITY PEN 35 ESPEROCT 31 EMGALITY SYRINGE 35 ESTARYLLA 85 EMOQUETTE 85 estradiol 77 EMSAM 51 estradiol/norethindrone acetate 77 emtricitabine 55 ESTRING 77 emtricitabine/tenofovir disoproxil fumarate 55 eszopiclone 62 EMTRIVA 55 ethambutol hcl 35 enalapril maleate 102 ethinyl estradiol/drospirenone 85 enalapril maleate/hydrochlorothiazide 102 ethosuximide 23 ENBREL 93 ethynodiol diacetate-ethinyl estradiol 85 ENBREL MINI 93 etidronate disodium 92 ENBREL SURECLICK 93 etodolac 99 ENDARI 80 etonogestrel/ethinyl estradiol 85 ENDOCET 3,4 etoposide 40 ENGERIX-B ADULT 58 EUCRISA 14 ENGERIX-B PEDIATRIC-ADOLESCENT 58 EURAX 13 enoxaparin sodium 20 EUTHYROX 108 ENPRESSE 85 everolimus 40 ENSKYCE 85 EVOTAZ 56 entacapone 51 exemestane 40 entecavir 62 EZ FLU 2018-2019 (FLUCELVAX) 58 ENTRESTO 101 ezetimibe 33 ENULOSE 75 EPCLUSA 81 F EPIDIOLEX 21 FALMINA 85 epinastine hcl 77 famciclovir 62 epinephrine 108 famotidine 60 EPIVIR HBV 55 FANAPT 52 eplerenone 102 FASENRA PEN 14 epoprostenol sodium (glycine) 104 febuxostat 91 ergocalciferol (vitamin d2) 110 FEIBA NF 31 ERGOMAR 3 felbamate 21 ERIVEDGE 39 felodipine 66 ERLEADA 39 FEMYNOR 85 erlotinib hcl 40 fenofibrate 33

PAGE 116 LAST UPDATED 12/2020 fenofibrate nanocrystallized 33 fluorometholone 13 fenofibrate,micronized 34 FLUOROPLEX 40 fentanyl 4 fluorouracil 40 FERRIPROX 82 fluoxetine hcl 24 FETZIMA 24 fluphenazine hcl 54 finasteride 91 flurbiprofen 99 FIRAZYR 92 flurbiprofen sodium 14 flecainide acetate 16 flutamide 40 FLOLAN 104 fluticasone propionate 13,15 FLOVENT DISKUS 70 fluticasone propionate/salmeterol xinafoate 70 FLOVENT HFA 70 fluvoxamine maleate 24 FLUAD 2018-2019 58 FLUZONE HIGH-DOSE 2018-2019 59 FLUAD 2019-2020 58 FLUZONE HIGH-DOSE 2019-2020 59 FLUAD 2020-2021 58 FLUZONE HIGH-DOSE QUAD 2020-21 59 FLUAD QUAD 2020-2021 58 FLUZONE QUAD 2018-2019 59 FLUARIX QUAD 2018-2019 58 FLUZONE QUAD 2019-2020 59 FLUARIX QUAD 2019-2020 58 FLUZONE QUAD 2020-2021 59 FLUARIX QUAD 2020-2021 58 FLUZONE QUAD PEDI 2018-2019 59 FLUBLOK QUAD 2018-2019 58 FLUZONE QUAD PEDI 2019-2020 59 FLUBLOK QUAD 2019-2020 58 FML S.O.P. 13 FLUBLOK QUAD 2020-2021 58 folic acid 110 FLUCELVAX QUAD 2018-2019 58 FOLLISTIM AQ 81 FLUCELVAX QUAD 2019-2020 58 fondaparinux sodium 19 FLUCELVAX QUAD 2020-2021 58 FORTEO 100 fluconazole 28 fosamprenavir calcium 56 fludrocortisone acetate 83 fosfomycin tromethamine 10 FLULAVAL QUAD 2018-2019 58 fosinopril sodium 102 FLULAVAL QUAD 2019-2020 58 fosinopril sodium/hydrochlorothiazide 102 FLULAVAL QUAD 2020-2021 58 FREESTYLE LIBRE 10 DAY READER 72 FLUMIST QUAD 2018-2019 58 FREESTYLE LIBRE 10 DAY SENSOR 72 FLUMIST QUAD 2019-2020 58 FREESTYLE LIBRE 14 DAY READER 72 FLUMIST QUAD 2020-2021 59 FREESTYLE LIBRE 14 DAY SENSOR 73 flunisolide 13 FREESTYLE LIBRE 2 READER 73 fluocinolone acetonide 15 FREESTYLE LIBRE 2 SENSOR 73 fluocinolone acetonide oil 13 FULPHILA 65 fluocinolone acetonide/shower cap 15 furosemide 74 fluocinonide 15 FUZEON 54 fluocinonide/emollient base 15 FYAVOLV 77 FLUORABON 92 FYCOMPA 21 fluoride (sodium) 92 FLUORITAB 92

PAGE 117 LAST UPDATED 12/2020

G H gabapentin 21 HAEGARDA 92 GALAFOLD 98 haloperidol 54 galantamine hbr 64 haloperidol lactate 54 ganirelix acetate 81 HARVONI 81 GARDASIL 9 59 HAVRIX 59 gatifloxacin 11 HEATHER 85 GAVILYTE-C 79 HELIXATE FS 31 GAVILYTE-G 79 HEMLIBRA 31 GAVILYTE-N 79 HEMOFIL M 31 gemfibrozil 34 heparin sodium,porcine 20 GENERLAC 75 heparin sodium,porcine/pf 20 GENGRAF 98 HEPLISAV-B 59 gentamicin sulfate 12 HIBERIX 59 GENVOYA 55 homatropine hbr 78 GIANVI 85 HUMALOG 90 GILENYA 96 HUMALOG JUNIOR KWIKPEN 90 GILOTRIF 40 HUMALOG KWIKPEN U-100 90 GLASSIA 103 HUMALOG KWIKPEN U-200 90 glatiramer acetate 96 HUMALOG MIX 50-50 90 GLATOPA 97 HUMALOG MIX 50-50 KWIKPEN 90 GLEOSTINE 40 HUMALOG MIX 75-25 90 glimepiride 26 HUMALOG MIX 75-25 KWIKPEN 90 glipizide 26 HUMATE-P 31 glipizide/metformin hcl 27 HUMIRA 94 GLUCAGEN 33 HUMIRA PEDIATRIC CROHN'S 94 GLUCAGON EMERGENCY KIT 33 HUMIRA PEN 94 glyburide 27 HUMIRA PEN CROHN'S-UC-HS 94 glyburide,micronized 27 HUMIRA PEN PSOR-UVEITS-ADOL HS 94 glycopyrrolate 19 HUMIRA(CF) 94 GRANIX 65 HUMIRA(CF) PEDIATRIC CROHN'S 80,94 GRASTEK 57 HUMIRA(CF) PEN 95 griseofulvin ultramicrosize 28 HUMIRA(CF) PEN CROHN'S-UC-HS 95 griseofulvin, microsize 28 HUMIRA(CF) PEN PSOR-UV-ADOL HS 95 guanfacine hcl 68,89 HUMULIN R U-500 90 GVOKE HYPOPEN 1-PACK 33 HUMULIN R U-500 KWIKPEN 90 GVOKE HYPOPEN 2-PACK 33 HYCAMTIN 40 GVOKE PFS 1-PACK SYRINGE 33 hydralazine hcl 89 GVOKE PFS 2-PACK SYRINGE 33 hydrochlorothiazide 74 hydrocodone bitartrate/acetaminophen 4

PAGE 118 LAST UPDATED 12/2020 hydrocodone/ibuprofen 4 INTELENCE 55 hydrocortisone 15,83 INTRON A 61 hydrocortisone acetate 16 INTROVALE 85 hydrocortisone acetate/pramoxine hcl 16 INVIRASE 56 hydrocortisone valerate 16 INVOKAMET 26 hydrocortisone/iodoquinol 13 INVOKAMET XR 26 hydromorphone hcl 4 INVOKANA 26 hydroxychloroquine sulfate 52 ipratropium bromide 19,78 hydroxyprogesterone caproate/pf 89 ipratropium bromide/albuterol sulfate 19 hydroxyurea 40 irbesartan 101 hydroxyzine hcl 62 irbesartan/hydrochlorothiazide 101 hydroxyzine pamoate 62 IRESSA 42 hyoscyamine sulfate 19 ISENTRESS 54 ISENTRESS HD 54 I ISIBLOOM 85 ibandronate sodium 92 isoniazid 36 IBRANCE 40,41 isosorbide dinitrate 109 ibuprofen 99 isosorbide mononitrate 109 ICLUSIG 41 isotretinoin 107 icosapent ethyl 33 ISTURISA 98 IDELVION 31 itraconazole 28 IDHIFA 41 ivermectin 10 ILARIS 98 IXINITY 31 imatinib mesylate 41 IMBRUVICA 41 J imipramine hcl 25 JAKAFI 42 imiquimod 106 JARDIANCE 26 INBRIJA 51 JASMIEL 85 INCASSIA 85 JENCYCLA 85 INCRUSE ELLIPTA 19 JENTADUETO 25 indapamide 74 JENTADUETO XR 25 indomethacin 99 JINTELI 77 INFANRIX DTAP 57 JIVI 31 INGREZZA 69 JOLESSA 85 INGREZZA INITIATION PACK 69 JOLIVETTE 85 INLYTA 42 JULEBER 85 INPEN (FOR HUMALOG) 73 JULUCA 54 INPEN (FOR NOVOLOG OR FIASP) 73 JUNEL 85 INREBIC 42 JUNEL FE 85 insulin lispro 90 JUXTAPID 33 insulin lispro protamine and insulin lispro 90

PAGE 119 LAST UPDATED 12/2020 leflunomide 95 K LENVIMA 43 KALBITOR 92 LESSINA 86 KALETRA 56 letrozole 43 KALYDECO 71 leucovorin calcium 91 KARIVA 85 LEUKERAN 43 KELNOR 1-35 86 leuprolide acetate 81 KELNOR 1-50 86 levalbuterol tartrate 64 ketoconazole 28 LEVEMIR 89 ketorolac tromethamine 14,100 LEVEMIR FLEXTOUCH 90 KINERET 95 levetiracetam 21,22 KINRIX 59 levobunolol hcl 29 KISQALI 42 levocarnitine 98,99 KISQALI FEMARA CO-PACK 43 levocarnitine (with sugar) 98 KLOR-CON M10 75 levofloxacin 17 KLOR-CON M15 75 LEVONEST 86 KLOR-CON M20 75 levonorgestrel/ethinyl estradiol 86 KOATE 31 levonorgestrel/ethinyl estradiol and ethinyl estradiol 86 KOGENATE FS 31 LEVORA-28 86 KOSELUGO 43 levothyroxine sodium 109 KOVALTRY 31 LEXIVA 56 KURVELO 86 lidocaine 105 lidocaine hcl 78 L lidocaine/prilocaine 105 labetalol hcl 67 LILLOW 86 LACRISERT 78 linezolid 18 lactulose 75 LINZESS 80 lamivudine 55 liothyronine sodium 109 lamivudine/zidovudine 55 lisinopril 102 lamotrigine 21 lisinopril/hydrochlorothiazide 102 lansoprazole 60 LITETOUCH 73 LANTUS 89 lithium carbonate 68 LANTUS SOLOSTAR 89 lithium citrate 68 lapatinib ditosylate 43 LOMAIRA 8 LARIN 86 LONSURF 44 LARIN FE 86 lopinavir/ritonavir 56 LARISSIA 86 LOPREEZA 77 latanoprost 30 lorazepam 63 LATUDA 52 LORAZEPAM INTENSOL 63 ledipasvir/sofosbuvir 81 LORBRENA 44 LEENA 86 LORCET 4

PAGE 120 LAST UPDATED 12/2020 LORCET HD 5 metformin hcl 25 LORCET PLUS 5 methadone hcl 5 LORYNA 86 METHADONE INTENSOL 5 losartan potassium 102 METHADOSE 5 losartan potassium/hydrochlorothiazide 102 methazolamide 29 LOTEMAX 13 methimazole 108 LOTEMAX SM 13 methocarbamol 105 loteprednol etabonate 13 methotrexate sodium 45 lovastatin 34 methotrexate sodium/pf 45 LOW-OGESTREL 86 methyldopa 89 loxapine succinate 52 methylergonovine maleate 100 LUMIGAN 30 methylphenidate hcl 9 LUTERA 86 methylprednisolone 83 LYNPARZA 44 metoclopramide hcl 80 LYZA 86 metolazone 74 metoprolol succinate 67 M metoprolol tartrate 67 MAKENA 89 metoprolol tartrate/hydrochlorothiazide 67 malathion 13 metronidazole 12,52 MARLISSA 86 mexiletine hcl 16 MATULANE 44 MICROCHAMBER 73 MATZIM LA 66 MICROGESTIN 86 MAVENCLAD 98 MICROGESTIN FE 86 MAVYRET 82 MICROSPACER 73 MAYZENT 97 midodrine hcl 108 MEDROL 83 miglitol 25 medroxyprogesterone acetate 89 miglustat 99 mefloquine hcl 52 MILI 86 megestrol acetate 89 MILLIPRED 83 MEKINIST 44,45 MIMVEY LO 77 MEKTOVI 45 minocycline hcl 18 meloxicam 100 minoxidil 89 melphalan 45 mirtazapine 23 memantine hcl 68 misoprostol 60 MENACTRA 59 modafinil 10 MENOPUR 81 MODERNA COVID19 VACC(UNAPPROV) 59 MENQUADFI 59 moexipril hcl 102 MENVEO A-C-Y-W-135-DIP 59 mometasone furoate 16 mercaptopurine 45 MONDOXYNE NL 18 mesalamine 79 MONO-LINYAH 86 METADATE ER 9 MONONESSA 86

PAGE 121 LAST UPDATED 12/2020 MONONINE 31 nimodipine 66 montelukast sodium 14 NINLARO 45 morphine sulfate 5,6 NITRO-BID 109 MOVANTIK 80 nitrofurantoin 10 moxifloxacin hcl 11,17 nitrofurantoin macrocrystal 10 MULTAQ 17 nitrofurantoin monohydrate/macrocrystals 10 multivitamin combination no.51/ferrous fumarate/folic nitroglycerin 109 acid 110 NORA-BE 86 mupirocin 12 NORDITROPIN FLEXPRO 88 mupirocin calcium 12 norethindrone 87 mycophenolate mofetil 98 norethindrone acetate 89 MYLERAN 45 norethindrone acetate-ethinyl estradiol 77,87 MYORISAN 107 norethindrone acetate-ethinyl estradiol/ferrous MYRBETRIQ 64 fumarate 87 MYZILRA 86 norgestimate-ethinyl estradiol 87 NORLYDA 87 N NORLYROC 87 nabumetone 100 NORPACE CR 16 nadolol 67 NORTREL 87 naloxone hcl 69 nortriptyline hcl 25 naltrexone hcl 69 NORVIR 56 naproxen 100 NOURIANZ 68 naratriptan hcl 35 NOVAREL 81 NARCAN 69 NOVOEIGHT 31 nateglinide 26 NOVOPEN ECHO 73 NAYZILAM 23 NOVOSEVEN RT 32 NECON 86 NUBEQA 45 nefazodone hcl 24 NUCALA 14 neomycin sulfate 17 NUPLAZID 53 neomycin sulfate/bacitracin/polymyxin b 11 NURTEC ODT 35 neomycin sulfate/polymyxin b sulfate/gramicidin d 11 NUWIQ 32 neomycin sulfate/polymyxin b sulfate/hydrocortisone 11 NUZYRA 108 neomycin/polymyxin b sulfate/dexamethasone 11 nystatin 28,29 NERLYNX 45 NEUPRO 75 O nevirapine 55 O-CAL PRENATAL 110 NEXAVAR 45 OBIZUR 32 NICOTROL 63 OCELLA 87 NICOTROL NS 63 octreotide acetate 107,108 nifedipine 66 ODACTRA 57 NIKKI 86 ODEFSEY 55

PAGE 122 LAST UPDATED 12/2020 ODOMZO 46 pantoprazole sodium 60 OFEV 103 PANZYGA 57 ofloxacin 11 paregoric 79 OGESTREL 87 PAROEX 12 olanzapine 53 paroxetine hcl 24 olmesartan medoxomil 102 PAXIL 24 olmesartan medoxomil/hydrochlorothiazide 102 PEDIARIX 59 olopatadine hcl 77 PEDVAXHIB 59 OLUMIANT 95 PEGASYS 61 omega-3 acid ethyl esters 33 PEGASYS PROCLICK 61 omeprazole 60 PEGINTRON 61 OMNIPOD 73 PEMAZYRE 46 OMNIPOD DASH 5 PACK POD 73 penicillamine 82 OMNIPOD DASH PDM KIT 73 penicillin v potassium 101 ondansetron 27 PENTACEL 59 ondansetron hcl 27 PENTACEL ACTHIB COMPONENT 59 OPSUMIT 104 PENTACEL DTAP-IPV COMPONENT 59 OPTICHAMBER 73 pentoxifylline 65 OPTICHAMBER DIAMOND 73 perindopril erbumine 102 ORENCIA 95 PERIOGARD 12 ORENCIA CLICKJECT 95 permethrin 13 ORILISSA 81 perphenazine 54 ORKAMBI 71 PFIZER COVID19 VACC (UNAPPROV) 59 ORSYTHIA 87 PHENADOZ 78 oseltamivir phosphate 61 phenazopyridine hcl 105 OTEZLA 95,96 phenelzine sulfate 24 OVIDREL 81 phenobarbital 62 OXBRYTA 64 phenoxybenzamine hcl 3 oxcarbazepine 22 phentermine hcl 8 OXERVATE 78 phenylephrine hcl 78 oxybutynin chloride 80 phenylephrine hcl/promethazine hcl 78 oxycodone hcl 6 phenytoin 23 oxycodone hcl/acetaminophen 7 phenytoin sodium extended 23 oxycodone hcl/aspirin 7 PHILITH 87 OXYCONTIN 7 PHOSLYRA 90 OZEMPIC 26 PHOSPHOLINE IODIDE 29 phytonadione (vit k1) 110 P PICATO 46 PACERONE 17 pilocarpine hcl 29,64 PALFORZIA 57 pimecrolimus 107 paliperidone 53 PIMTREA 87

PAGE 123 LAST UPDATED 12/2020 pioglitazone hcl 27 prenatal vits with calcium no.72/ferrous fumarate/folic pioglitazone hcl/glimepiride 27 acid 110 pioglitazone hcl/metformin hcl 27 prenatal vits with calcium no.72/iron,carbonyl/folic PIRMELLA 87 acid 110 piroxicam 100 PRENATE ELITE 110 PLEGRIDY 97 pretomanid 36 PLEGRIDY PEN 97 PREVALITE 33 PNEUMOVAX 23 59 PREVIFEM 87 POCKET CHAMBER 73 PREVNAR 13 59 podofilox 107 PREVYMIS 61 polymyxin b sulfate/trimethoprim 11 PREZCOBIX 56 POMALYST 46 PREZISTA 56 PORTIA 87 PRIFTIN 36 posaconazole 28 primidone 23 potassium chloride 76 probenecid 76 potassium citrate 75 probenecid/colchicine 76 PRADAXA 20 PROCHAMBER 73 pramipexole di-hcl 75 prochlorperazine 27 prasugrel hcl 56 prochlorperazine maleate 27 pravastatin sodium 34 PROCTO-MED HC 16 praziquantel 10 PROCTOFOAM-HC 16 prazosin hcl 67 PROCTOSOL-HC 16 prednisolone 83 PROCTOZONE-HC 16 prednisolone acetate 13 PROFILNINE 32 prednisolone sodium phosphate 13,83 progesterone, micronized 89 prednisone 83 PROLASTIN C 103 PREDNISONE INTENSOL 83 PROMACTA 65 pregabalin 22 promethazine hcl 78,79 PREGNYL 81 promethazine hcl/dextromethorphan hbr 103 PREMARIN 77 PROMETHEGAN 79 PREMPHASE 77 propafenone hcl 16 PREMPRO 77 propantheline bromide 19 PRENATA 110 propranolol hcl 67 PRENATABS FA 110 propranolol hcl/hydrochlorothiazide 68 PRENATABS RX 110 propylthiouracil 108 prenatal vitamin with calcium no.76/iron,carbonyl/folic PROQUAD 59 acid 110 PULMICORT FLEXHALER 70 prenatal vitamins with calcium/ferrous fumarate/folic PULMOZYME 103 acid 110 PUREFE OB PLUS 110 prenatal vits with calcium 118/ferrous fumarate/folic pyrazinamide 36 acid 110 pyridostigmine bromide 64

PAGE 124 LAST UPDATED 12/2020 REYVOW 35 Q RHOPRESSA 30 QINLOCK 46 ribavirin 62 QNASL 13 RIDAURA 81 QNASL CHILDREN 13 rifabutin 36 QUASENSE 87 rifampin 36 quetiapine fumarate 53 riluzole 68 QUILLICHEW ER 9 rimantadine hcl 61 QUILLIVANT XR 10 RINVOQ 96 quinapril hcl 102 risedronate sodium 92 quinapril hcl/hydrochlorothiazide 102 risperidone 53 quinidine sulfate 16 ritonavir 56 QVAR REDIHALER 70 rivastigmine 64 rivastigmine tartrate 64 R RIXUBIS 32 rabeprazole sodium 61 rizatriptan benzoate 35 RAGWITEK 57 ROCKLATAN 30 raloxifene hcl 76 ropinirole hcl 75 ramipril 102 ROSADAN 12 rasagiline mesylate 51 rosuvastatin calcium 34 RASUVO 46 ROZLYTREK 46 REBETOL 62 RUCONEST 93 REBIF 97 rufinamide 22 REBIF REBIDOSE 97 RUZURGI 99 REBINYN 32 RYBELSUS 26 RECLIPSEN 87 RYDAPT 47 RECOMBINATE 32 RYTARY 51 RECOMBIVAX HB 59 RELENZA 61 S repaglinide 26 salsalate 100 REPATHA PUSHTRONEX 34 SANDOSTATIN LAR DEPOT 108 REPATHA SURECLICK 34 SAPHRIS 53 REPATHA SYRINGE 34 sapropterin dihydrochloride 99 RESTASIS 14 SAVELLA 69 RESTASIS MULTIDOSE 14 scopolamine 27 RETACRIT 65 SECUADO 53 RETEVMO 46 selegiline hcl 51 REVCOVI 76 selenium sulfide 13 REVLIMID 46 SELZENTRY 54 REXULTI 53 SENSIPAR 100 REYATAZ 56 SEREVENT DISKUS 64

PAGE 125 LAST UPDATED 12/2020 SEROPHENE 76 STRIBILD 55 sertraline hcl 24 STRIVERDI RESPIMAT 64 SETLAKIN 87 SUBVENITE 22 sevelamer carbonate 90 SUCRAID 76 SEVENFACT 32 sucralfate 60 SHAROBEL 87 sulfacetamide sodium 11,13 SHINGRIX 59 sulfacetamide sodium/prednisolone sodium SHINGRIX ADJUVANT COMPONENT 101 phosphate 11 SHINGRIX GE ANTIGEN COMPONENT 60 sulfacetamide sodium/sulfur 105,106 SIGNIFOR 108 sulfacetamide sodium/sulfur/urea 13 sildenafil citrate 109 sulfamethoxazole/trimethoprim 17 SILICONE MASK 73 sulfasalazine 17 silver sulfadiazine 13 SULFATRIM 17 SIMBRINZA 29 sulindac 100 SIMPESSE 87 sumatriptan 35 simvastatin 34 sumatriptan succinate 35 sirolimus 98 SUNOSI 10 SIRTURO 36 SUPREP 79 SIVEXTRO 18 SUTENT 47 SKYRIZI 107 SYEDA 87 SKYRIZI (2 SYRINGES) KIT 107 SYLATRON 61 sodium chloride/sodium bicarbonate/potassium SYMDEKO 71 chloride/peg 79 SYMJEPI 108 sodium phenylbutyrate 75 SYMPROIC 80 sodium polystyrene sulfonate 90 SYMTUZA 56 sofosbuvir/velpatasvir 82 SYNJARDY 26 solifenacin succinate 80 SYNJARDY XR 26 SOLIQUA 100-33 90 SYNTHROID 109 SOLTAMOX 76 SOLU-CORTEF 83 T sotalol hcl 68 TABLOID 47 SOVALDI 82 TABRECTA 47 spironolactone 102 tacrolimus 98,107 spironolactone/hydrochlorothiazide 102 tadalafil 109 SPRINTEC 87 TAFINLAR 47 SPRYCEL 47 TAGRISSO 47 SRONYX 87 TAKHZYRO 93 SSD 13 TALICIA 60 STIMATE 88 tamoxifen citrate 76 STIVARGA 47 tamsulosin hcl 3 STRENSIQ 76 TARINA FE 87

PAGE 126 LAST UPDATED 12/2020 TARINA FE 1-20 EQ 87 tolterodine tartrate 80 TASIGNA 47 topiramate 22 tazarotene 107 torsemide 74 TAZORAC 107 TOUJEO MAX SOLOSTAR 90 TAZTIA XT 66 TOUJEO SOLOSTAR 90 TAZVERIK 48 TRACLEER 104 telmisartan 102 TRADJENTA 25 temazepam 63 tramadol hcl 7 temozolomide 48 trandolapril 102 TENCON 3 tranexamic acid 32 TENIVAC 57 tranylcypromine sulfate 24 tenofovir disoproxil fumarate 55 travoprost 30 terazosin hcl 67 trazodone hcl 24 terbinafine hcl 27 TRECATOR 36 terconazole 28 TRELEGY ELLIPTA 70 testosterone 83 treprostinil sodium 104 testosterone cypionate 83 tretinoin 48,105 testosterone enanthate 83 TRETTEN 32 testosterone propionate 83 TRI FEMYNOR 87 tetanus and diphtheria toxoids, adult 57 TRI-ESTARYLLA 88 tetanus,diphtheria toxoid ped/pf 57 TRI-LEGEST FE 88 tetrabenazine 69 TRI-LINYAH 88 THALOMID 97 TRI-LO-ESTARYLLA 88 theophylline anhydrous 107 TRI-LO-MARZIA 88 THIOLA 99 TRI-LO-SPRINTEC 88 THIOLA EC 99 TRI-MILI 88 thioridazine hcl 54 TRI-PREVIFEM 88 thiothixene 54 TRI-SPRINTEC 88 TIADYLT ER 66 TRI-VYLIBRA 88 tiagabine hcl 22 TRI-VYLIBRA LO 88 TIBSOVO 48 triamcinolone acetonide 16 TILIA FE 87 triamterene/hydrochlorothiazide 74 timolol maleate 29 TRIDERM 16 TIVICAY 54 trifluoperazine hcl 54 TIVICAY PD 54 trifluridine 11 tizanidine hcl 105 trihexyphenidyl hcl 51 TOBRADEX 11 TRIJARDY XR 26 tobramycin 11 TRIKAFTA 71 tobramycin in 0.225 % sodium chloride 17 TRIKLO 33 tobramycin/dexamethasone 11 TRILYTE WITH FLAVOR PACKETS 79 TOBREX 11 trimethobenzamide hcl 27

PAGE 127 LAST UPDATED 12/2020 trimethoprim 10 VAXCHORA ACTIVE COMPONENT 60 TRINATE 110 VAXCHORA BUFFER COMPONENT 101 TRINTELLIX 24 VAXCHORA VACCINE 60 TRIUMEQ 55 VELETRI 104 TRIVORA-28 88 VELIVET 88 trospium chloride 80 VEMLIDY 62 TRULICITY 26 venlafaxine hcl 24 TRUMENBA 60 VENTAVIS 104 TRUVADA 55 VENTOLIN HFA 64 TULANA 88 verapamil hcl 66 TURALIO 48 VERSACLOZ 53 TWINRIX 60 VERZENIO 48 TYBOST 99 VGO 20 73 TYKERB 48 VGO 30 73 TYMLOS 100 VGO 40 73 TYVASO 104 VICTOZA 2-PAK 26 TYVASO REFILL KIT 104 VICTOZA 3-PAK 26 TYVASO STARTER KIT 104 VIENVA 88 vigabatrin 22 U VIGADRONE 22 UDENYCA 65 VIIBRYD 25 UPTRAVI 104 VIMPAT 22 urea 106 VIORELE 88 ursodiol 79 VIREAD 55 VISTOGARD 91 V VITRAKVI 48,49 V-GO 20 73 VIVOTIF 60 V-GO 30 73 VIZIMPRO 49 V-GO 40 73 VONVENDI 32 valacyclovir hcl 62 voriconazole 28 VALCHLOR 48 VORTEX 74 valganciclovir hcl 62 VOSEVI 82 valproic acid 22 VOTRIENT 49 valproic acid (as sodium salt) (valproate sodium) 22 VRAYLAR 53 valsartan 102 VUMERITY 97 valsartan/hydrochlorothiazide 102 VYFEMLA 88 VALTOCO 63 VYLIBRA 88 vancomycin hcl 18 VYNDAMAX 66 VAQTA 60 VYNDAQEL 66 VARIVAX VACCINE 60 VYVANSE 9 VASCEPA 33

PAGE 128 LAST UPDATED 12/2020 zonisamide 22 W ZONTIVITY 56 warfarin sodium 19 ZOSTAVAX 60 WERA 88 ZOVIA 1-35E 88 WILATE 32 ZYKADIA 50

X XALKORI 49 XARELTO 19,20 XENICAL 80 XENLETA 18 XERMELO 79 XIFAXAN 18 XOSPATA 49 XPOVIO 49 XTANDI 50 XULANE 88 XULTOPHY 100-3.6 90 XYNTHA 32 XYNTHA SOLOFUSE 32 XYREM 68 XYWAV 68

Y YUVAFEM 77

Z zaleplon 62 ZARAH 88 ZEBUTAL 3 ZEJULA 50 ZELBORAF 50 ZEMAIRA 103 ZENATANE 107 zidovudine 55,56 ZIEXTENZO 65 ZIOPTAN 30 ziprasidone hcl 53 ZIRGAN 11 ZOLINZA 50 zolpidem tartrate 62

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