California Essential Drug List

The Essential Drug List (formulary) includes a list of drugs covered by Health Net. The drug list is updated at least monthly and is subject to change. All previous versions are no longer in effect. You can view the most current drug list by going to our website at www.healthnet.com. Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information.

For California Individual & Family Plans: Drug Lists Select Health Net Large Group – Formulary (pdf).

For Small Business Group: Drug Lists Select Health Net Small Business Group – Formulary (pdf).

NOTE: To search the drug list online, open the (pdf) document. Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug and press the “Enter” key. If you have questions or need more information call us toll free.

California Individual & Family Plans (off-Exchange) If you have questions about your pharmacy coverage call Customer Service at 1-800-839-2172

California Individual & Family Plans (on-Exchange) If you have questions about your pharmacy coverage call Customer Service at 1-888-926-4988

Hours of Operation 8:00am – 7:00pm Monday through Friday 8:00am – 5:00pm Saturday

Small Business Group If you have questions about your pharmacy coverage call Customer Service at 1-800-361-3366

Hours of Operation 8:00am – 6:00pm Monday through Friday

Updated September 1, 2021

Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC

Table of Contents

What If I Have Questions Regarding My Pharmacy Benefit? ...... ii What is the Drug List? ...... ii How do I find a drug on the Drug List? ...... ii How are the drugs listed in the categorical list? ...... ii How much will I pay for my drugs? ...... iii Tier description table Are there any limits on my drug coverage? ...... iv How often does the Drug List change? ...... v How can I get prior authorization or an exception to the rules for drug coverage? ... v Are all contraceptives covered? ...... vi What blood glucose supplies covered? ...... vi What drugs are under my medical benefit? ...... vii Can I go to any pharmacy? ...... vii Can I use a mail order pharmacy? ...... vii How can I save money on my prescription drugs? ...... vii Definitions ...... viii

Categorical list of prescription drugs ……………………………………………...... 1

Alphabetical index of prescription drugs …………………………………….. Index 1

Welcome to Health Net

What If I Have Questions Regarding My Pharmacy Benefit? If you have questions about your pharmacy coverage contact Customer Service at the phone number listed on your Health Net ID card or on the cover of this book. Customer Service can help you with questions about your prescription drug benefits, including, but not limited to:  information about drugs covered under the medical benefit  the processes for submitting an exception request, requesting prior authorization and step therapy exceptions  actual dollar amounts of cost sharing for drugs including drugs subject to coinsurance

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

How do I find a drug in the Drug List? You can search for a drug by using the search tool, alphabetical index or by categorical list. There are three ways to find out if your drug is covered.

Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key.

Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered.

Categorical list: The drugs are grouped into therapeutic categories. If you know what therapeutic category your drug is in look through the list to find the category. Then look under the category and class for your drug.

If a generic equivalent for a brand name drug is not available in the market or not covered, the generic drug will not be listed separately. The presence of a drug on the drug list does not guarantee that your doctor will prescribe the drug for a particular medical condition.

How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its therapeutic category and class.

Example: Drug Name Drug Tier Requirements/ Limits

MAVYRET (glecaprevir-pibrentasvir) TABS 3 PA terbutaline sulfate tabs 1

The generic drug name for a brand drug is included after the brand name in parentheses and all Bold italicized lowercase letters.

Brand Drug Example: MAVYRET (glecaprevir-pibrentasvir) TABS

If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all bold and italicized lowercase letters.

Generic Drug Example: terbutaline sulfate tabs If a generic drug is marketed under a proprietary, trademark-protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface in all CAPITAL letters.

Generic Drug Marketed Under A Proprietary Brand Name Example: levothyroxine sodium (LEVOXYL) TABS

How much will I pay for my drugs? To see how much you will pay for a drug, check the abbreviations in the Drug Tier column on the formulary.

Drug Class / Plan Benefit Phase Maximum Cost Share Days Supply Oral Cancer Drugs Before Deductible Is Met $250 30 Days All other (non-oral After Deductible Is Met $250 30 Days cancer) Drugs Bronze Plan Members After Deductible Is Met $500 30 Days Note: For oral chemotherapy drugs - Notwithstanding any deductible, the total amount of copayment or coinsurance an insured is required to pay shall not exceed two hundred dollars ($250) for an individual prescription of up to a 30-day supply.

Below is a description for each tier. Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information. Tier Description 1 Drugs in this tier include generic drugs and low-cost preferred brand drugs. 2 Drugs in this tier are higher cost generic drugs and preferred brand drugs Drugs in this tier are non-preferred brand drugs, brand drugs with generic equivalents on a lower tier, or drugs that have a preferred alternative at a lower 3 tier. iii

Tier 4 Drugs include drugs that are made using biotechnology, drugs that must be distributed through a specialty pharmacy, drugs that require special training for self-administration, or drugs that require regular monitoring of care by a 4 pharmacy, and drugs that cost more than six hundred dollars for a one-month supply. Includes preventive benefit drugs, including contraceptives, covered at no cost to 5 members under the Affordable Care Act. A deductible does not apply. A Brand name is listed for reference only, when a generic equivalent is available. 7 Generic drugs will be used whenever one is available, unless a Brand is specifically requested. You may be asked to pay a higher copayment for the Brand if a generic is available. Refer to your plan documents for coverage details.

Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list:

Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations. AC Anti-cancer Oral cancer drugs are subject to a maximum $250 copayment for a one-month supply, before any deductible has been met, per state law (or $750 maximum for a three-month supply through mail order, if applicable). LA Limited Access Some drugs may be subject to limited access or restricted access. This means that a drug may only be available at select pharmacies. Limited access may be due to the following reasons:  The FDA or the manufacturer has restricted distribution of a drug to certain facilities, pharmacies or prescribers, or  Certain drugs require special handling, coordination of care, or patient education that cannot be provided at a retail pharmacy. If the drug is approved, we will let you know how to get limited access drugs. PA Prior Authorization This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you do not get approval, we may not cover the drug.

PV Preventive Drugs Drugs under the Affordable Care Act (ACA) as preventive health drugs, including contraceptive drugs and devices, covered at no charge. Preventive health drugs are determined based on evidence-based recommendations by the United States Preventive Services Task Force. Members in grandfathered Groups will pay a copayment. QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net. Health Net covers a 12-month supply when dispensed at one time of all self-administered hormonal contraceptives on the Formulary. RX/OTC Prescription & Certain drugs are available both in a prescription form and in Over-the- an OTC form. Only prescription drugs are covered by your Counter (OTC) plan with the exception of some insulin, insulin supplies and some covered preventive drugs. OTC drugs on the drug list, including OTC preventive drugs and contraceptives, require a prescription to be covered. ST Step Therapy Step therapy is when you are required to use one drug before another, in a stepwise fashion. Unless an exception is made, one or more preferred drugs must be tried first before progressing to a drug that is subject to step therapy.

How often does the Drug List change? The formulary will be updated with changes on a monthly basis. The types of changes may include the following:

 Removal of a drug or dosage form of a drug from the formulary;  Any change in tier placement of a drug that results in an increase in cost sharing;  Adding or changing utilization management procedures applicable to a drug.

If these changes occur, you will be notified at least 60 days in advance of the change, unless the drug is removed for safety reasons.

How can I get prior authorization or an exception to the rules for drug coverage? Requests for prior authorization may be submitted electronically, by phone at 1-800-548-5524, or by fax at 1-800-314-6223. Once your doctor’s request is received, we will notify your doctor of our decision within 72 hours. If Health Net fails to respond to a completed prior authorization or step therapy exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving a request based on exigent circumstances, the request is deemed approved and the health insurer may not deny the request thereafter.

If your doctor believes that waiting 72 hours for a standard decision could seriously harm your health, your doctor can ask for a fast (expedited) decision. This applies only to requests for drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.

If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called step therapy. Step therapy is when you are required to use one drug before another, in a stepwise fashion. The required first step drug or preferred drug is a proven, cost-effective medication. Unless an exception is made, one or more preferred drugs must be tried before progressing to a drug that is subject to step therapy. You or your doctor can request an exception if your health may be harmed by waiting. Your doctor must submit a supporting statement to us explaining why you need the drug. You or your doctor may appeal the denial of an exception request. The denial documents provide more information on appeal rights and procedures if there is a medical need to use a second step drug without trying a first step drug, an exception to coverage may be requested by the prescriber. A request for an exception to a step therapy requirement may be submitted in the same manner as a request for prior authorization. The request shall be treated in the same manner, and shall be responded to in the same manner, as a request for prior authorization for prescription drugs. If you have already tried and failed the preferred drug(s), or if you are already taking a drug that is subject to step therapy when you switch to enrolled in a Health Net plan, you will not have to undergo step therapy and the drug will be approved for coverage when medically necessary.

If a drug is not on the drug list, and is not specifically excluded from coverage, your doctor can ask for an exception. To request an exception, your doctor can submit a prior authorization request along with a supporting statement explaining why you need the drug. Requests for prior authorization may be submitted electronically or by telephone or fax. If we approve an exception for a drug that is not on the drug list, the non-preferred brand drug tier (Tier 3) or Tier 4 (Specialty) copayment applies.

Health Net will cover all medically necessary drugs. If Health Net fails to respond to a completed prior authorization or step therapy exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving an expedited request, the request will be approved and Health Net may not deny the request thereafter.

Are all contraceptives covered? Contraceptive benefits include coverage for a variety of U.S. Food and Drug Administration (FDA)- approved prescription contraceptive methods. If your doctor determines that none of the covered methods on the drug list or if a covered therapeutic equivalent of a drug, device, or product is not available, and is medically necessary for you, Health Net will provide coverage. Coverage is subject to limitations and restrictions. Prior authorization or step therapy may be required for some other FDA- approved prescription contraceptive drugs, devices, or products prescribed by your doctor.

What blood glucose supplies covered? Specific brands of blood glucose monitors, blood glucose testing strips, lancets, ketone testing strips, pen delivery systems for injecting insulin and insulin needles and syringes are covered on the drug list. A prescription from your doctor is required to obtain these from a pharmacy.

Insulin pumps and all related necessary supplies, podiatric devices to prevent or treat diabetes-related complications and visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin are covered under the medical benefit.

What drugs are under my medical benefit? Drugs that are not considered self-injectable and are administered by your doctor will be covered under your medical benefit. If your doctor does not have the drug, your doctor will give you instructions on where you can receive the drug. Certain drugs that are self-administered are covered under your pharmacy benefit. Refer to your Evidence of Coverage or Certificate of Insurance for coverage information and exceptions.

Can I go to any pharmacy? Except in emergency and urgent situations, Health Net does not cover drugs dispensed by non-network pharmacies. Health Net contracts with most U.S. chain pharmacies and many independent pharmacies. These pharmacies are called in-network pharmacies. To find an in-network pharmacy near you, visit our website at Find a pharmacy or call us at the telephone number on your Health Net ID card or listed on the front cover of this book. Some injectable and high cost drugs are considered specialty drugs. These drugs must be filled at an in-network specialty pharmacy. Specialty drugs are noted on the drug list in the Requirements/Limits column with the abbreviation “LA” or a statement indicating the drug must be dispensed from a network specialty pharmacy. After your drug has been approved, we will arrange for the specialty pharmacy to contact you to set up delivery.

Can I use a mail order pharmacy? For certain kinds of prescription drugs, you can use the Health Net contracted Mail Order Pharmacy. Generally, the drugs available through mail order are drugs that you take on a regular basis for a chronic or long-term medical condition. Tier 4 or Specialty drugs are not available through mail order.

To use the mail order pharmacy, your doctor must provide a new prescription that allows up to a 90-day supply of each drug. Mail order forms are available on our website at Forms and Brochures - Pharmacy or you may call us at the telephone number on your Health Net ID card or on the front cover of this book to request a form.

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

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Definitions Brand drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drug is listed in this formulary in all CAPITAL letters. Coinsurance: Is a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment: Is a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible: Is the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If the plan has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. The plan pays the rest. Drug Tier: Is a group of prescription drugs that correspond to a specified cost sharing tier. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug. Enrollee: Is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this formulary template shall also include subscribers as defined in this section below. Exception request: Is a request for coverage of a non-formulary drug. If you, your designee, or your doctor submits a request for coverage of a non-formulary drug, the plan must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances: Is when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or prescription drug list: Is the list of drugs that is covered by the plan under the prescription drug benefit of the policy. Generic drug: Is a drug that is the same as its brand name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in the drug list in bold and italicized lowercase letters. Medically Necessary: Is a health care benefit needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Plans usually do not cover health care benefits that are not medically necessary. Non-formulary drug: Is a prescription drug that is not listed on the drug list. Out-of-pocket costs: Are your expenses for health care benefits that aren't reimbursed by the plan. Out- of-pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are paid by the Member and not covered by the plan. Prescribing provider: This is a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition.

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Prescription: Is an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual. Prescription drug: Is a drug that by law requires a prescription. Prior Authorization: Is a decision by the plan that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in the drug list, your doctor must request approval from the plan to cover the drug before you fill your prescription. The plan must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy: Is a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in the drug list, you may have to try one or more other drugs before the plan will cover that drug for your medical condition. If your doctor submits a request for an exception to the step therapy requirement, the plan must grant the request when it is medically necessary for you to take the drug. Subscriber: Means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- dextroamphetamine OBESITY/ANOREXIANTS - Drugs to Treat sulfate tabs 10 mg, 5 1 ADHD, Sleep and Eating Disorders mg Amphetamines PA; ST; methamphetamine hcl 2 (Dextroamphetamine tabs Sulfate) PROCENTRA 1 VYVANSE CAPS 10 MG, QL(1 ea daily) SOLN 20 MG, 30 MG, 40 MG, 50 (Dextroamphetamine MG, 60 MG, 70 MG 2 Sulfate) ZENZEDI TABS 10 1 (lisdexamfetamine MG, 5 MG dimesylate) amphetamine- QL(2 ea VYVANSE CHEW 10 MG, Limited to 1 per dextroamphetamine daily,90 day(s) 20 MG, 30 MG, 40 MG, 50 day;QL(1 ea limit) cp24 1.25 mg-1.25 mg- MG, 60 MG 2 daily) 1.25 mg-1.25 mg, 2.5 (lisdexamfetamine mg-2.5 mg-2.5 mg-2.5 dimesylate) mg, 3.75 mg-3.75 mg- 1 Analeptics 3.75 mg-3.75 mg, 5 mg-5 mg-5 mg-5 mg, caffeine citrate soln 1 6.25 mg-6.25 mg-6.25 Anorexiants Non-Amphetamine mg-6.25 mg, 7.5 mg- PA 7.5 mg-7.5 mg-7.5 mg benzphetamine hcl tabs 1 amphetamine- diethylpropion hcl tabs 1 PA dextroamphetamine tabs 1.25 mg-1.25 mg- diethylpropion hcl tb24 1 PA 1.25 mg-1.25 mg, 2.5 LOMAIRA TABS PA mg-2.5 mg-2.5 mg-2.5 1 3 mg, 3.125 mg-3.125 (phentermine hcl) mg-3.125 mg-3.125 phentermine hcl caps 1 PA mg, 5 mg-5 mg-5 mg-5 mg, 7.5 mg-7.5 mg-7.5 phentermine hcl tabs 1 PA mg-7.5 mg PHENTERMINE PA amphetamine- QL(90 ea per HYDROCHLORIDE CAPS 3 dextroamphetamine fill retail) (phentermine hcl) tabs 1.875 mg-1.875 1 QSYMIA CP24 PA; QL(1 ea mg-1.875 mg-1.875 (phentermine hcl- 3 daily) mg, 3.75 mg-3.75 mg- topiramate) 3.75 mg-3.75 mg Anti-Obesity Agents dextroamphetamine CONTRAVE TB12 PA sulfate cp24 10 mg, 15 1 (naltrexone hcl- 3 mg, 5 mg bupropion hcl) dextroamphetamine 1 SAXENDA SOPN PA; QL(0.5 ml sulfate soln 5 mg/5ml (liraglutide (weight 3 daily) management))

1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA XENICAL CAPS (orlistat) 3 methylphenidate hcl 1 tabs 10 mg, 5 mg Attention-Deficit/Hyperactivity Disorder (ADHD) QL(3 ea daily) methylphenidate hcl 1 atomoxetine hcl caps QL(2 ea daily) tabs 20 mg 10 mg, 18 mg, 25 mg, 1 methylphenidate hcl QL(1 ea 40 mg tb24 18 mg, 27 mg, 54 1 daily,90 day(s) QL(1 ea daily) limit) atomoxetine hcl caps 1 mg 100 mg, 60 mg, 80 mg methylphenidate hcl QL(2 ea clonidine hcl (adhd) QL(4 ea daily) 1 daily,90 day(s) 1 tb24 36 mg tb12 limit) guanfacine hcl (adhd) QL(1 ea daily) methylphenidate hcl QL(1 ea 1 1 daily,90 ea per tb24 tbcr 10 mg, 20 mg fill retail) Stimulants - Misc. methylphenidate hcl QL(1 ea daily) armodafinil tabs 1 PA; ST tbcr 18 mg, 27 mg, 36 1 mg DAYTRANA PTCH QL(1 ea daily) 3 methylphenidate hcl QL(2 ea daily) (methylphenidate) 1 tbcr 54 mg dexmethylphenidate hcl QL(1 ea daily) modafinil tabs 2 ST; QL(1 ea cp24 10 mg, 15 mg, 20 1 daily) mg, 25 mg, 30 mg, 35 QUILLIVANT XR SRER PA; ST;QL(12 3 mg, 40 mg, 5 mg (methylphenidate hcl) ml daily) dexmethylphenidate hcl QL(2 ea daily) AMINOGLYCOSIDES - Drugs to Treat Bacterial 1 tabs 10 mg, 2.5 mg, 5 Infections mg methylphenidate hcl Aminoglycosides chew 10 mg, 2.5 mg, 5 1 ARIKAYCE SUSP PA mg (amikacin sulfate 4 liposome) QL(1 ea daily) methylphenidate hcl BETHKIS NEBU PA; LA 1 7 cp24 10 mg, 20 mg, 30 (tobramycin) mg, 40 mg neomycin sulfate tabs 1 methylphenidate hcl QL(1 ea 1 daily,90 ea per cp24 60 mg fill retail) paromomycin sulfate 1 caps methylphenidate hcl PA cpcr 10 mg, 40 mg, 50 1 streptomycin sulfate 4 mg, 60 mg solr QL(2 ea daily) TOBI PODHALER CAPS PA methylphenidate hcl 1 4 cpcr 20 mg, 30 mg (tobramycin) tobramycin nebu 300 PA; LA methylphenidate hcl 4 mg/4ml soln 10 mg/5ml, 5 1 PA mg/5ml tobramycin nebu 300 2 mg/5ml

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use RINVOQ TB24 PA; ST 4 tobramycin nebu 300 AcariaHealth (upadacitinib) 2 Specialty Rx at XELJANZ TABS 10 MG PA; ST mg/5ml 1-844-538- 4 4661 (tofacitinib citrate) XELJANZ TABS 5 MG PA; ST;QL(2 PA 4 tobramycin sulfate soln 4 (tofacitinib citrate) ea daily) XELJANZ XR TB24 11 MG PA; ST;QL(1 ANALGESICS - ANTI-INFLAMMATORY - Drugs 4 to Treat Pain, Swelling, Muscle and Joint (tofacitinib citrate) ea daily) Conditions XELJANZ XR TB24 22 MG PA; QL(1 ea 4 Anti-TNF-alpha - Monoclonal Antibodies (tofacitinib citrate) daily) PA; ST; Must Antirheumatic Antimetabolites HUMIRA PEDIATRIC use CROHNS DISEASE METHOTREXATE TABS 4 AcariaHealth STARTER PACK PSKT Specialty Rx at (methotrexate sodium 3 (adalimumab) 1-844-538- (antirheumatic)) 4661 PA; ST; Must PA; ST; Must OTREXUP SOAJ 10 use use MG/0.4ML (methotrexate 4 AcariaHealth HUMIRA PEN PNKT AcariaHealth Specialty Rx at 4 (antirheumatic)) (adalimumab) Specialty Rx at 1-844-538- 1-844-538- 4661;;LA 4661 OTREXUP SOAJ 12.5 PA; ST;LA PA; ST; Must MG/0.4ML, 15 MG/0.4ML, use 17.5 MG/0.4ML, 20 HUMIRA PEN-CD/UC/HS MG/0.4ML, 22.5 STARTER PNKT 4 AcariaHealth 4 Specialty Rx at MG/0.4ML, 25 MG/0.4ML (adalimumab) 1-844-538- (methotrexate 4661 (antirheumatic)) PA; ST; Must RASUVO SOAJ 10 PA; ST; Must HUMIRA PEN-PEDIATRIC use MG/0.2ML, 12.5 use UC STARTER PACK 4 AcariaHealth MG/0.25ML, 15 MG/0.3ML, AcariaHealth Specialty Rx at PNKT (adalimumab) 17.5 MG/0.35ML, 22.5 Specialty Rx at 1-844-538- MG/0.45ML, 25 MG/0.5ML, 4 1-844-538- 4661 30 MG/0.6ML, 7.5 4661;;LA PA; ST; Must MG/0.15ML HUMIRA PEN-PS/UV use (methotrexate STARTER PNKT 4 AcariaHealth (antirheumatic)) Specialty Rx at (adalimumab) 1-844-538- RASUVO SOAJ 20 PA; ST;LA 4661 MG/0.4ML (methotrexate 4 PA; ST; Must (antirheumatic)) use Gold Compounds HUMIRA PSKT 4 AcariaHealth RIDAURA CAPS (adalimumab) Specialty Rx at 2 1-844-538- (auranofin) 4661 Interleukin-1 Blockers Antirheumatic - Enzyme Inhibitors

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; ST; Must diclofenac sodium tbec 1 ARCALYST SOLR use AcariaHlth 4 Specialty Rx at (rilonacept) diclofenac w/ 1 1-844-538- misoprostol tbec 4661 etodolac caps 200 mg, 1 Interleukin-6 Receptor Inhibitors 300 mg PA; ST; MUST etodolac tabs 400 mg, ACTEMRA ACTPEN SOAJ USE ACARIA 1 4 SPECIALTY 500 mg (tocilizumab) RX 844-538- QL(2 ea daily) etodolac tb24 400 mg, 1 4661 500 mg, 600 mg ACTEMRA SOSY PA 4 fenoprofen calcium 1 (tocilizumab) tabs PA; ST; Must KEVZARA SOAJ use AcariaHlth flurbiprofen tabs 1 4 Specialty Rx at (sarilumab) 1-844-538- ibuprofen tabs 1 4661 INDOCIN SUPP RE 50 MG PA; ST; Must 3 (indomethacin) KEVZARA SOSY use AcariaHlth 4 Specialty Rx at INDOCIN SUSP OR 25 ( ) 2 sarilumab 1-844-538- MG/5ML (indomethacin) 4661 indomethacin caps 25 1 Nonsteroidal Anti-inflammatory Agents (NSAIDs) mg, 50 mg (Diclofenac Potassium) 1 indomethacin cpcr 75 1 CATAFLAM TABS mg (Ibuprofen) IBU TABS 1 ketoprofen caps 50 mg, 1 75 mg (Nabumetone) RELAFEN 1 QL(4 ea daily) TABS 500 MG ketoprofen cp24 200 1 (Nabumetone) RELAFEN 1 QL(3 ea daily) mg TABS 750 MG KETOROLAC QL(1 ea daily,5 ST; AL(At least TROMETHAMINE SOLN day(s) limit) celecoxib caps 100 mg, 1 50 mg 60 yrs old) NA 15.75 MG/SPRAY 3 ST; QL(2 ea (ketorolac tromethamine) celecoxib caps 200 mg 1 daily); AL(At least 60 yrs QL(20 ea per ketorolac tromethamine 1 old) tabs or 10 mg fill retail) ST; QL(1 ea meclofenamate sodium 1 daily); AL(At 1 celecoxib caps 400 mg least 60 yrs caps old) mefenamic acid caps 1 diclofenac potassium 1 tabs meloxicam tabs 15 mg 1 QL(1 ea daily) diclofenac sodium tb24 1 meloxicam tabs 7.5 mg 1 QL(2 ea daily)

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ea daily) PA; ST; Must nabumetone tabs 500 1 mg ORENCIA CLICKJECT use AcariaHlth 4 Specialty Rx at QL(3 ea daily) SOAJ (abatacept) nabumetone tabs 750 1 1-844-538- mg 4661 PA; ST; Must naproxen sodium tabs 1 275 mg, 550 mg ORENCIA SOSY use AcariaHlth 4 Specialty Rx at (abatacept) naproxen susp 125 1 1-844-538- mg/5ml 4661 naproxen tabs 250 mg, 1 Soluble Tumor Necrosis Factor Receptor Agents 375 mg, 500 mg PA; ST; Must oxaprozin tabs 1 ENBREL MINI SOCT use AcariaHlth 4 Specialty Rx at (etanercept) piroxicam caps 10 mg 1 1-844-538- 4661;SP piroxicam caps 20 mg 1 QL(1 ea daily) PA; ST; Must use AcariaHlth SPRIX SOLN ( QL(1 ea daily,5 ENBREL SOLN 25 Specialty Rx at ketorolac 3 4 tromethamine) day(s) limit) MG/0.5ML (etanercept) 1-844-538- 4661;QL(0.143 QL(2 ea daily) sulindac tabs 150 mg 1 ml daily); SP PA; ST; Must sulindac tabs 200 mg 1 ENBREL SOLR 25 MG use AcariaHlth 4 Specialty Rx at tolmetin sodium caps 1 (etanercept) 1-844-538- 4661;SP tolmetin sodium tabs 1 PA; ST; Must ENBREL SOSY 25 use AcariaHlth Phosphodiesterase 4 (PDE4) Inhibitors MG/0.5ML, 50 MG/ML 4 Specialty Rx at OTEZLA TABS PA; ST 4 (etanercept) 1-844-538- (apremilast) 4661;SP PA; ST; Must PA; ST; Must use ENBREL SURECLICK use AcariaHlth OTEZLA TBPK 4 AcariaHealth 4 Specialty Rx at (apremilast) Specialty Rx at SOAJ (etanercept) 1-844-538- 1-844-538- 4661;SP 4661;LA ANALGESICS - NonNarcotic - Drugs to Treat Pyrimidine Synthesis Inhibitors Pain, Muscle and Joint Conditions leflunomide tabs 10 mg 1 QL(2 ea daily) Analgesic Combinations (Acetaminophen- 1 QL(1 ea daily) leflunomide tabs 20 mg Salicylamide- 1 Phenyltoloxamine) Selective Costimulation Modulators DURAXIN CAPS (Butalbital-Acetaminophen) 1 BUPAP, TENCON TABS (Butalbital-Acetaminophen- 1 Caffeine) BAC TABS 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Butalbital-Acetaminophen- (Aspirin) ADULT ASPIRIN PV Caffeine) ESGIC, 1 REGIMEN, ASPIR-LOW, PHRENILIN FORTE, ASPIRIN 81, ASPIRIN ZEBUTAL CAPS ADULT LOW DOSE, butalbital- ASPIRIN ADULT LOW STRENGTH, ASPIRIN EC acetaminophen tabs 1 LOW DOSE, ASPIRIN 325 mg-50 mg, 50 mg- ENTERIC COATED 300 mg, 50 mg-325 mg ADULT LOW STRENGTH, butalbital- ASPIRIN LOW DOSE, 1 BAYER ASPIRIN EC LOW acetaminophen- DOSE, BAYER LOW caffeine caps DOSE, CVS ASPIRIN butalbital- ADULT LOW STRENGTH, acetaminophen- 1 CVS ASPIRIN EC, CVS caffeine tabs ASPIRIN LOW DOSE, CVS ASPIRIN LOW butalbital-aspirin- 1 STRENGTH, ECOTRIN caffeine caps LOW STRENGTH, EQ ASPIRIN ADULT LOW Salicylates DOSE, EQL ASPIRIN LOW 5 DOSE, GNP ASPIRIN LOW DOSE, GOODSENSE ASPIRIN LOW DOSE, H-E-B ASPIRIN, HM ASPIRIN EC LOW DOSE, KLS ASPIRIN LOW DOSE, KP ASPIRIN, MINIPRIN LOW DOSE, QC ASPIRIN LOW DOSE, RA ASPIRIN EC ADULT LOW STRENGTH, SB ASPIRIN, SB ASPIRIN ADULT LOW STRENGTH, SB LOW DOSE ASA EC, SM ASPIRIN ADULT LOW STRENGTH, SM ASPIRIN EC LOW STRENGTH, ST JOSEPH ASPIRIN, TGT ASPIRIN, TGT ASPIRIN LOW DOSE TBEC

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN 81 LOW PV (Aspirin) ASPIRIN ADULT, PV DOSE, ASPIRIN ADULT BAYER ADVANCED LOW STRENGTH, ASPIRIN REGULAR ASPIRIN CHILDRENS, STRENGTH, BAYER ASPIRIN LOW DOSE, ASPIRIN, CVS ASPIRIN, ASPIRIN LOW EQ ASPIRIN, EQL STRENGTH, BAYER ASPIRIN, GOODSENSE CHEWABLE LOW DOSE, ASPIRIN ADULTS, HM CHILDRENS ASPIRIN, ADULT ASPIRIN, 5 CHILDRENS ASPIRIN MEDIQUE ASPIRIN, LOW STRENGTH, CVS NORWICH ASPIRIN, PX ASPIRIN ADULT LOW ASPIRIN, QC ASPIRIN, RA DOSE, EQ ASPIRIN LOW ASPIRIN, RA PAIN DOSE, EQL ASPIRIN LOW RELIEF ASPIRIN, SB DOSE, GNP ADULT ASPIRIN, SM ADULT ASPIRIN LOW ASPIRIN, SM ASPIRIN, STRENGTH, TGT ASPIRIN TABS GOODSENSE ASPIRIN (Aspirin) GNP ASPIRIN, PV ADULT LOW STRENGTH, 5 GOODSENSE ASPIRIN, 5 PX ASPIRIN, QC ASPIRIN HM ASPIRIN TABS 325 LOW DOSE, QC MG CHEWABLE ASPIRIN LOW DOSE, QC (Aspirin) GNP ASPIRIN, PV CHILDRENS ASPIRIN, RA GOODSENSE ASPIRIN, 5 ASPIRIN ADULT LOW PX ENTERIC ASPIRIN, RA DOSE, RA ASPIRIN ASPIRIN EC TBEC 81 MG ADULT LOW STRENGTH, (Aspirin) GOODSENSE PV RA ASPIRIN CHILDRENS, ASPIRIN, HM ASPIRIN 5 SB CHILDRENS ASPIRIN, CHEW 81 MG SM ASPIRIN ADULT LOW 5 PV STRENGTH, SM ASPIRIN aspirin chew 81 mg LOW DOSE, SM PV CHILDRENS ASPIRIN, ST aspirin tabs 325 mg 5 JOSEPH LOW DOSE PV ASPIRIN, TGT ASPIRIN, aspirin tbec 81 mg 5 TGT CHILDRENS ASPIRIN CHEW diflunisal tabs 1 salsalate tabs 1 ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions Opioid Agonists (Methadone Hcl) METHADONE 1 HYDROCHLORIDE INTENSOL CONC (Methadone Hcl) METHADOSE TBSO 40 1 MG

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits codeine sulfate tabs 1 methadone hcl conc 10 1 mg/ml CONZIP CP24 ( tramadol 7 methadone hcl soln 10 1 hcl) mg/5ml, 5 mg/5ml EMBEDA CPCR 0.8 MG- PA; ST methadone hcl tabs 10 QL(12 ea daily) 20 MG (morphine- 3 1 mg, 5 mg naltrexone) EMBEDA CPCR 1.2 MG- PA methadone hcl tbso 40 1 30 MG, 2 MG-50 MG, 2.4 mg MG-60 MG, 3.2 MG-80 3 QL(1 ea daily) morphine sulfate beads 1 MG, 4 MG-100 MG cp24 (morphine-naltrexone) morphine sulfate cp24 QL(2 ea daily) fentanyl citrate lpop bu PA; ST or 10 mg, 100 mg, 20 1 1200 mcg, 200 mcg, 2 mg, 30 mg, 40 mg, 50 400 mcg, 600 mcg, 800 mg, 60 mg, 80 mg mcg morphine sulfate soln PA; ST;QL(4 1 fentanyl citrate lpop bu 2 or 10 mg/5ml 1600 mcg ea daily) morphine sulfate soln Not available fentanyl pt72 100 Limit 15 per or 100 mg/5ml, 20 1 through mail month;QL(0.5 order mcg/hr, 12 mcg/hr, 25 1 mg/5ml, 20 mg/ml mcg/hr, 50 mcg/hr, 75 ea daily) mcg/hr morphine sulfate supp re 10 mg, 20 mg, 30 1 fentanyl pt72 37.5 PA; Limit 15 mg mcg/hr, 62.5 mcg/hr, 1 patches per month;QL(0.5 morphine sulfate tabs 1 87.5 mcg/hr ea daily) or 15 mg, 30 mg QL(3 ea daily) hydromorphone hcl liqd 1 morphine sulfate tbcr or 1 mg/ml 100 mg, 15 mg, 200 1 mg, 30 mg, 60 mg hydromorphone hcl 1 tabs 2 mg, 4 mg, 8 mg NUCYNTA ER TB12 QL(2 ea daily) 2 hydromorphone hcl QL(4 ea daily) (tapentadol hcl) 1 NUCYNTA TABS QL(6 ea daily) tb24 12 mg, 16 mg, 8 2 mg (tapentadol hcl) QL(2 ea daily) OXAYDO TABS 5 MG hydromorphone hcl 1 2 tb24 32 mg (oxycodone hcl) KADIAN CP24 200 MG QL(2 ea daily) OXAYDO TABS 7.5 MG QL(4 ea daily) 3 3 (morphine sulfate) (oxycodone hcl) PA; ST oxycodone hcl caps 5 levorphanol tartrate 1 1 tabs mg oxycodone hcl conc meperidine hcl soln 1 1 100 mg/5ml 1 meperidine hcl tabs oxycodone hcl soln 5 1 mg/5ml

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxycodone hcl tabs 10 (Oxycodone W/ QL(6 ea daily) mg, 15 mg, 20 mg, 5 1 Acetaminophen) 1 mg ENDOCET TABS 5 MG- 325 MG oxycodone hcl tabs 30 QL(4 ea daily) 1 acetaminophen w/ mg codeine soln 12 QL(8 ea daily) 1 oxymorphone hcl tabs 1 mg/5ml-120 mg/5ml, 10 mg 120 mg/5ml-12 mg/5ml oxymorphone hcl tabs 1 acetaminophen w/ 5 mg codeine tabs 15 mg- 1 oxymorphone hcl tb12 QL(2 ea daily) 300 mg, 30 mg-300 mg, 300 mg-30 mg 10 mg, 15 mg, 20 mg, 1 30 mg, 40 mg, 5 mg, acetaminophen w/ QL(6 ea daily) 7.5 mg codeine tabs 60 mg- 1 tramadol hcl cp24 100 300 mg mg, 150 mg, 200 mg, 1 butalbital- PA 300 mg acetaminophen- QL(8 ea daily) caffeine w/ codeine 1 tramadol hcl tabs 50 1 mg caps 30 mg-40 mg-50 QL(3 ea daily) mg-300 mg tramadol hcl tb24 100 1 mg butalbital- acetaminophen- tramadol hcl tb24 100 1 mg, 200 mg, 300 mg caffeine w/ codeine 1 QL(1 ea daily) caps 30 mg-40 mg-50 tramadol hcl tb24 200 1 mg mg-325 mg, 325 mg-30 mg-40 mg-50 mg Opioid Combinations butalbital-aspirin- 1 (Butalbital-Aspirin-Caffeine caffeine w/cod caps W/Cod) 1 ASCOMP/CODEINE CAPS hydrocodone- (Hydrocodone- QL(240 ea per acetaminophen soln 2.5 mg/5ml-108 Acetaminophen) LORCET, 1 fill retail) 1 LORCET HD, LORCET mg/5ml, 5 mg/10ml-217 PLUS TABS mg/10ml, 7.5 mg/15ml- (Hydrocodone-Ibuprofen) 1 325 mg/15ml IBUDONE TABS hydrocodone- (Oxycodone W/ QL(4 ea daily) acetaminophen tabs 10 1 Acetaminophen) 1 ENDOCET TABS 10 MG- mg-300 mg, 300 mg-5 325 MG, 7.5 MG-325 MG mg, 5 mg-300 mg (Oxycodone W/ Acetaminophen) 1 ENDOCET TABS 2.5 MG- 325 MG

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocodone- QL(240 ea per PRIMLEV TABS acetaminophen tabs 10 fill retail) (oxycodone w/ 3 acetaminophen) mg-325 mg, 325 mg-10 1 mg, 325 mg-7.5 mg, 5 PROLATE TABS 10 MG- mg-325 mg, 7.5 mg- 300 MG, 5 MG-300 MG, 325 mg 7.5 MG-300 MG 3 (oxycodone w/ hydrocodone- QL(6 ea daily) acetaminophen) acetaminophen tabs 1 QL(8 ea daily) 7.5 mg-300 mg tramadol- 1 acetaminophen tabs hydrocodone-ibuprofen Not available 1 through mail tabs 10 mg-200 mg Opioid Partial Agonists order QL(3 ea daily) buprenorphine hcl subl 1 hydrocodone-ibuprofen 2 mg tabs 10 mg-200 mg, QL(4 ea daily) buprenorphine hcl subl 1 200 mg-5 mg, 5 mg- 1 8 mg 200 mg, 7.5 mg-200 mg buprenorphine hcl- QL(3 ea daily) naloxone hcl dihydrate 1 LORTAB ELIX film 0.5 mg-2 mg, 1 mg- (hydrocodone- 3 4 mg, 2 mg-8 mg acetaminophen) QL(2 ea daily) NALOCET TABS buprenorphine hcl- (oxycodone w/ 3 naloxone hcl dihydrate 1 acetaminophen) film 3 mg-12 mg oxycodone w/ QL(4 ea daily) buprenorphine hcl- naloxone hcl dihydrate acetaminophen tabs 10 1 1 mg-325 mg, 7.5 mg- subl 0.5 mg-2 mg, 2 325 mg mg-8 mg BUPRENORPHINE PTWK Limited to 4 oxycodone w/ TD 10 MCG/HR, 15 patches per acetaminophen tabs 1 MCG/HR, 20 MCG/HR, 5 3 month;QL(4 ea 2.5 mg-325 mg, 325 MCG/HR per 28 days mg-2.5 mg (buprenorphine) retail) oxycodone w/ QL(6 ea daily) BUPRENORPHINE PTWK QL(4 ea per 28 TD 10 MCG/HR, 15 days retail) acetaminophen tabs 1 325 mg-5 mg, 5 mg- MCG/HR, 20 MCG/HR, 5 3 325 mg MCG/HR, 7.5 MCG/HR (buprenorphine) QL(4 ea daily) oxycodone-ibuprofen 1 tabs Limited to 4 buprenorphine ptwk td patches per OXYCODONE/ACETAMIN 3 month;QL(4 ea OPHEN TABS 7.5 mcg/hr per 28 days (oxycodone w/ 3 retail) acetaminophen)

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 7.5mls testosterone gel 1 %, QL(10 gm butorphanol tartrate 1 per 25 mg/2.5gm, 50 1 daily) soln month;QL(0.25 mg/5gm ml daily) QL(4 gm daily) testosterone gel 10 1 pentazocine w/ 1 naloxone tabs mg/act testosterone gel 25 1.5 GM/50 PROBUPHINE IMPLANT PA 1 ML;QL(10 gm KIT IMPL 4 mg/2.5gm daily) (buprenorphine hcl) Limit 300gms SUBLOCADE SOSY PA; Covered testosterone gel 50 per 4 under the 1 (buprenorphine) mg/5gm month;QL(10 Medical Benefit gm daily) ANDROGENS-ANABOLIC - Drugs to Regulate QL(6 ml daily) testosterone soln 30 1 Hormones mg/act Anabolic Steroids ANORECTAL AND RELATED PRODUCTS - ANADROL-50 TABS 3 Rectal Drugs to Treat Pain, Swelling and Itching (oxymetholone) Intrarectal Steroids QL(2 ea daily) oxandrolone tabs 10 2 (Hydrocortisone QL(60 ml daily) mg (Intrarectal)) COLOCORT 1 ENEM oxandrolone tabs 2.5 2 mg CORTIFOAM FOAM (hydrocortisone acetate 2 Androgens (intrarectal)) ST; QL(60 ea ANDRODERM PT24 hydrocortisone QL(60 ml daily) 3 per fill 1 (testosterone) retail,120 ea (intrarectal) enem per fill mail) UCERIS FOAM RE 2 PA; ST danazol caps 1 MG/ACT (budesonide 3 (intrarectal)) METHITEST TABS 2 (methyltestosterone) Rectal Combinations methyltestosterone ANALPRAM-HC LOTN 1 (hydrocortisone acetate 3 caps w/ pramoxine) STRIANT MISC QL(2 ea daily) 3 PROCTOFOAM HC FOAM (testosterone) (hydrocortisone acetate 2 TESTIM GEL PA; QL(10 gm 7 w/ pramoxine) (testosterone) daily) testosterone gel 1 %, Limited to 300 Rectal Steroids gms per (Hydrocortisone (Rectal)) 1.62 %, 20.25 PROCTO-MED HC, mg/1.25gm, 25 1 month;QL(10 1 gm daily) PROCTOSOL HC, mg/2.5gm, 40.5 PROCTOZONE-HC CREA mg/2.5gm, 50 mg/5gm hydrocortisone (rectal) 1 crea Vasodilating Agents 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RECTIV OINT Antiprotozoal Agents (nitroglycerin (intra- 3 ALINIA SUSR 100 MG/5ML 3 anal)) (nitazoxanide) ANTHELMINTICS - Drugs to Treat Worm 2 Infections atovaquone susp Anthelmintics nitazoxanide tabs or 1 albendazole tabs 1 Carbapenems PA BENZNIDAZOLE TABS AL(At least 2 doripenem solr 4 2 yrs old - Up to (benznidazole) 12 yrs old) ertapenem sodium solr 4 PA ivermectin tabs or 3 mg 1 imipenem-cilastatin solr 2 PA praziquantel tabs 1 INVANZ SOLR PA 7 ANTI-INFECTIVE AGENTS - MISC. - Drugs to (ertapenem sodium) Treat Bacterial Infections meropenem solr 4 PA Anti-infective Agents - Misc. MERREM SOLR PA 7 metronidazole caps 1 (meropenem) PRIMAXIN IV SOLR PA 7 metronidazole tabs 1 (imipenem-cilastatin) pentamidine 1 Glycopeptides isethionate solr FIRVANQ SOLR PA 3 PRIMSOL SOLN ( ) 3 vancomycin hcl (trimethoprim hcl) PA vancomycin hcl caps 1 tinidazole tabs 250 mg 1 PA; ST 125 mg ST vancomycin hcl caps 1 tinidazole tabs 500 mg 1 250 mg trimethoprim tabs 1 Leprostatics QL(4 ea daily) XIFAXAN TABS 200 MG PA; QL(9 ea dapsone tabs 100 mg 1 3 (rifaximin) per fill retail) dapsone tabs 25 mg 1 XIFAXAN TABS 550 MG PA; QL(2 ea 3 (rifaximin) daily) Lincosamides Anti-infective Misc. - Combinations clindamycin hcl caps 1 (Sulfamethoxazole- Trimethoprim) SULFATRIM 1 clindamycin palmitate 1 PEDIATRIC SUSP hydrochloride solr sulfamethoxazole- 1 Monobactams trimethoprim susp CAYSTON SOLR PA 4 (aztreonam lysine) sulfamethoxazole- 1 trimethoprim tabs Oxazolidinones

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(210 ml per NITRO-BID OINT linezolid susr 100 1 2 mg/5ml 90 days retail) (nitroglycerin) NITRO-DUR PT24 0.3 QL(1 ea daily) 1 QL(20 ea per linezolid tabs 600 mg 90 days retail) MG/HR, 0.8 MG/HR 2 SIVEXTRO TABS QL(6 ea per 90 (nitroglycerin) 2 (tedizolid phosphate) days retail) nitroglycerin pt24 td 0.1 QL(1 ea daily) Urinary Anti-infectives mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr fosfomycin 1 tromethamine pack nitroglycerin soln tl 0.4 1 mg/spray methenamine hippurate 1 tabs nitroglycerin subl sl 0.3 1 methenamine mg, 0.4 mg, 0.6 mg mandelate tabs 0.5 gm, 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety 1 gm Antianxiety Agents - Misc. nitrofurantoin 1 macrocrystal caps buspirone hcl tabs 1 nitrofurantoin monohyd 1 PA; macro caps hydroxyzine hcl soln im 4 administered 25 mg/ml, 50 mg/ml under the nitrofurantoin susp 1 medical benefit ANTIANGINAL AGENTS - Drugs to Treat Chest hydroxyzine hcl syrp or 1 Pain 10 mg/5ml Antianginals-Other hydroxyzine hcl tabs or 1 10 mg, 25 mg, 50 mg ranolazine tb12 1000 1 mg hydroxyzine pamoate 1 caps ranolazine tb12 500 mg 1 QL(4 ea daily) Benzodiazepines Nitrates (Alprazolam) 1 ALPRAZOLAM XR TB24 (Nitroglycerin) MINITRAN 1 QL(1 ea daily) PT24 (Diazepam) DIAZEPAM 1 DILATRATE SR CPCR INTENSOL CONC 3 (isosorbide dinitrate) (Lorazepam) LORAZEPAM 1 GONITRO PACK PA INTENSOL CONC 3 ALPRAZOLAM INTENSOL (nitroglycerin) 3 CONC (alprazolam) isosorbide dinitrate 1 tabs alprazolam tabs 0.25 1 mg, 0.5 mg, 1 mg, 2 mg isosorbide dinitrate tbcr 1 alprazolam tb24 0.5 1 isosorbide mononitrate 1 mg, 1 mg, 2 mg, 3 mg tabs alprazolam tbdp 0.25 2 isosorbide mononitrate 1 mg, 0.5 mg, 1 mg, 2 mg tb24 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits chlordiazepoxide hcl 1 propafenone hcl cp12 caps 225 mg, 325 mg, 425 1 mg clorazepate 1 QL(6 ea daily) dipotassium tabs propafenone hcl tabs 1 150 mg diazepam conc 5 1 QL(3 ea daily) mg/ml propafenone hcl tabs 1 225 mg, 300 mg diazepam soln 5 1 mg/5ml Antiarrhythmics Type III QL(4 ea daily) diazepam tabs 10 mg 1 (Amiodarone Hcl) 1 PACERONE TABS diazepam tabs 2 mg, 5 1 amiodarone hcl tabs 1 mg lorazepam conc 1 dofetilide caps 1 MULTAQ TABS 1 2 lorazepam tabs (dronedarone hcl) oxazepam caps 10 mg, 1 ANTIASTHMATIC AND BRONCHODILATOR 15 mg AGENTS - Drugs to Treat Lung Conditions oxazepam caps 30 mg 1 QL(2 ea daily) Anti-Inflammatory Agents ANTIARRHYTHMICS - Drugs to treat abnormal cromolyn sodium nebu 1 heart rhythms Antiasthmatic - Monoclonal Antibodies Antiarrhythmics Type I-A PA; Must use AcariaHealth disopyramide 1 FASENRA SOSY phosphate caps 4 Specialty Rx at (benralizumab) 1-844-538- NORPACE CR CP12 100 4661 MG (disopyramide 2 NUCALA SOAJ 100 PA phosphate) 4 MG/ML (mepolizumab) NORPACE CR CP12 150 PA; Must use MG (disopyramide 3 NUCALA SOLR 100 MG 4 Acaria phosphate) (mepolizumab) Specialty (844) 538-4661;SP quinidine gluconate 1 NUCALA SOSY 100 PA tbcr 4 MG/ML (mepolizumab) quinidine sulfate tabs 1 XOLAIR SOSY PA 4 Antiarrhythmics Type I-B (omalizumab) mexiletine hcl caps 1 Bronchodilators - Anticholinergics ATROVENT HFA AERS Limit 2 inhalers Antiarrhythmics Type I-C ( 2 per ipratropium bromide month;QL(0.86 flecainide acetate tabs 1 hfa) gm daily) INCRUSE ELLIPTA AEPB QL(1 ea daily) 2 (umeclidinium bromide) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ipratropium bromide FLOVENT DISKUS AEPB QL(8 ea daily) 1 250 MCG/BLIST soln 2 SPIRIVA HANDIHALER QL(1 ea daily) (fluticasone propionate CAPS (tiotropium 2 (inhalation)) bromide monohydrate) FLOVENT DISKUS AEPB QL(40 ea daily) 50 MCG/BLIST SPIRIVA RESPIMAT Limit 1 Inhaler 2 AERS 1.25 MCG/ACT per (fluticasone propionate (tiotropium bromide 2 month;QL(0.14 (inhalation)) monohydrate) 3 gm daily) FLOVENT HFA AERO 110 Limit 2 inhalers MCG/ACT, 220 MCG/ACT per SPIRIVA RESPIMAT Limit 1 inhaler (fluticasone propionate 2 month;QL(0.8 AERS 2.5 MCG/ACT per gm daily) (tiotropium bromide 2 month;QL(0.14 hfa) monohydrate) gm daily) FLOVENT HFA AERO 44 Limit 1 inhaler MCG/ACT ( 2 per Leukotriene Modulators fluticasone month;QL(0.36 QL(1 ea daily) propionate hfa) gm daily) montelukast sodium 1 chew Limit 1 inhaler PULMICORT FLEXHALER QL(1 ea daily) per month;QL(1 montelukast sodium 1 AEPB (budesonide 2 ea per fill pack (inhalation)) retail,3 ea per QL(1 ea daily) fill mail) montelukast sodium 1 tabs QVAR REDIHALER AERB Limit 1 inhaler 40 MCG/ACT per zafirlukast tabs 10 mg 1 (beclomethasone 2 month;QL(0.36 gm daily) zafirlukast tabs 20 mg 1 QL(2 ea daily) dipropionate hfa) QVAR REDIHALER AERB Limit 2 Inhalers zileuton tb12 1 ST 80 MCG/ACT per (beclomethasone 2 month;QL(0.72 ZYFLO TABS (zileuton) 3 ST dipropionate hfa) gm daily) Steroid Inhalants Sympathomimetics ARNUITY ELLIPTA AEPB QL(1 ea daily) (Fluticasone-Salmeterol) 1 QL(2 ea daily) WIXELA INHUB AEPB (fluticasone furoate 2 (inhalation)) Limit 1 inhaler ADVAIR HFA AERO per QL(8 ml daily) 2 budesonide (inhalation) 2 (fluticasone-salmeterol) month;QL(0.4 susp 0.25 mg/2ml gm daily) QL(4 ml daily) albuterol sulfate aers in QL(0.47 gm budesonide (inhalation) 2 1 susp 0.5 mg/2ml 108 mcg/act daily) QL(2 ml daily) albuterol sulfate aers in QL(1.2 gm budesonide (inhalation) 1 1 susp 1 mg/2ml 108 mcg/act daily) FLOVENT DISKUS AEPB QL(20 ea daily) albuterol sulfate aers in QL(0.72 gm 100 MCG/BLIST 1 daily) 2 108 mcg/act (fluticasone propionate QL(0.57 gm albuterol sulfate aers in 1 (inhalation)) 108 mcg/act daily)

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits albuterol sulfate nebu levalbuterol tartrate QL(0.6 gm 1 daily) in 0.083 %, 0.5 %, 0.63 1 aero mg/3ml, 1.25 mg/3ml, Limit 2 inhalers PROAIR RESPICLICK 2.5 mg/0.5ml 3 per ALBUTEROL SULFATE AEPB (albuterol sulfate) month;QL(0.07 ea daily) NEBU IN 0.5 % (albuterol 2 sulfate) SEREVENT DISKUS QL(2 ea daily) AEPB (salmeterol 2 albuterol sulfate syrp or 1 xinafoate) 2 mg/5ml STIOLTO RESPIMAT QL(0.14 gm albuterol sulfate tabs or 1 AERS (tiotropium 2 daily) 2 mg, 4 mg bromide-olodaterol hcl) QL(2 ea daily) albuterol sulfate tb12 or 1 Limit 1 inhaler 4 mg, 8 mg STRIVERDI RESPIMAT 2 per ANORO ELLIPTA AEPB QL(2 ea daily) AERS (olodaterol hcl) month;QL(0.14 (umeclidinium- 2 gm daily) vilanterol) terbutaline sulfate tabs 1 ARCAPTA NEOHALER QL(1 ea daily) TRELEGY ELLIPTA AEPB QL(2 ea daily) CAPS ( 3 indacaterol (fluticasone- 2 ) maleate umeclidinium-vilanterol) BREO ELLIPTA AEPB QL(2 ea daily) (fluticasone furoate- 2 Xanthines ELIXOPHYLLIN ELIX vilanterol) 3 Limit 1 inhaler (theophylline) budesonide-formoterol THEO-24 CP24 1 per 2 fumarate dihydrate month;QL(0.34 (theophylline) aero gm daily) theophylline soln 80 1 COMBIVENT RESPIMAT Limit 1 inhaler mg/15ml per AERS (ipratropium- 3 QL(2 ea daily) month;QL(0.2 theophylline tb12 300 1 albuterol) gm daily) mg QL(2 ea daily) QL(1 ea daily) fluticasone-salmeterol theophylline tb12 450 1 aepb 50 mcg/act-100 mg mcg/act, 50 mcg/act- QL(1 ea daily) theophylline tb24 400 1 250 mcg/act, 50 mg, 600 mg mcg/dose-100 1 mcg/dose, 50 ANTICOAGULANTS - Blood Thinners mcg/dose-250 Coumarin Anticoagulants mcg/dose, 50 (Warfarin Sodium) 1 mcg/dose-500 JANTOVEN TABS mcg/dose warfarin sodium tabs 1 ipratropium-albuterol 1 soln Direct Factor Xa Inhibitors levalbuterol hcl nebu 1 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BEVYXXA CAPS QL(42 ea per FRAGMIN SOLN 10000 PA 3 (betrixaban maleate) 42 days retail) UNIT/ML, 12500 ELIQUIS STARTER PACK UNIT/0.5ML, 15000 2 UNIT/0.6ML, 18000 TBPK (apixaban) UNT/0.72ML, 5000 4 ELIQUIS TABS 2.5 MG QL(2 ea daily) UNIT/0.2ML, 7500 2 (apixaban) UNIT/0.3ML, 95000 ELIQUIS TABS 5 MG UNIT/3.8ML (dalteparin 2 (apixaban) sodium) XARELTO STARTER FRAGMIN SOLN 2500 PACK TBPK 2 UNIT/0.2ML (dalteparin 4 (rivaroxaban) sodium) XARELTO TABS 10 MG, PA heparin sodium 4 15 MG, 2.5 MG 2 (porcine) soln (rivaroxaban) XARELTO TABS 20 MG QL(1 ea daily) ANTICONVULSANTS - Drugs to Treat Seizures 2 (rivaroxaban) AMPA Glutamate Receptor Antagonists FYCOMPA SUSP Heparins And Heparinoid-Like Agents 3 ARIXTRA SOLN 10 PA (perampanel) MG/0.8ML, 5 MG/0.4ML, FYCOMPA TABS 7 3 7.5 MG/0.6ML (perampanel) (fondaparinux sodium) Anticonvulsants - Benzodiazepines PA; QL(4 ml ARIXTRA SOLN 2.5 clobazam susp 2.5 MG/0.5ML ( 7 per 90 days 1 fondaparinux retail,4 ml per mg/ml sodium) 90 days mail) clobazam tabs 10 mg 1 QL(1 ea daily) PA; QL(0.1 ml enoxaparin sodium 2 soln ij 300 mg/3ml daily) clobazam tabs 20 mg 1 QL(2 ea daily) enoxaparin sodium QL(4 ml per 7 soln sc 100 mg/ml, 120 days retail) clonazepam tabs 1 mg/0.8ml, 150 mg/ml, 2 30 mg/0.3ml, 40 clonazepam tbdp 1 mg/0.4ml, 60 mg/0.6ml, QL(0.14 ea diazepam 1 80 mg/0.8ml (anticonvulsant) gel daily) fondaparinux sodium PA NAYZILAM SOLN PA; QL(10 ea soln 10 mg/0.8ml, 5 4 (midazolam 4 per 30 days mg/0.4ml, 7.5 mg/0.6ml (anticonvulsant)) retail) PA; QL(4 ml Anticonvulsants - Misc. fondaparinux sodium per 90 days 4 (Carbamazepine) EPITOL 1 soln 2.5 mg/0.5ml retail,4 ml per TABS 90 days mail)

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lamotrigine) SUBVENITE ST DIACOMIT CAPS 250 MG PA; QL(12 ea 4 STARTER KIT/BLUE, (stiripentol) daily) SUBVENITE STARTER 1 DIACOMIT CAPS 500 MG PA; QL(6 ea KIT/GREEN, SUBVENITE 4 daily) STARTER KIT/ORANGE (stiripentol) KIT DIACOMIT PACK 250 MG PA; QL(12 ea 4 (stiripentol) daily) (Lamotrigine) SUBVENITE 1 TABS DIACOMIT PACK 500 MG PA; QL(6 ea 4 (Levetiracetam) QL(3 ea daily) (stiripentol) daily) ROWEEPRA TABS 1000 1 EPIDIOLEX SOLN PA; ST MG 4 (cannabidiol) (Levetiracetam) QL(6 ea daily) ROWEEPRA TABS 500 1 gabapentin caps 1 MG, 750 MG gabapentin soln 1 (Levetiracetam) 1 QL(4 ea daily) ROWEEPRA XR TB24 APTIOM TABS PA; QL(2 ea gabapentin tabs 1 (eslicarbazepine 3 daily) KEPPRA SOLN 100 7 acetate) MG/ML (levetiracetam) BANZEL SUSP 40 MG/ML KEPPRA TABS 1000 MG QL(3 ea daily) 7 7 (rufinamide) (levetiracetam) BANZEL TABS 200 MG KEPPRA TABS 250 MG, QL(6 ea daily) 7 (rufinamide) 500 MG, 750 MG 7 BANZEL TABS 400 MG QL(8 ea daily) (levetiracetam) 7 ( ) KEPPRA XR TB24 QL(4 ea daily) rufinamide 7 (levetiracetam) carbamazepine chew 1 100 mg LAMICTAL CHEWABLE carbamazepine cp12 DISPERSIBLE CHEW 7 (lamotrigine) 100 mg, 200 mg, 300 1 LAMICTAL ODT KIT PA; ST mg 3 (lamotrigine) carbamazepine susp 1 LAMICTAL ODT TBDP 100 PA 100 mg/5ml MG, 200 MG, 25 MG, 50 7 carbamazepine tabs 1 MG (lamotrigine) 200 mg LAMICTAL TABS 7 ( ) carbamazepine tb12 1 lamotrigine 100 mg LAMICTAL XR KIT PA; ST 3 QL(8 ea daily) (lamotrigine) carbamazepine tb12 1 200 mg LAMICTAL XR TB24 100 PA; QL(1 ea QL(4 ea daily) MG, 200 MG, 25 MG, 50 7 daily) carbamazepine tb12 1 400 mg MG (lamotrigine) CARBATROL CP12 LAMICTAL XR TB24 250 PA 7 7 (carbamazepine) MG (lamotrigine) LAMICTAL XR TB24 300 QL(2 ea daily) 7 MG (lamotrigine) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEURONTIN TABS lamotrigine chew 25 1 7 mg, 5 mg (gabapentin) PA; ST QL(40 ml daily) lamotrigine kit 1 oxcarbazepine susp 1 300 mg/5ml, 60 mg/ml lamotrigine kit 25 mg 1 ST oxcarbazepine tabs 1 lamotrigine tabs 100 150 mg QL(8 ea daily) mg, 150 mg, 200 mg, 1 oxcarbazepine tabs 1 25 mg 300 mg QL(4 ea daily) lamotrigine tb24 100 PA; QL(1 ea oxcarbazepine tabs 1 mg, 200 mg, 25 mg, 50 1 daily) 600 mg mg OXTELLAR XR TB24 150 ST PA MG, 300 MG 3 lamotrigine tb24 250 1 mg (oxcarbazepine) OXTELLAR XR TB24 600 ST; QL(4 ea QL(2 ea daily) 3 lamotrigine tb24 300 1 MG (oxcarbazepine) daily) mg pregabalin caps 100 PA; ST;QL(3 PA lamotrigine tbdp 100 mg, 150 mg, 200 mg, 1 ea daily) mg, 200 mg, 25 mg, 50 1 25 mg, 50 mg, 75 mg mg PA; ST;QL(2 pregabalin caps 225 1 levetiracetam soln 100 1 mg, 300 mg ea daily) mg/ml, 500 mg/5ml pregabalin soln 20 PA levetiracetam tabs QL(3 ea daily) 1 1 mg/ml 1000 mg QL(6 ea daily) primidone tabs 1 levetiracetam tabs 250 1 mg, 500 mg, 750 mg QUDEXY XR CS24 100 PA; ST;QL(1 QL(4 ea daily) MG, 150 MG, 200 MG 7 ea daily) levetiracetam tb24 500 1 mg, 750 mg (topiramate) QUDEXY XR CS24 25 MG, PA; ST;QL(2 LYRICA CAPS 100 MG, PA; ST;QL(3 7 150 MG, 200 MG, 25 MG, ea daily) 50 MG (topiramate) ea daily) 50 MG, 75 MG 7 rufinamide susp 40 1 (pregabalin) mg/ml LYRICA CAPS 225 MG, PA; ST;QL(2 7 300 MG (pregabalin) ea daily) rufinamide tabs 200 mg 1 LYRICA SOLN 20 MG/ML PA QL(8 ea daily) 7 rufinamide tabs 400 mg 1 (pregabalin) TEGRETOL SUSP MYSOLINE TABS 7 7 (primidone) (carbamazepine) TEGRETOL TABS NEURONTIN CAPS 7 7 (gabapentin) (carbamazepine) NEURONTIN SOLN TEGRETOL-XR TB12 100 7 7 (gabapentin) MG (carbamazepine) TOPAMAX SPRINKLE 7 CPSP (topiramate) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPAMAX TABS 100 MG QL(4 ea daily) ZONEGRAN CAPS 100 QL(6 ea daily) 7 7 (topiramate) MG (zonisamide) TOPAMAX TABS 200 MG QL(2 ea daily) ZONEGRAN CAPS 25 MG 7 7 (topiramate) (zonisamide) TOPAMAX TABS 25 MG QL(6 ea daily) 7 zonisamide caps 100 1 (topiramate) mg TOPAMAX TABS 50 MG QL(8 ea daily) 7 zonisamide caps 25 1 (topiramate) mg, 50 mg topiramate cpsp 15 mg, 1 Carbamates 25 mg topiramate cs24 100 PA; ST;QL(1 felbamate susp 1 1 ea daily) mg, 150 mg, 200 mg felbamate tabs 1 topiramate cs24 25 mg, PA; ST;QL(2 1 FELBATOL SUSP 600 50 mg ea daily) 7 MG/5ML (felbamate) QL(4 ea daily) topiramate tabs 100 mg 1 GABA Modulators QL(2 ea daily) topiramate tabs 200 mg 1 (Vigabatrin) VIGADRONE 4 QL(6 ea daily) PACK GABITRIL TABS topiramate tabs 25 mg 1 7 (tiagabine hcl) QL(8 ea daily) topiramate tabs 50 mg 1 SABRIL PACK QL(6 ea daily) 7 TRILEPTAL SUSP 300 QL(40 ml daily) (vigabatrin) MG/5ML SABRIL TABS 7 7 (oxcarbazepine) (vigabatrin) TRILEPTAL TABS 150 MG 7 tiagabine hcl tabs 1 (oxcarbazepine) TRILEPTAL TABS 300 MG QL(8 ea daily) vigabatrin pack 4 QL(6 ea daily) 7 (oxcarbazepine) TRILEPTAL TABS 600 MG QL(4 ea daily) vigabatrin tabs 4 7 (oxcarbazepine) Hydantoins TROKENDI XR CP24 100 PA 3 (Phenytoin) PHENYTOIN 1 MG, 50 MG (topiramate) INFATABS CHEW TROKENDI XR CP24 200 PA; QL(2 ea 3 DILANTIN CAPS 100 MG MG (topiramate) daily) (phenytoin sodium 7 TROKENDI XR CP24 25 PA; ST extended) 3 MG (topiramate) DILANTIN CAPS 30 MG VIMPAT SOLN 10 MG/ML QL(40 ml daily) (phenytoin sodium 3 2 (lacosamide) extended) VIMPAT TABS 100 MG, DILANTIN INFATABS 7 150 MG, 200 MG, 50 MG 2 CHEW (phenytoin) (lacosamide) DILANTIN-125 SUSP 7 (phenytoin)

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEGANONE TABS 3 mirtazapine tbdp 1 (ethotoin) Antidepressants - Misc. phenytoin chew 1 bupropion hcl tabs 100 1 phenytoin sodium 1 mg, 75 mg extended caps bupropion hcl tb12 100 1 phenytoin susp 1 mg, 150 mg, 200 mg QL(1 ea daily) bupropion hcl tb24 150 1 Succinimides mg, 300 mg CELONTIN CAPS 3 ST; QL(1 ea (methsuximide) bupropion hcl tb24 450 1 mg daily) ethosuximide caps 1 FORFIVO XL TB24 ST; QL(1 ea 7 (bupropion hcl) daily) ethosuximide soln 1 1 ZARONTIN CAPS maprotiline hcl tabs 7 (ethosuximide) Monoamine Oxidase Inhibitors (MAOIs) ZARONTIN SOLN EMSAM PT24 QL(1 ea daily) 7 3 (ethosuximide) (selegiline) Valproic Acid MARPLAN TABS 3 DEPAKENE CAPS (isocarboxazid) 7 (valproic acid) phenelzine sulfate tabs 1 DEPAKOTE ER TB24 7 (divalproex sodium) tranylcypromine sulfate 2 DEPAKOTE SPRINKLES tabs CSDR (divalproex 7 Selective Serotonin Reuptake Inhibitors (SSRIs) sodium) citalopram QL(20 ml daily) DEPAKOTE TBEC hydrobromide soln 10 1 7 (divalproex sodium) mg/5ml divalproex sodium csdr 1 citalopram QL(1 ea daily) hydrobromide tabs 10 1 divalproex sodium tb24 1 mg, 20 mg, 40 mg escitalopram oxalate 1 divalproex sodium tbec 1 soln 5 mg/5ml QL(1 ea daily) valproate sodium soln 1 escitalopram oxalate 1 tabs 10 mg, 20 mg valproic acid caps or 1 QL(2 ea daily) escitalopram oxalate 1 ANTIDEPRESSANTS - Drugs to Treat tabs 5 mg Depression fluoxetine hcl caps 10 1 Alpha-2 Receptor Antagonists (Tetracyclics) mg, 20 mg QL(1 ea daily) fluoxetine hcl caps 40 1 mirtazapine tabs 1 mg

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily) fluoxetine hcl cpdr 90 1 duloxetine hcl cpep 20 1 mg mg, 30 mg, 60 mg QL(15 ml daily) FETZIMA CP24 120 MG, ST; QL(1 ea fluoxetine hcl soln 20 1 mg/5ml 40 MG, 80 MG 3 daily) fluoxetine hcl tabs 10 (levomilnacipran hcl) 1 FETZIMA CP24 20 MG ST; QL(2 ea mg 3 (levomilnacipran hcl) daily) QL(1 ea daily) fluoxetine hcl tabs 20 1 mg, 60 mg FETZIMA TITRATION ST PACK C4PK 3 QL(3 ea daily) fluvoxamine maleate 2 (levomilnacipran hcl) cp24 100 mg venlafaxine hcl cp24 QL(2 ea daily) fluvoxamine maleate 2 150 mg, 37.5 mg, 75 1 cp24 150 mg mg QL(3 ea daily) fluvoxamine maleate 1 venlafaxine hcl tabs tabs 100 mg 100 mg, 25 mg, 37.5 1 mg, 50 mg, 75 mg fluvoxamine maleate 1 tabs 25 mg, 50 mg venlafaxine hcl tb24 QL(1 ea daily) paroxetine hcl tabs 1 150 mg, 37.5 mg, 75 1 mg paroxetine hcl tb24 1 venlafaxine hcl tb24 1 PAXIL SUSP 10 MG/5ML 225 mg 3 (paroxetine hcl) Tricyclic Agents sertraline hcl conc 20 1 amitriptyline hcl tabs 1 mg/ml QL(2 ea daily) amoxapine tabs 1 sertraline hcl tabs 100 1 mg, 25 mg, 50 mg clomipramine hcl caps 2 Serotonin Modulators nefazodone hcl tabs 1 desipramine hcl tabs 1 trazodone hcl tabs 1 doxepin hcl caps 1 TRINTELLIX TABS ST; QL(1 ea doxepin hcl conc 1 3 (vortioxetine hbr) daily) imipramine hcl tabs 10 VIIBRYD STARTER PACK PA 1 3 mg, 25 mg KIT (vilazodone hcl) imipramine hcl tabs 50 QL(4 ea daily) VIIBRYD TABS 10 MG, 40 ST 1 3 mg MG (vilazodone hcl) VIIBRYD TABS 20 MG ST; QL(2 ea imipramine pamoate 1 3 (vilazodone hcl) daily) caps Serotonin-Norepinephrine Reuptake Inhibitors nortriptyline hcl caps 1 QL(1 ea daily) desvenlafaxine 1 nortriptyline hcl soln 1 succinate tb24 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits protriptyline hcl tabs 1 repaglinide-metformin 1 hcl tabs trimipramine maleate 1 SYNJARDY TABS caps (empagliflozin- 2 ANTIDIABETICS - Drugs to Regulate Blood metformin hcl) Sugar SYNJARDY XR TB24 Alpha-Glucosidase Inhibitors (empagliflozin- 2 metformin hcl) acarbose tabs or 100 1 mg, 25 mg, 50 mg TRIJARDY XR TB24 (empagliflozin- 2 1 miglitol tabs linagliptin-metformin) Antidiabetic - Amylin Analogs XIGDUO XR TB24 10 MG- QL(1 ea daily) SYMLINPEN 120 SOPN PA 1000 MG, 10 MG-500 MG 2 2 (pramlintide acetate) (dapagliflozin- ) SYMLINPEN 60 SOPN PA metformin hcl 2 (pramlintide acetate) XIGDUO XR TB24 2.5 MG- QL(2 ea daily) 1000 MG, 5 MG-1000 MG, Antidiabetic Combinations 5 MG-500 MG 2 (dapagliflozin- glipizide-metformin hcl 1 tabs metformin hcl) Biguanides glyburide-metformin 1 tabs metformin hcl soln 500 1 GLYXAMBI TABS mg/5ml (empagliflozin- 2 Only Covered linagliptin) Ca On/Off JANUMET TABS 50 MG- Individual 1000 MG (sitagliptin- 2 metformin hcl tabs Exchange 5 Plans Covered metformin hcl) 1000 mg, 500 mg, 850 at PV Tier- JANUMET TABS 50 MG- QL(2 ea daily) mg Student Plans 500 MG (sitagliptin- 2 and all others metformin hcl) at Tier 1 for generic;PV JANUMET XR TB24 100 QL(1 ea daily) MG-1000 MG (sitagliptin- 2 metformin hcl tb24 500 1 metformin hcl) mg, 750 mg JANUMET XR TB24 50 QL(2 ea daily) METFORMIN MG-1000 MG, 50 MG-500 HYDROCHLORIDE SOLN 1 MG, 500 MG-50 MG 2 (metformin hcl) (sitagliptin-metformin Diabetic Other hcl) diazoxide susp 1 pioglitazone hcl- 1 glimepiride tabs PA; QL(1 ea glucagon (rdna) kit 4 per fill retail,2 pioglitazone hcl- 1 ea per 30 days metformin hcl tabs retail)

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCAGON PA; QL(1 ea HUMALOG JUNIOR Limit 45mls per EMERGENCY KIT KIT 7 per fill retail,2 KWIKPEN SOPN (insulin 2 month;QL(1.5 ea per 30 days lispro) ml daily) (glucagon (rdna)) retail) HUMALOG KWIKPEN Limit 45mls per Dipeptidyl Peptidase-4 (DPP-4) Inhibitors SOPN 100 UNIT/ML 2 month;QL(1.5 ml daily) alogliptin benzoate tabs 1 (insulin lispro) HUMALOG KWIKPEN Limit 24mls per JANUVIA TABS 100 MG, QL(1 ea daily) SOPN 200 UNIT/ML 2 month;QL(0.8 50 MG (sitagliptin 2 (insulin lispro) ml daily) phosphate) HUMALOG MIX 50/50 Limit 45mls per JANUVIA TABS 25 MG month;QL(1.5 2 KWIKPEN SUPN (insulin (sitagliptin phosphate) lispro protamine & 2 ml daily) Incretin Mimetic Agents (GLP-1 Receptor lispro) PA; Not HUMALOG MIX 50/50 Limit 45mls per OZEMPIC SOPN 2 month;QL(1.5 2 available SUSP (insulin lispro 2 MG/1.5ML (semaglutide) through Mail protamine & lispro) ml daily) Order HUMALOG MIX 75/25 Limit 45mls per PA; Not month;QL(1.5 RYBELSUS TABS KWIKPEN SUPN (insulin 4 available 2 ml daily) (semaglutide) through Mail lispro protamine & Order lispro) PA; Not HUMALOG MIX 75/25 Limit 40mls per TRULICITY SOPN month;QL(1.34 2 available SUSP (insulin lispro 2 (dulaglutide) through mail protamine & lispro) ml daily) order HUMALOG SOCT (insulin Limit 45mls per PA; Not 2 month;QL(1.5 VICTOZA SOPN lispro) 2 available ml daily) (liraglutide) through mail HUMALOG SOLN (insulin Limit 45mls per order 2 month;QL(1.5 Insulin Sensitizing Agents lispro) ml daily) AVANDIA TABS HUMULIN 70/30 KWIKPEN QL(1.5 ml 2 (rosiglitazone maleate) SUPN (insulin nph daily) isophane & reg 2 pioglitazone hcl tabs 15 1 mg (human)) QL(1 ea daily) HUMULIN 70/30 SUSP Limit 40mls per pioglitazone hcl tabs 30 1 mg, 45 mg (insulin nph isophane & 2 month;QL(1.34 reg (human)) ml daily) Insulin HUMULIN N KWIKPEN Limit 45mls per AFREZZA POWD ( QL(6 ea daily) insulin 3 SUPN (insulin nph 2 month;QL(1.5 regular (human)) (human) (isophane)) ml daily) AFREZZA POWD ( insulin 3 HUMULIN N SUSP Limit 45mls per regular (human)) (insulin nph (human) 2 month;QL(1.5 AFREZZA POWD 12 UNIT, QL(3 ea daily) (isophane)) ml daily) 4 UNIT, 8 UNIT (insulin 3 regular (human))

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMULIN R SOLN Limit 40mls per Limited to 27 (insulin regular 2 month;QL(1.34 TRESIBA FLEXTOUCH mls /month (human)) ml daily) SOPN 200 UNIT/ML 2 without prior (insulin degludec) authorization;Q HUMULIN R SOLN Limit 45mls per L(0.9 ml daily) (insulin regular 2 month;QL(1.5 TRESIBA SOLN (insulin (human)) ml daily) 2 degludec) HUMULIN R U-500 QL(1.34 ml daily) Meglitinide Analogues (CONCENTRATED) 2 SOLN (insulin regular nateglinide tabs 1 (human)) HUMULIN R U-500 Limit 40mls per repaglinide tabs 1 KWIKPEN SOPN (insulin 2 month;QL(1.34 regular (human)) ml daily) Sodium-Glucose Co-Transporter 2 (SGLT2) INSULIN LISPRO Limit 45mls per FARXIGA TABS QL(1 ea daily) PROTAMINE/INSULIN month;QL(1.5 (dapagliflozin 2 LISPRO KWIKPEN SUPN 2 ml daily) propanediol) (insulin lispro protamine JARDIANCE TABS QL(1 ea daily) 2 & lispro) (empagliflozin) LANTUS SOLN (insulin Limit 45mls per Sulfonylureas 2 month;QL(1.5 ) glargine ml daily) (Glipizide) GLIPIZIDE XL 1 TB24 LANTUS SOLOSTAR Limit 45mls per 2 month;QL(1.5 glimepiride tabs 1 SOPN (insulin glargine) ml daily) Limit 45mls per glipizide tabs 1 LEVEMIR FLEXTOUCH 2 month;QL(1.5 SOPN (insulin detemir) ml daily,135 ml glipizide tb24 1 per fill mail) Limit 45mls per glyburide micronized 1 LEVEMIR SOLN ( tabs insulin 2 month;QL(1.5 ml daily,135 ml detemir) glyburide tabs 1.25 mg, 1 per fill mail) 2.5 mg, 5 mg Limit 2 pens TOUJEO MAX SOLOSTAR tolbutamide tabs 1 2 per SOPN (insulin glargine) month;QL(0.2 ml daily) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea Limit 3 pens TOUJEO SOLOSTAR Antidiarrheal - Chloride Channel Antagonists 2 per SOPN (insulin glargine) month;QL(0.15 MYTESI TBEC PA; QL(2 ea 3 ml daily) (crofelemer) daily) TRESIBA FLEXTOUCH Limit 45mls per Antiperistaltic Agents SOPN 100 UNIT/ML 2 month;QL(1.5 (insulin degludec) ml daily)

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Loperamide Hcl) ANTI- RX/OTC PA; Must use DIARRHEAL, CVS ANTI- JADENU SPRINKLE PACK AcariaHealth DIARRHEAL, EQ ANTI- 7 Specialty Rx at DIARRHEAL, GNP ANTI- (deferasirox) 1-844-538- DIARRHEAL, HM ANTI- 4661;LA DIARRHEAL, HM 1 JADENU TABS PA 7 LOPERAMIDE HCL, QC (deferasirox) ANTI-DIARRHEAL, RA ANTI-DIARRHEAL, SM Antidotes and Specific Antagonists ANTI-DIARRHEAL, TGT ANDEXXA SOLR PA LOPERAMIDE HCL CAPS (coagulation factor xa 4 diphenoxylate w/ 1 recomb inact-zhzo atropine liqd (andexanet alfa)) diphenoxylate w/ 1 VISTOGARD PACK atropine tabs (uridine triacetate 4 RX/OTC (emergency treatment)) loperamide hcl caps 2 1 mg Opioid Antagonists QL(2.4 ml EVZIO SOAJ ( PA opium tincture tinc 2 naloxone 4 daily) hcl) paregoric tinc 1 PA naloxone hcl soaj 2 4 mg/0.4ml ANTIDOTES AND SPECIFIC ANTAGONISTS naloxone hcl sosy 2 1 Antidotes - Chelating Agents mg/2ml CHEMET CAPS 3 naltrexone hcl tabs 1 (succimer) NARCAN LIQD QL(4 ea per 30 PA; Must use 2 (naloxone hcl) days retail) deferasirox pack 180 AcariaHealth 4 Specialty Rx at mg, 360 mg, 90 mg ANTIEMETICS - Drugs to Treat Nausea and 1-844-538- Vomiting 4661;LA deferasirox tabs 180 PA 5-HT3 Receptor Antagonists 4 PA; ST; Limit 2 mg, 360 mg, 90 mg ANZEMET TABS per PA 3 deferasirox tbso 125 4 (dolasetron mesylate) month;QL(0.07 mg, 250 mg, 500 mg ea daily) PA; ST; Limit 2 deferiprone tabs 4 PA granisetron hcl tabs 1 tablets per EXJADE TBSO PA day;QL(2 ea 7 (deferasirox) daily) FERRIPROX SOLN 100 PA ondansetron hcl soln 4 Limit 50mls per 4 1 month;QL(1.67 MG/ML (deferiprone) mg/5ml ml daily) FERRIPROX TABS 500 PA 7 ondansetron hcl tabs 4 Limit 20 per MG (deferiprone) 1 month;QL(0.67 mg, 8 mg ea daily)

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 20 per Antifungals ondansetron tbdp 1 month;QL(0.67 ea daily) flucytosine caps 1 SANCUSO PTCH PA; QL(0.04 ea 4 griseofulvin microsize 1 (granisetron) daily) susp ZUPLENZ FILM Limit 20 per 3 month;QL(0.67 griseofulvin microsize 1 (ondansetron) ea daily) tabs Antiemetics - Anticholinergic griseofulvin 1 ultramicrosize tabs scopolamine pt72 1 nystatin tabs 1 trimethobenzamide hcl 1 caps QL(1 ea terbinafine hcl tabs 1 daily,90 ea per Antiemetics - Miscellaneous 365 days retail) AKYNZEO CAPS QL(2 ea per 28 Imidazole-Related Antifungals days retail) (netupitant- 3 CRESEMBA CAPS Not available palonosetron) (isavuconazonium 3 through mail QL(4 ea daily) order doxylamine-pyridoxine 1 sulfate) tbec fluconazole susr 1 PA dronabinol caps 10 mg, 2 5 mg fluconazole tabs 1 PA; ST dronabinol caps 2.5 mg 2 PA; ST itraconazole caps 100 1 SYNDROS SOLN PA mg 4 ( ) PA dronabinol itraconazole soln 10 1 Substance P/Neurokinin 1 (NK1) Receptor mg/ml Limit 3 per ketoconazole tabs 1 aprepitant caps 1 month;QL(0.1 NOXAFIL SUSP 40 MG/ML ea daily) 3 (posaconazole) aprepitant caps 125 Limit 1 per 1 year;QL(0.04 posaconazole tbec 1 mg, 80 mg ea daily) TOLSURA CAPS PA Limit 2 per 4 aprepitant caps 40 mg 1 month;QL(0.07 (itraconazole) ea daily) voriconazole susr 40 1 Limit 3 per mg/ml 1 month;QL(0.1 aprepitant misc QL(2 ea daily) ea daily) voriconazole tabs 200 1 EMEND SUSR 125 QL(1 ea per 30 mg, 50 mg 3 MG/5ML (aprepitant) days retail) ANTIHISTAMINES - Drugs to Treat Allergies VARUBI TBPK QL(4 ea per fill 3 (rolapitant hcl) retail) Antihistamines - Alkylamines (Dexchlorpheniramine 1 ANTIFUNGALS - Drugs to Treat Fungal Infections Maleate) RYCLORA SOLN

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Promethazine Hcl) dexchlorpheniramine 1 maleate soln PROMETHEGAN SUPP 2 12.5 MG, 25 MG Antihistamines - Ethanolamines (Promethazine Hcl) QL(3 ea daily) carbinoxamine maleate 1 PROMETHEGAN SUPP 50 2 soln 4 mg/5ml MG PHENERGAN SOLN PA carbinoxamine maleate 1 7 tabs 4 mg (promethazine hcl) PA CARBINOXAMINE promethazine hcl soln ij 4 MALEATE TABS 6 MG 25 mg/ml, 50 mg/ml (carbinoxamine 3 promethazine hcl soln 1 maleate) or 6.25 mg/5ml clemastine fumarate 1 promethazine hcl supp 2 tabs 2.68 mg re 12.5 mg, 25 mg diphenhydramine hcl PA QL(3 ea daily) 4 promethazine hcl supp 2 soln re 50 mg RYVENT TABS promethazine hcl syrp 1 (carbinoxamine 3 or 6.25 mg/5ml maleate) promethazine hcl tabs 1 Antihistamines - Non-Sedating or 12.5 mg (Levocetirizine QL(1 ea daily); QL(6 ea daily) promethazine hcl tabs 1 Dihydrochloride) ALLERGY RX/OTC or 25 mg RELIEF 24HR, CVS 1 ALLERGY RELIEF, GNP QL(3 ea daily) promethazine hcl tabs 1 ALLERGY RELIEF 24 or 50 mg HOUR TABS Antihistamines - Piperidines PA; ST;QL(1 desloratadine tabs 5 1 mg ea daily) cyproheptadine hcl syrp 1 desloratadine tbdp 2.5 PA; ST 1 cyproheptadine hcl tabs 1 mg PA ANTIHYPERLIPIDEMICS - Drugs to Treat High desloratadine tbdp 5 1 mg Cholesterol levocetirizine PA; RX/OTC Antihyperlipidemics - Combinations 1 QL(1 ea daily) dihydrochloride soln ezetimibe-simvastatin 1 2.5 mg/5ml tabs levocetirizine QL(1 ea daily); Antihyperlipidemics - Misc. dihydrochloride tabs 5 1 RX/OTC PA mg icosapent ethyl caps 1 QL(4 ea daily) Antihistamines - Phenothiazines omega-3-acid ethyl 1 (Promethazine Hcl) esters caps 2 VASCEPA CAPS 0.5 GM PA; ST PHENADOZ SUPP 3 (icosapent ethyl)

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VASCEPA CAPS 1 GM PA FENOFIBRATE TABS 160 QL(1 ea daily) 3 2 (icosapent ethyl) MG (fenofibrate) Bile Acid Sequestrants fenofibrate tabs 48 mg 1 (Cholestyramine Light) 1 PREVALITE PACK fenofibrate tabs 54 mg 1 QL(2 ea daily) (Cholestyramine Light) 1 FENOFIBRIC ACID TABS PREVALITE POWD 2 105 MG (fenofibric acid) cholestyramine light 1 FIBRICOR TABS 7 pack (fenofibric acid) cholestyramine light 1 powd gemfibrozil tabs 1 LIPOFEN CAPS cholestyramine pack or 1 7 4 gm (fenofibrate) TRIGLIDE TABS QL(1 ea daily) cholestyramine powd 1 2 or 4 gm/dose (fenofibrate) QL(1 ea daily) HMG CoA Reductase Inhibitors colesevelam hcl pack 1 3.75 gm QL(1 ea daily) atorvastatin calcium 1 QL(7 ea daily) tabs colesevelam hcl tabs 1 625 mg fluvastatin sodium caps 1 QL(1 ea daily) colestipol hcl gran 5 gm 1 fluvastatin sodium tb24 1 QL(1 ea daily) colestipol hcl pack 5 2 LIVALO TABS ST; QL(1 ea gm 3 (pitavastatin calcium) daily) colestipol hcl tabs 1 gm 1 $0 copay for 1 Generic only, Fibric Acid Derivatives lovastatin tabs age 40 to ANTARA CAPS 75;PV 3 (fenofibrate micronized) $0 copay for choline fenofibrate cpdr QL(1 ea daily) Generic only, 1 pravastatin sodium tabs 1 age 40 to 135 mg 75;QL(1 ea choline fenofibrate cpdr 1 daily); PV 45 mg QL(1 ea daily) rosuvastatin calcium 1 fenofibrate caps 150 1 tabs mg, 50 mg simvastatin tabs 10 mg, QL(1 ea daily) QL(1 ea daily) 1 fenofibrate micronized 1 20 mg, 40 mg, 5 mg, 80 caps 130 mg, 200 mg mg fenofibrate micronized Intestinal Cholesterol Absorption Inhibitors caps 134 mg, 43 mg, 1 67 mg ezetimibe tabs 1 QL(1 ea daily) Microsomal Triglyceride Transfer Protein (MTP) fenofibrate tabs 145 1 mg, 160 mg

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JUXTAPID CAPS 10 MG, PA ramipril caps 1 QL(2 ea daily) 20 MG, 30 MG, 40 MG, 60 4 MG (lomitapide trandolapril tabs 1 mesylate) JUXTAPID CAPS 5 MG PA; ST Agents for Pheochromocytoma 4 (lomitapide mesylate) metyrosine caps 1 Nicotinic Acid Derivatives Not available phenoxybenzamine hcl 1 (Niacin caps through mail (Antihyperlipidemic)) 1 NIACOR TABS Angiotensin II Receptor Antagonists niacin candesartan cilexetil 1 tabs 16 mg, 4 mg, 8 mg (antihyperlipidemic) 1 tbcr 1000 mg, 500 mg, QL(1 ea daily) candesartan cilexetil 1 750 mg tabs 32 mg Proprotein Convertase Subtilisin/Kexin Type 9 EDARBI TABS 40 MG 3 PRALUENT SOAJ PA (azilsartan medoxomil) 4 (alirocumab) EDARBI TABS 80 MG QL(1 ea daily) 3 REPATHA SURECLICK PA; ST (azilsartan medoxomil) 4 SOAJ (evolocumab) irbesartan tabs 1 ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure losartan potassium tabs or 100 mg, 25 mg, 50 1 ACE Inhibitors mg benazepril hcl tabs 1 olmesartan medoxomil 1 tabs 20 mg, 5 mg captopril tabs 1 QL(1 ea daily) olmesartan medoxomil 1 enalapril maleate tabs QL(2 ea daily) tabs 40 mg 10 mg, 2.5 mg, 20 mg, 1 telmisartan tabs 20 mg, 1 5 mg 40 mg fosinopril sodium tabs 1 telmisartan tabs 80 mg 1 QL(1 ea daily) lisinopril tabs 10 mg, QL(2 ea daily) 2.5 mg, 20 mg, 30 mg, 1 valsartan tabs 160 mg 1 5 mg valsartan tabs 320 mg, 1 lisinopril tabs 40 mg 1 QL(2 ea daily) 40 mg, 80 mg Antiadrenergic Antihypertensives moexipril hcl tabs 1 clonidine hcl tabs 1 perindopril erbumine 1 tabs doxazosin mesylate 1 tabs QBRELIS SOLN QL(5 ml daily) 3 (lisinopril) guanfacine hcl tabs 1 quinapril hcl tabs 1

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHYLDOPA TABS 2 captopril & (methyldopa) hydrochlorothiazide 1 prazosin hcl caps 1 tabs EDARBYCLOR TABS QL(1 ea daily) terazosin hcl caps 1 1 (azilsartan medoxomil- 3 mg, 2 mg, 5 mg chlorthalidone) QL(2 ea daily) terazosin hcl caps 10 1 enalapril maleate & mg hydrochlorothiazide 1 Antihypertensive Combinations tabs amlodipine besylate- QL(1 ea daily) EXFORGE HCT TABS benazepril hcl caps 10 (amlodipine-valsartan- 2 mg-20 mg, 10 mg-40 1 hydrochlorothiazide) mg, 5 mg-10 mg, 5 mg- fosinopril sodium & 20 mg, 5 mg-40 mg hydrochlorothiazide 1 amlodipine besylate- tabs benazepril hcl caps 2.5 1 irbesartan- mg-10 mg hydrochlorothiazide 1 amlodipine besylate- QL(1 ea daily) tabs valsartan tabs 10 mg- 1 lisinopril & 160 mg hydrochlorothiazide 1 amlodipine besylate- tabs 10 mg-12.5 mg, 12.5 mg-20 mg valsartan tabs 10 mg- 1 320 mg, 5 mg-160 mg, lisinopril & QL(2 ea daily) 5 mg-320 mg hydrochlorothiazide 1 amlodipine-valsartan- tabs 20 mg-25 mg hydrochlorothiazide 1 losartan potassium & tabs hydrochlorothiazide 1 tabs atenolol & 1 chlorthalidone tabs methyldopa & benazepril & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs metoprolol & BENAZEPRIL hydrochlorothiazide 1 HCL/HYDROCHLOROTHI tabs 2 AZIDE TABS (benazepril olmesartan medoxomil- ST & hydrochlorothiazide) amlodipine- 1 bisoprolol & hydrochlorothiazide hydrochlorothiazide 1 tabs tabs olmesartan medoxomil- candesartan cilexetil- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs 12.5 mg-20 mg tabs

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olmesartan medoxomil- QL(1 ea daily) Vasodilators hydrochlorothiazide 1 tabs 12.5 mg-40 mg, hydralazine hcl tabs 1 25 mg-40 mg minoxidil tabs 1 propranolol & hydrochlorothiazide 1 ANTIMALARIALS - Drugs to Treat Malaria tabs (Parasitic Infections) quinapril- Antimalarial Combinations atovaquone-proguanil hydrochlorothiazide 1 1 tabs 10 mg-12.5 mg, hcl tabs 12.5 mg-20 mg COARTEM TABS Limit 24 doses quinapril- QL(1 ea daily) ( 2 per artemether- month;QL(0.8 hydrochlorothiazide 1 lumefantrine) ea daily) tabs 20 mg-25 mg Antimalarials TEKTURNA HCT TABS ST (aliskiren- 3 chloroquine phosphate 1 hydrochlorothiazide) tabs hydroxychloroquine telmisartan-amlodipine 1 1 tabs sulfate tabs KRINTAFEL TABS QL(2 ea per 30 telmisartan- 2 days retail) hydrochlorothiazide 1 (tafenoquine succinate) tabs QL(6 ea per fill mefloquine hcl tabs 1 retail,6 ea per trandolapril-verapamil 1 fill mail) hcl tbcr primaquine phosphate 1 valsartan- tabs hydrochlorothiazide pyrimethamine tabs 1 PA tabs 12.5 mg-160 mg, 1 12.5 mg-320 mg, 12.5 1 PA; QL(2 ea mg-80 mg, 25 mg-320 quinine sulfate caps daily) mg ANTIMYASTHENIC/CHOLINERGIC AGENTS valsartan- QL(1 ea daily) hydrochlorothiazide 1 Antimyasthenic/Cholinergic Agents tabs 25 mg-160 mg FIRDAPSE TABS PA; ST (amifampridine 4 Antihypertensives - Misc. phosphate) VECAMYL TABS 3 GUANIDINE HCL TABS (mecamylamine hcl) 2 (guanidine hcl) Direct Renin Inhibitors MESTINON SOLN 60 PA aliskiren fumarate tabs 1 MG/5ML (pyridostigmine 7 bromide) Selective Aldosterone Receptor Antagonists PA pyridostigmine bromide 4 eplerenone tabs 1 soln 60 mg/5ml

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AC pyridostigmine bromide 1 cyclophosphamide 1 tabs 60 mg caps 25 mg, 50 mg CYCLOPHOSPHAMIDE pyridostigmine bromide 1 tbcr 180 mg TABS 25 MG, 50 MG 2 RUZURGI TABS PA; QL(10 ea (cyclophosphamide) 4 GLEOSTINE CAPS AC (amifampridine) daily) 2 (lomustine) ANTIMYCOBACTERIAL AGENTS - Drugs to LEUKERAN TABS AC Treat Tuberculosis (Bacterial Infections) 2 (chlorambucil) Anti TB Combinations PA; LA RIFAMATE CAPS melphalan hcl solr 4 2 (isoniazid & rifampin) melphalan tabs 1 AC RIFATER TABS MYLERAN TABS AC (isoniazid-rifampin w/ 3 2 pyrazinamide) (busulfan) Antimycobacterial Agents temozolomide caps 1 AC cycloserine caps 1 Antimetabolites AC ethambutol hcl tabs 1 capecitabine tabs 1 PA isoniazid syrp 1 fludarabine phosphate 4 solr isoniazid tabs 1 mercaptopurine tabs 1 AC PASER PACK 3 methotrexate sodium PA; LA (aminosalicylic acid) soln ij 1 gm/40ml, 250 4 PRIFTIN TABS 3 mg/10ml, 50 mg/2ml (rifapentine) PA; LA methotrexate sodium 4 pyrazinamide tabs 1 solr ij 1 gm AC methotrexate sodium 1 rifabutin caps 1 tabs or 2.5 mg ONUREG TABS PA; AC rifampin caps 1 4 (azacitidine) TRECATOR TABS 2 PURIXAN SUSP AL(Up to 13 yrs (ethionamide) 3 (mercaptopurine) old ); AC ANTINEOPLASTICS AND ADJUNCTIVE TABLOID TABS AC THERAPIES - Drugs to Treat Cancer 2 (thioguanine) Alkylating Agents TREXALL TABS AC ALKERAN SOLR IV 50 MG PA; LA 3 7 (methotrexate sodium) (melphalan hcl) XATMEP SOLN PA; AC 4 busulfan soln 4 PA (methotrexate) BUSULFEX SOLN PA Antineoplastic - Angiogenesis Inhibitors 7 (busulfan) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use PA; Must use AcariaHealth AcariaHealth INLYTA TABS (axitinib) 4 Specialty Rx at erlotinib hcl tabs 4 Specialty Rx at 1-844-538- 1-844-538- 4661;LA; AC 4661;LA; AC LENVIMA 10 MG DAILY PA; AC PA; Must use GILOTRIF TABS ( DOSE CPPK (lenvatinib 4 afatinib 4 Accredo SP mesylate) dimaleate) pharmacy;LA; AC LENVIMA 12MG DAILY AC DOSE CPPK (lenvatinib 4 IRESSA TABS (gefitinib) 4 mesylate) TAGRISSO TABS PA; AC 4 LENVIMA 14 MG DAILY PA; AC (osimertinib mesylate) DOSE CPPK (lenvatinib 4 PA; Must use mesylate) TARCEVA TABS (erlotinib AcariaHealth LENVIMA 18 MG DAILY PA; AC 7 Specialty Rx at hcl) DOSE CPPK (lenvatinib 4 1-844-538- mesylate) 4661;LA; AC VIZIMPRO TABS PA; AC LENVIMA 20 MG DAILY PA; AC 4 DOSE CPPK (lenvatinib 4 (dacomitinib) mesylate) Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO TABS PA LENVIMA 24 MG DAILY PA; AC 4 DOSE CPPK (lenvatinib 4 (glasdegib maleate) mesylate) PA; Must use LENVIMA 4 MG DAILY ERIVEDGE CAPS AcariaHealth DOSE CPPK (lenvatinib 4 4 Specialty Rx at (vismodegib) 1-844-538- mesylate) 4661;LA; AC LENVIMA 8 MG DAILY PA; AC ODOMZO CAPS AC 4 DOSE CPPK (lenvatinib 4 (sonidegib phosphate) mesylate) Antineoplastic - Hormonal and Related Agents Antineoplastic - Anti-HER2 Agents PA; Must use TUKYSA TABS PA; AC 4 abiraterone acetate AcariaHealth (tucatinib) 4 Specialty Rx at tabs 1-844-538- Antineoplastic - BCL-2 Inhibitors 4661;LA; AC VENCLEXTA STARTING PA; AC 5 QL(1 ea daily); PACK TBPK 4 anastrozole tabs or PV; AC (venetoclax) 1 QL(1 ea daily); VENCLEXTA TABS 10 MG PA; QL(2 ea bicalutamide tabs AC 4 daily); AC (venetoclax) ELIGARD KIT (leuprolide PA VENCLEXTA TABS 100 PA; QL(4 ea 3 4 acetate (3 month)) MG (venetoclax) daily); AC ELIGARD KIT (leuprolide PA VENCLEXTA TABS 50 MG PA; AC 3 4 acetate (4 month)) (venetoclax) Antineoplastic - EGFR Inhibitors 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELIGARD KIT ( PA PA; AC: Must leuprolide 3 acetate (6 month)) use XTANDI TABS AcariaHealth ELIGARD KIT ( PA 4 leuprolide 3 (enzalutamide) Specialty Rx at acetate) 1-844-538- EMCYT CAPS AC 4661;AC ( YONSA TABS PA; AC estramustine 2 4 phosphate sodium) (abiraterone acetate) ERLEADA TABS PA; AC PA; Must use 4 (apalutamide) ZYTIGA TABS AcariaHealth 7 Specialty Rx at exemestane tabs 5 PV; AC (abiraterone acetate) 1-844-538- 4661;LA; AC AC flutamide caps 1 Antineoplastic - Immunomodulators letrozole tabs 1 AC PA; Must use POMALYST CAPS Exactus 1 PA 4 Specialty Rx 1- leuprolide acetate kit (pomalidomide) 866-458- LYSODREN TABS AC 9246;LA; AC 2 (mitotane) Antineoplastic - PDGFR-alpha Inhibitors megestrol acetate susp 1 AC AYVAKIT TABS 100 MG, PA; QL(1 ea 200 MG, 300 MG 4 daily); SP megestrol acetate tabs 1 AC (avapritinib) AYVAKIT TABS 25 MG, 50 PA; QL(1 ea AC 4 nilutamide tabs 1 MG (avapritinib) daily); SP; AC PA; See plan Antineoplastic - XPO1 Inhibitors documents for XPOVIO 100 MG ONCE PA NUBEQA TABS 4 specific WEEKLY TBPK 4 (darolutamide) Coverage; Not available thru (selinexor) Mail;AC XPOVIO 60 MG ONCE PA SOLTAMOX SOLN PV; AC WEEKLY TBPK 4 5 (tamoxifen citrate) (selinexor) PV; AC XPOVIO 80 MG ONCE PA tamoxifen citrate tabs 5 WEEKLY TBPK 4 (selinexor) 1 AC toremifene citrate tabs XPOVIO 80 MG TWICE PA PA; AC: Must WEEKLY TBPK 4 use (selinexor) XTANDI CAPS 4 AcariaHealth XPOVIO TBPK PA; AC (enzalutamide) Specialty Rx at 4 1-844-538- (selinexor) 4661;AC Antineoplastic Antibiotics mitoxantrone hcl conc 2 PA Antineoplastic Combinations

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INQOVI TABS PA BRAFTOVI CAPS PA; AC 4 (decitabine- 4 (encorafenib) cedazuridine) BRUKINSA CAPS PA; AC 4 KISQALI FEMARA 200 PA; AC (zanubrutinib) DOSE TBPK (ribociclib 3 CABOMETYX TABS PA; AC 4 succinate-letrozole) (cabozantinib s-malate) KISQALI FEMARA 400 PA; AC CALQUENCE CAPS PA; AC 4 DOSE TBPK (ribociclib 3 (acalabrutinib) succinate-letrozole) CAPRELSA TABS PA; AC 4 KISQALI FEMARA 600 PA; AC (vandetanib) DOSE TBPK (ribociclib 3 COMETRIQ KIT PA; AC 4 succinate-letrozole) (cabozantinib s-malate) LONSURF TABS PA; AC COPIKTRA CAPS PA; AC 4 4 (trifluridine-tipiracil) (duvelisib) Antineoplastic Enzyme Inhibitors COTELLIC TABS PA; AC 4 PA; Must use (cobimetinib fumarate) AFINITOR DISPERZ TBSO AcariaHealth PA; Must use 4 Specialty Rx at (everolimus) AcariaHealth 1-844-538- everolimus tabs 4 Specialty Rx at 4661;LA; AC 1-844-538- PA; Must use 4661;LA; AC AcariaHealth FARYDAK CAPS 10 MG PA; LA; AC AFINITOR TABS 10 MG 3 4 Specialty Rx at (panobinostat lactate) (everolimus) 1-844-538- 4661;LA; AC FARYDAK CAPS 15 MG, PA; Must use 20 MG ( 4 Caremark SP PA; Must use panobinostat pharmacy;LA; AFINITOR TABS 2.5 MG, 5 AcariaHealth lactate) AC 7 Specialty Rx at MG, 7.5 MG (everolimus) 1-844-538- PA; PA; Must 4661;LA; AC IBRANCE CAPS 100 MG, use AcariaHealth ALECENSA CAPS PA; AC 125 MG, 75 MG 3 4 Specialty Rx at (alectinib hcl) (palbociclib) 1-844-538- ALUNBRIG TABS PA; AC 4661;LA; AC 4 (brigatinib) PA; Must use ALUNBRIG TBPK PA; AC IBRANCE TABS 100 MG, AcariaHealth 4 (brigatinib) 125 MG, 75 MG 3 Specialty Rx at (palbociclib) 1-844-538- BALVERSA TABS PA; AC 4 4661;AC (erdafitinib) ICLUSIG TABS 10 MG, 30 PA; LA; AC 4 PA; Must use MG (ponatinib hcl) AcariaHealth BOSULIF TABS 100 MG, ICLUSIG TABS 15 MG, 45 PA; AC 4 Specialty Rx at 4 500 MG (bosutinib) 1-844-538- MG (ponatinib hcl) 4661;LA; AC IDHIFA TABS PA; AC 4 BOSULIF TABS 400 MG PA; AC (enasidenib mesylate) 4 (bosutinib)

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA PIQRAY 200MG DAILY PA; AC imatinib mesylate tabs 4 4 100 mg, 400 mg DOSE TBPK (alpelisib) PA; AC PIQRAY 250MG DAILY PA; AC imatinib mesylate tabs 4 4 100 mg, 400 mg DOSE TBPK (alpelisib) IMBRUVICA CAPS 140 PA; AC PIQRAY 300MG DAILY PA; AC 4 4 MG, 70 MG (ibrutinib) DOSE TBPK (alpelisib) QINLOCK TABS PA; AC IMBRUVICA TABS 140 PA; QL(1 ea 4 MG, 280 MG, 420 MG, 560 4 daily); AC (ripretinib) MG (ibrutinib) RETEVMO CAPS PA; AC 4 INREBIC CAPS PA; AC (selpercatinib) 4 (fedratinib hcl) ROMIDEPSIN SOLR PA 4 PA (romidepsin) ISTODAX (OVERFILL) 4 SOLR (romidepsin) ROZLYTREK CAPS PA; AC 4 JAKAFI TABS ( PA; AC (entrectinib) ruxolitinib 4 phosphate) RUBRACA TABS PA; AC 4 PA; PA; Must (rucaparib camsylate) use RYDAPT CAPS PA; AC KISQALI TBPK ( 4 ribociclib 3 AcariaHealth (midostaurin) succinate) Specialty Rx at 1-844-538- PA; Must use 4661;AC SPRYCEL TABS 100 MG, AcariaHealth 140 MG, 80 MG 4 Specialty Rx at KOSELUGO CAPS PA 4 (dasatinib) 1-844-538- (selumetinib sulfate) 4661;LA; AC PA; AC SPRYCEL TABS 20 MG, PA; AC lapatinib ditosylate tabs 4 4 50 MG, 70 MG (dasatinib) LORBRENA TABS PA; AC 4 PA; Must use (lorlatinib) STIVARGA TABS AcariaHealth LYNPARZA TABS PA; Refer to 4 Specialty Rx at 4 Accredo SP (regorafenib) (olaparib) 1-844-538- Rx;AC 4661;LA; AC MEKINIST TABS PA; AC PA; Must use (trametinib dimethyl 4 AcariaHealth sulfoxide) sunitinib malate caps 4 Specialty Rx at 1-844-538- MEKTOVI TABS PA; AC 4 4661;LA; AC (binimetinib) PA; Must use NERLYNX TABS PA; AC 4 SUTENT CAPS (sunitinib AcariaHealth (neratinib maleate) 7 Specialty Rx at malate) NEXAVAR TABS PA; LA; AC 1-844-538- 4 (sorafenib tosylate) 4661;LA; AC TABRECTA TABS PA; AC PA; Limited to 4 NINLARO CAPS (capmatinib hcl) 4 3 capsules per (ixazomib citrate) month;;QL(0.1 ea daily); AC

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use ZELBORAF TABS PA; AC 4 TAFINLAR CAPS AcariaHealth (vemurafenib) 4 Specialty Rx at ( ) ZOLINZA CAPS PA; AC dabrafenib mesylate 1-844-538- 4 4661;LA; AC (vorinostat) TALZENNA CAPS PA; AC ZYDELIG TABS PA; AC 4 3 (talazoparib tosylate) (idelalisib) ZYKADIA CAPS AC PA; Must use 4 (ceritinib) TASIGNA CAPS (nilotinib AcariaHealth 4 Specialty Rx at ZYKADIA TABS AC hcl) 4 1-844-538- (ceritinib) 4661;AC TAZVERIK TABS PA Antineoplastics Misc. 4 ACTIMMUNE SOLN PA; LA (tazemetostat hbr) 4 PA (interferon gamma-1b) temsirolimus soln 4 ALFERON N SOLN PA; LA 4 TIBSOVO TABS PA; AC (interferon alfa-n3) 4 (ivosidenib) bexarotene caps 4 PA; AC TORISEL SOLN PA 7 (temsirolimus) hydroxyurea caps or 1 AC TURALIO CAPS PA; AC INTRON A SOLN PA; LA 4 4 (pexidartinib hcl) (interferon alfa-2b) TYKERB TABS (lapatinib PA; AC INTRON A SOLR PA; LA 7 4 ditosylate) (interferon alfa-2b) VELCADE SOLR PA MATULANE CAPS PA; AC 4 4 (bortezomib) (procarbazine hcl) VERZENIO TABS PA; AC 4 SYLATRON KIT PA; Must use (abemaciclib) (peginterferon alfa-2b 4 AcariaHlth Sp VITRAKVI CAPS PA; AC Rx 1-844-538- 4 (antineoplastic)) (larotrectinib sulfate) 4661 VITRAKVI SOLN PA; AC TARGRETIN CAPS OR 75 PA; AC 4 7 (larotrectinib sulfate) MG (bexarotene) VOTRIENT TABS PA; AC tretinoin AC 4 2 (pazopanib hcl) (chemotherapy) caps PA; Must use Chemotherapy Rescue/Antidote/Protective Agents XALKORI CAPS AcariaHealth leucovorin calcium solr PA 4 Specialty Rx at (crizotinib) 1-844-538- ij 100 mg, 200 mg, 350 4 4661;LA; AC mg, 50 mg XOSPATA TABS PA; AC leucovorin calcium tabs AC 4 (gilteritinib fumarate) or 10 mg, 15 mg, 25 1 ZEJULA CAPS ( PA; AC mg, 5 mg niraparib 4 tosylate) MESNEX TABS (mesna) 3 AC Mitotic Inhibitors 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Etoposide) TOPOSAR PA entacapone tabs 1 SOLN 1 GM/50ML, 500 2 MG/25ML tolcapone tabs 1 (Etoposide) TOPOSAR 2 PA; AC SOLN 100 MG/5ML Antiparkinson Dopaminergics ETOPOPHOS SOLR PA 3 amantadine hcl caps 1 (etoposide phosphate) AC 1 etoposide caps or 50 1 amantadine hcl syrp mg PA amantadine hcl tabs 1 etoposide soln iv 1 2 gm/50ml, 500 mg/25ml bromocriptine mesylate 1 PA; AC caps etoposide soln iv 100 2 mg/5ml bromocriptine mesylate 1 Topoisomerase I Inhibitors tabs HYCAMTIN CAPS OR 0.25 PA; AC carbidopa-levodopa MG, 1 MG (topotecan 4 tabs 10 mg-100 mg, 1 hcl) 100 mg-10 mg, 25 mg- HYCAMTIN SOLR IV 4 MG PA; LA 100 mg, 25 mg-250 mg 7 (topotecan hcl) QL(8 ea daily) carbidopa-levodopa 1 tbcr 25 mg-100 mg topotecan hcl solr 4 PA; LA carbidopa-levodopa 1 ANTIPARKINSON AND RELATED THERAPY tbcr 50 mg-200 mg AGENTS - Drugs to Treat Parkinson's Disease carbidopa-levodopa Antiparkinson Adjunctive Therapy tbdp 10 mg-100 mg, 25 1 carbidopa tabs 2 mg-100 mg, 25 mg-250 mg Antiparkinson Anticholinergics carbidopa-levodopa- PA; entacapone tabs 12.5 benztropine mesylate 4 administered mg-50 mg-200 mg, soln ij 1 mg/ml under the medical benefit 18.75 mg-75 mg-200 1 benztropine mesylate mg, 25 mg-100 mg-200 mg, 37.5 mg-150 mg- tabs or 0.5 mg, 1 mg, 2 1 mg 200 mg, 50 mg-200 mg-200 mg PA; COGENTIN SOLN carbidopa-levodopa- 7 administered (benztropine mesylate) under the entacapone tabs 18.75 medical benefit mg-75 mg-200 mg, 2 trihexyphenidyl hcl soln 1 31.25 mg-125 mg-200 mg trihexyphenidyl hcl tabs 1 CARBIDOPA/LEVODOPA ODT TBDP (carbidopa- 3 Antiparkinson COMT Inhibitors levodopa)

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DUOPA SUSP PA RYTARY CPCR 36.25 MG- PA; QL(10 ea 3 145 MG, 48.75 MG-195 daily) (carbidopa-levodopa) 3 INBRIJA CAPS PA MG, 61.25 MG-245 MG 3 (levodopa) (carbidopa-levodopa) NEUPRO PT24 Antiparkinson Monoamine Oxidase Inhibitors 3 ( ) rotigotine rasagiline mesylate 1 pramipexole tabs QL(2 ea daily) dihydrochloride tabs 1 selegiline hcl caps 1 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg selegiline hcl tabs 1 QL(2 ea daily) pramipexole QL(4 ea daily) XADAGO TABS PA 3 dihydrochloride tabs 1 1 (safinamide mesylate) mg ZELAPAR TBDP 3 pramipexole QL(3 ea daily) (selegiline hcl) 1 dihydrochloride tabs ANTIPSYCHOTICS/ANTIMANIC AGENTS - 1.5 mg Drugs to Treat Mood Disorders pramipexole Antimanic Agents dihydrochloride tb24 2 lithium carbonate caps 0.375 mg, 0.75 mg, 1.5 1 mg, 2.25 mg, 4.5 mg 150 mg, 600 mg lithium carbonate caps QL(6 ea daily) pramipexole QL(1 ea daily) 1 dihydrochloride tb24 3 2 300 mg mg lithium carbonate tabs 1 pramipexole 300 mg dihydrochloride tb24 1 lithium carbonate tbcr 1 3.75 mg 300 mg, 450 mg ropinirole hydrochloride LITHIUM SOLN (lithium) 3 tabs 0.25 mg, 0.5 mg, 1 1 LITHOBID TBCR ( mg, 2 mg, 3 mg, 4 mg, lithium 7 5 mg carbonate) QL(2 ea daily) Antipsychotics - Misc. ropinirole hydrochloride 2 tb24 12 mg EQUETRO CP12 (carbamazepine 3 ropinirole hydrochloride 2 tb24 2 mg, 4 mg, 6 mg (antipsychotic)) LATUDA TABS ropinirole hydrochloride 3 1 (lurasidone hcl) tb24 8 mg NUPLAZID CAPS PA; QL(1 ea RYTARY CPCR 23.75 MG- PA; ST;QL(10 4 (pimavanserin tartrate) daily) 95 MG (carbidopa- 3 ea daily) NUPLAZID TABS PA; QL(1 ea levodopa) 4 (pimavanserin tartrate) daily) VRAYLAR CAPS QL(1 ea daily) 4 (cariprazine hcl)

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VRAYLAR CPPK QL(1 ea daily) 4 loxapine succinate 1 (cariprazine hcl) caps ziprasidone hcl caps 20 1 olanzapine tabs 10 mg, 1 mg, 40 mg 2.5 mg, 5 mg, 7.5 mg ziprasidone hcl caps 60 QL(2 ea daily) QL(1 ea daily) 1 olanzapine tabs 15 mg, 1 mg, 80 mg 20 mg Benzisoxazoles olanzapine tbdp 10 mg, 2 FANAPT TABS QL(2 ea daily) 15 mg, 20 mg, 5 mg 4 (iloperidone) quetiapine fumarate FANAPT TITRATION tabs 100 mg, 25 mg, 50 1 PACK TABS 4 mg (iloperidone) QL(4 ea daily) quetiapine fumarate 1 paliperidone tb24 1 tabs 200 mg QL(2 ea daily) PA; quetiapine fumarate 1 PERSERIS PRSY tabs 300 mg, 400 mg 4 administered (risperidone) under the quetiapine fumarate PA medical benefit tb24 150 mg, 200 mg, 1 risperidone soln 1 1 300 mg, 400 mg mg/ml PA; ST quetiapine fumarate 1 risperidone tabs 0.25 tb24 50 mg mg, 0.5 mg, 1 mg, 2 1 SAPHRIS SUBL 5 MG 3 mg, 4 mg (asenapine maleate) 1 QL(2 ea daily) SECUADO PT24 QL(1 ea daily) risperidone tabs 3 mg 3 (asenapine) risperidone tbdp 0.25 VERSACLOZ SUSP QL(18 ml daily) mg, 0.5 mg, 1 mg, 2 1 3 mg, 3 mg, 4 mg (clozapine) Dihydroindolones Butyrophenones molindone hcl tabs 1 haloperidol lactate conc 1 Phenothiazines haloperidol tabs 1 (Prochlorperazine) 1 QL(2 ea daily) Dibenzapines COMPRO SUPP chlorpromazine hcl tabs 2 asenapine maleate 1 subl fluphenazine hcl conc 1 clozapine tabs 100 mg, 1 200 mg, 25 mg, 50 mg fluphenazine hcl elix 1 clozapine tbdp 12.5 1 mg, 150 mg, 200 mg fluphenazine hcl tabs 1 FAZACLO TBDP 150 MG, 7 perphenazine tabs 1 200 MG (clozapine)

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APTIVUS CAPS prochlorperazine 1 2 maleate tabs (tipranavir) APTIVUS SOLN prochlorperazine supp 1 QL(2 ea daily) 2 (tipranavir) thioridazine hcl tabs 10 1 mg, 100 mg, 25 mg atazanavir sulfate caps 1 QL(4 ea daily) BIKTARVY TABS thioridazine hcl tabs 50 1 mg (bictegravir- emtricitabine-tenofovir 2 trifluoperazine hcl tabs 1 alafenamide fumarate) Quinolinone Derivatives CIMDUO TABS (lamivudine-tenofovir 2 aripiprazole soln 1 1 mg/ml disoproxil fumarate) COMPLERA TABS aripiprazole tabs 10 1 (emtricitabine- mg, 2 mg, 30 mg, 5 mg rilpivirine-tenofovir 2 aripiprazole tabs 15 mg 1 QL(2 ea daily) disoproxil fumarate) CRIXIVAN CAPS QL(1 ea daily) 2 aripiprazole tabs 20 mg 1 (indinavir sulfate) aripiprazole tbdp 10 PA DELSTRIGO TABS 1 (doravirine-lamivudine- mg, 15 mg 2 REXULTI TABS tenofovir disoproxil 3 (brexpiprazole) fumarate) DESCOVY TABS Grand Thioxanthenes (emtricitabine-tenofovir 5 Fathered Plans thiothixene caps 1 alafenamide fumarate) at Tier 2;PV

ANTISEPTICS & DISINFECTANTS didanosine cpdr 1 DOVATO TABS Antiseptics & Disinfectants (dolutegravir sodium- 2 formaldehyde soln 1 lamivudine) EDURANT TABS 2 ANTIVIRALS - Drugs to Treat Viral Infections (rilpivirine hcl) Antiretrovirals efavirenz caps 1 abacavir sulfate soln 1 efavirenz tabs 1 abacavir sulfate tabs 1 efavirenz-emtricitabine- QL(1 ea daily) tenofovir disoproxil 1 abacavir sulfate- 1 lamivudine tabs fumarate tabs abacavir sulfate- emtricitabine caps 1 lamivudine-zidovudine 1 tabs

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits emtricitabine-tenofovir lamivudine-zidovudine 1 disoproxil fumarate tabs tabs 100 mg-150 mg, 1 LEXIVA SUSP 50 MG/ML 133 mg-200 mg, 167 (fosamprenavir 2 mg-250 mg calcium) PV emtricitabine-tenofovir lopinavir-ritonavir soln 1 disoproxil fumarate 5 tabs 200 mg-300 mg lopinavir-ritonavir tabs 1 EMTRIVA SOLN 10 2 MG/ML (emtricitabine) nevirapine susp 1 etravirine tabs 1 nevirapine tabs 1 EVOTAZ TABS nevirapine tb24 1 (atazanavir sulfate- 2 ) NORVIR PACK 100 MG cobicistat 2 fosamprenavir calcium (ritonavir) 1 NORVIR SOLN 80 MG/ML tabs 2 FUZEON SOLR PA; ST;LA (ritonavir) 4 (enfuvirtide) ODEFSEY TABS (emtricitabine- GENVOYA TABS 2 (elvitegravir-cobicistat- rilpivirine-tenofovir emtricitabine-tenofovir 2 alafenamide fumarate) PIFELTRO TABS alafenamide) 2 INTELENCE TABS 25 MG (doravirine) 2 PREZCOBIX TABS QL(1 ea daily) (etravirine) 2 INVIRASE TABS (darunavir-cobicistat) 2 (saquinavir mesylate) PREZISTA SUSP 100 ISENTRESS CHEW MG/ML (darunavir 3 2 (raltegravir potassium) ethanolate) ISENTRESS HD TABS PREZISTA TABS 150 MG, 2 600 MG, 75 MG, 800 MG (raltegravir potassium) 2 (darunavir ethanolate) ISENTRESS PACK 2 RESCRIPTOR TABS (raltegravir potassium) 2 (delavirdine mesylate) ISENTRESS TABS 2 REYATAZ PACK 50 MG (raltegravir potassium) 2 (atazanavir sulfate) JULUCA TABS (dolutegravir sodium- 2 ritonavir tabs 1 rilpivirine hcl) RUKOBIA TB12 lamivudine soln 1 (fostemsavir 4 tromethamine) lamivudine tabs 1 SELZENTRY SOLN 2 (maraviroc)

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELZENTRY TABS 2 zidovudine caps 1 (maraviroc) zidovudine syrp 1 stavudine caps 15 mg, 1 20 mg, 30 mg, 40 mg 1 STAVUDINE CAPS 15 MG, zidovudine tabs 20 MG, 30 MG, 40 MG 2 CMV Agents ( ) stavudine PA STRIBILD TABS cidofovir soln 4 (elvitegravir-cobicistat- 2 Limit 630mls emtricitabine-tenofovir valganciclovir hcl solr 1 per df) 50 mg/ml month;QL(21 ml daily) SYMTUZA TABS QL(1 ea daily) (darunavir-cobicistat- valganciclovir hcl tabs 1 emtricitabine-tenofovir 2 450 mg alafenamide) Hepatitis Agents TEMIXYS TABS (Ribavirin (Hepatitis C)) PA (lamivudine-tenofovir 2 RIBASPHERE CAPS 200 1 disoproxil fumarate) MG 2 tenofovir disoproxil 1 adefovir dipivoxil tabs fumarate tabs BARACLUDE SOLN 0.05 TIVICAY TABS 4 2 MG/ML (entecavir) (dolutegravir sodium) TRIUMEQ TABS entecavir tabs 2 (abacavir-dolutegravir- 2 PA; PA; Must lamivudine) EPCLUSA TABS 400 MG- use TRUVADA TABS 200 MG- PV 100 MG ( 3 AcariaHealth sofosbuvir- Specialty Rx at 300 MG (emtricitabine- ) 7 velpatasvir 1-844-538- tenofovir disoproxil 4661 fumarate) EPIVIR HBV SOLN 5 TYBOST TABS 2 MG/ML (lamivudine 3 (cobicistat) (hbv)) VIDEX EC CPDR 125 MG 2 1 (didanosine) lamivudine (hbv) tabs VIRACEPT TABS PA; MUST 2 MAVYRET TABS (nelfinavir mesylate) USE ACARIA (glecaprevir- 4 SPECIALTY VIREAD POWD 40 MG/GM pibrentasvir) RX 844-538- (tenofovir disoproxil 2 4661 fumarate) PEGASYS PROCLICK PA VIREAD TABS 150 MG, SOLN (peginterferon 3 200 MG, 250 MG 2 alfa-2a) (tenofovir disoproxil PEGASYS SOLN PA 3 fumarate) (peginterferon alfa-2a)

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEGINTRON KIT PA 3 Respiratory Syncytial Virus (RSV) Agents (peginterferon alfa-2b) 1 PA ribavirin solr ribavirin (hepatitis c) 1 caps BETA BLOCKERS - Drugs to Treat High Blood VEMLIDY TABS ST Pressure (tenofovir alafenamide 4 Alpha-Beta Blockers fumarate) carvedilol phosphate 1 PA; PA; Must cp24 VOSEVI TABS use carvedilol tabs 12.5 mg, ( 3 AcariaHealth 1 sofosbuvir-velpatasvir- Specialty Rx at 25 mg, 6.25 mg voxilaprevir) 1-844-538- QL(2 ea daily) carvedilol tabs 3.125 1 4661 mg Herpes Agents labetalol hcl tabs 1 acyclovir caps 200 mg 1 Beta Blockers Cardio-Selective acyclovir susp 200 1 acebutolol hcl caps or 1 mg/5ml 200 mg, 400 mg acyclovir tabs 400 mg 1 atenolol tabs or 100 1 mg, 25 mg, 50 mg acyclovir tabs 800 mg 1 QL(5 ea daily) betaxolol hcl tabs 1 famciclovir tabs or 125 1 QL(1 ea daily) mg, 250 mg, 500 mg bisoprolol fumarate 1 valacyclovir hcl tabs 1 QL(4 ea daily) tabs or 10 mg, 5 mg 1 BYSTOLIC TABS gm, 1000 mg 2 ( ) QL(8 ea daily) nebivolol hcl valacyclovir hcl tabs 1 500 mg metoprolol succinate 1 tb24 Influenza Agents metoprolol tartrate tabs QL(10 ea per or 100 mg, 25 mg, 37.5 1 oseltamivir phosphate fill retail,10 ea 1 per fill mail); mg, 50 mg, 75 mg caps or 30 mg, 45 mg AL(At least 1 Beta Blockers Non-Selective yrs old) (Sotalol Hcl) SORINE 1 oseltamivir phosphate 1 TABS caps or 75 mg INDERAL XL CP24 QL(75 ml (propranolol hcl 3 oseltamivir phosphate 1 daily,5 day(s) sustained-release susr or 6 mg/ml limit); AL(At beads) least 1 yrs old) INNOPRAN XL CP24 RELENZA DISKHALER 3 AEPB (zanamivir) (propranolol hcl sustained-release 3 rimantadine 1 beads) hydrochloride tabs

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nadolol tabs 1 diltiazem hcl coated QL(1 ea daily) beads cp24 120 mg, 1 pindolol tabs 1 180 mg, 240 mg, 300 mg, 360 mg propranolol hcl cp24 or 120 mg, 160 mg, 60 1 diltiazem hcl coated 1 mg, 80 mg beads tb24 360 mg diltiazem hcl cp12 120 propranolol hcl soln or 1 1 20 mg/5ml, 40 mg/5ml mg, 60 mg, 90 mg propranolol hcl tabs or diltiazem hcl cp24 180 1 10 mg, 20 mg, 40 mg, 1 mg, 240 mg 60 mg, 80 mg diltiazem hcl extended 1 release beads cp24 sotalol hcl (afib/afl) tabs 1 diltiazem hcl tabs 120 sotalol hcl tabs 1 mg, 30 mg, 60 mg, 90 1 mg SOTYLIZE SOLN ( sotalol 3 QL(1 ea daily) hcl) felodipine tb24 10 mg 1 timolol maleate tabs or QL(6 ea daily) 1 felodipine tb24 2.5 mg, 1 10 mg 5 mg QL(2 ea daily) timolol maleate tabs or 1 isradipine caps 1 20 mg, 5 mg CALCIUM CHANNEL BLOCKERS - Drugs to nicardipine hcl caps 1 Treat High Blood Pressure nifedipine caps 10 mg, 1 Calcium Channel Blockers 20 mg (Diltiazem Hcl Coated QL(1 ea daily) 1 nifedipine tb24 30 mg, 1 Beads) CARTIA XT CP24 60 mg (Diltiazem Hcl Coated 1 QL(1 ea daily) Beads) MATZIM LA TB24 nifedipine tb24 30 mg, 1 (Diltiazem Hcl Extended 60 mg, 90 mg Release Beads) TAZTIA 1 nimodipine caps 1 XT, TIADYLT ER CP24 (Diltiazem Hcl) DILT-XR 1 nisoldipine tb24 1 CP24 QL(1 ea daily) NYMALIZE SOLN 30 amlodipine besylate 1 MG/10ML, 60 MG/20ML 3 tabs 10 mg, 5 mg (nimodipine) QL(2 ea daily) amlodipine besylate 1 verapamil hcl cp24 100 tabs 2.5 mg mg, 120 mg, 200 mg, 1 CARDIZEM LA TB24 120 240 mg, 300 mg MG (diltiazem hcl 2 QL(2 ea daily) verapamil hcl cp24 180 1 coated beads) mg QL(1 ea daily) verapamil hcl cp24 360 1 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENTRESTO TABS 24 MG- PA; QL(2 ea verapamil hcl tabs 120 1 mg, 40 mg, 80 mg 26 MG (sacubitril- 3 daily) valsartan) verapamil hcl tbcr 120 1 mg ENTRESTO TABS 49 MG- PA 51 MG, 97 MG-103 MG QL(2 ea daily) 3 verapamil hcl tbcr 180 1 (sacubitril-valsartan) mg, 240 mg VERELAN CP24 360 MG QL(1 ea daily) Impotence Agents 7 (verapamil hcl) PA; Check plan documents for VERELAN PM CP24 7 coverage;QL(8 (verapamil hcl) sildenafil citrate tabs 1 ea per 30 days CARDIOTONICS - Drugs to Treat Heart Failure retail); AL(At and Abnormal Heart Rhythm least 21 yrs old) Cardiac Glycosides PA; Check plan (Digoxin) DIGITEK, DIGOX 1 documents for TABS tadalafil tabs 10 mg, 20 coverage;QL(8 1 ea per 30 days digoxin soln 0.05 mg/ml 1 mg, 5 mg retail); AL(At least 21 yrs digoxin tabs 0.125 mg, 1 125 mcg, 250 mcg old) PA; QL(1 ea LANOXIN TABS 125 MCG, 7 1 daily,30 ea per 250 MCG (digoxin) tadalafil tabs 2.5 mg fill retail,90 ea LANOXIN TABS 62.5 MCG per fill mail) 3 (digoxin) Peripheral Vasodilators CARDIOVASCULAR AGENTS - MISC. - Drugs to 1 Treat Heart and Circulation Conditions isoxsuprine hcl tabs Cardiovascular Agents Misc. - Combinations Prostaglandin Vasodilators ORENITRAM TBCR PA amlodipine besylate- PA 4 atorvastatin calcium (treprostinil diolamine) TYVASO REFILL SOLN PA tabs 10 mg-10 mg, 2.5 4 (treprostinil) mg-10 mg, 2.5 mg-20 1 mg, 2.5 mg-40 mg, 5 TYVASO SOLN PA 4 mg-10 mg, 5 mg-20 (treprostinil) mg, 5 mg-40 mg, 5 mg- TYVASO STARTER SOLN PA 4 80 mg (treprostinil) amlodipine besylate- VENTAVIS SOLN PA 4 atorvastatin calcium (iloprost) tabs 10 mg-20 mg, 10 1 Pulmonary Hypertension - Endothelin Receptor mg-40 mg, 10 mg-80 PA; Must use mg ambrisentan tabs 10 AcariaHealth 4 Specialty Rx at BIDIL TABS (isosorbide mg dinitrate-hydralazine 3 1-844-538- hcl) 4661 - ST 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use REVATIO SUSR 10 PA AcariaHealth MG/ML (sildenafil citrate 7 ambrisentan tabs 5 mg 4 Specialty Rx at (pulmonary 1-844-538- ) 4661 - ST for 5 hypertension) mg sildenafil citrate PA PA; ST; MUST (pulmonary 4 USE ACARIA hypertension) susr 10 bosentan tabs 125 mg 4 SPECIALTY mg/ml RX 844-538- sildenafil citrate PA; QL(3 ea 4661 daily) PA; ST; Must (pulmonary 1 use hypertension) tabs 20 mg bosentan tabs 62.5 mg 4 AcariaHealth Specialty Rx at PA; New 1-844-538- commercial 4661 tadalafil (pulmonary 4 members to be PA; Must use hypertension) tabs referred to AcariaHealth;Q LETAIRIS TABS 10 MG AcariaHealth 7 Specialty Rx at L(2 ea daily) (ambrisentan) 1-844-538- Pulmonary Hypertension - Prostacyclin Receptor 4661 - ST UPTRAVI TABS OR 1000 PA PA; Must use MCG, 1200 MCG, 1400 AcariaHealth MCG, 1600 MCG, 400 LETAIRIS TABS 5 MG 4 7 Specialty Rx at MCG, 600 MCG, 800 MCG (ambrisentan) 1-844-538- 4661 - ST for 5 (selexipag) UPTRAVI TABS OR 200 PA; ST mg 4 OPSUMIT TABS PA; ST MCG (selexipag) 4 UPTRAVI TBPK OR PA; ST (macitentan) 4 TRACLEER TBSO 32 MG PA; ST (selexipag) 4 (bosentan) Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 0.5 MG PA; ST Pulmonary Hypertension - Phosphodiesterase 4 PA; New (riociguat) (Tadalafil (Pulmonary commercial ADEMPAS TABS 1 MG, PA Hypertension)) ALYQ 4 members to be 1.5 MG, 2 MG, 2.5 MG 4 TABS referred to (riociguat) AcariaHealth;Q L(2 ea daily) Sinus Node Inhibitors PA; New CORLANOR SOLN 5 ST; QL(15 ml 3 daily) ADCIRCA TABS (tadalafil commercial MG/5ML (ivabradine hcl) members to be CORLANOR TABS 5 MG, ST; QL(2 ea (pulmonary 7 3 referred to 7.5 MG (ivabradine hcl) daily) hypertension)) AcariaHealth;Q L(2 ea daily) Transthyretin Stabilizers VYNDAMAX CAPS PA; QL(1 ea 4 (tafamidis) daily)

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VYNDAQEL CAPS PA; QL(4 ea Cephalosporins - 3rd Generation (tafamidis meglumine 4 daily) (cardiac)) cefdinir caps 1 CEPHALOSPORINS - Drugs to Treat Bacterial cefdinir susr 1 Infections Cephalosporins - 1st Generation cefditoren pivoxil tabs 1 cefadroxil caps 1 cefixime caps 1 cefadroxil susr 1 cefixime susr 1 cefadroxil tabs 1 cefpodoxime proxetil 1 susr cefazolin sodium solr 4 PA cefpodoxime proxetil 1 tabs cephalexin caps 1 SUPRAX CHEW 100 MG, 3 cephalexin susr 1 200 MG (cefixime) SUPRAX SUSR 500 3 cephalexin tabs 1 MG/5ML (cefixime) Cephalosporins - 2nd Generation CHEMICALS cefaclor caps 1 Bulk Chemicals - P's CEFACLOR ER TB12 PROGESTERONE 3 (cefaclor monohydrate) CONCENTRATE CREA 3 (progesterone (bulk)) cefaclor susr 1 CONTRACEPTIVES - Drugs to Prevent CEFOTAN SOLR PA Pregnancy 7 (cefotetan disodium) Combination Contraceptives - Oral cefotetan disodium solr 4 PA (Desogestrel & Ethinyl PV Estradiol) APRI, CYRED, PA cefoxitin sodium solr ij 4 CYRED EQ, 10 gm EMOQUETTE, ENSKYCE, 5 PA ISIBLOOM, JULEBER, cefoxitin sodium solr iv 4 KALLIGA, RECLIPSEN 1 gm, 2 gm TABS CEFOXITIN SODIUM PA (Desogestrel-Ethinyl PV SOLR IV 1 GM-4 %, 2 GM- Estradiol (Biphasic)) 2.2 % (cefoxitin sodium 4 AZURETTE, BEKYREE, 5 and dextrose) KARIVA, PIMTREA, SIMLIYA, VIORELE, cefprozil susr 1 VOLNEA TABS (Desogestrel-Ethinyl PV cefprozil tabs 1 Estradiol (Triphasic)) 5 CAZIANT, VELIVET TABS cefuroxime axetil tabs 1

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Drospirenone-Ethinyl PV (Norethin Acet & Estrad- PV Estradiol) GIANVI, Fe) AUROVELA 24 FE, JASMIEL, LO- AUROVELA FE 1.5/30, ZUMANDIMINE, LORYNA, 5 AUROVELA FE 1/20, NIKKI, OCELLA, SYEDA, BLISOVI 24 FE, BLISOVI VESTURA, ZARAH, FE 1.5/30, BLISOVI FE ZUMANDIMINE TABS 1/20, HAILEY 24 FE, (Drospirenone-Ethinyl PV HAILEY FE 1.5/30, HAILEY Estradiol-Levomefolate 5 FE 1/20, JUNEL FE 1.5/30, Calcium) TYDEMY TABS JUNEL FE 1/20, JUNEL FE 5 24, LARIN 24 FE, LARIN (Ethynodiol Diacet & Eth PV FE 1.5/30, LARIN FE 1/20, Estrad) KELNOR 1/35, 5 LOESTRIN FE 1.5/30, KELNOR 1/50, ZOVIA LOESTRIN FE 1/20, 1/35, ZOVIA 1/35E TABS MICROGESTIN 24 FE, (Levonorgestrel & Eth PV MICROGESTIN FE 1.5/30, Estradiol) AFIRMELLE, MICROGESTIN FE 1/20, ALTAVERA, AUBRA, TARINA 24 FE, TARINA AUBRA EQ, AVIANE, FE 1/20, TARINA FE 1/20 AYUNA, CHATEAL, EQ TABS CHATEAL EQ, DELYLA, (Norethin Acet & Estrad- PV FALMINA, KURVELO, 5 Fe) CHARLOTTE 24 FE, 5 LARISSIA, LESSINA, MELODETTA 24 FE, LEVORA 0.15/30-28, MIBELAS 24 FE CHEW LILLOW, LUTERA, MARLISSA, ORSYTHIA, (Norethin Acet & Estrad- PV PORTIA-28, SRONYX, Fe) GEMMILY, MERZEE, 5 VIENVA TABS TAYSOFY CAPS (Levonorgestrel-Eth PV (Norethindrone & Eth PV Estradiol (Triphasic)) Estradiol) ALYACEN 1/35, ENPRESSE-28, 5 BALZIVA, BRIELLYN, LEVONEST, TRIVORA-28 CYCLAFEM 1/35, TABS DASETTA 1/35, NECON 5 0.5/35-28, NORTREL (Levonorgestrel-Ethinyl PV 0.5/35 (28), NORTREL Estradiol (91-Day)) 1/35, PHILITH, PIRMELLA AMETHIA, AMETHIA LO, 1/35, VYFEMLA, WERA ASHLYNA, CAMRESE, TABS CAMRESE LO, DAYSEE, 5 FAYOSIM, ICLEVIA, (Norethindrone & Ethinyl PV INTROVALE, JAIMIESS, Estradiol-Fe) KAITLIB FE, 5 JOLESSA, LOJAIMIESS, LAYOLIS FE, WYMZYA FE RIVELSA, SETLAKIN, CHEW SIMPESSE TABS (Levonorgestrel-Ethinyl PV Estradiol (Continuous)) 5 AMETHYST, DOLISHALE TABS

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethindrone Acet & Eth PV BEYAZ TABS PV Estra) AUROVELA 1.5/30, (drospirenone-ethinyl AUROVELA 1/20, HAILEY estradiol-levomefolate 7 1.5/30, JUNEL 1.5/30, ) JUNEL 1/20, LARIN 1.5/30, calcium 5 PV LARIN 1/20, LOESTRIN desogestrel & ethinyl 5 1.5/30-21, LOESTRIN estradiol tabs 1/20-21, MICROGESTIN PV 1.5/30, MICROGESTIN desogestrel-ethinyl 5 1/20 TABS estradiol (biphasic) tabs PV (Norethindrone Acetate- PV drospirenone-ethinyl 5 Ethinyl Estradiol-Fe) TILIA 5 estradiol tabs FE, TRI-LEGEST FE TABS drospirenone-ethinyl PV (Norethindrone-Eth PV estradiol-levomefolate 5 Estradiol (Triphasic)) ALYACEN 7/7/7, calcium tabs ESTROSTEP FE TABS PV ARANELLE, CYCLAFEM 5 7/7/7, DASETTA 7/7/7, (norethindrone acetate- 7 LEENA, NORTREL 7/7/7, ethinyl estradiol-fe) NYLIA 7/7/7, PIRMELLA PV 7/7/7 TABS ethynodiol diacet & eth 5 estrad tabs (Norgestimate-Ethinyl PV Estradiol (Triphasic)) TRI GENERESS FE CHEW PV FEMYNOR, TRI- (norethindrone & 7 ESTARYLLA, TRI-LINYAH, ethinyl estradiol-fe) TRI-LO-ESTARYLLA, TRI- PV LO-MARZIA, TRI-LO-MILI, 5 levonorgestrel & eth 5 TRI-LO-SPRINTEC, TRI- estradiol tabs MILI, TRI-NYMYO, TRI- levonorgestrel-eth PV PREVIFEM, TRI- estradiol (triphasic) 5 SPRINTEC, TRI-VYLIBRA, tabs TRI-VYLIBRA LO TABS PV (Norgestimate-Ethinyl PV levonorgestrel-ethinyl 5 Estradiol) ESTARYLLA, estradiol (91-day) tabs FEMYNOR, MILI, MONO- 5 levonorgestrel-ethinyl PV LINYAH, NYMYO, estradiol (continuous) 5 PREVIFEM, SPRINTEC 28, VYLIBRA TABS tabs (Norgestrel & Ethinyl PV LO LOESTRIN FE TABS PV (norethindrone acetate- Estradiol) CRYSELLE-28, 5 ELINEST, LOW- 5 ethinyl estradiol-fe fum OGESTREL, OGESTREL (biphasic)) TABS LOSEASONIQUE TABS PV BALCOLTRA TABS QL(1 ea daily); (levonorgestrel-ethinyl 7 (levonorgestrel-ethinyl PV 5 estradiol (91-day)) estradiol-ferrous MINASTRIN 24 FE CHEW PV bisglycinate) (norethin acet & estrad- 7 fe)

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MIRCETTE TABS PV SEASONIQUE TABS PV (desogestrel-ethinyl 7 (levonorgestrel-ethinyl 7 estradiol (biphasic)) estradiol (91-day)) NATAZIA TABS PV TAYTULLA CAPS PV (estradiol valerate- 5 (norethin acet & estrad- 7 dienogest) fe) NEXTSTELLIS TABS PV TYBLUME CHEW PV 5 (drospirenone-estetrol) (levonorgestrel & eth 5 PV estradiol) norethin acet & estrad- 5 fe caps YASMIN 28 TABS PV PV (drospirenone-ethinyl 7 norethin acet & estrad- 5 fe chew estradiol) PV YAZ TABS PV norethin acet & estrad- 5 fe tabs (drospirenone-ethinyl 7 estradiol) PV norethindrone & ethinyl 5 estradiol-fe chew Combination Contraceptives - Transdermal PV (Norelgestromin-Ethinyl 365 rtl day(s) norethindrone acet & 5 Estradiol) XULANE, 5 supply,; PV eth estra tabs ZAFEMY PTWK norgestimate-ethinyl PV TWIRLA PTWK QL(3 ea per 28 estradiol (triphasic) 5 (levonorgestrel-ethinyl 5 days retail); PV tabs estradiol) PV norgestimate-ethinyl 5 Combination Contraceptives - Vaginal estradiol tabs (Etonogestrel-Ethinyl 5 PV ORTHO TRI-CYCLEN LO PV Estradiol) ELURYNG RING TABS (norgestimate- 7 ANNOVERA RING QL(1 ea daily); ethinyl estradiol (segesterone acetate- 5 PV (triphasic)) ethinyl estradiol) ORTHO-NOVUM 1/35 PV PV etonogestrel-ethinyl 5 TABS (norethindrone & 7 estradiol ring eth estradiol) NUVARING RING PV ORTHO-NOVUM 7/7/7 PV (etonogestrel-ethinyl 7 TABS (norethindrone- 7 estradiol) eth estradiol (triphasic)) Emergency Contraceptives QUARTETTE TABS PV (Levonorgestrel PV (levonorgestrel-ethinyl 7 (Emergency Oc)) AFTERA, estradiol (91-day)) AFTERPILL, ECONTRA SAFYRAL TABS PV EZ, ECONTRA ONE- (drospirenone-ethinyl STEP, MY CHOICE, MY 5 estradiol-levomefolate 7 WAY, NEW DAY, OPCICON ONE-STEP, calcium) OPTION 2, PREVENTEZA, REACT, TAKE ACTION TABS

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELLA TABS ( PV ulipristal 5 dexamethasone soln 1 acetate) 0.5 mg/5ml PV levonorgestrel 5 dexamethasone tabs (emergency oc) tabs 0.5 mg, 0.75 mg, 1 mg, 1 PLAN B ONE-STEP TABS PV 1.5 mg, 2 mg, 4 mg, 6 (levonorgestrel 7 mg (emergency oc)) dexamethasone tbpk 1 Progestin Contraceptives - Oral 1.5 mg (Norethindrone PV hydrocortisone tabs 1 (Contraceptive)) CAMILA, MEDROL TABS 2 MG DEBLITANE, ERRIN, 2 HEATHER, INCASSIA, (methylprednisolone) JENCYCLA, LYLEQ, 5 methylprednisolone LYZA, NORA-BE, 1 NORLYDA, NORLYROC, tabs SHAROBEL, TULANA methylprednisolone 1 TABS tbpk norethindrone PV MILLIPRED DP TBPK 5 3 (contraceptive) tabs (prednisolone) ORTHO MICRONOR PV MILLIPRED TABS 2 TABS (norethindrone 7 (prednisolone) (contraceptive)) prednisolone sodium SLYND TABS QL(1 ea daily); 5 phosphate soln or 10 (drospirenone) PV mg/5ml, 15 mg/5ml, 20 1 CORTICOSTEROIDS - Steroid Hormone Drugs to mg/5ml, 25 mg/5ml, 5 Treat Systemic Swelling Conditions mg/5ml, 6.7 mg/5ml Glucocorticosteroids prednisolone sodium phosphate tbdp or 10 1 (Dexamethasone) 1 DECADRON ELIX mg, 15 mg, 30 mg (Dexamethasone) 1 1 DECADRON TABS prednisolone soln PREDNISONE INTENSOL (Dexamethasone) 2 DEXPAK 13 DAY, 1 CONC (prednisone) TAPERDEX 12-DAY TBPK prednisone soln 1 budesonide cpep 3 mg 2 QL(3 ea daily) prednisone tabs 1 budesonide tb24 9 mg 1 PA prednisone tbpk 1 cortisone acetate tabs 2 Mineralocorticoids dexamethasone elix 1 fludrocortisone acetate 0.5 mg/5ml 1 tabs DEXAMETHASONE INTENSOL CONC 2 COUGH/COLD/ALLERGY - Drugs to Treat (dexamethasone) Cough, Cold and Allergy Symptoms 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antitussives GILTUSS SINUS & RX/OTC CONGESTION TABS (Hydrocodone W/ 3 Homatropine) HYDROMET 1 (phenylephrine- SYRP guaifenesin) GILTUSS TR TABS RX/OTC benzonatate caps 100 1 mg, 150 mg, 200 mg (phenylephrine w/ dm- 3 gg) hydrocodone w/ 1 homatropine syrp guaifenesin-codeine 1 soln hydrocodone w/ 1 homatropine tabs hydrocodone polistirex- chlorpheniramine 1 Cough/Cold/Allergy Combinations polistirex suer (Guaifenesin-Codeine) G TUSSIN AC, MAXI-TUSS 1 NEOTUSS PLUS LIQD AC, VIRTUSSIN A/C SOLN (phenylephrine- 3 (Guaifenesin-Codeine) chlorphen-dm) GUAIATUSSIN AC, 1 PRO-RED AC SYRP GUAIFENESIN AC SYRP (phenylephrine- 3 (Guaifenesin-Codeine) 1 dexchlorpheniramine- VIRTUSSIN AC/ALC LIQD codeine) (Pseudoephedrine W/ promethazine & QL(30 ml daily) Codeine-Gg) 1 1 GUAIFENESIN DAC SOLN phenylephrine syrp QL(30 ml daily) ACTIDOM DMX LIQD promethazine 1 (phenylephrine w/ dm- 3 w/codeine soln QL(30 ml daily) gg) promethazine 1 CODITUSSIN AC LIQD w/codeine syrp 3 (guaifenesin-codeine) promethazine-dm syrp 1 QL(30 ml daily) DOCTOR MANZANILLA PE SYRUP promethazine- ANTIHISTAMINE/DECON phenylephrine-codeine 1 GESTANT LIQD 3 syrp (triprolidine- pseudoephed- 1 phenylephrine) bromphen-dm syrp DOMETUSS-DMX LIQD pseudoephed-cpm w/ 1 (phenylephrine w/ dm- 3 hydrocod soln gg) TUSNEL TABS GILPHEX TR TABS RX/OTC (pseudoephedrine w/ 3 (phenylephrine- 3 dm-gg) guaifenesin) TUSSICAPS CP12 GILTUSS COUGH & COLD RX/OTC (hydrocodone TABS (phenylephrine 3 polistirex- 3 w/ dm-gg) chlorpheniramine polistirex)

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUSSLIN LIQD (Isotretinoin) ACCUTANE, QL(4 ea (phenylephrine w/ dm- 3 AMNESTEEM, CLARAVIS, 1 daily,150 gg) MYORISAN, ZENATANE day(s) limit) CAPS 10 MG TUSSLIN PEDIATRIC (Isotretinoin) ACCUTANE, QL(5 ea LIQD (phenylephrine w/ 3 AMNESTEEM, CLARAVIS, 1 daily,150 dm-gg) MYORISAN, ZENATANE day(s) limit) VIRTUSSIN DAC SOLN CAPS 20 MG (pseudoephedrine w/ 2 (Isotretinoin) ACCUTANE, QL(2 ea codeine-gg) AMNESTEEM, CLARAVIS, 1 daily,150 MYORISAN, ZENATANE day(s) limit) Misc. Respiratory Inhalants CAPS 40 MG (Sodium Chloride (Isotretinoin) ACCUTANE, QL(3 ea (Inhalant)) NEBUSAL 1 CLARAVIS, MYORISAN, 1 daily,150 NEBU 3 % ZENATANE CAPS 30 MG day(s) limit) (Sodium Chloride (Sulfacetamide Sodium W/ (Inhalant)) PULMOSAL 1 Sulfur) BP 10-1, 1 NEBU SULFAMEZ WASH EMUL HYPERSAL NEBU 3.5 % (Sulfacetamide Sodium W/ 1 (sodium chloride 3 Sulfur) SSS 10-5 FOAM (inhalant)) (Sulfacetamide Sodium- NEBUSAL NEBU 6 % Sulfur In Urea Vehicle) BP 1 (sodium chloride 3 CLEANSING WASH EMUL (inhalant)) (Tretinoin) AVITA CREA 1 sodium chloride 1 (inhalant) nebu (Tretinoin) AVITA GEL 1 Mucolytics Limit 45gms 1 per acetylcysteine soln 1 adapalene crea 0.1 % month;QL(1.5 gm daily) DERMATOLOGICALS - Drugs to Treat Skin Conditions Limit 45gms per Acne Products adapalene gel 0.1 % 1 month;QL(1.5 Limit 45gms gm daily); RX/OTC (Adapalene) ADAPALENE per 1 month;QL(1.5 TREATMENT GEL QL(45 gm per gm daily); adapalene gel 0.3 % 1 fill retail,135 gm RX/OTC per fill mail) (Clindamycin Phosphate adapalene lotn 0.1 % 1 (Topical)) CLINDACIN ETZ 1 PLEDGETS, CLINDACIN-P adapalene-benzoyl 1 SWAB peroxide gel (Clindamycin Phosphate- AZELEX CREA ( Benzoyl Peroxide 1 azelaic 3 (Refrigerate)) NEUAC GEL acid (acne)) (Erythromycin (Acne Aid)) QL(2 gm daily) 1 benzoyl peroxide- 1 ERY PADS erythromycin gel

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea clindamycin phosphate 1 isotretinoin caps 35 mg, (topical) foam 1 daily,150 40 mg day(s) limit) clindamycin phosphate 1 RIAX FOAM ( (topical) gel benzoyl 3 peroxide) clindamycin phosphate 1 SODIUM (topical) lotn SULFACETAMIDE/SULFU R CLEANSER IN UREA clindamycin phosphate 1 (topical) soln EMUL (sulfacetamide 3 sodium-sulfur in urea clindamycin phosphate 1 (topical) swab vehicle) clindamycin phosphate- sulfacetamide sodium 1 benzoyl peroxide 1 (acne) lotn (refrigerate) gel sulfacetamide sodium clindamycin phosphate- w/ sulfur crea 4.8 %-9.8 1 benzoyl peroxide gel 1 1 % %-5 % sulfacetamide sodium w/ sulfur liqd 4.8 %-9.8 2 clindamycin phosphate- 1 tretinoin gel %, 9.8 %-4.8 % PA; ST sulfacetamide sodium PA dapsone (topical) gel 5 1 % w/ sulfur lotn 4.8 %-9.8 1 DIFFERIN LOTN 0.1 % % 3 QL(1 gm daily) (adapalene) sulfacetamide sodium 1 w/ sulfur lotn 5 %-10 % erythromycin (acne aid) 1 gel Limit 50gms TAZAROTENE FOAM 3 per erythromycin (acne aid) 1 (tazarotene (acne)) month;QL(1.67 pads gm daily) erythromycin (acne aid) 1 tretinoin crea 1 soln Limit 50gms tretinoin gel 1 FABIOR FOAM 3 per (tazarotene (acne)) month;QL(1.67 Limit 45gms gm daily) tretinoin microsphere 1 per gel 0.04 % month;QL(1.7 isotretinoin caps 10 QL(4 ea gm daily) 1 daily,150 mg, 25 mg day(s) limit) tretinoin microsphere QL(1.67 gm 1 daily) QL(5 ea gel 0.1 % isotretinoin caps 20 mg 1 daily,150 Agents for External Genital and Perianal Warts day(s) limit) VEREGEN OINT QL(30 gm per 3 QL(3 ea (sinecatechins) fill retail) isotretinoin caps 30 mg 1 daily,150 day(s) limit) Anti-inflammatory Agents - Topical

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diclofenac Sodium RX/OTC ciclopirox soln ex 8 % 1 (Topical)) ARTHRITIS PAIN RELIEVER, clotrimazole w/ Limit 1 tube per ASPERCREME 1 month;QL(1.5 ARTHRITIS PAIN betamethasone crea gm daily) RELIEVER, CVS 1 QL(2 ml daily) DICLOFENAC SODIIUM, clotrimazole w/ 1 GNP ARTHRITIS PAIN, betamethasone lotn GOODSENSE ARTHRITIS econazole nitrate crea 1 PAIN, QC DICLOFENAC SODIIUM GEL ERTACZO CREA PA; QL(1 gm 4 RX/OTC (sertaconazole nitrate) daily) diclofenac sodium 1 (topical) gel 1 % EXELDERM CREA 7 diclofenac sodium QL(5 ml daily) (sulconazole nitrate) 1 EXELDERM SOLN (topical) soln 1.5 % 2 PENNSAID SOLN PA; QL(4 gm (sulconazole nitrate) daily) EXELDERM SOLN (diclofenac sodium 3 7 (topical)) (sulconazole nitrate) Antibiotics - Topical EXODERM LOTN ( 3 ALTABAX OINT sodium thiosulfate- 3 ) (retapamulin) salicylic acid CENTANY OINT iodoquinol- 2 (mupirocin) hydrocortisone in aloe 1 vehicle crea gentamicin sulfate 1 QL(2 gm daily) (topical) crea ketoconazole (topical) 1 crea gentamicin sulfate 1 (topical) oint ketoconazole (topical) 2 foam mupirocin oint 1 ketoconazole (topical) 1 Antifungals - Topical sham (Iodoquinol-Hydrocortisone naftifine hcl crea 1 In Aloe Vehicle) 1 IODOQUIMEZ-HC CREA naftifine hcl gel 1 (Ketoconazole (Topical)) 2 NAFTIN GEL 2 % KETODAN FOAM 3 (Nystatin (Topical)) (naftifine hcl) NYAMYC, NYSTOP 1 nystatin (topical) crea 1 POWD ciclopirox gel ex 0.77 % 1 nystatin (topical) oint 1 ciclopirox olamine crea 1 nystatin (topical) powd 1 nystatin-triamcinolone 1 ciclopirox olamine susp 1 crea ciclopirox sham ex 1 % 1 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily) nystatin-triamcinolone 1 acitretin caps 25 mg 2 oint calcipotriene crea 2 QL(5 gm daily) oxiconazole nitrate 1 crea calcipotriene foam 1 PA OXISTAT LOTN 3 CALCIPOTRIENE FOAM PA (oxiconazole nitrate) 3 (calcipotriene) sulconazole nitrate 1 crea calcipotriene oint 1 QL(5 gm daily) sulconazole nitrate soln 1 calcipotriene soln 1 Antineoplastic or Premalignant Lesion Agents - Limit 100gms CARAC CREA QL(1 gm daily) per 7 calcitriol (topical) oint 1 (fluorouracil (topical)) month;QL(3.4 PA gm daily) diclofenac sodium 2 (actinic keratoses) gel COSENTYX PA; ST;LA SENSOREADY PEN SOAJ 4 FLUOROPLEX CREA 2 (secukinumab) (fluorouracil (topical)) COSENTYX SOSY 150 PA; ST;LA QL(1 gm daily) 4 fluorouracil (topical) 1 MG/ML (secukinumab) crea 0.5 % COSENTYX SOSY 75 PA MG/0.5ML fluorouracil (topical) 1 4 crea 5 % (secukinumab) ILUMYA SOSY PA; ST fluorouracil (topical) 1 4 soln 2 %, 5 % (tildrakizumab-asmn) PANRETIN GEL PA 3 methoxsalen rapid caps 1 (alitretinoin) PA; QL(1 ml PICATO GEL ( SKYRIZI PEN SOAJ ingenol 3 4 per 84 days mebutate) (risankizumab-rzaa) retail) TARGRETIN GEL EX 1 % PA 4 SKYRIZI PSKT 75 PA (bexarotene (topical)) MG/0.83ML 4 VALCHLOR GEL PA; ST (risankizumab-rzaa) (mechlorethamine hcl 4 SKYRIZI SOSY 150 PA; QL(1 ml (topical)) MG/ML (risankizumab- 4 per 84 days retail) Antipruritics - Topical rzaa) QL(3 gm daily) SORILUX FOAM PA doxepin hcl 1 3 (antipruritic) crea (calcipotriene) PA; Must use Antipsoriatics STELARA SOLN SC 45 AcariaHealth (Calcipotriene) 1 QL(5 gm daily) 4 Specialty Rx at CALCITRENE OINT MG/0.5ML (ustekinumab) 1-844-538- 4661;LA acitretin caps 10 mg 2 QL(1 ea daily) acitretin caps 17.5 mg 2

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use silver sulfadiazine crea 1 STELARA SOSY SC 90 AcariaHealth 4 Specialty Rx at MG/ML (ustekinumab) SULFAMYLON CREA 85 1-844-538- MG/GM (mafenide 3 4661;LA acetate) tazarotene crea 1 Corticosteroids - Topical TAZORAC CREA 0.05 % (Clobetasol Propionate 2 (tazarotene) Emollient Base) CLOBETASOL TAZORAC GEL 0.05 %, 2 PROPIONATE E, 1 0.1 % (tazarotene) CLOBETASOL PA; Must use PROPIONATE TREMFYA SOPN AcariaHealth EMOLLIENT CREA 4 Specialty Rx at (guselkumab) (Clobetasol Propionate 1 1-844-538- Emulsion) TOVET FOAM 4661;LA (Clobetasol Propionate) 1 PA; Must use CLODAN SHAM TREMFYA SOSY AcariaHealth 4 Specialty Rx at (Desonide) DESRX GEL 1 (guselkumab) 1-844-538- 4661;LA (Diflorasone Diacetate) 1 PSORCON CREA Antiseborrheic Products (Flurandrenolide) NOLIX 1 (Sulfacetamide Sodium) CREA SODIUM 1 (Fluticasone Propionate) 1 SULFACETAMIDE WASH BESER LOTN LIQD 10 % (Hydrocortisone (Topical)) selenium sulfide lotn 1 ALA SCALP, ALA-SCALP 1 2.5 % LOTN SODIUM (Hydrocortisone (Topical)) 1 SULFACETAMIDE WASH ALA-CORT CREA LIQD 0.5 %-10 % 3 (Triamcinolone Acetonide 1 (sulfacetamide sodium (Topical)) TRIDERM CREA in bakuchiol vehicle) ALA-SCALP LOTN (hydrocortisone 3 sulfacetamide sodium 1 liqd (topical)) alclometasone sulfacetamide sodium 1 1 sham dipropionate crea Antivirals - Topical alclometasone 1 dipropionate oint acyclovir topical oint 1 QL(1 gm daily) amcinonide crea 1 Burn Products 1 (Silver Sulfadiazine) SSD 1 amcinonide lotn CREA AMCINONIDE OINT 3 mafenide acetate pack 1 (amcinonide)

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APEXICON E CREA clobetasol propionate 1 (diflorasone diacetate 2 crea emollient base) clobetasol propionate 1 betamethasone emollient base crea dipropionate (topical) 1 clobetasol propionate 1 crea emulsion foam betamethasone clobetasol propionate 1 dipropionate (topical) 1 foam lotn clobetasol propionate 1 betamethasone gel dipropionate (topical) 1 clobetasol propionate oint 1 liqd betamethasone clobetasol propionate dipropionate 1 1 augmented crea lotn clobetasol propionate betamethasone 1 dipropionate 1 oint augmented gel clobetasol propionate 1 betamethasone sham dipropionate 1 clobetasol propionate 1 augmented lotn soln betamethasone clocortolone pivalate 1 dipropionate 1 crea CLODERM CREA augmented oint 7 (clocortolone pivalate) betamethasone 1 valerate crea CORDRAN TAPE 4 MCG/SQCM 3 betamethasone 1 (flurandrenolide) valerate foam CORTANE-B LOTN betamethasone 1 (hydrocortisone- valerate lotn pramoxine- 3 betamethasone 1 chloroxylenol) valerate oint desonide crea 1 calcipotriene- ST betamethasone 2 desonide gel 1 dipropionate oint calcipotriene- ST; QL(2 gm desonide lotn 1 betamethasone 1 daily) dipropionate susp desonide oint 1 CAPEX SHAM desoximetasone crea 1 (fluocinolone 2 0.05 %, 0.25 % acetonide)

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desoximetasone gel 1 hydrocortisone (topical) 1 0.05 % crea ST desoximetasone liqd 1 hydrocortisone (topical) 1 0.25 % lotn desoximetasone oint 1 hydrocortisone (topical) 1 0.05 %, 0.25 % oint diflorasone diacetate 1 hydrocortisone butyrate 1 crea crea diflorasone diacetate 1 hydrocortisone butyrate oint hydrophilic lipo base 1 EPIFOAM FOAM crea 3 (pramoxine-hc) hydrocortisone butyrate 1 oint fluocinolone acetonide 1 crea hydrocortisone butyrate 1 soln fluocinolone acetonide 1 oil hydrocortisone valerate 1 crea fluocinolone acetonide 1 oint hydrocortisone valerate 1 oint fluocinolone acetonide 1 soln mometasone furoate 1 fluocinonide crea 1 crea mometasone furoate 1 fluocinonide emulsified 1 oint base crea mometasone furoate 1 fluocinonide gel 1 soln NUCORT LOTN fluocinonide oint 1 (hydrocortisone acetate 3 fluocinonide soln 1 (topical)) PRAMOSONE LOTN 3 flurandrenolide crea 1 (pramoxine-hc) PRAMOSONE OINT fluticasone propionate 1 3 crea (pramoxine-hc) prednicarbate crea 1 fluticasone propionate 1 lotn prednicarbate oint 1 fluticasone propionate 1 oint TEXACORT SOLN (hydrocortisone 3 halobetasol propionate 1 crea (topical)) triamcinolone acetonide halobetasol propionate 1 oint (topical) aers 0.147 1 mg/gm 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits triamcinolone tacrolimus (topical) oint QL(2 gm daily); 1 AL(At least 2 acetonide (topical) crea 1 0.03 % 0.025 %, 0.1 %, 0.5 % yrs old) tacrolimus (topical) oint QL(2 gm daily); triamcinolone 1 AL(At least 15 acetonide (topical) lotn 1 0.1 % yrs old) 0.025 %, 0.1 % Keratolytic/Antimitotic Agents triamcinolone (Salicylic Acid) KERALYT 1 acetonide (topical) oint 1 SHAM 0.025 %, 0.1 %, 0.5 % BENSAL HP OINT RX/OTC 3 Eczema Agents (salicylic acid) PA; MUST CONDYLOX GEL 2 DUPIXENT SOPN 300 USE ACARIA (podofilox) 4 SPECIALTY MG/2ML (dupilumab) MG217 PSORIASIS RX/OTC RX 844-538- MULTI-SYMTOM OINT 4661 3 (salicylic acid) DUPIXENT SOSY 200 PA 4 MG/1.14ML ( ) PODOCON 25 IN dupilumab BENZOIN TINCTURE PA; Must use SOLN (podophyllum 3 DUPIXENT SOSY 300 AcariaHealth 4 Specialty Rx at resin) MG/2ML (dupilumab) 1-844-538- podofilox soln 1 4661;;LA Emollient/Keratolytic Agents salicylic acid crea 6 % 1 (Urea) UREA-C40 LOTN 1 salicylic acid in ammonium lactate 1 CEROVEL LOTN (urea) 3 vehicle foam urea lotn 1 salicylic acid lotn 6 % 1 urea susp 1 salicylic acid sham 6 % 1 SALIMEZ CREA ( Emollients salicylic 3 HYLINATE LOTN acid) (hyaluronate sodium 3 Liniments (emollient)) MEDROX-RX OINT PA Enzymes - Topical (capsaicin-menthol- 3 SANTYL OINT methyl salicylate) 3 (collagenase) Local Anesthetics - Topical Immunomodulating Agents - Topical CETACAINE AERO (butamben-tetracaine- 3 imiquimod crea 5 % 1 benzocaine) Immunosuppressive Agents - Topical lidocaine hcl soln 1 pimecrolimus crea 1 QL(2 gm daily)

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limited to 3 metronidazole (topical) 1 1 patches per gel 1 % lidocaine ptch ex 5 % day;QL(3 ea QL(2 ml daily) daily) metronidazole (topical) 1 lotn 0.75 % lidocaine-prilocaine 1 crea MIRVASO GEL PA; ST ( 3 PREMIUM SCAR PATCH brimonidine tartrate ) PTCH (allantoin- 3 (topical) lidocaine-petrolatum) NORITATE CREA PA (metronidazole 4 Misc. Topical (topical)) DRYSOL SOLN ORACEA CPDR PA; ST;QL(1 2 7 (aluminum chloride) (doxycycline (rosacea)) ea daily) XERAC AC SOLN RHOFADE CREA PA; ST (aluminum chloride in 3 (oxymetazoline hcl 3 alcohol) (topical)) Phosphodiesterase 4 (PDE4) Inhibitors - Topical Scabicides & Pediculicides PA; ST; Limited EUCRISA OINT ivermectin RX/OTC 3 to 60 gm per 1 (crisaborole) month;QL(2 gm (pediculicide) lotn daily) IVERMECTIN LOTN EX RX/OTC Rosacea Agents 0.5 % (ivermectin 3 (pediculicide)) (Metronidazole (Topical)) 1 ROSADAN CREA malathion lotn 1 Limit 45gms QL(2 gm daily) (Metronidazole (Topical)) 1 per permethrin crea 1 ROSADAN GEL month;QL(1.5 gm daily) Wound Care Products 1 Limit 15gms azelaic acid gel REGRANEX GEL 3 per PA; ST;QL(1 (becaplermin) month;QL(0.5 doxycycline (rosacea) 1 cpdr ea daily) gm daily) FINACEA FOAM ( azelaic 3 DIAGNOSTIC PRODUCTS acid) Diagnostic Drugs ivermectin (rosacea) PA; QL(1.5 gm 1 daily) GLUCAGEN DIAGNOSTIC PA crea SOLR (glucagon hcl 4 IVERMECTIN CREA EX 1 PA; QL(1.5 gm rdna (diagnostic)) % ( 3 daily) ivermectin METOPIRONE CAPS ) 3 (rosacea) (metyrapone) metronidazole (topical) 1 crea 0.75 % Diagnostic Tests Limit 45gms metronidazole (topical) 1 per gel 0.75 % month;QL(1.5 gm daily) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE INSULINX Limit 200 per PANCREAZE CPEP 10500 BLOODGLUCOSE TEST month without UNIT-35500 UNIT-61500 STRIPS STRP ( 2 authorization;Q UNIT, 16800 UNIT-56800 glucose L(6.7 ea daily); UNIT-98400 UNIT, 21000 blood) RX/OTC UNIT-54700 UNIT-83900 Limit 200 per UNIT, 2600 UNIT-8800 3 FREESTYLE INSULINX month without UNIT-15200 UNIT, 4200 BLOODGLUCOSE TEST 2 authorization;Q UNIT-14200 UNIT-24600 STRP (glucose blood) L(6.7 ea daily); UNIT (pancrelipase RX/OTC (lipase-protease- Limit 200 per amylase)) FREESTYLE LITE TEST month without PERTZYE CPEP STRIPS STRP (glucose 2 authorization;Q (pancrelipase (lipase- 3 blood) L(6.7 ea daily); RX/OTC protease-amylase)) SUCRAID SOLN PA; AC Limit 200 per 4 FREESTYLE TEST month without (sacrosidase) STRIPS STRP (glucose 2 authorization;Q VIOKACE TABS blood) L(6.7 ea daily); (pancrelipase (lipase- 3 RX/OTC protease-amylase)) Limit 200 per ZENPEP CPEP ONETOUCH ULTRA STRP month without 2 authorization;Q (pancrelipase (lipase- 2 (glucose blood) L(6.7 ea daily); protease-amylase)) RX/OTC DIURETICS - Drugs to Treat Heart, Circulation Limit 200 per Conditions and Blood Pressure ONETOUCH VERIO TEST month without STRIPS STRP (glucose 2 authorization;Q Carbonic Anhydrase Inhibitors L(6.7 ea daily); QL(2 ea daily) blood) acetazolamide cp12 1 RX/OTC 500 mg Limit 200 per acetazolamide tabs 125 PRECISION XTRA BLOOD month without 1 GLUCOSE TEST STRIPS 2 authorization;Q mg QL(4 ea daily) STRP (glucose blood) L(6.7 ea daily); acetazolamide tabs 250 1 RX/OTC mg KEVEYIS TABS PA DIGESTIVE AIDS - Drugs to Treat Low Digestive 4 Enzymes (dichlorphenamide) Digestive Enzymes methazolamide tabs 1 CREON CPEP (pancrelipase (lipase- 2 Diuretic Combinations protease-amylase)) ALDACTAZIDE TABS 50 MG-50 MG (spironolactone & 2 hydrochlorothiazide) amiloride & hydrochlorothiazide 1 tabs

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits spironolactone & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs indapamide tabs 1 triamterene & hydrochlorothiazide 1 metolazone tabs 1 caps 25 mg-37.5 mg ENDOCRINE AND METABOLIC AGENTS - triamterene & QL(2 ea daily) MISC. - Drugs to Treat Bone Disease and hydrochlorothiazide 1 Regulate Hormones tabs 25 mg-37.5 mg, 37.5 mg-25 mg Bone Density Regulators alendronate sodium 1 triamterene & QL(1 ea daily) soln 70 mg/75ml hydrochlorothiazide 1 QL(1 ea daily) tabs 50 mg-75 mg alendronate sodium 1 tabs 10 mg, 5 mg Loop Diuretics alendronate sodium Limit 1 tab per bumetanide tabs 0.5 1 1 week;QL(0.144 mg, 1 mg tabs 35 mg ea daily) QL(5 ea daily) bumetanide tabs 2 mg 1 alendronate sodium 1 tabs 40 mg ST ethacrynic acid tabs 1 alendronate sodium Limit 1 tab per 1 week;QL(0.15 furosemide soln 1 tabs 70 mg ea daily) PA; LA calcitonin (salmon) soln 4 furosemide tabs 1 ij 200 unit/ml torsemide tabs 10 mg, 1 calcitonin (salmon) soln 1 20 mg, 5 mg na 200 unit/act QL(2 ea daily) torsemide tabs 100 mg 1 etidronate disodium 1 tabs Potassium Sparing Diuretics FOSAMAX PLUS D TABS PA; Limit 4 per amiloride hcl tabs 1 (alendronate sodium- 3 month;QL(0.15 cholecalciferol) ea daily) spironolactone tabs 1 ibandronate sodium Limit 1 per 1 month;QL(0.04 triamterene caps 1 tabs ea daily) MIACALCIN SOLN PA; LA Thiazides and Thiazide-Like Diuretics 7 (calcitonin (salmon)) chlorothiazide tabs 1 NATPARA CART PA; LA (parathyroid hormone 4 1 chlorthalidone tabs (recombinant)) DIURIL SUSP PROLIA SOSY PA; LA 3 4 (chlorothiazide) (denosumab) hydrochlorothiazide 1 caps

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; Limited to 1 raloxifene hcl tabs 5 PV risedronate sodium 1 per tabs 150 mg month;QL(0.04 Insulin-Like Growth Factors (Somatomedins) ea daily) INCRELEX SOLN PA; LA 4 risedronate sodium ST (mecasermin) tabs 30 mg, 35 mg, 5 1 mg LHRH/GnRH Agonist Analog Pituitary TYMLOS SOPN PA; LA FENSOLVI KIT PA 4 (abaloparatide) (leuprolide acetate 3 (cpp) (6 month)) Fertility Regulators SYNAREL SOLN 2 Check plan (nafarelin acetate) documents for coverage;QL(1 Metabolic Modifiers clomiphene citrate tabs 1 5 ea per fill BUPHENYL POWD PA retail,00 ea per (sodium 7 fill mail,15 ea ) per 30 days phenylbutyrate retail) BUPHENYL TABS PA (sodium 7 Growth Hormone Receptor Antagonists phenylbutyrate) SOMAVERT SOLR PA; LA 4 (pegvisomant) calcitriol caps 0.25 mcg 1 Growth Hormones calcitriol caps 0.5 mcg 1 QL(4 ea daily) HUMATROPE COMBO PA; Must use PACK SOLR 4 AcariaHlth Sp calcitriol soln 1 mcg/ml 1 Rx 1-844-538- (somatropin) 4661;LA CARBAGLU TABS PA 4 HUMATROPE SOLR PA; LA (carglumic acid) 4 (somatropin) cinacalcet hcl tabs 1 PA NORDITROPIN FLEXPRO PA; LA 4 CYSTADANE POWD PA SOPN (somatropin) 4 (betaine) SEROSTIM SOLR PA; LA (somatropin (non- 4 doxercalciferol caps 2 ) refrigerated) GALAFOLD CAPS PA; QL(0.5 ea ZOMACTON SOLR PA 4 4 (migalastat hcl) daily) ( ) somatropin Specialty Drug ZORBTIVE SOLR PA; LA KUVAN PACK ( 7 refer to (somatropin (non- 4 sapropterin Caremark SP refrigerated)) dihydrochloride) RX Hormone Receptor Modulators KUVAN TABS Specialty Drug refer to EVISTA TABS ( PV (sapropterin 7 raloxifene 7 Caremark SP hcl) dihydrochloride) RX OSPHENA TABS 3 levocarnitine (metabolic 1 (ospemifene) modifiers) soln

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levocarnitine (metabolic DESMOPRESSIN 1 ACETATE SOLN NA 1.5 modifiers) tabs 3 MYALEPT SOLR PA; LA MG/ML (desmopressin 4 (metreleptin) acetate) PA desmopressin acetate 1 nitisinone caps 10 mg 4 spray refrigerated soln nitisinone caps 2 mg, 5 PA 1 desmopressin acetate 1 mg spray soln PA NITYR TABS (nitisinone) 4 desmopressin acetate 1 tabs or 0.1 mg ORFADIN CAPS 10 MG PA 7 QL(6 ea daily) (nitisinone) desmopressin acetate 1 tabs or 0.2 mg ORFADIN CAPS 20 MG PA 3 NOCTIVA EMUL PA (nitisinone) 3 (desmopressin acetate) ORFADIN SUSP 4 MG/ML PA 4 STIMATE SOLN (nitisinone) 3 (desmopressin acetate) PALYNZIQ SOSY PA 4 (pegvaliase-pqpz) Prolactin Inhibitors paricalcitol caps 1 cabergoline tabs 1 RAVICTI LIQD ( Somatostatic Agents glycerol 4 phenylbutyrate) octreotide acetate soln PA Specialty Drug 100 mcg/ml, 200 4 sapropterin 4 refer to mcg/ml, 50 mcg/ml dihydrochloride pack Caremark SP PA; LA RX octreotide acetate soln 1000 mcg/ml, 500 4 Specialty Drug mcg/ml sapropterin 4 refer to dihydrochloride tabs Caremark SP SANDOSTATIN SOLN 500 PA; LA RX MCG/ML (octreotide 7 PA acetate) sodium phenylbutyrate 4 powd SIGNIFOR SOLN PA; LA PA (pasireotide 4 sodium phenylbutyrate 4 tabs diaspartate) STRENSIQ SOLN PA Vasopressin Receptor Antagonists 4 (asfotase alfa) JYNARQUE TBPK 15 MG PA 4 XURIDEN PACK ( (tolvaptan) uridine 4 triacetate) ESTROGENS - Hormone Replacement/Modifying Posterior Pituitary Hormones Drugs DDAVP SOLN NA 0.01 % Estrogen Combinations (desmopressin acetate 2 (Estradiol & Norethindrone refrigerated) Acetate) AMABELZ, 1 LOPREEZA, MIMVEY, MIMVEY LO TABS 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethindrone Acetate- DIVIGEL GEL 0.25 Ethinyl Estradiol) 1 MG/0.25GM, 0.5 FYAVOLV, JINTELI TABS MG/0.5GM, 1 MG/GM 3 ANGELIQ TABS (estradiol) (drospirenone- 3 ELESTRIN GEL 3 estradiol) (estradiol) CLIMARA PRO PTWK estradiol pttw td 0.025 Limit 8 patches (estradiol- 2 mg/24hr, 0.0375 per levonorgestrel) mg/24hr, 0.05 mg/24hr, 1 month;QL(0.29 ea daily) COMBIPATCH PTTW 0.075 mg/24hr, 0.1 (estradiol & 3 mg/24hr norethindrone acetate) estradiol ptwk td 0.025 Limit 4 patches DUAVEE TABS mg/24hr, 0.05 mg/24hr, per (conjugated estrogens- 3 0.06 mg/24hr, 0.075 1 month;QL(0.14 bazedoxifene) mg/24hr, 0.1 mg/24hr, 3 ea daily) estradiol & 37.5 mcg/24hr norethindrone acetate 1 estradiol tabs or 0.5 1 tabs mg, 1 mg, 2 mg norethindrone acetate- Limit 50gms 1 ESTROGEL GEL ethinyl estradiol tabs 3 per ORIAHNN CPPK PA (estradiol) month;QL(1.67 gm daily) (elagolix sodium- 4 EVAMIST SOLN estradiol-norethindrone 3 (estradiol) acetate) MENEST TABS PREFEST TABS 2 3 (esterified estrogens) (estradiol-norgestimate) Limit 4 patches PREMPHASE TABS MENOSTAR PTWK per (conjugated estrogens- 3 2 (estradiol) month;QL(0.14 medroxyprogesterone 3 ea daily) acetate) PREMARIN TABS OR 0.3 QL(1 ea daily) PREMPRO TABS MG, 0.45 MG, 0.625 MG, 2 (conjugated estrogens- 1.25 MG (estrogens, 2 medroxyprogesterone conjugated) acetate) PREMARIN TABS OR 0.9 Estrogens MG (estrogens, 2 Limit 8 patches conjugated) (Estradiol) DOTTI, 1 per FLUOROQUINOLONES - Drugs to Treat Bacterial LYLLANA PTTW month;QL(0.29 Infections ea daily) Fluoroquinolones Limit 8 patches CIPRO SUSR 5 2 per ALORA PTTW (estradiol) month;QL(0.29 GM/100ML, 500 MG/5ML 2 ea daily) (ciprofloxacin)

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ciprofloxacin hcl tabs 1 Inflammatory Bowel Agents AVSOLA SOLR PA 4 ciprofloxacin susr 1 (infliximab-axxq) levofloxacin soln 25 balsalazide disodium Limit 280 caps 1 1 per month;QL(9 mg/ml caps ea daily) levofloxacin tabs 250 QL(14 ea per CIMZIA KIT PA; LA 1 fill retail) 4 mg, 500 mg, 750 mg (certolizumab pegol) 1 CIMZIA STARTER KIT KIT PA; LA moxifloxacin hcl tabs 4 (certolizumab pegol) ofloxacin tabs 300 mg 1 DIPENTUM CAPS 3 QL(28 ea per (olsalazine sodium) 1 90 days PA; Must use ofloxacin tabs 400 mg retail,28 ea per INFLECTRA SOLR AcariaHealth 90 days mail) 4 Specialty Rx at (infliximab-dyyb) GASTROINTESTINAL AGENTS - MISC. - 1-844-538- Miscellaneous Gastrointestinal Drugs 4661 QL(4 ea daily) Farnesoid X Receptor (FXR) Agonists mesalamine cp24 or 1 0.375 gm OCALIVA TABS 10 MG PA 4 QL(6 ea daily) (obeticholic acid) mesalamine cpdr or 1 OCALIVA TABS 5 MG PA; ST 400 mg 4 QL(60 ml daily) (obeticholic acid) mesalamine enem re 4 1 gm Gallstone Solubilizing Agents QL(1 ea daily) CHENODAL TABS PA mesalamine supp re 4 1 (chenodiol) 1000 mg QL(4 ea daily) mesalamine tbec or 1.2 1 ursodiol caps 300 mg 2 gm ursodiol tabs 250 mg, 1 mesalamine tbec or 1 500 mg 800 mg PENTASA CPCR 250 MG PA Gastrointestinal Chloride Channel Activators 3 (mesalamine) lubiprostone caps 1 PENTASA CPCR 500 MG PA; QL(8 ea 3 Gastrointestinal Stimulants (mesalamine) daily) PA; Must use metoclopramide hcl 1 soln RENFLEXIS SOLR AcariaHealth 4 Specialty Rx at (infliximab-abda) metoclopramide hcl 1 1-844-538- tabs 4661 SFROWASA ENEM metoclopramide hcl 1 2 tbdp (mesalamine) METOCLOPRAMIDE ODT STELARA SOLN IV 130 PA; LA TBDP (metoclopramide 3 MG/26ML (ustekinumab 4 hcl) (iv))

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(8 ea daily) RX/OTC sulfasalazine tabs 1 calcium acetate 1 (phosphate binder) tabs QL(8 ea daily) sulfasalazine tbec 1 FOSRENOL PACK 1000 MG, 750 MG (lanthanum 3 Intestinal Acidifiers carbonate) (Lactulose lanthanum carbonate QL(3 ea daily) (Encephalopathy)) 1 1 ENULOSE, GENERLAC chew 1000 mg SOLN lanthanum carbonate 1 lactulose 1 chew 500 mg (encephalopathy) soln QL(4 ea daily) lanthanum carbonate 1 Irritable Bowel Syndrome (IBS) Agents chew 750 mg alosetron hcl tabs 2 PHOSLYRA SOLN (calcium acetate 3 LINZESS CAPS 2 (phosphate binder)) (linaclotide) sevelamer carbonate VIBERZI TABS 100 MG PA 1 3 pack 0.8 gm (eluxadoline) sevelamer carbonate QL(5 ea daily) VIBERZI TABS 75 MG PA; ST 1 3 pack 2.4 gm (eluxadoline) sevelamer carbonate 1 Peripheral Opioid Receptor Antagonists tabs 800 mg alvimopan caps 1 PA; ST sevelamer hcl tabs 400 1 MOVANTIK TABS 12.5 MG mg 3 (naloxegol oxalate) sevelamer hcl tabs 800 PA; ST;QL(16 1 ea daily) MOVANTIK TABS 25 MG QL(1 ea daily) mg 3 (naloxegol oxalate) Short Bowel Syndrome (SBS) Agents RELISTOR SOLN SC 12 PA; LA PA; ST; MG/0.6ML, 8 MG/0.4ML GATTEX KIT Specialty Drug 4 4 refer to (methylnaltrexone (teduglutide (rdna)) bromide) Caremark SP RX;LA RELISTOR TABS OR 150 PA; ST MG (methylnaltrexone 4 Tryptophan Hydroxylase Inhibitors bromide) XERMELO TABS PA; ST; Not 4 available Phosphate Binder Agents (telotristat etiprate) through mail (Calcium Acetate RX/OTC (Phosphate Binder)) 1 GENITOURINARY AGENTS - MISCELLANEOUS CALPHRON TABS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System AURYXIA TABS ( PA; ST ferric 3 citrate) Acidifiers K-PHOS NO 2 TABS calcium acetate (potassium & sodium 2 (phosphate binder) 1 acid phosphates) caps Alkalinizers 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pot & Sod Citrates dutasteride-tamsulosin 1 W/Citric Ac) CYTRA-3 1 hcl caps SYRP QL(1 ea daily); (Potassium Citrate-Citric finasteride tabs 1 AL(At least 40 Acid) CYTRA K 1 yrs old) CRYSTALS, TARON- CRYSTALS PACK silodosin caps 4 mg 1 (Potassium Citrate-Citric 1 RX/OTC QL(1 ea daily) Acid) CYTRA-K SOLN silodosin caps 8 mg 1 (Sodium Citrate & Citric 1 RX/OTC QL(2 ea daily) Acid) CYTRA-2 SOLN tamsulosin hcl caps 1 ORACIT SOLN ( sodium 3 Urinary Stone Agents citrate & citric acid) LITHOSTAT TABS 3 (acetohydroxamic acid) pot & sod citrates 1 w/citric ac soln THIOLA EC TBEC 3 (tiopronin) potassium citrate 1 (alkalinizer) tbcr tiopronin tabs 1 RX/OTC potassium citrate-citric 1 acid soln GOUT AGENTS - Drugs to Treat Gout RX/OTC sodium citrate & citric 1 Gout Agent Combinations acid soln colchicine w/ 1 Cystinosis Agents probenecid tabs CYSTAGON CAPS PA 4 Gout Agents (cysteamine bitartrate) QL(3 ea daily) PROCYSBI CPDR 25 MG, allopurinol tabs 100 mg 1 75 MG (cysteamine 4 1 QL(2 ea daily) bitartrate) allopurinol tabs 300 mg PROCYSBI PACK 300 MG, PA colchicine caps 1 75 MG (cysteamine 4 bitartrate) colchicine tabs 1 Interstitial Cystitis Agents febuxostat tabs 40 mg 1 QL(2 ea daily) ELMIRON CAPS QL(3 ea daily) (pentosan polysulfate 3 febuxostat tabs 80 mg 1 QL(1 ea daily) sodium) MITIGARE CAPS 7 Prostatic Hypertrophy Agents (colchicine) QL(1 ea daily) alfuzosin hcl tb24 1 Uricosurics CARDURA XL TB24 probenecid tabs 1 (doxazosin mesylate 3 (bph)) HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders 1 AL(At least 40 dutasteride caps yrs old) Antihemophilic Products

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVATE SOLR PA; LA PA; MUST CORIFACT KIT (factor USE ACARIA (antihemophilic factor 4 (rcmb) plasma/albumin xiii concentrate 4 SPECIALTY free (rahf-pfm)) (human)) RX 844-538- 4661;LA PA; Must use ADYNOVATE SOLR AcariaHealth ELOCTATE SOLR PA; Must use (antihemophilic factor 4 Specialty Rx at AcariaHealth (antihemophilic factor 4 Specialty Rx at (recombinant) pegylated) 1-844-538- (rcmb) fc fusion 4661;LA 1-844-538- protein(bdd-rfviiifc)) 4661;LA PA; Must use AFSTYLA KIT PA; MUST AcariaHealth FEIBA SOLR (antihemophilic factor 4 Specialty Rx at USE ACARIA (recombinant) single 1-844-538- (antiinhibitor coagulant 4 SPECIALTY chain) 4661;LA complex) RX 844-538- 4661;LA ALPHANATE SOLR PA; Must use ( AcariaHealth PA; MUST antihemophilic HEMOFIL M SOLR USE ACARIA factor/von willebrand 4 Specialty Rx at 1-844-538- (antihemophilic factor 3 SPECIALTY factor complex 4661;LA (human)) RX 844-538- (human)) 4661;LA ALPHANATE/VON PA; Must use HUMATE-P SOLR PA; Must use WILLEBRANDFACTOR AcariaHealth (antihemophilic AcariaHealth COMPLEX/HUMAN SOLR Specialty Rx at factor/von willebrand 4 Specialty Rx at (antihemophilic 4 1-844-538- factor complex 1-844-538- 4661;LA 4661;LA factor/von willebrand (human)) factor complex IDELVION SOLR 1000 PA; Must use (human)) UNIT, 2000 UNIT, 250 AcariaHealth PA; Must use UNIT, 500 UNIT Specialty Rx at 4 ALPHANINE SD SOLR AcariaHealth (coagulation factor ix 1-844-538- 4 Specialty Rx at 4661;LA (coagulation factor ix) recomb albumin fusion 1-844-538- protein (rix-fp)) 4661;LA PA; Must use IDELVION SOLR 3500 PA; MUST ALPROLIX SOLR USE ACARIA AcariaHealth UNIT (coagulation factor (coagulation factor ix 4 SPECIALTY 4 Specialty Rx at ix recomb albumin (recomb) fc fusion protein 1-844-538- RX 844-538- fusion protein (rix-fp)) 4661;LA (rfixfc)) 4661;LA PA; Must use PA; Must use IXINITY SOLR BENEFIX KIT AcariaHealth AcariaHealth ( 4 (coagulation factor ix 4 Specialty Rx at coagulation factor ix Specialty Rx at 1-844-538- (recombinant)) 1-844-538- (recombinant)) 4661;LA 4661;LA PA; Must use PA; Must use COAGADEX SOLR JIVI SOLR (antihemophil AcariaHealth AcariaHealth 4 (coagulation factor x 4 Specialty Rx at fact(rcmb) pegylated-aucl Specialty Rx at 1-844-538- (bdd-rfviii peg-aucl)) 1-844-538- (human)) 4661;LA 4661;;LA

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use PA; Must use KCENTRA KIT AcariaHealth PROFILNINE SOLR AcariaHealth (prothrombin complex 4 Specialty Rx at 4 Specialty Rx at (factor ix complex) concentrate human) 1-844-538- 1-844-538- 4661;LA 4661;LA PA; MUST REBINYN SOLR PA; KOATE SOLR USE ACARIA administered (coagulation factor ix 4 (antihemophilic factor 3 SPECIALTY (recombinant) under the (human)) RX 844-538- glycopegylated) medical benefit 4661;LA PA; Must use PA; MUST RECOMBINATE SOLR KOATE-DVI SOLR AcariaHealth USE ACARIA (antihemophilic factor 4 Specialty Rx at (antihemophilic factor 3 SPECIALTY (recombinant) (rfviii)) 1-844-538- (human)) RX 844-538- 4661;LA 4661;LA PA; Must use KOVALTRY SOLR PA; LA RIXUBIS SOLR AcariaHealth (antihemophilic factor 4 (coagulation factor ix 4 Specialty Rx at (rcmb) plasma/albumin (recombinant)) 1-844-538- free (rahf-pfm)) 4661;LA PA; Must use TRETTEN SOLR PA; Must use MONONINE SOLR AcariaHealth (coagulation factor xiii AcariaHealth 4 Specialty Rx at 4 Specialty Rx at (coagulation factor ix) 1-844-538- a-subunit 1-844-538- 4661;LA (recombinant)) 4661;LA NOVOEIGHT SOLR PA; Must use PA; Must use AcariaHealth VONVENDI SOLR (von AcariaHealth (antihemophilic factor 4 Specialty Rx at willebrand factor 4 Specialty Rx at (rcmb) bd truncated (bd 1-844-538- (recombinant)) 1-844-538- trunc-rfviii)) 4661;LA 4661;LA NOVOSEVEN RT SOLR PA; Must use WILATE KIT PA; Must use (coagulation factor viia 4 AcariaHlth Sp (antihemophilic AcariaHealth Rx 1-844-538- factor/von willebrand 4 Specialty Rx at (recombinant)) 4661;LA 1-844-538- factor complex 4661;LA NUWIQ KIT PA; MUST (human)) USE ACARIA (antihemophilic factor 4 SPECIALTY XYNTHA KIT PA; Must use (rcmb) simoctocog AcariaHealth RX 844-538- (antihemophilic factor alfa(bdd-rfviii,sim)) 4661;LA 4 Specialty Rx at (rcmb) moroctocog 1-844-538- OBIZUR SOLR PA; Must use alfa(bdd-rfviii,mor)) 4661;LA AcariaHealth (antihemophilic factor 4 Specialty Rx at XYNTHA SOLOFUSE KIT PA; Must use (recombinant porcine) AcariaHealth 1-844-538- (antihemophilic factor (rpfviii)) 4661;LA 4 Specialty Rx at (rcmb) moroctocog 1-844-538- PA; Must use alfa(bdd-rfviii,mor)) 4661;LA PROFILNINE SD SOLR AcariaHealth 4 Specialty Rx at Bradykinin B2 Receptor Antagonists (factor ix complex) 1-844-538- 4661;LA

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use QL(2 ea daily) clopidogrel bisulfate 1 AcariaHealth tabs (Icatibant Acetate) 4 Specialty Rx at SAJAZIR SOLN 1-844-538- dipyridamole tabs 1 4661 ;LA PA; Must use prasugrel hcl tabs 1 FIRAZYR SOLN (icatibant AcariaHealth 7 Specialty Rx at HEMATOPOIETIC AGENTS - Drugs to Treat acetate) 1-844-538- Blood Disorders 4661 ;LA Agents for Gaucher Disease PA; Must use CERDELGA CAPS PA 4 AcariaHealth (eliglustat tartrate) icatibant acetate soln 4 Specialty Rx at CEREZYME SOLR PA; LA 1-844-538- 4 4661 ;LA (imiglucerase) Complement Inhibitors miglustat caps 4 PA; ST PA; Specialty HAEGARDA SOLR (c1 ZAVESCA CAPS PA; ST 4 drug-Health 7 esterase inhibitor Net will refer to (miglustat) ) (human) SP Pharmacy Agents for Sickle Cell Disease Hemataologic - Tyrosine Kinase Inhibitors DROXIA CAPS TAVALISSE TABS 100 MG PA; ST (hydroxyurea (sickle 2 4 (fostamatinib disodium) cell anemia)) TAVALISSE TABS 150 MG PA SIKLOS TABS 100 MG PA; ST;AC 4 (fostamatinib disodium) (hydroxyurea (sickle 4 ) Hematorheologic Agents cell anemia) QL(3 ea daily) SIKLOS TABS 1000 MG PA; AC pentoxifylline tbcr 1 (hydroxyurea (sickle 4 Human Protein C cell anemia)) CEPROTIN SOLR PA; LA Folic Acid/Folates (protein c concentrate 4 (Folic Acid) CVS FOLIC PV (human)) ACID, FOLATE, GNP FOLIC ACID, HM FOLIC Platelet Aggregation Inhibitors ACID, PX FOLIC ACID, QC 5 1 FOLIC ACID, RA FOLIC anagrelide hcl caps ACID, SM FOLIC ACID, YL FOLIC ACID TABS aspirin-dipyridamole 1 cp12 (Folic Acid) KP FOLIC 1 RX/OTC BRILINTA TABS 60 MG QL(2 ea daily) ACID TABS 1 MG 2 (ticagrelor) (Folic Acid) KP FOLIC 5 PV ACID TABS 800 MCG BRILINTA TABS 90 MG 2 RX/OTC (ticagrelor) folic acid tabs 1 mg 1 QL(2 ea daily) PV cilostazol tabs 1 folic acid tabs 400 mcg, 5 800 mcg Hematopoietic Growth Factors 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FULPHILA SOSY PA PA; Must use 4 (pegfilgrastim-jmdb) ZARXIO SOSY AcariaHealth PA; Must use 4 Specialty Rx at (filgrastim-sndz) 1-844-538- GRANIX SOLN (tbo- AcariaHealth 4 Specialty Rx at 4661;;LA filgrastim) ZIEXTENZO SOSY PA; ST 1-844-538- 4 4661 (pegfilgrastim-bmez) PA; Must use Hematopoietic Mixtures GRANIX SOSY (tbo- AcariaHealth 4 Specialty Rx at FOLIVANE-F CAPS filgrastim) (ferrous fumarate-iron 1-844-538- 2 4661 polysaccharide LEUKINE SOLR PA; LA complex-folic acid-c-b3) 4 (sargramostim) INTEGRA F CAPS MULPLETA TABS PA (ferrous fumarate-iron 4 2 (lusutrombopag) polysaccharide NIVESTYM SOLN 300 PA; ST complex-folic acid-c-b3) 4 MCG/ML (filgrastim-aafi) HEMOSTATICS - Drugs to Stop Bleeding/Treat NIVESTYM SOLN 480 PA Blood Disorders MCG/1.6ML (filgrastim- 4 Hemostatics - Systemic aafi) aminocaproic acid soln 1 NIVESTYM SOSY 300 PA MCG/0.5ML, 480 aminocaproic acid tabs 1 MCG/0.8ML (filgrastim- 4 CYKLOKAPRON SOLN PA aafi) 7 ( ) PROMACTA PACK 12.5 PA; QL(1 ea tranexamic acid PA MG (eltrombopag 4 daily) tranexamic acid soln iv 4 olamine) 1000 mg/10ml PROMACTA PACK 25 MG PA tranexamic acid tabs or QL(6 ea daily,5 4 1 (eltrombopag olamine) 650 mg day(s) limit) PROMACTA TABS 12.5 PA; QL(1 ea HYPNOTICS/SEDATIVES/SLEEP DISORDER MG, 25 MG, 50 MG, 75 MG 4 daily) AGENTS (eltrombopag olamine) Barbiturate Hypnotics RETACRIT SOLN 10000 PA BUTISOL SODIUM TABS UNIT/ML, 2000 UNIT/ML, 3 20000 UNIT/2ML, 3000 (butabarbital sodium) 4 UNIT/ML, 4000 UNIT/ML, phenobarbital elix 1 40000 UNIT/ML (epoetin alfa-epbx) phenobarbital soln 1 PA; ST; Must use phenobarbital tabs 1 UDENYCA SOSY 4 AcariaHealth (pegfilgrastim-cbqv) Specialty Rx at Non-Barbiturate Hypnotics 1-844-538- DORAL TABS 7 4661 (quazepam)

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits estazolam tabs 1 (Peg 3350-Kcl-Nacl-Na PV Sulfate-Na Ascorbate- 1 QL(1 ea daily) Ascorbic Acid) PEG- 5 eszopiclone tabs 3350/ELECTROLYTES/AS QL(2 ea daily) CORBATE SOLR flurazepam hcl caps 15 1 mg (Peg 3350-Kcl-Sod Bicarb- QL(4000 ml per QL(1 ea daily) Sod Chloride-Sod Sulfate) 5 fill retail); PV flurazepam hcl caps 30 1 GAVILYTE-C, GAVILYTE- mg G SOLR midazolam hcl syrp 1 (Peg 3350-Potassium PV Chloride-Sod Bicarbonate- QL(2 ea daily) Sod Chloride) GAVILYTE- 5 temazepam caps 15 1 mg N/FLAVOR PACK, QL(1 ea daily) TRILYTE SOLR temazepam caps 22.5 1 mg, 30 mg COLYTE-FLAVOR PACKS QL(4000 ml per SOLR (peg 3350-kcl-sod fill retail); PV 7 temazepam caps 7.5 1 bicarb-sod chloride-sod mg sulfate) triazolam tabs 0.125 1 GOLYTELY SOLR 2.82 PA; QL(4000 mg GM-5.53 GM-6.36 GM-21.5 ea per fill retail); PV triazolam tabs 0.25 mg 1 QL(1 ea daily) GM-227.1 GM (peg 3350- 5 kcl-sod bicarb-sod zaleplon caps 1 QL(1 ea daily) chloride-sod sulfate) GOLYTELY SOLR 2.97 QL(4000 ml per QL(1 ea daily) zolpidem tartrate tabs 1 GM-5.86 GM-6.74 GM- fill retail); PV or 10 mg, 5 mg 22.74 GM-236 GM (peg QL(1 ea daily) 7 zolpidem tartrate tbcr 1 3350-kcl-sod bicarb- or 12.5 mg, 6.25 mg sod chloride-sod Orexin Receptor Antagonists sulfate) BELSOMRA TABS ST; QL(1 ea NULYTELY SOLR (peg PV 2 (suvorexant) daily) 3350-potassium chloride-sod 7 Selective Melatonin Receptor Agonists bicarbonate-sod HETLIOZ CAPS PA; ST 4 chloride) (tasimelteon) NULYTELY/FLAVOR PV 1 ST; QL(1 ea ramelteon tabs daily) PACKS SOLR (peg 3350- potassium chloride-sod 7 LAXATIVES - Bowel Treatment Drugs bicarbonate-sod chloride) Laxative Combinations PV (Bisacodyl-Peg 3350-Pot QL(1 ea per fill peg 3350-kcl-nacl-na Chloride-Sod Bicarb-Sod 5 retail); PV sulfate-na ascorbate- 5 Chloride) PEG-PREP KIT ascorbic acid solr peg 3350-kcl-sod QL(4000 ml per bicarb-sod chloride-sod 5 fill retail); PV sulfate solr

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits peg 3350-potassium PV (Bisacodyl) ALOPHEN, Available for BISACODYL EC, members in chloride-sod 5 bicarbonate-sod CORRECT, CORRECTOL, non- CVS BISACODYL, CVS C- grandfathered chloride solr LAX LAXATIVE, CVS plans ages 50- Laxatives - Miscellaneous GENTLE LAXATIVE, CVS 74;AL(At least GENTLE LAXATIVE 50 yrs old - Up (Lactulose) CONSTULOSE 1 SOLN WOMENS, DUCODYL, EQ to 74 yrs old); GENTLE LAXATIVE, EQL PV (Polyethylene Glycol 3350) Limit 528gms GENTLE LAXATIVE, EQL CLEARLAX, CVS per LAXATIVE, EQL WOMANS PURELAX, EQ month;QL(17.6 LAXATIVE, EX-LAX CLEARLAX, EQL gm daily) ULTRA, FEENAMINT, CLEARLAX, GAVILAX, GENTLE LAXATIVE, GNP GENTLELAX, GLYCOLAX, BISA-LAX, GNP GENTLE GNP CLEARLAX, LAXATIVE, GNP GOODSENSE CLEARLAX, 1 WOMENS GENTLE HM CLEARLAX, KLS LAXATIVE, GOODSENSE 1 LAXACLEAR, MM BISACODYL EC, CLEARLAX, QC NATURA- GOODSENSE WOMENS LAX, SB POLYETHYLENE LAXATIVE, HM LAXATIVE, GLYCOL 3350, SM KP BISACODYL, CLEARLAX, SMOOTH LAXATIVE, PX LAXATIVE, LAX, TGT POWDERLAX QC GENTLE LAXATIVE, POWD RA WOMENS LAXATIVE, (Polyethylene Glycol 3350) Limit 528gms SB BISACODYL 1 per LAXATIVE EC, SB RA LAXATIVE POWD 17 month;QL(17.6 GM/SCOOP GENTLE LAX-WOMEN, gm daily) SM GENTLE LAXATIVE, SM WOMANS LAXATIVE, lactulose soln 1 STIMULANT LAXATIVE, Limit 528gms TGT GENTLE LAXATIVE, TGT WOMENS LAXATIVE, polyethylene glycol 1 per 3350 powd month;QL(17.6 VERACOLATE, WOMANS gm daily) LAXATIVE, WOMENS LAXATIVE TBEC Saline Laxatives (Bisacodyl) BISACODYL Available for OSMOPREP TABS PA; PV LAXATIVE, CVS members in (sodium phosphate BISACODYL, CVS non- monobasic-sodium 5 GENTLE LAXATIVE, grandfathered phosphate dibasic) GENTLE LAXATIVE, GNP plans ages 50- GENTLE LAXATIVE, HM 1 74;AL(At least Stimulant Laxatives LAXATIVE, LAXATIVE, QC 50 yrs old - Up GENTLE LAXATIVE, RA to 74 yrs old); FAST RELIEF LAXATIVE, PV SB LAXATIVE, SM LAXATIVE, THE MAGIC BULLET SUPP

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Available for (Erythromycin Stearate) members in ERYTHROCIN STEARATE 1 non- TABS grandfathered erythromycin base (Bisacodyl) RA LAXATIVE 1 plans ages 50- 1 TBEC 5 MG 74;AL(At least cpep 50 yrs old - Up erythromycin base tabs 1 to 74 yrs old); PV erythromycin base tbec 1 Available for members in erythromycin non- ethylsuccinate susr 200 1 grandfathered mg/5ml, 400 mg/5ml bisacodyl supp 1 plans ages 50- 74;AL(At least erythromycin 50 yrs old - Up ethylsuccinate tabs 400 1 to 74 yrs old); mg PV Fidaxomicin MACROLIDES - Drugs to Treat Bacterial DIFICID TABS 200 MG 3 Infections (fidaxomicin) Azithromycin MEDICAL DEVICES AND SUPPLIES azithromycin pack 1 gm 1 Contraceptives azithromycin susr 100 1 CAYA DPRH (diaphragm QL(1 ea per mg/5ml, 200 mg/5ml 5 365 days ) QL(6 ea per fill arc-spring retail); PV azithromycin tabs 250 1 mg retail) FC FEMALE CONDOM PV QL(3 ea daily) MISC (condoms - 5 azithromycin tabs 500 1 mg female) QL(10 ea per FC2 FEMALE CONDOM PV azithromycin tabs 600 1 mg fill retail) MISC (condoms - 5 female) Clarithromycin FEMCAP DEVI ( PV cervical 5 clarithromycin susr 125 1 caps) mg/5ml, 250 mg/5ml OMNIFLEX DIAPHRAGM PV 5 clarithromycin tabs 250 1 DPRH (diaphragms) mg, 500 mg WIDE-SEAL SILICONE PV QL(14 ea per DIAPHRAGM KIT 60 clarithromycin tb24 500 1 mg fill retail) DPRH (diaphragm wide 5 ) Erythromycins seal WIDE-SEAL SILICONE PV (Erythromycin Base) ERY- 1 TAB TBEC DIAPHRAGM KIT 65 DPRH (diaphragm wide 5 (Erythromycin Ethylsuccinate) E.E.S. 400 1 seal) TABS

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WIDE-SEAL SILICONE PV QL(6.67 ea DIAPHRAGM KIT 70 ACCU-CHEK SAFE-T-PRO daily,200 ea 5 2 per fill DPRH (diaphragm wide LANCETS MISC (lancets) seal) retail,600 ea per fill mail) WIDE-SEAL SILICONE PV DIAPHRAGM KIT 75 QL(6.67 ea 5 ACCU-CHEK SAFE-T-PRO daily,200 ea DPRH (diaphragm wide PLUSLANCETS MISC 2 per fill seal) (lancets) retail,600 ea WIDE-SEAL SILICONE PV per fill mail) DIAPHRAGM KIT 80 QL(6.67 ea DPRH ( 5 diaphragm wide ACCU-CHEK SOFTCLIX daily,200 ea 2 per fill seal) LANCETS MISC (lancets) WIDE-SEAL SILICONE PV retail,600 ea DIAPHRAGM KIT 85 per fill mail) DPRH (diaphragm wide 5 QL(6.67 ea seal) ACTI-LANCE LANCETS daily,200 ea 2 per fill WIDE-SEAL SILICONE PV 28G MISC (lancets) retail,600 ea DIAPHRAGM KIT 90 5 per fill mail) DPRH (diaphragm wide QL(6.67 ea seal) ACTI-LANCE LITE daily,200 ea WIDE-SEAL SILICONE PV SAFETY LANCETS 28G 2 per fill DIAPHRAGM KIT 95 MISC (lancets) retail,600 ea DPRH (diaphragm wide 5 per fill mail) seal) QL(6.67 ea ACTI-LANCE SPECIAL daily,200 ea Diabetic Supplies SAFETY LANCETS 17G 2 per fill 1ST TIER UNILET QL(6.67 ea MISC (lancets) retail,600 ea COMFORTOUCH daily,200 ea per fill mail) LANCETS 28G MISC 2 per fill QL(6.67 ea retail,600 ea (lancets) ACTI-LANCE SPECIAL daily,200 ea per fill mail) SAFETYLANCETS 17G 2 per fill 1ST TIER UNILET QL(6.67 ea MISC (lancets) retail,600 ea COMFORTOUCH daily,200 ea per fill mail) LANCETS 30G MISC 2 per fill QL(6.67 ea retail,600 ea (lancets) ACTI-LANCE UNIVERSAL daily,200 ea per fill mail) SAFETY LANCETS 23G 2 per fill QL(6.67 ea MISC (lancets) retail,600 ea ACCU-CHEK FASTCLIX daily,200 ea per fill mail) LANCETS MISC 2 per fill QL(6.67 ea (lancets) retail,600 ea ADVANCED MOBILE daily,200 ea per fill mail) LANCET 30G MISC 2 per fill QL(6.67 ea (lancets) retail,600 ea ACCU-CHEK MULTICLIX daily,200 ea per fill mail) LANCETS MISC 2 per fill (lancets) retail,600 ea per fill mail)

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea ASSURE HAEMOLANCE ADVOCATE LANCETS daily,200 ea daily,200 ea 2 per fill PLUS HIGH FLOW 18G 2 per fill 30G MISC ( ) lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE HAEMOLANCE ADVOCATE LANCETS daily,200 ea daily,200 ea 2 per fill PLUS LOW FLOW 25G 2 per fill ) MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ADVOCATE SAFETY daily,200 ea ASSURE HAEMOLANCE daily,200 ea LANCETS 26G MISC 2 per fill PLUS MICRO FLOW 28G 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ADVOCATE SAFETY daily,200 ea ASSURE HAEMOLANCE daily,200 ea LANCETS MISC 2 per fill PLUS NORMAL FLOW 2 per fill (lancets) retail,600 ea 21G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea AGAMATRIX ULTRA-THIN daily,200 ea ASSURE HAEMOLANCE daily,200 ea LANCETS 33G MISC 2 per fill PLUS PEDIATRIC BLADE 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE LANCE AIMSCO TWIST LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS 21G MISC 2 per fill ) 32G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea AIMSCO TWIST LANCETS daily,200 ea ASSURE LANCE daily,200 ea 2 per fill 2 per fill 33G MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea AQUALANCE LANCETS daily,200 ea ASSURE LANCE PLUS daily,200 ea ULTRA THIN 30G MISC 2 per fill SAFETYLANCETS 25G 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE COMFORT daily,200 ea ASSURE LANCE PLUS daily,200 ea LANCETS ULTRA THIN 2 per fill SAFETYLANCETS 30G 2 per fill 28G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea ASSURE LANCE SAFETY daily,200 ea CAREONE LANCET daily,200 ea LANCET 28G MISC 2 per fill SUPER THIN/30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE LANCETS MISC daily,200 ea CAREONE LANCET THIN daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea AURORA LANCET SUPER daily,200 ea CARESENS LANCETS daily,200 ea 2 per fill 2 per fill THIN30G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CARETOUCH SAFETY AURORA LANCET THIN daily,200 ea daily,200 ea 2 per fill LANCETS/26G MISC 2 per fill ) 23G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CARETOUCH SAFETY BD LANCET ULTRAFINE daily,200 ea daily,200 ea 2 per fill LANCETS/28G MISC 2 per fill ) 30G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CARETOUCH SAFETY BD LANCET ULTRAFINE daily,200 ea daily,200 ea 2 per fill LANCETS/30G MISC 2 per fill ) 33G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea BD MICROTAINER daily,200 ea CARETOUCH TWIST daily,200 ea LANCETS MISC 2 per fill LANCETS 28G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea BULLSEYE MINI SAFETY daily,200 ea CARETOUCH TWIST daily,200 ea LANCETS MISC 2 per fill LANCETS 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea BULLSEYE SAFETY daily,200 ea CARETOUCH TWIST daily,200 ea LANCETS MISC 2 per fill LANCETS 33G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea CLEANLET LANCETS 28G daily,200 ea COMFORT LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CLEVER CHEK LANCETS daily,200 ea COMFORT TOUCH daily,200 ea ULTRATHIN 30G MISC 2 per fill LANCETS ULTRA THIN 2 per fill (lancets) retail,600 ea 31G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea COMFORT TOUCH PLUS QL(6.67 ea CLEVER CHEK LANCETS daily,200 ea daily,200 ea ULTRATHIN MISC SAFETY LANCETS 2 per fill PRESSURE ACTIVATED 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) 30G MISC (lancets) per fill mail) QL(6.67 ea QL(6.67 ea CLEVER CHOICE daily,200 ea CVS LANCETS 21G MISC daily,200 ea COMFORT EZLANCETS 2 per fill 2 per fill ) 21G MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CLEVER CHOICE daily,200 ea CVS LANCETS MICRO daily,200 ea COMFORT EZLANCETS 2 per fill 2 per fill ) 23G MISC (lancets) retail,600 ea THIN 33G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CLEVER CHOICE daily,200 ea CVS LANCETS MICRO- daily,200 ea COMFORT EZLANCETS 2 per fill 2 per fill ) 28G MISC (lancets) retail,600 ea THIN 33G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea COAGUCHEK LANCETS daily,200 ea CVS LANCETS ORIGINAL daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea COMFORT ASSURED daily,200 ea CVS LANCETS THIN 26G daily,200 ea LANCETS MICRO THIN 2 per fill 2 per fill ) 33G MISC (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea COMFORT ASSURED daily,200 ea CVS LANCETS ULTRA daily,200 ea LANCETS SUPER THIN 2 per fill 2 per fill ) 28G MISC (lancets) retail,600 ea THIN 30G MISC (lancets retail,600 ea per fill mail) per fill mail)

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea CVS LANCETS ULTRA- daily,200 ea DRUG MART UNILET daily,200 ea 2 per fill LANCETSULTRA THIN 2 per fill THIN 30G MISC ( ) lancets retail,600 ea 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CVS ULTRA THIN daily,200 ea DRUG MART UNILET daily,200 ea LANCETS MISC 2 per fill MICRO THIN LANCETS 2 per fill (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DIATHRIVE LANCETS daily,200 ea E-Z JECT LANCETS 21G daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DIATHRIVE LANCETS daily,200 ea E-Z JECT LANCETS daily,200 ea ULTRA THIN 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea COLOR MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DROPLET LANCETS daily,200 ea E-Z JECT LANCETS MISC daily,200 ea ULTRA THIN 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DROPLET PERSONAL daily,200 ea E-Z JECT LANCETS daily,200 ea LANCETS30G MISC 2 per fill SUPER THIN 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DRUG MART LANCETS daily,200 ea E-Z JECT LANCETS THIN daily,200 ea 2 per fill 2 per fill THIN MISC (lancets) retail,600 ea 26G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DRUG MART ON-THE-GO daily,200 ea E-ZJECT LANCETS daily,200 ea LANCETS GENTLE 30G 2 per fill MICRO-THIN 33G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DRUG MART UNILET daily,200 ea EASY COMFORT daily,200 ea LANCETSSUPER THIN 2 per fill LANCETS 30G/PULL TOP 2 per fill 30G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea EASY COMFORT daily,200 ea EASY TOUCH LANCETS daily,200 ea LANCETS 30G/THIN TOP 2 per fill 28G/TWIST MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EASY COMFORT daily,200 ea EASY TOUCH LANCETS daily,200 ea LANCETS MISC 2 per fill 30G/BUTTON-ACTIVATED 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea EASY COMFORT daily,200 ea daily,200 ea LANCETS TWIST TOP 30G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) EASY TOUCH LANCETS QL(6.67 ea QL(6.67 ea daily,200 ea EASY TOUCH LANCETS daily,200 ea 21G/PRESSURE 30G/PULL-TOP MISC ACTIVATED MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) EASY TOUCH LANCETS QL(6.67 ea QL(6.67 ea daily,200 ea EASY TOUCH LANCETS daily,200 ea 23G/PRESSURE 30G/TWIST MISC ACTIVATED MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) EASY TOUCH LANCETS QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea 26G/PRESSURE daily,200 ea 32G/PRESSURE daily,200 ea ACTIVATED MISC 2 per fill ACTIVATED MISC 2 per fill retail,600 ea retail,600 ea (lancets) per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea EASY TOUCH LANCETS daily,200 ea EASY TOUCH LANCETS daily,200 ea 26G/PULL-TOP MISC 2 per fill 32G/PULL-TOP MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) EASY TOUCH LANCETS QL(6.67 ea QL(6.67 ea 28G/PRESSURE daily,200 ea EASY TOUCH LANCETS daily,200 ea 32G/TWIST MISC ACTIVATED MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EASY TOUCH LANCETS daily,200 ea EASY TOUCH LANCETS daily,200 ea 28G/PULL-TOP MISC 2 per fill 33G/TWIST MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH SAFETY QL(6.67 ea EMBRACE PRESSURE QL(6.67 ea LANCETS21G/PRESSURE daily,200 ea ACTIVATED SAFETY daily,200 ea ACTIVATED MISC 2 per fill LANCET/28G MISC 2 per fill retail,600 ea retail,600 ea (lancets) per fill mail) (lancets) per fill mail) EASY TOUCH SAFETY QL(6.67 ea QL(6.67 ea LANCETS23G/PRESSURE daily,200 ea EQL COLOR LANCETS daily,200 ea ACTIVATED MISC 2 per fill 2 per fill retail,600 ea 21G MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) EASY TOUCH SAFETY QL(6.67 ea QL(6.67 ea daily,200 ea EQL COLOR LANCETS daily,200 ea LANCETS26G/BUTTON MICRO THIN 33G MISC ACTIVATED MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) EASY TOUCH SAFETY QL(6.67 ea QL(6.67 ea daily,200 ea EQL SUPER THIN daily,200 ea LANCETS26G/PRESSURE LANCETS 30G MISC ACTIVATED MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) EASY TOUCH SAFETY QL(6.67 ea QL(6.67 ea LANCETS28G/BUTTON daily,200 ea EQL THIN LANCETS 26G daily,200 ea ACTIVATED MISC 2 per fill 2 per fill retail,600 ea MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) EASY TOUCH SAFETY QL(6.67 ea QL(6.67 ea LANCETS28G/PRESSURE daily,200 ea EZ-LETS LANCETS 21G daily,200 ea ACTIVATED MISC 2 per fill 2 per fill retail,600 ea MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EASY TWIST & CAP daily,200 ea EZ-LETS LANCETS 26G daily,200 ea LANCETS MISC 2 per fill SUPER-SOFT MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EMBRACE LANCETS daily,200 ea EZ-LETS LANCETS 28G daily,200 ea ULTRA THIN 30G MISC 2 per fill ULTRA-SOFT MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) EMBRACE PRESSURE QL(6.67 ea QL(6.67 ea ACTIVATED SAFETY daily,200 ea EZ-LETS LANCETS 30G daily,200 ea LANCET/21G MISC 2 per fill 2 per fill retail,600 ea MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail)

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea FIFTY50 SAFETY SEAL daily,200 ea FREESTYLE UNISTICK II daily,200 ea LANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea FIFTY50 SAFETY SEAL daily,200 ea GENTEEL BUTTERFLY daily,200 ea LANCETS 32G MISC 2 per fill TOUCH LANCETS MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea FIFTY50 UNILET daily,200 ea GENTLE-LET GP daily,200 ea LANCETS 33G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea GENTLE-LET LANCETS QL(6.67 ea daily,200 ea GENERAL PURPOSE daily,200 ea FINE 30 MISC (lancets) 2 per fill STYLE/FINE POINT MISC 2 per fill retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea GENTLE-LET LANCETS QL(6.67 ea FINGERSTIX LANCETS daily,200 ea GENERAL PURPOSE daily,200 ea 2 per fill STYLE/MEDIUM POINT 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) MISC (lancets) per fill mail) QL(6.67 ea QL(6.67 ea GENTLE-LET LANCETS FORA LANCETS MISC daily,200 ea daily,200 ea 2 per fill SAFETY STYLE/FINE 2 per fill ) (lancets retail,600 ea POINT MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea FREDS PHARMACY daily,200 ea GENTLE-LET LANCETS daily,200 ea UNILET LANCETS SUPER 2 per fill SAFETY STYLE/MEDIUM 2 per fill THIN 30G MISC (lancets) retail,600 ea POINT MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea FREDS PHARMACY daily,200 ea GLOBAL INJECT EASE daily,200 ea UNILET LANCETS ULTRA 2 per fill LANCETS 28G MISC 2 per fill THIN 28G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GLOBAL INJECT EASE FREESTYLE LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS 30G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea GLUCOCOM LANCETS daily,200 ea GNP STERILE LANCETS daily,200 ea 2 per fill 2 per fill 28G MISC (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GLUCOCOM LANCETS daily,200 ea GNP STERILE LANCETS daily,200 ea 2 per fill 2 per fill 30G MISC (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GLUCOCOM LANCETS daily,200 ea GOJJI STERILE LANCETS daily,200 ea 2 per fill 2 per fill 33G MISC (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea GOODSENSE COLOR QL(6.67 ea GNP LANCETS 21G MISC daily,200 ea LANCETS MICRO-THIN daily,200 ea 2 per fill 33G UNIVERSAL MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea GOODSENSE LANCETS GNP LANCETS MICRO daily,200 ea daily,200 ea 2 per fill MICRO-THIN 33G MISC 2 per fill ) THIN 33G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea GOODSENSE LANCETS QL(6.67 ea GNP LANCETS SUPER daily,200 ea MICRO-THIN 33G daily,200 ea 2 per fill UNIVERSAL MISC 2 per fill THIN 30G MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea GOODSENSE LANCETS QL(6.67 ea GNP LANCETS THIN 26G daily,200 ea ULTRA-THIN 26G daily,200 ea 2 per fill UNIVERSAL MISC 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea GOODSENSE LANCETS GNP LANCETS THIN daily,200 ea daily,200 ea 2 per fill ULTRA-THIN 30G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea GOODSENSE LANCETS QL(6.67 ea GNP STERILE LANCETS daily,200 ea ULTRA-THIN 30G daily,200 ea 2 per fill UNIVERSAL MISC 2 per fill 28G MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail)

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea H-E-B INCONTROL daily,200 ea HAEMOLANCE PLUS daily,200 ea LANCETS MICRO THIN 2 per fill PEDIATRIC FLOW MISC 2 per fill 33G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea H-E-B INCONTROL daily,200 ea HEALTHY ACCENTS daily,200 ea LANCETS SUPER THIN 2 per fill UNILET LANCETS SUPER 2 per fill 30G MISC (lancets) retail,600 ea THIN 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea H-E-B INCONTROL daily,200 ea HY-VEE LANCETS MISC daily,200 ea LANCETS ULTRA THIN 2 per fill 2 per fill ) 28G MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea HAEMOLANCE LOW daily,200 ea HY-VEE THIN LANCETS daily,200 ea FLOW LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea IN TOUCH STERILE HAEMOLANCE MISC daily,200 ea daily,200 ea 2 per fill LANCETS30G MISC 2 per fill ) (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea HAEMOLANCE PLUS daily,200 ea KINNEY LANCETS MISC daily,200 ea HIGH FLOW MISC 2 per fill 2 per fill ) (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea HAEMOLANCE PLUS daily,200 ea KINNEY THIN LANCETS daily,200 ea LOW FLOW MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea HAEMOLANCE PLUS daily,200 ea KROGER HEALTHPRO daily,200 ea MAX FLOW MISC 2 per fill TWIST LANCETS/26G 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea HAEMOLANCE PLUS daily,200 ea KROGER LANCETS 21G daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea KROGER LANCETS daily,200 ea LANCETS 30G TWIST daily,200 ea MICRO THIN33G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea TOP MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER LANCETS MISC daily,200 ea LANCETS 30G/TWIST daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea TOP MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER LANCETS daily,200 ea LANCETS 31G TWIST daily,200 ea SUPER THIN MISC 2 per fill 2 per fill ) (lancets) retail,600 ea TOP MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER LANCETS THIN daily,200 ea LANCETS 33G EXTRA daily,200 ea 2 per fill 2 per fill 26G MISC (lancets) retail,600 ea FINE MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS 33G KROGER LANCETS THIN daily,200 ea daily,200 ea 2 per fill UNIVERSAL DESIGN 2 per fill ) MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER LANCETS daily,200 ea LANCETS MICRO THIN daily,200 ea ULTRATHIN30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 33G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS 26G TWIST daily,200 ea daily,200 ea 2 per fill LANCETS MISC (lancets) 2 per fill TOP MISC (lancets) retail,600 ea retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS 28G MISC daily,200 ea LANCETS SAFETY SEAL daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea 21G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS 30G MISC daily,200 ea LANCETS SAFETY SEAL daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea 26G MISC (lancets) retail,600 ea per fill mail) per fill mail)

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea LIBERTY MEDICAL LANCETS SAFETY SEAL daily,200 ea daily,200 ea 2 per fill LANCETS 30G MISC 2 per fill 28G MISC ( ) lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LIFESCAN UNISTIK 2 LANCETS SAFETY SEAL daily,200 ea daily,200 ea 2 per fill DEEP PENETRATION 2 per fill ) 30G MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS SUPER THIN daily,200 ea LIFESCAN UNISTIK II daily,200 ea 2 per fill 2 per fill 28G MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS THIN MISC daily,200 ea LITE TOUCH LANCETS daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LITETOUCH LANCETS LANCETS TWIST TOP daily,200 ea daily,200 ea 2 per fill MICRO THIN 33G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LIVE BETTER LANCET LANCETS ULTRA FINE daily,200 ea daily,200 ea 2 per fill SUPERTHIN 30G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LIVE BETTER LANCET LANCETS ULTRA THIN daily,200 ea daily,200 ea 2 per fill ULTRATHIN 28G MISC 2 per fill ) 30G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LONGS LANCETS LANCETS ULTRA THIN daily,200 ea daily,200 ea 2 per fill STANDARD MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETSBULLSEYE daily,200 ea LONGS LANCETS THIN daily,200 ea 2 per fill 2 per fill SAFETY MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea MEDLANCE PLUS LONGS LANCETS ULTRA daily,200 ea daily,200 ea 2 per fill LANCETS LITE 25G MISC 2 per fill THIN MISC ( ) lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDICHOICE PRE-SET daily,200 ea MEDLANCE PLUS daily,200 ea SAFETY LANCET DUAL 2 per fill 2 per fill ) USE MISC (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDICHOICE PRE-SET daily,200 ea MEDLANCE PLUS LITE daily,200 ea SAFETY LANCET LOW 2 per fill LANCETS 25G MISC 2 per fill FLOW MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) MEDICHOICE PRE-SET QL(6.67 ea QL(6.67 ea daily,200 ea MEDLANCE PLUS daily,200 ea SAFETY LANCET SPECIAL LANCETS MEDIUM FLOW MISC 2 per fill 2 per fill retail,600 ea 0.8MM MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) MEDICHOICE PRE-SET QL(6.67 ea QL(6.67 ea daily,200 ea MEDLANCE PLUS daily,200 ea SAFETY LANCET SUPERLITE 30G MISC MODERATE FLOW MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea MEDLANCE PLUS QL(6.67 ea MEDICHOICE SAFETY daily,200 ea daily,200 ea LANCETEXTRA MISC SUPERLITE 2 per fill 30G/COMFORT MAX 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) MISC (lancets) per fill mail) QL(6.67 ea QL(6.67 ea MEDICHOICE SAFETY daily,200 ea MEDLANCE PLUS daily,200 ea LANCETNORMAL MISC 2 per fill UNIVERSAL LANCETS 2 per fill (lancets) retail,600 ea 21G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDISENSE THIN daily,200 ea MEDLANCE PLUS/LITE daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 25G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE PLUS EXTRA daily,200 ea MEDLANCE/EXTRA MISC daily,200 ea LANCETS 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail)

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea MEDLANCE/LITE MISC daily,200 ea MICROLET LANCETS daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea MICROTAINER SAFETY QL(6.67 ea MEDLANCE/UNIVERSAL daily,200 ea FLOW daily,200 ea 2 per fill LANCET/STERILE/SINGL 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) E-USE MISC (lancets) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER COLOR daily,200 ea MM TWIST LANCETS daily,200 ea LANCETS UNIVERSAL 2 per fill 2 per fill ) 33G MISC (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER LANCETS MISC daily,200 ea MONOLET LANCETS daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER LANCETS THIN daily,200 ea MONOLET OPD LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER LANCETS daily,200 ea MONOLETTOR SAFETY daily,200 ea UNIVERSAL21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER LANCETS daily,200 ea MPD SAFETY LANCET daily,200 ea UNIVERSAL30G MISC 2 per fill 21G/1.8MM MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER LANCETS daily,200 ea MPD SAFETY LANCET daily,200 ea UNIVERSAL33G MISC 2 per fill 28G/1.8MM MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER SUPER THIN daily,200 ea MPD SAFETY LANCET daily,200 ea LANCETS MISC 2 per fill 30G/1.8MM MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea MPD SAFETY LANCETS daily,200 ea ONETOUCH DELICA daily,200 ea 23G/1.8MM MISC 2 per fill LANCETS FINE 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MYGLUCOHEALTH MGH daily,200 ea ONETOUCH DELICA daily,200 ea SOFTLANCE LANCETS 2 per fill PLUS LANCETS EXTRA 2 per fill 30G MISC (lancets) retail,600 ea FINE 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ONETOUCH DELICA NOVA SAFETY LANCETS daily,200 ea daily,200 ea 2 per fill PLUS LANCETS FINE 30G 2 per fill ) 23G MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea NOVA SAFETY LANCETS daily,200 ea ONETOUCH FINEPOINT daily,200 ea 2 per fill 2 per fill 28G MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea ONETOUCH ULTRA 2 KIT QL(1 ea per NOVA SUREFLEX daily,200 ea (blood glucose 2 365 days LANCETS MISC 2 per fill monitoring supplies) retail); RX/OTC (lancets) retail,600 ea per fill mail) QL(6.67 ea ONETOUCH ULTRASOFT daily,200 ea QL(6.67 ea 2 per fill ON CALL LANCETS MISC daily,200 ea LANCETS MISC (lancets) retail,600 ea 2 per fill per fill mail) (lancets) retail,600 ea per fill mail) ONETOUCH VERIO FLEX QL(1 ea per BLOOD GLUCOSE 365 days QL(6.67 ea MONITORING SYSTEM 2 retail); RX/OTC ON CALL PLUS LANCETS daily,200 ea 2 per fill KIT (blood glucose MISC (lancets) retail,600 ea monitoring supplies) per fill mail) QL(6.67 ea QL(6.67 ea PC LANCETS SUPER daily,200 ea 2 per fill ONETOUCH CLUB daily,200 ea THIN 30G MISC (lancets) LANCETS FINE POINT 2 per fill retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PERFECT LANCETS 30G daily,200 ea 2 per fill ONETOUCH DELICA daily,200 ea MISC (lancets) LANCETS EXTRA FINE 2 per fill retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) PERFECT PRESSURE QL(6.67 ea ACTIVATED SAFETY daily,200 ea LANCETS 28G MISC 2 per fill retail,600 ea (lancets) per fill mail)

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea PHARMACIST CHOICE daily,200 ea PREFERRED PLUS daily,200 ea ULTRA THIN LANCETS 2 per fill LANCETS COLORED 21G 2 per fill 28G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PHARMACIST CHOICE daily,200 ea PREFERRED PLUS daily,200 ea ULTRA THIN LANCETS 2 per fill LANCETS SUPER THIN 2 per fill 30G MISC (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PHARMACIST CHOICE daily,200 ea PREFERRED PLUS daily,200 ea ULTRA THIN LANCETS 2 per fill LANCETS THIN 26G MISC 2 per fill 31G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PHARMACIST CHOICE daily,200 ea PRESSURE ACTIVATED daily,200 ea ULTRA THIN LANCETS 2 per fill SAFETYLANCET 21G 2 per fill 33G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PHARMACIST CHOICE daily,200 ea PRO COMFORT daily,200 ea ULTRA THIN LANCETS 2 per fill LANCETS 30G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PHARMACY COUNTER daily,200 ea PRO COMFORT daily,200 ea LANCETS MISC 2 per fill LANCETS 31G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PRODIGY PRESSURE PIP LANCETS/28G MISC daily,200 ea daily,200 ea 2 per fill ACTIVATED SAFETY 2 per fill ) (lancets retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PIP LANCETS/30G MISC daily,200 ea PRODIGY SAFETY daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PRECISION THINS GP daily,200 ea PRODIGY TWIST TOP daily,200 ea 2 per fill 2 per fill LANCET MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail)

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea PSS SELECT GP daily,200 ea QC LANCETS ULTRA daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PSS SELECT SAFETY daily,200 ea QC UNILET LANCETS daily,200 ea LANCETS MISC 2 per fill 28G/ULTRA THIN MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PURE COMFORT daily,200 ea QC UNILET LANCETS daily,200 ea LANCETS 30G MISC 2 per fill 33G/MICRO THIN MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PUSH BUTTON SAFETY daily,200 ea RA E-ZJECT LANCETS daily,200 ea LANCETS 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 28G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PUSH BUTTON SAFETY daily,200 ea RA E-ZJECT LANCETS daily,200 ea LANCETS 28G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN 26G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PX LANCETS MICROTHIN daily,200 ea RA E-ZJECT LANCETS daily,200 ea 2 per fill 2 per fill 33G MISC (lancets) retail,600 ea THIN 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RA E-ZJECT LANCETS PX LANCETS ULTRA daily,200 ea daily,200 ea 2 per fill ULTRATHIN 30G MISC 2 per fill ) THIN 28G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY PX LANCETS ULTRA daily,200 ea daily,200 ea 2 per fill LANCETS/21G/2.2MM 2 per fill ) THIN MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY QC LANCETS SUPER daily,200 ea daily,200 ea 2 per fill LANCETS/23G/1.8MM 2 per fill ) THIN MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea READYLANCE SAFETY daily,200 ea RELION ULTRA THIN daily,200 ea LANCETS/26G/1.8MM 2 per fill LANCETS30G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY daily,200 ea RELION ULTRA THIN daily,200 ea LANCETS/28G/1.8MM 2 per fill PLUS LANCETS 32G 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY daily,200 ea RELION ULTRA THIN daily,200 ea LANCETS/30G/1.6MM 2 per fill PLUS LANCETS 33G 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea REALITY LANCETS MISC daily,200 ea REXALL LANCETS ULTRA daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea THIN MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea REALITY TRIGGER daily,200 ea RIGHTEST GL300 daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RELION LANCETS daily,200 ea SAFE-T-LANCE LOW daily,200 ea MICRO-THIN33G MISC 2 per fill FLOW 25G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAFE-T-LANCE NORMAL RELION LANCETS THIN daily,200 ea daily,200 ea 2 per fill FLOW21G MISC 2 per fill ) 26G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RELION LANCETS daily,200 ea SAFE-T-LANCE PLUS daily,200 ea ULTRA-THIN30G MISC 2 per fill SAFETYLANCET HIGH 2 per fill (lancets) retail,600 ea FLOW MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RELION ULTRA THIN daily,200 ea SAFE-T-LANCE PLUS daily,200 ea LANCETS/30G MISC 2 per fill SAFETYLANCET LOW 2 per fill (lancets) retail,600 ea FLOW MISC (lancets) retail,600 ea per fill mail) per fill mail)

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFE-T-LANCE PLUS QL(6.67 ea QL(6.67 ea SAFETYLANCET daily,200 ea SAFETY SEAL LANCETS daily,200 ea NORMAL FLOW MISC 2 per fill 2 per fill retail,600 ea 28G MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) SAFETY LANCET QL(6.67 ea QL(6.67 ea 21G/PRESSURE daily,200 ea SAFETY SEAL LANCETS daily,200 ea ACTIVATED MISC 2 per fill 2 per fill retail,600 ea 30G MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) SAFETY LANCET QL(6.67 ea QL(6.67 ea daily,200 ea SAPS HEALTH CARE daily,200 ea 23G/PRESSURE TWIST TOP LANCETS ACTIVATED MISC 2 per fill 2 per fill retail,600 ea MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) SAFETY LANCET QL(6.67 ea QL(6.67 ea daily,200 ea SAPS HEALTH TWIST daily,200 ea 28G/PRESSURE TOP LANCETS 30G MISC ACTIVATED MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) SAFETY LANCET QL(6.67 ea QL(6.67 ea daily,200 ea SAPSCARE TWIST TOP daily,200 ea 30G/PRESSURE LANCETS 30G MISC ACTIVATED MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAFETY LANCETS 21G daily,200 ea SB LANCETS THIN MISC daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAFETY LANCETS 28G daily,200 ea SB LANCETS ULTRA daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea THIN MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SHOPKO ON-THE-GO SAFETY LANCETS MISC daily,200 ea daily,200 ea 2 per fill COMFORTLANCETS 30G 2 per fill ) (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SHOPKO UNILET SAFETY LET LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS SUPER THIN 2 per fill ) MISC (lancets retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail)

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea SHOPKO UNILET SOLUS V2 PRESSURE daily,200 ea ACTIVATED SAFETY daily,200 ea LANCETS ULTRA THIN 2 per fill LANCETS 28G MISC 2 per fill 28G MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea SIDE BUTTON SAFETY daily,200 ea SOLUS V2 TWIST daily,200 ea LANCET21G MISC 2 per fill LANCETS 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SINGLE-LET MISC daily,200 ea STERILANCE TL MISC daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SM MICRO THIN daily,200 ea SUPER THIN LANCETS daily,200 ea LANCETS 33G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SMART SENSE COLOR daily,200 ea SURE COMFORT daily,200 ea LANCETS UNIVERSAL 2 per fill LANCETS 18G MISC 2 per fill 33G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) SMART SENSE QL(6.67 ea QL(6.67 ea daily,200 ea SURE COMFORT daily,200 ea STANDARD LANCETS LANCETS 21G MISC UNIVERSAL 21G MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) SMART SENSE SUPER QL(6.67 ea QL(6.67 ea daily,200 ea SURE COMFORT daily,200 ea THIN LANCETS LANCETS 23G MISC UNIVERSAL 30G MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SMART SENSE THIN daily,200 ea SURE COMFORT daily,200 ea LANCETSUNIVERSAL 2 per fill LANCETS 28G MISC 2 per fill 26G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE COMFORT SMARTEST LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS 30G MISC 2 per fill ) 28G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea SURE-LANCE FLAT daily,200 ea TGT LANCET MICRO daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN 33G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE-LANCE LANCETS daily,200 ea TGT LANCET THIN 26G daily,200 ea 2 per fill 2 per fill 26G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE-LANCE THIN daily,200 ea TGT LANCET ULTRA daily,200 ea LANCETS 28G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE-LANCE ULTRA daily,200 ea THINLETS GP LANCETS daily,200 ea THIN LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE-TOUCH LANCETS daily,200 ea TODAYS HEALTH SUPER daily,200 ea UNIVERSAL MISC 2 per fill THINLANCETS 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TODAYS HEALTH ULTRA SURELITE LANCETS daily,200 ea daily,200 ea 2 per fill THINLANCETS 28G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TOPCARE LANCETS TECHLITE AST LANCETS daily,200 ea daily,200 ea 2 per fill MICRO-THIN 33G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TECHLITE LANCETS 30G daily,200 ea TRAVEL LANCETS 30G daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRAVEL LANCETS TECHLITE LANCETS daily,200 ea daily,200 ea 2 per fill ADVANCED 28G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea TRUE COMFORT TWIST daily,200 ea ULTILET CLASSIC daily,200 ea TOP LANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS LANCETS daily,200 ea ULTILET LANCETS 33G daily,200 ea 2 per fill 2 per fill 26G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS LANCETS daily,200 ea ULTILET LANCETS MISC daily,200 ea 2 per fill 2 per fill 28G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS LANCETS daily,200 ea ULTILET SAFETY daily,200 ea 28G SUPER THIN MISC 2 per fill LANCETS 21G X 2.2MM 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ULTILET SAFETY TRUEPLUS LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS 23G MISC 2 per fill ) 30G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS LANCETS daily,200 ea ULTRA THIN LANCETS daily,200 ea 30G ULTRA THIN MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 31G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS LANCETS daily,200 ea ULTRA-CARE LANCETS daily,200 ea 33G MICRO THIN MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS LANCETS daily,200 ea ULTRA-THIN II AUTO daily,200 ea 2 per fill 2 per fill 33G MISC (lancets) retail,600 ea LANCET MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS SAFETY daily,200 ea ULTRA-THIN II LANCETS daily,200 ea LANCETS 28G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 28G MISC (lancets retail,600 ea per fill mail) per fill mail)

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea UNILET LANCETS ULTRA-THIN II LANCETS daily,200 ea daily,200 ea 2 per fill SUPER-THIN30G MISC 2 per fill 30G MISC ( ) lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNILET LANCETS UNILET COMFORTOUCH daily,200 ea daily,200 ea 2 per fill ULTRA-THIN 28G MISC 2 per fill ) LANCET MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNILET EXCELITE II MISC daily,200 ea UNILET SUPERLITE daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea LANCET MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNILET EXCELITE MISC daily,200 ea UNISTIK 3 GENTLE MISC daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK PRO SAFETY UNILET G.P. LANCET daily,200 ea daily,200 ea 2 per fill LANCET 21G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK PRO SAFETY UNILET G.P. SUPERLITE daily,200 ea daily,200 ea 2 per fill LANCET 25G MISC 2 per fill ) LANCET MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK PRO SAFETY UNILET GP 28 ULTRA daily,200 ea daily,200 ea 2 per fill LANCET 28G MISC 2 per fill ) THIN MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK SAFETY UNILET LANCET MISC daily,200 ea daily,200 ea 2 per fill LANCETS 28G MISC 2 per fill ) (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNILET LANCETS daily,200 ea UNISTIK SAFETY daily,200 ea MICRO-THIN33G MISC 2 per fill LANCETS 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea UNISTIK TOUCH SAFETY daily,200 ea VALUE PLUS LANCETS daily,200 ea LANCETS 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN 26G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK TOUCH SAFETY daily,200 ea VALUMARK LANCET daily,200 ea LANCETS 23G MISC 2 per fill SUPER THIN 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK TOUCH SAFETY daily,200 ea VALUMARK LANCET daily,200 ea LANCETS 28G MISC 2 per fill ULTRA THIN 28G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK TOUCH SAFETY daily,200 ea VIDA MIA UNILET daily,200 ea LANCETS 30G MISC 2 per fill LANCETS SUPER THIN 2 per fill (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea VIDA MIA UNILET UNIVERSAL 1 LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS ULTRA THIN 2 per fill ) THIN26G MISC (lancets retail,600 ea 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNIVERSAL 1 LANCETS daily,200 ea VITALET PRO LANCETS daily,200 ea ULTRA THIN 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNIVERSAL 1 daily,200 ea VITALET PRO PLUS daily,200 ea LANCETS/33G/MICRO- 2 per fill 2 per fill ) THIN MISC (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea VALUE PLUS LANCETS daily,200 ea VIVAGUARD LANCETS daily,200 ea STANDARD 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea VALUE PLUS LANCETS daily,200 ea WALGREENS ADVANCED daily,200 ea SUPERTHIN 30G MISC 2 per fill TRAVELLANCETS 28G 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WALGREENS COMFORT QL(6.67 ea Limited to 1 daily,200 ea device per ASSUREDLANCETS BD PEN MINI MISC MICRO THIN/33G MISC 2 per fill year;QL(1 ea retail,600 ea (injection device for 3 per fill retail,1 (lancets) per fill mail) insulin) ea per 365 QL(6.67 ea days retail); WALGREENS COMFORT RX/OTC ASSUREDLANCETS daily,200 ea SUPER THIN/28G MISC 2 per fill Limited to 1 retail,600 ea device per (lancets) per fill mail) BD PEN MISC (injection year;QL(1 ea QL(6.67 ea 3 per fill retail,1 device for insulin) ea per 365 WALGREENS LANCETS daily,200 ea 2 per fill days retail); MISC (lancets) retail,600 ea RX/OTC per fill mail) BD PEN NEEDLE/MICRO/ULTRA- QL(6.67 ea 2 WALGREENS THIN daily,200 ea FINE/32G X 6MM MISC LANCETS MISC 2 per fill (insulin pen needle) (lancets) retail,600 ea Limit 200 per per fill mail) BD PEN NEEDLE/MINI/ULTRA- month without QL(6.67 ea FINE/31G X 5MM MISC 2 authorization;Q WALGREENS ULTRA L(6.67 ea daily,200 ea ( ) THIN LANCETS MISC 2 per fill insulin pen needle daily); RX/OTC (lancets) retail,600 ea BD PEN per fill mail) NEEDLE/ORIGINAL/ULTR QL(6.67 ea A-FINE/29G X 12.7MM 2 ZEVRX TWIST TOP daily,200 ea MISC (insulin pen LANCETS 30G MISC 2 per fill needle) (lancets) retail,600 ea per fill mail) BD PEN RX/OTC NEEDLE/SHORT/ULTRA- Parenteral Therapy Supplies FINE/31G X 8MM MISC 2 BD AUTOSHIELD 29G X (insulin pen needle) 5/16" MISC (insulin pen 2 BD SAFETYGLIDE QL(6.67 ea needle) INSULIN daily) BD AUTOSHIELD DUO SYRINGE/0.5ML/31G X 2 30G X 5MM MISC 2 15/64" MISC (insulin (insulin pen needle) syringe/needle u-100) BD ECLIPSE NEEDLE BD SAFETYGLIDE Limit 200 per 30G X1/2" MISC (needle 2 INSULIN month;QL(6.67 SYRINGE/1ML/31G X ea daily) (disp) 30 g) 2 15/64" MISC (insulin BD NEEDLE/30G X 1/2" syringe/needle u-100) MISC (needle (disp) 30 2 g) BD VEO INSULIN QL(6.67 ea SYRINGE ULTR-FINE/U- daily) 100/0.5ML/31G X 15/64" 2 MISC (insulin syringe/needle u-100)

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD VEO INSULIN QL(6.67 ea HYPODERMIC NEEDLE SYRINGE ULTRA- daily) 30GX1/2" MISC (needle 2 FINE/0.5ML/31G X 6MM 2 (disp) 30 g) MISC (insulin INSULIN SYRINGES AND 2 MO syringe/needle u-100) PEN NEEDLES BD VEO INSULIN Limit 200 per Limited to 1 SYRINGE ULTRA- month;QL(6.67 device per FINE/1ML/31G X 6MM 2 ea daily) NOVOPEN ECHO DEVI year;QL(1 ea MISC (insulin (injection device for 3 per fill retail,1 syringe/needle u-100) insulin) ea per 365 BD VEO INSULIN Limit 200 per days retail); SYRINGE ULTRA-FINE/U- month;QL(6.67 RX/OTC 100/1ML/31G X 15/64" 2 ea daily) POLY HUB NEEDLE/30G MISC (insulin X 1/2" MISC (needle 2 syringe/needle u-100) (disp) 30 g) DROPLET INSULIN Limit 200 per RELION INSULIN QL(6.67 ea SYRINGE U-100/1ML/31G month;QL(6.67 SYRINGE 0.5ML/31G X daily) 2 X 15/64" MISC (insulin 2 ea daily) 15/64" MISC (insulin syringe/needle u-100) syringe/needle u-100) DROPLET INSULIN QL(6.67 ea RELION INSULIN Limit 200 per SYRINGE/U- daily) SYRINGE month;QL(6.67 100/0.5ML/31G X 15/64" 2 1ML/31GX15/64" MISC 2 ea daily) MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) DROPLET INSULIN Limit 200 per RELION INSULIN Limit 200 per SYRINGE/U-100/1ML/31G month;QL(6.67 SYRINGE/U-100/1ML/31G month;QL(6.67 2 X 15/64" MISC (insulin 2 ea daily) X 15/64" MISC (insulin ea daily) syringe/needle u-100) syringe/needle u-100) EASY TOUCH FLIPLOCK TECHLITE INSULIN QL(6.67 ea NEEDLES 30GX1/2" MISC 2 SYRINGEU- daily) (needle (disp) 30 g) 100/0.5ML/31G X 15/64" 2 EASY TOUCH MISC (insulin HYPODERMIC NEEDLES syringe/needle u-100) 30GX1/2" MISC (needle 2 TECHLITE INSULIN Limit 200 per (disp) 30 g) SYRINGEU-100/1ML/31G month;QL(6.67 2 ea daily) GLOBAL EASY GLIDE QL(6.67 ea X 15/64" MISC (insulin INSULIN daily) syringe/needle u-100) SYRINGE/0.5ML/31G X 2 ULTILET INSULIN QL(6.67 ea 15/64" MISC (insulin SYRINGE/U- daily) syringe/needle u-100) 100/0.5ML/31GX6MM 2 GLOBAL EASY GLIDE Limit 200 per MISC (insulin INSULIN month;QL(6.67 syringe/needle u-100) SYRINGE/1ML/31G X 2 ea daily) MIGRAINE PRODUCTS - Drugs to Treat Migraine 15/64" MISC (insulin Headaches ) syringe/needle u-100 Calcitonin Gene-Related Peptide (CGRP)

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AIMOVIG SOAJ PA; ST IMITREX STATDOSE PA 2 (erenumab-aooe) REFILL SOCT 6 MG/0.5ML 7 EMGALITY SOAJ 120 PA; ST (sumatriptan succinate) MG/ML (galcanezumab- 2 IMITREX STATDOSE PA gnlm) SYSTEM SOAJ 7 EMGALITY SOSY 120 PA; ST (sumatriptan succinate) MG/ML (galcanezumab- 2 Limit 9 per 1 ) naratriptan hcl tabs month;QL(0.3 gnlm ea daily) Migraine Combinations Limit 18 tabs rizatriptan benzoate per (Ergotamine W/ Caffeine) 1 1 MIGERGOT SUPP tabs month;QL(0.6 ea daily) ergotamine w/ caffeine 1 tabs Limit 18 tabs rizatriptan benzoate 1 per Migraine Products tbdp month;QL(0.6 D.H.E. 45 SOLN PA ea daily) (dihydroergotamine 7 Limit 6 mesylate) sumatriptan soln 20 1 sprayers per month;QL(2 ea PA mg/act dihydroergotamine daily) mesylate soln ij 1 2 sumatriptan soln 5 Limit 6 per mg/ml 1 month;QL(0.2 dihydroergotamine PA; QL(0.27 ml mg/act ea daily) mesylate soln na 4 1 daily) sumatriptan succinate PA mg/ml soaj sc 4 mg/0.5ml, 6 4 ERGOMAR SUBL mg/0.5ml 2 (ergotamine tartrate) PA; ST sumatriptan succinate 4 Serotonin Agonists soct sc 4 mg/0.5ml Limit 6 per PA sumatriptan succinate 4 almotriptan malate tabs 1 month;QL(0.2 soct sc 6 mg/0.5ml ea daily) PA; ST; Limit eletriptan hydrobromide Limit 6 tabs per sumatriptan succinate 2mls per 1 month;QL(0.2 4 tabs soln sc 6 mg/0.5ml month;QL(0.07 ea daily) ml daily) frovatriptan succinate Limit 9 per sumatriptan succinate PA 1 month;QL(0.3 4 tabs ea daily) sosy sc 6 mg/0.5ml PA; ST; Limit sumatriptan succinate Limit 9 per IMITREX SOLN SC 6 tabs or 100 mg, 25 mg, 1 month;QL(2 ea MG/0.5ML (sumatriptan 7 2mls per month;QL(0.07 50 mg daily) succinate) ml daily) QL(6 ea per 30 IMITREX STATDOSE PA; ST zolmitriptan soln na 2.5 1 days retail,18 REFILL SOCT 4 MG/0.5ML 7 mg, 5 mg ea per 90 days (sumatriptan succinate) mail)

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 6 per AL(Up to 6 yrs zolmitriptan tabs or 2.5 sodium fluoride tabs 1 1 month;QL(0.2 0.5 mg, 1 mg old ); PV mg, 5 mg ea daily) Phosphate zolmitriptan tbdp or 2.5 Limit 6 tabs per 1 month;QL(0.2 (Pot Phosphate Monobasic mg, 5 mg ea daily) W/ Sod Phosphate Dibasic & Monobasic) PHOSPHA MINERALS & ELECTROLYTES 250 NEUTRAL, 1 PHOSPHO-TRIN 250 Calcium NEUTRAL, VIRT-PHOS CALCIFOL WAFR 250 NEUTRAL TABS (calcium carbonate-folic K-PHOS TABS 3 acid-vit d-b6-b12- (potassium phosphate 2 boron-magnesium) monobasic) CALCIUM-FOLIC ACID pot phosphate PLUS D WAFR (calcium monobasic w/ sod 1 carbonate-folic acid-vit 3 phosphate dibasic & d-b6-b12-boron- monobasic tabs magnesium) Potassium MAGNEBIND 400 TABS (Potassium Bicarbonate) 1 (calcium carbonate- 3 EFFER-K TBEF 25 MEQ magnesium carbonate) (Potassium Bicarbonate) K- Electrolyte Mixtures PRIME, KLOR-CON/EF 1 potassium chloride in PA TBEF dextrose & sodium 4 (Potassium Chloride Microencapsulated Crystals chloride soln Er) KLOR-CON M10, 1 Fluoride KLOR-CON M15, KLOR- (Sodium Fluoride) AL(Up to 6 yrs CON M20 TBCR (Potassium Chloride) FLUORITAB, FLURA- 1 old ); PV DROPS, NAFRINSE KLOR-CON 10, KLOR- 1 DROPS SOLN CON 8 TBCR (Potassium Chloride) (Sodium Fluoride) 1 AL(Up to 6 yrs 1 NAFRINSE CHEW old ); PV KLOR-CON PACK FLORIVA LIQD ( (Potassium Chloride) sodium 3 fluoride-vitamin d) KLOR-CON SPRINKLE 1 CPCR FLUORABON SOLN AL(Up to 6 yrs 2 old ); PV EFFER-K TBEF 0.84 GM-1 (sodium fluoride) GM, 1.68 GM-2 GM sodium fluoride chew AL(Up to 6 yrs (potassium 3 0.25 mg, 0.5 mg, 1 mg, 1 old ); PV bicarbonate-citric acid) 2.2 mg K-TAB TBCR 8 MEQ 7 sodium fluoride soln AL(Up to 6 yrs (potassium chloride) 1 old ); RX/OTC; 0.5 mg/ml PV potassium chloride cpcr 1 or 10 meq, 8 meq

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride Must use Exactus microencapsulated 1 THALOMID CAPS crystals er tbcr 10 meq, 3 Specialty Rx 1- (thalidomide) 866-458- 20 meq 9246;AC potassium chloride 1 Immunosuppressive Agents pack or 20 meq (Cyclosporine Modified (For POTASSIUM CHLORIDE PA Microemulsion)) 1 SOLN IV 20 MEQ/100ML 4 GENGRAF CAPS (potassium chloride) (Cyclosporine Modified (For Microemulsion)) 1 potassium chloride soln 1 or 10 %, 20 % GENGRAF SOLN ASTAGRAF XL CP24 ST potassium chloride tbcr 3 or 10 meq, 20 meq, 8 1 (tacrolimus) AZASAN TABS meq 3 (azathioprine) Sodium azathioprine tabs 1 3 QL(500 ml sodium chloride soln daily) cyclosporine caps 1 Zinc GALZIN CAPS ( cyclosporine modified zinc 3 acetate (oral)) (for microemulsion) 1 WILZIN CAPS ( caps zinc 3 acetate (oral)) cyclosporine modified (for microemulsion) 1 MISCELLANEOUS THERAPEUTIC CLASSES soln Chelating Agents everolimus (immunosuppressant) 1 (Trientine Hcl) CLOVIQUE 4 PA CAPS tabs D-PENAMINE TABS 2 mycophenolate mofetil 1 (penicillamine) caps or 250 mg PA penicillamine caps 1 mycophenolate mofetil 1 susr or 200 mg/ml penicillamine tabs 1 mycophenolate mofetil 1 SYPRINE CAPS ( PA tabs or 500 mg trientine 7 hcl) mycophenolate sodium 1 tbec trientine hcl caps 4 PA PROGRAF PACK 0.2 MG, PA 4 Immunomodulators 1 MG (tacrolimus) PA; Must use SANDIMMUNE SOLN 100 3 REVLIMID CAPS Exactus MG/ML (cyclosporine) 4 Specialty Rx 1- (lenalidomide) 866-458- sirolimus soln 1 9246;LA; AC

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sirolimus tabs 1 Anti-infectives - Throat clotrimazole troc 1 tacrolimus caps 1 THYMOGLOBULIN SOLR PA; nystatin (mouth-throat) 1 administered susp (anti-thymocyte globulin 3 (rabbit), lymphocyte under the ORAVIG TABS immune globulin) medical benefit (miconazole (mouth- 3 ZORTRESS TABS 1 MG throat)) (everolimus 2 Antiseptics - Mouth/Throat (immunosuppressant)) (Chlorhexidine Gluconate Potassium Removing Agents (Mouth-Throat)) PAROEX, 1 PERIOGARD SOLN (Sodium Polystyrene Sulfonate) KIONEX, SPS 1 chlorhexidine gluconate 1 SUSP (mouth-throat) soln LOKELMA PACK ST Steroids - Mouth/Throat/Dental (sodium zirconium 3 (Triamcinolone Acetonide cyclosilicate) (Mouth)) ORALONE 1 DENTAL PASTE PSTE sodium polystyrene 1 sulfonate powd triamcinolone acetonide 1 (mouth) pste sodium polystyrene 1 sulfonate susp Throat Products - Misc. Systemic Lupus Erythematosus Agents cevimeline hcl caps 1 QL(3 ea daily) PA; MUST MUCOTROL WAFR (oral BENLYSTA SOAJ USE ACARIA 3 4 SPECIALTY wound care products) (belimumab) RX 844-538- QL(6 ea daily) pilocarpine hcl (oral) 1 4661;LA tabs 5 mg PA; MUST pilocarpine hcl (oral) QL(4 ea daily) BENLYSTA SOSY USE ACARIA 1 4 SPECIALTY tabs 7.5 mg (belimumab) RX 844-538- 4661;LA MULTIVITAMINS MOUTH/THROAT/DENTAL AGENTS Multiple Vitamins & Fluoride-Folic Acid MULTIVITAMIN WITH Anesthetics Topical Oral FLUORIDE CHEW 0.3 MG- FIRST-MOUTHWASH BLM 0.5 MG-1.05 MG-1.05 MG- SUSP 1.2 MG-4.5 MCG-13.5 MG- (diphenhydramine- 15 UNIT-60 MG-400 UNIT- 3 2500 UNIT, 0.3 MG-1 MG- lidocaine-alum 1.05 MG-1.05 MG-1.2 MG- 3 hydroxide-mg 4.5 MCG-13.5 MG-15 hydroxide-simeth) UNIT-60 MG-400 UNIT- 2500 UNIT (multiple lidocaine hcl (mouth- 1 throat) soln vitamins & fluoride-folic acid) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MULTIVITAMIN WITH RX/OTC (Pediatric Multivitamins AL(Up to 6 yrs FLUORIDE CHEW 1.05 W/Fl) old ); RX/OTC MG-0.25 MG-0.3 MG-1.05 MULTIVITAMIN/FLUORID MG-1.2 MG-4.5 MCG-13.5 E CHEW 0.25 MG-0.3 MG- MG-15 UNIT-60 MG-400 3 1.05 MG-1.05 MG-1.2 MG- UNIT-2500 UNIT (multiple 4.5 MCG-13.5 MG-15 vitamins & fluoride-folic UNIT-60 MG-400 UNIT- ) 2500 UNIT, 0.25 MG-1.05 acid MG-1.05 MG-1.2 MG-4.5 MULTIVITAMIN/FLUORID RX/OTC MCG-13.5 MG-15 UNIT-60 E CHEW 0.25 MG-0.3 MG- MG-300 MCG-400 UNIT- 1.05 MG-1.05 MG-1.2 MG- 2500 UNIT, 0.3 MG-0.5 4.5 MCG-13.5 MG-15 MG-1.05 MG-1.05 MG-1.2 UNIT-60 MG-400 UNIT- 3 MG-4.5 MCG-13.5 MG-15 2500 UNIT (multiple UNIT-60 MG-400 UNIT- vitamins & fluoride-folic 2500 UNIT, 0.3 MG-1 MG- 1 acid) 1.05 MG-1.05 MG-1.2 MG- 4.5 MCG-13.5 MG-15 Multiple Vitamins w/ Minerals UNIT-60 MG-400 UNIT- THRIVITE 19 TABS 2500 UNIT, 0.5 MG-1.05 (multiple vitamins w/ 3 MG-1.05 MG-1.2 MG-4.5 minerals & folic acid) MCG-13.5 MG-15 UNIT-60 MG-300 MCG-400 UNIT- Ped MV w/ Fluoride 2500 UNIT, 1 MG-1.05 (Pediatric Multivitamins AL(Up to 6 yrs MG-1.05 MG-1.2 MG-4.5 MCG-13.5 MG-15 UNIT-60 W/Fl) MULTI- 1 old ); RX/OTC VITAMIN/FLUORIDE MG-300 MCG-400 UNIT- DROPS SOLN 2500 UNIT, 1.2 MG-0.25 MG-1.05 MG-1.05 MG-4.5 (Pediatric Multivitamins AL(Up to 6 yrs MCG-13.5 MG-15 UNIT-60 W/Fl) MULTIVITAMIN old ); RX/OTC MG-300 MCG-400 UNIT- WITH FLUORIDE SOLN 2500 UNIT 0.25 MG/ML-0.4 MG/ML- 0.5 MG/ML-0.6 MG/ML-2 (Pediatric Multivitamins AL(Up to 6 yrs MCG/ML-5 UNIT/ML-8 W/Fl) old ); RX/OTC MG/ML-35 MG/ML-400 1 MULTIVITAMIN/FLUORID UNIT/ML-1500 UNIT/ML, E SOLN 0.25 MG/ML-0.4 0.4 MG/ML-0.5 MG/ML-0.5 MG/ML-0.5 MG/ML-0.6 MG/ML-0.6 MG/ML-2 MG/ML-2 MCG/ML-5 MCG/ML-5 UNIT/ML-8 UNIT/ML-8 MG/ML-35 MG/ML-35 MG/ML-400 MG/ML-400 UNIT/ML-1500 UNIT/ML-1500 UNIT/ML UNIT/ML, 0.4 MG/ML-0.5 MG/ML-0.5 MG/ML-0.6 1 MG/ML-2 MCG/ML-5 UNIT/ML-8 MG/ML-35 MG/ML-400 UNIT/ML-1500 UNIT/ML, 0.6 MG/ML-0.25 MG/ML-0.4 MG/ML-0.5 MG/ML-2 MCG/ML-5 UNIT/ML-8 MG/ML-35 MG/ML-400 UNIT/ML-1500 UNIT/ML

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Multivitamins AL(Up to 6 yrs QUFLORA PEDIATRIC AL(Up to 6 yrs W/Fl) 1 old ); RX/OTC SOLN (pediatric 2 old ); RX/OTC MULTIVITAMINS/FLUORI multivitamins w/fl) DE CHEW TRI-VI-FLOR SUSP (Pediatric Multivitamins AL(Up to 6 yrs (pediatric vitamins acd W/Fl) POLY-VI-FLOR old ) 3 CHEW 0.25 MG-15 UNIT- & l-methylfolate w/ 200 MCG-400 UNIT, 0.5 1 fluoride) MG-15 UNIT-200 MCG- TRI-VI-FLORO SUSP 400 UNIT, 1 MG-15 UNIT- (pediatric vitamins acd 200 MCG-400 UNIT & l-methylfolate w/ 3 (Pediatric Vitamins Acd W/ AL(Up to 6 yrs fluoride) Fluoride) MULTIVITAMIN old ); RX/OTC SELECT/FLUORIDE, 1 Ped Multi Vitamins w/Fl & FE VITAMINS (Ped Multivitamins W/Fl & AL(Up to 6 yrs A/C/D/FLUORIDE SOLN Iron) MULTI- old ); RX/OTC (Pediatric Vitamins Acd W/ AL(Up to 6 yrs VIT/IRON/FLUORIDE, Fluoride) TRI- old ); RX/OTC MULTI- 1 VITAMIN/FLUORIDE/IRON VITE/FLUORIDE SOLN 1 0.25 MG/ML-35 MG/ML- , 400 UNIT/ML-1500 MULTIVITAMIN/FLUORID UNIT/ML E/IRON SOLN (Pediatric Vitamins Acd W/ AL(Up to 6 yrs POLY-VI-FLOR/IRON AL(Up to 6 yrs Fluoride) TRI- old ) CHEW 0.5 MG-10 MG-15 old ) VITE/FLUORIDE SOLN 0.5 1 UNIT-200 MCG-400 UNIT 3 MG/ML-35 MG/ML-400 (ped multivitamins w/fl UNIT/ML-1500 UNIT/ML & iron) FLORIVA PLUS SOLN AL(Up to 6 yrs POLY-VI-FLOR/IRON (pediatric multivitamins 2 old ); RX/OTC SUSP 200 MCG/ML-0.25 w/fl) MG/ML-7 MG/ML (ped 3 MULTIVITAMIN + AL(Up to 6 yrs multivitamins w/fl & FLUORIDE CHEW old ); RX/OTC ) 2 iron (pediatric multivitamins QUFLORA FE PEDIATRIC AL(Up to 6 yrs w/fl) LIQD (ped multivitamins 2 old ) pediatric vitamins acd AL(Up to 6 yrs w/fl & iron) 1 old ) w/ fluoride soln Pediatric Multiple Vitamins & Minerals w/ Fluoride POLY-VI-FLOR SUSP 0.25 FLORIVA CHEW MG/ML-200 MCG/ML 3 (pediatric multiple (pediatric multivitamins vitamins & minerals w/ 3 w/fl) fluoride) QUFLORA GUMMIES AL(Up to 6 yrs CHEW (pediatric 2 old ) Prenatal Vitamins multivitamins w/fl) QUFLORA PEDIATRIC AL(Up to 6 yrs CHEW (pediatric 2 old ); RX/OTC multivitamins w/fl)

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Prenatal Vit W/ Docusate- RX/OTC CITRANATAL ASSURE Fe Fumarate-Folic Acid) MISC (prenatal w/o vit a PRENATAL 19 TABS 1 w/ fe carbonyl-fe 3 MG-3 MG-3 MG-7 MG-12 1 ) MCG-15 MG-20 MG-20 gluconate-dss-fa-dha MG-25 MG-29 MG-30 CITRANATAL B-CALM UNIT-100 MG-200 MG-400 MISC (prenatal w/o vit a UNIT-1000 UNIT w/ fe carbonyl-fe 3 (Prenatal Vit W/ Docusate- gluconate-fa & vit b6) Iron Carbonyl-Folic Acid) 1 CITRANATAL BLOOM INATAL GT TABS DHA MISC (prenatal w/o (Prenatal Vit W/ Ferrous vit a w/ fe carbonyl-fe 2 Fumarate-Folic Acid) PRENATAL 19 CHEW 6 gluconate-dss-fa-dha) CITRANATAL BLOOM MG-1 MG-3 MG-3 MG-7 1 MG-12 MCG-20 MG-20 TABS (prenatal vit w/ MG-25 MG-29 MG-30 docusate-fe carbonyl-fe 3 UNIT-100 MG-200 MG-400 gluconate-folic acid) UNIT-1000 UNIT CITRANATAL DHA MISC (Prenatal Vit W/ Ferrous (prenatal w/o vit a w/ fe Fumarate-L Methylfolate- 1 2 Folic Acid) PNV-SELECT carbonyl-fe gluconate- TABS dss-fa-dha) (Prenatal Vit W/ Iron CITRANATAL ESSENCE Carbonyl-Folic Acid) 1 THPK (prenatal w/o vit PRENATABS RX TABS a w/ fe carbonyl-fe 2 (Prenatal Without A W/ Fe gluconate-fa-dha) Fumarate-L Methylfolate- 1 CITRANATAL HARMONY Fa-Dha) PNV-DHA CAPS CAPS (prenatal w/o vit ATABEX EC TBEC a w/ fe fumarate-fe 3 (prenatal vit w/ carbonyl-dss-fa-dha) docusate-iron carbonyl- 2 folic acid) CITRANATAL MEDLEY CAPS (prenatal w/o vit BAL-CARE DHA MISC a w/ fe fumarate-fe 3 (prenatal w/fe carbonyl-fa-dha) polysacch cmplx-sod 2 feredetate-fa-omega 3) CITRANATAL RX TABS (prenatal without vit a C-NATE DHA CAPS w/ fe carbonyl-fe gluc- 3 (prenatal vit w/ ferrous docusate-fa) fumarate-fa-omega 3 3 fatty acids) COMPLETENATE CHEW (prenatal vit w/ ferrous 2 CITRANATAL 90 DHA fumarate-folic acid) MISC (prenatal w/o vit a w/ fe carbonyl-fe 2 CONCEPT DHA CAPS gluconate-dss-fa-dha) (prenatal vit w/ fe fum- iron polysacch complex 2 -fa-omega 3)

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONCEPT OB CAPS NATELLE ONE CAPS (prenatal without a vit (prenatal without vit a w/ fe fum-iron 2 w/ fe fum-fa-omega 3 polysacch complex -fa) fatty acids) DUET DHA 400 MISC NEEVO DHA CAPS (prenatal w/fe (prenatal without vit a polysacch cmplx-sod 3 w/ fe fumarate-l 3 feredetate-fa-omega 3) methylfolate-omegas) DUET DHA BALANCED NEONATAL COMPLETE RX/OTC MISC (prenatal w/fe TABS (prenatal vit w/ polysacch cmplx-sod 3 ferrous fumarate-folic 2 feredetate-fa-omega 3) acid) FOLET DHA THPK NEONATAL PLUS TABS RX/OTC (prenatal vit w/fe (prenatal vit w/ ferrous 2 3 carbonyl-fe bisglyc- fumarate-folic acid) methylfol-dss & dha) NESTABS DHA MISC FOLET ONE CAPS (prenatal vit without vit 2 (prenatal w/o a w/fe a w/ fe bisglycinate-fa- 3 carbonyl-fe bisglyc-l omeg 3) methylfol-dss-dha) NESTABS ONE CAPS FOLIVANE-OB CAPS (prenatal w/o a w/fe 3 (prenatal without a vit carbonyl-fe bisglyc-l 2 w/ fe fum-iron methylfol-dha) polysacch complex -fa) NESTABS TABS M-NATAL PLUS TABS RX/OTC (prenatal vit without vit 3 (prenatal vit w/ ferrous 2 a w/ fe bisglycinate-folic fumarate-folic acid) acid) MARNATAL-F CAPS NEXA PLUS CAPS (prenatal without vit a (prenatal w/o vit a w/fe w/ iron polysaccharide 2 fumarate-docusate ca- 3 complex-fa) folic acid-dha) MYNATAL ADVANCE NIVA-PLUS TABS RX/OTC TABS (prenatal vit w/ (prenatal vit w/ ferrous 2 2 docusate-iron carbonyl- fumarate-folic acid) folic acid) O-CAL FA TABS RX/OTC MYNATAL ULTRACAPLET (prenatal vit w/ ferrous 2 TABS (prenatal vit w/ fumarate-folic acid) 2 docusate-iron carbonyl- OB COMPLETE ONE folic acid) CAPS (prenatal w/o vit 3 NATACHEW CHEW a w/ fe carbonyl-fe (prenatal vit w/ fe fum- aspart glyc-fa-fish oil) fe bisglycinate chelate- 3 folic acid)

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OB COMPLETE PETITE PR NATAL 430 MISC CAPS (prenatal w/o vit (prenatal mv & min w/fe a w/ fe carbonyl-fe 3 bisglyc-fe prot succ-fa- 3 aspart glyc-fa-omega 3) ca-omega 3) OB COMPLETE PREMIER PRENA 1 TRUE MISC TABS (prenatal vit w/ (prenatal without a w/ iron carbonyl-fe aspart 3 fe amino acid chelate- 2 glycinate-fa) fa-dha) OB COMPLETE/DHA PRENA1 CHEW CHEW CAPS (prenat vit w/ iron (prenatal w/ vit b2-b6- carbonyl-fe asp glyc-fa- 3 b12-cholecalciferol-folic 3 omega fatty acid) acid) OBSTETRIX ONE CAPS PRENA1 PEARL CPCR (prenatal w/o a w/fe (prenatal without a w/ carbonyl-fe bisglyc-l 3 fe fumarate-sod 3 methylfol-dss-dha) feredetate-fa-dha) ONE VITE WOMENS RX/OTC PRENAISSANCE CAPS PRENATALVITAMIN PLUS (prenatal w/o vit a w/ fe 3 TABS (prenatal vit w/ 2 fumarate-dss-fa-dha) ferrous fumarate-folic PRENAISSANCE PLUS acid) CAPS (prenatal w/o vit PNV TABS 29-1 TABS a w/ fe carbonyl-dss-fa- 3 (prenatal vit w/ iron 2 dha) carbonyl-folic acid) PRENATAL + DHA THPK PNV-DHA+DOCUSATE (prenatal w/o vit a w/ CAPS (prenatal w/o vit 3 3 ferrous fumarate-folic a w/ fe fumarate-dss- acid-dha) fa-dha) PRENATAL 19 CHEW 1 PNV-OMEGA CAPS MG-3 MG-3 MG-7 MG-12 (prenatal without a w/ MCG-15 MG-20 MG-20 MG-29 MG-30 UNIT-100 fe fumarate-l 3 2 methylfolate-fa-omega MG-200 MG-400 UNIT- 3) 1000 UNIT (prenatal vit w/ ferrous fumarate- PR NATAL 400 EC MISC folic acid) (prenatal mv & min w/fe bisglyc-fe prot succ-fa- 3 ca-omega 3) PR NATAL 430 EC MISC (prenatal mv & min w/fe bisglyc-fe prot succ-fa- 3 ca-omega 3)

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 19 TABS 1 RX/OTC PRENATE ESSENTIAL MG-3 MG-3 MG-7 MG-12 CAPS (prenatal w/o a MCG-15 MG-20 MG-20 w/ fe asparto glyc-l 3 MG-25 MG-29 MG-30 ) UNIT-100 MG-200 MG-400 methylfolate-fa-dha UNIT-1000 UNIT, 3 MG-12 PRENATE MINI CAPS MCG-1 MG-3 MG-7 MG-15 3 (prenatal w/o vit a w/ fe MG-20 MG-20 MG-25 MG- carbonyl-fe asp glyc- 3 29 MG-30 UNIT-100 MG- methfol-fa-dha) 200 MG-400 UNIT-1000 PRENATE PIXIE CAPS UNIT (prenatal vit w/ docusate-fe fumarate- (prenatal w/o a w/ fe asparto glyc-l 3 folic acid) methylfolate-fa-dha) PRENATAL PLUS IRON PRENATE RESTORE TABS (prenatal vit w/ 2 CAPS (prenatal without iron carbonyl-folic acid) a w/ fe fumarate-l 3 PRENATAL TABS RX/OTC methylfolate-fa-dha) (prenatal vit w/ ferrous 2 PRENATRIX TABS RX/OTC fumarate-folic acid) (prenatal vit w/ ferrous 2 PRENATAL VITAMINS RX/OTC ) PLUS LOW IRON TABS fumarate-folic acid (prenatal vit w/ ferrous 2 PRENATRYL TABS RX/OTC fumarate-folic acid) (prenatal vit w/ ferrous 2 ) PRENATAL-U CAPS fumarate-folic acid (prenatal without a vit PREPLUS TABS RX/OTC w/ fe fumarate-folic 2 (prenatal vit w/ ferrous 2 acid) fumarate-folic acid) PRENATE CHEW PROVIDA DHA CAPS (prenatal without a w/fe (prenatal multivitamins 2 & minerals w/ l- 3 fum-fe polysacch methylfolate-fa) complex-fa-dha) PRENATE DHA CAPS R-NATAL OB CAPS (prenatal w/o a w/ fe (prenatal w/o vit a w/ fe 2 asparto glyc-l 3 carbonyl-folic acid-dha) methylfolate-fa-dha) RELNATE DHA CAPS (prenatal vit w/ ferrous PRENATE ELITE TABS 3 (prenatal w/ fe asparto fumarate-fa-omega 3 glycinate-l methylfolate- 3 fatty acids) folic acid) SE-NATAL 19 CHEW 15 MG-1 MG-7 MG-12 MCG-3 PRENATE ENHANCE MG-3 MG-20 MG-20 MG- CAPS (prenatal without 3 29 MG-30 UNIT-100 MG- a w/ fe fumarate-l 200 MG-400 UNIT-1000 2 methylfolate-fa-dha) UNIT (prenatal vit w/ ferrous fumarate-folic acid) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SE-NATAL 19 TABS 1 MG- RX/OTC THRIVITE RX TABS 3 MG-3 MG-7 MG-12 (prenatal vit w/ iron 2 MCG-15 MG-20 MG-20 carbonyl-folic acid) MG-29 MG-30 UNIT-100 MG-200 MG-400 UNIT- 3 TL-CARE DHA CAPS 1000 UNIT (prenatal vit (prenatal w/fe 3 w/ docusate-fe fumarate-fa-dss-fish oil) fumarate-folic acid) TL-SELECT CAPS SELECT-OB CHEW 0.4 (prenatal w/o vit a w/ fe 3 MG-0.6 MG-1.6 MG-1.8 fumarate-dss-fa-dha) MG-2.5 MG-5 MCG-15 TRI-TABS DHA MISC MG-15 MG-25 MG-29 MG- 2 (prenatal vit without vit 30 UNIT-60 MG-400 UNIT- a w/ fe bisglycinate-fa- 2 1700 UNIT (prenatal vit omeg 3) w/ iron polysaccharide TRICARE PRENATAL cmplx-l methylfolate-fa) DHA ONE CAPS SELECT-OB CHEW 2.5 (prenatal w/fe 3 MG-1 MG-1.6 MG-1.8 MG- fumarate-fa-dss-fish oil) 5 MCG-15 MG-15 MG-25 MG-29 MG-30 UNIT-1700 TRICARE TABS RX/OTC UNIT-400 UNIT-60 MG 3 (prenatal vit w/ ferrous 2 (prenatal vit w/ iron fumarate-folic acid) polysaccharide TRINATAL RX 1 TABS complex-folic acid) (prenatal vit w/ ferrous 2 SELECT-OB+DHA MISC fumarate-folic acid) (prenatal mv & min w/fe TRISTART DHA CAPS 3 polysaccharide (prenatal without a w/ 3 complex-fa-dha) fe carbonyl-l TARON-BC MISC methylfolate-fa-dha) (prenatal without vit a TRISTART ONE CAPS 3 w/ iron carbonyl-folic (prenatal without a w/ 3 acid & vit b6) fe carbonyl-l TARON-C DHA CAPS methylfolate-fa-dha) (prenatal vit w/ fe fum- ULTIMATECARE ONE 2 iron polysacch complex CAPS (prenatal vit w/ 3 -fa-omega 3) iron carbonyl-fe aspart TARON-PREX CAPS glyc-fa-omega 3) (prenatal w/o vit a w/ fe 3 VENA-BAL DHA MISC fumarate-dss-fa-dha) (prenatal w/fe 2 THERANATAL CORE RX/OTC polysacch cmplx-sod NUTRITION TABS feredetate-fa-omega 3) 2 (prenatal vit w/ ferrous VINATE DHA RF CAPS fumarate-folic acid) (prenatal without vit a w/ fe fumarate-l 3 methylfolate-omegas)

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VINATE ONE TABS VITAMEDMD ONE (prenatal vit w/ ferrous 2 RX/QUATREFOLIC CAPS fumarate-folic acid) (prenatal without a w/ 3 VIRT-C DHA CAPS fe fumarate-l (prenatal vit w/ fe fum- methylfolate-fa-dha) iron polysacch complex 2 VITAMEDMD REDICHEW -fa-omega 3) RX CHEW (prenatal w/ VIRT-NATE DHA CAPS vit b2-b6-b12- 3 (prenatal vit w/ ferrous cholecalciferol-folic fumarate-fa-omega 3 3 acid) fatty acids) VITAPEARL CPCR (prenatal without a w/ VIRT-PN DHA CAPS 3 (prenatal without a w/ fe fumarate-sod fe fumarate-l 3 feredetate-fa-dha) methylfolate-fa-dha) VITATHELY/GINGER RX/OTC TABS (prenatal vit w/ VIRT-PN PLUS CAPS 2 (prenatal without a w/ ferrous fumarate-folic fe fumarate-l 3 acid) methylfolate-fa-omega VITATRUE MISC (prenatal without a w/ 3) 2 VITAFOL FE+ CPPK 0.4 fe amino acid chelate- MG-0.6 MG-1.6 MG-1.8 fa-dha) MG-2 MG-2.5 MG-15 MG- VIVA DHA CAPS 20 MG-20 UNIT-25 MCG- (prenatal vit w/ ferrous 25 MG-50 MG-60 MG-90 3 MG-150 MCG-200 MG-415 3 fumarate-fa-omega 3 MG-1000 UNIT-1100 UNIT fatty acids) (prenatal vit w/ fe VOL-PLUS TABS RX/OTC polysacch complex-l (prenatal vit w/ ferrous 2 methylfol-fa-dha-dss) fumarate-folic acid) VITAFOL GUMMIES VOL-TAB RX TABS CHEW (prenatal vit w/ (prenatal vit w/ iron 2 ferric phosphate-fa- 3 carbonyl-folic acid) omega 3 fatty acids) VP-PNV-DHA CAPS (prenatal vit w/ ferrous VITAFOL-NANO TABS 3 (prenatal w/o a vit w/ fe fumarate-fa-omega 3 fumarate-l methylfolate- 3 fatty acids) folic acid) WESTAB PLUS TABS RX/OTC VITAFOL-ONE CAPS (prenatal vit w/ ferrous 2 (prenatal mv & min w/fe fumarate-folic acid) 3 polysaccharide WESTGEL DHA CAPS complex-fa-dha) (prenatal without a w/ fe carbonyl-l 3 methylfolate-fa-dha)

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZATEAN-PN DHA CAPS PA; (prenatal without a w/ LIORESAL INTRATHECAL administered fe fumarate-l 3 SOLN 10 MG/20ML, 40 7 under the ) MG/20ML (baclofen) medical methylfolate-fa-dha benefit;LA ZATEAN-PN PLUS CAPS metaxalone tabs 400 (prenatal without a w/ 1 mg fe fumarate-l 3 QL(4 ea daily) methylfolate-fa-omega metaxalone tabs 800 1 3) mg MUSCULOSKELETAL THERAPY AGENTS - methocarbamol tabs 1 Drugs to Treat Spasms orphenadrine citrate 1 Central Muscle Relaxants tb12 (Carisoprodol) VANADOM 1 tizanidine hcl caps 2 TABS 1 mg, 4 mg, 6 mg (Chlorzoxazone) 1 LORZONE TABS tizanidine hcl tabs 2 mg 1 (Cyclobenzaprine Hcl) 1 QL(9 ea daily) FEXMID TABS tizanidine hcl tabs 4 mg 1 PA; Direct Muscle Relaxants baclofen soln it 40 administered 4 under the dantrolene sodium 1 mg/20ml, 500 mcg/ml medical caps benefit;LA Muscle Relaxant Combinations baclofen tabs or 10 mg 1 QL(6 ea daily) carisoprodol w/ aspirin 1 & codeine tabs baclofen tabs or 20 mg 1 QL(4 ea daily) carisoprodol w/ aspirin 1 baclofen tabs or 5 mg 1 tabs orphenadrine w/ aspirin carisoprodol tabs 1 & caff tabs 25 mg-30 1 chlorzoxazone tabs 1 mg-385 mg NASAL AGENTS - SYSTEMIC AND TOPICAL - cyclobenzaprine hcl 1 Drugs to treat the Nose or Sinus tabs Nasal Agent Combinations PA; Limit 1 inhaler GABLOFEN SOLN administered azelastine hcl- 4 under the 1 per (baclofen) fluticasone propionate month;QL(0.77 medical susp benefit;LA gm daily) PA; Nasal Antiallergy LIORESAL INTRATHECAL administered Limit 1 sprayer SOLN 0.05 MG/ML, 10 4 under the azelastine hcl soln 0.1 1 per MG/5ML (baclofen) medical %, 137 mcg/spray month;QL(1.2 benefit;LA ml daily)

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ml daily) (Triamcinolone Acetonide QL(1.2 ml azelastine hcl soln 0.15 1 % (Nasal)) CVS NASAL daily) ALLERGY SPRAY, EQ olopatadine hcl (nasal) 1 NASAL ALLERGY SPRAY, soln GNP 24 HOUR NASAL Nasal Anticholinergics ALLERGY SPRAY, GOODSENSE NASAL 1 ipratropium bromide 1 ALLERGY SPRAY, NASAL (nasal) soln ALLERGY 24 HOUR, NASAL ALLERGY 24 Nasal Steroids HOUR MULTI-SYMPTOM, (Fluticasone Propionate Limit 2 inhalers RA NASAL ALLERGY per SPRAY AERO (Nasal)) ALLERGY NASAL 1 month;QL(1.2 Limit 2 inhalers SPRAY 24 HOUR SUSP ml daily); 50 MCG/ACT fluticasone propionate per RX/OTC 1 month;QL(1.2 (Fluticasone Propionate Limit 2 inhalers (nasal) susp ml daily); (Nasal)) ALLERGY per RX/OTC RELIEF, CLARISPRAY, month;QL(1.2 Limit 2 inhalers CVS FLUTICASONE ml daily); mometasone furoate 1 per PROPRIONATE NASAL RX/OTC (nasal) susp month;QL(1.22 SPRAY, EQ ALLERGY gm daily) RELIEF, EQL QL(1.2 ml FLUTICASONE triamcinolone acetonide 1 PROPIONATE, EQL (nasal) aero daily) FLUTICASONE PROPIONATE NEUROMUSCULAR AGENTS - Drugs to CHILDRENS, GNP Relax/Paralyze Muscles FLUTICASONE 1 ALS Agents PROPIONATE, GNP FLUTICASONE riluzole tabs 1 PROPIONATE CHILDRENS, HM Spinal Muscular Atrophy Agents (SMA) ALLERGY RELIEF NASAL EVRYSDI SOLR PA 4 SPRAY 24HR, KLS (risdiplam) ALLER-FLO, QC ALLERGY RELIEF, QC NUTRIENTS FLUTICASONE PROPIONATE, SM Lipids ALLERGY RELIEF NASAL DOJOLVI LIQD PA 4 SPRAY SUSP (triheptanoin) (Triamcinolone Acetonide QL(1.2 ml OPHTHALMIC AGENTS - Drugs to Treat the Eye (Nasal)) ALLERGY NASAL 1 daily) SPRAY 24 HOUR AERO 55 MCG/ACT Artificial Tears and Lubricants LACRISERT INST 3 (artificial tear insert) Beta-blockers - Ophthalmic (Timolol Maleate (Ophth)) TIMOLOL MALEATE IN 1 OCUDOSE SOLN 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISOPTO ATROPINE SOLN betaxolol hcl (ophth) 1 soln (atropine sulfate 2 (ophthalmic)) BETIMOL SOLN (timolol) 2 phenylephrine hcl BETOPTIC-S SUSP 1 2 (mydriatic) soln (betaxolol hcl (ophth)) tropicamide soln 1 carteolol hcl (ophth) 1 soln Miotics COMBIGAN SOLN PHOSPHOLINE IODIDE (brimonidine tartrate- 3 SOLR (echothiophate 2 timolol maleate) iodide) dorzolamide hcl-timolol QL(0.5 ml 1 pilocarpine hcl soln 1 maleate soln daily) levobunolol hcl soln 1 Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % 2 timolol maleate (ophth) 1 (brimonidine tartrate) solg 0.25 %, 0.5 % apraclonidine hcl soln 1 timolol maleate (ophth) 1 soln 0.25 %, 0.5 % brimonidine tartrate 1 TIMOPTIC OCUDOSE soln SOLN 0.25 % (timolol 3 IOPIDINE SOLN 3 maleate (ophth)) (apraclonidine hcl) TIMOPTIC-XE SOLG SIMBRINZA SUSP (timolol maleate 7 (brinzolamide- 3 (ophth)) brimonidine tartrate) Cycloplegic Mydriatics Ophthalmic Anti-infectives (Bacitracin-Polymyxin B (Homatropine Hbr) 1 HOMATROPAIRE SOLN (Ophth)) AK-POLY-BAC, 1 (Phenylephrine Hcl POLYCIN OINT (Mydriatic)) ALTAFRIN 1 (Gentamicin Sulfate 1 SOLN (Ophth)) GENTAK OINT (Neomycin-Bacitracin Zn- atropine sulfate 1 (ophthalmic) oint Polymyxin) NEO-POLYCIN 1 OINT ATROPINE SULFATE AZASITE SOLN Limit 5mls per SOLN OP 1 % (atropine 2 3 month;QL(0.17 sulfate (ophthalmic)) (azithromycin (ophth)) ml daily) CYCLOMYDRIL SOLN bacitracin (ophthalmic) 2 (cyclopentolate w/ 3 oint phenylephrine) bacitracin-polymyxin b 1 cyclopentolate hcl soln 1 (ophth) oint BESIVANCE SUSP 1 3 homatropine hbr soln (besifloxacin hcl)

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BETADINE OPHTHALMIC TOBREX OINT 2 PREP SOLN (povidone- 3 (tobramycin (ophth)) iodine (ophth)) trifluridine soln 1 CILOXAN OINT ZIRGAN GEL (ciprofloxacin hcl 2 3 (ophth)) (ganciclovir ophthalmic) Ophthalmic Immunomodulators ciprofloxacin hcl 1 (ophth) soln RESTASIS EMUL QL(2 ml erythromycin (ophth) 2 daily,64 ml per 1 (cyclosporine (ophth)) fill retail) oint RESTASIS MULTIDOSE QL(2 ml gatifloxacin (ophth) 1 EMUL (cyclosporine 2 daily,64 ml per soln (ophth)) fill retail) gentamicin sulfate 1 Ophthalmic Local Anesthetics (ophth) soln (Tetracaine Hcl (Ophth)) KLARITY-A SOLN Limit 5mls per ALTACAINE, TETCAINE, 3 month;QL(0.17 1 (azithromycin (ophth)) TETRAVISC, TETRAVISC ml daily) FORTE SOLN levofloxacin (ophth) AKTEN GEL ( 1 lidocaine 3 soln hcl (ophth)) moxifloxacin hcl (ophth) 1 soln proparacaine hcl soln 1 NATACYN SUSP tetracaine hcl (ophth) 2 1 (natamycin) soln Ophthalmic Nerve Growth Factors neomycin-bacitracin 1 zn-polymyxin oint OXERVATE SOLN PA 4 (cenegermin-bkbj) neomycin-polymyxin- 1 gramicidin soln Ophthalmic Steroids QL(5 ml per fill (Bacitracin-Poly-Neomycin- QL(4 gm per fill ofloxacin (ophth) soln 1 retail,5 ml per Hc) NEO-POLYCIN HC 1 retail,4 gm per fill mail) OINT fill mail) polymyxin b- 1 (Prednisolone Acetate trimethoprim soln (Ophth)) PREDNISOLONE 1 POVIDONE IODINE SOLN ACETATE P-F SUSP ALREX SUSP (povidone-iodine 3 3 (ophth)) (loteprednol etabonate) sulfacetamide sodium bacitracin-poly- QL(4 gm per fill 1 1 retail,4 gm per (ophth) oint neomycin-hc oint fill mail) sulfacetamide sodium 1 BLEPHAMIDE S.O.P. (ophth) soln OINT (sulfacetamide 2 tobramycin (ophth) soln 1 sod-prednisolone)

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BLEPHAMIDE SUSP PREDNISOLONE SODIUM ( PHOSPHATE SOLN OP 1 sulfacetamide sod- 2 3 prednisolone) % (prednisolone sodium dexamethasone phosphate (ophth)) sodium phosphate 1 PREDNISOLONE SODIUM (ophth) soln PHOSPHATE/MOXIFLOXA CIN SOLN 3 DUREZOL EMUL 3 (prednisolone- (difluprednate) moxifloxacin) FLAREX SUSP sulfacetamide sod- 1 (fluorometholone 2 prednisolone soln acetate) TOBRADEX OINT fluorometholone 1 (tobramycin- 3 (ophth) susp dexamethasone) FML FORTE SUSP TOBRADEX ST SUSP (fluorometholone 2 (tobramycin- 3 (ophth)) dexamethasone) FML OINT QL(5 ml per fill tobramycin- 1 (fluorometholone 2 dexamethasone susp retail) (ophth)) ZYLET SUSP QL(5 ml per fill LOTEMAX OINT 3 (loteprednol etabonate- 3 retail) (loteprednol etabonate) tobramycin) loteprednol etabonate 1 gel Ophthalmic Surgical Aids GELFILM OP FILM loteprednol etabonate 1 (gelatin adsorbable 3 susp (ophth)) MAXIDEX SUSP (dexamethasone 2 Ophthalmics - Misc. (ophth)) (Olopatadine Hcl) CVS QL(0.09 ml OLOPATADINE daily); RX/OTC neomycin-polymy- 1 HYDROCHLORIDE, EYE dexameth oint ALLERGY ITCH RELIEF, neomycin-polymy- EYE ALLERGY 1 1 ITCH/REDNESSRELIEF, dexameth susp HM EYE ALLERGY ITCH/REDNESS RELIEF neomycin-polymyxin-hc 1 (ophth) susp SOLN PRED-G S.O.P. OINT (Olopatadine Hcl) CVS Limit 10mls per (gentamicin- 3 OLOPATADINE month;QL(0.34 HYDROCHLORIDE, EYE ml daily); ) prednisolone acetate ALLERGY ITCH RELIEF, RX/OTC PRED-G SUSP EYE ALLERGY 1 (gentamicin- 3 ITCH/REDNESSRELIEF, prednisolone acetate) HM EYE ALLERGY ITCH/REDNESS RELIEF prednisolone acetate 1 SOLN (ophth) susp 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Olopatadine Hcl) GNP Limit 10mls per flurbiprofen sodium 1 OLOPATADINE 1 month;QL(0.34 soln HYDROCHLORIDE SOLN ml daily); ILEVRO SUSP 0.1 % RX/OTC 3 ( ) (Olopatadine Hcl) GNP QL(0.09 ml nepafenac ketorolac tromethamine OLOPATADINE 1 daily); RX/OTC 1 HYDROCHLORIDE SOLN (ophth) soln 0.2 % LASTACAFT SOLN ST 3 ACUVAIL SOLN (alcaftadine) (ketorolac 3 NEVANAC SUSP 3 tromethamine (ophth)) (nepafenac) ALOCRIL SOLN Limit 10mls per (nedocromil sodium 3 olopatadine hcl soln 0.1 1 month;QL(0.34 (ophth)) % ml daily); ALOMIDE SOLN RX/OTC (lodoxamide 2 QL(0.09 ml olopatadine hcl soln 0.2 1 tromethamine) % daily); RX/OTC PAREMYD SOLN azelastine hcl (ophth) 1 soln (hydroxyamphetamine- 3 ST; QL(0.34 ml tropicamide) bepotastine besilate 1 soln daily) PROLENSA SOLN Limit 10mls per (bromfenac sodium 3 brinzolamide susp 1 month;QL(0.4 (ophth)) ml daily) Prostaglandins - Ophthalmic bromfenac sodium 1 Limit 2.5mls (ophth) soln bimatoprost soln 1 per BROMSITE SOLN month;QL(0.09 (bromfenac sodium 3 ml daily) (ophth)) 1 QL(0.09 ml latanoprost soln op daily) cromolyn sodium 1 Limit 2.5mls (ophth) soln LUMIGAN SOLN 2 per CYSTARAN SOLN month;QL(0.09 4 (bimatoprost) (cysteamine hcl) ml daily) Limit 2.5mls diclofenac sodium 1 (ophth) soln 1 per travoprost soln month;QL(0.09 Limit 10mls per ml daily) 1 month;QL(0.34 dorzolamide hcl soln ZIOPTAN SOLN ml daily) 3 (tafluprost) DORZOLAMIDE HCL Limit 10mls per 2 month;QL(0.34 OTIC AGENTS - Drugs to Treat the Ear SOLN (dorzolamide hcl) ml daily) Otic Agents - Miscellaneous epinastine hcl (ophth) 1 soln acetic acid (otic) soln 1

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Otic Anti-infectives OXYTOCICS - Drugs to Prevent/Control Uterine CETRAXAL SOLN QL(14 ea per Bleeding 7 (ciprofloxacin hcl (otic)) fill retail) Abortifacients/Agents for Cervical Ripening QL(14 ea per CERVIDIL INST ciprofloxacin hcl (otic) 1 3 soln fill retail) (dinoprostone) PREPIDIL GEL ofloxacin (otic) soln 1 3 (dinoprostone) Otic Combinations PROSTIN E2 SUPP 3 (Pramoxine-Hc- (dinoprostone) Chloroxylenol) CORTIC- 1 ND, EXOTIC-HC SOLN Oxytocics CIPRO HC SUSP (Methylergonovine Maleate) METHERGINE 1 (ciprofloxacin- 3 TABS hydrocortisone) methylergonovine 1 ciprofloxacin- 1 maleate tabs dexamethasone susp PASSIVE IMMUNIZING AND TREATMENT ciprofloxacin- Limit 15mls per AGENTS - Antibody Drugs to Treat Low Immune fluocinolone acetonide 1 month;QL(0.5 System ea daily) soln Immune Serums COLY-MYCIN S SUSP CARIMUNE PA; LA (neomycin-colistin-hc- 3 NANOFILTERED SOLR 6 thonzonium) GM (immune globulin 4 CORTISPORIN-TC SUSP (human) iv) (neomycin-colistin-hc- 3 FLEBOGAMMA DIF SOLN PA; LA thonzonium) 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, neomycin-polymyxin-hc 1 4 (otic) soln 20 GM/200ML, 5 GM/100ML (immune neomycin-polymyxin-hc 1 globulin (human) iv) (otic) susp GAMMAGARD LIQUID PA; Covered OTOVEL SOLN Limit 15mls per SOLN 1 GM/10ML under Medical (ciprofloxacin- 7 month;QL(0.5 (immune globulin 4 Benefit;LA ea daily) fluocinolone acetonide) (human) iv or PRAMOTIC LIQD subcutaneous) (pramoxine- 3 GAMMAGARD LIQUID PA; Must use chloroxylenol) SOLN 2.5 GM/25ML AcariaHlth Sp (immune globulin 4 Rx 1-844-538- Otic Steroids (human) iv or 4661;LA (Fluocinolone Acetonide 1 subcutaneous) (Otic)) FLAC OIL GAMMAKED SOLN PA; Covered fluocinolone acetonide under Medical 1 (immune globulin 4 (otic) oil (human) iv or Benefit;LA QL(10 ml per subcutaneous) hydrocortisone w/acetic 2 acid soln fill retail) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GAMMAPLEX SOLN 10 PA; LA Aminopenicillins GM/100ML, 10 GM/200ML, 20 GM/200ML, 5 4 amoxicillin caps 1 GM/100ML (immune globulin (human) iv) amoxicillin chew 1 GAMUNEX-C SOLN 1 PA; Covered amoxicillin susr 1 GM/10ML (immune under Medical 4 Benefit;LA globulin (human) iv or amoxicillin tabs 1 subcutaneous) GAMUNEX-C SOLN 2.5 PA; Must use ampicillin caps 1 GM/25ML ( AcariaHlth Sp immune 4 PA globulin (human) iv or Rx 1-844-538- ampicillin sodium solr 4 subcutaneous) 4661;LA Natural Penicillins OCTAGAM SOLN 1 PA; LA GM/20ML, 10 GM/100ML, (Penicillin G Potassium) 4 PA 10 GM/200ML, 2 PFIZERPEN SOLR GM/20ML, 2.5 GM/50ML, BICILLIN L-A SUSP PA 4 20 GM/200ML, 25 4 (penicillin g benzathine) GM/500ML, 5 GM/100ML PENICILLIN G PA (immune globulin POTASSIUM IN ISO- (human) iv) OSMOTIC DEXTROSE 4 PRIVIGEN SOLN 10 PA; LA SOLN (penicillin g pot in GM/100ML, 20 GM/200ML, dextrose) 4 40 GM/400ML (immune PA penicillin g potassium 4 globulin (human) iv) solr Monoclonal Antibodies PENICILLIN G PROCAINE PA REGEN-COV SOLN IV PA; Must use SUSP (penicillin g 4 1332 MG/11.1ML-1332 AcariaHealth procaine) MG/11.1ML, 300 Specialty Rx at PA MG/2.5ML-1332 1-844-538- penicillin g sodium solr 4 MG/11.1ML, 300 4 4661;LA MG/2.5ML-300 MG/2.5ML penicillin v potassium 1 (casirivimab- solr imdevimab) penicillin v potassium 1 Passive Immunizing Agents - Combinations tabs HYQVIA KIT 20 PA; Some Penicillin Combinations GM/200ML-1600 members may amoxicillin & pot 1 UNIT/10ML, 200 obtain their clavulanate chew UNT/1.25ML-2.5 medications GM/25ML, 30 GM/300ML- through their amoxicillin & pot 1 2400 UNIT/15ML, 5 4 Medical clavulanate susr GM/50ML-400 UNIT/2.5ML Group;LA amoxicillin & pot 1 (immune globulin clavulanate tabs (human)-hyaluronidase (human recombinant)) amoxicillin & pot 1 clavulanate tb12 PENICILLINS - Drugs to Treat Bacterial Infections 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA ampicillin & sulbactam 4 medroxyprogesterone sodium solr acetate tabs 2.5 mg, 5 1 AUGMENTIN SUSR 31.25 mg MG/5ML-125 MG/5ML AC 2 megestrol acetate 1 (amoxicillin & pot (appetite) susp clavulanate) norethindrone acetate 1 BICILLIN C-R SUSP PA tabs (penicillin g benzathine 4 QL(1 ea daily) & procaine) progesterone caps or 1 100 mg, 200 mg piperacillin sodium- PA progesterone oil im 50 PA tazobactam sodium 4 1 solr mg/ml UNASYN BULK PACK PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL SOLR (ampicillin & 7 AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions sulbactam sodium) UNASYN SOLR PA Agents for Chemical Dependency (ampicillin & sulbactam 7 acamprosate calcium 1 sodium) tbec ZOSYN SOLR PA disulfiram tabs 1 (piperacillin sodium- 7 tazobactam sodium) LUCEMYRA TABS PA; QL(224 ea 4 per 14 days Penicillinase-Resistant Penicillins (lofexidine hcl) retail) dicloxacillin sodium 1 Anti-Cataplectic Agents caps XYREM SOLN (sodium PA; ST PA 4 nafcillin sodium solr ij 1 4 oxybate) gm Antidementia Agents NAFCILLIN SODIUM PA donepezil QL(1 ea daily) SOLR IV 10 GM (nafcillin 4 1 hydrochloride tabs sodium) donepezil QL(1 ea daily) nafcillin sodium solr iv PA 1 4 hydrochloride tbdp 10 gm, 2 gm QL(1 ea daily) NAFCILLIN SOLN PA galantamine 1 (nafcillin sodium in 4 hydrobromide cp24 16 dextrose) mg, 24 mg, 8 mg PA galantamine oxacillin sodium solr 4 hydrobromide soln 4 1 PROGESTINS - Hormone Replacement/Modifying mg/ml Drugs galantamine Progestins hydrobromide tabs 12 1 medroxyprogesterone QL(1 ea daily) mg, 4 mg, 8 mg 1 PA acetate tabs 10 mg memantine hcl cp24 14 1 mg, 21 mg, 28 mg

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; ST AUSTEDO TABS 12 MG, 9 PA memantine hcl cp24 7 1 4 mg MG (deutetrabenazine) AUSTEDO TABS 6 MG PA; ST memantine hcl soln 10 1 4 mg/5ml, 2 mg/ml (deutetrabenazine) INGREZZA CAPS PA 1 4 memantine hcl tabs (valbenazine tosylate) memantine hcl tabs 10 QL(2 ea daily) INGREZZA CPPK PA 1 4 mg (valbenazine tosylate) QL(4 ea daily) PA; Specialty memantine hcl tabs 5 1 mg 4 drug-Health tetrabenazine tabs Net will refer to NAMENDA XR TITRATION PA; ST SP Pharmacy PACK CP24 (memantine 3 PA; Specialty hcl) XENAZINE TABS 7 drug-Health NAMZARIC C4PK 10 MG PA (tetrabenazine) Net will refer to (memantine hcl- 3 SP Pharmacy donepezil hcl) Multiple Sclerosis Agents rivastigmine pt24 1 (Glatiramer Acetate) 1 PA GLATOPA SOSY rivastigmine tartrate AUBAGIO TABS PA 1 3 caps (teriflunomide) Combination Psychotherapeutics AVONEX PEN AJKT PA; LA 4 (interferon beta-1a) chlordiazepoxide- 1 amitriptyline tabs AVONEX PSKT PA; LA 4 olanzapine-fluoxetine (interferon beta-1a) BETASERON KIT PA hcl caps 12 mg-25 mg, 1 4 12 mg-50 mg, 6 mg-25 (interferon beta-1b) mg dalfampridine tb12 1 PA olanzapine-fluoxetine hcl caps 3 mg-25 mg, 6 2 dimethyl fumarate cpdr 2 PA; LA mg-50 mg dimethyl fumarate misc 2 PA; LA perphenazine- 1 EXTAVIA KIT ( PA; LA amitriptyline tabs interferon 2 Fibromyalgia Agents beta-1b) GILENYA CAPS PA SAVELLA TABS 100 MG, PA; QL(2 ea 3 25 MG, 50 MG 3 daily) (fingolimod hcl) (milnacipran hcl) glatiramer acetate sosy 1 PA SAVELLA TABS 12.5 MG PA; ST;QL(2 3 (milnacipran hcl) ea daily) MAVENCLAD TBPK PA; ST (cladribine (multiple 4 SAVELLA TITRATION PA; QL(2 ea ) PACK MISC 3 daily) sclerosis) MAYZENT TABS PA (milnacipran hcl) 3 (siponimod fumarate) Movement Disorder Drug Therapy 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEGRIDY SOPN SC PA; LA 4 fluoxetine hcl (pmdd) 1 (peginterferon beta-1a) tabs 10 mg, 20 mg PLEGRIDY SOSY IM PA 4 Pseudobulbar Affect (PBA) Agents (peginterferon beta-1a) NUEDEXTA CAPS PA PLEGRIDY SOSY SC PA; LA 4 (dextromethorphan hbr- 4 (peginterferon beta-1a) quinidine sulfate) PLEGRIDY STARTER PA; LA Psychotherapeutic and Neurological Agents - PACK SOPN 4 (peginterferon beta-1a) ergoloid mesylates tabs 1 PLEGRIDY STARTER PA; LA PACK SOSY 4 pimozide tabs 1 (peginterferon beta-1a) Restless Leg Syndrome (RLS) Agents REBIF REBIDOSE SOAJ PA; LA 4 Limited to 1 (interferon beta-1a) HORIZANT TBCR 300 MG 3 tablet REBIF REBIDOSE PA; LA (gabapentin enacarbil) daily;QL(1 ea TITRATIONPACK SOAJ 4 daily) (interferon beta-1a) HORIZANT TBCR 600 MG QL(2 ea daily) 3 REBIF SOSY ( PA; LA (gabapentin enacarbil) interferon 4 beta-1a) Smoking Deterrents REBIF TITRATION PACK PA; LA (Nicotine Polacrilex) CVS PV SOSY (interferon beta- 4 NICOTINE LOZENGE, 1a) CVS NICOTINE PA; Must use POLACRILEX, EQ NICOTINE LOZENGES, TYSABRI CONC AcariaHealth 4 Specialty Rx at EQ NICOTINE (natalizumab) 1-844-538- POLACRILEX, EQL 4661;;LA NICOTINE POLACRILEX, GNP NICOTINE MINI Postherpetic Neuralgia (PHN)/Neuropathic Pain LOZENGE, GNP GRALISE MISC PA NICOTINE POLACRILEX, (gabapentin (once- 3 GNP NICOTINE POLACRILEX MINI, daily)) GOODSENSE NICOTINE, 5 GRALISE TABS 300 MG PA; ST GOODSENSE NICOTINE (gabapentin (once- 3 POLACRILEX, HM daily)) NICOTINE POLACRILEX, GRALISE TABS 600 MG PA; ST;QL(3 KLS QUIT2, KLS QUIT4, ea daily) NICOTINE MINI (gabapentin (once- 3 LOZENGE, NICOTINE daily)) POLACRILEX MINI, PX Premenstrual Dysphoric Disorder (PMDD) Agents STOP SMOKING AID, RA MINI NICOTINE, RA fluoxetine hcl (pmdd) 1 NICOTINE POLACRILEX, caps 10 mg SM NICOTINE, SM fluoxetine hcl (pmdd) QL(1 ea daily) NICOTINE POLACRILEX, 1 TGT NICOTINE caps 20 mg POLACRILEX LOZG

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS PV (Nicotine) CVS NICOTINE PV NICOTINE, CVS TRANSDERMALSYSTEM, NICOTINE POLACRILEX, CVS NICOTINE CVS NICOTINE TRANSDERMALSYSTEM POLACRILEX STARTER, STEP 1, CVS NICOTINE EQ NICOTINE TRANSDERMALSYSTEM POLACRILEX, EQL STEP 2, CVS NICOTINE NICOTINE POLACRILEX, TRANSDERMALSYSTEM/ EQL NICOTINE STEP 3, EQ NICOTINE, POLACRILEX REFILL, EQ NICOTINE STEP 3, EQL NICOTINE GNP NICOTINE POLACRILEX STARTER, TRANSDERMALSYSTEM, GNP NICOTINE GUM, GNP NICOTINE GNP NICOTINE 5 TRANSDERMALSYSTEM POLACRILEX, STEP 2, HABITROL, HM GOODSENSE NICOTINE NICOTINE GUM, GOODSENSE TRANSDERMAL SYSTEM, NICOTINE POLACRILEX HM NICOTINE GUM, HM NICOTINE TRANSDERMAL SYSTEM POLACRILEX, KLS QUIT2, STEP 1, HM NICOTINE KLS QUIT4, PX STOP TRANSDERMAL SYSTEM SMOKING AID, RA STEP 2, HM NICOTINE NICOTINE, RA NICOTINE TRANSDERMAL SYSTEM GUM, SM NICOTINE, SM STEP 3, HM NICOTINE NICOTINE POLACRILEX, TRANSDERMALSYSTEM, TGT NICOTINE GUM, TGT NICOTINE STEP 1, 5 NICOTINE POLACRILEX, NICOTINE STEP 3, THRIVE GUM NICOTINE TRANSDERMAL SYSTEM STEP 1, NICOTINE TRANSDERMAL SYSTEM STEP 1/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 2, NICOTINE TRANSDERMAL SYSTEM STEP 2/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 3, NICOTINE TRANSDERMAL SYSTSTEM STEP 3/CLEAR, QC NICOTINE TRANSDERMAL SYSTEM/STEP 1, QC NICOTINE TRANSDERMAL SYSTEM/STEP 2, RA NICOTINE, RA NICOTINE TRANSDERMAL SYSTEM, SM NICOTINE TRANSDERMAL SYSTEM, 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM NICOTINE nicotine polacrilex lozg 5 PV TRANSDERMAL SYSTEM/STEP 1/CLEAR, 5 PV SM NICOTINE nicotine pt24 TRANSDERMAL NICOTINE PV SYSTEM/STEP 2/CLEAR, TRANSDERMAL SYSTEM 5 SM NICOTINE KIT (nicotine) TRANSDERMAL NICOTROL INHALER PV SYSTEM/STEP 3/CLEAR, 5 TGT NICOTINE STEP INHA (nicotine) ONE, TGT NICOTINE NICOTROL NS SOLN PV 5 STEP THREE, TGT (nicotine) NICOTINE STEP TWO PT24 Transthyretin Amyloidosis Agents TEGSEDI SOSY PA APO-VARENICLINE TABS PV 4 0.5 MG (varenicline 5 (inotersen sodium) tartrate) RESPIRATORY AGENTS - MISC. - Drugs to APO-VARENICLINE TABS QL(2 ea daily); Treat Lung Conditions 1 MG (varenicline 5 PV Cystic Fibrosis Agents tartrate) PA; Must use PV KALYDECO PACK 25 MG AcariaHlth Sp bupropion hcl (smoking 5 4 deterrent) tb12 (ivacaftor) Rx 1-844-538- 4662;LA CHANTIX CONTINUING QL(2 ea daily); MONTHPAK TABS 5 PV KALYDECO PACK 50 MG, PA; Must use (varenicline tartrate) 4 Accredo SP 75 MG (ivacaftor) pharmacy;LA CHANTIX STARTING PV PA; Must use MONTH PAK TABS KALYDECO TABS 150 MG 5 4 Accredo SP (varenicline tartrate) (ivacaftor) pharmacy;LA CHANTIX TABS 0.5 MG PV 5 PA; MUST (varenicline tartrate) ORKAMBI PACK 100 MG- USE ACARIA CHANTIX TABS 1 MG QL(2 ea daily); 125 MG, 150 MG-188 MG 4 SPECIALTY 5 (varenicline tartrate) PV (lumacaftor-ivacaftor) RX 844-538- 4661;LA NICODERM CQ PT24 PV 7 PA; Must use (nicotine) ORKAMBI TABS 100 MG- AcariaHealth NICORETTE GUM PV 125 MG, 125 MG-200 MG 7 4 Specialty Rx at (nicotine polacrilex) (lumacaftor-ivacaftor) 1-844-538- NICORETTE LOZG PV 4661;LA 7 (nicotine polacrilex) PULMOZYME SOLN PA; QL(5 ml 2 daily) NICORETTE MINI LOZG PV (dornase alfa) 7 SYMDEKO TBPK PA; LA (nicotine polacrilex) 4 NICORETTE STARTER PV (tezacaftor-ivacaftor) KIT GUM (nicotine 7 polacrilex) nicotine polacrilex gum 5 PV

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use doxycycline TRIKAFTA TBPK 25 MG- AcariaHealth (monohydrate) caps 2 50 MG ( 4 Specialty Rx at 100 mg, 50 mg, 75 mg elexacaftor- 1-844-538- tezacaftor-ivacaftor) 4661;QL(3 ea doxycycline ST daily); LA (monohydrate) caps 2 PA; Must use 150 mg TRIKAFTA TBPK 50 MG- AcariaHlth Sp doxycycline 100 MG (elexacaftor- 4 Rx 1-844-538- (monohydrate) susr 25 1 tezacaftor-ivacaftor) 4662;QL(3 ea daily); LA mg/5ml Pulmonary Fibrosis Agents doxycycline 1 PA; Must use (monohydrate) tabs 100 mg, 50 mg ESBRIET CAPS Exactus 4 Specialty Rx 1- ST (pirfenidone) doxycycline 866-458- (monohydrate) tabs 2 9246;LA 150 mg PA; Must use doxycycline ST ESBRIET TABS Exactus 4 Specialty Rx 1- (monohydrate) tabs 75 1 (pirfenidone) 866-458- mg 9246;LA doxycycline hyclate OFEV CAPS ( PA; QL(1 ea 1 nintedanib 4 caps 100 mg, 50 mg esylate) daily) doxycycline hyclate 1 SULFONAMIDES - Drugs to Treat Bacterial tabs 100 mg, 20 mg Infections MINOCIN CAPS PA 7 Sulfonamides (minocycline hcl) SULFADIAZINE TABS 3 minocycline hcl caps 1 (sulfadiazine) 100 mg, 50 mg, 75 mg TETRACYCLINES - Drugs to Treat Bacterial ST minocycline hcl cp24 3 Infections 135 mg, 45 mg, 90 mg Tetracyclines minocycline hcl tabs 1 (Doxycycline 100 mg, 50 mg (Monohydrate)) AVIDOXY 1 PA minocycline hcl tabs 75 1 TABS mg (Doxycycline (Monohydrate)) 2 tetracycline hcl caps 1 MONDOXYNE NL, OKEBO CAPS VIBRAMYCIN SYRP 50 (Doxycycline Hyclate) MG/5ML (doxycycline 2 MORGIDOX 1X100MG, calcium) MORGIDOX 1X50MG, 1 XIMINO CP24 135 MG, 45 ST MORGIDOX 2X100MG MG, 90 MG (minocycline 3 CAPS hcl) demeclocycline hcl 1 tabs 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) THYROID AGENTS - Drugs to Regulate Thyroid levothyroxine sodium 1 Hormones caps or 125 mcg Antithyroid Agents levothyroxine sodium tabs or 100 mcg, 137 methimazole tabs 1 mcg, 150 mcg, 25 mcg, 1 propylthiouracil tabs 1 QL(3 ea daily) 300 mcg, 50 mcg, 75 mcg, 88 mcg Thyroid Hormones levothyroxine sodium QL(1 ea daily) (Levothyroxine Sodium) QL(1 ea daily) tabs or 112 mcg, 125 1 EUTHYROX, LEVO-T, mcg, 175 mcg, 200 LEVOXYL, UNITHROID 1 TABS 112 MCG, 125 MCG, mcg 175 MCG, 200 MCG QL(2 ea daily) liothyronine sodium 1 (Levothyroxine Sodium) tabs 25 mcg, 50 mcg EUTHYROX, LEVOXYL liothyronine sodium TABS 100 MCG, 137 MCG, 1 1 150 MCG, 25 MCG, 50 tabs 5 mcg NATURE-THROID NT-2.5 MCG, 75 MCG, 88 MCG 2 (Levothyroxine Sodium) TABS (thyroid) LEVO-T, UNITHROID NATURE-THROID TABS TABS 100 MCG, 137 MCG, 1 113.75 MG, 146.25 MG, 150 MCG, 25 MCG, 300 16.25 MG, 195 MG, 260 MCG, 50 MCG, 75 MCG, MG, 32.5 MG, 325 MG, 2 88 MCG 48.75 MG, 65 MG, 81.25 (Thyroid) NP THYROID 15, MG, 97.5 MG (thyroid) NP THYROID 30, NP NATURE-THROID TABS 1 3 THYROID 60, NP 130 MG (thyroid) THYROID 90 TABS SYNTHROID TABS 100 ARMOUR THYROID TABS MCG, 137 MCG, 150 MCG, 120 MG, 180 MG, 240 MG, 2 25 MCG, 300 MCG, 50 2 30 MG, 300 MG, 60 MG, MCG, 75 MCG, 88 MCG 90 MG (thyroid) (levothyroxine sodium) ARMOUR THYROID TABS 2 SYNTHROID TABS 112 QL(1 ea daily) 15 MG (thyroid) MCG, 125 MCG, 175 MCG, CYTOMEL TABS 25 MCG, QL(2 ea daily) 200 MCG (levothyroxine 2 50 MCG (liothyronine 2 sodium) sodium) thyroid tabs 1 CYTOMEL TABS 5 MCG 2 TIROSINT CAPS 75 MCG (liothyronine sodium) 2 levothyroxine sodium (levothyroxine sodium) WESTHROID TABS 130 caps or 100 mcg, 112 3 MG (thyroid) mcg, 13 mcg, 137 mcg, 1 150 mcg, 175 mcg, 200 WESTHROID TABS 195 mcg, 25 mcg, 50 mcg, MG, 32.5 MG, 65 MG, 97.5 2 75 mcg, 88 mcg MG (thyroid)

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WP THYROID TABS hyoscyamine sulfate 1 113.75 MG, 16.25 MG, tabs 32.5 MG, 48.75 MG, 65 2 MG, 81.25 MG, 97.5 MG hyoscyamine sulfate 1 (thyroid) tb12 WP THYROID TABS 130 hyoscyamine sulfate 3 1 MG (thyroid) tbdp ULCER DRUGS - Drugs to Treat Bowel, Intestine methscopolamine 1 and Stomach Conditions bromide tabs Antispasmodics propantheline bromide 1 (Hyoscyamine Sulfate) ED- tabs SPAZ, NULEV, OSCIMIN 1 H-2 Antagonists TBDP (Famotidine) ACID RX/OTC (Hyoscyamine Sulfate) CONTROL MAXIMUM OSCIMIN SR, SYMAX-SR 1 STRENGTH, ACID TB12 REDUCER MAXIMUM STRENGTH, PX ACID (Hyoscyamine Sulfate) 1 OSCIMIN TABS REDUCER MAXIMUM 1 (Hyoscyamine Sulfate) STRENGTH, RA ACID OSCIMIN, SYMAX-SL 1 REDUCER MAXIMUM SUBL STRENGTH, SM ACID REDUCER MAXIMUM BELLADONNA/OPIUM STRENGTH TABS 20 MG SUPP (belladonna 3 alkaloids & opium) chlordiazepoxide hcl- 1 clidinium bromide caps CUVPOSA SOLN 2 (glycopyrrolate) dicyclomine hcl caps 1 dicyclomine hcl soln 1 dicyclomine hcl tabs 1 GLYCATE TABS 3 (glycopyrrolate) glycopyrrolate tabs or 1 1 mg, 2 mg GLYCOPYRROLATE TABS OR 1.5 MG 3 (glycopyrrolate) hyoscyamine sulfate 1 subl

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID RX/OTC (Lansoprazole) CVS QL(2 ea daily); CONTROLLER MAXIMUM 1 AL(Up to 12 yrs LANSOPRAZOLE TBDD STRENGTH, CVS ACID old ); RX/OTC CONTROLLER MAXIMUM (Lansoprazole) CVS QL(1 ea daily); STRENGTH, EQ LANSOPRAZOLE, EQ RX/OTC FAMOTIDINE MAXIMUM LANSOPRAZOLE, GNP STRENGTH, EQL LANSOPRAZOLE, HEARTBURN GOODSENSE PREVENTION/MAXIMUM LANSOPRAZOLE, STRENGTH, FAMOTIDINE HEARTBURN 1 MAXIMUM STRENGTH, TREATMENT 24 HOUR, GNP ACID REDUCER HM LANSOPRAZOLE, MAXIMUMSTRENGTH, KLS LANSOPRAZOLE, QC HEARTBURN RELIEF 1 LANSOPRAZOLE, RA MAXIMUMSTRENGTH, LANSOPRAZOLE, SM HM FAMOTIDINE, KLS LANSOPRAZOLE CPDR ACID CONTROLLER MAXIMUM STRENGTH, ACIPHEX SPRINKLE PA MM ACID-PEP MAXIMUM CPSP 10 MG 3 STRENGTH, MM (rabeprazole sodium) FAMOTIDINE, QC ACID ACIPHEX SPRINKLE PA; ST CONTROLLER MAXIMUM CPSP 5 MG (rabeprazole 3 STRENGTH, SB ACID sodium) CONTROLLER MAXIMUM STRENGTH, ZANTAC 360 esomeprazole PA MAXIMUM STRENGTH magnesium pack 10 1 TABS mg, 20 mg, 40 mg cimetidine tabs 300 FIRST-OMEPRAZOLE 1 3 mg, 800 mg SUSP (omeprazole) QL(4 ea daily) QL(1 ea daily); cimetidine tabs 400 mg 1 lansoprazole cpdr 15 1 mg RX/OTC famotidine susr 40 1 QL(1 ea daily) lansoprazole cpdr 30 1 mg/5ml mg RX/OTC famotidine tabs 20 mg 1 lansoprazole tbdd 15 QL(2 ea daily); 1 AL(Up to 12 yrs famotidine tabs 40 mg 1 QL(2 ea daily) mg old ); RX/OTC lansoprazole tbdd 30 QL(1 ea daily); nizatidine caps 1 1 AL(Up to 12 yrs mg old ) nizatidine soln 1 NEXIUM PACK 2.5 MG, 5 PA Misc. Anti-Ulcer MG (esomeprazole 3 magnesium) sucralfate susp 1 1 gm/10ml OMEPRAZOLE + SYRSPEND SFALKA 3 sucralfate tabs 1 gm 1 QL(4 ea daily) SUSP (omeprazole) Proton Pump Inhibitors omeprazole cpdr 10 mg 1

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); QL(4 ea daily) omeprazole cpdr 20 mg 1 oxybutynin chloride 1 RX/OTC tabs 5 mg omeprazole cpdr 40 mg 1 QL(1 ea daily) oxybutynin chloride tb24 10 mg, 15 mg, 5 1 pantoprazole sodium QL(1 ea daily) 1 mg pack solifenacin succinate QL(1 ea daily) pantoprazole sodium QL(1 ea daily) 1 1 tabs 10 mg tbec PRILOSEC PACK PA solifenacin succinate 1 (omeprazole 3 tabs 5 mg QL(1 ea daily) magnesium) tolterodine tartrate cp24 1 RABEPRAZOLE SODIUM PA 2 mg, 4 mg DR SPRINKLE CPSP 3 QL(2 ea daily) tolterodine tartrate tabs 1 (rabeprazole sodium) 1 mg, 2 mg rabeprazole sodium PA; ST;QL(1 TOVIAZ TB24 QL(1 ea daily) 2 2 tbec ea daily) (fesoterodine fumarate) Ulcer Drugs - Prostaglandins trospium chloride cp24 1 60 mg misoprostol tabs 1 QL(2 ea daily) trospium chloride tabs 1 Ulcer Therapy Combinations 20 mg amoxicillin- Urinary Antispasmodics - Cholinergic Agonists clarithromycin w/ 2 bethanechol chloride 1 lansoprazole misc tabs HELIDAC THERAPY MISC Urinary Antispasmodics - Direct Muscle Relaxants (metronidazole- 3 tetracycline w/ bismuth flavoxate hcl tabs 1 subsalicylate) OMECLAMOX-PAK MISC VACCINES (amoxicillin- 3 Viral Vaccines clarithromycin w/ FLUMIST PV omeprazole) QUADRIVALENT SUSP PYLERA CAPS (bismuth (influenza virus vaccine 5 live quadrivalent) subcitrate potassium- 3 metronidazole- tetracycline) VAGINAL AND RELATED PRODUCTS URINARY ANTISPASMODICS - Drugs to Treat Spermicides Miscellaneous Bladder Spasms ENCARE SUPP PV 5 Urinary Antispasmodic - Antimuscarinics (nonoxynol-9) darifenacin OPTIONS CONCEPTROL PV 1 VAGINAL hydrobromide tb24 CONTRACEPTIVE GEL 7 QL(15 ml daily) oxybutynin chloride 1 (nonoxynol-9) syrp 5 mg/5ml

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTIONS GYNOL II PV PHEXXI GEL (lactic PV VAGINALCONTRACEPTIV 5 acid-citric acid- 5 E GEL (nonoxynol-9) potassium bitartrate) SHUR-SEAL GEL PV 5 Vaginal Estrogens (nonoxynol-9) (Estradiol Vaginal) TODAY SPONGE MISC PV 1 5 YUVAFEM TABS (nonoxynol-9) VCF VAGINAL PV estradiol vaginal crea 1 CONTRACEPTIVE FILM 5 estradiol vaginal tabs 1 FILM (nonoxynol-9) ESTRING RING QL(1 ea per fill VCF VAGINAL PV 3 CONTRACEPTIVE FOAM 5 (estradiol vaginal) mail) FOAM (nonoxynol-9) FEMRING RING QL(1 ea per 90 VCF VAGINAL PV ( 3 days retail,1 ea estradiol acetate per 90 days CONTRACEPTIVEGEL 5 vaginal) GEL (nonoxynol-9) mail) PREMARIN CREA VA QL(2 gm daily) Vaginal Anti-infectives 0.625 MG/GM 2 (Metronidazole Vaginal) 1 (estrogens, conjugated VANDAZOLE GEL vaginal) (Miconazole Nitrate Vaginal) MICONAZOLE 3 1 Vaginal Progestins SUPP CRINONE GEL PA AVC CREA (progesterone 3 3 (sulfanilamide vaginal) (vaginal)) CLEOCIN SUPP VA 100 ENDOMETRIN INST PA; ST MG (clindamycin 3 (progesterone 3 phosphate vaginal) (vaginal)) VASOPRESSORS - Drugs to Treat Heart and clindamycin phosphate 1 vaginal crea Circulation Conditions CLINDESSE CREA Anaphylaxis Therapy Agents (clindamycin phosphate 3 Limited to 2 (one dose)) epinephrine auto-injectors GYNAZOLE-1 CREA (anaphylaxis) soaj 0.15 3 per fill;QL(2 ea per fill retail,4 (butoconazole nitrate 3 mg/0.15ml, 0.3 mg/0.3ml ea per 30 days (one dose)) retail) metronidazole vaginal 1 epinephrine QL(2 ea per fill gel (anaphylaxis) soaj 0.15 3 retail,4 ea per 30 days retail) terconazole vaginal 1 mg/0.3ml, 0.3 mg/0.3ml crea terconazole vaginal 1 supp Vaginal Contraceptive - pH Modulators

135 Drug Requirements/ Drug Name Tier Limits Limited to 2 EPINEPHRINE SOAJ IJ pens per fill; 4 0.3 MG/0.3ML pens per ( 3 month;QL(2 ea epinephrine per fill retail,4 (anaphylaxis)) ea per 30 days retail) Neurogenic Orthostatic Hypotension (NOH) - droxidopa caps 4 PA NORTHERA CAPS PA 7 (droxidopa) Vasopressors midodrine hcl tabs 1

VITAMINS Oil Soluble Vitamins ergocalciferol caps 1 phytonadione tabs 1 Water Soluble Vitamins POTABA CAPS (potassium 3 aminobenzoate)

136 Index 1ST TIER UNILET adapalene treatment 55 aliskiren fumarate 32 COMFORTOUCH LANCETS adapalene-benzoyl ALKERAN 33 28G 79 peroxide 55 allergy nasal spray 24 hour 118 1ST TIER UNILET ADCIRCA 48 COMFORTOUCH LANCETS allergy relief 118 adefovir dipivoxil 44 30G 79 allergy relief 24hr 28 ADEMPAS 48 abacavir sulfate 42 allopurinol 71 adult aspirin regimen 6 abacavir sulfate-lamivudine 42 almotriptan malate 105 abacavir sulfate-lamivudine- ADVAIR HFA 15 ALOCRIL 122 zidovudine 42 ADVANCED MOBILE LANCET abiraterone acetate 34 30G 79 alogliptin benzoate 24 acamprosate calcium 125 ADVATE 72 ALOMIDE 122 acarbose 23 ADVOCATE LANCETS 80 alophen 77 ACCU-CHEK FASTCLIX ADVOCATE LANCETS ALORA 68 LANCETS 79 30G 80 alosetron hcl 70 ADVOCATE SAFETY ACCU-CHEK MULTICLIX ALPHAGAN P 119 LANCETS 79 LANCETS 80 ACCU-CHEK SAFE-T-PRO ADVOCATE SAFETY ALPHANATE 72 LANCETS 79 LANCETS 26G 80 ALPHANATE/VON ACCU-CHEK SAFE-T-PRO ADYNOVATE 72 WILLEBRANDFACTOR PLUSLANCETS 79 AFINITOR 36 COMPLEX/HUMAN 72 ACCU-CHEK SOFTCLIX ALPHANINE SD 72 AFINITOR DISPERZ 36 LANCETS 79 alprazolam 13 afirmelle 50 accutane 55 ALPRAZOLAM INTENSOL 13 AFREZZA 24 acebutolol hcl 45 alprazolam xr 13 AFSTYLA 72 acetaminophen w/ codeine 9 ALPROLIX 72 aftera 52 acetazolamide 64 ALREX 120 acetic acid (otic) 122 AGAMATRIX ULTRA-THIN LANCETS 33G 80 ALTABAX 57 acetylcysteine 55 AIMOVIG 105 altacaine 120 acid control maximum AIMSCO TWIST LANCETS altafrin 119 strength 132 32G 80 acid controller maximum AIMSCO TWIST LANCETS ALUNBRIG 36 strength 133 33G 80 alvimopan 70 ACIPHEX SPRINKLE 133 ak-poly-bac 119 alyacen 1/35 50 acitretin 58 AKTEN 120 alyacen 7/7/7 51 ACTEMRA 4 AKYNZEO 27 alyq 48 ACTEMRA ACTPEN 4 ala scalp 59 amabelz 67 ACTI-LANCE LANCETS amantadine hcl 39 28G 79 ala-cort 59 ACTI-LANCE LITE SAFETY ALA-SCALP 59 ambrisentan 47,48 LANCETS 28G 79 albendazole 12 amcinonide 59 ACTI-LANCE SPECIAL SAFETY albuterol sulfate 15,16 AMCINONIDE 59 LANCETS 17G 79 ACTI-LANCE SPECIAL ALBUTEROL SULFATE 16 amethia 50 SAFETYLANCETS 17G 79 albuterol sulfate 16 amethyst 50 ACTI-LANCE UNIVERSAL alclometasone amiloride & SAFETY LANCETS 23G 79 dipropionate 59 hydrochlorothiazide 64 ACTIDOM DMX 54 ALDACTAZIDE 64 amiloride hcl 65 ACTIMMUNE 38 ALECENSA 36 aminocaproic acid 75 ACUVAIL 122 alendronate sodium 65 amiodarone hcl 14 acyclovir 45 ALFERON N 38 amitriptyline hcl 22 acyclovir topical 59 alfuzosin hcl 71 amlodipine besylate 46 adapalene 55 ALINIA 12 amlodipine besylate-atorvastatin calcium 47

Index 1 amlodipine besylate-benazepril aspirin 7 AVC 135 hcl 31 aspirin 81 low dose 7 avidoxy 130 amlodipine besylate- valsartan 31 aspirin adult 7 avita 55 amlodipine-valsartan- aspirin-dipyridamole 74 AVONEX 126 hydrochlorothiazide 31 ASSURE COMFORT AVONEX PEN 126 amoxapine 22 LANCETS ULTRA THIN AVSOLA 69 28G 80 amoxicillin 124 AYVAKIT 35 amoxicillin & pot ASSURE HAEMOLANCE clavulanate 124 PLUS HIGH FLOW 18G 80 AZASAN 107 amoxicillin-clarithromycin w/ ASSURE HAEMOLANCE AZASITE 119 lansoprazole 134 PLUS LOW FLOW 25G 80 ASSURE HAEMOLANCE azathioprine 107 amphetamine- azelaic acid 63 dextroamphetamine 1 PLUS MICRO FLOW 28G 80 ASSURE HAEMOLANCE ampicillin 124 azelastine hcl 117,118 PLUS NORMAL FLOW azelastine hcl (ophth) 122 ampicillin & sulbactam 21G 80 sodium 125 ASSURE HAEMOLANCE azelastine hcl-fluticasone ampicillin sodium 124 PLUS PEDIATRIC BLADE 80 propionate 117 ANADROL-50 11 ASSURE LANCE AZELEX 55 anagrelide hcl 74 LANCETS 80 azithromycin 78 ASSURE LANCE LANCETS azurette 49 ANALPRAM-HC 11 21G 80 anastrozole 34 ASSURE LANCE PLUS bac 5 ANDEXXA 26 SAFETYLANCETS 25G 80 bacitracin (ophthalmic) 119 ASSURE LANCE PLUS bacitracin-poly-neomycin-hc ANDRODERM 11 SAFETYLANCETS 30G 80 120 ANGELIQ 68 ASSURE LANCE SAFETY bacitracin-polymyxin b ANNOVERA 52 LANCET 28G 81 (ophth) 119 ANORO ELLIPTA 16 ASSURE LANCETS 81 baclofen 117 ANTARA 29 ASTAGRAF XL 107 BAL-CARE DHA 111 anti-diarrheal 26 ATABEX EC 111 BALCOLTRA 51 ANZEMET 26 atazanavir sulfate 42 balsalazide disodium 69 APEXICON E 60 atenolol 45 BALVERSA 36 APO-VARENICLINE 129 atenolol & chlorthalidone 31 BANZEL 18 apraclonidine hcl 119 atomoxetine hcl 2 BARACLUDE 44 aprepitant 27 atorvastatin calcium 29 BD AUTOSHIELD 29G X atovaquone 12 5/16" 103 apri 49 BD AUTOSHIELD DUO 30G X APTIOM 18 atovaquone-proguanil hcl 32 5MM 103 APTIVUS 42 ATROPINE SULFATE 119 BD ECLIPSE NEEDLE 30G AQUALANCE LANCETS ULTRA atropine sulfate X1/2" 103 THIN 30G 80 (ophthalmic) 119 BD LANCET ULTRAFINE ATROVENT HFA 14 30G 81 ARCALYST 4 BD LANCET ULTRAFINE ARCAPTA NEOHALER 16 AUBAGIO 126 33G 81 ARIKAYCE 2 AUGMENTIN 125 BD MICROTAINER aripiprazole 42 AURORA LANCET SUPER LANCETS 81 THIN30G 81 BD NEEDLE/30G X 1/2" 103 ARIXTRA 17 AURORA LANCET THIN BD PEN 103 armodafinil 2 23G 81 BD PEN MINI 103 ARMOUR THYROID 131 aurovela 1.5/30 51 BD PEN ARNUITY ELLIPTA 15 aurovela 24 fe 50 NEEDLE/MICRO/ULTRA- arthritis pain reliever 57 AURYXIA 70 FINE/32G X 6MM 103 ascomp/codeine 9 AUSTEDO 126 BD PEN NEEDLE/MINI/ULTRA- FINE/31G X 5MM 103 asenapine maleate 41 AVANDIA 24

Index 2 BD PEN bethanechol chloride 134 buprenorphine hcl-naloxone hcl NEEDLE/ORIGINAL/ULTRA- BETHKIS 2 dihydrate 10 FINE/29G X 12.7MM 103 bupropion hcl 21 BETIMOL 119 BD PEN bupropion hcl (smoking NEEDLE/SHORT/ULTRA- BETOPTIC-S 119 deterrent) 129 FINE/31G X 8MM 103 BEVYXXA 17 buspirone hcl 13 BD SAFETYGLIDE INSULIN SYRINGE/0.5ML/31G X bexarotene 38 busulfan 33 15/64" 103 BEYAZ 51 BUSULFEX 33 BD SAFETYGLIDE INSULIN bicalutamide 34 butalbital-acetaminophen 6 SYRINGE/1ML/31G X BICILLIN C-R 125 butalbital-acetaminophen- 15/64" 103 BICILLIN L-A 124 caffeine 6 BD VEO INSULIN SYRINGE butalbital-acetaminophen- ULTR-FINE/U-100/0.5ML/31G X BIDIL 47 caffeine w/ codeine 9 15/64" 103 BIKTARVY 42 butalbital-aspirin-caffeine 6 BD VEO INSULIN SYRINGE bimatoprost 122 ULTRA-FINE/0.5ML/31G X butalbital-aspirin-caffeine 6MM 104 bisacodyl 78 w/cod 9 BD VEO INSULIN SYRINGE bisacodyl laxative 77 BUTISOL SODIUM 75 ULTRA-FINE/1ML/31G X bisoprolol & butorphanol tartrate 11 6MM 104 hydrochlorothiazide 31 BYSTOLIC 45 BD VEO INSULIN SYRINGE bisoprolol fumarate 45 ULTRA-FINE/U-100/1ML/31G X C-NATE DHA 111 15/64" 104 BLEPHAMIDE 121 cabergoline 67 BELLADONNA/OPIUM 132 BLEPHAMIDE S.O.P. 120 CABOMETYX 36 BELSOMRA 76 bosentan 48 caffeine citrate 1 benazepril & BOSULIF 36 CALCIFOL 106 hydrochlorothiazide 31 bp 10-1 55 calcipotriene 58 benazepril hcl 30 bp cleansing wash 55 CALCIPOTRIENE 58 BENAZEPRIL BRAFTOVI 36 calcipotriene-betamethasone HCL/HYDROCHLOROTHIAZIDE dipropionate 60 31 BREO ELLIPTA 16 calcitonin (salmon) 65 BENEFIX 72 BRILINTA 74 calcitrene 58 BENLYSTA 108 brimonidine tartrate 119 calcitriol 66 BENSAL HP 62 brinzolamide 122 calcitriol (topical) 58 BENZNIDAZOLE 12 bromfenac sodium (ophth) 122 calcium acetate (phosphate 54 benzonatate bromocriptine mesylate 39 binder) 70 benzoyl peroxide- BROMSITE 122 CALCIUM-FOLIC ACID PLUS erythromycin 55 D 106 benzphetamine hcl 1 BRUKINSA 36 calphron 70 benztropine mesylate 39 budesonide 53 CALQUENCE 36 bepotastine besilate 122 budesonide (inhalation) 15 camila 53 beser 59 budesonide-formoterol fumarate dihydrate 16 candesartan cilexetil 30 BESIVANCE 119 BULLSEYE MINI SAFETY candesartan cilexetil- BETADINE OPHTHALMIC LANCETS 81 hydrochlorothiazide 31 PREP 120 BULLSEYE SAFETY capecitabine 33 betamethasone dipropionate LANCETS 81 CAPEX 60 (topical) 60 bumetanide 65 betamethasone dipropionate CAPRELSA 36 augmented 60 bupap 5 captopril 30 betamethasone valerate 60 BUPHENYL 66 captopril & BETASERON 126 BUPRENORPHINE 10 hydrochlorothiazide 31 CARAC 58 betaxolol hcl 45 buprenorphine 10 CARBAGLU 66 betaxolol hcl (ophth) 119 buprenorphine hcl 10

Index 3 carbamazepine 18 cefotetan disodium 49 CIMZIA 69 CARBATROL 18 cefoxitin sodium 49 CIMZIA STARTER KIT 69 carbidopa 39 CEFOXITIN SODIUM 49 cinacalcet hcl 66 carbidopa-levodopa 39 cefpodoxime proxetil 49 CIPRO 68 carbidopa-levodopa-entacapone cefprozil 49 CIPRO HC 123 39 cefuroxime axetil 49 ciprofloxacin 69 CARBIDOPA/LEVODOPA ODT 39 celecoxib 4 ciprofloxacin hcl 69 carbinoxamine maleate 28 CELONTIN 21 ciprofloxacin hcl (ophth) 120 CARBINOXAMINE CENTANY 57 ciprofloxacin hcl (otic) 123 MALEATE 28 cephalexin 49 ciprofloxacin-dexamethasone CARDIZEM LA 46 CEPROTIN 74 123 ciprofloxacin-fluocinolone CARDURA XL 71 CERDELGA 74 CAREONE LANCET SUPER acetonide 123 THIN/30G 81 CEREZYME 74 citalopram hydrobromide 21 CAREONE LANCET THIN 81 CEROVEL 62 CITRANATAL 90 DHA 111 CARESENS LANCETS 81 CERVIDIL 123 CITRANATAL ASSURE 111 CARETOUCH SAFETY CETACAINE 62 CITRANATAL B-CALM 111 LANCETS/26G 81 CETRAXAL 123 CITRANATAL BLOOM 111 CARETOUCH SAFETY cevimeline hcl 108 CITRANATAL BLOOM LANCETS/28G 81 DHA 111 CARETOUCH SAFETY CHANTIX 129 LANCETS/30G 81 CHANTIX CONTINUING CITRANATAL DHA 111 CARETOUCH TWIST LANCETS MONTHPAK 129 CITRANATAL ESSENCE 111 28G 81 CHANTIX STARTING MONTH CITRANATAL HARMONY 111 PAK 129 CARETOUCH TWIST LANCETS CITRANATAL MEDLEY 111 30G 81 charlotte 24 fe 50 CITRANATAL RX 111 CARETOUCH TWIST LANCETS CHEMET 26 33G 81 clarithromycin 78 CHENODAL 69 CARIMUNE CLEANLET LANCETS 28G 82 NANOFILTERED 123 chlordiazepoxide hcl 14 clearlax 77 carisoprodol 117 chlordiazepoxide hcl-clidinium clemastine fumarate 28 carisoprodol w/ aspirin 117 bromide 132 chlordiazepoxide-amitriptyline carisoprodol w/ aspirin & CLEOCIN 135 126 CLEVER CHEK LANCETS codeine 117 chlorhexidine gluconate carteolol hcl (ophth) 119 ULTRATHIN 82 (mouth-throat) 108 CLEVER CHEK LANCETS cartia xt 46 chloroquine phosphate 32 ULTRATHIN 30G 82 carvedilol 45 chlorothiazide 65 CLEVER CHOICE COMFORT carvedilol phosphate 45 chlorpromazine hcl 41 EZLANCETS 21G 82 CLEVER CHOICE COMFORT cataflam 4 chlorthalidone 65 EZLANCETS 23G 82 CAYA 78 chlorzoxazone 117 CLEVER CHOICE COMFORT CAYSTON 12 cholestyramine 29 EZLANCETS 28G 82 caziant 49 cholestyramine light 29 CLIMARA PRO 68 cefaclor 49 choline fenofibrate 29 clindacin etz pledgets 55 CEFACLOR ER 49 ciclopirox 57 clindamycin hcl 12 cefadroxil 49 clindamycin palmitate ciclopirox olamine 57 hydrochloride 12 cefazolin sodium 49 cidofovir 44 clindamycin phosphate cefdinir 49 cilostazol 74 (topical) 56 cefditoren pivoxil 49 CILOXAN 120 clindamycin phosphate vaginal 135 cefixime 49 CIMDUO 42 clindamycin phosphate-benzoyl CEFOTAN 49 cimetidine 133 peroxide 56

Index 4 clindamycin phosphate-benzoyl COMFORT LANCETS 82 cvs nasal allergy spray 118 peroxide (refrigerate) 56 COMFORT TOUCH LANCETS cvs nicotine 128 clindamycin phosphate- ULTRA THIN 31G 82 cvs nicotine lozenge 127 tretinoin 56 COMFORT TOUCH PLUS CLINDESSE 135 SAFETY LANCETS cvs nicotine transdermalsystem 128 clobazam 17 PRESSURE ACTIVATED cvs olopatadine 30G 82 clobetasol propionate 60 hydrochloride 121 COMPLERA 42 clobetasol propionate e 59 CVS ULTRA THIN clobetasol propionate emollient COMPLETENATE 111 LANCETS 83 base 60 compro 41 cyclobenzaprine hcl 117 clobetasol propionate CONCEPT DHA 111 CYCLOMYDRIL 119 emulsion 60 CONCEPT OB 112 cyclopentolate hcl 119 clocortolone pivalate 60 CONDYLOX 62 cyclophosphamide 33 clodan 59 constulose 77 CYCLOPHOSPHAMIDE 33 CLODERM 60 CONTRAVE 1 cycloserine 33 clomiphene citrate 66 CONZIP 8 cyclosporine 107 clomipramine hcl 22 COPIKTRA 36 cyclosporine modified (for clonazepam 17 CORDRAN 60 microemulsion) 107 clonidine hcl 30 CYKLOKAPRON 75 CORIFACT 72 clonidine hcl (adhd) 2 cyproheptadine hcl 28 CORLANOR 48 clopidogrel bisulfate 74 CYSTADANE 66 CORTANE-B 60 clorazepate dipotassium 14 CYSTAGON 71 cortic-nd 123 clotrimazole 108 CYSTARAN 122 CORTIFOAM 11 clotrimazole w/ CYTOMEL 131 cortisone acetate 53 betamethasone 57 cytra k crystals 71 clovique 107 CORTISPORIN-TC 123 cytra-2 71 clozapine 41 COSENTYX 58 cytra-3 71 COAGADEX 72 COSENTYX SENSOREADY cytra-k 71 COAGUCHEK LANCETS 82 PEN 58 COTELLIC 36 D-PENAMINE 107 COARTEM 32 CREON 64 D.H.E. 45 105 codeine sulfate 8 CRESEMBA 27 dalfampridine 126 CODITUSSIN AC 54 CRINONE 135 danazol 11 COGENTIN 39 CRIXIVAN 42 dantrolene sodium 117 colchicine 71 cromolyn sodium 14 dapsone 12 colchicine w/ probenecid 71 cromolyn sodium (ophth) 122 dapsone (topical) 56 colesevelam hcl 29 cryselle-28 51 darifenacin hydrobromide 134 colestipol hcl 29 CUVPOSA 132 DAURISMO 34 colocort 11 cvs folic acid 74 DAYTRANA 2 COLY-MYCIN S 123 CVS LANCETS 21G 82 DDAVP 67 COLYTE-FLAVOR PACKS 76 CVS LANCETS MICRO THIN decadron 53 COMBIGAN 119 33G 82 deferasirox 26 COMBIPATCH 68 CVS LANCETS MICRO-THIN deferiprone 26 COMBIVENT RESPIMAT 16 33G 82 CVS LANCETS ORIGINAL82 DELSTRIGO 42 COMETRIQ 36 demeclocycline hcl 130 COMFORT ASSURED CVS LANCETS THIN 26G 82 LANCETS MICRO THIN CVS LANCETS ULTRA THIN DEPAKENE 21 33G 82 30G 82 DEPAKOTE 21 CVS LANCETS ULTRA-THIN COMFORT ASSURED DEPAKOTE ER 21 LANCETS SUPER THIN 30G 83 28G 82 cvs lansoprazole 133 DEPAKOTE SPRINKLES 21

Index 5 DESCOVY 42 digitek 47 DROPLET INSULIN SYRINGE desipramine hcl 22 digoxin 47 U-100/1ML/31G X 15/64" 104 DROPLET INSULIN desloratadine 28 dihydroergotamine SYRINGE/U-100/0.5ML/31G X DESMOPRESSIN mesylate 105 15/64" 104 ACETATE 67 DILANTIN 20 DROPLET INSULIN desmopressin acetate 67 DILANTIN INFATABS 20 SYRINGE/U-100/1ML/31G X desmopressin acetate spray 67 DILANTIN-125 20 15/64" 104 desmopressin acetate spray DROPLET LANCETS ULTRA DILATRATE SR 13 THIN 30G 83 refrigerated 67 dilt-xr 46 desogestrel & ethinyl DROPLET PERSONAL estradiol 51 diltiazem hcl 46 LANCETS30G 83 desogestrel-ethinyl estradiol diltiazem hcl coated beads 46 drospirenone-ethinyl (biphasic) 51 estradiol 51 diltiazem hcl extended release drospirenone-ethinyl estradiol- desonide 60 beads 46 levomefolate calcium 51 desoximetasone 60,61 dimethyl fumarate 126 DROXIA 74 desrx 59 DIPENTUM 69 droxidopa 136 desvenlafaxine succinate 22 diphenhydramine hcl 28 DRUG MART LANCETS dexamethasone 53 diphenoxylate w/ atropine 26 THIN 83 DEXAMETHASONE dipyridamole 74 DRUG MART ON-THE-GO LANCETS GENTLE 30G 83 INTENSOL 53 disopyramide phosphate 14 dexamethasone sodium DRUG MART UNILET phosphate (ophth) 121 disulfiram 125 LANCETSSUPER THIN 30G83 dexchlorpheniramine DIURIL 65 DRUG MART UNILET maleate 28 divalproex sodium 21 LANCETSULTRA THIN 28G 83 dexmethylphenidate hcl 2 DRUG MART UNILET MICRO DIVIGEL 68 THIN LANCETS 33G 83 dexpak 13 day 53 DOCTOR MANZANILLA PE DRYSOL 63 SYRUP dextroamphetamine sulfate 1 DUAVEE 68 DIACOMIT 18 ANTIHISTAMINE/DECONGES TANT 54 DUET DHA 400 112 DIATHRIVE LANCETS 83 dofetilide 14 DUET DHA BALANCED 112 DIATHRIVE LANCETS ULTRA THIN 30G 83 DOJOLVI 118 duloxetine hcl 22 diazepam 14 DOMETUSS-DMX 54 DUOPA 40 diazepam (anticonvulsant) 17 donepezil hydrochloride 125 DUPIXENT 62 diazepam intensol 13 DORAL 75 duraxin 5 diazoxide 23 doripenem 12 DUREZOL 121 diclofenac potassium 4 dorzolamide hcl 122 dutasteride 71 diclofenac sodium 4 DORZOLAMIDE HCL 122 dutasteride-tamsulosin hcl 71 diclofenac sodium (actinic dorzolamide hcl-timolol E-Z JECT LANCETS 83 keratoses) 58 maleate 119 E-Z JECT LANCETS 21G 83 diclofenac sodium (ophth) 122 dotti 68 E-Z JECT LANCETS diclofenac sodium (topical) 57 DOVATO 42 COLOR 83 diclofenac w/ misoprostol 4 doxazosin mesylate 30 E-Z JECT LANCETS SUPER THIN 30G 83 dicloxacillin sodium 125 doxepin hcl 22 E-Z JECT LANCETS THIN dicyclomine hcl 132 doxepin hcl (antipruritic) 58 26G 83 didanosine 42 doxercalciferol 66 E-ZJECT LANCETS MICRO- THIN 33G 83 diethylpropion hcl 1 doxycycline (monohydrate) 130 e.e.s. 400 78 DIFFERIN 56 doxycycline (rosacea) 63 EASY COMFORT LANCETS84 DIFICID 78 doxycycline hyclate 130 EASY COMFORT LANCETS diflorasone diacetate 61 doxylamine-pyridoxine 27 30G/PULL TOP 83 diflunisal 7 dronabinol 27

Index 6 EASY COMFORT LANCETS EASY TOUCH SAFETY endocet 9 30G/THIN TOP 84 LANCETS28G/PRESSURE ENDOMETRIN 135 EASY COMFORT LANCETS ACTIVATED 85 TWIST TOP 84 EASY TWIST & CAP enoxaparin sodium 17 EASY TOUCH FLIPLOCK LANCETS 85 enpresse-28 50 NEEDLES 30GX1/2" 104 econazole nitrate 57 entacapone 39 EASY TOUCH HYPODERMIC ed-spaz 132 NEEDLES 30GX1/2" 104 entecavir 44 EASY TOUCH LANCETS EDARBI 30 ENTRESTO 47 21G/PRESSURE EDARBYCLOR 31 enulose 70 ACTIVATED 84 EDURANT 42 EPCLUSA 44 EASY TOUCH LANCETS 23G/PRESSURE efavirenz 42 EPIDIOLEX 18 ACTIVATED 84 efavirenz-emtricitabine- EPIFOAM 61 tenofovir disoproxil EASY TOUCH LANCETS epinastine hcl (ophth) 122 26G/PRESSURE fumarate 42 ACTIVATED 84 effer-k 106 EPINEPHRINE 136 EASY TOUCH LANCETS EFFER-K 106 epinephrine (anaphylaxis) 135 26G/PULL-TOP 84 ELESTRIN 68 epitol 17 EASY TOUCH LANCETS EPIVIR HBV 44 28G/PRESSURE eletriptan hydrobromide 105 ACTIVATED 84 ELIGARD 34 eplerenone 32 EASY TOUCH LANCETS ELIQUIS 17 EQL COLOR LANCETS 21G85 28G/PULL-TOP 84 ELIQUIS STARTER PACK 17 EQL COLOR LANCETS MICRO EASY TOUCH LANCETS THIN 33G 85 28G/TWIST 84 ELIXOPHYLLIN 16 EQL SUPER THIN LANCETS EASY TOUCH LANCETS ELLA 53 30G 85 30G/BUTTON-ACTIVATED 84 ELMIRON 71 EQL THIN LANCETS 26G 85 EASY TOUCH LANCETS 30G/PRESSURE ELOCTATE 72 EQUETRO 40 ACTIVATED 84 eluryng 52 ergocalciferol 136 EASY TOUCH LANCETS EMBEDA 8 ergoloid mesylates 127 30G/PULL-TOP 84 EMBRACE LANCETS ULTRA ERGOMAR 105 EASY TOUCH LANCETS THIN 30G 85 ergotamine w/ caffeine 105 30G/TWIST 84 EMBRACE PRESSURE EASY TOUCH LANCETS ACTIVATED SAFETY ERIVEDGE 34 32G/PRESSURE LANCET/21G 85 ERLEADA 35 ACTIVATED 84 EMBRACE PRESSURE EASY TOUCH LANCETS erlotinib hcl 34 ACTIVATED SAFETY ERTACZO 57 32G/PULL-TOP 84 LANCET/28G 85 EASY TOUCH LANCETS ertapenem sodium 12 EMCYT 35 32G/TWIST 84 ery 55 EASY TOUCH LANCETS EMEND 27 ery-tab 78 33G/TWIST 84 EMGALITY 105 erythrocin stearate 78 EASY TOUCH SAFETY EMSAM 21 LANCETS21G/PRESSURE erythromycin (acne aid) 56 emtricitabine 42 ACTIVATED 85 120 EASY TOUCH SAFETY emtricitabine-tenofovir erythromycin (ophth) LANCETS23G/PRESSURE disoproxil fumarate 43 erythromycin base 78 ACTIVATED 85 EMTRIVA 43 erythromycin ethylsuccinate 78 EASY TOUCH SAFETY enalapril maleate 30 ESBRIET 130 LANCETS26G/BUTTON enalapril maleate & escitalopram oxalate 21 ACTIVATED 85 hydrochlorothiazide 31 EASY TOUCH SAFETY esgic 6 ENBREL 5 LANCETS26G/PRESSURE esomeprazole magnesium 133 ENBREL MINI 5 ACTIVATED 85 estarylla 51 EASY TOUCH SAFETY ENBREL SURECLICK 5 estazolam 76 LANCETS28G/BUTTON ENCARE 134 ACTIVATED 85 estradiol 68

Index 7 estradiol & norethindrone FARXIGA 25 flecainide acetate 14 acetate 68 FARYDAK 36 FLORIVA 106 estradiol vaginal 135 FASENRA 14 FLORIVA PLUS 110 ESTRING 135 FAZACLO 41 FLOVENT DISKUS 15 ESTROGEL 68 FC FEMALE CONDOM 78 FLOVENT HFA 15 ESTROSTEP FE 51 FC2 FEMALE CONDOM 78 fluconazole 27 eszopiclone 76 febuxostat 71 flucytosine 27 ethacrynic acid 65 FEIBA 72 fludarabine phosphate 33 ethambutol hcl 33 felbamate 20 fludrocortisone acetate 53 ethosuximide 21 FELBATOL 20 FLUMIST QUADRIVALENT134 ethynodiol diacet & eth estrad 51 felodipine 46 fluocinolone acetonide 61 etidronate disodium 65 FEMCAP 78 fluocinolone acetonide (otic) 123 etodolac 4 FEMRING 135 fluocinonide 61 etonogestrel-ethinyl estradiol52 fenofibrate 29 fluocinonide emulsified base 61 ETOPOPHOS 39 FENOFIBRATE 29 FLUORABON 106 etoposide 39 fenofibrate 29 fluoritab 106 etravirine 43 fenofibrate micronized 29 fluorometholone (ophth) 121 EUCRISA 63 FENOFIBRIC ACID 29 FLUOROPLEX 58 euthyrox 131 fenoprofen calcium 4 fluorouracil (topical) 58 EVAMIST 68 FENSOLVI 66 fluoxetine hcl 21,22 everolimus 36 fentanyl 8 fluoxetine hcl (pmdd) 127 everolimus fentanyl citrate 8 fluphenazine hcl 41 (immunosuppressant) 107 FERRIPROX 26 flurandrenolide 61 EVISTA 66 FETZIMA 22 EVOTAZ 43 FETZIMA TITRATION flurazepam hcl 76 EVRYSDI 118 PACK 22 flurbiprofen 4 EVZIO 26 fexmid 117 flurbiprofen sodium 122 EXELDERM 57 FIBRICOR 29 flutamide 35 exemestane 35 FIFTY50 SAFETY SEAL fluticasone propionate 61 LANCETS 30G 86 EXFORGE HCT 31 fluticasone propionate FIFTY50 SAFETY SEAL (nasal) 118 EXJADE 26 LANCETS 32G 86 fluticasone-salmeterol 16 EXODERM 57 FIFTY50 UNILET LANCETS fluvastatin sodium 29 EXTAVIA 126 33G 86 fluvoxamine maleate 22 eye allergy FINACEA 63 itch/rednessrelief 121 finasteride 71 FML 121 EZ-LETS LANCETS 21G 85 FINE 30 86 FML FORTE 121 EZ-LETS LANCETS 26G FINGERSTIX LANCETS 86 FOLET DHA 112 SUPER-SOFT 85 FIRAZYR 74 FOLET ONE 112 EZ-LETS LANCETS 28G ULTRA-SOFT 85 FIRDAPSE 32 folic acid 74 EZ-LETS LANCETS 30G 85 FIRST-MOUTHWASH FOLIVANE-F 75 BLM 108 ezetimibe 29 FOLIVANE-OB 112 FIRST-OMEPRAZOLE 133 ezetimibe-simvastatin 28 fondaparinux sodium 17 FIRVANQ 12 FABIOR 56 FORA LANCETS 86 flac 123 famciclovir 45 FORFIVO XL 21 FLAREX 121 famotidine 133 formaldehyde 42 flavoxate hcl 134 FANAPT 41 FOSAMAX PLUS D 65 FLEBOGAMMA DIF 123 FANAPT TITRATION PACK 41 fosamprenavir calcium 43

Index 8 fosfomycin tromethamine 13 gentamicin sulfate GLUCOCOM LANCETS fosinopril sodium 30 (ophth) 120 33G 87 fosinopril sodium & gentamicin sulfate (topical) 57 glyburide 25 hydrochlorothiazide 31 GENTEEL BUTTERFLY glyburide micronized 25 FOSRENOL 70 TOUCH LANCETS 86 glyburide-metformin 23 GENTLE-LET GP FRAGMIN 17 LANCETS 86 GLYCATE 132 FREDS PHARMACY UNILET GENTLE-LET LANCETS glycopyrrolate 132 LANCETS SUPER THIN GENERAL PURPOSE GLYCOPYRROLATE 132 30G 86 STYLE/FINE POINT 86 FREDS PHARMACY UNILET GENTLE-LET LANCETS GLYXAMBI 23 LANCETS ULTRA THIN GENERAL PURPOSE gnp aspirin 7 28G 86 STYLE/MEDIUM POINT 86 GNP LANCETS 21G 87 FREESTYLE INSULINX GENTLE-LET LANCETS GNP LANCETS MICRO THIN BLOODGLUCOSE TEST 64 SAFETY STYLE/FINE 33G 87 FREESTYLE INSULINX POINT 86 GNP LANCETS SUPER THIN BLOODGLUCOSE TEST GENTLE-LET LANCETS 30G 87 STRIPS 64 SAFETY STYLE/MEDIUM GNP LANCETS THIN 87 FREESTYLE LANCETS 86 POINT 86 GNP LANCETS THIN 26G 87 FREESTYLE LITE TEST GENVOYA 43 STRIPS 64 gnp olopatadine gianvi 50 hydrochloride 122 FREESTYLE TEST STRIPS 64 GILENYA 126 GNP STERILE LANCETS FREESTYLE UNISTICK II GILOTRIF 34 28G 87 LANCETS 86 GNP STERILE LANCETS frovatriptan succinate 105 GILPHEX TR 54 30G 87 FULPHILA 75 GILTUSS COUGH & GNP STERILE LANCETS COLD 54 furosemide 65 33G 87 GILTUSS SINUS & GOJJI STERILE LANCETS FUZEON 43 CONGESTION 54 30G 87 fyavolv 68 GILTUSS TR 54 GOLYTELY 76 FYCOMPA 17 glatiramer acetate 126 GONITRO 13 g tussin ac 54 glatopa 126 goodsense aspirin 7 gabapentin 18 GLEOSTINE 33 GOODSENSE COLOR GABITRIL 20 glimepiride 25 LANCETS MICRO-THIN 33G glipizide 25 UNIVERSAL 87 GABLOFEN 117 GOODSENSE LANCETS GALAFOLD 66 glipizide xl 25 MICRO-THIN 33G 87 galantamine hydrobromide 125 glipizide-metformin hcl 23 GOODSENSE LANCETS GALZIN 107 GLOBAL EASY GLIDE MICRO-THIN 33G INSULIN SYRINGE/0.5ML/31G UNIVERSAL 87 GAMMAGARD LIQUID 123 X 15/64" 104 GOODSENSE LANCETS GAMMAKED 123 GLOBAL EASY GLIDE ULTRA-THIN 26G GAMMAPLEX 124 INSULIN SYRINGE/1ML/31G X UNIVERSAL 87 GAMUNEX-C 124 15/64" 104 GOODSENSE LANCETS GLOBAL INJECT EASE ULTRA-THIN 30G 87 gatifloxacin (ophth) 120 LANCETS 28G 86 GOODSENSE LANCETS GATTEX 70 GLOBAL INJECT EASE ULTRA-THIN 30G gavilyte-c 76 LANCETS 30G 86 UNIVERSAL 87 GLUCAGEN gavilyte-n/flavor pack 76 GRALISE 127 DIAGNOSTIC 63 granisetron hcl 26 GELFILM OP 121 glucagon (rdna) 23 GRANIX 75 gemfibrozil 29 GLUCAGON EMERGENCY gemmily 50 KIT 24 griseofulvin microsize 27 GENERESS FE 51 GLUCOCOM LANCETS griseofulvin ultramicrosize 27 28G 87 guaiatussin ac 54 gengraf 107 GLUCOCOM LANCETS gentak 119 30G 87 guaifenesin dac 54

Index 9 guaifenesin-codeine 54 HUMIRA PEDIATRIC CROHNS HYQVIA 124 guanfacine hcl 30 DISEASE STARTER PACK 3 ibandronate sodium 65 HUMIRA PEN 3 guanfacine hcl (adhd) 2 IBRANCE 36 HUMIRA PEN-CD/UC/HS GUANIDINE HCL 32 STARTER 3 ibu 4 GYNAZOLE-1 135 HUMIRA PEN-PEDIATRIC UC ibudone 9 H-E-B INCONTROL LANCETS STARTER PACK 3 ibuprofen 4 HUMIRA PEN-PS/UV MICRO THIN 33G 88 icatibant acetate 74 H-E-B INCONTROL LANCETS STARTER 3 SUPER THIN 30G 88 HUMULIN 70/30 24 ICLUSIG 36 H-E-B INCONTROL LANCETS HUMULIN 70/30 icosapent ethyl 28 ULTRA THIN 28G 88 KWIKPEN 24 IDELVION 72 HAEGARDA 74 HUMULIN N 24 IDHIFA 36 HAEMOLANCE 88 HUMULIN N KWIKPEN 24 ILEVRO 122 HAEMOLANCE LOW FLOW HUMULIN R 25 LANCETS 88 ILUMYA 58 HUMULIN R U-500 imatinib mesylate 37 HAEMOLANCE PLUS 88 (CONCENTRATED) 25 HAEMOLANCE PLUS HIGH HUMULIN R U-500 IMBRUVICA 37 FLOW 88 KWIKPEN 25 imipenem-cilastatin 12 HAEMOLANCE PLUS LOW HY-VEE LANCETS 88 imipramine hcl 22 FLOW 88 HAEMOLANCE PLUS MAX HY-VEE THIN LANCETS 88 imipramine pamoate 22 FLOW 88 HYCAMTIN 39 imiquimod 62 HAEMOLANCE PLUS hydralazine hcl 32 IMITREX 105 PEDIATRIC FLOW 88 hydrochlorothiazide 65 IMITREX STATDOSE halobetasol propionate 61 hydrocodone polistirex- REFILL 105 haloperidol 41 chlorpheniramine polistirex 54 IMITREX STATDOSE haloperidol lactate 41 hydrocodone w/ SYSTEM 105 HEALTHY ACCENTS UNILET homatropine 54 IN TOUCH STERILE LANCETS SUPER THIN hydrocodone- LANCETS30G 88 30G 88 acetaminophen 9,10 inatal gt 111 HELIDAC THERAPY 134 hydrocodone-ibuprofen 10 INBRIJA 40 HEMOFIL M 72 hydrocortisone 53 INCRELEX 66 heparin sodium (porcine) 17 hydrocortisone (intrarectal) 11 INCRUSE ELLIPTA 14 HETLIOZ 76 hydrocortisone (rectal) 11 indapamide 65 homatropaire 119 hydrocortisone (topical) 61 INDERAL XL 45 homatropine hbr 119 hydrocortisone butyrate 61 INDOCIN 4 HORIZANT 127 hydrocortisone butyrate indomethacin 4 hydrophilic lipo base 61 INFLECTRA 69 HUMALOG 24 hydrocortisone valerate 61 HUMALOG JUNIOR hydrocortisone w/acetic INGREZZA 126 KWIKPEN 24 acid 123 INLYTA 34 HUMALOG KWIKPEN 24 hydromet 54 INNOPRAN XL 45 HUMALOG MIX 50/50 24 hydromorphone hcl 8 INQOVI 36 HUMALOG MIX 50/50 KWIKPEN 24 hydroxychloroquine sulfate 32 INREBIC 37 HUMALOG MIX 75/25 24 hydroxyurea 38 INSULIN LISPRO hydroxyzine hcl 13 PROTAMINE/INSULIN LISPRO HUMALOG MIX 75/25 KWIKPEN 25 KWIKPEN 24 hydroxyzine pamoate 13 INSULIN SYRINGES AND PEN HUMATE-P 72 HYLINATE 62 NEEDLES 104 HUMATROPE 66 hyoscyamine sulfate 132 INTEGRA F 75 HUMATROPE COMBO HYPERSAL 55 INTELENCE 43 PACK 66 HYPODERMIC NEEDLE INTRON A 38 HUMIRA 3 30GX1/2" 104

Index 10 INVANZ 12 KALYDECO 129 KROGER LANCETS INVIRASE 43 KCENTRA 73 ULTRATHIN30G 89 KUVAN 66 iodoquimez-hc 57 kelnor 1/35 50 labetalol hcl 45 iodoquinol-hydrocortisone in aloe KEPPRA 18 LACRISERT 118 vehicle 57 KEPPRA XR 18 IOPIDINE 119 lactulose 77 keralyt 62 ipratropium bromide 15 lactulose (encephalopathy) 70 ketoconazole 27 ipratropium bromide (nasal)118 LAMICTAL 18 ketoconazole (topical) 57 ipratropium-albuterol 16 LAMICTAL CHEWABLE ketodan 57 irbesartan 30 DISPERSIBLE 18 ketoprofen 4 irbesartan-hydrochlorothiazide LAMICTAL ODT 18 31 KETOROLAC LAMICTAL XR 18 TROMETHAMINE 4 IRESSA 34 lamivudine 43 ketorolac tromethamine 4 ISENTRESS 43 ketorolac tromethamine lamivudine (hbv) 44 ISENTRESS HD 43 (ophth) 122 lamivudine-zidovudine 43 isoniazid 33 KEVEYIS 64 lamotrigine 19 ISOPTO ATROPINE 119 KEVZARA 4 LANCETS 89 isosorbide dinitrate 13 KINNEY LANCETS 88 LANCETS 26G TWIST TOP 89 isosorbide mononitrate 13 KINNEY THIN LANCETS 88 LANCETS 28G 89 isotretinoin 56 kionex 108 LANCETS 30G 89 isoxsuprine hcl 47 KISQALI 37 LANCETS 30G TWIST TOP 89 isradipine 46 KISQALI FEMARA 200 LANCETS 30G/TWIST TOP 89 ISTODAX (OVERFILL) 37 DOSE 36 LANCETS 31G TWIST TOP 89 KISQALI FEMARA 400 itraconazole 27 DOSE 36 LANCETS 33G EXTRA ivermectin 12 KISQALI FEMARA 600 FINE 89 DOSE 36 LANCETS 33G UNIVERSAL IVERMECTIN 63 DESIGN 89 ivermectin (pediculicide) 63 KLARITY-A 120 LANCETS MICRO THIN ivermectin (rosacea) 63 klor-con 106 33G 89 LANCETS SAFETY SEAL IXINITY 72 klor-con 10 106 klor-con m10 106 21G 89 JADENU 26 LANCETS SAFETY SEAL JADENU SPRINKLE 26 klor-con sprinkle 106 26G 89 JAKAFI 37 KOATE 73 LANCETS SAFETY SEAL KOATE-DVI 73 28G 90 jantoven 16 LANCETS SAFETY SEAL JANUMET 23 KOSELUGO 37 30G 90 JANUMET XR 23 KOVALTRY 73 LANCETS SUPER THIN 28G 90 JANUVIA 24 kp folic acid 74 LANCETS THIN 90 JARDIANCE 25 KRINTAFEL 32 KROGER HEALTHPRO TWIST LANCETS TWIST TOP 90 JIVI 72 LANCETS/26G 88 LANCETS ULTRA FINE 90 JULUCA 43 KROGER LANCETS 89 LANCETS ULTRA THIN 90 JUXTAPID 30 KROGER LANCETS 21G 88 LANCETS ULTRA THIN JYNARQUE 67 KROGER LANCETS MICRO 30G 90 K-PHOS 106 THIN33G 89 LANCETSBULLSEYE K-PHOS NO 2 70 KROGER LANCETS SUPER SAFETY 90 THIN 89 LANOXIN 47 k-prime 106 KROGER LANCETS THIN 89 lansoprazole 133 K-TAB 106 KROGER LANCETS THIN lanthanum carbonate 70 KADIAN 8 26G 89 LANTUS 25 kaitlib fe 50

Index 11 LANTUS SOLOSTAR 25 LEXIVA 43 losartan potassium & lapatinib ditosylate 37 LIBERTY MEDICAL LANCETS hydrochlorothiazide 31 LOSEASONIQUE 51 LASTACAFT 122 30G 90 lidocaine 63 LOTEMAX 121 latanoprost 122 lidocaine hcl 62 loteprednol etabonate 121 LATUDA 40 lidocaine hcl (mouth- lovastatin 29 leflunomide 5 throat) 108 loxapine succinate 41 LENVIMA 10 MG DAILY lidocaine-prilocaine 63 lubiprostone 69 DOSE 34 LIFESCAN UNISTIK 2 DEEP LENVIMA 12MG DAILY PENETRATION 90 LUCEMYRA 125 DOSE 34 LIFESCAN UNISTIK II LUMIGAN 122 LENVIMA 14 MG DAILY LANCETS 90 DOSE 34 LYNPARZA 37 LENVIMA 18 MG DAILY linezolid 13 LYRICA 19 DOSE 34 LINZESS 70 LYSODREN 35 LENVIMA 20 MG DAILY LIORESAL DOSE 34 INTRATHECAL 117 M-NATAL PLUS 112 LENVIMA 24 MG DAILY liothyronine sodium 131 mafenide acetate 59 DOSE 34 LIPOFEN 29 MAGNEBIND 400 106 LENVIMA 4 MG DAILY malathion 63 DOSE 34 lisinopril 30 LENVIMA 8 MG DAILY lisinopril & maprotiline hcl 21 DOSE 34 hydrochlorothiazide 31 MARNATAL-F 112 LETAIRIS 48 LITE TOUCH LANCETS 90 MARPLAN 21 letrozole 35 LITETOUCH LANCETS MICRO MATULANE 38 THIN 33G 90 leucovorin calcium 38 LITHIUM 40 matzim la 46 LEUKERAN 33 lithium carbonate 40 MAVENCLAD 126 LEUKINE 75 LITHOBID 40 MAVYRET 44 leuprolide acetate 35 LITHOSTAT 71 MAXIDEX 121 levalbuterol hcl 16 LIVALO 29 MAYZENT 126 levalbuterol tartrate 16 LIVE BETTER LANCET meclofenamate sodium 4 LEVEMIR 25 SUPERTHIN 30G 90 MEDICHOICE PRE-SET LEVEMIR FLEXTOUCH 25 LIVE BETTER LANCET SAFETY LANCET DUAL levetiracetam 19 ULTRATHIN 28G 90 USE 91 LO LOESTRIN FE 51 MEDICHOICE PRE-SET levo-t 131 LOKELMA 108 SAFETY LANCET LOW levobunolol hcl 119 FLOW 91 levocarnitine (metabolic LOMAIRA 1 MEDICHOICE PRE-SET modifiers) 66 LONGS LANCETS SAFETY LANCET MEDIUM levocetirizine dihydrochloride28 STANDARD 90 FLOW 91 LONGS LANCETS THIN 90 MEDICHOICE PRE-SET levofloxacin 69 LONGS LANCETS ULTRA SAFETY LANCET MODERATE levofloxacin (ophth) 120 THIN 91 FLOW 91 levonorgestrel & eth LONSURF 36 MEDICHOICE SAFETY estradiol 51 LANCETEXTRA 91 levonorgestrel (emergency loperamide hcl 26 MEDICHOICE SAFETY oc) 53 lopinavir-ritonavir 43 LANCETNORMAL 91 levonorgestrel-eth estradiol lorazepam 14 MEDISENSE THIN (triphasic) 51 lorazepam intensol 13 LANCETS 91 levonorgestrel-ethinyl estradiol MEDLANCE PLUS EXTRA (91-day) 51 LORBRENA 37 LANCETS 21G 91 levonorgestrel-ethinyl estradiol lorcet 9 MEDLANCE PLUS (continuous) 51 LORTAB 10 LANCETS 91 levorphanol tartrate 8 MEDLANCE PLUS LANCETS lorzone 117 LITE 25G 91 levothyroxine sodium 131 losartan potassium 30

Index 12 MEDLANCE PLUS LITE metformin hcl 23 midazolam hcl 76 LANCETS 25G 91 METFORMIN midodrine hcl 136 MEDLANCE PLUS SPECIAL HYDROCHLORIDE 23 migergot 105 LANCETS 0.8MM 91 methadone hcl 8 MEDLANCE PLUS SUPERLITE miglitol 23 methadone hydrochloride 30G 91 miglustat 74 MEDLANCE PLUS SUPERLITE intensol 7 30G/COMFORT MAX 91 methadose 7 MILLIPRED 53 MEDLANCE PLUS UNIVERSAL methamphetamine hcl 1 MILLIPRED DP 53 LANCETS 21G 91 methazolamide 64 MINASTRIN 24 FE 51 MEDLANCE PLUS/LITE minitran 13 25G 91 methenamine hippurate 13 MEDLANCE/EXTRA 91 methenamine mandelate 13 MINOCIN 130 MEDLANCE/LITE 92 methergine 123 minocycline hcl 130 MEDLANCE/UNIVERSAL 92 methimazole 131 minoxidil 32 MEDROL 53 METHITEST 11 MIRCETTE 52 MEDROX-RX 62 methocarbamol 117 mirtazapine 21 medroxyprogesterone METHOTREXATE 3 MIRVASO 63 acetate 125 methotrexate sodium 33 misoprostol 134 mefenamic acid 4 methoxsalen rapid 58 MITIGARE 71 mefloquine hcl 32 methscopolamine mitoxantrone hcl 35 megestrol acetate 35 bromide 132 MM TWIST LANCETS 92 megestrol acetate METHYLDOPA 31 modafinil 2 (appetite) 125 methyldopa & MEIJER COLOR LANCETS hydrochlorothiazide 31 moexipril hcl 30 UNIVERSAL 33G 92 methylergonovine molindone hcl 41 MEIJER LANCETS 92 maleate 123 mometasone furoate 61 MEIJER LANCETS THIN 92 methylphenidate hcl 2 mometasone furoate MEIJER LANCETS methylprednisolone 53 (nasal) 118 UNIVERSAL21G 92 methyltestosterone 11 mondoxyne nl 130 MEIJER LANCETS metoclopramide hcl 69 MONOLET LANCETS 92 UNIVERSAL30G 92 MEIJER LANCETS METOCLOPRAMIDE ODT 69 MONOLET OPD LANCETS 92 UNIVERSAL33G 92 metolazone 65 MONOLETTOR SAFETY MEIJER SUPER THIN LANCETS 92 METOPIRONE 63 MONONINE 73 LANCETS 92 metoprolol & MEKINIST 37 hydrochlorothiazide 31 montelukast sodium 15 MEKTOVI 37 metoprolol succinate 45 morgidox 1x100mg 130 meloxicam 4 metoprolol tartrate 45 morphine sulfate 8 melphalan 33 metronidazole 12 morphine sulfate beads 8 melphalan hcl 33 metronidazole (topical) 63 MOVANTIK 70 memantine hcl 125,126 metronidazole vaginal 135 moxifloxacin hcl 69 MENEST 68 metyrosine 30 moxifloxacin hcl (ophth) 120 MENOSTAR 68 mexiletine hcl 14 MPD SAFETY LANCET 21G/1.8MM 92 meperidine hcl 8 MG217 PSORIASIS MULTI- MPD SAFETY LANCET mercaptopurine 33 SYMTOM 62 28G/1.8MM 92 meropenem 12 MIACALCIN 65 MPD SAFETY LANCET MERREM 12 miconazole 3 135 30G/1.8MM 92 MPD SAFETY LANCETS mesalamine 69 MICROLET LANCETS 92 MICROTAINER SAFETY 23G/1.8MM 93 MESNEX 38 FLOW MUCOTROL 108 MESTINON 32 LANCET/STERILE/SINGLE- MULPLETA 75 metaxalone 117 USE 92 MULTAQ 14

Index 13 multi-vit/iron/fluoride 110 NATPARA 65 NICOTROL INHALER 129 multi-vitamin/fluoride drops 109 NATURE-THROID 131 NICOTROL NS 129 MULTIVITAMIN + NATURE-THROID NT- nifedipine 46 FLUORIDE 110 2.5 131 nilutamide 35 multivitamin select/fluoride 110 NAYZILAM 17 nimodipine 46 MULTIVITAMIN WITH nebusal 55 NINLARO 37 FLUORIDE 108,109 NEBUSAL 55 multivitamin with fluoride 109 nisoldipine 46 NEEVO DHA 112 MULTIVITAMIN/FLUORIDE nitazoxanide 12 nefazodone hcl 22 109 nitisinone 67 neo-polycin 119 multivitamin/fluoride 109 NITRO-BID 13 neo-polycin hc 120 multivitamins/fluoride 110 NITRO-DUR 13 neomycin sulfate 2 mupirocin 57 nitrofurantoin 13 MYALEPT 67 neomycin-bacitracin zn- polymyxin 120 nitrofurantoin macrocrystal 13 mycophenolate mofetil 107 neomycin-polymy- nitrofurantoin monohyd mycophenolate sodium 107 dexameth 121 macro 13 MYGLUCOHEALTH MGH neomycin-polymyxin-gramicidin nitroglycerin 13 SOFTLANCE LANCETS 120 NITYR 67 30G 93 neomycin-polymyxin-hc NIVA-PLUS 112 MYLERAN 33 (ophth) 121 NIVESTYM 75 MYNATAL ADVANCE 112 neomycin-polymyxin-hc (otic) 123 nizatidine 133 MYNATAL ULTRACAPLET 112 NEONATAL COMPLETE 112 NOCTIVA 67 MYSOLINE 19 NEONATAL PLUS 112 nolix 59 MYTESI 25 NEOTUSS PLUS 54 NORDITROPIN FLEXPRO 66 nabumetone 5 NERLYNX 37 norethin acet & estrad-fe 52 nadolol 46 NESTABS 112 norethindrone & ethinyl estradiol- NAFCILLIN 125 NESTABS DHA 112 fe 52 nafcillin sodium 125 NESTABS ONE 112 norethindrone NAFCILLIN SODIUM 125 (contraceptive) 53 neuac 55 norethindrone acet & eth nafcillin sodium 125 NEUPRO 40 estra 52 nafrinse 106 NEURONTIN 19 norethindrone acetate 125 naftifine hcl 57 NEVANAC 122 norethindrone acetate-ethinyl estradiol 68 NAFTIN 57 nevirapine 43 NALOCET 10 norgestimate-ethinyl NEXA PLUS 112 estradiol 52 naloxone hcl 26 NEXAVAR 37 norgestimate-ethinyl estradiol naltrexone hcl 26 NEXIUM 133 (triphasic) 52 NAMENDA XR TITRATION NORITATE 63 NEXTSTELLIS 52 PACK 126 NORPACE CR 14 niacin (antihyperlipidemic) 30 NAMZARIC 126 NORTHERA 136 niacor 30 naproxen 5 nortriptyline hcl 22 nicardipine hcl 46 naproxen sodium 5 NORVIR 43 NICODERM CQ 129 naratriptan hcl 105 NOVA SAFETY LANCETS NARCAN 26 NICORETTE 129 23G 93 NATACHEW 112 NICORETTE MINI 129 NOVA SAFETY LANCETS 28G 93 NATACYN 120 NICORETTE STARTER KIT 129 NOVA SUREFLEX NATAZIA 52 nicotine 129 LANCETS 93 nateglinide 25 nicotine polacrilex 129 NOVOEIGHT 73 NATELLE ONE 112 NICOTINE TRANSDERMAL NOVOPEN ECHO 104 SYSTEM 129

Index 14 NOVOSEVEN RT 73 omega-3-acid ethyl esters 28 ORKAMBI 129 NOXAFIL 27 omeprazole 133,134 orphenadrine citrate 117 np thyroid 15 131 OMEPRAZOLE + SYRSPEND orphenadrine w/ aspirin & NUBEQA 35 SFALKA 133 caff 117 OMNIFLEX DIAPHRAGM 78 ORTHO MICRONOR 53 NUCALA 14 ON CALL LANCETS 93 ORTHO TRI-CYCLEN LO 52 NUCORT 61 ON CALL PLUS LANCETS93 ORTHO-NOVUM 1/35 52 NUCYNTA 8 ondansetron 27 ORTHO-NOVUM 7/7/7 52 NUCYNTA ER 8 ondansetron hcl 26 oscimin 132 NUEDEXTA 127 ONE VITE WOMENS oscimin sr 132 NULYTELY 76 PRENATALVITAMIN oseltamivir phosphate 45 NULYTELY/FLAVOR PLUS 113 PACKS 76 ONETOUCH CLUB LANCETS OSMOPREP 77 NUPLAZID 40 FINE POINT 93 OSPHENA 66 NUVARING 52 ONETOUCH DELICA OTEZLA 5 LANCETS EXTRA FINE NUWIQ 73 33G 93 OTOVEL 123 nyamyc 57 ONETOUCH DELICA OTREXUP 3 NYMALIZE 46 LANCETS FINE 30G 93 oxacillin sodium 125 nystatin 27 ONETOUCH DELICA PLUS oxandrolone 11 LANCETS EXTRA FINE nystatin (mouth-throat) 108 33G 93 oxaprozin 5 nystatin (topical) 57 ONETOUCH DELICA PLUS OXAYDO 8 nystatin-triamcinolone 57 LANCETS FINE 30G 93 oxazepam 14 ONETOUCH FINEPOINT O-CAL FA 112 LANCETS 93 oxcarbazepine 19 OB COMPLETE ONE 112 ONETOUCH ULTRA 64 OXERVATE 120 OB COMPLETE PETITE 113 ONETOUCH ULTRA 2 93 oxiconazole nitrate 58 OB COMPLETE PREMIER 113 ONETOUCH ULTRASOFT OXISTAT 58 OB COMPLETE/DHA 113 LANCETS 93 OXTELLAR XR 19 OBIZUR 73 ONETOUCH VERIO FLEX oxybutynin chloride 134 BLOOD GLUCOSE OBSTETRIX ONE 113 MONITORING SYSTEM 93 oxycodone hcl 8,9 OCALIVA 69 ONETOUCH VERIO TEST oxycodone w/ OCTAGAM 124 STRIPS 64 acetaminophen 10 oxycodone-ibuprofen 10 octreotide acetate 67 ONUREG 33 opium tincture 26 OXYCODONE/ACETAMINOPHE ODEFSEY 43 N 10 48 ODOMZO 34 OPSUMIT oxymorphone hcl 9 OPTIONS CONCEPTROL OFEV 130 VAGINAL OZEMPIC 24 ofloxacin 69 CONTRACEPTIVE 134 pacerone 14 ofloxacin (ophth) 120 OPTIONS GYNOL II paliperidone 41 ofloxacin (otic) 123 VAGINALCONTRACEPTIVE PALYNZIQ 67 135 olanzapine 41 ORACEA 63 PANCREAZE 64 olanzapine-fluoxetine hcl 126 ORACIT 71 PANRETIN 58 olmesartan medoxomil 30 oralone dental paste 108 pantoprazole sodium 134 olmesartan medoxomil- paregoric 26 amlodipine-hydrochlorothiazide ORAVIG 108 31 ORENCIA 5 PAREMYD 122 olmesartan medoxomil- ORENCIA CLICKJECT 5 paricalcitol 67 hydrochlorothiazide 31,32 ORENITRAM 47 paroex 108 olopatadine hcl 122 ORFADIN 67 paromomycin sulfate 2 olopatadine hcl (nasal) 118 ORIAHNN 68 paroxetine hcl 22 OMECLAMOX-PAK 134

Index 15 PASER 33 PHARMACIST CHOICE pnv-dha 111 PAXIL 22 ULTRA THIN LANCETS PNV-DHA+DOCUSATE 113 33G 94 PC LANCETS SUPER THIN PHARMACY COUNTER PNV-OMEGA 113 30G 93 LANCETS 94 pnv-select 111 pediatric vitamins acd w/ fluoride 110 phenadoz 28 PODOCON 25 IN BENZOIN peg 3350-kcl-nacl-na sulfate-na phenelzine sulfate 21 TINCTURE 62 ascorbate-ascorbic acid 76 PHENERGAN 28 podofilox 62 POLY HUB NEEDLE/30G X peg 3350-kcl-sod bicarb-sod phenobarbital 75 chloride-sod sulfate 76 1/2" 104 peg 3350-potassium chloride-sod phenoxybenzamine hcl 30 poly-vi-flor 110 bicarbonate-sod chloride 77 phentermine hcl 1 POLY-VI-FLOR 110 peg-3350/electrolytes/ascorbate PHENTERMINE POLY-VI-FLOR/IRON 110 76 HYDROCHLORIDE 1 peg-prep 76 phenylephrine hcl polyethylene glycol 3350 77 PEGANONE 21 (mydriatic) 119 polymyxin b-trimethoprim 120 PEGASYS 44 phenytoin 21 POMALYST 35 PEGASYS PROCLICK 44 phenytoin infatabs 20 posaconazole 27 phenytoin sodium pot & sod citrates w/citric ac 71 PEGINTRON 45 extended 21 penicillamine 107 pot phosphate monobasic w/ sod PHEXXI 135 phosphate dibasic & penicillin g potassium 124 PHOSLYRA 70 monobasic 106 PENICILLIN G POTASSIUM IN phospha 250 neutral 106 POTABA 136 ISO-OSMOTIC DEXTROSE 124 PHOSPHOLINE IODIDE 119 potassium chloride 106,107 PENICILLIN G PROCAINE 124 phytonadione 136 POTASSIUM CHLORIDE 107 penicillin g sodium 124 PICATO 58 potassium chloride 107 penicillin v potassium 124 PIFELTRO 43 potassium chloride in dextrose & sodium chloride 106 PENNSAID 57 pilocarpine hcl 119 potassium chloride pentamidine isethionate 12 pilocarpine hcl (oral) 108 microencapsulated crystals PENTASA 69 pimecrolimus 62 er 107 pimozide 127 potassium citrate pentazocine w/ naloxone 11 (alkalinizer) 71 pentoxifylline 74 pindolol 46 potassium citrate-citric acid 71 PERFECT LANCETS 30G 93 pioglitazone hcl 24 POVIDONE IODINE 120 pioglitazone hcl- PERFECT PRESSURE PR NATAL 400 EC 113 ACTIVATED SAFETY LANCETS glimepiride 23 28G 93 pioglitazone hcl-metformin PR NATAL 430 113 perindopril erbumine 30 hcl 23 PR NATAL 430 EC 113 permethrin 63 PIP LANCETS/28G 94 PRALUENT 30 perphenazine 41 PIP LANCETS/30G 94 pramipexole dihydrochloride 40 piperacillin sodium-tazobactam PRAMOSONE 61 perphenazine-amitriptyline 126 sodium 125 PERSERIS 41 PIQRAY 200MG DAILY PRAMOTIC 123 PERTZYE 64 DOSE 37 prasugrel hcl 74 pfizerpen 124 PIQRAY 250MG DAILY pravastatin sodium 29 DOSE 37 PHARMACIST CHOICE ULTRA PIQRAY 300MG DAILY praziquantel 12 THIN LANCETS 94 DOSE 37 prazosin hcl 31 PHARMACIST CHOICE ULTRA PRECISION THINS GP THIN LANCETS 28G 94 piroxicam 5 PLAN B ONE-STEP 53 LANCET 94 PHARMACIST CHOICE ULTRA PRECISION XTRA BLOOD THIN LANCETS 30G 94 PLEGRIDY 127 GLUCOSE TEST STRIPS 64 PHARMACIST CHOICE ULTRA PLEGRIDY STARTER PRED-G 121 THIN LANCETS 31G 94 PACK 127 PRED-G S.O.P. 121 PNV TABS 29-1 113

Index 16 prednicarbate 61 PREPIDIL 123 promethazine w/codeine 54 prednisolone 53 PREPLUS 114 promethazine-dm 54 prednisolone acetate PRESSURE ACTIVATED promethazine-phenylephrine- (ophth) 121 SAFETYLANCET 21G 94 codeine 54 prednisolone acetate p-f 120 prevalite 29 promethegan 28 prednisolone sodium PREZCOBIX 43 propafenone hcl 14 phosphate 53 PREZISTA 43 propantheline bromide 132 PREDNISOLONE SODIUM PHOSPHATE 121 PRIFTIN 33 proparacaine hcl 120 PREDNISOLONE SODIUM PRILOSEC 134 propranolol & PHOSPHATE/MOXIFLOXACIN primaquine phosphate 32 hydrochlorothiazide 32 121 propranolol hcl 46 PRIMAXIN IV 12 prednisone 53 propylthiouracil 131 primidone 19 PREDNISONE INTENSOL 53 PROSTIN E2 123 PRIMLEV 10 PREFERRED PLUS LANCETS protriptyline hcl 23 COLORED 21G 94 PRIMSOL 12 PROVIDA DHA 114 PREFERRED PLUS LANCETS PRIVIGEN 124 SUPER THIN 30G 94 PRO COMFORT LANCETS pseudoephed-bromphen-dm 54 PREFERRED PLUS LANCETS 30G 94 pseudoephed-cpm w/ THIN 26G 94 PRO COMFORT LANCETS hydrocod 54 PREFEST 68 31G 94 psorcon 59 pregabalin 19 PRO-RED AC 54 PSS SELECT GP LANCETS 95 PREMARIN 68,135 PROAIR RESPICLICK 16 PSS SELECT SAFETY PREMIUM SCAR PATCH 63 probenecid 71 LANCETS 95 PULMICORT FLEXHALER 15 PREMPHASE 68 PROBUPHINE IMPLANT pulmosal 55 PREMPRO 68 KIT 11 procentra 1 PULMOZYME 129 PRENA 1 TRUE 113 prochlorperazine 42 PURE COMFORT LANCETS PRENA1 CHEW 113 prochlorperazine maleate 42 30G 95 PRENA1 PEARL 113 PURIXAN 33 procto-med hc 11 PRENAISSANCE 113 PUSH BUTTON SAFETY PROCTOFOAM HC 11 PRENAISSANCE PLUS 113 LANCETS 21G 95 PROCYSBI 71 PUSH BUTTON SAFETY prenatabs rx 111 PRODIGY PRESSURE LANCETS 28G 95 PRENATAL 114 ACTIVATED SAFETY PX LANCETS MICROTHIN PRENATAL + DHA 113 LANCETS 94 33G 95 prenatal 19 111 PRODIGY SAFETY PX LANCETS ULTRA THIN 95 LANCETS 94 PRENATAL 19 113,114 PX LANCETS ULTRA THIN PRODIGY TWIST TOP 28G 95 PRENATAL PLUS IRON 114 LANCETS 94 PYLERA 134 PRENATAL VITAMINS PLUS PROFILNINE 73 pyrazinamide 33 LOW IRON 114 PROFILNINE SD 73 PRENATAL-U 114 pyridostigmine bromide 32,33 progesterone 125 pyrimethamine 32 PRENATE 114 PROGESTERONE PRENATE DHA 114 CONCENTRATE 49 QBRELIS 30 PRENATE ELITE 114 PROGRAF 107 QC LANCETS SUPER THIN 95 PRENATE ENHANCE 114 PROLATE 10 QC LANCETS ULTRA THIN 95 PRENATE ESSENTIAL 114 PROLENSA 122 QC UNILET LANCETS 28G/ULTRA THIN 95 PRENATE MINI 114 PROLIA 65 QC UNILET LANCETS PRENATE PIXIE 114 PROMACTA 75 33G/MICRO THIN 95 PRENATE RESTORE 114 promethazine & QINLOCK 37 PRENATRIX 114 phenylephrine 54 QSYMIA 1 promethazine hcl 28 PRENATRYL 114 QUARTETTE 52

Index 17 QUDEXY XR 19 RECOMBINATE 73 rifampin 33 quetiapine fumarate 41 RECTIV 12 RIFATER 33 QUFLORA FE PEDIATRIC 110 REGEN-COV 124 RIGHTEST GL300 QUFLORA GUMMIES 110 REGRANEX 63 LANCETS 96 riluzole 118 QUFLORA PEDIATRIC 110 relafen 4 rimantadine hydrochloride 45 QUILLIVANT XR 2 RELENZA DISKHALER 45 RINVOQ 3 quinapril hcl 30 RELION INSULIN SYRINGE quinapril-hydrochlorothiazide 0.5ML/31G X 15/64" 104 risedronate sodium 66 32 RELION INSULIN SYRINGE risperidone 41 quinidine gluconate 14 1ML/31GX15/64" 104 ritonavir 43 RELION INSULIN SYRINGE/U- quinidine sulfate 14 100/1ML/31G X 15/64" 104 rivastigmine 126 quinine sulfate 32 RELION LANCETS MICRO- rivastigmine tartrate 126 QVAR REDIHALER 15 THIN33G 96 RIXUBIS 73 RELION LANCETS THIN R-NATAL OB 114 26G 96 rizatriptan benzoate 105 RA E-ZJECT LANCETS 28G95 RELION LANCETS ULTRA- ROMIDEPSIN 37 RA E-ZJECT LANCETS THIN THIN30G 96 ropinirole hydrochloride 40 26G 95 RELION ULTRA THIN rosadan 63 RA E-ZJECT LANCETS THIN LANCETS/30G 96 28G 95 RELION ULTRA THIN rosuvastatin calcium 29 RA E-ZJECT LANCETS LANCETS30G 96 roweepra 18 ULTRATHIN 30G 95 RELION ULTRA THIN PLUS roweepra xr 18 LANCETS 32G 96 ra laxative 77,78 ROZLYTREK 37 rabeprazole sodium 134 RELION ULTRA THIN PLUS LANCETS 33G 96 RUBRACA 37 RABEPRAZOLE SODIUM DR SPRINKLE 134 RELISTOR 70 rufinamide 19 raloxifene hcl 66 RELNATE DHA 114 RUKOBIA 43 ramelteon 76 RENFLEXIS 69 RUZURGI 33 ramipril 30 repaglinide 25 RYBELSUS 24 ranolazine 13 repaglinide-metformin hcl 23 ryclora 27 rasagiline mesylate 40 REPATHA SURECLICK 30 RYDAPT 37 RASUVO 3 RESCRIPTOR 43 RYTARY 40 RAVICTI 67 RESTASIS 120 RYVENT 28 READYLANCE SAFETY RESTASIS MULTIDOSE 120 SABRIL 20 LANCETS/21G/2.2MM 95 RETACRIT 75 SAFE-T-LANCE LOW FLOW READYLANCE SAFETY RETEVMO 37 25G 96 LANCETS/23G/1.8MM 95 SAFE-T-LANCE NORMAL READYLANCE SAFETY REVATIO 48 FLOW21G 96 LANCETS/26G/1.8MM 96 REVLIMID 107 SAFE-T-LANCE PLUS READYLANCE SAFETY REXALL LANCETS ULTRA SAFETYLANCET HIGH LANCETS/28G/1.8MM 96 THIN 96 FLOW 96 READYLANCE SAFETY REXULTI 42 SAFE-T-LANCE PLUS LANCETS/30G/1.6MM 96 REYATAZ 43 SAFETYLANCET LOW REALITY LANCETS 96 FLOW 96 REALITY TRIGGER RHOFADE 63 SAFE-T-LANCE PLUS LANCETS 96 RIAX 56 SAFETYLANCET NORMAL REBIF 127 ribasphere 44 FLOW 97 SAFETY LANCET REBIF REBIDOSE 127 ribavirin 45 21G/PRESSURE REBIF REBIDOSE ribavirin (hepatitis c) 45 ACTIVATED 97 TITRATIONPACK 127 RIDAURA 3 SAFETY LANCET REBIF TITRATION PACK 127 rifabutin 33 23G/PRESSURE REBINYN 73 ACTIVATED 97 RIFAMATE 33

Index 18 SAFETY LANCET sertraline hcl 22 SODIUM SULFACETAMIDE 28G/PRESSURE sevelamer carbonate 70 WASH 59 ACTIVATED 97 SODIUM SAFETY LANCET sevelamer hcl 70 SULFACETAMIDE/SULFUR 30G/PRESSURE SFROWASA 69 CLEANSER IN UREA 56 ACTIVATED 97 SHOPKO ON-THE-GO solifenacin succinate 134 SAFETY LANCETS 97 COMFORTLANCETS 30G 97 SOLTAMOX 35 SAFETY LANCETS 21G 97 SHOPKO UNILET LANCETS SOLUS V2 PRESSURE SUPER THIN 30G 97 ACTIVATED SAFETY LANCETS SAFETY LANCETS 28G 97 SHOPKO UNILET LANCETS SAFETY LET LANCETS 97 28G 98 ULTRA THIN 28G 98 SOLUS V2 TWIST LANCETS SAFETY SEAL LANCETS SHUR-SEAL 135 30G 98 28G 97 SIDE BUTTON SAFETY SOMAVERT 66 SAFETY SEAL LANCETS LANCET21G 98 SORILUX 58 30G 97 SIGNIFOR 67 SAFYRAL 52 sorine 45 SIKLOS 74 sajazir 74 sotalol hcl 46 sildenafil citrate 47 salicylic acid 62 sildenafil citrate (pulmonary sotalol hcl (afib/afl) 46 salicylic acid in ammonium hypertension) 48 SOTYLIZE 46 lactate vehicle 62 silodosin 71 SPIRIVA HANDIHALER 15 SALIMEZ 62 silver sulfadiazine 59 SPIRIVA RESPIMAT 15 salsalate 7 SIMBRINZA 119 spironolactone 65 SANCUSO 27 simvastatin 29 spironolactone & SANDIMMUNE 107 SINGLE-LET 98 hydrochlorothiazide 65 SANDOSTATIN 67 SPRIX 5 sirolimus 107 SANTYL 62 SPRYCEL 37 SIVEXTRO 13 SAPHRIS 41 ssd 59 SKYRIZI 58 sapropterin dihydrochloride 67 sss 10-5 55 SKYRIZI PEN 58 SAPS HEALTH CARE TWIST stavudine 44 SLYND 53 TOP LANCETS 97 STAVUDINE 44 SAPS HEALTH TWIST TOP SM MICRO THIN LANCETS LANCETS 30G 97 33G 98 STELARA 59,69 SAPSCARE TWIST TOP SMART SENSE COLOR STERILANCE TL 98 LANCETS 30G 97 LANCETS UNIVERSAL STIMATE 67 33G 98 SAVELLA 126 STIOLTO RESPIMAT 16 SAVELLA TITRATION SMART SENSE STANDARD PACK 126 LANCETS UNIVERSAL STIVARGA 37 21G 98 STRENSIQ 67 SAXENDA 1 SMART SENSE SUPER THIN SB LANCETS THIN 97 LANCETS UNIVERSAL streptomycin sulfate 2 SB LANCETS ULTRA THIN 97 30G 98 STRIANT 11 scopolamine 27 SMART SENSE THIN STRIBILD 44 LANCETSUNIVERSAL STRIVERDI RESPIMAT 16 SE-NATAL 19 114,115 26G 98 SEASONIQUE 52 SMARTEST LANCETS SUBLOCADE 11 SECUADO 41 28G 98 subvenite 18 SELECT-OB 115 sodium chloride 107 subvenite starter kit/blue 18 SELECT-OB+DHA 115 sodium chloride (inhalant) 55 SUCRAID 64 selegiline hcl 40 sodium citrate & citric acid 71 sucralfate 133 selenium sulfide 59 sodium fluoride 106 sulconazole nitrate 58 SELZENTRY 43 sodium phenylbutyrate 67 sulfacetamide sod- sodium polystyrene prednisolone 121 SEREVENT DISKUS 16 sulfonate 108 sulfacetamide sodium 59 SEROSTIM 66 sodium sulfacetamide sulfacetamide sodium (acne)56 wash 59

Index 19 sulfacetamide sodium tacrolimus (topical) 62 TESTIM 11 (ophth) 120 tadalafil 47 testosterone 11 sulfacetamide sodium w/ sulfur 56 tadalafil (pulmonary tetrabenazine 126 hypertension) 48 SULFADIAZINE 130 tetracaine hcl (ophth) 120 TAFINLAR 38 sulfamethoxazole-trimethoprim tetracycline hcl 130 TAGRISSO 34 12 TEXACORT 61 SULFAMYLON 59 TALZENNA 38 TGT LANCET MICRO THIN sulfasalazine 70 tamoxifen citrate 35 33G 99 sulfatrim pediatric 12 tamsulosin hcl 71 TGT LANCET THIN 26G 99 sulindac 5 TARCEVA 34 TGT LANCET ULTRA THIN 30G 99 sumatriptan 105 TARGRETIN 38,58 THALOMID 107 sumatriptan succinate 105 TARON-BC 115 THEO-24 16 sunitinib malate 37 TARON-C DHA 115 theophylline 16 TARON-PREX 115 SUPER THIN LANCETS 98 THERANATAL CORE SUPRAX 49 TASIGNA 38 NUTRITION 115 SURE COMFORT LANCETS TAVALISSE 74 THINLETS GP LANCETS 99 18G 98 TAYTULLA 52 THIOLA EC 71 SURE COMFORT LANCETS 21G 98 TAZAROTENE 56 thioridazine hcl 42 SURE COMFORT LANCETS tazarotene 59 thiothixene 42 23G 98 TAZORAC 59 THRIVITE 19 109 SURE COMFORT LANCETS taztia xt 46 28G 98 THRIVITE RX 115 SURE COMFORT LANCETS TAZVERIK 38 THYMOGLOBULIN 108 30G 98 TECHLITE AST LANCETS 99 thyroid 131 SURE-LANCE FLAT TECHLITE INSULIN tiagabine hcl 20 LANCETS 99 SYRINGEU-100/0.5ML/31G X SURE-LANCE LANCETS 15/64" 104 TIBSOVO 38 26G 99 TECHLITE INSULIN tilia fe 51 SURE-LANCE THIN LANCETS SYRINGEU-100/1ML/31G X timolol maleate 46 28G 99 15/64" 104 timolol maleate (ophth) 119 SURE-LANCE ULTRA THIN TECHLITE LANCETS 99 LANCETS 99 timolol maleate in ocudose 118 TECHLITE LANCETS 30G 99 SURE-TOUCH LANCETS TIMOPTIC OCUDOSE 119 TEGRETOL 19 UNIVERSAL 99 TIMOPTIC-XE 119 SURELITE LANCETS 99 TEGRETOL-XR 19 tinidazole 12 SUTENT 37 TEGSEDI 129 tiopronin 71 SYLATRON 38 TEKTURNA HCT 32 TIROSINT 131 SYMDEKO 129 telmisartan 30 TIVICAY 44 SYMLINPEN 120 23 telmisartan-amlodipine 32 tizanidine hcl 117 SYMLINPEN 60 23 telmisartan-hydrochlorothiazide TL-CARE DHA 115 SYMTUZA 44 32 TL-SELECT 115 SYNAREL 66 temazepam 76 TOBI PODHALER 2 SYNDROS 27 TEMIXYS 44 TOBRADEX 121 SYNJARDY 23 temozolomide 33 TOBRADEX ST 121 SYNJARDY XR 23 temsirolimus 38 tenofovir disoproxil tobramycin 2 SYNTHROID 131 fumarate 44 tobramycin (ophth) 120 SYPRINE 107 terazosin hcl 31 tobramycin sulfate 3 TABLOID 33 terbinafine hcl 27 tobramycin- TABRECTA 37 terbutaline sulfate 16 dexamethasone 121 tacrolimus 108 terconazole vaginal 135 TOBREX 120

Index 20 TODAY SPONGE 135 TRI-VI-FLOR 110 TRUEPLUS SAFETY LANCETS TODAYS HEALTH SUPER TRI-VI-FLORO 110 28G 100 TRULICITY 24 THINLANCETS 30G 99 tri-vite/fluoride 110 TODAYS HEALTH ULTRA TRUVADA 44 THINLANCETS 28G 99 triamcinolone acetonide (mouth) 108 TUKYSA 34 tolbutamide 25 triamcinolone acetonide TURALIO 38 tolcapone 39 (nasal) 118 TUSNEL 54 tolmetin sodium 5 triamcinolone acetonide TUSSICAPS 54 TOLSURA 27 (topical) 61,62 triamterene 65 TUSSLIN 55 tolterodine tartrate 134 triamterene & TUSSLIN PEDIATRIC 55 TOPAMAX 20 hydrochlorothiazide 65 TWIRLA 52 TOPAMAX SPRINKLE 19 triazolam 76 TYBLUME 52 TOPCARE LANCETS MICRO- TRICARE 115 TYBOST 44 THIN 33G 99 TRICARE PRENATAL DHA topiramate 20 ONE 115 tydemy 50 toposar 39 triderm 59 TYKERB 38 topotecan hcl 39 trientine hcl 107 TYMLOS 66 toremifene citrate 35 trifluoperazine hcl 42 TYSABRI 127 TORISEL 38 trifluridine 120 TYVASO 47 torsemide 65 TRIGLIDE 29 TYVASO REFILL 47 TOUJEO MAX SOLOSTAR 25 trihexyphenidyl hcl 39 TYVASO STARTER 47 TOUJEO SOLOSTAR 25 TRIJARDY XR 23 UCERIS 11 tovet 59 TRIKAFTA 130 UDENYCA 75 TOVIAZ 134 TRILEPTAL 20 ULTILET CLASSIC LANCETS 100 TRACLEER 48 trimethobenzamide hcl 27 ULTILET INSULIN SYRINGE/U- tramadol hcl 9 trimethoprim 12 100/0.5ML/31GX6MM 104 tramadol-acetaminophen 10 trimipramine maleate 23 ULTILET LANCETS 100 trandolapril 30 TRINATAL RX 1 115 ULTILET LANCETS 33G 100 trandolapril-verapamil hcl 32 TRINTELLIX 22 ULTILET SAFETY LANCETS tranexamic acid 75 21G X 2.2MM 100 TRISTART DHA 115 ULTILET SAFETY LANCETS tranylcypromine sulfate 21 TRISTART ONE 115 23G 100 TRAVEL LANCETS 30G 99 TRIUMEQ 44 ULTIMATECARE ONE 115 TRAVEL LANCETS ADVANCED TROKENDI XR 20 ULTRA THIN LANCETS 28G 99 tropicamide 119 31G 100 travoprost 122 ULTRA-CARE LANCETS trospium chloride 134 trazodone hcl 22 30G 100 TRUE COMFORT TWIST TOP ULTRA-THIN II AUTO TRECATOR 33 LANCETS 30G 100 LANCET 100 TRELEGY ELLIPTA 16 TRUEPLUS LANCETS ULTRA-THIN II LANCETS TREMFYA 59 26G 100 28G 100 TRUEPLUS LANCETS TRESIBA 25 ULTRA-THIN II LANCETS 28G 100 30G 101 TRESIBA FLEXTOUCH 25 TRUEPLUS LANCETS 28G UNASYN 125 SUPER THIN 100 tretinoin 56 UNASYN BULK PACK 125 tretinoin (chemotherapy) 38 TRUEPLUS LANCETS 30G 100 UNILET COMFORTOUCH tretinoin microsphere 56 TRUEPLUS LANCETS 30G LANCET 101 TRETTEN 73 ULTRA THIN 100 UNILET EXCELITE 101 TREXALL 33 TRUEPLUS LANCETS UNILET EXCELITE II 101 33G 100 UNILET G.P. LANCET 101 tri femynor 51 TRUEPLUS LANCETS 33G TRI-TABS DHA 115 MICRO THIN 100

Index 21 UNILET G.P. SUPERLITE VALUE PLUS LANCETS THIN VIREAD 44 LANCET 101 26G 102 VIRT-C DHA 116 UNILET GP 28 ULTRA VALUMARK LANCET SUPER THIN 101 THIN 30G 102 VIRT-NATE DHA 116 UNILET LANCET 101 VALUMARK LANCET ULTRA VIRT-PN DHA 116 UNILET LANCETS MICRO- THIN 28G 102 VIRT-PN PLUS 116 THIN33G 101 vanadom 117 virtussin ac/alc 54 UNILET LANCETS SUPER- vancomycin hcl 12 VIRTUSSIN DAC 55 THIN30G 101 vandazole 135 UNILET LANCETS ULTRA-THIN VISTOGARD 26 28G 101 VARUBI 27 VITAFOL FE+ 116 UNILET SUPERLITE VASCEPA 28,29 VITAFOL GUMMIES 116 LANCET 101 VCF VAGINAL UNISTIK 3 GENTLE 101 CONTRACEPTIVE FILM 135 VITAFOL-NANO 116 UNISTIK PRO SAFETY LANCET VCF VAGINAL VITAFOL-ONE 116 21G 101 CONTRACEPTIVE VITALET PRO LANCETS 102 UNISTIK PRO SAFETY LANCET FOAM 135 VITALET PRO PLUS 25G 101 VCF VAGINAL LANCETS 102 UNISTIK PRO SAFETY LANCET CONTRACEPTIVEGEL 135 VITAMEDMD ONE 28G 101 VECAMYL 32 RX/QUATREFOLIC 116 UNISTIK SAFETY LANCETS VELCADE 38 VITAMEDMD REDICHEW 28G 101 VEMLIDY 45 RX 116 UNISTIK SAFETY LANCETS VITAPEARL 116 30G 101 VENA-BAL DHA 115 VITATHELY/GINGER 116 UNISTIK TOUCH SAFETY VENCLEXTA 34 LANCETS 21G 102 VENCLEXTA STARTING VITATRUE 116 UNISTIK TOUCH SAFETY PACK 34 VITRAKVI 38 LANCETS 23G 102 UNISTIK TOUCH SAFETY venlafaxine hcl 22 VIVA DHA 116 LANCETS 28G 102 VENTAVIS 47 VIVAGUARD LANCETS 102 UNISTIK TOUCH SAFETY verapamil hcl 46,47 VIZIMPRO 34 LANCETS 30G 102 VEREGEN 56 VOL-PLUS 116 UNIVERSAL 1 LANCETS THIN26G 102 VERELAN 47 VOL-TAB RX 116 UNIVERSAL 1 LANCETS ULTRA VERELAN PM 47 VONVENDI 73 THIN 30G 102 VERSACLOZ 41 voriconazole 27 UNIVERSAL 1 LANCETS/33G/MICRO-THIN VERZENIO 38 VOSEVI 45 102 VIBERZI 70 VOTRIENT 38 UPTRAVI 48 VIBRAMYCIN 130 VP-PNV-DHA 116 urea 62 VICTOZA 24 VRAYLAR 40 urea-c40 62 VIDA MIA UNILET LANCETS VYNDAMAX 48 SUPER THIN 30G 102 VYNDAQEL 49 ursodiol 69 VIDA MIA UNILET LANCETS valacyclovir hcl 45 ULTRA THIN 28G 102 VYVANSE 1 VALCHLOR 58 VIDEX EC 44 WALGREENS ADVANCED TRAVELLANCETS 28G 102 valganciclovir hcl 44 vigabatrin 20 WALGREENS COMFORT valproate sodium 21 vigadrone 20 ASSUREDLANCETS MICRO valproic acid 21 VIIBRYD 22 THIN/33G 103 valsartan 30 VIIBRYD STARTER PACK 22 WALGREENS COMFORT ASSUREDLANCETS SUPER valsartan-hydrochlorothiazide VIMPAT 20 32 THIN/28G 103 VALUE PLUS LANCETS VINATE DHA RF 115 WALGREENS LANCETS 103 STANDARD 21G 102 VINATE ONE 116 WALGREENS THIN VALUE PLUS LANCETS VIOKACE 64 LANCETS 103 SUPERTHIN 30G 102 WALGREENS ULTRA THIN VIRACEPT 44 LANCETS 103

Index 22 warfarin sodium 16 XURIDEN 67 WESTAB PLUS 116 XYNTHA 73 WESTGEL DHA 116 XYNTHA SOLOFUSE 73 WESTHROID 131 XYREM 125 WIDE-SEAL SILICONE YASMIN 28 52 DIAPHRAGM KIT 60 78 YAZ 52 WIDE-SEAL SILICONE DIAPHRAGM KIT 65 78 YONSA 35 WIDE-SEAL SILICONE yuvafem 135 DIAPHRAGM KIT 70 79 zafirlukast 15 WIDE-SEAL SILICONE DIAPHRAGM KIT 75 79 zaleplon 76 WIDE-SEAL SILICONE ZARONTIN 21 DIAPHRAGM KIT 80 79 ZARXIO 75 WIDE-SEAL SILICONE ZATEAN-PN DHA 117 DIAPHRAGM KIT 85 79 WIDE-SEAL SILICONE ZATEAN-PN PLUS 117 DIAPHRAGM KIT 90 79 ZAVESCA 74 WIDE-SEAL SILICONE ZEJULA 38 DIAPHRAGM KIT 95 79 ZELAPAR 40 WILATE 73 ZELBORAF 38 WILZIN 107 ZENPEP 64 wixela inhub 15 zenzedi 1 WP THYROID 132 ZEVRX TWIST TOP LANCETS XADAGO 40 30G 103 XALKORI 38 zidovudine 44 XARELTO 17 ZIEXTENZO 75 XARELTO STARTER PACK 17 zileuton 15 XATMEP 33 ZIOPTAN 122 XELJANZ 3 ziprasidone hcl 41 XELJANZ XR 3 ZIRGAN 120 XENAZINE 126 ZOLINZA 38 XENICAL 2 zolmitriptan 105 XERAC AC 63 zolpidem tartrate 76 XERMELO 70 ZOMACTON 66 XIFAXAN 12 ZONEGRAN 20 XIGDUO XR 23 zonisamide 20 XIMINO 130 ZORBTIVE 66 XOLAIR 14 ZORTRESS 108 XOSPATA 38 ZOSYN 125 XPOVIO 35 ZUPLENZ 27 XPOVIO 100 MG ONCE ZYDELIG 38 WEEKLY 35 XPOVIO 60 MG ONCE ZYFLO 15 WEEKLY 35 ZYKADIA 38 XPOVIO 80 MG ONCE ZYLET 121 WEEKLY 35 XPOVIO 80 MG TWICE ZYTIGA 35 WEEKLY 35 XTANDI 35 xulane 52

Index 23