(KPIC) PPO and Out-Of-Area Indemnity (OOA) Drug Formulary

Kaiser Permanente Insurance Company (KPIC) PPO and Out-of-Area Indemnity (OOA) Drug Formulary

This Drug Formulary was updated: December 1, 2019

NOTE: This drug formulary is updated often and is subject to change. Upon revision, all previous versions of the drug formulary are no longer in effect.

This document contains information regarding the drugs that are covered when you participate in the California Grandfathered PPO and Out-of- Area Indemnity (OOA) Health Insurance Plans for Large Groups offered by Kaiser Permanente Insurance Company(KPIC) and fill your prescription at a MedImpact network pharmacy. Please note that this Formulary does not have a specialty drug tier. If you are covered by a KPIC PPO plan with a specialty drug tier, please see the KPIC PPO and Out-of- Area Indemnity (OOA) Formulary with Specialty Drug Tier.

Access to the most current version of the Formulary can be obtained by visiting kp.org/kpic-ca-rx-ppo-gf.

For help understanding your KPIC insurance plan benefits, including cost sharing for drugs under the prescription drug benefit and under the medical benefit, please call 1-800-788-0710 or 711 (TTY) Monday through Friday, 7 a.m. to 7 p.m.

For help with this Formulary, including the processes for submitting an exception request and requesting prior authorization and step therapy exceptions, please call MedImpact 24 hours a day, 7 days a week, at 1- 800-788-2949 or 711 (TTY).

For information about your cost share for the outpatient prescription drug benefits in your specific plan, please visit: kp.org/kpic-ca-rx-ppo-gf.

For help in your preferred language, please see the “Kaiser Permanente Insurance Company Notice of Language Assistance” in this document.

KPIC PPO GF Table of Contents

Informational Section...... 2 Alternative Therapy - Vitamins And Minerals...... 10 Analgesic, Anti-Inflammatory Or Antipyretic - Drugs For Pain And Fever...... 10 Anesthetics - Drugs For Pain And Fever...... 36 Anorectal Preparations - Rectal Preparations...... 38 Antidotes And Other Reversal Agents - Drugs For Overdose Or Poisoning...... 39 Anti-Infective Agents - Drugs For Infections...... 41 Antineoplastics - Drugs For Cancer...... 66 Antiseptics And Disinfectants - Antiseptics And Disinfectants...... 79 Biologicals - Biological Agents...... 79 Cardiovascular Therapy Agents - Drugs For The Heart...... 87 Central Nervous System Agents - Drugs For The Nervous System...... 114 Chemical Dependency, Agents To Treat - Drugs For Addiction...... 168 Chemicals-Pharmaceutical Adjuvants...... 170 Cognitive Disorder Therapy - Drugs For The Nervous System...... 172 Contraceptives - Drugs For Women...... 174 Dermatological - Drugs For The Skin...... 186 Diagnostic Agents...... 239 Drugs To Treat Erectile Dysfunction - Drugs For The Urinary System...... 240 Eating Disorder Therapy - Drugs For Eating Disorders...... 240 Electrolyte Balance-Nutritional Products - Drugs For Nutrition...... 240 Endocrine - Hormones...... 256 Enzymes - Vitamins And Minerals...... 299 Fdb Class Obsolete-Not Used...... 299 Gastrointestinal Therapy Agents - Drugs For The Stomach...... 300 Genitourinary Therapy - Drugs For The Urinary System...... 319 Gout And Hyperuricemia Therapy - Drugs For Pain And Fever...... 326 Hematological Agents - Drugs For The Blood...... 327 Hepatobiliary System Treatment Agents - Drugs For The Liver...... 341 Immunosuppressive Agents - Drugs For Organ Transplants...... 341 Locomotor System - Drugs For Muscles, Ligaments, Tendons, And Bones...... 343 Medical Supplies And Durable Medical Equipment (Dme) - Medical Supplies And Durable Medical Equipment...... 346 Medical Supply, Fdb Superset...... 436 Metabolic Disease Enzyme Replacement Agents - Drugs For Metabolic Disease...... 496 Metabolic Modifiers - Drugs That Alter Metabolism...... 496 Mouth-Throat-Dental - Preparations - Drugs For The Mouth And Throat...... 498 Multiple Sclerosis Agents - Drugs For The Nervous System...... 502 Ophthalmic Agents - Drugs For The Eye...... 505 Otic (Ear) - Drugs For The Ear...... 520 Respiratory Therapy Agents - Drugs For The Lungs...... 522 Vaginal Products - Drugs For Women...... 542

TOC-1 Formulary Information

Notice: The Formulary is updated with changes on a monthly basis. Updates will be effective on the first day of the month. During the policy year, the following types of changes may be made:

• Removal of a drug or dosage form of a drug from the Formulary; • A change in tier placement of a drug that results in an increase or decrease in cost sharing; and • Adding or changing utilization management procedures applicable to a drug.

How to Use This Document This Formulary provides a list of the approved prescription medications covered under your KPIC Grandfathered PPO or OOA health insurance plan. This document applies only to prescribed outpatient prescription drugs obtained through a retail pharmacy within the MedImpact network. This document does not apply to medications administered in the doctor’s office or in the hospital which are covered under your medical benefit. For information on drugs covered under your medical benefit, please see the General Benefits section of your Certificate of Insurance.

The Formulary may be accessed using either the categorical list of drugs or the alphabetical index. The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB), a widely-accepted independent drug classification system.

A prescription drug may be located by looking up the therapeutic category and class to which the drug belongs or the brand or generic name of the drug in the alphabetical index. A drug is listed alphabetically by the brand and generic name in the therapeutic category and class to which it belongs. The generic name for a brand name drug is included after the brand name in parentheses and all lowercase italicized letters. 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 lowercase italicized letters. If a generic drug is marketed under a proprietary, trademark protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface with the first letter of each word capitalized. If a generic equivalent for a brand name drug is not available on the market or is not covered, the drug will not be separately listed by its generic name.

EXAMPLE of how drugs are listed on the Formulary: Brand name drug. The brand name antibiotic drug “Moxatag” would be listed as follows: Under the Prescription Drug Name Column, therapeutic category “ANTI-INFECTIVE AGENTS”, drug class “AMINOPENICILLIAN ANTIBIOTIC – ANTIBIOTICS”, the prescription brand name drug is listed in all capital letters,” MOXATAG” followed by the generic equivalent of the drug shown in parenthesis, all lower case italicized “(amoxicillin)”.

ANTI-INFECTIVE AGENTS – DRUGS FOR INFECTIONS

AMINOPENICILLIAN ANTIBIOTIC – ANTIBIOTICS

MOXATAG ORAL TABLET, ER MULITPHASE 24 HR 775 MG (amoxicillin) 2

Generic drug. The generic antibiotic drug “amoxicillin” would be listed as follows: Under the therapeutic category “ANTI-INFECTIVE AGENTS”, drug class “AMINOPENICILLIAN ANTIBIOTIC – ANTIBIOTICS”, the prescription generic drug is listed in lower case italics “amoxicillin”.

ANTI-INFECTIVE AGENTS – DRUGS FOR INFECTIONS

AMINOPENICILLIAN ANTIBIOTIC – ANTIBIOTICS

amoxicillin oral capsule 250 mg, 500 mg 1

KPIC PPO GF Drug Tiers Tier Benefit Design The Formulary applies to a tier benefit design, where the insured shares the cost of prescription drug therapy based on the drug’s tier and copay or coinsurance. In most instances, generically available drugs will be covered in a separate lower tier (lower copay), and branded drugs listed on the Formulary will be covered under a higher tier (higher copay).

If you request a brand-name drug when a generic drug is prescribed, you may be responsible for paying the brand-name copay plus the difference in cost between the generic drug and the brand-name drug. Please see your Certificate of Insurance for details.

For all drugs within the Drug Formulary table, the tier level is denoted throughout the document using the following symbols (refer to table below).

Tier Definitions: Symbol Guideline Description

T1 Tier 1 Generic Drugs

T2 Tier 2 Brand Name Drugs

T3 Tier 3 Other pharmacy items and certain DME, such as test strips and lancets, available at the pharmacy and through your medical benefit T4 Tier 4 Self-administered Injectable Medications

PV Preventive Drugs Preventive-care benefits required under the Affordable Care Act (ACA). (Preventive Drugs covered at no cost if your group elected to include ACA preventive-care benefits under their grandfathered plan.)

Maintaining and Updating the Formulary The MedImpact Healthcare Systems Pharmacy and Therapeutics (P&T) and Formulary Committees provide physicians and pharmacists with a method to evaluate the safety, efficacy and competitive prices for commercially available drug products. The MedImpact P&T and Formulary Committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary.

The Formulary is updated by the MedImpact P&T and Formulary Committees using a structured approach to the drug selection process to ensure continuing patient access to rational drug therapies.

The MedImpact P&T and Formulary Committees use the following criteria in the evaluation of drug selection for the Formulary: • Drug safety profile • Drug efficacy • Comparison of relevant therapeutic benefits to current formulary drugs of similar use, and to minimize therapeutic duplication where possible • Lower costs relative to comparable therapies

What medications are covered? Your prescription drug benefit will generally cover prescribed generic and brand-name drugs listed on the Formulary as long as the drug is medically necessary, the prescription is filled by a MedImpact network pharmacy provider, and other coverage rules are followed. Over-the-counter (OTC) medications are not generally covered, however, certain preventive OTC medications are covered when prescribed by a physician, such as over the counter FDA-approved female contraceptives, and some durable medical equipment, prescribed by a physician to treat diabetes, and inhalation spacers to assist with inhalation devices are also covered.

KPIC PPO GF The Formulary lists the pharmacy benefits covered under your outpatient prescription drug benefit and obtained from a MedImpact network participating retail pharmacy. This Formulary does not apply to drugs and devices that are obtained through the medical benefit portion of your coverage: for example, medications provided or administered in the doctor’s office or in the hospital or, unless specifically stated otherwise, devices covered under the Durable Medical Equipment benefit that are obtained at the doctor’s office or through a Durable Medical Equipment vendor.

Diabetes medication and equipment. Your outpatient prescription drug coverage includes the following prescription items for the management and treatment of diabetes: • Insulin • Needles and syringes for injecting insulin • Prescriptive medications for the treatment of diabetes • Glucagon

Other pharmacy items. Some Durable Medical Equipment that is covered through your medical benefit is also available at the pharmacy: disposable blood glucose and ketone urine test strips; blood glucose monitors; lancets and lancet puncture devices; pen delivery systems for the administration of insulin; visual aids excluding eyewear to assist in insulin dosing; and peak flow meters.

Contraceptives. Your outpatient prescription drug coverage includes all prescribed FDA-approved contraceptive drugs, including over the counter FDA-approved female contraceptive methods when prescribed by a licensed health care professional authorized to prescribe drugs. All such medications require a prescription from your doctor.

Elective coverage of preventive drugs at no cost. Additionally, if your plan covers preventive drugs at no cost (because your group elected to include preventive-care benefits required under the Affordable Care Act in their grandfathered plan), then the drugs identified in the table below are covered at no cost share regardless of the drug tier indicated on the Formulary. All medications in the list are covered with no cost if the insured has a prescription from his or her doctor. However, some medications are only covered at no cost for patients who meet the criteria listed in the Formulary.

Note: The presence of a prescription drug on the Formulary does not guarantee that you will be prescribed that prescription drug by your prescribing provider for a particular medical condition.

Note: The total amount of the copayment or coinsurance charged for covered prescribed orally administered anti-cancer drugs shall not exceed $200 for a 30-day supply.

What drugs are not covered? • Over-the-counter (OTC) medications or their equivalents, except for those OTC medications included in this Formulary. • Any drug products used for cosmetic purposes. • Experimental drug products or any drug product used in an experimental manner. Refer to your Certificate of Insurance for additional information. • Replacement of lost or stolen medication. • Medications administered by a clinician unless otherwise specified in the Formulary listing. • Foreign-sourced drugs or drugs not approved by the U.S. Food & Drug Administration, except in certain cases of drug shortage, when allowed under the individual's pharmacy benefit. • Weight loss drugs • Sexual dysfunction drugs

Non-formulary drugs Non-formulary drugs are covered when medically necessary.

KPIC PPO GF How do I request an exception to the KPIC Formulary? You, your designee, or your prescribing provider can request an exception to obtain coverage of a drug that is not on the Formulary by calling MedImpact at 1-800- 788-2949. Upon receipt of your exception request, MedImpact will notify you within 72 hours for non-urgent requests and within 24 hours if exigent circumstances exist of the request approval or other outcome. (Urgent circumstances exist when an insured is suffering from a health condition that may seriously jeopardize the insured’s life, health or ability to regain maximum function or when you are using a drug while undergoing a current course of treatment.) If a standard exception request is granted, coverage of the non-formulary drug will be granted for the duration of the prescription, including refills. If an exception based on urgent circumstances is granted, coverage of the non-formulary drug will be granted for the duration of the urgency. You may appeal the denial of an exception request. Please refer to your Certificate of Insurance for more information on appeal rights and procedures.

Are there any restrictions on the drugs covered on the KPIC Formulary? Yes, for certain drugs within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols (refer to table below).

Guideline Symbol Table: Symbol Guidelines Description AGE Age Edit Coverage depends on patient age. Requires a prior authorization based on specific clinical criteria. PA Prior Authorization See “What is a Prior Authorization?” below for additional information. Coverage is limited to specific quantities per prescription QL Quantity Limit and/or time period. Prior authorization is required for quantities exceeding the restriction. Coverage depends on previous use of another drug. ST Step Therapy Prior authorization may be required. See “What is Step Therapy?” below for additional information.

What is a Prior Authorization? A prior authorization (“PA”) is a technique that is used to encourage safe and competitively priced medication use. Many drugs have multiple indications so PAs are placed on drugs to make sure the drug is appropriate and safe for the insured.

How does the program work? Drugs marked with a PA mean that your prescriber must first show that you have a medically necessary need for that particular drug. This means that to receive coverage your prescriber will need to work with MedImpact to receive pre-approval of the drug. Prior authorized drugs have specific clinical criteria that you must meet in order to obtain coverage. Prior authorized drugs have specific clinical criteria that you must meet in order to obtain coverage. Refer to Prior Authorization / Limits column in the Formulary for drugs that require a PA.

Upon receipt of your PA request, MedImpact will notify the licensed prescribing provider within 72 hours for non- urgent requests and within 24 hours if urgent circumstances exist of the request approval or other outcome. If MedImpact fails to respond within 72 hours for non-urgent requests, and within 24 hours if urgent circumstances exist, from receipt of a request form from a licensed doctor; the request shall be deemed to have been approved. If you are not satisfied with the outcome, you can request a waiver by calling MedImpact at 1-800-788-2949.

What are Quantity Limits? Coverage for certain drugs may be limited to specific quantities per prescription and/or time period. Prior authorization is required for quantities exceeding the quantity limit guideline.

What is Step Therapy? Selected prescription drugs require step therapy. The step therapy program encourages safe and competitively priced medication use. Under this program, a “step” approach is required to receive coverage for certain high-cost medications. This means that to receive coverage you may need to first try a proven, lower cost medication before using a more costly treatment.

KPIC PPO GF How does the program work? The step therapy program requires that you have a prescription history for a “first- line” medication before your benefit plan will cover a “second-line” medication. A first-line medication is recognized as safe and effective in treating a specific medical condition, as well as keeping costs down. A second-line medication is a less-preferred or sometimes more costly treatment option. Refer to Step Therapy Edits in the Index section at the end of the Formulary for a complete list of medications requiring step therapy and their criteria.

Prior authorization may be required. Upon receipt of your request for a second-line drug, MedImpact will notify the licensed prescribing provider within 72 hours for non-urgent requests and within 24 hours if urgent circumstances exist of the request approval or other outcome. If you are not satisfied with the outcome, you can request a waiver by calling MedImpact at 1-800- 788-2949.

Note: If you have transitioned from a prior health insurance coverage to a new KPIC health insurance policy, any prescription drug that is currently being prescribed and considered safe and effective to treat a medical condition may not be subject to step therapy if, under your prior coverage: 1) The drug was not previously subject to step therapy; or 2) Step therapy was already obtained.

This does not apply if MedImpact’s P&T Committee and/or your provider determines that such drug is no longer safe or effective to treat your medical condition. Prior authorization may be required for the continued coverage of a prescription drug prescribed pursuant to step therapy imposed under your prior coverage, and the prescribing provider is not precluded from prescribing another drug covered by the new policy that is medically appropriate for your condition.

The Pharmacy Network This drug Formulary only applies to prescribed drugs, medicines and supplies purchased from a MedImpact network retail pharmacy. To fill your covered prescriptions, please visit a MedImpact network pharmacy. When visiting a MedImpact network pharmacy, please give the pharmacist your KPIC ID card with the MedImpact logo. The network of MedImpact pharmacies includes over 60,000 chain and independent pharmacies nationwide. To find a MedImpact network pharmacy near you, call 1-800-788-2949.

What drugs are eligible to be mailed from the mail-order pharmacy? Most maintenance drugs can be mailed from our mail-order pharmacy. Drugs eligible for mail order, however, cannot be mailed outside the United States. You can order refills through our mail-order service online at walgreens.com/mailservice or by phone, 1-866-525-1590 or 1-877-924-7889 (TTY). There is no extra charge for mail order. The appropriate out-of-pocket cost according to your prescription drug benefit will apply.

Please refer to your Certificate of Insurance for complete details of your prescription drug benefit or call KPIC Customer Service at 1-800-788-0710.

Benefit Coverage and Limitations This printed Formulary does not provide information regarding the specific coverage and limitations you may be subject to. Specific benefit inclusions, exclusions, and out-of-pocket costs are not reflected in the Formulary.

The Formulary applies only to outpatient drugs provided to you, and does not apply to medications used in an inpatient setting. For specific questions regarding your coverage, please call KPIC Customer Service at 1-800-788-0710.

Definition of Terms The following s terms apply to your prescription drug coverage and the drug Formulary.

“Brand name drug” means a drug that is marketed under a proprietary, trademark-protected name. A brand name drug is listed in this Formulary in all CAPITAL letters.

“Coinsurance” means a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit.

KPIC PPO GF “Copayment” means a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit.

“Deductible” means the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If your health insurance policy has a deductible, it may have either 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. Your insurance company pays the rest.

“Drug Tier” means a group of prescription drugs that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug.

“Exception request” means a request for coverage of a non-formulary drug. If you, your designee, or your prescribing health care provider submits a request for coverage of a non-formulary drug, your insurer must cover the non-formulary drug when it is medically necessary for you to take the drug.

“Exigent circumstances” means when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non- formulary drug.

“Formulary” or “prescription drug list” means the list of drugs that is covered by your health insurance policy under the prescription drug benefit of the policy.

“Generic drug” means 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 this Formulary in italicized lowercase letters.

“Medically Necessary” means health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health care benefits that are not medically necessary. The fact that a Physician may prescribe, authorize, or direct a service does not of itself make it Medically Necessary or covered by the Group Policy.

“Non-formulary drug” means a prescription drug that is not listed on this Formulary.

“Out-of-pocket costs” means your expenses for health care benefits that aren’t reimbursed by your health insurance. Out-of- pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are not covered.

“Over-the-counter (OTC) drugs” are medicines sold directly to a consumer without requiring a prescription from a healthcare professional. For purposes of this Formulary, OTC drugs that are covered under your outpatient prescription drug benefit require a prescription from your doctor.

“Prescribing provider” means a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition.

“Prescription” means an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual.

“Prescription drug” means a drug that by law requires a prescription.

“Prior Authorization” means a decision by your health insurer that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in this Formulary, your prescribing provider must request approval from your health insurer to cover the drug before you fill your prescription. Your health insurer must grant a prior authorization request when it is medically necessary for you to take the drug.

KPIC PPO GF “Self-injectable drug” means a self-administered injectable medication that is covered under the outpatient prescription drug benefit. Self-injectable drugs (except for insulin and other prescriptive self-administered injectable medications for treatment of diabetes) are covered under a specific drug tier, as indicated in the Tier Definition table under the Drug Tier section in this Formulary.

“Step therapy” means a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in this Formulary, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical condition. If your prescribing provider submits a request for an exception to the step therapy requirement, your health insurer must grant the request when it is medically necessary for you to take the drug.

Kaiser Permanente Insurance Company (KPIC) underwrites the PPO and OOA Plans. KPIC is a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP). Nondiscrimination Notice Kaiser Permanente Insurance Company (KPIC) does not discriminate based on race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability. Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). We can provide no cost aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters and written information in other formats; large print, audio, and accessible electronic formats. We also provide no cost language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. To request these services, please call 1-800-464-4000 (TTY users call 711). If you believe that KPIC failed to provide these services or there is a concern of discrimination based on race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability you can file a complaint by phone or mail with the KPIC Civil Rights Coordinator. If you need help filing a grievance, the KPIC Civil Rights Coordinator is able to help you. KPIC Civil Rights Coordinator Grievance 1557 5855 Copley Drive, Suite 250 San Diego, CA 92111 1-888-251-7052

You may also contact the California Department of Insurance regarding your complaint.

By Phone: California Department of Insurance 1-800-927-HELP (1-800-927-4357) TDD: 1-800-482-4TDD (1-800-482-4833)

By Mail: California Department of Insurance Consumer Communications Bureau 300 S. Spring Street Los Angeles, CA 90013

Electronically: www.insurance.ca.gov

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex. You can file the complaint electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

KPIC-ND18-010-CA (3/2018)

Coverage Prescription Drug Name Drug Tier Requirements and Limits Alternative Therapy - Vitamins And Minerals Alternative Therapy - Unclassified - Vitamins And Minerals balsam peru (bulk) liquid Tier 3 ESTROVEN CMPLT MENOPAUSE RLF ORAL TABLET 4 Tier 3 MG (rhubarb) NUMOISYN MUCOUS MEMBRANE LIQUID (flaxseed) Tier 3 Analgesic, Anti-Inflammatory Or Antipyretic - Drugs For Pain And Fever Analgesic Opioid Agonists - Arthritis And Pain Drugs ABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, Tier 3 PA 300 MCG, 400 MCG, 600 MCG, 800 MCG (fentanyl) ST: Requires 7 consecutive days therapy of current ARYMO ER ORAL TABLET,ORAL ONLY,EXTND Tier 3 short-acting opioid RELEASE 15 MG, 30 MG, 60 MG (morphine) prescription; QL (3 EA per 1 day) QL (12 EA per 1 day); Age codeine sulfate oral tablet 15 mg, 30 mg Tier 1 (Min 12 Years) QL (6 EA per 1 day); Age codeine sulfate oral tablet 60 mg Tier 1 (Min 12 Years) DEMEROL (PF) INJECTION SYRINGE 100 MG/ML, 25 Tier 4 MG/ML, 50 MG/ML, 75 MG/ML (meperidine) DILAUDID (PF) INJECTION SYRINGE 0.5 MG/0.5 ML, 1 Tier 4 MG/ML, 2 MG/ML, 4 MG/ML (hydromorphone) DSUVIA SUBLINGUAL TABLET IN APPLICATOR 30 MCG Tier 3 (sufentanil) fentanyl citrate (pf) intravenous patient control.analgesia Tier 4 soln 1,500 mcg/30 ml (50 mcg/ml)

Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

10 Coverage Prescription Drug Name Drug Tier Requirements and Limits fentanyl citrate (pf)-0.9%nacl intravenous pt controlled Tier 4 analgesia syring 500 mcg/50 ml (10 mcg/ml) fentanyl citrate buccal lozenge on a handle 1,200 mcg, Tier 1 PA 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate buccal tablet, effervescent 100 mcg, 200 Tier 1 PA mcg, 400 mcg, 600 mcg, 800 mcg PA; ST: Requires 7 consecutive days therapy fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, Tier 1 of current short-acting 25 mcg/hr, 50 mcg/hr, 75 mcg/hr opioid prescription; QL (1 EA per 3 days) PA; ST: Requires 7 consecutive days therapy fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 Tier 1 of current short-acting mcg/hour, 87.5 mcg/hour opioid prescription; QL (1 EA per 3 days) FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, Tier 3 PA 200 MCG, 400 MCG, 600 MCG, 800 MCG (fentanyl) hydromorphone (pf)-0.9 % nacl intravenous pt controlled Tier 4 analgesia syring 30 mg/30 ml (1 mg/ml) hydromorphone in 0.9 % nacl injection pt controlled Tier 4 analgesia syring 55 mg/55 ml (1 mg/ml) hydromorphone oral liquid 1 mg/ml Tier 1 hydromorphone oral tablet 2 mg, 4 mg, 8 mg Tier 1 PA; ST: Requires 7 consecutive days therapy hydromorphone oral tablet extended release 24 hr 12 mg, Tier 1 of current short-acting 16 mg, 8 mg opioid prescription; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

11 Coverage Prescription Drug Name Drug Tier Requirements and Limits PA; ST: Requires 7 consecutive days therapy hydromorphone oral tablet extended release 24 hr 32 mg Tier 1 of current short-acting opioid prescription; QL (2 EA per 1 day) hydromorphone rectal suppository 3 mg Tier 1 ST: Requires 7 consecutive HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 days therapy of current HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 Tier 2 short-acting opioid MG (hydrocodone) prescription; QL (1 EA per 1 day) ST: Requires 7 consecutive days therapy of current KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS Tier 3 short-acting opioid 200 MG (morphine) prescription; QL (1 EA per 1 day) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY Tier 3 PA (fentanyl) ST: Requires 7 consecutive days therapy of current levorphanol tartrate oral tablet 2 mg Tier 1 short-acting opioid prescription ST: Requires 7 consecutive days therapy of current levorphanol tartrate oral tablet 3 mg Tier 1 short-acting opioid prescription meperidine (pf) injection solution 100 mg/ml, 50 mg/ml Tier 4 meperidine (pf) injection solution 25 mg/ml Tier 4 meperidine injection cartridge 10 mg/ml Tier 4 meperidine oral solution 50 mg/5 ml Tier 1 QL (30 ML per 1 day) meperidine oral tablet 100 mg, 50 mg Tier 1 QL (6 EA per 1 day) methadone injection solution 10 mg/ml Tier 4 QL (4 ML per 1 day) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

12 Coverage Prescription Drug Name Drug Tier Requirements and Limits methadone (Methadone Intensol Oral Concentrate 10 Tier 1 QL (4 ML per 1 day) Mg/Ml) methadone oral concentrate 10 mg/ml Tier 1 QL (4 ML per 1 day) methadone oral solution 10 mg/5 ml Tier 1 QL (20 ML per 1 day) methadone oral solution 5 mg/5 ml Tier 1 QL (40 ML per 1 day) methadone oral tablet 10 mg Tier 1 QL (4 EA per 1 day) methadone oral tablet 5 mg Tier 1 QL (8 EA per 1 day) methadone oral tablet,soluble 40 mg Tier 1 QL (1 EA per 1 day) methadone (Methadose Oral Tablet,Soluble 40 Mg) Tier 1 QL (1 EA per 1 day) ST: Requires 7 consecutive MORPHABOND ER ORAL TABLET,ORAL days therapy of current ONLY,EXT.REL.12 HR 100 MG, 15 MG, 30 MG, 60 MG Tier 3 short-acting opioid (morphine) prescription; QL (2 EA per 1 day) morphine (pf) intravenous syringe 1 mg/2 ml Tier 4 morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) Tier 1 morphine in 0.9 % sodium chlor intravenous pt controlled Tier 4 analgesia syring 275 mg/55 ml (5 mg/ml) morphine in 0.9 % sodium chlor intravenous solution 1 Tier 4 mg/ml morphine in 0.9 % sodium chlor intravenous solution 5 Tier 4 mg/ml morphine in 0.9 % sodium chlor intravenous syringe 0.5 Tier 4 mg/ml morphine intramuscular pen injector 10 mg/0.7 ml Tier 4 morphine intravenous pt controlled analgesia syring 30 Tier 4 mg/30 ml (1 mg/ml)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

13 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current morphine oral capsule, er multiphase 24 hr 120 mg Tier 1 short-acting opioid prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive days therapy of current morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, Tier 1 short-acting opioid 60 mg, 75 mg, 90 mg prescription; QL (1 EA per 1 day) ST: Requires 7 consecutive days therapy of current morphine oral capsule,extend.release pellets 10 mg, 100 Tier 1 short-acting opioid mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg prescription; QL (2 EA per 1 day) morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) Tier 1 morphine oral tablet 15 mg, 30 mg Tier 2 ST: Requires 7 consecutive days therapy of current morphine oral tablet extended release 100 mg, 15 mg, 200 Tier 1 short-acting opioid mg, 30 mg, 60 mg prescription; QL (3 EA per 1 day) morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg Tier 1 ST: Requires 7 consecutive NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 days therapy of current HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG Tier 2 short-acting opioid (tapentadol) prescription; QL (2 EA per 1 day) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG Tier 2 QL (6 EA per 1 day) (tapentadol) OXAYDO ORAL TABLET, ORAL ONLY 5 MG, 7.5 MG Tier 3 (oxycodone) oxycodone oral capsule 5 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

14 Coverage Prescription Drug Name Drug Tier Requirements and Limits oxycodone oral concentrate 20 mg/ml Tier 1 oxycodone oral solution 5 mg/5 ml Tier 1 oxycodone oral syringe 10 mg/0.5 ml Tier 1 oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg Tier 1 ST: Requires 7 consecutive days therapy of current oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, Tier 1 short-acting opioid 20 mg, 30 mg, 40 mg, 60 mg prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive days therapy of current oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg Tier 1 short-acting opioid prescription; QL (4 EA per 1 day) ST: Requires 7 consecutive days therapy of current OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR Tier 2 short-acting opioid 15 MG, 30 MG, 60 MG (oxycodone) prescription; QL (2 EA per 1 day) oxymorphone oral tablet 10 mg, 5 mg Tier 1 ST: Requires 7 consecutive days therapy of current oxymorphone oral tablet extended release 12 hr 10 mg, 15 Tier 1 short-acting opioid mg, 20 mg, 5 mg, 7.5 mg prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive days therapy of current oxymorphone oral tablet extended release 12 hr 30 mg, 40 Tier 1 short-acting opioid mg prescription; QL (4 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

15 Coverage Prescription Drug Name Drug Tier Requirements and Limits SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL 1,200 MCG (600 MCG/SPRAY X 2), 1,600 MCG (800 MCG/SPRAY X 2), 100 MCG/SPRAY, 200 MCG/SPRAY, Tier 3 PA 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY (fentanyl) ST: Requires 7 consecutive days therapy of current tramadol oral capsule,er biphase 24 hr 17-83 300 mg Tier 1 short-acting opioid prescription; QL (1 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral capsule,er biphase 24 hr 25-75 100 mg, 200 Tier 1 short-acting opioid mg prescription; QL (1 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral capsule,er biphase 24 hr 25-75 150 mg Tier 1 short-acting opioid prescription; QL (1 EA per 1 day); Age (Min 12 Years) QL (8 EA per 1 day); Age tramadol oral tablet 50 mg Tier 1 (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral tablet extended release 24 hr 100 mg Tier 1 short-acting opioid prescription; QL (3 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral tablet extended release 24 hr 200 mg, 300 mg Tier 1 short-acting opioid prescription; QL (1 EA per 1 day); Age (Min 12 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

16 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current tramadol oral tablet, er multiphase 24 hr 100 mg Tier 1 short-acting opioid prescription; QL (3 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current tramadol oral tablet, er multiphase 24 hr 200 mg, 300 mg Tier 1 short-acting opioid prescription; QL (1 EA per 1 day); Age (Min 12 Years) ST: Requires 7 consecutive days therapy of current XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT Tier 3 short-acting opioid CRUSH) 13.5 MG, 18 MG, 9 MG (oxycodone) prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive days therapy of current XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT Tier 3 short-acting opioid CRUSH) 27 MG (oxycodone) prescription; QL (4 EA per 1 day) ST: Requires 7 consecutive days therapy of current XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT Tier 3 short-acting opioid CRUSH) 36 MG (oxycodone) prescription; QL (8 EA per 1 day) ST: Requires 7 consecutive ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR days therapy of current 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG Tier 3 short-acting opioid (hydrocodone) prescription; QL (2 EA per 1 day) Analgesic Opioid Codeine Combinations - Arthritis And Pain Drugs acetaminophen-codeine oral solution 120 mg-12 mg /5 ml QL (150 ML per 1 day); Tier 1 (5 ml), 120-12 mg/5 ml Age (Min 12 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

17 Coverage Prescription Drug Name Drug Tier Requirements and Limits acetaminophen-codeine oral solution 300 mg-30 mg /12.5 Tier 1 Age (Min 12 Years) ml QL (12 EA per 1 day); Age acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg Tier 1 (Min 12 Years) QL (6 EA per 1 day); Age acetaminophen-codeine oral tablet 300-60 mg Tier 1 (Min 12 Years) codeine (Ascomp With Codeine Oral Capsule 30-50-325-40 QL (6 EA per 1 day); Age Tier 1 Mg) (Min 12 Years) codeine (Butalbital Compound W/Codeine Oral Capsule 30- QL (6 EA per 1 day); Age Tier 1 50-325-40 Mg) (Min 12 Years) butalbital-acetaminop-caf-cod oral capsule 50-300-40-30 QL (6 EA per 1 day); Age Tier 1 mg, 50-325-40-30 mg (Min 12 Years) QL (6 EA per 1 day); Age codeine-butalbital-asa-caff oral capsule 30-50-325-40 mg Tier 1 (Min 12 Years) Analgesic Opioid Dihydrocodeine Combinations - Arthritis And Pain Drugs ST: Must meet the following requirement: acetaminophen-caff-dihydrocod oral capsule 320.5-30-16 Acetaminophen With Tier 1 mg Codeine in 120 days; QL (10 EA per 1 day); Age (Min 12 Years) ST: Must meet the following requirement: Acetaminophen With acetaminophen (Dvorah Oral Tablet 325-30-16 Mg) Tier 1 Codeine in 120 days; QL (10 EA per 1 day); Age (Min 12 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

18 Coverage Prescription Drug Name Drug Tier Requirements and Limits Analgesic Opioid Dihydrocodeine, Non- Salicylate Analgesic,Xanthine - Arthritis And Pain Drugs ST: Must meet the following requirement: acetaminophen-caff-dihydrocod oral capsule 320.5-30-16 Acetaminophen With Tier 1 mg Codeine in 120 days; QL (10 EA per 1 day); Age (Min 12 Years) Analgesic Opioid Hydrocodone And Non- Salicylate Combinations - Arthritis And Pain Drugs ST: Must meet the following requirement: APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16- generic Norco Tier 3 325 MG (benzhydrocodone) (Hydrocodone/acetaminop hen) tablet in 120 days; QL (12 EA per 1 day) ST: Must meet the following requirement: benzhydrocodone-acetaminophen oral tablet 4.08-325 mg, generic Norco Tier 1 6.12-325 mg, 8.16-325 mg (Hydrocodone/acetaminop hen) tablet in 120 days; QL (12 EA per 1 day) hydrocodone-acetaminophen oral tablet 2.5-325 mg Tier 1 QL (12 EA per 1 day) LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML Tier 3 QL (200 ML per 1 day) (hydrocodone) hydrocodone (Vicodin Es Oral Tablet 7.5-300 Mg) Tier 1 QL (13 EA per 1 day) hydrocodone (Vicodin Hp Oral Tablet 10-300 Mg) Tier 1 QL (13 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

19 Coverage Prescription Drug Name Drug Tier Requirements and Limits Analgesic Opioid Hydrocodone Combinations - Arthritis And Pain Drugs hydrocodone-acetaminophen oral solution 10-325 mg/15 Tier 1 QL (184 ML per 1 day) ml(15 ml) hydrocodone-acetaminophen oral solution 7.5-325 mg/15 Tier 1 QL (184 ML per 1 day) ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 Tier 1 QL (13 EA per 1 day) mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 Tier 1 QL (12 EA per 1 day) mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, Tier 1 7.5-200 mg hydrocodone (Lorcet (Hydrocodone) Oral Tablet 5-325 Mg) Tier 1 QL (12 EA per 1 day) hydrocodone (Lorcet Hd Oral Tablet 10-325 Mg) Tier 1 QL (12 EA per 1 day) hydrocodone (Lorcet Plus Oral Tablet 7.5-325 Mg) Tier 1 QL (12 EA per 1 day) LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML Tier 3 QL (200 ML per 1 day) (hydrocodone) hydrocodone (Vicodin Es Oral Tablet 7.5-300 Mg) Tier 1 QL (13 EA per 1 day) hydrocodone (Vicodin Hp Oral Tablet 10-300 Mg) Tier 1 QL (13 EA per 1 day) Analgesic Opioid Oxycodone And Non- Salicylate Combinations - Arthritis And Pain Drugs oxycodone (Endocet Oral Tablet 10-325 Mg, 2.5-325 Mg, Tier 1 QL (12 EA per 1 day) 7.5-325 Mg) PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 Tier 3 QL (13 EA per 1 day) MG (oxycodone) Analgesic Opioid Oxycodone And Nsaid Combinations - Arthritis And Pain Drugs ibuprofen-oxycodone oral tablet 400-5 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

20 Coverage Prescription Drug Name Drug Tier Requirements and Limits Analgesic Opioid Oxycodone And Salicylate Combinations - Arthritis And Pain Drugs oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 Analgesic Opioid Oxycodone Combinations - Arthritis And Pain Drugs oxycodone (Endocet Oral Tablet 10-325 Mg, 2.5-325 Mg, 5- Tier 1 QL (12 EA per 1 day) 325 Mg, 7.5-325 Mg) ibuprofen-oxycodone oral tablet 400-5 mg Tier 1 NALOCET ORAL TABLET 2.5-300 MG (oxycodone) Tier 1 QL (12 EA per 1 day) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 Tier 1 QL (12 EA per 1 day) mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1 PRIMLEV ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300 Tier 3 QL (13 EA per 1 day) MG (oxycodone) Analgesic Opioid Partial-Mixed Agonists - Arthritis And Pain Drugs ST: Requires 7 consecutive days therapy of current BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, Tier 3 short-acting opioid 600 MCG, 75 MCG, 750 MCG, 900 MCG (buprenorphine) prescription; QL (2 EA per 1 day) ST: Requires 7 consecutive BUPRENEX INJECTION SOLUTION 0.3 MG/ML days therapy of current Tier 4 (buprenorphine) short-acting opioid prescription ST: Requires 7 consecutive days therapy of current buprenorphine hcl injection solution 0.3 mg/ml Tier 4 short-acting opioid prescription

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

21 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Requires 7 consecutive days therapy of current buprenorphine hcl injection syringe 0.3 mg/ml Tier 4 short-acting opioid prescription ST: Requires 7 consecutive days therapy of current buprenorphine transdermal patch weekly 10 mcg/hour, 15 Tier 1 short-acting opioid mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour prescription; QL (4 EA per 28 days) butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml Tier 4 butorphanol tartrate nasal spray,non-aerosol 10 mg/ml Tier 1 nalbuphine injection solution 10 mg/ml, 20 mg/ml Tier 4 pentazocine-naloxone oral tablet 50-0.5 mg Tier 1 Analgesic Opioid Tramadol Combinations - Arthritis And Pain Drugs QL (10 EA per 1 day); Age tramadol-acetaminophen oral tablet 37.5-325 mg Tier 1 (Min 12 Years) Analgesic Or Antipyretic Non-Opioid/Sedative Combinations - Arthritis And Pain Drugs ST: Must meet the following requirement: generic butalbital (Allzital Oral Tablet 25-325 Mg) Tier 3 Butalbital/acetaminophen 50mg-325mg combination product in 120 days; QL (12 EA per 1 day) butalbital-acetaminophen oral capsule 50-300 mg Tier 1 QL (6 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

22 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: generic butalbital-acetaminophen oral tablet 50-300 mg Tier 1 Butalbital/acetaminophen 50mg-325mg combination product in 120 days; QL (6 EA per 1 day) butalbital-acetaminophen oral tablet 50-325 mg Tier 1 butalbital-acetaminophen-caff oral capsule 50-300-40 mg, Tier 1 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg Tier 1 butalbital (Fioricet Oral Capsule 50-300-40 Mg) Tier 1 butalbital (Tencon Oral Tablet 50-325 Mg) Tier 1 VANATOL LQ ORAL SOLUTION 50-325-40 MG/15 ML Tier 3 (butalbital) VANATOL S ORAL SOLUTION 50-325-40 MG/15 ML Tier 3 (butalbital) butalbital (Zebutal Oral Capsule 50-325-40 Mg) Tier 1 Anti-Inflammatory - Interleukin-1 Receptor Antagonist - Arthritis And Pain Drugs ARCALYST SUBCUTANEOUS RECON SOLN 220 MG Tier 4 (rilonacept) Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agnts,Tnf-Alpha Sel - Arthritis And Pain Drugs CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 4 PA 400 MG (200 MG X 2 VIALS) (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 4 PA 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 4 PA (200 MG/ML X 2) (certolizumab pegol)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

23 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS Tier 4 PA PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 4 PA (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 Tier 4 PA MG/0.8 ML (adalimumab) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, Tier 4 PA 20 MG/0.4 ML, 40 MG/0.8 ML (adalimumab) HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 Tier 4 PA MG/0.8 ML-40 MG/0.4 ML (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS Tier 4 PA PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 4 PA (adalimumab) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT Tier 4 PA 40 MG/0.4 ML, 80 MG/0.8 ML (adalimumab) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 Tier 4 PA ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab) SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML Tier 4 (golimumab) SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, Tier 4 PA 50 MG/0.5 ML (golimumab) SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 Tier 4 PA MG/0.5 ML (golimumab) Dmard - Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agents - Arthritis And Pain Drugs CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 4 PA 400 MG (200 MG X 2 VIALS) (certolizumab pegol)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

24 Coverage Prescription Drug Name Drug Tier Requirements and Limits CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 4 PA 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 4 PA (200 MG/ML X 2) (certolizumab pegol) ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML Tier 4 PA (1 ML) (etanercept) ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) Tier 4 PA (etanercept) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5), Tier 4 PA 50 MG/ML (1 ML) (etanercept) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR Tier 4 PA 50 MG/ML (1 ML) (etanercept) HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS Tier 4 PA PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 4 PA (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 Tier 4 PA MG/0.8 ML (adalimumab) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, Tier 4 PA 20 MG/0.4 ML, 40 MG/0.8 ML (adalimumab) HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML Tier 4 PA (adalimumab) HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS Tier 4 PA PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 4 PA (adalimumab) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT Tier 4 PA 40 MG/0.4 ML, 80 MG/0.8 ML (adalimumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

25 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 Tier 4 PA ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab) SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML Tier 4 (golimumab) SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, Tier 4 PA 50 MG/0.5 ML (golimumab) SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 Tier 4 PA MG/0.5 ML (golimumab) Dmard - Antimetabolites - Arthritis And Pain Drugs methotrexate sodium oral tablet 2.5 mg Tier 1 OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 Tier 4 QL (1.6 ML per 28 days) ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML (methotrexate) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 following requirement: Tier 4 MG/0.2 ML (methotrexate) Otrexup in 120 days; QL (0.8 ML per 28 days) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 12.5 following requirement: Tier 4 MG/0.25 ML (methotrexate) Otrexup in 120 days; QL (1 ML per 28 days) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 15 following requirement: Tier 4 MG/0.3 ML (methotrexate) Otrexup in 120 days; QL (1.2 ML per 28 days) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 17.5 following requirement: Tier 4 MG/0.35 ML (methotrexate) Otrexup in 120 days; QL (1.4 ML per 28 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

26 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 20 following requirement: Tier 4 MG/0.4 ML (methotrexate) Otrexup in 120 days; QL (1.6 ML per 28 days) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 22.5 following requirement: Tier 4 MG/0.45 ML (methotrexate) Otrexup in 120 days; QL (1.8 ML per 28 days) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 25 following requirement: Tier 4 MG/0.5 ML (methotrexate) Otrexup in 120 days; QL (2 ML per 28 days) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 30 following requirement: Tier 4 MG/0.6 ML (methotrexate) Otrexup in 120 days; QL (2.4 ML per 28 days) ST: Must meet the RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 7.5 following requirement: Tier 4 MG/0.15 ML (methotrexate) Otrexup in 120 days; QL (0.6 ML per 28 days) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG Tier 2 (methotrexate) SP; ST: Must meet any of the following requirements: Methotrexate Sodium, Methotrexate Sodium/pf, XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) Tier 3 Rheumatrex, or Trexall in 120 days if 12 years of age and older; QL (120 ML per 60 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

27 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dmard - Antinflammatory, Select. Costimulation Modulator,T-Cell Inhib. - Arthritis And Pain Drugs ORENCIA CLICKJECT SUBCUTANEOUS AUTO- Tier 4 PA INJECTOR 125 MG/ML (abatacept) ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 Tier 4 PA MG/0.4 ML, 87.5 MG/0.7 ML (abatacept) Dmard - Gold Compounds - Arthritis And Pain Drugs RIDAURA ORAL CAPSULE 3 MG (auranofin) Tier 3 SP Dmard - Immunosuppressives - Arthritis And Pain Drugs AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) Tier 3 cyclosporine oral capsule 100 mg Tier 1 cyclosporine (Gengraf Oral Capsule 100 Mg, 25 Mg) Tier 1 cyclosporine (Gengraf Oral Solution 100 Mg/Ml) Tier 1 SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 3 SP (cyclosporine) Dmard - Interleukin-1 Receptor Antagonist (Il- 1Ra) - Arthritis And Pain Drugs KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML Tier 4 PA (anakinra) Dmard - Interleukin-6 (Il-6) Receptor Inhibitors, Monoclonal Antibody - Arthritis And Pain Drugs ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR Tier 4 PA 162 MG/0.9 ML (tocilizumab) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML Tier 4 PA (tocilizumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

28 Coverage Prescription Drug Name Drug Tier Requirements and Limits KEVZARA SUBCUTANEOUS PEN INJECTOR 150 Tier 4 PA MG/1.14 ML, 200 MG/1.14 ML (sarilumab) KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, Tier 4 PA 200 MG/1.14 ML (sarilumab) Dmard - Janus Kinase (Jak) Inhibitors - Arthritis And Pain Drugs OLUMIANT ORAL TABLET 2 MG (baricitinib) Tier 3 PA; SP RINVOQ ER ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 PA; SP 15 MG (upadacitinib) XELJANZ ORAL TABLET 5 MG (tofacitinib) Tier 3 PA; SP XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 PA; SP HR 11 MG (tofacitinib) Dmard - Other - Arthritis And Pain Drugs CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) Tier 2 PA DEPEN TITRATABS ORAL TABLET 250 MG Tier 2 PA (penicillamine) D-PENAMINE ORAL TABLET 125 MG (penicillamine) Tier 3 PA; SP Dmard - Phosphodiesterase-4 (Pde4) Inhibitors - Arthritis And Pain Drugs OTEZLA ORAL TABLET 30 MG (apremilast) Tier 3 PA; SP OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) Tier 3 PA; SP (apremilast) Dmard - Pyrimidine Synthesis Inhibitors - Arthritis And Pain Drugs leflunomide oral tablet 10 mg, 20 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

29 Coverage Prescription Drug Name Drug Tier Requirements and Limits Immunomodulator B-Lymphocyte Stimulator (Blys)-Specific Inhibitor Mcab - Arthritis And Pain Drugs BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 Tier 4 PA MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML Tier 4 PA (belimumab) Nsaid Analgesic And Histamine H2 Receptor Antagonist Combinations - Arthritis And Pain Drugs ST: Must meet the following requirement: DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen) Tier 3 generic Ibuprofen 400, 600, or 800mg in 120 days; QL (3 EA per 1 day) Nsaid Analgesic And Prostaglandin Analog Combinations - Arthritis And Pain Drugs diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 50- Tier 1 200 mg-mcg, 75-200 mg-mcg Nsaid Analgesic And Proton Pump Inhibitor Combinations - Arthritis And Pain Drugs ST: Must meet any of the following requirements: VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC Tier 3 Naprelan, Naproxen, or 375-20 MG, 500-20 MG (naproxen) Naproxen Sodium in 120 days Nsaid Analgesic And Topical Irritant Counter- Irritant Combinations - Arthritis And Pain Drugs COMFORT PAC-IBUPROFEN KIT 800 MG (ibuprofen) Tier 3 COMFORT PAC-MELOXICAM KIT 15 MG (meloxicam) Tier 3 COMFORT PAC-NAPROXEN KIT 500 MG (naproxen) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

30 Coverage Prescription Drug Name Drug Tier Requirements and Limits FLEXIPAK KIT 75 MG- 0.025 % (diclofenac) Tier 3 INFLAMMACIN KIT 75 MG- 0.025 % (diclofenac) Tier 3 INFLATHERM(DICLOFENAC-MENTHOL) KIT, GEL AND Tier 3 TABLET DELAY REL 75 MG-3 %- 3 % (diclofenac) NUDICLO TABPAK KIT 75 MG- 0.025 % (diclofenac) Tier 3 NUDROXIPAK DSDR-50 KIT, LIQUID AND TABLET DEL Tier 3 REL 50 MG-0.025 %- 25 %-6 % (diclofenac) NUDROXIPAK DSDR-75 KIT, LIQUID AND TABLET DEL Tier 3 REL 75 MG-0.025 %- 25 %-6 % (diclofenac) NUDROXIPAK E-400 KIT, LIQUID AND TABLET 400 MG- Tier 3 0.025 %- 25 %-6 % (etodolac) NUDROXIPAK I-800 KIT, LIQUID AND TABLET 800 MG- Tier 3 0.025 %- 25 %-6 % (ibuprofen) NUDROXIPAK N-500 KIT, LIQUID AND TABLET 500 MG- Tier 3 0.025 %- 25 %-6 % (nabumetone) XENAFLAMM KIT 75 MG- 0.025 % (diclofenac) Tier 3 Nsaid Analgesic, Cyclooxygenase-2 (Cox-2) Selective Inhibitors - Arthritis And Pain Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg Tier 1 NUDROXIPAK KIT, LIQUID AND CAPSULE 200 MG-0.025 Tier 3 %- 25 %-6 % (celecoxib) Nsaid Analgesics (Cox Non-Specific) - Anthranilic Acid Derivatives - Arthritis And Pain Drugs meclofenamate oral capsule 100 mg, 50 mg Tier 1 mefenamic acid oral capsule 250 mg Tier 1 Nsaid Analgesics (Cox Non-Specific) - Other - Arthritis And Pain Drugs ketorolac injection cartridge 15 mg/ml, 30 mg/ml Tier 4 ketorolac injection solution 15 mg/ml, 30 mg/ml (1 ml) Tier 4 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

31 Coverage Prescription Drug Name Drug Tier Requirements and Limits ketorolac injection solution 30 mg/ml Tier 4 ketorolac injection syringe 15 mg/ml, 30 mg/ml Tier 4 ketorolac intramuscular cartridge 60 mg/2 ml Tier 4 ketorolac intramuscular solution 60 mg/2 ml Tier 4 ketorolac intramuscular syringe 60 mg/2 ml Tier 4 ketorolac oral tablet 10 mg Tier 1 QL (20 EA per 5 days) nabumetone oral tablet 500 mg, 750 mg Tier 1 RELAFEN DS ORAL TABLET 1,000 MG (nabumetone) Tier 3 QL (2 EA per 1 day) ST: Must meet the following requirement: SPRIX NASAL SPRAY,NON-AEROSOL 15.75 MG/SPRAY Generic nonsteroidal anti- Tier 3 (ketorolac) inflammatory drug in 120 days; QL (5 EA per 30 days) sulindac oral tablet 150 mg, 200 mg Tier 1 tolmetin oral capsule 400 mg Tier 1 tolmetin oral tablet 200 mg, 600 mg Tier 1 TORONOVA II SUIK KIT 30 MG/ML (ketorolac) Tier 3 TORONOVA SUIK KIT 30 MG/ML (ketorolac) Tier 3 Nsaid Analgesics (Cox Non-Specific) - Oxicam Derivatives - Arthritis And Pain Drugs meloxicam oral tablet 15 mg, 7.5 mg Tier 1 piroxicam oral capsule 10 mg, 20 mg Tier 1 ST: Must meet the following requirement: QMIIZ ODT ORAL TABLET,DISINTEGRATING 15 MG, 7.5 Tier 3 generic Meloxicam tablet in MG (meloxicam) 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

32 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Diclofenac Potassium, VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) Tier 3 Diclofenac Sodium, or Meloxicam in 365 days; QL (1 EA per 1 day) Nsaid Analgesics (Cox Non-Specific) - Phenylacetic Acid Derivatives - Arthritis And Pain Drugs CAMBIA ORAL POWDER IN PACKET 50 MG (diclofenac) Tier 3 QL (3 EA per 10 days) diclofenac potassium oral tablet 50 mg Tier 1 diclofenac sodium oral tablet extended release 24 hr 100 Tier 1 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, Tier 1 50 mg, 75 mg ST: Must meet any of the following requirements: Diclo Gel, Diclofenac Sodium, Diclofenac ZIPSOR ORAL CAPSULE 25 MG (diclofenac) Tier 3 Sodium/misoprostol, Diclofono, Diclozor, Dyloject, Pennsaid, or Vopac Mds in 120 days; QL (4 EA per 1 day) ST: Must meet any of the following requirements: Diclo Gel, Diclofenac Sodium, Diclofono, ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) Tier 3 Diclozor, Dyloject, Pennsaid, or Vopac Mds in 120 days; QL (3 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

33 Coverage Prescription Drug Name Drug Tier Requirements and Limits Nsaid Analgesics (Cox Non-Specific) - Propionic Acid Derivatives - Arthritis And Pain Drugs EC-NAPROXEN ORAL TABLET,DELAYED RELEASE Tier 1 (DR/EC) 375 MG, 500 MG (naproxen) fenoprofen oral capsule 200 mg, 400 mg Tier 1 fenoprofen oral tablet 600 mg Tier 1 flurbiprofen oral tablet 100 mg, 50 mg Tier 1 ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) Tier 1 ibuprofen oral suspension 100 mg/5 ml Tier 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 ketoprofen oral capsule 25 mg, 50 mg, 75 mg Tier 1 ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg Tier 1 NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR Tier 3 750 MG (naproxen) naproxen oral suspension 125 mg/5 ml Tier 1 naproxen oral tablet 250 mg, 375 mg, 500 mg Tier 1 naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 Tier 1 mg naproxen sodium oral tablet 275 mg, 550 mg Tier 1 naproxen sodium oral tablet, er multiphase 24 hr 375 mg, Tier 1 500 mg oxaprozin oral tablet 600 mg Tier 1 Nsaid Analgesics, (Cox Non-Specific) - Indole Acetic Acid Derivatives - Arthritis And Pain Drugs etodolac oral capsule 200 mg, 300 mg Tier 1 etodolac oral tablet 400 mg, 500 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

34 Coverage Prescription Drug Name Drug Tier Requirements and Limits etodolac oral tablet extended release 24 hr 400 mg, 500 Tier 1 mg, 600 mg INDOCIN ORAL SUSPENSION 25 MG/5 ML Tier 2 (indomethacin) INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) Tier 3 PA indomethacin oral capsule 25 mg, 50 mg Tier 1 indomethacin oral capsule, extended release 75 mg Tier 1 ST: Must meet the TIVORBEX ORAL CAPSULE 20 MG, 40 MG following requirement: Tier 3 (indomethacin) Indomethacin in 120 days; QL (3 EA per 1 day) Salicylate Analgesic And Sedative Combinations - Arthritis And Pain Drugs butalbital-aspirin-caffeine oral capsule 50-325-40 mg Tier 1 butalbital-aspirin-caffeine oral tablet 50-325-40 mg Tier 1 Salicylate Analgesic Combinations - Arthritis And Pain Drugs choline,magnesium salicylate oral liquid 500 mg/5 ml Tier 1 Salicylate Analgesics - Arthritis And Pain Drugs ADULT ASPIRIN REGIMEN ORAL TABLET,DELAYED Tier 0 RELEASE (DR/EC) 81 MG (aspirin) ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED Tier 0 RELEASE (DR/EC) 81 MG (aspirin) ASPIR-81 ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 0 81 MG (aspirin) ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG Tier 0 (aspirin) ASPIRIN LOW DOSE ORAL TABLET,DELAYED RELEASE Tier 0 (DR/EC) 81 MG (aspirin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

35 Coverage Prescription Drug Name Drug Tier Requirements and Limits aspirin oral tablet 325 mg Tier 0 aspirin oral tablet,chewable 81 mg Tier 0 aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg Tier 0 ASPIR-LOW ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 0 81 MG (aspirin) ASPIR-TRIN ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 0 325 MG (aspirin) CHILDREN'S ASPIRIN ORAL TABLET,CHEWABLE 81 MG Tier 0 (aspirin) diflunisal oral tablet 500 mg Tier 1 DURLAZA ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 3 PA 162.5 MG (aspirin) E.C. PRIN ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 0 325 MG (aspirin) ECOTRIN ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 0 325 MG (aspirin) LITE COAT ASPIRIN ORAL TABLET 325 MG (aspirin) Tier 0 LO-DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE Tier 0 (DR/EC) 81 MG (aspirin) salsalate oral tablet 500 mg, 750 mg Tier 1 ST JOSEPH ASPIRIN ORAL TABLET,CHEWABLE 81 MG Tier 0 (aspirin) ST. JOSEPH ASPIRIN ORAL TABLET,DELAYED Tier 0 RELEASE (DR/EC) 81 MG (aspirin) Anesthetics - Drugs For Pain And Fever Anesthetic - Non-Parenteral - Drugs For Sedation ketamine sublingual troche 100 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

36 Coverage Prescription Drug Name Drug Tier Requirements and Limits General Anesthetic - Inhalant Volatile - Drugs For Sedation desflurane inhalation liquid 100 % Tier 1 isoflurane inhalation liquid 99.9 % Tier 1 sevoflurane inhalation liquid Tier 1 SUPRANE INHALATION LIQUID 100 % (desflurane) Tier 3 isoflurane (Terrell Inhalation Liquid 99.9 %) Tier 1 General Anesthetic - Parenteral, Benzodiazepines - Drugs For Sedation midazolam (pf) injection solution 5 mg/ml Tier 4 midazolam injection solution 5 mg/ml Tier 4 General Anesthetic Adjuncts - Opioid - Drugs For Sedation fentanyl citrate (pf) intravenous patient control.analgesia Tier 4 soln 1,500 mcg/30 ml (50 mcg/ml) Local Anesthetic - Amides - Drugs For Sedation ACCUCAINE KIT KIT 10 MG/ML (1 %) (lidocaine) Tier 3 lidocaine hcl laryngotracheal solution 4 % Tier 1 ST: Must meet the following requirement: lidocaine topical ointment 5 % Tier 1 Lidocaine 3% cream in 120 days; QL (240 GM per 30 days) MARVONA SUIK (PF) KIT 0.5 % (5 MG/ML) (bupivacaine) Tier 3 P-CARE MG (PF) KIT 0.5 % (5 MG/ML) (bupivacaine) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

37 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anorectal Preparations - Rectal Preparations Anal Fissure Pain/Treatment Agents - Nitrates - Rectal Preparations RECTIV RECTAL OINTMENT 0.4 % (W/W) (nitroglycerin) Tier 3 Anorectal - Glucocorticoids - Rectal Preparations ANUCORT-HC RECTAL SUPPOSITORY 25 MG Tier 1 (hydrocortisone) hydrocortisone acetate rectal suppository 25 mg, 30 mg Tier 1 hydrocortisone topical cream with perineal applicator 1 %, Tier 1 2.5 % MICORT-HC TOPICAL CREAM WITH PERINEAL Tier 3 APPLICATOR 2.5 %, 2.5 % (4 GRAM) (hydrocortisone) hydrocortisone (Procto-Med Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) hydrocortisone (Procto-Pak Topical Cream With Perineal Tier 1 Applicator 1 %) hydrocortisone (Proctosol Hc Topical Cream With Perineal Tier 1 Applicator 2.5 %) hydrocortisone (Proctozone-Hc Topical Cream With Tier 1 Perineal Applicator 2.5 %) Anorectal - Hemorrhoidal Rectal Glucocorticoid-Local Anesthetic Comb - Rectal Preparations ANA-LEX KIT RECTAL KIT 2-2 % (hydrocortisone) Tier 1 hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 %, 2.5- Tier 1 1 % (4g) lidocaine hcl-hydrocortison ac rectal cream 3-0.5 % Tier 1 lidocaine hcl-hydrocortison ac rectal gel 3 %-2.5 % (7 gram) Tier 1 lidocaine hcl-hydrocortison ac rectal kit 2 %-2 % (7 gram) Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

38 Coverage Prescription Drug Name Drug Tier Requirements and Limits lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 3-1 % (7 Tier 1 gram) lidocaine-hydrocortisone-aloe rectal gel 2.8-0.55 % Tier 1 lidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 gram) Tier 1 PROCORT RECTAL CREAM 1.85-1.15 % (hydrocortisone) Tier 3 hydrocortisone (Proctofoam Hc Rectal Foam 1-1 %) Tier 2 ZYPRAM RECTAL KIT,CREAM AND TOWELETTE 2.35-1 Tier 3 % (hydrocortisone) Antidotes And Other Reversal Agents - Drugs For Overdose Or Poisoning Antidote - Cholinesterase Reactivating Agent - Drugs For Overdose Or Poisoning pralidoxime intramuscular pen injector 600 mg/2 ml Tier 4 Antidote - Cholinesterase Reactivating Agent And Muscarinic Antagonist - Drugs For Overdose Or Poisoning DUODOTE INTRAMUSCULAR PEN INJECTOR 600-2.1 Tier 4 MG/2ML-MG/0.7ML (pralidoxime) Antidote - Cyanide Poisoning - Drugs For Overdose Or Poisoning amyl nitrite inhalation solution 0.3 ml Tier 1 Antidote - Radioactive Agents - Drugs For Overdose Or Poisoning RADIOGARDASE ORAL CAPSULE 0.5 GRAM (prussian Tier 3 blue (insoluble)) Antidote Others - Drugs For Overdose Or Poisoning GALZIN ORAL CAPSULE 25 MG (ZINC), 50 MG (ZINC) Tier 3 (zinc acetate)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

39 Coverage Prescription Drug Name Drug Tier Requirements and Limits RADIOGARDASE ORAL CAPSULE 0.5 GRAM (prussian Tier 3 blue (insoluble)) Chelating Agents - Copper - Drugs For Overdose Or Poisoning trientine (Clovique Oral Capsule 250 Mg) Tier 3 PA; SP CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) Tier 2 PA DEPEN TITRATABS ORAL TABLET 250 MG Tier 2 PA (penicillamine) D-PENAMINE ORAL TABLET 125 MG (penicillamine) Tier 3 PA; SP penicillamine oral capsule 250 mg Tier 1 PA trientine oral capsule 250 mg Tier 3 PA; SP Chelating Agents - Iron - Drugs For Overdose Or Poisoning deferasirox oral tablet, dispersible 125 mg, 250 mg, 500 mg Tier 3 PA; SP deferoxamine injection recon soln 2 gram, 500 mg Tier 4 PA FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) Tier 3 PA; SP FERRIPROX ORAL TABLET 1,000 MG, 500 MG Tier 3 PA; SP (deferiprone) JADENU ORAL TABLET 180 MG, 360 MG, 90 MG Tier 3 PA; SP (deferasirox) JADENU SPRINKLE ORAL GRANULES IN PACKET 180 Tier 3 PA; SP MG, 360 MG, 90 MG (deferasirox) Chelating Agents - Lead Poisoning - Drugs For Overdose Or Poisoning CHEMET ORAL CAPSULE 100 MG (succimer) Tier 3 Mu-Opioid Receptor Antagonists, Peripherally- Acting - Drugs For Overdose Or Poisoning ENTEREG ORAL CAPSULE 12 MG (alvimopan) Tier 3 MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol) Tier 2 QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

40 Coverage Prescription Drug Name Drug Tier Requirements and Limits RELISTOR ORAL TABLET 150 MG (methylnaltrexone) Tier 3 PA; QL (3 EA per 1 day) RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML Tier 4 PA; QL (0.6 ML per 1 day) (methylnaltrexone) RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML Tier 4 PA; QL (0.6 ML per 1 day) (methylnaltrexone) RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML Tier 4 PA; QL (0.4 ML per 1 day) (methylnaltrexone) ST: Must meet the following requirement: SYMPROIC ORAL TABLET 0.2 MG (naldemedine) Tier 3 Movantik in 120 days; QL (1 EA per 1 day) Opioid Reversal Agents - Opioid Antagonists - Drugs For Overdose Or Poisoning EVZIO INJECTION AUTO-INJECTOR 2 MG/0.4 ML Tier 4 QL (0.8 ML per 365 days) (naloxone) naloxone injection syringe 0.4 mg/ml, 1 mg/ml Tier 4 naltrexone oral tablet 50 mg Tier 1 NARCAN NASAL SPRAY,NON-AEROSOL 4 Tier 2 QL (4 EA per 30 days) MG/ACTUATION (naloxone) Anti-Infective Agents - Drugs For Infections Amebicides - Drugs For Parasites paromomycin oral capsule 250 mg Tier 1 Aminoglycoside Antibiotic - Antibiotics ARIKAYCE INHALATION SUSPENSION FOR Tier 3 PA; SP NEBULIZATION 590 MG/8.4 ML (amikacin) neomycin oral tablet 500 mg Tier 1 Aminomethylcycline Antibiotics - Antibiotics NUZYRA (7 DAY WITH LOAD DOSE) ORAL TABLET 150 Tier 3 PA MG (omadacycline) NUZYRA (7 DAY) ORAL TABLET 150 MG (omadacycline) Tier 3 PA

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

41 Coverage Prescription Drug Name Drug Tier Requirements and Limits NUZYRA ORAL TABLET 150 MG (omadacycline) Tier 3 PA Aminopenicillin Antibiotic - Antibiotics amoxicillin oral capsule 250 mg, 500 mg Tier 1 amoxicillin oral suspension for reconstitution 125 mg/5 ml, Tier 1 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg Tier 1 amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1 ampicillin oral capsule 250 mg, 500 mg Tier 1 MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR 775 Tier 3 MG (amoxicillin) Aminopenicillin Antibiotic - Beta-Lactamase Inhibitor Combinations - Antibiotics amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600- Tier 1 42.9 mg/5 ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 Tier 1 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended release 12 Tier 1 hr 1,000-62.5 mg amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 Tier 1 mg, 400-57 mg ST: Must meet the following requirement: AUGMENTIN ORAL SUSPENSION FOR Tier 3 Amoxicillin/Potassium RECONSTITUTION 125-31.25 MG/5 ML (amoxicillin) Clavulanate in 120 days; QL (150 ML per 30 days) Anthelmintic Agents - Benzimidazole Derivatives - Drugs For Parasites albendazole oral tablet 200 mg Tier 1 EGATEN ORAL TABLET 250 MG (triclabendazole) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

42 Coverage Prescription Drug Name Drug Tier Requirements and Limits EMVERM ORAL TABLET,CHEWABLE 100 MG Tier 3 PA (mebendazole) Anthelmintic Agents - Macrocyclic Lactones - Drugs For Parasites ivermectin oral tablet 3 mg Tier 1 Anthelmintic Agents Other - Drugs For Parasites ivermectin oral tablet 3 mg Tier 1 praziquantel oral tablet 600 mg Tier 1 Antibacterial Folate Antagonist - Other Combinations - Antibiotics sulfamethoxazole-trimethoprim oral suspension 200-40 Tier 1 mg/5 ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800- Tier 1 160 mg SULFATRIM ORAL SUSPENSION 200-40 MG/5 ML Tier 1 (sulfamethoxazole) Antibacterial Folate Antagonist Others - Antibiotics PRIMSOL ORAL SOLUTION 50 MG/5 ML (trimethoprim) Tier 2 trimethoprim oral tablet 100 mg Tier 1 TRIMPEX ORAL SOLUTION 50 MG/5 ML (trimethoprim) Tier 2 Antibacterial Other - Antibiotics MONUROL ORAL PACKET 3 GRAM (fosfomycin) Tier 3 Antifungal - Allylamines - Drugs For Fungus terbinafine hcl oral tablet 250 mg Tier 1 Antifungal - Amphoteric Polyene Macrolides - Drugs For Fungus nystatin oral tablet 500,000 unit Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

43 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antifungal - Imidazoles - Drugs For Fungus ketoconazole oral tablet 200 mg Tier 1 ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET Tier 3 50 MG (miconazole) Antifungal - Triazoles - Drugs For Fungus CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium) Tier 3 fluconazole oral suspension for reconstitution 10 mg/ml, 40 Tier 1 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg Tier 1 itraconazole oral capsule 100 mg Tier 1 itraconazole oral solution 10 mg/ml Tier 1 NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) Tier 3 (posaconazole) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 3 100 MG (posaconazole) ONMEL ORAL TABLET 200 MG (itraconazole) Tier 3 posaconazole oral tablet,delayed release (dr/ec) 100 mg Tier 1 TOLSURA ORAL CAPSULE, SOLID DISPERSION 65 MG Tier 3 PA (itraconazole) voriconazole oral suspension for reconstitution 200 mg/5 ml Tier 1 (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg Tier 1 Antifungal Other - Drugs For Fungus flucytosine oral capsule 250 mg, 500 mg Tier 1 griseofulvin microsize oral suspension 125 mg/5 ml Tier 1 griseofulvin microsize oral tablet 500 mg Tier 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

44 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anti-Infective Immunologic Adjuvants - Interferons - Drugs For Infections ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 Tier 4 ML (interferon gamma-1b,recomb.) Antileprotic - Immunomodulators - Antibiotics THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, Tier 2 PA; QL (2 EA per 1 day) 50 MG (thalidomide) Antileprotic - Sulfone Agents - Antibiotics dapsone oral tablet 100 mg, 25 mg Tier 1 Antimalarial Combinations - Drugs For Parasites atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg Tier 1 COARTEM ORAL TABLET 20-120 MG (artemether) Tier 3 Antimalarials - Drugs For Parasites ARAKODA ORAL TABLET 100 MG (tafenoquine) Tier 3 chloroquine phosphate oral tablet 250 mg Tier 1 chloroquine phosphate oral tablet 500 mg Tier 1 DARAPRIM ORAL TABLET 25 MG (pyrimethamine) Tier 3 PA; SP hydroxychloroquine oral tablet 200 mg Tier 1 KRINTAFEL ORAL TABLET 150 MG (tafenoquine) Tier 2 QL (2 EA per 1 FILL) mefloquine oral tablet 250 mg Tier 1 primaquine oral tablet 26.3 mg Tier 2 quinine sulfate oral capsule 324 mg Tier 1 Antiprotozoal Agents - Nitroimidazole Derivatives - Drugs For Parasites benznidazole oral tablet 100 mg, 12.5 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

45 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiprotozoal Agents - Other - Drugs For Parasites ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 Tier 3 MG/5 ML (nitazoxanide) ALINIA ORAL TABLET 500 MG (nitazoxanide) Tier 3 atovaquone oral suspension 750 mg/5 ml Tier 1 IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) Tier 3 PA Antiprotozoal Agents (Antiparasitic) - 5- Nitrothiazolyl Derivatives - Drugs For Parasites ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 Tier 3 MG/5 ML (nitazoxanide) Antiprotozoal-Antibacterial 1St Generation 2- Methyl-5-Nitroimidazole - Drugs For Infections metronidazole oral capsule 375 mg Tier 1 metronidazole oral tablet 250 mg, 500 mg Tier 1 Antiprotozoal-Antibacterial 2Nd Generation 2- Methyl-5-Nitroimidazole - Drugs For Infections ST: Must meet 2 of the following requirements: Clindamycin HCL, Clindamycin Palmitate SOLOSEC ORAL GRANULES DEL RELEASE IN PACKET Tier 3 HCL, Clindamycin 2 GRAM (secnidazole) Phosphate, Metronidazole, Tinidazole, or Vandazole in 365 days; QL (1 EA per 30 days) tinidazole oral tablet 250 mg, 500 mg Tier 1 Antiretroviral - Ccr5 Co-Receptor Antagonist - Drugs For Viral Infections SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) Tier 2

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

46 Coverage Prescription Drug Name Drug Tier Requirements and Limits SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 Tier 2 MG (maraviroc) Antiretroviral - Hiv-1 Fusion Inhibitors - Drugs For Viral Infections FUZEON SUBCUTANEOUS RECON SOLN 90 MG Tier 4 (enfuvirtide) Antiretroviral - Hiv-1 Integrase Strand Transfer Inhibitors - Drugs For Viral Infections ISENTRESS HD ORAL TABLET 600 MG (raltegravir) Tier 2 ISENTRESS ORAL POWDER IN PACKET 100 MG Tier 2 (raltegravir) ISENTRESS ORAL TABLET 400 MG (raltegravir) Tier 2 ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG Tier 2 (raltegravir) TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Tier 2 (dolutegravir) Antiretroviral - Integrase Inhibitor And Nnrti Combinations - Drugs For Viral Infections JULUCA ORAL TABLET 50-25 MG (dolutegravir) Tier 2 Antiretroviral - Integrase Inhibitor And Nrti Combinations - Drugs For Viral Infections DOVATO ORAL TABLET 50-300 MG (dolutegravir) Tier 2 Antiretroviral - Non-Nucleoside Reverse Transcriptase Inhib (Nnrti) - Drugs For Viral Infections EDURANT ORAL TABLET 25 MG (rilpivirine) Tier 2 efavirenz oral capsule 200 mg, 50 mg Tier 1 efavirenz oral tablet 600 mg Tier 1 INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG Tier 2 (etravirine) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

47 Coverage Prescription Drug Name Drug Tier Requirements and Limits nevirapine oral suspension 50 mg/5 ml Tier 1 nevirapine oral tablet 200 mg Tier 1 nevirapine oral tablet extended release 24 hr 100 mg, 400 Tier 1 mg PIFELTRO ORAL TABLET 100 MG (doravirine) Tier 2 RESCRIPTOR ORAL TABLET 200 MG (delavirdine) Tier 2 Antiretroviral - Nucleoside And Nucleotide Analog Rtis Combinations - Drugs For Viral Infections CIMDUO ORAL TABLET 300-300 MG (lamivudine) Tier 2 DESCOVY ORAL TABLET 200-25 MG (emtricitabine) Tier 2 TEMIXYS ORAL TABLET 300-300 MG (lamivudine) Tier 2 TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167- Tier 2 250 MG, 200-300 MG (emtricitabine) Antiretroviral - Nucleoside Reverse Transcriptase Inhibitors (Nrti) - Drugs For Viral Infections abacavir oral solution 20 mg/ml Tier 1 abacavir oral tablet 300 mg Tier 1 didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 Tier 1 mg, 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) Tier 2 EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) Tier 2 lamivudine oral solution 10 mg/ml Tier 1 lamivudine oral tablet 150 mg, 300 mg Tier 1 stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg Tier 1 VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 Tier 2 MG/ML (FINAL) (didanosine) zidovudine oral capsule 100 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

48 Coverage Prescription Drug Name Drug Tier Requirements and Limits zidovudine oral syrup 10 mg/ml Tier 1 zidovudine oral tablet 300 mg Tier 1 Antiretroviral - Nucleotide Analog Reverse Transcriptase Inhibitors - Drugs For Viral Infections tenofovir disoproxil fumarate oral tablet 300 mg Tier 1 VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) Tier 2 (tenofovir) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Tier 2 (tenofovir) Antiretroviral Combinations - Protease Inhibitors - Drugs For Viral Infections EVOTAZ ORAL TABLET 300-150 MG (atazanavir) Tier 2 KALETRA ORAL TABLET 100-25 MG, 200-50 MG Tier 2 (lopinavir) lopinavir-ritonavir oral solution 400-100 mg/5 ml Tier 1 PREZCOBIX ORAL TABLET 800-150 MG-MG (darunavir) Tier 2 Antiretroviral- Nucleoside And Nucleotide Analogs,Integrase Inhibitors - Drugs For Viral Infections BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir) Tier 2 GENVOYA ORAL TABLET 150-150-200-10 MG Tier 2 (elvitegravir) STRIBILD ORAL TABLET 150-150-200-300 MG Tier 2 (elvitegravir) Antiretroviral- Nucleoside And Nucleotide Analogs,Protease Inhibitors - Drugs For Viral Infections SYMTUZA ORAL TABLET 800-150-200-10 MG (darunavir) Tier 2

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

49 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiretroviral-Nucleoside Analogs And Integrase Inhibitor Combinations - Drugs For Viral Infections TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir) Tier 2 Antiretroviral-Nucleoside Reverse Transcriptase Inhibitors (Nrti) Comb - Drugs For Viral Infections abacavir-lamivudine oral tablet 600-300 mg Tier 1 abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg Tier 1 lamivudine-zidovudine oral tablet 150-300 mg Tier 1 Antiretroviral-Nucleoside, Nucleotide Analogs And Non-Nucleoside Rti - Drugs For Viral Infections ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz) Tier 2 COMPLERA ORAL TABLET 200-25-300 MG (emtricitabine) Tier 2 DELSTRIGO ORAL TABLET 100-300-300 MG (doravirine) Tier 2 ODEFSEY ORAL TABLET 200-25-25 MG (emtricitabine) Tier 2 SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz) Tier 2 SYMFI ORAL TABLET 600-300-300 MG (efavirenz) Tier 2 Antitubercular - Aminobenzoic Acid Analogs - Antibiotics PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 Tier 3 GRAM (aminosalicylic acid) Antitubercular - D-Alanine Analogs - Antibiotics cycloserine oral capsule 250 mg Tier 1 Antitubercular - Diarylquinoline Antibiotics - Antibiotics SIRTURO ORAL TABLET 100 MG (bedaquiline) Tier 3 PA; SP

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

50 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antitubercular - Isonicotinic Acid Derivatives - Antibiotics isoniazid oral solution 50 mg/5 ml Tier 1 isoniazid oral tablet 100 mg, 300 mg Tier 1 Antitubercular - Niacinamide Derivatives - Antibiotics pyrazinamide oral tablet 500 mg Tier 1 Antitubercular - Rifamycin And Derivatives - Antibiotics PRIFTIN ORAL TABLET 150 MG (rifapentine) Tier 3 rifabutin oral capsule 150 mg Tier 1 rifampin oral capsule 150 mg, 300 mg Tier 1 Antitubercular Agents Other - Antibiotics ethambutol oral tablet 100 mg, 400 mg Tier 1 TRECATOR ORAL TABLET 250 MG (ethionamide) Tier 3 Antitubercular Combinations - Antibiotics RIFAMATE ORAL CAPSULE 300-150 MG (rifampin) Tier 2 RIFATER ORAL TABLET 50-120-300 MG (rifampin) Tier 3 Cephalosporin Antibiotics - 1St Generation - Antibiotics cefadroxil oral capsule 500 mg Tier 1 cefadroxil oral suspension for reconstitution 250 mg/5 ml, Tier 1 500 mg/5 ml cefadroxil oral tablet 1 gram Tier 1 cephalexin oral capsule 250 mg, 500 mg, 750 mg Tier 1 cephalexin oral suspension for reconstitution 125 mg/5 ml, Tier 1 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

51 Coverage Prescription Drug Name Drug Tier Requirements and Limits Cephalosporin Antibiotics - 2Nd Generation - Antibiotics cefaclor oral capsule 250 mg, 500 mg Tier 1 cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 Tier 1 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 500 mg Tier 1 cefprozil oral suspension for reconstitution 125 mg/5 ml, Tier 1 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg Tier 1 cefuroxime axetil oral tablet 250 mg, 500 mg Tier 1 Cephalosporin Antibiotics - 3Rd Generation - Antibiotics cefdinir oral capsule 300 mg Tier 1 cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 Tier 1 mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg Tier 1 cefixime oral capsule 400 mg Tier 1 cefixime oral suspension for reconstitution 100 mg/5 ml, 200 Tier 1 mg/5 ml cefpodoxime oral suspension for reconstitution 100 mg/5 Tier 1 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg Tier 1 SUPRAX ORAL CAPSULE 400 MG (cefixime) Tier 2 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION Tier 2 500 MG/5 ML (cefixime) SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG Tier 2 (cefixime) Cmv Antiviral Agent - Nucleoside Analogs - Drugs For Viral Infections valganciclovir oral recon soln 50 mg/ml Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

52 Coverage Prescription Drug Name Drug Tier Requirements and Limits valganciclovir oral tablet 450 mg Tier 1 Cmv Antiviral Agent - Terminase Complex Inhibitors - Drugs For Viral Infections PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) Tier 3 PA; SP Fluoroquinolone Antibiotics - Antibiotics BAXDELA ORAL TABLET 450 MG (delafloxacin) Tier 3 PA CIPRO ORAL SUSPENSION,MICROCAPSULE RECON Tier 2 250 MG/5 ML, 500 MG/5 ML (ciprofloxacin) CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 Tier 3 MG, 500 MG (ciprofloxacin) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 Tier 1 mg ciprofloxacin oral suspension,microcapsule recon 250 mg/5 Tier 1 ml, 500 mg/5 ml FACTIVE ORAL TABLET 320 MG (gemifloxacin) Tier 3 levofloxacin oral solution 250 mg/10 ml Tier 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg Tier 1 moxifloxacin oral tablet 400 mg Tier 1 ofloxacin oral tablet 300 mg, 400 mg Tier 1 Glycopeptide Antibiotics - Antibiotics FIRVANQ ORAL RECON SOLN 25 MG/ML (vancomycin) Tier 2 QL (300 ML per 1 FILL) vancomycin oral capsule 125 mg Tier 1 QL (56 EA per 1 FILL) vancomycin oral capsule 250 mg Tier 1 QL (112 EA per 1 FILL) vancomycin oral recon soln 50 mg/ml Tier 1 QL (600 ML per 1 FILL) Hepatitis B Treatment- Nucleoside Analogs (Antiviral) - Drugs For Viral Infections BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) Tier 2 QL (630 ML per 30 days) entecavir oral tablet 0.5 mg, 1 mg Tier 1 QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

53 Coverage Prescription Drug Name Drug Tier Requirements and Limits EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) Tier 2 QL (720 ML per 30 days) (lamivudine) lamivudine oral tablet 100 mg Tier 1 QL (1 EA per 1 day) Hepatitis B Treatment- Nucleotide Analogs (Antiviral) - Drugs For Viral Infections adefovir oral tablet 10 mg Tier 1 QL (1 EA per 1 day) ST: Must meet the following requirement: VEMLIDY ORAL TABLET 25 MG (tenofovir) Tier 2 Tenofovir 300mg in 120 days; QL (1 EA per 1 day) VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) Tier 2 (tenofovir) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Tier 2 (tenofovir) Hepatitis C - Interferons - Drugs For Viral Infections PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR Tier 2 PA 180 MCG/0.5 ML (peginterferon alfa-2a) PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML Tier 2 PA (peginterferon alfa-2a) PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML Tier 2 PA (peginterferon alfa-2a) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML Tier 2 PA (peginterferon alfa-2b) Hepatitis C - Ns5a Inhibitor And Ns3/4A Protease Inhibitor Combination - Drugs For Viral Infections MAVYRET ORAL TABLET 100-40 MG (glecaprevir) Tier 3 PA; SP ZEPATIER ORAL TABLET 50-100 MG (elbasvir) Tier 3 PA; SP

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

54 Coverage Prescription Drug Name Drug Tier Requirements and Limits Hepatitis C - Ns5a, Ns3/4A Protease, Nucleo.Ns5b Polymerase Inhib Comb - Drugs For Viral Infections VOSEVI ORAL TABLET 400-100-100 MG (sofosbuvir) Tier 3 PA; SP Hepatitis C - Ns5b Polymerase And Ns5a Inhibitor Combinations - Drugs For Viral Infections EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir) Tier 3 PA; SP HARVONI ORAL TABLET 45-200 MG, 90-400 MG Tier 3 PA; SP (ledipasvir) Hepatitis C - Nucleos(T)Ide Analog Ns5b Polymerase Inhibitors - Drugs For Viral Infections SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) Tier 3 PA; SP Hepatitis C - Nucleoside Analogs - Drugs For Viral Infections ribavirin (Ribasphere Oral Capsule 200 Mg) Tier 1 ST: Must meet the following requirement: RIBASPHERE ORAL TABLET 600 MG (ribavirin) Tier 1 Ribavirin 200mg capsules or tablets in 120 days ST: Must meet the ribavirin (Ribasphere Ribapak Oral Tablets,Dose Pack 600 following requirement: Mg (7)- 400 Mg (7), 600 Mg (7)- 600 Mg (7), 600-400 Mg Tier 1 Ribavirin 200mg capsules (28)-Mg (28), 600-600 Mg (28)-Mg (28)) or tablets in 120 days ribavirin oral capsule 200 mg Tier 1 ribavirin oral tablet 200 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

55 Coverage Prescription Drug Name Drug Tier Requirements and Limits Hepatitis C- Ns5a, Ns3/4A Protease And Non- Nucleo.Ns5b Poly Inh. Comb - Drugs For Viral Infections VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG-75 Tier 3 PA; SP MG -50 MG/250 MG (ombitasvir) Herpes Antiviral Agent - Purine Analogs - Drugs For Viral Infections acyclovir oral capsule 200 mg Tier 1 acyclovir oral suspension 200 mg/5 ml Tier 1 acyclovir oral tablet 400 mg, 800 mg Tier 1 SITAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET Tier 3 QL (4 EA per 365 days) 50 MG (acyclovir) valacyclovir oral tablet 1 gram, 500 mg Tier 1 Herpes Antiviral Agent - Thymidine Analogs - Drugs For Viral Infections famciclovir oral tablet 125 mg, 250 mg, 500 mg Tier 1 Influenza Antiviral Agents - Neuraminidase Inhibitors - Drugs For Viral Infections oseltamivir oral capsule 30 mg Tier 1 QL (40 EA per 180 days) oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (20 EA per 180 days) oseltamivir oral suspension for reconstitution 6 mg/ml Tier 1 QL (360 ML per 180 days) RELENZA DISKHALER INHALATION BLISTER WITH Tier 3 QL (40 EA per 180 days) DEVICE 5 MG/ACTUATION (zanamivir) Influenza Antiviral Agents - Pa Endonuclease Inhibitor - Drugs For Viral Infections XOFLUZA ORAL TABLET 20 MG, 40 MG (baloxavir Tier 2 QL (4 EA per 180 days) marboxil)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

56 Coverage Prescription Drug Name Drug Tier Requirements and Limits Influenza-A Antiviral Agents - Drugs For Viral Infections rimantadine oral tablet 100 mg Tier 1 Lincosamide Antibiotics - Antibiotics clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg Tier 1 clindamycin palmitate hcl oral recon soln 75 mg/5 ml Tier 1 clindamycin (Clindamycin Pediatric Oral Recon Soln 75 Tier 1 Mg/5 Ml) Macrolide Antibiotics - Antibiotics azithromycin oral packet 1 gram Tier 1 azithromycin oral suspension for reconstitution 100 mg/5 ml, Tier 1 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg Tier 1 clarithromycin oral suspension for reconstitution 125 mg/5 Tier 1 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg Tier 1 clarithromycin oral tablet extended release 24 hr 500 mg Tier 1 ST: Must meet the following requirement: DIFICID ORAL TABLET 200 MG (fidaxomicin) Tier 2 Vancomycin HCL in 120 days; QL (20 EA per 30 days) erythromycin base (E.E.S. 400 Oral Tablet 400 Mg) Tier 1 ERYPED 400 ORAL SUSPENSION FOR Tier 2 RECONSTITUTION 400 MG/5 ML (erythromycin base) erythromycin base (Ery-Tab Oral Tablet,Delayed Release Tier 1 (Dr/Ec) 250 Mg, 500 Mg) erythromycin base (Ery-Tab Oral Tablet,Delayed Release Tier 2 (Dr/Ec) 333 Mg)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

57 Coverage Prescription Drug Name Drug Tier Requirements and Limits erythromycin base (Erythrocin (As Stearate) Oral Tablet 250 Tier 1 Mg) erythromycin ethylsuccinate oral suspension for Tier 1 reconstitution 200 mg/5 ml, 400 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg Tier 1 erythromycin oral capsule,delayed release(dr/ec) 250 mg Tier 1 erythromycin oral tablet 250 mg, 500 mg Tier 1 erythromycin oral tablet,delayed release (dr/ec) 250 mg, Tier 1 333 mg, 500 mg Misc Anti-Infective - Drugs For Infections methenamine hippurate oral tablet 1 gram Tier 1 methenamine mandelate oral tablet 0.5 g, 1 gram Tier 1 NEBUPENT INHALATION RECON SOLN 300 MG Tier 2 (pentamidine isethionate) pentamidine inhalation recon soln 300 mg Tier 1 UROQID-ACID NO.2 ORAL TABLET 500-500 MG Tier 3 (methenamine) Misc Anti-Infective Combinations - Drugs For Infections HYOPHEN ORAL TABLET 81.6-0.12-10.8 MG Tier 1 (methenamine) methen-sod phos-meth blue-hyos oral tablet 81.6-40.8-0.12 Tier 1 mg PHOSPHASAL ORAL TABLET 81.6-10.8-40.8 MG Tier 2 (methenamine) URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG Tier 2 (methenamine) URIMAR-T ORAL TABLET 120-0.12-10.8 MG Tier 1 (methenamine) URIN DS ORAL TABLET 81.6-10.8-40.8 MG Tier 2 (methenamine) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

58 Coverage Prescription Drug Name Drug Tier Requirements and Limits URO-458 ORAL TABLET 81-10.8-40.8 MG (methenamine) Tier 1 UROGESIC-BLUE ORAL TABLET 81.6-40.8-0.12 MG Tier 1 (methenamine) URO-MP ORAL CAPSULE 118-10-40.8-36 MG Tier 1 (methenamine) USTELL ORAL CAPSULE 120-0.12 MG (methenamine) Tier 1 VILAMIT MB ORAL CAPSULE 118-10-40.8-36 MG Tier 1 (methenamine) Oxazolidinone Antibiotics - Antibiotics linezolid oral suspension for reconstitution 100 mg/5 ml Tier 1 linezolid oral tablet 600 mg Tier 1 ST: Must meet the following requirement: SIVEXTRO ORAL TABLET 200 MG (tedizolid) Tier 2 Linezolid 600mg tablets in 120 days; QL (6 EA per 6 days) Penicillin Antibiotic - Natural - Antibiotics penicillin v potassium oral recon soln 125 mg/5 ml, 250 Tier 1 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg Tier 1 Penicillin Antibiotic - Penicillinase-Resistant - Antibiotics dicloxacillin oral capsule 250 mg, 500 mg Tier 1 Pleuromutilin Antibiotics - Antibiotics XENLETA ORAL TABLET 600 MG (lefamulin) Tier 3 PA Protease Inhibitors (Non-Peptidic) Antiretroviral - Drugs For Viral Infections APTIVUS ORAL CAPSULE 250 MG (tipranavir) Tier 2 APTIVUS ORAL SOLUTION 100 MG/ML (tipranavir) Tier 2 PREZCOBIX ORAL TABLET 800-150 MG-MG (darunavir) Tier 2 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

59 Coverage Prescription Drug Name Drug Tier Requirements and Limits PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir) Tier 2 PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 Tier 2 MG (darunavir) Protease Inhibitors (Peptidic) Antiretroviral - Drugs For Viral Infections atazanavir oral capsule 150 mg, 200 mg, 300 mg Tier 1 CRIXIVAN ORAL CAPSULE 200 MG, 400 MG (indinavir) Tier 2 EVOTAZ ORAL TABLET 300-150 MG (atazanavir) Tier 2 fosamprenavir oral tablet 700 mg Tier 1 INVIRASE ORAL TABLET 500 MG (saquinavir) Tier 2 LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir) Tier 2 NORVIR ORAL CAPSULE 100 MG (ritonavir) Tier 2 NORVIR ORAL POWDER IN PACKET 100 MG (ritonavir) Tier 2 NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) Tier 2 REYATAZ ORAL POWDER IN PACKET 50 MG Tier 2 (atazanavir) ritonavir oral tablet 100 mg Tier 1 VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir) Tier 2 Respiratory Syncytial Virus (Rsv) Antiviral Agents - Drugs For Viral Infections ribavirin inhalation recon soln 6 gram Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

60 Coverage Prescription Drug Name Drug Tier Requirements and Limits Rifamycins And Related Derivative Antibiotics - Antibiotics ST: Must meet any of the following requirements: Azithromycin, Cipro, Cipro XR, Ciprofloxacin HCL, AEMCOLO ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 3 Ciprofloxacin, 194 MG (rifamycin) Ciprofloxacin/ciprofloxacin HCL, Levofloxacin, or Ofloxacin in 120 days; QL (12 EA per 1 FILL) XIFAXAN ORAL TABLET 200 MG (rifaximin) Tier 3 PA XIFAXAN ORAL TABLET 550 MG (rifaximin) Tier 2 PA Sulfonamide Antibiotic - Antibiotics sulfadiazine oral tablet 500 mg Tier 1 Tetracycline And Tetracycline Antibiotic Combinations - Antibiotics ST: Must meet the following requirement: generic Doxycycline AVIDOXY DK KIT 100 MG-2 % -SPF 30 (doxycycline) Tier 3 Monohydrate 100mg capsules in 120 days; QL (1 EA per 30 days) ST: Must meet the following requirement: BENZODOX 30 KIT, CLEANSER ER AND TABLET 100-4.4 generic Doxycycline Tier 3 MG-% (doxycycline) Monohydrate 100mg capsules in 120 days; QL (1 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

61 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: BENZODOX 60 KIT, CLEANSER ER AND TABLET 100-4.4 generic Doxycycline Tier 3 MG-% (doxycycline) Monohydrate 100mg capsules in 120 days; QL (1 EA per 30 days) Tetracycline Antibiotics - Antibiotics ST: Must meet the following requirement: minocycline (Coremino Oral Tablet Extended Release 24 Hr Generic immediate-release Tier 1 135 Mg, 45 Mg, 90 Mg) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) demeclocycline oral tablet 150 mg, 300 mg Tier 1 ST: Must meet the following requirement: DORYX MPC ORAL TABLET,DELAYED RELEASE Doxycycline Monohydrate Tier 3 (DR/EC) 120 MG (doxycycline) or Hyclate 100mg tablets or capsules in 120 days; QL (2 EA per 1 day) doxycycline hyclate oral capsule 100 mg, 50 mg Tier 1 QL (2 EA per 1 day) doxycycline hyclate oral tablet 100 mg Tier 1 QL (2 EA per 1 day) ST: Must meet the following requirement: generic Doxycycline doxycycline hyclate oral tablet 150 mg Tier 1 Monohydrate 150mg tablets in 120 days; QL (2 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

62 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: Doxycycline Hyclate 50mg doxycycline hyclate oral tablet 50 mg Tier 1 capsules or Doxycycline Monohydrate 50mg capsules or tablets in 120 days; QL (4 EA per 1 day) ST: Must meet the following requirement: generic Doxycycline doxycycline hyclate oral tablet 75 mg Tier 1 Monohydrate 75mg tablets in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: doxycycline hyclate oral tablet,delayed release (dr/ec) 100 Doxycycline Monohydrate Tier 1 mg or Hyclate 100mg tablets or capsules in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: doxycycline hyclate oral tablet,delayed release (dr/ec) 150 gnereic Doxycycline Tier 1 mg Monohydrate 150mg tablets in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: doxycycline hyclate oral tablet,delayed release (dr/ec) 200 Doxycycline Monohydrate Tier 1 mg or Hyclate 100mg tablets or capsules in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

63 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: Doxycycline Hyclate 50mg doxycycline hyclate oral tablet,delayed release (dr/ec) 50 Tier 1 tablets or Doxycycline mg Monohydrate 50mg capsules or tablets in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: doxycycline hyclate oral tablet,delayed release (dr/ec) 75 generic Doxycycline Tier 1 mg Monohydrate 75mg tablets in 120 days; QL (2 EA per 1 day) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 Tier 1 QL (2 EA per 1 day) mg ST: Must meet the following requirement: generic Doxycycline doxycycline monohydrate oral capsule 75 mg Tier 1 Monohydrate 75mg tablets in 120 days; QL (2 EA per 1 day) doxycycline monohydrate oral suspension for reconstitution Tier 1 25 mg/5 ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 Tier 1 QL (2 EA per 1 day) mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg Tier 1 minocycline oral tablet 100 mg, 50 mg, 75 mg Tier 1 ST: Must meet the following requirement: MINOLIRA ER ORAL TABLET, IR - ER, BIPHASIC 24HR Generic immediate-release Tier 3 105 MG, 135 MG (minocycline) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) doxycycline (Mondoxyne Nl Oral Capsule 100 Mg) Tier 1 QL (2 EA per 1 day) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

64 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: generic Doxycycline doxycycline (Mondoxyne Nl Oral Capsule 75 Mg) Tier 1 Monohydrate 75mg tablets in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: generic Doxycycline MORGIDOX 1X 50 KIT 50 MG (doxycycline) Tier 3 Monohydrate 100mg capsules in 120 days; QL (1 EA per 30 days) ST: Must meet the following requirement: generic Doxycycline MORGIDOX 1X100 KIT 100 MG (doxycycline) Tier 3 Monohydrate 100mg capsules in 120 days; QL (1 EA per 30 days) ST: Must meet the following requirement: generic Doxycycline MORGIDOX 2X100 KIT 100 MG (doxycycline) Tier 3 Monohydrate 100mg capsules in 120 days; QL (1 EA per 30 days) NUZYRA (7 DAY WITH LOAD DOSE) ORAL TABLET 150 Tier 3 PA MG (omadacycline) NUZYRA (7 DAY) ORAL TABLET 150 MG (omadacycline) Tier 3 PA NUZYRA ORAL TABLET 150 MG (omadacycline) Tier 3 PA ST: Must meet the following requirement: generic Doxycycline doxycycline (Okebo Oral Capsule 75 Mg) Tier 1 Monohydrate 75mg tablets in 120 days; QL (2 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

65 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Doryx Mpc, Doxycycline SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG Hyclate, Doxycycline Tier 3 (sarecycline) Monohydrate, Minocycline HCL, or Vibramycin in 120 days; QL (1 EA per 1 day); Age (Min 9 Years) ST: Must meet the following requirement: SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR Generic immediate-release Tier 3 105 MG, 80 MG (minocycline) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) tetracycline oral capsule 250 mg, 500 mg Tier 1 VIBRAMYCIN ORAL SYRUP 50 MG/5 ML (doxycycline) Tier 2 ST: Must meet the following requirement: XIMINO ORAL CAPSULE,EXTENDED RELEASE 24HR Generic immediate-release Tier 3 135 MG, 45 MG, 90 MG (minocycline) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) Antineoplastics - Drugs For Cancer Antineoplasic-Epiderm.Growth Factor-Egfr (Erbb1),Her-2 (Erbb2)R.Inhib - Drugs For Cancer TYKERB ORAL TABLET 250 MG (lapatinib) Tier 3 PA; SP Antineoplastic - Cyp17 (17 Alpha- Hydroxylase/C17,20-Lyase) Inhibitor - Drugs For Cancer PA; SP; QL (4 EA per 1 YONSA ORAL TABLET 125 MG (abiraterone) Tier 3 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

66 Coverage Prescription Drug Name Drug Tier Requirements and Limits ZYTIGA ORAL TABLET 500 MG (abiraterone) Tier 3 PA; SP Antineoplastic - 1St Generation Egfr Tyrosine Kinase Inhibitor - Drugs For Cancer erlotinib oral tablet 100 mg, 150 mg, 25 mg Tier 3 PA; SP IRESSA ORAL TABLET 250 MG (gefitinib) Tier 3 PA; SP Antineoplastic - 2Nd Generation Egfr Tyrosine Kinase Inhibitor - Drugs For Cancer GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG (afatinib) Tier 3 PA; SP NERLYNX ORAL TABLET 40 MG (neratinib) Tier 3 PA; SP VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG Tier 3 PA; SP (dacomitinib) Antineoplastic - 3Rd Generation Egfr Tyrosine Kinase Inhibitor - Drugs For Cancer TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib) Tier 3 PA; SP Antineoplastic - Alkylating Agent - Alkyl Sulfonates - Drugs For Cancer MYLERAN ORAL TABLET 2 MG (busulfan) Tier 3 SP Antineoplastic - Alkylating Agent - Methylhydrazines - Drugs For Cancer MATULANE ORAL CAPSULE 50 MG (procarbazine) Tier 3 SP Antineoplastic - Alkylating Agent - Nitrogen Mustards - Drugs For Cancer cyclophosphamide oral capsule 25 mg, 50 mg Tier 1 LEUKERAN ORAL TABLET 2 MG (chlorambucil) Tier 3 SP melphalan oral tablet 2 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

67 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Alkylating Agent - Nitrosoureas - Drugs For Cancer GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 Tier 3 PA; SP MG (lomustine) Antineoplastic - Alkylating Agent - Triazenes - Drugs For Cancer temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 Tier 3 PA; SP mg, 250 mg, 5 mg Antineoplastic - Anaplastic Lymphoma Kinase (Alk) Inhibitors - Drugs For Cancer ALECENSA ORAL CAPSULE 150 MG (alectinib) Tier 3 PA; SP ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG Tier 3 PA; SP (brigatinib) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 Tier 3 PA; SP MG (23) (brigatinib) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) Tier 3 PA; SP XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) Tier 3 PA; SP ZYKADIA ORAL TABLET 150 MG (ceritinib) Tier 3 PA; SP Antineoplastic - Antiadrenals - Drugs For Cancer LYSODREN ORAL TABLET 500 MG (mitotane) Tier 3 SP Antineoplastic - Antiandrogens - Drugs For Cancer abiraterone oral tablet 250 mg Tier 3 PA; SP bicalutamide oral tablet 50 mg Tier 1 ERLEADA ORAL TABLET 60 MG (apalutamide) Tier 3 PA; SP flutamide oral capsule 125 mg Tier 1 nilutamide oral tablet 150 mg Tier 3 SP; QL (2 EA per 1 day) NUBEQA ORAL TABLET 300 MG (darolutamide) Tier 3 PA; SP

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

68 Coverage Prescription Drug Name Drug Tier Requirements and Limits XTANDI ORAL CAPSULE 40 MG (enzalutamide) Tier 3 PA; SP PA; SP; QL (4 EA per 1 YONSA ORAL TABLET 125 MG (abiraterone) Tier 3 day) ZYTIGA ORAL TABLET 500 MG (abiraterone) Tier 3 PA; SP Antineoplastic - Antimetabolite - Folic Acid Analogs - Drugs For Cancer methotrexate sodium (pf) injection recon soln 1 gram Tier 4 methotrexate sodium (pf) injection solution 25 mg/ml Tier 4 methotrexate sodium injection solution 25 mg/ml Tier 4 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG Tier 2 (methotrexate) Antineoplastic - Antimetabolite - Purine Analogs - Drugs For Cancer mercaptopurine oral tablet 50 mg Tier 1 SP; ST: Must meet the PURIXAN ORAL SUSPENSION 20 MG/ML following requirement: Tier 3 (mercaptopurine) Mercaptopurine in 120 days TABLOID ORAL TABLET 40 MG (thioguanine) Tier 3 SP Antineoplastic - Antimetabolite - Pyrimidine Analogs - Drugs For Cancer PA; QL (28 EA per 21 capecitabine oral tablet 150 mg Tier 1 days) PA; QL (112 EA per 21 capecitabine oral tablet 500 mg Tier 1 days) Antineoplastic - Antimetabolite - Urea Derivatives - Drugs For Cancer hydroxyurea oral capsule 500 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

69 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Antimetabolites - Pyrimidine Analog Combinations - Drugs For Cancer LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG Tier 3 PA; SP (trifluridine) Antineoplastic - Aromatase Inhibitors - Drugs For Cancer anastrozole oral tablet 1 mg Tier 1 exemestane oral tablet 25 mg Tier 1 letrozole oral tablet 2.5 mg Tier 1 Antineoplastic - B-Cell Lymphoma-2 (Bcl-2) Inhibitors - Drugs For Cancer VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG Tier 3 PA; SP (venetoclax) VENCLEXTA STARTING PACK ORAL TABLETS,DOSE Tier 3 PA; SP PACK 10 MG-50 MG- 100 MG (venetoclax) Antineoplastic - Braf Kinase Inhibitors - Drugs For Cancer PA; SP; QL (6 EA per 1 BRAFTOVI ORAL CAPSULE 50 MG, 75 MG (encorafenib) Tier 3 day) TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib) Tier 3 PA; SP PA; SP; QL (8 EA per 1 ZELBORAF ORAL TABLET 240 MG (vemurafenib) Tier 3 day) Antineoplastic - Bruton's Tyrosine Kinase (Btk) Inhibitor - Drugs For Cancer CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) Tier 3 PA; SP IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) Tier 3 PA; SP IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, Tier 3 PA; SP 560 MG (ibrutinib)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

70 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Cyclin-Dependent Kinase (Cdk) 4/6 Inhibitors - Drugs For Cancer IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG Tier 3 PA; SP (palbociclib) KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) Tier 3 PA; SP (ribociclib) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 Tier 3 PA; SP MG (abemaciclib) Antineoplastic - Epipodophyllotoxins - Drugs For Cancer etoposide oral capsule 50 mg Tier 1 Antineoplastic - Estrogens - Drugs For Cancer EMCYT ORAL CAPSULE 140 MG (estramustine) Tier 3 SP Antineoplastic - Fibroblast Growth Factor Receptor (Fgfr) Kinase Inhib - Drugs For Cancer BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG (erdafitinib) Tier 3 PA; SP Antineoplastic - Fms-Like Tyrosine Kinase 3 (Flt3) Inhibitors - Drugs For Cancer XOSPATA ORAL TABLET 40 MG (gilteritinib) Tier 3 PA; SP Antineoplastic - Hedgehog Pathway Inhibitor - Drugs For Cancer DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib) Tier 3 PA; SP PA; SP; QL (1 EA per 1 ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) Tier 3 day) ODOMZO ORAL CAPSULE 200 MG (sonidegib) Tier 3 PA; SP

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

71 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Histone Deacetylase (Hdac) Inhibitors - Drugs For Cancer FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG Tier 3 PA; SP (panobinostat) ZOLINZA ORAL CAPSULE 100 MG (vorinostat) Tier 3 SP Antineoplastic - Interferons - Drugs For Cancer INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) Tier 2 PA (interferon alfa-2b,recomb.) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, Tier 2 PA 6 MILLION UNIT/ML (interferon alfa-2b,recomb.) SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, Tier 2 600 MCG (peginterferon alfa-2b) Antineoplastic - Janus Kinase (Jak) Inhibitors - Drugs For Cancer JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 Tier 3 PA; SP MG (ruxolitinib) Antineoplastic - Janus Kinase(Jak),Fms-Like Tyrosine Kinase(Flt) Inhib - Drugs For Cancer INREBIC ORAL CAPSULE 100 MG (fedratinib) Tier 3 PA; SP Antineoplastic - Kinase Inhibitor And Aromatase Inhibitor Combination - Drugs For Cancer KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)- Tier 3 PA; SP 2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG (ribociclib) Antineoplastic - Lhrh (Gnrh) Agonist Analog Pituitary Suppressants - Drugs For Cancer ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 Tier 4 PA MG (leuprolide)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

72 Coverage Prescription Drug Name Drug Tier Requirements and Limits ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG Tier 4 PA (leuprolide) ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG Tier 4 PA (leuprolide) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 Tier 4 PA MONTH) (leuprolide) leuprolide subcutaneous kit 1 mg/0.2 ml Tier 4 PA Antineoplastic - Lhrh (Gnrh) Antagonist Pituitary Suppressants - Drugs For Cancer FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS Tier 4 QL (2 EA per 365 days) RECON SOLN 120 MG (degarelix) FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS Tier 4 QL (1 EA per 30 days) RECON SOLN 80 MG (degarelix) FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG Tier 4 QL (2 EA per 365 days) (degarelix) Antineoplastic - Mast Cell Stabilizers - Drugs For Cancer cromolyn oral concentrate 100 mg/5 ml Tier 1 Antineoplastic - Mek1 And Mek2 Kinase Inhibitors - Drugs For Cancer PA; SP; QL (63 EA per 28 COTELLIC ORAL TABLET 20 MG (cobimetinib) Tier 3 days) MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib) Tier 3 PA; SP PA; SP; QL (6 EA per 1 MEKTOVI ORAL TABLET 15 MG (binimetinib) Tier 3 day) Antineoplastic - Mtor Kinase Inhibitors - Drugs For Cancer AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 Tier 3 PA; SP MG, 3 MG, 5 MG (everolimus)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

73 Coverage Prescription Drug Name Drug Tier Requirements and Limits AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG Tier 3 PA; SP (everolimus) Antineoplastic - Multikinase Inhibitors - Drugs For Cancer CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG Tier 3 PA; SP (cabozantinib) COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 PA; SP; QL (112 EA per 28 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY Tier 3 days) (20 MG X 3/DAY) (cabozantinib) PA; SP; QL (2 EA per 1 ICLUSIG ORAL TABLET 15 MG (ponatinib) Tier 3 day) PA; SP; QL (1 EA per 1 ICLUSIG ORAL TABLET 45 MG (ponatinib) Tier 3 day) PA; SP; QL (4 EA per 1 NEXAVAR ORAL TABLET 200 MG (sorafenib) Tier 3 day) PA; SP; QL (3 EA per 1 STIVARGA ORAL TABLET 40 MG (regorafenib) Tier 3 day) Antineoplastic - Mutant Isocitrate Dehydrogenase 1 (Midh1) Inhibitors - Drugs For Cancer TIBSOVO ORAL TABLET 250 MG (ivosidenib) Tier 3 PA; SP Antineoplastic - Mutant Isocitrate Dehydrogenase 2 (Midh2) Inhibitors - Drugs For Cancer IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib) Tier 3 PA; SP Antineoplastic - Phosphatidylinositol 3-Kinase (Pi3k) Inhibitors - Drugs For Cancer COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) Tier 3 PA; SP ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) Tier 3 PA; SP

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

74 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Pi3k-Alpha Inhibitors - Drugs For Cancer PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1), 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X Tier 3 PA; SP 2) (alpelisib) Antineoplastic - Pi3k-Delta And Gamma Inhibitors - Drugs For Cancer COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) Tier 3 PA; SP Antineoplastic - Pi3k-Delta Inhibitors - Drugs For Cancer ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) Tier 3 PA; SP Antineoplastic - Poly (Adp-Ribose) Polymerase (Parp) Inhibitors - Drugs For Cancer LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) Tier 3 PA; SP RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA; SP; QL (4 EA per 1 Tier 3 (rucaparib) day) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib) Tier 3 PA; SP ZEJULA ORAL CAPSULE 100 MG (niraparib) Tier 3 PA; SP Antineoplastic - Progestins - Drugs For Cancer megestrol oral tablet 20 mg, 40 mg Tier 1 Antineoplastic - Proteasome Enzyme Inhibitors - Drugs For Cancer NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG Tier 3 PA; SP (ixazomib) Antineoplastic - Protein-Tyrosine Kinase Inhibitors - Drugs For Cancer PA; SP; QL (3 EA per 1 BOSULIF ORAL TABLET 100 MG (bosutinib) Tier 3 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

75 Coverage Prescription Drug Name Drug Tier Requirements and Limits PA; SP; QL (1 EA per 1 BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) Tier 3 day) CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) Tier 3 PA; SP PA; SP; QL (2 EA per 1 CAPRELSA ORAL TABLET 100 MG (vandetanib) Tier 3 day) PA; SP; QL (1 EA per 1 CAPRELSA ORAL TABLET 300 MG (vandetanib) Tier 3 day) PA; SP; QL (3 EA per 1 imatinib oral tablet 100 mg Tier 3 day) PA; SP; QL (2 EA per 1 imatinib oral tablet 400 mg Tier 3 day) IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) Tier 3 PA; SP IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, Tier 3 PA; SP 560 MG (ibrutinib) PA; SP; QL (6 EA per 1 INLYTA ORAL TABLET 1 MG (axitinib) Tier 3 day) PA; SP; QL (4 EA per 1 INLYTA ORAL TABLET 5 MG (axitinib) Tier 3 day) LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X Tier 3 PA; SP 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2) (lenvatinib) OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib) Tier 3 PA; SP ROZLYTREK ORAL CAPSULE 100 MG, 200 MG Tier 3 PA; SP (entrectinib) RYDAPT ORAL CAPSULE 25 MG (midostaurin) Tier 3 PA; SP SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 Tier 3 PA; SP MG, 70 MG, 80 MG (dasatinib) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 PA; SP; QL (1 EA per 1 Tier 3 MG (sunitinib) day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

76 Coverage Prescription Drug Name Drug Tier Requirements and Limits TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG PA; SP; QL (4 EA per 1 Tier 3 (nilotinib) day) TURALIO ORAL CAPSULE 200 MG (pexidartinib) Tier 3 PA; SP PA; SP; QL (4 EA per 1 VOTRIENT ORAL TABLET 200 MG (pazopanib) Tier 3 day) Antineoplastic - Radiopharmaceuticals - Drugs For Cancer HICON ORAL KIT 1,000 MCI/ML (1 ML), 250 MCI/0.25 ML, Tier 3 500 MCI/0.5 ML (iodine-131) Antineoplastic - Retinoids - Drugs For Cancer tretinoin (chemotherapy) oral capsule 10 mg Tier 3 SP Antineoplastic - Selective Estrogen Receptor Modulators (Serms) - Drugs For Cancer SOLTAMOX ORAL SOLUTION 10 MG/5 ML (tamoxifen) Tier 2 tamoxifen oral tablet 10 mg, 20 mg Tier 0 toremifene oral tablet 60 mg Tier 3 PA; SP Antineoplastic - Selective Inhibitiors Of Nuclear Export (Sine) - Drugs For Cancer XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5), 160 MG/WEEK (20 MG X 8), 60 MG/WEEK (20 MG X 3), 80 Tier 3 PA; SP MG/WEEK (20 MG X 4) (selinexor) Antineoplastic - Selective Retinoid X Receptor Agonists - Drugs For Cancer bexarotene oral capsule 75 mg Tier 3 PA; SP Antineoplastic - Thalidomide Analogs - Drugs For Cancer POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG Tier 3 PA; SP (pomalidomide) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 Tier 3 PA; SP MG, 25 MG, 5 MG (lenalidomide) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

77 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antineoplastic - Topoisomerase I Inhibitors - Drugs For Cancer HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan) Tier 3 SP Antineoplastic - Tropomyosin Receptor Kinase (Trk) Inhibitor - Drugs For Cancer VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib) Tier 3 PA; SP VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib) Tier 3 PA; SP Antineoplastic -Cephalotaxines - Drugs For Cancer SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG Tier 4 PA (omacetaxine mepesuccinate) Fluorouracil And Related Rescue Agents - Drugs For Cancer VISTOGARD ORAL GRANULES IN PACKET 10 GRAM SP; QL (24 EA per 14 Tier 3 (uridine) days) Methotrexate Rescue Agents - Drugs For Cancer leucovorin calcium oral tablet 15 mg Tier 1 Methotrexate Rescue Agents - Folic Acid Antagonist Type - Drugs For Cancer leucovorin calcium oral tablet 10 mg, 15 mg Tier 1 leucovorin calcium oral tablet 25 mg, 5 mg Tier 1 Urinary Tract Protective Agents Used In Conjunction With Chemotherapy - Drugs For Cancer MESNEX ORAL TABLET 400 MG (mesna) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

78 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiseptics And Disinfectants - Antiseptics And Disinfectants Antiseptic - Chlorine Releasing - Antiseptics And Disinfectants DELUO TOPICAL SPRAY,NON-AEROSOL 0.018 %-0.004 Tier 3 % -0.06 % (hypochlorous acid) HYCLODEX TOPICAL SPRAY,NON-AEROSOL 0.012 %- Tier 3 0.002 % -0.046 % (hypochlorous acid) MICROCYN TOPICAL SPRAY,NON-AEROSOL 0.003 %- Tier 3 0.004 % -0.023 % (hypochlorous acid) Antiseptic - Iodine/Iodophores - Antiseptics And Disinfectants IODOFLEX TOPICAL PADS, MEDICATED 0.9 % Tier 3 (cadexomer iodine) IODOSORB TOPICAL GEL 0.9 % (cadexomer iodine) Tier 3 LUGOLS TOPICAL SOLUTION 5-10 % (iodine) Tier 1 STRONG IODINE TOPICAL SOLUTION 5-10 % (iodine) Tier 1 Antiseptic - Oxidizing Agents - Antiseptics And Disinfectants hydrogen peroxide (bulk) solution 30 % Tier 3 hydrogen peroxide solution 3 % Tier 1 Biologicals - Biological Agents Allergenic Extracts - Grass Pollen - Biological Agents GRASTEK SUBLINGUAL TABLET 2,800 BAU (grass Tier 2 PA pollen-timothy, standard) ORALAIR SUBLINGUAL TABLET 100 INDX REACTIVITY, 300 INDX REACTIVITY (grass pollen-orchard grass, Tier 2 PA standard)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

79 Coverage Prescription Drug Name Drug Tier Requirements and Limits ORALAIR SUBLINGUAL TABLET 100 IR (3) /300 IR (6) Tier 3 PA (grass pollen-orchard grass, standard) Allergenic Extracts - Mite Extracts - Biological Agents ODACTRA SUBLINGUAL TABLET 12 SQ-HDM (mite- Tier 2 PA Dermatophagoides farinae, standardized) Allergenic Extracts - Weed Pollen - Biological Agents RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT Tier 2 PA (weed pollen-short ragweed) Antivenoms - Scorpion Antivenoms - Biological Agents ANASCORP INTRAVENOUS RECON SOLN 120 MG Tier 4 (centruroides(scorpion) immune F(ab)2 antivenom(eq)) Hepatitis A And Hepatitis B Vaccine Combinations - Vaccines TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA QL (4 ML per 365 days); Tier 0 UNIT- 20 MCG/ML (hepatitis A virus vaccine) Age (Min 18 Years) Hepatitis A Vaccine - Single Agents - Vaccines HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 QL (2 ML per 365 days); Tier 0 ELISA UNIT/ML (hepatitis A virus vaccine) Age (Min 18 Years) HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA QL (2 ML per 365 days); Tier 0 UNIT/ML (hepatitis A virus vaccine) Age (Min 18 Years) VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 QL (2 ML per 365 days); Tier 0 UNIT/ML (hepatitis A virus vaccine) Age (Min 18 Years) VAQTA (PF) INTRAMUSCULAR SYRINGE 50 UNIT/ML QL (2 ML per 365 days); Tier 0 (hepatitis A virus vaccine) Age (Min 18 Years) Hepatitis B Vaccines - Single Agents - Vaccines ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 QL (3 ML per 365 days); Tier 0 MCG/ML (hepatitis B virus vaccine) Age (Min 18 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

80 Coverage Prescription Drug Name Drug Tier Requirements and Limits ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 QL (3 ML per 365 days); Tier 0 MCG/ML (hepatitis B virus vaccine) Age (Min 18 Years) HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION 20 QL (1 ML per 365 days); Tier 0 MCG/0.5 ML (hepatitis B virus vaccine) Age (Min 18 Years) HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 20 QL (1 ML per 365 days); Tier 0 MCG/0.5 ML (hepatitis B virus vaccine) Age (Min 18 Years) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION QL (3 ML per 365 days); Tier 0 10 MCG/ML, 40 MCG/ML (hepatitis B virus vaccine) Age (Min 18 Years) RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 QL (3 ML per 365 days); Tier 0 MCG/ML (hepatitis B virus vaccine) Age (Min 18 Years) Immune Globulin - Gamma Globulin (Igg), Human - Biological Agents CUTAQUIG SUBCUTANEOUS SOLUTION 16.5 % Tier 4 PA (immune globulin,gamma (IgG)-hipp human) CUVITRU SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 Tier 4 PA GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %) (immune globulin,gamma (IgG) human) GAMMAGARD LIQUID INJECTION SOLUTION 10 % Tier 4 PA (immune globulin,gamma (IgG) human) GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 Tier 4 PA GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %) (immune globulin,gamma (IgG) human) GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 Tier 4 PA GRAM/50 ML (10 %) (immune globulin,gamma (IgG) human) HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 Tier 4 PA GRAM/20 ML (20 %) (immune globulin,gamma (IgG) human) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

81 Coverage Prescription Drug Name Drug Tier Requirements and Limits HYQVIA IG COMPONENT SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 Tier 4 PA GRAM/50 ML (10 %) (immune globulin,gamma (IgG) human) HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 Tier 4 PA %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) (immune globulin,gamma (IgG) human) XEMBIFY SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 Tier 4 PA GRAM/20 ML (20 %) (immune globulin,gamma (IgG)-klhw human) Live Vaccine And Live Virus Formulations - Vaccines adenovirus vac live type-4, 7 oral tablet,delayed release Tier 3 (dr/ec) adenovirus vaccine live type-4 oral tablet,delayed release Tier 3 (dr/ec) adenovirus vaccine live type-7 oral tablet,delayed release Tier 3 (dr/ec) ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML (rotavirus vacc,live oral, 89-12 Tier 3 strain,g1p(8) type) ROTATEQ VACCINE ORAL SOLUTION 2 ML (rotavirus Tier 3 vacc, live oral pentavalent) VAXCHORA ACTIVE COMPONENT ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF Tier 3 UNIT (cholera vaccine) VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2 Tier 3 BILLION UNIT (typhoid vaccine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

82 Coverage Prescription Drug Name Drug Tier Requirements and Limits Toxoid Vaccine Combinations - Vaccines ADACEL(TDAP ADOLESN/ADULT)(PF) QL (0.5 ML per 365 days); INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)- Tier 0 Age (Min 18 Years) 5LF/0.5 ML (diphtheria,pertussis (acellular),tetanus vaccine) ADACEL(TDAP ADOLESN/ADULT)(PF) QL (0.5 ML per 365 days); INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)- Tier 0 Age (Min 18 Years) 5LF/0.5 ML (diphtheria,pertussis (acellular),tetanus vaccine) BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 2.5- QL (0.5 ML per 365 days); 8-5 LF-MCG-LF/0.5ML (diphtheria,pertussis Tier 0 Age (Min 18 Years) (acellular),tetanus vaccine) BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-8-5 QL (0.5 ML per 365 days); LF-MCG-LF/0.5ML (diphtheria,pertussis (acellular),tetanus Tier 0 Age (Min 18 Years) vaccine) TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 QL (0.5 ML per 365 days); Tier 0 ML (tetanus and diphtheria toxoids) Age (Min 18 Years) TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF QL (0.5 ML per 365 days); Tier 0 UNIT- 2 LF UNIT/0.5ML (tetanus and diphtheria toxoids) Age (Min 18 Years) TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF QL (0.5 ML per 365 days); Tier 0 UNIT/0.5 ML (tetanus and diphtheria toxoids) Age (Min 18 Years) Vaccine Bacterial - Gram Negative Bacilli (Non- Enteric) - Vaccines VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2 Tier 3 BILLION UNIT (typhoid vaccine) Vaccine Bacterial - Gram Negative Cocci - Vaccines MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 QL (0.5 ML per 365 days); MCG/0.5 ML (meningococcal vaccine A,C,Y and W-135, dip Tier 0 Age (Min 11 Years and tox con) Max 23 Years) MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT QL (1 EA per 365 days); 10-5 MCG/0.5 ML (meningococcal vaccine A,C,Y and W- Tier 0 Age (Min 11 Years and 135, dip tox con) Max 23 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

83 Coverage Prescription Drug Name Drug Tier Requirements and Limits Vaccine Bacterial - Gram Positive Cocci - Vaccines PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML QL (0.5 ML per 365 days); Tier 0 (pneumococcal vaccine) Age (Min 65 Years) PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML QL (0.5 ML per 365 days); Tier 0 (pneumococcal vaccine) Age (Min 65 Years) PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML QL (0.5 ML per 365 days); Tier 0 (pneumococcal vaccine) Age (Min 65 Years) Vaccine Bacterial - Meningococcal Group B Vaccines - Vaccines BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 QL (1 ML per 365 days); MCG/0.5 ML (Neisseria meningitidis group B, NHBA Tier 0 Age (Min 10 Years and recombinant) Max 25 Years) QL (1.5 ML per 365 days); TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 Tier 0 Age (Min 10 Years and ML (Neisseria meningitidis grp B,lipidated fHBP, rec.) Max 25 Years) Vaccine Bacterial - Toxin-Producing Bacilli - Vaccines VAXCHORA ACTIVE COMPONENT ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF Tier 3 UNIT (cholera vaccine) VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT Tier 3 (cholera vaccine) Vaccine Viral - Adenovirus - Vaccines adenovirus vac live type-4, 7 oral tablet,delayed release Tier 3 (dr/ec) adenovirus vaccine live type-4 oral tablet,delayed release Tier 3 (dr/ec) adenovirus vaccine live type-7 oral tablet,delayed release Tier 3 (dr/ec)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

84 Coverage Prescription Drug Name Drug Tier Requirements and Limits Vaccine Viral - Human Papillomavirus (Hpv) Vaccines - Vaccines QL (1.5 ML per 365 days); GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 Tier 0 Age (Min 9 Years and Max ML (human papillomavirus vaccine, 9-valent) 26 Years) QL (1.5 ML per 365 days); GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML Tier 0 Age (Min 9 Years and Max (human papillomavirus vaccine, 9-valent) 26 Years) Vaccine Viral - Influenza A And B - Vaccines AFLURIA QD 2019-20(3YR UP)(PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus Tier 0 QL (0.5 ML per 180 days) vaccine qv 2019-20 (36 months up)) AFLURIA QD 2019-20(6-35MO)(PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML (influenza virus Tier 0 QL (0.25 ML per 180 days) vaccine qv 2019-2020(6 mos-35 mos)) AFLURIA QUAD 2019-20(6MO UP) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza Tier 0 QL (0.5 ML per 180 days) virus vaccine quad 2019-20 (6 months up)) FLUAD 2019-2020 (65 YR UP)(PF) INTRAMUSCULAR QL (0.5 ML per 180 days); SYRINGE 45 MCG (15 MCG X 3)/0.5 ML (influenza virus Tier 0 Age (Min 65 Years) vaccine trival 2019-2020(65 yr up)) FLUARIX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus Tier 0 QL (0.5 ML per 180 days) vaccine quad 2019-20 (6 months up)) FLUBLOK QUAD 2019-2020 (PF) INTRAMUSCULAR QL (0.5 ML per 180 days); SYRINGE 180 MCG (45 MCG X 4)/0.5 ML (influenza virus Tier 0 Age (Min 18 Years) vaccine qv 2019-20 (18 yr up),rcmb) FLUCELVAX QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus Tier 0 QL (0.5 ML per 180 days) vac qv 19-20 (4 yrs up)cell deriv.) FLUCELVAX QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza Tier 0 QL (0.5 ML per 180 days) virus vac qv 19-20 (4 yrs up)cell deriv.) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

85 Coverage Prescription Drug Name Drug Tier Requirements and Limits FLULAVAL QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus Tier 0 QL (0.5 ML per 180 days) vaccine quad 2019-20 (6 months up)) FLULAVAL QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza Tier 0 QL (0.5 ML per 180 days) virus vaccine quad 2019-20 (6 months up)) FLUMIST QUAD 2019-2020 NASAL NASAL SPRAY SYRINGE 10EXP6.5-7.5 FF UNIT/0.2 ML (influenza virus Tier 0 QL (1 EA per 180 days) vaccine qval 2019-2020 (2-49 yrs)) FLUZONE HIGH-DOSE 2019-20 (PF) INTRAMUSCULAR QL (0.5 ML per 180 days); SYRINGE 180 MCG/0.5 ML (influenza virus vaccine trival Tier 0 Age (Min 65 Years) 2019-2020(65 yr up)) FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza Tier 0 QL (0.5 ML per 180 days) virus vaccine quad 2019-20 (6 months up)) FLUZONE QUAD 2019-2020 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML (influenza virus Tier 0 QL (0.5 ML per 180 days) vaccine quad 2019-20 (6 months up)) FLUZONE QUAD 2019-2020 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML (influenza Tier 0 QL (0.5 ML per 180 days) virus vaccine quad 2019-20 (6 months up)) FLUZONE QUAD PEDI 2019-20 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML (influenza virus Tier 0 QL (0.25 ML per 180 days) vaccine qv 2019-2020(6 mos-35 mos)) Vaccine Viral - Varicella - Vaccines SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR QL (2 EA per 365 days); RECONSTITUTION 50 MCG/0.5 ML (varicella-zoster virus Tier 0 Age (Min 50 Years) glycoprotein E, recombinant) SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR QL (2 EA per 365 days); Tier 0 RECONSTITUTION 50 MCG (varicella-zoster virus Age (Min 50 Years) glycoprotein E, recombinant)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

86 Coverage Prescription Drug Name Drug Tier Requirements and Limits VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR QL (2 EA per 365 days); RECONSTITUTION 1,350 UNIT/0.5 ML (varicella virus Tier 0 Age (Min 18 Years) vaccine live) ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR QL (1 EA per 365 days); RECONSTITUTION 19,400 UNIT/0.65 ML (varicella virus Tier 0 Age (Min 60 Years) vaccine live) Vaccine Viral Combinations - Vaccines M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000- QL (2 EA per 365 days); 12,500 TCID50/0.5 ML (measles, mumps, and rubella Tier 0 Age (Min 18 Years) vaccine live) PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR QL (2 EA per 365 days); RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5 Tier 0 Age (Min 18 Years) (measles, mumps, rubella,and varicella live vaccine) Cardiovascular Therapy Agents - Drugs For The Heart Ace Inhibitor And Calcium Channel Blocker Combinations - Drugs For High Blood Pressure amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, Tier 1 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg ST: Must meet 2 of the following requirements: Amlodipine Besylate, Amlodipine Besylate/benazepril, Benazepril HCL, Captopril, PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 Enalapril Maleate, Epaned, Tier 3 MG (perindopril) Fosinopril Sodium, Lisinopril, Moexipril HCL, Perindopril Erbumine, Qbrelis, Quinapril HCL, Ramipril, or Trandolapril in 365 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

87 Coverage Prescription Drug Name Drug Tier Requirements and Limits trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 Tier 1 mg, 2-180 mg, 2-240 mg, 4-240 mg Ace Inhibitor And Diuretic Combinations - Drugs For High Blood Pressure benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 Tier 1 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 Tier 1 mg fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 Tier 1 mg, 20-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20- Tier 1 12.5 mg, 20-25 mg Ace Inhibitors - Drugs For High Blood Pressure benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg Tier 1 enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 ST: Must meet the following requirement: Enalapril Maleate in 120 EPANED ORAL SOLUTION 1 MG/ML (enalaprilat) Tier 3 days if 12 years of age and older; QL (1200 ML per 30 days) fosinopril oral tablet 10 mg, 20 mg, 40 mg Tier 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 Tier 1 mg moexipril oral tablet 15 mg, 7.5 mg Tier 1 perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

88 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) Tier 3 Lisinopril in 120 days if 12 years of age and older; QL (1200 ML per 30 days) quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg Tier 1 trandolapril oral tablet 1 mg, 2 mg, 4 mg Tier 1 Aldosterone Receptor Antagonists - Drugs For High Blood Pressure eplerenone oral tablet 25 mg, 50 mg Tier 1 spironolactone oral tablet 100 mg, 25 mg, 50 mg Tier 1 Alpha-Beta Blockers - Drugs For High Blood Pressure carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg Tier 1 carvedilol phosphate oral capsule, er multiphase 24 hr 10 Tier 1 mg, 20 mg, 40 mg, 80 mg labetalol oral tablet 100 mg, 200 mg, 300 mg Tier 1 Angiotensin Ii Receptor Blocker (Arb)-Calcium Channel Blocker Comb. - Drugs For High Blood Pressure amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 Tier 1 mg, 5-40 mg amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5- Tier 1 160 mg, 5-320 mg telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 Tier 1 mg, 80-5 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

89 Coverage Prescription Drug Name Drug Tier Requirements and Limits Angiotensin Ii Receptor Blocker (Arb)-Calcium Channel Blocker-Diuretic - Drugs For High Blood Pressure amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, Tier 1 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg olmesartan-amlodipin-hcthiazid oral tablet 20-5-12.5 mg, Tier 1 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg Angiotensin Ii Receptor Blocker (Arb)-Diuretic Combinations - Drugs For High Blood Pressure candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32- Tier 1 12.5 mg, 32-25 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

90 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Amlodipine Besylate/benazepril, Benazepril HCL, Benazepril/hydrochlorothia zide, Captopril, Captopril/hydrochlorothiazi de, Enalapril Maleate, Enalapril/hydrochlorothiazi de, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazi de, Irbesartan, EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG Tier 2 Irbesartan/hydrochlorothiaz (azilsartan) ide, Lisinopril, Lisinopril/hydrochlorothiazi de, Losartan Potassium, Losartan/hydrochlorothiazi de, Moexipril HCL, Moexipril/hydrochlorothiazi de, Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazi de, Ramipril, Trandolapril, Trandolapril/verapamil HCL, or Valsartan/hydrochlorothiazi de in 120 days irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- Tier 1 12.5 mg losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100- Tier 1 25 mg, 50-12.5 mg olmesartan-hydrochlorothiazide oral tablet 20-12.5 mg, 40- Tier 1 12.5 mg, 40-25 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

91 Coverage Prescription Drug Name Drug Tier Requirements and Limits telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80- Tier 1 12.5 mg, 80-25 mg valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160- Tier 1 25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg Angiotensin Ii Receptor Blocker-Neprilysin Inhibitor Comb. (Arni) - Drugs For High Blood Pressure ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 Tier 2 QL (2 EA per 1 day) MG (sacubitril) Angiotensin Ii Receptor Blockers (Arbs) - Drugs For High Blood Pressure candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

92 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Amlodipine Besylate/benazepril, Benazepril HCL, Benazepril/hydrochlorothia zide, Captopril, Captopril/hydrochlorothiazi de, Enalapril Maleate, Enalapril/hydrochlorothiazi de, Epaned, Fosinopril Sodium, Fosinopril/hydrochlorothiazi de, Irbesartan, EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan) Tier 2 Irbesartan/hydrochlorothiaz ide, Lisinopril, Lisinopril/hydrochlorothiazi de, Losartan Potassium, Losartan/hydrochlorothiazi de, Moexipril HCL, Moexipril/hydrochlorothiazi de, Perindopril Erbumine, Qbrelis, Quinapril HCL, Quinapril/hydrochlorothiazi de, Ramipril, Trandolapril, Trandolapril/verapamil HCL, or Valsartan/hydrochlorothiazi de in 120 days eprosartan oral tablet 600 mg Tier 1 irbesartan oral tablet 150 mg, 300 mg, 75 mg Tier 1 losartan oral tablet 100 mg, 25 mg, 50 mg Tier 1 olmesartan oral tablet 20 mg, 40 mg, 5 mg Tier 1 telmisartan oral tablet 20 mg, 40 mg, 80 mg Tier 1 valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

93 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antianginal - Coronary Vasodilators (Nitrates) - Drugs For Angina amyl nitrite inhalation solution 0.3 ml Tier 1 DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE Tier 3 40 MG (isosorbide) ST: Must meet the following requirements: GONITRO SUBLINGUAL POWDER IN PACKET 400 MCG Tier 3 Two generic sublingual (nitroglycerin) Nitroglycerin products in 365 days ISORDIL ORAL TABLET 40 MG (isosorbide) Tier 2 isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg Tier 1 isosorbide dinitrate oral tablet extended release 40 mg Tier 1 isosorbide mononitrate oral tablet 10 mg, 20 mg Tier 1 isosorbide mononitrate oral tablet extended release 24 hr Tier 1 120 mg, 30 mg, 60 mg nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 Tier 1 Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) nitroglycerin (Nitro-Bid Transdermal Ointment 2 %) Tier 2 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 Tier 2 MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin oral capsule, extended release 2.5 mg, 6.5 mg, Tier 1 9 mg nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg Tier 1 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 Tier 1 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual spray,non-aerosol 400 mcg/spray Tier 1 NITROMIST TRANSLINGUAL AEROSOL,SPRAY 400 Tier 3 MCG/SPRAY (nitroglycerin) nitroglycerin (Nitro-Time Oral Capsule, Extended Release Tier 1 2.5 Mg, 6.5 Mg, 9 Mg)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

94 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antianginal And Anti-Ischemic Agents, Non- Hemodynamic - Drugs For Angina ranolazine oral tablet extended release 12 hr 1,000 mg Tier 1 QL (60 EA per 30 days) ranolazine oral tablet extended release 12 hr 500 mg Tier 1 QL (120 EA per 30 days) Antiarrhythmic - Class Ia - Drugs For Abnormal Heart Rhythms disopyramide phosphate oral capsule 100 mg, 150 mg Tier 1 NORPACE CR ORAL CAPSULE, EXTENDED RELEASE Tier 2 100 MG, 150 MG (disopyramide) quinidine gluconate oral tablet extended release 324 mg Tier 1 quinidine sulfate oral tablet 200 mg, 300 mg Tier 1 Antiarrhythmic - Class Ib - Drugs For Abnormal Heart Rhythms mexiletine oral capsule 150 mg, 200 mg, 250 mg Tier 1 Antiarrhythmic - Class Ic - Drugs For Abnormal Heart Rhythms flecainide oral tablet 100 mg, 150 mg, 50 mg Tier 1 propafenone oral capsule,extended release 12 hr 225 mg, Tier 1 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg Tier 1 Antiarrhythmic - Class Ii - Drugs For Abnormal Heart Rhythms sotalol (Sorine Oral Tablet 120 Mg, 160 Mg, 240 Mg, 80 Tier 1 Mg) sotalol (Sotalol Af Oral Tablet 120 Mg, 160 Mg, 80 Mg) Tier 1 sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

95 Coverage Prescription Drug Name Drug Tier Requirements and Limits QL: 8 BOTTLES IN 30 DAYS; ST: Must meet the SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol) Tier 3 following requirement: Sotalol HCL in 120 days Antiarrhythmic - Class Iii - Drugs For Abnormal Heart Rhythms amiodarone oral tablet 100 mg, 200 mg, 400 mg Tier 1 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg Tier 1 MULTAQ ORAL TABLET 400 MG (dronedarone) Tier 2 amiodarone (Pacerone Oral Tablet 100 Mg, 200 Mg, 400 Tier 1 Mg) Antiarrhythmic - Class Iv - Drugs For Abnormal Heart Rhythms verapamil oral tablet 120 mg, 40 mg, 80 mg Tier 1 Antihyperlipidemic - Bile Acid Sequestrants - Drugs For Cholesterol cholestyramine (with sugar) oral powder 4 gram Tier 1 cholestyramine (with sugar) oral powder in packet 4 gram Tier 1 cholestyramine (Cholestyramine Light Oral Powder 4 Gram) Tier 1 cholestyramine (Cholestyramine Light Oral Powder In Tier 1 Packet 4 Gram) colesevelam oral powder in packet 3.75 gram Tier 1 colesevelam oral tablet 625 mg Tier 1 COLESTID FLAVORED ORAL PACKET 7.5 GRAM Tier 3 (colestipol) colestipol oral granules 5 gram Tier 1 colestipol oral packet 5 gram Tier 1 colestipol oral tablet 1 gram Tier 1 cholestyramine (Prevalite Oral Powder 4 Gram) Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

96 Coverage Prescription Drug Name Drug Tier Requirements and Limits cholestyramine (Prevalite Oral Powder In Packet 4 Gram) Tier 1 Antihyperlipidemic - Fibric Acid Derivatives - Drugs For Cholesterol ST: Must meet any of the following requirements: Antara, Fenofibrate ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate) Tier 3 Nanocrystallized, Fenofibrate, Fenofibrate micronized, Gemfibrozil, or Triglide in 120 days fenofibrate micronized oral capsule 130 mg, 134 mg, 200 Tier 1 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg Tier 1 fenofibrate oral capsule 150 mg, 50 mg Tier 1 fenofibrate oral tablet 120 mg, 160 mg, 40 mg, 54 mg Tier 1 fenofibric acid (choline) oral capsule,delayed release(dr/ec) Tier 1 135 mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg Tier 1 gemfibrozil oral tablet 600 mg Tier 1 Antihyperlipidemic - Hmg Coa Reductase Inhibitors (Statins) - Drugs For Cholesterol ST: Must meet 2 of the following requirements: Altoprev, Atorvastatin ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Calcium, Lovastatin, 20 MG, 40 MG, 60 MG (lovastatin) Pravastatin Sodium, or Simvastatin in 365 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

97 Coverage Prescription Drug Name Drug Tier Requirements and Limits $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF atorvastatin oral tablet 10 mg, 20 mg Tier 1 CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) atorvastatin oral tablet 40 mg, 80 mg Tier 1 QL (1 EA per 1 day) ST: Must meet the following requirement: EZALLOR SPRINKLE ORAL CAPSULE, SPRINKLE 10 Tier 3 Generic Rosuvastatin MG, 20 MG, 40 MG, 5 MG (rosuvastatin) Calcium in 120 days; QL (1 EA per 1 day) FLOLIPID ORAL SUSPENSION 20 MG/5 ML (4 MG/ML), Tier 3 PA 40 MG/5 ML (8 MG/ML) (simvastatin) $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 fluvastatin oral capsule 20 mg, 40 mg Tier 1 DAYS; ST: Must meet 2 of the following requirements: Altoprev, Atorvastatin Calcium, Lovastatin, Pravastatin Sodium, or Simvastatin in 365 days; QL (2 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

98 Coverage Prescription Drug Name Drug Tier Requirements and Limits $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 fluvastatin oral tablet extended release 24 hr 80 mg Tier 1 DAYS; ST: Must meet 2 of the following requirements: Altoprev, Atorvastatin Calcium, Lovastatin, Pravastatin Sodium, or Simvastatin in 365 days; QL (1 EA per 1 day) $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin) Tier 2 CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF lovastatin oral tablet 10 mg, 20 mg, 40 mg Tier 1 CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (2 EA per 1 day) $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg Tier 1 CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

99 Coverage Prescription Drug Name Drug Tier Requirements and Limits $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF rosuvastatin oral tablet 10 mg, 5 mg Tier 1 CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) rosuvastatin oral tablet 20 mg, 40 mg Tier 1 QL (1 EA per 1 day) $0 COPAY IF AGE 40-75 YEARS AND NO HISTORY OF simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL (1 EA per 1 day) ST: Must meet the following requirement: simvastatin oral tablet 80 mg Tier 1 Ezetimibe/simvastatin in 365 days; QL (1 EA per 1 day) ST: Must meet the ZYPITAMAG ORAL TABLET 1 MG, 2 MG, 4 MG following requirement: Tier 3 (pitavastatin) Livalo in 120 days; QL (1 EA per 1 day) Antihyperlipidemic - Nicotinic Acid Derivatives - Drugs For Cholesterol niacin oral tablet 500 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

100 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Altoprev, Antara, Atorvastatin Calcium, Fenofibrate, Fenofibrate niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, Tier 1 micronized, Fenofibrate 750 mg Nanocrystallized, Flolipid, Gemfibrozil, Lovastatin, Pravastatin Sodium, Simvastatin, or Triglide in 365 days niacin (Niacor Oral Tablet 500 Mg) Tier 1 Antihyperlipidemic - Omega-3 Fatty Acid Type - Drugs For Cholesterol omega-3 fatty acids (Triklo Oral Capsule 1 Gram) Tier 1 QL (4 EA per 1 day) VASCEPA ORAL CAPSULE 0.5 GRAM (icosapent ethyl) Tier 2 QL (8 EA per 1 day) VASCEPA ORAL CAPSULE 1 GRAM (icosapent ethyl) Tier 2 QL (4 EA per 1 day) Antihyperlipidemic - Selective Cholesterol Absorption Inhibitor - Drugs For Cholesterol ezetimibe oral tablet 10 mg Tier 1 QL (1 EA per 1 day) Antihyperlipidemic Agents - Dietary Source - Drugs For Cholesterol omega-3 acid ethyl esters oral capsule 1 gram Tier 1 QL (4 EA per 1 day) omega-3 fatty acids (Triklo Oral Capsule 1 Gram) Tier 1 QL (4 EA per 1 day) VASCEPA ORAL CAPSULE 0.5 GRAM (icosapent ethyl) Tier 2 QL (8 EA per 1 day) VASCEPA ORAL CAPSULE 1 GRAM (icosapent ethyl) Tier 2 QL (4 EA per 1 day) Antihyperlipidemic Agents - Dietary Source Combinations - Drugs For Cholesterol LIPOCHOL PLUS ORAL TABLET 0.5 MG (methionine) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

101 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperlipidemic Hmg Coa Reduct Inhib And Calcium Channel Blocker - Drugs For Cholesterol amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10- 40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 Tier 1 QL (1 EA per 1 day) mg, 5-20 mg, 5-40 mg, 5-80 mg Antihyperlipidemic-Hmg Coa Reduct Inhib And Cholesterol Absorp Inhibit - Drugs For Cholesterol ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10- Tier 1 QL (1 EA per 1 day) 40 mg ST: Must meet the following requirement: ezetimibe-simvastatin oral tablet 10-80 mg Tier 1 Simvastatin in 365 days; QL (1 EA per 1 day) Antihyperlipidemic-Microsomal Triglyceride Transfer Protein (Mtp)Inhib - Drugs For Cholesterol JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 Tier 3 PA; SP MG, 5 MG, 60 MG (lomitapide) Anti-Pcsk9 Monoclonal Antibodies - Drugs For Cholesterol PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 Tier 4 PA MG/ML, 75 MG/ML (alirocumab) REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE Tier 4 PA INJECTOR 420 MG/3.5 ML (evolocumab) REPATHA SURECLICK SUBCUTANEOUS PEN Tier 4 PA INJECTOR 140 MG/ML (evolocumab) REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 Tier 4 PA MG/ML (evolocumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

102 Coverage Prescription Drug Name Drug Tier Requirements and Limits Beta Blockers Cardiac Selective - Drugs For High Blood Pressure atenolol oral tablet 100 mg, 25 mg, 50 mg Tier 1 betaxolol oral tablet 10 mg, 20 mg Tier 1 bisoprolol fumarate oral tablet 10 mg, 5 mg Tier 1 BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG Tier 2 (nebivolol) KAPSPARGO SPRINKLE ORAL CAPSULE,SPRINKLE,ER Tier 3 24HR 100 MG, 200 MG, 25 MG, 50 MG (metoprolol) metoprolol succinate oral tablet extended release 24 hr 100 Tier 1 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 50 mg Tier 1 metoprolol tartrate oral tablet 25 mg, 37.5 mg, 75 mg Tier 1 Beta Blockers Cardiac Selective, Intrinsic Sympathomimetic Activity - Drugs For High Blood Pressure acebutolol oral capsule 200 mg, 400 mg Tier 1 Beta Blockers Non-Cardiac Select., Intrinsic Sympathomimetic Activity - Drugs For High Blood Pressure LEVATOL ORAL TABLET 20 MG (penbutolol) Tier 3 pindolol oral tablet 10 mg, 5 mg Tier 1 Beta Blockers Non-Cardiac Selective - Drugs For High Blood Pressure ST: Must meet the following requirement: Propranolol HCL in 120 HEMANGEOL ORAL SOLUTION 4.28 MG/ML (propranolol) Tier 3 days if 1 year of age and older; QL (360 ML per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

103 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the INDERAL XL ORAL CAPSULE,EXTENDED RELEASE following requirement: Tier 3 24HR 120 MG, 80 MG (propranolol) Propranolol HCL in 120 days ST: Must meet the INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE following requirement: Tier 3 24HR 120 MG, 80 MG (propranolol) Propranolol HCL in 120 days nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 1 propranolol oral capsule,extended release 24 hr 120 mg, Tier 1 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml Tier 1 (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg Tier 1 timolol maleate oral tablet 10 mg, 20 mg, 5 mg Tier 1 Bradykinin B2 Receptor Antagonists - Drugs For The Heart icatibant subcutaneous syringe 30 mg/3 ml Tier 4 PA Calcium Channel Blockers - Benzothiazepines - Drugs For High Blood Pressure CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 Tier 3 HR 120 MG (diltiazem) diltiazem (Cartia Xt Oral Capsule,Extended Release 24Hr Tier 1 120 Mg, 180 Mg, 240 Mg, 300 Mg) diltiazem hcl oral capsule,ext.rel 24h degradable 180 mg, Tier 1 240 mg diltiazem hcl oral capsule,extended release 12 hr 120 mg, Tier 1 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24 hr 120 mg, Tier 1 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

104 Coverage Prescription Drug Name Drug Tier Requirements and Limits diltiazem hcl oral capsule,extended release 24hr 120 mg, Tier 1 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg Tier 1 diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 Tier 1 mg, 300 mg, 360 mg, 420 mg diltiazem (Dilt-Xr Oral Capsule,Ext.Rel 24H Degradable 120 Tier 1 Mg, 180 Mg, 240 Mg) diltiazem (Matzim La Oral Tablet Extended Release 24 Hr Tier 1 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) diltiazem (Taztia Xt Oral Capsule,Extended Release 24 Hr Tier 1 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) Calcium Channel Blockers - Dihydropyridines - Cerebrovascular Specific - Drugs For High Blood Pressure nimodipine oral capsule 30 mg Tier 1 NYMALIZE ORAL SOLUTION 30 MG/10 ML, 60 MG/20 ML Tier 3 PA; SP (nimodipine) Calcium Channel Blockers - Dihydropyridines - Drugs For High Blood Pressure amlodipine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, Tier 1 5 mg isradipine oral capsule 2.5 mg, 5 mg Tier 1 KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine) Tier 3 QL (10 ML per 1 day) nicardipine oral capsule 20 mg, 30 mg Tier 1 nifedipine oral capsule 10 mg, 20 mg Tier 1 nifedipine oral tablet extended release 24hr 30 mg, 60 mg, Tier 1 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

105 Coverage Prescription Drug Name Drug Tier Requirements and Limits nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, Tier 1 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg Calcium Channel Blockers - Phenylakylamines - Drugs For High Blood Pressure verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, Tier 1 300 mg verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 Tier 1 mg, 240 mg, 360 mg verapamil oral tablet extended release 120 mg, 180 mg, Tier 1 240 mg Cardiac Selective Beta Blocker-Thiazide Diuretic And Related Comb. - Drugs For High Blood Pressure atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg Tier 1 bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5- Tier 1 6.25 mg, 5-6.25 mg DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 QL (2 EA per 1 day) 100-12.5 MG (metoprolol) DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 QL (1 EA per 1 day) 25-12.5 MG, 50-12.5 MG (metoprolol) metoprolol su-hydrochlorothiaz oral tablet extended release Tier 1 QL (2 EA per 1 day) 24 hr 100-12.5 mg metoprolol su-hydrochlorothiaz oral tablet extended release Tier 1 QL (1 EA per 1 day) 24 hr 25-12.5 mg metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100- Tier 1 50 mg, 50-25 mg Cardiovascular Sympathomimetic - Anaphylaxis Therapy Single Agents - Drugs For Serious Allergic Reaction AUVI-Q INJECTION AUTO-INJECTOR 0.1 MG/0.1 ML, Tier 4 QL (2 EA per 365 days) 0.15 MG/0.15 ML, 0.3 MG/0.3 ML (epinephrine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

106 Coverage Prescription Drug Name Drug Tier Requirements and Limits epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 Tier 4 QL (4 EA per 1 FILL) mg/0.3 ml, 0.3 mg/0.3 ml EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 Tier 4 QL (4 EA per 1 FILL) ML (epinephrine) EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML Tier 4 QL (4 EA per 1 FILL) (epinephrine) EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 Tier 4 QL (4 EA per 1 FILL) MG/0.3 ML (epinephrine) EPIPEN JR INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML Tier 4 QL (4 EA per 1 FILL) (epinephrine) SYMJEPI INJECTION SYRINGE 0.15 MG/0.3 ML, 0.3 Tier 4 QL (4 EA per 1 FILL) MG/0.3 ML (epinephrine) Cardiovascular Sympathomimetics - Drugs For Serious Allergic Reaction midodrine oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG Tier 3 PA; SP (droxidopa) Central Alpha-2 Agonists-Thiazide Diuretic And Related Comb. - Drugs For High Blood Pressure methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250- Tier 1 25 mg Central Alpha-2 Receptor Agonists - Drugs For High Blood Pressure clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg Tier 1 clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 Tier 1 hr, 0.3 mg/24 hr guanfacine oral tablet 1 mg, 2 mg Tier 1 methyldopa oral tablet 250 mg, 500 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

107 Coverage Prescription Drug Name Drug Tier Requirements and Limits Digitalis Glycosides - Drugs For The Heart digoxin (Digitek Oral Tablet 125 Mcg (0.125 Mg), 250 Mcg Tier 1 (0.25 Mg)) digoxin (Digox Oral Tablet 125 Mcg (0.125 Mg), 250 Mcg Tier 1 (0.25 Mg)) digoxin oral solution 50 mcg/ml (0.05 mg/ml) Tier 2 digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg) Tier 1 LANOXIN ORAL TABLET 187.5 MCG (0.1875 MG), 62.5 Tier 3 MCG (0.0625 MG) (digoxin) Direct Acting Vasodilators - Drugs For High Blood Pressure hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg Tier 1 minoxidil oral tablet 10 mg, 2.5 mg Tier 1 Diuretic - Aldosterone Receptor Antagonist, Non-Selective - Drugs For High Blood Pressure ST: Must meet the following requirement: CAROSPIR ORAL SUSPENSION 25 MG/5 ML Tier 3 Spironolactone in 120 (spironolactone) days; QL (600 ML per 30 days) Diuretic - Carbonic Anhydrase Inhibitors - Drugs For High Blood Pressure acetazolamide oral capsule, extended release 500 mg Tier 1 acetazolamide oral tablet 125 mg, 250 mg Tier 1 methazolamide oral tablet 25 mg, 50 mg Tier 1 Diuretic - Loop - Drugs For High Blood Pressure bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 ethacrynic acid oral tablet 25 mg Tier 1 furosemide oral solution 10 mg/ml Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

108 Coverage Prescription Drug Name Drug Tier Requirements and Limits furosemide oral solution 40 mg/5 ml (8 mg/ml) Tier 1 furosemide oral tablet 20 mg, 40 mg, 80 mg Tier 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg Tier 1 Diuretic - Potassium Sparing - Drugs For High Blood Pressure amiloride oral tablet 5 mg Tier 1 triamterene oral capsule 100 mg, 50 mg Tier 1 Diuretic - Potassium Sparing-Thiazide And Related Combinations - Drugs For High Blood Pressure ALDACTAZIDE ORAL TABLET 50-50 MG (spironolactone) Tier 3 amiloride-hydrochlorothiazide oral tablet 5-50 mg Tier 1 spironolacton-hydrochlorothiaz oral tablet 25-25 mg Tier 1 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg Tier 1 triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50 Tier 1 mg Diuretic - Selective Arginine Vasopressin V2 Receptor Antagonists - Drugs For High Blood Pressure JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) Tier 3 PA; SP JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 Tier 3 PA; SP MG (PM) (tolvaptan) SP; QL (30 EA per 365 SAMSCA ORAL TABLET 15 MG (tolvaptan) Tier 3 days) SP; QL (60 EA per 365 SAMSCA ORAL TABLET 30 MG (tolvaptan) Tier 3 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

109 Coverage Prescription Drug Name Drug Tier Requirements and Limits Diuretic - Thiazides And Related - Drugs For High Blood Pressure chlorothiazide oral tablet 250 mg, 500 mg Tier 1 chlorthalidone oral tablet 25 mg, 50 mg Tier 1 DIURIL ORAL SUSPENSION 250 MG/5 ML (chlorothiazide) Tier 3 hydrochlorothiazide oral capsule 12.5 mg Tier 1 hydrochlorothiazide oral tablet 12.5 mg Tier 1 hydrochlorothiazide oral tablet 25 mg, 50 mg Tier 1 indapamide oral tablet 1.25 mg, 2.5 mg Tier 1 methyclothiazide oral tablet 5 mg Tier 1 metolazone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 Ganglionic Blocking, Non-Depolarizing - Drugs For High Blood Pressure VECAMYL ORAL TABLET 2.5 MG (mecamylamine) Tier 3 PA Hyperpolarization-Activated Cyclic Nucleotide- Gated Channel Inhibitors - Drugs For High Blood Pressure CORLANOR ORAL SOLUTION 5 MG/5 ML (ivabradine) Tier 2 QL (20 ML per 1 day) ST: Must meet any of the following requirements: Bisoprolol Fumarate, CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine) Tier 2 Carvedilol, or Metoprolol Succinate in 120 days; QL (2 EA per 1 day) Hypertrophic Cardiomyopathy Treatment Agents, Ablative - Drugs For The Heart ABLYSINOL INTRA-ARTERIAL SOLUTION 99 % (ethyl Tier 3 alcohol)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

110 Coverage Prescription Drug Name Drug Tier Requirements and Limits Muscarinic Receptor Antagonists (Anticholinergic) - Drugs For Abnormal Heart Rhythms ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 Tier 4 ML, 1 MG/0.7 ML, 2 MG/0.7 ML (atropine) Non-Cardiac Selective Beta Blocker-Thiazide Diuretic And Related Comb. - Drugs For High Blood Pressure nadolol-bendroflumethiazide oral tablet 80-5 mg Tier 1 propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 Tier 1 mg Pah Agents - Selective Prostacyclin Receptor (Ip) Agonists - Drugs For High Blood Pressure UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 Tier 3 PA; SP MCG (selexipag) UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- Tier 3 PA; SP 800 MCG (60) (selexipag) Peripheral Alpha-1 Receptor Blockers - Drugs For High Blood Pressure CARDURA XL ORAL TABLET EXTENDED RELEASE Tier 3 24HR 4 MG, 8 MG (doxazosin) doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg Tier 1 phenoxybenzamine oral capsule 10 mg Tier 3 PA; SP prazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1 terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 Peripheral Vasodilators, Single Agents - Drugs For High Blood Pressure isoxsuprine oral tablet 10 mg, 20 mg Tier 1 papaverine injection solution 30 mg/ml Tier 4 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

111 Coverage Prescription Drug Name Drug Tier Requirements and Limits Pheochromocytoma, Agents To Treat - Drugs For High Blood Pressure DEMSER ORAL CAPSULE 250 MG (metyrosine) Tier 3 Plasma Kallikrein Inhibitor Agents, Recombinant Monoclonal Antibody - Drugs For The Heart TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML Tier 4 PA (150 MG/ML) (lanadelumab-flyo) Pulmonary Antihypertensive Agents - Prostacyclin-Type - Drugs For High Blood Pressure ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 Tier 3 PA; SP MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil) REMODULIN INJECTION SOLUTION 1 MG/ML, 10 Tier 4 PA MG/ML, 2.5 MG/ML, 5 MG/ML (treprostinil) treprostinil sodium injection solution 1 mg/ml, 10 mg/ml, 2.5 Tier 4 PA mg/ml, 5 mg/ml TYVASO INHALATION SOLUTION FOR NEBULIZATION Tier 3 PA; SP 1.74 MG/2.9 ML (0.6 MG/ML) (treprostinil) TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML Tier 3 PA; SP (treprostinil) TYVASO REFILL KIT INHALATION SOLUTION FOR Tier 3 PA; SP NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) (treprostinil) TYVASO STARTER KIT INHALATION SOLUTION FOR Tier 3 PA; SP NEBULIZATION 1.74 MG/2.9 ML (treprostinil) VENTAVIS INHALATION SOLUTION FOR NEBULIZATION Tier 3 PA; SP 10 MCG/ML, 20 MCG/ML (iloprost)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

112 Coverage Prescription Drug Name Drug Tier Requirements and Limits Pulmonary Antihypertensive Agents-Soluble Guanylate Cyclase Stimulator - Drugs For High Blood Pressure ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, Tier 3 PA; SP 2.5 MG (riociguat) Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists - Drugs For High Blood Pressure ambrisentan oral tablet 10 mg, 5 mg Tier 3 PA; SP bosentan oral tablet 125 mg, 62.5 mg Tier 3 PA; SP LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) Tier 3 PA; SP OPSUMIT ORAL TABLET 10 MG (macitentan) Tier 3 PA; SP TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) Tier 3 PA; SP TRACLEER ORAL TABLET FOR SUSPENSION 32 MG Tier 3 PA; SP (bosentan) Pulmonary Arterial Hypertension Agents- Selective Cgmp-Pde5 Inhibitors - Drugs For High Blood Pressure tadalafil (Alyq Oral Tablet 20 Mg) Tier 3 PA; SP REVATIO ORAL SUSPENSION FOR RECONSTITUTION Tier 3 PA; SP 10 MG/ML (sildenafil) sildenafil (pulm.hypertension) oral suspension for Tier 3 PA; SP reconstitution 10 mg/ml sildenafil (pulm.hypertension) oral tablet 20 mg Tier 1 PA tadalafil (pulm. hypertension) oral tablet 20 mg Tier 3 PA; SP Renin Inhibitor, Direct - Drugs For High Blood Pressure aliskiren oral tablet 150 mg, 300 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

113 Coverage Prescription Drug Name Drug Tier Requirements and Limits Renin Inhibitor, Direct And Diuretic Combinations - Drugs For High Blood Pressure TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 Tier 3 MG, 300-12.5 MG, 300-25 MG (aliskiren) Vasodilator Combinations - Drugs For High Blood Pressure BIDIL ORAL TABLET 20-37.5 MG (isosorbide) Tier 2 Central Nervous System Agents - Drugs For The Nervous System Agents To Treat Episodic Cluster Headaches - Drugs For Migraine Headaches EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 Tier 4 PA MG/3 ML (100 MG/ML X 3) (galcanezumab-gnlm) Antianxiety Agent - Antihistamine Type - Drugs For Anxiety hydroxyzine hcl oral solution 10 mg/5 ml Tier 1 hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg Tier 1 Antianxiety Agent - Benzodiazepines - Drugs For Anxiety ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 Tier 2 MG/ML (alprazolam) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg Tier 1 alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, Tier 1 2 mg, 3 mg alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, Tier 1 2 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg Tier 1 clonazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

114 Coverage Prescription Drug Name Drug Tier Requirements and Limits clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, Tier 1 0.5 mg, 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg Tier 1 diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) Tier 1 diazepam oral concentrate 5 mg/ml Tier 1 diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 diazepam oral tablet 10 mg, 2 mg, 5 mg Tier 1 lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) Tier 1 lorazepam oral concentrate 2 mg/ml Tier 1 lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 oxazepam oral capsule 10 mg, 15 mg, 30 mg Tier 1 Antianxiety Agent - Dicarbamate Type - Drugs For Anxiety meprobamate oral tablet 200 mg, 400 mg Tier 1 Antianxiety Agent - Non-Benzodiazepine - Drugs For Anxiety buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

115 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anticonvulsant - Ampa-Type Glutamate Receptor Antagonists - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Fycompa, Gabapentin, Gralise, Lamictal, Lamictal FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) Tier 3 XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (680 ML per 28 days) ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Fycompa, Gabapentin, Gralise, Lamictal, Lamictal FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG Tier 3 XR, Lamotrigine, (perampanel) Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (30 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

116 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Fycompa, Gabapentin, Gralise, Lamictal, Lamictal FYCOMPA ORAL TABLET 2 MG (perampanel) Tier 3 XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (120 EA per 30 days) ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Fycompa, Gabapentin, Gralise, Lamictal, Lamictal FYCOMPA ORAL TABLET 4 MG, 6 MG (perampanel) Tier 3 XR, Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (60 EA per 30 days) Anticonvulsant - Barbiturates And Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain primidone oral tablet 250 mg, 50 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

117 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anticonvulsant - Benzodiazepines - Drugs For Seizures /Personality Disorder/Nerve Pain clobazam oral suspension 2.5 mg/ml Tier 1 QL (480 ML per 30 days) clobazam oral tablet 10 mg, 20 mg Tier 1 QL (2 EA per 1 day) diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 Tier 1 QL (1 EA per 1 FILL) mg NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY Tier 3 QL (10 EA per 30 days) (0.1 ML) (midazolam) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG (clobazam) Tier 3 PA Anticonvulsant - Cannabinoid Type - Drugs For Seizures /Personality Disorder/Nerve Pain EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) Tier 3 PA; SP Anticonvulsant - Carbamates - Drugs For Seizures /Personality Disorder/Nerve Pain felbamate oral suspension 600 mg/5 ml Tier 1 QL (30 ML per 1 day) felbamate oral tablet 400 mg Tier 1 QL (9 EA per 1 day) felbamate oral tablet 600 mg Tier 1 QL (6 EA per 1 day) Anticonvulsant - Carboxylic Acid Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain divalproex oral capsule, delayed rel sprinkle 125 mg Tier 1 divalproex oral tablet extended release 24 hr 250 mg, 500 Tier 1 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 Tier 1 mg, 500 mg valproic acid (as sodium salt) oral solution 250 mg/5 ml Tier 1 valproic acid (as sodium salt) oral solution 500 mg/10 ml (10 Tier 1 ml) valproic acid oral capsule 250 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

118 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anticonvulsant - Functionalized Amino Acid - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) Tier 2 Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, or Valproic Acid in 365 days; QL (1200 ML per 30 days) ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG Tier 2 Lamotrigine, (lacosamide) Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (2 EA per 1 day) VIMPAT ORAL TABLETS,DOSE PACK 50 MG (14)- 100 Tier 3 MG (14) (lacosamide)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

119 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anticonvulsant - Gaba Analogs - Drugs For Seizures /Personality Disorder/Nerve Pain ACTIVE-PAC KIT,GEL AND CAPSULE 300-4-1 MG-%-% Tier 3 (gabapentin) gabapentin oral capsule 100 mg, 300 mg, 400 mg Tier 1 gabapentin oral solution 250 mg/5 ml Tier 1 gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 Tier 1 ml) gabapentin oral tablet 600 mg, 800 mg Tier 1 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 Tier 2 MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) Tier 2 pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, Tier 1 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml Tier 1 Anticonvulsant - Gaba Re-Uptake Inhibitor, Nipecotic Acid Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain tiagabine oral tablet 12 mg, 2 mg, 4 mg Tier 1 QL (4 EA per 1 day) tiagabine oral tablet 16 mg Tier 1 QL (3 EA per 1 day) Anticonvulsant - Gaba Transaminase (Gaba-T) Inhibitor - Drugs For Seizures /Personality Disorder/Nerve Pain SABRIL ORAL TABLET 500 MG (vigabatrin) Tier 3 SP; QL (6 EA per 1 day) vigabatrin oral powder in packet 500 mg Tier 3 SP; QL (6 EA per 1 day) vigabatrin oral tablet 500 mg Tier 3 SP; QL (6 EA per 1 day) vigabatrin (Vigadrone Oral Powder In Packet 500 Mg) Tier 3 SP; QL (6 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

120 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anticonvulsant - Hydantoins - Drugs For Seizures /Personality Disorder/Nerve Pain DILANTIN ORAL CAPSULE 30 MG (phenytoin) Tier 2 PEGANONE ORAL TABLET 250 MG (ethotoin) Tier 3 phenytoin oral suspension 100 mg/4 ml Tier 1 phenytoin oral suspension 125 mg/5 ml Tier 1 phenytoin oral tablet,chewable 50 mg Tier 1 phenytoin sodium extended oral capsule 100 mg, 200 mg, Tier 1 300 mg Anticonvulsant - Iminostilbene Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, APTIOM ORAL TABLET 200 MG, 400 MG Lamotrigine, Tier 3 (eslicarbazepine) Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid (as Sodium Salt), Valproic Acid, or Zonisamide in 365 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

121 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, APTIOM ORAL TABLET 600 MG, 800 MG Lamotrigine, Tier 3 (eslicarbazepine) Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid (as Sodium Salt), Valproic Acid, or Zonisamide in 365 days; QL (2 EA per 1 day) carbamazepine oral capsule, er multiphase 12 hr 100 mg, Tier 1 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml Tier 1 carbamazepine oral tablet 200 mg Tier 1 carbamazepine oral tablet extended release 12 hr 100 mg, Tier 1 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg Tier 1 carbamazepine (Epitol Oral Tablet 200 Mg) Tier 1 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 Tier 3 MG, 200 MG, 300 MG (carbamazepine) oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) Tier 1 oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

122 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 Lamotrigine, HR 150 MG, 300 MG (oxcarbazepine) Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (1 EA per 1 day) ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 Lamotrigine, HR 600 MG (oxcarbazepine) Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (4 EA per 1 day) Anticonvulsant - Monosaccharide Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain topiramate oral capsule, sprinkle 15 mg, 25 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

123 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: topiramate oral capsule,sprinkle,er 24hr 100 mg, 25 mg, 50 Immediate-release Tier 1 mg Topiramate tablets or sprinkles in 120 days; QL (1 EA per 1 day) ST: Must meet the following requirement: Immediate-release topiramate oral capsule,sprinkle,er 24hr 150 mg, 200 mg Tier 1 Topiramate tablets or sprinkles in 120 days; QL (2 EA per 1 day) topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg Tier 1 ST: Must meet the following requirement: TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE Tier 2 Immediate-release 24HR 100 MG, 200 MG (topiramate) Topiramate in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE Tier 2 Immediate-release 24HR 25 MG (topiramate) Topiramate in 120 days; QL (8 EA per 1 day) ST: Must meet the following requirement: TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE Tier 2 Immediate-release 24HR 50 MG (topiramate) Topiramate in 120 days; QL (4 EA per 1 day) Anticonvulsant - Phenyltriazine Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7) Tier 3 (lamotrigine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

124 Coverage Prescription Drug Name Drug Tier Requirements and Limits LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 Tier 3 MG (7) (lamotrigine) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)- Tier 3 100MG (7) (lamotrigine) lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg Tier 1 lamotrigine oral tablet disintegrating, dose pk 25 mg (21) - 50 mg (7), 25 mg(14)-50 mg (14)-100 mg (7), 50 mg (42) - Tier 1 100 mg (14) lamotrigine oral tablet extended release 24hr 100 mg Tier 1 QL (3 EA per 1 day) lamotrigine oral tablet extended release 24hr 200 mg, 250 Tier 1 QL (2 EA per 1 day) mg, 300 mg lamotrigine oral tablet extended release 24hr 25 mg, 50 mg Tier 1 QL (6 EA per 1 day) lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg Tier 1 lamotrigine oral tablet,disintegrating 100 mg Tier 1 QL (3 EA per 1 day) lamotrigine oral tablet,disintegrating 200 mg Tier 1 QL (2 EA per 1 day) lamotrigine oral tablet,disintegrating 25 mg, 50 mg Tier 1 QL (6 EA per 1 day) lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) - Tier 1 100 mg (7), 25 mg (84) -100 mg (14) lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Tier 1 Mg, 25 Mg) lamotrigine (Subvenite Starter (Blue) Kit Oral Tablets,Dose Tier 1 Pack 25 Mg (35)) lamotrigine (Subvenite Starter (Green) Kit Oral Tier 1 Tablets,Dose Pack 25 Mg (84) -100 Mg (14)) lamotrigine (Subvenite Starter (Orange) Kit Oral Tier 1 Tablets,Dose Pack 25 Mg (42) -100 Mg (7))

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

125 Coverage Prescription Drug Name Drug Tier Requirements and Limits Anticonvulsant - Pyrrolidine Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) Tier 3 Lamotrigine, Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (600 ML per 30 days) ST: Must meet 2 of the following requirements: Carbamazepine, Divalproex Sodium, Equetro, Fanatrex, Gabapentin, Gralise, Lamictal, Lamictal XR, BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, Tier 3 Lamotrigine, 75 MG (brivaracetam) Levetiracetam, Neuraptine, Oxcarbazepine, Oxtellar XR, Spritam, Stavzor, Topiramate, Trokendi XR, Valproic Acid, or Zonisamide in 365 days; QL (2 EA per 1 day) levetiracetam oral solution 100 mg/ml Tier 1 levetiracetam oral solution 500 mg/5 ml (5 ml) Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

126 Coverage Prescription Drug Name Drug Tier Requirements and Limits levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 Tier 1 mg levetiracetam oral tablet extended release 24 hr 500 mg, Tier 1 750 mg ST: Must meet the SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG following requirement: Tier 3 (levetiracetam) Levetiracetam in 120 days; QL (2 EA per 1 day) ST: Must meet the SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, following requirement: Tier 3 500 MG, 750 MG (levetiracetam) Levetiracetam in 120 days; QL (4 EA per 1 day) Anticonvulsant - Succinimides - Drugs For Seizures /Personality Disorder/Nerve Pain CELONTIN ORAL CAPSULE 300 MG (methsuximide) Tier 3 ethosuximide oral capsule 250 mg Tier 1 ethosuximide oral solution 250 mg/5 ml Tier 1 Anticonvulsant - Sulfonamide Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain zonisamide oral capsule 100 mg, 25 mg, 50 mg Tier 1 Anticonvulsant - Triazole Derivatives - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet any of the following requirements: Divalproex Sodium, Lamictal, Lamictal Xr, BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) Tier 3 Lamotrigine, Stavzor, Topiramate, Trokendi XR, or Valproic Acid in 120 days; QL (80 ML per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

127 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Divalproex Sodium, Lamictal, Lamictal Xr, BANZEL ORAL TABLET 200 MG (rufinamide) Tier 3 Lamotrigine, Stavzor, Topiramate, Trokendi XR, or Valproic Acid in 120 days; QL (16 EA per 1 day) ST: Must meet any of the following requirements: Divalproex Sodium, Lamictal, Lamictal Xr, BANZEL ORAL TABLET 400 MG (rufinamide) Tier 3 Lamotrigine, Stavzor, Topiramate, Trokendi XR, or Valproic Acid in 120 days; QL (8 EA per 1 day) Anticonvulsant Others - Drugs For Seizures /Personality Disorder/Nerve Pain DIACOMIT ORAL CAPSULE 250 MG, 500 MG (stiripentol) Tier 3 PA; SP DIACOMIT ORAL POWDER IN PACKET 250 MG, 500 MG Tier 3 PA; SP (stiripentol) Antidepressant - Alpha-2 Receptor Antagonists (Nassa) - Drugs For Depression mirtazapine oral tablet 15 mg, 30 mg, 45 mg Tier 1 mirtazapine oral tablet 7.5 mg Tier 1 mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg Tier 1 Antidepressant - Mao Inhibitor Nonselective And Irreversible-Types A,B - Drugs For Depression EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, Tier 3 QL (1 EA per 1 day) 6 MG/24 HR, 9 MG/24 HR (selegiline) MARPLAN ORAL TABLET 10 MG (isocarboxazid) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

128 Coverage Prescription Drug Name Drug Tier Requirements and Limits phenelzine oral tablet 15 mg Tier 1 tranylcypromine oral tablet 10 mg Tier 1 Antidepressant - N-Methyl D-Aspartate (Nmda) Receptor Antagonist - Drugs For Depression SPRAVATO NASAL SPRAY,NON-AEROSOL 28 MG, 56 Tier 3 PA; SP MG (28 MG X 2), 84 MG (28 MG X 3) (esketamine) Antidepressant - Selective Serotonin Reuptake Inhibitors (Ssris) - Drugs For Depression citalopram oral solution 10 mg/5 ml Tier 1 citalopram oral tablet 10 mg, 20 mg, 40 mg Tier 1 escitalopram oxalate oral solution 5 mg/5 ml Tier 1 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg Tier 1 fluoxetine oral capsule 10 mg, 20 mg, 40 mg Tier 1 fluoxetine oral capsule,delayed release(dr/ec) 90 mg Tier 1 fluoxetine oral solution 20 mg/5 ml (4 mg/ml) Tier 1 fluoxetine oral tablet 10 mg, 20 mg Tier 1 fluoxetine oral tablet 60 mg Tier 1 fluvoxamine oral capsule,extended release 24hr 100 mg, Tier 1 QL (2 EA per 1 day) 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg Tier 1 paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg Tier 1 paroxetine hcl oral tablet extended release 24 hr 12.5 mg, Tier 1 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML (paroxetine) Tier 2 ST: Must meet the following requirement: PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG Tier 3 Paroxetine HCL or Paxil in (paroxetine) 120 days; QL (1 EA per 1 day) sertraline oral concentrate 20 mg/ml Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

129 Coverage Prescription Drug Name Drug Tier Requirements and Limits sertraline oral tablet 100 mg, 25 mg, 50 mg Tier 1 Antidepressant - Serotonin-2 Antagonist- Reuptake Inhibitors (Saris) - Drugs For Depression nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, Tier 1 50 mg trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg Tier 1 Antidepressant - Serotonin-Norepinephrine Reuptake Inhibitors (Snris) - Drugs For Depression ST: Must meet 2 of the following requirements: Bupropion HCL, Citalopram Hydrobromide, desvenlafaxine oral tablet extended release 24 hr 100 mg, Escitalopram Oxalate, Tier 2 50 mg Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in 365 days; QL (1 EA per 1 day) ST: Must meet 2 of the following requirements: Bupropion HCL, Citalopram Hydrobromide, Desvenlafaxine ER, desvenlafaxine oral tablet extended release 24hr 100 mg, Desvenlafaxine, Tier 1 50 mg Escitalopram Oxalate, Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in 365 days; QL (1 EA per 1 day) desvenlafaxine succinate oral tablet extended release 24 hr Tier 1 100 mg, 25 mg, 50 mg Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

130 Coverage Prescription Drug Name Drug Tier Requirements and Limits DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (6 EA per 1 day) SPRINKLE 20 MG (duloxetine) DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (4 EA per 1 day) SPRINKLE 30 MG (duloxetine) DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (3 EA per 1 day) SPRINKLE 40 MG (duloxetine) DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (2 EA per 1 day) SPRINKLE 60 MG (duloxetine) duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 Tier 1 mg, 60 mg ST: Must meet the following requirement: duloxetine oral capsule,delayed release(dr/ec) 40 mg Tier 1 Generic Duloxetine two 20mg capsules in 120 days; QL (1 EA per 1 day) ST: Must meet 2 of the following requirements: Bupropion HCL, Citalopram Hydrobromide, FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK Escitalopram Oxalate, Tier 2 20 MG (2)- 40 MG (26) (levomilnacipran) Fetzima, Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in 365 days; QL (1 EA per 1 day) ST: Must meet 2 of the following requirements: Bupropion HCL, Citalopram Hydrobromide, FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR Escitalopram Oxalate, Tier 2 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran) Fetzima, Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in 365 days; QL (1 EA per 1 day) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

131 Coverage Prescription Drug Name Drug Tier Requirements and Limits SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 Tier 2 MG (milnacipran) SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 Tier 2 MG(8)-50 MG(42) (milnacipran) venlafaxine oral capsule,extended release 24hr 150 mg, Tier 1 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 Tier 1 mg venlafaxine oral tablet extended release 24hr 150 mg, 225 Tier 1 mg, 37.5 mg, 75 mg Antidepressant - Ssri And 5Ht1a Partial Agonist - Drugs For Depression ST: Must meet any of the following requirements: Bupropion HCL, Citalopram Hydrobromide, VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG Escitalopram Oxalate, Tier 2 (vilazodone) Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in 120 days; QL (1 EA per 1 day) ST: Must meet any of the following requirements: Bupropion HCL, Citalopram Hydrobromide, VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG Escitalopram Oxalate, Tier 2 (23) (vilazodone) Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

132 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antidepressant - Ssri And Serotonin (5-Ht) Receptor Modulator - Drugs For Depression ST: Must meet any of the following requirements: Bupropion HCL, Citalopram Hydrobromide, TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG Escitalopram Oxalate, Tier 2 (vortioxetine) Fluoxetine HCL, Mirtazapine, Paroxetine HCL, Paxil, Sertraline HCL, or Venlafaxine HCL in 120 days; QL (1 EA per 1 day) Antidepressant - Tricyclic And Antipsychotic, Phenothiazine Comb - Drugs For Depression perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4- Tier 1 10 mg, 4-25 mg, 4-50 mg Antidepressant - Tricyclic-Benzodiazepine Combinations - Drugs For Depression amitriptyline-chlordiazepoxide oral tablet 12.5-5 mg, 25-10 Tier 1 mg Antidepressant-Norepinephrine And Dopamine Reuptake Inhibitors (Ndris) - Drugs For Depression ST: Must meet the APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR following requirement: Tier 3 174 MG, 348 MG, 522 MG (bupropion) Bupropion HCL in 120 days; QL (1 EA per 1 day) bupropion hcl oral tablet 100 mg, 75 mg Tier 1 bupropion hcl oral tablet extended release 24 hr 150 mg, Tier 1 300 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

133 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: bupropion hcl oral tablet extended release 24 hr 450 mg Tier 1 Bupropion HCL in 120 days; QL (1 EA per 1 day) bupropion hcl oral tablet sustained-release 12 hr 100 mg, Tier 1 150 mg, 200 mg Antidepressant-Tricyclics And Related (Non- Select Reuptake Inhibitors) - Drugs For Depression amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 Tier 1 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg Tier 1 clomipramine oral capsule 25 mg, 50 mg, 75 mg Tier 1 desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 Tier 1 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 Tier 1 mg, 75 mg doxepin oral concentrate 10 mg/ml Tier 1 imipramine hcl oral tablet 10 mg, 25 mg, 50 mg Tier 1 imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, Tier 1 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg Tier 1 nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg Tier 1 nortriptyline oral solution 10 mg/5 ml Tier 1 protriptyline oral tablet 10 mg, 5 mg Tier 1 trimipramine oral capsule 100 mg, 25 mg, 50 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

134 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiparkinson - Dopaminergic-Periph Comt- Dopa-Decarboxylase Inhib Comb - Drugs For Parkinson carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5- Tier 1 150-200 mg, 50-200-200 mg Antiparkinson - Dopaminerg-Peripheral Dopa- Decarboxylase Inhibit Comb - Drugs For Parkinson carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25- Tier 1 250 mg carbidopa-levodopa oral tablet extended release 25-100 Tier 1 mg, 50-200 mg carbidopa-levodopa oral tablet,disintegrating 10-100 mg, Tier 1 25-100 mg, 25-250 mg DUOPA J-TUBE INTESTINAL PUMP SUSPENSION 4.63- Tier 3 PA; SP 20 MG/ML (carbidopa) ST: Must meet the RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75- following requirement: 95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG Tier 3 Carbidopa/levodopa in 120 (carbidopa) days; QL (10 EA per 1 day) Antiparkinson Adjuvant - Adenosine Receptor Antagonist - Drugs For Parkinson NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) Tier 3 PA Antiparkinson Adjuvant - Central/Peripheral Comt Inhibitors - Drugs For Parkinson ST: Must meet the following requirement: tolcapone oral tablet 100 mg Tier 1 Entacapone in 120 days; QL (3 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

135 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiparkinson Adjuvant - Peripheral Comt Inhibitors - Drugs For Parkinson entacapone oral tablet 200 mg Tier 1 Antiparkinson Adjuvant - Peripheral Dopa- Decarboxylase Inhibitors - Drugs For Parkinson carbidopa oral tablet 25 mg Tier 1 Antiparkinson Therapy - Anticholinergic Agents - Drugs For Parkinson benztropine oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 trihexyphenidyl oral elixir 0.4 mg/ml Tier 1 trihexyphenidyl oral tablet 2 mg, 5 mg Tier 1 Antiparkinson Therapy - Dopamine Precursors - Drugs For Parkinson INBRIJA INHALATION CAPSULE 42 MG (levodopa) Tier 3 PA; SP INBRIJA INHALATION CAPSULE, W/INHALATION Tier 3 PA; SP DEVICE 42 MG (levodopa) Antiparkinson Therapy - Ergot Alkaloids And Derivatives - Drugs For Parkinson bromocriptine oral capsule 5 mg Tier 1 bromocriptine oral tablet 2.5 mg Tier 1 Antiparkinson Therapy - Monoamine Oxidase Inhibitor(Mao-B) - Drugs For Parkinson rasagiline oral tablet 0.5 mg, 1 mg Tier 1 QL (1 EA per 1 day) selegiline hcl oral capsule 5 mg Tier 1 selegiline hcl oral tablet 5 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

136 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: XADAGO ORAL TABLET 100 MG, 50 MG (safinamide) Tier 3 Carbidopa/levodopa, Duopa, or Rytary in 120 days; QL (1 EA per 1 day) ZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG Tier 3 QL (2 EA per 1 day) (selegiline) Antiparkinson Therapy - Non-Ergot Dopamine Agonist Agents - Drugs For Parkinson amantadine hcl oral capsule 100 mg Tier 1 amantadine hcl oral solution 50 mg/5 ml Tier 1 amantadine hcl oral tablet 100 mg Tier 1 APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML Tier 4 PA (apomorphine) GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 3 PA; SP 137 MG, 68.5 MG (amantadine) ST: Must meet the following requirement: NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 Immediate-release HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, Tier 2 Pramipexole or immediate- 6 MG/24 HOUR, 8 MG/24 HOUR (rotigotine) release Ropinirole in 120 days; QL (1 EA per 1 day) OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR Tier 3 PA 129 MG, 193 MG, 258 MG (amantadine) pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 Tier 1 mg, 1 mg, 1.5 mg ST: Must meet the following requirement: pramipexole oral tablet extended release 24 hr 0.375 mg, Immediate-release Tier 1 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg Pramipexole or immediate- release Ropinirole in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

137 Coverage Prescription Drug Name Drug Tier Requirements and Limits ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 Tier 1 mg, 5 mg ST: Must meet the following requirement: ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 Immediate-release Tier 1 mg, 6 mg, 8 mg Pramipexole or immediate- release Ropinirole in 120 days; QL (1 EA per 1 day) Antipsychotic - Atypical Dopamine-Serotonin Antag- Benzisothiazolones - Drugs For Severe Mental Disorders ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG Clozapine, Olanzapine, Tier 2 (lurasidone) Perseris, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (30 EA per 30 days) ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, Clozapine, Olanzapine, LATUDA ORAL TABLET 80 MG (lurasidone) Tier 2 Perseris, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (60 EA per 30 days) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

138 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antipsychotic - Atypical Dopamine-Serotonin Antag- Benzisoxazole Deriv - Drugs For Severe Mental Disorders ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 Abilify, Aripiprazole, Tier 3 MG, 6 MG, 8 MG (iloperidone) Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (2 EA per 1 day) ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- Tier 3 Clozapine, Olanzapine, 4MG(2)-6MG(2) (iloperidone) Quetiapine Fumarate, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (8 EA per 28 days) paliperidone oral tablet extended release 24hr 1.5 mg, 3 Tier 1 QL (1 EA per 1 day) mg, 9 mg paliperidone oral tablet extended release 24hr 6 mg Tier 1 QL (2 EA per 1 day) risperidone oral solution 1 mg/ml Tier 1 QL (8 ML per 1 day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 Tier 1 QL (2 EA per 1 day) mg risperidone oral tablet,disintegrating 0.25 mg Tier 1 QL (2 EA per 1 day) risperidone oral tablet,disintegrating 0.5 mg, 1 mg, 2 mg, 3 Tier 1 QL (2 EA per 1 day) mg, 4 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

139 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antipsychotic - Atypical Dopamine-Serotonin Antag-Dibenzodiazepine Der - Drugs For Severe Mental Disorders clozapine oral tablet 100 mg, 25 mg Tier 1 QL (3 EA per 1 day) clozapine oral tablet 200 mg, 50 mg Tier 1 QL (3 EA per 1 day) ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 Tier 1 Clozapine, Olanzapine, mg, 200 mg, 25 mg Perseris, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (3 EA per 1 day) ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) Tier 3 Clozapine, Olanzapine, Perseris, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (18 ML per 1 day) Antipsychotic - Butyrophenone Derivatives - Drugs For Severe Mental Disorders haloperidol lactate oral concentrate 2 mg/ml Tier 1 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 Tier 1 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

140 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antipsychotic - Dibenzoxazepine Derivatives - Drugs For Severe Mental Disorders ADASUVE INHALATION AEROSOL POWDR BREATH Tier 3 SP ACTIVATED 10 MG (loxapine) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg Tier 1 Antipsychotic - Dihydroindolones - Drugs For Severe Mental Disorders molindone oral tablet 10 mg Tier 1 QL (8 EA per 1 day) molindone oral tablet 25 mg Tier 1 QL (9 EA per 1 day) molindone oral tablet 5 mg Tier 1 Antipsychotic - Diphenylbutylpiperidine Derivatives - Drugs For Severe Mental Disorders pimozide oral tablet 1 mg, 2 mg Tier 1 Antipsychotic - Phenothiazines, Aliphatic - Drugs For Severe Mental Disorders chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, Tier 1 50 mg Antipsychotic - Phenothiazines, Piperazine - Drugs For Severe Mental Disorders fluphenazine hcl oral concentrate 5 mg/ml Tier 1 fluphenazine hcl oral elixir 2.5 mg/5 ml Tier 1 fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg Tier 1 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg Tier 1 prochlorperazine maleate oral tablet 10 mg, 5 mg Tier 1 trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg Tier 1 Antipsychotic - Phenothiazines, Piperidine - Drugs For Severe Mental Disorders thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

141 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antipsychotic - Thioxanthenes - Drugs For Severe Mental Disorders thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Tier 1 Antipsychotic -Atypical Dopamine-Serotonin Antag-Dibenzothiazepine Der - Drugs For Severe Mental Disorders SEROQUEL XR ORAL TABLET, EXT REL 24HR DOSE Tier 3 PACK 50 MG(3)-200 MG (1)-300 MG(11) (quetiapine) Antipsychotic-Atyp Selective Serotonin 5-Ht2a Inverse Agonists (Ssia) - Drugs For Severe Mental Disorders NUPLAZID ORAL CAPSULE 34 MG (pimavanserin) Tier 3 PA; SP NUPLAZID ORAL TABLET 10 MG (pimavanserin) Tier 3 PA; SP Antipsychotic-Atypical,D2 Receptor Partial Agonist-5Ht Serotonin Mixed - Drugs For Severe Mental Disorders ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG Tier 3 PA; SP (aripiprazole)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

142 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, Citalopram Hydrobromide, Clozapine, Drizalma Sprinkle, Duloxetine HCL, Escitalopram Oxalate, REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 Fluoxetine HCL, Tier 2 MG, 4 MG (brexpiprazole) Olanzapine, Paroxetine HCL, Paroxetine Mesylate, Paxil, Perseris, Pexeva, Quetiapine Fumarate, Risperidone, Seroquel XR, Sertraline HCL, Venlafaxine HCL, Versacloz, or Ziprasidone HCL in 365 days; QL (1 EA per 1 day) Antipsychotic-Atypical,D3/D2 Receptor Partial Agonist-Serotonin Mixed - Drugs For Severe Mental Disorders ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine) Tier 2 Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

143 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 Tier 2 Clozapine, Olanzapine, MG (6) (cariprazine) Quetiapine Fumarate, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (7 EA per 28 days) Attention Deficit-Hyperact. Disorder (Adhd)- Alpha-2 Receptor Agonist - Drugs For Attention Deficit Disorder clonidine hcl oral tablet extended release 12 hr 0.1 mg Tier 1 QL (120 EA per 30 days) guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 Tier 1 QL (1 EA per 1 day) mg, 4 mg Attention Deficit-Hyperactivity (Adhd) Therapy, Stimulant-Type - Drugs For Attention Deficit Disorder ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE Tier 1 QL (1 EA per 1 day) 24HR 10 MG, 15 MG, 5 MG (dextroamphetamine) ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE Tier 1 QL (2 EA per 1 day) 24HR 20 MG, 25 MG, 30 MG (dextroamphetamine) ST: Must meet the ADHANSIA XR ORAL CAPSULE, ER BIPHASIC 20-80 25 following requirement: MG, 35 MG, 45 MG, 55 MG, 70 MG, 85 MG Tier 3 Methylphenidate HCL or (methylphenidate) Ritalin LA in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

144 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 24HR Tier 3 Dextroamphetamine/amph 1.25 MG/ML (amphetamine) etamine in 120 days; QL (450 ML per 30 days) ST: Must meet the ADZENYS XR-ODT ORAL TABLET,DISINTEG ER following requirement: BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 Tier 3 Dextroamphetamine/amph MG, 9.4 MG (amphetamine) etamine in 120 days; QL (1 EA per 1 day) ST: Must meet the APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC 40- following requirement: 60 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG Tier 3 Methylphenidate HCL or (methylphenidate) Ritalin LA in 120 days; QL (1 EA per 1 day) CONCERTA ORAL TABLET EXTENDED RELEASE 24HR Tier 1 QL (1 EA per 1 day) 18 MG, 27 MG, 54 MG (methylphenidate) CONCERTA ORAL TABLET EXTENDED RELEASE 24HR Tier 1 QL (2 EA per 1 day) 36 MG (methylphenidate) ST: Must meet the following requirement: COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER Tier 3 Methylphenidate HCL or BIPHASE 24H 17.3 MG, 8.6 MG (methylphenidate) Ritalin LA in 120 days; QL (1 EA per 1 day) ST: Must meet the following requirement: COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER Tier 3 Methylphenidate HCL or BIPHASE 24H 25.9 MG (methylphenidate) Ritalin LA in 120 days; QL (2 EA per 1 day) ST: Must meet any of the following requirements: DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG/9 Methylphenidate HCL, HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR Tier 3 Quillivant XR, or Ritalin LA (methylphenidate) in 120 days; QL (1 EA per 1 day) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

145 Coverage Prescription Drug Name Drug Tier Requirements and Limits dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, Tier 1 QL (1 EA per 1 day) 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 QL (2 EA per 1 day) ST: Must meet the following requirement: DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR Tier 3 Dextroamphetamine/amph 2.5 MG/ML (amphetamine) etamine in 120 days; QL (240 ML per 30 days) ST: Must meet the JORNAY PM ORAL CAPSULE,DEL REL,EXT REL following requirement: SPRINK 100 MG, 20 MG, 40 MG, 60 MG, 80 MG Tier 3 Methylphenidate HCL or (methylphenidate) Ritalin LA in 120 days; QL (1 EA per 1 day) methylphenidate (Metadate Er Oral Tablet Extended Tier 1 QL (90 EA per 30 days) Release 20 Mg) methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, Tier 1 QL (1 EA per 1 day) 20 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule, er biphasic 30-70 30 mg Tier 1 QL (2 EA per 1 day) methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, Tier 1 QL (1 EA per 1 day) 20 mg, 40 mg, 60 mg methylphenidate hcl oral capsule,er biphasic 50-50 30 mg Tier 1 QL (2 EA per 1 day) methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml Tier 1 methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Tier 1 QL (90 EA per 30 days) methylphenidate hcl oral tablet extended release 10 mg Tier 1 QL (3 EA per 1 day) methylphenidate hcl oral tablet extended release 20 mg Tier 1 QL (90 EA per 30 days) ST: Must meet the following requirement: methylphenidate hcl oral tablet extended release 24hr 72 Tier 1 Methylphenidate HCL or mg Ritalin LA in 120 days; QL (1 EA per 1 day) methylphenidate hcl oral tablet,chewable 10 mg, 2.5 mg, 5 Tier 1 QL (90 EA per 30 days) mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

146 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 Tier 3 Dextroamphetamine/amph MG, 25 MG, 37.5 MG, 50 MG (dextroamphetamine) etamine in 120 days; QL (1 EA per 1 day) ST: Must meet the following requirement: QUILLICHEW ER ORAL TABLET,CHEW,IR- Tier 2 Methylphenidate HCL or ER.BIPHASIC24HR 20 MG, 40 MG (methylphenidate) Ritalin LA in 120 days; QL (1 EA per 1 day) ST: Must meet the following requirement: QUILLICHEW ER ORAL TABLET,CHEW,IR- Tier 2 Methylphenidate HCL or ER.BIPHASIC24HR 30 MG (methylphenidate) Ritalin LA in 120 days; QL (2 EA per 1 day) 120mL BOTTLE; ST: Must meet the following QUILLIVANT XR ORAL SUSPENSION,EXT REL requirement: Tier 2 24HR,RECON 5 MG/ML (25 MG/5 ML) (methylphenidate) Methylphenidate HCL or Ritalin LA in 120 days; QL (240 ML per 30 days) ST: Must meet the following requirement: methylphenidate (Relexxii Oral Tablet Extended Release Tier 3 Methylphenidate HCL or 24Hr 72 Mg) Ritalin LA in 120 days; QL (1 EA per 1 day) ST: Must meet any of the following requirements: generic mixed VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 amphetamine salts, Tier 2 MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine) Methylphenidate IR/ER/LA/CD, an SSRI, or Topiramate in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

147 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: generic mixed VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 amphetamine salts, Tier 2 MG, 40 MG, 50 MG, 60 MG (lisdexamfetamine) Methylphenidate IR/ER/LA/CD, an SSRI, or Topiramate in 120 days; QL (1 EA per 1 day) dextroamphetamine (Zenzedi Oral Tablet 10 Mg) Tier 1 QL (180 EA per 30 days) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 15 MG (dextroamphetamine) Tier 3 Dextroamphetamine Sulfate in 120 days; QL (3 EA per 1 day) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG Tier 3 Dextroamphetamine (dextroamphetamine) Sulfate in 120 days; QL (90 EA per 30 days) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 20 MG, 30 MG Tier 3 Dextroamphetamine (dextroamphetamine) Sulfate in 120 days; QL (2 EA per 1 day) dextroamphetamine (Zenzedi Oral Tablet 5 Mg) Tier 1 QL (90 EA per 30 days) Attention Deficit-Hyperactivity Disorder (Adhd) Therapy, Nri-Type - Drugs For Attention Deficit Disorder atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg Tier 1 QL (60 EA per 30 days) atomoxetine oral capsule 100 mg, 60 mg, 80 mg Tier 1 QL (30 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

148 Coverage Prescription Drug Name Drug Tier Requirements and Limits Benzodiazepines - Drugs For Seizures /Personality Disorder/Nerve Pain ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 Tier 2 MG/ML (alprazolam) diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) Tier 1 diazepam oral concentrate 5 mg/ml Tier 1 diazepam oral solution 5 mg/5 ml (1 mg/ml) Tier 1 diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 Tier 1 QL (1 EA per 1 FILL) mg flurazepam oral capsule 15 mg, 30 mg Tier 1 lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) Tier 1 ST: Must meet any of the following requirements: Eszopiclone, Flurazepam quazepam oral tablet 15 mg Tier 1 HCL, Temazepam, Zaleplon, or Zolpidem Tartrate in 120 days Bipolar Therapy Agents - Anticonvulsant Type - Drugs For Seizures /Personality Disorder/Nerve Pain carbamazepine (Epitol Oral Tablet 200 Mg) Tier 1 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 Tier 3 MG, 200 MG, 300 MG (carbamazepine) lamotrigine oral tablet disintegrating, dose pk 25 mg (21) - 50 mg (7), 25 mg(14)-50 mg (14)-100 mg (7), 50 mg (42) - Tier 1 100 mg (14) lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) - Tier 1 100 mg (7), 25 mg (84) -100 mg (14) lamotrigine (Subvenite Starter (Blue) Kit Oral Tablets,Dose Tier 1 Pack 25 Mg (35))

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

149 Coverage Prescription Drug Name Drug Tier Requirements and Limits lamotrigine (Subvenite Starter (Green) Kit Oral Tier 1 Tablets,Dose Pack 25 Mg (84) -100 Mg (14)) lamotrigine (Subvenite Starter (Orange) Kit Oral Tier 1 Tablets,Dose Pack 25 Mg (42) -100 Mg (7)) Bipolar Therapy Agents - Atypical Antipsychotics - Drugs For Severe Mental Disorders ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG Tier 3 PA; SP (aripiprazole) aripiprazole oral solution 1 mg/ml Tier 1 QL (30 ML per 1 day) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, Tier 1 QL (1 EA per 1 day) 5 mg aripiprazole oral tablet,disintegrating 10 mg Tier 1 QL (3 EA per 1 day) aripiprazole oral tablet,disintegrating 15 mg Tier 1 QL (2 EA per 1 day) olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, Tier 1 QL (1 EA per 1 day) 7.5 mg olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 Tier 1 QL (1 EA per 1 day) mg olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3- Tier 1 QL (1 EA per 1 day) 25 mg, 6-25 mg, 6-50 mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 Tier 1 QL (3 EA per 1 day) mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg, 200 Tier 1 QL (1 EA per 1 day) mg, 300 mg, 400 mg, 50 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

150 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG Tier 2 Clozapine, Olanzapine, (asenapine) Perseris, Quetiapine Fumarate, Risperidone, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (2 EA per 1 day) ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG Abilify, Aripiprazole, Tier 2 (cariprazine) Clozapine, Olanzapine, Quetiapine Fumarate, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (1 EA per 1 day) ST: Must meet 2 of the following requirements: Abilify Discmelt, Abilify Maintena, Abilify Mycite, Abilify, Aripiprazole, VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 Tier 2 Clozapine, Olanzapine, MG (6) (cariprazine) Quetiapine Fumarate, Seroquel XR, Versacloz, or Ziprasidone HCL in 365 days; QL (7 EA per 28 days) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Tier 1 QL (2 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

151 Coverage Prescription Drug Name Drug Tier Requirements and Limits Bipolar Therapy Agents - Lithium - Drugs For Severe Mental Disorders lithium carbonate oral capsule 150 mg, 600 mg Tier 1 lithium carbonate oral capsule 300 mg Tier 1 lithium carbonate oral tablet 300 mg Tier 1 lithium carbonate oral tablet extended release 300 mg, 450 Tier 1 mg lithium citrate oral solution 8 meq/5 ml Tier 1 Cannabis And Cannabinoid Receptor Agonists - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet the following requirement: CESAMET ORAL CAPSULE 1 MG (nabilone) Tier 3 Ondansetron or Ondansetron HCL in 120 days; QL (6 EA per 1 day) SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) Tier 3 QL (60 ML per 30 days) Cns Stimulant - Amphetamine Combinations - Drugs For Attention Deficit Disorder ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE Tier 1 QL (1 EA per 1 day) 24HR 10 MG, 15 MG, 5 MG (dextroamphetamine) ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE Tier 1 QL (2 EA per 1 day) 24HR 20 MG, 25 MG, 30 MG (dextroamphetamine) ST: Must meet the following requirement: ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 24HR Tier 3 Dextroamphetamine/amph 1.25 MG/ML (amphetamine) etamine in 120 days; QL (450 ML per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

152 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the ADZENYS XR-ODT ORAL TABLET,DISINTEG ER following requirement: BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 Tier 3 Dextroamphetamine/amph MG, 9.4 MG (amphetamine) etamine in 120 days; QL (1 EA per 1 day) dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 Tier 1 QL (2 EA per 1 day) mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg ST: Must meet the following requirement: DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR Tier 3 Dextroamphetamine/amph 2.5 MG/ML (amphetamine) etamine in 120 days; QL (240 ML per 30 days) ST: Must meet the following requirement: MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 Tier 3 Dextroamphetamine/amph MG, 25 MG, 37.5 MG, 50 MG (dextroamphetamine) etamine in 120 days; QL (1 EA per 1 day) Cns Stimulant - Amphetamines - Drugs For Attention Deficit Disorder amphetamine sulfate oral tablet 10 mg, 5 mg Tier 1 PA dextroamphetamine oral capsule, extended release 10 mg, Tier 1 QL (60 EA per 30 days) 5 mg dextroamphetamine oral capsule, extended release 15 mg Tier 1 QL (120 EA per 30 days) dextroamphetamine oral solution 5 mg/5 ml Tier 1 QL (1800 ML per 30 days) dextroamphetamine oral tablet 10 mg Tier 1 QL (180 EA per 30 days) dextroamphetamine oral tablet 5 mg Tier 1 QL (90 EA per 30 days) ST: Must meet the following requirement: EVEKEO ODT ORAL TABLET,DISINTEGRATING 10 MG Tier 3 Dextroamphetamine/amph (amphetamine) etamine in 120 days; QL (4 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

153 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: EVEKEO ODT ORAL TABLET,DISINTEGRATING 15 MG, Tier 3 Dextroamphetamine/amph 20 MG (amphetamine) etamine in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: EVEKEO ODT ORAL TABLET,DISINTEGRATING 5 MG Tier 3 Dextroamphetamine/amph (amphetamine) etamine in 120 days; QL (8 EA per 1 day) methamphetamine oral tablet 5 mg Tier 1 QL (150 EA per 30 days) dextroamphetamine (Zenzedi Oral Tablet 10 Mg) Tier 1 QL (180 EA per 30 days) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 15 MG (dextroamphetamine) Tier 3 Dextroamphetamine Sulfate in 120 days; QL (3 EA per 1 day) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG Tier 3 Dextroamphetamine (dextroamphetamine) Sulfate in 120 days; QL (90 EA per 30 days) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 20 MG, 30 MG Tier 3 Dextroamphetamine (dextroamphetamine) Sulfate in 120 days; QL (2 EA per 1 day) dextroamphetamine (Zenzedi Oral Tablet 5 Mg) Tier 1 QL (90 EA per 30 days) Cns Stimulant - Analeptics - Drugs For Attention Deficit Disorder caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

154 Coverage Prescription Drug Name Drug Tier Requirements and Limits Diabetic Peripheral Neuropathy Agents - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL, Divalproex Sodium, Doxepin HCL, Drizalma Sprinkle, Duloxetine HCL, Fanatrex, Gabapentin, LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Gralise, Imipramine HCL, 165 MG, 82.5 MG (pregabalin) Imipramine Pamoate, Lyrica, Maprotiline HCL, Neuraptine, Nortriptyline HCL, Pregabalin, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in 365 days; QL (3 EA per 1 day) ST: Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL, Divalproex Sodium, Doxepin HCL, Drizalma Sprinkle, Duloxetine HCL, Fanatrex, Gabapentin, LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Gralise, Imipramine HCL, 330 MG (pregabalin) Imipramine Pamoate, Lyrica, Maprotiline HCL, Neuraptine, Nortriptyline HCL, Pregabalin, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in 365 days; QL (2 EA per 1 day) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

155 Coverage Prescription Drug Name Drug Tier Requirements and Limits Fibromyalgia Agents - Gaba Analogs - Drugs For Seizures /Personality Disorder/Nerve Pain LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 300 Tier 2 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) Tier 2 Fibromyalgia Agents - Serotonin- Norepinephrine Reuptake-Inhib (Snris) - Drugs For Seizures /Personality Disorder/Nerve Pain DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (6 EA per 1 day) SPRINKLE 20 MG (duloxetine) DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (4 EA per 1 day) SPRINKLE 30 MG (duloxetine) DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (3 EA per 1 day) SPRINKLE 40 MG (duloxetine) DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 QL (2 EA per 1 day) SPRINKLE 60 MG (duloxetine) SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 Tier 2 MG (milnacipran) SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 Tier 2 MG(8)-50 MG(42) (milnacipran) Hypnotics - Melatonin M1/M2 Receptor Agonists - Drugs For Insomnia HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) Tier 3 PA; SP ST: Must meet any of the following requirements: ramelteon oral tablet 8 mg Tier 1 Eszopiclone, Zaleplon, or Zolpidem Tartrate in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

156 Coverage Prescription Drug Name Drug Tier Requirements and Limits Migraine Therapy - Calcitonin Gene-Related Peptide Inhibitors - Drugs For Migraine Headaches AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 4 PA INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe) AJOVY SUBCUTANEOUS SYRINGE 225 MG/1.5 ML Tier 4 PA (fremanezumab-vfrm) EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 Tier 4 PA MG/ML (galcanezumab-gnlm) EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 Tier 4 PA MG/ML (galcanezumab-gnlm) Migraine Therapy - Cgrp Receptor Blockers, Monoclonal Antibody - Drugs For Migraine Headaches AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 4 PA INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe) Migraine Therapy - Ergot Alkaloids And Derivatives - Drugs For Migraine Headaches dihydroergotamine injection solution 1 mg/ml Tier 4 QL (15 ML per 14 days) dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump Tier 1 QL (8 ML per 28 days) act. (4 mg/ml) ERGOMAR SUBLINGUAL TABLET 2 MG (ergotamine) Tier 3 QL (10 EA per 7 days) Migraine Therapy - Ergot Combinations - Drugs For Migraine Headaches ergotamine-caffeine oral tablet 1-100 mg Tier 1 QL (10 EA per 7 days) MIGERGOT RECTAL SUPPOSITORY 2-100 MG Tier 3 QL (5 EA per 7 days) (ergotamine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

157 Coverage Prescription Drug Name Drug Tier Requirements and Limits Migraine Therapy - Selective Serotonin Agonists 5-Ht(1) - Drugs For Migraine Headaches ST: Must meet the following requirement: Rizatriptan Benzoate or almotriptan malate oral tablet 12.5 mg, 6.25 mg Tier 1 Sumatriptan Succinate in 180 days; QL (12 EA per 30 days) ST: Must meet the following requirement: Rizatriptan Benzoate or eletriptan oral tablet 20 mg, 40 mg Tier 1 Sumatriptan Succinate in 180 days; QL (12 EA per 30 days) ST: Must meet the following requirement: Rizatriptan Benzoate or frovatriptan oral tablet 2.5 mg Tier 1 Sumatriptan Succinate in 180 days; QL (18 EA per 30 days) MIGRANOW KIT,GEL AND TABLET 50 MG- 10 %-4 % Tier 3 (sumatriptan) naratriptan oral tablet 1 mg, 2.5 mg Tier 1 QL (18 EA per 30 days) ST: Must meet the ONZETRA XSAIL NASAL AEROSOL POWDR BREATH following requirement: Tier 3 ACTIVATED 11 MG (sumatriptan) Sumatriptan in 180 days; QL (16 EA per 30 days) rizatriptan oral tablet 10 mg, 5 mg Tier 1 QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg Tier 1 QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 Tier 1 QL (6 EA per 15 days) mg/actuation sumatriptan succinate oral tablet 100 mg Tier 1 QL (9 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

158 Coverage Prescription Drug Name Drug Tier Requirements and Limits sumatriptan succinate oral tablet 25 mg, 50 mg Tier 1 QL (3 EA per 5 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, Tier 4 QL (4 ML per 28 days) 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 Tier 4 QL (4 ML per 28 days) ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 ml Tier 4 QL (5 ML per 28 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml Tier 4 QL (4 ML per 28 days) TOSYMRA NASAL SPRAY,NON-AEROSOL 10 Tier 3 QL (30 EA per 30 days) MG/ACTUATION (sumatriptan) ST: Must meet the following requirement: ZEMBRACE SYMTOUCH SUBCUTANEOUS PEN Tier 4 Sumatriptan Succinate in INJECTOR 3 MG/0.5 ML (sumatriptan) 120 days; QL (8 ML per 28 days) ST: Must meet the following requirement: Rizatriptan Benzoate or zolmitriptan oral tablet 2.5 mg, 5 mg Tier 1 Sumatriptan Succinate in 180 days; QL (12 EA per 30 days) ST: Must meet the following requirement: Rizatriptan Benzoate or zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Tier 1 Sumatriptan Succinate in 180 days; QL (12 EA per 30 days) ST: Must meet the following requirement: ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG Rizatriptan Benzoate or Tier 2 (zolmitriptan) Sumatriptan Succinate in 180 days; QL (12 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

159 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG Rizatriptan Benzoate or Tier 2 (zolmitriptan) Sumatriptan Succinate in 180 days; QL (6 EA per 15 days) Migraine Therapy - Serotonin Agonist 5-Ht(1) And Nsaid Comb. - Drugs For Migraine Headaches ST: Must meet any of the following requirements: Almotriptan Malate, Eletriptan Hydrobromide, Frovatriptan Succinate, Naratriptan HCL, Onzetra Xsail, Rizatriptan Benzoate, Sumatriptan sumatriptan-naproxen oral tablet 85-500 mg Tier 1 Succinate/Naproxen Sodium, Sumatriptan Succinate, Sumatriptan, Sumavel Dosepro, Tosymra, Treximet, Zecuity, Zembrace Symtouch, Zolmitriptan, or Zomig in 180 days; QL (9 EA per 30 days) Movement Disorder Drug Therapy - Drugs For The Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 3 PA; SP (deutetrabenazine) INGREZZA INITIATION PACK ORAL CAPSULE,DOSE Tier 3 PA; SP PACK 40 MG (7)- 80 MG (21) (valbenazine) INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine) Tier 3 PA; SP tetrabenazine oral tablet 12.5 mg, 25 mg Tier 3 PA; SP Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

160 Coverage Prescription Drug Name Drug Tier Requirements and Limits Movement Disorder Therapy - Huntington's Disease - Drugs For The Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 3 PA; SP (deutetrabenazine) Movement Disorder Therapy - Restless Legs Syndrome - Drugs For The Nervous System ST: Must meet any of the following requirements: Fanatrex, Gabapentin, HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG Gralise, Neuraptine, Tier 3 (gabapentin) Pramipexole Di-HCL, or Ropinirole HCL in 120 days; QL (30 EA per 30 days) ST: Must meet any of the following requirements: Fanatrex, Gabapentin, HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG Tier 3 Gralise, Neuraptine, (gabapentin) Pramipexole Di-HCL, or Ropinirole HCL in 120 days; QL (2 EA per 1 day) Movement Disorder Therapy - Tardive Dyskinesia - Drugs For The Nervous System AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG Tier 3 PA; SP (deutetrabenazine) INGREZZA INITIATION PACK ORAL CAPSULE,DOSE Tier 3 PA; SP PACK 40 MG (7)- 80 MG (21) (valbenazine) INGREZZA ORAL CAPSULE 80 MG (valbenazine) Tier 3 PA; SP Narcolepsy And Cataplexy Therapy Agents - Sedative-Type - Drugs For Sleep Disorder XYREM ORAL SOLUTION 500 MG/ML (gamma- Tier 3 PA; SP hydroxybutyric acid)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

161 Coverage Prescription Drug Name Drug Tier Requirements and Limits Narcolepsy Therapy Agents - Dopamine And Ne Reuptake Inhibitor (Dnri) - Drugs For Sleep Disorder SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol) Tier 3 PA Narcolepsy Therapy Agents - H3-Receptor Antagonist/Inverse Agonist - Drugs For Sleep Disorder WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant) Tier 3 PA; SP Narcolepsy Therapy Agents - Non- Sympathomimetic - Drugs For Sleep Disorder armodafinil oral tablet 150 mg, 200 mg, 250 mg Tier 1 QL (1 EA per 1 day) armodafinil oral tablet 50 mg Tier 1 QL (3 EA per 1 day) modafinil oral tablet 100 mg, 200 mg Tier 1 QL (2 EA per 1 day) Narcolepsy Therapy Agents- Stimulant- Type,Sympathomimetic,Amphetamines - Drugs For Sleep Disorder dextroamphetamine (Zenzedi Oral Tablet 10 Mg) Tier 1 QL (180 EA per 30 days) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 15 MG (dextroamphetamine) Tier 3 Dextroamphetamine Sulfate in 120 days; QL (3 EA per 1 day) ST: Must meet the following requirement: ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG Tier 3 Dextroamphetamine (dextroamphetamine) Sulfate in 120 days; QL (90 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

162 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: ZENZEDI ORAL TABLET 20 MG, 30 MG Tier 3 Dextroamphetamine (dextroamphetamine) Sulfate in 120 days; QL (2 EA per 1 day) dextroamphetamine (Zenzedi Oral Tablet 5 Mg) Tier 1 QL (90 EA per 30 days) Neuropathic Pain Therapy - Drugs For Seizures /Personality Disorder/Nerve Pain ST: Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL, Divalproex Sodium, Doxepin HCL, Drizalma Sprinkle, Duloxetine HCL, Fanatrex, Gabapentin, LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Gralise, Imipramine HCL, 165 MG, 82.5 MG (pregabalin) Imipramine Pamoate, Lyrica, Maprotiline HCL, Neuraptine, Nortriptyline HCL, Pregabalin, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in 365 days; QL (3 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

163 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL, Divalproex Sodium, Doxepin HCL, Drizalma Sprinkle, Duloxetine HCL, Fanatrex, Gabapentin, LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Gralise, Imipramine HCL, 330 MG (pregabalin) Imipramine Pamoate, Lyrica, Maprotiline HCL, Neuraptine, Nortriptyline HCL, Pregabalin, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in 365 days; QL (2 EA per 1 day) Postherpetic Neuralgia Agents - Drugs For Seizures /Personality Disorder/Nerve Pain ACTIVE-PAC KIT,GEL AND CAPSULE 300-4-1 MG-%-% Tier 3 (gabapentin) ST: Must meet the GRALISE 30-DAY STARTER PACK ORAL TABLET following requirement: EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69) Tier 3 Gabapentin or Gralise in (gabapentin) 120 days; QL (39 EA per 15 days) ST: Must meet the following requirement: GRALISE ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Gabapentin or Gralise in 300 MG, 600 MG (gabapentin) 120 days; QL (3 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

164 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL, Divalproex Sodium, Doxepin HCL, Drizalma Sprinkle, Duloxetine HCL, Fanatrex, Gabapentin, LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Gralise, Imipramine HCL, 165 MG, 82.5 MG (pregabalin) Imipramine Pamoate, Lyrica, Maprotiline HCL, Neuraptine, Nortriptyline HCL, Pregabalin, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in 365 days; QL (3 EA per 1 day) ST: Must meet 2 of the following requirements: Amitriptyline HCL, Desipramine HCL, Divalproex Sodium, Doxepin HCL, Drizalma Sprinkle, Duloxetine HCL, Fanatrex, Gabapentin, LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR Tier 3 Gralise, Imipramine HCL, 330 MG (pregabalin) Imipramine Pamoate, Lyrica, Maprotiline HCL, Neuraptine, Nortriptyline HCL, Pregabalin, Stavzor, Valproic Acid (as Sodium Salt), Valproic Acid, or Venlafaxine HCL in 365 days; QL (2 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

165 Coverage Prescription Drug Name Drug Tier Requirements and Limits Pseudobulbar Affect (Pba) Agents, Nmda Antagonists Type - Drugs For Severe Mental Disorders NUEDEXTA ORAL CAPSULE 20-10 MG Tier 3 PA (dextromethorphan) Sedative-Hypnotic - Barbiturates - Drugs For Insomnia phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) Tier 1 phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8 Tier 1 mg, 97.2 mg phenobarbital oral tablet 15 mg, 30 mg, 60 mg Tier 1 SECONAL SODIUM ORAL CAPSULE 100 MG Tier 3 (secobarbital) Sedative-Hypnotic - Benzodiazepines - Drugs For Insomnia estazolam oral tablet 1 mg, 2 mg Tier 1 flurazepam oral capsule 15 mg, 30 mg Tier 1 midazolam oral syrup 2 mg/ml Tier 1 ST: Must meet any of the following requirements: Eszopiclone, Flurazepam quazepam oral tablet 15 mg Tier 1 HCL, Temazepam, Zaleplon, or Zolpidem Tartrate in 120 days temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg Tier 1 triazolam oral tablet 0.125 mg, 0.25 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

166 Coverage Prescription Drug Name Drug Tier Requirements and Limits Sedative-Hypnotic - Gaba-Receptor Modulators - Drugs For Insomnia ST: Must meet the following requirement: EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG (zolpidem) Tier 3 Edluar or Zolpidem Tartrate in 180 days; QL (1 EA per 1 day) eszopiclone oral tablet 1 mg, 2 mg, 3 mg Tier 1 QL (1 EA per 1 day) zaleplon oral capsule 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) zolpidem oral tablet 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 Tier 1 QL (1 EA per 1 day) mg zolpidem sublingual tablet 1.75 mg, 3.5 mg Tier 1 QL (1 EA per 1 day) Sedative-Hypnotic - Orexin Receptor Antagonist - Drugs For Insomnia ST: Must meet any of the following requirements: BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG Tier 2 Eszopiclone, Zaleplon, or (suvorexant) Zolpidem Tartrate in 120 days; QL (1 EA per 1 day) Sedative-Hypnotic - Tricyclic Antidepressant Type - Drugs For Insomnia ST: Must meet any of the following requirements: Doxepin solution or 10mg SILENOR ORAL TABLET 3 MG (doxepin) Tier 2 capsules, Eszopiclone, Silenor, Zaleplon, or Zolpidem Tartrate in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

167 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Doxepin HCL, Eszopiclone, SILENOR ORAL TABLET 6 MG (doxepin) Tier 2 Silenor, Zaleplon, or Zolpidem Tartrate in 120 days; QL (1 EA per 1 day) Sedative-Hypnotic Combinations Other - Drugs For Insomnia MKO (MIDAZOLAM-KETAMINE-ONDAN) SUBLINGUAL Tier 1 TROCHE 3-25-2 MG (midazolam) Chemical Dependency, Agents To Treat - Drugs For Addiction Agents For Opioid Withdrawal, Central Alpha-2 Adrenergic Agonist-Type - Drugs For Opioid Addiction LUCEMYRA ORAL TABLET 0.18 MG (lofexidine) Tier 3 PA Agents For Opioid Withdrawal, Opioid-Type - Drugs For Opioid Addiction BUNAVAIL BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG, 6.3-1 Tier 3 MG (buprenorphine) buprenorphine hcl sublingual tablet 2 mg, 8 mg Tier 1 buprenorphine-naloxone sublingual film 12-3 mg, 2-0.5 mg, Tier 1 4-1 mg, 8-2 mg buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg Tier 1 ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG Tier 2 (buprenorphine) Alcohol Abstinence Therapy - Glutamate And Gaba System Type - Drugs For Alcohol Addiction acamprosate oral tablet,delayed release (dr/ec) 333 mg Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

168 Coverage Prescription Drug Name Drug Tier Requirements and Limits Alcohol Deterrents - Drugs For Alcohol Addiction disulfiram oral tablet 250 mg, 500 mg Tier 1 Smoking Deterrents - Ne And Dopamine Reuptake Inhibitor (Ndri)-Type - Drugs For Smoking Addiction bupropion hcl (smoking deter) oral tablet extended release QL (2 EA per 1 day); Age Tier 0 12 hr 150 mg (Min 18 Years) Smoking Deterrents - Nicotine-Type - Drugs For Smoking Addiction QL (24 EA per 1 day); Age NICORELIEF BUCCAL GUM 2 MG, 4 MG (nicotine) Tier 0 (Min 18 Years) QL (24 EA per 1 day); Age nicotine (polacrilex) buccal gum 2 mg, 4 mg Tier 0 (Min 18 Years) QL (20 EA per 1 day); Age nicotine (polacrilex) buccal lozenge 2 mg, 4 mg Tier 0 (Min 18 Years) QL (20 EA per 1 day); Age nicotine (polacrilex) buccal mini lozenge 2 mg, 4 mg Tier 0 (Min 18 Years) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 QL (1 EA per 1 day); Age Tier 0 hr, 7 mg/24 hr (Min 18 Years) nicotine transdermal patch, td daily, sequential 21-14-7 QL (1 EA per 1 day); Age Tier 0 mg/24 hr (Min 18 Years) ST: Must meet any of the following requirements: Nicotine, Nicotine Patch, or NICOTROL INHALATION CARTRIDGE 10 MG (nicotine) Tier 0 Pyrithione Zinc in 120 days; QL (1008 EA per 90 days); Age (Min 18 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

169 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 Nicotine, Nicotine Patch, or Tier 0 MG/ML (nicotine) Pyrithione Zinc in 120 days; QL (160 ML per 90 days); Age (Min 18 Years) QL (24 EA per 1 day); Age QUIT 2 BUCCAL GUM 2 MG (nicotine) Tier 0 (Min 18 Years) QL (20 EA per 1 day); Age QUIT 2 BUCCAL LOZENGE 2 MG (nicotine) Tier 0 (Min 18 Years) QL (24 EA per 1 day); Age QUIT 4 BUCCAL GUM 4 MG (nicotine) Tier 0 (Min 18 Years) QL (20 EA per 1 day); Age QUIT 4 BUCCAL LOZENGE 4 MG (nicotine) Tier 0 (Min 18 Years) STOP SMOKING AID BUCCAL LOZENGE 2 MG, 4 MG QL (20 EA per 1 day); Age Tier 0 (nicotine) (Min 18 Years) Smoking Deterrents - Nicotinic Receptor Partial Agonist, Alpha4beta2 - Drugs For Smoking Addiction CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 QL (2 EA per 1 day); Age Tier 0 MG (varenicline) (Min 18 Years) QL (2 EA per 1 day); Age CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline) Tier 0 (Min 18 Years) CHANTIX STARTING MONTH BOX ORAL QL (2 EA per 1 day); Age TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) Tier 0 (Min 18 Years) (varenicline) Chemicals-Pharmaceutical Adjuvants Bulk Chemicals alum, ammonium (bulk) powder Tier 3 balsam peru (bulk) liquid Tier 3 benzoin (bulk) topical tincture Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

170 Coverage Prescription Drug Name Drug Tier Requirements and Limits BRIJ L4 LIQUID 100 % (laureth 4) Tier 3 citric acid (bulk) powder Tier 3 citric acid anhydrous (bulk) granules 100 % Tier 3 citric acid monohydrate (bulk) granules 100 % Tier 3 dimethyl sulfoxide (bulk) liquid 99.99 % Tier 3 glutathione (bulk) powder 100 % Tier 3 guaiacol liquid Tier 3 hydrogen peroxide (bulk) solution 30 % Tier 3 hydroxyethyl methacrylate,bulk liquid 96 % Tier 3 niacin (bulk) powder Tier 3 talc (bulk) powder 100 % Tier 3 vitamin e acetate (bulk) liquid 125 unit/ml Tier 3 Chemicals - Cryopreservative Agents CRYOSERV SOLUTION 99 % (dimethyl sulfoxide) Tier 3 Chemicals - Solvents dimethyl sulfoxide (bulk) liquid 99 % Tier 3 isopropyl alcohol solution 70 %, 91 %, 99 % Tier 3 MURI-LUBE OIL (mineral oil) Tier 3 propylene glycol (bulk) liquid 99.5 % (not less than, usp) Tier 3 sodium succinate powder Tier 3 Pharmaceutical Adjuvant - Anticorrosive Agents butylated hydroxytoluene powder Tier 3 Pharmaceutical Adjuvant - Flavoring Agents ethyl acetate liquid Tier 3 Pharmaceutical Adjuvant - Inhalation Vehicles HYPER-SAL INHALATION SOLUTION FOR Tier 3 NEBULIZATION 3.5 % (sodium chloride for inhalation) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

171 Coverage Prescription Drug Name Drug Tier Requirements and Limits NEBUSAL INHALATION SOLUTION FOR NEBULIZATION Tier 1 3 % (sodium chloride for inhalation) NEBUSAL INHALATION SOLUTION FOR NEBULIZATION Tier 3 6 % (sodium chloride for inhalation) sodium chloride inhalation solution for nebulization 0.9 %, Tier 1 10 %, 3 %, 7 % Pharmaceutical Adjuvant - Surfactants polysorbate 80 solution Tier 3 Pharmaceutical Adjuvant - Suspending Agents hydroxypropyl cellulose powder Tier 3 hypromellose powder Tier 3 METHOCEL E 4 M POWDER (hypromellose) Tier 3 Pharmaceutical Adjuvant - Tableting cellulose (bulk) powder Tier 3 Pharmaceutical Adjuvant - Vaccine Adjuvants SHINGRIX ADJUVANT COMPONENT-PF QL (1 ML per 365 days); INTRAMUSCULAR SUSPENSION (vaccine adjuvant Tier 0 Age (Min 50 Years) system, AS01B liposomal) VAXCHORA BUFFER COMPONENT ORAL SUSPENSION Tier 3 FOR RECONSTITUTION (sodium bicarbonate) Cognitive Disorder Therapy - Drugs For The Nervous System Alzheimer's Disease Therapy - Cholinesterase Inhibitors - Drugs For Alzheimer's Disease donepezil oral tablet 10 mg, 23 mg, 5 mg Tier 1 donepezil oral tablet,disintegrating 10 mg, 5 mg Tier 1 galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 Tier 1 QL (30 EA per 30 days) mg, 8 mg galantamine oral solution 4 mg/ml Tier 1 QL (200 ML per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

172 Coverage Prescription Drug Name Drug Tier Requirements and Limits galantamine oral tablet 12 mg, 4 mg, 8 mg Tier 1 QL (60 EA per 30 days) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 Tier 1 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, Tier 1 QL (30 EA per 30 days) 4.6 mg/24 hr, 9.5 mg/24 hr Alzheimer's Disease Therapy - Nmda Receptor Antagonists - Drugs For Alzheimer's Disease memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 Tier 1 QL (30 EA per 30 days) mg, 7 mg memantine oral solution 2 mg/ml Tier 1 QL (300 ML per 30 days) memantine oral tablet 10 mg, 5 mg Tier 1 QL (60 EA per 30 days) memantine oral tablets,dose pack 5-10 mg Tier 1 QL (49 EA per 28 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE Tier 2 QL (28 EA per 28 days) PACK 7-14-21-28 MG (memantine) Alzheimer's Thx - Nmda Receptor Antag. And Cholinesterase Inhib. Comb - Drugs For Alzheimer's Disease ST: Must meet 2 of the following requirements: NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK Donepezil HCL, Memantine Tier 2 7/14/21/28 MG-10 MG (memantine) HCL, or Namenda XR in 365 days; QL (28 EA per 28 days) ST: Must meet 2 of the following requirements: NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 Donepezil HCL, Memantine Tier 2 MG, 21-10 MG, 28-10 MG, 7-10 MG (memantine) HCL, or Namenda XR in 365 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

173 Coverage Prescription Drug Name Drug Tier Requirements and Limits Cognitive Disorder Therapy - Cerebral Vasodilators - Drugs For Alzheimer's Disease ergoloid oral tablet 1 mg Tier 1 Contraceptives - Drugs For Women Contraceptive Implant - Progestin - Birth Control Pills NEXPLANON SUBDERMAL IMPLANT 68 MG Tier 4 QL (1 EA per 365 days) (etonogestrel) Contraceptive Injectable - Progestin - Birth Control Pills DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE Tier 4 104 MG/0.65 ML (medroxyprogesterone) medroxyprogesterone intramuscular suspension 150 mg/ml Tier 4 medroxyprogesterone intramuscular syringe 150 mg/ml Tier 4 Contraceptive Intrauterine - Copper Iud - Birth Control Pills PARAGARD T 380A INTRAUTERINE INTRAUTERINE Tier 0 DEVICE 380 SQUARE MM (copper) Contraceptive Intrauterine - Progesterone Iud - Birth Control Pills KYLEENA INTRAUTERINE INTRAUTERINE DEVICE 17.5 Tier 0 MCG/24 HRS (5 YRS) 19.5 MG (levonorgestrel) LILETTA INTRAUTERINE INTRAUTERINE DEVICE 19.5 Tier 0 MCG/24 HRS (5 YRS) 52 MG (levonorgestrel) MIRENA INTRAUTERINE INTRAUTERINE DEVICE 20 Tier 0 MCG/24 HOURS (5 YRS) 52 MG (levonorgestrel) SKYLA INTRAUTERINE INTRAUTERINE DEVICE 14 Tier 0 MCG/24 HRS (3 YRS) 13.5 MG (levonorgestrel)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

174 Coverage Prescription Drug Name Drug Tier Requirements and Limits Contraceptive Oral - Biphasic - Birth Control Pills levonorgestrel-ethinyl estradiol (Amethia Lo Oral Tablets,Dose Pack,3 Month 0.10 Mg-20 Mcg (84)/10 Mcg Tier 0 (7)) levonorgestrel-ethinyl estradiol (Amethia Oral Tablets,Dose Tier 0 Pack,3 Month 0.15 Mg-30 Mcg (84)/10 Mcg (7)) levonorgestrel-ethinyl estradiol (Ashlyna Oral Tablets,Dose Tier 0 Pack,3 Month 0.15 Mg-30 Mcg (84)/10 Mcg (7)) desogestrel-ethinyl estradiol (Azurette (28) Oral Tablet 0.15- Tier 0 0.02 Mgx21 /0.01 Mg X 5) desogestrel-ethinyl estradiol (Bekyree (28) Oral Tablet 0.15- Tier 0 0.02 Mgx21 /0.01 Mg X 5) CAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7) (levonorgestrel-ethinyl Tier 0 estradiol) CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) (levonorgestrel-ethinyl Tier 0 estradiol) levonorgestrel-ethinyl estradiol (Daysee Oral Tablets,Dose Tier 0 Pack,3 Month 0.15 Mg-30 Mcg (84)/10 Mcg (7)) desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 mgx21 Tier 0 /0.01 mg x 5 desogestrel-ethinyl estradiol (Kariva (28) Oral Tablet 0.15- Tier 0 0.02 Mgx21 /0.01 Mg X 5) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 Tier 0 mcg (7) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 Tier 0 MCG (2) (norethindrone) desogestrel-ethinyl estradiol (Pimtrea (28) Oral Tablet 0.15- Tier 0 0.02 Mgx21 /0.01 Mg X 5)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

175 Coverage Prescription Drug Name Drug Tier Requirements and Limits desogestrel-ethinyl estradiol (Simliya (28) Oral Tablet 0.15- Tier 0 0.02 Mgx21 /0.01 Mg X 5) levonorgestrel-ethinyl estradiol (Simpesse Oral Tablets,Dose Pack,3 Month 0.15 Mg-30 Mcg (84)/10 Mcg Tier 0 (7)) desogestrel-ethinyl estradiol (Viorele (28) Oral Tablet 0.15- Tier 0 0.02 Mgx21 /0.01 Mg X 5) Contraceptive Oral - Monophasic - Birth Control Pills levonorgestrel (Afirmelle Oral Tablet 0.1-20 Mg-Mcg) Tier 0 levonorgestrel (Altavera (28) Oral Tablet 0.15-0.03 Mg) Tier 0 norethindrone (Alyacen 1/35 (28) Oral Tablet 1-35 Mg-Mcg) Tier 0 levonorgestrel (Amethyst (28) Oral Tablet 90-20 Mcg (28)) Tier 0 desogestrel (Apri Oral Tablet 0.15-0.03 Mg) Tier 0 levonorgestrel (Aubra Eq Oral Tablet 0.1-20 Mg-Mcg) Tier 0 levonorgestrel (Aubra Oral Tablet 0.1-20 Mg-Mcg) Tier 0 norethindrone (Aurovela 1.5/30 (21) Oral Tablet 1.5-30 Mg- Tier 0 Mcg) norethindrone (Aurovela 1/20 (21) Oral Tablet 1-20 Mg- Tier 0 Mcg) norethindrone (Aurovela 24 Fe Oral Tablet 1 Mg-20 Mcg Tier 0 (24)/75 Mg (4)) norethindrone (Aurovela Fe 1.5/30 (28) Oral Tablet 1.5 Mg- Tier 0 30 Mcg (21)/75 Mg (7)) norethindrone (Aurovela Fe 1-20 (28) Oral Tablet 1 Mg-20 Tier 0 Mcg (21)/75 Mg (7)) levonorgestrel (Aviane Oral Tablet 0.1-20 Mg-Mcg) Tier 0 levonorgestrel (Ayuna Oral Tablet 0.15-0.03 Mg) Tier 0

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

176 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirements: BALCOLTRA ORAL TABLET 0.1 MG-0.02 MG (21)/36.5 Tier 0 Two generic oral MG(7) (levonorgestrel) contraceptives in 365 days; QL (28 EA per 28 days) norethindrone (Balziva (28) Oral Tablet 0.4-35 Mg-Mcg) Tier 0 norethindrone (Blisovi 24 Fe Oral Tablet 1 Mg-20 Mcg Tier 0 (24)/75 Mg (4)) norethindrone (Blisovi Fe 1.5/30 (28) Oral Tablet 1.5 Mg-30 Tier 0 Mcg (21)/75 Mg (7)) norethindrone (Blisovi Fe 1/20 (28) Oral Tablet 1 Mg-20 Tier 0 Mcg (21)/75 Mg (7)) norethindrone (Briellyn Oral Tablet 0.4-35 Mg-Mcg) Tier 0 levonorgestrel (Chateal (28) Oral Tablet 0.15-0.03 Mg) Tier 0 levonorgestrel (Chateal Eq (28) Oral Tablet 0.15-0.03 Mg) Tier 0 norgestrel (Cryselle (28) Oral Tablet 0.3-30 Mg-Mcg) Tier 0 norethindrone (Cyclafem 1/35 (28) Oral Tablet 1-35 Mg- Tier 0 Mcg) desogestrel (Cyred Eq Oral Tablet 0.15-0.03 Mg) Tier 0 desogestrel (Cyred Oral Tablet 0.15-0.03 Mg) Tier 0 norethindrone (Dasetta 1/35 (28) Oral Tablet 1-35 Mg-Mcg) Tier 0 desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg Tier 0 drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-0.451 mg Tier 0 (24) (4), 3-0.03-0.451 mg (21) (7) drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 Tier 0 mg norgestrel (Elinest Oral Tablet 0.3-30 Mg-Mcg) Tier 0 desogestrel (Emoquette Oral Tablet 0.15-0.03 Mg) Tier 0 desogestrel (Enskyce Oral Tablet 0.15-0.03 Mg) Tier 0 norgestimate (Estarylla Oral Tablet 0.25-35 Mg-Mcg) Tier 0

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

177 Coverage Prescription Drug Name Drug Tier Requirements and Limits ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 Tier 0 mg-mcg levonorgestrel (Falmina (28) Oral Tablet 0.1-20 Mg-Mcg) Tier 0 norgestimate (Femynor Oral Tablet 0.25-35 Mg-Mcg) Tier 0 GIANVI (28) ORAL TABLET 3-0.02 MG (ethinyl estradiol) Tier 0 norethindrone (Hailey 24 Fe Oral Tablet 1 Mg-20 Mcg Tier 0 (24)/75 Mg (4)) norethindrone (Hailey Oral Tablet 1.5-30 Mg-Mcg) Tier 0 levonorgestrel (Introvale Oral Tablets,Dose Pack,3 Month Tier 0 0.15 Mg-30 Mcg (91)) desogestrel (Isibloom Oral Tablet 0.15-0.03 Mg) Tier 0 ethinyl estradiol (Jasmiel (28) Oral Tablet 3-0.02 Mg) Tier 0 JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 Tier 0 MG-30 MCG (91) (levonorgestrel) desogestrel (Juleber Oral Tablet 0.15-0.03 Mg) Tier 0 norethindrone (Junel 1.5/30 (21) Oral Tablet 1.5-30 Mg- Tier 0 Mcg) norethindrone (Junel 1/20 (21) Oral Tablet 1-20 Mg-Mcg) Tier 0 norethindrone (Junel Fe 1.5/30 (28) Oral Tablet 1.5 Mg-30 Tier 0 Mcg (21)/75 Mg (7)) norethindrone (Junel Fe 1/20 (28) Oral Tablet 1 Mg-20 Mcg Tier 0 (21)/75 Mg (7)) norethindrone (Junel Fe 24 Oral Tablet 1 Mg-20 Mcg Tier 0 (24)/75 Mg (4)) norethindrone (Kaitlib Fe Oral Tablet,Chewable 0.8Mg- Tier 0 25Mcg(24) And 75 Mg (4)) desogestrel (Kalliga Oral Tablet 0.15-0.03 Mg) Tier 0 ethynodiol (Kelnor 1/35 (28) Oral Tablet 1-35 Mg-Mcg) Tier 0 ethynodiol (Kelnor 1-50 Oral Tablet 1-50 Mg-Mcg) Tier 0 levonorgestrel (Kurvelo (28) Oral Tablet 0.15-0.03 Mg) Tier 0

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

178 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone (Larin 1.5/30 (21) Oral Tablet 1.5-30 Mg- Tier 0 Mcg) norethindrone (Larin 1/20 (21) Oral Tablet 1-20 Mg-Mcg) Tier 0 norethindrone (Larin 24 Fe Oral Tablet 1 Mg-20 Mcg (24)/75 Tier 0 Mg (4)) norethindrone (Larin Fe 1.5/30 (28) Oral Tablet 1.5 Mg-30 Tier 0 Mcg (21)/75 Mg (7)) norethindrone (Larin Fe 1/20 (28) Oral Tablet 1 Mg-20 Mcg Tier 0 (21)/75 Mg (7)) levonorgestrel (Larissia Oral Tablet 0.1-20 Mg-Mcg) Tier 0 LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG- Tier 0 25MCG(24) AND 75 MG (4) (norethindrone) levonorgestrel (Lessina Oral Tablet 0.1-20 Mg-Mcg) Tier 0 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, Tier 0 0.15-0.03 mg, 90-20 mcg (28) levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month Tier 0 0.15 mg-30 mcg (91) levonorgestrel (Levora-28 Oral Tablet 0.15-0.03 Mg) Tier 0 levonorgestrel (Lillow (28) Oral Tablet 0.15-0.03 Mg) Tier 0 ethinyl estradiol (Loryna (28) Oral Tablet 3-0.02 Mg) Tier 0 norgestrel (Low-Ogestrel (28) Oral Tablet 0.3-30 Mg-Mcg) Tier 0 ethinyl estradiol (Lo-Zumandimine (28) Oral Tablet 3-0.02 Tier 0 Mg) levonorgestrel (Lutera (28) Oral Tablet 0.1-20 Mg-Mcg) Tier 0 levonorgestrel (Marlissa (28) Oral Tablet 0.15-0.03 Mg) Tier 0 norethindrone (Melodetta 24 Fe Oral Tablet,Chewable 1 Tier 0 Mg-20 Mcg(24) /75 Mg (4)) norethindrone (Mibelas 24 Fe Oral Tablet,Chewable 1 Mg- Tier 0 20 Mcg(24) /75 Mg (4)) norethindrone (Microgestin 1.5/30 (21) Oral Tablet 1.5-30 Tier 0 Mg-Mcg) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

179 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone (Microgestin 1/20 (21) Oral Tablet 1-20 Mg- Tier 0 Mcg) norethindrone (Microgestin Fe 1.5/30 (28) Oral Tablet 1.5 Tier 0 Mg-30 Mcg (21)/75 Mg (7)) norethindrone (Microgestin Fe 1/20 (28) Oral Tablet 1 Mg- Tier 0 20 Mcg (21)/75 Mg (7)) norgestimate (Mili Oral Tablet 0.25-35 Mg-Mcg) Tier 0 norgestimate (Mono-Linyah Oral Tablet 0.25-35 Mg-Mcg) Tier 0 norethindrone (Necon 0.5/35 (28) Oral Tablet 0.5-35 Mg- Tier 0 Mcg) ethinyl estradiol (Nikki (28) Oral Tablet 3-0.02 Mg) Tier 0 noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg- Tier 0 35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5- Tier 0 30 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg Tier 0 (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4) norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 Tier 0 mcg(24) /75 mg (4) norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg Tier 0 norethindrone (Nortrel 0.5/35 (28) Oral Tablet 0.5-35 Mg- Tier 0 Mcg) NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG (21) Tier 0 (norethindrone) norethindrone (Nortrel 1/35 (28) Oral Tablet 1-35 Mg-Mcg) Tier 0 OCELLA ORAL TABLET 3-0.03 MG (ethinyl estradiol) Tier 0 OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG Tier 0 (norgestrel) levonorgestrel (Orsythia Oral Tablet 0.1-20 Mg-Mcg) Tier 0 norethindrone (Philith Oral Tablet 0.4-35 Mg-Mcg) Tier 0 norethindrone (Pirmella Oral Tablet 1-35 Mg-Mcg) Tier 0 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

180 Coverage Prescription Drug Name Drug Tier Requirements and Limits levonorgestrel (Portia 28 Oral Tablet 0.15-0.03 Mg) Tier 0 norgestimate (Previfem Oral Tablet 0.25-35 Mg-Mcg) Tier 0 desogestrel (Reclipsen (28) Oral Tablet 0.15-0.03 Mg) Tier 0 levonorgestrel (Setlakin Oral Tablets,Dose Pack,3 Month Tier 0 0.15 Mg-30 Mcg (91)) norgestimate (Sprintec (28) Oral Tablet 0.25-35 Mg-Mcg) Tier 0 levonorgestrel (Sronyx Oral Tablet 0.1-20 Mg-Mcg) Tier 0 ethinyl estradiol (Syeda Oral Tablet 3-0.03 Mg) Tier 0 norethindrone (Tarina 24 Fe Oral Tablet 1 Mg-20 Mcg Tier 0 (24)/75 Mg (4)) norethindrone (Tarina Fe 1/20 (28) Oral Tablet 1 Mg-20 Tier 0 Mcg (21)/75 Mg (7)) norethindrone (Tarina Fe 1-20 Eq (28) Oral Tablet 1 Mg-20 Tier 0 Mcg (21)/75 Mg (7)) TAYTULLA ORAL CAPSULE 1 MG-20 MCG (24)/75 MG (4) Tier 0 (norethindrone) drospirenone (Tydemy Oral Tablet 3-0.03-0.451 Mg (21) Tier 0 (7)) levonorgestrel (Vienva Oral Tablet 0.1-20 Mg-Mcg) Tier 0 norethindrone (Vyfemla (28) Oral Tablet 0.4-35 Mg-Mcg) Tier 0 norgestimate (Vylibra Oral Tablet 0.25-35 Mg-Mcg) Tier 0 norethindrone (Wera (28) Oral Tablet 0.5-35 Mg-Mcg) Tier 0 norethindrone (Wymzya Fe Oral Tablet,Chewable 0.4Mg- Tier 0 35Mcg(21) And 75 Mg (7)) ethinyl estradiol (Zarah Oral Tablet 3-0.03 Mg) Tier 0 ethynodiol (Zovia 1/35E (28) Oral Tablet 1-35 Mg-Mcg) Tier 0 ethinyl estradiol (Zumandimine (28) Oral Tablet 3-0.03 Mg) Tier 0 Contraceptive Oral - Progestin - Birth Control Pills norethindrone (Camila Oral Tablet 0.35 Mg) Tier 0 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

181 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone (Deblitane Oral Tablet 0.35 Mg) Tier 0 norethindrone (Errin Oral Tablet 0.35 Mg) Tier 0 norethindrone (Heather Oral Tablet 0.35 Mg) Tier 0 norethindrone (Incassia Oral Tablet 0.35 Mg) Tier 0 norethindrone (Jencycla Oral Tablet 0.35 Mg) Tier 0 norethindrone (Lyza Oral Tablet 0.35 Mg) Tier 0 NORA-BE ORAL TABLET 0.35 MG (norethindrone) Tier 0 norethindrone (contraceptive) oral tablet 0.35 mg Tier 0 norethindrone (Norlyda Oral Tablet 0.35 Mg) Tier 0 norethindrone (Sharobel Oral Tablet 0.35 Mg) Tier 0 SLYND ORAL TABLET 4 MG (28) (drospirenone) Tier 0 QL (28 EA per 28 days) norethindrone (Tulana Oral Tablet 0.35 Mg) Tier 0 Contraceptive Oral - Quadraphasic - Birth Control Pills levonorgestrel-ethinyl estradiol (Fayosim Oral Tablets,Dose Tier 0 Pack,3 Month 0.15 Mg-20 Mcg/ 0.15 Mg-25 Mcg) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month Tier 0 0.15 mg-20 mcg/ 0.15 mg-25 mcg NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 Tier 0 MG (estradiol) RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG-25 MCG (levonorgestrel-ethinyl Tier 0 estradiol) Contraceptive Oral - Triphasic - Birth Control Pills norethindrone (Alyacen 7/7/7 (28) Oral Tablet 0.5/0.75/1 Tier 0 Mg- 35 Mcg) norethindrone (Aranelle (28) Oral Tablet 0.5/1/0.5-35 Mg- Tier 0 Mcg)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

182 Coverage Prescription Drug Name Drug Tier Requirements and Limits desogestrel (Caziant (28) Oral Tablet 0.1/.125/.15-25 Mg- Tier 0 Mcg) norethindrone (Cyclafem 7/7/7 (28) Oral Tablet 0.5/0.75/1 Tier 0 Mg- 35 Mcg) norethindrone (Dasetta 7/7/7 (28) Oral Tablet 0.5/0.75/1 Tier 0 Mg- 35 Mcg) levonorgestrel (Enpresse Oral Tablet 50-30 (6)/75-40 Tier 0 (5)/125-30(10)) LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG Tier 0 (norethindrone) levonorgestrel (Levonest (28) Oral Tablet 50-30 (6)/75-40 Tier 0 (5)/125-30(10)) levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-40 Tier 0 (5)/125-30(10) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 Tier 0 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28) norethindrone (Nortrel 7/7/7 (28) Oral Tablet 0.5/0.75/1 Mg- Tier 0 35 Mcg) norethindrone (Pirmella Oral Tablet 0.5/0.75/1 Mg- 35 Mcg) Tier 0 norethindrone (Tilia Fe Oral Tablet 1-20(5)/1-30(7) /1Mg- Tier 0 35Mcg (9)) norgestimate (Tri Femynor Oral Tablet 0.18/0.215/0.25 Mg- Tier 0 35 Mcg (28)) norgestimate (Tri-Estarylla Oral Tablet 0.18/0.215/0.25 Mg- Tier 0 35 Mcg (28)) norethindrone (Tri-Legest Fe Oral Tablet 1-20(5)/1-30(7) Tier 0 /1Mg-35Mcg (9)) norgestimate (Tri-Linyah Oral Tablet 0.18/0.215/0.25 Mg-35 Tier 0 Mcg (28)) norgestimate (Tri-Lo-Estarylla Oral Tablet 0.18/0.215/0.25 Tier 0 Mg-25 Mcg)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

183 Coverage Prescription Drug Name Drug Tier Requirements and Limits norgestimate (Tri-Lo-Marzia Oral Tablet 0.18/0.215/0.25 Tier 0 Mg-25 Mcg) norgestimate (Tri-Lo-Mili Oral Tablet 0.18/0.215/0.25 Mg-25 Tier 0 Mcg) norgestimate (Tri-Lo-Sprintec Oral Tablet 0.18/0.215/0.25 Tier 0 Mg-25 Mcg) norgestimate (Tri-Mili Oral Tablet 0.18/0.215/0.25 Mg-35 Tier 0 Mcg (28)) norgestimate (Tri-Previfem (28) Oral Tablet 0.18/0.215/0.25 Tier 0 Mg-35 Mcg (28)) norgestimate (Tri-Sprintec (28) Oral Tablet 0.18/0.215/0.25 Tier 0 Mg-35 Mcg (28)) levonorgestrel (Trivora (28) Oral Tablet 50-30 (6)/75-40 Tier 0 (5)/125-30(10)) norgestimate (Tri-Vylibra Lo Oral Tablet 0.18/0.215/0.25 Tier 0 Mg-25 Mcg) norgestimate (Tri-Vylibra Oral Tablet 0.18/0.215/0.25 Mg-35 Tier 0 Mcg (28)) desogestrel (Velivet Triphasic Regimen (28) Oral Tablet Tier 0 0.1/.125/.15-25 Mg-Mcg) Contraceptive Transdermal Combinations - Birth Control Pills XULANE TRANSDERMAL PATCH WEEKLY 150-35 Tier 0 MCG/24 HR (norelgestromin) Contraceptives - Intravaginal, Systemic - Birth Control Pills NUVARING VAGINAL RING 0.12-0.015 MG/24 HR Tier 0 (etonogestrel)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

184 Coverage Prescription Drug Name Drug Tier Requirements and Limits Contraceptives - Intravaginal, Systemic - Estrogen And Progestin Comb. - Birth Control Pills ST: Must meet the ANNOVERA VAGINAL RING 0.15-0.013 MG/24 HOUR following requirement: Tier 0 (segesterone) Nuvaring in 120 days; QL (1 EA per 365 days) Emergency Contraceptives - Birth Control Pills AFTERA ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 ECONTRA ONE-STEP ORAL TABLET 1.5 MG Tier 0 (levonorgestrel) ELLA ORAL TABLET 30 MG (ulipristal) Tier 0 levonorgestrel oral tablet 1.5 mg Tier 0 MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 MY WAY ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 OPCICON ONE-STEP ORAL TABLET 1.5 MG Tier 0 (levonorgestrel) OPTION-2 ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 Emergency Contraceptives - Progesterone Agonist/Antagonist Type - Birth Control Pills ELLA ORAL TABLET 30 MG (ulipristal) Tier 0 Emergency Contraceptives - Progestin Type - Birth Control Pills levonorgestrel oral tablet 1.5 mg Tier 0 MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) Tier 0

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

185 Coverage Prescription Drug Name Drug Tier Requirements and Limits OPCICON ONE-STEP ORAL TABLET 1.5 MG Tier 0 (levonorgestrel) OPTION-2 ORAL TABLET 1.5 MG (levonorgestrel) Tier 0 Spermicides - Birth Control Pills GYNOL II VAGINAL GEL 3 % (nonoxynol 9) Tier 0 TODAY CONTRACEPTIVE SPONGE VAGINAL Tier 0 CONTRACEPTIVE SPONGE 1,000 MG (nonoxynol 9) VAGINAL CONTRACEPTIVE FILM VAGINAL FILM 28 % Tier 0 (nonoxynol 9) VAGINAL CONTRACEPTIVE FOAM VAGINAL FOAM 12.5 Tier 0 % (nonoxynol 9) VCF CONTRACEPTIVE FILM VAGINAL FILM 28 % Tier 0 (nonoxynol 9) VCF CONTRACEPTIVE GEL VAGINAL GEL 4 % Tier 0 (nonoxynol 9) Dermatological - Drugs For The Skin Acne Therapy Systemic - Retinoids And Derivatives - Drugs For The Skin ST: Must meet the ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 following requirement: Tier 3 MG, 35 MG, 40 MG (isotretinoin) Absorica or Isotretinoin in 120 days isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Tier 1 Mg) isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 Tier 1 Mg) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg Tier 1 isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, Tier 1 40 Mg) isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, Tier 1 40 Mg)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

186 Coverage Prescription Drug Name Drug Tier Requirements and Limits Acne Therapy Systemic - Tetracycline Antibiotic - Drugs For The Skin ST: Must meet the following requirement: minocycline (Coremino Oral Tablet Extended Release 24 Hr Generic immediate-release Tier 1 135 Mg, 45 Mg, 90 Mg) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) ST: Must meet the following requirement: minocycline oral tablet extended release 24 hr 105 mg, 115 Generic immediate-release Tier 1 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) ST: Must meet the following requirement: MINOLIRA ER ORAL TABLET, IR - ER, BIPHASIC 24HR Generic immediate-release Tier 3 105 MG, 135 MG (minocycline) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) ST: Must meet any of the following requirements: Doryx Mpc, Doxycycline SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG Hyclate, Doxycycline Tier 3 (sarecycline) Monohydrate, Minocycline HCL, or Vibramycin in 120 days; QL (1 EA per 1 day); Age (Min 9 Years) ST: Must meet the following requirement: SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR Generic immediate-release Tier 3 105 MG, 80 MG (minocycline) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

187 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: XIMINO ORAL CAPSULE,EXTENDED RELEASE 24HR Generic immediate-release Tier 3 135 MG, 45 MG, 90 MG (minocycline) Minocycline in 120 days; QL (1 EA per 1 day); Age (Min 12 Years) Acne Therapy Topical - Anti-Infective - Drugs For The Skin ACZONE TOPICAL GEL WITH PUMP 7.5 % (dapsone) Tier 3 azelaic acid topical gel 15 % Tier 1 AZELEX TOPICAL CREAM 20 % (azelaic acid) Tier 3 clindamycin phosphate topical foam 1 % Tier 1 clindamycin phosphate topical gel 1 % Tier 1 ST: Must meet the following requirement: clindamycin phosphate topical gel, once daily 1 % Tier 1 Clindamycin Phosphate 1% gel in 120 days clindamycin phosphate topical lotion 1 % Tier 1 clindamycin phosphate topical solution 1 % Tier 1 QL (180 ML per 1 FILL) clindamycin phosphate topical swab 1 % Tier 1 clindamycin-niacinamide topical gel 1-4 % Tier 1 dapsone topical gel 5 % Tier 1 erythromycin base (Ery Pads Topical Swab 2 %) Tier 1 erythromycin with ethanol topical gel 2 % Tier 1 erythromycin with ethanol topical solution 2 % Tier 1 QL (180 ML per 1 FILL) FINACEA TOPICAL FOAM 15 % (azelaic acid) Tier 2 metronidazole topical cream 0.75 % Tier 1 metronidazole topical lotion 0.75 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

188 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the NORITATE TOPICAL CREAM 1 % (metronidazole) Tier 3 following requirement: Metronidazole in 120 days NUCARACLINPAK TOPICAL KIT,GEL AND LOTION 1 %- Tier 3 SPF 50 (clindamycin) metronidazole (Rosadan Topical Cream 0.75 %) Tier 1 sulfacetamide sodium (acne) topical suspension 10 % Tier 1 sulfacetamide-niacinamide topical cream 10-4 % Tier 1 Acne Therapy Topical - Anti-Infective Combinations Other - Drugs For The Skin CLINDACIN ETZ TOPICAL KIT 1 % (clindamycin) Tier 3 CLINDACIN PAC TOPICAL KIT 1 % (clindamycin) Tier 3 clindamycin-niacinamide topical lotion 1-4 % Tier 1 dapsone-niacinamide topical gel 6-4 %, 8.5-4 % Tier 1 dapsone-spironolactone-niacin topical gel 6-5-2 %, 8.5-5-2 Tier 1 % Acne Therapy Topical - Anti-Infective- Keratolytic Combinations - Drugs For The Skin AVAR LS TOPICAL FOAM 10-2 % (sulfacetamide) Tier 3 AVAR LS TOPICAL PADS, MEDICATED 10-2 % Tier 3 (sulfacetamide) AVAR TOPICAL PADS, MEDICATED 9.5-5 % Tier 3 (sulfacetamide) benzoyl per-clindamycin-niacin topical gel 2.5-1-4 %, 5-1-4 Tier 1 % BP 10-1 TOPICAL CLEANSER 10-1 % (sulfacetamide) Tier 1 CLEANSING WASH TOPICAL CLEANSER 10-4-10 % Tier 1 (sulfacetamide) clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % Tier 1 base) -5 %

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

189 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: clindamycin-benzoyl peroxide topical gel with pump 1.2-2.5 Tier 1 Clindamycin % Phosphate/Benzoyl Peroxide gel in 120 days clindamycin-benzoyl peroxide topical gel with pump 1-5 % Tier 1 erythromycin-benzoyl peroxide topical gel 3-5 % Tier 1 NEUAC KIT TOPICAL COMBO PACK,CREAM AND GEL Tier 3 1.2-5 % (clindamycin) clindamycin (Neuac Topical Gel 1.2 %(1 % Base) -5 %) Tier 1 NUCARARXPAK TOPICAL KIT,GEL AND LOTION 1 %-2.5 Tier 3 %- SPF 50 (clindamycin) ONEXTON TOPICAL GEL 1.2 %(1 % BASE) -3.75 % Tier 3 (clindamycin) ST: Must meet the following requirement: ONEXTON TOPICAL GEL WITH PUMP 1.2 %(1 % BASE) - Tier 2 Clindamycin 3.75 % (clindamycin) Phosphate/Benzoyl Peroxide gel in 120 days PLEXION CLEANSING CLOTHS TOPICAL PADS, Tier 3 MEDICATED 9.8-4.8 % (sulfacetamide) ROSANIL TOPICAL CLEANSER 10-5 % (W/W) Tier 3 QL (1419 GM per 1 FILL) (sulfacetamide) ROSULA CLEANSING CLOTHS TOPICAL PADS, Tier 1 MEDICATED 10-5 % (sulfacetamide) ROSULA TOPICAL CLEANSER 10-4.5 % (sulfacetamide) Tier 3 SSS 10-5 TOPICAL FOAM 10-5 % (sulfacetamide) Tier 1 sulfacetamide sodium-sulfur topical cleanser 10-2 %, 9-4 %, Tier 1 9-4.5 %, 9.8-4.8 % sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) Tier 1 QL (1419 GM per 1 FILL) sulfacetamide sodium-sulfur topical cream 10-2 %, 9.8-4.8 Tier 1 %

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

190 Coverage Prescription Drug Name Drug Tier Requirements and Limits sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10- Tier 1 5 % (w/w), 9.8-4.8 % sulfacetamide sodium-sulfur topical pads, medicated 10-4 Tier 1 % sulfacetamide sodium-sulfur topical suspension 10-5 %, 8-4 Tier 1 % sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 % Tier 1 QL (1419 ML per 1 FILL) sulfacetamide-sulfur-cleansr23 topical kit 9-4.5 % Tier 1 SULFACLEANSE 8-4 TOPICAL SUSPENSION 8-4 % Tier 1 (sulfacetamide) SUMADAN TOPICAL KIT 9-4.5 % (sulfacetamide) Tier 3 SUMAXIN CP TOPICAL KIT 10-4 % (sulfacetamide) Tier 3 Acne Therapy Topical - Anti-Infective-Retinoid Combinations - Drugs For The Skin adapalene-benzoyl-clindamycin topical gel 0.3-2.5-1 % Tier 1 ST: Must meet the following requirement: clindamycin-tretinoin topical gel 1.2-0.025 % Tier 1 Clindamycin gel or Tretinoin gel 0.025% in 120 days tretinoin-benzoyl-clinda-niac topical gel 0.025-2.5-1-2 %, Tier 1 0.025-5-1-2 %, 0.05-5-1-2 % tretinoin-clindamycin-niacin topical cream 0.025-1-4 % Tier 1 tretinoin-clinda-spiron-niacin topical gel 0.025-1-2-4 % Tier 1 Acne Therapy Topical - Keratolytic - Drugs For The Skin BENZEPRO (MICROSPHERES) TOPICAL CLEANSER 7 Tier 1 % (benzoyl peroxide) BENZEPRO TOPICAL TOWELETTE 6 % (benzoyl Tier 1 peroxide) benzoyl peroxide topical cleanser 7 % Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

191 Coverage Prescription Drug Name Drug Tier Requirements and Limits benzoyl peroxide topical foam 9.8 % Tier 1 BPO TOPICAL GEL 4 %, 8 % (benzoyl peroxide) Tier 1 INOVA TOPICAL COMBO PACK 4-5 %, 8-5 % (benzoyl Tier 3 peroxide) PACNEX HP TOPICAL PADS, MEDICATED 7 % (benzoyl Tier 3 peroxide) PACNEX LP TOPICAL PADS, MEDICATED 4.25 % Tier 3 (benzoyl peroxide) PR BENZOYL PEROXIDE TOPICAL CLEANSER 7 % Tier 1 (benzoyl peroxide) Acne Therapy Topical - Keratolytic Combinations Other - Drugs For The Skin INOVA 4-1 TOPICAL COMBO PACK 1-4-5 % (salicylic Tier 3 acid) INOVA 8-2 TOPICAL COMBO PACK 2-8-5 % (salicylic Tier 3 acid) Acne Therapy Topical - Keratolytic- Glucocorticoid Combinations - Drugs For The Skin VANOXIDE-HC TOPICAL SUSPENSION 5-0.5 % (benzoyl Tier 2 peroxide) Acne Therapy Topical - Retinoid Combinations Other - Drugs For The Skin ST: Must meet the adapalene-benzoyl peroxide topical gel with pump 0.1-2.5 following requirement: Tier 1 % Adapalene 0.1% gel in 120 days; Age (Max 25 Years) adapalene-benzoyl perox-niacin topical gel 0.3-2.5-4 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

192 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the EPIDUO FORTE TOPICAL GEL WITH PUMP 0.3-2.5 % following requirement: Tier 2 (adapalene) Adapalene 0.1% gel in 120 days; Age (Max 25 Years) tretinoin-hyaluronate-niacin topical cream 0.025-0.5-4 %, Tier 1 0.05-0.5-4 %, 0.1-0.5-4 % tretinoin-niacinamide topical cream 0.025-4 %, 0.05-4 % Tier 1 tretinoin-niacinamide topical gel 0.025-4 %, 0.05-4 % Tier 1 tretinoin-spironolact-niacin topical gel 0.025-5-2 %, 0.05-5-2 Tier 1 % Acne Therapy Topical - Retinoids And Derivatives - Drugs For The Skin adapalene topical cream 0.1 % Tier 1 Age (Max 25 Years) adapalene topical gel 0.1 %, 0.3 % Tier 1 Age (Max 25 Years) adapalene topical gel with pump 0.3 % Tier 1 Age (Max 25 Years) adapalene topical lotion 0.1 % Tier 1 Age (Max 25 Years) ST: Must meet the following requirement: adapalene topical solution 0.1 % Tier 3 Adapalene 0.1% gel in 120 days; Age (Max 25 Years) ST: Must meet the following requirement: adapalene topical swab 0.1 % Tier 1 Adapalene 0.1% gel in 120 days; QL (1 EA per 1 day); Age (Max 25 Years) ST: Must meet any of the following requirements: AKLIEF TOPICAL CREAM 0.005 % (trifarotene) Tier 3 Adapalene, Tazarotene, or Tretinoin in 120 days; Age (Max 25 Years) ALTRENO TOPICAL LOTION 0.05 % (tretinoin) Tier 3 Age (Max 25 Years) AVITA TOPICAL CREAM 0.025 % (tretinoin) Tier 1 Age (Max 25 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

193 Coverage Prescription Drug Name Drug Tier Requirements and Limits AVITA TOPICAL GEL 0.025 % (tretinoin) Tier 1 Age (Max 25 Years) ST: Must meet any of the following requirements: FABIOR TOPICAL FOAM 0.1 % (tazarotene) Tier 3 Adapalene, Tazarotene, or Tretinoin in 120 days; Age (Min 12 Years) ST: Must meet the following requirements: RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.06 Generic Tretinoin Tier 3 %, 0.08 % (tretinoin) Microspheres 0.04% and 0.10% in 365 days; Age (Max 25 Years) tazarotene-niacinamide topical cream 0.05-4 %, 0.1-4 % Tier 1 tretinoin microspheres topical gel 0.04 %, 0.1 % Tier 1 Age (Max 25 Years) tretinoin microspheres topical gel with pump 0.04 %, 0.1 % Tier 1 Age (Max 25 Years) tretinoin topical cream 0.025 %, 0.05 %, 0.1 % Tier 1 Age (Max 25 Years) tretinoin topical gel 0.01 %, 0.025 %, 0.05 % Tier 1 Age (Max 25 Years) TRETIN-X CREAM KIT TOPICAL COMBO PACK 0.025 %, Tier 3 Age (Max 25 Years) 0.05 %, 0.1 % (tretinoin) TRETIN-X TOPICAL CREAM 0.075 % (tretinoin) Tier 3 Age (Max 25 Years) Acne Therapy Topical Combinations Other - Drugs For The Skin spironolactone-niacinamide topical gel 5-4 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

194 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antipsoriatic - Retinoid (Vitamin A Derivative) - Glucocorticoid - Drugs For The Skin ST: Must meet any of the following requirements: Betamethasone augmented 0.05% (cream, gel, lotion, ointment), Clobetasol, DUOBRII TOPICAL LOTION 0.01-0.045 % (halobetasol) Tier 3 Desoximetasone (cream, gel, ointment), Fluocinonide (cream, gel), or Halobetasol (cream, ointment) in 120 days; QL (200 GM per 28 days) Antipsoriatic - Vitamin D Analog - Glucocorticoid Combinations - Drugs For The Skin ST: Must meet the calcipotriene-betamethasone topical ointment 0.005-0.064 following requirement: Tier 1 % Topical Anti-inflammatory Steroidal in 120 days ST: Must meet the following requirement: ENSTILAR TOPICAL FOAM 0.005-0.064 % (calcipotriene) Tier 3 Topical Anti-inflammatory Steroidal in 120 days ST: Must meet the TACLONEX TOPICAL SUSPENSION 0.005-0.064 % following requirement: Tier 3 (calcipotriene) Topical Anti-inflammatory Steroidal in 120 days Antipsoriatic Agents - Interleukin 12 And Il-23 Inhibitors,Mc Antibody - Drugs For The Skin STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML Tier 4 PA (ustekinumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

195 Coverage Prescription Drug Name Drug Tier Requirements and Limits STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 Tier 4 PA MG/ML (ustekinumab) Antipsoriatic Agents - Interleukin-23 (Il-23) Antagonist, Mc Antibody - Drugs For The Skin SKYRIZI SUBCUTANEOUS SYRINGE 75 MG/0.83 ML Tier 4 PA (risankizumab-rzaa) SKYRIZI SUBCUTANEOUS SYRINGE KIT Tier 4 PA 150MG/1.66ML(75 MG/0.83 ML X2) (risankizumab-rzaa) TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 Tier 4 PA MG/ML (guselkumab) TREMFYA SUBCUTANEOUS SYRINGE 100 MG/ML Tier 4 PA (guselkumab) Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody - Drugs For The Skin COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE Tier 4 PA 150 MG/ML (secukinumab) COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN Tier 4 PA INJECTOR 150 MG/ML (secukinumab) COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 Tier 4 PA MG/ML (secukinumab) COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML Tier 4 PA (secukinumab) SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML Tier 4 PA (brodalumab) TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS Tier 4 PA AUTO-INJECTOR 80 MG/ML (ixekizumab) TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS Tier 4 PA AUTO-INJECTOR 80 MG/ML (ixekizumab) TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO- Tier 4 PA INJECTOR 80 MG/ML (ixekizumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

196 Coverage Prescription Drug Name Drug Tier Requirements and Limits TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML Tier 4 PA (ixekizumab) Dermatitis Or Eczema Agents, Systemic- Interleukin-4 (Il-4Ra) Antag.Mab - Drugs For The Skin DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML Tier 4 PA (dupilumab) Dermatitis Or Eczema Agents, Topical - Phosphodiesterase-4 Inhibitors - Drugs For The Skin ST: Must meet the following requirement: EUCRISA TOPICAL OINTMENT 2 % (crisaborole) Tier 2 Topical Anti-inflammatory Steroidal in 120 days Dermatological - Antibacterial Aminoglycosides - Drugs For The Skin gentamicin topical cream 0.1 % Tier 1 QL (90 GM per 1 FILL) gentamicin topical ointment 0.1 % Tier 1 Dermatological - Antibacterial And Antifungal Agents - Drugs For The Skin QUINJA TOPICAL GEL 1.25-1 % (iodoquinol) Tier 3 Dermatological - Antibacterial Other - Drugs For The Skin CENTANY AT TOPICAL OINTMENT KIT 2 % (mupirocin) Tier 3 mupirocin calcium topical cream 2 % Tier 1 QL (90 GM per 1 FILL) mupirocin topical ointment 2 % Tier 1 NORMLGEL AG TOPICAL GEL 0.11 % (silver) Tier 3 silver nitrate topical solution 0.5 % Tier 1 silver nitrate topical solution 10 %, 25 %, 50 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

197 Coverage Prescription Drug Name Drug Tier Requirements and Limits SILVRSTAT TOPICAL GEL 32 PPM (silver) Tier 3 SOLOX GEL TOPICAL GEL 55 PPM (silver) Tier 3 Dermatological - Antibacterial Pleuromutilin Derivatives - Drugs For The Skin ST: Must meet the following requirement: ALTABAX TOPICAL OINTMENT 1 % (retapamulin) Tier 3 Mupirocin ointment in 120 days Dermatological - Antibacterial Quinolones - Drugs For The Skin ST: Must meet the following requirement: XEPI TOPICAL CREAM 1 % (ozenoxacin) Tier 3 Mupirocin ointment in 120 days Dermatological - Antibacterial Sulfonamides - Drugs For The Skin SSS 10-5 TOPICAL CREAM 10-5 % (W/W) (sulfacetamide) Tier 1 sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) Tier 1 Dermatological - Antibacterial,Antifungal Agent With Glucocorticoid - Drugs For The Skin ALA-QUIN TOPICAL CREAM 3-0.5 % (clioquinol) Tier 3 ALCORTIN A TOPICAL GEL IN PACKET 2-1-1 % Tier 3 (hydrocortisone) hydrocortisone-iodoquinl-aloe2 topical gel 2-1-1 % Tier 1 hydrocortisone-iodoquinol-aloe topical cream in packet 1.9- Tier 1 1 % ketoconazole-iodoquinol-hc topical cream 2-1-2.5 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

198 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antibacterial-Glucocorticoid Combinations - Drugs For The Skin CORTISPORIN TOPICAL CREAM 3.5-10,000-0.5 MG/G- Tier 2 UNIT/G-% (neomycin) CORTISPORIN TOPICAL OINTMENT 1 % (neomycin) Tier 2 ST: Must meet 2 of the following requirements: Bacitracin Zinc, Bacitracin, NEO-SYNALAR KIT TOPICAL CREAM 0.5 % (0.35 % Tier 3 Capex Shampoo, BASE)-0.025 % (neomycin) Fluocinolone Acetonide, Iluvien, Retisert, or Yutiq in 365 days ST: Must meet 2 of the following requirements: Bacitracin Zinc, Bacitracin, NEO-SYNALAR TOPICAL CREAM 0.5 % (0.35 % BASE)- Tier 3 Capex Shampoo, 0.025 % (neomycin) Fluocinolone Acetonide, Iluvien, Retisert, or Yutiq in 365 days Dermatological - Anticholinergic Hyperhidrosis Treatment Agents - Drugs For The Skin QBREXZA TOPICAL TOWELETTE 2.4 % (glycopyrronium) Tier 3 PA Dermatological - Antifungal Allylamines - Drugs For The Skin naftifine topical cream 1 % Tier 1 naftifine topical cream 2 % Tier 1 QL (180 GM per 1 FILL) naftifine topical gel 1 % Tier 1 NAFTIN TOPICAL GEL 1 % (naftifine) Tier 2 NAFTIN TOPICAL GEL 2 % (naftifine) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

199 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antifungal Amphoteric Polyene Macrolides - Drugs For The Skin nystatin (Nyamyc Topical Powder 100,000 Unit/Gram) Tier 1 nystatin topical cream 100,000 unit/gram Tier 1 nystatin topical ointment 100,000 unit/gram Tier 1 nystatin topical powder 100,000 unit/gram Tier 1 nystatin (Nystop Topical Powder 100,000 Unit/Gram) Tier 1 Dermatological - Antifungal Benzylamines - Drugs For The Skin MENTAX TOPICAL CREAM 1 % (butenafine) Tier 3 Dermatological - Antifungal Combinations Other - Drugs For The Skin EXODERM TOPICAL LOTION 25-1 % (sodium thiosulfate) Tier 1 flucona-ibuprof-itracon-terbin topical solution 4-2-1-4 % Tier 1 Dermatological - Antifungal Hydroxypyridinone - Drugs For The Skin CICLODAN KIT TOPICAL COMBO PACK 0.77 % Tier 3 (ciclopirox) ciclopirox topical cream 0.77 % Tier 1 QL (180 GM per 1 FILL) ciclopirox topical gel 0.77 % Tier 1 ciclopirox topical shampoo 1 % Tier 1 ciclopirox topical solution 8 % Tier 1 QL (19.8 ML per 1 FILL) ciclopirox topical suspension 0.77 % Tier 1 QL (180 ML per 1 FILL) ciclopirox-salicylic acid topical shampoo 0.77-2 % Tier 1 ciclopirox-ure-camph-menth-euc topical solution 8 % Tier 1 QL (19.8 ML per 1 FILL) LOPROX KIT TOPICAL COMBO PACK 0.77 % (ciclopirox) Tier 3 LOPROX KIT TOPICAL KIT, SUSPENSION AND Tier 3 CLEANSER 0.77 % (ciclopirox)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

200 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antifungal Imidazole And Related Agents - Drugs For The Skin clotrimazole topical cream 1 % Tier 1 clotrimazole topical solution 1 % Tier 1 econazole topical cream 1 % Tier 1 QL (170 GM per 1 FILL) ECOZA TOPICAL FOAM 1 % (econazole) Tier 3 ERTACZO TOPICAL CREAM 2 % (sertaconazole) Tier 3 EXELDERM TOPICAL CREAM 1 % (sulconazole) Tier 2 EXELDERM TOPICAL SOLUTION 1 % (sulconazole) Tier 2 ketoconazole topical cream 2 % Tier 1 QL (180 GM per 1 FILL) ketoconazole topical foam 2 % Tier 1 ketoconazole topical shampoo 2 % Tier 1 KETODAN KIT TOPICAL COMBO PACK 2 % Tier 3 (ketoconazole) ketoconazole (Ketodan Topical Foam 2 %) Tier 1 ST: Must meet the following requirements: luliconazole topical cream 1 % Tier 1 Clotrimazole and Ketoconazole in 365 days; QL (60 GM per 28 days) miconazole nitrate-zinc ox-pet topical ointment 0.25-15- Tier 1 81.35 % oxiconazole topical cream 1 % Tier 1 QL (180 GM per 1 FILL) OXISTAT TOPICAL LOTION 1 % (oxiconazole) Tier 3 PEDIZOL PAK TOPICAL KIT, CREAM AND SOLUTION 2-2 Tier 3 % (ketoconazole) XOLEGEL TOPICAL GEL 2 % (ketoconazole) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

201 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antifungal Oxaborole - Drugs For The Skin KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 % Tier 3 PA (tavaborole) Dermatological - Antifungal Triazole - Drugs For The Skin JUBLIA TOPICAL SOLUTION WITH APPLICATOR 10 % Tier 3 PA (efinaconazole) Dermatological - Antifungal-Glucocorticoid Combinations - Drugs For The Skin ciclopirox-clobetasol topical shampoo 0.77-0.05 % Tier 1 clotrimazole-betamethasone topical cream 1-0.05 % Tier 1 clotrimazole-betamethasone topical lotion 1-0.05 % Tier 1 DERMACINRX THERAZOLE PAK TOPICAL COMBO Tier 3 PACK 1-0.05-20 % (clotrimazole) DERMAZENE TOPICAL CREAM 1-1 % (hydrocortisone) Tier 1 DERMAZENE TOPICAL CREAM IN PACKET 1-1 % Tier 3 (hydrocortisone) hydrocortisone-iodoquinol topical cream 1-1 % Tier 1 nystatin-triamcinolone topical cream 100,000-0.1 unit/g-% Tier 1 nystatin-triamcinolone topical ointment 100,000-0.1 Tier 1 unit/gram-% Dermatological - Antineoplastic Alkylating Agents - Drugs For The Skin VALCHLOR TOPICAL GEL 0.016 % (mechlorethamine) Tier 3 PA; SP Dermatological - Antineoplastic Antimetabolites - Drugs For The Skin FLUOROPLEX TOPICAL CREAM 1 % (fluorouracil) Tier 3 fluorouracil topical cream 0.5 % Tier 1 PA

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

202 Coverage Prescription Drug Name Drug Tier Requirements and Limits fluorouracil topical cream 5 % Tier 1 fluorouracil topical solution 2 %, 5 % Tier 1 TOLAK TOPICAL CREAM 4 % (fluorouracil) Tier 2 Dermatological - Antineoplastic Or Premalig. Lesions -Diterpene Esters - Drugs For The Skin PICATO TOPICAL GEL 0.015 % (ingenol mebutate) Tier 2 QL (3 EA per 28 days) PICATO TOPICAL GEL 0.05 % (ingenol mebutate) Tier 2 QL (2 EA per 28 days) Dermatological - Antineoplastic Or Premalignant Lesions - Nsaid's - Drugs For The Skin diclofenac sodium topical gel 3 % Tier 1 QL (100 GM per 1 FILL) Dermatological - Antineoplastic Retinoids - Drugs For The Skin PANRETIN TOPICAL GEL 0.1 % (alitretinoin) Tier 3 SP Dermatological - Antineoplastic Selective Retinoid X Receptor Agonist - Drugs For The Skin TARGRETIN TOPICAL GEL 1 % (bexarotene) Tier 3 PA; SP Dermatological - Antiperspirants - Drugs For The Skin DRYSOL DAB-O-MATIC TOPICAL SOLUTION 20 % Tier 2 (aluminum) DRYSOL TOPICAL SOLUTION 20 % (aluminum) Tier 2 Dermatological - Antipsoriatic Agents Systemic, Photosensitizing - Drugs For The Skin methoxsalen oral capsule,liqd-filled,rapid rel 10 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

203 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antipsoriatic Agents Systemic, Vitamin A Derivatives - Drugs For The Skin acitretin oral capsule 10 mg, 17.5 mg, 25 mg Tier 3 SP Dermatological - Antipsoriatic Agents Topical - Drugs For The Skin ST: Must meet any of the following requirements: Betamethasone augmented 0.05% (cream, gel, lotion, ointment), Clobetasol, BRYHALI TOPICAL LOTION 0.01 % (halobetasol) Tier 3 Desoximetasone (cream, gel, ointment), Fluocinonide (cream, gel), or Halobetasol (cream, ointment) in 120 days; QL (400 GM per 1 FILL) ST: Must meet the following requirement: calcipotriene scalp solution 0.005 % Tier 1 Topical Anti-inflammatory Steroidal in 120 days ST: Must meet the following requirement: calcipotriene topical cream 0.005 % Tier 1 Topical Anti-inflammatory Steroidal in 120 days ST: Must meet the following requirement: calcipotriene topical ointment 0.005 % Tier 1 Topical Anti-inflammatory Steroidal in 120 days ST: Must meet the following requirement: calcipotriene (Calcitrene Topical Ointment 0.005 %) Tier 1 Topical Anti-inflammatory Steroidal in 120 days Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

204 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: calcitriol topical ointment 3 mcg/gram Tier 1 Topical Anti-inflammatory Steroidal in 120 days ST: Must meet the following requirement: DRITHOCREME HP TOPICAL CREAM 1 % (anthralin) Tier 2 Topical Anti-inflammatory Steroidal in 120 days ST: Must meet any of the following requirements: Clobetasol Propionate, Clobetasol halobetasol propionate topical foam 0.05 % Tier 1 Propionate/emollient, or Halobetasol Propionate in 120 days; QL (100 GM per 1 FILL) ST: Must meet the following requirement: Betamethasone 0.05% (ointment, augmented IMPOYZ TOPICAL CREAM 0.025 % (clobetasol) Tier 3 cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) in 120 days ST: Must meet any of the following requirements: Clobetasol Propionate, Clobetasol LEXETTE TOPICAL FOAM 0.05 % (halobetasol) Tier 3 Propionate/emollient, or Halobetasol Propionate in 120 days; QL (100 GM per 1 FILL) NUDERMRXPAK TOPICAL KIT 0.005-5 % (calcipotriene) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

205 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: SORILUX TOPICAL FOAM 0.005 % (calcipotriene) Tier 3 Topical Anti-inflammatory Steroidal in 120 days tazarotene topical cream 0.1 % Tier 1 TAZORAC TOPICAL CREAM 0.05 % (tazarotene) Tier 2 TAZORAC TOPICAL GEL 0.05 %, 0.1 % (tazarotene) Tier 2 ST: Must meet any of the following requirements: Betamethasone augmented (ointment, gel, lotion), Clobetasol (spray, lotion, gel, ointment, ULTRAVATE TOPICAL LOTION 0.05 % (halobetasol) Tier 3 cream, solution), Fluocinonide 0.1% cream, or Halobetasol 0.05% (cream, ointment) in 120 days; QL (100 ML per 1 FILL) ST: Must meet the following requirement: ZITHRANOL TOPICAL SHAMPOO 1 % (anthralin) Tier 3 Topical Anti-inflammatory Steroidal in 120 days Dermatological - Antipsoriatics Systemic, Phosphodiesterase 4 Inhib. - Drugs For The Skin OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) Tier 3 PA; SP (apremilast) Dermatological - Antiseborrheic - Drugs For The Skin ESKATA TOPICAL SOLUTION WITH APPLICATOR 40 % Tier 3 (hydrogen peroxide)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

206 Coverage Prescription Drug Name Drug Tier Requirements and Limits LOUTREX TOPICAL CREAM (emollient combination no.85) Tier 1 OVACE PLUS SHAMPOO TOPICAL SHAMPOO 10 % Tier 2 (sulfacetamide) OVACE PLUS TOPICAL CREAM 10 % (sulfacetamide) Tier 3 OVACE PLUS TOPICAL FOAM 9.8 % (sulfacetamide) Tier 3 ST: Must meet the following requirement: OVACE PLUS TOPICAL LOTION 9.8 % (sulfacetamide) Tier 3 Ciclopirox or Ketoconazole in 120 days PROMISEB TOPICAL CREAM (emollient combination Tier 3 no.43) selenium sulfide topical lotion 2.5 % Tier 1 selenium sulfide topical shampoo 2.25 %, 2.3 % Tier 1 sulfacetamide sodium topical cleanser 10 % Tier 1 sulfacetamide sodium topical cleanser, gel 10 % Tier 1 sulfacetamide sodium topical shampoo 10 % Tier 1 TERSI FOAM TOPICAL FOAM 2.25 % (selenium sulfide) Tier 3 Dermatological - Antiviral, Herpes - Drugs For The Skin ST: Must meet 2 of the following requirements: acyclovir topical cream 5 % Tier 1 Acyclovir, Famciclovir, or Valacyclovir HCL in 365 days acyclovir topical ointment 5 % Tier 1 ST: Must meet 2 of the following requirements: DENAVIR TOPICAL CREAM 1 % (penciclovir) Tier 3 Acyclovir, Famciclovir, or Valacyclovir HCL in 365 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

207 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Antiviral-Glucocorticoid Combinations - Drugs For The Skin ST: Must meet any of the following requirements: Acyclovir, Famciclovir, XERESE TOPICAL CREAM 5-1 % (acyclovir) Tier 3 Sitavig, or Valacyclovir HCL in 120 days; QL (10 GM per 365 days) Dermatological - Burn Products Anti-Infective - Drugs For The Skin mafenide acetate topical packet 50 gram Tier 1 silver sulfadiazine topical cream 1 % Tier 1 SSD TOPICAL CREAM 1 % (silver sulfadiazine) Tier 1 SULFAMYLON TOPICAL CREAM 85 MG/G (mafenide) Tier 3 SULFAMYLON TOPICAL PACKET 50 GRAM (mafenide) Tier 3 Dermatological - Calcineurin Inhibitors - Drugs For The Skin ST: Must meet the following requirement: pimecrolimus topical cream 1 % Tier 1 Topical Anti-inflammatory Steroidal in 120 days tacrolimus topical ointment 0.03 %, 0.1 % Tier 1 tacrolimus-hyaluronate-niacin topical cream 0.1-1-4 % Tier 1 tacrolimus-niacinamide topical ointment 0.1-4 % Tier 1 Dermatological - Depigmenting Agents - Drugs For The Skin hydroquinone microspheres topical cream,extended release Tier 1 4 % hydroquinone topical cream 4 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

208 Coverage Prescription Drug Name Drug Tier Requirements and Limits OBAGI ELASTIDERM TOPICAL CREAM 4 % Tier 1 (hydroquinone) OBAGI NU-DERM BLENDER TOPICAL CREAM 4 % Tier 1 (hydroquinone) OBAGI NU-DERM CLEAR TOPICAL CREAM 4 % Tier 1 (hydroquinone) Dermatological - Depigmenting Combinations - Drugs For The Skin hydroquinone-hydrocortisone topical emulsion 6-0.5 % Tier 1 lactic acid-niacinamide topical cream 10-4 % Tier 1 OBAGI NU-DERM SUNFADER TOPICAL CREAM 4 %- Tier 3 SPF 15 (hydroquinone) OBAGI-C CLARIFYING SERUM TOPICAL LIQUID 4-10 % Tier 3 (hydroquinone) OBAGI-C THERAPY NIGHT TOPICAL CREAM 4 % Tier 3 (hydroquinone) TRI-LUMA TOPICAL CREAM 0.01-4-0.05 % (fluocinolone Tier 3 acetonide) Dermatological - Emollient Combinations Other - Drugs For The Skin HPR PLUS HYDROGEL TOPICAL KIT,CREAM AND GEL Tier 1 (emollient combination no.53) HPR PLUS-MB HYDROGEL TOPICAL COMBO PACK,GEL AND FOAM 96.53-3-0.4 -0.066 % (emollient combination Tier 1 no.53) MB HYDROGEL (CYCLOMETHICONE) TOPICAL Tier 1 KIT,CREAM AND GEL (emollient combination no.53) MB HYDROGEL TOPICAL KIT,CREAM AND GEL 96.53-3- Tier 1 0.4 -0.066 % (emollient combination no.53)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

209 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Emollient Mixtures - Drugs For The Skin ATOPADERM TOPICAL CREAM (emollient combination Tier 3 no.53) ATRAPRO CP TOPICAL COMBO PACK,CREAM AND Tier 3 GEL (emollient combination no.47) ATRAPRO HYDROGEL TOPICAL GEL (emollient Tier 3 combination no.60) AVO CREAM TOPICAL EMULSION (emollient combination Tier 1 no. 10) CELACYN TOPICAL GEL WITH PUMP (emollient Tier 3 combination no.60) CERACADE TOPICAL EMULSION (emollient combination Tier 3 no.103) CERAMAX TOPICAL CREAM (emollient combination Tier 3 no.101) CERAMAX TOPICAL LOTION (emollient combination Tier 3 no.101) DEXERYL TOPICAL CREAM (emollient combination Tier 3 no.104) EMULSION SB TOPICAL EMULSION (emollient Tier 1 combination no. 32) ENTTY TOPICAL SPRAY,NON-AEROSOL (palm oil) Tier 3 EPICERAM TOPICAL EMULSION, EXTENDED RELEASE Tier 3 PA (emollient combination no. 32) HPR PLUS TOPICAL CREAM (emollient combination Tier 3 no.53) HPR PLUS TOPICAL FOAM (emollient combination no.53) Tier 3 HPR TOPICAL FOAM (emollient combination no.44) Tier 3 HYLATOPIC TOPICAL FOAM (emollient combination Tier 3 no.44)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

210 Coverage Prescription Drug Name Drug Tier Requirements and Limits HYLATOPICPLUS TOPICAL CREAM (emollient Tier 3 combination no.53) HYLATOPICPLUS TOPICAL FOAM (emollient combination Tier 3 no.53) HYLATOPICPLUS TOPICAL LOTION (emollient Tier 3 combination no.53) LEVICYN ANTIPRURITIC SG TOPICAL SPRAY GEL Tier 3 (emollient combination no.60) LOUTREX TOPICAL CREAM (emollient combination no.85) Tier 1 LOYON TOPICAL SPRAY,NON-AEROSOL (dicaprylyl Tier 3 carbonate) LUXAMEND TOPICAL CREAM (emollient combination no. Tier 3 10) NEOCERA TOPICAL CREAM (emollient combination Tier 3 no.109) NEOSALUS TOPICAL CREAM (emollient combination Tier 3 no.47) NEOSALUS TOPICAL FOAM (emollient combination no.38) Tier 3 NEOSALUS TOPICAL LOTION (emollient combination Tier 3 no.47) NIVATOPIC PLUS TOPICAL CREAM (emollient Tier 3 combination no.53) NUTRASEB TOPICAL CREAM (emollient combination Tier 3 no.107) PENLEN TOPICAL SPRAY,NON-AEROSOL (palm oil) Tier 3 PRESERA TOPICAL FOAM (emollient combination no.80) Tier 3 PRUCLAIR TOPICAL CREAM (vitamin E (dl-alpha Tier 1 tocopherol)) PRUMYX TOPICAL CREAM (emollient combination no.35) Tier 1 PRUTECT TOPICAL EMULSION (emollient combination Tier 1 no. 10)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

211 Coverage Prescription Drug Name Drug Tier Requirements and Limits SEBUDERM TOPICAL GEL (emollient combination no.60) Tier 3 SONAFINE TOPICAL EMULSION (emollient combination Tier 1 no. 10) XCLAIR TOPICAL CREAM (hyaluronic acid) Tier 3 Dermatological - Emollients - Drugs For The Skin ammonium lactate topical cream 12 % Tier 1 ammonium lactate topical lotion 12 % Tier 1 KIVIK TOPICAL EMULSION (palm oil) Tier 3 PHLAG SPRAY TOPICAL SPRAY,NON-AEROSOL (palm Tier 3 oil) RADIAGEL TOPICAL GEL (emollient base) Tier 3 SYNERDERM TOPICAL SPRAY,NON-AEROSOL (palm Tier 3 oil) urea topical cream 39 % Tier 1 Dermatological - Enzymes - Drugs For The Skin SANTYL TOPICAL OINTMENT 250 UNIT/GRAM Tier 3 (collagenase Clostridium histolyticum) Dermatological - Eyelid Cleansers - Drugs For The Skin ACUICYN TOPICAL SPRAY,NON-AEROSOL 0.01 % Tier 3 (hypochlorous acid) AVENOVA TOPICAL SPRAY,NON-AEROSOL 0.01 % Tier 3 (hypochlorous acid) HYPOCYN TOPICAL SPRAY,NON-AEROSOL 0.01 % Tier 3 (hypochlorous acid) Dermatological - Glucocorticoid - Drugs For The Skin ADVANCED ALLERGY COLLECT KIT TOPICAL KIT 2.5 % Tier 1 (hydrocortisone) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

212 Coverage Prescription Drug Name Drug Tier Requirements and Limits hydrocortisone (Ala-Cort Topical Cream 1 %) Tier 1 hydrocortisone (Ala-Scalp Topical Lotion 2 %) Tier 1 alclometasone topical cream 0.05 % Tier 1 alclometasone topical ointment 0.05 % Tier 1 amcinonide topical cream 0.1 % Tier 1 amcinonide topical lotion 0.1 % Tier 1 ST: Must meet the following requirement: Betamethasone 0.05% (ointment, augmented amcinonide topical ointment 0.1 % Tier 1 cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) in 120 days ST: Must meet the following requirement: Betamethasone 0.05% (ointment, augmented APEXICON E TOPICAL CREAM 0.05 % (diflorasone) Tier 3 cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) in 120 days betamethasone dipropionate topical cream 0.05 % Tier 1 betamethasone dipropionate topical lotion 0.05 % Tier 1 betamethasone dipropionate topical ointment 0.05 % Tier 1 betamethasone valerate topical cream 0.1 % Tier 1 betamethasone valerate topical foam 0.12 % Tier 1 betamethasone valerate topical lotion 0.1 % Tier 1 betamethasone valerate topical ointment 0.1 % Tier 1 betamethasone, augmented topical cream 0.05 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

213 Coverage Prescription Drug Name Drug Tier Requirements and Limits betamethasone, augmented topical gel 0.05 % Tier 1 betamethasone, augmented topical lotion 0.05 % Tier 1 betamethasone, augmented topical ointment 0.05 % Tier 1 CAPEX TOPICAL SHAMPOO 0.01 % (fluocinolone Tier 3 acetonide) clobetasol scalp solution 0.05 % Tier 1 clobetasol topical cream 0.05 % Tier 1 clobetasol topical foam 0.05 % Tier 1 clobetasol topical gel 0.05 % Tier 1 clobetasol topical lotion 0.05 % Tier 1 clobetasol topical ointment 0.05 % Tier 1 clobetasol topical shampoo 0.05 % Tier 1 clobetasol topical spray,non-aerosol 0.05 % Tier 1 clobetasol-emollient topical cream 0.05 % Tier 1 clobetasol-emollient topical foam 0.05 % Tier 1 clocortolone pivalate topical cream 0.1 % Tier 1 ST: Must meet any of the following requirements: Betamethasone augmented (ointment, gel, lotion), Clobetasol (spray, CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 lotion, gel, ointment, Tier 3 MCG/CM2 (flurandrenolide) cream, solution), Fluocinonide 0.1% cream, or Halobetasol 0.05% (cream, ointment) in 120 days; QL (2 EA per 30 days) ST: Must meet the following requirement: CORDRAN TOPICAL CREAM 0.025 % (flurandrenolide) Tier 3 Topical Anti-inflammatory Steroidal in 120 days Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

214 Coverage Prescription Drug Name Drug Tier Requirements and Limits clobetasol (Cormax Scalp Solution 0.05 %) Tier 1 DESONATE TOPICAL GEL 0.05 % (desonide) Tier 3 desonide topical cream 0.05 % Tier 1 desonide topical lotion 0.05 % Tier 1 desonide topical ointment 0.05 % Tier 1 desoximetasone topical cream 0.05 %, 0.25 % Tier 1 desoximetasone topical gel 0.05 % Tier 1 desoximetasone topical ointment 0.05 %, 0.25 % Tier 1 ST: Must meet any of the following requirements: Betamethasone augmented 0.05% (cream, gel, lotion, ointment), desoximetasone topical spray,non-aerosol 0.25 % Tier 1 Clobetasol, Desoximetasone (cream, gel, ointment), Fluocinonide (cream, gel), or Halobetasol (cream, ointment) in 120 days ST: Must meet the following requirement: Betamethasone 0.05% (ointment, augmented diflorasone topical cream 0.05 % Tier 1 cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

215 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Betamethasone augmented 0.05% (cream, gel, lotion, ointment), diflorasone topical ointment 0.05 % Tier 1 Clobetasol, Desoximetasone (cream, gel, ointment), Fluocinonide (cream, gel), or Halobetasol (cream, ointment) in 120 days fluocinolone and shower cap scalp oil 0.01 % Tier 1 fluocinolone topical cream 0.01 %, 0.025 % Tier 1 fluocinolone topical oil 0.01 % Tier 1 fluocinolone topical ointment 0.025 % Tier 1 fluocinolone topical solution 0.01 % Tier 1 fluocinonide topical cream 0.05 %, 0.1 % Tier 1 fluocinonide topical gel 0.05 % Tier 1 fluocinonide topical ointment 0.05 % Tier 1 fluocinonide topical solution 0.05 % Tier 1 fluocinonide (Fluocinonide-E Topical Cream 0.05 %) Tier 1 fluocinonide-emollient topical cream 0.05 % Tier 1 FLUOVIX TOPICAL KIT 0.1 % (fluocinonide) Tier 3 flurandrenolide topical cream 0.05 % Tier 1 flurandrenolide topical lotion 0.05 % Tier 1 flurandrenolide topical ointment 0.05 % Tier 1 fluticasone propionate topical cream 0.05 % Tier 1 fluticasone propionate topical lotion 0.05 % Tier 1 fluticasone propionate topical ointment 0.005 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

216 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: Betamethasone 0.05% (ointment, augmented halcinonide topical cream 0.1 % Tier 1 cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) in 120 days halobetasol propionate topical cream 0.05 % Tier 1 halobetasol propionate topical ointment 0.05 % Tier 1 ST: Must meet the following requirement: Betamethasone 0.05% (ointment, augmented HALOG TOPICAL CREAM 0.1 % (halcinonide) Tier 3 cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) in 120 days ST: Must meet the following requirement: Betamethasone 0.05% (ointment, augmented HALOG TOPICAL OINTMENT 0.1 % (halcinonide) Tier 3 cream), Desoximetasone (cream, gel, ointment), Fluocinonide 0.05% (gel, ointment, solution, cream) in 120 days hydrocortisone butyrate topical cream 0.1 % Tier 1 hydrocortisone butyrate topical lotion 0.1 % Tier 1 hydrocortisone butyrate topical ointment 0.1 % Tier 1 hydrocortisone butyrate topical solution 0.1 % Tier 1 hydrocortisone butyr-emollient topical cream 0.1 % Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

217 Coverage Prescription Drug Name Drug Tier Requirements and Limits hydrocortisone topical cream 1 %, 2.5 % Tier 1 hydrocortisone topical cream with perineal applicator 1 %, Tier 1 2.5 % hydrocortisone topical lotion 2.5 % Tier 1 hydrocortisone topical ointment 1 %, 2.5 % Tier 1 hydrocortisone valerate topical cream 0.2 % Tier 1 hydrocortisone valerate topical ointment 0.2 % Tier 1 MICORT-HC TOPICAL CREAM WITH PERINEAL Tier 3 APPLICATOR 2.5 % (hydrocortisone) mometasone topical cream 0.1 % Tier 1 mometasone topical ointment 0.1 % Tier 1 mometasone topical solution 0.1 % Tier 1 PANDEL TOPICAL CREAM 0.1 % (hydrocortisone) Tier 2 prednicarbate topical cream 0.1 % Tier 1 prednicarbate topical ointment 0.1 % Tier 1 hydrocortisone (Procto-Pak Topical Cream With Perineal Tier 1 Applicator 1 %) hydrocortisone (Proctosol Hc Topical Cream With Perineal Tier 1 Applicator 2.5 %) SCALACORT DK TOPICAL COMBO PACK 2-2-2 % Tier 2 (hydrocortisone) ST: Must meet the following requirement: SERNIVO TOPICAL SPRAY WITH PUMP 0.05 % Tier 3 Triamcinolone Acetonide (betamethasone) 0.147mg/G spray in 120 days SILALITE PAK TOPICAL KIT,OINTMENT AND SHEET 0.1 Tier 3 % (triamcinolone) SILAZONE-II TOPICAL KIT 0.1 % (triamcinolone) Tier 3 TEXACORT TOPICAL SOLUTION 2.5 % (hydrocortisone) Tier 2

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

218 Coverage Prescription Drug Name Drug Tier Requirements and Limits triamcinolone acetonide topical aerosol 0.147 mg/gram Tier 1 triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 Tier 1 % triamcinolone acetonide topical lotion 0.025 %, 0.1 % Tier 1 triamcinolone acetonide topical ointment 0.025 %, 0.1 %, Tier 1 0.5 % triamcinolone (Trianex Topical Ointment 0.05 %) Tier 1 triamcinolone (Triderm Topical Cream 0.1 %, 0.5 %) Tier 1 VERDESO TOPICAL FOAM 0.05 % (desonide) Tier 3 Dermatological - Glucocorticoid Combinations Other - Drugs For The Skin clobetasol-calcipotriene topical solution 0.05-0.005 % Tier 1 clobetasol-levocetirizine topical shampoo 0.05-2 % Tier 1 clobetasol-niacinamide topical cream 0.05-4 % Tier 1 clobetasol-niacinamide topical ointment 0.05-4 % Tier 1 clobetasol-niacinamide topical solution 0.05-4 % Tier 1 fluocinolone-niacinamide topical cream 0.01-4 %, 0.025-4 % Tier 1 Dermatological - Glucocorticoid-Emollient Combinations - Drugs For The Skin BESER KIT TOPICAL KIT,LOTION AND Tier 3 CREAM,EMOLLIENT 0.05 % (fluticasone) ELLZIA PAK TOPICAL KIT,OINTMENT AND CREAM 0.1-5 Tier 1 % (triamcinolone) NOXIPAK TOPICAL KIT 0.01-20 % (fluocinolone acetonide) Tier 3 NUCORT TOPICAL LOTION 2 % (hydrocortisone) Tier 3 QUINIXIL TOPICAL CREAM 0.1-5 % (mometasone furoate) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

219 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 3 of the following requirements: Amerigel Barrier, Dimethicone, Scar Treatment, Silicone Disc, SANADERMRX TOPICAL KIT 0.1-5 % (triamcinolone) Tier 1 Silicone Roll, Silicone Scar, Silicone Sheet, Silicone Tape, or Triamcinolone Acetonide in 365 days; QL (1 EA per 30 days) SYNALAR CREAM KIT TOPICAL CREAM 0.025 % Tier 3 (fluocinolone acetonide) SYNALAR OINTMENT KIT TOPICAL COMBO PACK,OINTMENT AND CREAM 0.025 % (fluocinolone Tier 3 acetonide) TOVET KIT TOPICAL COMBO PACK 0.05 % (clobetasol) Tier 3 WHYTEDERM TDPAK TOPICAL KIT 0.1-2 % Tier 3 (triamcinolone) WHYTEDERM TRILASIL PAK TOPICAL KIT 0.1-2 % Tier 3 (triamcinolone) Dermatological - Glucocorticoid-Local Anesthetic Combinations - Drugs For The Skin ANALPRAM-HC TOPICAL LOTION 2.5-1 % Tier 2 (hydrocortisone) EPIFOAM TOPICAL FOAM 1-1 % (hydrocortisone) Tier 3 hydrocortisone-pramoxine topical cream 2.5-1 % Tier 1 lidocaine hcl-hydrocortison ac topical cream 3-0.5 % Tier 1 NOVACORT TOPICAL GEL WITH PERINEAL Tier 3 APPLICATOR 2-1 % (hydrocortisone) PRAMOSONE TOPICAL CREAM 1-1 % (hydrocortisone) Tier 2 PRAMOSONE TOPICAL LOTION 1-1 %, 2.5-1 % Tier 2 (hydrocortisone)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

220 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRAMOSONE TOPICAL OINTMENT 1-1 %, 2.5-1 % Tier 2 (hydrocortisone) Dermatological - Glucocorticoid-Skin Cleanser Combinations - Drugs For The Skin AQUA GLYCOLIC HC TOPICAL COMBO PACK 2 % Tier 3 (hydrocortisone) CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER Tier 3 0.05 % (clobetasol) SYNALAR TS TOPICAL KIT 0.01 % (fluocinolone Tier 3 acetonide) XILAPAK TOPICAL KIT 0.01 % (fluocinolone acetonide) Tier 3 Dermatological - Immunomodulator - Catechins - Genital Wart/Hpv Tx - Drugs For The Skin ST: Must meet the following requirements: VEREGEN TOPICAL OINTMENT 15 % (sinecatechins) Tier 3 Imiquimod and Podofilox in 120 days Dermatological - Immunomodulator - Imidazoquinolinamines - Drugs For The Skin ST: Must meet any of the following requirements: Diclofenac 3%, generic imiquimod topical cream in metered-dose pump 3.75 % Tier 1 Fluorouracil 5%, or Imiquimod 5% in 120 days; QL (7.5 GM per 28 days) imiquimod topical cream in packet 5 % Tier 1 QL (24 EA per 30 days) ST: Must meet any of the following requirements: ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP Diclofenac 3%, generic Tier 3 2.5 % (imiquimod) Fluorouracil 5%, or Imiquimod 5% in 120 days; QL (7.5 GM per 28 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

221 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: ZYCLARA TOPICAL CREAM IN PACKET 3.75 % Diclofenac 3%, generic Tier 3 (imiquimod) Fluorouracil 5%, or Imiquimod 5% in 120 days; QL (1 EA per 1 day) Dermatological - Immunomodulator - Interferons - Drugs For The Skin ALFERON N INJECTION SOLUTION 5 MILLION UNIT/ML Tier 4 (interferon alfa-n3) Dermatological - Immunomodulator Combinations - Drugs For The Skin imiquimod-levocetirizin-niacin topical gel 5-1-2 % Tier 1 Dermatological - Keratolytic Combinations Other - Drugs For The Skin salicylic-cimetidine-lidocaine topical cream 40-10-5 % Tier 1 URAMAXIN GT TOPICAL KIT,CREAM AND GEL 45 % Tier 3 (urea) Dermatological - Keratolytic-Antimitotic Combinations - Drugs For The Skin SALVAX DUO PLUS TOPICAL FOAM 6-35 % (salicylic Tier 3 acid) silver nitrate applicators topical stick 75-25 % Tier 1 Dermatological - Keratolytic-Antimitotic Single Agents - Drugs For The Skin BENSAL HP TOPICAL OINTMENT 3 % (salicylic acid) Tier 3 cantharidin in acetone topical solution 0.7 % Tier 1 CEM-UREA TOPICAL GEL 45 % (urea) Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

222 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the CONDYLOX TOPICAL GEL 0.5 % (podofilox) Tier 3 following requirement: Podofilox in 120 days HYDRO 35 TOPICAL FOAM 35 % (urea) Tier 3 KERAFOAM TOPICAL FOAM 30 %, 42 % (urea) Tier 3 KERALYT SCALP COMPLETE TOPICAL KIT,SHAMPOO Tier 3 AND GEL 6-6 % (salicylic acid) PODOCON TOPICAL LIQUID 25 % (podophyllum) Tier 1 podofilox topical solution 0.5 % Tier 1 RYNODERM TOPICAL CREAM 37.5 % (urea) Tier 3 SALEX TOPICAL COMBO PACK 6 % (salicylic acid) Tier 3 salicylic acid er-ceramides topical kit,cleanser and cream er Tier 1 6 % salicylic acid topical cream 6 % Tier 1 salicylic acid topical cream,extended release 6 % Tier 1 salicylic acid topical film forming liquid w/appl 27.5 % Tier 1 salicylic acid topical film-forming soln er w/ appl 28.5 % Tier 1 salicylic acid topical foam 6 % Tier 1 salicylic acid topical gel 6 % Tier 1 salicylic acid topical liquid 26 % Tier 1 salicylic acid topical lotion 6 % Tier 1 salicylic acid topical lotion,extended release 6 % Tier 1 salicylic acid topical ointment 3 % Tier 1 salicylic acid topical shampoo 6 % Tier 1 SALIMEZ FORTE TOPICAL CREAM 10 % (salicylic acid) Tier 3 SALVAX TOPICAL FOAM 6 % (salicylic acid) Tier 1 TRI-CHLOR TOPICAL SOLUTION 80 % (trichloroacetic Tier 3 acid) trichloroacetic acid topical recon soln 100 %, 20 %, 25 %, Tier 3 30 %, 35 %, 40 %, 50 %, 75 %, 80 %, 90 % Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

223 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRASAL-ER TOPICAL FILM-FORMING SOLN ER W/ Tier 3 APPL 28.5 % (salicylic acid) UMECTA TOPICAL FOAM 40 % (urea) Tier 1 URAMAXIN TOPICAL FOAM 20 % (urea) Tier 3 UREA NAIL STICK TOPICAL SOLUTION 50 % (urea) Tier 1 urea topical cream 40 %, 41 %, 45 %, 47 %, 50 % Tier 1 urea topical foam 35 % Tier 1 urea topical gel 45 % Tier 1 urea topical lotion 40 % Tier 1 UREVAZ TOPICAL CREAM 44 % (urea) Tier 3 XALIX TOPICAL FILM-FORMING SOLN ER W/ APPL 28 % Tier 3 (salicylic acid) Dermatological - Liver Derivative Complex - Drugs For The Skin NEXAVIR INJECTION SOLUTION 25.5 MG/ML (liver Tier 4 extract (beef and pork)) Dermatological - Local Anesthetic Combinations - Drugs For The Skin ADAZIN TOPICAL CREAM 2-2-10-0.035 % (lidocaine) Tier 3 ANODYNE LPT TOPICAL KIT 2.5-2.5 % (lidocaine) Tier 1 ASTERO TOPICAL GEL WITH PUMP 4 % (lidocaine) Tier 3 CETACAINE ANESTHETIC TOPICAL LIQUID 2-2-14 % Tier 3 (tetracaine) CETACAINE TOPICAL AEROSOL,SPRAY 2 %-2 %-14 % Tier 3 (200 MG/SEC) (tetracaine) DOLOTRANZ TOPICAL KIT,CREAM AND GEL 4-2.5-2.5 % Tier 3 (lidocaine) KAMDOY TOPICAL SPRAY,NON-AEROSOL (lidocaine) Tier 3 LDO PLUS TOPICAL GEL WITH PUMP 4 % (lidocaine) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

224 Coverage Prescription Drug Name Drug Tier Requirements and Limits lidocaine-prilocaine topical cream 2.5-2.5 % Tier 1 lidocaine-prilocaine topical kit 2.5-2.5 % Tier 1 LIDORXKIT TOPICAL COMBO PACK,OINTMENT AND Tier 3 CREAM 5 % (lidocaine) LMR PLUS TOPICAL KIT 5-6 % (lidocaine) Tier 3 MENTHO-CAINE TOPICAL KIT,OINTMENT AND SPRAY Tier 3 5-8 % (lidocaine) NUVAKAAN TOPICAL KIT 2.5-2.5 % (lidocaine) Tier 1 PAINGO KFT TOPICAL CREAM 2.5-2.5-30-10 % Tier 3 (lidocaine) PRIZOTRAL TOPICAL CREAM 2.5-2.5-3.88 % (lidocaine) Tier 3 SOLUPAK TOPICAL KIT,OINTMENT AND SPRAY 5-10-3 Tier 3 % (lidocaine) WPR PLUS TOPICAL KIT,CREAM AND GEL 4-30-10 % Tier 3 (lidocaine) Dermatological - Local Anesthetic Gas Combinations - Drugs For The Skin ACCUCAINE KIT KIT 10 MG/ML (1 %) (lidocaine) Tier 3 PAIN EASE MEDIUM STREAM SPRAY TOPICAL Tier 3 AEROSOL,SPRAY (norflurane) PAIN EASE MIST SPRAY TOPICAL AEROSOL,SPRAY Tier 3 (norflurane) SPRAY AND STRETCH TOPICAL AEROSOL,SPRAY Tier 3 (norflurane) Dermatological - Local Anesthetic Gas Single Agents - Drugs For The Skin ethyl chloride topical aerosol,spray 100 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

225 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Miscellaneous Single Agents - Drugs For The Skin NEURAPTINE TOPICAL CREAM IN PACKET 10 % Tier 3 (gabapentin) NEURAPTINE TOPICAL CREAM, METERED-DOSE Tier 3 APPLICATOR 10 % (gabapentin) Dermatological - Nsaid And Local Anesthetic Combination - Drugs For The Skin DICLOVIX TOPICAL KIT, PATCH, SOLUTION DROPS 1.5- Tier 3 2.5-4-2 % (diclofenac) TRIXYLITRAL TOPICAL KIT, CREAM AND SOLUTION Tier 3 1.5-3.88 % (diclofenac) Dermatological - Nsaid Combinations - Drugs For The Skin diclofenac (Capsfenac Pak Topical Kit, Cream And Solution Tier 3 1.5-0.025 %) DERMACINRX LEXITRAL TOPICAL COMBO Tier 3 PACK,SOLUTION AND CREAM 1.5-0.025 % (diclofenac) diclofenac-hyaluronate-niacin topical gel 3-2-4 % Tier 1 DICLOFEX DC TOPICAL COMBO PACK,SOLUTION AND Tier 3 CREAM 1.5-0.025 % (diclofenac) DICLOPAK TOPICAL KIT, CREAM AND SOLUTION 1.5- Tier 3 0.025 % (diclofenac) DICLOPR TOPICAL COMBO PACK,CREAM AND GEL 1- Tier 3 30-10 % (diclofenac) DICLOSAICIN TOPICAL COMBO PACK,SOLUTION AND Tier 3 CREAM 1.5-0.025 % (diclofenac) DICLOTRAL TOPICAL COMBO PACK,SOLUTION AND Tier 3 CREAM 1.5-0.025 % (diclofenac) DIMENTHO TOPICAL KIT 1.5-10 % (diclofenac) Tier 3 DITHOL TOPICAL COMBO PACK 1.5-10 % (diclofenac) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

226 Coverage Prescription Drug Name Drug Tier Requirements and Limits INFLAMMA-K TOPICAL KIT, PATCH, SOLUTION DROPS Tier 3 1.5-10-6-3.1 % (diclofenac) NUDICLO SOLUPAK TOPICAL KIT, CREAM AND Tier 3 SOLUTION 1.5-0.025 % (diclofenac) SURE RESULT DSS PREMIUM PACK TOPICAL COMBO Tier 3 PACK,SOLUTION AND CREAM 1.5-0.025 % (diclofenac) VAROPHEN (DICLOFENAC) TOPICAL KIT, CREAM AND Tier 3 SOLUTION 1.5-15-10 % (diclofenac) XELITRAL TOPICAL COMBO PACK,SOLUTION AND Tier 3 CREAM 1.5-0.025 % (diclofenac) Dermatological - Nsaid Single Agents - Drugs For The Skin DICLO GEL TOPICAL KIT 1 % (diclofenac) Tier 3 DICLO GEL-XRYLIX SHEET TOPICAL KIT 1 % Tier 3 (diclofenac) diclofenac epolamine transdermal patch 12 hour 1.3 % Tier 1 diclofenac sodium topical drops 1.5 % Tier 1 diclofenac sodium topical gel 1 % Tier 1 DICLOFONO TOPICAL GEL IN PACKET 1.6 % (diclofenac) Tier 3 DICLOZOR TOPICAL KIT 1 % (diclofenac) Tier 3 FROTEK TOPICAL CREAM IN PACKET 10 % (ketoprofen) Tier 3 FROTEK TOPICAL CREAM, METERED-DOSE Tier 3 APPLICATOR 10 % (ketoprofen) LEXIXRYL TOPICAL KIT 1.5 % (diclofenac) Tier 3 ST: Must meet the PENNSAID TOPICAL SOLUTION IN METERED-DOSE following requirement: Tier 3 PUMP 20 MG/GRAM /ACTUATION(2 %) (diclofenac) Diclofenac Sodium in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

227 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the PENNSAID TOPICAL SOLUTION IN PACKET 2 % following requirement: Tier 3 (diclofenac) Diclofenac Sodium in 120 days XRYLIX (DICLOFENAC-KINES TAPE) TOPICAL KIT 1.5 % Tier 3 (diclofenac) Dermatological - Photodynamic Therapy Agents Topical - Drugs For The Skin AMELUZ TOPICAL GEL 10 % (aminolevulinic acid HCl) Tier 3 LEVULAN TOPICAL SOLUTION 20 % (aminolevulinic acid Tier 3 HCl) Dermatological - Protectant Combinations - Drugs For The Skin ST: Must meet the following requirement: BEAU RX TOPICAL GEL (dimethyl siloxane) Tier 3 Kelo-cote or Recedo in 120 days; QL (30 GM per 30 days) HYGEL TOPICAL GEL 2.5 % (hyaluronic acid) Tier 3 KELARX TOPICAL GEL (dimethicone) Tier 3 LURADROX TOPICAL GEL IN PACKET 0.1 % (hyaluronic Tier 3 acid) PR CREAM TOPICAL CREAM (protectives combination Tier 1 no.2) RADIAPLEXRX TOPICAL GEL (hyaluronic acid) Tier 3 RECEDO TOPICAL GEL (polydimethylsiloxanes) Tier 3 SCARCIN GEL TOPICAL GEL (protectives combination Tier 3 no.6) SCARCIN ROLL-ON TOPICAL LIQUID ROLL-ON Tier 3 (protectives combination no.5)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

228 Coverage Prescription Drug Name Drug Tier Requirements and Limits SCARSILK GEL TOPICAL GEL (protectives combination Tier 3 no.6) SILIPAC TOPICAL KIT (dimethicone) Tier 3 Dermatological - Protectants - Drugs For The Skin BIONECT TOPICAL CREAM 0.2 % (hyaluronic acid) Tier 3 BIONECT TOPICAL FOAM 0.2 % (hyaluronic acid) Tier 3 BIONECT TOPICAL GEL 0.2 % (hyaluronic acid) Tier 3 LDO PLUS TOPICAL GEL WITH PUMP 4 % (lidocaine) Tier 3 NUVAIL TOPICAL NAIL FILM SOLUTION 16 % (poly- Tier 3 ureaurethane) PHARMABASE BARRIER TOPICAL OINTMENT 9.38 % Tier 1 (zinc oxide) SCARCARE TOPICAL KIT 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) talc (bulk) powder 100 % Tier 3 TETRIX TOPICAL CREAM (protectives combination no.2) Tier 3 VASELINE WHITE PETROLEUM TOPICAL OINTMENT IN Tier 1 PACKET (petrolatum,white) zinc oxide topical ointment 20 % Tier 1 zinc oxide topical paste 25 % Tier 1 Dermatological - Rosacea Therapy, Systemic - Drugs For The Skin ST: Must meet the following requirement: generic Doxycycline doxycycline monohydrate oral capsule,ir - delay rel,biphase Tier 1 Monohydrate 50mg 40 mg capsules in 120 days; QL (1 EA per 1 day); Age (Min 18 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

229 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Rosacea Therapy, Topical - Drugs For The Skin CLEANSING WASH TOPICAL CLEANSER 10-4-10 % Tier 1 (sulfacetamide) FINACEA TOPICAL FOAM 15 % (azelaic acid) Tier 2 ST: Must meet the following requirement: ivermectin topical cream 1 % Tier 1 Finacea gel or foam in 120 days ivermectin-metronidazol-niacin topical gel 1-1-4 % Tier 1 metronidazole topical gel 0.75 %, 1 % Tier 1 metronidazole topical gel with pump 1 % Tier 1 MIRVASO TOPICAL GEL 0.33 % (brimonidine) Tier 3 MIRVASO TOPICAL GEL WITH PUMP 0.33 % Tier 3 (brimonidine) ST: Must meet the NORITATE TOPICAL CREAM 1 % (metronidazole) Tier 3 following requirement: Metronidazole in 120 days RHOFADE TOPICAL CREAM 1 % (oxymetazoline) Tier 3 metronidazole (Rosadan Topical Cream 0.75 %) Tier 1 ROSADAN TOPICAL KIT, CLEANSER AND GEL 0.75 % Tier 3 (metronidazole) ROSADAN TOPICAL KIT,CLEANSER AND CREAM 0.75 Tier 3 % (metronidazole) sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 % Tier 1 QL (1419 ML per 1 FILL) Dermatological - Soap And/Or Cleanser Combinations - Drugs For The Skin SAF-CLENS AF DERMAL WOUND TOPICAL CLEANSER Tier 3 (skin cleanser)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

230 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological - Tissue/Wound Adhesives - Drugs For The Skin SURGISEAL STYLUS TOPICAL LIQUID (octyl 2- Tier 3 cyanoacrylate) SURGISEAL TEARDROP APPLICATOR TOPICAL LIQUID Tier 3 (octyl 2-cyanoacrylate) SURGISEAL TWIST TOPICAL LIQUID (octyl 2- Tier 3 cyanoacrylate) Dermatological - Tissue/Wound Adhesives - Fibrin Sealants - Drugs For The Skin ARTISS TOPICAL SYRINGE 2.5 TO 6.5 UNIT/ML (10ML), 2.5 TO 6.5 UNIT/ML (2 ML), 2.5 TO 6.5 UNIT/ML (4 ML) Tier 3 (thrombin (human plasma derived)) TISSEEL VHSD (APROTININ, SYN) TOPICAL KIT 10 ML, Tier 3 2 ML, 4 ML (thrombin (human plasma derived)) TISSEEL VHSD (APROTININ, SYN) TOPICAL SYRINGE Tier 3 10 ML, 2 ML, 4 ML (thrombin (human plasma derived)) Dermatological - Topical Local Anesthetic Amides - Drugs For The Skin ANASTIA TOPICAL LOTION 2.75 % (lidocaine) Tier 3 lidocaine (Glydo Mucous Membrane Jelly In Applicator 2 %) Tier 1 L.E.T. (LIDO-EPINEPH-TETRA) TOPICAL GEL 4-0.05-0.5 Tier 1 % (lidocaine) L.E.T. (LIDO-EPINEPH-TETRA) TOPICAL SOLUTION 4- Tier 1 0.05-0.5 % (lidocaine) lidocaine hcl mucous membrane jelly 2 % Tier 1 lidocaine hcl mucous membrane jelly in applicator 2 % Tier 1 lidocaine hcl topical cream 3 %, 3.88 % Tier 1 lidocaine hcl topical lotion 3 % Tier 1 lidocaine topical adhesive patch,medicated 5 % Tier 1 QL (90 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

231 Coverage Prescription Drug Name Drug Tier Requirements and Limits lidocaine-racepinep-tetracaine topical solution 4-0.05-0.5 % Tier 1 lidocaine-tetracaine topical cream 7-7 % Tier 1 LIDOPAC TOPICAL KIT 5 % (lidocaine) Tier 3 LIDOPIN TOPICAL CREAM 3.25 % (lidocaine) Tier 3 LIDOPURE PATCH TOPICAL COMBO PACK 5 % Tier 1 (lidocaine) LIDORX TOPICAL GEL WITH PUMP 3 % (lidocaine) Tier 3 LIDOTRANS 5 PAK TOPICAL KIT 5 %- 6 CM X 7 CM Tier 3 (lidocaine) LIDOTREX (WITH VITAMIN E) TOPICAL GEL 2 % (vitamin Tier 3 E (d-alpha tocopherol)) LIDOTREX TOPICAL GEL 2 %-1 % -1.2 % (lidocaine) Tier 3 LIDOVEX TOPICAL CREAM 3.75 % (lidocaine) Tier 3 LIDTOPIC MAX TOPICAL CREAM, METERED-DOSE Tier 3 APPLICATOR 10 % (lidocaine) NUMBONEX TOPICAL LOTION 2.75 % (lidocaine) Tier 3 REGENECARE TOPICAL GEL 2 % (lidocaine) Tier 3 REGENECARE WITH ALOE TOPICAL GEL 2 % (vitamin E Tier 3 (d-alpha tocopherol)) SUVICORT TOPICAL GEL 2 %-1 % -1 % (lidocaine) Tier 3 SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING Tier 3 70-70 MG (lidocaine) TRANZAREL TOPICAL GEL 4 % (lidocaine) Tier 3 VEXASYN TOPICAL GEL 2 %-1 % -1.2 % (lidocaine) Tier 3 XRYLIDERM TOPICAL KIT 5 % (lidocaine) Tier 3 ZEYOCAINE TOPICAL KIT,OINTMENT AND TAPE 5 % Tier 3 (lidocaine) ZILACAINE PATCH TOPICAL COMBO PACK 5 % Tier 3 (lidocaine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

232 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED 1.8 % Tier 3 Lidocaine 5% patch in 120 (lidocaine) days; QL (90 EA per 30 days) Dermatological - Topical Local Anesthetic Esters - Drugs For The Skin ANACAINE TOPICAL OINTMENT 10 % (benzocaine) Tier 3 PONTOCAINE TOPICAL SOLUTION 2 % (tetracaine) Tier 3 Dermatological - Topical Local Anesthetics And Combinations - Drugs For The Skin DERMACINRX PHN PAK TOPICAL KIT, PATCH, Tier 3 MEDICATED, CREAM 5 % (lidocaine) DERMACINRX ZRM PAK TOPICAL KIT, PATCH, Tier 3 MEDICATED, CREAM 5-5 % (lidocaine) DERMAZYL KIT TOPICAL KIT, PATCH, MEDICATED, Tier 3 CREAM 5-5 % (lidocaine) NEURCAINE TOPICAL KIT, PATCH, MEDICATED, Tier 3 CREAM 5 % (lidocaine) Dermatological Antipruritics - Antihistamines - Drugs For The Skin ST: Must meet the following requirement: doxepin topical cream 5 % Tier 1 Topical Anti-inflammatory Steroidal in 120 days Dermatological Antipruritics Other - Drugs For The Skin LEVICYN ANTIPRURITIC TOPICAL GEL (sodium Tier 3 magnesium fluorosilicate)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

233 Coverage Prescription Drug Name Drug Tier Requirements and Limits Dermatological Irritants-Counter-Irritant Single Agents - Drugs For The Skin methyl salicylate oil Tier 1 methyl salicylate topical liquid Tier 1 QUTENZA TOPICAL KIT 8 % (capsaicin) Tier 3 PA WINTERGREEN OIL OIL (methyl salicylate) Tier 1 Human Cellular Regenerative Tissue Matrix - Drugs For The Skin EPIFIX AMNIOTIC MEMBRANE TOPICAL SHEET 14 MM, 2 X 3 CM, 4 X 4 CM, 5 X 6 CM, 7 X 7 CM (human Tier 3 regenerative tissue matrix) GRAFIX CORE TOPICAL SHEET 1.5 X 2 CM, 14 MM, 16 MM, 2 X 3 CM, 3 X 4 CM, 5 X 5 CM (human regenerative Tier 3 tissue matrix) GRAFIX PRIME TOPICAL SHEET 1.5 X 2 CM, 14 MM, 16 MM, 2 X 3 CM, 3 X 4 CM, 5 X 5 CM (human regenerative Tier 3 tissue matrix) GRAFIX XC TOPICAL SHEET 7.5 X 15 CM (human Tier 3 regenerative tissue matrix) STRAVIX TOPICAL SHEET 2 X 4 CM, 3 X 6 CM (human Tier 3 regenerative tissue matrix) TRUSKIN TOPICAL SHEET 2 X 4 CM, 4 X 8 CM (human Tier 3 regenerative tissue matrix) Nail Protectives - Drugs For The Skin GENADUR (WITH LEXINAL) KIT 2,500 MCG (biotin) Tier 3 GENADUR TOPICAL LIQUID (carbitol) Tier 3 Ovine (Sheep) Skin Dressings, Non-Living - Drugs For The Skin ENDOFORM FENESTRATED TOPICAL SHEET 2 X 2 ", 4 Tier 3 X 5 " (extracellular matrix (ECM), ovine derived)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

234 Coverage Prescription Drug Name Drug Tier Requirements and Limits ENDOFORM TOPICAL SHEET 2 X 2 ", 4 X 5 " Tier 3 (extracellular matrix (ECM), ovine derived) KERAMATRIX TOPICAL SHEET 2 X 2 ", 4 X 4 " (tissue Tier 3 matrix, keratin-based, ovine derived) Porcine Skin Dressings, Non-Living - Drugs For The Skin MATRISTEM MICROMATRIX TOPICAL POWDER 100 MG, 20 MG, 200 MG, 30 MG, 60 MG (extracellular matrix Tier 3 (ecm), porcine derived) MATRISTEM TOPICAL SHEET 10 X 15 CM, 3 X 3 1/2 CM, 3 X 7 CM, 7 X 10 CM (extracellular matrix (ecm), porcine Tier 3 derived) Scabicide And Pediculicide Single Agents - Drugs For The Skin crotamiton (Crotan Topical Lotion 10 %) Tier 3 EURAX TOPICAL CREAM 10 % (crotamiton) Tier 3 EURAX TOPICAL LOTION 10 % (crotamiton) Tier 3 lindane topical shampoo 1 % Tier 1 malathion topical lotion 0.5 % Tier 1 permethrin topical cream 5 % Tier 1 SKLICE TOPICAL LOTION 0.5 % (ivermectin) Tier 3 spinosad topical suspension 0.9 % Tier 1 ULESFIA TOPICAL LOTION 5 % (benzyl alcohol) Tier 3 Skin Replacement, Live Tissue Dressings - Drugs For The Skin APLIGRAF TOPICAL DISK (cultured skin substitute,human Tier 3 and bovine) DERMAGRAFT TOPICAL SHEET 2 X 3 " (cultured skin Tier 3 substitute,human and bovine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

235 Coverage Prescription Drug Name Drug Tier Requirements and Limits OASIS ULTRA FENESTRATED TOPICAL SHEET 3 X 3.5 Tier 3 CM, 3 X 7 CM (porcine acellular small intestine submucosa) OASIS WOUND MATRIX FENESTRATED TOPICAL SHEET 3 X 3.5 CM, 3 X 7 CM (porcine acellular small Tier 3 intestine submucosa) OASIS WOUND MATRIX MESHED TOPICAL SHEET 5 X 7 CM, 7 X 10 CM, 7 X 20 CM (porcine acellular small intestine Tier 3 submucosa) Wound Care - Cleanser Combinations - Drugs For The Skin ATRAPRO DERMAL SPRAY TOPICAL SPRAY,NON- Tier 3 AEROSOL 0.003-0.004 % (hypochlorous acid) DELUO TOPICAL SPRAY,NON-AEROSOL 0.018 %-0.004 Tier 3 % -0.06 % (hypochlorous acid) EPICYN TOPICAL SPRAY,NON-AEROSOL (hypochlorous Tier 3 acid) LEVICYN DERMAL TOPICAL SPRAY,NON-AEROSOL Tier 3 0.009 % (hypochlorous acid) MICROCYN TOPICAL SPRAY,NON-AEROSOL 0.003 %- Tier 3 0.004 % -0.023 % (hypochlorous acid) Wound Care - Cleansers - Drugs For The Skin VASHE WOUND THERAPY IRRIGATION IRRIGATION Tier 3 SOLUTION 0.033 % (sodium chloride irrigating solution) Wound Care - Dressings - Drugs For The Skin ACESO AG TOPICAL BANDAGE 4 X 4 " (silver) Tier 3 ACTICOAT 7 DRESSING TOPICAL BANDAGE 2 X 2 ", 4 X Tier 3 5 ", 6 X 6 " (silver) ACTICOAT DRESSING TOPICAL BANDAGE 16 X 16 ", 2 Tier 3 X 2 ", 4 X 4 ", 4 X 48 ", 4 X 8 ", 5 X 5 ", 8 X 16 " (silver) ACTICOAT FLEX 3 DRESSING TOPICAL BANDAGE 16 X Tier 3 16 ", 2 X 2 ", 4 X 4 ", 4 X 48 ", 4 X 8 ", 8 X 16 " (silver)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

236 Coverage Prescription Drug Name Drug Tier Requirements and Limits ACTICOAT FLEX 7 DRESSING TOPICAL BANDAGE 1 X Tier 3 24 ", 16 X 16 ", 2 X 2 ", 4 X 5 ", 6 X 6 ", 8 X 16 " (silver) ACTICOAT SURGICAL DRESSING TOPICAL BANDAGE 4 Tier 3 X 10 ", 4 X 13 3/4 ", 4 X 4 3/4 ", 4 X 8 " (silver) ALLEVYN ADHESIVE DRESSING TOPICAL BANDAGE 3 Tier 3 X 3 ", 5 X 5 ", 7 X 7 ", 9 X 9 " (foam bandage) ALLEVYN AG ADHESIVE TOPICAL BANDAGE 5 %- 3" X Tier 3 3", 5 %- 5" X 5", 5 %- 7" X 7" (silver sulfadiazine) ALLEVYN AG GENTLE DRESSING TOPICAL BANDAGE 5 %- 2" X 2", 5 %- 4" X 4", 5 %- 6" X 6", 5 %- 8" X 8" (silver Tier 3 sulfadiazine) ALLEVYN AG TOPICAL BANDAGE 5 %- 2" X 2", 5 %- 4" X Tier 3 4", 5 %- 6" X 6", 5 %- 8" X 8" (silver sulfadiazine) ALLEVYN HEEL TOPICAL BANDAGE 4 1/2 X 5 1/2 " (foam Tier 3 bandage) ALLEVYN LIFE DRESSING TOPICAL BANDAGE 4 X 4 " Tier 3 (foam bandage) ALLEVYN TOPICAL BANDAGE 2 X 2 ", 4 X 4 ", 6 X 6 ", 8 X Tier 3 8 " (foam bandage) BIOSTEP AG TOPICAL BANDAGE 2 X 2 ", 4 X 4 " Tier 3 (dressing, collagen) BIOSTEP TOPICAL BANDAGE 2 X 2 ", 4 X 4 " (dressing, Tier 3 collagen) CARRASYN HYDROGEL WOUND DRESS TOPICAL GEL Tier 3 (gel dressing) COLLATYL TOPICAL GEL 1 % (collagen, hydrolyzed Tier 3 (bovine), type 1) CURAFIL GEL WOUND TOPICAL GEL (gel dressing) Tier 3 CURITY AMD (WITH POLYHEXAMETH) TOPICAL Tier 3 SPONGE 0.2 %- 2" X 2" (polyhexamethylene biguanide) CURITY AMD (WITH POLYHEXAMETH) TOPICAL STRIP Tier 3 0.2 %- 1/2" X 3 FEET (polyhexamethylene biguanide)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

237 Coverage Prescription Drug Name Drug Tier Requirements and Limits HYDROFERA BLUE READY TOPICAL BANDAGE 2 1/2 X Tier 3 2 1/2 ", 4 X 5 ", 8 X 8 " (methylene blue) HYDROFERA BLUE TOPICAL BANDAGE 2 X 2 ", 2 X 2 3/4 ", 2.25 X 8 ", 2.5 ", 4 X 4 ", 6 X 6 ", 9 MM (polyvinyl Tier 3 alcohol) KERAGEL TOPICAL GEL (gel dressing) Tier 3 KERAGELT TOPICAL GEL (gel dressing) Tier 3 KERLIX AMD TOPICAL BANDAGE 0.2 %- 4.5" X 4.1 YARD Tier 3 (polyhexamethylene biguanide) KERLIX AMD TOPICAL SPONGE 0.2 %- 6" X 6.75" Tier 3 (polyhexamethylene biguanide) MEDIHONEY (CAL ALGINATE-HONEY) TOPICAL Tier 3 BANDAGE 2 X 2 ", 3/4 X 12 ", 4 X 5 " (alginic acid) MEDIHONEY (HONEY) TOPICAL GEL 80 % (honey) Tier 3 MEDIHONEY (HONEY) TOPICAL PASTE 100 % (honey) Tier 3 MEDIHONEY (HYDROCOLLOID-HONEY) TOPICAL Tier 3 BANDAGE 2 X 2 ", 4 X 5 " (honey) PROTYL AG TOPICAL GEL 1 % (collagen, hydrolyzed Tier 3 (bovine), type 1) REPLICARE DRESSING TOPICAL BANDAGE 1 1/2 X 2 Tier 3 1/2 ", 4 X 4 ", 6 X 6 ", 8 X 8 " (hydrocolloid dressing) REPLICARE THIN TOPICAL BANDAGE 2 X 2 3/4 ", 3 1/2 X Tier 3 5 1/2 ", 6 X 8 " (hydrocolloid dressing) REPLICARE ULTRA DRESSING TOPICAL BANDAGE 4 X Tier 3 4 ", 6 X 6 ", 7 X 8 " (hydrocolloid dressing) RESTORE CALCIUM ALGINATE TOPICAL BANDAGE 4 X Tier 3 4 3/4 " (silver) RESTORE CONTACT LAYER SILVER TOPICAL Tier 3 BANDAGE 4 X 5 ", 6 X 8 " (silver) RESTORE FOAM DRESSING SILVER TOPICAL Tier 3 BANDAGE 4 X 4 ", 6 X 8 " (silver)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

238 Coverage Prescription Drug Name Drug Tier Requirements and Limits RESTORE TOPICAL BANDAGE 1 X 12 ", 2 X 2 " (silver) Tier 3 SPECTRAGEL TOPICAL GEL (gel dressing) Tier 3 Wound Care - Growth Factor Agents - Drugs For The Skin REGRANEX TOPICAL GEL 0.01 % (becaplermin) Tier 2 Wound Care Combinations Other - Drugs For The Skin balsam peru-castor oil topical ointment Tier 1 BPCO TOPICAL OINTMENT (balsam peru) Tier 1 DERMACINRX CLORHEXACIN TOPICAL KIT 2-4-5 % Tier 3 (mupirocin) DERMACINRX SURGICAL PHARMAPAK TOPICAL KIT 2- Tier 3 4-5 % (mupirocin) DERMAWERX SURGICAL PLUS PAK TOPICAL KIT 2-4-5 Tier 3 % (mupirocin) DERMULCERA TOPICAL OINTMENT (balsam peru) Tier 3 LEVICYN ANTIPRURITIC TOPICAL GEL (sodium Tier 3 magnesium fluorosilicate) NUSURGEPAK SURGICAL PREP TOPICAL KIT 2-4-5 % Tier 3 (mupirocin) VENELEX TOPICAL OINTMENT (balsam peru) Tier 3 VENELEX TOPICAL OINTMENT IN PACKET (balsam Tier 3 peru) WHYTEDERM SURGIPAK TOPICAL KIT 2-4-2 % Tier 3 (mupirocin) Diagnostic Agents Diagnostic Radiopharmaceuticals - Endocrine sodium iodide-123 oral capsule 3.7 mbq (100 microci), 7.4 Tier 1 mbq (200 microci) sodium iodide-131 oral capsule 3.7 mbq (100 microci) Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

239 Coverage Prescription Drug Name Drug Tier Requirements and Limits Diagnostic Radiopharmaceuticals - Radiolabeling Reagents INDICLOR SOLUTION 5 MCI/0.5 ML (185 MBQ) (indium- Tier 3 111) Drugs To Treat Erectile Dysfunction - Drugs For The Urinary System Erectile Dysfunction (Ed) Drugs-Sel.Cgmp Phosphodiesterase Type5 Inhib - Drugs For Erectile Dysfunction tadalafil oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg Tier 1 PA Eating Disorder Therapy - Drugs For Eating Disorders Appetite Stimulants - Cannabinoids - Drugs For Eating Disorders SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) Tier 3 QL (60 ML per 30 days) Appetite Stimulants - Progestin Hormone Type - Drugs For Eating Disorders megestrol oral suspension 400 mg/10 ml (10 ml) Tier 1 megestrol oral suspension 400 mg/10 ml (40 mg/ml) Tier 1 ST: Must meet the following requirement: megestrol oral suspension 625 mg/5 ml Tier 1 Megestrol Acetate 40mg/mL suspension in 120 days Electrolyte Balance-Nutritional Products - Drugs For Nutrition Amino Acid - Carnitine Derivatives - Drugs For Nutrition levocarnitine oral tablet 330 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

240 Coverage Prescription Drug Name Drug Tier Requirements and Limits B-Complex Vitamin Combinations - Drugs For Nutrition BALANCED B-50 COMPLEX (FOLIC) ORAL TABLET 50 Tier 3 MCG (vitamin B complex) B-Complex Vitamins - Drugs For Nutrition B COMPLEX 100 INJECTION SOLUTION 100-2-100-2-2 Tier 4 MG/ML (thiamine (vitamin B1)) Dietary Product - Sweeteners - Drugs For Nutrition saccharin powder Tier 3 Diluents - Insulin Diluting Solutions - Drugs For Nutrition DILUTING MEDIUM FOR NOVOLOG INJECTION Tier 4 SOLUTION (diluent medium for insulin aspart no.1) Diluents - Sodium Chloride - Drugs For Nutrition sodium chlor 0.9% bacteriostat injection solution 0.9 % Tier 4 sodium chloride 0.9 % injection solution Tier 4 sodium chloride injection syringe 0.9 % Tier 4 Diluents - Vaccine Diluents - Drugs For Nutrition DILUENT FOR ROTARIX ORAL SYRINGE (calcium Tier 3 carbonate) Electrolyte Depleters - Ion Exchange Resin - Drugs For Nutrition LOKELMA ORAL POWDER IN PACKET 10 GRAM, 5 Tier 2 GRAM (cyclosilicate) sodium polystyrene sulfonate oral powder Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

241 Coverage Prescription Drug Name Drug Tier Requirements and Limits sodium polystyrene sulfonate oral suspension 15 gram/60 Tier 1 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml Tier 1 sodium polystyrene sulfonate rectal enema 50 gram/200 ml Tier 1 polystyrene sulfonate (Sps (With Sorbitol) Oral Suspension Tier 1 15-20 Gram/60 Ml) SPS (WITH SORBITOL) RECTAL ENEMA 30-40 Tier 3 GRAM/120 ML (polystyrene sulfonate) VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 Tier 3 PA GRAM, 8.4 GRAM (patiromer) Irrigation Solutions - Drugs For Nutrition AQUA CARE SODIUM CHLORIDE IRRIGATION Tier 1 SOLUTION 0.9 % (sodium chloride irrigating solution) AQUA CARE STERILE WATER IRRIGATION SOLUTION Tier 1 (water for irrigation, sterile) lactated ringers irrigation solution Tier 3 PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQ/L Tier 3 (physiological irrigating solution combination no.1) PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5- 3-98 MEQ/L (physiological irrigating solution combination Tier 3 no.1) ringer's irrigation solution Tier 1 sodium chloride irrigation solution 0.9 % Tier 1 TIS-U-SOL PENTALYTE IRRIGATION IRRIGATION Tier 3 SOLUTION 800-40-20-8.75- 6.25 MG/100 ML (sodium) water for irrigation, sterile irrigation solution Tier 1 Minerals And Electrolytes - Calcium Replacement - Drugs For Nutrition calcium acetate oral tablet 667 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

242 Coverage Prescription Drug Name Drug Tier Requirements and Limits Minerals And Electrolytes - Iodine - Drugs For Nutrition LUGOLS ORAL SOLUTION 5 % (potassium iodide) Tier 3 SSKI ORAL SOLUTION 1 GRAM/ML (potassium iodide) Tier 1 STRONG IODINE ORAL SOLUTION 5 % (potassium Tier 1 iodide) Minerals And Electrolytes - Iron - Drugs For Nutrition AURYXIA ORAL TABLET 210 MG IRON (ferric salts) Tier 3 QL (12 EA per 1 day) CHILDREN'S IRON ORAL DROPS 15 MG IRON (75 Tier 0 Age (Max 1 Years) MG)/ML (iron) ferrous sulfate oral drops 15 mg iron (75 mg)/ml Tier 0 Age (Max 1 Years) PEDIA IRON ORAL DROPS 15 MG IRON (75 MG)/ML Tier 0 Age (Max 1 Years) (iron) polysaccharide iron complex oral capsule 150 mg iron Tier 1 Minerals And Electrolytes - Iron Combinations - Drugs For Nutrition ELITE-OB ORAL TABLET 50 MG IRON- 1.25 MG (prenatal Tier 3 vitamins no.123) OB COMPLETE ORAL TABLET 50 MG IRON- 1.25 MG Tier 3 (prenatal vitamins no.123) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG Tier 3 (prenatal vitamins with calcium no.83) Minerals And Electrolytes - Potassium, Oral - Drugs For Nutrition EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 Tier 3 MEQ (potassium bicarbonate) EFFER-K ORAL TABLET, EFFERVESCENT 25 MEQ Tier 1 (potassium bicarbonate)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

243 Coverage Prescription Drug Name Drug Tier Requirements and Limits potassium (Klor-Con M10 Oral Tablet,Er Particles/Crystals Tier 1 10 Meq) potassium (Klor-Con M15 Oral Tablet,Er Particles/Crystals Tier 1 15 Meq) potassium (Klor-Con M20 Oral Tablet,Er Particles/Crystals Tier 1 20 Meq) potassium (Klor-Con Sprinkle Oral Capsule, Extended Tier 1 Release 8 Meq) potassium chloride oral capsule, extended release 10 meq, Tier 1 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml Tier 1 potassium chloride oral packet 20 meq Tier 1 potassium chloride oral tablet extended release 10 meq, 20 Tier 1 meq, 8 meq potassium chloride oral tablet,er particles/crystals 10 meq, Tier 1 20 meq Multivitamin And Mineral Combinations - Drugs For Nutrition ELITE-OB ORAL TABLET 50 MG IRON- 1.25 MG (prenatal Tier 3 vitamins no.123) OB COMPLETE ORAL TABLET 50 MG IRON- 1.25 MG Tier 3 (prenatal vitamins no.123) REMEDIENT ORAL CAPSULE 3.6 MG- 1,000 MCG Tier 3 (multivitamin with minerals combination no.70) Multivitamins - Drugs For Nutrition ENBRACE HR ORAL CAPSULE,IR - DELAY REL,BIPHASE 1.5 MG IRON- 8.73 MG-6.4 MG (prenatal Tier 3 vitamins no.92) FOLET ONE ORAL CAPSULE 38 MG IRON-1 MG -25 MG- Tier 3 225 MG (prenatal vitamins no.80)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

244 Coverage Prescription Drug Name Drug Tier Requirements and Limits NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenatal Tier 3 vitamins no.111) OBSTETRIX ONE ORAL CAPSULE 38 MG IRON-1 MG -25 Tier 3 MG-225 MG (prenatal vitamins no.80) PRENATE AM ORAL TABLET 1-500 MG (prenatal vitamins Tier 3 with calcium no.114) PRENATE CHEWABLE ORAL TABLET,CHEWABLE 1 MG Tier 3 (prenatal vitamins with calcium no.112) PRENATE ESSENTIAL(IRON-ASP-GL) ORAL CAPSULE Tier 3 18 MG IRON- 1 MG-300 MG (prenatal vitamins no.84) VINATE DHA RF ORAL CAPSULE 27 MG IRON-1.13 MG- Tier 1 581.28 MG (prenatal vitamins no.64) Nutritional Product - Nutritional Therapy - Drugs For Nutrition GLUCERNA HUNGER SMART ORAL LIQUID (nut. tx, Tier 3 glucose intolerance,lactose-free,soy) VITAL AF 1.2 CAL ORAL LIQUID 0.08 GRAM- 1.2 Tier 3 KCAL/ML (nutritional therapy, impaired digestive function) Prenatal Vitamins And Minerals - Drugs For Nutrition BAL-CARE DHA ESSENTIAL ORAL COMBO PACK,TABLET AND CAP,DR 27 MG IRON-1 MG -374 MG Tier 1 (prenatal vitamins with calcium no.100) BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG (prenatal vitamins with calcium Tier 1 no.81) CADEAU DHA ORAL CAPSULE 29 MG IRON- 1 MG-150 Tier 3 MG (prenatal vitamins no.83) CALCIUM PNV ORAL CAPSULE 28-1-250 MG (prenatal Tier 1 vitamins with calcium no.70) CITRANATAL (DUAL-IRON) ORAL TABLET 27 MG IRON- Tier 3 1 MG -50 MG (prenatal vitamins no.81) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

245 Coverage Prescription Drug Name Drug Tier Requirements and Limits CITRANATAL 90 DHA (ALGAL OIL) ORAL COMBO PACK 90 MG IRON-1 MG -50 MG-300 MG (prenatal vitamins Tier 3 no.72) CITRANATAL ASSURE ORAL COMBO PACK 35 MG Tier 3 IRON-1 MG -50 MG-300 MG (prenatal vitamins no.73) CITRANATAL DHA (ALGAL OIL) ORAL COMBO PACK 27 Tier 3 MG IRON-1 MG -50 MG-250 MG (prenatal vitamins no.76) CITRANATAL HARMONY (IRON FUM) ORAL CAPSULE 27 MG IRON-1 MG -50 MG-260 MG (prenatal vitamins Tier 3 no.59) C-NATE DHA ORAL CAPSULE 28 MG IRON-1 MG -200 Tier 1 MG (prenatal vitamins no.11) COMPLETE NATAL DHA ORAL COMBO PACK 29-1-250 Tier 3 MG (prenatal vitamins with calcium no.2) COMPLETENATE ORAL TABLET,CHEWABLE 29 MG Tier 1 IRON- 1 MG (prenatal vitamins no.14) DUET DHA BALANCED ORAL COMBO PACK 25 MG IRON-1 MG -267 MG-233 MG (prenatal vitamins with Tier 3 calcium no.117) DUET DHA WITH OMEGA-3 ORAL COMBO PACK 25 MG IRON-1 MG -400 MG (prenatal vitamins with calcium Tier 3 no.106) ELITE-OB ORAL TABLET 50 MG IRON- 1.25 MG (prenatal Tier 3 vitamins no.123) ENBRACE HR ORAL CAPSULE,IR - DELAY REL,BIPHASE 1.5 MG IRON- 8.73 MG-6.4 MG (prenatal Tier 3 vitamins no.92) EXTRA-VIRT PLUS DHA ORAL CAPSULE 29 MG IRON- Tier 1 1.25 MG-55 MG (prenatal vitamins no.57) FOLET ONE ORAL CAPSULE 38 MG IRON-1 MG -25 MG- Tier 3 225 MG (prenatal vitamins no.80) FOLIVANE-OB ORAL CAPSULE 85-1 MG (prenatal Tier 1 vitamins no.15) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

246 Coverage Prescription Drug Name Drug Tier Requirements and Limits KOSHER PRENATAL PLUS IRON ORAL TABLET 30 MG Tier 1 IRON- 1 MG (prenatal vitamins no.108) MARNATAL-F ORAL CAPSULE 60 MG IRON-1 MG Tier 1 (prenatal vitamins with calcium no.65) M-NATAL PLUS ORAL TABLET 27 MG IRON- 1 MG Tier 1 (prenatal vitamins with calcium no.72) MYNATAL ADVANCE ORAL TABLET 90-1-50 MG Tier 1 (prenatal vitamins with calcium no.15) MYNATAL ORAL CAPSULE 65 MG IRON- 1 MG (prenatal Tier 1 vitamins with calcium) MYNATAL ORAL TABLET 90-1-50 MG (prenatal vitamins Tier 1 with calcium) MYNATAL PLUS ORAL TABLET 65 MG IRON- 1 MG Tier 1 (prenatal vitamins with calcium) MYNATAL-Z ORAL TABLET 65 MG IRON- 1 MG (prenatal Tier 1 vitamins with calcium) MYNATE 90 PLUS ORAL TABLET EXTENDED RELEASE Tier 1 90 MG IRON-1 MG (prenatal vitamins with calcium) NATACHEW (FE BIS-GLYCINATE) ORAL TABLET,CHEWABLE 28 MG IRON -1 MG (prenatal Tier 3 vitamins no.55) NESTABS ABC ORAL COMBO PACK 32 MG IRON-1 MG - Tier 3 120 MG-180 MG (prenatal vitamins with calcium no.86) NESTABS DHA ORAL COMBO PACK 32 MG IRON- 1,000 Tier 3 MCG-230MG (prenatal vitamins with calcium no.87) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenatal Tier 3 vitamins no.111) NEWGEN ORAL TABLET 32-1,000 MG-MCG (prenatal Tier 1 vitamins with calcium no.86) NEXA PLUS ORAL CAPSULE 29 MG IRON-1.25 MG-55 Tier 3 MG (prenatal vitamins no.53)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

247 Coverage Prescription Drug Name Drug Tier Requirements and Limits OB COMPLETE ONE ORAL CAPSULE 40-10-1-300 MG Tier 3 (prenatal vitamins with calcium no.85) OB COMPLETE ORAL TABLET 50 MG IRON- 1.25 MG Tier 3 (prenatal vitamins no.123) OB COMPLETE PETITE ORAL CAPSULE 35 MG IRON-5 Tier 3 MG IRON-1 MG (prenatal vitamins no.56) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG Tier 3 (prenatal vitamins with calcium no.83) OB COMPLETE WITH DHA ORAL CAPSULE 30 MG Tier 3 IRON-10 MG IRON-1 MG (prenatal vitamins no.30) OBSTETRIX DHA ORAL COMBO PACK,TABLET AND CAP,DR 29 MG IRON-1 MG -50 MG (prenatal vitamins Tier 1 no.12) OBSTETRIX EC ORAL TABLET,DELAYED RELEASE (DR/EC) 29 MG IRON-1 MG -50 MG (prenatal vitamins Tier 3 no.127) O-CAL PRENATAL ORAL TABLET 15 MG IRON- 1,000 Tier 1 MCG (prenatal vitamins with calcium no.127) PNV 29-1 ORAL TABLET 29 MG IRON- 1 MG (prenatal Tier 1 vitamins with calcium no.76) PNV-DHA + DOCUSATE ORAL CAPSULE 27-1.25-55-300 Tier 1 MG (prenatal vitamins with calcium no.66) PNV-DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG Tier 1 (prenatal vitamins with calcium no.47) PNV-FERROUS FUMARATE-DOCU-FA ORAL TABLET 29 MG IRON- 1 MG-25 MG (prenatal vitamins with calcium Tier 1 no.115) PNV-OMEGA ORAL CAPSULE 28-1-300 MG (prenatal Tier 1 vitamins with calcium no.68) PNV-SELECT ORAL TABLET 27-1 MG (prenatal vitamins Tier 1 with calcium no.40)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

248 Coverage Prescription Drug Name Drug Tier Requirements and Limits PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-400 MG (prenatal vitamins with calcium Tier 1 no.19) PR NATAL 400 ORAL COMBO PACK 29-1-400 MG Tier 1 (prenatal vitamins with calcium no.53) PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-430 MG (prenatal vitamins with calcium Tier 1 no.55) PR NATAL 430 ORAL COMBO PACK 29 MG IRON-1 MG - Tier 1 430 MG (prenatal vitamins with calcium no.54) PRENA1 CHEW ORAL TABLET,CHEW,IR - DR,BIPHASE Tier 1 1.4 MG (prenatal vitamins no.42) PRENA1 PEARL ORAL CAPSULE,IR - DELAY Tier 1 REL,BIPHASE 30-1.4-200 MG (prenatal vitamins no.71) PRENA1 TRUE ORAL COMBO PACK 30 MG IRON- 1.4 Tier 1 MG-300 MG (prenatal vitamins no.105) PRENAISSANCE ORAL CAPSULE 29-1.25-55-325 MG Tier 1 (prenatal vitamins with calcium no.80) PRENAISSANCE PLUS ORAL CAPSULE 28-1-50-250 MG Tier 1 (prenatal vitamins with calcium no.69) PRENATA ORAL TABLET,CHEWABLE 29 MG IRON- 1 Tier 3 MG (prenatal vitamins no.37) PRENATABS FA ORAL TABLET 29-1 MG (prenatal Tier 1 vitamins with calcium no.78) PRENATABS RX ORAL TABLET 29 MG IRON- 1 MG Tier 1 (prenatal vitamins with calcium no.76) PRENATAL 19 (WITH DOCUSATE) ORAL TABLET 29 MG Tier 1 IRON- 1 MG-25 MG (prenatal vitamins with calcium no.115) PRENATAL 19 ORAL TABLET,CHEWABLE 29 MG IRON- Tier 1 1 MG (prenatal vitamins with calcium no.115) PRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 Tier 1 MG (prenatal vitamins with calcium no.74)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

249 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 Tier 1 MG IRON- 1 MG (prenatal vitamins with calcium no.72) PRENATAL PLUS DHA ORAL COMBO PACK 27 MG IRON-1 MG -312 MG-250 MG (prenatal vitamins with Tier 3 calcium no.72) PRENATAL PLUS ORAL TABLET 29 MG IRON- 1 MG Tier 1 (prenatal vitamins with calcium no.72) PRENATAL VITAMIN PLUS LOW IRON ORAL TABLET 27 Tier 1 MG IRON- 1 MG (prenatal vitamins with calcium no.72) PRENATAL-U ORAL CAPSULE 106.5-1 MG (prenatal Tier 1 vitamins no.5) PRENATE AM ORAL TABLET 1-500 MG (prenatal vitamins Tier 3 with calcium no.114) PRENATE CHEWABLE ORAL TABLET,CHEWABLE 1 MG Tier 3 (prenatal vitamins with calcium no.112) PRENATE DHA (FERR ASP GLYCIN) ORAL CAPSULE 18 Tier 3 MG IRON-1 MG -300 MG (prenatal vitamins no.78) PRENATE DHA ORAL CAPSULE 28 MG IRON-1 MG -300 Tier 3 MG (prenatal vitamins no.38) PRENATE ELITE (IRON ASP GLYC) ORAL TABLET 20 Tier 3 MG IRON- 1 MG (prenatal vitamins no.114) PRENATE ELITE ORAL TABLET 26 MG IRON- 1 MG Tier 3 (prenatal vitamins no.36) PRENATE ENHANCE ORAL CAPSULE 28 MG IRON- 1 Tier 3 MG-400 MG (prenatal vitamins no.68) PRENATE ESSENTIAL ORAL CAPSULE 29 MG IRON-1 Tier 3 MG -300 MG (prenatal vitamins no.35) PRENATE ESSENTIAL(IRON-ASP-GL) ORAL CAPSULE Tier 3 18 MG IRON- 1 MG-300 MG (prenatal vitamins no.84) PRENATE MINI (FERR ASP GLYCIN) ORAL CAPSULE Tier 3 18-1-350 MG (prenatal vitamins no.87)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

250 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRENATE PIXIE ORAL CAPSULE 10 MG IRON- 1 MG-200 Tier 3 MG (prenatal vitamins no.85) PRENATE RESTORE ORAL CAPSULE 27 MG IRON- 1 Tier 3 MG-400 MG (prenatal vitamins no.69) PRENATE STAR ORAL TABLET 20 MG IRON- 1 MG Tier 3 (prenatal vitamins no.77) PREPLUS ORAL TABLET 27 MG IRON- 1 MG (prenatal Tier 1 vitamins with calcium no.72) PRETAB ORAL TABLET 29-1 MG (prenatal vitamins with Tier 1 calcium no.78) PRIMACARE ORAL CAPSULE 30-1-300 MG (prenatal Tier 3 vitamins no.118) PROVIDA OB ORAL CAPSULE 40 MG IRON- 1.25 MG Tier 3 (prenatal vitamins no.65) PUREFE OB PLUS ORAL CAPSULE 106 MG IRON- 1 MG Tier 1 (prenatal vitamins no.4) R-NATAL OB ORAL CAPSULE 20 MG IRON- 1 MG-320 Tier 1 MG (prenatal vitamins no.66) SELECT-OB (FOLIC ACID) ORAL TABLET,CHEWABLE 29 Tier 1 MG IRON- 1 MG (prenatal vitamins no.128) SELECT-OB + DHA ORAL COMBO PACK 29 MG IRON-1 Tier 3 MG -250 MG (prenatal vitamins no.33) SELECT-OB ORAL TABLET,CHEWABLE 29 MG IRON- 1 Tier 1 MG (prenatal vitamins no.13) SE-NATAL 19 (WITH DOCUSATE) ORAL TABLET 29 MG Tier 1 IRON- 1 MG-25 MG (prenatal vitamins with calcium no.119) SE-NATAL 19 ORAL TABLET,CHEWABLE 29 MG IRON- 1 Tier 1 MG (prenatal vitamins with calcium no.118) TARON-C DHA ORAL CAPSULE 35-1-200 MG (prenatal Tier 1 vitamins no.16)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

251 Coverage Prescription Drug Name Drug Tier Requirements and Limits TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-1.2 MG-55 MG-265 MG (prenatal vitamins with Tier 1 calcium no.39) THRIVITE RX ORAL TABLET 29 MG IRON- 1 MG (prenatal Tier 3 vitamins with calcium no.76) TRICARE ORAL TABLET 27 MG IRON- 1 MG (prenatal Tier 3 vitamins with calcium no.103) TRINATE ORAL TABLET 28 MG IRON- 1 MG (prenatal Tier 1 vitamins with calcium no.73) TRISTART DHA ORAL CAPSULE 31 MG IRON- 1 MG-200 Tier 3 MG (prenatal vitamins no.93) TRIVEEN-DUO DHA ORAL COMBO PACK 29-1-400 MG Tier 1 (prenatal vitamins with calcium no.53) TRIVEEN-PRX RNF ORAL CAPSULE 26-1.2-55-300 MG Tier 1 (prenatal vitamins with calcium no.66) TRUST NATAL DHA ORAL COMBO PACK 29-1-250 MG Tier 3 (prenatal vitamins with calcium no.2) VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG (prenatal vitamins with calcium Tier 1 no.81) VINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- Tier 1 1 MG (prenatal vitamins with calcium no.109) VINATE DHA RF ORAL CAPSULE 27 MG IRON-1.13 MG- Tier 1 581.28 MG (prenatal vitamins no.64) VINATE GT ORAL TABLET 90-1-50 MG (prenatal vitamins Tier 1 with calcium no.16) VINATE II ORAL TABLET 29 MG IRON- 1 MG (prenatal Tier 1 vitamins with calcium) VINATE M ORAL TABLET 27 MG IRON-1 MG (prenatal Tier 1 vitamins with calcium no.136) VINATE ONE ORAL TABLET 60 MG IRON-1 MG (prenatal Tier 1 vitamins with calcium no.27)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

252 Coverage Prescription Drug Name Drug Tier Requirements and Limits VINATE ULTRA ORAL TABLET 90-1-50 MG (prenatal Tier 1 vitamins with calcium no.18) VIRT-C DHA ORAL CAPSULE 35-1-200 MG (prenatal Tier 1 vitamins no.16) VIRT-NATE DHA ORAL CAPSULE 28 MG IRON-1 MG - Tier 1 200 MG (prenatal vitamins no.11) VIRT-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 Tier 1 MG (prenatal vitamins with calcium no.47) VIRT-PN PLUS ORAL CAPSULE 28-1-300 MG (prenatal Tier 1 vitamins with calcium no.68) VITAFOL FE+ (WITH DOCUSATE) ORAL CAPSULE 90 Tier 3 MG IRON-1 MG -50 MG-200 MG (prenatal vitamins no.102) VITAFOL GUMMIES ORAL TABLET,CHEWABLE 3.33 MG Tier 3 IRON- 0.33 MG (prenatal vitamins no.112) VITAFOL NANO ORAL TABLET 18 MG IRON- 1 MG Tier 1 (prenatal vitamins no.75) VITAFOL ULTRA ORAL CAPSULE 29 MG IRON- 1 MG- Tier 3 200 MG (prenatal vitamins no.67) VITAFOL-OB ORAL TABLET 65-1 MG (prenatal vitamins Tier 3 with calcium no.10) VITAFOL-OB+DHA ORAL COMBO PACK 65-1-250 MG Tier 1 (prenatal vitamins with calcium no.10) VITAFOL-ONE ORAL CAPSULE 29 MG IRON- 1 MG-200 Tier 3 MG (prenatal vitamins no.26) VITAMED MD ONE RX ORAL CAPSULE 30 MG IRON- Tier 3 1MG -200 MG (prenatal vitamins no.25) VIVA DHA ORAL CAPSULE 28 MG IRON-1 MG -200 MG Tier 1 (prenatal vitamins no.11) VP-CH PLUS ORAL CAPSULE 29 MG IRON-1 MG -50 Tier 1 MG-265 MG (prenatal vitamins no.59) VP-CH-PNV ORAL CAPSULE 30 MG IRON-1 MG -50 MG- Tier 1 260 MG (prenatal vitamins no.34)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

253 Coverage Prescription Drug Name Drug Tier Requirements and Limits VP-PNV-DHA ORAL CAPSULE 28 MG IRON- 1 MG-200 Tier 1 MG (prenatal vitamins no.52) ZATEAN-PN DHA ORAL CAPSULE 27 MG IRON-1 MG - Tier 1 300 MG (prenatal vitamins with calcium no.47) ZATEAN-PN PLUS ORAL CAPSULE 28-1-300 MG Tier 1 (prenatal vitamins with calcium no.68) Prenatal Vitamins With Low Or No Iron (Less Than 27 Mg) - Drugs For Nutrition AZESCO ORAL TABLET 13 MG IRON- 1 MG (prenatal Tier 3 QL (2 EA per 1 day) vitamins no.147) ZINGIBER ORAL TABLET 1.2 MG-40 MG- 124.1 MG-100 Tier 1 MG (prenatal vitamins without iron) Sodium Chloride, Parenteral - Drugs For Nutrition BD POSIFLUSH NORMAL SALINE 0.9 INJECTION Tier 4 SYRINGE (sodium chloride 0.9 % (flush)) BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE Tier 4 (sodium chloride 0.9 % (flush)) BD PRE-FILLED SALINE BLUNT CAN INJECTION Tier 4 SYRINGE (sodium chloride 0.9 % (flush)) NORMAL SALINE FLUSH INJECTION SYRINGE (sodium Tier 4 chloride 0.9 % (flush)) sodium chloride 0.45 % intravenous parenteral solution 0.45 Tier 4 % sodium chloride 0.45 % intravenous piggyback 0.45 % Tier 4 sodium chloride 0.9 % (flush) injection syringe Tier 4 sodium chloride 0.9 % intravenous parenteral solution Tier 4 sodium chloride 0.9 % intravenous piggyback Tier 4

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

254 Coverage Prescription Drug Name Drug Tier Requirements and Limits Vitamins - B-1, Thiamine And Derivatives - Drugs For Nutrition thiamine hcl (vitamin b1) injection solution 100 mg/ml Tier 4 Vitamins - B-12, Cyanocobalamin And Derivatives - Drugs For Nutrition cyanocobalamin (vitamin b-12) injection solution 1,000 Tier 4 mcg/ml cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg Tier 1 hydroxocobalamin intramuscular solution 1,000 mcg/ml Tier 4 NASCOBAL NASAL SPRAY,NON-AEROSOL 500 Tier 3 MCG/SPRAY (cyanocobalamin (vitamin B12)) Vitamins - B-3, Niacin And Derivatives - Drugs For Nutrition niacin oral tablet 500 mg Tier 1 Vitamins - B-6, Pyridoxine And Derivatives - Drugs For Nutrition pyridoxine (vitamin b6) injection solution 100 mg/ml Tier 4 Vitamins - C, Ascorbic Acid And Derivatives - Drugs For Nutrition ASCOR INTRAVENOUS SOLUTION 500 MG/ML (ascorbic Tier 4 acid) ascorbic acid (vitamin c) injection solution 500 mg/ml Tier 4 ascorbic acid(vitamin c)(bulk) granules 100 % Tier 3 Vitamins - D Derivatives - Drugs For Nutrition calcitriol oral capsule 0.25 mcg, 0.5 mcg Tier 1 calcitriol oral solution 1 mcg/ml Tier 1 ergocalciferol (vitamin d2) oral capsule 50,000 unit Tier 1 ergocalciferol (vitamin D2) (Vitamin D2 Oral Capsule 50,000 Tier 1 Unit) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

255 Coverage Prescription Drug Name Drug Tier Requirements and Limits Vitamins - E - Drugs For Nutrition vitamin e acetate (bulk) liquid 125 unit/ml Tier 3 Vitamins - Folic Acid And Derivatives - Drugs For Nutrition folic acid injection solution 5 mg/ml Tier 4 folic acid oral tablet 1 mg Tier 1 folic acid oral tablet 400 mcg, 800 mcg Tier 0 Vitamins - K, Phytonadione And Derivatives - Drugs For Nutrition phytonadione (vitamin k1) injection solution 10 mg/ml Tier 4 phytonadione (vitamin k1) injection syringe 1 mg/0.5 ml Tier 4 phytonadione (vitamin k1) oral tablet 5 mg Tier 1 phytonadione (vitamin K1) (Vitamin K Injection Solution 1 Tier 4 Mg/0.5 Ml) phytonadione (vitamin K1) (Vitamin K1 Injection Solution 10 Tier 4 Mg/Ml) Vitamins - Paba - Drugs For Nutrition POTABA ORAL CAPSULE 500 MG (aminobenzoic acid) Tier 3 Endocrine - Hormones Abortifacients Or Cervical Ripening Agents - Prostaglandin Analogs - Drugs For Women CERVIDIL VAGINAL INSERT, EXTENDED RELEASE 10 Tier 3 MG (dinoprostone) PREPIDIL VAGINAL GEL 0.5 MG/3 G (dinoprostone) Tier 3 PROSTIN E2 VAGINAL SUPPOSITORY 20 MG Tier 3 (dinoprostone) Abortifacients- Progesterone Receptor Antagonist - Drugs For Women MIFEPREX ORAL TABLET 200 MG (mifepristone) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

256 Coverage Prescription Drug Name Drug Tier Requirements and Limits mifepristone oral tablet 200 mg Tier 1 Agents To Treat Hypoglycemia (Hyperglycemics) - Drugs For Diabetes BAQSIMI NASAL SPRAY,NON-AEROSOL 3 Tier 2 MG/ACTUATION (glucagon) GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG Tier 3 (glucagon) GLUCAGON EMERGENCY KIT (HUMAN) INJECTION Tier 2 RECON SOLN 1 MG (glucagon) glucose oral tablet,chewable 4 gram Tier 1 GVOKE SYRINGE SUBCUTANEOUS SYRINGE 0.5 Tier 4 MG/0.1 ML, 1 MG/0.2 ML (glucagon) PROGLYCEM ORAL SUSPENSION 50 MG/ML (diazoxide) Tier 3 Amyloidosis Agents- Transthyretin (Ttr) Stabilizer - Hormones VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) Tier 3 PA; SP VYNDAQEL ORAL CAPSULE 20 MG (tafamidis) Tier 3 PA; SP Amyloidosis Agents-Ttr Suppression, Antisense Oligonucleotide-Based - Hormones TEGSEDI SUBCUTANEOUS SYRINGE 284 MG/1.5 ML Tier 4 PA (inotersen) Anabolic Steroid - Single Agents - Drugs For Men ANADROL-50 ORAL TABLET 50 MG (oxymetholone) Tier 3 PA oxandrolone oral tablet 10 mg, 2.5 mg Tier 1 PA Androgen - Single Agents - Drugs For Men ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 Tier 3 PA MG/24 HOUR, 4 MG/24 HR (testosterone) METHITEST ORAL TABLET 10 MG (methyltestosterone) Tier 3 PA

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

257 Coverage Prescription Drug Name Drug Tier Requirements and Limits methyltestosterone oral capsule 10 mg Tier 1 PA NATESTO NASAL GEL IN METERED-DOSE PUMP 5.5 Tier 3 PA MG/0.122 GRAM/ACTUATION (testosterone) STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR Tier 3 PA 30 MG (testosterone) testosterone cypionate intramuscular oil 100 mg/ml, 200 Tier 4 PA mg/ml testosterone enanthate intramuscular oil 200 mg/ml Tier 4 PA testosterone transdermal gel 50 mg/5 gram (1 %) Tier 1 PA testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1 %), 20.25 Tier 1 PA mg/1.25 gram (1.62 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram), 1.62 % (20.25 mg/1.25 Tier 1 PA gram), 1.62 % (40.5 mg/2.5 gram) testosterone transdermal solution in metered pump w/app Tier 1 PA 30 mg/actuation (1.5 ml) XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 Tier 4 PA MG/0.5 ML, 50 MG/0.5 ML, 75 MG/0.5 ML (testosterone) Antidiuretic And Vasopressor Hormones - Hormones DDAVP NASAL SOLUTION 0.1 MG/ML (REFRIGERATE) Tier 2 (desmopressin) desmopressin injection solution 4 mcg/ml Tier 4 desmopressin nasal spray with pump 10 mcg/spray (0.1 ml) Tier 1 desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 Tier 1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg Tier 1 NOCDURNA (MEN) SUBLINGUAL Tier 3 QL (1 EA per 1 day) TABLET,DISINTEGRATING 55.3 MCG (desmopressin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

258 Coverage Prescription Drug Name Drug Tier Requirements and Limits NOCDURNA (WOMEN) SUBLINGUAL Tier 3 QL (1 EA per 1 day) TABLET,DISINTEGRATING 27.7 MCG (desmopressin) NOCTIVA NASAL SPRAY,NON-AEROSOL 0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY (0.1 ML) Tier 3 QL (3.8 GM per 30 days) (desmopressin) STIMATE NASAL SPRAY,NON-AEROSOL 150 Tier 3 MCG/SPRAY (0.1 ML) (desmopressin) Antihyperglycemic - Alpha-Glucosidase Inhibitors - Drugs For Diabetes acarbose oral tablet 100 mg, 25 mg, 50 mg Tier 1 miglitol oral tablet 100 mg, 25 mg, 50 mg Tier 1 Antihyperglycemic - Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors - Drugs For Diabetes ST: Must meet any of the following requirements: Janumet, Janumet XR, alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg Tier 3 Januvia, Jentadueto, Jentadueto XR, or Tradjenta in 120 days JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG Tier 2 (sitagliptin) ST: Must meet any of the following requirements: NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG Janumet, Janumet XR, Tier 3 (alogliptin) Januvia, Jentadueto, Jentadueto XR, or Tradjenta in 120 days ST: Must meet any of the following requirements: Janumet, Janumet XR, ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin) Tier 3 Januvia, Jentadueto, Jentadueto XR, or Tradjenta in 120 days Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

259 Coverage Prescription Drug Name Drug Tier Requirements and Limits TRADJENTA ORAL TABLET 5 MG (linagliptin) Tier 2 Antihyperglycemic - Dopamine Receptor Agonists - Drugs For Diabetes ST: Must meet any of the following requirements: Glipizide/metformin HCL, CYCLOSET ORAL TABLET 0.8 MG (bromocriptine) Tier 3 Glyburide/metformin HCL, Metformin HCL, or Riomet in 180 days Antihyperglycemic - Glucocorticoid (Cortisol) Receptor Blocker (Gr-Ii) - Drugs For Diabetes KORLYM ORAL TABLET 300 MG (mifepristone) Tier 3 PA; SP Antihyperglycemic - Meglitinide Analog And Biguanide Combinations - Drugs For Diabetes repaglinide-metformin oral tablet 1-500 mg, 2-500 mg Tier 1 Antihyperglycemic - Meglitinide Analogs - Drugs For Diabetes nateglinide oral tablet 120 mg, 60 mg Tier 1 repaglinide oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

260 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic - Sglt-2 Inhibitor And Biguanide Combinations - Drugs For Diabetes ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, Glyburide/metformin HCL, Tier 3 50-1,000 MG, 50-500 MG (canagliflozin) Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

261 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR Glyburide/metformin HCL, 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG Tier 3 Jardiance, Metformin HCL, (canagliflozin) Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

262 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, SEGLUROMET ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, Glyburide/metformin HCL, Tier 3 7.5-1,000 MG, 7.5-500 MG (ertugliflozin) Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days ST: Must meet any of the following requirements: Metformin (IR/ER), a SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, sulfonylurea, Pioglitazone Tier 2 5-1,000 MG, 5-500 MG (empagliflozin) or a combination product containing any two of the three previous agents in 120 days ST: Must meet any of the following requirements: Metformin (IR/ER), a SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR sulfonylurea, Pioglitazone 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG Tier 2 or a combination product (empagliflozin) containing any two of the three previous agents in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

263 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Metformin (IR/ER), a XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10- sulfonylurea, Pioglitazone 1,000 MG, 10-500 MG, 2.5-1,000 MG, 5-1,000 MG, 5-500 Tier 2 or a combination product MG (dapagliflozin) containing any two of the three previous agents in 120 days Antihyperglycemic - Sglt-2 Inhibitor And Dpp-4 Inhibitor Combinations - Drugs For Diabetes ST: Must meet any of the following requirements: Metformin (IR/ER), a GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG sulfonylurea, Pioglitazone Tier 2 (empagliflozin) or a combination product containing any two of the three previous agents in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

264 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL, QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin) Tier 3 Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

265 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG Glyburide/metformin HCL, Tier 3 (ertugliflozin) Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days Antihyperglycemic - Sodium Glucose Cotransporter-2 (Sglt2) Inhibitors - Drugs For Diabetes ST: Must meet any of the following requirements: Metformin (IR/ER), a sulfonylurea, Pioglitazone FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin) Tier 2 or a combination product containing any two of the three previous agents in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

266 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL, INVOKANA ORAL TABLET 100 MG, 300 MG (canagliflozin) Tier 3 Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days ST: Must meet any of the following requirements: Metformin (IR/ER), a sulfonylurea, Pioglitazone JARDIANCE ORAL TABLET 10 MG, 25 MG (empagliflozin) Tier 2 or a combination product containing any two of the three previous agents in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

267 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Farxiga, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL, STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin) Tier 3 Jardiance, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Synjardy XR, Synjardy, Tolazamide, Tolbutamide, or Xigduo XR in 365 days Antihyperglycemic - Sulfonylurea And Biguanide Combinations - Drugs For Diabetes glipizide-metformin oral tablet 2.5-250 mg, 2.5-500 mg, 5- Tier 1 500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5- Tier 1 500 mg Antihyperglycemic - Sulfonylurea Derivatives - Drugs For Diabetes glimepiride oral tablet 1 mg, 2 mg, 4 mg Tier 1 glipizide oral tablet 10 mg, 5 mg Tier 1 glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 Tier 1 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

268 Coverage Prescription Drug Name Drug Tier Requirements and Limits glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg Tier 1 tolazamide oral tablet 250 mg, 500 mg Tier 1 tolbutamide oral tablet 500 mg Tier 1 Antihyperglycemic - Thiazolidinedione And Biguanide Combinations - Drugs For Diabetes ST: Must meet any of the following requirements: Avandamet, Avandaryl, Avandia, Chlorpropamide, Diabeta, Glimepiride, ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 Glipizide, Tier 2 HR 15-1,000 MG (pioglitazone) Glipizide/metformin HCL, Glyburide, Glyburide/metformin HCL, Metformin HCL, Riomet, Tolazamide, or Tolbutamide in 120 days ST: Must meet any of the following requirements: Avandamet, Avandaryl, Avandia, Chlorpropamide, Diabeta, Glimepiride, Glipizide, pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg Tier 1 Glipizide/metformin HCL, Glyburide, Glyburide/metformin HCL, Metformin HCL, Riomet, Tolazamide, or Tolbutamide in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

269 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic - Thiazolidinedione And Sulfonylurea Combinations - Drugs For Diabetes ST: Must meet any of the following requirements: Avandamet, Avandaryl, Avandia, Chlorpropamide, Diabeta, Glimepiride, Glipizide, pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg Tier 1 Glipizide/metformin HCL, Glyburide, Glyburide/metformin HCL, Metformin HCL, Riomet, Tolazamide, or Tolbutamide in 120 days Antihyperglycemic, Amylin Analog-Type - Drugs For Diabetes SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR Tier 2 2,700 MCG/2.7 ML (pramlintide) SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 Tier 2 MCG/1.5 ML (pramlintide)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

270 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic, Incretin Mimetic,Glp-1 Receptor Agonist Analog-Type - Drugs For Diabetes ST: Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 micronized, Tier 4 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML (lixisenatide) Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, Tolbutamide, or Trulicity in 365 days ST: Must meet any of the following requirements: Metformin (IR/ER), a BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR sulfonylurea, Pioglitazone Tier 2 2 MG/0.85 ML (exenatide) or a combination product containing any two of the three previous agents in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

271 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Metformin (IR/ER), a BYDUREON SUBCUTANEOUS PEN INJECTOR 2 sulfonylurea, Pioglitazone Tier 2 MG/0.65 ML (exenatide) or a combination product containing any two of the three previous agents in 120 days ST: Must meet any of the following requirements: Metformin (IR/ER), a BYETTA SUBCUTANEOUS PEN INJECTOR 10 sulfonylurea, Pioglitazone MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 Tier 2 or a combination product MCG/ML) 1.2 ML (exenatide) containing any two of the three previous agents in 120 days ST: Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG micronized, OR 0.5 MG(2 MG/1.5 ML), 1 MG/DOSE (2 MG/1.5 ML) Tier 4 Glyburide/metformin HCL, (semaglutide) Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, Tolbutamide, or Trulicity in 365 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

272 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG micronized, Tier 3 (semaglutide) Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, Tolbutamide, or Trulicity in 365 days ST: Must meet any of the following requirements: Metformin (IR/ER), a TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 sulfonylurea, Pioglitazone Tier 2 MG/0.5 ML, 1.5 MG/0.5 ML (dulaglutide) or a combination product containing any two of the three previous agents in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

273 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 Tier 3 Glyburide/metformin HCL, MG/0.1 ML (18 MG/3 ML) (liraglutide) Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, Tolbutamide, or Trulicity in 365 days if 18 years of age and older

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

274 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 Tier 3 Glyburide/metformin HCL, MG/0.1 ML (18 MG/3 ML) (liraglutide) Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, Tolbutamide, or Trulicity in 365 days if 18 years of age and older Antihyperglycemic-Dipeptidyl Peptidase-4 Inhibit And Thiazolidinedione - Drugs For Diabetes ST: Must meet any of the following requirements: alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, Janumet, Janumet XR, Tier 3 12.5-45 mg, 25-15 mg, 25-30 mg, 25-45 mg Januvia, Jentadueto, Jentadueto XR, or Tradjenta in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

275 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic-Dipeptidyl Peptidase-4(Dpp- 4)Inhibitor And Biguanide - Drugs For Diabetes ST: Must meet any of the following requirements: Janumet, Janumet XR, alogliptin-metformin oral tablet 12.5-1,000 mg, 12.5-500 mg Tier 3 Januvia, Jentadueto, Jentadueto XR, or Tradjenta in 120 days JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG Tier 2 (sitagliptin) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR Tier 2 100-1,000 MG, 50-1,000 MG, 50-500 MG (sitagliptin) JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, Tier 2 2.5-850 MG (linagliptin) JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC Tier 2 24HR 2.5-1,000 MG, 5-1,000 MG (linagliptin) ST: Must meet any of the following requirements: KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 Janumet, Janumet XR, Tier 3 HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG (saxagliptin) Januvia, Jentadueto, Jentadueto XR, or Tradjenta in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

276 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihyperglycemic-Insulin, Long Acting And Glp-1 Receptor Agonist Comb - Drugs For Diabetes ST: Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL, Lantus Solostar, Lantus, SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 Tier 2 Levemir Flextouch, UNIT-33 MCG/ML (insulin glargine) Levemir, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, Tolbutamide, Toujeo Solostar, Tresiba Flextouch U-100, Tresiba Flextouch U-200, Tresiba, or Trulicity in 365 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

277 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Actoplus Met XR, Bydureon Bcise, Bydureon Pen, Bydureon, Byetta, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, Glyburide/metformin HCL, Lantus Solostar, Lantus, XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 Tier 2 Levemir Flextouch, UNIT-3.6 MG /ML (3 ML) (insulin degludec) Levemir, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, Tolbutamide, Toujeo Solostar, Tresiba Flextouch U-100, Tresiba Flextouch U-200, Tresiba, or Trulicity in 365 days Antithyroid Agents, Thionamides - Imidazole Derivatives - Drugs For Thyroid methimazole oral tablet 10 mg, 5 mg Tier 1 Antithyroid Agents, Thionamides - Thiouracil Derivatives - Drugs For Thyroid propylthiouracil oral tablet 50 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

278 Coverage Prescription Drug Name Drug Tier Requirements and Limits Bone Formation Stimulating Agents - Parathyroid Hormone Rel Peptides - Drugs For Menopause And Bone Loss TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG Tier 4 PA (3,120 MCG/1.56 ML) (abaloparatide) Bone Formation Stimulating Agents - Parathyroid Hormone-Type - Drugs For Menopause And Bone Loss FORTEO SUBCUTANEOUS PEN INJECTOR 20 PA; QL (2.4 ML per 28 Tier 4 MCG/DOSE - 600 MCG/2.4 ML (teriparatide) days) Bone Resorption Inhibitors - Bisphosphonate And Vitamin D Combinations - Drugs For Menopause And Bone Loss FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 Tier 2 MG- 5,600 UNIT (alendronic acid) Bone Resorption Inhibitors - Bisphosphonates - Drugs For Menopause And Bone Loss alendronate oral solution 70 mg/75 ml Tier 1 QL (75 ML per 7 days) alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg Tier 1 ST: Must meet 2 of the following requirements: Alendronate Sodium, BINOSTO ORAL TABLET, EFFERVESCENT 70 MG Tier 3 Fosamax Plus D, or (alendronic acid) Ibandronate Sodium in 365 days; QL (4 EA per 28 days) etidronate disodium oral tablet 200 mg, 400 mg Tier 1 ibandronate oral tablet 150 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

279 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirements: Alendronate Sodium and risedronate oral tablet 150 mg Tier 1 Ibandronate Sodium in 365 days; QL (1 EA per 30 days) ST: Must meet the following requirements: risedronate oral tablet 30 mg, 5 mg Tier 1 Alendronate Sodium and Ibandronate Sodium in 365 days; QL (1 EA per 1 day) ST: Must meet the following requirements: risedronate oral tablet 35 mg Tier 1 Alendronate Sodium and Ibandronate Sodium in 365 days; QL (1 EA per 7 days) ST: Must meet the following requirements: risedronate oral tablet,delayed release (dr/ec) 35 mg Tier 1 Alendronate Sodium and Ibandronate Sodium in 365 days; QL (1 EA per 7 days) Calcimimetic, Parathyroid Calcium Receptor Sensitivity Enhancer - Drugs For Menopause And Bone Loss cinacalcet oral tablet 30 mg, 60 mg Tier 3 SP; QL (2 EA per 1 day) cinacalcet oral tablet 90 mg Tier 3 SP; QL (4 EA per 1 day) Calcitonins - Drugs For Menopause And Bone Loss calcitonin (salmon) nasal spray,non-aerosol 200 Tier 1 unit/actuation MIACALCIN INJECTION SOLUTION 200 UNIT/ML Tier 4 (calcitonin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

280 Coverage Prescription Drug Name Drug Tier Requirements and Limits Estrogen And Progestin With Antimineralocorticoid Activity,Combination - Drugs For Women ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG Tier 3 (drospirenone) Estrogen And Selective Estrogen Receptor Modulator (Serm) Combinations - Drugs For Women DUAVEE ORAL TABLET 0.45-20 MG (estrogens, Tier 2 conjugated) Estrogen-Androgen - Drugs For Women COVARYX H.S. ORAL TABLET 0.625-1.25 MG Tier 1 (estrogens,esterified) COVARYX ORAL TABLET 1.25-2.5 MG Tier 1 (estrogens,esterified) EEMT HS ORAL TABLET 0.625-1.25 MG Tier 1 (estrogens,esterified) EEMT ORAL TABLET 1.25-2.5 MG (estrogens,esterified) Tier 1 estrogens-methyltestosterone oral tablet 0.625-1.25 mg, Tier 1 1.25-2.5 mg Estrogen-Progestin - Drugs For Women estradiol (Amabelz Oral Tablet 0.5-0.1 Mg, 1-0.5 Mg) Tier 1 BIJUVA ORAL CAPSULE 1-100 MG (estradiol) Tier 3 CLIMARA PRO TRANSDERMAL PATCH WEEKLY 0.045- Tier 3 QL (1 EA per 7 days) 0.015 MG/24 HR (estradiol) COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY Tier 2 QL (2 EA per 7 days) 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR (estradiol) estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 Tier 1 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

281 Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone (Fyavolv Oral Tablet 0.5-2.5 Mg-Mcg, 1-5 Tier 1 Mg-Mcg) norethindrone (Jinteli Oral Tablet 1-5 Mg-Mcg) Tier 1 LOPREEZA ORAL TABLET 0.5-0.1 MG, 1-0.5 MG Tier 1 (estradiol) estradiol (Mimvey Lo Oral Tablet 0.5-0.1 Mg) Tier 1 estradiol (Mimvey Oral Tablet 1-0.5 Mg) Tier 1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, Tier 1 1-5 mg-mcg PREFEST ORAL TABLET 1 MG (15)/1 MG- 0.09 MG (15) Tier 3 (estradiol) PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG- Tier 2 5MG(14) (estrogens, conjugated) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, Tier 2 0.625-2.5 MG, 0.625-5 MG (estrogens, conjugated) Estrogens - Drugs For Women ALORA TRANSDERMAL PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 Tier 2 QL (2 EA per 7 days) HR (estradiol) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML Tier 4 (estradiol) estradiol (Depo-Estradiol Intramuscular Oil 5 Mg/Ml) Tier 4 DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %), 0.75 MG/0.75 Tier 2 GRAM (0.1%), 1 MG/GRAM (0.1 %) (estradiol) estradiol (Dotti Transdermal Patch Semiweekly 0.025 Mg/24 Hr, 0.0375 Mg/24 Hr, 0.05 Mg/24 Hr, 0.075 Mg/24 Hr, 0.1 Tier 1 QL (2 EA per 7 days) Mg/24 Hr) ELESTRIN TRANSDERMAL GEL IN METERED-DOSE Tier 3 PUMP 0.87 GRAM/ACTUATION (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

282 Coverage Prescription Drug Name Drug Tier Requirements and Limits estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 Tier 1 QL (2 EA per 7 days) hr estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 Tier 1 QL (1 EA per 7 days) mg/24 hr estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml Tier 4 ESTROGEL TRANSDERMAL GEL IN METERED-DOSE Tier 3 PUMP 1.25 GRAM/ACTUATION (estradiol) EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL 1.53 Tier 3 MG/SPRAY (1.7%) (estradiol) estrogens,esterified (Menest Oral Tablet 0.3 Mg, 0.625 Mg, Tier 2 1.25 Mg) MENEST ORAL TABLET 2.5 MG (estrogens,esterified) Tier 2 MENOSTAR TRANSDERMAL PATCH WEEKLY 14 Tier 3 QL (1 EA per 7 days) MCG/24 HR (estradiol) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, Tier 2 0.9 MG, 1.25 MG (estrogens, conjugated) Fertility Enhancer - Luteal Phase Supporting, Progesterone-Type - Drugs For Women ST: Must meet the CRINONE VAGINAL GEL 8 % (progesterone) Tier 3 following requirement: Endometrin in 120 days ENDOMETRIN VAGINAL INSERT 100 MG (progesterone) Tier 2 Fertility Enhancer - Ovulation Stimulant - Synthetic (Non-Fsh) - Drugs For Women clomiphene citrate oral tablet 50 mg Tier 1 Follicle-Stimulating And Luteinizing Hormones - Drugs For Women MENOPUR SUBCUTANEOUS RECON SOLN 75 UNIT Tier 4 (menotropins)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

283 Coverage Prescription Drug Name Drug Tier Requirements and Limits Follicle-Stimulating Hormone (Fsh) - Drugs For Women BRAVELLE INJECTION RECON SOLN 75 UNIT (follitropin Tier 4 (FSH)) ST: Must meet any of the FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE 300 following requirements: UNIT/0.36 ML, 600 UNIT/0.72 ML, 900 UNIT/1.08 ML Tier 4 Gonal-F RFF, Gonal-F RFF (follitropin (FSH)) Redi-ject, or Gonal-F in 120 days GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR 300/0.5 UNIT/ML, 450/0.75 UNIT/ML, 900/1.5 Tier 4 UNIT/ML (follitropin (FSH)) GONAL-F RFF SUBCUTANEOUS RECON SOLN 75 UNIT Tier 4 (follitropin (FSH)) GONAL-F SUBCUTANEOUS RECON SOLN 1,050 UNIT, Tier 4 450 UNIT (follitropin (FSH)) Glucocorticoid Salt Combinations - Drugs For Inflammation BETALOAN SUIK KIT 6 MG/ML (betamethasone) Tier 3 POD-CARE 100CG KIT 6 MG/ML (betamethasone) Tier 3 Glucocorticoids - Drugs For Inflammation hydrocortisone (A-Hydrocort Injection Recon Soln 100 Mg) Tier 4 cortisone oral tablet 25 mg Tier 1 dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 Tier 1 Mg, 6 Mg) DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML Tier 3 (dexamethasone) dexamethasone oral elixir 0.5 mg/5 ml Tier 1 dexamethasone oral solution 0.5 mg/5 ml Tier 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1.5 mg, 4 mg, Tier 1 6 mg Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

284 Coverage Prescription Drug Name Drug Tier Requirements and Limits dexamethasone oral tablet 1 mg, 2 mg Tier 1 ST: Must meet the dexamethasone oral tablets,dose pack 1.5 mg (21 tabs), 1.5 following requirement: Tier 1 mg (35 tabs), 1.5 mg (51 tabs) generic Dexamethasone 1.5mg tablets in 120 days DEXONTO IONTOPHORETIC SOLUTION 0.4 % Tier 3 (dexamethasone) ST: Must meet the dexamethasone (Dexpak 10 Day Oral Tablets,Dose Pack following requirement: Tier 1 1.5 Mg (35 Tabs)) generic Dexamethasone 1.5mg tablets in 120 days ST: Must meet the dexamethasone (Dexpak 13 Day Oral Tablets,Dose Pack following requirement: Tier 1 1.5 Mg (51 Tabs)) generic Dexamethasone 1.5mg tablets in 120 days ST: Must meet the dexamethasone (Dexpak 6 Day Oral Tablets,Dose Pack 1.5 following requirement: Tier 1 Mg (21 Tabs)) generic Dexamethasone 1.5mg tablets in 120 days DMT SUIK KIT 10 MG/ML (dexamethasone) Tier 3 ST: Must meet the dexamethasone (Dxevo Oral Tablets,Dose Pack 1.5 Mg (39 following requirement: Tier 3 Tabs)) generic Dexamethasone 1.5mg tablets in 120 days EMFLAZA ORAL SUSPENSION 22.75 MG/ML (deflazacort) Tier 3 PA; SP EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG Tier 3 PA; SP (deflazacort) ST: Must meet the dexamethasone (Hidex Oral Tablets,Dose Pack 1.5 Mg (21 following requirement: Tier 1 Tabs)) generic Dexamethasone 1.5mg tablets in 120 days hydrocortisone oral tablet 10 mg, 20 mg, 5 mg Tier 1 MEDROL ORAL TABLET 2 MG (methylprednisolone) Tier 2 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

285 Coverage Prescription Drug Name Drug Tier Requirements and Limits MEDROLOAN II SUIK KIT 40 MG/ML (methylprednisolone) Tier 3 MEDROLOAN SUIK KIT 40 MG/ML (methylprednisolone) Tier 3 methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg Tier 1 methylprednisolone oral tablets,dose pack 4 mg Tier 1 MILLIPRED DP ORAL TABLETS,DOSE PACK 5 MG (21 Tier 2 TABS), 5 MG (48 TABS) (prednisolone) MILLIPRED ORAL TABLET 5 MG (prednisolone) Tier 2 P-CARE D40G KIT 40 MG/ML (methylprednisolone) Tier 3 P-CARE D80G KIT 40 MG/ML (methylprednisolone) Tier 3 P-CARE K40G KIT 40 MG/ML (triamcinolone) Tier 3 P-CARE K80G KIT 40 MG/ML (triamcinolone) Tier 3 POD-CARE 100KG KIT 40 MG/ML (triamcinolone) Tier 3 prednisolone oral solution 15 mg/5 ml Tier 1 prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 5 mg base/5 Tier 1 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral solution 25 mg/5 ml (5 Tier 1 mg/ml) prednisolone sodium phosphate oral tablet,disintegrating 10 Tier 1 mg, 15 mg, 30 mg PREDNISONE INTENSOL ORAL CONCENTRATE 5 Tier 2 MG/ML (prednisone) prednisone oral solution 5 mg/5 ml Tier 1 prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, Tier 1 50 mg prednisone oral tablets,dose pack 10 mg, 5 mg Tier 1 RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 Tier 3 PA MG, 2 MG, 5 MG (prednisone) SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 Tier 4 ML (hydrocortisone)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

286 Coverage Prescription Drug Name Drug Tier Requirements and Limits SOLU-CORTEF INJECTION RECON SOLN 100 MG Tier 4 (hydrocortisone) ST: Must meet the dexamethasone (Taperdex Oral Tablets,Dose Pack 1.5 Mg following requirement: Tier 1 (21 Tabs), 1.5 Mg (49 Tabs)) generic Dexamethasone 1.5mg tablets in 120 days ST: Must meet the TAPERDEX ORAL TABLETS,DOSE PACK 1.5 MG (27 following requirement: Tier 1 TABS) (dexamethasone) generic Dexamethasone 1.5mg tablets in 120 days TRILOAN II SUIK KIT 40 MG/ML (triamcinolone) Tier 3 TRILOAN SUIK KIT 40 MG/ML (triamcinolone) Tier 3 Gonadotropin Inhibitor Pituitary Suppressants - Drugs For Women danazol oral capsule 100 mg, 200 mg, 50 mg Tier 1 Growth Hormone Receptor Antagonists - Drugs For Growth SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 Tier 4 MG, 20 MG, 25 MG, 30 MG (pegvisomant) Growth Hormone Releasing Hormones (Ghrh) - Drugs For Growth EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG Tier 4 PA (tesamorelin) Growth Hormones - Drugs For Growth GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 Tier 4 PA ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML (somatropin) GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML Tier 4 PA (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) (somatropin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

287 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), Tier 4 PA 24 MG (72 UNIT), 6 MG (18 UNIT) (somatropin) HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG Tier 4 PA (somatropin) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 Tier 4 PA MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) (somatropin) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 Tier 4 PA MG/ML), 5 MG/2 ML (2.5 MG/ML) (somatropin) OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 Tier 4 PA ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) (somatropin) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG Tier 4 PA (somatropin) SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE Tier 4 PA 8.8 MG/1.51 ML (FINAL CONC.) (somatropin) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG Tier 4 PA (somatropin) SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 Tier 4 PA MG, 6 MG (somatropin) ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG, 5 Tier 4 PA MG (somatropin) ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Tier 4 PA (somatropin) Human Chorionic Gonadotropin (Hcg) - Drugs For Women ST: Must meet the chorionic gonadotropin, human intramuscular recon soln following requirement: Tier 4 10,000 unit Novarel or Ovidrel in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

288 Coverage Prescription Drug Name Drug Tier Requirements and Limits NOVAREL INTRAMUSCULAR RECON SOLN 10,000 Tier 4 UNIT, 5,000 UNIT (chorionic gonadotropin, human (hCG)) OVIDREL SUBCUTANEOUS SYRINGE 250 MCG/0.5 ML Tier 4 (chorionic gonadotropin, human (hCG)) ST: Must meet the PREGNYL INTRAMUSCULAR RECON SOLN 10,000 UNIT following requirement: Tier 4 (chorionic gonadotropin, human (hCG)) Novarel or Ovidrel in 120 days Human Insulins - Fixed Combinations - Drugs For Diabetes HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) (insulin isophane Tier 2 (NPH)) HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) (insulin isophane Tier 2 (NPH)) ST: Must meet the NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS following requirement: SUSPENSION 100 UNIT/ML (70-30) (insulin isophane Tier 3 Humulin 70-30 or Humulin (NPH)) 70/30 Kwikpen in 120 days ST: Must meet the NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS following requirement: INSULIN PEN 100 UNIT/ML (70-30) (insulin isophane Tier 3 Humulin 70-30 or Humulin (NPH)) 70/30 Kwikpen in 120 days Human Insulins - Intermediate Acting - Drugs For Diabetes HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) (insulin isophane Tier 3 (NPH)) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS Tier 2 SUSPENSION 100 UNIT/ML (insulin isophane (NPH))

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

289 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS Tier 3 following requirement: SUSPENSION 100 UNIT/ML (insulin isophane (NPH)) Humulin N in 120 days Human Insulins - Rapid Acting - Drugs For Diabetes AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 Tier 3 PA UNIT (60), 8 UNIT, 8 UNIT (90)/ 12 UNIT (90) (insulin regular) Human Insulins - Short Acting - Drugs For Diabetes AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 Tier 3 PA UNIT (60), 8 UNIT (insulin regular) HUMULIN R REGULAR U-100 INSULN INJECTION Tier 2 SOLUTION 100 UNIT/ML (insulin regular) HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS Tier 2 SOLUTION 500 UNIT/ML (insulin regular) HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS Tier 2 INSULIN PEN 500 UNIT/ML (3 ML) (insulin regular) MYXREDLIN INTRAVENOUS SOLUTION 100 UNIT/100 Tier 3 ML (1 UNIT/ML) (insulin regular) ST: Must meet the NOVOLIN R REGULAR U-100 INSULN INJECTION following requirement: Tier 3 SOLUTION 100 UNIT/ML (insulin regular) Humulin R or Humulin R U- 500 in 120 days Insulin Analogs - Fixed Combinations - Drugs For Diabetes HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) (insulin lispro Tier 2 protamine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

290 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) (insulin lispro Tier 2 protamine) HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) (insulin lispro Tier 2 protamine) HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) (insulin lispro Tier 2 protamine) ST: Must meet any of the NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS following requirements: SOLUTION 100 UNIT/ML (70-30) (insulin aspart protamine Tier 3 Humalog Mix 75-25 or human) Humalog Mix 75-25 Kwikpen in 120 days ST: Must meet any of the NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS following requirements: INSULIN PEN 100 UNIT/ML (70-30) (insulin aspart Tier 3 Humalog Mix 75-25 or protamine human) Humalog Mix 75-25 Kwikpen in 120 days Insulin Analogs - Long Acting - Drugs For Diabetes ST: Must meet any of the following requirements: Lantus Solostar, Lantus, Levemir Flextouch, BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS Tier 3 Levemir, Toujeo Max INSULIN PEN 100 UNIT/ML (3 ML) (insulin glargine) Solostar, Toujeo Solostar, Tresiba Flextouch U-100, or Tresiba Flextouch U-200 in 120 days LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS Tier 2 INSULIN PEN 100 UNIT/ML (3 ML) (insulin glargine) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION Tier 2 100 UNIT/ML (insulin glargine) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

291 Coverage Prescription Drug Name Drug Tier Requirements and Limits LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS Tier 2 INSULIN PEN 100 UNIT/ML (3 ML) (insulin detemir) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION Tier 2 100 UNIT/ML (insulin detemir) TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS Tier 2 INSULIN PEN 300 UNIT/ML (3 ML) (insulin glargine) TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS Tier 2 INSULIN PEN 300 UNIT/ML (1.5 ML) (insulin glargine) TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN Tier 2 PEN 100 UNIT/ML (3 ML) (insulin degludec) TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN Tier 2 PEN 200 UNIT/ML (3 ML) (insulin degludec) TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION Tier 2 100 UNIT/ML (insulin degludec) Insulin Analogs - Rapid Acting - Drugs For Diabetes ST: Must meet any of the following requirements: ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 INSULIN PEN 100 UNIT/ML (insulin lispro) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days ST: Must meet any of the following requirements: ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 SOLUTION 100 UNIT/ML (insulin lispro) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

292 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 INSULIN PEN 100 UNIT/ML (insulin glulisine) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days ST: Must meet any of the following requirements: APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION Humalog Junior Kwikpen, Tier 3 100 UNIT/ML (insulin glulisine) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days ST: Must meet any of the following requirements: FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 INSULIN PEN 100 UNIT/ML (3 ML) (insulin aspart) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days ST: Must meet any of the following requirements: FIASP PENFILL U-100 INSULIN SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 CARTRIDGE 100 UNIT/ML (3 ML) (insulin aspart) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days ST: Must meet any of the following requirements: FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 Humalog Junior Kwikpen, Tier 3 UNIT/ML (insulin aspart) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS Tier 2 INSULIN PEN, HALF-UNIT 100 UNIT/ML (insulin lispro) HUMALOG KWIKPEN INSULIN SUBCUTANEOUS Tier 1 INSULIN PEN 100 UNIT/ML (insulin lispro)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

293 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMALOG KWIKPEN INSULIN SUBCUTANEOUS Tier 2 INSULIN PEN 200 UNIT/ML (3 ML) (insulin lispro) HUMALOG U-100 INSULIN SUBCUTANEOUS Tier 2 CARTRIDGE 100 UNIT/ML (insulin lispro) HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION Tier 1 100 UNIT/ML (insulin lispro) ST: Must meet any of the following requirements: NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 INSULIN PEN 100 UNIT/ML (3 ML) (insulin aspart) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days ST: Must meet any of the following requirements: NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 CARTRIDGE 100 UNIT/ML (insulin aspart) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days ST: Must meet any of the following requirements: NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS Humalog Junior Kwikpen, Tier 3 SOLUTION 100 UNIT/ML (insulin aspart) Humalog Kwikpen U-200, Humalog, or Insulin Lispro in 120 days Insulin Response Enhancers - Biguanides - Drugs For Diabetes DM2 COMBO PACK, TABLET AND STRIP 500 MG Tier 3 (metformin) metformin oral solution 500 mg/5 ml Tier 1 metformin oral tablet 1,000 mg, 500 mg, 850 mg Tier 1 metformin oral tablet extended release 24 hr 500 mg, 750 Tier 1 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

294 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the metformin oral tablet extended release 24hr 1,000 mg, 500 Tier 1 following requirement: mg Metformin HCL in 120 days ST: Must meet the metformin oral tablet,er gast.retention 24 hr 1,000 mg, 500 Tier 1 following requirement: mg Metformin HCL in 120 days RIOMET ORAL SOLUTION 500 MG/5 ML (metformin) Tier 2 Insulin Response Enhancers - Thiazolidinediones (Ppar-Gamma Agonists) - Drugs For Diabetes ST: Must meet any of the following requirements: Actoplus Met XR, Chlorpropamide, Diabeta, Glimepiride, Glipizide, Glipizide/metformin HCL, Glyburide, Glyburide micronized, AVANDIA ORAL TABLET 2 MG, 4 MG (rosiglitazone) Tier 3 Glyburide/metformin HCL, Metformin HCL, Pioglitazone HCL, Pioglitazone HCL/glimepiride, Pioglitazone HCL/metformin HCL, Riomet, Tolazamide, or Tolbutamide in 120 days pioglitazone oral tablet 15 mg, 30 mg, 45 mg Tier 1 Insulin-Like Growth Factor-1 (Igf-1) - Hormones INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML Tier 4 PA (mecasermin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

295 Coverage Prescription Drug Name Drug Tier Requirements and Limits Leptin Hormone Analogs - Hormones MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML Tier 4 QL (1 EA per 1 day) (FINAL CONC.) (metreleptin) Lhrh (Gnrh) Agonist Analog Pituitary Supp. And Progestin Comb. - Drugs For Women LUPANETA PACK (1 MONTH) KIT. SYRINGE AND Tier 3 SP TABLET 3.75 MG -5 MG (30) (leuprolide) LUPANETA PACK (3 MONTH) KIT. SYRINGE AND Tier 3 SP TABLET 11.25 MG -5 MG (90) (leuprolide) Lhrh (Gnrh) Agonist Analog Pituitary Suppressants - Drugs For Women SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML Tier 3 PA; SP (nafarelin) Lhrh (Gnrh) Antagonists - Drugs For Women CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix) Tier 4 ST: Must meet the ganirelix subcutaneous syringe 250 mcg/0.5 ml Tier 4 following requirement: Cetrotide in 120 days ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix) Tier 3 Menopausal Symptoms Suppressant-Ssri Antidepressant Type - Drugs For Women ST: Must meet any of the following requirements: paroxetine mesylate(menop.sym) oral capsule 7.5 mg Tier 1 Paroxetine HCL, Paxil, or Venlafaxine HCL in 120 days; QL (1 EA per 1 day) Mineralocorticoids - Drugs For Inflammation fludrocortisone oral tablet 0.1 mg Tier 1 Oxytocic - Ergot Alkaloids - Drugs For Women methylergonovine oral tablet 0.2 mg Tier 1 QL (28 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

296 Coverage Prescription Drug Name Drug Tier Requirements and Limits Parathyroid Hormones - Drugs For Menopause And Bone Loss NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 Tier 4 PA MCG/DOSE (parathyroid hormone) Progestins - Drugs For Women medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg Tier 1 norethindrone acetate oral tablet 5 mg Tier 1 progesterone intramuscular oil 50 mg/ml Tier 4 progesterone micronized oral capsule 100 mg, 200 mg Tier 1 Prolactin Inhibitor - Ergot Derivative Dopamine Receptor Agonists - Drugs For Women cabergoline oral tablet 0.5 mg Tier 1 Selective Estrogen Receptor Modulators (Serms) - Drugs For Menopause And Bone Loss raloxifene oral tablet 60 mg Tier 0 QL (1 EA per 1 day) Somatostatic Agents - Drugs For Growth octreotide acetate injection solution 1,000 mcg/ml, 100 Tier 4 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 Tier 4 mcg/ml (1 ml), 500 mcg/ml (1 ml) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 Tier 4 PA ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) (pasireotide) Thyroid Hormone Combinations - Synthetic T3 And T4 - Drugs For Thyroid THYROLAR-1 ORAL TABLET 12.5-50 MCG (liotrix) Tier 3 THYROLAR-1/2 ORAL TABLET 6.25-25 MCG (liotrix) Tier 3 THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG (liotrix) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

297 Coverage Prescription Drug Name Drug Tier Requirements and Limits THYROLAR-2 ORAL TABLET 25-100 MCG (liotrix) Tier 3 THYROLAR-3 ORAL TABLET 37.5-150 MCG (liotrix) Tier 3 Thyroid Hormones - Animal Source (Porcine) - Drugs For Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 Tier 2 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG (thyroid) NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 Tier 1 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 Tier 1 MG, 90 MG (thyroid) thyroid (pork) oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 Tier 1 mg WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, Tier 1 65 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG Tier 1 (thyroid) Thyroid Hormones - Synthetic T3 (Triiodothyronine) - Drugs For Thyroid liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg Tier 1 Thyroid Hormones - Synthetic T4 (Thyroxine) - Drugs For Thyroid EUTHYROX ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, Tier 1 50 MCG, 75 MCG, 88 MCG (levothyroxine) levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 Tier 1 mcg, 75 mcg, 88 mcg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

298 Coverage Prescription Drug Name Drug Tier Requirements and Limits TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, Tier 3 25 MCG, 50 MCG, 75 MCG, 88 MCG (levothyroxine) TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 Tier 3 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine) Enzymes - Vitamins And Minerals Enzymes - Vitamins And Minerals HYQVIA HY COMPONENT SUBCUTANEOUS SOLUTION 1,600 UNIT/10 ML, 2,400 UNIT/15 ML, 200 UNIT/1.25 ML, Tier 4 400 UNIT/2.5 ML, 800 UNIT/5 ML (hyaluronidase) Fdb Class Obsolete-Not Used Alternative Therapy - Homeopathic Products AURUMHEEL ORAL DROPS (homeopathic drugs) Tier 3 CANTHARIS COMPOSITUM ORAL DROPS (homeopathic Tier 3 drugs) CRALONIN ORAL DROPS (homeopathic drugs) Tier 3 EYE ORAL TABLET,SOLUBLE (homeopathic drugs) Tier 3 LAMIOFLUR ORAL DROPS (homeopathic drugs) Tier 3 PLANTAGO-HOMACCORD ORAL DROPS (homeopathic Tier 3 drugs) POPULUS COMPOSITUM ORAL DROPS (homeopathic Tier 3 drugs) PSORINOHEEL ORAL DROPS (homeopathic drugs) Tier 3 RENEEL ORAL TABLET,SOLUBLE (homeopathic drugs) Tier 3 SABAL-HOMACCORD ORAL DROPS (homeopathic drugs) Tier 3 SYZYGIUM COMPOSITUM ORAL DROPS (homeopathic Tier 3 drugs) VERTIGOHEEL ORAL DROPS (homeopathic drugs) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

299 Coverage Prescription Drug Name Drug Tier Requirements and Limits VERTIGOHEEL ORAL TABLET,SOLUBLE (homeopathic Tier 3 drugs) Arginine Vasopressin (Avp) V2 Receptor Antagonist, Selective - Drugs For High Blood Pressure JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) Tier 3 PA; SP SP; QL (30 EA per 365 SAMSCA ORAL TABLET 15 MG (tolvaptan) Tier 3 days) SP; QL (60 EA per 365 SAMSCA ORAL TABLET 30 MG (tolvaptan) Tier 3 days) Gastrointestinal Therapy Agents - Drugs For The Stomach Antacid - Magnesium - Drugs For Ulcers And Stomach Acid magnesium oxide oral tablet 400 mg (241.3 mg Tier 1 magnesium) Antidiarrheal - Antiperistaltic Agents - Drugs For Diarrhea loperamide oral capsule 2 mg Tier 1 opium tincture oral tincture 10 mg/ml (morphine) Tier 1 paregoric oral liquid 2 mg/5 ml Tier 1 Antidiarrheal - Gastrointestinal Chloride Channel Inhibitors - Drugs For Diarrhea ST: Must meet the MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC) 125 following requirement: Tier 3 MG (crofelemer) Antiretrovirals in 120 days; QL (2 EA per 1 day) Antidiarrheal - Tryptophan Hydroxylase Inhibitor - Drugs For Diarrhea XERMELO ORAL TABLET 250 MG (telotristat ethyl) Tier 3 PA; SP Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

300 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antidiarrheal Antiperistaltic-Anticholinergic Combinations - Drugs For Diarrhea diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml Tier 1 diphenoxylate-atropine oral tablet 2.5-0.025 mg Tier 1 ST: Must meet the following requirement: MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin) Tier 3 Diphenoxylate HCL/Atropine in 120 days; QL (8 EA per 1 day) Antidiarrheal Opioid Agents - Drugs For Diarrhea paregoric oral liquid 2 mg/5 ml Tier 1 Antiemetic - Anticholinergics - Drugs For Vomiting And Nausea scopolamine base transdermal patch 3 day 1 mg over 3 Tier 1 days Antiemetic - Antihistamines - Drugs For Vomiting And Nausea meclizine oral tablet 12.5 mg, 25 mg Tier 1 Antiemetic - Antihistamine-Vitamin Combinations - Drugs For Vomiting And Nausea BONJESTA ORAL TABLET,IR,DELAYED REL,BIPHASIC Tier 3 QL (60 EA per 30 days) 20-20 MG (doxylamine) doxylamine-pyridoxine (vit b6) oral tablet,delayed release Tier 1 QL (120 EA per 30 days) (dr/ec) 10-10 mg

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

301 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antiemetic - Cannabinoid Type - Drugs For Vomiting And Nausea ST: Must meet the following requirement: CESAMET ORAL CAPSULE 1 MG (nabilone) Tier 3 Ondansetron or Ondansetron HCL in 120 days; QL (6 EA per 1 day) dronabinol oral capsule 10 mg, 2.5 mg, 5 mg Tier 1 QL (2 EA per 1 day) SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) Tier 3 QL (60 ML per 30 days) Antiemetic - Dopamine (D2)/5-Ht3 Antagonists - Drugs For Vomiting And Nausea trimethobenzamide oral capsule 300 mg Tier 1 Antiemetic - Phenothiazines - Drugs For Vomiting And Nausea prochlorperazine (Compro Rectal Suppository 25 Mg) Tier 1 promethazine (Phenadoz Rectal Suppository 12.5 Mg, 25 Tier 1 Mg) prochlorperazine rectal suppository 25 mg Tier 1 promethazine rectal suppository 50 mg Tier 1 Antiemetic - Selective Serotonin 5-Ht3 Antagonists - Drugs For Vomiting And Nausea ST: Must meet the following requirement: Ondansetron or granisetron hcl oral tablet 1 mg Tier 1 Ondansetron HCL in 120 days; QL (8 EA per 30 days) ondansetron hcl oral solution 4 mg/5 ml Tier 1 QL (50 ML per 15 days) ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg Tier 1 ondansetron oral tablet,disintegrating 4 mg, 8 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

302 Coverage Prescription Drug Name Drug Tier Requirements and Limits SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 Tier 3 QL (1 EA per 7 days) HOUR (granisetron) ST: Must meet the following requirement: ZUPLENZ ORAL FILM 4 MG (ondansetron) Tier 3 Ondansetron or Ondansetron HCL in 120 days; QL (2 EA per 3 days) ST: Must meet the following requirement: ZUPLENZ ORAL FILM 8 MG (ondansetron) Tier 3 Ondansetron or Ondansetron HCL in 120 days; QL (1 EA per 3 days) Antiemetic - Substance P-Neurokinin 1 (Nk1) Receptor Antagonists - Drugs For Vomiting And Nausea aprepitant oral capsule 125 mg Tier 1 QL (1 EA per 21 days) aprepitant oral capsule 40 mg Tier 1 QL (1 EA per 28 days) aprepitant oral capsule 80 mg Tier 1 QL (2 EA per 21 days) aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) Tier 1 QL (3 EA per 21 days) EMEND ORAL SUSPENSION FOR RECONSTITUTION Tier 2 QL (3 EA per 21 days) 125 MG (25 MG/ ML FINAL CONC.) (aprepitant) VARUBI ORAL TABLET 90 MG (rolapitant) Tier 3 QL (2 EA per 14 days) Antiemetic - Substance P-Neurokinin 1 And 5- Ht3 Recept Antagonist Comb - Drugs For Vomiting And Nausea AKYNZEO (NETUPITANT) ORAL CAPSULE 300-0.5 MG Tier 2 QL (1 EA per 28 days) (netupitant) Bile Acids - Drugs For The Stomach CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) Tier 3 PA; SP

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

303 Coverage Prescription Drug Name Drug Tier Requirements and Limits Chronic Idiopathic Const. Agents - Guanylate Cyclase-C (Gc-C) Agonists - Drugs For Constipation ST: Must meet the following requirement: TRULANCE ORAL TABLET 3 MG (plecanatide) Tier 3 Linzess in 120 days; QL (1 EA per 1 day) Colonic Acidifier (Ammonia Inhibitor) - Drugs For The Stomach lactulose (Enulose Oral Solution 10 Gram/15 Ml) Tier 1 lactulose (Generlac Oral Solution 10 Gram/15 Ml) Tier 1 lactulose oral solution 10 gram/15 ml (15 ml) Tier 1 Digestive Enzyme Mixtures - Drugs For The Stomach CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 Tier 2 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT (lipase) PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800- Tier 3 56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000- 54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT (lipase) PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 UNIT, 24,000-86,250- 90,750 UNIT, Tier 3 4,000-14,375- 15,125 UNIT, 8,000-28,750- 30,250 UNIT (lipase) VIOKACE ORAL TABLET 10,440-39,150- 39,150 UNIT, Tier 3 20,880-78,300- 78,300 UNIT (lipase)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

304 Coverage Prescription Drug Name Drug Tier Requirements and Limits ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 Tier 2 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT (lipase) Digestive Enzymes - Drugs For The Stomach SUCRAID ORAL SOLUTION 8,500 UNIT/ML (sacrosidase) Tier 3 PA; SP Gallstone Solubilizing (Litholysis) Agents - Drugs For The Stomach chenodiol (Chenodal Oral Tablet 250 Mg) Tier 3 PA; SP ursodiol oral capsule 300 mg Tier 1 ursodiol oral tablet 250 mg, 500 mg Tier 1 Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists - Drugs For Ulcers And Stomach Acid cimetidine hcl oral solution 300 mg/5 ml Tier 1 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg Tier 1 famotidine oral suspension 40 mg/5 ml (8 mg/ml) Tier 1 famotidine oral tablet 20 mg, 40 mg Tier 1 nizatidine oral capsule 150 mg, 300 mg Tier 1 nizatidine oral solution 150 mg/10 ml Tier 1 ranitidine hcl oral capsule 150 mg, 300 mg Tier 1 ranitidine hcl oral syrup 15 mg/ml Tier 1 ranitidine hcl oral tablet 150 mg, 300 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

305 Coverage Prescription Drug Name Drug Tier Requirements and Limits Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (Ppis) - Drugs For Ulcers And Stomach Acid ST: Must meet 2 of the following requirements: First-lansoprazole, First- ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL Tier 3 omeprazole, Lansoprazole, SPRINKLE 10 MG, 5 MG (rabeprazole) Omeprazole, Pantoprazole Sodium, or Protonix in 365 days; QL (1 EA per 1 day) ST: Must meet any of the following requirements: Lansoprazole, DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS Tier 3 Omeprazole, Pantoprazole 30 MG, 60 MG (dexlansoprazole) Sodium, Prilosec OTC, or Protonix in 120 days; QL (1 EA per 1 day) ESOMEP-EZS ORAL KIT, CAP DR AND SPRAY 20 MG Tier 3 (esomeprazole) esomeprazole magnesium oral capsule,delayed Tier 1 QL (1 EA per 1 day) release(dr/ec) 20 mg esomeprazole magnesium oral capsule,delayed Tier 1 QL (2 EA per 1 day) release(dr/ec) 40 mg lansoprazole oral capsule,delayed release(dr/ec) 15 mg, 30 Tier 1 mg ST: Must meet any of the following requirements: Lansoprazole, lansoprazole oral tablet,disintegrat, delay rel 15 mg, 30 mg Tier 1 Omeprazole, or Pantoprazole Sodium in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

306 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Lansoprazole, NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN Tier 2 Omeprazole, Pantoprazole PACKET 10 MG, 2.5 MG, 20 MG, 5 MG (esomeprazole) Sodium, Prilosec OTC, or Protonix in 120 days; QL (1 EA per 1 day) ST: Must meet any of the following requirements: Lansoprazole, NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN Tier 2 Omeprazole, Pantoprazole PACKET 40 MG (esomeprazole) Sodium, Prilosec OTC, or Protonix in 120 days; QL (2 EA per 1 day) omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 Tier 1 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 Tier 1 mg PRILOSEC ORAL SUSP,DELAYED RELEASE FOR Tier 3 RECON 10 MG, 2.5 MG (omeprazole) ST: Must meet any of the following requirements: PROTONIX ORAL GRANULES DR FOR SUSP IN Omeprazole Magnesium, Tier 3 PACKET 40 MG (pantoprazole) Omeprazole, Pantoprazole Sodium, Prilosec OTC, or Prilosec in 120 days ST: Must meet 2 of the following requirements: First-lansoprazole, First- rabeprazole oral capsule, delayed rel sprinkle 10 mg Tier 1 omeprazole, Lansoprazole, Omeprazole, Pantoprazole Sodium, or Protonix in 365 days; QL (1 EA per 1 day) rabeprazole oral tablet,delayed release (dr/ec) 20 mg Tier 1 QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

307 Coverage Prescription Drug Name Drug Tier Requirements and Limits Gastric Acid Secretion Reducing-Proton Pump Inhibitor And Antacid Comb - Drugs For Ulcers And Stomach Acid ST: Must meet any of the following requirements: Lansoprazole, omeprazole-sodium bicarbonate oral capsule 20-1.1 mg- Tier 1 Omeprazole, Pantoprazole gram, 40-1.1 mg-gram Sodium, Prilosec OTC, or Protonix in 120 days; QL (1 EA per 1 day) ST: Must meet any of the following requirements: Lansoprazole, omeprazole-sodium bicarbonate oral packet 20-1,680 mg, Tier 1 Omeprazole, Pantoprazole 40-1,680 mg Sodium, Prilosec OTC, or Protonix in 120 days; QL (1 EA per 1 day) Gastric Mucosa - Cytoprotective Prostaglandin Analogs - Drugs For Ulcers And Stomach Acid misoprostol oral tablet 100 mcg, 200 mcg Tier 1 Gastrointestinal - Prokinetic Agents - 5-Ht4 Receptor Agonists - Drugs For The Stomach ST: Must meet the following requirement: MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride) Tier 3 Linzess in 120 days; QL (1 EA per 1 day) Gastrointestinal Prokinetic Agents - D2 Antagonist/5-Ht4 Agonists - Drugs For The Stomach metoclopramide hcl oral solution 5 mg/5 ml Tier 1 metoclopramide hcl oral tablet 10 mg, 5 mg Tier 1 metoclopramide hcl oral tablet,disintegrating 10 mg, 5 mg Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

308 Coverage Prescription Drug Name Drug Tier Requirements and Limits Gi Antispasmodic - Belladonna Alkaloids - Drugs For Stomach Cramps ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine) hyoscyamine sulfate oral drops 0.125 mg/ml Tier 1 hyoscyamine sulfate oral elixir 0.125 mg/5 ml Tier 1 hyoscyamine sulfate oral tablet 0.125 mg Tier 1 hyoscyamine sulfate oral tablet extended release 12 hr Tier 1 0.375 mg hyoscyamine sulfate oral tablet,disintegrating 0.125 mg Tier 1 hyoscyamine sulfate sublingual tablet 0.125 mg Tier 1 HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine) Tier 1 HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine) Tier 1 methscopolamine oral tablet 2.5 mg, 5 mg Tier 1 OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine) Tier 1 OSCIMIN ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine) SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE 0.125 MG-0.25 MG (0.375 MG) Tier 3 (hyoscyamine) Gi Antispasmodic - Quaternary Ammonium Compounds - Drugs For Stomach Cramps glycopyrrolate oral tablet 1 mg, 2 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

309 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: glycopyrrolate oral tablet 1.5 mg Tier 1 Glycopyrrolate 1mg or 2mg in 120 days; QL (3 EA per 1 day) propantheline oral tablet 15 mg Tier 1 Gi Antispasmodic - Synthetic Tertiary Amines - Drugs For Stomach Cramps dicyclomine oral capsule 10 mg Tier 1 dicyclomine oral solution 10 mg/5 ml Tier 1 dicyclomine oral tablet 20 mg Tier 1 Gi Antispasmodic Combinations Other - Drugs For Stomach Cramps belladonna alkaloids-opium rectal suppository 16.2-30 mg, Tier 1 16.2-60 mg chlordiazepoxide-clidinium oral capsule 5-2.5 mg Tier 1 ST: Must meet 2 of the following requirements: DONNATAL ORAL ELIXIR 16.2 MG-0.1037 MG/5 ML (5 Dicyclomine HCL, Tier 3 ML) (phenobarbital) Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (1200 ML per 30 days) ST: Must meet 2 of the following requirements: phenobarbital (Donnatal Oral Elixir 16.2-0.1037 -0.0194 Dicyclomine HCL, Tier 3 Mg/5 Ml) Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (1200 ML per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

310 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: phenobarbital (Donnatal Oral Tablet 16.2-0.1037 -0.0194 Dicyclomine HCL, Tier 3 Mg) Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (8 EA per 1 day) ST: Must meet 2 of the following requirements: phenobarb-hyoscy-atropine-scop oral elixir 16.2 mg-0.1037 Dicyclomine HCL, Tier 1 mg/5 ml (5 ml) Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (1200 ML per 30 days) ST: Must meet 2 of the following requirements: phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 - Dicyclomine HCL, Tier 3 0.0194 mg/5 ml Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (1200 ML per 30 days) ST: Must meet 2 of the following requirements: phenobarb-hyoscy-atropine-scop oral tablet 16.2-0.1037 - Dicyclomine HCL, Tier 1 0.0194 mg Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (8 EA per 1 day) ST: Must meet 2 of the following requirements: PHENOHYTRO ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 Dicyclomine HCL, Tier 3 ML (phenobarbital) Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (1200 ML per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

311 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: PHENOHYTRO ORAL TABLET 16.2-0.1037 -0.0194 MG Dicyclomine HCL, Tier 3 (phenobarbital) Hyoscyamine Sulfate, or Symax Duotab in 365 days; QL (8 EA per 1 day) Ibs Agent - Gastrointestinal Chloride Channel Activator Agents - Drugs For Irritable Bowel Syndrome ST: Must meet the following requirement: AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) Tier 3 Linzess or Movantik in 120 days; QL (2 EA per 1 day) Ibs Agent - Selective Partial 5-Ht4 Receptor Agonists - Drugs For Irritable Bowel Syndrome ST: Must meet the following requirement: ZELNORM ORAL TABLET 6 MG (tegaserod) Tier 3 Linzess in 120 days; QL (2 EA per 1 day); Age (Max 64 Years) Inflammatory Bowel Agent - Interleukin-12 And Il-23 Inhibitors, Mc Ab - Drugs For Inflammatory Bowel Disease STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML Tier 4 PA (ustekinumab) STELARA SUBCUTANEOUS SYRINGE 90 MG/ML Tier 4 PA (ustekinumab) Inflammatory Bowel Agent - Aminosalicylates And Related Agents - Drugs For Inflammatory Bowel Disease APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 2 0.375 GRAM (mesalamine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

312 Coverage Prescription Drug Name Drug Tier Requirements and Limits balsalazide oral capsule 750 mg Tier 1 ST: Must meet any of the following requirements: DIPENTUM ORAL CAPSULE 250 MG (olsalazine) Tier 3 Apriso, Balsalazide Disodium, Mesalamine, or Pentasa in 120 days LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 Tier 1 GRAM (mesalamine) ST: Must meet any of the following requirements: mesalamine oral capsule (with del rel tablets) 400 mg Tier 1 Apriso, Balsalazide Disodium, Mesalamine, or Pentasa in 120 days mesalamine oral tablet,delayed release (dr/ec) 800 mg Tier 1 mesalamine rectal enema 4 gram/60 ml Tier 1 mesalamine rectal suppository 1,000 mg Tier 1 mesalamine with cleansing wipe rectal enema kit 4 gram/60 Tier 1 ml PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 Tier 2 MG, 500 MG (mesalamine) sulfasalazine oral tablet 500 mg Tier 1 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg Tier 1 Inflammatory Bowel Agent - Glucocorticoids - Drugs For Inflammatory Bowel Disease budesonide oral capsule,delayed,extend.release 3 mg Tier 1 ST: Must meet the following requirement: budesonide oral tablet,delayed and ext.release 9 mg Tier 1 Balsalazide Disodium in 120 days CORTIFOAM RECTAL FOAM 10 % (80 MG) Tier 3 (hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml Tier 1 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

313 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: UCERIS RECTAL FOAM 2 MG/ACTUATION (budesonide) Tier 3 Mesalamine enema in 120 days Inflammatory Bowel Agent - Janus Kinase (Jak) Inhibitors - Drugs For Inflammatory Bowel Disease XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib) Tier 3 PA; SP Inflammatory Bowel Agent - Tumor Necrosis Factor Alpha Blockers - Drugs For Inflammatory Bowel Disease CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT Tier 4 PA 400 MG (200 MG X 2 VIALS) (certolizumab pegol) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT Tier 4 PA 400 MG/2 ML (200 MG/ML X 2) (certolizumab pegol) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML Tier 4 PA (200 MG/ML X 2) (certolizumab pegol) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS Tier 4 PA SYRINGE KIT 40 MG/0.8 ML (adalimumab) HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS Tier 4 PA PEN INJECTOR KIT 40 MG/0.8 ML (adalimumab) HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML Tier 4 PA (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 Tier 4 PA MG/0.8 ML (adalimumab) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, Tier 4 PA 20 MG/0.4 ML, 40 MG/0.8 ML (adalimumab) HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 Tier 4 PA MG/0.8 ML-40 MG/0.4 ML (adalimumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

314 Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS Tier 4 PA PEN INJECTOR KIT 80 MG/0.8 ML (adalimumab) HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML Tier 4 PA (adalimumab) HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT Tier 4 PA 40 MG/0.4 ML, 80 MG/0.8 ML (adalimumab) HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 Tier 4 PA ML, 20 MG/0.2 ML, 40 MG/0.4 ML (adalimumab) SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML Tier 4 PA (golimumab) SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML Tier 4 PA (golimumab) Intestinal Flora Modifiers - Drugs For Diarrhea CULTURELLE GUMMY ORAL TABLET,CHEWABLE 1.5 Tier 3 BILLION CELL-1 GRAM (Bacillus subtilis) Irritable Bowel Syndrome (Ibs) Agents - Drugs For Irritable Bowel Syndrome alosetron oral tablet 0.5 mg, 1 mg Tier 1 ST: Must meet the following requirement: AMITIZA ORAL CAPSULE 24 MCG, 8 MCG (lubiprostone) Tier 3 Linzess or Movantik in 120 days; QL (2 EA per 1 day) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG Tier 2 QL (1 EA per 1 day) (linaclotide) VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) Tier 3 PA ST: Must meet the following requirement: ZELNORM ORAL TABLET 6 MG (tegaserod) Tier 3 Linzess in 120 days; QL (2 EA per 1 day); Age (Max 64 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

315 Coverage Prescription Drug Name Drug Tier Requirements and Limits Laxative - Saline And Osmotic - Drugs To Prevent Constipation lactulose (Constulose Oral Solution 10 Gram/15 Ml) Tier 1 GIALAX ORAL KIT 17 GRAM/ SCOOP (polyethylene glycol Tier 3 3350) ST: Must meet the following requirement: KRISTALOSE ORAL PACKET 20 GRAM (lactulose) Tier 3 Generic Lactulose solution in 120 days; QL (2 EA per 1 day) ST: Must meet the following requirement: lactulose oral packet 10 gram Tier 1 Generic Lactulose solution in 120 days; QL (3 EA per 1 day) lactulose oral solution 10 gram/15 ml Tier 1 lactulose oral solution 20 gram/30 ml Tier 1 sorbitol solution 70 % Tier 3 Laxative - Saline/Osmotic Mixtures - Drugs To Prevent Constipation polyethylene glycol 3350 (Gavilyte-C Oral Recon Soln 240- $0 COPAY IF AGE 50-75 Tier 1 22.72-6.72 -5.84 Gram) YEARS polyethylene glycol 3350 (Gavilyte-G Oral Recon Soln 236- $0 COPAY IF AGE 50-75 Tier 1 22.74-6.74 -5.86 Gram) YEARS $0 COPAY IF AGE 50-75 sodium (Gavilyte-N Oral Recon Soln 420 Gram) Tier 1 YEARS GOLYTELY ORAL POWDER IN PACKET 227.1-21.5-6.36 $0 COPAY IF AGE 50-75 Tier 2 GRAM (polyethylene glycol 3350) YEARS MOVIPREP ORAL POWDER IN PACKET 100-7.5-2.691 $0 COPAY IF AGE 50-75 Tier 3 GRAM (polyethylene glycol 3350) YEARS OSMOPREP ORAL TABLET 1.5 GRAM (sodium $0 COPAY IF AGE 50-75 Tier 3 phosphate) YEARS Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

316 Coverage Prescription Drug Name Drug Tier Requirements and Limits peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 $0 COPAY IF AGE 50-75 Tier 1 gram, 240-22.72-6.72 -5.84 gram YEARS $0 COPAY IF AGE 50-75 peg-electrolyte soln oral recon soln 420 gram Tier 1 YEARS PLENVU ORAL POWDER IN PACKET, SEQUENTIAL 140- $0 COPAY IF AGE 50-75 Tier 3 9-5.2 GRAM (polyethylene glycol 3350) YEARS SUPREP BOWEL PREP KIT ORAL RECON SOLN 17.5- $0 COPAY IF AGE 50-75 Tier 2 3.13-1.6 GRAM (sodium sulfate) YEARS sodium (Trilyte With Flavor Packets Oral Recon Soln 420 $0 COPAY IF AGE 50-75 Tier 1 Gram) YEARS Laxative - Stimulant And Saline/Osmotic Combinations - Drugs To Prevent Constipation CLENPIQ ORAL SOLUTION 10 MG-3.5 GRAM -12 $0 COPAY IF AGE 50-75 Tier 2 GRAM/160 ML (picosulfuric acid) YEARS $0 COPAY IF AGE 50-75 PEG-PREP ORAL KIT 5-210 MG-GRAM (bisacodyl) Tier 1 YEARS PREPOPIK ORAL POWDER IN PACKET 10 MG-3.5 $0 COPAY IF AGE 50-75 Tier 2 GRAM-12 GRAM (picosulfuric acid) YEARS Peptic Ulcer - Gastric Lumen Adherent Cytoprotectives - Drugs For Ulcers And Stomach Acid CARAFATE ORAL SUSPENSION 100 MG/ML (sucralfate) Tier 2 sucralfate oral tablet 1 gram Tier 1 Peptic Ulcer - Treatment Of H. Pylori: Antibiotic-Bismuth Combinations - Drugs For Ulcers And Stomach Acid PYLERA ORAL CAPSULE 140-125-125 MG (colloidal Tier 3 bismuth subcitrate)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

317 Coverage Prescription Drug Name Drug Tier Requirements and Limits Peptic Ulcer-Treatment H. Pylori-Proton Pump Inhibitor And Antibiotics - Drugs For Ulcers And Stomach Acid amoxicil-clarithromy-lansopraz oral combo pack 500-500-30 Tier 1 QL (112 EA per 10 days) mg OMECLAMOX-PAK ORAL COMBO PACK 20 MG-500 MG- Tier 3 500 MG (40) (omeprazole) Short Bowel Syndrome (Sbs) - Glucagon-Like Peptide-2 (Glp-2) Analog - Drugs For The Stomach GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG Tier 4 PA (teduglutide) GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG Tier 4 PA (teduglutide) Short Bowel Syndrome (Sbs) Agents - Drugs For The Stomach SAIZEN SUBCUTANEOUS RECON SOLN 8.8 MG Tier 4 PA (somatropin) ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Tier 4 PA (somatropin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

318 Coverage Prescription Drug Name Drug Tier Requirements and Limits Genitourinary Therapy - Drugs For The Urinary System Bph Agent- 5-Alpha Reductase Inhib And Alpha-1 Adrenoceptor Antag Comb - Drugs For The Prostate ST: Must meet any of the following requirements: Alfuzosin HCL, Doxazosin dutasteride-tamsulosin oral capsule, er multiphase 24 hr Tier 1 Mesylate, Finasteride 5mg, 0.5-0.4 mg Prazosin HCL, Silodosin, Tamsulosin HCL, or Terazosin HCL in 120 days Cystinosis Therapy (Cystine Depleting Agents) - Drugs For The Urinary System CYSTAGON ORAL CAPSULE 150 MG, 50 MG Tier 3 SP (cysteamine) PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE Tier 3 PA; SP 25 MG, 75 MG (cysteamine) G.U. Irrigants - Anti-Infective - Drugs For The Urinary System neomycin-polymyxin b gu irrigation solution 40 mg-200,000 Tier 1 unit/ml G.U. Irrigants - Drugs For The Urinary System acetic acid irrigation solution 0.25 % Tier 1 glycine urologic solution irrigation solution 1.5 % Tier 1 RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 Tier 3 MG-980.4MG/30ML (citric acid) RESECTISOL TRANSURETHRAL SOLUTION 5 % Tier 3 (mannitol) sorbitol irrigation solution 3 %, 3.3 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

319 Coverage Prescription Drug Name Drug Tier Requirements and Limits sorbitol-mannitol transurethral solution 2.7-0.54 gram/100 Tier 1 ml Interstitial Cystitis Agents - Drugs For The Urinary System ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate Tier 2 sodium) Kidney Stone Agents - Drugs For The Urinary System THIOLA EC ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 3 SP 100 MG, 300 MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) Tier 3 SP Overactive Bladder Agents - Beta -3 Adrenergic Receptor Agonist - Drugs For The Bladder ST: Must meet the MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 following requirement: Tier 2 HR 25 MG, 50 MG (mirabegron) Oxybutynin Chloride in 120 days Phosphate Binders - Calcium-Based - Drugs For The Urinary System calcium acetate oral tablet 667 mg Tier 1 PHOSLYRA ORAL SOLUTION 667 MG (169 MG Tier 3 CALCIUM)/5 ML (calcium) Phosphate Binders - Drugs For The Urinary System AURYXIA ORAL TABLET 210 MG IRON (ferric salts) Tier 3 QL (12 EA per 1 day) calcium acetate oral capsule 667 mg Tier 1 calcium acetate oral tablet 667 mg Tier 1 FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 Tier 3 MG (lanthanum) lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

320 Coverage Prescription Drug Name Drug Tier Requirements and Limits PHOSLYRA ORAL SOLUTION 667 MG (169 MG Tier 3 CALCIUM)/5 ML (calcium) sevelamer carbonate oral powder in packet 0.8 gram, 2.4 Tier 1 gram sevelamer carbonate oral tablet 800 mg Tier 1 sevelamer hcl oral tablet 400 mg, 800 mg Tier 1 VELPHORO ORAL TABLET,CHEWABLE 500 MG Tier 2 (sucroferric oxyhydroxide) Phosphate Binders - Iron-Based - Drugs For The Urinary System AURYXIA ORAL TABLET 210 MG IRON (ferric salts) Tier 3 QL (12 EA per 1 day) VELPHORO ORAL TABLET,CHEWABLE 500 MG Tier 2 (sucroferric oxyhydroxide) Polycystic Kidney Disease - Vasopressin V2 Receptor Antagonists - Drugs For The Urinary System JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) Tier 3 PA; SP SP; QL (30 EA per 365 SAMSCA ORAL TABLET 15 MG (tolvaptan) Tier 3 days) SP; QL (60 EA per 365 SAMSCA ORAL TABLET 30 MG (tolvaptan) Tier 3 days) Prostatic Hypertrophy Agent - Alpha-1- Adrenoceptor Antagonists - Drugs For The Prostate alfuzosin oral tablet extended release 24 hr 10 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

321 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: Alfuzosin HCL, Doxazosin silodosin oral capsule 4 mg, 8 mg Tier 1 Mesylate, Finasteride 5mg, Prazosin HCL, Silodosin, Tamsulosin HCL, or Terazosin HCL in 120 days tamsulosin oral capsule 0.4 mg Tier 1 Prostatic Hypertrophy Agent - Type Ii 5-Alpha Reductase Inhibitors - Drugs For The Prostate finasteride oral tablet 5 mg Tier 1 Prostatic Hypertrophy Agent-Type I And Ii 5- Alpha Reductase Inhibitors - Drugs For The Prostate dutasteride oral capsule 0.5 mg Tier 1 Urinary Acidifier - Bacterial Urease Inhibitor - Drugs For Infections LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic Tier 3 acid) Urinary Acidifier - Phosphates - Drugs For Infections K-PHOS NO 2 ORAL TABLET 305-700 MG (sodium Tier 3 phosphate) K-PHOS ORIGINAL ORAL TABLET,SOLUBLE 500 MG Tier 3 (potassium phosphate) Urinary Alkalinizer - Citrates - Drugs For Infections CYTRA K CRYSTALS ORAL PACKET 3,300-1,002 MG Tier 1 (potassium citrate) ORACIT ORAL SOLUTION 490-640 MG/5 ML (citric acid) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

322 Coverage Prescription Drug Name Drug Tier Requirements and Limits potassium citrate oral tablet extended release 10 meq Tier 1 (1,080 mg), 15 meq, 5 meq (540 mg) SHOHL'S MODIFIED ORAL SOLUTION 500-300 MG/5 ML Tier 3 (citric acid) Urinary Analgesics - Drugs For Infections phenazopyridine oral tablet 100 mg, 200 mg Tier 1 Urinary Antibacterial - Methenamine And Salts - Drugs For Infections UROQID-ACID NO.2 ORAL TABLET 500-500 MG Tier 3 (methenamine) Urinary Antibacterial - Nitrofuran Derivatives - Drugs For Infections nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg Tier 1 nitrofurantoin macrocrystal oral capsule 25 mg Tier 1 QL (4 EA per 1 day) nitrofurantoin monohyd/m-cryst oral capsule 100 mg Tier 1 nitrofurantoin oral suspension 25 mg/5 ml Tier 1 Urinary Antibacterial - Quinolones - Drugs For Infections CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR 1,000 Tier 3 MG, 500 MG (ciprofloxacin) Urinary Anti-Infective Methenamine-Antispas- Analg Combinations - Drugs For Infections HYOPHEN ORAL TABLET 81.6-0.12-10.8 MG Tier 1 (methenamine) URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG Tier 2 (methenamine) URIMAR-T ORAL TABLET 120-0.12-10.8 MG Tier 1 (methenamine) URIN DS ORAL TABLET 81.6-10.8-40.8 MG Tier 2 (methenamine) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

323 Coverage Prescription Drug Name Drug Tier Requirements and Limits URO-458 ORAL TABLET 81-10.8-40.8 MG (methenamine) Tier 1 URO-MP ORAL CAPSULE 118-10-40.8-36 MG Tier 1 (methenamine) USTELL ORAL CAPSULE 120-0.12 MG (methenamine) Tier 1 VILAMIT MB ORAL CAPSULE 118-10-40.8-36 MG Tier 1 (methenamine) Urinary Anti-Infective Methenamine- Antispasmodic Combinations - Drugs For Infections methen-sod phos-meth blue-hyos oral tablet 81.6-40.8-0.12 Tier 1 mg Urinary Antispasmodic - Antichol., M(3) Muscarinic Selective (Bladder) - Drugs For The Bladder ST: Must meet the darifenacin oral tablet extended release 24 hr 15 mg, 7.5 following requirement: Tier 1 mg Oxybutynin Chloride in 120 days ST: Must meet the following requirement: solifenacin oral tablet 10 mg, 5 mg Tier 1 Oxybutynin Chloride in 120 days Urinary Antispasmodic - Anticholinergics, Non- Selective - Drugs For The Bladder ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine) hyoscyamine sulfate oral drops 0.125 mg/ml Tier 1 HYOSYNE ORAL DROPS 0.125 MG/ML (hyoscyamine) Tier 1 HYOSYNE ORAL ELIXIR 0.125 MG/5 ML (hyoscyamine) Tier 1 OSCIMIN ORAL TABLET 0.125 MG (hyoscyamine) Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

324 Coverage Prescription Drug Name Drug Tier Requirements and Limits OSCIMIN ORAL TABLET,DISINTEGRATING 0.125 MG Tier 1 (hyoscyamine) OSCIMIN SL SUBLINGUAL TABLET 0.125 MG Tier 1 (hyoscyamine) OSCIMIN SR ORAL TABLET EXTENDED RELEASE 12 Tier 1 HR 0.375 MG (hyoscyamine) SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE 0.125 MG-0.25 MG (0.375 MG) Tier 3 (hyoscyamine) Urinary Antispasmodic - Smooth Muscle Relaxants - Drugs For The Bladder flavoxate oral tablet 100 mg Tier 1 ST: Must meet the GELNIQUE TRANSDERMAL GEL IN METERED-DOSE following requirement: Tier 3 PUMP 100 MG/GRAM (10 %) (oxybutynin) Oxybutynin Chloride in 120 days ST: Must meet the GELNIQUE TRANSDERMAL GEL IN PACKET 10 % (100 following requirement: Tier 3 MG/GRAM) (oxybutynin) Oxybutynin Chloride in 120 days oxybutynin chloride oral syrup 5 mg/5 ml Tier 1 oxybutynin chloride oral tablet 5 mg Tier 1 oxybutynin chloride oral tablet extended release 24hr 10 Tier 1 mg, 15 mg, 5 mg ST: Must meet the OXYTROL TRANSDERMAL PATCH SEMIWEEKLY 3.9 following requirement: Tier 3 MG/24 HR (oxybutynin) Oxybutynin Chloride in 120 days ST: Must meet the following requirement: tolterodine oral capsule,extended release 24hr 2 mg, 4 mg Tier 1 Oxybutynin Chloride in 120 days

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

325 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: tolterodine oral tablet 1 mg, 2 mg Tier 1 Oxybutynin Chloride in 120 days ST: Must meet the TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 following requirement: Tier 2 MG, 8 MG (fesoterodine) Oxybutynin Chloride in 120 days ST: Must meet the following requirement: trospium oral capsule,extended release 24hr 60 mg Tier 1 Oxybutynin Chloride in 120 days ST: Must meet the following requirement: trospium oral tablet 20 mg Tier 1 Oxybutynin Chloride in 120 days Urinary Retention Therapy - Parasympathomimetic Agents - Drugs For The Bladder bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg Tier 1 Gout And Hyperuricemia Therapy - Drugs For Pain And Fever Gout Acute Therapy - Antimitotics - Gout Drugs colchicine oral capsule 0.6 mg Tier 1 QL (2 EA per 1 day) colchicine oral tablet 0.6 mg Tier 1 QL (4 EA per 1 day) GLOPERBA ORAL SOLUTION 0.6 MG/5 ML (colchicine) Tier 3 Gout And Hyperuricemia - Antimitotic- Uricosuric Combinations - Gout Drugs probenecid-colchicine oral tablet 500-0.5 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

326 Coverage Prescription Drug Name Drug Tier Requirements and Limits Hyperuricemia Therapy - Uricosurics - Gout Drugs probenecid oral tablet 500 mg Tier 1 Hyperuricemia Therapy - Xanthine Oxidase Inhibitors - Gout Drugs allopurinol oral tablet 100 mg, 300 mg Tier 1 ST: Must meet the following requirement: febuxostat oral tablet 40 mg, 80 mg Tier 1 Allopurinol or Febuxostat in 120 days; QL (30 EA per 30 days) Hyperuricemia Tx - Urat1 Inhibitor And Xanthine Oxidase Inhibitor Comb - Gout Drugs ST: Must meet the DUZALLO ORAL TABLET 200-200 MG, 200-300 MG following requirement: Tier 3 (lesinurad) Allopurinol in 120 days; QL (1 EA per 1 day) Hematological Agents - Drugs For The Blood Agents To Treat Attp- Anti Von Willebrand Factor (Vwf) A1 Domain - Drugs For The Blood CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) Tier 4 PA CABLIVI INJECTION RECON SOLN 11 MG (caplacizumab- Tier 4 PA yhdp) Anticoagulants - Citrate-Based - Drugs To Prevent Blood Clots ACD SOLUTION A SOLUTION 2.45-2.2 GRAM- 800 Tier 3 MG/100 ML (dextrose in water) anticoag citrate phos dextrose solution 2.63-222 gram- Tier 1 mg/100ml sodium citrate in 0.9 % nacl solution 0.5 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

327 Coverage Prescription Drug Name Drug Tier Requirements and Limits sodium citrate intra-catheter syringe 4 % (3 ml), 4 % (4 ml), Tier 1 4 % (5 ml) sodium citrate solution 4 gram /100 ml (4 %) Tier 1 Anticoagulants - Coumarin - Drugs To Prevent Blood Clots warfarin (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, 2.5 Mg, Tier 1 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, Tier 1 5 mg, 6 mg, 7.5 mg Anti-Inhibitor Coagulation Complex - Drugs To Prevent Bleeding FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 350-650 UNIT, 700-1,300 UNIT (anti-inhibitor Tier 4 coagulant complex) Blood Cell And Platelet Disorder Tx-Spleen Tyrosine Kinase Inhibitors - Drugs For The Blood TAVALISSE ORAL TABLET 100 MG, 150 MG Tier 3 PA; SP (fostamatinib) C1 Esterase Inhibitor Agents - Drugs For The Blood BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) (C1 Tier 4 PA esterase inhibitor) BERINERT INTRAVENOUS RECON SOLN 500 UNIT (10 Tier 4 PA ML) (C1 esterase inhibitor) CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) Tier 4 PA (C1 esterase inhibitor) HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 Tier 4 PA UNIT, 3,000 UNIT (C1 esterase inhibitor) RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT Tier 4 PA (C1 esterase inhibitor, recombinant) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

328 Coverage Prescription Drug Name Drug Tier Requirements and Limits Direct Factor Xa Inhibitors - Drugs To Prevent Blood Clots BEVYXXA ORAL CAPSULE 40 MG, 80 MG (betrixaban) Tier 3 QL (43 EA per 42 days) ELIQUIS ORAL TABLET 2.5 MG (apixaban) Tier 2 QL (2 EA per 1 day) ELIQUIS ORAL TABLET 5 MG (apixaban) Tier 2 QL (74 EA per 30 days) ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) Tier 2 QL (74 EA per 30 days) (apixaban) ST: Must meet the following requirement: SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG Tier 3 Eliquis and Xarelto in 365 (edoxaban) days; QL (30 EA per 30 days) XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) Tier 2 QL (1 EA per 1 day) XARELTO ORAL TABLET 15 MG, 2.5 MG (rivaroxaban) Tier 2 QL (2 EA per 1 day) XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 Tier 2 QL (51 EA per 30 days) MG (9) (rivaroxaban) Erythropoietins - Drugs For The Blood ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 Tier 4 PA MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 Tier 4 PA MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML (darbepoetin alfa) EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 Tier 4 PA UNIT/ML, 4,000 UNIT/ML (epoetin alfa) MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 150 MCG/0.3 ML, 200 MCG/0.3 ML, 30 MCG/0.3 ML, 50 Tier 4 PA MCG/0.3 ML, 75 MCG/0.3 ML (epoetin beta)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

329 Coverage Prescription Drug Name Drug Tier Requirements and Limits PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 Tier 4 PA UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML (epoetin alfa) RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML Tier 4 PA (epoetin alfa-epbx) Factor Ix Preparations - Drugs To Prevent Bleeding ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) Tier 4 UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT (factor IX) ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT Tier 4 (factor IX) BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, Tier 4 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT (factor IX) IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,500 (+/-) UNIT, Tier 4 500 (+/-) UNIT (factor IX) IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT (factor Tier 4 IX) MONONINE INTRAVENOUS RECON SOLN 1,000 (+/-) Tier 4 UNIT (factor IX) PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT (factor II Tier 4 (prothrombin)) REBINYN INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, Tier 4 2,000 (+/-) UNIT, 500 (+/-) UNIT (factor IX) RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, Tier 4 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT (factor IX)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

330 Coverage Prescription Drug Name Drug Tier Requirements and Limits Factor Vii Preparations - Drugs To Prevent Bleeding NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 Tier 4 MG (8,000 MCG) (coagulation factor VIIa (recombinant)) Factor Viii Preparations (Ahf) - Drugs To Prevent Bleeding ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 Tier 4 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT (antihemophilic factor VIII) ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, Tier 4 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT (antihemophilic factor VIII) AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, Tier 4 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE (antihemophilic factor VIII) ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 Tier 4 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML (antihemophilic factor VIII) ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 Tier 4 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT (antihemophilic factor VIII) HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801- Tier 4 1,500 UNIT (antihemophilic factor VIII) HEMOFIL M LOW INTRAVENOUS RECON SOLN 220-400 Tier 4 UNIT (antihemophilic factor VIII)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

331 Coverage Prescription Drug Name Drug Tier Requirements and Limits HEMOFIL M MID INTRAVENOUS RECON SOLN 401-800 Tier 4 UNIT (antihemophilic factor VIII) HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN Tier 4 1,501-2,000 UNIT (antihemophilic factor VIII) HUMATE-P INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, 250-600 UNIT, 500-1,200 UNIT (antihemophilic factor Tier 4 VIII) JIVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT Tier 4 (antihemophilic factor VIII) KOATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, Tier 4 250 (+/-) UNIT, 500 (+/-) UNIT (antihemophilic factor VIII) KOGENATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, Tier 4 500 (+/-) UNIT (antihemophilic factor VIII) KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, Tier 4 500 (+/-) UNIT (antihemophilic factor VIII) NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, Tier 4 3,000 (+/-) UNIT, 500 (+/-) UNIT (antihemophilic factor VIII) NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, Tier 4 4,000 UNIT, 500 (+/-) UNIT (antihemophilic factor VIII) OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT Tier 4 RANGE (antihemophilic factor VIII) RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, Tier 4 500 (+/-) UNIT (antihemophilic factor VIII) WILATE INTRAVENOUS RECON SOLN 1,000-1,000 UNIT, 450-450 UNIT, 500-500 UNIT, 900-900 UNIT Tier 4 (antihemophilic factor VIII)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

332 Coverage Prescription Drug Name Drug Tier Requirements and Limits XYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT Tier 4 (antihemophilic factor VIII) XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1,000 (+/- ) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, Tier 4 500 (+/-) UNIT (antihemophilic factor VIII) Factor Viii-Mimetic Agent, Monoclonal Antibody - Drugs For The Blood HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7 ML, Tier 4 PA 150 MG/ML, 30 MG/ML, 60 MG/0.4 ML (emicizumab-kxwh) Factor X Preparations - Drugs To Prevent Bleeding COAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE (coagulation factor Tier 4 X) Factor Xiii Preparations - Drugs To Prevent Bleeding CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 Tier 4 UNIT (factor XIII) TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT Tier 4 (factor XIII A-subunit, recombinant) Granulocyte Colony-Stimulating Factor (G-Csf) - Drugs For The Blood FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 4 PA (pegfilgrastim-jmdb) GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 Tier 4 PA MCG/1.6 ML (tbo-filgrastim) GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, Tier 4 PA 480 MCG/0.8 ML (tbo-filgrastim) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML Tier 4 PA (pegfilgrastim)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

333 Coverage Prescription Drug Name Drug Tier Requirements and Limits NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE Tier 4 PA INJECTOR 6 MG/0.6 ML (pegfilgrastim) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 Tier 4 PA MCG/1.6 ML (filgrastim) NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 Tier 4 PA MCG/0.8 ML (filgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 Tier 4 PA MCG/1.6 ML (filgrastim-aafi) NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 Tier 4 PA ML, 480 MCG/0.8 ML (filgrastim-aafi) UDENYCA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML Tier 4 PA (pegfilgrastim-cbqv) ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 Tier 4 PA MCG/0.8 ML (filgrastim-sndz) Granulocyte-Macrophage Colony-Stimulating Factor (Gm-Csf) - Drugs For The Blood LEUKINE INJECTION RECON SOLN 250 MCG Tier 4 PA (sargramostim) Hematorheologic Agents - Drugs For The Blood pentoxifylline oral tablet extended release 400 mg Tier 1 Hemostatic Systemic - Antifibrinolytic Agents - Drugs To Prevent Bleeding aminocaproic acid oral solution 250 mg/ml (25 %) Tier 1 aminocaproic acid oral tablet 1,000 mg, 500 mg Tier 1 tranexamic acid oral tablet 650 mg Tier 1 Hemostatic Systemic- Von Willebrand Factor (Vwf) Preparations - Drugs To Prevent Bleeding VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE (von Willebrand Tier 4 factor, human)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

334 Coverage Prescription Drug Name Drug Tier Requirements and Limits Hemostatic Topical Agents - Drugs To Prevent Bleeding ASTRINGYN TOPICAL SOLUTION 259 MG/G (ferric Tier 3 subsulfate) AVITENE FLOUR TOPICAL POWDER (microfibrillar Tier 3 collagen hemostat) AVITENE TOPICAL POWDER IN PACKET (microfibrillar Tier 3 collagen hemostat) AVITENE TOPICAL SHEET 35 X 35 MM, 70 X 35 MM, 70 Tier 3 X 70 MM (microfibrillar collagen hemostat) ENDO AVITENE TOPICAL SHEET 10 MM, 5 MM Tier 3 (microfibrillar collagen hemostat) GELFILM IMPLANT FILM (gelatin) Tier 3 GEL-FLOW NT TOPICAL SYRINGE (gelatin Tier 3 sponge,absorbable) GEL-FLOW TOPICAL SYRINGE KIT 5,000 UNIT (thrombin Tier 3 (bovine)) GELFOAM JMI POWDER TOPICAL KIT 5,000 UNIT Tier 3 (thrombin (bovine)) GELFOAM JMI SPONGE TOPICAL COMBO PACK 5,000 Tier 3 UNIT (thrombin (bovine)) GELFOAM SPONGE SIZE 200 TOPICAL SPONGE 200 Tier 3 (gelatin sponge,absorbable) GELFOAM TOPICAL SPONGE 4 (gelatin Tier 3 sponge,absorbable) MONSEL'S TOPICAL SOLUTION WITH APPLICATOR 0.2 Tier 1 TO 0.22 GRAM/ML (ferric subsulfate) RECOTHROM SPRAY KIT TOPICAL RECON SOLN Tier 3 20,000 UNIT (thrombin (recombinant)) RECOTHROM TOPICAL RECON SOLN 20,000 UNIT, Tier 3 5,000 UNIT (thrombin (recombinant))

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

335 Coverage Prescription Drug Name Drug Tier Requirements and Limits SYRINGE AVITENE TOPICAL POWDER (microfibrillar Tier 3 collagen hemostat) THROMBI-GEL TOPICAL PADS, MEDICATED 10 CM2, Tier 1 100 CM2, 40 CM2 (thrombin (bovine)) THROMBIN-JMI NASAL NASAL SPRAY SYRINGE 5,000 Tier 1 UNIT (thrombin (bovine)) THROMBIN-JMI TOPICAL RECON SOLN 20,000 UNIT, Tier 1 5,000 UNIT (thrombin (bovine)) THROMBIN-JMI TOPICAL SPRAY SYRINGE 20,000 UNIT, Tier 1 5,000 UNIT (thrombin (bovine)) THROMBIN-JMI TOPICAL SPRAY,NON-AEROSOL 20,000 Tier 1 UNIT (thrombin (bovine)) THROMBI-PAD TOPICAL PADS, MEDICATED 3 X 3 " Tier 1 (thrombin (bovine)) ULTRAFOAM TOPICAL SPONGE 2 X 6.25 X 7 CM-CM- MM, 8 X 12.5 X 1 CM, 8 X 12.5 X 3 CM-CM-MM, 8 X 6.25 X Tier 3 1 CM (microfibrillar collagen hemostat) Hemostatic Topical Combinations - Drugs To Prevent Bleeding EVARREST TOPICAL ADHESIVE PATCH,MEDICATED 2 Tier 3 X 4 ", 4 X 4 " (fibrinogen) EVICEL TOPICAL SOLUTION 800-1,200 UNIT /ML (1 ML X 2), 800-1,200 UNIT /ML(2ML X 2), 800-1,200 UNIT /ML(5 Tier 3 ML X 2) (thrombin (human plasma derived)) TACHOSIL TOPICAL ADHESIVE PATCH,MEDICATED 4.8 Tier 3 X 4.8 CM, 9.5 X 4.8 CM (fibrinogen) Heparin Flush Formulations - Drugs To Prevent Blood Clots heparin (porcine) in 0.9% nacl intravenous parenteral Tier 4 solution 2,500 unit/500 ml (5 unit/ml) heparin lock flush (porcine) intravenous syringe 10 unit/ml Tier 4

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

336 Coverage Prescription Drug Name Drug Tier Requirements and Limits heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) Tier 4 Heparins - Drugs To Prevent Blood Clots HEP FLUSH-10 (PF) INTRAVENOUS SOLUTION 10 Tier 4 UNIT/ML (heparin (porcine)) heparin (porcine) in 0.9% nacl intravenous parenteral solution 2,500 unit/500 ml (5 unit/ml), 5,000 unit/500 ml (10 Tier 4 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 Tier 4 unit/ml) heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) Tier 4 heparin (porcine) injection solution 1,000 unit/ml, 10,000 Tier 4 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml Tier 4 heparin flush(porcine)-0.9nacl intravenous kit 100 unit/ml Tier 4 heparin lock flush (porcine) intravenous solution 10 unit/ml, Tier 4 100 unit/ml heparin lock flush (porcine) intravenous syringe 10 unit/ml Tier 4 heparin lock flush (porcine) intravenous syringe 100 unit/ml Tier 4 HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 10 Tier 4 UNIT/ML (heparin (porcine)) HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML Tier 4 (heparin (porcine)) HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS Tier 4 SYRINGE 10 UNIT/ML, 100 UNIT/ML (heparin (porcine)) heparin, porcine (pf) injection solution 1,000 unit/ml Tier 4 heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml, Tier 4 5,000 unit/ml heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) Tier 4 heparin, porcine (pf) intravenous syringe 1 unit/ml Tier 4

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

337 Coverage Prescription Drug Name Drug Tier Requirements and Limits heparin, porcine (pf) intravenous syringe 10 unit/ml, 100 Tier 4 unit/ml heparin, porcine (pf) subcutaneous syringe 5,000 unit/0.5 ml Tier 4 Indirect Factor Xa Inhibitors - Drugs To Prevent Blood Clots fondaparinux subcutaneous syringe 10 mg/0.8 ml Tier 4 QL (24 ML per 30 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml Tier 4 QL (15 ML per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml Tier 4 QL (12 ML per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml Tier 4 QL (18 ML per 30 days) Low Molecular Weight Heparins - Drugs To Prevent Blood Clots enoxaparin subcutaneous solution 300 mg/3 ml Tier 4 QL (30 ML per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, Tier 4 80 mg/0.8 ml FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA Tier 4 QL (7.6 ML per 30 days) UNIT/ML (dalteparin,porcine) FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA Tier 4 QL (60 ML per 30 days) UNIT/ML (dalteparin,porcine) FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA Tier 4 QL (30 ML per 30 days) UNIT/0.5 ML (dalteparin,porcine) FRAGMIN SUBCUTANEOUS SYRINGE 15,000 ANTI-XA Tier 4 QL (36 ML per 30 days) UNIT/0.6 ML (dalteparin,porcine) FRAGMIN SUBCUTANEOUS SYRINGE 18,000 ANTI-XA Tier 4 QL (43.2 ML per 30 days) UNIT/0.72 ML (dalteparin,porcine) FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML Tier 4 QL (12 ML per 30 days) (dalteparin,porcine) FRAGMIN SUBCUTANEOUS SYRINGE 7,500 ANTI-XA Tier 4 QL (18 ML per 30 days) UNIT/0.3 ML (dalteparin,porcine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

338 Coverage Prescription Drug Name Drug Tier Requirements and Limits Platelet Aggregation Inhib - Cyclopentyl- Triazolo-Pyrimidines (Cptps) - Drugs For The Blood BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) Tier 2 QL (2 EA per 1 day) Platelet Aggregation Inhibitor Combinations - Drugs For The Blood aspirin-dipyridamole oral capsule, er multiphase 12 hr 25- Tier 1 200 mg Platelet Aggregation Inhibitors - Phosphodiesterase Iii Inhibitors - Drugs For The Blood cilostazol oral tablet 100 mg, 50 mg Tier 1 Platelet Aggregation Inhibitors - Quinazoline Agents - Drugs For The Blood anagrelide oral capsule 0.5 mg, 1 mg Tier 1 Platelet Aggregation Inhibitors - Salicylates - Drugs For The Blood ADULT LOW DOSE ASPIRIN ORAL TABLET,DELAYED Tier 0 RELEASE (DR/EC) 81 MG (aspirin) ASPIRIN CHILDRENS ORAL TABLET,CHEWABLE 81 MG Tier 0 (aspirin) ASPIR-LOW ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 0 81 MG (aspirin) ASPIR-TRIN ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 0 325 MG (aspirin) DURLAZA ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 3 PA 162.5 MG (aspirin) LO-DOSE ASPIRIN ORAL TABLET,DELAYED RELEASE Tier 0 (DR/EC) 81 MG (aspirin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

339 Coverage Prescription Drug Name Drug Tier Requirements and Limits Platelet Aggregation Inhibitors - Thienopyridine Agents - Drugs For The Blood clopidogrel oral tablet 300 mg Tier 1 QL (4 EA per 30 days) clopidogrel oral tablet 75 mg Tier 1 prasugrel oral tablet 10 mg, 5 mg Tier 1 QL (1 EA per 1 day) Platelet Aggregation Inhibitors-Salicylates And Proton Pump Inhib Comb - Drugs For The Blood aspirin-omeprazole oral tablet,ir,delayed rel,biphasic 325-40 Tier 1 PA mg, 81-40 mg YOSPRALA ORAL TABLET,IR,DELAYED REL,BIPHASIC Tier 3 PA 325-40 MG, 81-40 MG (aspirin) Platelet Aggregation Inhib-Pdesterase And Adenosine Deaminase Inhibitr - Drugs For The Blood dipyridamole oral tablet 25 mg, 50 mg, 75 mg Tier 1 Platelet Aggregation Inhib-Protease- Activ.Receptor-1(Par-1) Antagonist - Drugs For The Blood ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar) Tier 3 QL (1 EA per 1 day) Sickle Cell Anemia Agents - Drugs For The Blood DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG Tier 3 (hydroxyurea) ENDARI ORAL POWDER IN PACKET 5 GRAM (glutamine) Tier 3 PA; SP ST: Must meet the following requirement: SIKLOS ORAL TABLET 1,000 MG (hydroxyurea) Tier 3 Droxia or Hydroxyurea in 365 days SIKLOS ORAL TABLET 100 MG (hydroxyurea) Tier 3 QL (2 EA per 1 day) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

340 Coverage Prescription Drug Name Drug Tier Requirements and Limits Thrombin Inhibitor - Selective Direct And Reversible - Drugs To Prevent Blood Clots ST: Must meet the PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG following requirements: Tier 3 (dabigatran etexilate) Eliquis and Xarelto in 120 days; QL (2 EA per 1 day) Thrombopoietin Receptor Agonists - Drugs For The Blood DOPTELET (10 TAB PACK) ORAL TABLET 20 MG Tier 3 PA; SP (avatrombopag) DOPTELET (15 TAB PACK) ORAL TABLET 20 MG Tier 3 PA; SP (avatrombopag) DOPTELET (30 TAB PACK) ORAL TABLET 20 MG Tier 3 PA; SP (avatrombopag) MULPLETA ORAL TABLET 3 MG (lusutrombopag) Tier 3 PA; SP PROMACTA ORAL POWDER IN PACKET 12.5 MG Tier 3 PA; SP (eltrombopag) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 Tier 3 PA; SP MG (eltrombopag) Hepatobiliary System Treatment Agents - Drugs For The Liver Farnesoid X Receptor (Fxr) Agonist, Bile Acid Analog - Drugs For The Liver OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) Tier 3 PA; SP Immunosuppressive Agents - Drugs For Organ Transplants Immunosuppressive - Calcineurin Inhibitors - Drugs For Organ Transplants ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE Tier 3 SP 24HR 0.5 MG, 1 MG, 5 MG (tacrolimus)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

341 Coverage Prescription Drug Name Drug Tier Requirements and Limits cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg Tier 1 cyclosporine modified oral solution 100 mg/ml Tier 1 cyclosporine oral capsule 100 mg, 25 mg Tier 1 ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 Tier 3 SP HR 0.75 MG, 1 MG, 4 MG (tacrolimus) cyclosporine (Gengraf Oral Capsule 100 Mg, 25 Mg) Tier 1 cyclosporine (Gengraf Oral Solution 100 Mg/Ml) Tier 1 PROGRAF ORAL CAPSULE 1 MG (tacrolimus) Tier 3 SP PROGRAF ORAL GRANULES IN PACKET 0.2 MG, 1 MG Tier 3 SP (tacrolimus) SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 3 SP (cyclosporine) tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Tier 1 Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors - Drugs For Organ Transplants mycophenolate mofetil oral capsule 250 mg Tier 1 mycophenolate mofetil oral suspension for reconstitution Tier 1 200 mg/ml mycophenolate mofetil oral tablet 500 mg Tier 1 mycophenolate sodium oral tablet,delayed release (dr/ec) Tier 1 180 mg, 360 mg Immunosuppressive - Mammalian Target Of Rapamycin (Mtor) Inhibitors - Drugs For Organ Transplants sirolimus oral solution 1 mg/ml Tier 1 sirolimus oral tablet 0.5 mg, 1 mg, 2 mg Tier 1 ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Tier 2 (everolimus) ZORTRESS ORAL TABLET 1 MG (everolimus) Tier 3 SP Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

342 Coverage Prescription Drug Name Drug Tier Requirements and Limits Immunosuppressive - Purine Analogs - Drugs For Organ Transplants AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) Tier 3 azathioprine oral tablet 50 mg Tier 1 Locomotor System - Drugs For Muscles, Ligaments, Tendons, And Bones Agents To Treat Periodic Paralysis - Carbonic Anhydrase Inhibitors - Drugs For Muscles, Ligaments, Tendons, And Bones KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) Tier 3 PA; SP Als Agents - Benzathiazoles - Drugs For Nerves And Muscles riluzole oral tablet 50 mg Tier 1 TIGLUTIK ORAL SUSPENSION 50 MG/10 ML (riluzole) Tier 3 PA; SP Antimyasthenic Agent - Reversible Cholinesterase Inhibitors - Drugs For Nerves And Muscles MESTINON ORAL SYRUP 60 MG/5 ML (pyridostigmine) Tier 2 pyridostigmine bromide oral syrup 60 mg/5 ml Tier 1 pyridostigmine bromide oral tablet 30 mg Tier 1 pyridostigmine bromide oral tablet 60 mg Tier 1 pyridostigmine bromide oral tablet extended release 180 mg Tier 1 Antimyasthenic Agents Other - Drugs For Nerves And Muscles guanidine oral tablet 125 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

343 Coverage Prescription Drug Name Drug Tier Requirements and Limits Skeletal Muscle Relaxant - Analgesic Salicylate Combinations - Drugs For Muscles, Ligaments, Tendons, And Bones carisoprodol-aspirin oral tablet 200-325 mg Tier 1 NORGESIC FORTE ORAL TABLET 50-770-60 MG Tier 3 QL (4 EA per 1 day) (orphenadrine) orphenadrine-asa-caffeine oral tablet 50-770-60 mg Tier 1 QL (4 EA per 1 day) orphenadrine (Orphengesic Forte Oral Tablet 50-770-60 Tier 1 QL (4 EA per 1 day) Mg) Skeletal Muscle Relaxant - Central Muscle Relaxants - Drugs For Muscles, Ligaments, Tendons, And Bones AMRIX ORAL CAPSULE,EXTENDED RELEASE 24HR 15 Tier 3 MG, 30 MG (cyclobenzaprine) baclofen oral tablet 10 mg, 20 mg Tier 1 baclofen oral tablet 5 mg Tier 1 carisoprodol oral tablet 250 mg, 350 mg Tier 1 QL (4 EA per 1 day) ST: Must meet the following requirement: chlorzoxazone oral tablet 250 mg, 375 mg, 750 mg Tier 1 Chlorzoxazone 500mg in 120 days; QL (4 EA per 1 day) chlorzoxazone oral tablet 500 mg Tier 1 cyclobenzaprine oral capsule,extended release 24hr 15 mg, Tier 1 30 mg cyclobenzaprine oral tablet 10 mg, 5 mg, 7.5 mg Tier 1 CYCLOTENS REFILL COMBO PACK 10 MG Tier 3 (cyclobenzaprine) CYCLOTENS STARTER COMBO PACK 10 MG Tier 3 (cyclobenzaprine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

344 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: chlorzoxazone (Lorzone Oral Tablet 375 Mg, 750 Mg) Tier 3 Chlorzoxazone 500mg in 120 days; QL (4 EA per 1 day) metaxalone (Metaxall Oral Tablet 800 Mg) Tier 1 metaxalone oral tablet 400 mg, 800 mg Tier 1 methocarbamol oral tablet 500 mg, 750 mg Tier 1 orphenadrine citrate oral tablet extended release 100 mg Tier 1 OZOBAX ORAL SOLUTION 5 MG/5 ML (baclofen) Tier 3 PA tizanidine oral capsule 2 mg, 4 mg, 6 mg Tier 1 tizanidine oral tablet 2 mg, 4 mg Tier 1 Skeletal Muscle Relaxant - Direct Muscle Relaxants - Drugs For Muscles, Ligaments, Tendons, And Bones dantrolene oral capsule 100 mg, 25 mg, 50 mg Tier 1 Skeletal Muscle Relaxant - Opioid Analgesic Combinations - Drugs For Muscles, Ligaments, Tendons, And Bones QL (8 EA per 1 day); Age carisoprodol-asa-codeine oral tablet 200-325-16 mg Tier 1 (Min 12 Years) Skeletal Muscle Relaxant And Topical Irritant Counter-Irritant Comb. - Drugs For Muscles, Ligaments, Tendons, And Bones COMFORT PAC-CYCLOBENZAPRINE KIT 10 MG Tier 3 (cyclobenzaprine) COMFORT PAC-TIZANIDINE KIT 4 MG (tizanidine) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

345 Coverage Prescription Drug Name Drug Tier Requirements and Limits Medical Supplies And Durable Medical Equipment (Dme) - Medical Supplies And Durable Medical Equipment Medical Supplies And Dme - Adhesive Bandages - Medical Supplies And Durable Medical Equipment ALLEVYN LIFE DRESSING TOPICAL BANDAGE 5 1/16 X Tier 3 5 1/16 ", 6 1/16 X 6 1/16 ", 8 1/4 X 8 1/4 " (foam bandage) Medical Supplies And Dme - Blood Coagulation Testing Supplies - Medical Supplies And Durable Medical Equipment COAGUCHEK XS (prothrombin time/INR test meter) Tier 3 Medical Supplies And Dme - Blood Collection Needles - Medical Supplies And Durable Medical Equipment MONOJECT BLOOD COLLECTION NEEDLE 20 GAUGE X 1", 20 X 1 1/2 ", 21 GAUGE X 1", 22 GAUGE X 1" (needles, Tier 3 blood collection) Medical Supplies And Dme - Blood Glucose Tests - Medical Supplies And Durable Medical Equipment ACCU-CHEK AVIVA PLUS TEST STRP STRIP (blood DME sugar diagnostic) ACCU-CHEK COMPACT PLUS TEST STRIP (blood sugar DME diagnostic, drum-type) ACCU-CHEK GUIDE STRIP (blood sugar diagnostic) DME ACCU-CHEK SMARTVIEW TEST STRIP STRIP (blood DME sugar diagnostic) ACCUTREND GLUCOSE STRIP (blood sugar diagnostic) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

346 Coverage Prescription Drug Name Drug Tier Requirements and Limits ADVANCED GLUC METER TEST STRIP STRIP (blood DME sugar diagnostic) ADVOCATE REDI-CODE PLUS STRIP (blood sugar DME diagnostic) ADVOCATE REDI-CODE STRIP (blood sugar diagnostic) DME ADVOCATE TEST STRIPS STRIP (blood sugar diagnostic) DME AGAMATRIX AMP TEST STRIPS STRIP (blood sugar DME diagnostic) ASSURE 4 STRIPS STRIP (blood sugar diagnostic) DME ASSURE PLATINUM STRIP (blood sugar diagnostic) DME ASSURE PRISM MULTI STRIP STRIP (blood sugar DME diagnostic) BIONIME RIGHTEST TEST STRIPS STRIP (blood sugar DME diagnostic) BLOOD GLUCOSE TEST STRIP (blood sugar diagnostic) DME BREEZE 2 TEST STRIPS STRIP (blood sugar diagnostic, DME disc-type) CARESENS N TEST STRIPS STRIP (blood sugar DME diagnostic) CARETOUCH TEST STRIP STRIP (blood sugar diagnostic) DME CHOICEDM CLARUS STRIP (blood sugar diagnostic) DME CLEVER CHOICE MICRO TEST STRIP STRIP (blood DME sugar diagnostic) CLEVER CHOICE PRO STRIP (blood sugar diagnostic) DME CLEVER CHOICE TALK TEST STRIP (blood sugar DME diagnostic) CLEVER CHOICE TEST STRIPS STRIP (blood sugar DME diagnostic) CLEVER CHOICE VOICE+ TEST STRIP (blood sugar DME diagnostic)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

347 Coverage Prescription Drug Name Drug Tier Requirements and Limits CONTOUR NEXT TEST STRIPS STRIP (blood sugar DME diagnostic) CONTOUR TEST STRIPS STRIP (blood sugar diagnostic) DME COOL GLUCOSE TEST STRIP STRIP (blood sugar DME diagnostic) DARIO BLOOD GLUCOSE TEST STRIP STRIP (blood DME sugar diagnostic) DIATRUE PLUS TEST STRIP STRIP (blood sugar DME diagnostic) EASY GLUCO G2 STRIP (blood sugar diagnostic) DME EASY PLUS II TEST STRIP (blood sugar diagnostic) DME EASY STEP STRIP (blood sugar diagnostic) DME EASY TALK GLUCOSE TEST STRIP (blood sugar DME diagnostic) EASY TOUCH TEST STRIP STRIP (blood sugar DME diagnostic) EASY TRAK GLUCOSE TEST STRIP (blood sugar DME diagnostic) EASYGLUCO PLUS STRIP (blood sugar diagnostic) DME EASYGLUCO TEST STRIP (blood sugar diagnostic) DME EASYMAX 15 STRIP (blood sugar diagnostic) DME EASYMAX STRIP (blood sugar diagnostic) DME ELEMENT COMPACT TEST STRIPS STRIP (blood sugar DME diagnostic) ELEMENT TEST STRIPS STRIP (blood sugar diagnostic) DME EMBRACE BLOOD GLUCOSE SYSTEM STRIP (blood DME sugar diagnostic) EMBRACE EVO TEST STRIPS STRIP (blood sugar DME diagnostic) EMBRACE PRO TEST STRIPS STRIP (blood sugar DME diagnostic) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

348 Coverage Prescription Drug Name Drug Tier Requirements and Limits EMBRACE TALK TEST STRIPS STRIP (blood sugar DME diagnostic) EVENCARE G2 STRIP (blood sugar diagnostic) DME EVENCARE G3 TEST STRIP (blood sugar diagnostic) DME EVENCARE MINI GLUCOSE TEST STR STRIP (blood DME sugar diagnostic) EVENCARE PROVIEW TEST STRIP STRIP (blood sugar DME diagnostic) EVENCARE TEST STRIP (blood sugar diagnostic) DME EVOLUTION TEST STRIPS STRIP (blood sugar DME diagnostic) EZ SMART PLUS TEST STRIP (blood sugar diagnostic) DME EZ SMART TEST STRIP (blood sugar diagnostic) DME FIFTY50 TEST STRIP STRIP (blood sugar diagnostic) DME FORA 6 CONNECT GLUCOSE STRIP STRIP (blood sugar DME diagnostic) FORA D15G STRIPS STRIP (blood sugar diagnostic) DME FORA D20 STRIP (blood sugar diagnostic) DME FORA D40-G31 TEST STRIPS STRIP (blood sugar DME diagnostic) FORA G20 STRIP (blood sugar diagnostic) DME FORA G30-PREMIUM V10 TEST STRP STRIP (blood DME sugar diagnostic) FORA GD50 TEST STRIPS STRIP (blood sugar diagnostic) DME FORA GTEL GLUCOSE TEST STRIP STRIP (blood sugar DME diagnostic) FORA TEST STRIP STRIP (blood sugar diagnostic) DME FORA TN'G VOICE TEST STRIPS STRIP (blood sugar DME diagnostic) FORA V10 STRIP (blood sugar diagnostic) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

349 Coverage Prescription Drug Name Drug Tier Requirements and Limits FORA V10-V12-D10-D20 STRIPS STRIP (blood sugar DME diagnostic) FORA V12 GLUCOSE STRIP (blood sugar diagnostic) DME FORA V20 STRIP (blood sugar diagnostic) DME FORA V30A STRIP (blood sugar diagnostic) DME FORACARE GD20 STRIP (blood sugar diagnostic) DME FORACARE GD40 STRIP (blood sugar diagnostic) DME FORTISCARE GLUCOSE TEST STRIPS STRIP (blood DME sugar diagnostic) FREESTYLE INSULINX STRIP (blood sugar diagnostic) DME FREESTYLE INSULINX TEST STRIPS STRIP (blood sugar DME diagnostic) FREESTYLE LITE STRIPS STRIP (blood sugar diagnostic) DME FREESTYLE PRECISION NEO STRIPS STRIP (blood DME sugar diagnostic) FREESTYLE TEST STRIP (blood sugar diagnostic) DME GE100 BLOOD GLUCOSE TEST STRIP STRIP (blood DME sugar diagnostic) GENSTRIP TEST STRIP STRIP (blood sugar diagnostic) DME GENULTIMATE TEST STRIP STRIP (blood sugar DME diagnostic) GLUCO NAVII TEST STRIP STRIP (blood sugar DME diagnostic) GLUCOCARD 01 SENSOR PLUS STRIP (blood sugar DME diagnostic) GLUCOCARD EXPRESSION STRIP (blood sugar DME diagnostic) GLUCOCARD SHINE TEST STRIPS STRIP (blood sugar DME diagnostic) GLUCOCARD VITAL SENSOR STRIP (blood sugar DME diagnostic) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

350 Coverage Prescription Drug Name Drug Tier Requirements and Limits GLUCOCARD VITAL TEST STRIPS STRIP (blood sugar DME diagnostic) GLUCOCOM GLUCOSE STRIP (blood sugar diagnostic) DME GM100 STRIP (blood sugar diagnostic) DME GOODLIFE AC-302 TEST STRIP STRIP (blood sugar DME diagnostic) HARMONY GLUCOSE TEST STRIP STRIP (blood sugar DME diagnostic) HEALTHPRO TEST STRIPS STRIP (blood sugar DME diagnostic) IGLUCOSE TEST STRIP STRIP (blood sugar diagnostic) DME INFINITY TEST STRIPS STRIP (blood sugar diagnostic) DME INFINITY VOICE TEST STRIP STRIP (blood sugar DME diagnostic) MICRO BLOOD GLUCOSE STRIP (blood sugar diagnostic) DME MICRODOT BLOOD GLUCOSE SYSTEM STRIP (blood DME sugar diagnostic) MICRODOT XTRA BLOOD GLUCOSE STRIP (blood sugar DME diagnostic) MYGLUCOHEALTH STRIP (blood sugar diagnostic) DME NEUTEK 2TEK TEST STRIPS STRIP (blood sugar DME diagnostic) NOVA MAX GLUCOSE TEST STRIP (blood sugar DME diagnostic) ON CALL EXPRESS TEST STRIP STRIP (blood sugar DME diagnostic) ON CALL PLUS TEST STRIP STRIP (blood sugar DME diagnostic) ON CALL VIVID TEST STRIP STRIP (blood sugar DME diagnostic)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

351 Coverage Prescription Drug Name Drug Tier Requirements and Limits ONETOUCH ULTRA BLUE TEST STRIP STRIP (blood DME sugar diagnostic) ONETOUCH VERIO STRIP (blood sugar diagnostic) DME OPTIUM EZ STRIP (blood sugar diagnostic) DME OPTIUM TEST STRIP (blood sugar diagnostic) DME OPTUMRX STRIP (blood sugar diagnostic) DME PHARMACIST CHOICE STRIP (blood sugar diagnostic) DME PRECISION PCX PLUS TEST STRIP (blood sugar DME diagnostic) PRECISION PCX TEST STRIP (blood sugar diagnostic) DME PRECISION POINT OF CARE TEST STRIP (blood sugar DME diagnostic) PRECISION Q-I-D TEST STRIP (blood sugar diagnostic) DME PRECISION XTRA TEST STRIP (blood sugar diagnostic) DME PREMIER TEST STRIP STRIP (blood sugar diagnostic) DME PREMIUM V10 STRIP (blood sugar diagnostic) DME PRO VOICE V8-V9 TEST STRIP STRIP (blood sugar DME diagnostic) PRODIGY NO CODING STRIP (blood sugar diagnostic) DME QUINTET AC STRIP (blood sugar diagnostic) DME QUINTET GLUCOSE TEST STRIPS STRIP (blood sugar DME diagnostic) REFUAH PLUS STRIP (blood sugar diagnostic) DME RELION CONFIRM-MICRO STRIP (blood sugar diagnostic) DME RELION PRIME TEST STRIPS STRIP (blood sugar DME diagnostic) RELION ULTIMA STRIP (blood sugar diagnostic) DME REVEAL TEST STRIP STRIP (blood sugar diagnostic) DME RIGHTEST GS250S TEST STRIPS STRIP (blood sugar DME diagnostic) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

352 Coverage Prescription Drug Name Drug Tier Requirements and Limits RIGHTEST GS260 TEST STRIPS STRIP (blood sugar DME diagnostic) RIGHTEST GS550 TEST STRIPS STRIP (blood sugar DME diagnostic) SIDEKICK BLOOD GLUCOSE SYSTEM KIT (blood sugar DME diagnostic) SMART SENSE TEST STRIPS STRIP (blood sugar DME diagnostic) SMARTEST TEST STRIP (blood sugar diagnostic) DME SOLUS V2 TEST STRIPS STRIP (blood sugar diagnostic) DME SURE-TEST EASYPLUS MINI STRIP (blood sugar DME diagnostic) TD GOLD TEST STRIP STRIP (blood sugar diagnostic) DME TELCARE TEST STRIPS STRIP (blood sugar diagnostic) DME TEST N'GO TEST STRIP (blood sugar diagnostic) DME TRUE METRIX GLUCOSE TEST STRIP STRIP (blood DME sugar diagnostic) TRUE METRIX PRO TEST STRIP STRIP (blood sugar DME diagnostic) TRUETEST TEST STRIPS STRIP (blood sugar diagnostic) DME TRUETRACK TEST STRIP (blood sugar diagnostic) DME ULTIMA TEST STRIPS STRIP (blood sugar diagnostic) DME ULTRATRAK STRIP (blood sugar diagnostic) DME ULTRATRAK ULTIMATE STRIP (blood sugar diagnostic) DME UNISTRIP1 TEST STRIP STRIP (blood sugar diagnostic) DME VERASENS TEST STRIP STRIP (blood sugar diagnostic) DME VIVAGUARD INO TEST STRIP STRIP (blood sugar DME diagnostic) WAVESENSE JAZZ STRIP (blood sugar diagnostic) DME WAVESENSE PRESTO STRIP (blood sugar diagnostic) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

353 Coverage Prescription Drug Name Drug Tier Requirements and Limits Medical Supplies And Dme - Blood Pressure Device Combinations - Medical Supplies And Durable Medical Equipment ADVOCATE DUO DEVICE (blood-glucose meter-wrist DME blood pressure monitor) ADVOCATE DUO METER KIT (blood-glucose meter-wrist DME blood pressure monitor) FORA D10 KIT (blood-glucose meter-wrist blood pressure DME monitor) FORA D15 GLUCOSE-BP MONITOR DEVICE (blood- DME glucose and pressure meter with adult cuff) FORA D40D GLUCOSE-BP MONITOR DEVICE (blood- DME glucose and pressure meter with adult cuff) Medical Supplies And Dme - Cervical Caps - Medical Supplies And Durable Medical Equipment FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM Tier 0 (cervical cap) Medical Supplies And Dme - Compression Stockings - Medical Supplies And Durable Medical Equipment T.E.D. KNEE LENGTH-M-LONG (compress. stocking,knee Tier 3 high, long length, small) T.E.D. KNEE LENGTH-S-REGULAR (compress. Tier 3 stocking,knee high,regular length, small) Medical Supplies And Dme - Dental Supplies Other - Medical Supplies And Durable Medical Equipment Q-CARE RX Q2 KIT 0.12 % (dental suction device) Tier 3 Q-CARE RX Q4 KIT 0.12 % (dental suction device) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

354 Coverage Prescription Drug Name Drug Tier Requirements and Limits Medical Supplies And Dme - Diaphragms - Medical Supplies And Durable Medical Equipment CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM Tier 0 (diaphragms, contoured) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 65 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 70 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 75 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 80 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 85 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 90 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 95 Tier 0 MM (diaphragms, wide seal) Medical Supplies And Dme - Drug Application Supplies - Medical Supplies And Durable Medical Equipment PCCA ACCUPEN-15 DEVICE (topical cream metered-dose Tier 3 device) Medical Supplies And Dme - Feeding Tubes And Supplies - Medical Supplies And Durable Medical Equipment ENTERAL GRAVITY BAG SET-ENFIT (feeder container) Tier 3 KANGAROO 924 SAFETY SCREW (pump set) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

355 Coverage Prescription Drug Name Drug Tier Requirements and Limits KANGAROO EPUMP SET (feeder container) Tier 3 KANGAROO GRAVITY SET (feeder container) Tier 3 RELIZORB CARTRIDGE (enteral pump accessory for fat Tier 3 hydrolysis) Medical Supplies And Dme - Female Condoms - Medical Supplies And Durable Medical Equipment FC2 FEMALE CONDOM (condoms, female) Tier 0 QL (30 EA per 30 days) Medical Supplies And Dme - Gauze Bandages - Medical Supplies And Durable Medical Equipment CURITY AMD TOPICAL BANDAGE 1 X 5 "-YARD, 1/4 X 36 Tier 3 " (gauze bandage) Medical Supplies And Dme - Gauze Pads And Dressings - Medical Supplies And Durable Medical Equipment ALLEVYN ADHESIVE DRESSING TOPICAL BANDAGE 9 Tier 3 X 9 " (foam bandage) CURITY IODOFORM PACKING STRIP TOPICAL BANDAGE 1 X 5 "-YARD, 1/2 X 5 "-YARD, 1/4 X 5 "-YARD, Tier 3 2 X 5 "-YARD (iodoform) RESTORE TOPICAL BANDAGE 2 X 2 " (silver) Tier 3 XEROFORM PETROLATUM DRESSING TOPICAL BANDAGE 1 X 8 ", 2 X 2 ", 4 X 3 "-YARD, 4 X 4 ", 5 X 9 " Tier 3 (bismuth tribromophenate) XEROFORM PETROLATUM OVERWRAP TOPICAL Tier 3 BANDAGE 1 X 8 ", 5 X 9 " (bismuth tribromophenate) XEROFORM TOPICAL BANDAGE 5 X 9 " (bismuth Tier 3 tribromophenate)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

356 Coverage Prescription Drug Name Drug Tier Requirements and Limits Medical Supplies And Dme - Glucose Monitoring Test Supplies - Medical Supplies And Durable Medical Equipment 1ST TIER UNILET COMFORTOUCH 28 GAUGE, 30 DME GAUGE (lancets) 2-IN-1 LANCET DEVICE 30 GAUGE (lancets) DME 2TEK CONTROL (HIGH-NORMAL) SOLUTION (blood- DME glucose calibration control, high) 2TEK GLUCOSE/BLOOD PRESSURE KIT (blood-glucose DME meter-wrist blood pressure monitor) ACCU-CHEK AVIVA CONTROL SOLN SOLUTION (blood- DME glucose calibration control, high) ACCU-CHEK AVIVA PLUS METER (blood-glucose meter) DME ACCU-CHEK COMPACT PLUS CARE KIT (blood-glucose DME meter, drum-type) ACCU-CHEK COMPACT PLUS CONTROL SOLUTION DME (blood-glucose calibration control, high) ACCU-CHEK FASTCLIX LANCET DRUM (lancets) DME ACCU-CHEK FASTCLIX LANCING DEV KIT (lancing DME device) ACCU-CHEK GUIDE GLUCOSE METER (blood-glucose DME meter) ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION (blood- DME glucose calibration control, high) ACCU-CHEK GUIDE ME GLUCOSE MTR (blood-glucose DME meter) ACCU-CHEK MULTICLIX LANCET (lancets) DME ACCU-CHEK MULTICLIX LANCET KIT (lancing device) DME ACCU-CHEK NANO (blood-glucose meter) DME ACCU-CHEK SAFE-T-PRO 23 GAUGE (lancets) DME ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE (lancets) DME Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

357 Coverage Prescription Drug Name Drug Tier Requirements and Limits ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION DME (blood-glucose calibration control, normal) ACCU-CHEK SOFT DEV LANCETS KIT (lancing device) DME ACCU-CHEK SOFTCLIX LANCETS (lancets) DME ACCUTREND GLUCOSE CONTROL SOLUTION (blood- DME glucose calibration control, high) ACTI-LANCE LANCETS 17 GAUGE, 23 GAUGE, 28 DME GAUGE (lancets) ADJUSTABLE LANCING DEVICE (lancing device) DME ADVANCED GLUCOSE METER (blood-glucose meter) DME ADVANCED LANCING DEVICE KIT (lancing device) DME ADVANCED TRAVEL LANCETS 28 GAUGE, 30 GAUGE DME (lancets) ADVOCATE BLOOD GLUCOSE MONITOR (blood-glucose DME meter) ADVOCATE CONTROL SOLUTION HIGH SOLUTION DME (blood-glucose calibration control, high) ADVOCATE DUO DEVICE (blood-glucose meter-wrist DME blood pressure monitor) ADVOCATE DUO METER KIT (blood-glucose meter-wrist DME blood pressure monitor) ADVOCATE LANCET 26 GAUGE, 30 GAUGE (lancets) DME ADVOCATE LANCING DEVICE (lancing device) DME ADVOCATE LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) ADVOCATE RAPID-SAFE LANCING (lancing device) DME ADVOCATE REDI-CODE GLU MONITOR (blood-glucose DME meter) ADVOCATE REDI-CODE GLU MONITOR KIT (blood- DME glucose meter) ADVOCATE REDI-CODE PLUS (blood-glucose meter) DME Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

358 Coverage Prescription Drug Name Drug Tier Requirements and Limits ADVOCATE REDI-CODE+ CTRL HIGH SOLUTION (blood- DME glucose calibration control, high) ADVOCATE REDI-CODE+ CTRL LOW SOLUTION (blood- DME glucose calibration control, low) AGAMATRIX AMP GLUC MONITOR SYS (blood-glucose DME meter) AGAMATRIX CONTROL HIGH SOLUTION (blood-glucose DME calibration control, high) AGAMATRIX CONTROL NORM-HI SOLUTION (blood- DME glucose calibration control, high) ALKALINE BATTERIES (diabetic supplies, miscellaneous) DME ALTERNATE SITE LANCET 26 GAUGE (lancets) DME ALTERNATE SITE LANCING DEVICE (lancing device) DME AQUA LANCE LANCING DEVICE (lancing device) DME ASSURE 4 CONTROL SOLUTION COMBO PACK (blood- DME glucose calibration control) ASSURE DOSE NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) ASSURE DOSE NORM-HI CONTROL SOLUTION (blood- DME glucose calibration control, high) ASSURE HAEMOLANCE PLUS 1.2 MM (blade lancet, DME safety) ASSURE HAEMOLANCE PLUS 18 GAUGE, 21 GAUGE, DME 25 GAUGE, 28 GAUGE (lancets) ASSURE LANCE 25 GAUGE, 28 GAUGE (lancets) DME ASSURE LANCE PLUS 21 GAUGE, 25 GAUGE, 30 DME GAUGE (lancets) ASSURE PLATINUM (blood-glucose meter) DME ASSURE PRISM CONTROL 1-2 SOLN SOLUTION (blood- DME glucose calibration control, high) ASSURE PRISM MULTI METER (blood-glucose meter) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

359 Coverage Prescription Drug Name Drug Tier Requirements and Limits AUTO-LANCET MINI (lancing device) DME AUTOLET IMPRESSION LANC DEV KIT (lancing device) DME AUTOLET LANCING DEVICE (lancing device) DME AUTOLET PLUS LANCING DEVICE (lancing device) DME BD MAGNI-GUIDE SYRINGE MAGNIFI (diabetic supplies, DME miscellaneous) BD MICROTAINER LANCET 1.5 X 2 MM (blade lancet, DME safety) BD MICROTAINER LANCET 21 GAUGE, 30 GAUGE DME (lancets) BD ULTRA FINE LANCETS 33 GAUGE (lancets) DME BD ULTRA-FINE II LANCETS 30 GAUGE (lancets) DME BIONIME RIGHTEST GM300 SYSTEM KIT (blood-glucose DME meter) blood glucose contrl hi,normal solution DME blood glucose control, normal solution DME blood glucose ctl high,nml,low solution DME BLOOD GLUCOSE MONITORING KIT (blood-glucose DME meter) blood-glucose meter DME blood-glucose meter kit DME BREEZE 2 CONTROL SOLUTION, LOW SOLUTION DME (blood-glucose calibration control, low) BREEZE 2 CONTROL SOLUTION, NML SOLUTION DME (blood-glucose calibration control, normal) BREEZE 2 CONTROL SOLUTION,HIGH SOLUTION DME (blood-glucose calibration control, high) BULLSEYE MINI SAFETY LANCETS 21 GAUGE, 25 DME GAUGE, 28 GAUGE (lancets) CARELANCE ULT LANCING DEVICE (lancing device) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

360 Coverage Prescription Drug Name Drug Tier Requirements and Limits CAREONE LANCING DEVICE (lancing device) DME CAREONE THIN LANCET (lancets) DME CAREONE ULTRA THIN LANCET (lancets) DME CARESENS CONTROL A AND B SOLUTION (blood- DME glucose calibration control, high) CARESENS CONTROL A NORMAL SOLUTION (blood- DME glucose calibration control, normal) CARESENS LANCETS 30 GAUGE (lancets) DME CARESENS N (blood-glucose meter) DME CARESENS N KIT (blood-glucose meter) DME CARESENS N VOICE (blood-glucose meter) DME CARESENS N VOICE KIT (blood-glucose meter) DME CARESENS PREM LANCING DEVICE (lancing device) DME CARETOUCH GLUCOSE MONITORING KIT (blood- DME glucose meter) CARETOUCH LANCING DEVICE (lancing device) DME CARETOUCH SAFETY LANCETS 26 GAUGE, 28 GAUGE DME (lancets) CARETOUCH TWIST LANCET 28 GAUGE, 30 GAUGE, 33 DME GAUGE (lancets) CHEMSTRIP BG LOG BOOK (diabetic supplies, DME miscellaneous) CHOICE DM CLARUS NORM CONTROL SOLUTION DME (blood-glucose calibration control, normal) CHOICEDM CLARUS (blood-glucose meter) DME CLEVER CHEK BLOOD GLUCOSE (blood-glucose meter) DME CLEVER CHEK BLOOD GLUCOSE SYST KIT (blood- DME glucose meter) CLEVER CHEK LANCETS 30 GAUGE (lancets) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

361 Coverage Prescription Drug Name Drug Tier Requirements and Limits CLEVER CHOICE BLOOD GLUC SYS (blood-glucose DME meter) CLEVER CHOICE GLUCOSE MONITOR (blood-glucose DME meter) CLEVER CHOICE LEVEL 1 CONTROL SOLUTION (blood- DME glucose calibration control, low) CLEVER CHOICE LEVEL 2 CONTROL SOLUTION (blood- DME glucose calibration control, normal) CLEVER CHOICE LEVEL 3 CONTROL SOLUTION (blood- DME glucose calibration control, high) CLEVER CHOICE MICRO (blood-glucose meter) DME CLEVER CHOICE PRO (blood-glucose meter) DME CLEVER CHOICE TALK GLUCOSE SYS (blood-glucose DME meter) COAGUCHEK LANCETS (lancets) DME COLOR LANCETS 21 GAUGE (lancets) DME COMFORT EZ LANCETS 21 GAUGE, 23 GAUGE, 28 DME GAUGE (lancets) COMFORT LANCETS (lancets) DME CONTOUR CONTROL SOLUTION, HIGH SOLUTION DME (blood-glucose calibration control, high) CONTOUR CONTROL SOLUTION, LOW SOLUTION DME (blood-glucose calibration control, low) CONTOUR CONTROL SOLUTION, NML SOLUTION DME (blood-glucose calibration control, normal) CONTOUR LINK KIT (blood-glucose meter) DME CONTOUR METER (blood-glucose meter) DME CONTOUR METER KIT (blood-glucose meter) DME CONTOUR NEXT EZ METER (blood-glucose meter) DME CONTOUR NEXT EZ METER KIT (blood-glucose meter) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

362 Coverage Prescription Drug Name Drug Tier Requirements and Limits CONTOUR NEXT LEV 1 CONTROL SOL SOLUTION DME (blood-glucose calibration control, low) CONTOUR NEXT LEV 2 CONTROL SOL SOLUTION DME (blood-glucose calibration control, normal) CONTOUR NEXT LINK 2.4 KIT (blood-glucose meter, DME wireless) CONTOUR NEXT LINK KIT (blood-glucose meter, wireless) DME CONTOUR NEXT METER (blood-glucose meter) DME CONTOUR NEXT ONE METER (blood-glucose meter) DME CONTROL AST MONITORING SYSTEM (blood-glucose DME meter) COOL BLOOD GLUCOSE METER (blood-glucose meter) DME COOL BLOOD GLUCOSE METER KIT (blood-glucose DME meter) COOL CONTROL A SOLUTION SOLUTION (blood-glucose DME calibration control, normal) COOL CONTROL B SOLUTION SOLUTION (blood-glucose DME calibration control, high) DARIO BLOOD GLUCOSE MONITOR DEVICE (blood- DME glucose meter,for mobile device) DEXCOM G4 RECEIVER (blood-glucose meter, DME PA continuous) DEXCOM G4 RECEIVER PEDIATRIC (blood-glucose DME PA meter, continuous) DEXCOM G4 RECEIVER-SHARE (PED) (blood-glucose DME PA meter, continuous) DEXCOM G4 RECEIVER-SHARE KIT (blood-glucose DME PA meter, continuous) DEXCOM G4 TRANSMITTER DEVICE (blood-glucose Tier 3 PA transmitter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

363 Coverage Prescription Drug Name Drug Tier Requirements and Limits DEXCOM G5 RECEIVER (blood-glucose meter, DME PA continuous) DEXCOM G5 TRANSMITTER DEVICE (blood-glucose Tier 3 PA transmitter) DEXCOM G5-G4 SENSOR DEVICE (blood-glucose sensor) Tier 3 PA DEXCOM G6 RECEIVER (blood-glucose meter, DME PA continuous) DEXCOM G6 SENSOR DEVICE (blood-glucose sensor) Tier 3 PA DEXCOM G6 TRANSMITTER DEVICE (blood-glucose Tier 3 PA transmitter) DEXCOM RECEIVER (blood-glucose meter, continuous) DME PA DIATRUE CONTROL SOLN NORMAL SOLUTION (blood- DME glucose calibration control, normal) DIATRUE CONTROL SOLUTION HIGH SOLUTION (blood- DME glucose calibration control, high) DIATRUE CONTROL SOLUTION LOW SOLUTION (blood- DME glucose calibration control, low) DIATRUE PLUS BLOOD GLUCOSE MET (blood-glucose DME meter) DROPLET LANCETS 30 GAUGE (lancets) DME DROPLET LANCING DEVICE (lancing device) DME EASY CHECK BLOOD GLUCOSE KIT (blood-glucose DME meter) EASY COMFORT LANCETS 30 GAUGE (lancets) DME EASY MINI EJECT LANCING DEVICE (lancing device) DME EASY PLUS II BLOOD GLUCOSE MET (blood-glucose DME meter) EASY PLUS II HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) EASY PLUS II LOW CONTROL SOLUTION (blood-glucose DME calibration control, low)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

364 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY STEP BLOOD GLUCOSE METER (blood-glucose DME meter) EASY STEP HIGH CONTROL SOLN SOLUTION (blood- DME glucose calibration control, high) EASY STEP LOW CONTROL SOLUTION SOLUTION DME (blood-glucose calibration control, low) EASY STEP NORMAL CONTROL SOLN SOLUTION DME (blood-glucose calibration control, normal) EASY TALK BLOOD GLUCOSE METER (blood-glucose DME meter) EASY TALK HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) EASY TALK LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) EASY TOUCH GLUCOSE MONITOR (blood-glucose DME meter) EASY TOUCH HIGH-LOW CONTROL SOLUTION (blood- DME glucose calibration control, high) EASY TOUCH LANCETS 26 GAUGE, 28 GAUGE, 30 DME GAUGE, 32 GAUGE (lancets) EASY TOUCH LANCING DEVICE (lancing device) DME EASY TOUCH SAFETY LANCETS 21 GAUGE, 23 GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE, 32 GAUGE DME (lancets) EASY TOUCH TWIST LANCETS 26 GAUGE, 28 GAUGE, DME 30 GAUGE, 32 GAUGE, 33 GAUGE (lancets) EASY TRAK BLOOD GLUCOSE METER (blood-glucose DME meter) EASY TRAK HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) EASY TRAK LOW CONTROL SOLUTION (blood-glucose DME calibration control, low)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

365 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TWIST AND CAP LANCETS 28 GAUGE (lancets) DME EASYGLUCO METER KIT (blood-glucose meter) DME EASYGLUCO MONITORING SYSTEM KIT (blood-glucose DME meter) EASYGLUCO PLUS NORMAL CONTROL SOLUTION DME (blood-glucose calibration control, normal) EASYMAX 15 LEVEL 1 SOLUTION (blood-glucose DME calibration control, low) EASYMAX 15 LEVEL 2 SOLUTION (blood-glucose DME calibration control, normal) EASYMAX L BLOOD GLUCOSE METER (blood-glucose DME meter) EASYMAX LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) EASYMAX NG (blood-glucose meter) DME EASYMAX NG KIT (blood-glucose meter) DME EASYMAX NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) EASYMAX V SPEAKING GLUCOSE SYS (blood-glucose DME meter) EASYMAX V2 BLOOD GLUCOSE METER (blood-glucose DME meter) EASY-TOUCH BLOOD GLUCOSE METER (blood-glucose DME meter) ELEMENT COMPACT GLUCOSE METER (blood-glucose DME meter) ELEMENT COMPACT HIGH CONTROL SOLUTION DME (blood-glucose calibration control, high) ELEMENT COMPACT NORMAL CONTROL SOLUTION DME (blood-glucose calibration control, normal)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

366 Coverage Prescription Drug Name Drug Tier Requirements and Limits ELEMENT COMPACT V GLUCOSE MTR (blood-glucose DME meter) ELEMENT HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) ELEMENT LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) ELEMENT NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) ELEMENT PLUS BLOOD GLUCOSE KIT KIT (blood- DME glucose meter) EMBRACE BLOOD GLUCOSE KIT (blood-glucose meter) DME EMBRACE BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) EMBRACE EVO BLOOD GLUCOSE KIT KIT (blood- DME glucose meter) EMBRACE EVO LEVEL 1 SOLUTION (blood-glucose DME calibration control, low) EMBRACE GLUCOSE CONTROL HIGH SOLUTION DME (blood-glucose calibration control, high) EMBRACE GLUCOSE CONTROL LOW SOLUTION (blood- DME glucose calibration control, low) EMBRACE LANCETS 30 GAUGE (lancets) DME EMBRACE PRO GLUCOSE METER (blood-glucose meter) DME EMBRACE PRO SOLUTION (blood-glucose calibration DME control, high) EMBRACE TALK BLOOD GLUCOSE SYS KIT (blood- DME glucose meter) EMBRACE TALK CONTROL-HIGH (L2) SOLUTION (blood- DME glucose calibration control, high) EMBRACE TALK CONTROL-LOW (L1) SOLUTION (blood- DME glucose calibration control, low)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

367 Coverage Prescription Drug Name Drug Tier Requirements and Limits EMBRACE TALK GLUCOSE MONITOR (blood-glucose DME meter) ENLITE GLUCOSE SENSOR DEVICE (blood-glucose Tier 3 sensor) ENLITE SERTER (diabetic supplies, miscellaneous) DME ENLITE SYSTEM (blood-glucose transmitter) Tier 3 EVENCARE G2 (blood-glucose meter) DME EVENCARE G2 SOLUTION (blood-glucose calibration DME control, high) EVENCARE G3 CONTROL SOLUTION (blood-glucose DME calibration control, high) EVENCARE G3 GLUCOSE METER KIT (blood-glucose DME meter) EVENCARE KIT (blood-glucose meter) DME EVENCARE MINI GLUCOSE CONTROL SOLUTION DME (blood-glucose calibration control, normal) EVENCARE MINI MONITOR SYSTEM (blood-glucose DME meter) EVENCARE PROVIEW CONTROL-L2,L3 SOLUTION DME (blood-glucose calibration control, high) EVENCARE SOLUTION (blood-glucose calibration control, DME high) EVERSENSE SMART TRANSMITTER DEVICE (blood- Tier 3 glucose transmitter) EVOLUTION BLOOD GLUCOSE METER KIT (blood- DME glucose meter) EVOLUTION NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) E-Z JECT LANCETS , 26 GAUGE, 30 GAUGE, 32 DME GAUGE, 33 GAUGE (lancets) E-Z JECT THIN LANCETS 28 GAUGE (lancets) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

368 Coverage Prescription Drug Name Drug Tier Requirements and Limits EZ SMART CONTROL SOLUTION (blood-glucose DME calibration control, low) EZ SMART LANCETS 28 GAUGE (lancets) DME EZ SMART PLUS SYSTEM KIT (blood-glucose meter) DME EZ SMART SYSTEM KIT (blood-glucose meter) DME EZ-VAC (diabetic supplies, miscellaneous) DME FIFTY50 SAFETY SEAL LANCETS 30 GAUGE, 32 GAUGE DME (lancets) FINE 30 UNIVERSAL LANCETS 30 GAUGE (lancets) DME FINGERSTIX LANCETS (lancets) DME FORA D10 KIT (blood-glucose meter-wrist blood pressure DME monitor) FORA D15 GLUCOSE-BP MONITOR DEVICE (blood- DME glucose and pressure meter with adult cuff) FORA D20 KIT (blood-glucose meter) DME FORA D40D GLUCOSE-BP MONITOR DEVICE (blood- DME glucose and pressure meter with adult cuff) FORA G20 KIT (blood-glucose meter) DME FORA G30A (blood-glucose meter) DME FORA GD50 BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) FORA HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) FORA LANCING DEVICE (lancing device) DME FORA LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) FORA NORMAL CONTROL SOLUTION (blood-glucose DME calibration control, normal) FORA PREMIUM V10 GLUCOSE METER (blood-glucose DME meter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

369 Coverage Prescription Drug Name Drug Tier Requirements and Limits FORA TEST N'GO VOICE METER (blood-glucose meter) DME FORA TN'G VOICE METER (blood-glucose meter) DME FORA V10 KIT (blood-glucose meter) DME FORA V12 BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) FORA V12 BLOOD GLUCOSE SYSTEM KIT (blood- DME glucose meter) FORA V20 KIT (blood-glucose meter) DME FORA V30A (blood-glucose meter) DME FORA V30A KIT (blood-glucose meter) DME FORACARE GD20 GLUCOSE METER (blood-glucose DME meter) FORACARE GD40A GLUCOSE METER (blood-glucose DME meter) FORACARE GD40B GLUCOSE METER (blood-glucose DME meter) FORACARE GDH HIGH CONTROL SOLUTION (blood- DME glucose calibration control, high) FORACARE GDH LOW CONTROL SOLUTION (blood- DME glucose calibration control, low) FORACARE GDH NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) FORACARE LANCETS 30 GAUGE (lancets) DME FORTISCARE BLOOD GLUCOSE SYST KIT (blood- DME glucose meter) FORTISCARE HIGH SOLUTION (blood-glucose calibration DME control, high) FORTISCARE LOW SOLUTION (blood-glucose calibration DME control, low) FORTISCARE NORMAL SOLUTION (blood-glucose DME calibration control, normal)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

370 Coverage Prescription Drug Name Drug Tier Requirements and Limits FREESTYLE CONTROL SOLUTION (blood-glucose DME calibration control, high) FREESTYLE FLASH SYSTEM KIT (blood-glucose meter) DME FREESTYLE FREEDOM KIT (blood-glucose meter) DME FREESTYLE FREEDOM LITE KIT (blood-glucose meter) DME FREESTYLE INSULINX (blood-glucose meter) DME FREESTYLE LANCETS 28 GAUGE (lancets) DME FREESTYLE LIBRE 10 DAY READER (flash glucose Tier 2 PA scanning reader) FREESTYLE LIBRE 10 DAY SENSOR KIT (flash glucose Tier 2 PA sensor) FREESTYLE LIBRE 14 DAY READER (flash glucose Tier 2 PA scanning reader) FREESTYLE LIBRE 14 DAY SENSOR KIT (flash glucose Tier 2 PA sensor) FREESTYLE LITE METER KIT (blood-glucose meter) DME FREESTYLE NAVIGATOR GLUC SENS DEVICE (blood- Tier 3 glucose sensor) FREESTYLE PRECISION NEO METER (blood-glucose DME meter) FREESTYLE SIDEKICK II KIT (blood-glucose meter) DME FREESTYLE SYSTEM KIT KIT (blood-glucose meter) DME FREESTYLE UNISTIK 2 (lancets) DME GDRIVE KIT (blood-glucose meter) DME GE100 BLOOD GLUCOSE SYSTEM KIT (blood-glucose DME meter) GE100 CONTROL SOLUTION NORMAL SOLUTION DME (blood-glucose calibration control, normal) GLUCO NAVII GLUCOSE MONITOR KIT (blood-glucose DME meter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

371 Coverage Prescription Drug Name Drug Tier Requirements and Limits GLUCOCARD 01 HI-NORMAL CONTROL SOLUTION DME (blood-glucose calibration control, high) GLUCOCARD 01 METER KIT (blood-glucose meter) DME GLUCOCARD 01 NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) GLUCOCARD EXPRESSION (blood-glucose meter) DME GLUCOCARD EXPRESSION KIT (blood-glucose meter) DME GLUCOCARD EXPRESSION SOLUTION (blood-glucose DME calibration control, normal) GLUCOCARD SHINE CONNEX METER (blood-glucose DME meter) GLUCOCARD SHINE EXPRESS METER (blood-glucose DME meter) GLUCOCARD SHINE METER (blood-glucose meter) DME GLUCOCARD SHINE METER KIT KIT (blood-glucose DME meter) GLUCOCARD SHINE SOLUTION (blood-glucose DME calibration control, normal) GLUCOCARD SHINE XL METER (blood-glucose meter) DME GLUCOCARD VITAL KIT (blood-glucose meter) DME GLUCOCOM AUTOLINK (diabetic supplies, miscellaneous) DME GLUCOCOM BLOOD GLUCOSE KIT (blood-glucose DME meter) GLUCOCOM CONTROL HIGH SOLUTION (blood-glucose DME calibration control, high) GLUCOCOM CONTROL NORMAL SOLUTION (blood- DME glucose calibration control, normal) GLUCOCOM LANCETS 28 GAUGE, 30 GAUGE, 33 DME GAUGE (lancets) GLUCOSE CONTROL SOLUTION (blood-glucose DME calibration control, normal)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

372 Coverage Prescription Drug Name Drug Tier Requirements and Limits GLUCOSE KETONE CONTROL SOLN SOLUTION (blood- DME glucose calibration control, normal) GM100 KIT (blood-glucose meter) DME GOODLIFE AC-302 GLUCOSE METER (blood-glucose DME meter) GUARDIAN CONNECT TRANSMITTER DEVICE (blood- Tier 3 PA glucose transmitter) GUARDIAN LINK 3 TRANSMITTER DEVICE (blood- Tier 3 glucose transmitter) GUARDIAN REAL-TIME GLU MONITOR (blood-glucose DME meter, continuous) GUARDIAN RT CHARGER (diabetic supplies, DME miscellaneous) GUARDIAN RT MONITOR SYSTEM (diabetic supplies, DME miscellaneous) GUARDIAN RT STARTER KIT KIT (diabetic supplies, DME miscellaneous) GUARDIAN RT TEST PLUG DEVICE (diabetic supplies, DME miscellaneous) GUARDIAN RT TRANSMITTER TAPE (diabetic supplies, DME miscellaneous) GUARDIAN SENSOR 3 DEVICE (blood-glucose sensor) Tier 3 PA HARMONY CONTROL L1,L3 SOLUTION (blood-glucose DME calibration control, high) HEALTHPRO GLUCOSE MONITOR (blood-glucose meter) DME HEALTHPRO HIGH-LOW CONTROL SOLUTION (blood- DME glucose calibration control, high) HEALTHY ACCENTS AUTOLET (lancing device) DME HEALTHY ACCENTS UNILET LANCET 30 GAUGE DME (lancets) HYPOLANCE AST LANCING KIT (lancing device) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

373 Coverage Prescription Drug Name Drug Tier Requirements and Limits IGLUCOSE BLOOD GLUCOSE MONITOR KIT (blood- DME glucose meter) INCONTROL LANCING DEVICE (lancing device) DME INCONTROL SUPER THIN LANCETS 30 GAUGE (lancets) DME INCONTROL ULTRA THIN LANCETS 28 GAUGE (lancets) DME INFINITY CONTROL SOLUTION HIGH SOLUTION (blood- DME glucose calibration control, high) INFINITY CONTROL SOLUTION LOW SOLUTION (blood- DME glucose calibration control, low) INFINITY CONTROL SOLUTION NORM SOLUTION DME (blood-glucose calibration control, normal) INFINITY METER KIT KIT (blood-glucose meter) DME INFINITY STARTER KIT KIT (blood-glucose meter) DME INFINITY VOICE CTRL SOLN-LVL 2 SOLUTION (blood- DME glucose calibration control, normal) INFINITY VOICE GLUCOSE MONITOR (blood-glucose DME meter) INJECT EASE LANCETS 28 GAUGE, 30 GAUGE (lancets) DME INSUL-CAP (diabetic supplies, miscellaneous) DME INSUL-EZE (diabetic supplies, miscellaneous) DME INVACARE LANCETS 30 GAUGE (lancets) DME JAZZ WIRELESS 2 METER KIT KIT (blood-glucose meter) DME lancets , 21 gauge, 26 gauge, 28 gauge, 30 gauge, 33 DME gauge LANCETS, SUPER THIN (lancets) DME LANCETS,THIN , 23 GAUGE, 28 GAUGE (lancets) DME LANCETS,ULTRA THIN , 26 GAUGE (lancets) DME lancing device DME LANCING DEVICE WITH LANCETS (lancing device) DME lancing device with lancets kit DME Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

374 Coverage Prescription Drug Name Drug Tier Requirements and Limits LANCING SYSTEM (lancing device) DME LANZO LANCING DEVICE KIT (lancing device) DME LITE TOUCH LANCETS 28 GAUGE, 30 GAUGE, 33 DME GAUGE (lancets) LITE TOUCH LANCING DEVICE (lancing device) DME MEDISENSE COMBO PACK (blood-glucose calibration DME control) MEDISENSE CONTROLS 1-HI 1-LO COMBO PACK DME (blood-glucose calibration control) MEDISENSE GLUCOSE KETONE COMBO PACK (blood- DME glucose calibration control) MEDISENSE MID CONTROL SOLUTION (blood-glucose DME calibration control, normal) MEDISENSE THIN LANCETS 28 GAUGE (lancets) DME MEDLANCE PLUS LANCETS 21 GAUGE, 25 GAUGE, 30 DME GAUGE (lancets) MEDLANCE PLUS SPECIAL BLADE 0.8 X 2 MM (blade DME lancet, safety) MEDPOINT NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) MEDTRONIC REMOTE CONTROL (diabetic supplies, DME miscellaneous) METER-CHECK SOLUTION (blood-glucose calibration DME control, normal) MICRO THIN LANCETS 33 GAUGE (lancets) DME MICRODOT BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) MICRODOT BLOOD GLUCOSE SYSTEM KIT (blood- DME glucose meter) MICRODOT HIGH-LOW CONTROL SOLUTION (blood- DME glucose calibration control, high)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

375 Coverage Prescription Drug Name Drug Tier Requirements and Limits MICRODOT NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) MICROLET 2 LANCING DEVICE KIT (lancing device) DME MICROLET LANCET (lancets) DME MICROLET NEXT LANCING DEVICE KIT (lancing device) DME MINI LANCING DEVICE (lancing device) DME MINILINK REAL-TIME TRANSMITTER DEVICE (blood- Tier 3 glucose transmitter) MINIMED 630G GUARDIAN START KT DEVICE (blood- Tier 3 glucose transmitter) MINIMED QUICK-SERTER-MMT 305 (diabetic supplies, DME miscellaneous) MONOLET LANCETS 21 GAUGE (lancets) DME MONOLET THIN LANCETS 28 GAUGE (lancets) DME MULTI-LANCET DEVICE 2 KIT (lancing device) DME MYGLUCOHEALTH CONTROL SOLUTION SOLUTION DME (blood-glucose calibration control, high) MYGLUCOHEALTH KIT (blood-glucose meter) DME MYGLUCOHEALTH LANCETS 30 GAUGE (lancets) DME NOVA MAX BLOOD GLUCOSE METER (blood-glucose DME meter) NOVA MAX GLUCOSE CONTROL SOLUTION (blood- DME glucose calibration control, normal) NOVA SAFETY LANCETS 23 GAUGE, 28 GAUGE DME (lancets) NOVA SUREFLEX LANCETS (lancets) DME NOVAMAX PLUS GLU-KET SOLUTION (blood-glucose DME calibration control, normal) ON CALL EXPRESS CONTROL SOLUTION (blood- DME glucose calibration control, high)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

376 Coverage Prescription Drug Name Drug Tier Requirements and Limits ON CALL EXPRESS METER (blood-glucose meter) DME ON CALL EXPRESS METER KIT (blood-glucose meter) DME ON CALL LANCET 30 GAUGE (lancets) DME ON CALL LANCING DEVICE (lancing device) DME ON CALL PLUS CONTROL SOLUTION (blood-glucose DME calibration control, high) ON CALL PLUS LANCET 30 GAUGE (lancets) DME ON CALL PLUS LANCING DEVICE (lancing device) DME ON CALL PLUS METER (blood-glucose meter) DME ON CALL PLUS METER KIT (blood-glucose meter) DME ON CALL VIVID CONTROL SOLUTION (blood-glucose DME calibration control, high) ON CALL VIVID METER (blood-glucose meter) DME ON CALL VIVID METER KIT (blood-glucose meter) DME ON CALL VIVID PAL METER (blood-glucose meter) DME ON CALL VIVID PAL METER KIT (blood-glucose meter) DME ONETOUCH DELICA LANC DEVICE KIT (lancing device) DME ONETOUCH DELICA LANCETS 30 GAUGE, 33 GAUGE DME (lancets) ONETOUCH DELICA PLUS LANC DEV KIT (lancing DME device) ONETOUCH DELICA PLUS LANCET 30 GAUGE, 33 DME GAUGE (lancets) ONETOUCH SURESOFT LANCING DEV 18 GAUGE, 21 DME GAUGE, 28 GAUGE (lancets) ONETOUCH ULTRA CONTROL SOLUTION (blood- DME glucose calibration control, normal) ONETOUCH ULTRA2 METER (blood-glucose meter) DME ONETOUCH ULTRA2 METER KIT (blood-glucose meter) DME ONETOUCH ULTRAMINI KIT (blood-glucose meter) DME Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

377 Coverage Prescription Drug Name Drug Tier Requirements and Limits ONETOUCH ULTRASOFT LANCETS (lancets) DME ONETOUCH VERIO FLEX (blood-glucose meter) DME ONETOUCH VERIO FLEX START KIT (blood-glucose DME meter) ONETOUCH VERIO HIGH CONTROL SOLUTION (blood- DME glucose calibration control, high) ONETOUCH VERIO IQ METER (blood-glucose meter) DME ONETOUCH VERIO IQ METER KIT (blood-glucose meter) DME ONETOUCH VERIO MID CONTROL SOLUTION (blood- DME glucose calibration control, normal) ONETOUCH VERIO SYSTEM (blood-glucose meter) DME ON-THE-GO LANCETS 30 GAUGE (lancets) DME OPTUMRX (blood-glucose meter) DME OPTUMRX KIT (blood-glucose meter) DME OPTUMRX SOLUTION (blood-glucose calibration control, DME high) OVAL TAPE (diabetic supplies, miscellaneous) DME PARADIGM REAL-TIME TRANSMIT-SN (blood-glucose Tier 3 transmitter) PARADIGM REMOTE CONTROL (diabetic supplies, DME miscellaneous) PHARMACIST CHOICE GLUCOSE SYS (blood-glucose DME meter) PIP LANCET 28 GAUGE, 30 GAUGE (lancets) DME PRECISION (blood-glucose meter) DME PRECISION GLUCOSE CONTROL SOLN COMBO PACK DME (blood-glucose calibration control) PRECISION GLUCOSE/KETONE CONTR COMBO PACK DME (blood-glucose calibration control) PRECISION XTRA MONITOR (blood-glucose meter) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

378 Coverage Prescription Drug Name Drug Tier Requirements and Limits PREMIER BLU GLUCOSE METER (blood-glucose meter) DME PREMIER COMPACT GLUCOSE METER KIT (blood- DME glucose meter) PREMIER VOICE GLUCOSE METER (blood-glucose DME meter) PREMIUM BLOOD GLUCOSE MONITOR (blood-glucose DME meter) PREMIUM V10 (blood-glucose meter) DME PRESSURE ACTIVATED LANCETS 21 GAUGE, 28 DME GAUGE (lancets) PRESTO PRO BLOOD GLUCOSE METER (blood-glucose DME meter) PRO COMFORT LANCET 30 GAUGE, 31 GAUGE DME (lancets) PRO VOICE V8 GLUCOSE MONITOR (blood-glucose DME meter) PRO VOICE V9 GLUCOSE MONITOR (blood-glucose DME meter) PRODIGY AUTOCODE METER KIT (blood-glucose meter) DME PRODIGY AUTOCODE MONITOR SYST (blood-glucose DME meter) PRODIGY CONTROL SOLUTION, LOW SOLUTION DME (blood-glucose calibration control, low) PRODIGY CONTROL SOLUTION,HIGH SOLUTION DME (blood-glucose calibration control, high) PRODIGY LANCETS 26 GAUGE, 28 GAUGE (lancets) DME PRODIGY LANCING DEVICE (lancing device) DME PRODIGY POCKET METER KIT (blood-glucose meter) DME PRODIGY TWIST TOP LANCET 28 GAUGE (lancets) DME PRODIGY VOICE GLUCOSE METER KIT (blood-glucose DME meter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

379 Coverage Prescription Drug Name Drug Tier Requirements and Limits PUSH BUTTON SAFETY LANCETS 21 GAUGE, 28 DME GAUGE (lancets) QUINTET AC (blood-glucose meter) DME QUINTET BLOOD GLUCOSE METER (blood-glucose DME meter) READYLANCE SAFETY LANCETS 21 GAUGE, 23 DME GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE (lancets) REFUAH PLUS GLUCOSE CONTROL SOLUTION (blood- DME glucose calibration control, high) REFUAH PLUS GLUCOSE MONITOR KIT (blood-glucose DME meter) RELIAMED LANCET 23 GAUGE, 28 GAUGE, 30 GAUGE DME (lancets) RELIAMED MINI LANCING DEVICE (lancing device) DME RELIAMED SAFETY SEAL LANCETS 28 GAUGE, 30 DME GAUGE (lancets) RELIAMED TWIST AND CAP LANCET 28 GAUGE DME (lancets) RELION ALL-IN-ONE METER KIT (blood-glucose meter) DME RELION CONFIRM KIT (blood-glucose meter) DME RELION MICRO GLUCOSE MONITOR (blood-glucose DME meter) RELION MICRO GLUCOSE MONITOR KIT (blood-glucose DME meter) RELION PRIME METER (blood-glucose meter) DME RELION THIN LANCETS 26 GAUGE (lancets) DME RELION ULTRA THIN PLUS LANCETS (lancets) DME REPLACEMENT PEDIATRIC MONITOR (diabetic supplies, DME miscellaneous) REVEAL BLOOD GLUCOSE METER KIT (blood-glucose DME meter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

380 Coverage Prescription Drug Name Drug Tier Requirements and Limits RIGHTEST CONTROL SOLUTION HIGH SOLUTION DME (blood-glucose calibration control, high) RIGHTEST CONTROL SOLUTION NORM SOLUTION DME (blood-glucose calibration control, normal) RIGHTEST GC250S CNTRL SOL NORM SOLUTION DME (blood-glucose calibration control, normal) RIGHTEST GD500 LANCING DEVICE (lancing device) DME RIGHTEST GL300 LANCETS 30 GAUGE (lancets) DME RIGHTEST GM250S GLUCOSE METER (blood-glucose DME meter) RIGHTEST GM260 GLUCOSE METER (blood-glucose DME meter) RIGHTEST GM550 SYSTEM KIT (blood-glucose meter) DME SAFETY LANCETS 21 GAUGE, 26 GAUGE, 28 GAUGE DME (lancets) SAFETY SEAL LANCETS 28 GAUGE, 30 GAUGE (lancets) DME SAFETY-LET LANCETS 30 GAUGE (lancets) DME SEN-SERTER (diabetic supplies, miscellaneous) DME SINGLE-LET (lancets) DME SMART CARESENS N KIT (blood-glucose meter) DME SMART SENSE LANCETS 21 GAUGE, 26 GAUGE, 33 DME GAUGE (lancets) SMART SENSE MONITORING SYSTEM (blood-glucose DME meter) SMARTDIABETES VANTAGE (lancing device) DME SMARTEST CONTROL SOLUTION (blood-glucose DME calibration control, normal) SMARTEST EJECT KIT (blood-glucose meter) DME SMARTEST LANCET (lancets) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

381 Coverage Prescription Drug Name Drug Tier Requirements and Limits SMARTEST PERSONA GLUCOSE METER (blood-glucose DME meter) SMARTEST PERSONA STARTER KIT (blood-glucose DME meter) SMARTEST PRONTO GLUCOSE METER (blood-glucose DME meter) SMARTEST PRONTO STARTER KIT (blood-glucose DME meter) SMARTEST PROTEGE KIT (blood-glucose meter) DME SMARTEST SMART CODE METER KIT (blood-glucose DME meter) SMARTEST TALKING METER KIT (blood-glucose meter) DME SOF-SENSOR DEVICE (blood-glucose sensor) Tier 3 SOF-SERTER INSERTION DEVICE (diabetic supplies, DME miscellaneous) SOFT TOUCH LANCETS (lancets) DME SOLUS V2 AUDIBLE METER (blood-glucose meter) DME SOLUS V2 AUDIBLE METER KIT (blood-glucose meter) DME SOLUS V2 CONTROL SOLUTION, LOW SOLUTION DME (blood-glucose calibration control, low) SOLUS V2 CONTROL SOLUTION,HIGH SOLUTION DME (blood-glucose calibration control, high) SOLUS V2 LANCETS 28 GAUGE, 30 GAUGE (lancets) DME SOLUS V2 LANCING DEVICE KIT (lancing device) DME STERILANCE TL 30 GAUGE, 32 GAUGE (lancets) DME SUPER THIN LANCETS , 28 GAUGE, 30 GAUGE DME (lancets) SURE COMFORT LANCETS 18 GAUGE, 21 GAUGE, 23 DME GAUGE, 28 GAUGE, 30 GAUGE (lancets) SURE COMFORT LANCING PEN (lancing device) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

382 Coverage Prescription Drug Name Drug Tier Requirements and Limits SUREFLEX DEVICE WITH LANCETS KIT (lancing device) DME SUREFLEX LANCING DEVICE (lancing device) DME SURE-LANCE , 26 GAUGE, 28 GAUGE (lancets) DME SURE-LANCE ULTRA THIN 30 GAUGE (lancets) DME SURE-PEN LANCING DEVICE (lancing device) DME SURE-TEST EASYPLUS MINI METER (blood-glucose DME meter) SURE-TEST EASYPLUS MINI SOLUTION (blood-glucose DME calibration control, normal) SURE-TOUCH LANCET (lancets) DME TD GOLD BLOOD GLUCOSE MONITOR (blood-glucose DME meter) TD GOLD LEVEL 1 CONTROL SOLUTION (blood-glucose DME calibration control, low) TD GOLD LEVEL 2 CONTROL SOLUTION (blood-glucose DME calibration control, normal) TD GOLD LEVEL 3 CONTROL SOLUTION (blood-glucose DME calibration control, high) TD GOLD VOICE GLUCOSE MONITOR (blood-glucose DME meter) TECHLITE LANCETS 25 GAUGE, 28 GAUGE, 30 GAUGE DME (lancets) TELCARE BGM KIT (blood-glucose meter) DME TELCARE BLOOD GLUCOSE KIT KIT (blood-glucose DME meter) TELCARE CONTROL SOLUTION (blood-glucose DME calibration control, high) TELCARE LANCETS 30 GAUGE (lancets) DME TEST N'GO BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) THIN LANCETS 26 GAUGE (lancets) DME Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

383 Coverage Prescription Drug Name Drug Tier Requirements and Limits TOPCARE UNIVERSAL1 LANCET , 33 GAUGE (lancets) DME TRUE COMFORT LANCET 30 GAUGE (lancets) DME TRUE METRIX AIR GLUCOSE METER (blood-glucose DME meter) TRUE METRIX AIR GLUCOSE METER KIT (blood-glucose DME meter) TRUE METRIX GLUCOSE METER (blood-glucose meter) DME TRUE METRIX GO GLUCOSE METER (blood-glucose DME meter) TRUE METRIX LEVEL 1 SOLUTION (blood-glucose DME calibration control, low) TRUE METRIX LEVEL 2 SOLUTION (blood-glucose DME calibration control, normal) TRUE METRIX LEVEL 3 SOLUTION (blood-glucose DME calibration control, high) TRUE2GO BLOOD GLUCOSE SYSTEM KIT (blood- DME glucose meter) TRUECONTROL LEVEL 0 SOLUTION (blood-glucose DME calibration control, high) TRUECONTROL LEVEL 1 SOLUTION (blood-glucose DME calibration control, low) TRUEDRAW LANCING DEVICE (lancing device) DME TRUEPLUS LANCETS 26 GAUGE, 28 GAUGE, 30 DME GAUGE, 33 GAUGE (lancets) TRUERESULT BLOOD GLUCOSE SYSTM KIT (blood- DME glucose meter) TRUETRACK BLOOD GLUCOSE SYSTEM KIT (blood- DME glucose meter) TRUETRACK SMART SYSTEM KIT (blood-glucose meter) DME TWIST LANCETS 30 GAUGE, 32 GAUGE (lancets) DME ULTI-LANCE (lancing device) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

384 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTI-LANCE KIT (lancing device) DME ULTILET BASIC LANCETS 30 GAUGE (lancets) DME ULTILET CLASSIC LANCETS , 28 GAUGE, 30 GAUGE, DME 33 GAUGE (lancets) ULTILET LANCETS 28 GAUGE, 30 GAUGE, 33 GAUGE DME (lancets) ULTILET SAFETY LANCETS 23 GAUGE (lancets) DME ULTIMA MONITOR (blood-glucose meter) DME ULTRA FINE LANCETS 30 GAUGE (lancets) DME ULTRA THIN II LANCETS 30 GAUGE (lancets) DME ULTRA THIN LANCETS , 28 GAUGE, 30 GAUGE, 31 DME GAUGE, 33 GAUGE (lancets) ULTRA THIN PLUS LANCETS 33 GAUGE (lancets) DME ULTRA TLC LANCETS (lancets) DME ULTRA-CARE LANCETS 30 GAUGE (lancets) DME ULTRALANCE LANCETS 26 GAUGE, 28 GAUGE (lancets) DME ULTRA-THIN II LANCETS 28 GAUGE (lancets) DME ULTRATRAK GLUCOSE METER (blood-glucose meter) DME ULTRATRAK GLUCOSE METER KIT (blood-glucose DME meter) ULTRATRAK HIGH-LOW CONTROL SOLUTION (blood- DME glucose calibration control, high) ULTRATRAK NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) ULTRATRAK ULTIMATE (blood-glucose meter) DME ULTRATRAK ULTIMATE SOLUTION (blood-glucose DME calibration control, high) UNILET COMFORTOUCH LANCET , 26 GAUGE (lancets) DME UNILET EXCELITE II LANCET (lancets) DME UNILET EXCELITE LANCET (lancets) DME Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

385 Coverage Prescription Drug Name Drug Tier Requirements and Limits UNILET GP LANCET (lancets) DME UNILET LANCET 28 GAUGE, 33 GAUGE (lancets) DME UNILET LANCETS 30 GAUGE (lancets) DME UNILET SUPER THIN LANCETS 30 GAUGE (lancets) DME UNISTIK 2 DEVICE KIT (lancing device) DME UNISTIK 2 EXTRA KIT (lancing device) DME UNISTIK 2 NORMAL LANCET,DEVICE KIT (lancing DME device) UNISTIK 3 COMFORT DEVICE KIT (lancing device) DME UNISTIK 3 COMFORT LANCET (lancets) DME UNISTIK 3 EXTRA LANCET 21 GAUGE (lancets) DME UNISTIK 3 GENTLE 30 GAUGE (lancets) DME UNISTIK 3 KIT (lancing device) DME UNISTIK 3 LANCETS 21 GAUGE (lancets) DME UNISTIK 3 NEONATAL DEVICE KIT (lancing device) DME UNISTIK 3 NEONATAL KIT (lancing device) DME UNISTIK 3 NORMAL LANCET 23 GAUGE (lancets) DME UNISTIK CZT LANCET 23 GAUGE, 28 GAUGE (lancets) DME UNISTIK PRO LANCET 21 GAUGE, 25 GAUGE, 28 DME GAUGE (lancets) UNISTIK SAFETY 28 GAUGE, 30 GAUGE (lancets) DME UNISTIK TOUCH LANCETS 21 GAUGE, 23 GAUGE, 28 DME GAUGE, 30 GAUGE (lancets) UNISTRIP HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) UNISTRIP LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) UNIVERSAL 1 LANCETS 21 GAUGE, 26 GAUGE, 30 DME GAUGE, 33 GAUGE (lancets)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

386 Coverage Prescription Drug Name Drug Tier Requirements and Limits VERASENS BLOOD GLUCOSE METER (blood-glucose DME meter) VERASENS CONTROL SOLN-LEVEL 1 SOLUTION DME (blood-glucose calibration control, normal) VERASENS METER STARTER KIT KIT (blood-glucose DME meter) VIVAGUARD INO CONTROL SOLUTION SOLUTION DME (blood-glucose calibration control, high) VIVAGUARD INO GLUCOSE METER (blood-glucose DME meter) VIVAGUARD LANCET 30 GAUGE (lancets) DME VIVAGUARD LANCING DEVICE (lancing device) DME WAVESENSE AMP KIT (blood-glucose meter) DME WAVESENSE CONTROL SOLUTION SOLUTION (blood- DME glucose calibration control, normal) WAVESENSE PRESTO (blood-glucose meter) DME WAVESENSE PRESTO KIT (blood-glucose meter) DME Medical Supplies And Dme - Incontinence Supplies - Medical Supplies And Durable Medical Equipment CURITY DRAINAGE BAG 2,000 ML (drainage bag) Tier 3 FLEXI-SEAL SIGNAL FMS RECTAL (fecal collector with Tier 3 charcoal filter) MONO-FLO DRAINAGE BAG 2,000 ML (drainage bag) Tier 3 Medical Supplies And Dme - Infant Diapers - Medical Supplies And Durable Medical Equipment BOYS TRAINING PANTS 4T-5T (diaper/brief,infant-toddler, Tier 3 disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

387 Coverage Prescription Drug Name Drug Tier Requirements and Limits DIAPERS, UNISEX SIZE 6 (diaper/brief,infant-toddler, Tier 3 disposable) GIRLS TRAINING PANTS 4T-5T (diaper/brief,infant-toddler, Tier 3 disposable) Medical Supplies And Dme - Insulin Needles- Syringes And Admin Supplies - Medical Supplies And Durable Medical Equipment 1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", Tier 1 32 GAUGE X 5/32" (pen needle, diabetic) 1ST TIER UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X Tier 1 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 33 GAUGE X 5/32" Tier 1 (pen needle, diabetic) ADVOCATE SYRINGES SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X Tier 1 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) ASSURE ID INSULIN SAFETY SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with Tier 1 needle, insulin, safety) ASSURE ID PEN NEEDLE NEEDLE 30 GAUGE X 3/16", 30 GAUGE X 5/16", 31 GAUGE X 3/16" (pen needle, Tier 1 diabetic, safety) AUTOJECT 2 INJECTION DEVICE SUBCUTANEOUS DME INSULIN PEN (insulin administration supplies) AUTOPEN 1 TO 21 UNITS SUBCUTANEOUS INSULIN DME PEN (insulin administration supplies)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

388 Coverage Prescription Drug Name Drug Tier Requirements and Limits AUTOPEN 2 TO 42 UNITS SUBCUTANEOUS INSULIN DME PEN (insulin administration supplies) BD AUTOSHIELD DUO PEN NEEDLE NEEDLE 30 Tier 1 GAUGE X 3/16" (pen needle, dual safety, diabetic) BD ECLIPSE LUER-LOK SYRINGE 1 ML 30 GAUGE X Tier 1 1/2" (syringe with needle,insulin disposable) BD INSULIN SYRINGE HALF UNIT SYRINGE 0.3 ML 31 Tier 1 GAUGE X 5/16" (syringe with needle,insulin disposable) BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) BD INSULIN SYRINGE SAFETY-LOK SYRINGE 1 ML 29 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) BD INSULIN SYRINGE SLIP TIP SYRINGE 1 ML (syringe Tier 1 without needle,insulin disposable) BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML Tier 1 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with needle,insulin disposable) BD INSULIN SYRINGE U-500 SYRINGE 1/2 ML 31 GAUGE X 15/64" (syringe, insulin U-500 with needle, Tier 1 disposable) BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 1 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE Tier 1 X 1/2" (syringe with needle,insulin disposable) BD NANO 2ND GEN PEN NEEDLE NEEDLE 32 GAUGE X Tier 1 5/32" (pen needle, diabetic) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

389 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 Tier 1 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2" (syringe with needle,insulin disposable) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 15/64", 1 ML 31 Tier 1 GAUGE X 15/64" (syringe with needle, insulin, safety) BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE Tier 1 X 5/8" (syringe with needle,insulin disposable) BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE 32 Tier 1 GAUGE X 1/4" (pen needle, diabetic) BD ULTRA-FINE MINI PEN NEEDLE NEEDLE 31 GAUGE Tier 1 X 3/16" (pen needle, diabetic) BD ULTRA-FINE NANO PEN NEEDLE NEEDLE 32 Tier 1 GAUGE X 5/32" (pen needle, diabetic) BD ULTRA-FINE ORIG PEN NEEDLE NEEDLE 29 GAUGE Tier 1 X 1/2" (pen needle, diabetic) BD ULTRA-FINE SHORT PEN NEEDLE NEEDLE 31 Tier 1 GAUGE X 5/16" (pen needle, diabetic) BD VEO INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 Tier 1 GAUGE X 15/64" (syringe with needle,insulin disposable) BD VEO INSULIN SYRINGE UF SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 Tier 1 GAUGE X 15/64" (syringe with needle,insulin disposable) CAREFINE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 Tier 1 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) CARETOUCH INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, Tier 1 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

390 Coverage Prescription Drug Name Drug Tier Requirements and Limits CARETOUCH PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 1 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) CLICKFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 Tier 1 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) COMFORT EZ INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 Tier 1 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin disposable) COMFORT EZ PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X Tier 1 5/16", 32 GAUGE X 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/16", 33 GAUGE X 5/32" (pen needle, diabetic) DROPLET INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 Tier 1 GAUGE X 5/16", 0.5ML 30 GAUGE X 15/64" (syringe with needle,insulin disposable) DROPLET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 15/64", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 1 ML 29 Tier 1 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 15/64", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

391 Coverage Prescription Drug Name Drug Tier Requirements and Limits DROPLET PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 1 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 Tier 1 GAUGE X 5/16" (pen needle, diabetic, safety) EASY COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 1 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 32 GAUGE X 5/16" (syringe with needle,insulin disposable) EASY COMFORT PEN NEEDLES NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 1 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/32" (pen needle, diabetic) EASY GLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 Tier 1 GAUGE X 15/64" (syringe with needle,insulin disposable) EASY GLIDE PEN NEEDLE NEEDLE 33 GAUGE X 5/32" Tier 1 (pen needle, diabetic) EASY TOUCH FLIPLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 1 5/16", 1 ML 31 GAUGE X 5/16" (syringe with needle, insulin, safety) EASY TOUCH INSULIN SAFETY SYR SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 29 Tier 1 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2" (syringe with needle, insulin, safety)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

392 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE Tier 1 X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 27 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin disposable) EASY TOUCH LUER LOCK INSULIN SYRINGE 1 ML Tier 1 (syringe without needle,insulin disposable) EASY TOUCH NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 1 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) EASY TOUCH PEN NEEDLE NEEDLE 30 GAUGE X 5/16" Tier 1 (pen needle, diabetic) EASY TOUCH SHEATHLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 1 5/16", 1 ML 31 GAUGE X 5/16" (syringe with needle, insulin, safety) EASY TOUCH UNI-SLIP SYRINGE 1 ML (syringe without Tier 1 needle,insulin disposable) EXEL INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, 1/2 ML 28 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) FREESTYLE PRECISION SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, Tier 1 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

393 Coverage Prescription Drug Name Drug Tier Requirements and Limits HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 1 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) HEALTHWISE PEN NEEDLE NEEDLE 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, Tier 1 diabetic) HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 Tier 1 GAUGE X 1/2" (pen needle, diabetic, safety) HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 1 GAUGE X 5/32" (pen needle, diabetic) INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", Tier 1 32 GAUGE X 5/32" (pen needle, diabetic) INPEN (FOR HUMALOG) SUBCUTANEOUS INSULIN PEN DME (insulin administration supplies) INPEN (FOR NOVOLOG) SUBCUTANEOUS INSULIN PEN DME (insulin administration supplies) insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x Tier 1 1/4" INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8", 1/2 ML 28 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable) insulin syringe needleless syringe 1 ml Tier 1 INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with needle,insulin Tier 1 disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

394 Coverage Prescription Drug Name Drug Tier Requirements and Limits insulin syringe-needle u-100 syringe 0.3 ml 29 gauge, 0.3 ml 29 gauge x 1/2", 0.3 ml 30, 0.3 ml 30 gauge x 1/2", 0.3 ml 30 gauge x 5/16", 0.3 ml 31 gauge x 1/4", 0.3 ml 31 gauge x 15/64", 0.3 ml 31 gauge x 5/16", 0.5 ml 29 gauge x 1/2", 0.5 ml 30 gauge x 1/2", 0.5 ml 30 gauge x 5/16", 0.5 ml 31 gauge x 5/16", 1 ml 27 gauge x 1/2", 1 ml 28 gauge, 1 ml 28 gauge x 1/2", 1 ml 29 gauge x 1/2", 1 ml 29 gauge x Tier 1 7/16", 1 ml 30 gauge x 1/2", 1 ml 30 gauge x 3/8", 1 ml 30 gauge x 5/16, 1 ml 30 gauge x 7/16", 1 ml 31 gauge x 1/4", 1 ml 31 gauge x 15/64", 1 ml 31 gauge x 5/16, 1/2 ml 27 gauge x 1/2", 1/2 ml 28 gauge, 1/2 ml 28 gauge x 1/2", 1/2 ml 29 , 1/2 ml 30 gauge, 1/2 ml 31 gauge x 1/4", 1/2 ml 31 gauge x 15/64" INSUPEN NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", Tier 1 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) LITE TOUCH INSULIN PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 1 GAUGE X 5/16" (pen needle, diabetic) LITE TOUCH INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML Tier 1 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin disposable) MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.3 ML 29 X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X Tier 1 1/2", 1 ML 30 GAUGE X 5/16" (syringe with needle, insulin, safety) MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16", 0.5 Tier 1 ML 30 GAUGE X 5/16" (syringe with needle, insulin, safety)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

395 Coverage Prescription Drug Name Drug Tier Requirements and Limits MAXICOMFORT II PEN NEEDLE NEEDLE 31 GAUGE X Tier 1 1/4" (pen needle, diabetic) MAXICOMFORT INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable) MAXI-COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable) MAXICOMFORT SAFETY PEN NEEDLE NEEDLE 29 GAUGE X 3/16", 29 GAUGE X 5/16" (pen needle, diabetic, Tier 1 safety) MICRODOT INSULIN PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen Tier 1 needle, diabetic) MINI ULTRA-THIN II NEEDLE 31 GAUGE X 3/16" (pen Tier 1 needle, diabetic) MINIMED SYRINGE RESERVOIR 1.8 ML, 3 ML (insulin Tier 1 pump syringe) MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 Tier 1 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 29 GAUGE X 1/2" (syringe with needle,insulin disposable) MONOJECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML , 1 ML Tier 1 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin disposable) MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE Tier 1 (syringe with needle,insulin disposable) MONOJECT ULTRA COMFORT INSULIN SYRINGE 1/2 Tier 1 ML 28 GAUGE (syringe with needle,insulin disposable) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

396 Coverage Prescription Drug Name Drug Tier Requirements and Limits NOVOFINE 32 NEEDLE 32 GAUGE X 1/4" (pen needle, Tier 1 diabetic) NOVOFINE AUTOCOVER NEEDLE 30 GAUGE X 1/3" (pen Tier 1 needle, diabetic, safety) NOVOFINE PLUS NEEDLE 32 GAUGE X 1/6" (pen needle, Tier 1 diabetic) NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN DME (insulin administration supplies) NOVOTWIST NEEDLE 32 GAUGE X 1/5" (pen needle, Tier 1 diabetic) PARADIGM RESERVOIR 1.8 ML, 3 ML (insulin pump Tier 1 syringe) PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X Tier 1 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) pen needle, diabetic needle 29 gauge x 1/2", 31 gauge x 1/4", 31 gauge x 3/16", 31 gauge x 5/16", 32 gauge x 1/4", Tier 1 32 gauge x 3/16", 32 gauge x 5/32" pen needle, diabetic needle 31 gauge x 1/3", 31 gauge x Tier 1 1/6" PENTIPS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 1 5/32" (pen needle, diabetic) PREVENT DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16" (pen needle, diabetic, Tier 1 safety) PRO COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE Tier 1 X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

397 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRO COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X Tier 1 5/32" (pen needle, diabetic) PRODIGY INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) RELION NEEDLES NEEDLE 31 GAUGE X 1/4" (pen Tier 1 needle, diabetic) RELION PEN NEEDLES NEEDLE 32 GAUGE X 5/32" (pen Tier 1 needle, diabetic) SAFESNAP INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 Tier 1 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe,needle,insulin, safety, self-cnt disp unit) SAFETY PEN NEEDLE NEEDLE 31 GAUGE X 3/16" (pen Tier 1 needle, diabetic, safety) SURE COMFORT INS. SYR. U-100 SYRINGE 0.5 ML 29 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) SURE COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 Tier 1 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 31 GAUGE X 1/4" (syringe with needle,insulin disposable) SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X Tier 1 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic) SURE-FINE PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16" (pen needle, Tier 1 diabetic) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

398 Coverage Prescription Drug Name Drug Tier Requirements and Limits SURE-JECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 Tier 1 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin disposable) TECHLITE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 Tier 1 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16" (syringe with needle,insulin disposable) TECHLITE INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 Tier 1 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) TECHLITE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 1 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, diabetic) TERUMO INSULIN SYRINGE SYRINGE 0.3 ML 30 X 3/8", 0.5 ML 29 GAUGE X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1/2 ML 27 GAUGE Tier 1 X 1/2", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin disposable) THINPRO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 X 3/8", 1 ML 28 GAUGE X Tier 1 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 ML 31 X 3/8", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin disposable) TOPCARE CLICKFINE NEEDLE 31 GAUGE X 1/4", 31 Tier 1 GAUGE X 5/16" (pen needle, diabetic) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

399 Coverage Prescription Drug Name Drug Tier Requirements and Limits TOPCARE ULTRA COMFORT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 Tier 1 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) TRUE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 31 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16 (syringe with Tier 1 needle,insulin disposable) TRUE COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, Tier 1 diabetic) TRUEPLUS INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 Tier 1 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin disposable) TRUEPLUS PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 1 GAUGE X 5/32" (pen needle, diabetic) ULTICARE INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 Tier 1 GAUGE X 1/4" (syringe with needle,insulin disposable) ULTICARE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 1/4", 1/2 ML 31 GAUGE Tier 1 X 1/4" (syringe with needle,insulin disposable) ULTICARE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 1 GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic) ULTICARE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 Tier 1 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

400 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X Tier 1 5/16", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 29 (syringe with needle,insulin disposable) ULTILET PEN NEEDLE NEEDLE 29 GAUGE, 32 GAUGE Tier 1 X 5/32" (pen needle, diabetic) ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 Tier 1 GAUGE X 5/16" (syringe with needle,insulin disposable) ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30, 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 Tier 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin disposable) ULTRA FLO PEN NEEDLE NEEDLE 31 GAUGE X 3/16" Tier 1 (pen needle, diabetic) ULTRA THIN PEN NEEDLE NEEDLE 32 GAUGE X 5/32" Tier 1 (pen needle, diabetic) ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 1 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) ULTRACARE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", Tier 1 32 GAUGE X 3/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

401 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 1 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) ULTRA-THIN II (SHORT) PEN NDL NEEDLE 31 GAUGE X Tier 1 5/16" (pen needle, diabetic) ULTRA-THIN II INS PEN NEEDLES NEEDLE 29 GAUGE X Tier 1 1/2" (pen needle, diabetic) ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable) UNIFINE PENTIPS NEEDLE 29 GAUGE, 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X Tier 1 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) UNIFINE PENTIPS PLUS NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 Tier 1 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) VANISHPOINT SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with needle,insulin Tier 1 disposable) VERIFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32" Tier 1 (pen needle, diabetic) Medical Supplies And Dme - Iv Sets-Tubing - Medical Supplies And Durable Medical Equipment BD INSYTE AUTOGUARD INFUSION SET 24 GAUGE X Tier 3 3/4" (intravenous catheter) BD INTEGRA SYRINGE SYRINGE 3 ML 25 GAUGE X 1" Tier 1 (syringe,safety with needle)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

402 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD SAFETYGLIDE SYRINGE SYRINGE 3 ML 25 GAUGE Tier 1 X 1" (syringe,safety with needle) BD SAF-T-INTIMA INFUSION SET 22 GAUGE X 3/4" Tier 3 (intravenous catheter kit) COMFORT INFUSION SET 31" INFUSION SET (infusion Tier 3 set for insulin pump) COMFORT SHORT INFUSION SET 23" INFUSION SET Tier 3 (infusion set for insulin pump) COMFORT SHORT INFUSION SET 31" INFUSION SET Tier 3 (infusion set for insulin pump) COMFORT SHORT INFUSION SET 43" INFUSION SET Tier 3 (infusion set for insulin pump) EASY TOUCH FLIPLOCK SYRINGE SYRINGE 3 ML 21 GAUGE X 1", 3 ML 25 GAUGE X 1" (syringe,safety with Tier 1 needle) EASY TOUCH SHEATHLOCK SYRG-NDL SYRINGE 3 ML 21 GAUGE X 1", 3 ML 25 GAUGE X 1" (syringe,safety with Tier 1 needle) ECLIPSE SYRINGE SYRINGE 3 ML 21 GAUGE X 1", 3 ML Tier 1 25 GAUGE X 1" (syringe,safety with needle) FILTERED EXTENSION SET INFUSION SET (intravenous Tier 3 admin extension set with filter) HI-VOLUME PUMPING CHAMBER SET (transfer sets) Tier 3 INFUSION SET 23" INFUSION SET (infusion set for insulin Tier 3 pump) INSYTE IV CATHETER INFUSION SET 14 X 1.75 ", 20 X Tier 3 1.16 " (intravenous catheter) INTEGRA SYRINGE SYRINGE 3 ML 21 GAUGE X 1" Tier 1 (syringe,safety with needle) MICROBORE EXTENSION SET INFUSION SET Tier 3 (intravenous admin extension set)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

403 Coverage Prescription Drug Name Drug Tier Requirements and Limits MONOJECT SAFETY SYRINGES SYRINGE 3 ML 21 Tier 1 GAUGE X 1" (syringe,safety with needle) NEXIVA INFUSION SET 18 X 1 1/4 ", 18 X 1 3/4 ", 20 GAUGE X 1", 20 X 1 1/4 ", 20 X 1 3/4 ", 22 GAUGE X 1", 24 Tier 3 GAUGE X 3/4", 24 X 0.56 " (intravenous catheter) PHASEAL SECONDARY SET INFUSION SET (intravenous Tier 3 piggyback administration set) PHASEAL Y-SITE (y-site line connector, closed system) Tier 3 RATE FLOW REGULATOR IV SET INFUSION SET Tier 3 (intravenous administration set) SILHOUETTE 23"-FULL SET INFUSION SET (infusion set Tier 3 for insulin pump) SILHOUETTE 43"-FULL SET INFUSION SET (infusion set Tier 3 for insulin pump) SILHOUETTE INFUSION SET (infusion set for insulin Tier 3 pump) SOF-SET CANNULA 24" TUBING INFUSION SET (infusion Tier 3 set for insulin pump) SOF-SET INFUSION SET (infusion set for insulin pump) Tier 3 SOF-SET MICRO 24" POLYFIN TUB INFUSION SET Tier 3 (infusion set for insulin pump) SOF-SET MICRO 42" POLYFIN TUB INFUSION SET Tier 3 (infusion set for insulin pump) SOF-SET QR 42" TUBING INFUSION SET (infusion set for Tier 3 insulin pump) SURGUARD2 SAFETY SYRINGE 3 ML 21 GAUGE X 1", 3 Tier 1 ML 25 GAUGE X 1" (syringe,safety with needle) ULTICARE SAFETY SYRINGE SYRINGE 3 ML 25 GAUGE Tier 1 X 1" (syringe,safety with needle)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

404 Coverage Prescription Drug Name Drug Tier Requirements and Limits Medical Supplies And Dme - Male Erectile Dysfunction Aids - Medical Supplies And Durable Medical Equipment RAPPORT VACUUM THERAPY KIT (vacuum erection Tier 3 device system) Medical Supplies And Dme - Miscellaneous Other - Medical Supplies And Durable Medical Equipment ACCU-CHEK SPIRIT CLIP CASE (subcutaneous infusion Tier 3 pump accessory) AMIELLE VAGINAL TRAINER KIT (medical supply, Tier 3 miscellaneous) ARGYLE TRACHEOSTOMY CARE TRAY (medical supply, Tier 3 miscellaneous) CEFALY COMBO PACK (TENS unit) Tier 3 OMNIPOD DASH INSULIN POD SUBCUTANEOUS Tier 4 CARTRIDGE (insulin pump cartridge) OMNIPOD INSULIN REFILL SUBCUTANEOUS Tier 4 CARTRIDGE (insulin pump cartridge) PRO COMFORT TENS ELECTRODE PAD (tens unit Tier 3 electrodes) PRO COMFORT TENS UNIT COMBO PACK (TENS unit) Tier 3 PRO-CEPTION VAGINAL (medical supply, miscellaneous) Tier 3 RECONSTITUBE KIT (medical supply, miscellaneous) Tier 3 SAFE-CLIP NEEDLE STORAGE DEV DEVICE (needle DME clipping and storage device) T.E.D. ANTI-EMBOLISM STOCKING (compress. Tier 3 stocking,knee high,regular length, small) T:FLEX SUBCUTANEOUS CARTRIDGE (insulin pump Tier 4 cartridge)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

405 Coverage Prescription Drug Name Drug Tier Requirements and Limits T:SLIM G4 SUBCUTANEOUS CARTRIDGE (insulin pump Tier 4 cartridge) T:SLIM SUBCUTANEOUS CARTRIDGE (insulin pump Tier 4 cartridge) TENS 502 DEVICE (TENS unit) Tier 3 TENS 504 DEVICE (TENS unit) Tier 3 Medical Supplies And Dme - Nebulizers - Medical Supplies And Durable Medical Equipment AEROECLIPSE II NEBULIZER (nebulizer) Tier 3 AERONEB GO NEBULIZER (nebulizer) Tier 3 AIRS DISPOSABLE NEBULIZER (nebulizer) Tier 3 ALTERA NEBULIZER (nebulizer) Tier 3 ALTERA NEBULIZER SYSTEM (nebulizer) Tier 3 AURA PORTANEB (nebulizer) Tier 3 DEVILBISS DISPOSABLE NEBULIZER (nebulizer) Tier 3 ERAPID NEBULIZER SYSTEM (nebulizer) Tier 3 FLYP NEBULIZER (nebulizer) Tier 3 INNOSPIRE GO NEBULIZER (nebulizer) Tier 3 LC D NEBULIZER SET (nebulizer) Tier 3 LC PLUS (nebulizer) Tier 3 LC PLUS NEBULIZER-PED MASK (nebulizer) Tier 3 LC STAR (nebulizer) Tier 3 MICROAIR MESH NEBULIZER (nebulizer) Tier 3 MINI PLUS NEBULIZER (nebulizer) Tier 3 PARI BABY NEBULIZER (nebulizer) Tier 3 PARI LC D NEBULIZER (nebulizer) Tier 3 PARI LC SPRINT NEBULIZER SET (nebulizer) Tier 3 PARI LC SPRINT SINUS (nebulizer) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

406 Coverage Prescription Drug Name Drug Tier Requirements and Limits PRODIGY MINI-MIST NEBULIZER (nebulizer) Tier 3 SIDESTREAM (nebulizer) Tier 3 SIDESTREAM NEBULIZER (nebulizer) Tier 3 SIDESTREAM PLUS (nebulizer) Tier 3 SINUSTAR NEBULIZER (nebulizer) Tier 3 SOOTHENEB MESH NEBULIZER (nebulizer) Tier 3 TRUNEB NEBULIZER (nebulizer) Tier 3 VIXONE NEBULIZER (nebulizer) Tier 3 VIXONE NEBULIZER-ADULT MASK (nebulizer) Tier 3 VIXONE NEBULIZER-PEDIATRIC MSK (nebulizer) Tier 3 Medical Supplies And Dme - Needles And Syringes - Medical Supplies And Durable Medical Equipment ALLERGIST TRAY 1/2 ML 27GX3/8" SYRINGE 1/2 ML 27 Tier 1 GAUGE X 3/8" (syringe with needle,disposable) ALLERGIST TRAY INTRADERMAL BEV SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 26 GAUGE X 3/8", 1 ML 27 Tier 1 GAUGE X 3/8" (syringe with needle,disposable) ALLERGIST TRAY REGULAR BEVEL SYRINGE 1 ML 27 Tier 1 GAUGE X 3/8" (syringe with needle,disposable) ALLERGY SYRINGE SYRINGE 1 ML 27 X 1/2" (syringe Tier 1 with needle,disposable) BD ALLERGIST TRAY REG BEVEL SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 27 X 1/2" (syringe with Tier 1 needle,disposable) BD ALLERGIST TRAY REG BEVEL TRAY 1/2 ML 27 X Tier 1 1/2" (syringe with needle, disposable kit-tray) BD ALLERGY SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2" Tier 1 (syringe with needle,disposable) BD BLUNT PLASTIC CANNULA SYRINGE 17 X 3 ML Tier 1 (syringe with cannula, disposable) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

407 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD BULK LUER-LOK NON-STERILE SYRINGE 10 ML, 20 Tier 1 ML, 5 ML, 60 ML (syringe, disposable) BD BULK SLIP TIP NON-STERILE SYRINGE 10 ML, 20 Tier 1 ML, 60 ML (syringe, disposable) BD BULK SYRINGE SLIP TIP SYRINGE 1 ML, 5 ML Tier 1 (syringe, disposable) BD ECCENTRIC TIP SYRINGE SYRINGE 10 ML (syringe, Tier 1 disposable) BD ECLIPSE LUER-LOK NEEDLE 30 X 1/2 " (needles, Tier 1 safety) BD ECLIPSE LUER-LOK SYRINGE 1 ML 27 X 1/2", 3 ML Tier 1 23 X 1", 3 ML 25 X 5/8" (syringe with needle,disposable) BD ECLIPSE LUER-LOK SYRINGE 3 ML 22 GAUGE X 1 Tier 1 1/2" (syringe,safety with needle) BD FILTER NEEDLE-5 MICRON NEEDLE 19 X 1 1/2 " Tier 3 (needles, filter) BD INTEGRA SYRINGE SYRINGE 3 ML 21 GAUGE X 1 Tier 1 1/2" (syringe with needle,disposable) BD INTEGRA SYRINGE SYRINGE 3 ML 22 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8" Tier 1 (syringe,safety with needle) BD INTERLINK BLUNT PLASTIC CAN SYRINGE 17 X 5 Tier 1 ML (syringe with cannula, disposable) BD INTERLINK SYRINGE SYRINGE 17 X 10 ML (syringe Tier 1 with cannula, disposable) BD LAB ECCENTRIC NON-STERILE SYRINGE 10 ML Tier 1 (syringe, disposable) BD LUER-LOK BULK SYRINGE SYRINGE 20 ML (syringe, Tier 1 disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

408 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD LUER-LOK SYRINGE SYRINGE 1 ML 20 GAUGE X 1", 10 ML 20 X 1 1/2", 10 ML 20 X 1", 10 ML 21 GAUGE X 1", 10 ML 21 X 1 1/2", 10 ML 22 X 1", 10 ML 23X 1 1/4 ", 3 ML 18 X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 GAUGE X 1 Tier 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/2 ", 3 ML 25 X 5/8", 3 ML 26 X 5/8", 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1" (syringe with needle,disposable) BD LUER-LOK SYRINGE SYRINGE 10 ML, 20 ML, 3 ML, 5 Tier 1 ML (syringe, disposable) BD LUER-LOK TIP CONTROL SYRING SYRINGE 10 ML Tier 1 (syringe, disposable) BD PRECISIONGLIDE SYRINGE 3 ML 22 GAUGE X 3/4" Tier 1 (syringe with needle,disposable) BD SAFETYGLIDE ALLERGIST TRAY SYRINGE 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2" (syringe with Tier 1 needle,disposable) BD SAFETYGLIDE SHIELDING REG SYRINGE 1 ML 25 Tier 1 GAUGE X 5/8" (syringe with needle,disposable) BD SAFETYGLIDE SHIELDING REG SYRINGE 3 ML 21 Tier 1 GAUGE X 1 1/2" (syringe,safety with needle) BD SAFETYGLIDE SYRINGE SYRINGE 10 ML 22 X 1 1/2", 3 ML 22 X 1 1/2", 3 ML 25 X 5/8" (syringe with Tier 1 needle,disposable) BD SAFETYGLIDE SYRINGE SYRINGE 5 ML 22 GAUGE Tier 1 X 1 1/2" (syringe,safety with needle) BD SAFETYGLIDE TB REG BEVEL SYRINGE 1 ML 27 X Tier 1 1/2" (syringe with needle,disposable) BD SAFETYGLIDE TUBERCULIN SYRINGE 1 ML 26 Tier 1 GAUGE X 3/8" (syringe with needle,disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

409 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD SAFETY-LOK DETACHABLE NEEDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X Tier 1 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2" (syringe,safety with needle) BD SAFETY-LOK TUBERCULIN SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2" (syringe,safety with Tier 1 needle) BD SAFETY-LOK WITH LUER-LOK SYRINGE 10 ML, 3 Tier 1 ML, 5 ML (syringe, disposable) BD SLIP TIP SYRINGE SYRINGE 1 ML 26 GAUGE X 5/8" Tier 1 (syringe with needle,disposable) BD SLIP TIP SYRINGE SYRINGE 10 ML, 3 ML (syringe, Tier 1 disposable) B-D SLIP TIP SYRINGE SYRINGE 20 ML (syringe, Tier 1 disposable) BD SPECIALTY USE NEEDLES NEEDLE 30 GAUGE X Tier 1 1/2" (needles, disposable) BD SYRINGE BULK STERILE PAK SYRINGE 10 ML, 60 Tier 1 ML (syringe, disposable) BD SYRINGE CATHETER TIP SYRINGE 60 ML (syringe, Tier 1 disposable) BD SYRINGE SYRINGE 1 ML, 60 ML (syringe, disposable) Tier 1 BD SYRINGE-DUAL CANNULA SYRINGE 10 ML 20 GAUGE AND 17 GAUGE (syringe with needle and cannula, Tier 1 disposable) BD TUBERCULIN SLIP-TIP SYRINGE 1 ML (syringe, Tier 1 disposable) BD TUBERCULIN SYRINGE SYRINGE 1 ML 21 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML Tier 1 27 X 1/2", 1/2 ML 27 X 1/2 " (syringe with needle,disposable) blunt needle, disposable needle 18 x 1 1/2 " Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

410 Coverage Prescription Drug Name Drug Tier Requirements and Limits CAREPOINT LUER SLIP SYRINGE SYRINGE 1 ML Tier 1 (syringe, disposable) DAVOL IRRIGATION SYRINGE SYRINGE (syringe, Tier 1 disposable irrigation) DAVOL PISTON IRRIGATION SYRINGE (syringe, Tier 1 disposable irrigation) DOVER BULB SYRINGE SYRINGE 60 ML (syringe, Tier 1 disposable irrigation) EASY GLIDE CATHETER TIP SYRING SYRINGE 60 ML Tier 1 (syringe, disposable) EASY GLIDE DENTAL IRRIG SYRING SYRINGE 10 ML Tier 1 (syringe, disposable) EASY GLIDE LUER LOCK SYRINGE SYRINGE 1 ML, 10 Tier 1 ML, 3 ML, 60 ML (syringe, disposable) EASY GLIDE LUER SLIP TB SYRING SYRINGE 1 ML Tier 1 (syringe, disposable) EASY TOUCH FLIPLOCK NEEDLE NEEDLE 30 X 1/2 " Tier 1 (needles, safety) EASY TOUCH FLIPLOCK SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2", 10 ML 18 GAUGE X 1 1/2", 10 ML 18 GAUGE X 1", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 18 GAUGE X 1 1/2", 3 ML 18 GAUGE X 1", 3 ML 19 GAUGE X 1 1/2", 3 ML 19 GAUGE X 1", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X Tier 1 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 18 GAUGE X 1", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1", 5 ML 25 GAUGE X 5/8" (syringe,safety with needle)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

411 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH FLURINGE FLIPLOCK SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8" (syringe,safety with Tier 1 needle) EASY TOUCH FLURINGE SHEATHLOCK SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8" (syringe,safety Tier 1 with needle) EASY TOUCH FLURINGE SYRINGE 1 ML 25 GAUGE X Tier 1 1", 1 ML 25 GAUGE X 5/8" (syringe with needle,disposable) EASY TOUCH HYPODERMIC NEEDLE NEEDLE 30 Tier 1 GAUGE X 1/2" (needles, disposable) EASY TOUCH LUER LOCK SYRINGE SYRINGE 1 ML, 10 Tier 1 ML, 3 ML, 5 ML (syringe, disposable) EASY TOUCH SHEATHLOCK SYRG-NDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X Tier 1 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1" (syringe,safety with needle) EASY TOUCH SHEATHLOCK SYRINGE SYRINGE 10 ML, Tier 1 3 ML (syringe, disposable) EASY TOUCH SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 Tier 1 ML 25 GAUGE X 1", 3 ML 25 X 5/8" (syringe with needle,disposable) EASY TOUCH TUBERCULIN FLIPLOCK SYRINGE 1 ML 26 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 Tier 1 GAUGE X 1/2" (syringe,safety with needle) EASY TOUCH TUBERCULIN SHEATHLK SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 5/8", 1 ML 27 Tier 1 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2" (syringe,safety with needle)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

412 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH UNI-SLIP SYRINGE 10 ML (syringe, Tier 1 disposable) ECLIPSE NEEDLE NEEDLE 23 GAUGE X 1", 25 X 5/8 ", Tier 3 27 GAUGE X 1/2" (needles, safety) ECLIPSE SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8" Tier 1 (syringe with needle,disposable) EXCEL SYRINGE SYRINGE 3 ML 23 X 1" (syringe with Tier 1 needle,disposable) EXEL HYPODERMIC NEEDLES NEEDLE 30 GAUGE X Tier 1 1/2" (needles, disposable) EXEL SYRINGE SYRINGE 10 ML, 30 ML, 50 ML (syringe, Tier 1 disposable) EXEL SYRINGE SYRINGE 3 ML 23 GAUGE X 1 1/2", 3 ML 25 X 5/8", 3 ML 27 GAUGE X 1 1/4" (syringe with Tier 1 needle,disposable) filter needles needle 19 x 1 ", 19 x 1 1/2 " Tier 3 INTERLINK SYRINGE AND CANNULA SYRINGE 15 X 10 Tier 1 ML (syringe with cannula, disposable) IRRIGATION SYRINGE SYRINGE (syringe, disposable Tier 1 irrigation) LUER LOCK SYRINGE SYRINGE 30 ML (syringe, Tier 1 disposable) LUER-LOK TIP SYRINGE 30 ML (syringe, disposable) Tier 1 MAGELLAN SAFETY NEEDLE NEEDLE 23 GAUGE X 5/8" Tier 3 (needles, safety) MAGELLAN SAFETY SYRINGE SYRINGE 1 ML 23 Tier 1 GAUGE X 1" (syringe,safety with needle) MAGELLAN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2" Tier 1 (syringe,safety with needle) MONOJECT 140CC PISTON SYRINGE SYRINGE Tier 1 (syringe, disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

413 Coverage Prescription Drug Name Drug Tier Requirements and Limits MONOJECT 35CC SYRINGE CATH TIP SYRINGE 35 ML Tier 1 (syringe, disposable) MONOJECT 3CC SYR 25GX1" SYRINGE 3 ML 25 GAUGE Tier 1 X 1" (syringe with needle,disposable) MONOJECT ALLERGY TRAY DETACH TRAY 1 ML 27 X Tier 1 1/2" (syringe with needle, disposable kit-tray) MONOJECT ALLERGY TRAY TRAY 0.5 ML 28 X 1/2", 1 Tier 1 ML 28 X 1/2" (syringe with needle, disposable kit-tray) MONOJECT CONTROL SYRINGE LUER SYRINGE 12 ML Tier 1 (syringe, disposable) MONOJECT DISPOSABLE SYRINGE SYRINGE 20 ML Tier 1 (syringe, disposable) MONOJECT ECCENTRIC NON-STERILE SYRINGE 12 Tier 1 ML, 35 ML (syringe, disposable) MONOJECT HYPODERMIC NEEDLES NEEDLE 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 5/8", 26 Tier 3 GAUGE X 1 1/2", 27 GAUGE X 1/2", 30 GAUGE X 3/4" (needles, disposable) MONOJECT LUER-LOCK TIP SYRINGE 12 ML, 3 ML Tier 1 (syringe, disposable) MONOJECT MAGELLAN SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X Tier 1 1" (syringe,safety with needle) MONOJECT PHARMACY TRAY LUER SYRINGE 12 ML, Tier 1 20 ML, 3 ML, 35 ML, 6 ML, 60 ML (syringe, disposable) MONOJECT PHARMACY TRAY REG TIP SYRINGE 1 ML Tier 1 (syringe, disposable) MONOJECT REG TIP NON-STERILE SYRINGE 12 ML, 20 Tier 1 ML, 3 ML, 6 ML (syringe, disposable) MONOJECT REGULAR LUER SYRINGE 12 ML, 35 ML, 6 Tier 1 ML (syringe, disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

414 Coverage Prescription Drug Name Drug Tier Requirements and Limits MONOJECT SAFETY LUER LOCK TIP SYRINGE 3 ML Tier 1 (syringe, disposable) MONOJECT SAFETY SYRINGES SYRINGE , 6 ML Tier 1 (syringe with needle,disposable) MONOJECT SAFETY SYRINGES SYRINGE 12 ML Tier 1 (syringe, disposable) MONOJECT SAFETY SYRINGES SYRINGE 12 ML 20 X 1 1/2", 12 ML 21X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 Tier 1 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8" (syringe,safety with needle) MONOJECT SMARTIP CANNULA SYRINGE 12 ML, 3 ML, Tier 1 6 ML (syringe with cannula, disposable) MONOJECT SYRINGE ECCENTRI LUER SYRINGE 60 ML Tier 1 (syringe, disposable) MONOJECT SYRINGE LUER LOK SYRINGE 35 ML, 6 ML, Tier 1 60 ML (syringe, disposable) MONOJECT SYRINGE REGULAR LUER SYRINGE 60 ML Tier 1 (syringe, disposable) MONOJECT SYRINGE SYRINGE 12 ML 18 GAUGE X 1", 12 ML 20 X 1 1/2", 12 ML 21 GAUGE X 1 1/2", 12 ML 21 GAUGE X 1", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 20 X 3/4", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 Tier 1 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/4", 3 ML 25 X 5/8", 3 ML 27 GAUGE X 1 1/4", 6 ML 20 X 1 1/2", 6 ML 21 X 1 1/2", 6 ML 21 X 1", 6 ML 22 X 1 1/2" (syringe with needle,disposable) MONOJECT SYRINGE SYRINGE 140 ML, 3 ML, 6 ML Tier 1 (syringe, disposable) MONOJECT SYRINGE TOOMEY TYPE SYRINGE 60 ML Tier 1 (syringe, disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

415 Coverage Prescription Drug Name Drug Tier Requirements and Limits MONOJECT TB LUER LOK SYRINGE 1 ML (syringe, Tier 1 disposable) MONOJECT TB REGULAR LUER TIP SYRINGE 1 ML Tier 1 (syringe, disposable) MONOJECT TB SAFETY SYRINGE SYRINGE 1 ML 25 Tier 1 GAUGE X 5/8" (syringe with needle,disposable) MONOJECT TB SAFETY SYRINGE SYRINGE 1 ML 28 Tier 1 GAUGE X 1/2" (syringe,safety with needle) MONOJECT TB SYRINGE 1 ML 28 GAUGE X 1/2" (syringe Tier 1 with needle,disposable) MONOJECT TUBERCULIN SYRINGE SYRINGE 1 ML Tier 1 (syringe, disposable) MONOJECT TUBERCULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2", 1 Tier 1 ML 28 GAUGE X 1/2", 1/2 ML 28 X 1/2" (syringe with needle,disposable) NORM-JECT SYRINGE 10 ML, 20 ML (syringe, disposable) Tier 1 NORM-JECT TUBERKULIN SYRINGE 1 ML (syringe, Tier 1 disposable) POLY HUB NEEDLE NEEDLE 30 GAUGE X 1/2" (needles, Tier 1 disposable) SAFESNAP SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 GAUGE X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML Tier 1 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 GAUGE X 1" (syringe, needle, safety, self-cont disposal unit)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

416 Coverage Prescription Drug Name Drug Tier Requirements and Limits SAFESNAP SYRINGE SYRINGE 10 ML, 3 ML, 5 ML Tier 1 (syringe, safety, self-cont disposal unit) safety needles needle 18 gauge x 1 1/2" Tier 3 SURGUARD2 SAFETY NEEDLE 18 GAUGE X 1 1/2", 18 GAUGE X 1", 19 GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X 1 1/2", 20 GAUGE X 1", 21 GAUGE X 1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 Tier 3 GAUGE X 1 1/2", 23 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 X 5/8 ", 26 GAUGE X 1/2", 27 GAUGE X 1/2" (needles, safety) SURGUARD2 SAFETY NEEDLE 30 GAUGE X 1 1/2" Tier 1 (needles, safety) SURGUARD2 SAFETY SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X Tier 1 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2" (syringe,safety with needle) syringe (disposable) syringe 20 ml, 3 ml, 30 ml, 5 ml, 60 ml Tier 1 SYRINGE 3CC/20GX1" SYRINGE 3 ML 20 GAUGE X 1" Tier 1 (syringe with needle,disposable) SYRINGE 3CC/21GX1" SYRINGE 3 ML 21 GAUGE X 1" Tier 1 (syringe with needle,disposable) SYRINGE 3CC/21GX1-1/2" SYRINGE 3 ML 21 GAUGE X 1 Tier 1 1/2" (syringe with needle,disposable) SYRINGE 3CC/22GX1" SYRINGE 3 ML 22 GAUGE X 1" Tier 1 (syringe with needle,disposable) SYRINGE 3CC/22GX3/4" SYRINGE 3 ML 22 GAUGE X Tier 1 3/4" (syringe with needle,disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

417 Coverage Prescription Drug Name Drug Tier Requirements and Limits SYRINGE 3CC/25GX1" SYRINGE 3 ML 25 GAUGE X 1" Tier 1 (syringe with needle,disposable) syringe with needle syringe 1 ml 25 gauge x 1", 3 ml 20 gauge x 1 1/2", 3 ml 21 gauge x 1 1/2", 3 ml 22 x 1 1/2", 3 Tier 1 ml 23 gauge x 1 1/2" syringe with needle, safety syringe 1 ml 25 gauge x 5/8", 3 Tier 1 ml 22 gauge x 1" SYRINGE WITHOUT NEEDLE SYRINGE (syringe, Tier 1 disposable) TERUMO ALLERGY SYRINGE SYRINGE 1 ML 27 X 1/2" Tier 1 (syringe with needle,disposable) TERUMO HYPODERMIC NEEDLE/SYRIN SYRINGE 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML Tier 1 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1" (syringe with needle,disposable) TERUMO SYRINGE SYRINGE 3 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8" (syringe Tier 1 with needle,disposable) TERUMO SYRINGE SYRINGE 30 ML (syringe, disposable) Tier 1 TOOMEY SYRINGE SYRINGE 70 ML (syringe, disposable Tier 1 irrigation) TUBERCULIN SYRINGE SYRINGE 1 ML (syringe, Tier 1 disposable) TUBERCULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 1 ML 27 X 1/2" (syringe with Tier 1 needle,disposable) tuberculin-allergy syringes syringe 1 ml 26 gauge x 3/8" Tier 1 ULTICARE SAFETY SYRINGE SYRINGE 3 ML (syringe, Tier 1 safety) ULTICARE SAFETY SYRINGE SYRINGE 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", Tier 1 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8" (syringe,safety with needle) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

418 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTICARE SYRINGE 1 ML 25 GAUGE X 5/8" (syringe with Tier 1 needle,disposable) ULTICARE SYRINGE 1.5 ML 22 GAUGE X 1 1/2" (syringe, Tier 1 needle, safety, self-cont disposal unit) ULTICARE TB SAFETY SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 27 GAUGE X 5/8", 1 ML 28 GAUGE X Tier 1 1/2" (syringe,safety with needle) VANISHPOINT SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 Tier 1 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2" (syringe with needle,disposable) VANISHPOINT SYRINGE SYRINGE 10 ML 21 GAUGE X 1 Tier 1 1/2", 5 ML 21 GAUGE X 1 1/2" (syringe,safety with needle) VANISHPOINT TUBERCULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 X 1/2" (syringe with Tier 1 needle,disposable) Medical Supplies And Dme - Parenteral Therapy Supplies - Medical Supplies And Durable Medical Equipment ACCU-CHEK LINKASSIST INS DEV (subcutaneous Tier 3 infusion pump accessory) ACCU-CHEK SPIRIT ADAPTER (subcutaneous infusion Tier 3 pump accessory) ACCU-CHEK SPIRIT CARTRIDGE SYS (subcutaneous Tier 3 infusion pump accessory) ACCU-CHEK SPIRIT CLIP CASE (subcutaneous infusion Tier 3 pump accessory) INSET 30 TUBING 23" BLUE (subcutaneous infusion pump Tier 3 accessory)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

419 Coverage Prescription Drug Name Drug Tier Requirements and Limits INSET 30 TUBING 23" GREY (subcutaneous infusion pump Tier 3 accessory) INSET 30 TUBING 23" PINK (subcutaneous infusion pump Tier 3 accessory) INSET 30 TUBING 43" GREY (subcutaneous infusion pump Tier 3 accessory) INTERLINK LEVER LOCK CANNULA (syringe accessory) Tier 3 I-PORT (injection ports) Tier 3 I-PORT ADVANCE 6 MM INJEC PORT (injection ports) Tier 3 I-PORT ADVANCE 9 MM INJEC PORT (injection ports) Tier 3 KENDALL DISINFECTANT CAP (alcohol swab cap) Tier 3 MONOJECT LUER ADAPTER INTRAVENOUS ADMIX Tier 3 ACCESSORY (intravenous equipment) myelogram tray tray Tier 3 PARADIGM INFUSION SET (subcutaneous infusion pump Tier 3 accessory) PARADIGM SILHOUETTE INFUS SET (subcutaneous Tier 3 infusion pump accessory) PHASEAL ASSEMBLY FIXTURE DEVICE (assembly Tier 3 sys,vial to transfer device,closed system) PHASEAL CONNECTOR LUER LOCK (connector luer lock, Tier 3 closed system) PHASEAL INFUSION ADAPTER (infusion adapter, closed Tier 3 system) PHASEAL INFUSION CLAMP (clamp, IV tubing) Tier 3 PHASEAL INJECTOR LUER (needle injector, luer, closed Tier 3 system) PHASEAL INJECTOR LUER LOCK (needle injector, luer Tier 3 lock, closed system) PHASEAL PROTECTOR DEVICE 13 MM, 20 MM, 28 MM Tier 3 (transfer device, closed system)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

420 Coverage Prescription Drug Name Drug Tier Requirements and Limits POLYFIN QR INFUSION SET (subcutaneous infusion Tier 3 pump accessory) POLYFIN QR/WINGS INFUSION SET (subcutaneous Tier 3 infusion pump accessory) SILHOUETTE (subcutaneous infusion pump accessory) Tier 3 SURE-T INFUSION SET (subcutaneous infusion pump Tier 3 accessory) VARITHENA ADMINISTRATION PACK (transfer sets) Tier 3 Medical Supplies And Dme - Peak Flow Meters - Medical Supplies And Durable Medical Equipment AEROGEAR ACTION ASTHMA KIT KIT (peak flow meter) DME AIRZONE PEAK FLOW METER DEVICE (peak flow meter) DME ASTHMA CHECK METER DEVICE (peak flow meter) DME ASTHMAPACK CHILDREN'S KIT (peak flow meter) DME IN-CHECK NASAL WITH MASK DEVICE (peak flow meter) DME IN-CHECK ORAL FLOW METER DEVICE (peak flow DME meter) MICROLIFE PEAK FLOW METER DEVICE (peak flow DME meter) MINI WRIGHT PEAK FLOW METER DEVICE (peak flow DME meter) MINI-WRIGHT PEAK FLOW METER DEVICE (peak flow DME meter) PEAK AIR PEAK FLOW METER DEVICE (peak flow meter) DME PERSONAL BEST FULL RANGE DEVICE (peak flow DME meter) PERSONAL BEST LOW RANGE DEVICE (peak flow DME meter) PIKO 1 DEVICE (peak flow meter) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

421 Coverage Prescription Drug Name Drug Tier Requirements and Limits POCKET PEAK FLOW METER DEVICE (peak flow meter) DME TRUZONE PEAK FLOW METER DEVICE (peak flow DME meter) Medical Supplies And Dme - Respiratory Therapy Supplies - Medical Supplies And Durable Medical Equipment ACE AEROSOL CLOUD ENHANCER SPACER (inhaler, Tier 3 assist devices) AEROBIKA OSCILLATING PEP SYSTM DEVICE (mucus Tier 3 clearing device) AEROCHAMBER MINI SPACER (inhaler, assist devices) Tier 3 AEROCHAMBER MV SPACER (inhaler, assist devices) Tier 3 AEROCHAMBER PLUS FLOW-VU SPACER (inhaler, Tier 3 assist devices) AEROCHAMBER PLUS FLOW-VU,L MSK SPACER Tier 3 (inhaler, assist device with large mask) AEROCHAMBER PLUS FLOW-VU,M MSK SPACER Tier 3 (inhaler, assist device with medium mask) AEROCHAMBER PLUS FLOW-VU,S MSK SPACER Tier 3 (inhaler, assist device with small mask) AEROCHAMBER PLUS Z STAT LG MSK SPACER Tier 3 (inhaler, assist device with large mask) AEROCHAMBER PLUS Z STAT MD MSK SPACER Tier 3 (inhaler, assist device with medium mask) AEROCHAMBER PLUS Z STAT SM MSK SPACER Tier 3 (inhaler, assist device with small mask) AEROCHAMBER PLUS Z STAT SPACER (inhaler, assist Tier 3 devices) AEROCHAMBER WITH FLOWSIGNAL SPACER (inhaler, Tier 3 assist devices)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

422 Coverage Prescription Drug Name Drug Tier Requirements and Limits AEROCHAMBER Z-STAT PLUS-FLW SG SPACER Tier 3 (inhaler, assist devices) AERONEB GO (nebulizer accessories) Tier 3 AEROTRACH PLUS SPACER (inhaler, assist devices) Tier 3 AEROVENT PLUS SPACER (inhaler, assist devices) Tier 3 ALL FLOW 1000 KIT (nebulizer accessories) Tier 3 ALL FLOW 1000 PFT FILTER (nebulizer accessories) Tier 3 ALL FLOW 3000 KIT (nebulizer accessories) Tier 3 ALL FLOW 3000 PFT FILTER (nebulizer accessories) Tier 3 ALL FLOW 4000 KIT (nebulizer accessories) Tier 3 ALL FLOW 4000 PFT FILTER (nebulizer accessories) Tier 3 ALL FLOW 5000 KIT (nebulizer accessories) Tier 3 ALL FLOW 5000 PFT FILTER (nebulizer accessories) Tier 3 ALL FLOW 6000 PFT FILTER (nebulizer accessories) Tier 3 BREATHERITE MDI SPACER SPACER (inhaler, assist Tier 3 devices) BREATHERITE SPACER-MASK, NEO. SPACER (inhaler, Tier 3 assist device with small mask) BREATHERITE SPACER-MASK,ADULT SPACER (inhaler, Tier 3 assist device with large mask) BREATHERITE SPACER-MASK,CHILD SPACER (inhaler, Tier 3 assist device with medium mask) BREATHERITE SPACER-MASK,INFANT SPACER Tier 3 (inhaler, assist device with small mask) BREATHERITE SPACER-MASK,S.CHLD SPACER Tier 3 (inhaler, assist device with small mask) BREATHERITE VALVED MDI CHAMBER SPACER Tier 3 (inhaler, assist devices) BREATHERITE VALVED MDI SPACER SPACER (inhaler, Tier 3 assist devices)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

423 Coverage Prescription Drug Name Drug Tier Requirements and Limits CLEVER CHOICE CHAMBER-LRG MASK SPACER Tier 3 (inhaler, assist device with large mask) CLEVER CHOICE CHAMBER-MED MASK SPACER Tier 3 (inhaler, assist device with medium mask) CLEVER CHOICE CHAMBER-SM MASK SPACER Tier 3 (inhaler, assist device with small mask) CLEVER CHOICE NEBULIZER DEVICE (nebulizer) Tier 3 CLEVER CHOICE WHISPER AIRE PED DEVICE Tier 3 (nebulizer) COMPACT SPACE CHAMBER PLUS SPACER (inhaler, Tier 3 assist devices) COMPACT SPACE CHAMBER SPACER (inhaler, assist Tier 3 devices) COMPACT SPACE CHAMBER-LRG MASK SPACER Tier 3 (inhaler, assist device with large mask) COMPACT SPACE CHAMBER-MED MASK SPACER Tier 3 (inhaler, assist device with medium mask) COMPACT SPACE CHAMBER-SM MASK SPACER Tier 3 (inhaler, assist device with small mask) COMP-AIR NEBULIZER COMPRESSOR DEVICE Tier 3 (nebulizer) DEVILBISS PULMO-AIDE COMPRESSR DEVICE Tier 3 (compressor, for nebulizer) DEVILBISS PULMOMATE COMPRESSOR DEVICE Tier 3 (compressor, for nebulizer) DEVILBISS PULMONEB LT COMP-NEB DEVICE Tier 3 (nebulizer) DEVILBISS TRAVELER COMPRESSOR DEVICE Tier 3 (nebulizer) EASIVENT HOLDING CHAMBER SPACER (inhaler, assist Tier 3 devices)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

424 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASIVENT MASK LARGE DEVICE (inhaler, assist devices, Tier 3 accessories) EASIVENT MASK MEDIUM DEVICE (inhaler, assist Tier 3 devices, accessories) EASIVENT MASK SMALL DEVICE (inhaler, assist devices, Tier 3 accessories) EBASE CONTROLLER DEVICE (compressor, for Tier 3 nebulizer) ERAPID NEBULIZER HANDSET (nebulizer accessories) Tier 3 FILTER PAD (nebulizer accessories) Tier 3 FLEXICHAMBER SPACER (inhaler, assist devices) Tier 3 FLEXICHAMBER-LG CHILD MASK DEVICE (inhaler, assist Tier 3 devices, accessories) FLEXICHAMBER-SM ADULT MASK DEVICE (inhaler, Tier 3 assist devices, accessories) FLEXICHAMBER-SM CHILD MASK DEVICE (inhaler, Tier 3 assist devices, accessories) HOME NEBULIZER PLUS SIDESTREAM DEVICE Tier 3 (nebulizer) INNOSPIRE DELUXE DEVICE (nebulizer) Tier 3 INNOSPIRE ELEGANCE DEVICE (nebulizer) Tier 3 INNOSPIRE ESSENCE DEVICE (nebulizer) Tier 3 INNOSPIRE MINI DEVICE (nebulizer) Tier 3 INNOSPIRE REPLACEMENT FILTER (nebulizer Tier 3 accessories) INSPIRACHAMBER SPACER (inhaler, assist devices) Tier 3 INSPIRACHAMBER WITH MASK-LARGE SPACER Tier 3 (inhaler, assist device with large mask) INSPIRACHAMBER WITH MASK-MED SPACER (inhaler, Tier 3 assist device with medium mask)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

425 Coverage Prescription Drug Name Drug Tier Requirements and Limits INSPIRACHAMBER WITH MASK-SMALL SPACER Tier 3 (inhaler, assist device with small mask) INSPIRATION ELITE FILTER (nebulizer accessories) Tier 3 LITE TOUCH-MEDIUM MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LITEAIRE MDI CHAMBER SPACER (inhaler, assist Tier 3 devices) LITETOUCH-LARGE MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LITETOUCH-SMALL MASK DEVICE (inhaler, assist Tier 3 devices, accessories) MICROCHAMBER SPACER (inhaler, assist devices) Tier 3 MICROSPACER SPACER (inhaler, assist devices) Tier 3 MISTASSIST DEVICE (spirometers and accessories) Tier 3 MISTASSIST KIT DEVICE (spirometer with drug delivery Tier 3 adapters) MOUTHPIECE REUSABLE MW (nebulizer accessories) Tier 3 MY MDI PORTABLE NEBULISER DEVICE (nebulizer) Tier 3 NOSE CLIP (nebulizer accessories) Tier 3 OMBRA COMPRESSOR SYSTEM DEVICE (nebulizer) Tier 3 OPTICHAMBER ADULT MASK-LARGE DEVICE (inhaler, Tier 3 assist devices, accessories) OPTICHAMBER DIAMOND LG MASK SPACER (inhaler, Tier 3 assist device with large mask) OPTICHAMBER DIAMOND VHC SPACER (inhaler, assist Tier 3 devices) OPTICHAMBER DIAMOND-MED MSK SPACER (inhaler, Tier 3 assist device with medium mask) OPTICHAMBER DIAMOND-SML MASK SPACER (inhaler, Tier 3 assist device with small mask) PARI BABY CONV KIT - SIZE 1 KIT (nebulizer accessories) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

426 Coverage Prescription Drug Name Drug Tier Requirements and Limits PARI BABY CONV KIT - SIZE 2 KIT (nebulizer accessories) Tier 3 PARI BABY CONV KIT - SIZE 3 KIT (nebulizer accessories) Tier 3 PARI BABY CONVERSION PACK 1 (nebulizer Tier 3 accessories) PARI BABY CONVERSION PACK 2 (nebulizer Tier 3 accessories) PARI LC FILTER WITH VALVE SET (nebulizer Tier 3 accessories) PARI LC MASK SET (nebulizer accessories) Tier 3 PARI SINUS AEROSOL SYSTEM DEVICE (nebulizer) Tier 3 PARI TREK S COMBO PACK DEVICE (nebulizer) Tier 3 PARI TREK S COMPACT COMPRESSOR DEVICE Tier 3 (nebulizer) PARI TREK S PORTABLE PWR KIT (nebulizer Tier 3 accessories) PEDIATRIC DINOSAUR NEBULIZER DEVICE (nebulizer) Tier 3 PEDIATRIC DOG NEBULIZER DEVICE (nebulizer) Tier 3 PEDIATRIC FROG NEBULIZER DEVICE (nebulizer) Tier 3 PFLEX INSPIRATORY TRAINER DEVICE (spirometers Tier 3 and accessories) PILLOW MASK CHILD (nebulizer accessories) Tier 3 POCKET CHAMBER SPACER (inhaler, assist devices) Tier 3 PORTABLE NEBULIZER SYSTEM DEVICE (nebulizer) Tier 3 PRIMEAIRE SPACER (inhaler, assist devices) Tier 3 PRO COMFORT SPACER-ADULT MASK SPACER Tier 3 (inhaler, assist device with large mask) PRO COMFORT SPACER-CHILD MASK SPACER (inhaler, Tier 3 assist device with small mask) PROCARE COMPRESSOR NEBULIZER DEVICE Tier 3 (nebulizer)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

427 Coverage Prescription Drug Name Drug Tier Requirements and Limits PROCARE PEDIATRIC NEBULIZER DEVICE (nebulizer) Tier 3 PROCARE SPACER WITH ADULT MASK SPACER Tier 3 (inhaler, assist device with large mask) PROCARE SPACER WITH CHILD MASK SPACER Tier 3 (inhaler, assist device with medium mask) PROCHAMBER SPACER (inhaler, assist devices) Tier 3 PRONEB ULTRA FILTER ASSEMBLY (nebulizer Tier 3 accessories) PRONEB ULTRA II DEVICE (nebulizer) Tier 3 PRONEB ULTRA II FILTER ASSEM (nebulizer Tier 3 accessories) PROVENT NASAL DEVICE (nasal exhalation resistance Tier 3 device) PROVENT STARTER NASAL DEVICE (nasal exhalation Tier 3 resistance device) PULMO-AIDE COMPRESSOR DEVICE (compressor, for Tier 3 nebulizer) PULMONEB LT COMPRESSOR NEBUL DEVICE Tier 3 (nebulizer) QUAKE VIBRATORY PEP DEVICE (mucus clearing Tier 3 device) REUSABLE NEBULIZER KIT KIT (nebulizer accessories) Tier 3 RITEFLO AEROCHAMBER SPACER (inhaler, assist Tier 3 devices) RUBBER MOUTHPIECE (nebulizer accessories) Tier 3 SAMI THE SEAL DEVICE (nebulizer) Tier 3 SAMI THE SEAL MASK (nebulizer accessories) Tier 3 SIDESTREAM MASK (nebulizer accessories) Tier 3 SILICONE MASK (nebulizer accessories) Tier 3 SILICONE MASK - INFANT DEVICE (inhaler, assist Tier 3 devices, accessories) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

428 Coverage Prescription Drug Name Drug Tier Requirements and Limits SINUSTAR AEROSOL DEVICE (nebulizer) Tier 3 SMARTMASK KIDS (nebulizer accessories) Tier 3 SOOTHENEB COMPRESSOR NEBULIZER DEVICE Tier 3 (nebulizer) SPACE CHAMBER PLUS SPACER (inhaler, assist Tier 3 devices) SUNRISE COMPRESSOR-NEBULIZER DEVICE Tier 3 (compressor, for nebulizer) THRESHOLD IMT TRAINER DEVICE (spirometers and Tier 3 accessories) THRESHOLD PEP DEVICE DEVICE (spirometers and Tier 3 accessories) VIOS AEROSOL DELIVERY SYSTEM DEVICE (nebulizer) Tier 3 VORTEX HOLDING CHAMBER CHILD SPACER (inhaler, Tier 3 assist device with medium mask) VORTEX HOLDING CHAMBER SPACER (inhaler, assist Tier 3 devices) VORTEX HOLDING CHAMBER TODDLER SPACER Tier 3 (inhaler, assist device with small mask) VORTEX VHC FROG MASK-CHILD SPACER (inhaler, Tier 3 assist device with medium mask) VORTEX VHC LADYBUG MASK-TODDLR SPACER Tier 3 (inhaler, assist device with small mask) WILLIS THE WHALE COMPRESSR NEB DEVICE Tier 3 (nebulizer) Medical Supplies And Dme - Scar Treatments - Medical Supplies And Durable Medical Equipment CELACYN TOPICAL GEL WITH PUMP (emollient Tier 3 combination no.60)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

429 Coverage Prescription Drug Name Drug Tier Requirements and Limits CELLPAD TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) CICATRACE PAD TOPICAL PAD 4.7 X 5.7 " (gel-matrix Tier 3 pad dressing, silicone) DERM-SILK TOPICAL PAD 2.5 X 2 " (gel-matrix pad Tier 3 dressing, silicone) KELOTOP TOPICAL PAD 4.7 X 5.7 " (gel-matrix pad Tier 3 dressing, silicone) NUVAKAAN TOPICAL KIT 2.5-2.5 % (lidocaine) Tier 1 SCARCARE TOPICAL KIT 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) SCARCINPAD TOPICAL PAD 1.57 X 5.12 " (gel-matrix pad Tier 3 dressing, silicone) SCARSILK TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) SILIVEX TOPICAL PAD 2 X 5.5 " (gel-matrix pad dressing, Tier 3 silicone) SIL-K TOPICAL PAD 2 X 5.5 " (gel-matrix pad dressing, Tier 3 silicone) SILTREX TOPICAL PAD 2 X 5.5 " (gel-matrix pad dressing, Tier 3 silicone) ZILACAINE PATCH TOPICAL COMBO PACK 5 % Tier 3 (lidocaine) Medical Supplies And Dme - Subcutaneous Administration Supply - Medical Supplies And Durable Medical Equipment ACCU-CHEK RAPID-D LINK 70 CM (subcutaneous Tier 3 administration set) ACCU-CHEK RAPID-D LINK INFUSION SET 10 X 20 MM- Tier 3 CM (subcutaneous administration set) INSUFLON INFUSION SET 25 X 18 MM (subcutaneous Tier 3 administration set) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

430 Coverage Prescription Drug Name Drug Tier Requirements and Limits Medical Supplies And Dme - Subcutaneous Insulin Delivery Devices - Medical Supplies And Durable Medical Equipment V-GO 20 DEVICE (subcutaneous insulin deliv. device, 20 Tier 3 unit, disp.) V-GO 30 DEVICE (subcutaneous insulin deliv. device, 30 Tier 3 unit. disp.) V-GO 40 DEVICE (subcutaneous insulin deliv. device, 40 Tier 3 unit, disp.) Medical Supplies And Dme - Subcutaneous Insulin Pump - Medical Supplies And Durable Medical Equipment ANIMAS VIBE (subcu insulin pump, continuous glucose Tier 3 mon. system) MINIMED 530G INSULIN PUMP (subcutaneous insulin Tier 3 pump) MINIMED 630G INSULIN PUMP (subcutaneous insulin Tier 3 pump) MINIMED 670G INSULIN PUMP (subcutaneous insulin Tier 3 pump) OMNIPOD INSULIN MANAGEMENT (subcutaneous insulin Tier 3 pump) ONETOUCH PING INSULIN PUMP (subcutaneous insulin Tier 3 pump) REVEL PEDIATRIC PROGRAM PUMP (subcutaneous Tier 3 insulin pump) REVEL PROGRAMMABLE PUMP (subcutaneous insulin Tier 3 pump) T:FLEX INSULIN DELIVERY PUMP (subcutaneous insulin Tier 3 pump) T:SLIM G4 INSULIN PUMP (subcutaneous insulin pump) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

431 Coverage Prescription Drug Name Drug Tier Requirements and Limits T:SLIM INSULIN DELIVERY SYSTEM (subcutaneous Tier 3 insulin pump) T:SLIM X2 BASAL-IQ INSULIN PMP (subcutaneous insulin Tier 3 pump) T:SLIM X2 INSULIN PUMP (subcutaneous insulin pump) Tier 3 Medical Supplies And Dme - Urinary Catheters And Related Devices - Medical Supplies And Durable Medical Equipment ADVANCE PLUS INTERMITTENT 10 FR, 10-16 FR-", 12 FR, 12-16 FR-", 14-16 FR-", 16-16 FR-", 18-16 FR-", 6-16 Tier 3 FR-", 8-16 FR-" (catheter) ADVANCE PLUS INTERMITTENT COMBO PACK 6 FR, 8- Tier 3 14 FR-" (urinary bag) APOGEE HC INTERMIT CATHETER 12-16 FR-", 14-16 Tier 3 FR-", 16-16 FR-" (catheter) APOGEE IC INTERMIT CATHETER 14-6 FR-" (catheter) Tier 3 DOVER COATED LATEX FOLEY COMBO PACK (urinary Tier 3 bag) DOVER FOLEY CATHETER 24 FR (catheter) Tier 3 DOVER LATEX FOLEY CATHETER 16 FR, 28 FR Tier 3 (catheter) DOVER RED RUBBER ROBINSON CATH 8 FR (catheter) Tier 3 DOVER UNIVERSAL TRAY (catheterization tray) Tier 3 FEMALE CATHETER 14 FR (catheter) Tier 3 KENGUARD FOLEY CATHETER 18-16 FR-" (catheter) Tier 3 KENGUARD FOLEY CATHETER TRAY (catheterization Tier 3 tray) LOFRIC 12-16 FR-", 14-16 FR-" (catheter) Tier 3 MAGIC3 INTERMITTENT CATHETER 12-16 FR-" Tier 3 (catheter) ROBINSON CLEAR VINYL CATHETER 16 FR (catheter) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

432 Coverage Prescription Drug Name Drug Tier Requirements and Limits SELF-CATHETER, FEMALE 14 FR (catheter) Tier 3 SILASTIC FOLEY CATHETER 20 FR (catheter) Tier 3 SPEEDICATH (FEMALE) 16 FR (catheter) Tier 3 TOUCH-TROL 10 FR (catheter) Tier 3 Medical Supplies And Dme - Urine Ketone Tests - Medical Supplies And Durable Medical Equipment KETONE CARE STRIP (urine acetone test,strips) DME Medical Supplies And Dme- Blood Collection Sets With Local Anesthetics - Medical Supplies And Durable Medical Equipment CADIRA COMPLIANT BLOOD STAT KIT 21 GAUGE X 3/4" Tier 3 -2.5 %-2.5 % (blood collection set) LIDO BDK KIT 21 GAUGE X 1"- 2.5 %-2.5 % (blood Tier 3 collection set) Medical Supplies And Dme-Eustachian Tube/Middle Ear Ventilator Devices - Medical Supplies And Durable Medical Equipment EAR POPPER INFLATION DEVICE NASAL DEVICE Tier 3 (middle ear inflation device) Medical Supplies And Dme-Glucose Monitoring And Insulin Admin Supplies - Medical Supplies And Durable Medical Equipment ACCU-CHEK COMBO SYSTEM KIT (subcutaneous insulin Tier 3 pump) AUTOSOFT 30 INFUSION SET (infusion set for insulin Tier 3 pump) AUTOSOFT 90 INFUSION SET (infusion set for insulin Tier 3 pump)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

433 Coverage Prescription Drug Name Drug Tier Requirements and Limits AUTOSOFT XC INFUSION SET 23" INFUSION SET Tier 3 (infusion set for insulin pump) AUTOSOFT XC INFUSION SET 43" INFUSION SET Tier 3 (infusion set for insulin pump) CLEO 90 INFUSION SET 24" INFUSION SET (infusion set Tier 3 for insulin pump) CLEO 90 INFUSION SET 31" INFUSION SET (infusion set Tier 3 for insulin pump) COMFORT INFUSION SET 23" INFUSION SET (infusion Tier 3 set for insulin pump) COMFORT INFUSION SET 31" INFUSION SET (infusion Tier 3 set for insulin pump) COMFORT INFUSION SET 32" INFUSION SET (infusion Tier 3 set for insulin pump) COMFORT INFUSION SET 43" INFUSION SET (infusion Tier 3 set for insulin pump) COMFORT SHORT INFUSION SET 31" INFUSION SET Tier 3 (infusion set for insulin pump) COMFORT SHORT INSULIN PUMP 23" INFUSION SET Tier 3 (infusion set for insulin pump) COMFORT SHORT INSULIN PUMP 32" INFUSION SET Tier 3 (infusion set for insulin pump) COMFORT SHORT INSULIN PUMP 43" INFUSION SET Tier 3 (infusion set for insulin pump) CONTACT DETACH INFUS SET 23" INFUSION SET Tier 3 (infusion set for insulin pump) CONTACT DETACH INFUS SET 32" INFUSION SET Tier 3 (infusion set for insulin pump) CONTACT DETACH INFUS SET 43" INFUSION SET Tier 3 (infusion set for insulin pump) INSET 30 INFUSION SET 23" INFUSION SET (infusion set Tier 3 for insulin pump)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

434 Coverage Prescription Drug Name Drug Tier Requirements and Limits INSET INFUSION SET 23" INFUSION SET (infusion set for Tier 3 insulin pump) MINIMED INFUSION SET INFUSION SET (infusion set for Tier 3 insulin pump) MINIMED INFUSION SET-MMT 390 INFUSION SET Tier 3 (infusion set for insulin pump) MINIMED INFUSION SET-MMT 391 INFUSION SET Tier 3 (infusion set for insulin pump) MINIMED INFUSION SET-MMT 392 INFUSION SET Tier 3 (infusion set for insulin pump) MINIMED INFUSION SET-MMT 393 INFUSION SET Tier 3 (infusion set for insulin pump) MIO INFUSION SET INFUSION SET (infusion set for Tier 3 insulin pump) QUICK-SET PARADIGM INFUSION SET (infusion set for Tier 3 insulin pump) SILHOUETTE 23"-FULL SET INFUSION SET (infusion set Tier 3 for insulin pump) SILHOUETTE 43"-FULL SET INFUSION SET (infusion set Tier 3 for insulin pump) SOF-SET CANNULA 24" TUBING INFUSION SET (infusion Tier 3 set for insulin pump) SOF-SET MICRO 24" POLYFIN TUB INFUSION SET Tier 3 (infusion set for insulin pump) SOF-SET MICRO 42" POLYFIN TUB INFUSION SET Tier 3 (infusion set for insulin pump) SOF-SET QR 42" TUBING INFUSION SET (infusion set for Tier 3 insulin pump) SURE-T PARADIGM INFUSION SET (infusion set for Tier 3 insulin pump) T:30 INFUSION SET INFUSION SET (infusion set for Tier 3 insulin pump)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

435 Coverage Prescription Drug Name Drug Tier Requirements and Limits T:90 INFUSION SET 23" INFUSION SET (infusion set for Tier 3 insulin pump) T:90 INFUSION SET 43" INFUSION SET (infusion set for Tier 3 insulin pump) TRUSTEEL INFUSION SET 23" INFUSION SET (infusion Tier 3 set for insulin pump) TRUSTEEL INFUSION SET 32" INFUSION SET (infusion Tier 3 set for insulin pump) VARISOFT INFUSION SET 23" INFUSION SET (infusion Tier 3 set for insulin pump) VARISOFT INFUSION SET 32" INFUSION SET (infusion Tier 3 set for insulin pump) VARISOFT INFUSION SET 43" INFUSION SET (infusion Tier 3 set for insulin pump) Medical Supply, Fdb Superset Medical Supply, Fdb Superset 2-IN-1 LANCET DEVICE 30 GAUGE (lancets) DME ACCU-CHEK AVIVA CONTROL SOLN SOLUTION (blood- DME glucose calibration control, high) ACCU-CHEK COMBO SYSTEM KIT (subcutaneous insulin Tier 3 pump) ACCU-CHEK COMPACT PLUS CARE KIT (blood-glucose DME meter, drum-type) ACCU-CHEK COMPACT PLUS CONTROL SOLUTION DME (blood-glucose calibration control, high) ACCU-CHEK FASTCLIX LANCET DRUM (lancets) DME ACCU-CHEK FASTCLIX LANCING DEV KIT (lancing DME device) ACCU-CHEK GUIDE ME GLUCOSE MTR (blood-glucose DME meter) ACCU-CHEK MULTICLIX LANCET KIT (lancing device) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

436 Coverage Prescription Drug Name Drug Tier Requirements and Limits ACCU-CHEK NANO (blood-glucose meter) DME ACCU-CHEK RAPID-D LINK 70 CM (subcutaneous Tier 3 administration set) ACCU-CHEK RAPID-D LINK INFUSION SET 10 X 20 MM- Tier 3 CM (subcutaneous administration set) ACCU-CHEK SAFE-T-PRO PLUS 23 GAUGE (lancets) DME ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION DME (blood-glucose calibration control, normal) ACCU-CHEK SOFT DEV LANCETS KIT (lancing device) DME ACCU-CHEK SPIRIT ADAPTER (subcutaneous infusion Tier 3 pump accessory) ACCU-CHEK SPIRIT CARTRIDGE SYS (subcutaneous Tier 3 infusion pump accessory) ACCU-CHEK SPIRIT CLIP CASE (subcutaneous infusion Tier 3 pump accessory) ACCUTREND GLUCOSE CONTROL SOLUTION (blood- DME glucose calibration control, high) ACE AEROSOL CLOUD ENHANCER SPACER (inhaler, Tier 3 assist devices) ADVANCE PLUS INTERMITTENT 10 FR, 10-16 FR-", 12 Tier 3 FR, 6-16 FR-", 8-16 FR-" (catheter) ADVANCE PLUS INTERMITTENT COMBO PACK 6 FR, 8- Tier 3 14 FR-" (urinary bag) ADVANCED TRAVEL LANCETS 30 GAUGE (lancets) DME ADVOCATE CONTROL SOLUTION HIGH SOLUTION DME (blood-glucose calibration control, high) ADVOCATE DUO DEVICE (blood-glucose meter-wrist DME blood pressure monitor) ADVOCATE DUO METER KIT (blood-glucose meter-wrist DME blood pressure monitor)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

437 Coverage Prescription Drug Name Drug Tier Requirements and Limits ADVOCATE LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 33 GAUGE X 5/32" Tier 1 (pen needle, diabetic) ADVOCATE RAPID-SAFE LANCING (lancing device) DME ADVOCATE REDI-CODE GLU MONITOR KIT (blood- DME glucose meter) ADVOCATE REDI-CODE+ CTRL HIGH SOLUTION (blood- DME glucose calibration control, high) ADVOCATE REDI-CODE+ CTRL LOW SOLUTION (blood- DME glucose calibration control, low) ADVOCATE SYRINGES SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X Tier 1 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) ADVOCATE TEST STRIPS STRIP (blood sugar diagnostic) DME AEROBIKA OSCILLATING PEP SYSTM DEVICE (mucus Tier 3 clearing device) AEROCHAMBER MINI SPACER (inhaler, assist devices) Tier 3 AEROCHAMBER MV SPACER (inhaler, assist devices) Tier 3 AEROCHAMBER PLUS Z STAT LG MSK SPACER Tier 3 (inhaler, assist device with large mask) AEROCHAMBER PLUS Z STAT MD MSK SPACER Tier 3 (inhaler, assist device with medium mask) AEROCHAMBER PLUS Z STAT SM MSK SPACER Tier 3 (inhaler, assist device with small mask) AEROCHAMBER PLUS Z STAT SPACER (inhaler, assist Tier 3 devices)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

438 Coverage Prescription Drug Name Drug Tier Requirements and Limits AEROCHAMBER WITH FLOWSIGNAL SPACER (inhaler, Tier 3 assist devices) AEROCHAMBER Z-STAT PLUS-FLW SG SPACER Tier 3 (inhaler, assist devices) AEROECLIPSE II NEBULIZER (nebulizer) Tier 3 AEROGEAR ACTION ASTHMA KIT KIT (peak flow meter) DME AEROTRACH PLUS SPACER (inhaler, assist devices) Tier 3 AEROVENT PLUS SPACER (inhaler, assist devices) Tier 3 AGAMATRIX AMP GLUC MONITOR SYS (blood-glucose DME meter) AGAMATRIX AMP TEST STRIPS STRIP (blood sugar DME diagnostic) AGAMATRIX CONTROL HIGH SOLUTION (blood-glucose DME calibration control, high) AGAMATRIX CONTROL NORM-HI SOLUTION (blood- DME glucose calibration control, high) AIRS DISPOSABLE NEBULIZER (nebulizer) Tier 3 AIRZONE PEAK FLOW METER DEVICE (peak flow meter) DME ALLERGIST TRAY 1/2 ML 27GX3/8" SYRINGE 1/2 ML 27 Tier 1 GAUGE X 3/8" (syringe with needle,disposable) ALLERGIST TRAY INTRADERMAL BEV SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 26 GAUGE X 3/8", 1 ML 27 Tier 1 GAUGE X 3/8" (syringe with needle,disposable) ALLERGIST TRAY REGULAR BEVEL SYRINGE 1 ML 27 Tier 1 GAUGE X 3/8" (syringe with needle,disposable) ALLERGY SYRINGE SYRINGE 1 ML 27 X 1/2" (syringe Tier 1 with needle,disposable) ALLEVYN ADHESIVE DRESSING TOPICAL BANDAGE 3 Tier 3 X 3 ", 5 X 5 ", 9 X 9 " (foam bandage) ALLEVYN HEEL TOPICAL BANDAGE 4 1/2 X 5 1/2 " (foam Tier 3 bandage)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

439 Coverage Prescription Drug Name Drug Tier Requirements and Limits ALLEVYN LIFE DRESSING TOPICAL BANDAGE 4 X 4 ", 5 1/16 X 5 1/16 ", 6 1/16 X 6 1/16 ", 8 1/4 X 8 1/4 " (foam Tier 3 bandage) ALLEVYN TOPICAL BANDAGE 2 X 2 ", 4 X 4 ", 6 X 6 ", 8 X Tier 3 8 " (foam bandage) ALTERNATE SITE LANCET 26 GAUGE (lancets) DME ALTERNATE SITE LANCING DEVICE (lancing device) DME APOGEE IC INTERMIT CATHETER 14-6 FR-" (catheter) Tier 3 ARGYLE TRACHEOSTOMY CARE TRAY (medical supply, Tier 3 miscellaneous) ASTHMA CHECK METER DEVICE (peak flow meter) DME ASTHMAPACK CHILDREN'S KIT (peak flow meter) DME AURA PORTANEB (nebulizer) Tier 3 AUTO-LANCET MINI (lancing device) DME AUTOPEN 1 TO 21 UNITS SUBCUTANEOUS INSULIN DME PEN (insulin administration supplies) AUTOPEN 2 TO 42 UNITS SUBCUTANEOUS INSULIN DME PEN (insulin administration supplies) BD ALLERGIST TRAY REG BEVEL SYRINGE 1 ML 26 GAUGE X 1/2", 1 ML 27 X 1/2" (syringe with Tier 1 needle,disposable) BD ALLERGIST TRAY REG BEVEL TRAY 1/2 ML 27 X Tier 1 1/2" (syringe with needle, disposable kit-tray) BD ALLERGY SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2" Tier 1 (syringe with needle,disposable) BD AUTOSHIELD DUO PEN NEEDLE NEEDLE 30 Tier 1 GAUGE X 3/16" (pen needle, dual safety, diabetic) BD BLUNT PLASTIC CANNULA SYRINGE 17 X 3 ML Tier 1 (syringe with cannula, disposable) BD BULK LUER-LOK NON-STERILE SYRINGE 10 ML, 20 Tier 1 ML, 5 ML, 60 ML (syringe, disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

440 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD BULK SLIP TIP NON-STERILE SYRINGE 10 ML, 20 Tier 1 ML, 60 ML (syringe, disposable) BD BULK SYRINGE SLIP TIP SYRINGE 1 ML, 5 ML Tier 1 (syringe, disposable) BD ECCENTRIC TIP SYRINGE SYRINGE 10 ML (syringe, Tier 1 disposable) BD ECLIPSE LUER-LOK NEEDLE 30 X 1/2 " (needles, Tier 1 safety) BD ECLIPSE LUER-LOK SYRINGE 1 ML 27 X 1/2", 3 ML Tier 1 23 X 1", 3 ML 25 X 5/8" (syringe with needle,disposable) BD ECLIPSE LUER-LOK SYRINGE 1 ML 30 GAUGE X Tier 1 1/2" (syringe with needle,insulin disposable) BD ECLIPSE LUER-LOK SYRINGE 3 ML 22 GAUGE X 1 Tier 1 1/2" (syringe,safety with needle) BD FILTER NEEDLE-5 MICRON NEEDLE 19 X 1 1/2 " Tier 3 (needles, filter) BD INSULIN SYRINGE HALF UNIT SYRINGE 0.3 ML 31 Tier 1 GAUGE X 5/16" (syringe with needle,insulin disposable) BD INSULIN SYRINGE MICRO-FINE SYRINGE 1 ML 28 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) BD INSULIN SYRINGE SAFETY-LOK SYRINGE 1 ML 29 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) BD INSULIN SYRINGE SLIP TIP SYRINGE 1 ML (syringe Tier 1 without needle,insulin disposable) BD INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 25 GAUGE X 5/8", 1 ML 25 X 1", 1 ML 26 X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML Tier 1 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with needle,insulin disposable) BD INSULIN SYRINGE U-500 SYRINGE 1/2 ML 31 GAUGE X 15/64" (syringe, insulin U-500 with needle, Tier 1 disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

441 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD INSYTE AUTOGUARD INFUSION SET 24 GAUGE X Tier 3 3/4" (intravenous catheter) BD INTEGRA SYRINGE SYRINGE 3 ML 21 GAUGE X 1 Tier 1 1/2" (syringe with needle,disposable) BD INTEGRA SYRINGE SYRINGE 3 ML 22 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 Tier 1 GAUGE X 5/8" (syringe,safety with needle) BD INTERLINK BLUNT PLASTIC CAN SYRINGE 17 X 5 Tier 1 ML (syringe with cannula, disposable) BD INTERLINK SYRINGE SYRINGE 17 X 10 ML (syringe Tier 1 with cannula, disposable) BD LAB ECCENTRIC NON-STERILE SYRINGE 10 ML Tier 1 (syringe, disposable) BD LO-DOSE MICRO-FINE IV SYRINGE 1/2 ML 28 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) BD LO-DOSE ULTRA-FINE SYRINGE 0.5 ML 29 GAUGE Tier 1 X 1/2" (syringe with needle,insulin disposable) BD LUER-LOK BULK SYRINGE SYRINGE 20 ML (syringe, Tier 1 disposable) BD LUER-LOK SYRINGE SYRINGE 1 ML 20 GAUGE X 1", 10 ML 20 X 1 1/2", 10 ML 20 X 1", 10 ML 21 GAUGE X 1", 10 ML 21 X 1 1/2", 10 ML 22 X 1", 10 ML 23X 1 1/4 ", 3 ML 18 X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 Tier 1 GAUGE X 1 1/2", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/2 ", 3 ML 25 X 5/8", 3 ML 26 X 5/8", 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1" (syringe with needle,disposable) BD LUER-LOK SYRINGE SYRINGE 20 ML, 3 ML, 5 ML Tier 1 (syringe, disposable) BD LUER-LOK TIP CONTROL SYRING SYRINGE 10 ML Tier 1 (syringe, disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

442 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD MAGNI-GUIDE SYRINGE MAGNIFI (diabetic supplies, DME miscellaneous) BD MICROTAINER LANCET 1.5 X 2 MM (blade lancet, DME safety) BD MICROTAINER LANCET 21 GAUGE, 30 GAUGE DME (lancets) BD NANO 2ND GEN PEN NEEDLE NEEDLE 32 GAUGE X Tier 1 5/32" (pen needle, diabetic) BD PRECISIONGLIDE SYRINGE 3 ML 22 GAUGE X 3/4" Tier 1 (syringe with needle,disposable) BD SAFETYGLIDE ALLERGIST TRAY SYRINGE 1 ML 26 GAUGE X 3/8", 1 ML 27 X 1/2" (syringe with Tier 1 needle,disposable) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 Tier 1 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2" (syringe with needle,insulin disposable) BD SAFETYGLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 15/64", 1 ML 31 Tier 1 GAUGE X 15/64" (syringe with needle, insulin, safety) BD SAFETYGLIDE SHIELDING REG SYRINGE 1 ML 25 Tier 1 GAUGE X 5/8" (syringe with needle,disposable) BD SAFETYGLIDE SHIELDING REG SYRINGE 3 ML 21 Tier 1 GAUGE X 1 1/2" (syringe,safety with needle) BD SAFETYGLIDE SYRINGE SYRINGE 1 ML 27 GAUGE Tier 1 X 5/8" (syringe with needle,insulin disposable) BD SAFETYGLIDE SYRINGE SYRINGE 10 ML 22 X 1 1/2", 3 ML 22 X 1 1/2", 3 ML 25 X 5/8" (syringe with Tier 1 needle,disposable) BD SAFETYGLIDE SYRINGE SYRINGE 3 ML 25 GAUGE Tier 1 X 1", 5 ML 22 GAUGE X 1 1/2" (syringe,safety with needle) BD SAFETYGLIDE TB REG BEVEL SYRINGE 1 ML 27 X Tier 1 1/2" (syringe with needle,disposable) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

443 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD SAFETYGLIDE TUBERCULIN SYRINGE 1 ML 26 Tier 1 GAUGE X 3/8" (syringe with needle,disposable) BD SAFETY-LOK DETACHABLE NEEDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X Tier 1 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2" (syringe,safety with needle) BD SAFETY-LOK TUBERCULIN SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2" (syringe,safety with Tier 1 needle) BD SAFETY-LOK WITH LUER-LOK SYRINGE 10 ML, 3 Tier 1 ML, 5 ML (syringe, disposable) BD SAF-T-INTIMA INFUSION SET 22 GAUGE X 3/4" Tier 3 (intravenous catheter kit) BD SLIP TIP SYRINGE SYRINGE 1 ML 26 GAUGE X 5/8" Tier 1 (syringe with needle,disposable) BD SLIP TIP SYRINGE SYRINGE 10 ML, 3 ML (syringe, Tier 1 disposable) B-D SLIP TIP SYRINGE SYRINGE 20 ML (syringe, Tier 1 disposable) BD SPECIALTY USE NEEDLES NEEDLE 30 GAUGE X Tier 1 1/2" (needles, disposable) BD SYRINGE BULK STERILE PAK SYRINGE 10 ML, 60 Tier 1 ML (syringe, disposable) BD SYRINGE CATHETER TIP SYRINGE 60 ML (syringe, Tier 1 disposable) BD SYRINGE SYRINGE 1 ML, 60 ML (syringe, disposable) Tier 1 BD SYRINGE-DUAL CANNULA SYRINGE 10 ML 20 GAUGE AND 17 GAUGE (syringe with needle and cannula, Tier 1 disposable) BD TUBERCULIN SLIP-TIP SYRINGE 1 ML (syringe, Tier 1 disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

444 Coverage Prescription Drug Name Drug Tier Requirements and Limits BD TUBERCULIN SYRINGE SYRINGE 1 ML 21 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 3/8", 1 ML Tier 1 27 X 1/2", 1/2 ML 27 X 1/2 " (syringe with needle,disposable) BD ULTRA FINE LANCETS 33 GAUGE (lancets) DME BD ULTRA-FINE MICRO PEN NEEDLE NEEDLE 32 Tier 1 GAUGE X 1/4" (pen needle, diabetic) BD VEO INSULIN SYR HALF UNIT SYRINGE 0.3 ML 31 Tier 1 GAUGE X 15/64" (syringe with needle,insulin disposable) BIONIME RIGHTEST GM300 SYSTEM KIT (blood-glucose DME meter) BIONIME RIGHTEST TEST STRIPS STRIP (blood sugar DME diagnostic) BIOSTEP TOPICAL BANDAGE 2 X 2 ", 4 X 4 " (dressing, Tier 3 collagen) blood glucose contrl hi,normal solution DME blood glucose ctl high,nml,low solution DME BLOOD GLUCOSE MONITORING KIT (blood-glucose DME meter) blunt needle, disposable needle 18 x 1 1/2 " Tier 3 BOYS TRAINING PANTS 4T-5T (diaper/brief,infant-toddler, Tier 3 disposable) BREEZE 2 CONTROL SOLUTION, LOW SOLUTION DME (blood-glucose calibration control, low) BREEZE 2 CONTROL SOLUTION, NML SOLUTION DME (blood-glucose calibration control, normal) BREEZE 2 CONTROL SOLUTION,HIGH SOLUTION DME (blood-glucose calibration control, high) BREEZE 2 TEST STRIPS STRIP (blood sugar diagnostic, DME disc-type)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

445 Coverage Prescription Drug Name Drug Tier Requirements and Limits CAREFINE PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 Tier 1 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) CARELANCE ULT LANCING DEVICE (lancing device) DME CAREONE THIN LANCET (lancets) DME CAREPOINT LUER SLIP SYRINGE SYRINGE 1 ML Tier 1 (syringe, disposable) CARESENS CONTROL A AND B SOLUTION (blood- DME glucose calibration control, high) CARESENS CONTROL A NORMAL SOLUTION (blood- DME glucose calibration control, normal) CARESENS LANCETS 30 GAUGE (lancets) DME CARESENS N KIT (blood-glucose meter) DME CARESENS N VOICE (blood-glucose meter) DME CARESENS N VOICE KIT (blood-glucose meter) DME CARESENS PREM LANCING DEVICE (lancing device) DME CARETOUCH GLUCOSE MONITORING KIT (blood- DME glucose meter) CARETOUCH INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 X 5/16", 1 ML 29 GAUGE X 5/16, Tier 1 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) CARETOUCH LANCING DEVICE (lancing device) DME CARETOUCH PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 1 3/16", 32 GAUGE X 5/32" (pen needle, diabetic) CARETOUCH SAFETY LANCETS 26 GAUGE, 28 GAUGE DME (lancets) CARETOUCH TWIST LANCET 28 GAUGE, 33 GAUGE DME (lancets) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

446 Coverage Prescription Drug Name Drug Tier Requirements and Limits CAYA CONTOURED VAGINAL DIAPHRAGM 65-80 MM Tier 0 (diaphragms, contoured) CEFALY COMBO PACK (TENS unit) Tier 3 CELLPAD TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) CHEMSTRIP BG LOG BOOK (diabetic supplies, DME miscellaneous) CHOICE DM CLARUS NORM CONTROL SOLUTION DME (blood-glucose calibration control, normal) CHOICEDM CLARUS (blood-glucose meter) DME CHOICEDM CLARUS STRIP (blood sugar diagnostic) DME CICATRACE PAD TOPICAL PAD 4.7 X 5.7 " (gel-matrix Tier 3 pad dressing, silicone) CLEVER CHEK BLOOD GLUCOSE (blood-glucose meter) DME CLEVER CHOICE CHAMBER-LRG MASK SPACER Tier 3 (inhaler, assist device with large mask) CLEVER CHOICE CHAMBER-MED MASK SPACER Tier 3 (inhaler, assist device with medium mask) CLEVER CHOICE CHAMBER-SM MASK SPACER Tier 3 (inhaler, assist device with small mask) CLEVER CHOICE GLUCOSE MONITOR (blood-glucose DME meter) CLEVER CHOICE LEVEL 1 CONTROL SOLUTION (blood- DME glucose calibration control, low) CLEVER CHOICE LEVEL 2 CONTROL SOLUTION (blood- DME glucose calibration control, normal) CLEVER CHOICE LEVEL 3 CONTROL SOLUTION (blood- DME glucose calibration control, high) CLEVER CHOICE MICRO (blood-glucose meter) DME CLEVER CHOICE MICRO TEST STRIP STRIP (blood DME sugar diagnostic)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

447 Coverage Prescription Drug Name Drug Tier Requirements and Limits CLEVER CHOICE NEBULIZER DEVICE (nebulizer) Tier 3 CLEVER CHOICE PRO (blood-glucose meter) DME CLEVER CHOICE PRO STRIP (blood sugar diagnostic) DME CLEVER CHOICE TALK GLUCOSE SYS (blood-glucose DME meter) CLEVER CHOICE TALK TEST STRIP (blood sugar DME diagnostic) CLEVER CHOICE WHISPER AIRE PED DEVICE Tier 3 (nebulizer) COAGUCHEK LANCETS (lancets) DME COAGUCHEK XS (prothrombin time/INR test meter) Tier 3 COLOR LANCETS 21 GAUGE (lancets) DME COMFORT EZ INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 Tier 1 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2" (syringe with needle,insulin disposable) COMFORT EZ PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 32 GAUGE X 5/16", 33 GAUGE X 1/4", 33 GAUGE X Tier 1 3/16", 33 GAUGE X 5/16" (pen needle, diabetic) COMFORT INFUSION SET 31" INFUSION SET (infusion Tier 3 set for insulin pump) COMFORT INFUSION SET 32" INFUSION SET (infusion Tier 3 set for insulin pump) COMFORT SHORT INFUSION SET 31" INFUSION SET Tier 3 (infusion set for insulin pump) COMFORT SHORT INSULIN PUMP 23" INFUSION SET Tier 3 (infusion set for insulin pump)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

448 Coverage Prescription Drug Name Drug Tier Requirements and Limits COMFORT SHORT INSULIN PUMP 32" INFUSION SET Tier 3 (infusion set for insulin pump) COMFORT SHORT INSULIN PUMP 43" INFUSION SET Tier 3 (infusion set for insulin pump) COMPACT SPACE CHAMBER PLUS SPACER (inhaler, Tier 3 assist devices) COMPACT SPACE CHAMBER SPACER (inhaler, assist Tier 3 devices) COMPACT SPACE CHAMBER-LRG MASK SPACER Tier 3 (inhaler, assist device with large mask) COMPACT SPACE CHAMBER-MED MASK SPACER Tier 3 (inhaler, assist device with medium mask) COMPACT SPACE CHAMBER-SM MASK SPACER Tier 3 (inhaler, assist device with small mask) COMP-AIR NEBULIZER COMPRESSOR DEVICE Tier 3 (nebulizer) CONCEPTION KIT (conception assistance supplies Tier 3 combination no.1) CONTOUR CONTROL SOLUTION, HIGH SOLUTION DME (blood-glucose calibration control, high) CONTOUR CONTROL SOLUTION, LOW SOLUTION DME (blood-glucose calibration control, low) CONTOUR CONTROL SOLUTION, NML SOLUTION DME (blood-glucose calibration control, normal) CONTOUR LINK KIT (blood-glucose meter) DME CONTOUR METER KIT (blood-glucose meter) DME CONTOUR NEXT EZ METER (blood-glucose meter) DME CONTOUR NEXT EZ METER KIT (blood-glucose meter) DME CONTOUR NEXT LEV 1 CONTROL SOL SOLUTION DME (blood-glucose calibration control, low)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

449 Coverage Prescription Drug Name Drug Tier Requirements and Limits CONTOUR NEXT LEV 2 CONTROL SOL SOLUTION DME (blood-glucose calibration control, normal) CONTOUR NEXT LINK 2.4 KIT (blood-glucose meter, DME wireless) CONTOUR NEXT METER (blood-glucose meter) DME CONTROL AST MONITORING SYSTEM (blood-glucose DME meter) COOL BLOOD GLUCOSE METER (blood-glucose meter) DME COOL BLOOD GLUCOSE METER KIT (blood-glucose DME meter) COOL CONTROL A SOLUTION SOLUTION (blood-glucose DME calibration control, normal) COOL CONTROL B SOLUTION SOLUTION (blood-glucose DME calibration control, high) COOL GLUCOSE TEST STRIP STRIP (blood sugar DME diagnostic) CURAFIL GEL WOUND TOPICAL GEL (gel dressing) Tier 3 CURITY AMD (WITH POLYHEXAMETH) TOPICAL Tier 3 SPONGE 0.2 %- 2" X 2" (polyhexamethylene biguanide) CURITY AMD (WITH POLYHEXAMETH) TOPICAL STRIP Tier 3 0.2 %- 1/2" X 3 FEET (polyhexamethylene biguanide) CURITY AMD TOPICAL BANDAGE 1 X 5 "-YARD, 1/4 X 36 Tier 3 " (gauze bandage) CURITY DRAINAGE BAG 2,000 ML (drainage bag) Tier 3 CURITY IODOFORM PACKING STRIP TOPICAL BANDAGE 1 X 5 "-YARD, 1/2 X 5 "-YARD, 1/4 X 5 "-YARD, Tier 3 2 X 5 "-YARD (iodoform) DARIO BLOOD GLUCOSE MONITOR DEVICE (blood- DME glucose meter,for mobile device) DAVOL IRRIGATION SYRINGE SYRINGE (syringe, Tier 1 disposable irrigation)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

450 Coverage Prescription Drug Name Drug Tier Requirements and Limits DAVOL PISTON IRRIGATION SYRINGE (syringe, Tier 1 disposable irrigation) DERM-SILK TOPICAL PAD 2.5 X 2 " (gel-matrix pad Tier 3 dressing, silicone) DEVILBISS DISPOSABLE NEBULIZER (nebulizer) Tier 3 DEVILBISS PULMO-AIDE COMPRESSR DEVICE Tier 3 (compressor, for nebulizer) DEVILBISS PULMOMATE COMPRESSOR DEVICE Tier 3 (compressor, for nebulizer) DEVILBISS PULMONEB LT COMP-NEB DEVICE Tier 3 (nebulizer) DEXCOM G4 TRANSMITTER DEVICE (blood-glucose Tier 3 PA transmitter) DEXCOM G5 TRANSMITTER DEVICE (blood-glucose Tier 3 PA transmitter) DEXCOM G5-G4 SENSOR DEVICE (blood-glucose sensor) Tier 3 PA DEXCOM G6 RECEIVER (blood-glucose meter, DME PA continuous) DEXCOM G6 SENSOR DEVICE (blood-glucose sensor) Tier 3 PA DEXCOM G6 TRANSMITTER DEVICE (blood-glucose Tier 3 PA transmitter) DEXCOM RECEIVER (blood-glucose meter, continuous) DME PA DIATRUE CONTROL SOLN NORMAL SOLUTION (blood- DME glucose calibration control, normal) DIATRUE CONTROL SOLUTION HIGH SOLUTION (blood- DME glucose calibration control, high) DIATRUE CONTROL SOLUTION LOW SOLUTION (blood- DME glucose calibration control, low) DIATRUE PLUS BLOOD GLUCOSE MET (blood-glucose DME meter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

451 Coverage Prescription Drug Name Drug Tier Requirements and Limits DIATRUE PLUS TEST STRIP STRIP (blood sugar DME diagnostic) DOVER BULB SYRINGE SYRINGE 60 ML (syringe, Tier 1 disposable irrigation) DOVER COATED LATEX FOLEY COMBO PACK (urinary Tier 3 bag) DOVER FOLEY CATHETER 24 FR (catheter) Tier 3 DOVER LATEX FOLEY CATHETER 16 FR, 28 FR Tier 3 (catheter) DOVER RED RUBBER ROBINSON CATH 8 FR (catheter) Tier 3 DOVER UNIVERSAL TRAY (catheterization tray) Tier 3 DROPLET INSULIN SYR HALF UNIT SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5ML 30 Tier 1 GAUGE X 15/64" (syringe with needle,insulin disposable) DROPLET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 15/64", 0.3 ML 30 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE Tier 1 X 15/64", 1 ML 30 GAUGE X 5/16 (syringe with needle,insulin disposable) DROPLET LANCETS 30 GAUGE (lancets) DME DROPLET PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 29 GAUGE X 3/8", 31 GAUGE X 1/4", 32 GAUGE X 1/4", 32 Tier 1 GAUGE X 3/16", 32 GAUGE X 5/16" (pen needle, diabetic) DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 Tier 1 GAUGE X 5/16" (pen needle, diabetic, safety) EAR POPPER INFLATION DEVICE NASAL DEVICE Tier 3 (middle ear inflation device) EASIVENT MASK LARGE DEVICE (inhaler, assist devices, Tier 3 accessories) EASIVENT MASK MEDIUM DEVICE (inhaler, assist Tier 3 devices, accessories)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

452 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASIVENT MASK SMALL DEVICE (inhaler, assist devices, Tier 3 accessories) EASY CHECK BLOOD GLUCOSE KIT (blood-glucose DME meter) EASY COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 1 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 32 GAUGE X 5/16" (syringe with needle,insulin disposable) EASY COMFORT PEN NEEDLES NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X Tier 1 5/32", 33 GAUGE X 1/4", 33 GAUGE X 3/16", 33 GAUGE X 5/32" (pen needle, diabetic) EASY GLIDE CATHETER TIP SYRING SYRINGE 60 ML Tier 1 (syringe, disposable) EASY GLIDE DENTAL IRRIG SYRING SYRINGE 10 ML Tier 1 (syringe, disposable) EASY GLIDE INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 15/64", 1 ML 31 GAUGE X 15/64", 1/2 ML 31 Tier 1 GAUGE X 15/64" (syringe with needle,insulin disposable) EASY GLIDE LUER LOCK SYRINGE SYRINGE 1 ML, 10 Tier 1 ML, 3 ML, 60 ML (syringe, disposable) EASY GLIDE LUER SLIP TB SYRING SYRINGE 1 ML Tier 1 (syringe, disposable) EASY GLIDE PEN NEEDLE NEEDLE 33 GAUGE X 5/32" Tier 1 (pen needle, diabetic) EASY GLUCO G2 STRIP (blood sugar diagnostic) DME EASY MINI EJECT LANCING DEVICE (lancing device) DME EASY PLUS II BLOOD GLUCOSE MET (blood-glucose DME meter) EASY PLUS II HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

453 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY PLUS II LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) EASY PLUS II TEST STRIP (blood sugar diagnostic) DME EASY STEP BLOOD GLUCOSE METER (blood-glucose DME meter) EASY STEP HIGH CONTROL SOLN SOLUTION (blood- DME glucose calibration control, high) EASY STEP LOW CONTROL SOLUTION SOLUTION DME (blood-glucose calibration control, low) EASY STEP NORMAL CONTROL SOLN SOLUTION DME (blood-glucose calibration control, normal) EASY STEP STRIP (blood sugar diagnostic) DME EASY TALK BLOOD GLUCOSE METER (blood-glucose DME meter) EASY TALK GLUCOSE TEST STRIP (blood sugar DME diagnostic) EASY TALK HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) EASY TALK LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) EASY TOUCH FLIPLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 1 5/16", 1 ML 31 GAUGE X 5/16" (syringe with needle, insulin, safety) EASY TOUCH FLIPLOCK NEEDLE NEEDLE 30 X 1/2 " Tier 1 (needles, safety)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

454 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH FLIPLOCK SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 26 GAUGE X 3/8", 1 ML 27 GAUGE X 1/2", 10 ML 18 GAUGE X 1 1/2", 10 ML 18 GAUGE X 1", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 18 GAUGE X 1 1/2", 3 ML 18 GAUGE X 1", 3 ML 19 GAUGE X 1 1/2", 3 ML 19 GAUGE X 1", 3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X Tier 1 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 18 GAUGE X 1", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1", 5 ML 25 GAUGE X 5/8" (syringe,safety with needle) EASY TOUCH FLURINGE FLIPLOCK SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8" (syringe,safety with Tier 1 needle) EASY TOUCH FLURINGE SHEATHLOCK SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8" (syringe,safety Tier 1 with needle) EASY TOUCH FLURINGE SYRINGE 1 ML 25 GAUGE X Tier 1 1", 1 ML 25 GAUGE X 5/8" (syringe with needle,disposable) EASY TOUCH HYPODERMIC NEEDLE NEEDLE 30 Tier 1 GAUGE X 1/2" (needles, disposable) EASY TOUCH INSULIN SAFETY SYR SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 29 Tier 1 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2" (syringe with needle, insulin, safety) EASY TOUCH LANCETS 26 GAUGE, 28 GAUGE, 30 DME GAUGE, 32 GAUGE (lancets) EASY TOUCH LANCING DEVICE (lancing device) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

455 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH LUER LOCK INSULIN SYRINGE 1 ML Tier 1 (syringe without needle,insulin disposable) EASY TOUCH LUER LOCK SYRINGE SYRINGE 1 ML, 10 Tier 1 ML, 3 ML, 5 ML (syringe, disposable) EASY TOUCH PEN NEEDLE NEEDLE 30 GAUGE X 5/16" Tier 1 (pen needle, diabetic) EASY TOUCH SAFETY LANCETS 32 GAUGE (lancets) DME EASY TOUCH SHEATHLOCK INSULIN SYRINGE 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X Tier 1 5/16", 1 ML 31 GAUGE X 5/16" (syringe with needle, insulin, safety) EASY TOUCH SHEATHLOCK SYRG-NDL SYRINGE 10 ML 21 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1 1/2", 10 ML 25 GAUGE X 1", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X Tier 1 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 21 GAUGE X 1 1/2", 5 ML 22 GAUGE X 1 1/2", 5 ML 25 GAUGE X 1" (syringe,safety with needle) EASY TOUCH SHEATHLOCK SYRINGE SYRINGE 10 ML, Tier 1 3 ML (syringe, disposable) EASY TOUCH SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 X 1", 3 Tier 1 ML 25 GAUGE X 1", 3 ML 25 X 5/8" (syringe with needle,disposable) EASY TOUCH TUBERCULIN FLIPLOCK SYRINGE 1 ML 26 GAUGE X 5/8", 1 ML 27 GAUGE X 1/2", 1 ML 28 Tier 1 GAUGE X 1/2" (syringe,safety with needle) EASY TOUCH TUBERCULIN SHEATHLK SYRINGE 1 ML 25 GAUGE X 5/8", 1 ML 26 GAUGE X 5/8", 1 ML 27 Tier 1 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2" (syringe,safety with needle) EASY TOUCH TWIST LANCETS 26 GAUGE, 28 GAUGE, DME 30 GAUGE, 32 GAUGE, 33 GAUGE (lancets) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

456 Coverage Prescription Drug Name Drug Tier Requirements and Limits EASY TOUCH UNI-SLIP SYRINGE 10 ML (syringe, Tier 1 disposable) EASY TRAK BLOOD GLUCOSE METER (blood-glucose DME meter) EASY TRAK GLUCOSE TEST STRIP (blood sugar DME diagnostic) EASY TRAK HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) EASY TRAK LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) EASY TWIST AND CAP LANCETS 28 GAUGE (lancets) DME EASYGLUCO PLUS NORMAL CONTROL SOLUTION DME (blood-glucose calibration control, normal) EASYGLUCO PLUS STRIP (blood sugar diagnostic) DME EASYMAX 15 LEVEL 1 SOLUTION (blood-glucose DME calibration control, low) EASYMAX 15 LEVEL 2 SOLUTION (blood-glucose DME calibration control, normal) EBASE CONTROLLER DEVICE (compressor, for Tier 3 nebulizer) ECLIPSE NEEDLE NEEDLE 23 GAUGE X 1", 25 X 5/8 ", Tier 3 27 GAUGE X 1/2" (needles, safety) ECLIPSE SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8" Tier 1 (syringe with needle,disposable) ECLIPSE SYRINGE SYRINGE 3 ML 21 GAUGE X 1", 3 ML Tier 1 25 GAUGE X 1" (syringe,safety with needle) ELEMENT COMPACT GLUCOSE METER (blood-glucose DME meter) ELEMENT COMPACT HIGH CONTROL SOLUTION DME (blood-glucose calibration control, high) ELEMENT COMPACT NORMAL CONTROL SOLUTION DME (blood-glucose calibration control, normal) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

457 Coverage Prescription Drug Name Drug Tier Requirements and Limits ELEMENT COMPACT TEST STRIPS STRIP (blood sugar DME diagnostic) ELEMENT COMPACT V GLUCOSE MTR (blood-glucose DME meter) ELEMENT HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) ELEMENT LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) ELEMENT NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) ELEMENT PLUS BLOOD GLUCOSE KIT KIT (blood- DME glucose meter) ELEMENT TEST STRIPS STRIP (blood sugar diagnostic) DME EMBRACE BLOOD GLUCOSE KIT (blood-glucose meter) DME EMBRACE BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) EMBRACE EVO BLOOD GLUCOSE KIT KIT (blood- DME glucose meter) EMBRACE EVO LEVEL 1 SOLUTION (blood-glucose DME calibration control, low) EMBRACE EVO TEST STRIPS STRIP (blood sugar DME diagnostic) EMBRACE GLUCOSE CONTROL HIGH SOLUTION DME (blood-glucose calibration control, high) EMBRACE GLUCOSE CONTROL LOW SOLUTION (blood- DME glucose calibration control, low) EMBRACE LANCETS 30 GAUGE (lancets) DME EMBRACE PRO SOLUTION (blood-glucose calibration DME control, high) EMBRACE TALK CONTROL-HIGH (L2) SOLUTION (blood- DME glucose calibration control, high)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

458 Coverage Prescription Drug Name Drug Tier Requirements and Limits EMBRACE TALK CONTROL-LOW (L1) SOLUTION (blood- DME glucose calibration control, low) ENLITE GLUCOSE SENSOR DEVICE (blood-glucose Tier 3 sensor) ENLITE SERTER (diabetic supplies, miscellaneous) DME ENLITE SYSTEM (blood-glucose transmitter) Tier 3 ENTERAL GRAVITY BAG SET-ENFIT (feeder container) Tier 3 ERAPID NEBULIZER HANDSET (nebulizer accessories) Tier 3 ERAPID NEBULIZER SYSTEM (nebulizer) Tier 3 EVENCARE KIT (blood-glucose meter) DME EVENCARE MINI GLUCOSE CONTROL SOLUTION DME (blood-glucose calibration control, normal) EVENCARE PROVIEW CONTROL-L2,L3 SOLUTION DME (blood-glucose calibration control, high) EVENCARE PROVIEW TEST STRIP STRIP (blood sugar DME diagnostic) EVENCARE SOLUTION (blood-glucose calibration control, DME high) EVENCARE TEST STRIP (blood sugar diagnostic) DME EVERSENSE SMART TRANSMITTER DEVICE (blood- Tier 3 glucose transmitter) EVOLUTION BLOOD GLUCOSE METER KIT (blood- DME glucose meter) EVOLUTION NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) EVOLUTION TEST STRIPS STRIP (blood sugar DME diagnostic) EXCEL SYRINGE SYRINGE 3 ML 23 X 1" (syringe with Tier 1 needle,disposable) EXEL HYPODERMIC NEEDLES NEEDLE 30 GAUGE X Tier 1 1/2" (needles, disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

459 Coverage Prescription Drug Name Drug Tier Requirements and Limits EXEL SYRINGE SYRINGE 10 ML, 30 ML, 50 ML (syringe, Tier 1 disposable) EXEL SYRINGE SYRINGE 3 ML 23 GAUGE X 1 1/2" Tier 1 (syringe with needle,disposable) E-Z JECT LANCETS 26 GAUGE, 32 GAUGE (lancets) DME EZ SMART LANCETS 28 GAUGE (lancets) DME EZ SMART PLUS SYSTEM KIT (blood-glucose meter) DME EZ SMART PLUS TEST STRIP (blood sugar diagnostic) DME EZ SMART SYSTEM KIT (blood-glucose meter) DME EZ-VAC (diabetic supplies, miscellaneous) DME FC2 FEMALE CONDOM (condoms, female) Tier 0 QL (30 EA per 30 days) FEMALE CATHETER 14 FR (catheter) Tier 3 FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM Tier 0 (cervical cap) FIFTY50 TEST STRIP STRIP (blood sugar diagnostic) DME filter needles needle 19 x 1 ", 19 x 1 1/2 " Tier 3 FILTER PAD (nebulizer accessories) Tier 3 FINGERSTIX LANCETS (lancets) DME FLEXICHAMBER SPACER (inhaler, assist devices) Tier 3 FLEXICHAMBER-LG CHILD MASK DEVICE (inhaler, assist Tier 3 devices, accessories) FLEXICHAMBER-SM ADULT MASK DEVICE (inhaler, Tier 3 assist devices, accessories) FLEXICHAMBER-SM CHILD MASK DEVICE (inhaler, Tier 3 assist devices, accessories) FLEXI-SEAL SIGNAL FMS RECTAL (fecal collector with Tier 3 charcoal filter) FORA 6 CONNECT GLUCOSE STRIP STRIP (blood sugar DME diagnostic)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

460 Coverage Prescription Drug Name Drug Tier Requirements and Limits FORA D10 KIT (blood-glucose meter-wrist blood pressure DME monitor) FORA D15 GLUCOSE-BP MONITOR DEVICE (blood- DME glucose and pressure meter with adult cuff) FORA D15G STRIPS STRIP (blood sugar diagnostic) DME FORA D20 KIT (blood-glucose meter) DME FORA D20 STRIP (blood sugar diagnostic) DME FORA D40D GLUCOSE-BP MONITOR DEVICE (blood- DME glucose and pressure meter with adult cuff) FORA D40-G31 TEST STRIPS STRIP (blood sugar DME diagnostic) FORA G20 KIT (blood-glucose meter) DME FORA G30A (blood-glucose meter) DME FORA G30-PREMIUM V10 TEST STRP STRIP (blood DME sugar diagnostic) FORA GD50 BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) FORA GD50 TEST STRIPS STRIP (blood sugar diagnostic) DME FORA GTEL GLUCOSE TEST STRIP STRIP (blood sugar DME diagnostic) FORA HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) FORA LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) FORA PREMIUM V10 GLUCOSE METER (blood-glucose DME meter) FORA TEST N'GO VOICE METER (blood-glucose meter) DME FORA TN'G VOICE METER (blood-glucose meter) DME FORA TN'G VOICE TEST STRIPS STRIP (blood sugar DME diagnostic) FORA V10 KIT (blood-glucose meter) DME Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

461 Coverage Prescription Drug Name Drug Tier Requirements and Limits FORA V12 BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) FORA V12 BLOOD GLUCOSE SYSTEM KIT (blood- DME glucose meter) FORA V20 KIT (blood-glucose meter) DME FORA V20 STRIP (blood sugar diagnostic) DME FORA V30A (blood-glucose meter) DME FORA V30A KIT (blood-glucose meter) DME FORA V30A STRIP (blood sugar diagnostic) DME FORACARE GD20 GLUCOSE METER (blood-glucose DME meter) FORACARE GD20 STRIP (blood sugar diagnostic) DME FORACARE GD40 STRIP (blood sugar diagnostic) DME FORACARE GD40A GLUCOSE METER (blood-glucose DME meter) FORACARE GD40B GLUCOSE METER (blood-glucose DME meter) FORACARE GDH HIGH CONTROL SOLUTION (blood- DME glucose calibration control, high) FORACARE GDH LOW CONTROL SOLUTION (blood- DME glucose calibration control, low) FORACARE GDH NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) FORACARE LANCETS 30 GAUGE (lancets) DME FORTISCARE GLUCOSE TEST STRIPS STRIP (blood DME sugar diagnostic) FORTISCARE HIGH SOLUTION (blood-glucose calibration DME control, high) FORTISCARE LOW SOLUTION (blood-glucose calibration DME control, low)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

462 Coverage Prescription Drug Name Drug Tier Requirements and Limits FORTISCARE NORMAL SOLUTION (blood-glucose DME calibration control, normal) FREESTYLE FLASH SYSTEM KIT (blood-glucose meter) DME FREESTYLE FREEDOM KIT (blood-glucose meter) DME FREESTYLE INSULINX TEST STRIPS STRIP (blood sugar DME diagnostic) FREESTYLE LANCETS 28 GAUGE (lancets) DME FREESTYLE LIBRE 10 DAY READER (flash glucose Tier 2 PA scanning reader) FREESTYLE LIBRE 10 DAY SENSOR KIT (flash glucose Tier 2 PA sensor) FREESTYLE LIBRE 14 DAY READER (flash glucose Tier 2 PA scanning reader) FREESTYLE LIBRE 14 DAY SENSOR KIT (flash glucose Tier 2 PA sensor) FREESTYLE NAVIGATOR GLUC SENS DEVICE (blood- Tier 3 glucose sensor) FREESTYLE PRECISION SYRINGE 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 5/16, Tier 1 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) FREESTYLE SIDEKICK II KIT (blood-glucose meter) DME FREESTYLE UNISTIK 2 (lancets) DME GDRIVE KIT (blood-glucose meter) DME GIRLS TRAINING PANTS 4T-5T (diaper/brief,infant-toddler, Tier 3 disposable) GLUCO NAVII GLUCOSE MONITOR KIT (blood-glucose DME meter) GLUCOCOM AUTOLINK (diabetic supplies, miscellaneous) DME GLUCOCOM CONTROL HIGH SOLUTION (blood-glucose DME calibration control, high)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

463 Coverage Prescription Drug Name Drug Tier Requirements and Limits GLUCOCOM CONTROL NORMAL SOLUTION (blood- DME glucose calibration control, normal) GLUCOCOM GLUCOSE STRIP (blood sugar diagnostic) DME GLUCOCOM LANCETS 28 GAUGE, 30 GAUGE, 33 DME GAUGE (lancets) GM100 KIT (blood-glucose meter) DME GM100 STRIP (blood sugar diagnostic) DME GOODLIFE AC-302 GLUCOSE METER (blood-glucose DME meter) GOODLIFE AC-302 TEST STRIP STRIP (blood sugar DME diagnostic) GUARDIAN CONNECT TRANSMITTER DEVICE (blood- Tier 3 PA glucose transmitter) GUARDIAN REAL-TIME GLU MONITOR (blood-glucose DME meter, continuous) GUARDIAN RT CHARGER (diabetic supplies, DME miscellaneous) GUARDIAN RT MONITOR SYSTEM (diabetic supplies, DME miscellaneous) GUARDIAN RT STARTER KIT KIT (diabetic supplies, DME miscellaneous) GUARDIAN RT TRANSMITTER TAPE (diabetic supplies, DME miscellaneous) GUARDIAN SENSOR 3 DEVICE (blood-glucose sensor) Tier 3 PA HARMONY CONTROL L1,L3 SOLUTION (blood-glucose DME calibration control, high) HARMONY GLUCOSE TEST STRIP STRIP (blood sugar DME diagnostic) HEALTHPRO GLUCOSE MONITOR (blood-glucose meter) DME HEALTHPRO HIGH-LOW CONTROL SOLUTION (blood- DME glucose calibration control, high)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

464 Coverage Prescription Drug Name Drug Tier Requirements and Limits HEALTHPRO TEST STRIPS STRIP (blood sugar DME diagnostic) HEALTHWISE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 1 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) HEALTHWISE PEN NEEDLE NEEDLE 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 5/32" (pen needle, Tier 1 diabetic) HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 32 Tier 1 GAUGE X 5/32" (pen needle, diabetic) HI-VOLUME PUMPING CHAMBER SET (transfer sets) Tier 3 HYDROFERA BLUE READY TOPICAL BANDAGE 2 1/2 X Tier 3 2 1/2 ", 4 X 5 ", 8 X 8 " (methylene blue) HYDROFERA BLUE TOPICAL BANDAGE 2 X 2 ", 2.25 X 8 Tier 3 ", 2.5 ", 9 MM (polyvinyl alcohol) IN-CHECK NASAL WITH MASK DEVICE (peak flow meter) DME IN-CHECK ORAL FLOW METER DEVICE (peak flow DME meter) INCONTROL LANCING DEVICE (lancing device) DME INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16" Tier 1 (pen needle, diabetic) INCONTROL SUPER THIN LANCETS 30 GAUGE (lancets) DME INCONTROL ULTRA THIN LANCETS 28 GAUGE (lancets) DME INFINITY CONTROL SOLUTION HIGH SOLUTION (blood- DME glucose calibration control, high) INFINITY CONTROL SOLUTION LOW SOLUTION (blood- DME glucose calibration control, low) INFINITY CONTROL SOLUTION NORM SOLUTION DME (blood-glucose calibration control, normal)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

465 Coverage Prescription Drug Name Drug Tier Requirements and Limits INFINITY METER KIT KIT (blood-glucose meter) DME INFINITY VOICE CTRL SOLN-LVL 2 SOLUTION (blood- DME glucose calibration control, normal) INFINITY VOICE GLUCOSE MONITOR (blood-glucose DME meter) INFINITY VOICE TEST STRIP STRIP (blood sugar DME diagnostic) INJECT EASE LANCETS 28 GAUGE, 30 GAUGE (lancets) DME INNOSPIRE DELUXE DEVICE (nebulizer) Tier 3 INNOSPIRE GO NEBULIZER (nebulizer) Tier 3 INNOSPIRE REPLACEMENT FILTER (nebulizer Tier 3 accessories) INSET 30 INFUSION SET 23" INFUSION SET (infusion set Tier 3 for insulin pump) INSET 30 TUBING 23" BLUE (subcutaneous infusion pump Tier 3 accessory) INSET 30 TUBING 23" GREY (subcutaneous infusion pump Tier 3 accessory) INSET 30 TUBING 23" PINK (subcutaneous infusion pump Tier 3 accessory) INSET 30 TUBING 43" GREY (subcutaneous infusion pump Tier 3 accessory) INSPIRACHAMBER SPACER (inhaler, assist devices) Tier 3 INSPIRACHAMBER WITH MASK-LARGE SPACER Tier 3 (inhaler, assist device with large mask) INSPIRACHAMBER WITH MASK-MED SPACER (inhaler, Tier 3 assist device with medium mask) INSPIRACHAMBER WITH MASK-SMALL SPACER Tier 3 (inhaler, assist device with small mask) INSPIRATION ELITE FILTER (nebulizer accessories) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

466 Coverage Prescription Drug Name Drug Tier Requirements and Limits INSUFLON INFUSION SET 25 X 18 MM (subcutaneous Tier 3 administration set) INSUL-CAP (diabetic supplies, miscellaneous) DME INSUL-EZE (diabetic supplies, miscellaneous) DME insulin syr/ndl u100 half mark syringe 0.3 ml 31 gauge x Tier 1 1/4" INSULIN SYRINGE MICROFINE SYRINGE 1 ML 27 GAUGE X 5/8", 1/2 ML 28 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable) insulin syringe needleless syringe 1 ml Tier 1 INSULIN SYRINGE SYRINGE 1 ML 29 GAUGE X 1/2" Tier 1 (syringe with needle,insulin disposable) insulin syringe-needle u-100 syringe 0.3 ml 31 gauge x 1/4", 1 ml 28 gauge, 1 ml 29 gauge x 7/16", 1 ml 30 gauge x 3/8", Tier 1 1 ml 31 gauge x 1/4", 1/2 ml 28 gauge, 1/2 ml 31 gauge x 1/4" INSUPEN NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 1/4", 32 GAUGE X 5/16", Tier 1 33 GAUGE X 5/32" (pen needle, diabetic) INSYTE IV CATHETER INFUSION SET 14 X 1.75 ", 20 X Tier 3 1.16 " (intravenous catheter) INTEGRA SYRINGE SYRINGE 3 ML 21 GAUGE X 1" Tier 1 (syringe,safety with needle) INTERLINK LEVER LOCK CANNULA (syringe accessory) Tier 3 INTERLINK SYRINGE AND CANNULA SYRINGE 15 X 10 Tier 1 ML (syringe with cannula, disposable) INVACARE LANCETS 30 GAUGE (lancets) DME I-PORT ADVANCE 6 MM INJEC PORT (injection ports) Tier 3 I-PORT ADVANCE 9 MM INJEC PORT (injection ports) Tier 3 IRRIGATION SYRINGE SYRINGE (syringe, disposable Tier 1 irrigation)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

467 Coverage Prescription Drug Name Drug Tier Requirements and Limits KANGAROO 924 SAFETY SCREW (pump set) Tier 3 KANGAROO EPUMP SET (feeder container) Tier 3 KANGAROO GRAVITY SET (feeder container) Tier 3 KELOTOP TOPICAL PAD 4.7 X 5.7 " (gel-matrix pad Tier 3 dressing, silicone) KENDALL DISINFECTANT CAP (alcohol swab cap) Tier 3 KENGUARD FOLEY CATHETER 18-16 FR-" (catheter) Tier 3 KENGUARD FOLEY CATHETER TRAY (catheterization Tier 3 tray) KERAGEL TOPICAL GEL (gel dressing) Tier 3 KETONE CARE STRIP (urine acetone test,strips) DME KETONE URINE TEST STRIP (urine acetone test,strips) DME KETOSTIX STRIP (urine acetone test,strips) DME LANCETS, SUPER THIN (lancets) DME LANCETS,THIN 28 GAUGE (lancets) DME LANCETS,ULTRA THIN (lancets) DME LANCING SYSTEM (lancing device) DME LANZO LANCING DEVICE KIT (lancing device) DME LC STAR (nebulizer) Tier 3 LITE TOUCH INSULIN PEN NEEDLES NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 Tier 1 GAUGE X 5/16" (pen needle, diabetic) LITE TOUCH INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 30 Tier 1 GAUGE X 7/16", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 29 , 1/2 ML 30 GAUGE (syringe with needle,insulin disposable) LITE TOUCH LANCETS 28 GAUGE, 30 GAUGE, 33 DME GAUGE (lancets) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

468 Coverage Prescription Drug Name Drug Tier Requirements and Limits LITE TOUCH LANCING DEVICE (lancing device) DME LITE TOUCH-MEDIUM MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LITEAIRE MDI CHAMBER SPACER (inhaler, assist Tier 3 devices) LITETOUCH-LARGE MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LITETOUCH-SMALL MASK DEVICE (inhaler, assist Tier 3 devices, accessories) LOFRIC 12-16 FR-", 14-16 FR-" (catheter) Tier 3 LUER LOCK SYRINGE SYRINGE 30 ML (syringe, Tier 1 disposable) LUER-LOK TIP SYRINGE 30 ML (syringe, disposable) Tier 1 MAGELLAN INSULIN SAFETY SYRNG SYRINGE 0.3 ML 29 X 1/2", 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X Tier 1 1/2", 1 ML 30 GAUGE X 5/16" (syringe with needle, insulin, safety) MAGELLAN SAFETY NEEDLE NEEDLE 23 GAUGE X 5/8" Tier 3 (needles, safety) MAGELLAN SAFETY SYRINGE SYRINGE 1 ML 23 Tier 1 GAUGE X 1" (syringe,safety with needle) MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16", 0.5 Tier 1 ML 30 GAUGE X 5/16" (syringe with needle, insulin, safety) MAGELLAN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2" Tier 1 (syringe,safety with needle) MAGIC3 INTERMITTENT CATHETER 12-16 FR-" Tier 3 (catheter) MAXICOMFORT II PEN NEEDLE NEEDLE 31 GAUGE X Tier 1 1/4" (pen needle, diabetic) MAXICOMFORT INSULIN SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1/2 ML 27 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

469 Coverage Prescription Drug Name Drug Tier Requirements and Limits MAXI-COMFORT INSULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1/2 ML 28 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable) MEDIHONEY (CAL ALGINATE-HONEY) TOPICAL Tier 3 BANDAGE 2 X 2 ", 3/4 X 12 ", 4 X 5 " (alginic acid) MEDIHONEY (HYDROCOLLOID-HONEY) TOPICAL Tier 3 BANDAGE 2 X 2 ", 4 X 5 " (honey) MEDISENSE CONTROLS 1-HI 1-LO COMBO PACK DME (blood-glucose calibration control) MEDPOINT NORMAL CONTROL SOLUTION (blood- DME glucose calibration control, normal) MEDTRONIC REMOTE CONTROL (diabetic supplies, DME miscellaneous) MICRO BLOOD GLUCOSE STRIP (blood sugar diagnostic) DME MICROBORE EXTENSION SET INFUSION SET Tier 3 (intravenous admin extension set) MICRODOT BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) MICRODOT BLOOD GLUCOSE SYSTEM KIT (blood- DME glucose meter) MICRODOT HIGH-LOW CONTROL SOLUTION (blood- DME glucose calibration control, high) MICRODOT XTRA BLOOD GLUCOSE STRIP (blood sugar DME diagnostic) MICROLET 2 LANCING DEVICE KIT (lancing device) DME MICROLET NEXT LANCING DEVICE KIT (lancing device) DME MICROLIFE PEAK FLOW METER DEVICE (peak flow DME meter) MINI LANCING DEVICE (lancing device) DME MINI PLUS NEBULIZER (nebulizer) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

470 Coverage Prescription Drug Name Drug Tier Requirements and Limits MINI ULTRA-THIN II NEEDLE 31 GAUGE X 3/16" (pen Tier 1 needle, diabetic) MINILINK REAL-TIME TRANSMITTER DEVICE (blood- Tier 3 glucose transmitter) MINIMED 630G GUARDIAN START KT DEVICE (blood- Tier 3 glucose transmitter) MINIMED 630G INSULIN PUMP (subcutaneous insulin Tier 3 pump) MINIMED INFUSION SET-MMT 390 INFUSION SET Tier 3 (infusion set for insulin pump) MINIMED INFUSION SET-MMT 391 INFUSION SET Tier 3 (infusion set for insulin pump) MINIMED INFUSION SET-MMT 392 INFUSION SET Tier 3 (infusion set for insulin pump) MINIMED INFUSION SET-MMT 393 INFUSION SET Tier 3 (infusion set for insulin pump) MINIMED QUICK-SERTER-MMT 305 (diabetic supplies, DME miscellaneous) MINIMED SYRINGE RESERVOIR 1.8 ML (insulin pump Tier 1 syringe) MINI-WRIGHT PEAK FLOW METER DEVICE (peak flow DME meter) MISTASSIST DEVICE (spirometers and accessories) Tier 3 MISTASSIST KIT DEVICE (spirometer with drug delivery Tier 3 adapters) MONO-FLO DRAINAGE BAG 2,000 ML (drainage bag) Tier 3 MONOJECT 35CC SYRINGE CATH TIP SYRINGE 35 ML Tier 1 (syringe, disposable) MONOJECT 3CC SYR 25GX1" SYRINGE 3 ML 25 GAUGE Tier 1 X 1" (syringe with needle,disposable) MONOJECT ALLERGY TRAY DETACH TRAY 1 ML 27 X Tier 1 1/2" (syringe with needle, disposable kit-tray) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

471 Coverage Prescription Drug Name Drug Tier Requirements and Limits MONOJECT ALLERGY TRAY TRAY 0.5 ML 28 X 1/2", 1 Tier 1 ML 28 X 1/2" (syringe with needle, disposable kit-tray) MONOJECT BLOOD COLLECTION NEEDLE 20 GAUGE X 1", 20 X 1 1/2 ", 21 GAUGE X 1", 22 GAUGE X 1" (needles, Tier 3 blood collection) MONOJECT CONTROL SYRINGE LUER SYRINGE 12 ML Tier 1 (syringe, disposable) MONOJECT ECCENTRIC NON-STERILE SYRINGE 12 Tier 1 ML, 35 ML (syringe, disposable) MONOJECT HYPODERMIC NEEDLES NEEDLE 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 5/8", 26 Tier 3 GAUGE X 1 1/2", 27 GAUGE X 1/2", 30 GAUGE X 3/4" (needles, disposable) MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 Tier 1 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 29 GAUGE X 1/2" (syringe with needle,insulin disposable) MONOJECT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 1 ML 25 Tier 1 GAUGE X 5/8", 1 ML 29 GAUGE X 1/2" (syringe with needle,insulin disposable) MONOJECT LUER ADAPTER INTRAVENOUS ADMIX Tier 3 ACCESSORY (intravenous equipment) MONOJECT LUER-LOCK TIP SYRINGE 12 ML, 3 ML Tier 1 (syringe, disposable) MONOJECT MAGELLAN SYRINGE SYRINGE 1 ML 25 GAUGE X 1", 1 ML 25 GAUGE X 5/8", 3 ML 20 GAUGE X Tier 1 1" (syringe,safety with needle) MONOJECT PHARMACY TRAY LUER SYRINGE 12 ML, Tier 1 20 ML, 3 ML, 35 ML, 6 ML, 60 ML (syringe, disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

472 Coverage Prescription Drug Name Drug Tier Requirements and Limits MONOJECT REG TIP NON-STERILE SYRINGE 12 ML, 20 Tier 1 ML, 3 ML, 6 ML (syringe, disposable) MONOJECT REGULAR LUER SYRINGE 12 ML, 6 ML Tier 1 (syringe, disposable) MONOJECT SAFETY LUER LOCK TIP SYRINGE 3 ML Tier 1 (syringe, disposable) MONOJECT SAFETY SYRINGES SYRINGE 12 ML Tier 1 (syringe, disposable) MONOJECT SAFETY SYRINGES SYRINGE 12 ML 20 X 1 1/2", 12 ML 21X 1 1/2", 3 ML 20 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X Tier 1 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 5/8" (syringe,safety with needle) MONOJECT SAFETY SYRINGES SYRINGE 6 ML (syringe Tier 1 with needle,disposable) MONOJECT SMARTIP CANNULA SYRINGE 12 ML, 3 ML, Tier 1 6 ML (syringe with cannula, disposable) MONOJECT SYRINGE ECCENTRI LUER SYRINGE 60 ML Tier 1 (syringe, disposable) MONOJECT SYRINGE LUER LOK SYRINGE 35 ML, 6 ML, Tier 1 60 ML (syringe, disposable) MONOJECT SYRINGE REGULAR LUER SYRINGE 60 ML Tier 1 (syringe, disposable) MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE Tier 1 (syringe with needle,insulin disposable) MONOJECT SYRINGE SYRINGE 12 ML 20 X 1 1/2", 12 ML 21 GAUGE X 1 1/2", 12 ML 21 GAUGE X 1", 3 ML 20 X Tier 1 3/4", 3 ML 25 GAUGE X 1", 3 ML 25 X 1 1/4", 6 ML 22 X 1 1/2" (syringe with needle,disposable) MONOJECT SYRINGE SYRINGE 140 ML (syringe, Tier 1 disposable) MONOJECT SYRINGE TOOMEY TYPE SYRINGE 60 ML Tier 1 (syringe, disposable) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

473 Coverage Prescription Drug Name Drug Tier Requirements and Limits MONOJECT TB LUER LOK SYRINGE 1 ML (syringe, Tier 1 disposable) MONOJECT TB REGULAR LUER TIP SYRINGE 1 ML Tier 1 (syringe, disposable) MONOJECT TB SAFETY SYRINGE SYRINGE 1 ML 25 Tier 1 GAUGE X 5/8" (syringe with needle,disposable) MONOJECT TB SAFETY SYRINGE SYRINGE 1 ML 28 Tier 1 GAUGE X 1/2" (syringe,safety with needle) MONOJECT TB SYRINGE 1 ML 28 GAUGE X 1/2" (syringe Tier 1 with needle,disposable) MONOJECT TUBERCULIN SYRINGE SYRINGE 1 ML Tier 1 (syringe, disposable) MONOJECT TUBERCULIN SYRINGE SYRINGE 1 ML 28 GAUGE X 1/2", 1/2 ML 28 X 1/2" (syringe with Tier 1 needle,disposable) MONOJECT ULTRA COMFORT INSULIN SYRINGE 1/2 Tier 1 ML 28 GAUGE (syringe with needle,insulin disposable) MONOLET THIN LANCETS 28 GAUGE (lancets) DME MOUTHPIECE REUSABLE MW (nebulizer accessories) Tier 3 MULTI-LANCET DEVICE 2 KIT (lancing device) DME MY MDI PORTABLE NEBULISER DEVICE (nebulizer) Tier 3 myelogram tray tray Tier 3 MYGLUCOHEALTH CONTROL SOLUTION SOLUTION DME (blood-glucose calibration control, high) MYGLUCOHEALTH KIT (blood-glucose meter) DME MYGLUCOHEALTH LANCETS 30 GAUGE (lancets) DME MYGLUCOHEALTH STRIP (blood sugar diagnostic) DME NEXIVA INFUSION SET 18 X 1 1/4 ", 18 X 1 3/4 ", 20 GAUGE X 1", 20 X 1 1/4 ", 20 X 1 3/4 ", 24 GAUGE X 3/4", Tier 3 24 X 0.56 " (intravenous catheter) NORM-JECT SYRINGE 10 ML, 20 ML (syringe, disposable) Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

474 Coverage Prescription Drug Name Drug Tier Requirements and Limits NORM-JECT TUBERKULIN SYRINGE 1 ML (syringe, Tier 1 disposable) NOSE CLIP (nebulizer accessories) Tier 3 NOVA MAX GLUCOSE CONTROL SOLUTION (blood- DME glucose calibration control, normal) NOVA SUREFLEX LANCETS (lancets) DME NOVAMAX PLUS GLU-KET SOLUTION (blood-glucose DME calibration control, normal) NOVOFINE 32 NEEDLE 32 GAUGE X 1/4" (pen needle, Tier 1 diabetic) NOVOFINE AUTOCOVER NEEDLE 30 GAUGE X 1/3" (pen Tier 1 needle, diabetic, safety) NOVOFINE PLUS NEEDLE 32 GAUGE X 1/6" (pen needle, Tier 1 diabetic) NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN DME (insulin administration supplies) NOVOTWIST NEEDLE 32 GAUGE X 1/5" (pen needle, Tier 1 diabetic) OASIS ULTRA FENESTRATED TOPICAL SHEET 3 X 3.5 Tier 3 CM, 3 X 7 CM (porcine acellular small intestine submucosa) OASIS WOUND MATRIX FENESTRATED TOPICAL SHEET 3 X 3.5 CM, 3 X 7 CM (porcine acellular small Tier 3 intestine submucosa) OASIS WOUND MATRIX MESHED TOPICAL SHEET 5 X 7 CM, 7 X 10 CM, 7 X 20 CM (porcine acellular small intestine Tier 3 submucosa) OMBRA COMPRESSOR SYSTEM DEVICE (nebulizer) Tier 3 OMNIPOD DASH INSULIN POD SUBCUTANEOUS Tier 4 CARTRIDGE (insulin pump cartridge) OMNIPOD INSULIN MANAGEMENT (subcutaneous insulin Tier 3 pump)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

475 Coverage Prescription Drug Name Drug Tier Requirements and Limits OMNIPOD INSULIN REFILL SUBCUTANEOUS Tier 4 CARTRIDGE (insulin pump cartridge) ON CALL EXPRESS CONTROL SOLUTION (blood- DME glucose calibration control, high) ON CALL EXPRESS METER (blood-glucose meter) DME ON CALL EXPRESS METER KIT (blood-glucose meter) DME ON CALL EXPRESS TEST STRIP STRIP (blood sugar DME diagnostic) ON CALL LANCET 30 GAUGE (lancets) DME ON CALL LANCING DEVICE (lancing device) DME ON CALL PLUS CONTROL SOLUTION (blood-glucose DME calibration control, high) ON CALL PLUS LANCET 30 GAUGE (lancets) DME ON CALL PLUS LANCING DEVICE (lancing device) DME ON CALL PLUS METER KIT (blood-glucose meter) DME ON CALL PLUS TEST STRIP STRIP (blood sugar DME diagnostic) ON CALL VIVID CONTROL SOLUTION (blood-glucose DME calibration control, high) ON CALL VIVID METER KIT (blood-glucose meter) DME ON CALL VIVID PAL METER KIT (blood-glucose meter) DME ONETOUCH DELICA LANC DEVICE KIT (lancing device) DME ONETOUCH DELICA LANCETS 30 GAUGE (lancets) DME ONETOUCH DELICA PLUS LANC DEV KIT (lancing DME device) ONETOUCH DELICA PLUS LANCET 30 GAUGE, 33 DME GAUGE (lancets) ONETOUCH SURESOFT LANCING DEV 18 GAUGE, 21 DME GAUGE, 28 GAUGE (lancets) ONETOUCH ULTRASOFT LANCETS (lancets) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

476 Coverage Prescription Drug Name Drug Tier Requirements and Limits ONETOUCH VERIO HIGH CONTROL SOLUTION (blood- DME glucose calibration control, high) ONETOUCH VERIO IQ METER (blood-glucose meter) DME ONETOUCH VERIO IQ METER KIT (blood-glucose meter) DME ONETOUCH VERIO MID CONTROL SOLUTION (blood- DME glucose calibration control, normal) ONETOUCH VERIO SYSTEM (blood-glucose meter) DME OPTICHAMBER ADULT MASK-LARGE DEVICE (inhaler, Tier 3 assist devices, accessories) OPTICHAMBER DIAMOND LG MASK SPACER (inhaler, Tier 3 assist device with large mask) OPTICHAMBER DIAMOND VHC SPACER (inhaler, assist Tier 3 devices) OPTICHAMBER DIAMOND-MED MSK SPACER (inhaler, Tier 3 assist device with medium mask) OPTICHAMBER DIAMOND-SML MASK SPACER (inhaler, Tier 3 assist device with small mask) OPTUMRX (blood-glucose meter) DME OPTUMRX KIT (blood-glucose meter) DME OPTUMRX SOLUTION (blood-glucose calibration control, DME high) OPTUMRX STRIP (blood sugar diagnostic) DME OVAL TAPE (diabetic supplies, miscellaneous) DME PARADIGM REAL-TIME TRANSMIT-SN (blood-glucose Tier 3 transmitter) PARADIGM REMOTE CONTROL (diabetic supplies, DME miscellaneous) PARADIGM RESERVOIR 1.8 ML, 3 ML (insulin pump Tier 1 syringe) PARI BABY CONV KIT - SIZE 1 KIT (nebulizer accessories) Tier 3 PARI BABY CONV KIT - SIZE 2 KIT (nebulizer accessories) Tier 3 Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

477 Coverage Prescription Drug Name Drug Tier Requirements and Limits PARI BABY CONV KIT - SIZE 3 KIT (nebulizer accessories) Tier 3 PARI BABY CONVERSION PACK 1 (nebulizer Tier 3 accessories) PARI BABY CONVERSION PACK 2 (nebulizer Tier 3 accessories) PARI LC D NEBULIZER (nebulizer) Tier 3 PARI LC FILTER WITH VALVE SET (nebulizer Tier 3 accessories) PARI LC MASK SET (nebulizer accessories) Tier 3 PCCA ACCUPEN-15 DEVICE (topical cream metered-dose Tier 3 device) PEAK AIR PEAK FLOW METER DEVICE (peak flow meter) DME PEDIATRIC DINOSAUR NEBULIZER DEVICE (nebulizer) Tier 3 PEDIATRIC DOG NEBULIZER DEVICE (nebulizer) Tier 3 PEDIATRIC FROG NEBULIZER DEVICE (nebulizer) Tier 3 pen needle, diabetic needle 32 gauge x 3/16" Tier 1 PERSONAL BEST FULL RANGE DEVICE (peak flow DME meter) PERSONAL BEST LOW RANGE DEVICE (peak flow DME meter) PFLEX INSPIRATORY TRAINER DEVICE (spirometers Tier 3 and accessories) PHARMACIST CHOICE STRIP (blood sugar diagnostic) DME PHASEAL ASSEMBLY FIXTURE DEVICE (assembly Tier 3 sys,vial to transfer device,closed system) PHASEAL INFUSION ADAPTER (infusion adapter, closed Tier 3 system) PHASEAL INJECTOR LUER (needle injector, luer, closed Tier 3 system) PHASEAL PROTECTOR DEVICE 28 MM (transfer device, Tier 3 closed system) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

478 Coverage Prescription Drug Name Drug Tier Requirements and Limits PHASEAL SECONDARY SET INFUSION SET (intravenous Tier 3 piggyback administration set) PHASEAL Y-SITE (y-site line connector, closed system) Tier 3 PIKO 1 DEVICE (peak flow meter) DME PILLOW MASK CHILD (nebulizer accessories) Tier 3 PIP LANCET 28 GAUGE (lancets) DME POCKET PEAK FLOW METER DEVICE (peak flow meter) DME POLY HUB NEEDLE NEEDLE 30 GAUGE X 1/2" (needles, Tier 1 disposable) POLYFIN QR INFUSION SET (subcutaneous infusion Tier 3 pump accessory) POLYFIN QR/WINGS INFUSION SET (subcutaneous Tier 3 infusion pump accessory) PORTABLE NEBULIZER SYSTEM DEVICE (nebulizer) Tier 3 PRECISION (blood-glucose meter) DME PRECISION GLUCOSE CONTROL SOLN COMBO PACK DME (blood-glucose calibration control) PRECISION GLUCOSE/KETONE CONTR COMBO PACK DME (blood-glucose calibration control) PREMIER BLU GLUCOSE METER (blood-glucose meter) DME PREMIER COMPACT GLUCOSE METER KIT (blood- DME glucose meter) PREMIER VOICE GLUCOSE METER (blood-glucose DME meter) PREMIUM V10 (blood-glucose meter) DME PREMIUM V10 STRIP (blood sugar diagnostic) DME PRESSURE ACTIVATED LANCETS 21 GAUGE, 28 DME GAUGE (lancets) PRESTO PRO BLOOD GLUCOSE METER (blood-glucose DME meter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

479 Coverage Prescription Drug Name Drug Tier Requirements and Limits PREVENT DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16" (pen needle, diabetic, Tier 1 safety) PRIMEAIRE SPACER (inhaler, assist devices) Tier 3 PRO COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE Tier 1 X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) PRO COMFORT LANCET 30 GAUGE, 31 GAUGE DME (lancets) PRO COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 5/16", 32 GAUGE X 1/4", 32 GAUGE X 3/16", 32 GAUGE X Tier 1 5/32" (pen needle, diabetic) PRO COMFORT SPACER-ADULT MASK SPACER Tier 3 (inhaler, assist device with large mask) PRO COMFORT SPACER-CHILD MASK SPACER (inhaler, Tier 3 assist device with small mask) PRO COMFORT TENS ELECTRODE PAD (tens unit Tier 3 electrodes) PRO COMFORT TENS UNIT COMBO PACK (TENS unit) Tier 3 PRO VOICE V8 GLUCOSE MONITOR (blood-glucose DME meter) PRO VOICE V8-V9 TEST STRIP STRIP (blood sugar DME diagnostic) PRO VOICE V9 GLUCOSE MONITOR (blood-glucose DME meter) PROCARE COMPRESSOR NEBULIZER DEVICE Tier 3 (nebulizer) PROCARE SPACER WITH ADULT MASK SPACER Tier 3 (inhaler, assist device with large mask)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

480 Coverage Prescription Drug Name Drug Tier Requirements and Limits PROCARE SPACER WITH CHILD MASK SPACER Tier 3 (inhaler, assist device with medium mask) PRO-CEPTION VAGINAL (medical supply, miscellaneous) Tier 3 PROCHAMBER SPACER (inhaler, assist devices) Tier 3 PRODIGY AUTOCODE MONITOR SYST (blood-glucose DME meter) PRODIGY CONTROL SOLUTION,HIGH SOLUTION DME (blood-glucose calibration control, high) PRODIGY INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) PRODIGY LANCETS 28 GAUGE (lancets) DME PRODIGY LANCING DEVICE (lancing device) DME PRODIGY VOICE GLUCOSE METER KIT (blood-glucose DME meter) PRONEB ULTRA FILTER ASSEMBLY (nebulizer Tier 3 accessories) PRONEB ULTRA II DEVICE (nebulizer) Tier 3 PRONEB ULTRA II FILTER ASSEM (nebulizer Tier 3 accessories) PROVENT NASAL DEVICE (nasal exhalation resistance Tier 3 device) PROVENT STARTER NASAL DEVICE (nasal exhalation Tier 3 resistance device) PULMONEB LT COMPRESSOR NEBUL DEVICE Tier 3 (nebulizer) PUSH BUTTON SAFETY LANCETS 21 GAUGE (lancets) DME QUAKE VIBRATORY PEP DEVICE (mucus clearing Tier 3 device) QUINTET AC (blood-glucose meter) DME QUINTET AC STRIP (blood sugar diagnostic) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

481 Coverage Prescription Drug Name Drug Tier Requirements and Limits QUINTET BLOOD GLUCOSE METER (blood-glucose DME meter) QUINTET GLUCOSE TEST STRIPS STRIP (blood sugar DME diagnostic) RAPPORT VACUUM THERAPY KIT (vacuum erection Tier 3 device system) RATE FLOW REGULATOR IV SET INFUSION SET Tier 3 (intravenous administration set) READYLANCE SAFETY LANCETS 21 GAUGE, 23 DME GAUGE, 26 GAUGE, 28 GAUGE, 30 GAUGE (lancets) RECONSTITUBE KIT (medical supply, miscellaneous) Tier 3 REFUAH PLUS GLUCOSE CONTROL SOLUTION (blood- DME glucose calibration control, high) REFUAH PLUS GLUCOSE MONITOR KIT (blood-glucose DME meter) REFUAH PLUS STRIP (blood sugar diagnostic) DME RELIAMED LANCET 23 GAUGE, 30 GAUGE (lancets) DME RELIAMED MINI LANCING DEVICE (lancing device) DME RELIAMED SAFETY SEAL LANCETS 28 GAUGE, 30 DME GAUGE (lancets) RELIAMED TWIST AND CAP LANCET 28 GAUGE DME (lancets) RELION ALL-IN-ONE METER KIT (blood-glucose meter) DME RELION MICRO GLUCOSE MONITOR (blood-glucose DME meter) RELION MICRO GLUCOSE MONITOR KIT (blood-glucose DME meter) RELION NEEDLES NEEDLE 31 GAUGE X 1/4" (pen Tier 1 needle, diabetic) RELION PEN NEEDLES NEEDLE 32 GAUGE X 5/32" (pen Tier 1 needle, diabetic)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

482 Coverage Prescription Drug Name Drug Tier Requirements and Limits RELION THIN LANCETS 26 GAUGE (lancets) DME RELION ULTIMA STRIP (blood sugar diagnostic) DME RELION ULTRA THIN PLUS LANCETS (lancets) DME RELIZORB CARTRIDGE (enteral pump accessory for fat Tier 3 hydrolysis) REPLACEMENT PEDIATRIC MONITOR (diabetic supplies, DME miscellaneous) REPLICARE DRESSING TOPICAL BANDAGE 1 1/2 X 2 Tier 3 1/2 ", 4 X 4 ", 6 X 6 ", 8 X 8 " (hydrocolloid dressing) REPLICARE THIN TOPICAL BANDAGE 2 X 2 3/4 ", 3 1/2 X Tier 3 5 1/2 ", 6 X 8 " (hydrocolloid dressing) REPLICARE ULTRA DRESSING TOPICAL BANDAGE 4 X Tier 3 4 ", 6 X 6 ", 7 X 8 " (hydrocolloid dressing) RESTORE TOPICAL BANDAGE 2 X 2 " (silver) Tier 3 RIGHTEST CONTROL SOLUTION HIGH SOLUTION DME (blood-glucose calibration control, high) RIGHTEST CONTROL SOLUTION NORM SOLUTION DME (blood-glucose calibration control, normal) RIGHTEST GC250S CNTRL SOL NORM SOLUTION DME (blood-glucose calibration control, normal) RIGHTEST GD500 LANCING DEVICE (lancing device) DME RIGHTEST GL300 LANCETS 30 GAUGE (lancets) DME RIGHTEST GM250S GLUCOSE METER (blood-glucose DME meter) RIGHTEST GM260 GLUCOSE METER (blood-glucose DME meter) RIGHTEST GM550 SYSTEM KIT (blood-glucose meter) DME RIGHTEST GS250S TEST STRIPS STRIP (blood sugar DME diagnostic) RIGHTEST GS260 TEST STRIPS STRIP (blood sugar DME diagnostic)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

483 Coverage Prescription Drug Name Drug Tier Requirements and Limits RIGHTEST GS550 TEST STRIPS STRIP (blood sugar DME diagnostic) RITEFLO AEROCHAMBER SPACER (inhaler, assist Tier 3 devices) ROBINSON CLEAR VINYL CATHETER 16 FR (catheter) Tier 3 RUBBER MOUTHPIECE (nebulizer accessories) Tier 3 SAFE-CLIP NEEDLE STORAGE DEV DEVICE (needle DME clipping and storage device) SAFESNAP SYRINGE SYRINGE 1 ML 25 GAUGE X 5/8", 10 ML 20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10 ML 21 GAUGE X 1 1/2", 10 ML 21 GAUGE X 1", 10 ML 22 GAUGE X 1 1/2", 10 ML 22 GAUGE X 1", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X 1 1/2", Tier 1 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8", 5 ML 20 GAUGE X 1 1/2", 5 ML 20 GAUGE X 1", 5 ML 21 GAUGE X 1 1/2" (syringe, needle, safety, self-cont disposal unit) SAFETY LANCETS 26 GAUGE (lancets) DME safety needles needle 18 gauge x 1 1/2" Tier 3 SAFETY-LET LANCETS 30 GAUGE (lancets) DME SAMI THE SEAL DEVICE (nebulizer) Tier 3 SAMI THE SEAL MASK (nebulizer accessories) Tier 3 SCARCINPAD TOPICAL PAD 1.57 X 5.12 " (gel-matrix pad Tier 3 dressing, silicone) SCARSILK TOPICAL PAD 2 X 5.5 " (gel-matrix pad Tier 3 dressing, silicone) SELF-CATHETER, FEMALE 14 FR (catheter) Tier 3 SEN-SERTER (diabetic supplies, miscellaneous) DME SIDEKICK BLOOD GLUCOSE SYSTEM KIT (blood sugar DME diagnostic) SIDESTREAM MASK (nebulizer accessories) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

484 Coverage Prescription Drug Name Drug Tier Requirements and Limits SIDESTREAM PLUS (nebulizer) Tier 3 SILASTIC FOLEY CATHETER 20 FR (catheter) Tier 3 SILHOUETTE 23"-FULL SET INFUSION SET (infusion set Tier 3 for insulin pump) SILHOUETTE 43"-FULL SET INFUSION SET (infusion set Tier 3 for insulin pump) SILICONE MASK - INFANT DEVICE (inhaler, assist Tier 3 devices, accessories) SIL-K TOPICAL PAD 2 X 5.5 " (gel-matrix pad dressing, Tier 3 silicone) SILTREX TOPICAL PAD 2 X 5.5 " (gel-matrix pad dressing, Tier 3 silicone) SINGLE-LET (lancets) DME SMART CARESENS N KIT (blood-glucose meter) DME SMART SENSE LANCETS 21 GAUGE, 33 GAUGE DME (lancets) SMARTDIABETES VANTAGE (lancing device) DME SMARTEST CONTROL SOLUTION (blood-glucose DME calibration control, normal) SMARTEST LANCET (lancets) DME SMARTEST PERSONA GLUCOSE METER (blood-glucose DME meter) SMARTEST PERSONA STARTER KIT (blood-glucose DME meter) SMARTEST PRONTO GLUCOSE METER (blood-glucose DME meter) SMARTEST PRONTO STARTER KIT (blood-glucose DME meter) SMARTEST TEST STRIP (blood sugar diagnostic) DME SOF-SERTER INSERTION DEVICE (diabetic supplies, DME miscellaneous)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

485 Coverage Prescription Drug Name Drug Tier Requirements and Limits SOF-SET CANNULA 24" TUBING INFUSION SET (infusion Tier 3 set for insulin pump) SOF-SET MICRO 24" POLYFIN TUB INFUSION SET Tier 3 (infusion set for insulin pump) SOF-SET MICRO 42" POLYFIN TUB INFUSION SET Tier 3 (infusion set for insulin pump) SOF-SET QR 42" TUBING INFUSION SET (infusion set for Tier 3 insulin pump) SOFT TOUCH LANCETS (lancets) DME SOLUS V2 AUDIBLE METER (blood-glucose meter) DME SOLUS V2 AUDIBLE METER KIT (blood-glucose meter) DME SOLUS V2 CONTROL SOLUTION, LOW SOLUTION DME (blood-glucose calibration control, low) SOLUS V2 CONTROL SOLUTION,HIGH SOLUTION DME (blood-glucose calibration control, high) SOLUS V2 LANCETS 28 GAUGE, 30 GAUGE (lancets) DME SOLUS V2 LANCING DEVICE KIT (lancing device) DME SOLUS V2 TEST STRIPS STRIP (blood sugar diagnostic) DME SOOTHENEB COMPRESSOR NEBULIZER DEVICE Tier 3 (nebulizer) SOOTHENEB MESH NEBULIZER (nebulizer) Tier 3 SPACE CHAMBER PLUS SPACER (inhaler, assist Tier 3 devices) SPECTRAGEL TOPICAL GEL (gel dressing) Tier 3 SPEEDICATH (FEMALE) 16 FR (catheter) Tier 3 STERILANCE TL 30 GAUGE, 32 GAUGE (lancets) DME SUNRISE COMPRESSOR-NEBULIZER DEVICE Tier 3 (compressor, for nebulizer) SUPER THIN LANCETS (lancets) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

486 Coverage Prescription Drug Name Drug Tier Requirements and Limits SURE COMFORT INS. SYR. U-100 SYRINGE 0.5 ML 29 Tier 1 GAUGE X 1/2" (syringe with needle,insulin disposable) SURE COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 1/4", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE Tier 1 X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2", 1/2 ML 31 GAUGE X 1/4" (syringe with needle,insulin disposable) SURE COMFORT LANCETS 18 GAUGE, 21 GAUGE, 23 DME GAUGE, 28 GAUGE (lancets) SURE COMFORT LANCING PEN (lancing device) DME SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X Tier 1 5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32" (pen needle, diabetic) SUREFLEX LANCING DEVICE (lancing device) DME SURE-JECT INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 31 Tier 1 GAUGE X 5/16 (syringe with needle,insulin disposable) SURE-LANCE 26 GAUGE (lancets) DME SURE-PEN LANCING DEVICE (lancing device) DME SURE-T INFUSION SET (subcutaneous infusion pump Tier 3 accessory) SURE-TOUCH LANCET (lancets) DME SURGUARD2 SAFETY NEEDLE 23 GAUGE X 1" (needles, Tier 3 safety) syringe (disposable) syringe 20 ml Tier 1 SYRINGE 3CC/20GX1" SYRINGE 3 ML 20 GAUGE X 1" Tier 1 (syringe with needle,disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

487 Coverage Prescription Drug Name Drug Tier Requirements and Limits SYRINGE 3CC/21GX1" SYRINGE 3 ML 21 GAUGE X 1" Tier 1 (syringe with needle,disposable) SYRINGE 3CC/21GX1-1/2" SYRINGE 3 ML 21 GAUGE X 1 Tier 1 1/2" (syringe with needle,disposable) SYRINGE 3CC/22GX1" SYRINGE 3 ML 22 GAUGE X 1" Tier 1 (syringe with needle,disposable) SYRINGE 3CC/22GX3/4" SYRINGE 3 ML 22 GAUGE X Tier 1 3/4" (syringe with needle,disposable) SYRINGE 3CC/25GX1" SYRINGE 3 ML 25 GAUGE X 1" Tier 1 (syringe with needle,disposable) syringe with needle syringe 3 ml 21 gauge x 1 1/2", 3 ml 23 Tier 1 gauge x 1 1/2" syringe with needle, safety syringe 1 ml 25 gauge x 5/8", 3 Tier 1 ml 22 gauge x 1" SYRINGE WITHOUT NEEDLE SYRINGE (syringe, Tier 1 disposable) T.E.D. KNEE LENGTH-M-LONG (compress. stocking,knee Tier 3 high, long length, small) T.E.D. KNEE LENGTH-S-REGULAR (compress. Tier 3 stocking,knee high,regular length, small) T:FLEX INSULIN DELIVERY PUMP (subcutaneous insulin Tier 3 pump) T:SLIM G4 INSULIN PUMP (subcutaneous insulin pump) Tier 3 T:SLIM G4 SUBCUTANEOUS CARTRIDGE (insulin pump Tier 4 cartridge) TELCARE BGM KIT (blood-glucose meter) DME TELCARE BLOOD GLUCOSE KIT KIT (blood-glucose DME meter) TELCARE CONTROL SOLUTION (blood-glucose DME calibration control, high) TELCARE LANCETS 30 GAUGE (lancets) DME

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

488 Coverage Prescription Drug Name Drug Tier Requirements and Limits TELCARE TEST STRIPS STRIP (blood sugar diagnostic) DME TENS 502 DEVICE (TENS unit) Tier 3 TENS 504 DEVICE (TENS unit) Tier 3 TERUMO ALLERGY SYRINGE SYRINGE 1 ML 27 X 1/2" Tier 1 (syringe with needle,disposable) TERUMO HYPODERMIC NEEDLE/SYRIN SYRINGE 5 ML 20 X 1 1/2", 5 ML 20 X 1", 5 ML 21 GAUGE X 1 1/2", 5 ML Tier 1 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5 ML 22 X 1" (syringe with needle,disposable) TERUMO INSULIN SYRINGE SYRINGE 0.3 ML 30 X 3/8", 0.5 ML 29 GAUGE X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2", 1/2 ML 27 GAUGE Tier 1 X 1/2", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin disposable) TERUMO SYRINGE SYRINGE 3 ML 23 GAUGE X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3 ML 25 X 5/8" (syringe Tier 1 with needle,disposable) TEST N'GO BLOOD GLUCOSE SYSTEM (blood-glucose DME meter) TEST N'GO TEST STRIP (blood sugar diagnostic) DME THINPRO INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 X 3/8", 0.3 ML 31 X 3/8", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 31 X 3/8", 1 ML 28 GAUGE X Tier 1 1/2", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 3/8", 1 ML 31 X 3/8", 1/2 ML 28 GAUGE X 1/2", 1/2 ML 30 X 3/8" (syringe with needle,insulin disposable) THRESHOLD IMT TRAINER DEVICE (spirometers and Tier 3 accessories) THRESHOLD PEP DEVICE DEVICE (spirometers and Tier 3 accessories) TOOMEY SYRINGE SYRINGE 70 ML (syringe, disposable Tier 1 irrigation)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

489 Coverage Prescription Drug Name Drug Tier Requirements and Limits TOPCARE CLICKFINE NEEDLE 31 GAUGE X 1/4", 31 Tier 1 GAUGE X 5/16" (pen needle, diabetic) TOPCARE ULTRA COMFORT SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 Tier 1 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) TOPCARE UNIVERSAL1 LANCET 33 GAUGE (lancets) DME TOUCH-TROL 10 FR (catheter) Tier 3 TRUE COMFORT INSULIN SYRINGE SYRINGE 0.5 ML 31 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16 (syringe with Tier 1 needle,insulin disposable) TRUE COMFORT LANCET 30 GAUGE (lancets) DME TRUE COMFORT PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 32 GAUGE X 5/32" (pen needle, Tier 1 diabetic) TRUE2GO BLOOD GLUCOSE SYSTEM KIT (blood- DME glucose meter) TRUECONTROL LEVEL 0 SOLUTION (blood-glucose DME calibration control, high) TRUECONTROL LEVEL 1 SOLUTION (blood-glucose DME calibration control, low) TRUEPLUS KETONE STRIP (urine acetone test,strips) DME TRUEPLUS LANCETS 26 GAUGE, 33 GAUGE (lancets) DME TRUERESULT BLOOD GLUCOSE SYSTM KIT (blood- DME glucose meter) TRUETRACK SMART SYSTEM KIT (blood-glucose meter) DME TRUNEB NEBULIZER (nebulizer) Tier 3 TRUZONE PEAK FLOW METER DEVICE (peak flow DME meter)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

490 Coverage Prescription Drug Name Drug Tier Requirements and Limits TUBERCULIN SYRINGE SYRINGE 1 ML (syringe, Tier 1 disposable) TUBERCULIN SYRINGE SYRINGE 1 ML 25 GAUGE X Tier 1 5/8", 1 ML 27 X 1/2" (syringe with needle,disposable) tuberculin-allergy syringes syringe 1 ml 26 gauge x 3/8" Tier 1 ULTICARE SAFETY SYRINGE SYRINGE 3 ML (syringe, Tier 1 safety) ULTICARE SAFETY SYRINGE SYRINGE 3 ML 21 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1 1/2", 3 ML 22 GAUGE X 1", Tier 1 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X 1", 3 ML 25 GAUGE X 5/8" (syringe,safety with needle) ULTICARE TB SAFETY SYRINGE SYRINGE 1 ML 27 GAUGE X 1/2", 1 ML 27 GAUGE X 5/8", 1 ML 28 GAUGE X Tier 1 1/2" (syringe,safety with needle) ULTI-LANCE (lancing device) DME ULTI-LANCE KIT (lancing device) DME ULTILET BASIC LANCETS 30 GAUGE (lancets) DME ULTILET CLASSIC LANCETS 33 GAUGE (lancets) DME ULTILET INSULIN SYRINGE SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X Tier 1 5/16", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 29 (syringe with needle,insulin disposable) ULTILET LANCETS 30 GAUGE, 33 GAUGE (lancets) DME ULTILET PEN NEEDLE NEEDLE 29 GAUGE, 32 GAUGE Tier 1 X 5/32" (pen needle, diabetic) ULTILET SAFETY LANCETS 23 GAUGE (lancets) DME ULTRA CMFT INS SYR HALF UNIT SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16" (syringe with Tier 1 needle,insulin disposable)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

491 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA COMFORT INSULIN SYRINGE SYRINGE 0.3 ML 31 GAUGE X 5/16", 1 ML 31 GAUGE X 5/16 (syringe with Tier 1 needle,insulin disposable) ULTRA FINE LANCETS 30 GAUGE (lancets) DME ULTRA FLO PEN NEEDLE NEEDLE 31 GAUGE X 3/16" Tier 1 (pen needle, diabetic) ULTRA THIN II LANCETS 30 GAUGE (lancets) DME ULTRA THIN LANCETS 33 GAUGE (lancets) DME ULTRA THIN PEN NEEDLE NEEDLE 32 GAUGE X 5/32" Tier 1 (pen needle, diabetic) ULTRA THIN PLUS LANCETS 33 GAUGE (lancets) DME ULTRACARE INSULIN SYRINGE SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 Tier 1 GAUGE X 5/16", 1 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) ULTRA-CARE LANCETS 30 GAUGE (lancets) DME ULTRACARE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4", Tier 1 32 GAUGE X 3/16", 32 GAUGE X 5/32", 33 GAUGE X 5/32" (pen needle, diabetic) ULTRALANCE LANCETS 26 GAUGE, 28 GAUGE (lancets) DME ULTRA-THIN II (SHORT) INS SYR SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.3 ML 31 GAUGE X 5/16", 0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X 5/16", 1 ML 30 Tier 1 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 (syringe with needle,insulin disposable) ULTRA-THIN II (SHORT) PEN NDL NEEDLE 31 GAUGE X Tier 1 5/16" (pen needle, diabetic) ULTRA-THIN II INS PEN NEEDLES NEEDLE 29 GAUGE X Tier 1 1/2" (pen needle, diabetic)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

492 Coverage Prescription Drug Name Drug Tier Requirements and Limits ULTRA-THIN II INSULIN SYRINGE SYRINGE 0.5 ML 29 GAUGE X 1/2", 1 ML 29 GAUGE X 1/2" (syringe with Tier 1 needle,insulin disposable) ULTRA-THIN II LANCETS 28 GAUGE (lancets) DME ULTRATRAK ULTIMATE (blood-glucose meter) DME ULTRATRAK ULTIMATE SOLUTION (blood-glucose DME calibration control, high) ULTRATRAK ULTIMATE STRIP (blood sugar diagnostic) DME UNIFINE PENTIPS NEEDLE 29 GAUGE (pen needle, Tier 1 diabetic) UNISTIK 3 COMFORT LANCET (lancets) DME UNISTIK 3 LANCETS 21 GAUGE (lancets) DME UNISTIK 3 NEONATAL DEVICE KIT (lancing device) DME UNISTIK 3 NEONATAL KIT (lancing device) DME UNISTIK 3 NORMAL LANCET 23 GAUGE (lancets) DME UNISTIK CZT LANCET 23 GAUGE, 28 GAUGE (lancets) DME UNISTIK PRO LANCET 21 GAUGE, 25 GAUGE, 28 DME GAUGE (lancets) UNISTIK SAFETY 28 GAUGE, 30 GAUGE (lancets) DME UNISTIK TOUCH LANCETS 28 GAUGE, 30 GAUGE DME (lancets) UNISTRIP HIGH CONTROL SOLUTION (blood-glucose DME calibration control, high) UNISTRIP LOW CONTROL SOLUTION (blood-glucose DME calibration control, low) UNISTRIP1 TEST STRIP STRIP (blood sugar diagnostic) DME VANISHPOINT SYRINGE SYRINGE 1 ML 25 GAUGE X 1" Tier 1 (syringe with needle,disposable) VAPRO PLUS INTERMITT CATHETER COMBO PACK 14 Tier 3 FR- 16" (urinary bag)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

493 Coverage Prescription Drug Name Drug Tier Requirements and Limits VARITHENA ADMINISTRATION PACK (transfer sets) Tier 3 VERASENS BLOOD GLUCOSE METER (blood-glucose DME meter) VERASENS CONTROL SOLN-LEVEL 1 SOLUTION DME (blood-glucose calibration control, normal) VERASENS METER STARTER KIT KIT (blood-glucose DME meter) VERIFINE PEN NEEDLE NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16", 32 GAUGE X 3/16", 32 GAUGE X 5/32" Tier 1 (pen needle, diabetic) V-GO 20 DEVICE (subcutaneous insulin deliv. device, 20 Tier 3 unit, disp.) V-GO 30 DEVICE (subcutaneous insulin deliv. device, 30 Tier 3 unit. disp.) V-GO 40 DEVICE (subcutaneous insulin deliv. device, 40 Tier 3 unit, disp.) VIVAGUARD INO CONTROL SOLUTION SOLUTION DME (blood-glucose calibration control, high) VIVAGUARD INO GLUCOSE METER (blood-glucose DME meter) VIVAGUARD INO TEST STRIP STRIP (blood sugar DME diagnostic) VIVAGUARD LANCET 30 GAUGE (lancets) DME VIVAGUARD LANCING DEVICE (lancing device) DME VIXONE NEBULIZER (nebulizer) Tier 3 VIXONE NEBULIZER-ADULT MASK (nebulizer) Tier 3 VIXONE NEBULIZER-PEDIATRIC MSK (nebulizer) Tier 3 VORTEX HOLDING CHAMBER CHILD SPACER (inhaler, Tier 3 assist device with medium mask) VORTEX HOLDING CHAMBER TODDLER SPACER Tier 3 (inhaler, assist device with small mask)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

494 Coverage Prescription Drug Name Drug Tier Requirements and Limits WAVESENSE AMP KIT (blood-glucose meter) DME WAVESENSE CONTROL SOLUTION SOLUTION (blood- DME glucose calibration control, normal) WAVESENSE PRESTO (blood-glucose meter) DME WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 65 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 70 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 75 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 80 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 85 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 90 Tier 0 MM (diaphragms, wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 95 Tier 0 MM (diaphragms, wide seal) WILLIS THE WHALE COMPRESSR NEB DEVICE Tier 3 (nebulizer) XEROFORM PETROLATUM DRESSING TOPICAL BANDAGE 2 X 2 ", 4 X 3 "-YARD, 4 X 4 " (bismuth Tier 3 tribromophenate) XEROFORM PETROLATUM OVERWRAP TOPICAL Tier 3 BANDAGE 1 X 8 ", 5 X 9 " (bismuth tribromophenate) XEROFORM TOPICAL BANDAGE 5 X 9 " (bismuth Tier 3 tribromophenate)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

495 Coverage Prescription Drug Name Drug Tier Requirements and Limits Metabolic Disease Enzyme Replacement Agents - Drugs For Metabolic Disease Metabolic Disease Enzyme Replacement, Hypophosphatasia - Drugs For Metabolic Disease STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45 ML, Tier 4 PA 28 MG/0.7 ML, 40 MG/ML, 80 MG/0.8 ML (asfotase alfa) Metabolic Dx Enzyme Replacement, Severe Combined Immune Deficiency - Drugs For Metabolic Disease REVCOVI INTRAMUSCULAR SOLUTION 2.4 MG/1.5 ML Tier 4 PA (1.6 MG/ML) (elapegademase-lvlr) Metabolic Modifiers - Drugs That Alter Metabolism Hyperparathyroid Treatment Agents - Vitamin D Analog-Type - Drugs That Alter Metabolism doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg Tier 1 paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg Tier 1 RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 Tier 2 QL (2 EA per 1 day) HR 30 MCG (calcifediol) Metabolic Modifier - Carnitine Replenisher Agents - Drugs That Alter Metabolism CARNITOR (SUGAR-FREE) ORAL SOLUTION 100 MG/ML Tier 3 (levocarnitine) levocarnitine (with sugar) oral solution 100 mg/ml Tier 1 levocarnitine oral solution 100 mg/ml Tier 1 levocarnitine oral tablet 330 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

496 Coverage Prescription Drug Name Drug Tier Requirements and Limits Metabolic Modifier - Gaucher's Disease, Type-1, Substrate Reduction Tx - Drugs That Alter Metabolism CERDELGA ORAL CAPSULE 84 MG (eliglustat) Tier 3 PA; SP miglustat oral capsule 100 mg Tier 3 PA; SP Metabolic Modifier - Hereditary Orotic Aciduria Treatment Agents - Drugs That Alter Metabolism XURIDEN ORAL GRANULES IN PACKET 2 GRAM Tier 3 PA; SP (uridine) Metabolic Modifier - Hereditary Tyrosinemia Treatment Agents - Drugs That Alter Metabolism nitisinone oral capsule 10 mg, 2 mg, 5 mg Tier 3 PA; SP NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) Tier 3 PA; SP ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG Tier 3 PA; SP (nitisinone) ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) Tier 3 PA; SP Metabolic Modifier - Homocystinuria Treatment Agents - Drugs That Alter Metabolism CYSTADANE ORAL POWDER 1 GRAM/1.7 ML (betaine) Tier 3 SP Metabolic Modifier - Urea Cycle Disorder Agents-Conjugating Agents - Drugs That Alter Metabolism RAVICTI ORAL LIQUID 1.1 GRAM/ML (glycerol Tier 3 PA; SP phenylbutyrate) sodium phenylbutyrate oral powder 0.94 gram/gram Tier 3 PA; SP sodium phenylbutyrate oral tablet 500 mg Tier 3 PA; SP

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

497 Coverage Prescription Drug Name Drug Tier Requirements and Limits Metabolic Modifier-Carbamoyl Phosphate Synthetase 1 (Cps 1) Activator - Drugs That Alter Metabolism CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG Tier 3 SP (carglumic acid) Pharmacoenhancer - Cytochrome P450 Inhibitors - Drugs That Alter Metabolism TYBOST ORAL TABLET 150 MG (cobicistat) Tier 2 Pharmacological Chaperone Tx - Alpha- Galactosidase A Enzyme Stabilizer - Drugs That Alter Metabolism GALAFOLD ORAL CAPSULE 123 MG (migalastat) Tier 3 PA; SP Phenylketonuria(Pku) Tx Agents - Cofactor Of Phenylalanine Hydroxylase - Drugs That Alter Metabolism KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG Tier 3 PA; SP (sapropterin) KUVAN ORAL TABLET,SOLUBLE 100 MG (sapropterin) Tier 3 PA; SP Phenylketonuria(Pku) Tx Agents - Phenylalanine Ammonia Lyase - Drugs That Alter Metabolism PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, Tier 4 PA 2.5 MG/0.5 ML, 20 MG/ML (pegvaliase-pqpz) Mouth-Throat-Dental - Preparations - Drugs For The Mouth And Throat Dental Product - Fluoride Preparations - Drugs For The Mouth And Throat CLINPRO 5000 DENTAL PASTE 1.1 % (fluoride) Tier 3 DENTA 5000 PLUS DENTAL CREAM 1.1 % (fluoride) Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

498 Coverage Prescription Drug Name Drug Tier Requirements and Limits DENTAGEL DENTAL GEL 1.1 % (fluoride) Tier 1 fluoride (sodium) dental cream 1.1 % Tier 1 fluoride (sodium) dental gel 1.1 % Tier 1 fluoride (sodium) oral drops 0.5 mg (1.1 mg sod.fluorid)/ml Tier 0 Age (Max 6 Years) fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. Tier 0 Age (Max 6 Years) fluoride) FLUORIDEX DAILY DEFENSE DENTAL PASTE 1.1 % Tier 3 (fluoride) FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE 1.1-5 Tier 3 % (fluoride) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 Tier 3 % (fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % Tier 3 (fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE Tier 3 1.1-5 % (fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % Tier 3 (fluoride) PREVIDENT DENTAL SOLUTION 0.2 % (fluoride) Tier 3 SF 5000 PLUS DENTAL CREAM 1.1 % (fluoride) Tier 1 SF DENTAL GEL 1.1 % (fluoride) Tier 1 SODIUM FLUORIDE 5000 PLUS DENTAL CREAM 1.1 % Tier 1 (fluoride) Dental Product - Local Anesthetics - Drugs For The Mouth And Throat KOVANAZE NASAL NASAL SPRAY SYRINGE 6-0.1 Tier 3 MG/0.2 ML (tetracaine) ORAQIX DENTAL CARTRIDGE 2.5-2.5 % (lidocaine) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

499 Coverage Prescription Drug Name Drug Tier Requirements and Limits Mouth And Throat - Antifungals - Drugs For The Mouth And Throat clotrimazole mucous membrane troche 10 mg Tier 1 nystatin oral suspension 100,000 unit/ml Tier 1 Mouth And Throat - Anti-Infective Mixtures - Drugs For The Mouth And Throat DEBACTEROL MUCOUS MEMBRANE SOLUTION 30-50 Tier 3 % (sulfuric acid) DEBACTEROL MUCOUS MEMBRANE SWAB 30-50 % Tier 3 (sulfuric acid) Mouth And Throat - Antiseptics - Drugs For The Mouth And Throat chlorhexidine gluconate mucous membrane mouthwash Tier 1 0.12 % chlorhexidine (Paroex Oral Rinse Mucous Membrane Tier 1 Mouthwash 0.12 %) chlorhexidine (Periogard Mucous Membrane Mouthwash Tier 1 0.12 %) Mouth And Throat - Artificial Saliva - Drugs For The Mouth And Throat AQUORAL MUCOUS MEMBRANE AEROSOL,SPRAY Tier 3 (saliva substitute combination no. 3) BOCASAL MUCOUS MEMBRANE POWDER IN PACKET Tier 3 538 MG (saliva substitute combination no. 5) CAPHOSOL MUCOUS MEMBRANE SOLUTION (saliva Tier 3 substitute combination no.2) MUCOSITISRX MUCOUS MEMBRANE POWDER IN Tier 3 PACKET 351 MG (saliva substitute combination no.11) NEUTRASAL MUCOUS MEMBRANE POWDER IN Tier 3 PACKET (saliva substitute combination no.10)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

500 Coverage Prescription Drug Name Drug Tier Requirements and Limits NUMOISYN MUCOUS MEMBRANE LIQUID (flaxseed) Tier 3 NUMOISYN MUCOUS MEMBRANE LOZENGE 0.3 GRAM Tier 3 (sorbitol) SALIVAMAX MUCOUS MEMBRANE POWDER IN Tier 3 PACKET 351 MG (saliva substitute combination no.11) XEROSTOMIA RELIEF MUCOUS MEMBRANE Tier 3 AEROSOL,SPRAY (saliva substitute combination no. 3) Mouth And Throat - Glucocorticoids - Drugs For The Mouth And Throat triamcinolone (Oralone Dental Paste 0.1 %) Tier 1 triamcinolone acetonide dental paste 0.1 % Tier 1 Mouth And Throat - Local Anesthetic Amides - Drugs For The Mouth And Throat lidocaine hcl mucous membrane solution 4 % (40 mg/ml) Tier 1 lidocaine (Lidocaine Viscous Mucous Membrane Solution 2 Tier 1 %) Mouth And Throat - Mucositis-Stomatitis Agents - Drugs For The Mouth And Throat EPISIL MUCOUS MEMBRANE GEL FORMING SOLUTION Tier 3 (mucositis and stomatitis anti-inflamm.agent comb 2) GELCLAIR MUCOUS MEMBRANE GEL IN PACKET Tier 3 (potassium sorbate) GELX MUCOUS MEMBRANE GEL (povidone) Tier 3 ORAMAGICRX MUCOUS MEMBRANE MOUTHWASH Tier 3 (potassium sorbate) Mouth And Throat - Protectants - Drugs For The Mouth And Throat GELX MUCOUS MEMBRANE GEL (povidone) Tier 3 MUGARD MUCOUS MEMBRANE SOLUTION (glycerin) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

501 Coverage Prescription Drug Name Drug Tier Requirements and Limits ORAFATE MUCOUS MEMBRANE PASTE 1 GRAM/10 ML Tier 3 (sucralfate) PROTHELIAL MUCOUS MEMBRANE PASTE 1 GRAM/10 Tier 3 ML (sucralfate) Mouth And Throat - Saliva Stimulants - Drugs For The Mouth And Throat cevimeline oral capsule 30 mg Tier 1 pilocarpine hcl oral tablet 5 mg, 7.5 mg Tier 1 Periodontal Product - Tetracycline Antiinfective, Local - Drugs For The Mouth And Throat ARESTIN DENTAL CARTRIDGE 1 MG (minocycline) Tier 3 PA; SP Periodontal Product - Tetracycline-Type, Collagenase Inhibitors - Drugs For The Mouth And Throat doxycycline hyclate oral tablet 20 mg Tier 1 Therapy For Drooling- Primary Or Secondary Sialorrhea-Anticholinergic - Drugs For The Mouth And Throat CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2 MG/ML) Tier 3 (glycopyrrolate) Multiple Sclerosis Agents - Drugs For The Nervous System Multiple Sclerosis Agent - Interferons - Drugs For Multiple Sclerosis AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 Tier 2 PA MCG (interferon beta-1a) AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 Tier 2 PA MCG/0.5 ML (interferon beta-1a)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

502 Coverage Prescription Drug Name Drug Tier Requirements and Limits AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 Tier 2 PA ML (interferon beta-1a) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon Tier 2 PA beta-1b) BETASERON SUBCUTANEOUS RECON SOLN 0.3 MG Tier 2 PA (interferon beta-1b) EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta- Tier 2 PA 1b) EXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG Tier 2 PA (interferon beta-1b) PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 Tier 4 PA MCG/0.5 ML (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 Tier 2 PA MCG/0.5 ML- 94 MCG/0.5 ML (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML Tier 4 PA (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- Tier 2 PA 94 MCG/0.5 ML (peginterferon beta-1a) REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 Tier 2 PA MCG/0.5 ML (interferon beta-1a) REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 44 Tier 4 PA MCG/0.5 ML (interferon beta-1a) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 Tier 2 PA MCG/0.5ML (6) (interferon beta-1a) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE Tier 2 PA 8.8MCG/0.2ML-22 MCG/0.5ML (6) (interferon beta-1a) Multiple Sclerosis Agent - Others - Drugs For Multiple Sclerosis COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 Tier 2 PA MG/ML (glatiramer (copolymer 1)) glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml Tier 1 PA Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

503 Coverage Prescription Drug Name Drug Tier Requirements and Limits glatiramer (copolymer 1) (Glatopa Subcutaneous Syringe Tier 1 PA 20 Mg/Ml, 40 Mg/Ml) TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), Tier 2 PA 240 MG (dimethyl fumarate) Multiple Sclerosis Agent - Potassium Channel Blocker - Drugs For Multiple Sclerosis dalfampridine oral tablet extended release 12 hr 10 mg Tier 3 PA; SP FIRDAPSE ORAL TABLET 10 MG (amifampridine) Tier 3 PA; SP RUZURGI ORAL TABLET 10 MG (amifampridine) Tier 3 PA; SP Multiple Sclerosis Agent - Purine Nucleoside Analogs - Drugs For Multiple Sclerosis MAVENCLAD (10 TABLET PACK) ORAL TABLET 10 MG Tier 3 PA; SP (cladribine) MAVENCLAD (4 TABLET PACK) ORAL TABLET 10 MG Tier 3 PA; SP (cladribine) MAVENCLAD (5 TABLET PACK) ORAL TABLET 10 MG Tier 3 PA; SP (cladribine) MAVENCLAD (6 TABLET PACK) ORAL TABLET 10 MG Tier 3 PA; SP (cladribine) MAVENCLAD (7 TABLET PACK) ORAL TABLET 10 MG Tier 3 PA; SP (cladribine) MAVENCLAD (8 TABLET PACK) ORAL TABLET 10 MG Tier 3 PA; SP (cladribine) MAVENCLAD (9 TABLET PACK) ORAL TABLET 10 MG Tier 3 PA; SP (cladribine) Multiple Sclerosis Agent - Pyrimidine Synthesis Inhibitors - Drugs For Multiple Sclerosis AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) Tier 2 PA

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

504 Coverage Prescription Drug Name Drug Tier Requirements and Limits Multiple Sclerosis Agent - Sphingosine 1- Phosphate Receptor Modulator - Drugs For Multiple Sclerosis GILENYA ORAL CAPSULE 0.25 MG (fingolimod) Tier 3 PA; SP GILENYA ORAL CAPSULE 0.5 MG (fingolimod) Tier 2 PA MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod) Tier 3 PA; SP MAYZENT STARTER PACK ORAL TABLETS,DOSE PACK Tier 3 PA; SP 0.25 MG (12 TABS) (siponimod) Ophthalmic Agents - Drugs For The Eye Artificial Tears And Lubricant Single Agents - Drugs For The Eye acetylcysteine (pf) in water ophthalmic (eye) drops 10 % Tier 1 KLARITY (CHONDROITIN) (PF) OPHTHALMIC (EYE) Tier 3 DROPS 0.25 % (chondroitin sulfate A) LACRISERT OPHTHALMIC (EYE) INSERT 5 MG Tier 3 (hydroxypropyl cellulose) Miotics - Cholinesterase Inhibitors - Drugs For Glaucoma PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS Tier 3 0.125 % (echothiophate) Miotics - Direct Acting - Drugs For Glaucoma pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % Tier 1 Mydriatic And Cycloplegic Combinations - Drugs For The Eye CYCLOMYDRIL OPHTHALMIC (EYE) DROPS 0.2-1 % Tier 3 (cyclopentolate) cyclopen-tropic-phenyleph-watr ophthalmic (eye) drops 1-1- Tier 1 2.5 % PAREMYD OPHTHALMIC (EYE) DROPS 1-0.25 % Tier 3 (hydroxyamphetamine) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

505 Coverage Prescription Drug Name Drug Tier Requirements and Limits phenyleph-tropicamide in water ophthalmic (eye) drops 2.5- Tier 1 1 % Ophth - Beta Blocker-Adrenerg-Carbonic Anhyd Inhib-Prostagladin Analog - Drugs For Glaucoma timol-brimon-dorzo-latanop(pf) ophthalmic (eye) drops 0.5 Tier 1 %-0.15 %- 2 %-0.005 % Ophthalmic - Adrenergic-Carbonic Anhydrase Inhibitor Combinations - Drugs For Glaucoma brimonidine-dorzolamide (pf) ophthalmic (eye) drops 0.15-2 Tier 1 % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 1-0.2 % (brinzolamide) Ophthalmic - Agents For Corneal Collagen Cross-Linking - Drugs For The Eye PHOTREXA CROSS-LINKING KIT OPHTHALMIC (EYE) COMBO, DROPS AND DROPS VISCOUS 0.146 % -0.146 Tier 3 % (riboflavin (vitamin B2)) PHOTREXA OPHTHALMIC (EYE) DROPS 0.146 % Tier 3 (riboflavin (vitamin B2)) PHOTREXA VISCOUS OPHTHALMIC (EYE) DROPS, Tier 3 VISCOUS 0.146 % (riboflavin (vitamin B2)) Ophthalmic - Antibacterial-Glucocorticoid Combinations - Anti-Infective/Anti- Inflammatories BLEPHAMIDE OPHTHALMIC (EYE) Tier 2 DROPS,SUSPENSION 10-0.2 % (sulfacetamide) sulfacetamide (Blephamide S.O.P. Ophthalmic (Eye) Tier 2 Ointment 10-0.2 %) gatifloxacin-dexamethasone ophthalmic (eye) drops 0.5-0.1 Tier 1 %

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

506 Coverage Prescription Drug Name Drug Tier Requirements and Limits neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5- Tier 1 400-10,000 mg-unit/g-1% neomycin-polymyxin b-dexameth ophthalmic (eye) Tier 1 drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment Tier 1 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-hc ophthalmic (eye) drops,suspension Tier 1 3.5-10,000-10 mg-unit-mg/ml neomycin (Neo-Polycin Hc Ophthalmic (Eye) Ointment 3.5- Tier 1 400-10,000 Mg-Unit/G-1%) PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3- Tier 3 1 % (gentamicin) PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT 0.3-0.6 Tier 3 % (gentamicin) prednisolone acet-gatifloxacin ophthalmic (eye) Tier 1 drops,suspension 1-0.5 % prednisolone sod ph-gatifloxac ophthalmic (eye) drops 1-0.5 Tier 1 % prednisolone sod ph-moxiflox ophthalmic (eye) drops 1-0.5 Tier 1 % prednisolone-moxifloxacin hcl ophthalmic (eye) Tier 1 drops,suspension 1-0.5 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %- Tier 1 0.23 % (0.25 %) TOBRADEX OPHTHALMIC (EYE) OINTMENT 0.3-0.1 % Tier 2 (tobramycin) TOBRADEX ST OPHTHALMIC (EYE) Tier 3 DROPS,SUSPENSION 0.3-0.05 % (tobramycin) tobramycin-dexamethasone ophthalmic (eye) Tier 1 drops,suspension 0.3-0.1 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3- Tier 2 0.5 % (tobramycin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

507 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Antibacterial-Glucocorticoid- Nsaid Combinations - Anti-Infective/Anti- Inflammatories prednisol ace-gatiflox-bromfen ophthalmic (eye) Tier 1 drops,suspension 1-0.5-0.075 % prednisoln sp-gatiflox-bromfen ophthalmic (eye) drops 1- Tier 1 0.5-0.075 % prednisoln sp-moxiflox-bromfen ophthalmic (eye) drops 1- Tier 1 0.5-0.075 % prednisolone-moxiflo-nepafenac ophthalmic (eye) Tier 1 drops,suspension 1-0.5-0.1 % prednisolone-moxiflox-bromfen ophthalmic (eye) Tier 1 drops,suspension 1-0.5-0.075 % Ophthalmic - Anticholinergics - Drugs For The Eye atropine in 0.9 % sod chloride ophthalmic (eye) drops 0.01 Tier 1 % atropine ophthalmic (eye) drops 1 % Tier 1 atropine ophthalmic (eye) drops, emulsion 0.01 % Tier 1 atropine ophthalmic (eye) ointment 1 % Tier 1 cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, 2 % Tier 1 HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 % Tier 1 (homatropine) homatropine hbr ophthalmic (eye) drops 5 % Tier 1 tropicamide ophthalmic (eye) drops 0.5 %, 1 % Tier 1 Ophthalmic - Antifibrotic Agents - Drugs For The Eye MITOSOL OPHTHALMIC (EYE) KIT 0.2 MG (mitomycin) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

508 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic - Antihistamines - Drugs For Itchy Eye azelastine ophthalmic (eye) drops 0.05 % Tier 1 ST: Must meet any of the following requirements: BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % Azelastine HCL, Epinastine Tier 3 (bepotastine) HCL, or Olopatadine HCL in 120 days; QL (10 ML per 30 days) epinastine ophthalmic (eye) drops 0.05 % Tier 1 ST: Must meet any of the following requirements: LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % Azelastine HCL, Epinastine Tier 3 (alcaftadine) HCL, or Olopatadine HCL in 120 days; QL (3 ML per 30 days) olopatadine ophthalmic (eye) drops 0.1 % Tier 1 olopatadine ophthalmic (eye) drops 0.2 % Tier 1 QL (3 ML per 30 days) ST: Must meet any of the following requirements: Azelastine HCL, Epinastine PAZEO OPHTHALMIC (EYE) DROPS 0.7 % (olopatadine) Tier 3 HCL, or Olopatadine HCL in 120 days; QL (2.5 ML per 30 days) Ophthalmic - Anti-Inflammatory, Glucocorticoids - Anti-Infective/Anti- Inflammatories ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % Tier 2 (loteprednol) dexamethasone sodium phosphate ophthalmic (eye) drops Tier 1 0.1 %

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

509 Coverage Prescription Drug Name Drug Tier Requirements and Limits DEXTENZA INTRACANALICULAR INSERT 0.4 MG Tier 3 (dexamethasone) DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % Tier 2 (difluprednate) FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 Tier 2 % (fluorometholone) fluorometholone ophthalmic (eye) drops,suspension 0.1 % Tier 1 FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 0.25 % (fluorometholone) FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % Tier 2 (fluorometholone) ST: Must meet any of the following requirements: INVELTYS OPHTHALMIC (EYE) DROPS,SUSPENSION 1 Alrex, Lotemax, or Tier 3 % (loteprednol) Loteprednol Etabonate in 120 days; QL (5.6 ML per 14 days) KLARITY-B (BETAMETH-CHOND)(PF) OPHTHALMIC Tier 3 (EYE) DROPS 0.1-0.25 % (betamethasone) KLARITY-L (LOTEPRED-CHOND)(PF) OPHTHALMIC Tier 3 (EYE) DROPS 0.2-0.25 %, 0.5-0.25 % (loteprednol) LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % Tier 2 (loteprednol) LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 0.5 % (loteprednol) LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % Tier 2 (loteprednol) LOTEMAX SM OPHTHALMIC (EYE) DROPS,GEL 0.38 % Tier 2 (loteprednol) loteprednol etabonate ophthalmic (eye) drops,suspension Tier 1 0.5 %

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

510 Coverage Prescription Drug Name Drug Tier Requirements and Limits MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 Tier 3 % (dexamethasone) PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 0.12 % (prednisolone) prednisolone acetate (pf) ophthalmic (eye) Tier 1 drops,suspension 1 % prednisolone acetate ophthalmic (eye) drops,suspension 1 Tier 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % Tier 1 Ophthalmic - Anti-Inflammatory, Immunomodulators - Anti-Infective/Anti- Inflammatories ST: Must meet the following requirement: CEQUA OPHTHALMIC (EYE) DROPPERETTE 0.09 % Tier 3 Restasis or Xiidra in 120 (cyclosporine) days; QL (60 EA per 30 days) CYCLOSPORINE IN KLARITY OPHTHALMIC (EYE) Tier 1 DROPS 0.1-0.25 % (cyclosporine) RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS Tier 2 QL (5.5 ML per 30 days) 0.05 % (cyclosporine) RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % Tier 2 QL (60 EA per 30 days) (cyclosporine) XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Tier 2 QL (60 EA per 30 days) (lifitegrast) Ophthalmic - Anti-Inflammatory, Nsaids - Anti- Infective/Anti-Inflammatories ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 Tier 3 % (ketorolac) bromfenac ophthalmic (eye) drops 0.09 % Tier 1 BROMSITE OPHTHALMIC (EYE) DROPS 0.075 % Tier 3 (bromfenac) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

511 Coverage Prescription Drug Name Drug Tier Requirements and Limits diclofenac sodium ophthalmic (eye) drops 0.1 % Tier 1 flurbiprofen sodium ophthalmic (eye) drops 0.03 % Tier 1 ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 Tier 2 % (nepafenac) ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % Tier 1 NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3 0.1 % (nepafenac) PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % Tier 2 (bromfenac) Ophthalmic - Beta Blocker-Adrenergic- Carbonic Anhydrase Inhibitor Comb - Drugs For Glaucoma timolol-brimonidi-dorzolam(pf) ophthalmic (eye) drops 0.5- Tier 1 0.15-2 % Ophthalmic - Beta Blocker-Carbonic Anhydrase Inhib-Prostagladin Analog - Drugs For Glaucoma timolol-dorzolamid-latanop(pf) ophthalmic (eye) drops 0.5-2- Tier 1 0.005 % Ophthalmic - Beta Blockers-Adrenergic Combinations - Drugs For Glaucoma COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-0.5 % Tier 2 (brimonidine) Ophthalmic - Beta Blockers-Carbonic Anhydrase Inhibitor Combinations - Drugs For Glaucoma COSOPT OPHTHALMIC (EYE) DROPS 22.3-6.8 MG/ML Tier 2 (dorzolamide)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

512 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: dorzolamide-timolol (pf) ophthalmic (eye) dropperette 2-0.5 Tier 1 Cosopt or Dorzolamide % HCL/timolol Maleat in 120 days; QL (2 EA per 1 day) dorzolamide-timolol (pf) ophthalmic (eye) drops 2-0.5 % Tier 1 dorzolamide-timolol ophthalmic (eye) drops 22.3-6.8 mg/ml Tier 1 Ophthalmic - Beta Blockers-Prostaglandin Analog Combinations - Drugs For Glaucoma timolol-latanoprost(pf) ophthalmic (eye) drops 0.5-0.005 % Tier 1 Ophthalmic - Carbonic Anhydrase Inhibitors - Drugs For Glaucoma AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % Tier 2 (brinzolamide) dorzolamide (pf) ophthalmic (eye) drops 2 % Tier 1 dorzolamide ophthalmic (eye) drops 2 % Tier 1 Ophthalmic - Chelating Agents - Drugs For The Eye edetate disodium ophthalmic (eye) drops 3 % Tier 1 Ophthalmic - Cystine Depleting Agents - Drugs For The Eye CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % Tier 3 PA; SP (cysteamine) Ophthalmic - Decongestants - Drugs For Itchy Eye phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 % Tier 1 Ophthalmic - Diagnostic Agents - Drugs For The Eye FLUCAINE OPHTHALMIC (EYE) DROPS 0.25-0.5 % Tier 1 (proparacaine) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

513 Coverage Prescription Drug Name Drug Tier Requirements and Limits fluorescein-proparacaine ophthalmic (eye) drops 0.25-0.5 % Tier 1 Ophthalmic - Glucocorticoid-Nsaid Combinations - Anti-Infective/Anti- Inflammatories prednisolone acetate-bromfenac ophthalmic (eye) Tier 1 drops,suspension 1-0.075 % prednisolone acetate-nepafenac ophthalmic (eye) Tier 1 drops,suspension 1-0.1 % prednisolone sod ph-bromfenac ophthalmic (eye) drops 1- Tier 1 0.075 % Ophthalmic - Human Nerve Growth Factor (Hngf) - Drugs For The Eye OXERVATE OPHTHALMIC (EYE) DROPS 0.002 % Tier 3 PA; SP (cenegermin-bkbj) Ophthalmic - Intraocular Pressure Reducing Agents, Beta-Blockers - Drugs For Glaucoma betaxolol ophthalmic (eye) drops 0.5 % Tier 1 BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % Tier 3 (timolol) BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3 0.25 % (betaxolol) carteolol ophthalmic (eye) drops 1 % Tier 1 levobunolol ophthalmic (eye) drops 0.5 % Tier 1 metipranolol ophthalmic (eye) drops 0.3 % Tier 1 timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % Tier 1 timolol maleate ophthalmic (eye) drops, once daily 0.5 % Tier 1 timolol maleate ophthalmic (eye) gel forming solution 0.25 Tier 1 %, 0.5 %

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

514 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) Tier 3 Timolol Maleate or DROPPERETTE 0.25 %, 0.5 % (timolol) Timoptic Ocudose in 120 days; QL (2 EA per 1 day) Ophthalmic - Local Anesthetic Combinations - Drugs For The Eye ALTAFLUOR BENOX OPHTHALMIC (EYE) DROPS 0.25- Tier 1 0.4 % (benoxinate) Ophthalmic - Local Anesthetic Esters - Drugs For The Eye proparacaine (Alcaine Ophthalmic (Eye) Drops 0.5 %) Tier 1 ALTACAINE OPHTHALMIC (EYE) DROPS 0.5 % Tier 1 (tetracaine) proparacaine ophthalmic (eye) drops 0.5 % Tier 1 tetracaine hcl (pf) ophthalmic (eye) drops 0.5 % Tier 1 tetracaine hcl ophthalmic (eye) drops 0.5 % Tier 1 TETRAVISC FORTE OPHTHALMIC (EYE) Tier 3 DROPPERETTE,HYPERVISCOUS 0.5 % (tetracaine) TETRAVISC FORTE OPHTHALMIC (EYE) Tier 3 DROPS,HYPERVISCOUS 0.5 % (tetracaine) TETRAVISC OPHTHALMIC (EYE) Tier 3 DROPPERETTE,VISCOUS 0.5 % (tetracaine) Ophthalmic - Local Anesthetic, Amides - Drugs For The Eye AKTEN (PF) OPHTHALMIC (EYE) GEL 3.5 % (lidocaine) Tier 3 Ophthalmic - Mast Cell Stabilizers - Drugs For Itchy Eye ALOCRIL OPHTHALMIC (EYE) DROPS 2 % (nedocromil) Tier 2

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

515 Coverage Prescription Drug Name Drug Tier Requirements and Limits ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % Tier 2 (lodoxamide) cromolyn ophthalmic (eye) drops 4 % Tier 1 Ophthalmic - Mydriatic-Nsaid Combinations - Anti-Infective/Anti-Inflammatories MYDRIATIC4(TROP-PROP-PE-KTRLC) OPHTHALMIC Tier 1 (EYE) DROPS 1-0.5-2.5-0.5 % (tropicamide) Ophthalmic - Rho Kinase Inhibitor And Prostaglandin Analog Combination - Drugs For Glaucoma ST: Must meet 2 of the following requirements: Alphagan P, Azopt, ROCKLATAN OPHTHALMIC (EYE) DROPS 0.02-0.005 % Tier 3 Combigan, Latanoprost, (netarsudil) Lumigan, Simbrinza, or Travatan Z in 365 days; QL (2.5 ML per 25 days) Ophthalmic - Surgical Aids Other - Drugs For The Eye GELFILM OPHTHALMIC (EYE) FILM (gelatin) Tier 3 Ophthalmic Antibacterial Mixtures - Anti- Infective/Anti-Inflammatories bacitracin (Ak-Poly-Bac Ophthalmic (Eye) Ointment 500- Tier 1 10,000 Unit/Gram) bacitracin-polymyxin b ophthalmic (eye) ointment 500- Tier 1 10,000 unit/gram neomycin-bacitracin-polymyxin ophthalmic (eye) ointment Tier 1 3.5-400-10,000 mg-unit-unit/g neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 Tier 1 mg-10,000 unit-0.025mg/ml

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

516 Coverage Prescription Drug Name Drug Tier Requirements and Limits neomycin (Neo-Polycin Ophthalmic (Eye) Ointment 3.5-400- Tier 1 10,000 Mg-Unit-Unit/G) bacitracin (Polycin Ophthalmic (Eye) Ointment 500-10,000 Tier 1 Unit/Gram) polymyxin b sulf-trimethoprim ophthalmic (eye) drops Tier 1 10,000 unit- 1 mg/ml Ophthalmic Antibiotic - Aminoglycosides - Anti-Infective/Anti-Inflammatories gentamicin (Gentak Ophthalmic (Eye) Ointment 0.3 % (3 Tier 1 Mg/Gram)) gentamicin ophthalmic (eye) drops 0.3 % Tier 1 tobramycin ophthalmic (eye) drops 0.3 % Tier 1 TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 2 (tobramycin) Ophthalmic Antibiotic - Dehydropeptidase Inhibitors - Anti-Infective/Anti-Inflammatories bacitracin ophthalmic (eye) ointment 500 unit/gram Tier 1 Ophthalmic Antibiotic - Fluoroquinolones - Anti-Infective/Anti-Inflammatories BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 2 0.6 % (besifloxacin) CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % Tier 2 (ciprofloxacin) ciprofloxacin hcl ophthalmic (eye) drops 0.3 % Tier 1 gatifloxacin ophthalmic (eye) drops 0.5 % Tier 1 levofloxacin ophthalmic (eye) drops 0.5 % Tier 1 MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % Tier 2 (moxifloxacin) moxifloxacin ophthalmic (eye) drops 0.5 % Tier 1 ofloxacin ophthalmic (eye) drops 0.3 % Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

517 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic Antibiotic - Macrolides - Anti- Infective/Anti-Inflammatories AZASITE OPHTHALMIC (EYE) DROPS 1 % (azithromycin) Tier 3 erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) Tier 1 KLARITY-A (AZITHRO-CHONDR)(PF) OPHTHALMIC Tier 3 (EYE) DROPS 1-0.25 % (azithromycin) Ophthalmic Antibiotic - Sulfonamides - Anti- Infective/Anti-Inflammatories sulfacetamide (Bleph-10 Ophthalmic (Eye) Drops 10 %) Tier 1 sulfacetamide sodium ophthalmic (eye) drops 10 % Tier 1 sulfacetamide sodium ophthalmic (eye) ointment 10 % Tier 1 Ophthalmic Antifungals - Anti-Infective/Anti- Inflammatories NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 Tier 3 % (natamycin) Ophthalmic Antifungals - Tetraene Polyene- Type - Drugs For The Eye NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 Tier 3 % (natamycin) Ophthalmic Antiseptics - Anti-Infective/Anti- Inflammatories BETADINE OPHTHALMIC PREP OPHTHALMIC (EYE) Tier 3 SOLUTION 5 % (povidone-iodine) Ophthalmic Antivirals - Anti-Infective/Anti- Inflammatories trifluridine ophthalmic (eye) drops 1 % Tier 1 ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % (ganciclovir) Tier 2

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

518 Coverage Prescription Drug Name Drug Tier Requirements and Limits Ophthalmic-Intraocular Press. Reducing, Sel. Alpha Adrenergic Agonists - Drugs For Glaucoma ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % Tier 2 (brimonidine) apraclonidine ophthalmic (eye) drops 0.5 % Tier 1 brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % Tier 1 IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 1 % Tier 3 (apraclonidine) Ophthalmic-Intraocular Pressure Reducing Agents, Prostaglandin Analogs - Drugs For Glaucoma bimatoprost ophthalmic (eye) drops 0.03 % Tier 1 QL (1 ML per 12 days) latanoprost (pf) ophthalmic (eye) drops 0.005 % Tier 1 latanoprost ophthalmic (eye) drops 0.005 % Tier 1 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % Tier 2 QL (2.5 ML per 25 days) (bimatoprost) TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.004 % Tier 2 QL (2.5 ML per 25 days) (travoprost) ST: Must meet 3 of the following requirements: Bimatoprost, Latanoprost, VYZULTA OPHTHALMIC (EYE) DROPS 0.024 % Latanoprost/pf, Lumigan, Tier 3 (latanoprostene bunod) Travatan Z, or Travoprost (benzalkonium) in 365 days; QL (2.5 ML per 25 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

519 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 3 of the following requirements: Bimatoprost, Latanoprost, XELPROS OPHTHALMIC (EYE) DROPS, EMULSION Latanoprost/pf, Lumigan, Tier 3 0.005 % (latanoprost) Travatan Z, or Travoprost (benzalkonium) in 365 days; QL (2.5 ML per 25 days) ST: Must meet 3 of the following requirements: Bimatoprost, Latanoprost, ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE Tier 3 Latanoprost/pf, Lumigan, 0.0015 % (tafluprost) Travatan Z, or Travoprost (benzalkonium) in 365 days; QL (1 EA per 1 day) Ophthalmic-Intraocular Pressure Reducing Agents, Rho Kinase Inhibitors - Drugs For Glaucoma ST: Must meet 2 of the following requirements: Alphagan P, Azopt, RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % Tier 3 Combigan, Latanoprost, (netarsudil) Lumigan, Simbrinza, or Travatan Z in 365 days; QL (2.5 ML per 30 days) Otic (Ear) - Drugs For The Ear Otic (Ear) - Anti-Infective-Glucocorticoid Combinations - Anti-Infective/Anti- Inflammatories CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2-1 % Tier 3 (ciprofloxacin) CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 % Tier 2 (ciprofloxacin)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

520 Coverage Prescription Drug Name Drug Tier Requirements and Limits ciprofloxacin-fluocinolone otic (ear) solution 0.3-0.025 % Tier 1 (0.25 ml) COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION 3.3-3- Tier 3 10-0.5 MG/ML (neomycin) CORTISPORIN-TC OTIC (EAR) DROPS,SUSPENSION Tier 3 3.3-3-10-0.5 MG/ML (neomycin) neomycin-polymyxin-hc otic (ear) drops,suspension 3.5- Tier 1 10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-10,000-1 Tier 1 mg/ml-unit/ml-% OTOVEL OTIC (EAR) SOLUTION 0.3-0.025 % (0.25 ML) Tier 3 (ciprofloxacin) Otic (Ear) - Anti-Infectives Other - Antibiotics acetic acid otic (ear) solution 2 % Tier 1 Otic (Ear) - Fluoroquinolones - Antibiotics ciprofloxacin hcl otic (ear) dropperette 0.2 % Tier 1 ofloxacin otic (ear) drops 0.3 % Tier 1 OTIPRIO INTRATYMPANIC SUSPENSION 6 % (6 MG/0.1 Tier 3 ML) (ciprofloxacin) Otic (Ear) - Glucocorticoids - Anti- Infective/Anti-Inflammatories fluocinolone acetonide oil otic (ear) drops 0.01 % Tier 1 hydrocortisone-acetic acid otic (ear) drops 1-2 % Tier 1 Otic (Ear) - Pinna Combinations - Antibiotics CORTANE-B TOPICAL LOTION 1-1-0.1 % (hydrocortisone) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

521 Coverage Prescription Drug Name Drug Tier Requirements and Limits Respiratory Therapy Agents - Drugs For The Lungs 1St Generation Antihistamine-Decongestant Combinations - Drugs For Cough And Cold CENTERGY ORAL DROPS 1-2 MG/ML (chlorpheniramine) Tier 1 promethazine-phenylephrine oral syrup 6.25-5 mg/5 ml Tier 1 1St Generation Antihistamine-Decongestant- Anticholinergic Combinations - Drugs For Cough And Cold RESPA-AR ORAL TABLET EXTENDED RELEASE 12 HR Tier 1 8-90-0.24 MG (pseudoephedrine) 2Nd Generation Antihistamine-Decongestant Combinations - Drugs For Cough And Cold ST: Must meet the following requirement: CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE Levocetirizine Tier 3 12 HR 2.5-120 MG (desloratadine) Dihydrochloride or Desloratadine in 120 days; QL (2 EA per 1 day) fexofenadine-pseudoephedrine oral tablet extended release Tier 1 24 hr 180-240 mg SEMPREX-D ORAL CAPSULE 8-60 MG Tier 3 (pseudoephedrine) Antihistamine - 1St Generation - Alkylamines - Drugs For Allergies dexchlorpheniramine maleate oral solution 2 mg/5 ml Tier 1 QL (236 ML per 1 FILL) Antihistamine - 1St Generation - Ethanolamines - Drugs For Allergies carbinoxamine maleate oral liquid 4 mg/5 ml Tier 1 Age (Min 2 Years) carbinoxamine maleate oral tablet 4 mg Tier 1 Age (Min 2 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

522 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirements: Carbinoxamine tablet carbinoxamine maleate oral tablet 6 mg Tier 1 (4mg) and solution (4mg/5mL) in 365 days; QL (4 EA per 1 day); Age (Min 2 Years) clemastine oral tablet 2.68 mg Tier 1 diphenhydramine (Diphen Oral Elixir 12.5 Mg/5 Ml) Tier 1 ST: Must meet the following requirement: KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 Carbinoxamine Maleate in Tier 3 HR 4 MG/5 ML (carbinoxamine) 120 days; QL (960 ML per 30 days); Age (Min 2 Years) Antihistamine - 1St Generation - Phenothiazines - Drugs For Allergies promethazine (Phenadoz Rectal Suppository 12.5 Mg, 25 Tier 1 Mg) promethazine injection solution 25 mg/ml, 50 mg/ml Tier 4 promethazine injection syringe 25 mg/ml Tier 4 promethazine oral syrup 6.25 mg/5 ml Tier 1 promethazine oral tablet 12.5 mg, 25 mg, 50 mg Tier 1 promethazine rectal suppository 12.5 mg, 25 mg, 50 mg Tier 1 promethazine (Promethegan Rectal Suppository 12.5 Mg, Tier 1 25 Mg, 50 Mg) Antihistamine - 1St Generation - Piperidines - Drugs For Allergies cyproheptadine oral syrup 2 mg/5 ml Tier 1 cyproheptadine oral tablet 4 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

523 Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihistamines - 1St Generation - Drugs For Allergies ST: Must meet the following requirements: Carbinoxamine tablet carbinoxamine maleate oral tablet 6 mg Tier 1 (4mg) and solution (4mg/5mL) in 365 days; QL (4 EA per 1 day); Age (Min 2 Years) clemastine oral tablet 2.68 mg Tier 1 dexchlorpheniramine maleate oral solution 2 mg/5 ml Tier 1 QL (236 ML per 1 FILL) diphenhydramine (Diphen Oral Elixir 12.5 Mg/5 Ml) Tier 1 ST: Must meet the following requirement: KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 Carbinoxamine Maleate in Tier 3 HR 4 MG/5 ML (carbinoxamine) 120 days; QL (960 ML per 30 days); Age (Min 2 Years) promethazine (Phenadoz Rectal Suppository 12.5 Mg, 25 Tier 1 Mg) promethazine rectal suppository 50 mg Tier 1 Antihistamines - 2Nd Generation - Drugs For Allergies cetirizine oral solution 1 mg/ml Tier 1 desloratadine oral tablet 5 mg Tier 1 QL (1 EA per 1 day) ST: Must meet the following requirement: Levocetirizine desloratadine oral tablet,disintegrating 2.5 mg, 5 mg Tier 1 Dihydrochloride or Desloratadine in 120 days; QL (1 EA per 1 day)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

524 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: Levocetirizine levocetirizine oral solution 2.5 mg/5 ml Tier 1 Dihydrochloride or Desloratadine in 120 days; QL (10 ML per 1 day) levocetirizine oral tablet 5 mg Tier 1 Antitussives - Non-Opioid - Drugs For Allergies benzonatate oral capsule 100 mg, 150 mg, 200 mg Tier 1 Asthma Therapy - 5-Lipoxygenase Inhibitors - Drugs For Asthma/Copd ST: Must meet the following requirement: zileuton oral tablet, er multiphase 12 hr 600 mg Tier 1 Montelukast Sodium and Zafirlukast in 365 days; QL (2 EA per 1 day) ST: Must meet the following requirement: ZYFLO ORAL TABLET 600 MG (zileuton) Tier 3 Montelukast Sodium and Zafirlukast in 365 days; QL (4 EA per 1 day) Asthma Therapy - Alpha/Beta Adrenergic Agents - Drugs For Asthma/Copd epinephrine injection syringe 0.1 mg/ml Tier 4

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

525 Coverage Prescription Drug Name Drug Tier Requirements and Limits Asthma Therapy - Inhaled Corticosteroids (Glucocorticoids) - Drugs For Asthma/Copd ST: Must meet 2 of the following requirements: Arnuity Ellipta, Flovent ALVESCO INHALATION HFA AEROSOL INHALER 160 Tier 3 Diskus, Flovent HFA, Qvar MCG/ACTUATION, 80 MCG/ACTUATION (ciclesonide) Redihaler, or Qvar in 365 days; QL (12.2 GM per 30 days) ST: Must meet 2 of the following requirements: ARMONAIR RESPICLICK INHALATION AEROSOL Arnuity Ellipta, Flovent POWDR BREATH ACTIVATED 232 MCG/ACTUATION, 55 Tier 3 Diskus, Flovent HFA, Qvar MCG/ACTUATION (fluticasone) Redihaler, or Qvar in 365 days; QL (1 EA per 30 days) ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 Tier 2 QL (30 EA per 30 days) MCG/ACTUATION (fluticasone furoate) ST: Must meet 2 of the following requirements: ASMANEX HFA INHALATION HFA AEROSOL INHALER Arnuity Ellipta, Flovent 100 MCG/ACTUATION, 200 MCG/ACTUATION Tier 3 Diskus, Flovent HFA, Qvar (mometasone furoate) Redihaler, or Qvar in 365 days; QL (13 GM per 30 days) ST: Must meet 2 of the ASMANEX TWISTHALER INHALATION AEROSOL following requirements: POWDR BREATH ACTIVATED 110 MCG/ ACTUATION Arnuity Ellipta, Flovent (30), 220 MCG/ ACTUATION (120), 220 MCG/ Tier 3 Diskus, Flovent HFA, Qvar ACTUATION (30), 220 MCG/ ACTUATION (60) Redihaler, or Qvar in 365 (mometasone furoate) days; QL (1 EA per 30 days) budesonide inhalation suspension for nebulization 0.25 Tier 1 QL (120 ML per 30 days) mg/2 ml, 0.5 mg/2 ml Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

526 Coverage Prescription Drug Name Drug Tier Requirements and Limits budesonide inhalation suspension for nebulization 1 mg/2 Tier 1 QL (60 ML per 30 days) ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE Tier 2 QL (60 EA per 30 days) 100 MCG/ACTUATION, 50 MCG/ACTUATION (fluticasone) FLOVENT DISKUS INHALATION BLISTER WITH DEVICE Tier 2 QL (120 EA per 30 days) 250 MCG/ACTUATION (fluticasone) FLOVENT HFA INHALATION HFA AEROSOL INHALER Tier 2 QL (12 GM per 30 days) 110 MCG/ACTUATION (fluticasone) FLOVENT HFA INHALATION HFA AEROSOL INHALER Tier 2 QL (24 GM per 30 days) 220 MCG/ACTUATION (fluticasone) FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 Tier 2 QL (21.2 GM per 30 days) MCG/ACTUATION (fluticasone) ST: Must meet 2 of the following requirements: PULMICORT FLEXHALER INHALATION AEROSOL Arnuity Ellipta, Flovent POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 Tier 3 Diskus, Flovent HFA, Qvar MCG/ACTUATION (budesonide) Redihaler, or Qvar in 365 days; QL (1 EA per 30 days) QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 Tier 2 QL (21.2 GM per 30 days) MCG/ACTUATION (beclomethasone) Asthma Therapy - Interleukin-4 (Il-4) Receptor Alpha Antagonists, Mab - Drugs For Asthma/Copd DUPIXENT SUBCUTANEOUS SYRINGE 200 MG/1.14 ML Tier 4 PA (dupilumab) Asthma Therapy - Interleukin-5 (Il-5) Receptor Alpha Antagonists, Mab - Drugs For Asthma/Copd FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 Tier 4 PA MG/ML (benralizumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

527 Coverage Prescription Drug Name Drug Tier Requirements and Limits Asthma Therapy - Leukotriene Receptor Antagonists - Drugs For Asthma/Copd montelukast oral granules in packet 4 mg Tier 1 montelukast oral tablet 10 mg Tier 1 montelukast oral tablet,chewable 4 mg, 5 mg Tier 1 zafirlukast oral tablet 10 mg, 20 mg Tier 1 Asthma Therapy - Mast Cell Stabilizers - Drugs For Asthma/Copd cromolyn inhalation solution for nebulization 20 mg/2 ml Tier 1 Asthma Therapy - Xanthines - Drugs For Asthma/Copd theophylline (Elixophyllin Oral Elixir 80 Mg/15 Ml) Tier 1 THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 2 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline (Theochron Oral Tablet Extended Release 12 Tier 1 Hr 100 Mg, 200 Mg, 300 Mg) theophylline oral elixir 80 mg/15 ml Tier 1 theophylline oral solution 80 mg/15 ml Tier 1 theophylline oral tablet extended release 12 hr 100 mg, 200 Tier 1 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 Tier 1 mg Asthma Therapy- Monoclonal Antibody - Interleukin-5 (Il-5) Antagonists - Drugs For Asthma/Copd NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML Tier 4 PA (mepolizumab) NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML Tier 4 PA (mepolizumab)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

528 Coverage Prescription Drug Name Drug Tier Requirements and Limits Asthma/Copd - Phosphodiesterase-4 (Pde4) Inhibitors - Drugs For Asthma/Copd ST: Must meet any of the following requirements: Breo Ellipta, Fluticasone DALIRESP ORAL TABLET 250 MCG, 500 MCG Tier 2 Propionate/salmeterol, (roflumilast) Serevent Diskus, Spiriva Respimat, or Spiriva in 120 days; QL (1 EA per 1 day) Asthma/Copd - Anticholinergic Agents, Inhaled Long Acting - Drugs For Asthma/Copd INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE Tier 2 QL (30 EA per 30 days) 62.5 MCG/ACTUATION (umeclidinium) LONHALA MAGNAIR REFILL INHALATION SOLUTION Tier 3 QL (60 ML per 30 days) FOR NEBULIZATION 25 MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER INHALATION SOLUTION Tier 3 QL (60 ML per 30 days) FOR NEBULIZATION 25 MCG/ML (glycopyrrolate) ST: Must meet any of the following requirements: SEEBRI NEOHALER INHALATION CAPSULE, Incruse Ellipta, Spiriva Tier 3 W/INHALATION DEVICE 15.6 MCG (glycopyrrolate) Respimat or Spiriva in 120 days; QL (60 EA per 30 days) SPIRIVA RESPIMAT INHALATION MIST 1.25 Tier 2 QL (4 GM per 30 days) MCG/ACTUATION, 2.5 MCG/ACTUATION (tiotropium) SPIRIVA WITH HANDIHALER INHALATION CAPSULE, Tier 2 QL (30 EA per 30 days) W/INHALATION DEVICE 18 MCG (tiotropium) ST: Must meet any of the following requirements: TUDORZA PRESSAIR INHALATION AEROSOL POWDR Incruse Ellipta, Spiriva Tier 3 BREATH ACTIVATED 400 MCG/ACTUATION (aclidinium) Respimat or Spiriva in 120 days; QL (1 EA per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

529 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet the following requirement: YUPELRI INHALATION SOLUTION FOR NEBULIZATION Tier 3 Lonhala Magnair in 120 175 MCG/3 ML (revefenacin) days; QL (90 ML per 30 days) Asthma/Copd - Anticholinergic Agents, Inhaled Short Acting - Drugs For Asthma/Copd ATROVENT HFA INHALATION HFA AEROSOL INHALER Tier 2 QL (25.8 GM per 30 days) 17 MCG/ACTUATION (ipratropium) ipratropium bromide inhalation solution 0.02 % Tier 1 Asthma/Copd - Beta 2-Adrenergic Agents, Inhaled, Ultra-Long Acting - Drugs For Asthma/Copd ST: Must meet the following requirement: ARCAPTA NEOHALER INHALATION CAPSULE, Tier 3 Striverdi Respimat or W/INHALATION DEVICE 75 MCG (indacaterol) Serevent Diskus in 120 days; QL (1 EA per 1 day) STRIVERDI RESPIMAT INHALATION MIST 2.5 Tier 2 QL (4 GM per 30 days) MCG/ACTUATION (olodaterol) Asthma/Copd Therapy - Beta 2-Adrenergic Agents, Inhaled, Long Acting - Drugs For Asthma/Copd BROVANA INHALATION SOLUTION FOR NEBULIZATION Tier 3 QL (120 ML per 30 days) 15 MCG/2 ML (arformoterol) PERFOROMIST INHALATION SOLUTION FOR Tier 2 QL (120 ML per 30 days) NEBULIZATION 20 MCG/2 ML (formoterol) SEREVENT DISKUS INHALATION BLISTER WITH Tier 2 QL (60 EA per 30 days) DEVICE 50 MCG/DOSE (salmeterol)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

530 Coverage Prescription Drug Name Drug Tier Requirements and Limits Asthma/Copd Therapy - Beta 2-Adrenergic Agents, Inhaled, Short Acting - Drugs For Asthma/Copd albuterol sulfate inhalation solution for nebulization 0.63 Tier 1 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate inhalation solution for nebulization 2.5 Tier 1 mg/0.5 ml levalbuterol hcl inhalation solution for nebulization 0.31 Tier 1 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol tartrate inhalation hfa aerosol inhaler 45 Tier 1 mcg/actuation PROAIR DIGIHALER INHALATION AERO POWDR BREATH ACT W/SENSOR 90 MCG/ACTUATION Tier 3 (albuterol) PROAIR HFA INHALATION HFA AEROSOL INHALER 90 Tier 1 MCG/ACTUATION (albuterol) PROAIR RESPICLICK INHALATION AEROSOL POWDR Tier 2 BREATH ACTIVATED 90 MCG/ACTUATION (albuterol) PROVENTIL HFA INHALATION HFA AEROSOL INHALER Tier 3 90 MCG/ACTUATION (albuterol) VENTOLIN HFA INHALATION HFA AEROSOL INHALER Tier 1 90 MCG/ACTUATION (albuterol) Asthma/Copd Therapy - Beta Adrenergic Agents - Drugs For Asthma/Copd albuterol sulfate oral syrup 2 mg/5 ml Tier 1 albuterol sulfate oral tablet 2 mg, 4 mg Tier 1 albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 Tier 1 mg metaproterenol oral syrup 10 mg/5 ml Tier 1 terbutaline oral tablet 2.5 mg, 5 mg Tier 1

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

531 Coverage Prescription Drug Name Drug Tier Requirements and Limits Asthma/Copd Therapy - Beta Adrenergic- Anticholinergic Combinations - Drugs For Asthma/Copd ANORO ELLIPTA INHALATION BLISTER WITH DEVICE Tier 2 QL (60 EA per 30 days) 62.5-25 MCG/ACTUATION (umeclidinium) BEVESPI AEROSPHERE INHALATION HFA AEROSOL Tier 2 QL (10.7 GM per 30 days) INHALER 9-4.8 MCG (glycopyrrolate) COMBIVENT RESPIMAT INHALATION MIST 20-100 Tier 2 MCG/ACTUATION (ipratropium) DUAKLIR PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400-12 MCG/ACTUATION Tier 3 PA; QL (1 EA per 30 days) (aclidinium) ipratropium-albuterol inhalation solution for nebulization 0.5 Tier 1 mg-3 mg(2.5 mg base)/3 ml STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 Tier 2 QL (4 GM per 30 days) MCG/ACTUATION (tiotropium) ST: Must meet 2 of the following requirements: UTIBRON NEOHALER INHALATION CAPSULE, Anoro Ellipta, Bevespi Tier 3 W/INHALATION DEVICE 27.5-15.6 MCG (indacaterol) Aerosphere, or Stiolto Respimat in 365 days; QL (60 EA per 30 days) Asthma/Copd Therapy - Beta Adrenergic- Glucocorticoid Combinations - Drugs For Asthma/Copd ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 Tier 1 QL (60 EA per 30 days) MCG/DOSE (fluticasone) ADVAIR HFA INHALATION HFA AEROSOL INHALER 115- 21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 Tier 2 QL (12 GM per 30 days) MCG/ACTUATION (fluticasone)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

532 Coverage Prescription Drug Name Drug Tier Requirements and Limits BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE (fluticasone Tier 2 QL (60 EA per 30 days) furoate) DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION (mometasone Tier 2 QL (13 GM per 30 days) furoate) fluticasone propion-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 Tier 3 QL (1 EA per 30 days) mcg/actuation, 55-14 mcg/actuation SYMBICORT INHALATION HFA AEROSOL INHALER 160- 4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION Tier 2 QL (10.2 GM per 30 days) (budesonide) Asthma/Copd Tx - Beta-Adrenergic- Anticholinergic-Glucocorticoid Comb, - Drugs For Cystic Fibrosis TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE Tier 2 QL (60 EA per 30 days) 100-62.5-25 MCG (fluticasone furoate) Corticosteroid Implant For Maintaining Sinus Patency - Drugs For The Nose SINUVA SINUS IMPLANT 1,350 MCG (mometasone Tier 3 furoate) Cystic Fibrosis - Inhaled Aminoglycosides - Drugs For Cystic Fibrosis BETHKIS INHALATION SOLUTION FOR NEBULIZATION Tier 3 PA; SP 300 MG/4 ML (tobramycin) TOBI PODHALER INHALATION CAPSULE 28 MG Tier 2 PA (tobramycin) TOBI PODHALER INHALATION CAPSULE, Tier 2 PA W/INHALATION DEVICE 28 MG (tobramycin) tobramycin in 0.225 % nacl inhalation solution for Tier 1 PA nebulization 300 mg/5 ml

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

533 Coverage Prescription Drug Name Drug Tier Requirements and Limits tobramycin with nebulizer inhalation solution for nebulization Tier 1 PA 300 mg/5 ml Cystic Fibrosis - Inhaled Monobactams - Drugs For Cystic Fibrosis CAYSTON INHALATION SOLUTION FOR NEBULIZATION Tier 2 PA 75 MG/ML (aztreonam) Cystic Fibrosis-Transmembrane Conductance Regulator (Cftr) Potentiator - Drugs For Cystic Fibrosis KALYDECO ORAL GRANULES IN PACKET 25 MG, 50 Tier 3 PA; SP MG, 75 MG (ivacaftor) KALYDECO ORAL TABLET 150 MG (ivacaftor) Tier 3 PA; SP Cystic Fib-Transmemb Conduct. Reg.(Cftr) Potentiator And Corrector Cmb - Drugs For Cystic Fibrosis ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, Tier 3 PA; SP 150-188 MG (lumacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG Tier 3 PA; SP (lumacaftor) SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG Tier 3 PA; SP (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N) (tezacaftor) TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 Tier 3 PA; SP MG(D) /150 MG (N) (elexacaftor) Elastase Inhibitors - Drugs For Asthma/Copd ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, Tier 4 500 MG (alpha-1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG Tier 4 (alpha-1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/- Tier 4 )/20 ML (alpha-1-proteinase inhibitor)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

534 Coverage Prescription Drug Name Drug Tier Requirements and Limits ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Tier 4 (alpha-1-proteinase inhibitor) Lung Surfactants - Drugs For The Lungs CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5 Tier 3 ML, 240 MG/3 ML (poractant alfa) INFASURF INTRATRACHEAL SUSPENSION 35 MG/ML Tier 3 (calfactant) SURFAXIN INTRATRACHEAL SUSPENSION 34 MG/ML Tier 3 (lucinactant) SURVANTA INTRATRACHEAL SUSPENSION 25 MG/ML Tier 3 (beractant) Mucolytics - Drugs For The Lungs acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) Tier 1 PULMOZYME INHALATION SOLUTION 1 MG/ML (dornase Tier 3 PA; SP alfa) Nasal Anesthetics - Allergy cocaine nasal solution 4 % Tier 1 Nasal Anticholinergics - Allergy ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 Tier 1 mcg (0.06 %) Nasal Antihistamine And Anti-Inflammatory Steroid Combinations - Allergy ST: Must meet the following requirement: DYMISTA NASAL SPRAY,NON-AEROSOL 137-50 Tier 3 Flunisolide or Fluticasone MCG/SPRAY (azelastine) Propionate in 365 days; QL (23 GM per 30 days) TICALAST NASAL KIT,SPRAY SUSPENSION AND Tier 3 SPRAY 137 MCG-50 MCG- 0.9 % (azelastine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

535 Coverage Prescription Drug Name Drug Tier Requirements and Limits Nasal Antihistamines - Allergy azelastine nasal aerosol,spray 137 mcg (0.1 %) Tier 1 QL (60 ML per 30 days) ST: Must meet the following requirement: azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) Tier 1 Azelastine 137mcg nasal solution in 120 days; QL (60 ML per 30 days) ST: Must meet the following requirement: olopatadine nasal spray,non-aerosol 0.6 % Tier 1 Azelastine 137mcg nasal solution in 120 days; QL (30.5 GM per 30 days) Nasal Corticosteroids - Allergy ST: Must meet the following requirement: BECONASE AQ NASAL SPRAY,NON-AEROSOL 42 MCG Tier 3 Flunisolide or Fluticasone (0.042 %) (beclomethasone) Propionate in 120 days; QL (25 GM per 30 days) flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) Tier 1 QL (25 ML per 30 days) fluticasone propionate nasal spray,suspension 50 Tier 1 QL (16 GM per 30 days) mcg/actuation mometasone nasal spray,non-aerosol 50 mcg/actuation Tier 1 QL (17 GM per 30 days) ST: Must meet the following requirement: OMNARIS NASAL SPRAY,NON-AEROSOL 50 MCG Tier 3 Flunisolide or Fluticasone (ciclesonide) Propionate in 120 days; QL (5 GM per 12 days) ST: Must meet any of the following requirements: QNASL NASAL HFA AEROSOL INHALER 40 Flunisolide, Fluticasone Tier 2 MCG/ACTUATION (beclomethasone) Propionate, or Qnasl in 120 days; QL (6.8 GM per 30 days)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

536 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: QNASL NASAL HFA AEROSOL INHALER 80 Flunisolide, Fluticasone Tier 2 MCG/ACTUATION (beclomethasone) Propionate, or Qnasl Children in 120 days; QL (10.6 GM per 30 days) TICANASE NASAL KIT,SPRAY SUSPENSION AND Tier 3 SPRAY 50 MCG- 0.9 % (fluticasone) TICASPRAY NASAL KIT,SPRAY SUSPENSION AND Tier 3 SPRAY 50 MCG- 0.9 % (fluticasone) ST: Must meet one of the following requirements: Flunisolide, Fluticasone XHANCE NASAL AEROSOL BREATH ACTIVATED 93 Tier 2 Propionate, or MCG/ACTUATION (fluticasone) Mometasone Furoate in 120 days; QL (32 ML per 30 days) ST: Must meet the following requirement: ZETONNA NASAL HFA AEROSOL INHALER 37 Tier 3 Flunisolide or Fluticasone MCG/ACTUATION (ciclesonide) Propionate in 120 days; QL (6.1 GM per 30 days) Nasal Post-Surgical Agents - Drugs For The Nose SINUVA SINUS IMPLANT 1,350 MCG (mometasone Tier 3 furoate) Nasal Preparations Other - Drugs For The Nose ALZAIR NASAL SPRAY,NON-AEROSOL (hypromellose) Tier 3 Nasal Sympathomimetic Decongestants (Intranasal) - Allergy ADRENALIN NASAL SOLUTION 1 MG/ML (epinephrine) Tier 3 TYZINE NASAL DROPS 0.1 % (tetrahydrozoline) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

537 Coverage Prescription Drug Name Drug Tier Requirements and Limits TYZINE NASAL SPRAY,NON-AEROSOL 0.1 % Tier 3 (tetrahydrozoline) Non-Opioid Antitussive-1St Gen.Antihistamine- Decongestant Combinations - Drugs For Cough And Cold brompheniramine (Bromfed Dm Oral Syrup 2-30-10 Mg/5 Tier 1 Ml) brompheniramine-pseudoeph-dm oral syrup 2-30-10 mg/5 Tier 1 ml CENTERGY DM ORAL DROPS 1-2-3 MG/ML Tier 1 (chlorpheniramine) Non-Opioid Antitussive-Antihistamine Combinations - Drugs For Cough And Cold promethazine-dm oral syrup 6.25-15 mg/5 ml Tier 1 Opioid Antitussive-1St Generation Antihistamine Combinations - Drugs For Cough And Cold hydrocodone-chlorpheniramine oral suspension,extended QL (10 ML per 1 day); Age Tier 1 rel 12 hr 10-8 mg/5 ml (Min 18 Years) QL (30 ML per 1 day); Age promethazine-codeine oral syrup 6.25-10 mg/5 ml Tier 1 (Min 18 Years) TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 QL (2 EA per 1 day); Age Tier 3 HR 10-8 MG, 5-4 MG (hydrocodone) (Min 18 Years) ST: Must meet the following requirement: TUXARIN ER ORAL TABLET EXTENDED RELEASE 12 Tier 3 Promethazine HCL/codeine HR 8-54.3 MG (chlorpheniramine) in 120 days; QL (2 EA per 1 day); Age (Min 18 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

538 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet 2 of the following requirements: Montelukast Sodium, TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 Promethazine Tier 3 HR 14.7-2.8 MG/5 ML (codeine) HCL/codeine, or Zafirlukast in 365 days; QL (200 ML per 10 days); Age (Min 18 Years) ZODRYL AC 25 ORAL SUSPENSION 1-3 MG/3 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL AC 30 ORAL SUSPENSION 1-3.5 MG/3.5 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL AC 35 ORAL SUSPENSION 1-4 MG/4 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL AC 40 ORAL SUSPENSION 1-4.5 MG/4.5 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL AC 50 ORAL SUSPENSION 2-5 MG/5 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL AC 60 ORAL SUSPENSION 2-7.5 MG/7.5 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL AC 80 ORAL SUSPENSION 2-10 MG/10 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) Z-TUSS AC ORAL LIQUID 2-9 MG/5 ML (chlorpheniramine) Tier 3 Age (Min 12 Years) Opioid Antitussive-1St Generation Antihistamine-Decongestant Comb. - Drugs For Cough And Cold CAPCOF ORAL LIQUID 2-5-10 MG/5 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) HISTEX-AC ORAL SYRUP 2.5-10-10 MG/5 ML (triprolidine) Tier 3 Age (Min 12 Years) MAR-COF BP ORAL LIQUID 2-30-7.5 MG/5 ML Tier 1 Age (Min 12 Years) (brompheniramine)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

539 Coverage Prescription Drug Name Drug Tier Requirements and Limits MAXI-TUSS CD ORAL LIQUID 4-10-10 MG/5 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) M-END PE ORAL LIQUID 1.33-3.33-6.33 MG/5 ML Tier 3 Age (Min 12 Years) (brompheniramine) POLY-TUSSIN AC ORAL LIQUID 4-10-10 MG/5 ML Tier 3 Age (Min 12 Years) (brompheniramine) promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5 QL (30 ML per 1 day); Age Tier 1 ml (Min 18 Years) RYDEX ORAL LIQUID 1.3-10-6.3 MG/5 ML Tier 1 Age (Min 12 Years) (brompheniramine) ZODRYL DAC 25 ORAL SUSPENSION 1-15-3 MG/3 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL DAC 30 ORAL SUSPENSION 1-15-3.5 MG/3.5 Tier 3 Age (Min 12 Years) ML (chlorpheniramine) ZODRYL DAC 35 ORAL SUSPENSION 1-15-4 MG/4 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL DAC 40 ORAL SUSPENSION 1-15-4.5 MG/4.5 Tier 3 Age (Min 12 Years) ML (chlorpheniramine) ZODRYL DAC 50 ORAL SUSPENSION 2-30-5 MG/5 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) ZODRYL DAC 60 ORAL SUSPENSION 2-30-7.5 MG/7.5 Tier 3 Age (Min 12 Years) ML (chlorpheniramine) ZODRYL DAC 80 ORAL SUSPENSION 2-30-10 MG/10 ML Tier 3 Age (Min 12 Years) (chlorpheniramine) Opioid Antitussive-Anticholinergic Combinations - Drugs For Cough And Cold QL (30 ML per 1 day); Age hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml Tier 1 (Min 18 Years) QL (6 EA per 1 day); Age hydrocodone-homatropine oral tablet 5-1.5 mg Tier 1 (Min 18 Years) QL (30 ML per 1 day); Age hydrocodone (Hydromet Oral Syrup 5-1.5 Mg/5 Ml) Tier 1 (Min 18 Years) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

540 Coverage Prescription Drug Name Drug Tier Requirements and Limits Opioid Antitussive-Decongestant-Expectorant Combinations - Drugs For Cough And Cold CODITUSSIN DAC ORAL LIQUID 30-10-200 MG/5 ML Tier 3 Age (Min 12 Years) (pseudoephedrine) GUAIFENESIN DAC ORAL SYRUP 30-10-100 MG/5 ML Tier 1 Age (Min 12 Years) (pseudoephedrine) LORTUSS EX ORAL SYRUP 30-10-100 MG/5 ML Tier 1 Age (Min 12 Years) (pseudoephedrine) VIRTUSSIN DAC ORAL SYRUP 30-10-100 MG/5 ML Tier 1 Age (Min 12 Years) (pseudoephedrine) ZODRYL DEC 25 ORAL SUSPENSION 15-3-60 MG/3 ML Tier 3 Age (Min 12 Years) (pseudoephedrine) ZODRYL DEC 30 ORAL SUSPENSION 15-3.5-70 MG/3.5 Tier 3 Age (Min 12 Years) ML (pseudoephedrine) ZODRYL DEC 35 ORAL SUSPENSION 15-4-80 MG/4 ML Tier 3 Age (Min 12 Years) (pseudoephedrine) ZODRYL DEC 40 ORAL SUSPENSION 15-4.5-90 MG/4.5 Tier 3 Age (Min 12 Years) ML (pseudoephedrine) ZODRYL DEC 50 ORAL SUSPENSION 30-5-100 MG/5 ML Tier 3 Age (Min 12 Years) (pseudoephedrine) ZODRYL DEC 60 ORAL SUSPENSION 30-7.5-150 MG/7.5 Tier 3 Age (Min 12 Years) ML (pseudoephedrine) ZODRYL DEC 80 ORAL SUSPENSION 30-10-200 MG/10 Tier 3 Age (Min 12 Years) ML (pseudoephedrine) Opioid Antitussive-Expectorant Combinations - Drugs For Cough And Cold codeine-guaifenesin oral liquid 10-100 mg/5 ml Tier 1 Age (Min 12 Years) CODITUSSIN AC ORAL LIQUID 10-200 MG/5 ML Tier 1 Age (Min 12 Years) (codeine) G TUSSIN AC ORAL LIQUID 10-100 MG/5 ML (codeine) Tier 1 Age (Min 12 Years)

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

541 Coverage Prescription Drug Name Drug Tier Requirements and Limits GUAIATUSSIN AC ORAL LIQUID 10-100 MG/5 ML Tier 1 Age (Min 12 Years) (codeine) GUAIFENESIN AC ORAL LIQUID 10-100 MG/5 ML Tier 1 Age (Min 12 Years) (codeine) MAR-COF CG ORAL LIQUID 7.5-225 MG/5 ML (codeine) Tier 1 Age (Min 12 Years) M-CLEAR WC ORAL LIQUID 6.3-100 MG/5 ML (codeine) Tier 3 Age (Min 12 Years) NINJACOF-XG ORAL LIQUID 8-200 MG/5 ML (codeine) Tier 1 Age (Min 12 Years) ROBAFEN AC ORAL LIQUID 10-100 MG/5 ML (codeine) Tier 1 Age (Min 12 Years) VIRTUSSIN AC ORAL LIQUID 10-100 MG/5 ML (codeine) Tier 1 Age (Min 12 Years) Pulmonary Fibrosis Treatment Agents - Antifibrotic Therapy - Drugs For The Lungs ESBRIET ORAL CAPSULE 267 MG (pirfenidone) Tier 3 PA; SP ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) Tier 3 PA; SP Pulmonary Fibrosis Treatment Agents - Multikinase Inhibitors - Drugs For The Lungs OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib) Tier 3 PA; SP Vaginal Products - Drugs For Women Vaginal Antibacterial - Lincosamides - Drugs For Infections ST: Must meet 2 of the following requirements: Clindamycin HCL, Clindamycin Palmitate CLEOCIN VAGINAL SUPPOSITORY 100 MG (clindamycin) Tier 3 HCL, Clindamycin Phosphate, Metronidazole, Tinidazole, or Vandazole in 365 days; QL (3 EA per 30 days) clindamycin phosphate vaginal cream 2 % Tier 1 CLINDESSE VAGINAL CREAM,EXTENDED RELEASE 2 Tier 3 % (clindamycin) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

542 Coverage Prescription Drug Name Drug Tier Requirements and Limits Vaginal Antibacterial - Sulfonamides - Drugs For Infections AVC VAGINAL VAGINAL CREAM 15 % (sulfanilamide) Tier 2 Vaginal Antifungal - Imidazoles - Drugs For Infections GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole) Tier 2 MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG Tier 1 (miconazole) Vaginal Antifungal - Triazoles - Drugs For Infections terconazole vaginal cream 0.4 %, 0.8 % Tier 1 terconazole vaginal suppository 80 mg Tier 1 Vaginal Antiprotozoal-Antibacterial - Nitroimidazole Derivatives - Drugs For Infections metronidazole vaginal gel 0.75 % Tier 1 NUVESSA VAGINAL GEL 1.3 % (metronidazole) Tier 3 VANDAZOLE VAGINAL GEL 0.75 % (metronidazole) Tier 2 Vaginal Antiseptic Mixtures - Drugs For Infections FEM PH VAGINAL GEL 0.9-0.025 % (acetic acid) Tier 3 RELAGARD VAGINAL GEL 0.9-0.025 % (acetic acid) Tier 3 TRIMO-SAN JELLY VAGINAL GEL 0.025-0.01 % Tier 3 (oxyquinoline) Vaginal Estrogens - Drugs For Women estradiol vaginal cream 0.01 % (0.1 mg/gram) Tier 1 estradiol vaginal tablet 10 mcg Tier 1 ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) Tier 2 QL (1 EA per 90 days) (estradiol) Tier 1 = Generic Drugs | Tier 2 = Brand Name Drugs | Tier 3 = Other pharmacy items and certain DME Tier 4 = - Self-administered Injectable Medications PV = Preventive-Care Benefits required under the Affordable Care Act (ACA) PA = Prior Authorization | ST = Step Therapy | QL = Quantity Limit | Age = Age Edit

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

543 Coverage Prescription Drug Name Drug Tier Requirements and Limits ST: Must meet any of the following requirements: FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR Estring, Intrarosa, Tier 3 (estradiol) Osphena, or Premarin in 120 days; QL (1 EA per 84 days) PREMARIN VAGINAL CREAM 0.625 MG/GRAM Tier 2 (estrogens, conjugated) estradiol (Yuvafem Vaginal Tablet 10 Mcg) Tier 1 Vaginal Progestins - Drugs For Women CRINONE VAGINAL GEL 4 % (progesterone) Tier 3

The categorical list of drugs in this Formulary groups drugs into drug categories and class based on the First National Databank (FDB).

544 Index of Drugs 1ST TIER UNIFINE ACCU-CHEK LINKASSIST ACTICOAT SURGICAL PENTIPS...... 388 INS DEV...... 419 DRESSING...... 237 1ST TIER UNIFINE ACCU-CHEK MULTICLIX ACTI-LANCE LANCETS...... 358 PENTIPS PLUS...... 388 LANCET...... 357, 436 ACTIMMUNE...... 45 1ST TIER UNILET ACCU-CHEK NANO....357, 437 ACTIVE-PAC...... 120, 164 COMFORTOUCH...... 357 ACCU-CHEK RAPID-D LINK ACTOPLUS MET XR...... 269 2-IN-1 LANCET DEVICE ...... 430, 437 ACUICYN...... 212 ...... 357, 436 ACCU-CHEK SAFE-T-PRO 357 ACUVAIL (PF)...... 511 2TEK CONTROL (HIGH- ACCU-CHEK SAFE-T-PRO acyclovir...... 56, 207 NORMAL)...... 357 PLUS...... 357, 437 ACZONE...... 188 2TEK GLUCOSE/BLOOD ACCU-CHEK SMARTVIEW ADACEL(TDAP PRESSURE...... 357 CONTRL SOL...... 358, 437 ADOLESN/ADULT)(PF)...... 83 abacavir...... 48 ACCU-CHEK SMARTVIEW adapalene...... 193 abacavir-lamivudine...... 50 TEST STRIP...... 346 adapalene-benzoyl peroxide192 abacavir-lamivudine- ACCU-CHEK SOFT DEV adapalene-benzoyl perox- zidovudine...... 50 LANCETS...... 358, 437 niacin...... 192 ABILIFY MYCITE...... 142, 150 ACCU-CHEK SOFTCLIX adapalene-benzoyl- abiraterone...... 68 LANCETS...... 358 clindamycin...... 191 ABLYSINOL...... 110 ACCU-CHEK SPIRIT ADASUVE...... 141 ABSORICA...... 186 ADAPTER...... 419, 437 ADAZIN...... 224 ABSTRAL...... 10 ACCU-CHEK SPIRIT ADDERALL XR...... 144, 152 acamprosate...... 168 CARTRIDGE SYS...... 419, 437 adefovir...... 54 acarbose...... 259 ACCU-CHEK SPIRIT CLIP ADEMPAS...... 113 ACCUCAINE KIT...... 37, 225 CASE...... 405, 419, 437 adenovirus vac live type-4, 7 ACCU-CHEK AVIVA ACCUTREND GLUCOSE... 346 ...... 82, 84 CONTROL SOLN...... 357, 436 ACCUTREND GLUCOSE adenovirus vaccine live type- ACCU-CHEK AVIVA PLUS CONTROL...... 358, 437 4...... 82, 84 METER...... 357 ACD SOLUTION A...... 327 adenovirus vaccine live type- ACCU-CHEK AVIVA PLUS ACE AEROSOL CLOUD 7...... 82, 84 TEST STRP...... 346 ENHANCER...... 422, 437 ADHANSIA XR...... 144 ACCU-CHEK COMBO acebutolol...... 103 ADJUSTABLE LANCING SYSTEM...... 433, 436 ACESO AG...... 236 DEVICE...... 358 ACCU-CHEK COMPACT acetaminophen-caff- ADLYXIN...... 271 PLUS CARE...... 357, 436 dihydrocod...... 18, 19 ADMELOG SOLOSTAR U- ACCU-CHEK COMPACT acetaminophen-codeine.. 17, 18 100 INSULIN...... 292 PLUS CONTROL...... 357, 436 acetazolamide...... 108 ADMELOG U-100 INSULIN ACCU-CHEK COMPACT acetic acid...... 319, 521 LISPRO...... 292 PLUS TEST...... 346 acetylcysteine...... 535 ADRENALIN...... 537 ACCU-CHEK FASTCLIX acetylcysteine (pf) in water.. 505 ADULT ASPIRIN REGIMEN..35 LANCET DRUM...... 357, 436 ACIPHEX SPRINKLE...... 306 ADULT LOW DOSE ACCU-CHEK FASTCLIX acitretin...... 204 ASPIRIN...... 35, 339 LANCING DEV...... 357, 436 ACTEMRA...... 28 ADVAIR DISKUS...... 532 ACCU-CHEK GUIDE...... 346 ACTEMRA ACTPEN...... 28 ADVAIR HFA...... 532 ACCU-CHEK GUIDE ACTICOAT 7 DRESSING....236 ADVANCE PLUS GLUCOSE METER...... 357 ACTICOAT DRESSING...... 236 INTERMITTENT...... 432, 437 ACCU-CHEK GUIDE L1-L2 ACTICOAT FLEX 3 ADVANCED ALLERGY CTRL SOL...... 357 DRESSING...... 236 COLLECT KIT...... 212 ACCU-CHEK GUIDE ME ACTICOAT FLEX 7 ADVANCED GLUC METER GLUCOSE MTR...... 357, 436 DRESSING...... 237 TEST STRIP...... 347 545 ADVANCED GLUCOSE AEROCHAMBER PLUS AKLIEF...... 193 METER...... 358 FLOW-VU,S MSK...... 422 Ak-Poly-Bac...... 516 ADVANCED LANCING AEROCHAMBER PLUS Z AKTEN (PF)...... 515 DEVICE...... 358 STAT...... 422, 438 AKYNZEO (NETUPITANT). 303 ADVANCED TRAVEL AEROCHAMBER PLUS Z Ala-Cort...... 213 LANCETS...... 358, 437 STAT LG MSK...... 422, 438 ALA-QUIN...... 198 ADVATE...... 331 AEROCHAMBER PLUS Z Ala-Scalp...... 213 ADVOCATE BLOOD STAT MD MSK...... 422, 438 albendazole...... 42 GLUCOSE MONITOR...... 358 AEROCHAMBER PLUS Z albuterol sulfate...... 531 ADVOCATE CONTROL STAT SM MSK...... 422, 438 Alcaine...... 515 SOLUTION HIGH...... 358, 437 AEROCHAMBER WITH alclometasone...... 213 ADVOCATE DUO 354, 358, 437 FLOWSIGNAL...... 422, 439 ALCORTIN A...... 198 ADVOCATE DUO METER AEROCHAMBER Z-STAT ALDACTAZIDE...... 109 ...... 354, 358, 437 PLUS-FLW SG...... 423, 439 ALECENSA...... 68 ADVOCATE LANCET...... 358 AEROECLIPSE II alendronate...... 279 ADVOCATE LANCING NEBULIZER...... 406, 439 ALFERON N...... 222 DEVICE...... 358 AEROGEAR ACTION alfuzosin...... 321 ADVOCATE LOW ASTHMA KIT...... 421, 439 ALINIA...... 46 CONTROL...... 358, 438 AERONEB GO...... 423 aliskiren...... 113 ADVOCATE PEN NEEDLE AERONEB GO NEBULIZER ALKALINE BATTERIES...... 359 ...... 388, 438 ...... 406 ALL FLOW 1000 KIT...... 423 ADVOCATE RAPID-SAFE AEROTRACH PLUS....423, 439 ALL FLOW 1000 PFT LANCING...... 358, 438 AEROVENT PLUS...... 423, 439 FILTER...... 423 ADVOCATE REDI-CODE....347 AFINITOR...... 74 ALL FLOW 3000 KIT...... 423 ADVOCATE REDI-CODE AFINITOR DISPERZ...... 73 ALL FLOW 3000 PFT GLU MONITOR...... 358, 438 Afirmelle...... 176 FILTER...... 423 ADVOCATE REDI-CODE AFLURIA QD 2019-20(3YR ALL FLOW 4000 KIT...... 423 PLUS...... 347, 358 UP)(PF)...... 85 ALL FLOW 4000 PFT ADVOCATE REDI-CODE+ AFLURIA QD 2019-20(6- FILTER...... 423 CTRL HIGH...... 359, 438 35MO)(PF)...... 85 ALL FLOW 5000 KIT...... 423 ADVOCATE REDI-CODE+ AFLURIA QUAD 2019- ALL FLOW 5000 PFT CTRL LOW...... 359, 438 20(6MO UP)...... 85 FILTER...... 423 ADVOCATE SYRINGES AFREZZA...... 290 ALL FLOW 6000 PFT ...... 388, 438 AFSTYLA...... 331 FILTER...... 423 ADVOCATE TEST STRIPS AFTERA...... 185 ALLERGIST TRAY 1/2 ML ...... 347, 438 AGAMATRIX AMP GLUC 27GX3/8"...... 407, 439 ADYNOVATE...... 331 MONITOR SYS...... 359, 439 ALLERGIST TRAY ADZENYS ER...... 145, 152 AGAMATRIX AMP TEST INTRADERMAL BEV...407, 439 ADZENYS XR-ODT.....145, 153 STRIPS...... 347, 439 ALLERGIST TRAY AEMCOLO...... 61 AGAMATRIX CONTROL REGULAR BEVEL...... 407, 439 AEROBIKA OSCILLATING HIGH...... 359, 439 ALLERGY SYRINGE...407, 439 PEP SYSTM...... 422, 438 AGAMATRIX CONTROL ALLEVYN...... 237, 440 AEROCHAMBER MINI 422, 438 NORM-HI...... 359, 439 ALLEVYN ADHESIVE AEROCHAMBER MV.. 422, 438 A-Hydrocort...... 284 DRESSING...... 237, 356, 439 AEROCHAMBER PLUS AIMOVIG AUTOINJECTOR 157 ALLEVYN AG...... 237 FLOW-VU...... 422 AIRS DISPOSABLE ALLEVYN AG ADHESIVE... 237 AEROCHAMBER PLUS NEBULIZER...... 406, 439 ALLEVYN AG GENTLE FLOW-VU,L MSK...... 422 AIRZONE PEAK FLOW DRESSING...... 237 AEROCHAMBER PLUS METER...... 421, 439 ALLEVYN HEEL...... 237, 439 FLOW-VU,M MSK...... 422 AJOVY...... 157 546 ALLEVYN LIFE DRESSING amiloride...... 109 APLENZIN...... 133 ...... 237, 346, 440 amiloride- APLIGRAF...... 235 allopurinol...... 327 hydrochlorothiazide...... 109 APOGEE HC INTERMIT Allzital...... 22 aminocaproic acid...... 334 CATHETER...... 432 almotriptan malate...... 158 amiodarone...... 96 APOGEE IC INTERMIT ALOCRIL...... 515 AMITIZA...... 312, 315 CATHETER...... 432, 440 alogliptin...... 259 amitriptyline...... 134 APOKYN...... 137 alogliptin-metformin...... 276 amitriptyline- apraclonidine...... 519 alogliptin-pioglitazone...... 275 chlordiazepoxide...... 133 aprepitant...... 303 ALOMIDE...... 516 amlodipine...... 105 Apri...... 176 ALORA...... 282 amlodipine-atorvastatin...... 102 APRISO...... 312 alosetron...... 315 amlodipine-benazepril...... 87 APTENSIO XR...... 145 ALPHAGAN P...... 519 amlodipine-olmesartan...... 89 APTIOM...... 121, 122 ALPHANATE...... 331 amlodipine-valsartan...... 89 APTIVUS...... 59 ALPHANINE SD...... 330 amlodipine-valsartan- AQUA CARE SODIUM alprazolam...... 114 hcthiazid...... 90 CHLORIDE...... 242 ALPRAZOLAM INTENSOL ammonium lactate...... 212 AQUA CARE STERILE ...... 114, 149 Amnesteem...... 186 WATER...... 242 ALPROLIX...... 330 amoxapine...... 134 AQUA GLYCOLIC HC...... 221 ALREX...... 509 amoxicil-clarithromy- AQUA LANCE LANCING ALTABAX...... 198 lansopraz...... 318 DEVICE...... 359 ALTACAINE...... 515 amoxicillin...... 42 AQUORAL...... 500 ALTAFLUOR BENOX...... 515 amoxicillin-pot clavulanate.....42 ARAKODA...... 45 Altavera (28)...... 176 amphetamine sulfate...... 153 ARALAST NP...... 534 ALTERA NEBULIZER...... 406 ampicillin...... 42 Aranelle (28)...... 182 ALTERA NEBULIZER AMRIX...... 344 ARANESP (IN SYSTEM...... 406 amyl nitrite...... 39, 94 POLYSORBATE)...... 329 ALTERNATE SITE LANCET ANACAINE...... 233 ARCALYST...... 23 ...... 359, 440 ANADROL-50...... 257 ARCAPTA NEOHALER...... 530 ALTERNATE SITE anagrelide...... 339 ARESTIN...... 502 LANCING DEVICE...... 359, 440 ANA-LEX KIT...... 38 ARGYLE TRACHEOSTOMY ALTOPREV...... 97 ANALPRAM-HC...... 220 CARE TRAY...... 405, 440 ALTRENO...... 193 ANASCORP...... 80 ARIKAYCE...... 41 alum, ammonium (bulk)...... 170 ANASTIA...... 231 aripiprazole...... 150 ALUNBRIG...... 68 anastrozole...... 70 armodafinil...... 162 ALVESCO...... 526 ANDRODERM...... 257 ARMONAIR RESPICLICK...526 Alyacen 1/35 (28)...... 176 ANGELIQ...... 281 ARMOUR THYROID...... 298 Alyacen 7/7/7 (28)...... 182 ANIMAS VIBE...... 431 ARNUITY ELLIPTA...... 526 Alyq...... 113 ANNOVERA...... 185 ARTISS...... 231 ALZAIR...... 537 ANODYNE LPT...... 224 ARYMO ER...... 10 Amabelz...... 281 ANORO ELLIPTA...... 532 Ascomp With Codeine...... 18 amantadine hcl...... 137 ANTARA...... 97 ASCOR...... 255 ambrisentan...... 113 anticoag citrate phos ascorbic acid (vitamin c)...... 255 amcinonide...... 213 dextrose...... 327 ascorbic acid(vitamin AMELUZ...... 228 ANUCORT-HC...... 38 c)(bulk)...... 255 Amethia...... 175 APADAZ...... 19 Ashlyna...... 175 Amethia Lo...... 175 APEXICON E...... 213 ASMANEX HFA...... 526 Amethyst (28)...... 176 APIDRA SOLOSTAR U-100 ASMANEX TWISTHALER...526 AMIELLE VAGINAL INSULIN...... 293 ASPIR-81...... 35 TRAINER...... 405 APIDRA U-100 INSULIN..... 293 aspirin...... 36 547 ASPIRIN CHILDRENS.. 35, 339 atropine in 0.9 % sod AZASAN...... 28, 343 ASPIRIN LOW DOSE...... 35 chloride...... 508 AZASITE...... 518 aspirin-dipyridamole...... 339 ATROVENT HFA...... 530 azathioprine...... 343 aspirin-omeprazole...... 340 AUBAGIO...... 504 azelaic acid...... 188 ASPIR-LOW...... 36, 339 Aubra...... 176 azelastine...... 509, 536 ASPIR-TRIN...... 36, 339 Aubra Eq...... 176 AZELEX...... 188 ASSURE 4 CONTROL AUGMENTIN...... 42 AZESCO...... 254 SOLUTION...... 359 AURA PORTANEB...... 406, 440 azithromycin...... 57 ASSURE 4 STRIPS...... 347 Aurovela 1.5/30 (21)...... 176 AZOPT...... 513 ASSURE DOSE NORMAL Aurovela 1/20 (21)...... 176 Azurette (28)...... 175 CONTROL...... 359 Aurovela 24 Fe...... 176 B COMPLEX 100...... 241 ASSURE DOSE NORM-HI Aurovela Fe 1.5/30 (28)...... 176 bacitracin...... 517 CONTROL...... 359 Aurovela Fe 1-20 (28)...... 176 bacitracin-polymyxin b...... 516 ASSURE HAEMOLANCE AURUMHEEL...... 299 baclofen...... 344 PLUS...... 359 AURYXIA...... 243, 320, 321 BALANCED B-50 ASSURE ID INSULIN AUSTEDO...... 160, 161 COMPLEX (FOLIC)...... 241 SAFETY...... 388 AUTOJECT 2 INJECTION BAL-CARE DHA...... 245 ASSURE ID PEN NEEDLE. 388 DEVICE...... 388 BAL-CARE DHA ASSURE LANCE...... 359 AUTO-LANCET MINI...360, 440 ESSENTIAL...... 245 ASSURE LANCE PLUS...... 359 AUTOLET IMPRESSION BALCOLTRA...... 177 ASSURE PLATINUM...347, 359 LANC DEV...... 360 balsalazide...... 313 ASSURE PRISM CONTROL AUTOLET LANCING balsam peru (bulk)...... 10, 170 1-2 SOLN...... 359 DEVICE...... 360 balsam peru-castor oil...... 239 ASSURE PRISM MULTI AUTOLET PLUS LANCING BALVERSA...... 71 METER...... 359 DEVICE...... 360 Balziva (28)...... 177 ASSURE PRISM MULTI AUTOPEN 1 TO 21 UNITS BANZEL...... 127, 128 STRIP...... 347 ...... 388, 440 BAQSIMI...... 257 ASTAGRAF XL...... 341 AUTOPEN 2 TO 42 UNITS BARACLUDE...... 53 ASTERO...... 224 ...... 389, 440 BASAGLAR KWIKPEN U- ASTHMA CHECK METER AUTOSOFT 30...... 433 100 INSULIN...... 291 ...... 421, 440 AUTOSOFT 90...... 433 BAXDELA...... 53 ASTHMAPACK AUTOSOFT XC INFUSION BD ALLERGIST TRAY REG CHILDREN'S...... 421, 440 SET 23"...... 434 BEVEL...... 407, 440 ASTRINGYN...... 335 AUTOSOFT XC INFUSION BD ALLERGY SYRINGE atazanavir...... 60 SET 43"...... 434 ...... 407, 440 atenolol...... 103 AUVI-Q...... 106 BD AUTOSHIELD DUO atenolol-chlorthalidone...... 106 AVANDIA...... 295 PEN NEEDLE...... 389, 440 atomoxetine...... 148 AVAR...... 189 BD BLUNT PLASTIC ATOPADERM...... 210 AVAR LS...... 189 CANNULA...... 407, 440 atorvastatin...... 98 AVC VAGINAL...... 543 BD BULK LUER-LOK NON- atovaquone...... 46 AVENOVA...... 212 STERILE...... 408, 440 atovaquone-proguanil...... 45 Aviane...... 176 BD BULK SLIP TIP NON- ATRAPRO CP...... 210 AVIDOXY DK...... 61 STERILE...... 408, 441 ATRAPRO DERMAL AVITA...... 193, 194 BD BULK SYRINGE SLIP SPRAY...... 236 AVITENE...... 335 TIP...... 408, 441 ATRAPRO HYDROGEL...... 210 AVITENE FLOUR...... 335 BD ECCENTRIC TIP ATRIPLA...... 50 AVO CREAM...... 210 SYRINGE...... 408, 441 ATROPEN...... 111 AVONEX...... 502, 503 BD ECLIPSE LUER-LOK atropine...... 508 AVONEX (WITH ALBUMIN) 502 ...... 389, 408, 441 Ayuna...... 176 548 BD FILTER NEEDLE-5 BD SAFETYGLIDE BD VEO INSULIN SYR MICRON...... 408, 441 ALLERGIST TRAY...... 409, 443 HALF UNIT...... 390, 445 BD INSULIN SYRINGE BD SAFETYGLIDE INSULIN BD VEO INSULIN SYRINGE ...... 389, 441 SYRINGE...... 390, 443 UF...... 390 BD INSULIN SYRINGE BD SAFETYGLIDE BEAU RX...... 228 HALF UNIT...... 389, 441 SHIELDING REG...... 409, 443 BECONASE AQ...... 536 BD INSULIN SYRINGE BD SAFETYGLIDE Bekyree (28)...... 175 MICRO-FINE...... 389, 441 SYRINGE.... 390, 403, 409, 443 BELBUCA...... 21 BD INSULIN SYRINGE BD SAFETYGLIDE TB REG belladonna alkaloids-opium. 310 SAFETY-LOK...... 389, 441 BEVEL...... 409, 443 BELSOMRA...... 167 BD INSULIN SYRINGE SLIP BD SAFETYGLIDE benazepril...... 88 TIP...... 389, 441 TUBERCULIN...... 409, 444 benazepril- BD INSULIN SYRINGE U- BD SAFETY-LOK hydrochlorothiazide...... 88 500...... 389, 441 DETACHABLE NEEDL410, 444 BENEFIX...... 330 BD INSULIN SYRINGE BD SAFETY-LOK BENLYSTA...... 30 ULTRA-FINE...... 389 TUBERCULIN...... 410, 444 BENSAL HP...... 222 BD INSYTE AUTOGUARD BD SAFETY-LOK WITH BENZEPRO...... 191 ...... 402, 442 LUER-LOK...... 410, 444 BENZEPRO BD INTEGRA SYRINGE BD SAF-T-INTIMA...... 403, 444 (MICROSPHERES)...... 191 ...... 402, 408, 442 BD SLIP TIP SYRINGE benzhydrocodone- BD INTERLINK BLUNT ...... 410, 444 acetaminophen...... 19 PLASTIC CAN...... 408, 442 B-D SLIP TIP SYRINGE benznidazole...... 45 BD INTERLINK SYRINGE ...... 410, 444 BENZODOX 30...... 61 ...... 408, 442 BD SPECIALTY USE BENZODOX 60...... 62 BD LAB ECCENTRIC NON- NEEDLES...... 410, 444 benzoin (bulk)...... 170 STERILE...... 408, 442 BD SYRINGE...... 410, 444 benzonatate...... 525 BD LO-DOSE MICRO-FINE BD SYRINGE BULK benzoyl per-clindamycin- IV...... 389, 442 STERILE PAK...... 410, 444 niacin...... 189 BD LO-DOSE ULTRA-FINE BD SYRINGE CATHETER benzoyl peroxide...... 191, 192 ...... 389, 442 TIP...... 410, 444 benztropine...... 136 BD LUER-LOK BULK BD SYRINGE-DUAL BEPREVE...... 509 SYRINGE...... 408, 442 CANNULA...... 410, 444 BERINERT...... 328 BD LUER-LOK SYRINGE BD TUBERCULIN SLIP-TIP BESER KIT...... 219 ...... 409, 442 ...... 410, 444 BESIVANCE...... 517 BD LUER-LOK TIP BD TUBERCULIN SYRINGE BETADINE OPHTHALMIC CONTROL SYRING.... 409, 442 ...... 410, 445 PREP...... 518 BD MAGNI-GUIDE BD ULTRA FINE LANCETS BETALOAN SUIK...... 284 SYRINGE MAGNIFI.... 360, 443 ...... 360, 445 betamethasone dipropionate BD MICROTAINER BD ULTRA-FINE II ...... 213 LANCET...... 360, 443 LANCETS...... 360 betamethasone valerate...... 213 BD NANO 2ND GEN PEN BD ULTRA-FINE MICRO betamethasone, augmented NEEDLE...... 389, 443 PEN NEEDLE...... 390, 445 ...... 213, 214 BD POSIFLUSH NORMAL BD ULTRA-FINE MINI PEN BETASERON...... 503 SALINE 0.9...... 254 NEEDLE...... 390 betaxolol...... 103, 514 BD PRECISIONGLIDE 409, 443 BD ULTRA-FINE NANO bethanechol chloride...... 326 BD PRE-FILLED NORMAL PEN NEEDLE...... 390 BETHKIS...... 533 SALINE...... 254 BD ULTRA-FINE ORIG PEN BETIMOL...... 514 BD PRE-FILLED SALINE NEEDLE...... 390 BETOPTIC S...... 514 BLUNT CAN...... 254 BD ULTRA-FINE SHORT BEVESPI AEROSPHERE... 532 PEN NEEDLE...... 390 BEVYXXA...... 329 549 bexarotene...... 77 BREATHERITE SPACER- buspirone...... 115 BEXSERO...... 84 MASK, NEO...... 423 Butalbital Compound bicalutamide...... 68 BREATHERITE SPACER- W/Codeine...... 18 BIDIL...... 114 MASK,ADULT...... 423 butalbital-acetaminop-caf- BIJUVA...... 281 BREATHERITE SPACER- cod...... 18 BIKTARVY...... 49 MASK,CHILD...... 423 butalbital-acetaminophen 22, 23 bimatoprost...... 519 BREATHERITE SPACER- butalbital-acetaminophen- BINOSTO...... 279 MASK,INFANT...... 423 caff...... 23 BIONECT...... 229 BREATHERITE SPACER- butalbital-aspirin-caffeine...... 35 BIONIME RIGHTEST MASK,S.CHLD...... 423 butorphanol tartrate...... 22 GM300 SYSTEM...... 360, 445 BREATHERITE VALVED butylated hydroxytoluene.....171 BIONIME RIGHTEST TEST MDI CHAMBER...... 423 BYDUREON...... 272 STRIPS...... 347, 445 BREATHERITE VALVED BYDUREON BCISE...... 271 BIOSTEP...... 237, 445 MDI SPACER...... 423 BYETTA...... 272 BIOSTEP AG...... 237 BREEZE 2 CONTROL BYSTOLIC...... 103 bisoprolol fumarate...... 103 SOLUTION, LOW...... 360, 445 cabergoline...... 297 bisoprolol- BREEZE 2 CONTROL CABLIVI...... 327 hydrochlorothiazide...... 106 SOLUTION, NML...... 360, 445 CABOMETYX...... 74 Bleph-10...... 518 BREEZE 2 CONTROL CADEAU DHA...... 245 BLEPHAMIDE...... 506 SOLUTION,HIGH...... 360, 445 CADIRA COMPLIANT Blephamide S.O.P...... 506 BREEZE 2 TEST STRIPS BLOOD STAT...... 433 Blisovi 24 Fe...... 177 ...... 347, 445 caffeine citrate...... 154 Blisovi Fe 1.5/30 (28)...... 177 BREO ELLIPTA...... 533 calcipotriene...... 204 Blisovi Fe 1/20 (28)...... 177 Briellyn...... 177 calcipotriene-betamethasone blood glucose contrl BRIJ L4...... 171 ...... 195 hi,normal...... 360, 445 BRILINTA...... 339 calcitonin (salmon)...... 280 blood glucose control, brimonidine...... 519 Calcitrene...... 204 normal...... 360 brimonidine-dorzolamide (pf) calcitriol...... 205, 255 blood glucose ctl ...... 506 calcium acetate...... 242, 320 high,nml,low...... 360, 445 BRIVIACT...... 126 CALCIUM PNV...... 245 BLOOD GLUCOSE Bromfed Dm...... 538 CALQUENCE...... 70, 76 MONITORING...... 360, 445 bromfenac...... 511 CAMBIA...... 33 BLOOD GLUCOSE TEST... 347 bromocriptine...... 136 Camila...... 181 blood-glucose meter...... 360 brompheniramine- CAMRESE...... 175 blunt needle, disposable pseudoeph-dm...... 538 CAMRESE LO...... 175 ...... 410, 445 BROMSITE...... 511 candesartan...... 92 BOCASAL...... 500 BROVANA...... 530 candesartan- BONJESTA...... 301 BRYHALI...... 204 hydrochlorothiazid...... 90 BOOSTRIX TDAP...... 83 budesonide...... 313, 526, 527 cantharidin in acetone...... 222 bosentan...... 113 BULLSEYE MINI SAFETY CANTHARIS BOSULIF...... 75, 76 LANCETS...... 360 COMPOSITUM...... 299 BOYS TRAINING PANTS bumetanide...... 108 CAPCOF...... 539 4T-5T...... 387, 445 BUNAVAIL...... 168 capecitabine...... 69 BP 10-1...... 189 BUPRENEX...... 21 CAPEX...... 214 BPCO...... 239 buprenorphine...... 22 CAPHOSOL...... 500 BPO...... 192 buprenorphine hcl....21, 22, 168 CAPRELSA...... 76 BRAFTOVI...... 70 buprenorphine-naloxone...... 168 Capsfenac Pak...... 226 BRAVELLE...... 284 bupropion hcl...... 133, 134 captopril...... 88 BREATHERITE MDI bupropion hcl (smoking captopril-hydrochlorothiazide.88 SPACER...... 423 deter)...... 169 CARAFATE...... 317 550 CARBAGLU...... 498 CARNITOR (SUGAR-FREE) CHEMSTRIP BG LOG carbamazepine...... 122 ...... 496 BOOK...... 361, 447 carbidopa...... 136 CAROSPIR...... 108 Chenodal...... 305 carbidopa-levodopa...... 135 CARRASYN HYDROGEL CHILDREN'S ASPIRIN...... 36 carbidopa-levodopa- WOUND DRESS...... 237 CHILDREN'S IRON...... 243 entacapone...... 135 carteolol...... 514 chlordiazepoxide hcl...... 114 carbinoxamine maleate Cartia Xt...... 104 chlordiazepoxide-clidinium.. 310 ...... 522, 523, 524 carvedilol...... 89 chlorhexidine gluconate...... 500 CARDIZEM LA...... 104 carvedilol phosphate...... 89 chloroquine phosphate...... 45 CARDURA XL...... 111 CAYA CONTOURED...355, 447 chlorothiazide...... 110 CAREFINE PEN NEEDLE CAYSTON...... 534 chlorpromazine...... 141 ...... 390, 446 Caziant (28)...... 183 chlorthalidone...... 110 CARELANCE ULT cefaclor...... 52 chlorzoxazone...... 344 LANCING DEVICE...... 360, 446 cefadroxil...... 51 CHOICE DM CLARUS CAREONE LANCING CEFALY...... 405, 447 NORM CONTROL...... 361, 447 DEVICE...... 361 cefdinir...... 52 CHOICEDM CLARUS CAREONE THIN LANCET cefditoren pivoxil...... 52 ...... 347, 361, 447 ...... 361, 446 cefixime...... 52 CHOLBAM...... 303 CAREONE ULTRA THIN cefpodoxime...... 52 cholestyramine (with sugar)...96 LANCET...... 361 cefprozil...... 52 Cholestyramine Light...... 96 CAREPOINT LUER SLIP cefuroxime axetil...... 52 choline,magnesium SYRINGE...... 411, 446 CELACYN...... 210, 429 salicylate...... 35 CARESENS CONTROL A celecoxib...... 31 chorionic gonadotropin, AND B...... 361, 446 CELLPAD...... 430, 447 human...... 288 CARESENS CONTROL A cellulose (bulk)...... 172 CICATRACE PAD...... 430, 447 NORMAL...... 361, 446 CELONTIN...... 127 CICLODAN KIT...... 200 CARESENS LANCETS CEM-UREA...... 222 ciclopirox...... 200 ...... 361, 446 CENTANY AT...... 197 ciclopirox-clobetasol...... 202 CARESENS N...... 361, 446 CENTERGY...... 522 ciclopirox-salicylic acid...... 200 CARESENS N TEST CENTERGY DM...... 538 ciclopirox-ure-camph-menth- STRIPS...... 347 cephalexin...... 51 euc...... 200 CARESENS N VOICE. 361, 446 CEQUA...... 511 cilostazol...... 339 CARESENS PREM CERACADE...... 210 CILOXAN...... 517 LANCING DEVICE...... 361, 446 CERAMAX...... 210 CIMDUO...... 48 CARETOUCH GLUCOSE CERDELGA...... 497 cimetidine...... 305 MONITORING...... 361, 446 CERVIDIL...... 256 cimetidine hcl...... 305 CARETOUCH INSULIN CESAMET...... 152, 302 CIMZIA...... 23, 25, 314 SYRINGE...... 390, 446 CETACAINE...... 224 CIMZIA POWDER FOR CARETOUCH LANCING CETACAINE ANESTHETIC 224 RECONST...... 23, 24, 314 DEVICE...... 361, 446 cetirizine...... 524 CIMZIA STARTER KIT CARETOUCH PEN CETROTIDE...... 296 ...... 23, 25, 314 NEEDLE...... 391, 446 cevimeline...... 502 cinacalcet...... 280 CARETOUCH SAFETY CHANTIX...... 170 CINRYZE...... 328 LANCETS...... 361, 446 CHANTIX CONTINUING CIPRO...... 53 CARETOUCH TEST STRIP 347 MONTH BOX...... 170 CIPRO HC...... 520 CARETOUCH TWIST CHANTIX STARTING CIPRO XR...... 53, 323 LANCET...... 361, 446 MONTH BOX...... 170 CIPRODEX...... 520 carisoprodol...... 344 Chateal (28)...... 177 ciprofloxacin...... 53 carisoprodol-asa-codeine.... 345 Chateal Eq (28)...... 177 ciprofloxacin hcl..... 53, 517, 521 carisoprodol-aspirin...... 344 CHEMET...... 40 ciprofloxacin-fluocinolone.... 521 551 citalopram...... 129 CLEVER CHOICE MICRO Clovique...... 40 CITRANATAL (DUAL-IRON) ...... 362, 447 clozapine...... 140 ...... 245 CLEVER CHOICE MICRO C-NATE DHA...... 246 CITRANATAL 90 DHA TEST STRIP...... 347, 447 COAGADEX...... 333 (ALGAL OIL)...... 246 CLEVER CHOICE COAGUCHEK LANCETS CITRANATAL ASSURE...... 246 NEBULIZER...... 424, 448 ...... 362, 448 CITRANATAL DHA (ALGAL CLEVER CHOICE PRO COAGUCHEK XS...... 346, 448 OIL)...... 246 ...... 347, 362, 448 COARTEM...... 45 CITRANATAL HARMONY CLEVER CHOICE TALK cocaine...... 535 (IRON FUM)...... 246 GLUCOSE SYS...... 362, 448 codeine sulfate...... 10 citric acid (bulk)...... 171 CLEVER CHOICE TALK codeine-butalbital-asa-caff.... 18 citric acid anhydrous (bulk)..171 TEST...... 347, 448 codeine-guaifenesin...... 541 citric acid monohydrate CLEVER CHOICE TEST CODITUSSIN AC...... 541 (bulk)...... 171 STRIPS...... 347 CODITUSSIN DAC...... 541 Claravis...... 186 CLEVER CHOICE VOICE+ colchicine...... 326 CLARINEX-D 12 HOUR...... 522 TEST...... 347 colesevelam...... 96 clarithromycin...... 57 CLEVER CHOICE COLESTID FLAVORED...... 96 CLEANSING WASH.... 189, 230 WHISPER AIRE PED.. 424, 448 colestipol...... 96 clemastine...... 523, 524 CLICKFINE PEN NEEDLE.. 391 COLLATYL...... 237 CLENPIQ...... 317 CLIMARA PRO...... 281 COLOR LANCETS...... 362, 448 CLEO 90 INFUSION SET CLINDACIN ETZ...... 189 COLY-MYCIN S...... 521 24"...... 434 CLINDACIN PAC...... 189 COMBIGAN...... 512 CLEO 90 INFUSION SET clindamycin hcl...... 57 COMBIPATCH...... 281 31"...... 434 clindamycin palmitate hcl...... 57 COMBIVENT RESPIMAT....532 CLEOCIN...... 542 Clindamycin Pediatric...... 57 COMETRIQ...... 74 CLEVER CHEK BLOOD clindamycin phosphate 188, 542 COMFORT EZ INSULIN GLUCOSE...... 361, 447 clindamycin-benzoyl SYRINGE...... 391, 448 CLEVER CHEK BLOOD peroxide...... 189, 190 COMFORT EZ LANCETS... 362 GLUCOSE SYST...... 361 clindamycin-niacinamide COMFORT EZ PEN CLEVER CHEK LANCETS..361 ...... 188, 189 NEEDLES...... 391, 448 CLEVER CHOICE BLOOD clindamycin-tretinoin...... 191 COMFORT INFUSION SET GLUC SYS...... 362 CLINDESSE...... 542 23"...... 434 CLEVER CHOICE CLINPRO 5000...... 498 COMFORT INFUSION SET CHAMBER-LRG MASK clobazam...... 118 31"...... 403, 434, 448 ...... 424, 447 clobetasol...... 214 COMFORT INFUSION SET CLEVER CHOICE clobetasol-calcipotriene...... 219 32"...... 434, 448 CHAMBER-MED MASK clobetasol-emollient...... 214 COMFORT INFUSION SET ...... 424, 447 clobetasol-levocetirizine...... 219 43"...... 434 CLEVER CHOICE clobetasol-niacinamide...... 219 COMFORT LANCETS...... 362 CHAMBER-SM MASK.424, 447 clocortolone pivalate...... 214 COMFORT PAC- CLEVER CHOICE CLODAN KIT...... 221 CYCLOBENZAPRINE...... 345 GLUCOSE MONITOR. 362, 447 clomiphene citrate...... 283 COMFORT PAC- CLEVER CHOICE LEVEL 1 clomipramine...... 134 IBUPROFEN...... 30 CONTROL...... 362, 447 clonazepam...... 114, 115 COMFORT PAC- CLEVER CHOICE LEVEL 2 clonidine...... 107 MELOXICAM...... 30 CONTROL...... 362, 447 clonidine hcl...... 107, 144 COMFORT PAC- CLEVER CHOICE LEVEL 3 clopidogrel...... 340 NAPROXEN...... 30 CONTROL...... 362, 447 clorazepate dipotassium...... 115 COMFORT PAC- clotrimazole...... 201, 500 TIZANIDINE...... 345 clotrimazole-betamethasone202 552 COMFORT SHORT CONTOUR NEXT EZ CRALONIN...... 299 INFUSION SET 23"...... 403 METER...... 362, 449 CREON...... 304 COMFORT SHORT CONTOUR NEXT LEV 1 CRESEMBA...... 44 INFUSION SET 31" CONTROL SOL...... 363, 449 CRINONE...... 283, 544 ...... 403, 434, 448 CONTOUR NEXT LEV 2 CRIXIVAN...... 60 COMFORT SHORT CONTROL SOL...... 363, 450 cromolyn...... 73, 516, 528 INFUSION SET 43"...... 403 CONTOUR NEXT LINK...... 363 Crotan...... 235 COMFORT SHORT CONTOUR NEXT LINK 2.4 CRYOSERV...... 171 INSULIN PUMP 23".....434, 448 ...... 363, 450 Cryselle (28)...... 177 COMFORT SHORT CONTOUR NEXT METER CULTURELLE GUMMY...... 315 INSULIN PUMP 32".....434, 449 ...... 363, 450 CUPRIMINE...... 29, 40 COMFORT SHORT CONTOUR NEXT ONE CURAFIL GEL WOUND INSULIN PUMP 43".....434, 449 METER...... 363 ...... 237, 450 COMPACT SPACE CONTOUR NEXT TEST CURITY AMD...... 356, 450 CHAMBER...... 424, 449 STRIPS...... 348 CURITY AMD (WITH COMPACT SPACE CONTOUR TEST STRIPS.. 348 POLYHEXAMETH)...... 237, 450 CHAMBER PLUS...... 424, 449 CONTROL AST CURITY DRAINAGE BAG COMPACT SPACE MONITORING SYSTEM ...... 387, 450 CHAMBER-LRG MASK ...... 363, 450 CURITY IODOFORM ...... 424, 449 COOL BLOOD GLUCOSE PACKING STRIP...... 356, 450 COMPACT SPACE METER...... 363, 450 CUROSURF...... 535 CHAMBER-MED MASK COOL CONTROL A CUTAQUIG...... 81 ...... 424, 449 SOLUTION...... 363, 450 CUVITRU...... 81 COMPACT SPACE COOL CONTROL B CUVPOSA...... 502 CHAMBER-SM MASK.424, 449 SOLUTION...... 363, 450 cyanocobalamin (vitamin b- COMP-AIR NEBULIZER COOL GLUCOSE TEST 12)...... 255 COMPRESSOR...... 424, 449 STRIP...... 348, 450 Cyclafem 1/35 (28)...... 177 COMPLERA...... 50 COPAXONE...... 503 Cyclafem 7/7/7 (28)...... 183 COMPLETE NATAL DHA....246 COPIKTRA...... 74, 75 cyclobenzaprine...... 344 COMPLETENATE...... 246 CORDRAN...... 214 CYCLOMYDRIL...... 505 Compro...... 302 CORDRAN TAPE LARGE cyclopentolate...... 508 CONCEPTION...... 449 ROLL...... 214 cyclopen-tropic-phenyleph- CONCERTA...... 145 Coremino...... 62, 187 watr...... 505 CONDYLOX...... 223 CORIFACT...... 333 cyclophosphamide...... 67 Constulose...... 316 CORLANOR...... 110 cycloserine...... 50 CONTACT DETACH INFUS Cormax...... 215 CYCLOSET...... 260 SET 23"...... 434 CORTANE-B...... 521 cyclosporine...... 28, 342 CONTACT DETACH INFUS CORTIFOAM...... 313 CYCLOSPORINE IN SET 32"...... 434 cortisone...... 284 KLARITY...... 511 CONTACT DETACH INFUS CORTISPORIN...... 199 cyclosporine modified...... 342 SET 43"...... 434 CORTISPORIN-TC...... 521 CYCLOTENS REFILL...... 344 CONTOUR CONTROL COSENTYX...... 196 CYCLOTENS STARTER.....344 SOLUTION, HIGH...... 362, 449 COSENTYX (2 SYRINGES) 196 cyproheptadine...... 523 CONTOUR CONTROL COSENTYX PEN...... 196 Cyred...... 177 SOLUTION, LOW...... 362, 449 COSENTYX PEN (2 PENS) 196 Cyred Eq...... 177 CONTOUR CONTROL COSOPT...... 512 CYSTADANE...... 497 SOLUTION, NML...... 362, 449 COTELLIC...... 73 CYSTAGON...... 319 CONTOUR LINK...... 362, 449 COTEMPLA XR-ODT...... 145 CYSTARAN...... 513 CONTOUR METER.....362, 449 COVARYX...... 281 CYTRA K CRYSTALS...... 322 COVARYX H.S...... 281 dalfampridine...... 504 553 DALIRESP...... 529 DERMAGRAFT...... 235 DEXCOM G5-G4 SENSOR danazol...... 287 DERMAWERX SURGICAL ...... 364, 451 dantrolene...... 345 PLUS PAK...... 239 DEXCOM G6 RECEIVER dapsone...... 45, 188 DERMAZENE...... 202 ...... 364, 451 dapsone-niacinamide...... 189 DERMAZYL KIT...... 233 DEXCOM G6 SENSOR dapsone-spironolactone- DERM-SILK...... 430, 451 ...... 364, 451 niacin...... 189 DERMULCERA...... 239 DEXCOM G6 DARAPRIM...... 45 DESCOVY...... 48 TRANSMITTER...... 364, 451 darifenacin...... 324 desflurane...... 37 DEXCOM RECEIVER. 364, 451 DARIO BLOOD GLUCOSE desipramine...... 134 DEXERYL...... 210 MONITOR...... 363, 450 desloratadine...... 524 DEXILANT...... 306 DARIO BLOOD GLUCOSE desmopressin...... 258 dexmethylphenidate...... 146 TEST STRIP...... 348 desog-e.estradiol/e.estradiol175 DEXONTO...... 285 Dasetta 1/35 (28)...... 177 desogestrel-ethinyl estradiol 177 Dexpak 10 Day...... 285 Dasetta 7/7/7 (28)...... 183 DESONATE...... 215 Dexpak 13 Day...... 285 DAURISMO...... 71 desonide...... 215 Dexpak 6 Day...... 285 DAVOL IRRIGATION desoximetasone...... 215 DEXTENZA...... 510 SYRINGE...... 411, 450 desvenlafaxine...... 130 dextroamphetamine...... 153 DAVOL PISTON desvenlafaxine succinate.... 130 dextroamphetamine- IRRIGATION...... 411, 451 DEVILBISS DISPOSABLE amphetamine...... 153 Daysee...... 175 NEBULIZER...... 406, 451 DIACOMIT...... 128 DAYTRANA...... 145 DEVILBISS PULMO-AIDE DIAPERS, UNISEX SIZE 6. 388 DDAVP...... 258 COMPRESSR...... 424, 451 DIATRUE CONTROL SOLN DEBACTEROL...... 500 DEVILBISS PULMOMATE NORMAL...... 364, 451 Deblitane...... 182 COMPRESSOR...... 424, 451 DIATRUE CONTROL Decadron...... 284 DEVILBISS PULMONEB LT SOLUTION HIGH...... 364, 451 deferasirox...... 40 COMP-NEB...... 424, 451 DIATRUE CONTROL deferoxamine...... 40 DEVILBISS TRAVELER SOLUTION LOW...... 364, 451 DELESTROGEN...... 282 COMPRESSOR...... 424 DIATRUE PLUS BLOOD DELSTRIGO...... 50 dexamethasone...... 284, 285 GLUCOSE MET...... 364, 451 DELUO...... 79, 236 DEXAMETHASONE DIATRUE PLUS TEST demeclocycline...... 62 INTENSOL...... 284 STRIP...... 348, 452 DEMEROL (PF)...... 10 dexamethasone sodium diazepam...... 115, 118, 149 DEMSER...... 112 phosphate...... 509 Diazepam Intensol...... 115, 149 DENAVIR...... 207 dexchlorpheniramine DICLO GEL...... 227 DENTA 5000 PLUS...... 498 maleate...... 522, 524 DICLO GEL-XRYLIX SHEET DENTAGEL...... 499 DEXCOM G4 RECEIVER....363 ...... 227 DEPEN TITRATABS...... 29, 40 DEXCOM G4 RECEIVER diclofenac epolamine...... 227 Depo-Estradiol...... 282 PEDIATRIC...... 363 diclofenac potassium...... 33 DEPO-SUBQ PROVERA DEXCOM G4 RECEIVER- diclofenac sodium 104...... 174 SHARE (PED)...... 363 ...... 33, 203, 227, 512 DERMACINRX DEXCOM G4 RECEIVER- diclofenac-hyaluronate- CLORHEXACIN...... 239 SHARE KIT...... 363 niacin...... 226 DERMACINRX LEXITRAL.. 226 DEXCOM G4 diclofenac-misoprostol...... 30 DERMACINRX PHN PAK....233 TRANSMITTER...... 363, 451 DICLOFEX DC...... 226 DERMACINRX SURGICAL DEXCOM G5 RECEIVER....364 DICLOFONO...... 227 PHARMAPAK...... 239 DEXCOM G5 DICLOPAK...... 226 DERMACINRX TRANSMITTER...... 364, 451 DICLOPR...... 226 THERAZOLE PAK...... 202 DICLOSAICIN...... 226 DERMACINRX ZRM PAK... 233 DICLOTRAL...... 226 554 DICLOVIX...... 226 DOVER BULB SYRINGE duloxetine...... 131 dicloxacillin...... 59 ...... 411, 452 DUOBRII...... 195 DICLOZOR...... 227 DOVER COATED LATEX DUODOTE...... 39 dicyclomine...... 310 FOLEY...... 432, 452 DUOPA...... 135 didanosine...... 48 DOVER FOLEY CATHETER DUPIXENT...... 197, 527 DIFICID...... 57 ...... 432, 452 DUREZOL...... 510 diflorasone...... 215, 216 DOVER LATEX FOLEY DURLAZA...... 36, 339 diflunisal...... 36 CATHETER...... 432, 452 dutasteride...... 322 Digitek...... 108 DOVER RED RUBBER dutasteride-tamsulosin...... 319 Digox...... 108 ROBINSON CATH...... 432, 452 DUTOPROL...... 106 digoxin...... 108 DOVER UNIVERSAL.. 432, 452 DUZALLO...... 327 dihydroergotamine...... 157 doxazosin...... 111 Dvorah...... 18 DILANTIN...... 121 doxepin...... 134, 233 Dxevo...... 285 DILATRATE-SR...... 94 doxercalciferol...... 496 DYANAVEL XR...... 146, 153 DILAUDID (PF)...... 10 doxycycline hyclate DYMISTA...... 535 diltiazem hcl...... 104, 105 ...... 62, 63, 64, 502 E.C. PRIN...... 36 Dilt-Xr...... 105 doxycycline monohydrate E.E.S. 400...... 57 DILUENT FOR ROTARIX....241 ...... 64, 229 EAR POPPER INFLATION DILUTING MEDIUM FOR doxylamine-pyridoxine (vit DEVICE...... 433, 452 NOVOLOG...... 241 b6)...... 301 EASIVENT HOLDING DIMENTHO...... 226 D-PENAMINE...... 29, 40 CHAMBER...... 424 dimethyl sulfoxide (bulk)...... 171 DRITHOCREME HP...... 205 EASIVENT MASK LARGE DIPENTUM...... 313 DRIZALMA SPRINKLE131, 156 ...... 425, 452 Diphen...... 523, 524 dronabinol...... 302 EASIVENT MASK MEDIUM diphenoxylate-atropine...... 301 DROPLET INSULIN SYR ...... 425, 452 dipyridamole...... 340 HALF UNIT...... 391, 452 EASIVENT MASK SMALL disopyramide phosphate...... 95 DROPLET INSULIN ...... 425, 453 disulfiram...... 169 SYRINGE...... 391, 452 EASY CHECK BLOOD DITHOL...... 226 DROPLET LANCETS.. 364, 452 GLUCOSE...... 364, 453 DIURIL...... 110 DROPLET LANCING EASY COMFORT INSULIN divalproex...... 118 DEVICE...... 364 SYRINGE...... 392, 453 DIVIGEL...... 282 DROPLET PEN NEEDLE EASY COMFORT DM2...... 294 ...... 392, 452 LANCETS...... 364 DMT SUIK...... 285 DROPSAFE PEN NEEDLE EASY COMFORT PEN dofetilide...... 96 ...... 392, 452 NEEDLES...... 392, 453 DOLOTRANZ...... 224 drospirenone-e.estradiol- EASY GLIDE CATHETER donepezil...... 172 lm.fa...... 177 TIP SYRING...... 411, 453 DONNATAL...... 310 drospirenone-ethinyl EASY GLIDE DENTAL Donnatal...... 310, 311 estradiol...... 177 IRRIG SYRING...... 411, 453 DOPTELET (10 TAB PACK)341 DROXIA...... 340 EASY GLIDE INSULIN DOPTELET (15 TAB PACK)341 DRYSOL...... 203 SYRINGE...... 392, 453 DOPTELET (30 TAB PACK)341 DRYSOL DAB-O-MATIC..... 203 EASY GLIDE LUER LOCK DORYX MPC...... 62 DSUVIA...... 10 SYRINGE...... 411, 453 dorzolamide...... 513 DUAKLIR PRESSAIR...... 532 EASY GLIDE LUER SLIP dorzolamide (pf)...... 513 DUAVEE...... 281 TB SYRING...... 411, 453 dorzolamide-timolol...... 513 DUET DHA BALANCED...... 246 EASY GLIDE PEN NEEDLE dorzolamide-timolol (pf)...... 513 DUET DHA WITH OMEGA-3 ...... 392, 453 Dotti...... 282 ...... 246 EASY GLUCO G2...... 348, 453 DOVATO...... 47 DUEXIS...... 30 EASY MINI EJECT DULERA...... 533 LANCING DEVICE...... 364, 453 555 EASY PLUS II BLOOD EASY TOUCH LANCETS EASYMAX 15...... 348 GLUCOSE MET...... 364, 453 ...... 365, 455 EASYMAX 15 LEVEL 1 EASY PLUS II HIGH EASY TOUCH LANCING ...... 366, 457 CONTROL...... 364, 453 DEVICE...... 365, 455 EASYMAX 15 LEVEL 2 EASY PLUS II LOW EASY TOUCH LUER LOCK ...... 366, 457 CONTROL...... 364, 454 INSULIN...... 393, 456 EASYMAX L BLOOD EASY PLUS II TEST... 348, 454 EASY TOUCH LUER LOCK GLUCOSE METER...... 366 EASY STEP...... 348, 454 SYRINGE...... 412, 456 EASYMAX LOW CONTROL366 EASY STEP BLOOD EASY TOUCH PEN EASYMAX NG...... 366 GLUCOSE METER..... 365, 454 NEEDLE...... 393, 456 EASYMAX NORMAL EASY STEP HIGH EASY TOUCH SAFETY CONTROL...... 366 CONTROL SOLN...... 365, 454 LANCETS...... 365, 456 EASYMAX V SPEAKING EASY STEP LOW EASY TOUCH GLUCOSE SYS...... 366 CONTROL SOLUTION365, 454 SHEATHLOCK INSULIN EASYMAX V2 BLOOD EASY STEP NORMAL ...... 393, 456 GLUCOSE METER...... 366 CONTROL SOLN...... 365, 454 EASY TOUCH EASY-TOUCH BLOOD EASY TALK BLOOD SHEATHLOCK SYRG-NDL GLUCOSE METER...... 366 GLUCOSE METER..... 365, 454 ...... 403, 412, 456 EBASE CONTROLLER EASY TALK GLUCOSE EASY TOUCH ...... 425, 457 TEST...... 348, 454 SHEATHLOCK SYRINGE ECLIPSE NEEDLE...... 413, 457 EASY TALK HIGH ...... 412, 456 ECLIPSE SYRINGE CONTROL...... 365, 454 EASY TOUCH TEST STRIP348 ...... 403, 413, 457 EASY TALK LOW EASY TOUCH EC-NAPROXEN...... 34 CONTROL...... 365, 454 TUBERCULIN FLIPLOCK econazole...... 201 EASY TOUCH..... 393, 412, 456 ...... 412, 456 ECONTRA EZ...... 185 EASY TOUCH FLIPLOCK EASY TOUCH ECONTRA ONE-STEP...... 185 INSULIN...... 392, 454 TUBERCULIN SHEATHLK ECOTRIN...... 36 EASY TOUCH FLIPLOCK ...... 412, 456 ECOZA...... 201 NEEDLE...... 411, 454 EASY TOUCH TWIST EDARBI...... 93 EASY TOUCH FLIPLOCK LANCETS...... 365, 456 EDARBYCLOR...... 91 SYRINGE...... 403, 411, 455 EASY TOUCH UNI-SLIP edetate disodium...... 513 EASY TOUCH FLURINGE ...... 393, 413, 457 EDLUAR...... 167 ...... 412, 455 EASY TRAK BLOOD ED-SPAZ...... 309, 324 EASY TOUCH FLURINGE GLUCOSE METER..... 365, 457 EDURANT...... 47 FLIPLOCK...... 412, 455 EASY TRAK GLUCOSE EEMT...... 281 EASY TOUCH FLURINGE TEST...... 348, 457 EEMT HS...... 281 SHEATHLOCK...... 412, 455 EASY TRAK HIGH efavirenz...... 47 EASY TOUCH GLUCOSE CONTROL...... 365, 457 EFFER-K...... 243 MONITOR...... 365 EASY TRAK LOW EGATEN...... 42 EASY TOUCH HIGH-LOW CONTROL...... 365, 457 EGRIFTA...... 287 CONTROL...... 365 EASY TWIST AND CAP ELEMENT COMPACT EASY TOUCH LANCETS...... 366, 457 GLUCOSE METER..... 366, 457 HYPODERMIC NEEDLE EASYGLUCO METER...... 366 ELEMENT COMPACT HIGH ...... 412, 455 EASYGLUCO CONTROL...... 366, 457 EASY TOUCH INSULIN MONITORING SYSTEM..... 366 ELEMENT COMPACT SAFETY SYR...... 392, 455 EASYGLUCO PLUS....348, 457 NORMAL CONTROL...366, 457 EASY TOUCH INSULIN EASYGLUCO PLUS ELEMENT COMPACT TEST SYRINGE...... 393 NORMAL CONTROL...366, 457 STRIPS...... 348, 458 EASYGLUCO TEST...... 348 ELEMENT COMPACT V EASYMAX...... 348 GLUCOSE MTR...... 367, 458 556 ELEMENT HIGH CONTROL EMBRACE TALK EPICYN...... 236 ...... 367, 458 CONTROL-LOW (L1).. 367, 459 EPIDIOLEX...... 118 ELEMENT LOW CONTROL EMBRACE TALK EPIDUO FORTE...... 193 ...... 367, 458 GLUCOSE MONITOR...... 368 EPIFIX AMNIOTIC ELEMENT NORMAL EMBRACE TALK TEST MEMBRANE...... 234 CONTROL...... 367, 458 STRIPS...... 349 EPIFOAM...... 220 ELEMENT PLUS BLOOD EMCYT...... 71 epinastine...... 509 GLUCOSE KIT...... 367, 458 EMEND...... 303 epinephrine...... 107, 525 ELEMENT TEST STRIPS EMFLAZA...... 285 EPIPEN...... 107 ...... 348, 458 EMGALITY PEN...... 157 EPIPEN 2-PAK...... 107 ELESTRIN...... 282 EMGALITY SYRINGE. 114, 157 EPIPEN JR...... 107 eletriptan...... 158 Emoquette...... 177 EPIPEN JR 2-PAK...... 107 ELIGARD...... 73 EMSAM...... 128 EPISIL...... 501 ELIGARD (3 MONTH)...... 72 EMTRIVA...... 48 Epitol...... 122, 149 ELIGARD (4 MONTH)...... 73 EMULSION SB...... 210 EPIVIR HBV...... 54 ELIGARD (6 MONTH)...... 73 EMVERM...... 43 eplerenone...... 89 Elinest...... 177 enalapril maleate...... 88 EPOGEN...... 329 ELIQUIS...... 329 enalapril-hydrochlorothiazide.88 eprosartan...... 93 ELITE-OB...... 243, 244, 246 ENBRACE HR...... 244, 246 EQUETRO...... 122, 149 Elixophyllin...... 528 ENBREL...... 25 ERAPID NEBULIZER ELLA...... 185 ENBREL MINI...... 25 HANDSET...... 425, 459 ELLZIA PAK...... 219 ENBREL SURECLICK...... 25 ERAPID NEBULIZER ELMIRON...... 320 ENDARI...... 340 SYSTEM...... 406, 459 ELOCTATE...... 331 ENDO AVITENE...... 335 ergocalciferol (vitamin d2)... 255 EMBRACE BLOOD Endocet...... 20, 21 ergoloid...... 174 GLUCOSE...... 367, 458 ENDOFORM...... 235 ERGOMAR...... 157 EMBRACE BLOOD ENDOFORM ergotamine-caffeine...... 157 GLUCOSE SYSTEM FENESTRATED...... 234 ERIVEDGE...... 71 ...... 348, 367, 458 ENDOMETRIN...... 283 ERLEADA...... 68 EMBRACE EVO BLOOD ENGERIX-B (PF)...... 80, 81 erlotinib...... 67 GLUCOSE KIT...... 367, 458 ENLITE GLUCOSE Errin...... 182 EMBRACE EVO LEVEL 1 SENSOR...... 368, 459 ERTACZO...... 201 ...... 367, 458 ENLITE SERTER...... 368, 459 Ery Pads...... 188 EMBRACE EVO TEST ENLITE SYSTEM...... 368, 459 ERYPED 400...... 57 STRIPS...... 348, 458 enoxaparin...... 338 Ery-Tab...... 57 EMBRACE GLUCOSE Enpresse...... 183 Erythrocin (As Stearate)...... 58 CONTROL HIGH...... 367, 458 Enskyce...... 177 erythromycin...... 58, 518 EMBRACE GLUCOSE ENSTILAR...... 195 erythromycin ethylsuccinate.. 58 CONTROL LOW...... 367, 458 entacapone...... 136 erythromycin with ethanol....188 EMBRACE LANCETS. 367, 458 entecavir...... 53 erythromycin-benzoyl EMBRACE PRO...... 367, 458 ENTERAL GRAVITY BAG peroxide...... 190 EMBRACE PRO GLUCOSE SET-ENFIT...... 355, 459 ESBRIET...... 542 METER...... 367 ENTEREG...... 40 escitalopram oxalate...... 129 EMBRACE PRO TEST ENTRESTO...... 92 ESKATA...... 206 STRIPS...... 348 ENTTY...... 210 ESOMEP-EZS...... 306 EMBRACE TALK BLOOD Enulose...... 304 esomeprazole magnesium.. 306 GLUCOSE SYS...... 367 ENVARSUS XR...... 342 Estarylla...... 177 EMBRACE TALK EPANED...... 88 estazolam...... 166 CONTROL-HIGH (L2). 367, 458 EPCLUSA...... 55 estradiol...... 282, 283, 543 EPICERAM...... 210 estradiol valerate...... 283 557 estradiol-norethindrone acet 281 EVZIO...... 41 fenofibric acid...... 97 ESTRING...... 543 EXCEL SYRINGE...... 413, 459 fenofibric acid (choline)...... 97 ESTROGEL...... 283 EXEL HYPODERMIC fenoprofen...... 34 estrogens- NEEDLES...... 413, 459 fentanyl...... 11 methyltestosterone...... 281 EXEL INSULIN...... 393 fentanyl citrate...... 11 ESTROVEN CMPLT EXEL SYRINGE...... 413, 460 fentanyl citrate (pf)...... 10, 37 MENOPAUSE RLF...... 10 EXELDERM...... 201 fentanyl citrate (pf)-0.9%nacl.11 eszopiclone...... 167 exemestane...... 70 FENTORA...... 11 ethacrynic acid...... 108 EXODERM...... 200 FERRIPROX...... 40 ethambutol...... 51 EXTAVIA...... 503 ferrous sulfate...... 243 ethosuximide...... 127 EXTRA-VIRT PLUS DHA.... 246 FETZIMA...... 131 ethyl acetate...... 171 EYE...... 299 fexofenadine- ethyl chloride...... 225 E-Z JECT LANCETS... 368, 460 pseudoephedrine...... 522 ethynodiol diac-eth estradiol 178 E-Z JECT THIN LANCETS..368 FIASP FLEXTOUCH U-100 etidronate disodium...... 279 EZ SMART CONTROL...... 369 INSULIN...... 293 etodolac...... 34, 35 EZ SMART LANCETS.369, 460 FIASP PENFILL U-100 etoposide...... 71 EZ SMART PLUS SYSTEM INSULIN...... 293 EUCRISA...... 197 ...... 369, 460 FIASP U-100 INSULIN...... 293 EURAX...... 235 EZ SMART PLUS TEST FIFTY50 SAFETY SEAL EUTHYROX...... 298 ...... 349, 460 LANCETS...... 369 EVAMIST...... 283 EZ SMART SYSTEM...369, 460 FIFTY50 TEST STRIP.349, 460 EVARREST...... 336 EZ SMART TEST...... 349 filter needles...... 413, 460 EVEKEO ODT...... 153, 154 EZALLOR SPRINKLE...... 98 FILTER PAD...... 425, 460 EVENCARE...... 368, 459 ezetimibe...... 101 FILTERED EXTENSION EVENCARE G2...... 349, 368 ezetimibe-simvastatin...... 102 SET...... 403 EVENCARE G3 CONTROL 368 EZ-VAC...... 369, 460 FINACEA...... 188, 230 EVENCARE G3 GLUCOSE FABIOR...... 194 finasteride...... 322 METER...... 368 FACTIVE...... 53 FINE 30 UNIVERSAL EVENCARE G3 TEST...... 349 Falmina (28)...... 178 LANCETS...... 369 EVENCARE MINI famciclovir...... 56 FINGERSTIX LANCETS GLUCOSE CONTROL 368, 459 famotidine...... 305 ...... 369, 460 EVENCARE MINI FANAPT...... 139 Fioricet...... 23 GLUCOSE TEST STR...... 349 FARXIGA...... 266 FIRDAPSE...... 504 EVENCARE MINI FARYDAK...... 72 FIRMAGON...... 73 MONITOR SYSTEM...... 368 FASENRA PEN...... 527 FIRMAGON KIT W EVENCARE PROVIEW Fayosim...... 182 DILUENT SYRINGE...... 73 CONTROL-L2,L3...... 368, 459 FC2 FEMALE CONDOM FIRVANQ...... 53 EVENCARE PROVIEW ...... 356, 460 FLAREX...... 510 TEST STRIP...... 349, 459 febuxostat...... 327 flavoxate...... 325 EVENCARE TEST...... 349, 459 FEIBA NF...... 328 flecainide...... 95 EVERSENSE SMART felbamate...... 118 FLEXICHAMBER...... 425, 460 TRANSMITTER...... 368, 459 felodipine...... 105 FLEXICHAMBER-LG CHILD EVICEL...... 336 FEM PH...... 543 MASK...... 425, 460 EVOLUTION BLOOD FEMALE CATHETER..432, 460 FLEXICHAMBER-SM GLUCOSE METER..... 368, 459 FEMCAP...... 354, 460 ADULT MASK...... 425, 460 EVOLUTION NORMAL FEMRING...... 544 FLEXICHAMBER-SM CONTROL...... 368, 459 Femynor...... 178 CHILD MASK...... 425, 460 EVOLUTION TEST STRIPS fenofibrate...... 97 FLEXIPAK...... 31 ...... 349, 459 fenofibrate micronized...... 97 EVOTAZ...... 49, 60 fenofibrate nanocrystallized...97 558 FLEXI-SEAL SIGNAL FMS flurbiprofen sodium...... 512 FORA PREMIUM V10 ...... 387, 460 flutamide...... 68 GLUCOSE METER..... 369, 461 FLOLIPID...... 98 fluticasone propionate. 216, 536 FORA TEST N'GO VOICE FLOVENT DISKUS...... 527 fluticasone propion- METER...... 370, 461 FLOVENT HFA...... 527 salmeterol...... 533 FORA TEST STRIP...... 349 FLUAD 2019-2020 (65 YR fluvastatin...... 98, 99 FORA TN'G VOICE METER UP)(PF)...... 85 fluvoxamine...... 129 ...... 370, 461 FLUARIX QUAD 2019-2020 FLUZONE HIGH-DOSE FORA TN'G VOICE TEST (PF)...... 85 2019-20 (PF)...... 86 STRIPS...... 349, 461 FLUBLOK QUAD 2019-2020 FLUZONE QUAD 2019- FORA V10...... 349, 370, 461 (PF)...... 85 2020...... 86 FORA V10-V12-D10-D20 FLUCAINE...... 513 FLUZONE QUAD 2019- STRIPS...... 350 FLUCELVAX QUAD 2019- 2020 (PF)...... 86 FORA V12 BLOOD 2020...... 85 FLUZONE QUAD PEDI GLUCOSE SYSTEM... 370, 462 FLUCELVAX QUAD 2019- 2019-20 (PF)...... 86 FORA V12 GLUCOSE...... 350 2020 (PF)...... 85 FLYP NEBULIZER...... 406 FORA V20...... 350, 370, 462 flucona-ibuprof-itracon-terbin FML FORTE...... 510 FORA V30A...... 350, 370, 462 ...... 200 FML S.O.P...... 510 FORACARE GD20...... 350, 462 fluconazole...... 44 FOLET ONE...... 244, 246 FORACARE GD20 flucytosine...... 44 folic acid...... 256 GLUCOSE METER..... 370, 462 fludrocortisone...... 296 FOLIVANE-OB...... 246 FORACARE GD40...... 350, 462 FLULAVAL QUAD 2019- FOLLISTIM AQ...... 284 FORACARE GD40A 2020...... 86 fondaparinux...... 338 GLUCOSE METER..... 370, 462 FLULAVAL QUAD 2019- FORA 6 CONNECT FORACARE GD40B 2020 (PF)...... 86 GLUCOSE STRIP...... 349, 460 GLUCOSE METER..... 370, 462 FLUMIST QUAD 2019-2020..86 FORA D10...... 354, 369, 461 FORACARE GDH HIGH flunisolide...... 536 FORA D15 GLUCOSE-BP CONTROL...... 370, 462 fluocinolone...... 216 MONITOR...... 354, 369, 461 FORACARE GDH LOW fluocinolone acetonide oil.... 521 FORA D15G STRIPS.. 349, 461 CONTROL...... 370, 462 fluocinolone and shower cap FORA D20...... 349, 369, 461 FORACARE GDH NORMAL ...... 216 FORA D40D GLUCOSE-BP CONTROL...... 370, 462 fluocinolone-niacinamide..... 219 MONITOR...... 354, 369, 461 FORACARE LANCETS fluocinonide...... 216 FORA D40-G31 TEST ...... 370, 462 Fluocinonide-E...... 216 STRIPS...... 349, 461 FORTEO...... 279 fluocinonide-emollient...... 216 FORA G20...... 349, 369, 461 FORTISCARE BLOOD fluorescein-proparacaine..... 514 FORA G30A...... 369, 461 GLUCOSE SYST...... 370 fluoride (sodium)...... 499 FORA G30-PREMIUM V10 FORTISCARE GLUCOSE FLUORIDEX DAILY TEST STRP...... 349, 461 TEST STRIPS...... 350, 462 DEFENSE...... 499 FORA GD50 BLOOD FORTISCARE HIGH... 370, 462 FLUORIDEX SENSITIVITY GLUCOSE SYSTEM... 369, 461 FORTISCARE LOW.... 370, 462 RELIEF...... 499 FORA GD50 TEST STRIPS FORTISCARE NORMAL fluorometholone...... 510 ...... 349, 461 ...... 370, 463 FLUOROPLEX...... 202 FORA GTEL GLUCOSE FOSAMAX PLUS D...... 279 fluorouracil...... 202, 203 TEST STRIP...... 349, 461 fosamprenavir...... 60 FLUOVIX...... 216 FORA HIGH CONTROL fosinopril...... 88 fluoxetine...... 129 ...... 369, 461 fosinopril- fluphenazine hcl...... 141 FORA LANCING DEVICE... 369 hydrochlorothiazide...... 88 flurandrenolide...... 216 FORA LOW CONTROL FOSRENOL...... 320 flurazepam...... 149, 166 ...... 369, 461 FRAGMIN...... 338 flurbiprofen...... 34 FORA NORMAL CONTROL369 FREESTYLE CONTROL..... 371 559 FREESTYLE FLASH GAMUNEX-C...... 81 GLEOSTINE...... 68 SYSTEM...... 371, 463 ganirelix...... 296 glimepiride...... 268 FREESTYLE FREEDOM GARDASIL 9 (PF)...... 85 glipizide...... 268 ...... 371, 463 gatifloxacin...... 517 glipizide-metformin...... 268 FREESTYLE FREEDOM gatifloxacin-dexamethasone 506 GLOPERBA...... 326 LITE...... 371 GATTEX 30-VIAL...... 318 GLUCAGEN HYPOKIT...... 257 FREESTYLE INSULINX GATTEX ONE-VIAL...... 318 GLUCAGON EMERGENCY ...... 350, 371 Gavilyte-C...... 316 KIT (HUMAN)...... 257 FREESTYLE INSULINX Gavilyte-G...... 316 GLUCERNA HUNGER TEST STRIPS...... 350, 463 Gavilyte-N...... 316 SMART...... 245 FREESTYLE LANCETS GDRIVE...... 371, 463 GLUCO NAVII GLUCOSE ...... 371, 463 GE100 BLOOD GLUCOSE MONITOR...... 371, 463 FREESTYLE LIBRE 10 DAY SYSTEM...... 371 GLUCO NAVII TEST STRIP350 READER...... 371, 463 GE100 BLOOD GLUCOSE GLUCOCARD 01 HI- FREESTYLE LIBRE 10 DAY TEST STRIP...... 350 NORMAL CONTROL...... 372 SENSOR...... 371, 463 GE100 CONTROL GLUCOCARD 01 METER... 372 FREESTYLE LIBRE 14 DAY SOLUTION NORMAL...... 371 GLUCOCARD 01 NORMAL READER...... 371, 463 GELCLAIR...... 501 CONTROL...... 372 FREESTYLE LIBRE 14 DAY GELFILM...... 335, 516 GLUCOCARD 01 SENSOR SENSOR...... 371, 463 GEL-FLOW...... 335 PLUS...... 350 FREESTYLE LITE METER. 371 GEL-FLOW NT...... 335 GLUCOCARD FREESTYLE LITE STRIPS. 350 GELFOAM...... 335 EXPRESSION...... 350, 372 FREESTYLE NAVIGATOR GELFOAM JMI POWDER... 335 GLUCOCARD SHINE...... 372 GLUC SENS...... 371, 463 GELFOAM JMI SPONGE....335 GLUCOCARD SHINE FREESTYLE PRECISION GELFOAM SPONGE SIZE CONNEX METER...... 372 ...... 393, 463 200...... 335 GLUCOCARD SHINE FREESTYLE PRECISION GELNIQUE...... 325 EXPRESS METER...... 372 NEO METER...... 371 GELX...... 501 GLUCOCARD SHINE FREESTYLE PRECISION gemfibrozil...... 97 METER...... 372 NEO STRIPS...... 350 GENADUR...... 234 GLUCOCARD SHINE FREESTYLE SIDEKICK II GENADUR (WITH METER KIT...... 372 ...... 371, 463 LEXINAL)...... 234 GLUCOCARD SHINE TEST FREESTYLE SYSTEM KIT. 371 Generlac...... 304 STRIPS...... 350 FREESTYLE TEST...... 350 Gengraf...... 28, 342 GLUCOCARD SHINE XL FREESTYLE UNISTIK 2 GENOTROPIN...... 287 METER...... 372 ...... 371, 463 GENOTROPIN MINIQUICK 287 GLUCOCARD VITAL...... 372 FROTEK...... 227 GENSTRIP TEST STRIP.... 350 GLUCOCARD VITAL frovatriptan...... 158 Gentak...... 517 SENSOR...... 350 FULPHILA...... 333 gentamicin...... 197, 517 GLUCOCARD VITAL TEST furosemide...... 108, 109 GENULTIMATE TEST STRIPS...... 351 FUZEON...... 47 STRIP...... 350 GLUCOCOM AUTOLINK Fyavolv...... 282 GENVOYA...... 49 ...... 372, 463 FYCOMPA...... 116, 117 GIALAX...... 316 GLUCOCOM BLOOD G TUSSIN AC...... 541 GIANVI (28)...... 178 GLUCOSE...... 372 gabapentin...... 120 GILENYA...... 505 GLUCOCOM CONTROL GALAFOLD...... 498 GILOTRIF...... 67 HIGH...... 372, 463 galantamine...... 172, 173 GIRLS TRAINING PANTS GLUCOCOM CONTROL GALZIN...... 39 4T-5T...... 388, 463 NORMAL...... 372, 464 GAMMAGARD LIQUID...... 81 glatiramer...... 503 GAMMAKED...... 81 Glatopa...... 504 560 GLUCOCOM GLUCOSE GUARDIAN RT CHARGER HEMOFIL M MID...... 332 ...... 351, 464 ...... 373, 464 HEMOFIL M SUPER HIGH. 332 GLUCOCOM LANCETS GUARDIAN RT MONITOR HEP FLUSH-10 (PF)...... 337 ...... 372, 464 SYSTEM...... 373, 464 heparin (porcine)...... 337 glucose...... 257 GUARDIAN RT STARTER heparin (porcine) in 0.9% GLUCOSE CONTROL...... 372 KIT...... 373, 464 nacl...... 336, 337 GLUCOSE KETONE GUARDIAN RT TEST PLUG heparin (porcine) in 5 % dex337 CONTROL SOLN...... 373 DEVICE...... 373 heparin flush(porcine)- glutathione (bulk)...... 171 GUARDIAN RT 0.9nacl...... 337 glyburide...... 269 TRANSMITTER TAPE.373, 464 HEPARIN LOCK...... 337 glyburide micronized...... 268 GUARDIAN SENSOR 3 HEPARIN LOCK FLUSH..... 337 glyburide-metformin...... 268 ...... 373, 464 heparin lock flush (porcine) glycine urologic solution...... 319 GVOKE SYRINGE...... 257 ...... 336, 337 glycopyrrolate...... 309, 310 GYNAZOLE-1...... 543 HEPARIN Glydo...... 231 GYNOL II...... 186 LOCKFLUSH(PORCINE)(PF GLYXAMBI...... 264 HAEGARDA...... 328 )...... 337 GM100...... 351, 373, 464 Hailey...... 178 heparin, porcine (pf).... 337, 338 GOCOVRI...... 137 Hailey 24 Fe...... 178 HEPLISAV-B (PF)...... 81 GOLYTELY...... 316 halcinonide...... 217 HETLIOZ...... 156 GONAL-F...... 284 halobetasol propionate 205, 217 HICON...... 77 GONAL-F RFF...... 284 HALOG...... 217 Hidex...... 285 GONAL-F RFF REDI-JECT.284 haloperidol...... 140 HISTEX-AC...... 539 GONITRO...... 94 haloperidol lactate...... 140 HI-VOLUME PUMPING GOODLIFE AC-302 HARMONY CONTROL CHAMBER SET...... 403, 465 GLUCOSE METER..... 373, 464 L1,L3...... 373, 464 HIZENTRA...... 81 GOODLIFE AC-302 TEST HARMONY GLUCOSE HOMATROPAIRE...... 508 STRIP...... 351, 464 TEST STRIP...... 351, 464 homatropine hbr...... 508 GRAFIX CORE...... 234 HARVONI...... 55 HOME NEBULIZER PLUS GRAFIX PRIME...... 234 HAVRIX (PF)...... 80 SIDESTREAM...... 425 GRAFIX XC...... 234 HEALTHPRO GLUCOSE HORIZANT...... 161 GRALISE...... 164 MONITOR...... 373, 464 HPR...... 210 GRALISE 30-DAY HEALTHPRO HIGH-LOW HPR PLUS...... 210 STARTER PACK...... 164 CONTROL...... 373, 464 HPR PLUS HYDROGEL..... 209 granisetron hcl...... 302 HEALTHPRO TEST STRIPS HPR PLUS-MB HYDROGEL GRANIX...... 333 ...... 351, 465 ...... 209 GRASTEK...... 79 HEALTHWISE INSULIN HUMALOG JUNIOR griseofulvin microsize...... 44 SYRINGE...... 394, 465 KWIKPEN U-100...... 293 griseofulvin ultramicrosize..... 44 HEALTHWISE PEN HUMALOG KWIKPEN guaiacol...... 171 NEEDLE...... 394, 465 INSULIN...... 293, 294 GUAIATUSSIN AC...... 542 HEALTHY ACCENTS HUMALOG MIX 50-50 GUAIFENESIN AC...... 542 AUTOLET...... 373 INSULN U-100...... 290 GUAIFENESIN DAC...... 541 HEALTHY ACCENTS HUMALOG MIX 50-50 guanfacine...... 107, 144 UNIFINE PENTIP...... 394, 465 KWIKPEN...... 291 guanidine...... 343 HEALTHY ACCENTS HUMALOG MIX 75-25 GUARDIAN CONNECT UNILET LANCET...... 373 KWIKPEN...... 291 TRANSMITTER...... 373, 464 Heather...... 182 HUMALOG MIX 75-25(U- GUARDIAN LINK 3 HEMANGEOL...... 103 100)INSULN...... 291 TRANSMITTER...... 373 HEMLIBRA...... 333 HUMALOG U-100 INSULIN 294 GUARDIAN REAL-TIME HEMOFIL M HIGH...... 331 HUMATE-P...... 332 GLU MONITOR...... 373, 464 HEMOFIL M LOW...... 331 HUMATROPE...... 288 561 HUMIRA...... 24, 25, 314 hydrocortisone-iodoquinl- ibuprofen-oxycodone...... 20, 21 HUMIRA PEDIATRIC aloe2...... 198 icatibant...... 104 CROHNS START...... 314 hydrocortisone-iodoquinol... 202 ICLUSIG...... 74 HUMIRA PEN...... 24, 25, 314 hydrocortisone-iodoquinol- IDELVION...... 330 HUMIRA PEN CROHNS- aloe...... 198 IDHIFA...... 74 UC-HS START...... 24, 25, 314 hydrocortisone-pramoxine IGLUCOSE BLOOD HUMIRA PEN PSOR- ...... 38, 220 GLUCOSE MONITOR...... 374 UVEITS-ADOL HS...24, 25, 314 HYDROFERA BLUE....238, 465 IGLUCOSE TEST STRIP.... 351 HUMIRA(CF)...... 24, 26, 315 HYDROFERA BLUE ILEVRO...... 512 HUMIRA(CF) PEDI READY...... 238, 465 imatinib...... 76 CROHNS STARTER hydrogen peroxide...... 79 IMBRUVICA...... 70, 76 ...... 24, 25, 314 hydrogen peroxide (bulk) imipramine hcl...... 134 HUMIRA(CF) PEN...24, 25, 315 ...... 79, 171 imipramine pamoate...... 134 HUMIRA(CF) PEN Hydromet...... 540 imiquimod...... 221 CROHNS-UC-HS.... 24, 25, 315 hydromorphone...... 11, 12 imiquimod-levocetirizin- HUMIRA(CF) PEN PSOR- hydromorphone (pf)-0.9 % niacin...... 222 UV-ADOL HS...... 24, 25, 315 nacl...... 11 IMPAVIDO...... 46 HUMULIN 70/30 U-100 hydromorphone in 0.9 % IMPOYZ...... 205 INSULIN...... 289 nacl...... 11 INBRIJA...... 136 HUMULIN 70/30 U-100 hydroquinone...... 208 Incassia...... 182 KWIKPEN...... 289 hydroquinone microspheres 208 IN-CHECK NASAL WITH HUMULIN N NPH INSULIN hydroquinone- MASK...... 421, 465 KWIKPEN...... 289 hydrocortisone...... 209 IN-CHECK ORAL FLOW HUMULIN N NPH U-100 hydroxocobalamin...... 255 METER...... 421, 465 INSULIN...... 289 hydroxychloroquine...... 45 INCONTROL LANCING HUMULIN R REGULAR U- hydroxyethyl DEVICE...... 374, 465 100 INSULN...... 290 methacrylate,bulk...... 171 INCONTROL PEN NEEDLE HUMULIN R U-500 (CONC) hydroxypropyl cellulose...... 172 ...... 394, 465 INSULIN...... 290 hydroxyurea...... 69 INCONTROL SUPER THIN HUMULIN R U-500 (CONC) hydroxyzine hcl...... 114 LANCETS...... 374, 465 KWIKPEN...... 290 hydroxyzine pamoate...... 114 INCONTROL ULTRA THIN HYCAMTIN...... 78 HYGEL...... 228 LANCETS...... 374, 465 HYCLODEX...... 79 HYLATOPIC...... 210 INCRELEX...... 295 hydralazine...... 108 HYLATOPICPLUS...... 211 INCRUSE ELLIPTA...... 529 HYDRO 35...... 223 HYOPHEN...... 58, 323 indapamide...... 110 hydrochlorothiazide...... 110 hyoscyamine sulfate.... 309, 324 INDERAL XL...... 104 hydrocodone- HYOSYNE...... 309, 324 INDICLOR...... 240 acetaminophen...... 19, 20 HYPER-SAL...... 171 INDOCIN...... 35 hydrocodone- HYPOCYN...... 212 indomethacin...... 35 chlorpheniramine...... 538 HYPOLANCE AST INFASURF...... 535 hydrocodone-homatropine...540 LANCING...... 373 INFINITY CONTROL hydrocodone-ibuprofen...... 20 hypromellose...... 172 SOLUTION HIGH...... 374, 465 hydrocortisone HYQVIA...... 82 INFINITY CONTROL ...... 38, 218, 285, 313 HYQVIA HY COMPONENT.299 SOLUTION LOW...... 374, 465 hydrocortisone acetate...... 38 HYQVIA IG COMPONENT....82 INFINITY CONTROL hydrocortisone butyrate...... 217 HYSINGLA ER...... 12 SOLUTION NORM...... 374, 465 hydrocortisone butyr- ibandronate...... 279 INFINITY METER KIT. 374, 466 emollient...... 217 IBRANCE...... 71 INFINITY STARTER KIT..... 374 hydrocortisone valerate...... 218 Ibu...... 34 INFINITY TEST STRIPS..... 351 hydrocortisone-acetic acid...521 ibuprofen...... 34 562 INFINITY VOICE CTRL INSPIRACHAMBER WITH ISENTRESS HD...... 47 SOLN-LVL 2...... 374, 466 MASK-SMALL...... 426, 466 Isibloom...... 178 INFINITY VOICE GLUCOSE INSPIRATION ELITE isoflurane...... 37 MONITOR...... 374, 466 FILTER...... 426, 466 isoniazid...... 51 INFINITY VOICE TEST INSUFLON...... 430, 467 isopropyl alcohol...... 171 STRIP...... 351, 466 INSUL-CAP...... 374, 467 ISORDIL...... 94 INFLAMMACIN...... 31 INSUL-EZE...... 374, 467 isosorbide dinitrate...... 94 INFLAMMA-K...... 227 insulin syr/ndl u100 half isosorbide mononitrate...... 94 INFLATHERM(DICLOFENA mark...... 394, 467 isotretinoin...... 186 C-MENTHOL)...... 31 INSULIN SYRINGE..... 394, 467 isoxsuprine...... 111 INFUSION SET 23"...... 403 INSULIN SYRINGE isradipine...... 105 INGREZZA...... 160, 161 MICROFINE...... 394, 467 itraconazole...... 44 INGREZZA INITIATION insulin syringe needleless ivermectin...... 43, 230 PACK...... 160, 161 ...... 394, 467 ivermectin-metronidazol- INJECT EASE LANCETS insulin syringe-needle u-100 niacin...... 230 ...... 374, 466 ...... 395, 467 IXINITY...... 330 INLYTA...... 76 INSUPEN...... 395, 467 JADENU...... 40 INNOPRAN XL...... 104 INSYTE IV CATHETER JADENU SPRINKLE...... 40 INNOSPIRE DELUXE. 425, 466 ...... 403, 467 JAKAFI...... 72 INNOSPIRE ELEGANCE.... 425 INTEGRA SYRINGE... 403, 467 Jantoven...... 328 INNOSPIRE ESSENCE...... 425 INTELENCE...... 47 JANUMET...... 276 INNOSPIRE GO INTERLINK LEVER LOCK JANUMET XR...... 276 NEBULIZER...... 406, 466 CANNULA...... 420, 467 JANUVIA...... 259 INNOSPIRE MINI...... 425 INTERLINK SYRINGE AND JARDIANCE...... 267 INNOSPIRE CANNULA...... 413, 467 Jasmiel (28)...... 178 REPLACEMENT FILTER INTRON A...... 72 JAZZ WIRELESS 2 METER ...... 425, 466 Introvale...... 178 KIT...... 374 INOVA...... 192 INVACARE LANCETS.374, 467 Jencycla...... 182 INOVA 4-1...... 192 INVELTYS...... 510 JENTADUETO...... 276 INOVA 8-2...... 192 INVIRASE...... 60 JENTADUETO XR...... 276 INPEN (FOR HUMALOG)... 394 INVOKAMET...... 261 Jinteli...... 282 INPEN (FOR NOVOLOG)... 394 INVOKAMET XR...... 262 JIVI...... 332 INREBIC...... 72 INVOKANA...... 267 JOLESSA...... 178 INSET 30 INFUSION SET IODOFLEX...... 79 JORNAY PM...... 146 23"...... 434, 466 IODOSORB...... 79 JUBLIA...... 202 INSET 30 TUBING 23" IOPIDINE...... 519 Juleber...... 178 BLUE...... 419, 466 I-PORT...... 420 JULUCA...... 47 INSET 30 TUBING 23" I-PORT ADVANCE 6 MM Junel 1.5/30 (21)...... 178 GREY...... 420, 466 INJEC PORT...... 420, 467 Junel 1/20 (21)...... 178 INSET 30 TUBING 23" PINK I-PORT ADVANCE 9 MM Junel Fe 1.5/30 (28)...... 178 ...... 420, 466 INJEC PORT...... 420, 467 Junel Fe 1/20 (28)...... 178 INSET 30 TUBING 43" ipratropium bromide.....530, 535 Junel Fe 24...... 178 GREY...... 420, 466 ipratropium-albuterol...... 532 JUXTAPID...... 102 INSET INFUSION SET 23"..435 irbesartan...... 93 JYNARQUE...... 109, 300, 321 INSPIRACHAMBER.... 425, 466 irbesartan- KADIAN...... 12 INSPIRACHAMBER WITH hydrochlorothiazide...... 91 Kaitlib Fe...... 178 MASK-LARGE...... 425, 466 IRESSA...... 67 KALETRA...... 49 INSPIRACHAMBER WITH IRRIGATION SYRINGE Kalliga...... 178 MASK-MED...... 425, 466 ...... 413, 467 KALYDECO...... 534 ISENTRESS...... 47 KAMDOY...... 224 563 KANGAROO 924 SAFETY KLARITY-L (LOTEPRED- LANCING SYSTEM.....375, 468 SCREW...... 355, 468 CHOND)(PF)...... 510 LANOXIN...... 108 KANGAROO EPUMP SET Klor-Con M10...... 244 lansoprazole...... 306 ...... 356, 468 Klor-Con M15...... 244 lanthanum...... 320 KANGAROO GRAVITY SET Klor-Con M20...... 244 LANTUS SOLOSTAR U-100 ...... 356, 468 Klor-Con Sprinkle...... 244 INSULIN...... 291 KAPSPARGO SPRINKLE... 103 KOATE...... 332 LANTUS U-100 INSULIN.... 291 KARBINAL ER...... 523, 524 KOGENATE FS...... 332 LANZO LANCING DEVICE Kariva (28)...... 175 KOMBIGLYZE XR...... 276 ...... 375, 468 KATERZIA...... 105 KORLYM...... 260 Larin 1.5/30 (21)...... 179 KELARX...... 228 KOSHER PRENATAL PLUS Larin 1/20 (21)...... 179 Kelnor 1/35 (28)...... 178 IRON...... 247 Larin 24 Fe...... 179 Kelnor 1-50...... 178 KOVALTRY...... 332 Larin Fe 1.5/30 (28)...... 179 KELOTOP...... 430, 468 KOVANAZE...... 499 Larin Fe 1/20 (28)...... 179 KENDALL DISINFECTANT K-PHOS NO 2...... 322 Larissia...... 179 CAP...... 420, 468 K-PHOS ORIGINAL...... 322 LASTACAFT...... 509 KENGUARD FOLEY KRINTAFEL...... 45 latanoprost...... 519 CATHETER...... 432, 468 KRISTALOSE...... 316 latanoprost (pf)...... 519 KERAFOAM...... 223 Kurvelo (28)...... 178 LATUDA...... 138 KERAGEL...... 238, 468 KUVAN...... 498 LAYOLIS FE...... 179 KERAGELT...... 238 KYLEENA...... 174 LAZANDA...... 12 KERALYT SCALP l norgest/e.estradiol-e.estrad LC D NEBULIZER SET...... 406 COMPLETE...... 223 ...... 175, 182 LC PLUS...... 406 KERAMATRIX...... 235 L.E.T. (LIDO-EPINEPH- LC PLUS NEBULIZER-PED KERLIX AMD...... 238 TETRA)...... 231 MASK...... 406 KERYDIN...... 202 labetalol...... 89 LC STAR...... 406, 468 ketamine...... 36 LACRISERT...... 505 LDO PLUS...... 224, 229 ketoconazole...... 44, 201 lactated ringers...... 242 LEENA 28...... 183 ketoconazole-iodoquinol-hc.198 lactic acid-niacinamide...... 209 leflunomide...... 29 Ketodan...... 201 lactulose...... 304, 316 LENVIMA...... 76 KETODAN KIT...... 201 LAMICTAL XR STARTER Lessina...... 179 KETONE CARE...... 433, 468 (BLUE)...... 124 LETAIRIS...... 113 KETONE URINE TEST...... 468 LAMICTAL XR STARTER letrozole...... 70 ketoprofen...... 34 (GREEN)...... 125 leucovorin calcium...... 78 ketorolac...... 31, 32, 512 LAMICTAL XR STARTER LEUKERAN...... 67 KETOSTIX...... 468 (ORANGE)...... 125 LEUKINE...... 334 KEVEYIS...... 343 LAMIOFLUR...... 299 leuprolide...... 73 KEVZARA...... 29 lamivudine...... 48, 54 levalbuterol hcl...... 531 KINERET...... 28 lamivudine-zidovudine...... 50 levalbuterol tartrate...... 531 KISQALI...... 71 lamotrigine...... 125, 149 LEVATOL...... 103 KISQALI FEMARA CO- lancets...... 374 LEVEMIR FLEXTOUCH U- PACK...... 72 LANCETS, SUPER THIN 100 INSULN...... 292 KIVIK...... 212 ...... 374, 468 LEVEMIR U-100 INSULIN...292 KLARITY (CHONDROITIN) LANCETS,THIN...... 374, 468 levetiracetam...... 126, 127 (PF)...... 505 LANCETS,ULTRA THIN LEVICYN ANTIPRURITIC KLARITY-A (AZITHRO- ...... 374, 468 ...... 233, 239 CHONDR)(PF)...... 518 lancing device...... 374 LEVICYN ANTIPRURITIC KLARITY-B (BETAMETH- LANCING DEVICE WITH SG...... 211 CHOND)(PF)...... 510 LANCETS...... 374 LEVICYN DERMAL...... 236 lancing device with lancets.. 374 levobunolol...... 514 564 levocarnitine...... 240, 496 LITE TOUCH INSULIN PEN lovastatin...... 99 levocarnitine (with sugar).....496 NEEDLES...... 395, 468 Low-Ogestrel (28)...... 179 levocetirizine...... 525 LITE TOUCH INSULIN loxapine succinate...... 141 levofloxacin...... 53, 517 SYRINGE...... 395, 468 LOYON...... 211 Levonest (28)...... 183 LITE TOUCH LANCETS Lo-Zumandimine (28)...... 179 levonorgestrel...... 185 ...... 375, 468 LUCEMYRA...... 168 levonorgestrel-ethinyl estrad179 LITE TOUCH LANCING LUER LOCK SYRINGE levonorg-eth estrad triphasic DEVICE...... 375, 469 ...... 413, 469 ...... 183 LITE TOUCH-MEDIUM LUER-LOK TIP...... 413, 469 Levora-28...... 179 MASK...... 426, 469 LUGOLS...... 79, 243 levorphanol tartrate...... 12 LITEAIRE MDI CHAMBER luliconazole...... 201 levothyroxine...... 298 ...... 426, 469 LUMIGAN...... 519 LEVULAN...... 228 LITETOUCH-LARGE MASK LUPANETA PACK (1 LEXETTE...... 205 ...... 426, 469 MONTH)...... 296 LEXIVA...... 60 LITETOUCH-SMALL MASK LUPANETA PACK (3 LEXIXRYL...... 227 ...... 426, 469 MONTH)...... 296 LIALDA...... 313 lithium carbonate...... 152 LURADROX...... 228 LIDO BDK...... 433 lithium citrate...... 152 Lutera (28)...... 179 lidocaine...... 37, 231 LITHOSTAT...... 322 LUXAMEND...... 211 lidocaine hcl...... 37, 231, 501 LIVALO...... 99 LYNPARZA...... 75 lidocaine hcl-hydrocortison LMR PLUS...... 225 LYRICA...... 120, 156 ac...... 38, 39, 220 LO LOESTRIN FE...... 175 LYRICA CR. 155, 163, 164, 165 Lidocaine Viscous...... 501 LO-DOSE ASPIRIN...... 36, 339 LYSODREN...... 68 lidocaine-hydrocortisone- LOFRIC...... 432, 469 Lyza...... 182 aloe...... 39 LOKELMA...... 241 mafenide acetate...... 208 lidocaine-prilocaine...... 225 LONHALA MAGNAIR MAGELLAN INSULIN lidocaine-racepinep- REFILL...... 529 SAFETY SYRNG...... 395, 469 tetracaine...... 232 LONHALA MAGNAIR MAGELLAN SAFETY lidocaine-tetracaine...... 232 STARTER...... 529 NEEDLE...... 413, 469 LIDOPAC...... 232 LONSURF...... 70 MAGELLAN SAFETY LIDOPIN...... 232 loperamide...... 300 SYRINGE...... 413, 469 LIDOPURE PATCH...... 232 lopinavir-ritonavir...... 49 MAGELLAN SYRINGE LIDORX...... 232 LOPREEZA...... 282 ...... 395, 413, 469 LIDORXKIT...... 225 LOPROX KIT...... 200 MAGIC3 INTERMITTENT LIDOTRANS 5 PAK...... 232 lorazepam...... 115 CATHETER...... 432, 469 LIDOTREX...... 232 Lorazepam Intensol..... 115, 149 magnesium oxide...... 300 LIDOTREX (WITH VITAMIN LORBRENA...... 68 malathion...... 235 E)...... 232 Lorcet (Hydrocodone)...... 20 maprotiline...... 134 LIDOVEX...... 232 Lorcet Hd...... 20 MAR-COF BP...... 539 LIDTOPIC MAX...... 232 Lorcet Plus...... 20 MAR-COF CG...... 542 LILETTA...... 174 LORTAB ELIXIR...... 19, 20 Marlissa (28)...... 179 Lillow (28)...... 179 LORTUSS EX...... 541 MARNATAL-F...... 247 lindane...... 235 Loryna (28)...... 179 MARPLAN...... 128 linezolid...... 59 Lorzone...... 345 MARVONA SUIK (PF)...... 37 LINZESS...... 315 losartan...... 93 MATRISTEM...... 235 liothyronine...... 298 losartan-hydrochlorothiazide. 91 MATRISTEM LIPOCHOL PLUS...... 101 LOTEMAX...... 510 MICROMATRIX...... 235 lisinopril...... 88 LOTEMAX SM...... 510 MATULANE...... 67 lisinopril-hydrochlorothiazide. 88 loteprednol etabonate...... 510 Matzim La...... 105 LITE COAT ASPIRIN...... 36 LOUTREX...... 207, 211 565 MAVENCLAD (10 TABLET MEDLANCE PLUS methazolamide...... 108 PACK)...... 504 LANCETS...... 375 methenamine hippurate...... 58 MAVENCLAD (4 TABLET MEDLANCE PLUS methenamine mandelate...... 58 PACK)...... 504 SPECIAL BLADE...... 375 methen-sod phos-meth blue- MAVENCLAD (5 TABLET MEDPOINT NORMAL hyos...... 58, 324 PACK)...... 504 CONTROL...... 375, 470 methimazole...... 278 MAVENCLAD (6 TABLET MEDROL...... 285 METHITEST...... 257 PACK)...... 504 MEDROLOAN II SUIK...... 286 methocarbamol...... 345 MAVENCLAD (7 TABLET MEDROLOAN SUIK...... 286 METHOCEL E 4 M...... 172 PACK)...... 504 medroxyprogesterone..174, 297 methotrexate sodium...... 26, 69 MAVENCLAD (8 TABLET MEDTRONIC REMOTE methotrexate sodium (pf)...... 69 PACK)...... 504 CONTROL...... 375, 470 methoxsalen...... 203 MAVENCLAD (9 TABLET mefenamic acid...... 31 methscopolamine...... 309 PACK)...... 504 mefloquine...... 45 methyclothiazide...... 110 MAVYRET...... 54 megestrol...... 75, 240 methyl salicylate...... 234 MAXICOMFORT II PEN MEKINIST...... 73 methyldopa...... 107 NEEDLE...... 396, 469 MEKTOVI...... 73 methyldopa- MAXICOMFORT INSULIN Melodetta 24 Fe...... 179 hydrochlorothiazide...... 107 SYRINGE...... 396, 469 meloxicam...... 32 methylergonovine...... 296 MAXI-COMFORT INSULIN melphalan...... 67 methylphenidate hcl...... 146 SYRINGE...... 396, 470 memantine...... 173 methylprednisolone...... 286 MAXICOMFORT SAFETY MENACTRA (PF)...... 83 methyltestosterone...... 258 PEN NEEDLE...... 396 M-END PE...... 540 metipranolol...... 514 MAXIDEX...... 511 Menest...... 283 metoclopramide hcl...... 308 MAXI-TUSS CD...... 540 MENEST...... 283 metolazone...... 110 MAYZENT...... 505 MENOPUR...... 283 metoprolol succinate...... 103 MAYZENT STARTER PACK MENOSTAR...... 283 metoprolol su- ...... 505 MENTAX...... 200 hydrochlorothiaz...... 106 MB HYDROGEL...... 209 MENTHO-CAINE...... 225 metoprolol ta- MB HYDROGEL MENVEO A-C-Y-W-135-DIP hydrochlorothiaz...... 106 (CYCLOMETHICONE)...... 209 (PF)...... 83 metoprolol tartrate...... 103 M-CLEAR WC...... 542 meperidine...... 12 metronidazole 46, 188, 230, 543 meclizine...... 301 meperidine (pf)...... 12 mexiletine...... 95 meclofenamate...... 31 meprobamate...... 115 MIACALCIN...... 280 MEDIHONEY (CAL mercaptopurine...... 69 Mibelas 24 Fe...... 179 ALGINATE-HONEY)....238, 470 mesalamine...... 313 miconazole nitrate-zinc ox- MEDIHONEY (HONEY)...... 238 mesalamine with cleansing pet...... 201 MEDIHONEY wipe...... 313 MICONAZOLE-3...... 543 (HYDROCOLLOID-HONEY) MESNEX...... 78 MICORT-HC...... 38, 218 ...... 238, 470 MESTINON...... 343 MICRO BLOOD GLUCOSE MEDISENSE...... 375 Metadate Er...... 146 ...... 351, 470 MEDISENSE CONTROLS metaproterenol...... 531 MICRO THIN LANCETS...... 375 1-HI 1-LO...... 375, 470 Metaxall...... 345 MICROAIR MESH MEDISENSE GLUCOSE metaxalone...... 345 NEBULIZER...... 406 KETONE...... 375 METER-CHECK...... 375 MICROBORE EXTENSION MEDISENSE MID metformin...... 294, 295 SET...... 403, 470 CONTROL...... 375 methadone...... 12, 13 MICROCHAMBER...... 426 MEDISENSE THIN Methadone Intensol...... 13 MICROCYN...... 79, 236 LANCETS...... 375 Methadose...... 13 methamphetamine...... 154 566 MICRODOT BLOOD MINIMED 630G INSULIN MONOJECT ALLERGY GLUCOSE SYSTEM PUMP...... 431, 471 TRAY...... 414, 472 ...... 351, 375, 470 MINIMED 670G INSULIN MONOJECT ALLERGY MICRODOT HIGH-LOW PUMP...... 431 TRAY DETACH...... 414, 471 CONTROL...... 375, 470 MINIMED INFUSION SET...435 MONOJECT BLOOD MICRODOT INSULIN PEN MINIMED INFUSION SET- COLLECTION...... 346, 472 NEEDLE...... 396 MMT 390...... 435, 471 MONOJECT CONTROL MICRODOT NORMAL MINIMED INFUSION SET- SYRINGE LUER...... 414, 472 CONTROL...... 376 MMT 391...... 435, 471 MONOJECT DISPOSABLE MICRODOT XTRA BLOOD MINIMED INFUSION SET- SYRINGE...... 414 GLUCOSE...... 351, 470 MMT 392...... 435, 471 MONOJECT ECCENTRIC Microgestin 1.5/30 (21)...... 179 MINIMED INFUSION SET- NON-STERILE...... 414, 472 Microgestin 1/20 (21)...... 180 MMT 393...... 435, 471 MONOJECT HYPODERMIC Microgestin Fe 1.5/30 (28)...180 MINIMED QUICK-SERTER- NEEDLES...... 414, 472 Microgestin Fe 1/20 (28)...... 180 MMT 305...... 376, 471 MONOJECT INSULIN MICROLET 2 LANCING MINIMED SYRINGE SAFETY SYRING...... 396, 472 DEVICE...... 376, 470 RESERVOIR...... 396, 471 MONOJECT INSULIN MICROLET LANCET...... 376 Minitran...... 94 SYRINGE...... 396, 472 MICROLET NEXT LANCING MINI-WRIGHT PEAK FLOW MONOJECT LUER DEVICE...... 376, 470 METER...... 421, 471 ADAPTER...... 420, 472 MICROLIFE PEAK FLOW minocycline...... 64, 187 MONOJECT LUER-LOCK METER...... 421, 470 MINOLIRA ER...... 64, 187 TIP...... 414, 472 MICROSPACER...... 426 minoxidil...... 108 MONOJECT MAGELLAN midazolam...... 37, 166 MIO INFUSION SET...... 435 SYRINGE...... 414, 472 midazolam (pf)...... 37 MIRCERA...... 329 MONOJECT PHARMACY midodrine...... 107 MIRENA...... 174 TRAY LUER...... 414, 472 MIFEPREX...... 256 mirtazapine...... 128 MONOJECT PHARMACY mifepristone...... 257 MIRVASO...... 230 TRAY REG TIP...... 414 MIGERGOT...... 157 misoprostol...... 308 MONOJECT REG TIP NON- miglitol...... 259 MISTASSIST...... 426, 471 STERILE...... 414, 473 miglustat...... 497 MISTASSIST KIT...... 426, 471 MONOJECT REGULAR MIGRANOW...... 158 MITOSOL...... 508 LUER...... 414, 473 Mili...... 180 MKO (MIDAZOLAM- MONOJECT SAFETY LUER MILLIPRED...... 286 KETAMINE-ONDAN)...... 168 LOCK TIP...... 415, 473 MILLIPRED DP...... 286 M-M-R II (PF)...... 87 MONOJECT SAFETY Mimvey...... 282 M-NATAL PLUS...... 247 SYRINGES...... 404, 415, 473 Mimvey Lo...... 282 modafinil...... 162 MONOJECT SMARTIP MINI LANCING DEVICE moexipril...... 88 CANNULA...... 415, 473 ...... 376, 470 molindone...... 141 MONOJECT SYRINGE MINI PLUS NEBULIZER mometasone...... 218, 536 ...... 396, 415, 473 ...... 406, 470 Mondoxyne Nl...... 64, 65 MONOJECT SYRINGE MINI ULTRA-THIN II....396, 471 MONO-FLO DRAINAGE ECCENTRI LUER...... 415, 473 MINI WRIGHT PEAK FLOW BAG...... 387, 471 MONOJECT SYRINGE METER...... 421 MONOJECT 140CC LUER LOK...... 415, 473 MINILINK REAL-TIME PISTON SYRINGE...... 413 MONOJECT SYRINGE TRANSMITTER...... 376, 471 MONOJECT 35CC REGULAR LUER...... 415, 473 MINIMED 530G INSULIN SYRINGE CATH TIP... 414, 471 MONOJECT SYRINGE PUMP...... 431 MONOJECT 3CC SYR TOOMEY TYPE...... 415, 473 MINIMED 630G GUARDIAN 25GX1"...... 414, 471 MONOJECT TB...... 416, 474 START KT...... 376, 471 567 MONOJECT TB LUER LOK mycophenolate mofetil...... 342 Necon 0.5/35 (28)...... 180 ...... 416, 474 mycophenolate sodium...... 342 nefazodone...... 130 MONOJECT TB REGULAR MYDAYIS...... 147, 153 NEOCERA...... 211 LUER TIP...... 416, 474 MYDRIATIC4(TROP-PROP- neomycin...... 41 MONOJECT TB SAFETY PE-KTRLC)...... 516 neomycin-bacitracin-poly-hc 507 SYRINGE...... 416, 474 myelogram tray...... 420, 474 neomycin-bacitracin- MONOJECT TUBERCULIN MYGLUCOHEALTH polymyxin...... 516 SYRINGE...... 416, 474 ...... 351, 376, 474 neomycin-polymyxin b gu.... 319 MONOJECT ULTRA MYGLUCOHEALTH neomycin-polymyxin b- COMFORT INSULIN... 396, 474 CONTROL SOLUTION376, 474 dexameth...... 507 MONOLET LANCETS...... 376 MYGLUCOHEALTH neomycin-polymyxin- MONOLET THIN LANCETS LANCETS...... 376, 474 gramicidin...... 516 ...... 376, 474 MYLERAN...... 67 neomycin-polymyxin-hc Mono-Linyah...... 180 MYNATAL...... 247 ...... 507, 521 MONONINE...... 330 MYNATAL ADVANCE...... 247 Neo-Polycin...... 517 MONSEL'S...... 335 MYNATAL PLUS...... 247 Neo-Polycin Hc...... 507 montelukast...... 528 MYNATAL-Z...... 247 NEOSALUS...... 211 MONUROL...... 43 MYNATE 90 PLUS...... 247 NEO-SYNALAR...... 199 MORGIDOX 1X 50...... 65 Myorisan...... 186 NEO-SYNALAR KIT...... 199 MORGIDOX 1X100...... 65 MYRBETRIQ...... 320 NERLYNX...... 67 MORGIDOX 2X100...... 65 MYTESI...... 300 NESINA...... 259 MORPHABOND ER...... 13 MYXREDLIN...... 290 NESTABS ABC...... 247 morphine...... 13, 14 nabumetone...... 32 NESTABS DHA...... 247 morphine (pf)...... 13 nadolol...... 104 NESTABS ONE...... 245, 247 morphine concentrate...... 13 nadolol-bendroflumethiazide111 Neuac...... 190 morphine in 0.9 % sodium naftifine...... 199 NEUAC KIT...... 190 chlor...... 13 NAFTIN...... 199 NEULASTA...... 333, 334 MOTEGRITY...... 308 nalbuphine...... 22 NEUPOGEN...... 334 MOTOFEN...... 301 NALOCET...... 21 NEUPRO...... 137 MOUTHPIECE REUSABLE naloxone...... 41 NEURAPTINE...... 226 MW...... 426, 474 naltrexone...... 41 NEURCAINE...... 233 MOVANTIK...... 40 NAMENDA XR...... 173 NEUTEK 2TEK TEST MOVIPREP...... 316 NAMZARIC...... 173 STRIPS...... 351 MOXATAG...... 42 NAPRELAN CR...... 34 NEUTRASAL...... 500 MOXEZA...... 517 naproxen...... 34 NEVANAC...... 512 moxifloxacin...... 53, 517 naproxen sodium...... 34 nevirapine...... 48 MUCOSITISRX...... 500 naratriptan...... 158 NEW DAY...... 185 MUGARD...... 501 NARCAN...... 41 NEWGEN...... 247 MULPLETA...... 341 NASCOBAL...... 255 NEXA PLUS...... 247 MULTAQ...... 96 NATACHEW (FE BIS- NEXAVAR...... 74 MULTI-LANCET DEVICE 2 GLYCINATE)...... 247 NEXAVIR...... 224 ...... 376, 474 NATACYN...... 518 NEXIUM PACKET...... 307 mupirocin...... 197 NATAZIA...... 182 NEXIVA...... 404, 474 mupirocin calcium...... 197 nateglinide...... 260 NEXPLANON...... 174 MURI-LUBE...... 171 NATESTO...... 258 niacin...... 100, 101, 255 MY CHOICE...... 185 NATPARA...... 297 niacin (bulk)...... 171 MY MDI PORTABLE NATURE-THROID...... 298 Niacor...... 101 NEBULISER...... 426, 474 NAYZILAM...... 118 nicardipine...... 105 MY WAY...... 185 NEBUPENT...... 58 NICORELIEF...... 169 MYALEPT...... 296 NEBUSAL...... 172 nicotine...... 169 568 nicotine (polacrilex)...... 169 NORTREL 1/35 (21)...... 180 NUCALA...... 528 NICOTROL...... 169 Nortrel 1/35 (28)...... 180 NUCARACLINPAK...... 189 NICOTROL NS...... 170 Nortrel 7/7/7 (28)...... 183 NUCARARXPAK...... 190 nifedipine...... 105 nortriptyline...... 134 NUCORT...... 219 Nikki (28)...... 180 NORVIR...... 60 NUCYNTA...... 14 nilutamide...... 68 NOSE CLIP...... 426, 475 NUCYNTA ER...... 14 nimodipine...... 105 NOURIANZ...... 135 NUDERMRXPAK...... 205 NINJACOF-XG...... 542 NOVA MAX BLOOD NUDICLO SOLUPAK...... 227 NINLARO...... 75 GLUCOSE METER...... 376 NUDICLO TABPAK...... 31 nisoldipine...... 106 NOVA MAX GLUCOSE NUDROXIPAK...... 31 nitisinone...... 497 CONTROL...... 376, 475 NUDROXIPAK DSDR-50...... 31 Nitro-Bid...... 94 NOVA MAX GLUCOSE NUDROXIPAK DSDR-75...... 31 NITRO-DUR...... 94 TEST...... 351 NUDROXIPAK E-400...... 31 nitrofurantoin...... 323 NOVA SAFETY LANCETS..376 NUDROXIPAK I-800...... 31 nitrofurantoin macrocrystal.. 323 NOVA SUREFLEX NUDROXIPAK N-500...... 31 nitrofurantoin monohyd/m- LANCETS...... 376, 475 NUEDEXTA...... 166 cryst...... 323 NOVACORT...... 220 NUMBONEX...... 232 nitroglycerin...... 94 NOVAMAX PLUS GLU-KET NUMOISYN...... 10, 501 NITROMIST...... 94 ...... 376, 475 NUPLAZID...... 142 Nitro-Time...... 94 NOVAREL...... 289 NUSURGEPAK SURGICAL NITYR...... 497 NOVOEIGHT...... 332 PREP...... 239 NIVATOPIC PLUS...... 211 NOVOFINE 32...... 397, 475 NUTRASEB...... 211 NIVESTYM...... 334 NOVOFINE AUTOCOVER NUTROPIN AQ NUSPIN..... 288 nizatidine...... 305 ...... 397, 475 NUVAIL...... 229 NOCDURNA (MEN)...... 258 NOVOFINE PLUS...... 397, 475 NUVAKAAN...... 225, 430 NOCDURNA (WOMEN)...... 259 NOVOLIN 70/30 U-100 NUVARING...... 184 NOCTIVA...... 259 INSULIN...... 289 NUVESSA...... 543 NORA-BE...... 182 NOVOLIN 70-30 FLEXPEN NUWIQ...... 332 NORDITROPIN FLEXPRO..288 U-100...... 289 NUZYRA...... 42, 65 noreth-ethinyl estradiol-iron. 180 NOVOLIN N NPH U-100 NUZYRA (7 DAY WITH norethindrone INSULIN...... 290 LOAD DOSE)...... 41, 65 (contraceptive)...... 182 NOVOLIN R REGULAR U- NUZYRA (7 DAY)...... 41, 65 norethindrone acetate...... 297 100 INSULN...... 290 Nyamyc...... 200 norethindrone ac-eth NOVOLOG FLEXPEN U- NYMALIZE...... 105 estradiol...... 180, 282 100 INSULIN...... 294 nystatin...... 43, 200, 500 norethindrone-e.estradiol- NOVOLOG MIX 70-30 U- nystatin-triamcinolone...... 202 iron...... 180 100 INSULN...... 291 Nystop...... 200 NORGESIC FORTE...... 344 NOVOLOG MIX 70- OASIS ULTRA norgestimate-ethinyl 30FLEXPEN U-100...... 291 FENESTRATED...... 236, 475 estradiol...... 180, 183 NOVOLOG PENFILL U-100 OASIS WOUND MATRIX NORITATE...... 189, 230 INSULIN...... 294 FENESTRATED...... 236, 475 Norlyda...... 182 NOVOLOG U-100 INSULIN OASIS WOUND MATRIX NORMAL SALINE FLUSH...254 ASPART...... 294 MESHED...... 236, 475 NORM-JECT...... 416, 474 NOVOPEN ECHO...... 397, 475 OB COMPLETE...243, 244, 248 NORM-JECT TUBERKULIN NOVOSEVEN RT...... 331 OB COMPLETE ONE...... 248 ...... 416, 475 NOVOTWIST...... 397, 475 OB COMPLETE PETITE..... 248 NORMLGEL AG...... 197 NOXAFIL...... 44 OB COMPLETE PREMIER NORPACE CR...... 95 NOXIPAK...... 219 ...... 243, 248 NORTHERA...... 107 NP THYROID...... 298 OB COMPLETE WITH DHA 248 Nortrel 0.5/35 (28)...... 180 NUBEQA...... 68 OBAGI ELASTIDERM...... 209 569 OBAGI NU-DERM ON CALL EXPRESS ONETOUCH VERIO FLEX BLENDER...... 209 METER...... 377, 476 START...... 378 OBAGI NU-DERM CLEAR.. 209 ON CALL EXPRESS TEST ONETOUCH VERIO HIGH OBAGI NU-DERM STRIP...... 351, 476 CONTROL...... 378, 477 SUNFADER...... 209 ON CALL LANCET...... 377, 476 ONETOUCH VERIO IQ OBAGI-C CLARIFYING ON CALL LANCING METER...... 378, 477 SERUM...... 209 DEVICE...... 377, 476 ONETOUCH VERIO MID OBAGI-C THERAPY NIGHT ON CALL PLUS CONTROL CONTROL...... 378, 477 ...... 209 ...... 377, 476 ONETOUCH VERIO OBIZUR...... 332 ON CALL PLUS LANCET SYSTEM...... 378, 477 OBSTETRIX DHA...... 248 ...... 377, 476 ONEXTON...... 190 OBSTETRIX EC...... 248 ON CALL PLUS LANCING ONGLYZA...... 259 OBSTETRIX ONE...... 245 DEVICE...... 377, 476 ONMEL...... 44 O-CAL PRENATAL...... 248 ON CALL PLUS METER ON-THE-GO LANCETS...... 378 OCALIVA...... 341 ...... 377, 476 ONZETRA XSAIL...... 158 OCELLA...... 180 ON CALL PLUS TEST OPCICON ONE-STEP 185, 186 octreotide acetate...... 297 STRIP...... 351, 476 opium tincture...... 300 ODACTRA...... 80 ON CALL VIVID CONTROL OPSUMIT...... 113 ODEFSEY...... 50 ...... 377, 476 OPTICHAMBER ADULT ODOMZO...... 71 ON CALL VIVID METER MASK-LARGE...... 426, 477 OFEV...... 76, 542 ...... 377, 476 OPTICHAMBER DIAMOND ofloxacin...... 53, 517, 521 ON CALL VIVID PAL LG MASK...... 426, 477 OGESTREL (28)...... 180 METER...... 377, 476 OPTICHAMBER DIAMOND Okebo...... 65 ON CALL VIVID TEST VHC...... 426, 477 olanzapine...... 150 STRIP...... 351 OPTICHAMBER DIAMOND- olanzapine-fluoxetine...... 150 ondansetron...... 302 MED MSK...... 426, 477 olmesartan...... 93 ondansetron hcl...... 302 OPTICHAMBER DIAMOND- olmesartan-amlodipin- ONETOUCH DELICA LANC SML MASK...... 426, 477 hcthiazid...... 90 DEVICE...... 377, 476 OPTION-2...... 185, 186 olmesartan- ONETOUCH DELICA OPTIUM EZ...... 352 hydrochlorothiazide...... 91 LANCETS...... 377, 476 OPTIUM TEST...... 352 olopatadine...... 509, 536 ONETOUCH DELICA PLUS OPTUMRX...... 352, 378, 477 OLUMIANT...... 29 LANC DEV...... 377, 476 ORACIT...... 322 OMBRA COMPRESSOR ONETOUCH DELICA PLUS ORAFATE...... 502 SYSTEM...... 426, 475 LANCET...... 377, 476 ORALAIR...... 79, 80 OMECLAMOX-PAK...... 318 ONETOUCH PING INSULIN Oralone...... 501 omega-3 acid ethyl esters... 101 PUMP...... 431 ORAMAGICRX...... 501 omeprazole...... 307 ONETOUCH SURESOFT ORAQIX...... 499 omeprazole-sodium LANCING DEV...... 377, 476 ORAVIG...... 44 bicarbonate...... 308 ONETOUCH ULTRA BLUE ORENCIA...... 28 OMNARIS...... 536 TEST STRIP...... 352 ORENCIA CLICKJECT...... 28 OMNIPOD DASH INSULIN ONETOUCH ULTRA ORENITRAM...... 112 POD...... 405, 475 CONTROL...... 377 ORFADIN...... 497 OMNIPOD INSULIN ONETOUCH ULTRA2 ORILISSA...... 296 MANAGEMENT...... 431, 475 METER...... 377 ORKAMBI...... 534 OMNIPOD INSULIN REFILL ONETOUCH ULTRAMINI....377 orphenadrine citrate...... 345 ...... 405, 476 ONETOUCH ULTRASOFT orphenadrine-asa-caffeine...344 OMNITROPE...... 288 LANCETS...... 378, 476 Orphengesic Forte...... 344 ON CALL EXPRESS ONETOUCH VERIO...... 352 Orsythia...... 180 CONTROL...... 376, 476 ONETOUCH VERIO FLEX..378 OSCIMIN...... 309, 324, 325 570 OSCIMIN SL...... 309, 325 PARADIGM REMOTE PCCA ACCUPEN-15...355, 478 OSCIMIN SR...... 309, 325 CONTROL...... 378, 477 PEAK AIR PEAK FLOW oseltamivir...... 56 PARADIGM RESERVOIR METER...... 421, 478 OSMOLEX ER...... 137 ...... 397, 477 PEDIA IRON...... 243 OSMOPREP...... 316 PARADIGM SILHOUETTE PEDIATRIC DINOSAUR OTEZLA...... 29 INFUS SET...... 420 NEBULIZER...... 427, 478 OTEZLA STARTER...... 29, 206 PARAGARD T 380A...... 174 PEDIATRIC DOG OTIPRIO...... 521 paregoric...... 300, 301 NEBULIZER...... 427, 478 OTOVEL...... 521 PAREMYD...... 505 PEDIATRIC FROG OTREXUP (PF)...... 26 PARI BABY CONV KIT - NEBULIZER...... 427, 478 OVACE PLUS...... 207 SIZE 1...... 426, 477 PEDIZOL PAK...... 201 OVACE PLUS SHAMPOO.. 207 PARI BABY CONV KIT - peg 3350-electrolytes...... 317 OVAL TAPE...... 378, 477 SIZE 2...... 427, 477 PEGANONE...... 121 OVIDREL...... 289 PARI BABY CONV KIT - PEGASYS...... 54 oxandrolone...... 257 SIZE 3...... 427, 478 PEGASYS PROCLICK...... 54 oxaprozin...... 34 PARI BABY CONVERSION peg-electrolyte soln...... 317 OXAYDO...... 14 PACK 1...... 427, 478 PEGINTRON...... 54 oxazepam...... 115 PARI BABY CONVERSION PEG-PREP...... 317 oxcarbazepine...... 122 PACK 2...... 427, 478 PEN NEEDLE...... 397 OXERVATE...... 514 PARI BABY NEBULIZER.... 406 pen needle, diabetic.... 397, 478 oxiconazole...... 201 PARI LC D NEBULIZER penicillamine...... 40 OXISTAT...... 201 ...... 406, 478 penicillin v potassium...... 59 OXTELLAR XR...... 123 PARI LC FILTER WITH PENLEN...... 211 oxybutynin chloride...... 325 VALVE SET...... 427, 478 PENNSAID...... 227, 228 oxycodone...... 14, 15 PARI LC MASK SET... 427, 478 pentamidine...... 58 oxycodone-acetaminophen... 21 PARI LC SPRINT PENTASA...... 313 oxycodone-aspirin...... 21 NEBULIZER SET...... 406 pentazocine-naloxone...... 22 OXYCONTIN...... 15 PARI LC SPRINT SINUS.... 406 PENTIPS...... 397 oxymorphone...... 15 PARI SINUS AEROSOL pentoxifylline...... 334 OXYTROL...... 325 SYSTEM...... 427 PERFOROMIST...... 530 OZEMPIC...... 272 PARI TREK S COMBO perindopril erbumine...... 88 OZOBAX...... 345 PACK...... 427 Periogard...... 500 Pacerone...... 96 PARI TREK S COMPACT permethrin...... 235 PACNEX HP...... 192 COMPRESSOR...... 427 perphenazine...... 141 PACNEX LP...... 192 PARI TREK S PORTABLE perphenazine-amitriptyline.. 133 PAIN EASE MEDIUM PWR KIT...... 427 PERSONAL BEST FULL STREAM SPRAY...... 225 paricalcitol...... 496 RANGE...... 421, 478 PAIN EASE MIST SPRAY...225 Paroex Oral Rinse...... 500 PERSONAL BEST LOW PAINGO KFT...... 225 paromomycin...... 41 RANGE...... 421, 478 paliperidone...... 139 paroxetine hcl...... 129 PERTZYE...... 304 PALYNZIQ...... 498 paroxetine PEXEVA...... 129 PANCREAZE...... 304 mesylate(menop.sym)...... 296 PFLEX INSPIRATORY PANDEL...... 218 PASER...... 50 TRAINER...... 427, 478 PANRETIN...... 203 PAXIL...... 129 PHARMABASE BARRIER...229 pantoprazole...... 307 PAZEO...... 509 PHARMACIST CHOICE papaverine...... 111 P-CARE D40G...... 286 ...... 352, 478 PARADIGM INFUSION SET P-CARE D80G...... 286 PHARMACIST CHOICE ...... 420 P-CARE K40G...... 286 GLUCOSE SYS...... 378 PARADIGM REAL-TIME P-CARE K80G...... 286 PHASEAL ASSEMBLY TRANSMIT-SN...... 378, 477 P-CARE MG (PF)...... 37 FIXTURE...... 420, 478 571 PHASEAL CONNECTOR pioglitazone-glimepiride...... 270 PR NATAL 400...... 249 LUER LOCK...... 420 pioglitazone-metformin...... 269 PR NATAL 400 EC...... 249 PHASEAL INFUSION PIP LANCET...... 378, 479 PR NATAL 430...... 249 ADAPTER...... 420, 478 PIQRAY...... 75 PR NATAL 430 EC...... 249 PHASEAL INFUSION Pirmella...... 180, 183 PRADAXA...... 341 CLAMP...... 420 piroxicam...... 32 pralidoxime...... 39 PHASEAL INJECTOR LUER PLANTAGO-HOMACCORD 299 PRALUENT PEN...... 102 ...... 420, 478 PLEGRIDY...... 503 pramipexole...... 137 PHASEAL INJECTOR LUER PLENVU...... 317 PRAMOSONE...... 220, 221 LOCK...... 420 PLEXION CLEANSING prasugrel...... 340 PHASEAL PROTECTOR CLOTHS...... 190 pravastatin...... 99 ...... 420, 478 PNEUMOVAX 23...... 84 praziquantel...... 43 PHASEAL SECONDARY PNV 29-1...... 248 prazosin...... 111 SET...... 404, 479 PNV-DHA...... 248 PRECISION...... 378, 479 PHASEAL Y-SITE...... 404, 479 PNV-DHA + DOCUSATE.... 248 PRECISION GLUCOSE Phenadoz...... 302, 523, 524 PNV-FERROUS CONTROL SOLN...... 378, 479 phenazopyridine...... 323 FUMARATE-DOCU-FA...... 248 PRECISION phenelzine...... 129 PNV-OMEGA...... 248 GLUCOSE/KETONE phenobarb-hyoscy-atropine- PNV-SELECT...... 248 CONTR...... 378, 479 scop...... 311 POCKET CHAMBER...... 427 PRECISION PCX PLUS phenobarbital...... 166 POCKET PEAK FLOW TEST...... 352 PHENOHYTRO...... 311, 312 METER...... 422, 479 PRECISION PCX TEST...... 352 phenoxybenzamine...... 111 POD-CARE 100CG...... 284 PRECISION POINT OF phenylephrine hcl...... 513 POD-CARE 100KG...... 286 CARE TEST...... 352 phenyleph-tropicamide in PODOCON...... 223 PRECISION Q-I-D TEST.....352 water...... 506 podofilox...... 223 PRECISION XTRA phenytoin...... 121 POLY HUB NEEDLE... 416, 479 MONITOR...... 378 phenytoin sodium extended.121 Polycin...... 517 PRECISION XTRA TEST.... 352 Philith...... 180 POLYFIN QR INFUSION PRED MILD...... 511 PHLAG SPRAY...... 212 SET...... 421, 479 PRED-G...... 507 PHOSLYRA...... 320, 321 POLYFIN QR/WINGS PRED-G S.O.P...... 507 PHOSPHASAL...... 58 INFUSION SET...... 421, 479 prednicarbate...... 218 PHOSPHOLINE IODIDE..... 505 polymyxin b sulf- prednisol ace-gatiflox- PHOTREXA...... 506 trimethoprim...... 517 bromfen...... 508 PHOTREXA CROSS- polysaccharide iron complex prednisoln sp-gatiflox- LINKING KIT...... 506 ...... 243 bromfen...... 508 PHOTREXA VISCOUS...... 506 polysorbate 80...... 172 prednisoln sp-moxiflox- PHYSIOLYTE...... 242 POLY-TUSSIN AC...... 540 bromfen...... 508 PHYSIOSOL IRRIGATION..242 POMALYST...... 77 prednisolone...... 286 phytonadione (vitamin k1)... 256 PONTOCAINE...... 233 prednisolone acetate...... 511 PICATO...... 203 POPULUS COMPOSITUM..299 prednisolone acetate (pf).....511 PIFELTRO...... 48 PORTABLE NEBULIZER prednisolone acetate- PIKO 1...... 421, 479 SYSTEM...... 427, 479 bromfenac...... 514 PILLOW MASK CHILD 427, 479 Portia 28...... 181 prednisolone acetate- pilocarpine hcl...... 502, 505 posaconazole...... 44 nepafenac...... 514 pimecrolimus...... 208 POTABA...... 256 prednisolone acet- pimozide...... 141 potassium chloride...... 244 gatifloxacin...... 507 Pimtrea (28)...... 175 potassium citrate...... 323 prednisolone sod ph- pindolol...... 103 PR BENZOYL PEROXIDE.. 192 bromfenac...... 514 pioglitazone...... 295 PR CREAM...... 228 572 prednisolone sod ph- PRENATE CHEWABLE primidone...... 117 gatifloxac...... 507 ...... 245, 250 PRIMLEV...... 20, 21 prednisolone sod ph- PRENATE DHA...... 250 PRIMSOL...... 43 moxiflox...... 507 PRENATE DHA (FERR ASP PRIZOTRAL...... 225 prednisolone sodium GLYCIN)...... 250 PRO COMFORT INSULIN phosphate...... 286, 511 PRENATE ELITE...... 250 SYRINGE...... 397, 480 prednisolone-moxiflo- PRENATE ELITE (IRON PRO COMFORT LANCET nepafenac...... 508 ASP GLYC)...... 250 ...... 379, 480 prednisolone-moxifloxacin PRENATE ENHANCE...... 250 PRO COMFORT PEN hcl...... 507 PRENATE ESSENTIAL...... 250 NEEDLE...... 398, 480 prednisolone-moxiflox- PRENATE PRO COMFORT SPACER- bromfen...... 508 ESSENTIAL(IRON-ASP-GL) ADULT MASK...... 427, 480 prednisone...... 286 ...... 245, 250 PRO COMFORT SPACER- PREDNISONE INTENSOL..286 PRENATE MINI (FERR ASP CHILD MASK...... 427, 480 PREFEST...... 282 GLYCIN)...... 250 PRO COMFORT TENS pregabalin...... 120 PRENATE PIXIE...... 251 ELECTRODE...... 405, 480 PREGNYL...... 289 PRENATE RESTORE...... 251 PRO COMFORT TENS PREMARIN...... 283, 544 PRENATE STAR...... 251 UNIT...... 405, 480 PREMIER BLU GLUCOSE PREPIDIL...... 256 PRO VOICE V8 GLUCOSE METER...... 379, 479 PREPLUS...... 251 MONITOR...... 379, 480 PREMIER COMPACT PREPOPIK...... 317 PRO VOICE V8-V9 TEST GLUCOSE METER..... 379, 479 PRESERA...... 211 STRIP...... 352, 480 PREMIER TEST STRIP...... 352 PRESSURE ACTIVATED PRO VOICE V9 GLUCOSE PREMIER VOICE LANCETS...... 379, 479 MONITOR...... 379, 480 GLUCOSE METER..... 379, 479 PRESTALIA...... 87 PROAIR DIGIHALER...... 531 PREMIUM BLOOD PRESTO PRO BLOOD PROAIR HFA...... 531 GLUCOSE MONITOR...... 379 GLUCOSE METER..... 379, 479 PROAIR RESPICLICK...... 531 PREMIUM V10.... 352, 379, 479 PRETAB...... 251 probenecid...... 327 PREMPHASE...... 282 Prevalite...... 96, 97 probenecid-colchicine...... 326 PREMPRO...... 282 PREVENT DROPSAFE PEN PROCARE COMPRESSOR PRENA1 CHEW...... 249 NEEDLE...... 397, 480 NEBULIZER...... 427, 480 PRENA1 PEARL...... 249 PREVIDENT...... 499 PROCARE PEDIATRIC PRENA1 TRUE...... 249 PREVIDENT 5000 NEBULIZER...... 428 PRENAISSANCE...... 249 BOOSTER PLUS...... 499 PROCARE SPACER WITH PRENAISSANCE PLUS...... 249 PREVIDENT 5000 DRY ADULT MASK...... 428, 480 PRENATA...... 249 MOUTH...... 499 PROCARE SPACER WITH PRENATABS FA...... 249 PREVIDENT 5000 ENAMEL CHILD MASK...... 428, 481 PRENATABS RX...... 249 PROTECT...... 499 PRO-CEPTION...... 405, 481 PRENATAL 19...... 249 PREVIDENT 5000 PROCHAMBER...... 428, 481 PRENATAL 19 (WITH SENSITIVE...... 499 prochlorperazine...... 302 DOCUSATE)...... 249 Previfem...... 181 prochlorperazine maleate.... 141 PRENATAL LOW IRON...... 249 PREVNAR 13 (PF)...... 84 PROCORT...... 39 PRENATAL PLUS...... 250 PREVYMIS...... 53 PROCRIT...... 330 PRENATAL PLUS PREZCOBIX...... 49, 59 Proctofoam Hc...... 39 (CALCIUM CARB)...... 250 PREZISTA...... 60 Procto-Med Hc...... 38 PRENATAL PLUS DHA...... 250 PRIFTIN...... 51 Procto-Pak...... 38, 218 PRENATAL VITAMIN PLUS PRILOSEC...... 307 Proctosol Hc...... 38, 218 LOW IRON...... 250 PRIMACARE...... 251 Proctozone-Hc...... 38 PRENATAL-U...... 250 primaquine...... 45 PROCYSBI...... 319 PRENATE AM...... 245, 250 PRIMEAIRE...... 427, 480 573 PRODIGY AUTOCODE propylene glycol (bulk)...... 171 QUINIXIL...... 219 METER...... 379 propylthiouracil...... 278 QUINJA...... 197 PRODIGY AUTOCODE PROQUAD (PF)...... 87 QUINTET AC...... 352, 380, 481 MONITOR SYST...... 379, 481 PROSTIN E2...... 256 QUINTET BLOOD PRODIGY CONTROL PROTHELIAL...... 502 GLUCOSE METER..... 380, 482 SOLUTION, LOW...... 379 PROTONIX...... 307 QUINTET GLUCOSE TEST PRODIGY CONTROL protriptyline...... 134 STRIPS...... 352, 482 SOLUTION,HIGH...... 379, 481 PROTYL AG...... 238 QUIT 2...... 170 PRODIGY INSULIN PROVENT...... 428, 481 QUIT 4...... 170 SYRINGE...... 398, 481 PROVENT STARTER. 428, 481 QUTENZA...... 234 PRODIGY LANCETS.. 379, 481 PROVENTIL HFA...... 531 QVAR REDIHALER...... 527 PRODIGY LANCING PROVIDA OB...... 251 rabeprazole...... 307 DEVICE...... 379, 481 PRUCLAIR...... 211 RADIAGEL...... 212 PRODIGY MINI-MIST PRUMYX...... 211 RADIAPLEXRX...... 228 NEBULIZER...... 407 PRUTECT...... 211 RADIOGARDASE...... 39, 40 PRODIGY NO CODING...... 352 PSORINOHEEL...... 299 RAGWITEK...... 80 PRODIGY POCKET METER PULMICORT FLEXHALER. 527 raloxifene...... 297 ...... 379 PULMO-AIDE ramelteon...... 156 PRODIGY TWIST TOP COMPRESSOR...... 428 ramipril...... 89 LANCET...... 379 PULMONEB LT ranitidine hcl...... 305 PRODIGY VOICE COMPRESSOR NEBUL ranolazine...... 95 GLUCOSE METER..... 379, 481 ...... 428, 481 RAPPORT VACUUM PROFILNINE...... 330 PULMOZYME...... 535 THERAPY...... 405, 482 progesterone...... 297 PUREFE OB PLUS...... 251 rasagiline...... 136 progesterone micronized..... 297 PURIXAN...... 69 RASUVO (PF)...... 26, 27 PROGLYCEM...... 257 PUSH BUTTON SAFETY RATE FLOW REGULATOR PROGRAF...... 342 LANCETS...... 380, 481 IV SET...... 404, 482 PROLASTIN-C...... 534 PYLERA...... 317 RAVICTI...... 497 PROLENSA...... 512 pyrazinamide...... 51 RAYALDEE...... 496 PROMACTA...... 341 pyridostigmine bromide...... 343 RAYOS...... 286 promethazine...... 302, 523, 524 pyridoxine (vitamin b6)...... 255 READYLANCE SAFETY promethazine-codeine...... 538 QBRELIS...... 89 LANCETS...... 380, 482 promethazine-dm...... 538 QBREXZA...... 199 REBIF (WITH ALBUMIN).... 503 promethazine-phenyleph- Q-CARE RX Q2...... 354 REBIF REBIDOSE...... 503 codeine...... 540 Q-CARE RX Q4...... 354 REBIF TITRATION PACK... 503 promethazine-phenylephrine QMIIZ ODT...... 32 REBINYN...... 330 ...... 522 QNASL...... 536, 537 RECEDO...... 228 Promethegan...... 523 QTERN...... 265 Reclipsen (28)...... 181 PROMISEB...... 207 QUAKE VIBRATORY PEP RECOMBINATE...... 332 PRONEB ULTRA FILTER ...... 428, 481 RECOMBIVAX HB (PF)...... 81 ASSEMBLY...... 428, 481 quazepam...... 149, 166 RECONSTITUBE...... 405, 482 PRONEB ULTRA II...... 428, 481 quetiapine...... 150 RECOTHROM...... 335 PRONEB ULTRA II FILTER QUICK-SET PARADIGM.....435 RECOTHROM SPRAY KIT. 335 ASSEM...... 428, 481 QUILLICHEW ER...... 147 RECTIV...... 38 propafenone...... 95 QUILLIVANT XR...... 147 REFUAH PLUS...... 352, 482 propantheline...... 310 quinapril...... 89 REFUAH PLUS GLUCOSE proparacaine...... 515 quinapril-hydrochlorothiazide.88 CONTROL...... 380, 482 propranolol...... 104 quinidine gluconate...... 95 REFUAH PLUS GLUCOSE propranolol- quinidine sulfate...... 95 MONITOR...... 380, 482 hydrochlorothiazid...... 111 quinine sulfate...... 45 REGENECARE...... 232 574 REGENECARE WITH ALOE RESECTISOL...... 319 RIGHTEST GM260 ...... 232 RESPA-AR...... 522 GLUCOSE METER..... 381, 483 REGRANEX...... 239 RESTASIS...... 511 RIGHTEST GM550 RELAFEN DS...... 32 RESTASIS MULTIDOSE.....511 SYSTEM...... 381, 483 RELAGARD...... 543 RESTORE...... 239, 356, 483 RIGHTEST GS250S TEST RELENZA DISKHALER...... 56 RESTORE CALCIUM STRIPS...... 352, 483 Relexxii...... 147 ALGINATE...... 238 RIGHTEST GS260 TEST RELIAMED LANCET... 380, 482 RESTORE CONTACT STRIPS...... 353, 483 RELIAMED MINI LANCING LAYER SILVER...... 238 RIGHTEST GS550 TEST DEVICE...... 380, 482 RESTORE FOAM STRIPS...... 353, 484 RELIAMED SAFETY SEAL DRESSING SILVER...... 238 riluzole...... 343 LANCETS...... 380, 482 RETACRIT...... 330 rimantadine...... 57 RELIAMED TWIST AND RETIN-A MICRO PUMP...... 194 ringer's...... 242 CAP LANCET...... 380, 482 REUSABLE NEBULIZER RINVOQ ER...... 29 RELION ALL-IN-ONE KIT...... 428 RIOMET...... 295 METER...... 380, 482 REVATIO...... 113 risedronate...... 280 RELION CONFIRM...... 380 REVCOVI...... 496 risperidone...... 139 RELION CONFIRM-MICRO 352 REVEAL BLOOD RITEFLO AEROCHAMBER RELION MICRO GLUCOSE GLUCOSE METER...... 380 ...... 428, 484 MONITOR...... 380, 482 REVEAL TEST STRIP...... 352 ritonavir...... 60 RELION NEEDLES..... 398, 482 REVEL PEDIATRIC rivastigmine...... 173 RELION PEN NEEDLES PROGRAM PUMP...... 431 rivastigmine tartrate...... 173 ...... 398, 482 REVEL PROGRAMMABLE RIVELSA...... 182 RELION PRIME METER..... 380 PUMP...... 431 RIXUBIS...... 330 RELION PRIME TEST REVLIMID...... 77 rizatriptan...... 158 STRIPS...... 352 REXULTI...... 143 R-NATAL OB...... 251 RELION THIN LANCETS REYATAZ...... 60 ROBAFEN AC...... 542 ...... 380, 483 RHOFADE...... 230 ROBINSON CLEAR VINYL RELION ULTIMA...... 352, 483 RHOPRESSA...... 520 CATHETER...... 432, 484 RELION ULTRA THIN PLUS Ribasphere...... 55 ROCKLATAN...... 516 LANCETS...... 380, 483 RIBASPHERE...... 55 ropinirole...... 138 RELISTOR...... 41 Ribasphere Ribapak...... 55 Rosadan...... 189, 230 RELIZORB...... 356, 483 ribavirin...... 55, 60 ROSADAN...... 230 REMEDIENT...... 244 RIDAURA...... 28 ROSANIL...... 190 REMODULIN...... 112 rifabutin...... 51 ROSULA...... 190 RENACIDIN...... 319 RIFAMATE...... 51 ROSULA CLEANSING RENEEL...... 299 rifampin...... 51 CLOTHS...... 190 repaglinide...... 260 RIFATER...... 51 rosuvastatin...... 100 repaglinide-metformin...... 260 RIGHTEST CONTROL ROTARIX...... 82 REPATHA PUSHTRONEX..102 SOLUTION HIGH...... 381, 483 ROTATEQ VACCINE...... 82 REPATHA SURECLICK...... 102 RIGHTEST CONTROL ROZLYTREK...... 76 REPATHA SYRINGE...... 102 SOLUTION NORM...... 381, 483 RUBBER MOUTHPIECE REPLACEMENT RIGHTEST GC250S CNTRL ...... 428, 484 PEDIATRIC MONITOR380, 483 SOL NORM...... 381, 483 RUBRACA...... 75 REPLICARE DRESSING RIGHTEST GD500 RUCONEST...... 328 ...... 238, 483 LANCING DEVICE...... 381, 483 RUZURGI...... 504 REPLICARE THIN...... 238, 483 RIGHTEST GL300 RYBELSUS...... 273 REPLICARE ULTRA LANCETS...... 381, 483 RYDAPT...... 76 DRESSING...... 238, 483 RIGHTEST GM250S RYDEX...... 540 RESCRIPTOR...... 48 GLUCOSE METER..... 381, 483 RYNODERM...... 223 575 RYTARY...... 135 SEEBRI NEOHALER...... 529 SILHOUETTE 23"-FULL SABAL-HOMACCORD...... 299 SEGLUROMET...... 263 SET...... 404, 435, 485 SABRIL...... 120 SELECT-OB...... 251 SILHOUETTE 43"-FULL saccharin...... 241 SELECT-OB (FOLIC ACID).251 SET...... 404, 435, 485 SAF-CLENS AF DERMAL SELECT-OB + DHA...... 251 SILICONE MASK...... 428 WOUND...... 230 selegiline hcl...... 136 SILICONE MASK - INFANT SAFE-CLIP NEEDLE selenium sulfide...... 207 ...... 428, 485 STORAGE DEV...... 405, 484 SELF-CATHETER, FEMALE SILIPAC...... 229 SAFESNAP INSULIN ...... 433, 484 SILIQ...... 196 SYRINGE...... 398 SELZENTRY...... 46, 47 SILIVEX...... 430 SAFESNAP SYRINGE SEMPREX-D...... 522 SIL-K...... 430, 485 ...... 416, 417, 484 SE-NATAL 19...... 251 silodosin...... 322 SAFETY LANCETS..... 381, 484 SE-NATAL 19 (WITH SILTREX...... 430, 485 safety needles...... 417, 484 DOCUSATE)...... 251 silver nitrate...... 197 SAFETY PEN NEEDLE...... 398 SEN-SERTER...... 381, 484 silver nitrate applicators...... 222 SAFETY SEAL LANCETS...381 SEREVENT DISKUS...... 530 silver sulfadiazine...... 208 SAFETY-LET LANCETS SERNIVO...... 218 SILVRSTAT...... 198 ...... 381, 484 SEROQUEL XR...... 142 SIMBRINZA...... 506 SAIZEN...... 288, 318 SEROSTIM...... 288 Simliya (28)...... 176 SAIZEN SAIZENPREP...... 288 sertraline...... 129, 130 Simpesse...... 176 SALEX...... 223 Setlakin...... 181 SIMPONI...... 24, 26, 315 salicylic acid...... 223 sevelamer carbonate...... 321 SIMPONI ARIA...... 24, 26 salicylic acid er-ceramides...223 sevelamer hcl...... 321 simvastatin...... 100 salicylic-cimetidine-lidocaine222 sevoflurane...... 37 SINGLE-LET...... 381, 485 SALIMEZ FORTE...... 223 SEYSARA...... 66, 187 SINUSTAR AEROSOL...... 429 SALIVAMAX...... 501 SF...... 499 SINUSTAR NEBULIZER..... 407 salsalate...... 36 SF 5000 PLUS...... 499 SINUVA...... 533, 537 SALVAX...... 223 Sharobel...... 182 sirolimus...... 342 SALVAX DUO PLUS...... 222 SHINGRIX (PF)...... 86 SIRTURO...... 50 SAMI THE SEAL...... 428, 484 SHINGRIX ADJUVANT SITAVIG...... 56 SAMI THE SEAL MASK COMPONENT-PF...... 172 SIVEXTRO...... 59 ...... 428, 484 SHINGRIX GE ANTIGEN SKLICE...... 235 SAMSCA...... 109, 300, 321 COMPONENT...... 86 SKYLA...... 174 SANADERMRX...... 220 SHOHL'S MODIFIED...... 323 SKYRIZI...... 196 SANCUSO...... 303 SIDEKICK BLOOD SLYND...... 182 SANDIMMUNE...... 28, 342 GLUCOSE SYSTEM... 353, 484 SMART CARESENS N381, 485 SANTYL...... 212 SIDESTREAM...... 407 SMART SENSE LANCETS SAPHRIS...... 151 SIDESTREAM MASK.. 428, 484 ...... 381, 485 SAVAYSA...... 329 SIDESTREAM NEBULIZER 407 SMART SENSE SAVELLA...... 132, 156 SIDESTREAM PLUS...407, 485 MONITORING SYSTEM..... 381 SCALACORT DK...... 218 SIGNIFOR...... 297 SMART SENSE TEST SCARCARE...... 229, 430 SIKLOS...... 340 STRIPS...... 353 SCARCIN GEL...... 228 SILALITE PAK...... 218 SMARTDIABETES SCARCIN ROLL-ON...... 228 SILASTIC FOLEY VANTAGE...... 381, 485 SCARCINPAD...... 430, 484 CATHETER...... 433, 485 SMARTEST CONTROL SCARSILK...... 430, 484 SILAZONE-II...... 218 ...... 381, 485 SCARSILK GEL...... 229 sildenafil SMARTEST EJECT...... 381 scopolamine base...... 301 (pulm.hypertension)...... 113 SMARTEST LANCET..381, 485 SEBUDERM...... 212 SILENOR...... 167, 168 SMARTEST PERSONA SECONAL SODIUM...... 166 SILHOUETTE...... 404, 421 GLUCOSE METER..... 382, 485 576 SMARTEST PERSONA SOLU-CORTEF...... 287 Sronyx...... 181 STARTER...... 382, 485 SOLU-CORTEF (PF)...... 286 SSD...... 208 SMARTEST PRONTO SOLUPAK...... 225 SSKI...... 243 GLUCOSE METER..... 382, 485 SOLUS V2 AUDIBLE SSS 10-5...... 190, 198 SMARTEST PRONTO METER...... 382, 486 ST JOSEPH ASPIRIN...... 36 STARTER...... 382, 485 SOLUS V2 CONTROL ST. JOSEPH ASPIRIN...... 36 SMARTEST PROTEGE...... 382 SOLUTION, LOW...... 382, 486 stavudine...... 48 SMARTEST SMART CODE SOLUS V2 CONTROL STEGLATRO...... 268 METER...... 382 SOLUTION,HIGH...... 382, 486 STEGLUJAN...... 266 SMARTEST TALKING SOLUS V2 LANCETS. 382, 486 STELARA...... 195, 196, 312 METER...... 382 SOLUS V2 LANCING STERILANCE TL...... 382, 486 SMARTEST TEST...... 353, 485 DEVICE...... 382, 486 STIMATE...... 259 SMARTMASK KIDS...... 429 SOLUS V2 TEST STRIPS STIOLTO RESPIMAT...... 532 sodium chlor 0.9% ...... 353, 486 STIVARGA...... 74 bacteriostat...... 241 SOMAVERT...... 287 STOP SMOKING AID...... 170 sodium chloride... 172, 241, 242 SONAFINE...... 212 STRAVIX...... 234 sodium chloride 0.45 %...... 254 SOOTHENEB STRENSIQ...... 496 sodium chloride 0.9 %. 241, 254 COMPRESSOR STRIANT...... 258 sodium chloride 0.9 % NEBULIZER...... 429, 486 STRIBILD...... 49 (flush)...... 254 SOOTHENEB MESH STRIVERDI RESPIMAT...... 530 sodium citrate...... 328 NEBULIZER...... 407, 486 STRONG IODINE...... 79, 243 sodium citrate in 0.9 % nacl.327 sorbitol...... 316, 319 SUBSYS...... 16 SODIUM FLUORIDE 5000 sorbitol-mannitol...... 320 Subvenite...... 125 PLUS...... 499 SORILUX...... 206 Subvenite Starter (Blue) Kit sodium iodide-123...... 239 Sorine...... 95 ...... 125, 149 sodium iodide-131...... 239 sotalol...... 95 Subvenite Starter (Green) sodium phenylbutyrate...... 497 Sotalol Af...... 95 Kit...... 125, 150 sodium polystyrene SOTYLIZE...... 96 Subvenite Starter (Orange) sulfonate...... 241, 242 SOVALDI...... 55 Kit...... 125, 150 sodium succinate...... 171 SPACE CHAMBER PLUS SUCRAID...... 305 SOF-SENSOR...... 382 ...... 429, 486 sucralfate...... 317 SOF-SERTER INSERTION SPECTRAGEL...... 239, 486 sulfacetamide sodium..207, 518 DEVICE...... 382, 485 SPEEDICATH (FEMALE) sulfacetamide sodium (acne) SOF-SET...... 404 ...... 433, 486 ...... 189 SOF-SET CANNULA 24" spinosad...... 235 sulfacetamide sodium-sulfur TUBING...... 404, 435, 486 SPIRIVA RESPIMAT...... 529 ...... 190, 191, 198 SOF-SET MICRO 24" SPIRIVA WITH sulfacetamide sod-sulfur- POLYFIN TUB..... 404, 435, 486 HANDIHALER...... 529 urea...... 191, 230 SOF-SET MICRO 42" spironolactone...... 89 sulfacetamide-niacinamide.. 189 POLYFIN TUB..... 404, 435, 486 spironolactone-niacinamide.194 sulfacetamide-prednisolone.507 SOF-SET QR 42" TUBING spironolacton- sulfacetamide-sulfur- ...... 404, 435, 486 hydrochlorothiaz...... 109 cleansr23...... 191 SOFT TOUCH LANCETS SPRAVATO...... 129 SULFACLEANSE 8-4...... 191 ...... 382, 486 SPRAY AND STRETCH...... 225 sulfadiazine...... 61 solifenacin...... 324 Sprintec (28)...... 181 sulfamethoxazole- SOLIQUA 100/33...... 277 SPRITAM...... 127 trimethoprim...... 43 SOLODYN...... 66, 187 SPRIX...... 32 SULFAMYLON...... 208 SOLOSEC...... 46 SPRYCEL...... 76 sulfasalazine...... 313 SOLOX GEL...... 198 Sps (With Sorbitol)...... 242 SULFATRIM...... 43 SOLTAMOX...... 77 SPS (WITH SORBITOL)...... 242 sulindac...... 32 577 SUMADAN...... 191 SURGISEAL TEARDROP SYZYGIUM COMPOSITUM 299 sumatriptan...... 158 APPLICATOR...... 231 T.E.D. ANTI-EMBOLISM sumatriptan succinate..158, 159 SURGISEAL TWIST...... 231 STOCKING...... 405 sumatriptan-naproxen...... 160 SURGUARD2 SAFETY T.E.D. KNEE LENGTH-M- SUMAXIN CP...... 191 ...... 404, 417, 487 LONG...... 354, 488 SUNOSI...... 162 SURVANTA...... 535 T.E.D. KNEE LENGTH-S- SUNRISE COMPRESSOR- SUTENT...... 76 REGULAR...... 354, 488 NEBULIZER...... 429, 486 SUVICORT...... 232 T:30 INFUSION SET...... 435 SUPER THIN LANCETS Syeda...... 181 T:90 INFUSION SET 23".....436 ...... 382, 486 SYLATRON...... 72 T:90 INFUSION SET 43".....436 SUPRANE...... 37 SYMAX DUOTAB...... 309, 325 T:FLEX...... 405 SUPRAX...... 52 SYMBICORT...... 533 T:FLEX INSULIN DELIVERY SUPREP BOWEL PREP KIT SYMDEKO...... 534 PUMP...... 431, 488 ...... 317 SYMFI...... 50 T:SLIM...... 406 SURE COMFORT INS. SYMFI LO...... 50 T:SLIM G4...... 406, 488 SYR. U-100...... 398, 487 SYMJEPI...... 107 T:SLIM G4 INSULIN PUMP SURE COMFORT INSULIN SYMLINPEN 120...... 270 ...... 431, 488 SYRINGE...... 398, 487 SYMLINPEN 60...... 270 T:SLIM INSULIN DELIVERY SURE COMFORT SYMPAZAN...... 118 SYSTEM...... 432 LANCETS...... 382, 487 SYMPROIC...... 41 T:SLIM X2 BASAL-IQ SURE COMFORT LANCING SYMTUZA...... 49 INSULIN PMP...... 432 PEN...... 382, 487 SYNALAR CREAM KIT...... 220 T:SLIM X2 INSULIN PUMP. 432 SURE COMFORT PEN SYNALAR OINTMENT KIT. 220 TABLOID...... 69 NEEDLE...... 398, 487 SYNALAR TS...... 221 TACHOSIL...... 336 SURE RESULT DSS SYNAREL...... 296 TACLONEX...... 195 PREMIUM PACK...... 227 SYNDROS...... 152, 240, 302 tacrolimus...... 208, 342 SURE-FINE PEN NEEDLES SYNERA...... 232 tacrolimus-hyaluronate- ...... 398 SYNERDERM...... 212 niacin...... 208 SUREFLEX DEVICE WITH SYNJARDY...... 263 tacrolimus-niacinamide...... 208 LANCETS...... 383 SYNJARDY XR...... 263 tadalafil...... 240 SUREFLEX LANCING SYNRIBO...... 78 tadalafil (pulm. hypertension) DEVICE...... 383, 487 syringe (disposable).... 417, 487 ...... 113 SURE-JECT INSULIN SYRINGE 3CC/20GX1" TAFINLAR...... 70 SYRINGE...... 399, 487 ...... 417, 487 TAGRISSO...... 67 SURE-LANCE...... 383, 487 SYRINGE 3CC/21GX1" TAKE ACTION...... 185 SURE-LANCE ULTRA THIN ...... 417, 488 TAKHZYRO...... 112 ...... 383 SYRINGE 3CC/21GX1-1/2" talc (bulk)...... 171, 229 SURE-PEN LANCING ...... 417, 488 TALTZ AUTOINJECTOR.....196 DEVICE...... 383, 487 SYRINGE 3CC/22GX1" TALTZ AUTOINJECTOR (2 SURE-T INFUSION SET ...... 417, 488 PACK)...... 196 ...... 421, 487 SYRINGE 3CC/22GX3/4" TALTZ AUTOINJECTOR (3 SURE-T PARADIGM...... 435 ...... 417, 488 PACK)...... 196 SURE-TEST EASYPLUS SYRINGE 3CC/25GX1" TALTZ SYRINGE...... 197 MINI...... 353, 383 ...... 418, 488 TALZENNA...... 75 SURE-TEST EASYPLUS SYRINGE AVITENE...... 336 tamoxifen...... 77 MINI METER...... 383 syringe with needle...... 418, 488 tamsulosin...... 322 SURE-TOUCH LANCET syringe with needle, safety Taperdex...... 287 ...... 383, 487 ...... 418, 488 TAPERDEX...... 287 SURFAXIN...... 535 SYRINGE WITHOUT TARGRETIN...... 203 SURGISEAL STYLUS...... 231 NEEDLE...... 418, 488 Tarina 24 Fe...... 181 578 Tarina Fe 1/20 (28)...... 181 TENS 502...... 406, 489 THYROLAR-1...... 297 Tarina Fe 1-20 Eq (28)...... 181 TENS 504...... 406, 489 THYROLAR-1/2...... 297 TARON-C DHA...... 251 terazosin...... 111 THYROLAR-1/4...... 297 TARON-PREX PRENATAL- terbinafine hcl...... 43 THYROLAR-2...... 298 DHA...... 252 terbutaline...... 531 THYROLAR-3...... 298 TASIGNA...... 77 terconazole...... 543 tiagabine...... 120 TAVALISSE...... 328 Terrell...... 37 TIBSOVO...... 74 TAYTULLA...... 181 TERSI FOAM...... 207 TICALAST...... 535 tazarotene...... 206 TERUMO ALLERGY TICANASE...... 537 tazarotene-niacinamide...... 194 SYRINGE...... 418, 489 TICASPRAY...... 537 TAZORAC...... 206 TERUMO HYPODERMIC TIGLUTIK...... 343 Taztia Xt...... 105 NEEDLE/SYRIN...... 418, 489 Tilia Fe...... 183 TD GOLD BLOOD TERUMO INSULIN timol-brimon-dorzo- GLUCOSE MONITOR...... 383 SYRINGE...... 399, 489 latanop(pf)...... 506 TD GOLD LEVEL 1 TERUMO SYRINGE....418, 489 timolol maleate...... 104, 514 CONTROL...... 383 TEST N'GO BLOOD timolol-brimonidi- TD GOLD LEVEL 2 GLUCOSE SYSTEM... 383, 489 dorzolam(pf)...... 512 CONTROL...... 383 TEST N'GO TEST...... 353, 489 timolol-dorzolamid- TD GOLD LEVEL 3 testosterone...... 258 latanop(pf)...... 512 CONTROL...... 383 testosterone cypionate...... 258 timolol-latanoprost(pf)...... 513 TD GOLD TEST STRIP...... 353 testosterone enanthate...... 258 TIMOPTIC OCUDOSE (PF) 515 TD GOLD VOICE tetrabenazine...... 160 tinidazole...... 46 GLUCOSE MONITOR...... 383 tetracaine hcl...... 515 TIROSINT...... 299 TDVAX...... 83 tetracaine hcl (pf)...... 515 TIROSINT-SOL...... 299 TECFIDERA...... 504 tetracycline...... 66 TISSEEL VHSD TECHLITE INSULIN SYR TETRAVISC...... 515 (APROTININ, SYN)...... 231 HALF UNIT...... 399 TETRAVISC FORTE...... 515 TIS-U-SOL PENTALYTE.....242 TECHLITE INSULIN TETRIX...... 229 TIVICAY...... 47 SYRINGE...... 399 TEXACORT...... 218 TIVORBEX...... 35 TECHLITE LANCETS...... 383 THALOMID...... 45 tizanidine...... 345 TECHLITE PEN NEEDLE... 399 THEO-24...... 528 TOBI PODHALER...... 533 TEGSEDI...... 257 Theochron...... 528 TOBRADEX...... 507 TEKTURNA HCT...... 114 theophylline...... 528 TOBRADEX ST...... 507 TELCARE BGM...... 383, 488 thiamine hcl (vitamin b1)...... 255 tobramycin...... 517 TELCARE BLOOD THIN LANCETS...... 383 tobramycin in 0.225 % nacl. 533 GLUCOSE KIT...... 383, 488 THINPRO INSULIN tobramycin with nebulizer.... 534 TELCARE CONTROL. 383, 488 SYRINGE...... 399, 489 tobramycin-dexamethasone 507 TELCARE LANCETS.. 383, 488 THIOLA...... 320 TOBREX...... 517 TELCARE TEST STRIPS THIOLA EC...... 320 TODAY CONTRACEPTIVE ...... 353, 489 thioridazine...... 141 SPONGE...... 186 telmisartan...... 93 thiothixene...... 142 TOLAK...... 203 telmisartan-amlodipine...... 89 THRESHOLD IMT TRAINER tolazamide...... 269 telmisartan- ...... 429, 489 tolbutamide...... 269 hydrochlorothiazid...... 92 THRESHOLD PEP DEVICE tolcapone...... 135 temazepam...... 166 ...... 429, 489 tolmetin...... 32 TEMIXYS...... 48 THRIVITE RX...... 252 TOLSURA...... 44 temozolomide...... 68 THROMBI-GEL...... 336 tolterodine...... 325, 326 Tencon...... 23 THROMBIN-JMI...... 336 TOOMEY SYRINGE....418, 489 TENIVAC (PF)...... 83 THROMBI-PAD...... 336 TOPCARE CLICKFINE399, 490 tenofovir disoproxil fumarate. 49 thyroid (pork)...... 298 579 TOPCARE ULTRA Tri Femynor...... 183 TRUE COMFORT INSULIN COMFORT...... 400, 490 triamcinolone acetonide SYRINGE...... 400, 490 TOPCARE UNIVERSAL1 ...... 219, 501 TRUE COMFORT LANCET LANCET...... 384, 490 triamterene...... 109 ...... 384, 490 topiramate...... 123, 124 triamterene- TRUE COMFORT PEN toremifene...... 77 hydrochlorothiazid...... 109 NEEDLE...... 400, 490 TORONOVA II SUIK...... 32 Trianex...... 219 TRUE METRIX AIR TORONOVA SUIK...... 32 triazolam...... 166 GLUCOSE METER...... 384 torsemide...... 109 TRICARE...... 252 TRUE METRIX GLUCOSE TOSYMRA...... 159 TRI-CHLOR...... 223 METER...... 384 TOUCH-TROL...... 433, 490 trichloroacetic acid...... 223 TRUE METRIX GLUCOSE TOUJEO MAX U-300 Triderm...... 219 TEST STRIP...... 353 SOLOSTAR...... 292 trientine...... 40 TRUE METRIX GO TOUJEO SOLOSTAR U-300 Tri-Estarylla...... 183 GLUCOSE METER...... 384 INSULIN...... 292 trifluoperazine...... 141 TRUE METRIX LEVEL 1..... 384 TOVET KIT...... 220 trifluridine...... 518 TRUE METRIX LEVEL 2..... 384 TOVIAZ...... 326 trihexyphenidyl...... 136 TRUE METRIX LEVEL 3..... 384 TRACLEER...... 113 TRIKAFTA...... 534 TRUE METRIX PRO TEST TRADJENTA...... 260 Triklo...... 101 STRIP...... 353 tramadol...... 16, 17 Tri-Legest Fe...... 183 TRUE2GO BLOOD tramadol-acetaminophen...... 22 Tri-Linyah...... 183 GLUCOSE SYSTEM... 384, 490 trandolapril...... 89 TRILOAN II SUIK...... 287 TRUECONTROL LEVEL 0 trandolapril-verapamil...... 88 TRILOAN SUIK...... 287 ...... 384, 490 tranexamic acid...... 334 Tri-Lo-Estarylla...... 183 TRUECONTROL LEVEL 1 tranylcypromine...... 129 Tri-Lo-Marzia...... 184 ...... 384, 490 TRANZAREL...... 232 Tri-Lo-Mili...... 184 TRUEDRAW LANCING TRAVATAN Z...... 519 Tri-Lo-Sprintec...... 184 DEVICE...... 384 trazodone...... 130 TRI-LUMA...... 209 TRUEPLUS INSULIN...... 400 TRECATOR...... 51 Trilyte With Flavor Packets..317 TRUEPLUS KETONE...... 490 TRELEGY ELLIPTA...... 533 trimethobenzamide...... 302 TRUEPLUS LANCETS 384, 490 TREMFYA...... 196 trimethoprim...... 43 TRUEPLUS PEN NEEDLE..400 treprostinil sodium...... 112 Tri-Mili...... 184 TRUERESULT BLOOD TRESIBA FLEXTOUCH U- trimipramine...... 134 GLUCOSE SYSTM...... 384, 490 100...... 292 TRIMO-SAN JELLY...... 543 TRUETEST TEST STRIPS. 353 TRESIBA FLEXTOUCH U- TRIMPEX...... 43 TRUETRACK BLOOD 200...... 292 TRINATE...... 252 GLUCOSE SYSTEM...... 384 TRESIBA U-100 INSULIN... 292 TRINTELLIX...... 133 TRUETRACK SMART tretinoin...... 194 Tri-Previfem (28)...... 184 SYSTEM...... 384, 490 tretinoin (chemotherapy)...... 77 Tri-Sprintec (28)...... 184 TRUETRACK TEST...... 353 tretinoin microspheres...... 194 TRISTART DHA...... 252 TRULANCE...... 304 tretinoin-benzoyl-clinda-niac 191 TRIUMEQ...... 50 TRULICITY...... 273 tretinoin-clindamycin-niacin. 191 TRIVEEN-DUO DHA...... 252 TRUMENBA...... 84 tretinoin-clinda-spiron-niacin191 TRIVEEN-PRX RNF...... 252 TRUNEB NEBULIZER.407, 490 tretinoin-hyaluronate-niacin. 193 Trivora (28)...... 184 TRUSKIN...... 234 tretinoin-niacinamide...... 193 Tri-Vylibra...... 184 TRUST NATAL DHA...... 252 tretinoin-spironolact-niacin...193 Tri-Vylibra Lo...... 184 TRUSTEEL INFUSION SET TRETIN-X...... 194 TRIXYLITRAL...... 226 23"...... 436 TRETIN-X CREAM KIT...... 194 TROKENDI XR...... 124 TRUSTEEL INFUSION SET TRETTEN...... 333 tropicamide...... 508 32"...... 436 TREXALL...... 27, 69 trospium...... 326 TRUVADA...... 48 580 TRUZONE PEAK FLOW ULTIMA TEST STRIPS...... 353 UNIFINE PENTIPS PLUS... 402 METER...... 422, 490 ULTRA CMFT INS SYR UNILET COMFORTOUCH TUBERCULIN SYRINGE HALF UNIT...... 401, 491 LANCET...... 385 ...... 418, 491 ULTRA COMFORT INSULIN UNILET EXCELITE II tuberculin-allergy syringes SYRINGE...... 401, 492 LANCET...... 385 ...... 418, 491 ULTRA FINE LANCETS UNILET EXCELITE TUDORZA PRESSAIR...... 529 ...... 385, 492 LANCET...... 385 Tulana...... 182 ULTRA FLO PEN NEEDLE UNILET GP LANCET...... 386 TURALIO...... 77 ...... 401, 492 UNILET LANCET...... 386 TUSSICAPS...... 538 ULTRA THIN II LANCETS UNILET LANCETS...... 386 TUXARIN ER...... 538 ...... 385, 492 UNILET SUPER THIN TUZISTRA XR...... 539 ULTRA THIN LANCETS LANCETS...... 386 TWINRIX (PF)...... 80 ...... 385, 492 UNISTIK 2 DEVICE...... 386 TWIST LANCETS...... 384 ULTRA THIN PEN NEEDLE UNISTIK 2 EXTRA...... 386 TYBOST...... 498 ...... 401, 492 UNISTIK 2 NORMAL Tydemy...... 181 ULTRA THIN PLUS LANCET,DEVICE...... 386 TYKERB...... 66 LANCETS...... 385, 492 UNISTIK 3...... 386 TYMLOS...... 279 ULTRA TLC LANCETS...... 385 UNISTIK 3 COMFORT TYVASO...... 112 ULTRACARE INSULIN DEVICE...... 386 TYVASO INSTITUTIONAL SYRINGE...... 401, 492 UNISTIK 3 COMFORT START KIT...... 112 ULTRA-CARE LANCETS LANCET...... 386, 493 TYVASO REFILL KIT...... 112 ...... 385, 492 UNISTIK 3 EXTRA LANCET TYVASO STARTER KIT...... 112 ULTRACARE PEN NEEDLE ...... 386 TYZINE...... 537, 538 ...... 401, 492 UNISTIK 3 GENTLE...... 386 UCERIS...... 314 ULTRAFOAM...... 336 UNISTIK 3 LANCETS..386, 493 UDENYCA...... 334 ULTRALANCE LANCETS UNISTIK 3 NEONATAL ULESFIA...... 235 ...... 385, 492 ...... 386, 493 ULTICARE...... 400, 419 ULTRASAL-ER...... 224 UNISTIK 3 NEONATAL ULTICARE INSULIN SYR ULTRA-THIN II (SHORT) DEVICE...... 386, 493 HALF UNIT...... 400 INS SYR...... 402, 492 UNISTIK 3 NORMAL ULTICARE INSULIN ULTRA-THIN II (SHORT) LANCET...... 386, 493 SYRINGE...... 400 PEN NDL...... 402, 492 UNISTIK CZT LANCET ULTICARE PEN NEEDLE... 400 ULTRA-THIN II INS PEN ...... 386, 493 ULTICARE SAFETY NEEDLES...... 402, 492 UNISTIK PRO LANCET SYRINGE...... 404, 418, 491 ULTRA-THIN II INSULIN ...... 386, 493 ULTICARE TB SAFETY SYRINGE...... 402, 493 UNISTIK SAFETY...... 386, 493 SYRINGE...... 419, 491 ULTRA-THIN II LANCETS UNISTIK TOUCH LANCETS ULTI-LANCE...... 384, 385, 491 ...... 385, 493 ...... 386, 493 ULTILET BASIC LANCETS ULTRATRAK...... 353 UNISTRIP HIGH CONTROL ...... 385, 491 ULTRATRAK GLUCOSE ...... 386, 493 ULTILET CLASSIC METER...... 385 UNISTRIP LOW CONTROL LANCETS...... 385, 491 ULTRATRAK HIGH-LOW ...... 386, 493 ULTILET INSULIN CONTROL...... 385 UNISTRIP1 TEST STRIP SYRINGE...... 401, 491 ULTRATRAK NORMAL ...... 353, 493 ULTILET LANCETS.....385, 491 CONTROL...... 385 UNIVERSAL 1 LANCETS....386 ULTILET PEN NEEDLE ULTRATRAK ULTIMATE UPTRAVI...... 111 ...... 401, 491 ...... 353, 385, 493 URAMAXIN...... 224 ULTILET SAFETY ULTRAVATE...... 206 URAMAXIN GT...... 222 LANCETS...... 385, 491 UMECTA...... 224 urea...... 212, 224 ULTIMA MONITOR...... 385 UNIFINE PENTIPS...... 402, 493 UREA NAIL STICK...... 224 581 URETRON D-S...... 58, 323 VASELINE WHITE VICTOZA 3-PAK...... 275 UREVAZ...... 224 PETROLEUM...... 229 VIDEX 2 GRAM PEDIATRIC.48 URIMAR-T...... 58, 323 VASHE WOUND THERAPY236 VIEKIRA PAK...... 56 URIN DS...... 58, 323 VAXCHORA ACTIVE Vienva...... 181 URO-458...... 59, 324 COMPONENT...... 82, 84 vigabatrin...... 120 UROGESIC-BLUE...... 59 VAXCHORA BUFFER Vigadrone...... 120 URO-MP...... 59, 324 COMPONENT...... 172 VIIBRYD...... 132 UROQID-ACID NO.2..... 58, 323 VAXCHORA VACCINE...... 84 VILAMIT MB...... 59, 324 ursodiol...... 305 VCF CONTRACEPTIVE VIMOVO...... 30 USTELL...... 59, 324 FILM...... 186 VIMPAT...... 119 UTIBRON NEOHALER...... 532 VCF CONTRACEPTIVE VINATE CARE...... 252 VAGINAL GEL...... 186 VINATE DHA RF...... 245, 252 CONTRACEPTIVE FILM.....186 VECAMYL...... 110 VINATE GT...... 252 VAGINAL Velivet Triphasic Regimen VINATE II...... 252 CONTRACEPTIVE FOAM...186 (28)...... 184 VINATE M...... 252 valacyclovir...... 56 VELPHORO...... 321 VINATE ONE...... 252 VALCHLOR...... 202 VELTASSA...... 242 VINATE ULTRA...... 253 valganciclovir...... 52, 53 VEMLIDY...... 54 VIOKACE...... 304 valproic acid...... 118 VENA-BAL DHA...... 252 Viorele (28)...... 176 valproic acid (as sodium VENCLEXTA...... 70 VIOS AEROSOL DELIVERY salt)...... 118 VENCLEXTA STARTING SYSTEM...... 429 valsartan...... 93 PACK...... 70 VIRACEPT...... 60 valsartan- VENELEX...... 239 VIREAD...... 49, 54 hydrochlorothiazide...... 92 venlafaxine...... 132 VIRT-C DHA...... 253 VANATOL LQ...... 23 VENTAVIS...... 112 VIRT-NATE DHA...... 253 VANATOL S...... 23 VENTOLIN HFA...... 531 VIRT-PN DHA...... 253 vancomycin...... 53 verapamil...... 96, 106 VIRT-PN PLUS...... 253 VANDAZOLE...... 543 VERASENS BLOOD VIRTUSSIN AC...... 542 VANISHPOINT SYRINGE GLUCOSE METER..... 387, 494 VIRTUSSIN DAC...... 541 ...... 402, 419, 493 VERASENS CONTROL VISTOGARD...... 78 VANISHPOINT SOLN-LEVEL 1...... 387, 494 VITAFOL FE+ (WITH TUBERCULIN SYRINGE.... 419 VERASENS METER DOCUSATE)...... 253 VANOXIDE-HC...... 192 STARTER KIT...... 387, 494 VITAFOL GUMMIES...... 253 VAPRO PLUS INTERMITT VERASENS TEST STRIP... 353 VITAFOL NANO...... 253 CATHETER...... 493 VERDESO...... 219 VITAFOL ULTRA...... 253 VAQTA (PF)...... 80 VEREGEN...... 221 VITAFOL-OB...... 253 VARISOFT INFUSION SET VERIFINE PEN NEEDLE VITAFOL-OB+DHA...... 253 23"...... 436 ...... 402, 494 VITAFOL-ONE...... 253 VARISOFT INFUSION SET VERSACLOZ...... 140 VITAL AF 1.2 CAL...... 245 32"...... 436 VERTIGOHEEL...... 299, 300 VITAMED MD ONE RX...... 253 VARISOFT INFUSION SET VERZENIO...... 71 Vitamin D2...... 255 43"...... 436 VEXASYN...... 232 vitamin e acetate (bulk)171, 256 VARITHENA V-GO 20...... 431, 494 Vitamin K...... 256 ADMINISTRATION PACK V-GO 30...... 431, 494 Vitamin K1...... 256 ...... 421, 494 V-GO 40...... 431, 494 VITRAKVI...... 78 VARIVAX (PF)...... 87 VIBERZI...... 315 VIVA DHA...... 253 VAROPHEN VIBRAMYCIN...... 66 VIVAGUARD INO (DICLOFENAC)...... 227 Vicodin Es...... 19, 20 CONTROL SOLUTION387, 494 VARUBI...... 303 Vicodin Hp...... 19, 20 VIVAGUARD INO VASCEPA...... 101 VICTOZA 2-PAK...... 274 GLUCOSE METER..... 387, 494 582 VIVAGUARD INO TEST WHYTEDERM TRILASIL XIFAXAN...... 61 STRIP...... 353, 494 PAK...... 220 XIGDUO XR...... 264 VIVAGUARD LANCET 387, 494 WIDE-SEAL DIAPHRAGM XIIDRA...... 511 VIVAGUARD LANCING 60...... 355, 495 XILAPAK...... 221 DEVICE...... 387, 494 WIDE-SEAL DIAPHRAGM XIMINO...... 66, 188 VIVLODEX...... 33 65...... 355, 495 XOFLUZA...... 56 VIVOTIF...... 82, 83 WIDE-SEAL DIAPHRAGM XOLEGEL...... 201 VIXONE NEBULIZER..407, 494 70...... 355, 495 XOSPATA...... 71 VIXONE NEBULIZER- WIDE-SEAL DIAPHRAGM XPOVIO...... 77 ADULT MASK...... 407, 494 75...... 355, 495 XRYLIDERM...... 232 VIXONE NEBULIZER- WIDE-SEAL DIAPHRAGM XRYLIX (DICLOFENAC- PEDIATRIC MSK...... 407, 494 80...... 355, 495 KINES TAPE)...... 228 VIZIMPRO...... 67 WIDE-SEAL DIAPHRAGM XTAMPZA ER...... 17 VONVENDI...... 334 85...... 355, 495 XTANDI...... 69 voriconazole...... 44 WIDE-SEAL DIAPHRAGM XULANE...... 184 VORTEX HOLDING 90...... 355, 495 XULTOPHY 100/3.6...... 278 CHAMBER...... 429 WIDE-SEAL DIAPHRAGM XURIDEN...... 497 VORTEX HOLDING 95...... 355, 495 XYNTHA...... 333 CHAMBER CHILD...... 429, 494 WILATE...... 332 XYNTHA SOLOFUSE...... 333 VORTEX HOLDING WILLIS THE WHALE XYOSTED...... 258 CHAMBER TODDLER 429, 494 COMPRESSR NEB..... 429, 495 XYREM...... 161 VORTEX VHC FROG WINTERGREEN OIL...... 234 YONSA...... 66, 69 MASK-CHILD...... 429 WP THYROID...... 298 YOSPRALA...... 340 VORTEX VHC LADYBUG WPR PLUS...... 225 YUPELRI...... 530 MASK-TODDLR...... 429 Wymzya Fe...... 181 Yuvafem...... 544 VOSEVI...... 55 XADAGO...... 137 zafirlukast...... 528 VOTRIENT...... 77 XALIX...... 224 zaleplon...... 167 VP-CH PLUS...... 253 XALKORI...... 68 Zarah...... 181 VP-CH-PNV...... 253 XARELTO...... 329 ZARXIO...... 334 VP-PNV-DHA...... 254 XATMEP...... 27 ZATEAN-PN DHA...... 254 VRAYLAR...... 143, 144, 151 XCLAIR...... 212 ZATEAN-PN PLUS...... 254 Vyfemla (28)...... 181 XELITRAL...... 227 Zebutal...... 23 Vylibra...... 181 XELJANZ...... 29, 314 ZEJULA...... 75 VYNDAMAX...... 257 XELJANZ XR...... 29 ZELAPAR...... 137 VYNDAQEL...... 257 XELPROS...... 520 ZELBORAF...... 70 VYVANSE...... 147, 148 XEMBIFY...... 82 ZELNORM...... 312, 315 VYZULTA...... 519 XENAFLAMM...... 31 ZEMAIRA...... 535 WAKIX...... 162 XENLETA...... 59 ZEMBRACE SYMTOUCH... 159 warfarin...... 328 XEPI...... 198 Zenatane...... 186 water for irrigation, sterile.... 242 XERESE...... 208 ZENPEP...... 305 WAVESENSE AMP..... 387, 495 XERMELO...... 300 Zenzedi...... 148, 154, 162, 163 WAVESENSE CONTROL XEROFORM...... 356, 495 ZENZEDI..... 148, 154, 162, 163 SOLUTION...... 387, 495 XEROFORM ZEPATIER...... 54 WAVESENSE JAZZ...... 353 PETROLATUM DRESSING ZETONNA...... 537 WAVESENSE PRESTO ...... 356, 495 ZEYOCAINE...... 232 ...... 353, 387, 495 XEROFORM zidovudine...... 48, 49 Wera (28)...... 181 PETROLATUM ZILACAINE PATCH.....232, 430 WESTHROID...... 298 OVERWRAP...... 356, 495 zileuton...... 525 WHYTEDERM SURGIPAK. 239 XEROSTOMIA RELIEF...... 501 zinc oxide...... 229 WHYTEDERM TDPAK...... 220 XHANCE...... 537 ZINGIBER...... 254 583 ZIOPTAN (PF)...... 520 ZYPRAM...... 39 ziprasidone hcl...... 151 ZYTIGA...... 67, 69 ZIPSOR...... 33 ZIRGAN...... 518 ZITHRANOL...... 206 ZODRYL AC 25...... 539 ZODRYL AC 30...... 539 ZODRYL AC 35...... 539 ZODRYL AC 40...... 539 ZODRYL AC 50...... 539 ZODRYL AC 60...... 539 ZODRYL AC 80...... 539 ZODRYL DAC 25...... 540 ZODRYL DAC 30...... 540 ZODRYL DAC 35...... 540 ZODRYL DAC 40...... 540 ZODRYL DAC 50...... 540 ZODRYL DAC 60...... 540 ZODRYL DAC 80...... 540 ZODRYL DEC 25...... 541 ZODRYL DEC 30...... 541 ZODRYL DEC 35...... 541 ZODRYL DEC 40...... 541 ZODRYL DEC 50...... 541 ZODRYL DEC 60...... 541 ZODRYL DEC 80...... 541 ZOHYDRO ER...... 17 ZOLINZA...... 72 zolmitriptan...... 159 zolpidem...... 167 ZOMACTON...... 288 ZOMIG...... 159, 160 zonisamide...... 127 ZONTIVITY...... 340 ZORBTIVE...... 288, 318 ZORTRESS...... 342 ZORVOLEX...... 33 ZOSTAVAX (PF)...... 87 Zovia 1/35E (28)...... 181 ZTLIDO...... 233 Z-TUSS AC...... 539 ZUBSOLV...... 168 Zumandimine (28)...... 181 ZUPLENZ...... 303 ZYCLARA...... 221, 222 ZYDELIG...... 74, 75 ZYFLO...... 525 ZYKADIA...... 68 ZYLET...... 507 ZYPITAMAG...... 100 584

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KPIC-ND18-010-CA (3/2018)