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2020 PROVIDENCE FORMULARY A Updates

November, 2019

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/22/2019 t:slim x2 insulin pump cartridge REMOVE FROM Non-Formulary FORMULARY 11/22/2019 autosoft xc infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 11/22/2019 varisoft infusion infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 11/22/2019 tiadylt er diltiazem hcl ADD TO FORMULARY Non-Preferred Generics 11/22/2019 NPLATE romiplostim ADD TO FORMULARY Injectables 11/27/2019 clocortolone pivalate ADD TO FORMULARY Non-Preferred pivalate Brands 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 11/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/27/2019 GABACAINE gabapentin/lidocaine REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 2 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

December, 2019

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/06/2019 EYLEA aflibercept REMOVE FROM Non-Formulary FORMULARY 12/06/2019 PRILO PATCH lidocaine/prilocaine REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/06/2019 xenon xe-133 xenon 133 in carbon dioxide REMOVE FROM Non-Formulary FORMULARY 12/14/2019 INSULIN insulin aspart ADD TO FORMULARY Non-Preferred ASPART Generics 12/14/2019 INSULIN insulin aspart ADD TO FORMULARY Non-Preferred ASPART Generics PENFILL 12/14/2019 INSULIN insulin aspart protamine ADD TO FORMULARY Non-Preferred ASPART PROT- human/insulin aspart Generics INSULN ASP 12/14/2019 INSULIN insulin aspart protamine ADD TO FORMULARY Non-Preferred ASPART PROT- human/insulin aspart Generics INSULN ASP 12/14/2019 INSULIN insulin aspart ADD TO FORMULARY Non-Preferred ASPART Generics FLEXPEN 12/14/2019 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 3 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/14/2019 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty 12/14/2019 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty 12/14/2019 EGRIFTA SV tesamorelin acetate ADD TO FORMULARY Non-Preferred Specialty 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 anthralin anthralin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 travoprost travoprost REMOVE FROM Non-Formulary FORMULARY 12/20/2019 metaproterenol metaproterenol sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 12/20/2019 ERYTHROCIN erythromycin stearate REMOVE FROM Non-Formulary STEARATE FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 4 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 ketamine hcl ketamine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 nitroprusside sodium REMOVE FROM Non-Formulary nitroprusside FORMULARY 12/20/2019 phenylephrine hcl phenylephrine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 b-6 pyridoxine hcl (vitamin b6) REMOVE FROM Non-Formulary FORMULARY 12/20/2019 phentermine hcl phentermine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 betamethasone acetate, REMOVE FROM Non-Formulary acetate micro micronized FORMULARY 12/20/2019 betamethasone betamethasone acetate, REMOVE FROM Non-Formulary acetate micro micronized FORMULARY 12/20/2019 ketamine hcl ketamine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 loperamide loperamide hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 8hr arthritis pain acetaminophen REMOVE FROM Non-Formulary FORMULARY 12/20/2019 sleep aid doxylamine succinate REMOVE FROM Non-Formulary FORMULARY 12/20/2019 KADIAN morphine sulfate REMOVE FROM Non-Formulary FORMULARY 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 5 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 venlafaxine hcl er venlafaxine hcl REMOVE FROM Non-Formulary FORMULARY 12/20/2019 povidone k-30 povidone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 povidone k-30 povidone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 testosterone testosterone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 adapalene- adapalene/benzoyl peroxide REMOVE FROM Non-Formulary benzoyl peroxide FORMULARY 12/20/2019 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 12/20/2019 versabase gel base no.239 REMOVE FROM Non-Formulary anhydrous hrt FORMULARY 12/20/2019 ABC COMPLETE multivit-calc-min/ferrous REMOVE FROM Non-Formulary SENIOR fumarate/folic acid/vit FORMULARY WOMEN'S k1/lutein 12/20/2019 REFRESH carboxymethylcellulose REMOVE FROM Non-Formulary RELIEVA PF sodium/glycerin/pf FORMULARY 12/20/2019 NOVOLIN N insulin nph human isophane REMOVE FROM Non-Formulary FLEXPEN FORMULARY 12/20/2019 NOVOLIN N insulin nph human isophane REMOVE FROM Non-Formulary FLEXPEN FORMULARY 12/20/2019 NOVOLIN R insulin regular, human REMOVE FROM Non-Formulary FLEXPEN FORMULARY 12/20/2019 NOVOLIN R insulin regular, human REMOVE FROM Non-Formulary FLEXPEN FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 6 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 senna sennosides REMOVE FROM Non-Formulary FORMULARY 12/20/2019 gerber good start lactobacillus reuteri REMOVE FROM Non-Formulary grow kids FORMULARY 12/20/2019 westab one /folic REMOVE FROM Non-Formulary acid/pyridoxine FORMULARY 12/20/2019 CLOZARIL clozapine REMOVE FROM Non-Formulary FORMULARY 12/20/2019 CLOZARIL clozapine REMOVE FROM Non-Formulary FORMULARY 12/20/2019 HEALON GV hyaluronate sodium ADD TO FORMULARY Injectables PRO 12/20/2019 MICROVIX LP lidocaine/prilocaine/benzalk REMOVE FROM Non-Formulary onium chloride/dressing FORMULARY 12/20/2019 LANOXIN digoxin REMOVE FROM Non-Formulary PEDIATRIC FORMULARY 12/20/2019 LANOXIN digoxin REMOVE FROM Non-Formulary FORMULARY 12/20/2019 norethindrone-eth norethindrone acetate- ADD TO FORMULARY Preventative -fe ethinyl estradiol/ferrous fumarate 12/20/2019 isosorbide isosorbide dinitrate REMOVE FROM Non-Formulary dinitrate FORMULARY 12/20/2019 sulconazole sulconazole nitrate ADD TO FORMULARY Non-Preferred nitrate Generics 12/20/2019 sulconazole sulconazole nitrate ADD TO FORMULARY Non-Preferred nitrate Generics 12/20/2019 dapsone dapsone REMOVE FROM Non-Formulary FORMULARY 12/20/2019 dapsone dapsone REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 7 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/20/2019 - etonogestrel/ethinyl estradiol REMOVE FROM Non-Formulary ethinyl estradiol FORMULARY 12/20/2019 eluryng etonogestrel/ethinyl estradiol REMOVE FROM Non-Formulary FORMULARY 12/27/2019 ciprofloxacin-d5w ciprofloxacin REMOVE FROM Non-Formulary lactate/dextrose 5 % in FORMULARY water 12/27/2019 cupric chloride cupric chloride REMOVE FROM Non-Formulary FORMULARY 12/27/2019 cupric chloride cupric chloride REMOVE FROM Non-Formulary FORMULARY 12/27/2019 amoxicillin- amoxicillin/ ADD TO FORMULARY Preferred clavulanate clavulanate Generics potass 12/27/2019 l-glutathione glutathione REMOVE FROM Non-Formulary FORMULARY 12/27/2019 l-glutathione glutathione REMOVE FROM Non-Formulary FORMULARY 12/27/2019 l-glutathione glutathione REMOVE FROM Non-Formulary FORMULARY 12/27/2019 l-glutathione glutathione REMOVE FROM Non-Formulary FORMULARY 12/27/2019 RHOFADE oxymetazoline hcl REMOVE FROM Non-Formulary FORMULARY 12/27/2019 GERBER GOOD lactobacillus reuteri REMOVE FROM Non-Formulary START GROW FORMULARY TODDLER 12/27/2019 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 12/27/2019 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 8 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/27/2019 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 12/27/2019 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 12/27/2019 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 12/27/2019 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 12/27/2019 amphetamine amphetamine REMOVE FROM Non-Formulary FORMULARY 12/27/2019 doxepin hcl doxepin hcl REMOVE FROM Non-Formulary FORMULARY 12/27/2019 doxepin hcl doxepin hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 9 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

January, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/02/2020 RINVOQ upadacitinib ADD TO FORMULARY Preferred Specialty 01/02/2020 RINVOQ upadacitinib ADD UM: QUANTITY 1 / 1 DAY 01/02/2020 NAYZILAM midazolam ADD TO FORMULARY Non-Preferred Brands 01/02/2020 NAYZILAM midazolam ADD UM: QUANTITY 2 / 30 days 01/02/2020 NAYZILAM midazolam REMOVE FROM Non-Preferred Non-Formulary FORMULARY Brands 01/02/2020 NAYZILAM midazolam REMOVE UM: QUANTITY 2 / 30 days 01/04/2020 hydrogen hydrogen peroxide REMOVE FROM Non-Formulary peroxide FORMULARY 01/04/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 01/04/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 01/04/2020 8hr arthritis pain acetaminophen REMOVE FROM Non-Formulary FORMULARY 01/04/2020 ZOLPIMIST zolpidem tartrate REMOVE FROM Non-Formulary FORMULARY 01/04/2020 ZOLPIMIST zolpidem tartrate REMOVE FROM Non-Formulary FORMULARY 01/04/2020 ez-lets lancets REMOVE FROM Non-Formulary FORMULARY 01/04/2020 allergy relief diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 01/07/2020 ANZEMET dolasetron mesylate ADD UM: MED Medical Drug 01/07/2020 ANZEMET dolasetron mesylate ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 10 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/07/2020 ANZEMET dolasetron mesylate ADD UM: MED Medical Drug 01/10/2020 dexcom g5 blood-glucose REMOVE UM: MED Medical Drug meter,continuous 01/10/2020 ADD TO FORMULARY Non-Preferred acetonide Generics 01/10/2020 bupivacaine hcl bupivacaine hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 albuterol sulfate albuterol sulfate REMOVE FROM Non-Formulary FORMULARY 01/10/2020 albuterol sulfate albuterol sulfate REMOVE FROM Non-Formulary FORMULARY 01/10/2020 tolnaftate tolnaftate REMOVE FROM Non-Formulary FORMULARY 01/10/2020 tolnaftate tolnaftate REMOVE FROM Non-Formulary FORMULARY 01/10/2020 beclomethasone beclomethasone REMOVE FROM Non-Formulary dipropionate dipropionate FORMULARY 01/10/2020 beclomethasone beclomethasone REMOVE FROM Non-Formulary dipropionate dipropionate FORMULARY 01/10/2020 beclomethasone beclomethasone REMOVE FROM Non-Formulary dipropionate dipropionate FORMULARY 01/10/2020 diltiazem hcl diltiazem hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 diltiazem hcl diltiazem hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 aluminum aluminum hydroxide REMOVE FROM Non-Formulary hydroxide FORMULARY 01/10/2020 insulin syringe syringe with REMOVE FROM Non-Formulary needle,disposable,insulin 1 FORMULARY ml

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 11 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 dexamethasone sodium REMOVE FROM Non-Formulary sodium phosphate FORMULARY phosphate 01/10/2020 betaine betaine hcl REMOVE FROM Non-Formulary hydrochloride FORMULARY 01/10/2020 betaine betaine hcl REMOVE FROM Non-Formulary hydrochloride FORMULARY 01/10/2020 midazolam hcl midazolam hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 bupropion hcl bupropion hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 metformin er metformin hcl REMOVE FROM Non-Formulary gastric FORMULARY 01/10/2020 metformin er metformin hcl REMOVE FROM Non-Formulary gastric FORMULARY 01/10/2020 mesalamine mesalamine REMOVE FROM Non-Formulary FORMULARY 01/10/2020 dantrolene dantrolene sodium REMOVE FROM Non-Formulary sodium FORMULARY 01/10/2020 dantrolene dantrolene sodium REMOVE FROM Non-Formulary sodium FORMULARY 01/10/2020 dantrolene dantrolene sodium REMOVE FROM Non-Formulary sodium FORMULARY 01/10/2020 dantrolene dantrolene sodium REMOVE FROM Non-Formulary sodium FORMULARY 01/10/2020 caffeine caffeine REMOVE FROM Non-Formulary FORMULARY 01/10/2020 blood pressure blood pressure test kit-wrist REMOVE FROM Non-Formulary monitor FORMULARY 01/10/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 12 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 01/10/2020 heparin sodium- heparin sodium,porcine in ADD TO FORMULARY Injectables 0.9% nacl 0.9 % sodium chloride/pf 01/10/2020 doxepin hcl doxepin hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 doxepin hcl doxepin hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 doxepin hcl doxepin hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 doxepin hcl doxepin hcl REMOVE FROM Non-Formulary FORMULARY 01/10/2020 stimulant laxative sennosides/docusate REMOVE FROM Non-Formulary plus sodium FORMULARY 01/10/2020 alpha alpha lipoic acid REMOVE FROM Non-Formulary FORMULARY 01/10/2020 bromfenac bromfenac sodium REMOVE FROM Non-Formulary sodium FORMULARY 01/10/2020 BOOST lactose-reduced food REMOVE FROM Non-Formulary SOOTHE FORMULARY 01/10/2020 BOOST lactose-reduced food REMOVE FROM Non-Formulary SOOTHE FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/10/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 13 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/10/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/10/2020 autolet lancing lancing device REMOVE FROM Non-Formulary device FORMULARY 01/10/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/10/2020 bardia red rubber catheter REMOVE FROM Non-Formulary catheter FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 aquacel ag burn silver/hydrocolloid dressing REMOVE FROM Non-Formulary FORMULARY 01/10/2020 xeroform non- bismuth REMOVE FROM Non-Formulary occlusive tribromophenate/petrolatum, FORMULARY dressng white 01/10/2020 ultra flo pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 01/10/2020 ultra flo insulin syringe with REMOVE FROM Non-Formulary syringe needle,insulin,0.3 ml FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 14 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 VANACOF DMX guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr/phenylephrine FORMULARY 01/10/2020 BENZEPRO benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY 01/10/2020 HEMATEX polysaccharide complex REMOVE FROM Non-Formulary FORMULARY 01/10/2020 benzodent benzocaine REMOVE FROM Non-Formulary FORMULARY 01/10/2020 geri-tussin guaifenesin REMOVE FROM Non-Formulary FORMULARY 01/10/2020 almost naked aloe vera/xanthan gum/lactic REMOVE FROM Non-Formulary acid FORMULARY 01/10/2020 westab max cyanocobalamin/folic REMOVE FROM Non-Formulary acid/pyridoxine FORMULARY 01/10/2020 midazolam hcl midazolam hcl ADD TO FORMULARY Injectables 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 ultiguard safe pen needle, diabetic, REMOVE FROM Non-Formulary pack remover and disposal unit FORMULARY 01/10/2020 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 01/10/2020 penicillamine penicillamine ADD TO FORMULARY Preferred Specialty 01/10/2020 - budesonide/formoterol REMOVE FROM Non-Formulary formoterol fumarate FORMULARY fumarate 01/10/2020 budesonide- budesonide/formoterol REMOVE FROM Non-Formulary formoterol fumarate FORMULARY fumarate 01/10/2020 simvastatin simvastatin REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 15 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/10/2020 DIVIGEL estradiol REMOVE FROM Non-Formulary FORMULARY 01/10/2020 RECARBRIO imipenem/cilastatin REMOVE FROM Non-Formulary sodium/relebactam FORMULARY 01/13/2020 FASENRA PEN benralizumab ADD UM: SPECIALTY Specialty Drug 01/14/2020 NUCALA mepolizumab ADD UM: LIMITEDACCESS Limited Access 01/16/2020 XYOSTED testosterone enanthate REMOVE FROM Injectables Non-Formulary FORMULARY 01/16/2020 XYOSTED testosterone enanthate REMOVE UM: MED Medical Drug 01/16/2020 XYOSTED testosterone enanthate REMOVE FROM Injectables Non-Formulary FORMULARY 01/16/2020 XYOSTED testosterone enanthate REMOVE UM: MED Medical Drug 01/16/2020 XYOSTED testosterone enanthate REMOVE FROM Injectables Non-Formulary FORMULARY 01/16/2020 XYOSTED testosterone enanthate REMOVE UM: MED Medical Drug 01/17/2020 virt-fefa plus iron fumarate,polysac REMOVE FROM Non-Formulary cplex/folic acid/vitb comp FORMULARY with c no.9 01/17/2020 preparation h REMOVE FROM Non-Formulary FORMULARY 01/17/2020 levorphanol levorphanol tartrate REMOVE FROM Non-Formulary tartrate FORMULARY 01/17/2020 ketotifen ketotifen fumarate REMOVE FROM Non-Formulary fumarate FORMULARY 01/17/2020 bacitracin bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 01/17/2020 buprenorphine buprenorphine hcl REMOVE FROM Non-Formulary hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 16 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 mesalamine mesalamine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 mesalamine mesalamine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 aminophylline aminophylline REMOVE FROM Non-Formulary FORMULARY 01/17/2020 aminophylline aminophylline REMOVE FROM Non-Formulary FORMULARY 01/17/2020 aminophylline aminophylline REMOVE FROM Non-Formulary FORMULARY 01/17/2020 aminophylline aminophylline REMOVE FROM Non-Formulary FORMULARY 01/17/2020 aminophylline aminophylline REMOVE FROM Non-Formulary FORMULARY 01/17/2020 penicillamine penicillamine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 penicillamine penicillamine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 penicillamine penicillamine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 acacia acacia REMOVE FROM Non-Formulary FORMULARY 01/17/2020 acacia acacia REMOVE FROM Non-Formulary FORMULARY 01/17/2020 acacia acacia REMOVE FROM Non-Formulary FORMULARY 01/17/2020 acacia acacia REMOVE FROM Non-Formulary FORMULARY 01/17/2020 water water for ,sterile REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 17 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 alcohol prep pads alcohol antiseptic pads REMOVE FROM Non-Formulary FORMULARY 01/17/2020 coenzyme q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 01/17/2020 indocyanine indocyanine green ADD TO FORMULARY Injectables green 01/17/2020 ketorolac ketorolac tromethamine ADD TO FORMULARY Injectables tromethamine 01/17/2020 mannitol mannitol ADD TO FORMULARY Injectables 01/17/2020 zinc sulfate zinc sulfate ADD TO FORMULARY Injectables 01/17/2020 buspirone hcl buspirone hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 buspirone hcl buspirone hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 buspirone hcl buspirone hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 buspirone hcl buspirone hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 buspirone hcl buspirone hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 PEPCID AC famotidine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 bupropion hcl bupropion hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 bupropion hcl bupropion hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 bupropion hcl bupropion hcl REMOVE FROM Non-Formulary FORMULARY 01/17/2020 bupropion hcl bupropion hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 18 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 pain relieving trolamine salicylate REMOVE FROM Non-Formulary FORMULARY 01/17/2020 urea REMOVE FROM Non-Formulary FORMULARY 01/17/2020 butalbital- butalbital/acetaminophen/caf REMOVE FROM Non-Formulary acetaminophen- feine FORMULARY caffe 01/17/2020 acesulfame acesulfame potassium REMOVE FROM Non-Formulary potassium FORMULARY 01/17/2020 acesulfame acesulfame potassium REMOVE FROM Non-Formulary potassium FORMULARY 01/17/2020 acesulfame acesulfame potassium REMOVE FROM Non-Formulary potassium FORMULARY 01/17/2020 acesulfame acesulfame potassium REMOVE FROM Non-Formulary potassium FORMULARY 01/17/2020 ethanolamine ethanolamine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 ethanolamine ethanolamine REMOVE FROM Non-Formulary FORMULARY 01/17/2020 propylthiouracil propylthiouracil REMOVE FROM Non-Formulary FORMULARY 01/17/2020 propylthiouracil propylthiouracil REMOVE FROM Non-Formulary FORMULARY 01/17/2020 propylthiouracil propylthiouracil REMOVE FROM Non-Formulary FORMULARY 01/17/2020 propylthiouracil propylthiouracil REMOVE FROM Non-Formulary FORMULARY 01/17/2020 diethylen glycol carbitol REMOVE FROM Non-Formulary m-ethyl ether FORMULARY 01/17/2020 diethylen glycol carbitol REMOVE FROM Non-Formulary m-ethyl ether FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 19 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 prednisolone sodium REMOVE FROM Non-Formulary sodium phosphate FORMULARY phosphate 01/17/2020 stimulant laxative sennosides/docusate REMOVE FROM Non-Formulary plus sodium FORMULARY 01/17/2020 TIVORBEX indomethacin, REMOVE FROM Non-Formulary submicronized FORMULARY 01/17/2020 LANOLIN modified lanolin REMOVE FROM Non-Formulary FORMULARY 01/17/2020 nifedipine nifedipine, micronized REMOVE FROM Non-Formulary micronized FORMULARY 01/17/2020 nifedipine nifedipine, micronized REMOVE FROM Non-Formulary micronized FORMULARY 01/17/2020 nifedipine nifedipine, micronized REMOVE FROM Non-Formulary micronized FORMULARY 01/17/2020 nifedipine nifedipine, micronized REMOVE FROM Non-Formulary micronized FORMULARY 01/17/2020 nifedipine nifedipine, micronized REMOVE FROM Non-Formulary micronized FORMULARY 01/17/2020 nifedipine nifedipine, micronized REMOVE FROM Non-Formulary micronized FORMULARY 01/17/2020 GLUCAGON glucagon hcl REMOVE FROM Non-Formulary EMERGENCY FORMULARY KIT 01/17/2020 triethanolamine triethanolamine salicylate REMOVE FROM Non-Formulary salicylate FORMULARY 01/17/2020 triethanolamine triethanolamine salicylate REMOVE FROM Non-Formulary salicylate FORMULARY 01/17/2020 triethanolamine triethanolamine salicylate REMOVE FROM Non-Formulary salicylate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 20 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 comfort shield diaper,brief,adult, REMOVE FROM Non-Formulary disposable FORMULARY 01/17/2020 comfort shield diaper,brief,adult, REMOVE FROM Non-Formulary disposable FORMULARY 01/17/2020 comfort shield diaper,brief,adult, REMOVE FROM Non-Formulary disposable FORMULARY 01/17/2020 hrt heavy cream vehicle cream base no.241 REMOVE FROM Non-Formulary base FORMULARY 01/17/2020 base, natatroche troche base no.240 REMOVE FROM Non-Formulary FORMULARY 01/17/2020 pure comfort alcohol antiseptic pads REMOVE FROM Non-Formulary alcohol pad FORMULARY 01/17/2020 pure comfort pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 01/17/2020 pure comfort pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 01/17/2020 pure comfort pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 01/17/2020 pure comfort pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 01/17/2020 CERASPORT sodium chloride/potassium REMOVE FROM Non-Formulary ENDURANCE chloride/sodium FORMULARY citrate/rice/whey 01/17/2020 CERASPORT sodium chloride/potassium REMOVE FROM Non-Formulary ENDURANCE chloride/sodium FORMULARY citrate/rice/whey 01/17/2020 daylogic acne benzoyl peroxide REMOVE FROM Non-Formulary treatment FORMULARY 01/17/2020 zinc sulfate zinc sulfate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 21 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/17/2020 CALDOLOR ibuprofen REMOVE FROM Non-Formulary FORMULARY 01/17/2020 XELJANZ XR tofacitinib citrate ADD TO FORMULARY Non-Preferred Specialty 01/17/2020 ESPEROCT antihemophilic factor (fviii) REMOVE FROM Non-Formulary rec, b-dom truncated peg- FORMULARY exei 01/17/2020 ESPEROCT antihemophilic factor (fviii) REMOVE FROM Non-Formulary rec, b-dom truncated peg- FORMULARY exei 01/17/2020 ESPEROCT antihemophilic factor (fviii) REMOVE FROM Non-Formulary rec, b-dom truncated peg- FORMULARY exei 01/17/2020 ESPEROCT antihemophilic factor (fviii) REMOVE FROM Non-Formulary rec, b-dom truncated peg- FORMULARY exei 01/17/2020 ESPEROCT antihemophilic factor (fviii) REMOVE FROM Non-Formulary rec, b-dom truncated peg- FORMULARY exei 01/22/2020 EGRIFTA SV tesamorelin acetate ADD UM: LIMITEDACCESS Limited Access 01/23/2020 HEALON GV hyaluronate sodium ADD UM: MED Medical Drug PRO 01/24/2020 sotradecol,sodiu sodium tetradecyl sulfate CHANGE UM: MED Medical Drug m tetradecyl sulfate 01/25/2020 clocortolone clocortolone pivalate ADD TO FORMULARY Non-Preferred pivalate Generics 01/25/2020 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 01/25/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 22 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/25/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 01/25/2020 calcium pantothenate REMOVE FROM Non-Formulary pantothenate FORMULARY 01/25/2020 calcium calcium pantothenate REMOVE FROM Non-Formulary pantothenate FORMULARY 01/25/2020 fiber laxative calcium polycarbophil REMOVE FROM Non-Formulary FORMULARY 01/25/2020 tetracaine hcl tetracaine hcl REMOVE FROM Non-Formulary FORMULARY 01/25/2020 allopurinol allopurinol REMOVE FROM Non-Formulary FORMULARY 01/25/2020 tolnaftate tolnaftate REMOVE FROM Non-Formulary FORMULARY 01/25/2020 antacid ultra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY 01/25/2020 almond oil almond oil REMOVE FROM Non-Formulary FORMULARY 01/25/2020 almond oil almond oil REMOVE FROM Non-Formulary FORMULARY 01/25/2020 aminobenzoic aminobenzoic acid REMOVE FROM Non-Formulary acid FORMULARY 01/25/2020 tropicamide tropicamide REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acyclovir acyclovir REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acyclovir acyclovir REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acyclovir acyclovir REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 23 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/25/2020 acetazolamide acetazolamide REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acetazolamide acetazolamide REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acetazolamide acetazolamide REMOVE FROM Non-Formulary FORMULARY 01/25/2020 clotrimazole REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acetylcysteine acetylcysteine REMOVE FROM Non-Formulary FORMULARY 01/25/2020 chlorhexidine chlorhexidine gluconate REMOVE FROM Non-Formulary gluconate FORMULARY 01/25/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 01/25/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 01/25/2020 adapalene adapalene REMOVE FROM Non-Formulary FORMULARY 01/25/2020 dextromethorpha dextromethorphan hbr REMOVE FROM Non-Formulary n hbr FORMULARY 01/25/2020 calcium calcium phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 01/25/2020 calcium calcium phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 01/25/2020 calcium calcium phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 01/25/2020 antacid extra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 24 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/25/2020 antacid extra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY 01/25/2020 sodium sodium phenylbutyrate REMOVE FROM Non-Formulary phenylbutyrate FORMULARY 01/25/2020 sodium sodium phenylbutyrate REMOVE FROM Non-Formulary phenylbutyrate FORMULARY 01/25/2020 sodium sodium phenylbutyrate REMOVE FROM Non-Formulary phenylbutyrate FORMULARY 01/25/2020 ursodiol ursodiol REMOVE FROM Non-Formulary FORMULARY 01/25/2020 ursodiol ursodiol REMOVE FROM Non-Formulary FORMULARY 01/25/2020 dextroamphetami dextroamphetamine sulfate REMOVE FROM Non-Formulary ne sulfate FORMULARY 01/25/2020 assure platinum blood sugar diagnostic REMOVE FROM Non-Formulary test strip FORMULARY 01/25/2020 lubricant eye propylene REMOVE FROM Non-Formulary glycol/polyethylene glycol FORMULARY 400 01/25/2020 pentylene glycol 1,2-pentanediol REMOVE FROM Non-Formulary FORMULARY 01/25/2020 sulfacetamide sulfacetamide sodium, REMOVE FROM Non-Formulary sodium monohydrate FORMULARY 01/25/2020 watermelon flavor watermelon flavor REMOVE FROM Non-Formulary FORMULARY 01/25/2020 watermelon flavor watermelon flavor REMOVE FROM Non-Formulary FORMULARY 01/25/2020 watermelon flavor watermelon flavor REMOVE FROM Non-Formulary FORMULARY 01/25/2020 redness relief naphazoline hcl/glycerin REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 25 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/25/2020 calcium calcium glucarate REMOVE FROM Non-Formulary saccharate FORMULARY 01/25/2020 calcium calcium glucarate REMOVE FROM Non-Formulary saccharate FORMULARY 01/25/2020 calcium calcium glucarate REMOVE FROM Non-Formulary saccharate FORMULARY 01/25/2020 hydroquinone REMOVE FROM Non-Formulary FORMULARY 01/25/2020 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 01/25/2020 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 01/25/2020 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 01/25/2020 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 01/25/2020 hydrocodone hydrocodone bitartrate REMOVE FROM Non-Formulary bitartrate er FORMULARY 01/25/2020 ACZONE dapsone REMOVE FROM Non-Formulary FORMULARY 01/25/2020 NUZYRA omadacycline tosylate REMOVE FROM Non-Formulary FORMULARY 01/25/2020 children's allergy diphenhydramine hcl REMOVE FROM Non-Formulary relief FORMULARY 01/25/2020 ensure plant- nutritional supplement/fiber REMOVE FROM Non-Formulary based protein FORMULARY 01/25/2020 ensure plant- nutritional supplement/fiber REMOVE FROM Non-Formulary based protein FORMULARY 01/25/2020 ensure plant- nutritional supplement/fiber REMOVE FROM Non-Formulary based protein FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 26 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/25/2020 ensure plant- nutritional supplement/fiber REMOVE FROM Non-Formulary based protein FORMULARY 01/25/2020 mucus d guaifenesin/pseudoephedrin REMOVE FROM Non-Formulary e hcl FORMULARY 01/25/2020 ensure plant- nutritional supplement/fiber REMOVE FROM Non-Formulary based protein FORMULARY 01/25/2020 ensure plant- nutritional supplement/fiber REMOVE FROM Non-Formulary based protein FORMULARY 01/25/2020 triprolidine hcl triprolidine hcl REMOVE FROM Non-Formulary FORMULARY 01/25/2020 vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 01/25/2020 dry eye relief polyethylene glycol REMOVE FROM Non-Formulary 400/hypromellose/glycerin FORMULARY 01/25/2020 capsaicin capsaicin REMOVE FROM Non-Formulary FORMULARY 01/25/2020 lidocaine lidocaine REMOVE FROM Non-Formulary FORMULARY 01/25/2020 BLINK TEARS polyethylene glycol 400 REMOVE FROM Non-Formulary FORMULARY 01/25/2020 BLINK TEARS polyethylene glycol 400 REMOVE FROM Non-Formulary FORMULARY 01/25/2020 CERASPORT sodium chloride/potassium REMOVE FROM Non-Formulary PLUS chloride/sodium citrate/rice FORMULARY syrup 01/25/2020 flavorx lemon flavoring agent REMOVE FROM Non-Formulary flavor FORMULARY 01/25/2020 hyoscyamine hyoscyamine sulfate ADD TO FORMULARY Injectables sulfate 01/25/2020 hyoscyamine hyoscyamine sulfate ADD TO FORMULARY Injectables sulfate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 27 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/25/2020 NEURONTIN gabapentin ADD TO FORMULARY Non-Preferred Brands 01/25/2020 calcipotriene- calcipotriene/betamethason REMOVE FROM Non-Formulary betamethasone e dipropionate FORMULARY 01/25/2020 calcipotriene- calcipotriene/betamethason REMOVE FROM Non-Formulary betamethasone e dipropionate FORMULARY 01/25/2020 calcipotriene calcipotriene REMOVE FROM Non-Formulary FORMULARY 01/25/2020 calcipotriene- calcipotriene/betamethason ADD TO FORMULARY Non-Formulary Non-Preferred betamethasone e dipropionate Generics 01/25/2020 calcipotriene- calcipotriene/betamethason ADD TO FORMULARY Non-Formulary Non-Preferred betamethasone e dipropionate Generics 01/27/2020 clocortolone clocortolone pivalate CHANGE TIER Non-Preferred Non-Preferred pivalate Brands Generics 01/29/2020 zohydro hydrocodone bitartrate CHANGE UM: QUANTITY 2 / 1 DAY er,hydrocodone bitartrate er 01/29/2020 zohydro hydrocodone bitartrate CHANGE UM: QUANTITY 2 / 1 DAY er,hydrocodone bitartrate er 01/29/2020 zohydro hydrocodone bitartrate CHANGE UM: QUANTITY 2 / 1 DAY er,hydrocodone bitartrate er 01/29/2020 zohydro hydrocodone bitartrate CHANGE UM: QUANTITY 2 / 1 DAY er,hydrocodone bitartrate er 01/29/2020 zohydro hydrocodone bitartrate CHANGE UM: QUANTITY 2 / 1 DAY er,hydrocodone bitartrate er 01/29/2020 zohydro hydrocodone bitartrate CHANGE UM: QUANTITY 2 / 1 DAY er,hydrocodone bitartrate er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 28 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 FORAXA lidocaine hcl/aloe REMOVE FROM Non-Formulary vera/collagen,bovine FORMULARY 01/31/2020 prilovixil lidocaine/prilocaine REMOVE FROM Non-Formulary FORMULARY 01/31/2020 apomorphine hcl apomorphine hcl REMOVE FROM Non-Formulary FORMULARY 01/31/2020 apomorphine hcl apomorphine hcl REMOVE FROM Non-Formulary FORMULARY 01/31/2020 apomorphine hcl apomorphine hcl REMOVE FROM Non-Formulary FORMULARY 01/31/2020 apomorphine hcl apomorphine hcl REMOVE FROM Non-Formulary FORMULARY 01/31/2020 stool softener docusate sodium REMOVE FROM Non-Formulary FORMULARY 01/31/2020 carisoprodol carisoprodol REMOVE FROM Non-Formulary FORMULARY 01/31/2020 carisoprodol carisoprodol REMOVE FROM Non-Formulary FORMULARY 01/31/2020 carisoprodol carisoprodol REMOVE FROM Non-Formulary FORMULARY 01/31/2020 carisoprodol carisoprodol REMOVE FROM Non-Formulary FORMULARY 01/31/2020 hydrocortisone hydrocortisone REMOVE FROM Non-Formulary FORMULARY 01/31/2020 hydrocortisone- hydrocortisone/aloe vera REMOVE FROM Non-Formulary aloe FORMULARY 01/31/2020 acetic acid acetic acid REMOVE FROM Non-Formulary FORMULARY 01/31/2020 azathioprine azathioprine REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 29 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 azathioprine azathioprine REMOVE FROM Non-Formulary FORMULARY 01/31/2020 azathioprine azathioprine REMOVE FROM Non-Formulary FORMULARY 01/31/2020 azathioprine azathioprine REMOVE FROM Non-Formulary FORMULARY 01/31/2020 benzethonium benzethonium chloride REMOVE FROM Non-Formulary chloride FORMULARY 01/31/2020 benzethonium benzethonium chloride REMOVE FROM Non-Formulary chloride FORMULARY 01/31/2020 benzethonium benzethonium chloride REMOVE FROM Non-Formulary chloride FORMULARY 01/31/2020 esomeprazole esomeprazole REMOVE FROM Non-Formulary magnesium FORMULARY 01/31/2020 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 01/31/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 01/31/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 01/31/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 01/31/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/31/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/31/2020 3 miconazole nitrate REMOVE FROM Non-Formulary FORMULARY 01/31/2020 OPTIRAY 320 ioversol ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 30 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 triacetin triacetin REMOVE FROM Non-Formulary FORMULARY 01/31/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/31/2020 stool softener- sennosides/docusate REMOVE FROM Non-Formulary stimulant lax sodium FORMULARY 01/31/2020 muscle rub ultra methyl REMOVE FROM Non-Formulary strength salicylate/menthol/camphor FORMULARY 01/31/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/31/2020 ascorbyl ascorbyl palmitate REMOVE FROM Non-Formulary palmitate FORMULARY 01/31/2020 ascorbyl ascorbyl palmitate REMOVE FROM Non-Formulary palmitate FORMULARY 01/31/2020 ascorbyl ascorbyl palmitate REMOVE FROM Non-Formulary palmitate FORMULARY 01/31/2020 ascorbyl ascorbyl palmitate REMOVE FROM Non-Formulary palmitate FORMULARY 01/31/2020 autolet lancing lancing device REMOVE FROM Non-Formulary device FORMULARY 01/31/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 01/31/2020 triprolidine hcl triprolidine hcl REMOVE FROM Non-Formulary FORMULARY 01/31/2020 healthpro glucose blood sugar diagnostic REMOVE FROM Non-Formulary test strips FORMULARY 01/31/2020 healthpro glucose blood sugar diagnostic REMOVE FROM Non-Formulary test strips FORMULARY 01/31/2020 healthpro glucose blood sugar diagnostic REMOVE FROM Non-Formulary test strips FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 31 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 healthpro glucose blood sugar diagnostic REMOVE FROM Non-Formulary test strips FORMULARY 01/31/2020 healthpro glucose blood sugar diagnostic REMOVE FROM Non-Formulary test strips FORMULARY 01/31/2020 ONZETRA XSAIL sumatriptan succinate REMOVE FROM Non-Formulary FORMULARY 01/31/2020 cbd-kings with lidocaine/methyl REMOVE FROM Non-Formulary lidocaine salicylate/menthol/camphor FORMULARY 01/31/2020 daily fiber psyllium husk REMOVE FROM Non-Formulary FORMULARY 01/31/2020 daily fiber psyllium husk (with sugar) REMOVE FROM Non-Formulary FORMULARY 01/31/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 01/31/2020 intense hydration dimethicone REMOVE FROM Non-Formulary skin cream FORMULARY 01/31/2020 B12 ACTIVE mecobalamin REMOVE FROM Non-Formulary FORMULARY 01/31/2020 PROBICHEW /inulin REMOVE FROM Non-Formulary FORMULARY 01/31/2020 hydromorphone hydromorphone hcl in sterile ADD TO FORMULARY Injectables hcl-water water/pf 01/31/2020 ketamine hcl- ketamine hcl in 0.9 % ADD TO FORMULARY Injectables 0.9% nacl sodium chloride 01/31/2020 tiadylt er diltiazem hcl ADD TO FORMULARY Non-Preferred Generics 01/31/2020 tiadylt er diltiazem hcl ADD TO FORMULARY Non-Preferred Generics 01/31/2020 tiadylt er diltiazem hcl ADD TO FORMULARY Non-Preferred Generics

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 32 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/31/2020 tiadylt er diltiazem hcl ADD TO FORMULARY Non-Preferred Generics 01/31/2020 tiadylt er diltiazem hcl ADD TO FORMULARY Non-Preferred Generics 01/31/2020 ASMANEX HFA furoate ADD TO FORMULARY Preferred Brands 01/31/2020 DULERA mometasone REMOVE FROM Non-Formulary furoate/formoterol fumarate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 33 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

February, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2020 SUNOSI solriamfetol hcl ADD UM: QUANTITY 1 / 1 DAY 02/01/2020 SUNOSI solriamfetol hcl ADD UM: QUANTITY 1 / 1 DAY 02/01/2020 GVOKE glucagon ADD TO FORMULARY Preferred Brands HYPOPEN 1- PACK,GVOKE HYPOPEN 2- PACK 02/01/2020 GVOKE PFS 1- glucagon ADD TO FORMULARY Preferred Brands PACK SYRINGE,GVOK E PFS 2-PACK SYRINGE 02/01/2020 GVOKE PFS 1- glucagon ADD TO FORMULARY Preferred Brands PACK SYRINGE,GVOK E PFS 2-PACK SYRINGE 02/01/2020 GVOKE glucagon ADD TO FORMULARY Preferred Brands HYPOPEN 1- PACK,GVOKE HYPOPEN 2- PACK 02/01/2020 soolantra,ivermec ivermectin CHANGE UM: QUANTITY 45 / 30 days tin 02/01/2020 triamterene triamterene REMOVE FROM Non-Preferred Non-Formulary FORMULARY Generics 02/01/2020 DYRENIUM triamterene REMOVE FROM Non-Preferred Non-Formulary FORMULARY Brands 02/01/2020 XENLETA lefamulin acetate ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 34 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2020 triamterene triamterene REMOVE FROM Non-Preferred Non-Formulary FORMULARY Generics 02/01/2020 DYRENIUM triamterene REMOVE FROM Non-Preferred Non-Formulary FORMULARY Brands 02/01/2020 TAKHZYRO lanadelumab-flyo ADD UM: QUANTITY 4 / 28 days 02/01/2020 RYBELSUS semaglutide ADD UM: QUANTITY 1 / 1 DAY 02/01/2020 RYBELSUS semaglutide ADD UM: QUANTITY 1 / 1 DAY 02/01/2020 RYBELSUS semaglutide ADD UM: QUANTITY 1 / 1 DAY 02/01/2020 RYBELSUS semaglutide ADD TO FORMULARY Preferred Brands 02/01/2020 RYBELSUS semaglutide ADD TO FORMULARY Preferred Brands 02/01/2020 RYBELSUS semaglutide ADD TO FORMULARY Preferred Brands 02/01/2020 HARVONI ledipasvir/sofosbuvir ADD TO FORMULARY Preferred Specialty 02/01/2020 XEMBIFY immune globulin,gamma ADD TO FORMULARY Non-Preferred (igg)-klhw human Specialty 02/01/2020 XEMBIFY immune globulin,gamma ADD TO FORMULARY Non-Preferred (igg)-klhw human Specialty 02/01/2020 XEMBIFY immune globulin,gamma ADD TO FORMULARY Non-Preferred (igg)-klhw human Specialty 02/01/2020 XEMBIFY immune globulin,gamma ADD TO FORMULARY Non-Preferred (igg)-klhw human Specialty 02/01/2020 FLEBOGAMMA immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access DIF (igg)/sorbitol/iga 0 to 50 mcg/ml 02/01/2020 NAYZILAM midazolam ADD UM: QUANTITY 2 / 30 days 02/01/2020 NAYZILAM midazolam ADD TO FORMULARY Non-Formulary Non-Preferred Brands 02/01/2020 NOURIANZ istradefylline ADD UM: QUANTITY 1 / 1 DAY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 35 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2020 NOURIANZ istradefylline ADD UM: QUANTITY 1 / 1 DAY 02/01/2020 NOURIANZ istradefylline ADD TO FORMULARY Non-Preferred Brands 02/01/2020 NOURIANZ istradefylline ADD TO FORMULARY Non-Preferred Brands 02/01/2020 SPRIX ketorolac tromethamine ADD UM: QUANTITY 5 / 30 days 02/01/2020 sporanox,itracon itraconazole CHANGE TIER Non-Preferred azole Brands 02/01/2020 orfadin,nitisinone nitisinone CHANGE UM: Limited Access LIMITEDACCESS 02/01/2020 orfadin,nitisinone nitisinone CHANGE UM: Limited Access LIMITEDACCESS 02/01/2020 orfadin,nitisinone nitisinone CHANGE UM: Limited Access LIMITEDACCESS 02/01/2020 KANJINTI trastuzumab-anns ADD UM: MED Medical Drug 02/01/2020 TYVASO REFILL treprostinil/nebulizer REMOVE UM: MED Medical Drug KIT accessories 02/01/2020 TYVASO treprostinil/nebulizer and REMOVE UM: MED Medical Drug STARTER accessories KIT,TYVASO INSTITUTIONAL START KIT 02/01/2020 TYVASO treprostinil REMOVE UM: MED Medical Drug 02/07/2020 pain reliever acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 extraprin aspirin/acetaminophen/caffei REMOVE FROM Non-Formulary ne FORMULARY 02/07/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 36 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 calcium lactate REMOVE FROM Non-Formulary FORMULARY 02/07/2020 calcium lactate calcium lactate REMOVE FROM Non-Formulary FORMULARY 02/07/2020 calcium lactate calcium lactate REMOVE FROM Non-Formulary FORMULARY 02/07/2020 eye wash sodium borate/boric REMOVE FROM Non-Formulary acid/water/sodium chloride FORMULARY 02/07/2020 calcium REMOVE FROM Non-Formulary gluconate FORMULARY 02/07/2020 calcium calcium gluconate REMOVE FROM Non-Formulary gluconate FORMULARY 02/07/2020 calcium calcium gluconate REMOVE FROM Non-Formulary gluconate FORMULARY 02/07/2020 NIZORAL A-D REMOVE FROM Non-Formulary FORMULARY 02/07/2020 STOOL docusate sodium REMOVE FROM Non-Formulary SOFTENER FORMULARY 02/07/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 antacid-antigas magnesium REMOVE FROM Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 02/07/2020 thymol thymol REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 37 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 cherry flavor cherry flavor REMOVE FROM Non-Formulary FORMULARY 02/07/2020 cherry flavor cherry flavor REMOVE FROM Non-Formulary FORMULARY 02/07/2020 cherry flavor cherry flavor REMOVE FROM Non-Formulary FORMULARY 02/07/2020 pain relief pm acetaminophen/diphenhydra REMOVE FROM Non-Formulary mine hcl FORMULARY 02/07/2020 glycerin glycerin REMOVE FROM Non-Formulary FORMULARY 02/07/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary er FORMULARY 02/07/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 02/07/2020 iron ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 02/07/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 insulin syringe syringe with REMOVE FROM Non-Formulary needle,disposable,insulin 1 FORMULARY ml 02/07/2020 calcium calcium glycerophosphate REMOVE FROM Non-Formulary glycerophosphate FORMULARY 02/07/2020 anise oil anise oil REMOVE FROM Non-Formulary FORMULARY 02/07/2020 alcohol prep pads alcohol antiseptic pads REMOVE FROM Non-Formulary FORMULARY 02/07/2020 benzoyl peroxide benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY 02/07/2020 benzoyl peroxide benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 38 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 benzoyl peroxide benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY 02/07/2020 taurine REMOVE FROM Non-Formulary FORMULARY 02/07/2020 taurine taurine REMOVE FROM Non-Formulary FORMULARY 02/07/2020 taurine taurine REMOVE FROM Non-Formulary FORMULARY 02/07/2020 AFRIN oxymetazoline hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 pain reliever pm acetaminophen/diphenhydra REMOVE FROM Non-Formulary mine hcl FORMULARY 02/07/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 02/07/2020 coenzyme q10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 02/07/2020 betahistine hcl betahistine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 betahistine hcl betahistine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 betahistine hcl betahistine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 betahistine hcl betahistine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 antacid calcium carbonate REMOVE FROM Non-Formulary FORMULARY 02/07/2020 daytime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/phenylephrine FORMULARY hcl/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 39 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 nighttime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/acetaminophen/doxylam FORMULARY ine 02/07/2020 nighttime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/acetaminophen/doxylam FORMULARY ine 02/07/2020 allergy relief cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 allergy relief cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 allergy relief cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 methylcellulose methylcellulose REMOVE FROM Non-Formulary FORMULARY 02/07/2020 mucosa guaifenesin REMOVE FROM Non-Formulary FORMULARY 02/07/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 02/07/2020 allergy relief fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 allergy relief fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 adult tussin guaifenesin/dextromethorph REMOVE FROM Non-Formulary cough congest an hbr FORMULARY dm 02/07/2020 PLIAGLIS lidocaine/tetracaine REMOVE FROM Non-Formulary FORMULARY 02/07/2020 mucus relief dm guaifenesin/dextromethorph REMOVE FROM Non-Formulary max er an hbr FORMULARY 02/07/2020 infants' pain-fever acetaminophen REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 40 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 infants' pain-fever acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 infants' pain-fever acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/07/2020 mucus relief dm guaifenesin/dextromethorph REMOVE FROM Non-Formulary max an hbr FORMULARY 02/07/2020 ultra lubricant eye propylene REMOVE FROM Non-Formulary glycol/polyethylene glycol FORMULARY 400 02/07/2020 healthpro glucose blood glucose calibration REMOVE FROM Non-Formulary control soln control high and low FORMULARY 02/07/2020 healthpro glucose blood-glucose meter REMOVE FROM Non-Formulary monitor FORMULARY 02/07/2020 triple antibiotic- neomycin sulf/bacitracin REMOVE FROM Non-Formulary pain relief zinc/polymyxin b FORMULARY sulf/pramoxine hcl 02/07/2020 airshield multivit-minerals/vit REMOVE FROM Non-Formulary c//lysine hcl/herbal FORMULARY no.124 02/07/2020 children's loratadine REMOVE FROM Non-Formulary loratadine FORMULARY 02/07/2020 YOSPRALA aspirin/omeprazole REMOVE FROM Non-Formulary FORMULARY 02/07/2020 YOSPRALA aspirin/omeprazole REMOVE FROM Non-Formulary FORMULARY 02/07/2020 ginkgo biloba ginkgo biloba leaf extract REMOVE FROM Non-Formulary FORMULARY 02/07/2020 agamatrix control blood glucose calibration REMOVE FROM Non-Formulary solution control solution, high FORMULARY 02/07/2020 agamatrix control blood glucose calibration REMOVE FROM Non-Formulary solution control solution, normal FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 41 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/07/2020 infant gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 02/07/2020 cold-hot extra menthol REMOVE FROM Non-Formulary strength FORMULARY 02/07/2020 menstrual relief acetaminophen/pyrilamine REMOVE FROM Non-Formulary maleate/caffeine FORMULARY 02/07/2020 tussin cough dextromethorphan hbr REMOVE FROM Non-Formulary FORMULARY 02/07/2020 nasal phenylephrine hcl REMOVE FROM Non-Formulary decongestant pe FORMULARY 02/07/2020 children's fever acetaminophen REMOVE FROM Non-Formulary reducer FORMULARY 02/07/2020 urinary pain relief phenazopyridine hcl REMOVE FROM Non-Formulary FORMULARY 02/07/2020 child cough-cold- phenylephrine REMOVE FROM Non-Formulary sore throat hcl/dextromethorphan FORMULARY hbr/acetaminophen/guaifen 02/07/2020 children's allergy loratadine REMOVE FROM Non-Formulary relief FORMULARY 02/07/2020 one daily with REMOVE FROM Non-Formulary women's minerals/ferrous FORMULARY multivitamin fumarate/folic acid/vit k 02/07/2020 weekly-d cholecalciferol (vitamin d3) REMOVE FROM Non-Formulary FORMULARY 02/07/2020 weekly-d cholecalciferol (vitamin d3) REMOVE FROM Non-Formulary FORMULARY 02/07/2020 gas relief- alpha-d-galactosidase REMOVE FROM Non-Formulary prevention FORMULARY 02/10/2020 XELJANZ XR tofacitinib citrate ADD UM: QUANTITY 1 / 1 DAY 02/11/2020 evzio,naloxone naloxone hcl CHANGE UM: QUANTITY 0.8 / 365 days hcl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 42 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/11/2020 travoprost travoprost ADD TO FORMULARY Non-Formulary Non-Preferred Generics 02/13/2020 TRAVATAN Z travoprost CHANGE TIER Preferred Brands Non-Preferred Brands 02/14/2020 OGIVRI trastuzumab-dkst ADD UM: MED Medical Drug 02/14/2020 OGIVRI trastuzumab-dkst ADD UM: MED Medical Drug 02/14/2020 HALUCORT emollient combination REMOVE FROM Non-Formulary no.56/ FORMULARY 02/14/2020 paraplatin carboplatin ADD TO FORMULARY Injectables 02/14/2020 paraplatin carboplatin ADD TO FORMULARY Injectables 02/14/2020 paraplatin carboplatin ADD TO FORMULARY Injectables 02/14/2020 paraplatin carboplatin ADD TO FORMULARY Injectables 02/14/2020 vtol lq butalbital/acetaminophen/caf ADD TO FORMULARY Non-Preferred feine Generics 02/14/2020 penicillamine penicillamine REMOVE FROM Non-Formulary FORMULARY 02/14/2020 potassium REMOVE FROM Non-Formulary chloride FORMULARY 02/14/2020 digital thermometer, electronic,oral REMOVE FROM Non-Formulary thermometer FORMULARY 02/14/2020 fiber laxative calcium polycarbophil REMOVE FROM Non-Formulary FORMULARY 02/14/2020 triple antibiotic neomycin sulfate/bacitracin REMOVE FROM Non-Formulary zinc/polymyxin b FORMULARY 02/14/2020 sodium ascorbate ascorbate sodium REMOVE FROM Non-Formulary FORMULARY 02/14/2020 sodium ascorbate ascorbate sodium REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 43 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/14/2020 sodium ascorbate ascorbate sodium REMOVE FROM Non-Formulary FORMULARY 02/14/2020 HOMINEX-1 infant formula, special REMOVE FROM Non-Formulary metabolic, iron, methionine- FORMULARY free 02/14/2020 KETONEX-1 infant formula with REMOVE FROM Non-Formulary iron,spec.metabolic,maple FORMULARY syrup urine dx 02/14/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary er FORMULARY 02/14/2020 CLARITIN loratadine REMOVE FROM Non-Formulary FORMULARY 02/14/2020 I-VALEX-1 infant formula,spec. REMOVE FROM Non-Formulary metabolic,isovaleric FORMULARY acidemia with iron 02/14/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 saccharin sodium saccharin sodium REMOVE FROM Non-Formulary FORMULARY 02/14/2020 propranolol hcl propranolol hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 propranolol hcl propranolol hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 propranolol hcl propranolol hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 propranolol hcl propranolol hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 bismuth citrate bismuth citrate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 44 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/14/2020 bismuth citrate bismuth citrate REMOVE FROM Non-Formulary FORMULARY 02/14/2020 bismuth citrate bismuth citrate REMOVE FROM Non-Formulary FORMULARY 02/14/2020 bismuth citrate bismuth citrate REMOVE FROM Non-Formulary FORMULARY 02/14/2020 mannitol mannitol REMOVE FROM Non-Formulary FORMULARY 02/14/2020 - glucosamine hcl/chondroitin REMOVE FROM Non-Formulary a FORMULARY 02/14/2020 allergy relief diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 nighttime sleep diphenhydramine hcl REMOVE FROM Non-Formulary aid FORMULARY 02/14/2020 pyridoxal-5- pyridoxal phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/14/2020 pyridoxal-5- pyridoxal phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/14/2020 pyridoxal-5- pyridoxal phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/14/2020 pyridoxal-5- pyridoxal phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/14/2020 sinus 12 hour pseudoephedrine hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 marshmallow marshmallow flavor REMOVE FROM Non-Formulary flavor FORMULARY 02/14/2020 marshmallow marshmallow flavor REMOVE FROM Non-Formulary flavor FORMULARY 02/14/2020 marshmallow marshmallow flavor REMOVE FROM Non-Formulary flavor FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 45 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/14/2020 anti-itch menthol/camphor REMOVE FROM Non-Formulary FORMULARY 02/14/2020 children's all day cetirizine hcl REMOVE FROM Non-Formulary allergy FORMULARY 02/14/2020 all day allergy cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 PREPARATION phenylephrine REMOVE FROM Non-Formulary H hcl/pramoxine FORMULARY hcl/glycerin/white petrolatum 02/14/2020 VUSION miconazole nitrate/zinc REMOVE FROM Non-Formulary oxide/petrolatum,white FORMULARY 02/14/2020 aspirin aspirin REMOVE FROM Non-Formulary FORMULARY 02/14/2020 raspberry flavor raspberry flavor REMOVE FROM Non-Formulary FORMULARY 02/14/2020 raspberry flavor raspberry flavor REMOVE FROM Non-Formulary FORMULARY 02/14/2020 raspberry flavor raspberry flavor REMOVE FROM Non-Formulary FORMULARY 02/14/2020 new image ostomy supply REMOVE FROM Non-Formulary ceraplus skn FORMULARY barrier 02/14/2020 acetamin-caff- acetaminophen/caffeine/dihy REMOVE FROM Non-Formulary dihydrocodeine drocodeine bitartrate FORMULARY 02/14/2020 temple thermometer, temple REMOVE FROM Non-Formulary thermometer electronic FORMULARY 02/14/2020 sodium hyaluronate sodium REMOVE FROM Non-Formulary hyaluronate FORMULARY 02/14/2020 sodium hyaluronate sodium REMOVE FROM Non-Formulary hyaluronate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 46 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/14/2020 no contact digital thermometer, infrared, non- REMOVE FROM Non-Formulary thermometer contact FORMULARY 02/14/2020 vanishpoint syringe with needle, insulin, REMOVE FROM Non-Formulary insulin syringe safety, 1 ml FORMULARY 02/14/2020 easy touch safety pen needle, diabetic, safety REMOVE FROM Non-Formulary pen needle FORMULARY 02/14/2020 ibuprofen ibuprofen REMOVE FROM Non-Formulary FORMULARY 02/14/2020 magnesium magnesium oxide REMOVE FROM Non-Formulary FORMULARY 02/14/2020 gentle laxative bisacodyl REMOVE FROM Non-Formulary FORMULARY 02/14/2020 natural laxative sennosides REMOVE FROM Non-Formulary FORMULARY 02/14/2020 antacid calcium carbonate REMOVE FROM Non-Formulary FORMULARY 02/14/2020 antacid extra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY 02/14/2020 naproxen pm naproxen REMOVE FROM Non-Formulary sodium/diphenhydramine hcl FORMULARY 02/14/2020 clear fiber dextrin REMOVE FROM Non-Formulary FORMULARY 02/14/2020 afrin oxymetazoline hcl REMOVE FROM Non-Formulary FORMULARY 02/17/2020 paraplatin,carbop carboplatin CHANGE UM: MED Medical Drug latin 02/18/2020 SKYRIZI (2 risankizumab-rzaa CHANGE UM: QUANTITY 1.66 / 84 days 1 / 84 days SYRINGES) KIT 02/22/2020 GLUTAREX-1 inf form, glutaric aciduria i REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 47 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/22/2020 sodium chloride sodium chloride 0.45 % ADD TO FORMULARY Injectables 02/22/2020 PHENEX-1 infant formula for pku, iron, REMOVE FROM Non-Formulary no.2 FORMULARY 02/22/2020 CYCLINEX-1 infant formula, special REMOVE FROM Non-Formulary metabolic, urea cycle FORMULARY disorder 02/22/2020 sodium chloride sodium chloride irrigating REMOVE FROM Non-Formulary solution FORMULARY 02/22/2020 morphine sulfate morphine sulfate REMOVE FROM Non-Formulary FORMULARY 02/22/2020 morphine sulfate morphine sulfate REMOVE FROM Non-Formulary FORMULARY 02/22/2020 water water for irrigation,sterile REMOVE FROM Non-Formulary FORMULARY 02/22/2020 water water for irrigation,sterile REMOVE FROM Non-Formulary FORMULARY 02/22/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 02/22/2020 metoclopramide metoclopramide hcl REMOVE FROM Non-Formulary hcl FORMULARY 02/22/2020 metoclopramide metoclopramide hcl REMOVE FROM Non-Formulary hcl FORMULARY 02/22/2020 hydromorphone hydromorphone hcl REMOVE FROM Non-Formulary hcl FORMULARY 02/22/2020 methylprednisolo acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY 02/22/2020 methylprednisolo methylprednisolone acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY 02/22/2020 methylprednisolo methylprednisolone acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 48 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/22/2020 PROPIMEX-1 infant formula,spec. REMOVE FROM Non-Formulary metabolic, propionic FORMULARY acidemia,with iron 02/22/2020 busulfan busulfan ADD TO FORMULARY Injectables 02/22/2020 stool softener- sennosides/docusate REMOVE FROM Non-Formulary laxative sodium FORMULARY 02/22/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 02/22/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 02/22/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 02/22/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 02/22/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 02/22/2020 niclosamide niclosamide REMOVE FROM Non-Formulary FORMULARY 02/22/2020 niclosamide niclosamide REMOVE FROM Non-Formulary FORMULARY 02/22/2020 niclosamide niclosamide REMOVE FROM Non-Formulary FORMULARY 02/22/2020 niclosamide niclosamide REMOVE FROM Non-Formulary FORMULARY 02/22/2020 niclosamide niclosamide REMOVE FROM Non-Formulary FORMULARY 02/22/2020 petrolatum petrolatum,white REMOVE FROM Non-Formulary FORMULARY 02/22/2020 TYREX-1 infant formula, special REMOVE FROM Non-Formulary metabolic, tyrosinemia, with FORMULARY iron

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 49 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/22/2020 ALOE VESTA petrolatum,white REMOVE FROM Non-Formulary FORMULARY 02/22/2020 blood pressure blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 02/22/2020 azelastine hcl azelastine hcl REMOVE FROM Non-Formulary FORMULARY 02/22/2020 azelastine hcl azelastine hcl REMOVE FROM Non-Formulary FORMULARY 02/22/2020 pentosan pentosan polysulfate sodium REMOVE FROM Non-Formulary polysulfate FORMULARY sodium 02/22/2020 pentosan pentosan polysulfate sodium REMOVE FROM Non-Formulary polysulfate FORMULARY sodium 02/22/2020 pentosan pentosan polysulfate sodium REMOVE FROM Non-Formulary polysulfate FORMULARY sodium 02/22/2020 peanut butter peanut butter flavor REMOVE FROM Non-Formulary flavor FORMULARY 02/22/2020 peanut butter peanut butter flavor REMOVE FROM Non-Formulary flavor FORMULARY 02/22/2020 peanut butter peanut butter flavor REMOVE FROM Non-Formulary flavor FORMULARY 02/22/2020 CHILDREN'S loratadine REMOVE FROM Non-Formulary CLARITIN FORMULARY 02/22/2020 prednisolone prednisolone, micronized REMOVE FROM Non-Formulary micronized FORMULARY 02/22/2020 prednisolone prednisolone, micronized REMOVE FROM Non-Formulary micronized FORMULARY 02/22/2020 prednisolone prednisolone acetate, REMOVE FROM Non-Formulary acetate micronize micronized FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 50 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/22/2020 triamcinolone , REMOVE FROM Non-Formulary diacetate micro micronized FORMULARY 02/22/2020 triamcinolone triamcinolone diacetate, REMOVE FROM Non-Formulary diacetate micro micronized FORMULARY 02/22/2020 triamcinolone triamcinolone diacetate, REMOVE FROM Non-Formulary diacetate micro micronized FORMULARY 02/22/2020 PRO-PHREE infant formula, special REMOVE FROM Non-Formulary metabolic with iron FORMULARY 02/22/2020 LANOLIN modified lanolin REMOVE FROM Non-Formulary FORMULARY 02/22/2020 dalfampridine dalfampridine REMOVE FROM Non-Formulary FORMULARY 02/22/2020 pure comfort lancets REMOVE FROM Non-Formulary lancets FORMULARY 02/22/2020 pure comfort lancets REMOVE FROM Non-Formulary safety lancets FORMULARY 02/22/2020 CHILDREN'S pyrilamine REMOVE FROM Non-Formulary DAYCLEAR maleate/chlophedianol hcl FORMULARY ALLERGY 02/22/2020 urinary pain relief phenazopyridine hcl REMOVE FROM Non-Formulary FORMULARY 02/22/2020 mlc lidocaine/methyl REMOVE FROM Non-Formulary salicylate/camphor FORMULARY 02/22/2020 phenylephrine phenylephrine hcl in 0.9 % ADD TO FORMULARY Injectables hcl-0.9% nacl sodium chloride 02/22/2020 oxycodone- oxycodone REMOVE FROM Non-Formulary acetaminophen hcl/acetaminophen FORMULARY 02/22/2020 irinotecan hcl irinotecan hcl REMOVE FROM Non-Formulary FORMULARY 02/22/2020 PROCYSBI cysteamine bitartrate ADD TO FORMULARY Non-Preferred Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 51 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/22/2020 PROCYSBI cysteamine bitartrate ADD TO FORMULARY Non-Preferred Specialty 02/22/2020 PROCYSBI cysteamine bitartrate ADD TO FORMULARY Non-Preferred Specialty 02/22/2020 PROCYSBI cysteamine bitartrate ADD TO FORMULARY Non-Preferred Specialty 02/22/2020 bivalirudin bivalirudin REMOVE FROM Non-Formulary FORMULARY 02/22/2020 propafenone hcl propafenone hcl ADD TO FORMULARY Non-Preferred Generics 02/22/2020 propafenone hcl propafenone hcl ADD TO FORMULARY Non-Preferred Generics 02/22/2020 propafenone hcl propafenone hcl ADD TO FORMULARY Non-Preferred Generics 02/25/2020 NEXIUM esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred Brands 02/26/2020 NEXIUM esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred Brands 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 52 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 53 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/26/2020 esomeprazole esomeprazole magnesium ADD TO FORMULARY Non-Formulary Non-Preferred magnesium Generics 02/27/2020 ENVARSUS XR REMOVE FROM Injectables Non-Formulary FORMULARY 02/27/2020 ENVARSUS XR tacrolimus REMOVE UM: MED Medical Drug 02/27/2020 ENVARSUS XR tacrolimus REMOVE FROM Injectables Non-Formulary FORMULARY 02/27/2020 ENVARSUS XR tacrolimus REMOVE UM: MED Medical Drug 02/27/2020 ENVARSUS XR tacrolimus REMOVE FROM Injectables Non-Formulary FORMULARY 02/27/2020 ENVARSUS XR tacrolimus REMOVE UM: MED Medical Drug 02/29/2020 sodium chloride sodium chloride irrigating REMOVE FROM Non-Formulary solution FORMULARY 02/29/2020 glyceryl glyceryl monostearate REMOVE FROM Non-Formulary monostearate FORMULARY 02/29/2020 isopropyl alcohol isopropyl alcohol REMOVE FROM Non-Formulary FORMULARY 02/29/2020 polysaccharide iron polysaccharide complex REMOVE FROM Non-Formulary iron FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 54 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 calcium oxide calcium oxide REMOVE FROM Non-Formulary FORMULARY 02/29/2020 calcium oxide calcium oxide REMOVE FROM Non-Formulary FORMULARY 02/29/2020 calcium oxide calcium oxide REMOVE FROM Non-Formulary FORMULARY 02/29/2020 alprazolam alprazolam REMOVE FROM Non-Formulary FORMULARY 02/29/2020 sodium chloride sodium chloride 0.45 % ADD TO FORMULARY Injectables 02/29/2020 gojji blood blood sugar diagnostic REMOVE FROM Non-Formulary glucose test strip FORMULARY 02/29/2020 flurbiprofen flurbiprofen REMOVE FROM Non-Formulary FORMULARY 02/29/2020 flurbiprofen flurbiprofen REMOVE FROM Non-Formulary FORMULARY 02/29/2020 flurbiprofen flurbiprofen REMOVE FROM Non-Formulary FORMULARY 02/29/2020 flurbiprofen flurbiprofen REMOVE FROM Non-Formulary FORMULARY 02/29/2020 flurbiprofen flurbiprofen REMOVE FROM Non-Formulary FORMULARY 02/29/2020 flurbiprofen flurbiprofen REMOVE FROM Non-Formulary FORMULARY 02/29/2020 chloroquine chloroquine phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/29/2020 chloroquine chloroquine phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/29/2020 chloroquine chloroquine phosphate REMOVE FROM Non-Formulary phosphate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 55 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 chloroquine chloroquine phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/29/2020 chloroquine chloroquine phosphate REMOVE FROM Non-Formulary phosphate FORMULARY 02/29/2020 bismuth bismuth subnitrate REMOVE FROM Non-Formulary subnitrate FORMULARY 02/29/2020 water water for irrigation,sterile REMOVE FROM Non-Formulary FORMULARY 02/29/2020 chlorambucil chlorambucil REMOVE FROM Non-Formulary FORMULARY 02/29/2020 chlorambucil chlorambucil REMOVE FROM Non-Formulary FORMULARY 02/29/2020 chlorambucil chlorambucil REMOVE FROM Non-Formulary FORMULARY 02/29/2020 naproxen sodium naproxen sodium REMOVE FROM Non-Formulary FORMULARY 02/29/2020 naproxen sodium naproxen sodium REMOVE FROM Non-Formulary FORMULARY 02/29/2020 naproxen sodium naproxen sodium REMOVE FROM Non-Formulary FORMULARY 02/29/2020 phenobarbital phenobarbital REMOVE FROM Non-Formulary FORMULARY 02/29/2020 phenobarbital phenobarbital REMOVE FROM Non-Formulary FORMULARY 02/29/2020 arginine arginine REMOVE FROM Non-Formulary FORMULARY 02/29/2020 arginine arginine REMOVE FROM Non-Formulary FORMULARY 02/29/2020 bismuth bismuth subgallate REMOVE FROM Non-Formulary subgallate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 56 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 petrolatum petrolatum, yellow REMOVE FROM Non-Formulary FORMULARY 02/29/2020 benadryl allergy diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 02/29/2020 sodium valproate valproic acid (as sodium REMOVE FROM Non-Formulary salt) (valproate sodium) FORMULARY 02/29/2020 sodium valproate valproic acid (as sodium REMOVE FROM Non-Formulary salt) (valproate sodium) FORMULARY 02/29/2020 sodium valproate valproic acid (as sodium REMOVE FROM Non-Formulary salt) (valproate sodium) FORMULARY 02/29/2020 antacid plus anti- magnesium REMOVE FROM Non-Formulary gas hydroxide/aluminum FORMULARY hydroxide/simethicone 02/29/2020 acidophilus lactobacillus acidophilus REMOVE FROM Non-Formulary FORMULARY 02/29/2020 pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY 02/29/2020 lice solution piperonyl REMOVE FROM Non-Formulary butoxide/pyrethrins/permethr FORMULARY in 02/29/2020 hydroxyurea hydroxyurea REMOVE FROM Non-Formulary FORMULARY 02/29/2020 hydroxyurea hydroxyurea REMOVE FROM Non-Formulary FORMULARY 02/29/2020 hydroxyurea hydroxyurea REMOVE FROM Non-Formulary FORMULARY 02/29/2020 nighttime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/acetaminophen/doxylam FORMULARY ine 02/29/2020 prodigy blood-glucose meter REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 57 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 folic acid folic acid REMOVE FROM Non-Formulary FORMULARY 02/29/2020 biotin biotin REMOVE FROM Non-Formulary FORMULARY 02/29/2020 biotin biotin REMOVE FROM Non-Formulary FORMULARY 02/29/2020 biotin biotin REMOVE FROM Non-Formulary FORMULARY 02/29/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 02/29/2020 wrist blood blood pressure test kit-wrist REMOVE FROM Non-Formulary pressure monitor FORMULARY 02/29/2020 cetyl esters cetyl esters REMOVE FROM Non-Formulary FORMULARY 02/29/2020 cetyl esters cetyl esters REMOVE FROM Non-Formulary FORMULARY 02/29/2020 cetyl esters cetyl esters REMOVE FROM Non-Formulary FORMULARY 02/29/2020 medicated pads witch hazel REMOVE FROM Non-Formulary FORMULARY 02/29/2020 gojji lancets lancets REMOVE FROM Non-Formulary FORMULARY 02/29/2020 anti-itch pramoxine hcl REMOVE FROM Non-Formulary FORMULARY 02/29/2020 banana cream banana creme flavor REMOVE FROM Non-Formulary flavor FORMULARY 02/29/2020 banana cream banana creme flavor REMOVE FROM Non-Formulary flavor FORMULARY 02/29/2020 banana cream banana creme flavor REMOVE FROM Non-Formulary flavor FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 58 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 24 hour allergy REMOVE FROM Non-Formulary FORMULARY 02/29/2020 wal-som doxylamine succinate REMOVE FROM Non-Formulary FORMULARY 02/29/2020 digestive bifido inf/bifido longum/l. REMOVE FROM Non-Formulary acidophilus/l. rhamnosus FORMULARY 02/29/2020 bitterness bitter mask flavoring REMOVE FROM Non-Formulary suppressor FORMULARY 02/29/2020 bitterness bitter mask flavoring REMOVE FROM Non-Formulary suppressor FORMULARY 02/29/2020 MCT OIL medium chain triglycerides REMOVE FROM Non-Formulary FORMULARY 02/29/2020 robitussin er dextromethorphan polistirex REMOVE FROM Non-Formulary FORMULARY 02/29/2020 robitussin er dextromethorphan polistirex REMOVE FROM Non-Formulary FORMULARY 02/29/2020 taperdex dexamethasone REMOVE FROM Non-Formulary FORMULARY 02/29/2020 gojji lancing lancing device REMOVE FROM Non-Formulary device FORMULARY 02/29/2020 blood pressure blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 02/29/2020 blood pressure blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 02/29/2020 blood pressure blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 02/29/2020 clever choice underpads REMOVE FROM Non-Formulary FORMULARY 02/29/2020 agamatrix presto blood sugar diagnostic REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 59 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 abouttime pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 02/29/2020 abouttime pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 02/29/2020 abouttime pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 02/29/2020 abouttime pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 02/29/2020 VB6 P5P pyridoxal phosphate REMOVE FROM Non-Formulary FORMULARY 02/29/2020 DOUBLE bacitracin zinc/polymyxin b REMOVE FROM Non-Formulary ANTIBIOTIC sulfate FORMULARY 02/29/2020 COMPLEAT nutritional supplement/fiber REMOVE FROM Non-Formulary PEDIATRIC FORMULARY 1.5 02/29/2020 COMPLEAT nutritional supplement/fiber REMOVE FROM Non-Formulary PEDIATRIC FORMULARY PEPTIDE 1.5 02/29/2020 COMPLEAT nutritional supplement/fiber REMOVE FROM Non-Formulary PEPTIDE 1.5 FORMULARY 02/29/2020 COMPLEAT nutritional supplement/fiber REMOVE FROM Non-Formulary PEPTIDE 1.5 FORMULARY 02/29/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary er FORMULARY 02/29/2020 magnesium oxide magnesium oxide REMOVE FROM Non-Formulary FORMULARY 02/29/2020 magnesium magnesium oxide REMOVE FROM Non-Formulary FORMULARY 02/29/2020 sinus pe plus chlorpheniramine REMOVE FROM Non-Formulary allergy maleate/phenylephrine hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 60 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 children's cold- brompheniramine REMOVE FROM Non-Formulary allergy maleate/phenylephrine hcl FORMULARY 02/29/2020 calcium 500-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 02/29/2020 allergy diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 02/29/2020 mucus dm max guaifenesin/dextromethorph REMOVE FROM Non-Formulary er an hbr FORMULARY 02/29/2020 oral pain reliever benzocaine REMOVE FROM Non-Formulary FORMULARY 02/29/2020 cough-cold hbp chlorpheniramine REMOVE FROM Non-Formulary maleate/dextromethorphan FORMULARY hbr 02/29/2020 naproxen pm naproxen REMOVE FROM Non-Formulary sodium/diphenhydramine hcl FORMULARY 02/29/2020 witch hazel witch hazel REMOVE FROM Non-Formulary FORMULARY 02/29/2020 robafen dm peak guaifenesin/dextromethorph REMOVE FROM Non-Formulary cold an hbr FORMULARY 02/29/2020 advantage with infant formula with REMOVE FROM Non-Formulary iron non-gmo iron/docosahexaenoic FORMULARY acid/arachidonic ac 02/29/2020 adriamycin doxorubicin hcl ADD TO FORMULARY Injectables 02/29/2020 adriamycin doxorubicin hcl ADD TO FORMULARY Injectables 02/29/2020 adriamycin doxorubicin hcl ADD TO FORMULARY Injectables 02/29/2020 butalbital- butalbital/acetaminophen REMOVE FROM Non-Formulary acetaminophen FORMULARY 02/29/2020 butalbital- butalbital/acetaminophen REMOVE FROM Non-Formulary acetaminophen FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 61 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/29/2020 prolate oxycodone REMOVE FROM Non-Formulary hcl/acetaminophen FORMULARY 02/29/2020 prolate oxycodone REMOVE FROM Non-Formulary hcl/acetaminophen FORMULARY 02/29/2020 prolate oxycodone REMOVE FROM Non-Formulary hcl/acetaminophen FORMULARY 02/29/2020 prolate oxycodone REMOVE FROM Non-Formulary hcl/acetaminophen FORMULARY 02/29/2020 prolate oxycodone REMOVE FROM Non-Formulary hcl/acetaminophen FORMULARY 02/29/2020 prolate oxycodone REMOVE FROM Non-Formulary hcl/acetaminophen FORMULARY 02/29/2020 LUVIRA omega-3 fatty REMOVE FROM Non-Formulary acids/docosahexaenoic FORMULARY acid/epa/ 02/29/2020 ORAPEUTIC xylitol/pectin/acemannan/so REMOVE FROM Non-Formulary dium bicarbonate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 62 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

March, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/01/2020 mesalamine er mesalamine ADD TO FORMULARY Non-Preferred Generics 03/01/2020 mesalamine mesalamine ADD TO FORMULARY Non-Formulary Non-Preferred Generics 03/06/2020 bethanechol bethanechol chloride REMOVE FROM Non-Formulary chloride FORMULARY 03/06/2020 bethanechol bethanechol chloride REMOVE FROM Non-Formulary chloride FORMULARY 03/06/2020 bethanechol bethanechol chloride REMOVE FROM Non-Formulary chloride FORMULARY 03/06/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 03/06/2020 multivitamin multivitamin REMOVE FROM Non-Formulary FORMULARY 03/06/2020 polyethylene polyethylene glycol 3350 REMOVE FROM Non-Formulary glycol 3350 FORMULARY 03/06/2020 water water for irrigation,sterile REMOVE FROM Non-Formulary FORMULARY 03/06/2020 valine valine REMOVE FROM Non-Formulary FORMULARY 03/06/2020 hydrocortisone hydrocortisone REMOVE FROM Non-Formulary FORMULARY 03/06/2020 gentle laxative bisacodyl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 lansoprazole lansoprazole REMOVE FROM Non-Formulary FORMULARY 03/06/2020 paroxetine cr paroxetine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 63 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 paroxetine cr paroxetine hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 underwear for diaper,brief,adult, REMOVE FROM Non-Formulary women disposable FORMULARY 03/06/2020 and d a and d/white REMOVE FROM Non-Formulary petrolatum/lanolin FORMULARY 03/06/2020 PATADAY olopatadine hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 PATADAY olopatadine hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 sinus pain- phenylephrine REMOVE FROM Non-Formulary congestion hcl/acetaminophen FORMULARY 03/06/2020 artificial tears polyvinyl alcohol/povidone REMOVE FROM Non-Formulary FORMULARY 03/06/2020 pain reliever acetaminophen REMOVE FROM Non-Formulary FORMULARY 03/06/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 naproxen- naproxen/esomeprazole REMOVE FROM Non-Formulary esomeprazole magnesium FORMULARY mag 03/06/2020 naproxen- naproxen/esomeprazole REMOVE FROM Non-Formulary esomeprazole magnesium FORMULARY mag

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 64 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 natural fiber psyllium husk REMOVE FROM Non-Formulary supplement FORMULARY 03/06/2020 reguloid psyllium husk REMOVE FROM Non-Formulary FORMULARY 03/06/2020 FLONASE fluticasone propionate REMOVE FROM Non-Formulary ALLERGY FORMULARY RELIEF 03/06/2020 freedom gel base no.145 REMOVE FROM Non-Formulary adaptaderm FORMULARY 03/06/2020 complete mv multivitamin with REMOVE FROM Non-Formulary adult 50 plus minerals/folic FORMULARY acid//lutein 03/06/2020 contour next test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 03/06/2020 fosaprepitant fosaprepitant dimeglumine REMOVE FROM Non-Formulary dimeglumine FORMULARY 03/06/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 03/06/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 03/06/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 03/06/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 03/06/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 03/06/2020 calcium silicate calcium silicate REMOVE FROM Non-Formulary FORMULARY 03/06/2020 calcium silicate calcium silicate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 65 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 calcium silicate calcium silicate REMOVE FROM Non-Formulary FORMULARY 03/06/2020 saccharin saccharin calcium REMOVE FROM Non-Formulary calcium FORMULARY 03/06/2020 saccharin saccharin calcium REMOVE FROM Non-Formulary calcium FORMULARY 03/06/2020 saccharin saccharin calcium REMOVE FROM Non-Formulary calcium FORMULARY 03/06/2020 saccharin saccharin calcium REMOVE FROM Non-Formulary calcium FORMULARY 03/06/2020 SENSI-CARE zinc oxide/petrolatum,white REMOVE FROM Non-Formulary FORMULARY 03/06/2020 MODULEN nutritional therapy for REMOVE FROM Non-Formulary impaired digestive function FORMULARY 03/06/2020 PATADAY olopatadine hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 PEDIASURE pediatric , iron, REMOVE FROM Non-Formulary REDUCED lactose free with fiber FORMULARY CALORIE 03/06/2020 athlete's foot terbinafine hcl REMOVE FROM Non-Formulary FORMULARY 03/06/2020 tussin dm guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 03/06/2020 tussin dm guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 03/06/2020 co q10-black ubidecarenone (coenzyme REMOVE FROM Non-Formulary pepper q-10)/black pepper extract FORMULARY 03/06/2020 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM Non-Formulary FORMULARY 03/06/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 66 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/06/2020 slow release iron ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 03/06/2020 tc99m mertiatide kit for prep tc-99m/mertiatide REMOVE FROM Non-Formulary prep (betiatide) FORMULARY 03/06/2020 IBRANCE palbociclib ADD TO FORMULARY Preferred Specialty 03/06/2020 IBRANCE palbociclib ADD TO FORMULARY Preferred Specialty 03/06/2020 IBRANCE palbociclib ADD TO FORMULARY Preferred Specialty 03/10/2020 omnipod dash 5 insulin pump cartridge ADD UM: QUANTITY 10 / 30 days pack pod 03/10/2020 omnipod insulin pump cartridge ADD UM: QUANTITY 10 / 30 days 03/10/2020 elavil amitriptyline hcl REMOVE FROM Preferred Non-Formulary FORMULARY Generics 03/12/2020 FORTICAL calcitonin,salmon,synthetic REMOVE FROM Non-Preferred Non-Formulary FORMULARY Generics 03/13/2020 clomiphene clomiphene citrate REMOVE FROM Non-Formulary citrate FORMULARY 03/13/2020 clomiphene clomiphene citrate REMOVE FROM Non-Formulary citrate FORMULARY 03/13/2020 clomiphene clomiphene citrate REMOVE FROM Non-Formulary citrate FORMULARY 03/13/2020 clomiphene clomiphene citrate REMOVE FROM Non-Formulary citrate FORMULARY 03/13/2020 clomiphene clomiphene citrate REMOVE FROM Non-Formulary citrate FORMULARY 03/13/2020 ciclopirox olamine REMOVE FROM Non-Formulary olamine FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 67 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/13/2020 ciclopirox ciclopirox olamine REMOVE FROM Non-Formulary olamine FORMULARY 03/13/2020 ciclopirox ciclopirox olamine REMOVE FROM Non-Formulary olamine FORMULARY 03/13/2020 ciclopirox ciclopirox olamine REMOVE FROM Non-Formulary olamine FORMULARY 03/13/2020 ciclopirox ciclopirox olamine REMOVE FROM Non-Formulary olamine FORMULARY 03/13/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 03/13/2020 chondroitin chondroitin sulfate a sodium REMOVE FROM Non-Formulary sulfate sodium FORMULARY 03/13/2020 chondroitin chondroitin sulfate a sodium REMOVE FROM Non-Formulary sulfate sodium FORMULARY 03/13/2020 chondroitin chondroitin sulfate a sodium REMOVE FROM Non-Formulary sulfate sodium FORMULARY 03/13/2020 cholecalciferol cholecalciferol (vitamin d3) REMOVE FROM Non-Formulary FORMULARY 03/13/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 03/13/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 03/13/2020 dry eye relief polyethylene glycol REMOVE FROM Non-Formulary 400/hypromellose/glycerin FORMULARY 03/13/2020 fish oil omega-3 fatty REMOVE FROM Non-Formulary acids/docosahexaenoic FORMULARY acid/epa/fish oil 03/13/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 03/13/2020 levonorgestrel levonorgestrel REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 68 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/13/2020 clarithromycin clarithromycin REMOVE FROM Non-Formulary FORMULARY 03/13/2020 clarithromycin clarithromycin REMOVE FROM Non-Formulary FORMULARY 03/13/2020 clarithromycin clarithromycin REMOVE FROM Non-Formulary FORMULARY 03/13/2020 acesulfame acesulfame potassium REMOVE FROM Non-Formulary potassium FORMULARY 03/13/2020 ropivacaine hcl ropivacaine hcl REMOVE FROM Non-Formulary FORMULARY 03/13/2020 ropivacaine hcl ropivacaine hcl REMOVE FROM Non-Formulary FORMULARY 03/13/2020 ropivacaine hcl ropivacaine hcl REMOVE FROM Non-Formulary FORMULARY 03/13/2020 chloride choline chloride REMOVE FROM Non-Formulary FORMULARY 03/13/2020 choline chloride choline chloride REMOVE FROM Non-Formulary FORMULARY 03/13/2020 choline chloride choline chloride REMOVE FROM Non-Formulary FORMULARY 03/13/2020 cisplatin cisplatin REMOVE FROM Non-Formulary FORMULARY 03/13/2020 cisplatin cisplatin REMOVE FROM Non-Formulary FORMULARY 03/13/2020 melatonin REMOVE FROM Non-Formulary FORMULARY 03/13/2020 embrace pro test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 03/13/2020 embrace pro blood-glucose meter REMOVE FROM Non-Formulary blood glucose mtr FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 69 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/13/2020 ANTIOXIDANT beta-carotene/ascorbic REMOVE FROM Non-Formulary FORMULA acid/vite ac/ yeast FORMULARY 03/13/2020 men 50 plus multivitamin with REMOVE FROM Non-Formulary multivitamin minerals/folic FORMULARY acid/lycopene/lutein 03/13/2020 advanced lactobacillus combo REMOVE FROM Non-Formulary probiotic no.37/bifido animalis/bifido FORMULARY longum 03/13/2020 butalbital- butalbital/acetaminophen REMOVE FROM Non-Formulary acetaminophen FORMULARY 03/13/2020 RELAFEN DS nabumetone REMOVE FROM Non-Formulary FORMULARY 03/13/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 03/13/2020 gojji multi- blood ketone and glucose REMOVE FROM Non-Formulary functional meter monitor FORMULARY 03/13/2020 gojji multi- blood ketone and glucose REMOVE FROM Non-Formulary functional meter monitor FORMULARY 03/13/2020 unifine pen needle, diabetic REMOVE FROM Non-Formulary safecontrol disposable, safety FORMULARY 03/13/2020 AQUA-D cholecalciferol (vit REMOVE FROM Non-Formulary CONCENTRATE d3)/tocophersolan FORMULARY 03/13/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 03/13/2020 aspirin ec aspirin REMOVE FROM Non-Formulary FORMULARY 03/13/2020 ziprasidone ziprasidone mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 03/13/2020 ziprasidone ziprasidone mesylate REMOVE FROM Non-Formulary mesylate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 70 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/13/2020 azelastine- azelastine hcl/fluticasone REMOVE FROM Non-Formulary fluticasone propionate FORMULARY 03/13/2020 jaimiess levonorgestrel/ethinyl ADD TO FORMULARY Preventative estradiol and ethinyl estradiol 03/13/2020 lojaimiess levonorgestrel/ethinyl ADD TO FORMULARY Preventative estradiol and ethinyl estradiol 03/13/2020 volnea -ethinyl ADD TO FORMULARY Preventative estradiol/ethinyl estradiol 03/13/2020 potassium potassium REMOVE FROM Non-Formulary phosphates phosphate,monobasic- FORMULARY dibasic 03/20/2020 PROCYSBI cysteamine bitartrate ADD UM: LIMITEDACCESS Limited Access 03/20/2020 PROCYSBI cysteamine bitartrate ADD UM: LIMITEDACCESS Limited Access 03/20/2020 ketamine hcl- ketamine hcl in 0.9 % ADD TO FORMULARY Injectables 0.9% nacl sodium chloride 03/20/2020 polyethylene polyethylene glycol 3350 REMOVE FROM Non-Formulary glycol 3350 FORMULARY 03/20/2020 l-glutamic acid glutamic acid REMOVE FROM Non-Formulary FORMULARY 03/20/2020 lice killing piperonyl REMOVE FROM Non-Formulary butoxide/pyrethrins FORMULARY 03/20/2020 aminocaproic aminocaproic acid REMOVE FROM Non-Formulary acid FORMULARY 03/20/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 03/20/2020 aspirin ec aspirin ADD TO FORMULARY Preventative 03/20/2020 dextrose in dextrose 5 % in lactated ADD TO FORMULARY Injectables lactated ringers ringers

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 71 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 phenazopyridine phenazopyridine hcl REMOVE FROM Non-Formulary hcl FORMULARY 03/20/2020 vecuronium vecuronium bromide REMOVE FROM Non-Formulary bromide FORMULARY 03/20/2020 water water for irrigation,sterile REMOVE FROM Non-Formulary FORMULARY 03/20/2020 ear wax removal carbamide peroxide REMOVE FROM Non-Formulary FORMULARY 03/20/2020 iron ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 03/20/2020 ketoprofen ketoprofen REMOVE FROM Non-Formulary FORMULARY 03/20/2020 zinc REMOVE FROM Non-Formulary FORMULARY 03/20/2020 glucosamine glucosamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 03/20/2020 chlorhexidine chlorhexidine gluconate REMOVE FROM Non-Formulary gluconate FORMULARY 03/20/2020 alum-mag magnesium REMOVE FROM Non-Formulary hydroxide- hydroxide/aluminum FORMULARY simethicone hydroxide/simethicone 03/20/2020 fluticasone fluticasone propionate REMOVE FROM Non-Formulary propionate FORMULARY 03/20/2020 petroleum jelly petrolatum,white REMOVE FROM Non-Formulary FORMULARY 03/20/2020 coenzyme q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 03/20/2020 calcium calcium carbonate REMOVE FROM Non-Formulary carbonate FORMULARY 03/20/2020 pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 72 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 chocolate flavor chocolate flavor REMOVE FROM Non-Formulary FORMULARY 03/20/2020 chocolate flavor chocolate flavor REMOVE FROM Non-Formulary FORMULARY 03/20/2020 chocolate flavor chocolate flavor REMOVE FROM Non-Formulary FORMULARY 03/20/2020 underwear men- diaper,brief,adult, REMOVE FROM Non-Formulary women disposable FORMULARY 03/20/2020 clotrimazole-3 clotrimazole REMOVE FROM Non-Formulary FORMULARY 03/20/2020 oxytocin oxytocin REMOVE FROM Non-Formulary FORMULARY 03/20/2020 oxytocin oxytocin REMOVE FROM Non-Formulary FORMULARY 03/20/2020 allergy relief fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 03/20/2020 stool softener- sennosides/docusate REMOVE FROM Non-Formulary stimulant lax sodium FORMULARY 03/20/2020 pentosan pentosan polysulfate sodium REMOVE FROM Non-Formulary polysulfate FORMULARY sodium 03/20/2020 butylated butylated hydroxyanisole REMOVE FROM Non-Formulary hydroxyanisole FORMULARY 03/20/2020 butylated butylated hydroxyanisole REMOVE FROM Non-Formulary hydroxyanisole FORMULARY 03/20/2020 butylated butylated hydroxyanisole REMOVE FROM Non-Formulary hydroxyanisole FORMULARY 03/20/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 03/20/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 73 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 MUCINEX FAST- diphenhydramine/phenyleph REMOVE FROM Non-Formulary MAX DAY-NITE rin/dextromethorph/acetamin FORMULARY COLD ophen/gg 03/20/2020 mucinex fast-max phenylephrine REMOVE FROM Non-Formulary cold-flu hcl/dextromethorphan FORMULARY hbr/acetaminophen/guaifen 03/20/2020 gojji blood ketone blood ketone test, strips REMOVE FROM Non-Formulary test strip FORMULARY 03/20/2020 gojji glucose blood glucose calibration REMOVE FROM Non-Formulary control solution control solution, normal FORMULARY 03/20/2020 gojji lancet- lancets with blood glucose REMOVE FROM Non-Formulary glucose test strp test strips FORMULARY 03/20/2020 gojji lancet- lancets with blood glucose REMOVE FROM Non-Formulary glucose test strp test strips FORMULARY 03/20/2020 hypersoniq nebulizer accessories REMOVE FROM Non-Formulary nebulizer FORMULARY cartridge 03/20/2020 intelligent mesh nebulizer REMOVE FROM Non-Formulary nebulizer FORMULARY 03/20/2020 cequr simplicity diabetic supplies,miscell REMOVE FROM Non-Formulary inserter FORMULARY 03/20/2020 TAB-A-VITE multivitamin/ferrous REMOVE FROM Non-Formulary MULTIVIT WITH fumarate/folic acid FORMULARY IRON 03/20/2020 AQUA-K phytonadione (vitamin REMOVE FROM Non-Formulary CONCENTRATE k1)/vitamin e tpgs FORMULARY 03/20/2020 GILTUSS chlorpheniramine REMOVE FROM Non-Formulary ALLERGY PLUS maleate/phenylephrine FORMULARY hcl/chlophedianol hcl 03/20/2020 allergy relief chlorpheniramine maleate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 74 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 alum-mag magnesium REMOVE FROM Non-Formulary hydroxide- hydroxide/aluminum FORMULARY simethicone hydroxide/simethicone 03/20/2020 senna-s sennosides/docusate REMOVE FROM Non-Formulary sodium FORMULARY 03/20/2020 antacid extra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY 03/20/2020 calcium-vit d3-vit calcium REMOVE FROM Non-Formulary k1 carbonate/cholecalciferol (vit FORMULARY d3)/vit k1 03/20/2020 calcium-vit d3-vit calcium REMOVE FROM Non-Formulary k1 carbonate/cholecalciferol (vit FORMULARY d3)/vit k1 03/20/2020 day-night severe dextromethorphan/phenylep REMOVE FROM Non-Formulary cold-flu hrine/acetaminophen/diphen FORMULARY hydramine 03/20/2020 giltuss diabetic guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 03/20/2020 pyrimethamine pyrimethamine ADD TO FORMULARY Non-Preferred Generics 03/20/2020 pyrimethamine pyrimethamine ADD TO FORMULARY Non-Preferred Generics 03/20/2020 pyrimethamine pyrimethamine ADD TO FORMULARY Non-Preferred Generics 03/20/2020 pyrimethamine pyrimethamine ADD TO FORMULARY Non-Preferred Generics 03/20/2020 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty 03/20/2020 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 75 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/20/2020 everolimus everolimus ADD TO FORMULARY Non-Preferred Specialty 03/23/2020 toradol,ketorolac ketorolac tromethamine CHANGE TIER Non-Preferred tromethamine Generics 03/23/2020 IBRANCE palbociclib ADD UM: LIMITEDACCESS Limited Access 03/23/2020 IBRANCE palbociclib ADD UM: LIMITEDACCESS Limited Access 03/23/2020 IBRANCE palbociclib ADD UM: LIMITEDACCESS Limited Access 03/25/2020 etonogestrel- etonogestrel/ethinyl estradiol ADD TO FORMULARY Non-Formulary Preventative ethinyl estradiol 03/25/2020 eluryng etonogestrel/ethinyl estradiol ADD TO FORMULARY Non-Formulary Preventative 03/25/2020 NOURIANZ istradefylline ADD UM: LIMITEDACCESS Limited Access 03/25/2020 NOURIANZ istradefylline ADD UM: LIMITEDACCESS Limited Access 03/25/2020 GLUCAGEN glucagon,human REMOVE FROM Injectables Non-Formulary recombinant FORMULARY 03/30/2020 PREVIDENT fluoride (sodium) REMOVE FROM Non-Formulary 5000 ORTHO FORMULARY DEFENSE 03/30/2020 b-complex thiamine ADD TO FORMULARY Injectables hcl/riboflavin/niacinamide/de xpanthenol/pyridoxine 03/30/2020 iliderm lidocaine hcl/palm oil REMOVE FROM Non-Formulary FORMULARY 03/30/2020 calamine calamine REMOVE FROM Non-Formulary FORMULARY 03/30/2020 calamine calamine REMOVE FROM Non-Formulary FORMULARY 03/30/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 76 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 03/30/2020 hydrochloric acid hydrochloric acid REMOVE FROM Non-Formulary FORMULARY 03/30/2020 haloperidol haloperidol REMOVE FROM Non-Formulary FORMULARY 03/30/2020 ascorbic acid REMOVE FROM Non-Formulary FORMULARY 03/30/2020 ADVIL ibuprofen REMOVE FROM Non-Formulary FORMULARY 03/30/2020 hyoscyamine hyoscyamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 03/30/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 03/30/2020 children's pain- acetaminophen REMOVE FROM Non-Formulary fever FORMULARY 03/30/2020 gluconate copper gluconate REMOVE FROM Non-Formulary FORMULARY 03/30/2020 copper gluconate copper gluconate REMOVE FROM Non-Formulary FORMULARY 03/30/2020 copper gluconate copper gluconate REMOVE FROM Non-Formulary FORMULARY 03/30/2020 infants' mylicon simethicone REMOVE FROM Non-Formulary FORMULARY 03/30/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 03/30/2020 allergy relief cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 03/30/2020 allergy relief cetirizine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 77 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2020 one daily multivitamin with REMOVE FROM Non-Formulary women's formula minerals/ferrous FORMULARY fumarate/folic acid/vit k 03/30/2020 fentanyl fentanyl REMOVE FROM Non-Formulary FORMULARY 03/30/2020 fentanyl fentanyl REMOVE FROM Non-Formulary FORMULARY 03/30/2020 HEMORRHOIDA phenylephrine REMOVE FROM Non-Formulary L hcl/hydrogenated vegetable FORMULARY SUPPOSITORY oil 03/30/2020 PENTACEL diphther,pertus(acel),tetanus REMOVE FROM Non-Formulary DTAP-IPV ,polio vacc,component 1 of FORMULARY COMPONENT 2/pf 03/30/2020 PENTACEL diphtheria,pertussis(acell),te REMOVE FROM Non-Formulary tanus,polio/haemophilus b/pf FORMULARY 03/30/2020 theraflu phenylephrine REMOVE FROM Non-Formulary expressmax sv hcl/dextromethorphan FORMULARY cld-flu hbr/acetaminophen/guaifen 03/30/2020 adult 50 plus eye vit c,e,zinc,copper REMOVE FROM Non-Formulary health 11/omega- FORMULARY 3/dha/epa/fish/lutein/zeaxant h 03/30/2020 giltuss allergy chlorpheniramine REMOVE FROM Non-Formulary plus maleate/phenylephrine FORMULARY hcl/dextromethorphan 03/30/2020 vitamin b-12 mecobalamin REMOVE FROM Non-Formulary FORMULARY 03/30/2020 MUCINEX triprolidine REMOVE FROM Non-Formulary NIGHTSHIFT hcl/phenylephrine/dextromet FORMULARY SINUS horphn/acetaminophen

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 78 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2020 GILTUSS MULTI- dextromethorphan/phenylep REMOVE FROM Non-Formulary SYMPTOM hrine/acetaminophen/chlorp FORMULARY COLD-FLU heniramin 03/30/2020 MUCINEX phenylephrine REMOVE FROM Non-Formulary JUNIOR COLD- hcl/dextromethorphan FORMULARY FLU hbr/acetaminophen/guaifen 03/30/2020 CHILDRENS guaifenesin/dextromethorph REMOVE FROM Non-Formulary GILTUSS an hbr/phenylephrine FORMULARY COUGH-COLD 03/30/2020 PROBIOTIC bacillus REMOVE FROM Non-Formulary coagulans/cholecalciferol FORMULARY (vit d3) 03/30/2020 quick-set infusion set for insulin pump REMOVE FROM Non-Formulary paradigm FORMULARY 03/30/2020 unifine pen needle, diabetic REMOVE FROM Non-Formulary safecontrol disposable, safety FORMULARY 03/30/2020 minimed sure t infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed sure t infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed sure t infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed sure t infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed sure t infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed sure t infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed sure t infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 79 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2020 minimed infusion set for insulin pump REMOVE FROM Non-Formulary silhouette FORMULARY 03/30/2020 minimed infusion set for insulin pump REMOVE FROM Non-Formulary silhouette FORMULARY 03/30/2020 minimed infusion set for insulin pump REMOVE FROM Non-Formulary silhouette FORMULARY 03/30/2020 minimed infusion set for insulin pump REMOVE FROM Non-Formulary silhouette FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary FORMULARY 03/30/2020 diazoxide diazoxide ADD TO FORMULARY Non-Preferred Generics 03/30/2020 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 80 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/30/2020 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 03/30/2020 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 03/30/2020 thiotepa thiotepa REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minocycline er minocycline hcl REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minocycline er minocycline hcl REMOVE FROM Non-Formulary FORMULARY 03/30/2020 minocycline er minocycline hcl REMOVE FROM Non-Formulary FORMULARY 03/30/2020 dexabliss dexamethasone REMOVE FROM Non-Formulary FORMULARY 03/30/2020 ANJESO meloxicam REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 81 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

April, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2020 REBLOZYL luspatercept-aamt ADD UM: MED Medical Drug 04/01/2020 SLYND drospirenone ADD TO FORMULARY Non-Preferred Brands 04/01/2020 TRIKAFTA elexacaftor/tezacaftor/ivacaft ADD TO FORMULARY Non-Preferred or Specialty 04/01/2020 ANNOVERA /ethinyl REMOVE UM: QUANTITY 1 / 365 days estradiol 04/01/2020 NPLATE romiplostim ADD UM: MED Medical Drug 04/01/2020 ASCENIV immune globulin,gamma ADD UM: MED Medical Drug (igg)-slra human 04/01/2020 metronidazole metronidazole ADD TO FORMULARY Non-Formulary Non-Preferred Generics 04/01/2020 REBLOZYL luspatercept-aamt ADD UM: MED Medical Drug 04/01/2020 FASENRA PEN benralizumab ADD TO FORMULARY Preferred Specialty 04/01/2020 FASENRA PEN benralizumab ADD UM: QUANTITY 1 / 56 days 04/01/2020 PROAIR albuterol sulfate ADD UM: 2 INHALERS/30 DIGIHALER QUANTITYCUSTOM DAYS 04/01/2020 LYNPARZA olaparib CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/01/2020 LYNPARZA olaparib CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/01/2020 RUBRACA rucaparib camsylate CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/01/2020 RUBRACA rucaparib camsylate CHANGE TIER Non-Preferred Preferred Specialty Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 82 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2020 RUBRACA rucaparib camsylate CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/01/2020 LYNPARZA olaparib CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/01/2020 WAKIX pitolisant hcl ADD UM: QUANTITY 2 / 1 DAY 04/01/2020 WAKIX pitolisant hcl ADD UM: QUANTITY 2 / 1 DAY 04/01/2020 MAYZENT siponimod ADD UM: QUANTITY 4 / 1 DAY 04/01/2020 DUPIXENT dupilumab CHANGE TIER Non-Preferred Preferred SYRINGE Specialty Specialty 04/01/2020 DUPIXENT dupilumab CHANGE TIER Non-Preferred Preferred SYRINGE Specialty Specialty 04/01/2020 NUCALA mepolizumab CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/01/2020 NUCALA mepolizumab CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/01/2020 EYLEA aflibercept ADD UM: MED Medical Drug 04/01/2020 OLUMIANT baricitinib ADD UM: QUANTITY 1 / 1 DAY 04/01/2020 FIRVANQ vancomycin hcl ADD TO FORMULARY Non-Formulary Preferred Brands 04/01/2020 BAQSIMI glucagon REMOVE FROM Preferred Brands Non-Formulary FORMULARY 04/01/2020 PROAIR albuterol sulfate CHANGE TIER Non-Preferred Non-Preferred RESPICLICK Generics Brands 04/01/2020 ZEPATIER elbasvir/grazoprevir ADD UM: SPECIALTY Specialty Drug 04/01/2020 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred bitartrate er Generics 04/01/2020 zohydro hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred er,hydrocodone Generics bitartrate er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 83 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2020 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred bitartrate er Generics 04/01/2020 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred bitartrate er Generics 04/01/2020 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred bitartrate er Generics 04/01/2020 hydrocodone hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred bitartrate er Generics 04/01/2020 ZOHYDRO ER hydrocodone bitartrate REMOVE FROM Non-Preferred Non-Formulary FORMULARY Generics 04/01/2020 TRUXIMA rituximab-abbs ADD UM: MED Medical Drug 04/01/2020 ZEPATIER elbasvir/grazoprevir REMOVE UM: SPECIALTY Specialty Drug 04/01/2020 FASENRA PEN benralizumab REMOVE UM: SPECIALTY Specialty Drug 04/03/2020 VERZENIO abemaciclib CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/03/2020 VERZENIO abemaciclib CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/03/2020 VERZENIO abemaciclib CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/03/2020 NUBEQA darolutamide CHANGE TIER Non-Preferred Preferred Specialty Specialty 04/03/2020 BRUKINSA zanubrutinib ADD TO FORMULARY Non-Preferred Specialty 04/03/2020 deferasirox deferasirox ADD UM: SPECIALTY Specialty Drug 04/03/2020 deferasirox deferasirox ADD UM: SPECIALTY Specialty Drug 04/03/2020 deferasirox deferasirox REMOVE UM: SPECIALTY Specialty Drug 04/03/2020 deferasirox deferasirox REMOVE UM: SPECIALTY Specialty Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 84 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/03/2020 cetirizine- cetirizine REMOVE FROM Non-Formulary pseudoephedrine hcl/pseudoephedrine hcl FORMULARY er 04/03/2020 cetirizine- cetirizine REMOVE FROM Non-Formulary pseudoephedrine hcl/pseudoephedrine hcl FORMULARY er 04/03/2020 polyethylene polyethylene glycol 3350 REMOVE FROM Non-Formulary glycol 3350 FORMULARY 04/03/2020 polyethylene polyethylene glycol 3350 REMOVE FROM Non-Formulary glycol 3350 FORMULARY 04/03/2020 sodium sodium bicarbonate REMOVE FROM Non-Formulary bicarbonate FORMULARY 04/03/2020 econazole nitrate econazole nitrate REMOVE FROM Non-Formulary FORMULARY 04/03/2020 edetate disodium edetate disodium REMOVE FROM Non-Formulary FORMULARY 04/03/2020 edetate disodium edetate disodium REMOVE FROM Non-Formulary FORMULARY 04/03/2020 edetate disodium edetate disodium REMOVE FROM Non-Formulary FORMULARY 04/03/2020 hydrochloric acid hydrochloric acid REMOVE FROM Non-Formulary FORMULARY 04/03/2020 hydrocortisone hydrocortisone acetate REMOVE FROM Non-Formulary acetate FORMULARY 04/03/2020 hydrocortisone hydrocortisone acetate REMOVE FROM Non-Formulary acetate FORMULARY 04/03/2020 sodium chloride sodium chloride irrigating REMOVE FROM Non-Formulary solution FORMULARY 04/03/2020 sodium chloride sodium chloride REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 85 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/03/2020 arginine hcl arginine hcl REMOVE FROM Non-Formulary FORMULARY 04/03/2020 arginine hcl arginine hcl REMOVE FROM Non-Formulary FORMULARY 04/03/2020 sodium sodium bicarbonate REMOVE FROM Non-Formulary bicarbonate FORMULARY 04/03/2020 ursodiol ursodiol REMOVE FROM Non-Formulary FORMULARY 04/03/2020 danazol REMOVE FROM Non-Formulary FORMULARY 04/03/2020 danazol danazol REMOVE FROM Non-Formulary FORMULARY 04/03/2020 danazol danazol REMOVE FROM Non-Formulary FORMULARY 04/03/2020 danazol danazol REMOVE FROM Non-Formulary FORMULARY 04/03/2020 danazol danazol REMOVE FROM Non-Formulary FORMULARY 04/03/2020 clotrimazole clotrimazole REMOVE FROM Non-Formulary FORMULARY 04/03/2020 diflunisal diflunisal REMOVE FROM Non-Formulary FORMULARY 04/03/2020 diflunisal diflunisal REMOVE FROM Non-Formulary FORMULARY 04/03/2020 diflunisal diflunisal REMOVE FROM Non-Formulary FORMULARY 04/03/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 04/03/2020 corn starch corn starch REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 86 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/03/2020 ondansetron hcl ondansetron hcl REMOVE FROM Non-Formulary FORMULARY 04/03/2020 dexamethasone dexamethasone, micronized REMOVE FROM Non-Formulary micronized FORMULARY 04/03/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 04/03/2020 healthylax polyethylene glycol 3350 REMOVE FROM Non-Formulary FORMULARY 04/03/2020 pain reliever adult acetaminophen REMOVE FROM Non-Formulary FORMULARY 04/03/2020 eye allergy relief naphazoline hcl/pheniramine REMOVE FROM Non-Formulary maleate FORMULARY 04/03/2020 eye allergy relief naphazoline hcl/pheniramine REMOVE FROM Non-Formulary maleate FORMULARY 04/03/2020 lubricant pm oil/petrolatum,white REMOVE FROM Non-Formulary FORMULARY 04/03/2020 bubble gum bubblegum flavor REMOVE FROM Non-Formulary flavor FORMULARY 04/03/2020 bubble gum bubblegum flavor REMOVE FROM Non-Formulary flavor FORMULARY 04/03/2020 bubble gum bubblegum flavor REMOVE FROM Non-Formulary flavor FORMULARY 04/03/2020 GELX povidone/taurine/zinc REMOVE FROM Non-Formulary gluconate/peg-40 castor oil FORMULARY 04/03/2020 tussin mucus- guaifenesin REMOVE FROM Non-Formulary chest congestion FORMULARY 04/03/2020 GENTEAL hypromellose REMOVE FROM Non-Formulary TEARS SEVERE FORMULARY 04/03/2020 corn oil corn oil REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 87 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/03/2020 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM Non-Formulary FORMULARY 04/03/2020 DAYTIME COLD- dextromethorphan REMOVE FROM Non-Formulary FLU RELIEF hbr/phenylephrine FORMULARY hcl/acetaminophen 04/03/2020 NIGHTTIME dextromethorphan REMOVE FROM Non-Formulary COLD-FLU hbr/acetaminophen/doxylam FORMULARY RELIEF ine 04/03/2020 GLYCOSADE nutritional therapy for REMOVE FROM Non-Formulary glycogen storage disease FORMULARY (gsd) 04/03/2020 CHILD DELSYM acetaminophen/dextrometho REMOVE FROM Non-Formulary COUGH-SORE rphan hbr FORMULARY THROAT 04/03/2020 DELSYM acetaminophen/dextrometho REMOVE FROM Non-Formulary COUGH-SORE rphan hbr FORMULARY THROAT 04/03/2020 PKU EXPLORE5 nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria(pku) with FORMULARY iron no.52 04/03/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 04/03/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 04/03/2020 standard 1.4 nutritional supplement/fiber REMOVE FROM Non-Formulary FORMULARY 04/03/2020 standard 1.4 nutritional supplement/fiber REMOVE FROM Non-Formulary FORMULARY 04/03/2020 pediatric peptide nutritional supplement/fiber REMOVE FROM Non-Formulary 1.0 FORMULARY 04/03/2020 beanaid alpha-d-galactosidase REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 88 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/03/2020 CHOLECAL DF cholecalciferol (vit d3)/folic REMOVE FROM Non-Formulary acid FORMULARY 04/03/2020 dexamethasone dexamethasone acetate, REMOVE FROM Non-Formulary acetate micro micronized FORMULARY 04/03/2020 corn oil corn oil REMOVE FROM Non-Formulary FORMULARY 04/03/2020 PROMACTA eltrombopag olamine ADD TO FORMULARY Non-Preferred Specialty 04/03/2020 PROMACTA eltrombopag olamine ADD TO FORMULARY Non-Preferred Specialty 04/03/2020 AJOVY fremanezumab-vfrm REMOVE FROM Non-Formulary AUTOINJECTOR FORMULARY 04/10/2020 EPINEPHRINE epinephrine ADD TO FORMULARY Injectables PROFESSIONAL EMS 04/10/2020 EPINEPHRINE epinephrine ADD TO FORMULARY Injectables PROFESSIONAL KIT 04/10/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 04/10/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 04/10/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 04/10/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 04/10/2020 labetalol hcl labetalol hcl ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 89 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 04/10/2020 quazepam quazepam REMOVE FROM Non-Formulary FORMULARY 04/10/2020 anti-diarrheal loperamide hcl REMOVE FROM Non-Formulary FORMULARY 04/10/2020 phenobarbital phenobarbital sodium ADD TO FORMULARY Injectables sodium 04/10/2020 sodium sodium bicarbonate REMOVE FROM Non-Formulary bicarbonate FORMULARY 04/10/2020 senna sennosides REMOVE FROM Non-Formulary FORMULARY 04/10/2020 benzoyl peroxide benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY 04/10/2020 succinylcholine succinylcholine chloride ADD TO FORMULARY Injectables chloride 04/10/2020 potassium potassium chloride REMOVE FROM Non-Formulary chloride FORMULARY 04/10/2020 potassium potassium chloride REMOVE FROM Non-Formulary chloride FORMULARY 04/10/2020 potassium potassium chloride REMOVE FROM Non-Formulary chloride FORMULARY 04/10/2020 betamethasone betamethasone dipropionate REMOVE FROM Non-Formulary dipropionate FORMULARY 04/10/2020 betamethasone betamethasone dipropionate REMOVE FROM Non-Formulary dipropionate FORMULARY 04/10/2020 hydroxychloroqui hydroxychloroquine sulfate REMOVE FROM Non-Formulary ne sulfate FORMULARY 04/10/2020 hydroxychloroqui hydroxychloroquine sulfate REMOVE FROM Non-Formulary ne sulfate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 90 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 glucose dextrose REMOVE FROM Non-Formulary FORMULARY 04/10/2020 chromium picolinate REMOVE FROM Non-Formulary picolinate FORMULARY 04/10/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 04/10/2020 benzoyl peroxide benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY 04/10/2020 benzoyl peroxide benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY 04/10/2020 INFANTS' acetaminophen REMOVE FROM Non-Formulary TYLENOL FORMULARY 04/10/2020 grape flavor grape flavor REMOVE FROM Non-Formulary FORMULARY 04/10/2020 grape flavor grape flavor REMOVE FROM Non-Formulary FORMULARY 04/10/2020 CEPACOL SORE benzocaine/menthol REMOVE FROM Non-Formulary THROAT FORMULARY 04/10/2020 zinc sulfate zinc sulfate REMOVE FROM Non-Formulary FORMULARY 04/10/2020 secura dimethicone REMOVE FROM Non-Formulary dimethicone FORMULARY 04/10/2020 OPCON-A naphazoline hcl/pheniramine REMOVE FROM Non-Formulary maleate FORMULARY 04/10/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 04/10/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 04/10/2020 dapsone dapsone REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 91 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 dapsone dapsone REMOVE FROM Non-Formulary FORMULARY 04/10/2020 gojji ketone blood-ketone control, normal REMOVE FROM Non-Formulary control solution FORMULARY 04/10/2020 vitajoy adult multi multivitamin with REMOVE FROM Non-Formulary minerals/folic acid FORMULARY 04/10/2020 therems multivitamin with folic acid REMOVE FROM Non-Formulary multivitamin FORMULARY 04/10/2020 alpha lipoic acid alpha lipoic acid REMOVE FROM Non-Formulary FORMULARY 04/10/2020 diaper rash zinc oxide REMOVE FROM Non-Formulary FORMULARY 04/10/2020 MUCINEX triprolidine REMOVE FROM Non-Formulary NIGHTSHFT hcl/phenylephrine/dextromet FORMULARY COLD-FLU CLR horphn/acetaminophen 04/10/2020 vitamin b b-complex with vitamin c REMOVE FROM Non-Formulary complex-vitamin FORMULARY c 04/10/2020 PKU nutritional therapy for REMOVE FROM Non-Formulary EXPLORE10 phenylketonuria(pku) with FORMULARY iron no.52 04/10/2020 PKU nutritional therapy for REMOVE FROM Non-Formulary EXPLORE10 phenylketonuria(pku) with FORMULARY iron no.52 04/10/2020 MUCINEX triprolidine REMOVE FROM Non-Formulary NIGHTSHIFT hcl/dextromethorphan FORMULARY COLD-FLU hbr/acetaminophen 04/10/2020 MUCINEX FAST- triprolidine/phenylephrine/de REMOVE FROM Non-Formulary MAX xtromethorph/acetamin/guaif FORMULARY NIGHTSHFT enes CLR 04/10/2020 carmustine carmustine ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 92 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/10/2020 potassium potassium chloride in ADD TO FORMULARY Injectables chloride in d5lr lactated ringers and 5 % dextrose 04/10/2020 PAXIL CR paroxetine hcl REMOVE FROM Non-Formulary FORMULARY 04/10/2020 INSULIN LISPRO insulin lispro protamine and REMOVE FROM Non-Formulary PROTAMINE insulin lispro FORMULARY MIX 04/10/2020 INSULIN LISPRO insulin lispro REMOVE FROM Non-Formulary JUNIOR FORMULARY KWIKPEN 04/10/2020 dihydroergotamin dihydroergotamine mesylate ADD TO FORMULARY Non-Preferred e mesylate Generics 04/10/2020 METFORMIN metformin hcl ADD TO FORMULARY Non-Preferred HCL Generics 04/10/2020 METFORMIN metformin hcl ADD TO FORMULARY Non-Preferred HCL Generics 04/10/2020 HIZENTRA immune globulin,gamma ADD TO FORMULARY Non-Preferred (igg)/proline/iga 0 to 50 Specialty mcg/ml 04/10/2020 HIZENTRA immune globulin,gamma ADD TO FORMULARY Non-Preferred (igg)/proline/iga 0 to 50 Specialty mcg/ml 04/10/2020 HIZENTRA immune globulin,gamma ADD TO FORMULARY Non-Preferred (igg)/proline/iga 0 to 50 Specialty mcg/ml 04/17/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 04/17/2020 butylated butylated hydroxytoluene REMOVE FROM Non-Formulary hydroxytoluene(b FORMULARY ht)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 93 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/17/2020 docusate sodium docusate sodium REMOVE FROM Non-Formulary FORMULARY 04/17/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 04/17/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 04/17/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 04/17/2020 loperamide loperamide hcl REMOVE FROM Non-Formulary FORMULARY 04/17/2020 PEPCID AC famotidine REMOVE FROM Non-Formulary FORMULARY 04/17/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 04/17/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 04/17/2020 azelastine- azelastine hcl/fluticasone REMOVE FROM Non-Formulary fluticasone propionate FORMULARY 04/17/2020 child fever acetaminophen REMOVE FROM Non-Formulary reducer-pain relvr FORMULARY 04/17/2020 infants' pain-fever acetaminophen REMOVE FROM Non-Formulary FORMULARY 04/17/2020 DILUENT FOR diluent for rabies vaccine, REMOVE FROM Non-Formulary IMOVAX human diploid (sterile water) FORMULARY 04/17/2020 reguloid psyllium husk (with sugar) REMOVE FROM Non-Formulary FORMULARY 04/17/2020 giltuss hbp guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 04/17/2020 GILTUSS benzocaine/menthol/zinc REMOVE FROM Non-Formulary BUCALSEP chloride FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 94 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/17/2020 PHENYLADE nutritional therapy for REMOVE FROM Non-Formulary GMP ULTRA phenylketonuria (pku) no.74 FORMULARY 04/17/2020 PHENYLADE nutritional therapy for REMOVE FROM Non-Formulary GMP ULTRA phenylketonuria (pku) no.74 FORMULARY 04/17/2020 onetouch verio blood-glucose meter REMOVE FROM Non-Formulary reflect meter FORMULARY 04/17/2020 spirit style-3 catheter male,external REMOVE FROM Non-Formulary FORMULARY 04/17/2020 underwear for diaper,brief,adult, REMOVE FROM Non-Formulary men disposable FORMULARY 04/17/2020 methylcobalamin mecobalamin REMOVE FROM Non-Formulary FORMULARY 04/17/2020 ROMIDEPSIN romidepsin REMOVE FROM Non-Formulary FORMULARY 04/21/2020 PROMACTA eltrombopag olamine ADD UM: LIMITEDACCESS Limited Access 04/23/2020 dihydroergotamin dihydroergotamine mesylate CHANGE TIER Non-Preferred e mesylate Generics 04/23/2020 dihydroergotamin dihydroergotamine mesylate CHANGE UM: QUANTITY 8 / 30 days e mesylate 04/23/2020 HIZENTRA immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)/proline/iga 0 to 50 mcg/ml 04/23/2020 HIZENTRA immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)/proline/iga 0 to 50 mcg/ml 04/23/2020 HIZENTRA immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)/proline/iga 0 to 50 mcg/ml 04/23/2020 k-tab er potassium chloride CHANGE TIER Non-Preferred Non-Preferred Brands Generics 04/24/2020 folic acid folic acid ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 95 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 sodium fluoride fluoride (sodium) REMOVE FROM Non-Formulary FORMULARY 04/24/2020 nicardipine hcl- nicardipine in sodium ADD TO FORMULARY Injectables 0.9% nacl chloride, iso-osmotic 04/24/2020 nicardipine hcl- nicardipine in sodium ADD TO FORMULARY Injectables 0.9% nacl chloride, iso-osmotic 04/24/2020 epinephrine-0.9% epinephrine hcl in 0.9 % ADD TO FORMULARY Injectables nacl sodium chloride 04/24/2020 hydrocortisone- hydrocortisone REMOVE FROM Non-Formulary pramoxine acetate/pramoxine hcl FORMULARY 04/24/2020 sodium chloride sodium chloride irrigating REMOVE FROM Non-Formulary solution FORMULARY 04/24/2020 hydrocortisone- hydrocortisone REMOVE FROM Non-Formulary pramoxine acetate/pramoxine hcl FORMULARY 04/24/2020 potassium potassium chloride in water REMOVE FROM Non-Formulary chloride for injection, sterile FORMULARY 04/24/2020 sodium sodium bicarbonate REMOVE FROM Non-Formulary bicarbonate FORMULARY 04/24/2020 niacinamide niacinamide REMOVE FROM Non-Formulary FORMULARY 04/24/2020 scandishake REMOVE FROM Non-Formulary FORMULARY 04/24/2020 sodium fluoride fluoride (sodium) REMOVE FROM Non-Formulary FORMULARY 04/24/2020 vitamin b folic acid/vitamin b complex REMOVE FROM Non-Formulary complex-vitamin and vitamin c FORMULARY c 04/24/2020 NEXAVIR liver extract (beef-pork) REMOVE FROM Non-Formulary FORMULARY 04/24/2020 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 96 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 04/24/2020 aller-tec d cetirizine REMOVE FROM Non-Formulary hcl/pseudoephedrine hcl FORMULARY 04/24/2020 all day allergy-d cetirizine REMOVE FROM Non-Formulary hcl/pseudoephedrine hcl FORMULARY 04/24/2020 sodium chloride sodium chloride REMOVE FROM Non-Formulary FORMULARY 04/24/2020 testosterone testosterone REMOVE FROM Non-Formulary FORMULARY 04/24/2020 autolet lancing lancing device REMOVE FROM Non-Formulary device FORMULARY 04/24/2020 ESOMEPRAZOL esomeprazole strontium REMOVE FROM Non-Formulary E STRONTIUM FORMULARY 04/24/2020 MUCINEX FAST- diphenhydramine REMOVE FROM Non-Formulary MAX NITE hcl/phenylephrine FORMULARY COLD-FLU hcl/acetaminophen 04/24/2020 mucinex sinus- oxymetazoline hcl REMOVE FROM Non-Formulary max FORMULARY 04/24/2020 AKOVAZ ephedrine sulfate REMOVE FROM Non-Formulary FORMULARY 04/24/2020 MUCINEX FAST- phenylephrine REMOVE FROM Non-Formulary MAX COLD-FLU hcl/dextromethorphan FORMULARY hbr/acetaminophen/guaifen 04/24/2020 MUCINEX FAST- phenylephrine REMOVE FROM Non-Formulary MAX COLD-FLU hcl/dextromethorphan FORMULARY hbr/acetaminophen/guaifen 04/24/2020 gojji multi- blood ketone and glucose REMOVE FROM Non-Formulary functional meter monitor FORMULARY 04/24/2020 gojji multi- blood ketone and glucose REMOVE FROM Non-Formulary functional meter monitor FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 97 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 bpco balsam peru/castor oil REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 98 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 easypoint needle needles, safety REMOVE FROM Non-Formulary FORMULARY 04/24/2020 enovatizer ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 04/24/2020 unifine pentips pen needle, diabetic REMOVE FROM Non-Formulary plus FORMULARY 04/24/2020 triprolidine hcl triprolidine hcl REMOVE FROM Non-Formulary FORMULARY 04/24/2020 saccharomyces saccharomyces boulardii REMOVE FROM Non-Formulary boulardii FORMULARY 04/24/2020 nasal pseudoephedrine hcl REMOVE FROM Non-Formulary decongestant FORMULARY 04/24/2020 calcium calcium carbonate REMOVE FROM Non-Formulary FORMULARY 04/24/2020 SYSTANE propylene REMOVE FROM Non-Formulary HYDRATION PF glycol/polyethylene glycol FORMULARY 400/pf 04/24/2020 NOURISH nutritional supplement/fiber REMOVE FROM Non-Formulary PEPTIDE FORMULARY 04/24/2020 LIQUID HOPE nutritional supplement/fiber REMOVE FROM Non-Formulary PEPTIDE FORMULARY 04/24/2020 ALAHIST D phenylephrine REMOVE FROM Non-Formulary hcl/pheniramine maleate FORMULARY 04/24/2020 KETO nutritional supplement/fiber REMOVE FROM Non-Formulary FORMULARY 04/24/2020 CHILD DELSYM diphenhydramine/phenyleph REMOVE FROM Non-Formulary COUGH PLUS rin/dextromethorph/acetamin FORMULARY DY-NT ophen/gg

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 99 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/24/2020 potassium potassium chloride in water ADD TO FORMULARY Non-Formulary Injectables chloride for injection, sterile 04/24/2020 sodium chloride 0.9 % sodium chloride ADD TO FORMULARY Injectables 04/24/2020 sodium chloride 0.9 % sodium chloride ADD TO FORMULARY Injectables 04/24/2020 dextrose in water dextrose 5 % in water ADD TO FORMULARY Injectables 04/24/2020 dextrose in water dextrose 5 % in water ADD TO FORMULARY Injectables 04/24/2020 norepinephrine norepinephrine bitartrate in ADD TO FORMULARY Injectables bitar-0.9% nacl 0.9 % sodium chloride 04/24/2020 AKOVAZ ephedrine sulfate ADD TO FORMULARY Non-Formulary Injectables 04/24/2020 AZESCHEW prenatal vitamins REMOVE FROM Non-Formulary no.165/ferrous fumarate/folic FORMULARY acid 04/24/2020 epinephrine-0.9% epinephrine hcl in 0.9 % REMOVE FROM Non-Formulary nacl sodium chloride FORMULARY 04/28/2020 cardene nicardipine in sodium CHANGE UM: MED Medical Drug i.v.,nicardipine chloride, iso-osmotic hcl-0.9% nacl 04/28/2020 cardene nicardipine in sodium CHANGE UM: MED Medical Drug i.v.,nicardipine chloride, iso-osmotic hcl-0.9% nacl 04/28/2020 TOBRAMYCIN tobramycin/nebulizer REMOVE FROM Injectables Non-Formulary FORMULARY 04/30/2020 ethacrynic acid ethacrynic acid CHANGE TIER Non-Preferred Generics

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 100 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

May, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 REYVOW lasmiditan succinate ADD UM: QUANTITY 4 / 30 days 05/01/2020 REYVOW lasmiditan succinate ADD UM: QUANTITY 4 / 30 days 05/01/2020 celebrex,celecoxi celecoxib REMOVE UM: QUANTITY b 05/01/2020 celebrex,celecoxi celecoxib REMOVE UM: QUANTITY b 05/01/2020 celebrex,celecoxi celecoxib REMOVE UM: QUANTITY b 05/01/2020 AYVAKIT avapritinib ADD TO FORMULARY Non-Preferred Specialty 05/01/2020 AYVAKIT avapritinib ADD TO FORMULARY Non-Preferred Specialty 05/01/2020 AYVAKIT avapritinib ADD TO FORMULARY Non-Preferred Specialty 05/01/2020 UBRELVY ubrogepant ADD UM: QUANTITY 8 / 30 days 05/01/2020 UBRELVY ubrogepant ADD UM: QUANTITY 8 / 30 days 05/01/2020 UBRELVY ubrogepant CHANGE UM: QUANTITY 8 / 30 days 10 / 30 days 05/01/2020 UBRELVY ubrogepant CHANGE UM: QUANTITY 8 / 30 days 10 / 30 days 05/01/2020 celebrex,celecoxi celecoxib REMOVE UM: QUANTITY b 05/01/2020 epinephrine epinephrine ADD TO FORMULARY Non-Preferred Generics 05/01/2020 anti-diarrheal loperamide hcl REMOVE FROM Non-Formulary FORMULARY 05/01/2020 nasal spray oxymetazoline hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 101 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 ketoconazole ketoconazole REMOVE FROM Non-Formulary FORMULARY 05/01/2020 ketoconazole ketoconazole REMOVE FROM Non-Formulary FORMULARY 05/01/2020 stool softener docusate sodium REMOVE FROM Non-Formulary FORMULARY 05/01/2020 dandruff pyrithione zinc REMOVE FROM Non-Formulary shampoo FORMULARY 05/01/2020 milk of magnesia magnesium hydroxide REMOVE FROM Non-Formulary FORMULARY 05/01/2020 ear wax removal carbamide peroxide REMOVE FROM Non-Formulary FORMULARY 05/01/2020 phentolamine phentolamine mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 05/01/2020 phentolamine phentolamine mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 05/01/2020 phentolamine phentolamine mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 05/01/2020 phentolamine phentolamine mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 05/01/2020 testosterone testosterone cypionate REMOVE FROM Non-Formulary cypionate FORMULARY 05/01/2020 ibuprofen ibuprofen REMOVE FROM Non-Formulary FORMULARY 05/01/2020 ibuprofen ibuprofen REMOVE FROM Non-Formulary FORMULARY 05/01/2020 mupirocin mupirocin calcium REMOVE FROM Non-Formulary FORMULARY 05/01/2020 mupirocin mupirocin calcium REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 102 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 caffeine citrate caffeine citrate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 zinc zinc gluconate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 nasal pseudoephedrine hcl REMOVE FROM Non-Formulary decongestant FORMULARY 05/01/2020 tamoxifen citrate tamoxifen citrate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 tamoxifen citrate tamoxifen citrate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 tamoxifen citrate tamoxifen citrate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 tamoxifen citrate tamoxifen citrate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 05/01/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 05/01/2020 4-aminopyridine dalfampridine REMOVE FROM Non-Formulary FORMULARY 05/01/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 nighttime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/acetaminophen/doxylam FORMULARY ine 05/01/2020 daytime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/phenylephrine FORMULARY hcl/acetaminophen 05/01/2020 tussin cf guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr/phenylephrine FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 103 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 chest congestion guaifenesin REMOVE FROM Non-Formulary relief FORMULARY 05/01/2020 children's allergy diphenhydramine hcl REMOVE FROM Non-Formulary relief FORMULARY 05/01/2020 children's allergy diphenhydramine hcl REMOVE FROM Non-Formulary relief FORMULARY 05/01/2020 butalbital- butalbital/acetaminophen/caf REMOVE FROM Non-Formulary acetaminophen- feine FORMULARY caffe 05/01/2020 nighttime severe diphenhydramine REMOVE FROM Non-Formulary cough-cold hcl/phenylephrine FORMULARY hcl/acetaminophen 05/01/2020 minocycline hcl minocycline hcl REMOVE FROM Non-Formulary er FORMULARY 05/01/2020 hydrocodone- hydrocodone REMOVE FROM Non-Formulary acetaminophen bitartrate/acetaminophen FORMULARY 05/01/2020 PROSOURCE TF amino acids/protein REMOVE FROM Non-Formulary hydrolysate FORMULARY 05/01/2020 ACNE benzoyl peroxide REMOVE FROM Non-Formulary MEDICATION FORMULARY 05/01/2020 ACNE benzoyl peroxide REMOVE FROM Non-Formulary MEDICATION FORMULARY 05/01/2020 mucus relief d guaifenesin/pseudoephedrin REMOVE FROM Non-Formulary e hcl FORMULARY 05/01/2020 mucus relief d guaifenesin/pseudoephedrin REMOVE FROM Non-Formulary e hcl FORMULARY 05/01/2020 unilet lancets lancets REMOVE FROM Non-Formulary FORMULARY 05/01/2020 clever choice inhaler,assist device with REMOVE FROM Non-Formulary holding chamber small mask FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 104 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 clever choice inhaler,assist device with REMOVE FROM Non-Formulary holding chamber medium mask FORMULARY 05/01/2020 clever choice inhaler,assist device with REMOVE FROM Non-Formulary holding chamber large mask FORMULARY 05/01/2020 polytoza silicone adhesive REMOVE FROM Non-Formulary FORMULARY 05/01/2020 aller-cort triamcinolone acetonide REMOVE FROM Non-Formulary FORMULARY 05/01/2020 calcium 500-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 05/01/2020 calcium 500-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 05/01/2020 omeprazole omeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 05/01/2020 zinc oxide zinc oxide REMOVE FROM Non-Formulary FORMULARY 05/01/2020 QUAD- l.acidophilus,paracasei/bifid REMOVE FROM Non-Formulary PROBIOTIC o animalis/strep FORMULARY thermophilus 05/01/2020 micafungin micafungin sodium ADD TO FORMULARY Injectables 05/01/2020 micafungin micafungin sodium ADD TO FORMULARY Injectables 05/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 05/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 05/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 05/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 105 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 05/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 05/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 05/01/2020 t:slim x2 control- subcutaneous insulin pump REMOVE FROM Non-Formulary iq FORMULARY 05/01/2020 t:slim x2 control- subcutaneous insulin pump REMOVE FROM Non-Formulary iq FORMULARY 05/01/2020 EMERPHED ephedrine sulfate REMOVE FROM Non-Formulary FORMULARY 05/01/2020 JELMYTO mitomycin REMOVE FROM Non-Formulary FORMULARY 05/06/2020 INSULIN insulin aspart protamine CHANGE TIER Non-Preferred Non-Preferred ASPART PROT- human/insulin aspart Generics Brands INSULN ASP 05/06/2020 INSULIN insulin aspart protamine CHANGE TIER Non-Preferred Non-Preferred ASPART PROT- human/insulin aspart Generics Brands INSULN ASP 05/06/2020 INSULIN insulin aspart CHANGE TIER Non-Preferred Non-Preferred ASPART Generics Brands 05/06/2020 INSULIN insulin aspart CHANGE TIER Non-Preferred Non-Preferred ASPART Generics Brands FLEXPEN 05/06/2020 INSULIN insulin aspart CHANGE TIER Non-Preferred Non-Preferred ASPART Generics Brands PENFILL

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 106 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/06/2020 TRUVADA emtricitabine/tenofovir ADD UM: CUSTOM ACA Eligible for disoproxil fumarate members not infected with HIV and are at higher risk of HIV infection 05/06/2020 tenofovir tenofovir disoproxil fumarate ADD UM: CUSTOM ACA Eligible for disoproxil members not fumarate infected with HIV and are at higher risk of HIV infection 05/06/2020 VIREAD tenofovir disoproxil fumarate ADD UM: CUSTOM ACA Eligible for members not infected with HIV and are at higher risk of HIV infection 05/06/2020 TRUVADA emtricitabine/tenofovir REMOVE UM: CUSTOM ACA Eligible for disoproxil fumarate members not infected with HIV and are at higher risk of HIV infection 05/06/2020 tenofovir tenofovir disoproxil fumarate REMOVE UM: CUSTOM ACA Eligible for disoproxil members not fumarate infected with HIV and are at higher risk of HIV infection 05/06/2020 VIREAD tenofovir disoproxil fumarate REMOVE UM: CUSTOM ACA Eligible for members not infected with HIV and are at higher risk of HIV infection

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 107 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/07/2020 amoxicillin er amoxicillin CHANGE TIER Non-Preferred Non-Preferred Brands Generics 05/07/2020 itraconazole itraconazole CHANGE TIER Non-Preferred Non-Preferred Brands Generics 05/07/2020 timolol maleate timolol maleate CHANGE TIER Non-Preferred Non-Preferred Brands Generics 05/07/2020 zileuton er zileuton CHANGE TIER Non-Preferred Non-Preferred Brands Generics 05/08/2020 klor-con m15 potassium chloride CHANGE TIER Non-Preferred Non-Preferred Generics Brands 05/08/2020 depo-estradiol estradiol cypionate CHANGE TIER Non-Preferred Non-Preferred Generics Brands 05/08/2020 PEPCID famotidine REMOVE FROM Non-Preferred Non-Formulary FORMULARY Brands 05/08/2020 pepcid famotidine CHANGE TIER Non-Preferred Preferred Brands Generics 05/08/2020 pepcid famotidine CHANGE TIER Non-Preferred Preferred Brands Generics 05/08/2020 HALOG REMOVE FROM Non-Formulary FORMULARY 05/08/2020 ibuprofen ibuprofen REMOVE FROM Non-Formulary FORMULARY 05/08/2020 ibuprofen ibuprofen REMOVE FROM Non-Formulary FORMULARY 05/08/2020 dihydroergotamin dihydroergotamine mesylate REMOVE FROM Non-Formulary e mesylate FORMULARY 05/08/2020 meclizine hcl meclizine hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 meclizine hcl meclizine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 108 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 meclizine hcl meclizine hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 meclizine hcl meclizine hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 dairy digestive lactase REMOVE FROM Non-Formulary FORMULARY 05/08/2020 isopropyl alcohol isopropyl alcohol REMOVE FROM Non-Formulary FORMULARY 05/08/2020 isopropyl alcohol isopropyl alcohol REMOVE FROM Non-Formulary FORMULARY 05/08/2020 hydrocortisone hydrocortisone REMOVE FROM Non-Formulary FORMULARY 05/08/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 05/08/2020 acid reducer famotidine REMOVE FROM Non-Formulary FORMULARY 05/08/2020 PEPCID AC famotidine REMOVE FROM Non-Formulary FORMULARY 05/08/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 05/08/2020 senna plus sennosides/docusate REMOVE FROM Non-Formulary sodium FORMULARY 05/08/2020 sleep aid doxylamine succinate REMOVE FROM Non-Formulary FORMULARY 05/08/2020 instant cold pack cold-hot pack REMOVE FROM Non-Formulary FORMULARY 05/08/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 05/08/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 109 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 heatwraps activated REMOVE FROM Non-Formulary charcoal/iron/sodium/water FORMULARY 05/08/2020 burn relief lidocaine/aloe vera REMOVE FROM Non-Formulary FORMULARY 05/08/2020 disulfiram disulfiram REMOVE FROM Non-Formulary FORMULARY 05/08/2020 disulfiram disulfiram REMOVE FROM Non-Formulary FORMULARY 05/08/2020 disulfiram disulfiram REMOVE FROM Non-Formulary FORMULARY 05/08/2020 MUCINEX D guaifenesin/pseudoephedrin REMOVE FROM Non-Formulary e hcl FORMULARY 05/08/2020 lubricant eye carboxymethylcellulose REMOVE FROM Non-Formulary drops sodium FORMULARY 05/08/2020 dairy relief lactase REMOVE FROM Non-Formulary FORMULARY 05/08/2020 anticoagulant sodium citrate REMOVE FROM Non-Formulary sodium citrate FORMULARY 05/08/2020 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 05/08/2020 wrist blood blood pressure test kit-wrist REMOVE FROM Non-Formulary pressure monitor FORMULARY 05/08/2020 nasal mist oxymetazoline hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 women's diaper,brief,adult, REMOVE FROM Non-Formulary underwear disposable FORMULARY 05/08/2020 cough drops menthol REMOVE FROM Non-Formulary FORMULARY 05/08/2020 a and d vitamins a and d/white REMOVE FROM Non-Formulary petrolatum/lanolin FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 110 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 ENFAMIL infant formula,soy,iron,lac- REMOVE FROM Non-Formulary PROSOBEE free/dha/arachidonic acid FORMULARY (ara) 05/08/2020 ENFAMIL infant formula,soy,iron,lac- REMOVE FROM Non-Formulary PROSOBEE free/dha/arachidonic acid FORMULARY (ara) 05/08/2020 nitrile exam gloves REMOVE FROM Non-Formulary gloves FORMULARY 05/08/2020 lubricant eye propylene REMOVE FROM Non-Formulary glycol/polyethylene glycol FORMULARY 400 05/08/2020 lubricant eye propylene REMOVE FROM Non-Formulary glycol/polyethylene glycol FORMULARY 400 05/08/2020 lubricant eye propylene glycol REMOVE FROM Non-Formulary drop FORMULARY 05/08/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 05/08/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 05/08/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 vardenafil hcl vardenafil hcl REMOVE FROM Non-Formulary FORMULARY 05/08/2020 NUFOLA pyridoxal REMOVE FROM Non-Formulary phosphate/levofolate FORMULARY calcium/mecobalamin/ala

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 111 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 05/08/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 05/08/2020 MULTIVITAMIN- b comp/c/folic acid/zinc REMOVE FROM Non-Formulary ZINC-STRESS sulfate/cupric sulfate/vitamin FORMULARY e ac 05/08/2020 CHILDREN'S guaifenesin/dextromethorph REMOVE FROM Non-Formulary MUCINEX an hbr/phenylephrine FORMULARY FREEFROM 05/08/2020 CEPACOL SORE dextromethorphan REMOVE FROM Non-Formulary THROAT- hbr/benzocaine FORMULARY COUGH 05/08/2020 heavy duty fabric benzalkonium chloride REMOVE FROM Non-Formulary antibac bndg FORMULARY 05/08/2020 copper compress arm brace REMOVE FROM Non-Formulary sleeve elbow FORMULARY 05/08/2020 cicasil gel-matrix pad dressing, REMOVE FROM Non-Formulary silicone FORMULARY 05/08/2020 finger injury kit finger splint REMOVE FROM Non-Formulary FORMULARY 05/08/2020 knee support leg brace REMOVE FROM Non-Formulary FORMULARY 05/08/2020 knee support leg brace REMOVE FROM Non-Formulary FORMULARY 05/08/2020 knee support leg brace REMOVE FROM Non-Formulary FORMULARY 05/08/2020 knee support leg brace REMOVE FROM Non-Formulary FORMULARY 05/08/2020 ankle support leg brace REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 112 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 wrist support arm brace REMOVE FROM Non-Formulary FORMULARY 05/08/2020 compression compression socks, x-large REMOVE FROM Non-Formulary socks FORMULARY 05/08/2020 compression compression socks, medium REMOVE FROM Non-Formulary socks FORMULARY 05/08/2020 clear bandages adhesive bandage REMOVE FROM Non-Formulary FORMULARY 05/08/2020 adhesive tape adhesive tape REMOVE FROM Non-Formulary FORMULARY 05/08/2020 daily acne wash REMOVE FROM Non-Formulary FORMULARY 05/08/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 05/08/2020 eczema care colloidal oatmeal REMOVE FROM Non-Formulary FORMULARY 05/08/2020 calcium citrate- calcium cit/vitamin REMOVE FROM Non-Formulary d3-magnesium d3/magnes ox/b6/zinc FORMULARY ox/copper/ 05/08/2020 cold and hot pain lidocaine/menthol REMOVE FROM Non-Formulary relief FORMULARY 05/08/2020 pain relief lidocaine REMOVE FROM Non-Formulary FORMULARY 05/08/2020 allergy- fexofenadine REMOVE FROM Non-Formulary congestion 12hr hcl/pseudoephedrine hcl FORMULARY 05/08/2020 merthiolate benzalkonium chloride REMOVE FROM Non-Formulary FORMULARY 05/08/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 113 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 05/08/2020 vitamin e oil vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 05/08/2020 antacid ultra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY 05/08/2020 ear drops for isopropyl alcohol in glycerin REMOVE FROM Non-Formulary swimmers FORMULARY 05/08/2020 anti-itch menthol/camphor REMOVE FROM Non-Formulary FORMULARY 05/08/2020 calcium citrate-vit calcium REMOVE FROM Non-Formulary d3 citrate/cholecalciferol FORMULARY (vitamin d3) 05/08/2020 calcium citrate-vit calcium REMOVE FROM Non-Formulary d3 citrate/cholecalciferol FORMULARY (vitamin d3) 05/08/2020 medicated foot menthol REMOVE FROM Non-Formulary FORMULARY 05/08/2020 iodine/sodium iodide REMOVE FROM Non-Formulary FORMULARY 05/08/2020 glycerin glycerin REMOVE FROM Non-Formulary FORMULARY 05/08/2020 senna plus sennosides/docusate REMOVE FROM Non-Formulary sodium FORMULARY 05/08/2020 dihydroergotamin dihydroergotamine mesylate ADD TO FORMULARY Non-Formulary Non-Preferred e mesylate Generics 05/08/2020 dihydroergotamin dihydroergotamine mesylate ADD TO FORMULARY Non-Preferred e mesylate Generics 05/08/2020 LORMATE mecobalamin/levomefolate REMOVE FROM Non-Formulary calcium/turmeric root extract FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 114 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/08/2020 NYMALIZE nimodipine REMOVE FROM Non-Formulary FORMULARY 05/08/2020 NYMALIZE nimodipine REMOVE FROM Non-Formulary FORMULARY 05/08/2020 DEFLUX dextranomer REMOVE FROM Non-Formulary microspheres/hyaluronate FORMULARY sodium in 0.9 % nacl 05/11/2020 abacavir abacavir sulfate CHANGE TIER Preferred Brands Non-Preferred Generics 05/14/2020 BETASERON interferon beta-1b CHANGE TIER Non-Preferred Preferred Specialty Specialty 05/16/2020 trivix triamcinolone REMOVE FROM Non-Formulary acetonide/dimethicone/silico FORMULARY ne, adhesive 05/16/2020 zionodil-100 lidocaine hcl REMOVE FROM Non-Formulary FORMULARY 05/16/2020 aspirin aspirin REMOVE FROM Non-Formulary FORMULARY 05/16/2020 aspirin aspirin REMOVE FROM Non-Formulary FORMULARY 05/16/2020 sodium chloride sodium chloride irrigating REMOVE FROM Non-Formulary solution FORMULARY 05/16/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 05/16/2020 magnesium oxide magnesium oxide REMOVE FROM Non-Formulary FORMULARY 05/16/2020 ear wax removal carbamide peroxide REMOVE FROM Non-Formulary FORMULARY 05/16/2020 sleep aid diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 115 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/16/2020 bisacodyl bisacodyl REMOVE FROM Non-Formulary FORMULARY 05/16/2020 TAGAMET HB cimetidine REMOVE FROM Non-Formulary FORMULARY 05/16/2020 vitamin b-6 pyridoxine hcl (vitamin b6) REMOVE FROM Non-Formulary FORMULARY 05/16/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 05/16/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 05/16/2020 docusate sodium docusate sodium REMOVE FROM Non-Formulary FORMULARY 05/16/2020 oyster shell calcium carbonate REMOVE FROM Non-Formulary calcium FORMULARY 05/16/2020 allergy relief loratadine REMOVE FROM Non-Formulary FORMULARY 05/16/2020 allergy relief loratadine REMOVE FROM Non-Formulary FORMULARY 05/16/2020 midazolam midazolam REMOVE FROM Non-Formulary FORMULARY 05/16/2020 midazolam midazolam REMOVE FROM Non-Formulary FORMULARY 05/16/2020 midazolam midazolam REMOVE FROM Non-Formulary FORMULARY 05/16/2020 midazolam midazolam REMOVE FROM Non-Formulary FORMULARY 05/16/2020 acid reducer famotidine REMOVE FROM Non-Formulary FORMULARY 05/16/2020 glucosamine glucosamine hcl/chondroitin REMOVE FROM Non-Formulary chondroitin sulf a/vitamin FORMULARY c/manganese/boron

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 116 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/16/2020 sinus congestion- phenylephrine REMOVE FROM Non-Formulary pain hcl/acetaminophen FORMULARY 05/16/2020 diclofenac diclofenac epolamine REMOVE FROM Non-Formulary epolamine FORMULARY 05/16/2020 self-adherent elastic bandage REMOVE FROM Non-Formulary gentle wrap FORMULARY 05/16/2020 sominex diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 05/16/2020 allergy relief cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 05/16/2020 cleansing eyelid eyelid cleanser combination REMOVE FROM Non-Formulary wipes no.8 FORMULARY 05/16/2020 probiotic formula bacillus coagulans/inulin REMOVE FROM Non-Formulary FORMULARY 05/16/2020 triprolidine hcl triprolidine hcl REMOVE FROM Non-Formulary FORMULARY 05/16/2020 nighttime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/acetaminophen/doxylam FORMULARY ine 05/16/2020 MUCINEX FAST- guaifenesin/dextromethorph REMOVE FROM Non-Formulary MAX CONGEST- an hbr/phenylephrine FORMULARY COUGH 05/16/2020 vitamin c fizzy ascorbic acid/multivit with REMOVE FROM Non-Formulary drink minerals FORMULARY 05/16/2020 GONITRO nitroglycerin REMOVE FROM Non-Formulary FORMULARY 05/16/2020 GONITRO nitroglycerin REMOVE FROM Non-Formulary FORMULARY 05/16/2020 QUZYTTIR cetirizine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 117 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/16/2020 premier urostomy urostomy pouch REMOVE FROM Non-Formulary pouch FORMULARY 05/16/2020 rolled gauze gauze bandage REMOVE FROM Non-Formulary FORMULARY 05/16/2020 reusable hot-cold cold-hot pack REMOVE FROM Non-Formulary compress FORMULARY 05/16/2020 reusable hot-cold cold-hot pack REMOVE FROM Non-Formulary wrap FORMULARY 05/16/2020 CHILD MUCINEX phenylephrine REMOVE FROM Non-Formulary FREEFROM DY hcl/dextromethorphan FORMULARY COLD hbr/acetaminophen/guaifen 05/16/2020 MUCINEX FAST- guaifenesin/phenylephrine REMOVE FROM Non-Formulary MAX CONG- hcl/acetaminophen FORMULARY HEADACHE 05/16/2020 MUCINEX diphenhydramine REMOVE FROM Non-Formulary SINUS-MAX hcl/phenylephrine/acetamino FORMULARY DAY-NIGHT phen/guaifenesin 05/16/2020 DELSYM diphenhydramine/phenyleph REMOVE FROM Non-Formulary COUGH PLUS rin/dextromethorph/acetamin FORMULARY DAY-NIGHT ophen/gg 05/16/2020 CHILD MUCINEX triprolidine REMOVE FROM Non-Formulary FREEFROM NT hcl/phenylephrine/dextromet FORMULARY COLD horphn/acetaminophen 05/16/2020 ULTIMATE b. breve/b. bifidum/b. REMOVE FROM Non-Formulary FLORA BABY infantis/b. longum/l. FORMULARY PROBIOTIC rhamnosus 05/16/2020 MUCINEX triprolidine/phenylephrine/de REMOVE FROM Non-Formulary SINUS-MAX xtromethorph/acetamin/guaif FORMULARY NIGHTSHIFT enes 05/16/2020 MUCINEX FAST- triprolidine/phenylephrine/de REMOVE FROM Non-Formulary MX CONG- xtromethorph/acetamin/guaif FORMULARY NIGHTSHFT enes

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 118 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/16/2020 daytime cold-flu dextromethorphan REMOVE FROM Non-Formulary relief hbr/phenylephrine FORMULARY hcl/acetaminophen 05/16/2020 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 05/16/2020 calcium-vitamin calcium phosphate, REMOVE FROM Non-Formulary d3 tribasic/cholecalciferol FORMULARY (vitamin d3) 05/16/2020 glucosa factor alpha lipoic acid/herbal REMOVE FROM Non-Formulary complex no.305 FORMULARY 05/16/2020 lidocaine pain lidocaine REMOVE FROM Non-Formulary relief FORMULARY 05/16/2020 child mucinex guaifenesin/dextromethorph REMOVE FROM Non-Formulary freefrom day cgh an hbr FORMULARY 05/16/2020 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Preventative 05/16/2020 robitussin cough- acetaminophen/dextrometho REMOVE FROM Non-Formulary sore throat rphan hbr FORMULARY 05/16/2020 percogesic magnesium salicylate REMOVE FROM Non-Formulary backache relief FORMULARY 05/16/2020 sodium chloride sodium chloride 0.45 % ADD TO FORMULARY Injectables 05/16/2020 dextrose 5%- dextrose 5 % and 0.2 % ADD TO FORMULARY Injectables 0.225% nacl sodium chloride 05/16/2020 diclofenac diclofenac epolamine ADD TO FORMULARY Non-Formulary Non-Preferred epolamine Generics 05/16/2020 BASADROX silver REMOVE FROM Non-Formulary FORMULARY 05/19/2020 MACRILEN macimorelin acetate ADD TO FORMULARY Non-Formulary Injectables 05/19/2020 MACRILEN macimorelin acetate ADD UM: MED Medical Drug 05/22/2020 zionodil lidocaine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 119 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 equacare jr nutritional therapy for REMOVE FROM Non-Formulary impaired digestive function FORMULARY 05/22/2020 equacare jr nutritional therapy for REMOVE FROM Non-Formulary impaired digestive function FORMULARY 05/22/2020 equacare jr nutritional therapy for REMOVE FROM Non-Formulary impaired digestive function FORMULARY 05/22/2020 equacare jr nutritional therapy for REMOVE FROM Non-Formulary impaired digestive function FORMULARY 05/22/2020 equacare jr nutritional therapy for REMOVE FROM Non-Formulary impaired digestive function FORMULARY 05/22/2020 equacare jr nutritional therapy for REMOVE FROM Non-Formulary impaired digestive function FORMULARY 05/22/2020 penicillamine penicillamine REMOVE FROM Non-Formulary FORMULARY 05/22/2020 isopropyl rubbing isopropyl alcohol REMOVE FROM Non-Formulary alcohol FORMULARY 05/22/2020 oyster shell calcium carbonate REMOVE FROM Non-Formulary calcium FORMULARY 05/22/2020 oyster shell calcium carbonate REMOVE FROM Non-Formulary calcium FORMULARY 05/22/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 05/22/2020 INSULIN LISPRO insulin lispro REMOVE FROM Non-Formulary FORMULARY 05/22/2020 nasal pseudoephedrine hcl REMOVE FROM Non-Formulary decongestant FORMULARY 05/22/2020 INSULIN LISPRO insulin lispro REMOVE FROM Non-Formulary KWIKPEN U-100 FORMULARY 05/22/2020 sleep aid diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 120 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 miconazole 3 miconazole nitrate REMOVE FROM Non-Formulary FORMULARY 05/22/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 05/22/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 05/22/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 05/22/2020 allergy relief-d cetirizine REMOVE FROM Non-Formulary hcl/pseudoephedrine hcl FORMULARY 05/22/2020 dexamethasone dexamethasone REMOVE FROM Non-Formulary FORMULARY 05/22/2020 sodium hyaluronate sodium REMOVE FROM Non-Formulary hyaluronate FORMULARY 05/22/2020 sodium hyaluronate sodium REMOVE FROM Non-Formulary hyaluronate FORMULARY 05/22/2020 sodium hyaluronate sodium REMOVE FROM Non-Formulary hyaluronate FORMULARY 05/22/2020 sodium hyaluronate sodium REMOVE FROM Non-Formulary hyaluronate FORMULARY 05/22/2020 levocetirizine levocetirizine REMOVE FROM Non-Formulary dihydrochloride dihydrochloride FORMULARY 05/22/2020 sleep aid diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 05/22/2020 sleep aid diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 05/22/2020 severe cold-flu phenylephrine REMOVE FROM Non-Formulary hcl/dextromethorphan FORMULARY hbr/acetaminophen/guaifen 05/22/2020 reguloid psyllium husk REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 121 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 CEPACOL SORE benzocaine/menthol REMOVE FROM Non-Formulary THROAT FORMULARY 05/22/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 05/22/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 05/22/2020 PKU SPHERE20 nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria (pku) no.67 FORMULARY 05/22/2020 aminolevulinic aminolevulinic acid hcl REMOVE FROM Non-Formulary acid hcl FORMULARY 05/22/2020 fish oil omega-3 fatty REMOVE FROM Non-Formulary acids/docosahexaenoic FORMULARY acid/epa/fish oil 05/22/2020 premier urostomy urostomy pouch REMOVE FROM Non-Formulary pouch FORMULARY 05/22/2020 percogesic magnesium salicylate REMOVE FROM Non-Formulary backache relief FORMULARY 05/22/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE FROM Non-Formulary -0.9% nacl % sodium chloride FORMULARY 05/22/2020 urinary pain relief phenazopyridine hcl REMOVE FROM Non-Formulary FORMULARY 05/22/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 05/22/2020 multivitamin with multivitamin with REMOVE FROM Non-Formulary minerals minerals/ferrous fumarate FORMULARY 05/22/2020 medicated selenium sulfide REMOVE FROM Non-Formulary dandruff FORMULARY shampoo 05/22/2020 calcium 500-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 122 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 loperamide hcl loperamide hcl REMOVE FROM Non-Formulary FORMULARY 05/22/2020 loperamide hcl loperamide hcl REMOVE FROM Non-Formulary FORMULARY 05/22/2020 allergy relief d-12 loratadine/pseudoephedrine REMOVE FROM Non-Formulary sulfate FORMULARY 05/22/2020 allergy relief d-12 loratadine/pseudoephedrine REMOVE FROM Non-Formulary sulfate FORMULARY 05/22/2020 ENSURE CLEAR nutritional therapy for REMOVE FROM Non-Formulary THERAPEUTIC impaired digestive function FORMULARY 05/22/2020 PKU SPHERE15 nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria (pku) no.67 FORMULARY 05/22/2020 PKU SPHERE15 nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria (pku) no.67 FORMULARY 05/22/2020 VITABEX IRON iron REMOVE FROM Non-Formulary bisglycinate/c/methylfolate/b FORMULARY 12/l. acidoph,plant/inulin 05/22/2020 glucosa immune herbal complex no.306 REMOVE FROM Non-Formulary booster FORMULARY 05/22/2020 tolvaptan tolvaptan ADD TO FORMULARY Non-Preferred Specialty 05/22/2020 JYNARQUE tolvaptan ADD TO FORMULARY Non-Preferred Specialty 05/22/2020 JYNARQUE tolvaptan ADD TO FORMULARY Non-Preferred Specialty 05/22/2020 DILAUDID hydromorphone hcl/pf REMOVE FROM Non-Formulary FORMULARY 05/22/2020 BOTRYTIS allergenic extract-botrytis REMOVE FROM Non-Formulary CINEREA cinerea FORMULARY 05/22/2020 BOTRYTIS allergenic extract-botrytis REMOVE FROM Non-Formulary CINEREA cinerea FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 123 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/22/2020 OSMOLEX ER amantadine hcl ADD TO FORMULARY Non-Preferred Brands 05/30/2020 FOSAMPRENAV fosamprenavir calcium ADD TO FORMULARY Preferred Brands IR CALCIUM 05/30/2020 metaxalone metaxalone REMOVE FROM Non-Formulary FORMULARY 05/30/2020 methylprednisolo methylprednisolone acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY 05/30/2020 methylprednisolo methylprednisolone acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY 05/30/2020 methylprednisolo methylprednisolone acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY 05/30/2020 methylprednisolo methylprednisolone acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY 05/30/2020 methylprednisolo methylprednisolone acetate, REMOVE FROM Non-Formulary ne ac micro micronized FORMULARY 05/30/2020 eye drops tetrahydrozoline hcl REMOVE FROM Non-Formulary FORMULARY 05/30/2020 lansoprazole lansoprazole REMOVE FROM Non-Formulary FORMULARY 05/30/2020 lansoprazole lansoprazole REMOVE FROM Non-Formulary FORMULARY 05/30/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 05/30/2020 edetate calcium edetate calcium disodium REMOVE FROM Non-Formulary disodium FORMULARY 05/30/2020 edetate calcium edetate calcium disodium REMOVE FROM Non-Formulary disodium FORMULARY 05/30/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 124 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/30/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 05/30/2020 pen needle pen needle, diabetic REMOVE FROM Non-Formulary FORMULARY 05/30/2020 7-keto dhea 7- REMOVE FROM Non-Formulary oxodehydroepiandrosterone, FORMULARY micronized 05/30/2020 CARVEDILOL carvedilol phosphate ADD TO FORMULARY Non-Preferred ER Brands 05/30/2020 CARVEDILOL carvedilol phosphate ADD TO FORMULARY Non-Preferred ER Brands 05/30/2020 SUPLENA CARB nutritional therapy, impaired REMOVE FROM Non-Formulary STEADY renal function,lactose- FORMULARY reduced 05/30/2020 finasteride REMOVE FROM Non-Formulary FORMULARY 05/30/2020 tutti frutti flavor tutti-frutti flavor REMOVE FROM Non-Formulary FORMULARY 05/30/2020 tutti frutti flavor tutti-frutti flavor REMOVE FROM Non-Formulary FORMULARY 05/30/2020 tutti frutti flavor tutti-frutti flavor REMOVE FROM Non-Formulary FORMULARY 05/30/2020 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 05/30/2020 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 05/30/2020 a and d vitamins a and d/white REMOVE FROM Non-Formulary petrolatum/lanolin FORMULARY 05/30/2020 robitussin cough- guaifenesin/dextromethorph REMOVE FROM Non-Formulary chest-cong dm an hbr FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 125 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/30/2020 alcohol wipes alcohol antiseptic pads REMOVE FROM Non-Formulary FORMULARY 05/30/2020 lmc lidocaine/methyl REMOVE FROM Non-Formulary salicylate/camphor FORMULARY 05/30/2020 children's allergy loratadine REMOVE FROM Non-Formulary relief FORMULARY 05/30/2020 MUCINEX FAST- triprolidine REMOVE FROM Non-Formulary MAX DM hcl/dextromethorphan/aceta FORMULARY NIGHTSHIFT minophen/guaifenesin 05/30/2020 DIGESTIVE bacillus coagulans/calcium REMOVE FROM Non-Formulary ADVANTAGE carbonate FORMULARY PROBIOTIC 05/30/2020 ALKALOL menthol/eucal/thymol/camph REMOVE FROM Non-Formulary NASAL WASH or/benz/sod chloride/pot FORMULARY chlorate 05/30/2020 TYR SPHERE20 nutritional therapy for REMOVE FROM Non-Formulary tyrosinemia with iron FORMULARY 05/30/2020 transparent transparent dressing REMOVE FROM Non-Formulary mepitel film dress FORMULARY 05/30/2020 hand sanitizer ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 05/30/2020 butterfly closures adhesive tape REMOVE FROM Non-Formulary FORMULARY 05/30/2020 OVEEZA folic REMOVE FROM Non-Formulary acid/b12/ala/ubiquinone/om FORMULARY ega-3/dha/epa 05/30/2020 DICLOVIX M diclofenac REMOVE FROM Non-Formulary sodium/menthol/kinesiology FORMULARY tape 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 126 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY 05/30/2020 ESSENTIAL nut.tx.impaired digest REMOVE FROM Non-Formulary CARE JR fxn/fiber FORMULARY 05/30/2020 rocuronium rocuronium bromide ADD TO FORMULARY Injectables bromide 05/30/2020 rocuronium rocuronium bromide ADD TO FORMULARY Injectables bromide 05/30/2020 chlorothiazide chlorothiazide sodium ADD TO FORMULARY Injectables sodium 05/30/2020 phenylephrine hcl phenylephrine hcl ADD TO FORMULARY Injectables 05/30/2020 phenylephrine hcl phenylephrine hcl ADD TO FORMULARY Injectables 05/30/2020 phenylephrine hcl phenylephrine hcl ADD TO FORMULARY Injectables 05/30/2020 ZEVALIN kit for prep yttrium- ADD TO FORMULARY Injectables 90/ibritumomab tiuxetan/albumin human 05/30/2020 fulvestrant fulvestrant ADD TO FORMULARY Injectables 05/30/2020 tolvaptan tolvaptan REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 127 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/30/2020 fosaprepitant fosaprepitant dimeglumine ADD TO FORMULARY Injectables dimeglumine 05/30/2020 fosaprepitant fosaprepitant dimeglumine ADD TO FORMULARY Injectables dimeglumine 05/30/2020 MARQIBO vincristine sulfate liposomal ADD TO FORMULARY Injectables 05/30/2020 succinylcholine succinylcholine chloride in ADD TO FORMULARY Injectables chloride-nacl sodium chloride,iso- osmotic/pf 05/30/2020 tolvaptan tolvaptan ADD TO FORMULARY Non-Formulary Non-Preferred Specialty 05/30/2020 SOVALDI sofosbuvir ADD TO FORMULARY Preferred Specialty 05/30/2020 SOVALDI sofosbuvir ADD TO FORMULARY Preferred Specialty 05/30/2020 HARVONI ledipasvir/sofosbuvir ADD TO FORMULARY Preferred Specialty 05/30/2020 HARVONI ledipasvir/sofosbuvir ADD TO FORMULARY Preferred Specialty 05/30/2020 CLADOSPORIU allergenic extract- REMOVE FROM Non-Formulary M cladosporium FORMULARY CLADOSPORIOI cladosporioides DES 05/30/2020 CLADOSPORIU allergenic extract- REMOVE FROM Non-Formulary M cladosporium FORMULARY CLADOSPORIOI cladosporioides DES 05/30/2020 AVSOLA infliximab-axxq ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 128 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

June, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2020 GIVLAARI givosiran sodium ADD TO FORMULARY Preferred Specialty 06/01/2020 MENOPUR menotropins ADD UM: SPECIALTY Specialty Drug 06/01/2020 TANZEUM albiglutide REMOVE UM: QUANTITY 4 / 28 days 06/01/2020 GONAL-F RFF follitropin alfa, recombinant ADD UM: SPECIALTY Specialty Drug REDI-JECT 06/01/2020 OVIDREL choriogonadotropin alfa ADD UM: SPECIALTY Specialty Drug 06/01/2020 GONAL-F RFF follitropin alfa, recombinant ADD UM: SPECIALTY Specialty Drug 06/01/2020 FOLLISTIM AQ follitropin beta,recombinant ADD UM: SPECIALTY Specialty Drug 06/01/2020 FOLLISTIM AQ follitropin beta,recombinant ADD UM: SPECIALTY Specialty Drug 06/01/2020 GONAL-F follitropin alfa, recombinant ADD UM: SPECIALTY Specialty Drug 06/01/2020 GONAL-F follitropin alfa, recombinant ADD UM: SPECIALTY Specialty Drug 06/01/2020 GONAL-F RFF follitropin alfa, recombinant ADD UM: SPECIALTY Specialty Drug REDI-JECT 06/01/2020 GONAL-F RFF follitropin alfa, recombinant ADD UM: SPECIALTY Specialty Drug REDI-JECT 06/01/2020 TRUVADA emtricitabine/tenofovir ADD UM: CUSTOM ACA Eligible for disoproxil fumarate members not infected with HIV and are at higher risk of HIV infection 06/01/2020 tenofovir tenofovir disoproxil fumarate ADD UM: CUSTOM ACA Eligible for disoproxil members not fumarate infected with HIV and are at higher risk of HIV infection

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 129 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2020 VIREAD tenofovir disoproxil fumarate ADD UM: CUSTOM ACA Eligible for members not infected with HIV and are at higher risk of HIV infection 06/01/2020 ZOHYDRO ER hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/01/2020 ZOHYDRO ER hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/01/2020 ZOHYDRO ER hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/01/2020 ZOHYDRO ER hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/01/2020 ZOHYDRO ER hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/01/2020 ZOHYDRO ER hydrocodone bitartrate ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/01/2020 PADCEV enfortumab vedotin-ejfv ADD UM: MED Medical Drug 06/01/2020 PADCEV enfortumab vedotin-ejfv ADD UM: MED Medical Drug 06/01/2020 ENHERTU fam-trastuzumab ADD UM: MED Medical Drug deruxtecan-nxki 06/01/2020 QUZYTTIR cetirizine hcl ADD UM: MED Medical Drug 06/01/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: MED Medical Drug rec, b-dom truncated peg- exei 06/01/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: MED Medical Drug rec, b-dom truncated peg- exei

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 130 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: MED Medical Drug rec, b-dom truncated peg- exei 06/01/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: MED Medical Drug rec, b-dom truncated peg- exei 06/01/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: MED Medical Drug rec, b-dom truncated peg- exei 06/01/2020 EZALLOR rosuvastatin calcium ADD UM: MED Medical Drug SPRINKLE 06/01/2020 sprix,ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 5 / 30 days tromethamine 06/01/2020 TANZEUM albiglutide REMOVE UM: QUANTITY 4 / 28 days 06/01/2020 pancrelipase lipase/protease/amylase REMOVE FROM Non-Preferred Non-Formulary 5,000 FORMULARY Generics 06/01/2020 AIMOVIG erenumab-aooe ADD TO FORMULARY Non-Formulary Preferred Brands AUTOINJECTOR 06/01/2020 AIMOVIG erenumab-aooe ADD TO FORMULARY Non-Formulary Preferred Brands AUTOINJECTOR 06/01/2020 AIMOVIG erenumab-aooe ADD TO FORMULARY Non-Formulary Preferred Brands AUTOINJECTOR (2 PACK) 06/01/2020 EMGALITY PEN galcanezumab-gnlm ADD TO FORMULARY Preferred Brands 06/01/2020 EMGALITY galcanezumab-gnlm ADD TO FORMULARY Non-Formulary Preferred Brands SYRINGE 06/01/2020 EMGALITY galcanezumab-gnlm ADD TO FORMULARY Non-Formulary Preferred Brands SYRINGE 06/01/2020 VYONDYS-53 golodirsen ADD UM: MED Medical Drug 06/01/2020 OXBRYTA voxelotor ADD UM: QUANTITY 3 / 1 DAY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 131 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2020 OXBRYTA voxelotor ADD UM: SPECIALTY Specialty Drug 06/01/2020 VALTOCO diazepam ADD TO FORMULARY Non-Preferred Brands 06/01/2020 VALTOCO diazepam ADD UM: QUANTITY 2 / 30 days 06/01/2020 VALTOCO diazepam ADD TO FORMULARY Non-Preferred Brands 06/01/2020 VALTOCO diazepam ADD UM: QUANTITY 2 / 30 days 06/01/2020 VALTOCO diazepam ADD TO FORMULARY Non-Preferred Brands 06/01/2020 VALTOCO diazepam ADD UM: QUANTITY 2 / 30 days 06/01/2020 VALTOCO diazepam ADD TO FORMULARY Non-Preferred Brands 06/01/2020 VALTOCO diazepam ADD UM: QUANTITY 2 / 30 days 06/01/2020 CAPLYTA lumateperone tosylate ADD TO FORMULARY Non-Preferred Brands 06/01/2020 butorphanol butorphanol tartrate CHANGE UM: QUANTITY 2.5 / 30 days 5 / 30 days tartrate 06/01/2020 butorphanol butorphanol tartrate CHANGE UM: QUANTITY 2.5 / 30 days 5 / 30 days tartrate,stadol ns 06/01/2020 midazolam hcl midazolam hcl/pf CHANGE TIER Injectables Non-Preferred Generics 06/01/2020 midazolam hcl midazolam hcl/pf REMOVE UM: MED Medical Drug 06/01/2020 midazolam hcl midazolam hcl/pf CHANGE TIER Injectables Non-Preferred Generics 06/01/2020 midazolam hcl midazolam hcl/pf REMOVE UM: MED Medical Drug 06/01/2020 midazolam hcl midazolam hcl/pf CHANGE TIER Injectables Non-Preferred Generics 06/01/2020 midazolam hcl midazolam hcl/pf REMOVE UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 132 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2020 midazolam hcl midazolam hcl CHANGE TIER Injectables Non-Preferred Generics 06/01/2020 midazolam hcl midazolam hcl REMOVE UM: MED Medical Drug 06/01/2020 midazolam hcl midazolam hcl CHANGE TIER Non-Preferred Generics 06/01/2020 midazolam hcl midazolam hcl REMOVE UM: MED Medical Drug 06/01/2020 midazolam hcl midazolam hcl/pf CHANGE TIER Injectables Non-Preferred Generics 06/01/2020 midazolam hcl midazolam hcl/pf REMOVE UM: MED Medical Drug 06/01/2020 midazolam hcl midazolam hcl/pf CHANGE TIER Injectables Non-Preferred Generics 06/01/2020 midazolam hcl midazolam hcl/pf REMOVE UM: MED Medical Drug 06/01/2020 camptosar,irinote irinotecan hcl CHANGE UM: MED Medical Drug can hcl 06/03/2020 mycamine,micafu micafungin sodium CHANGE UM: MED Medical Drug ngin 06/03/2020 mycamine,micafu micafungin sodium CHANGE UM: MED Medical Drug ngin 06/03/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 DAY xr,methylphenidat e er 06/03/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 DAY xr,methylphenidat e er 06/03/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 DAY xr,methylphenidat e er 06/03/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 DAY xr,methylphenidat e er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 133 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/03/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 DAY xr,methylphenidat e er 06/03/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 DAY xr,methylphenidat e er 06/03/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 DAY xr,methylphenidat e er 06/04/2020 estropipate estropipate REMOVE FROM Preferred Non-Formulary FORMULARY Generics 06/04/2020 pregnyl,novarel,c chorionic gonadotropin, ADD UM: MED Medical Drug horionic human gonadotropin,a.p. l.,chorigon,chorex -10,choron 10,gonadojec,go nic,profasi 06/04/2020 FOLLISTIM AQ follitropin beta,recombinant ADD UM: MED Medical Drug 06/04/2020 FOLLISTIM AQ follitropin beta,recombinant ADD UM: MED Medical Drug 06/04/2020 FOLLISTIM AQ follitropin beta,recombinant ADD UM: SPECIALTY Specialty Drug 06/04/2020 FOLLISTIM AQ follitropin beta,recombinant ADD UM: MED Medical Drug 06/04/2020 ganirelix ganirelix acetate ADD UM: MED Medical Drug acetate,antagon

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 134 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/04/2020 episnap,epy,adyp epinephrine CHANGE UM: MED Medical Drug hren,adyphren amp,epinephrine snap- v,epinephrinesna p- ems,epinephrine professional kit,epinephrine professional ems 06/04/2020 OVIDREL choriogonadotropin alfa ADD UM: MED Medical Drug 06/04/2020 GONAL-F follitropin alfa, ADD UM: MED Medical Drug RFF,GONAL-F recomb,follitropin alfa, RFF REDI-JECT recombinant 06/04/2020 GONAL-F follitropin alfa, ADD UM: MED Medical Drug RFF,GONAL-F recomb,follitropin alfa, RFF REDI-JECT recombinant 06/04/2020 GONAL-F follitropin alfa, ADD UM: MED Medical Drug RFF,GONAL-F recomb,follitropin alfa, RFF REDI-JECT recombinant 06/04/2020 GONAL-F RFF follitropin alfa, recombinant ADD UM: MED Medical Drug 06/04/2020 bretylium bretylium tosylate ADD UM: MED Medical Drug tosylate,bretylol 06/04/2020 hyoscyamine hyoscyamine sulfate ADD UM: MED Medical Drug sulfate 06/04/2020 a.p.l.,chorionic chorionic gonadotropin, ADD UM: MED Medical Drug gonadotropin,prof human asi,novarel 06/04/2020 MENOPUR menotropins ADD UM: MED Medical Drug 06/04/2020 BRAVELLE urofollitropin ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 135 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/04/2020 MIXED VESPID allergenic extract-venom- ADD UM: MED Medical Drug VENOM mixed vespid protein PROTEIN 06/04/2020 hydromorphone hydromorphone hcl in sterile ADD UM: MED Medical Drug hcl-water water/pf 06/04/2020 ketamine hcl- ketamine hcl in 0.9 % ADD UM: MED Medical Drug 0.9% nacl sodium chloride 06/04/2020 ketamine hcl- ketamine hcl in 0.9 % ADD UM: MED Medical Drug 0.9% nacl sodium chloride 06/04/2020 b-complex thiamine CHANGE UM: MED Medical Drug hcl/riboflavin/niacinamide/de xpanthenol/pyridoxine 06/04/2020 chorionic chorionic gonadotropin, ADD UM: MED Medical Drug gonadotropin human 06/04/2020 chorionic chorionic gonadotropin, ADD UM: MED Medical Drug gonadotropin human 06/06/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 06/06/2020 STOOL docusate sodium REMOVE FROM Non-Formulary SOFTENER FORMULARY 06/06/2020 senna sennosides REMOVE FROM Non-Formulary FORMULARY 06/06/2020 senna sennosides REMOVE FROM Non-Formulary FORMULARY 06/06/2020 senna sennosides REMOVE FROM Non-Formulary FORMULARY 06/06/2020 senna sennosides REMOVE FROM Non-Formulary FORMULARY 06/06/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 136 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/06/2020 MUSCLE RUB methyl salicylate/menthol REMOVE FROM Non-Formulary FORMULARY 06/06/2020 potassium potassium chloride REMOVE FROM Non-Formulary chloride FORMULARY 06/06/2020 triple antibiotic neomycin sulfate/bacitracin REMOVE FROM Non-Formulary zinc/polymyxin b FORMULARY 06/06/2020 vitamin c ascorbic acid REMOVE FROM Non-Formulary FORMULARY 06/06/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 06/06/2020 alprostadil alprostadil REMOVE FROM Non-Formulary FORMULARY 06/06/2020 senna laxative sennosides REMOVE FROM Non-Formulary FORMULARY 06/06/2020 gentle laxative bisacodyl REMOVE FROM Non-Formulary FORMULARY 06/06/2020 gentle laxative bisacodyl REMOVE FROM Non-Formulary FORMULARY 06/06/2020 gentle laxative bisacodyl REMOVE FROM Non-Formulary FORMULARY 06/06/2020 mitomycin mitomycin REMOVE FROM Non-Formulary FORMULARY 06/06/2020 mitomycin mitomycin REMOVE FROM Non-Formulary FORMULARY 06/06/2020 bacitracin zinc bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 06/06/2020 tussin cf guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr/phenylephrine FORMULARY 06/06/2020 premier drainable colostomy bags REMOVE FROM Non-Formulary pouch FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 137 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/06/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 06/06/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 06/06/2020 blood pressure blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 06/06/2020 blood pressure blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 06/06/2020 blood pressure blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 06/06/2020 vitamin a and d vitamins a and d/white REMOVE FROM Non-Formulary petrolatum/lanolin FORMULARY 06/06/2020 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 06/06/2020 minerin lanolin alcohols/mineral REMOVE FROM Non-Formulary oil/petrolatum,white/ceresin FORMULARY 06/06/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 06/06/2020 clonazepam clonazepam REMOVE FROM Non-Formulary FORMULARY 06/06/2020 COSAMIN glucosamine REMOVE FROM Non-Formulary AVOCA hcl/methylsulfonylmethane/b FORMULARY oswellia/herbal 182 06/06/2020 geri-dryl diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 06/06/2020 glucerna 1.2 cal nutritional tx. glucose REMOVE FROM Non-Formulary intolerance,lactose- FORMULARY free,soy/fiber 06/06/2020 hand sanitizer ethyl alcohol REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 138 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/06/2020 ear drops for isopropyl alcohol in glycerin REMOVE FROM Non-Formulary swimmers FORMULARY 06/06/2020 VENOFER iron sucrose complex REMOVE FROM Non-Formulary FORMULARY 06/06/2020 blue-emu lidocaine REMOVE FROM Non-Formulary lidocaine patch FORMULARY 06/06/2020 burn relief lidocaine hcl REMOVE FROM Non-Formulary FORMULARY 06/06/2020 eye health plus beta-carotene(a) w-c and REMOVE FROM Non-Formulary lutein e/lutein/minerals FORMULARY 06/06/2020 anti-diarrheal loperamide hcl REMOVE FROM Non-Formulary FORMULARY 06/06/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 06/06/2020 nighttime cough dextromethorphan REMOVE FROM Non-Formulary hbr/doxylamine succinate FORMULARY 06/06/2020 naproxen sodium naproxen sodium REMOVE FROM Non-Formulary FORMULARY 06/06/2020 MUCINEX phenylephrine REMOVE FROM Non-Formulary FREEFROM DAY hcl/dextromethorphan FORMULARY COLD-FLU hbr/acetaminophen/guaifen 06/06/2020 MUCINEX triprolidine REMOVE FROM Non-Formulary FREEFROM NT hcl/phenylephrine/dextromet FORMULARY COLD-FLU horphn/acetaminophen 06/06/2020 STAHIST TP phenylephrine hcl/triprolidine REMOVE FROM Non-Formulary hcl FORMULARY 06/06/2020 FIRST AID neomycin sulfate/bacitracin REMOVE FROM Non-Formulary ANTIBIOTIC zinc/polymyxin b FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 139 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/06/2020 CLADOSPORIU allergenic extract- REMOVE FROM Non-Formulary M cladosporium FORMULARY CLADOSPORIOI cladosporioides DES 06/06/2020 CLADOSPORIU allergenic extract- REMOVE FROM Non-Formulary M cladosporium FORMULARY CLADOSPORIOI cladosporioides DES 06/06/2020 CLADOSPORIU allergenic extract- REMOVE FROM Non-Formulary M cladosporium FORMULARY CLADOSPORIOI cladosporioides DES 06/06/2020 MUCOR allergenic extract-mucor REMOVE FROM Non-Formulary PLUMBEUS plumbeus FORMULARY 06/06/2020 MUCOR allergenic extract-mucor REMOVE FROM Non-Formulary PLUMBEUS plumbeus FORMULARY 06/06/2020 MUCOR allergenic extract-mucor REMOVE FROM Non-Formulary PLUMBEUS plumbeus FORMULARY 06/06/2020 doxercalciferol doxercalciferol ADD TO FORMULARY Injectables 06/06/2020 hailey fe norethindrone acetate- ADD TO FORMULARY Preventative ethinyl estradiol/ferrous fumarate 06/08/2020 UNIRETIC moexipril REMOVE FROM Non-Preferred Non-Formulary hcl/hydrochlorothiazide FORMULARY Brands 06/08/2020 moexipril- moexipril REMOVE FROM Preferred Non-Formulary hydrochlorothiazi hcl/hydrochlorothiazide FORMULARY Generics de 06/08/2020 moexipril- moexipril REMOVE FROM Preferred Non-Formulary hydrochlorothiazi hcl/hydrochlorothiazide FORMULARY Generics de

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 140 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/08/2020 moexipril- moexipril REMOVE FROM Preferred Non-Formulary hydrochlorothiazi hcl/hydrochlorothiazide FORMULARY Generics de 06/09/2020 INGREZZA valbenazine tosylate ADD UM: SPECIALTY Specialty Drug INITIATION PACK 06/11/2020 FIRDAPSE amifampridine phosphate ADD UM: SPECIALTY Specialty Drug 06/13/2020 NUVAKAAN-II lidocaine/prilocaine/silicone, REMOVE FROM Non-Formulary adhesive FORMULARY 06/13/2020 PRIZOTRAL-II lidocaine/prilocaine/lidocaine REMOVE FROM Non-Formulary hcl FORMULARY 06/13/2020 estradiol valerate estradiol valerate ADD TO FORMULARY Injectables 06/13/2020 empricaine-ii lidocaine/prilocaine REMOVE FROM Non-Formulary FORMULARY 06/13/2020 tetracaine hcl tetracaine hcl REMOVE FROM Non-Formulary FORMULARY 06/13/2020 sodium chloride sodium chloride irrigating REMOVE FROM Non-Formulary solution FORMULARY 06/13/2020 ribavirin ribavirin REMOVE FROM Non-Formulary FORMULARY 06/13/2020 calcium calcium carbonate REMOVE FROM Non-Formulary FORMULARY 06/13/2020 miconazole miconazole nitrate REMOVE FROM Non-Formulary nitrate FORMULARY 06/13/2020 bisacodyl bisacodyl REMOVE FROM Non-Formulary FORMULARY 06/13/2020 ziprasidone ziprasidone mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 06/13/2020 iodides ammonium iodide/potassium REMOVE FROM Non-Formulary iodide FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 141 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/13/2020 fentanyl citrate fentanyl citrate/pf REMOVE FROM Non-Formulary FORMULARY 06/13/2020 sodium sulfacetamide sodium/ REMOVE FROM Non-Formulary sulfacetamide- FORMULARY sulfur 06/13/2020 lidocaine- lidocaine/tetracaine REMOVE FROM Non-Formulary tetracaine FORMULARY 06/13/2020 brimonidine tartrate REMOVE FROM Non-Formulary tartrate FORMULARY 06/13/2020 DIGESTIVE bacillus REMOVE FROM Non-Formulary ADVANTAGE coagulans/protease/amylase FORMULARY INT BOWEL /lipase 06/13/2020 estradiol estradiol hemihydrate REMOVE FROM Non-Formulary hemihydrate FORMULARY 06/13/2020 estradiol estradiol hemihydrate REMOVE FROM Non-Formulary hemihydrate FORMULARY 06/13/2020 estradiol estradiol hemihydrate REMOVE FROM Non-Formulary hemihydrate FORMULARY 06/13/2020 reguloid psyllium husk/aspartame REMOVE FROM Non-Formulary FORMULARY 06/13/2020 TAB-A-VITE multivitamin/ferrous REMOVE FROM Non-Formulary MULTIVIT WITH fumarate/folic acid FORMULARY IRON 06/13/2020 cleansing eyelid eyelid cleanser combination REMOVE FROM Non-Formulary wipes ext str no.10 FORMULARY 06/13/2020 minimed mio infusion set for insulin pump REMOVE FROM Non-Formulary advance FORMULARY 06/13/2020 droplet pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 06/13/2020 is-d-10,000 cholecalciferol (vitamin d3) REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 142 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/13/2020 probiotic bacillus coagulans/inulin REMOVE FROM Non-Formulary FORMULARY 06/13/2020 lactobacillus lactobacillus REMOVE FROM Non-Formulary acidophilus/lactobacillus FORMULARY bulgaricus 06/13/2020 calcium 500-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 06/13/2020 NAN PRO-1 infant formula with REMOVE FROM Non-Formulary INFANT iron/dha/ara/l. reuteri FORMULARY 06/13/2020 NAN PRO-1 infant formula with REMOVE FROM Non-Formulary INFANT iron/dha/ara/l. reuteri FORMULARY 06/13/2020 DIGESTIVE bacillus coagulans REMOVE FROM Non-Formulary ADVANTAGE FORMULARY IMMUNE 06/13/2020 ALKA-SELTZER doxylamine/phenylephrine/d REMOVE FROM Non-Formulary PLUS COLD extromethorphan/acetamino FORMULARY DAY-NT phen/gg 06/13/2020 GERBER GOOD pediatric nut,milk REMOVE FROM Non-Formulary START A2 based,iron/a2 FORMULARY TODDLER casein/dha/ara/l. reuteri 06/13/2020 GERBER GOOD infant formula with iron/a2 REMOVE FROM Non-Formulary START A2 beta FORMULARY casein/dha/arach/l.reuteri 06/13/2020 SOOTHE XP light mineral oil/mineral oil/pf REMOVE FROM Non-Formulary FORMULARY 06/13/2020 GELUSIL magnesium REMOVE FROM Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 06/13/2020 ribavirin ribavirin ADD TO FORMULARY Non-Formulary Injectables 06/13/2020 vanadom carisoprodol ADD TO FORMULARY Non-Preferred Generics

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 143 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/13/2020 hailey fe norethindrone acetate- ADD TO FORMULARY Preventative ethinyl estradiol/ferrous fumarate 06/13/2020 LIPRITIN gabapentin/lidocaine/prilocai REMOVE FROM Non-Formulary ne/transparent dressing FORMULARY 06/13/2020 sodium fluoride fluoride (sodium) REMOVE FROM Non-Formulary FORMULARY 06/13/2020 sodium fluoride fluoride (sodium) REMOVE FROM Non-Formulary FORMULARY 06/13/2020 sodium fluoride sodium fluoride/potassium REMOVE FROM Non-Formulary sensitive nitrate FORMULARY 06/17/2020 VERZENIO abemaciclib CHANGE TIER Non-Preferred Preferred Specialty Specialty 06/19/2020 IBRANCE palbociclib CHANGE TIER Non-Preferred Preferred Specialty Specialty 06/19/2020 IBRANCE palbociclib CHANGE TIER Non-Preferred Preferred Specialty Specialty 06/19/2020 IBRANCE palbociclib CHANGE TIER Non-Preferred Preferred Specialty Specialty 06/19/2020 FLUOVIX PLUS /silicone, REMOVE FROM Non-Formulary adhesive FORMULARY 06/19/2020 eye drops tetrahydrozoline hcl/zinc REMOVE FROM Non-Formulary irritation relief sulfate FORMULARY 06/19/2020 ZYRTEC cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 06/19/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 06/19/2020 lidocaine lidocaine REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 144 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/19/2020 pure and gentle sodium REMOVE FROM Non-Formulary saline enema phosphate,monobasic/sodiu FORMULARY m phosphate,dibasic 06/19/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 06/19/2020 carisoprodol carisoprodol REMOVE FROM Non-Formulary FORMULARY 06/19/2020 magnesium oxide magnesium oxide REMOVE FROM Non-Formulary FORMULARY 06/19/2020 sodium sodium bicarbonate REMOVE FROM Non-Formulary bicarbonate FORMULARY 06/19/2020 niacin niacin REMOVE FROM Non-Formulary FORMULARY 06/19/2020 one step pregnancy test kit REMOVE FROM Non-Formulary pregnancy test FORMULARY 06/19/2020 vitamin b-1 thiamine hcl REMOVE FROM Non-Formulary FORMULARY 06/19/2020 epsom salt REMOVE FROM Non-Formulary FORMULARY 06/19/2020 allergy relief loratadine REMOVE FROM Non-Formulary FORMULARY 06/19/2020 allergy relief loratadine REMOVE FROM Non-Formulary FORMULARY 06/19/2020 CARVEDILOL carvedilol phosphate ADD TO FORMULARY Non-Preferred ER Brands 06/19/2020 CARVEDILOL carvedilol phosphate ADD TO FORMULARY Non-Preferred ER Brands 06/19/2020 blood pressure blood pressure test kit- REMOVE FROM Non-Formulary monitor medium FORMULARY 06/19/2020 hand sanitizer ethyl alcohol REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 145 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/19/2020 HYLATOPICPLU emollient combination no.53 REMOVE FROM Non-Formulary S FORMULARY 06/19/2020 airborne multivit-minerals/vit REMOVE FROM Non-Formulary c/glutamine/lysine hcl/herbal FORMULARY no.124 06/19/2020 HYLATOPICPLU emollient combination no.53 REMOVE FROM Non-Formulary S FORMULARY 06/19/2020 ENFAMIL infant formula with REMOVE FROM Non-Formulary NEURO iron/docosahexaenoic FORMULARY GENTLEASE acid/arachidonic ac NONGMO 06/19/2020 ENFAMIL infant formula with REMOVE FROM Non-Formulary NEURO iron/docosahexaenoic FORMULARY GENTLEASE acid/arachidonic ac NONGMO 06/19/2020 stratactx gel dressing REMOVE FROM Non-Formulary FORMULARY 06/19/2020 strataxrt gel dressing REMOVE FROM Non-Formulary FORMULARY 06/19/2020 droplet micron pen needle, diabetic REMOVE FROM Non-Formulary pen needle FORMULARY 06/19/2020 pheniramine pheniramine maleate REMOVE FROM Non-Formulary maleate FORMULARY 06/19/2020 pheniramine pheniramine maleate REMOVE FROM Non-Formulary maleate FORMULARY 06/19/2020 pheniramine pheniramine maleate REMOVE FROM Non-Formulary maleate FORMULARY 06/19/2020 pheniramine pheniramine maleate REMOVE FROM Non-Formulary maleate FORMULARY 06/19/2020 underwear men- diaper,brief,adult, REMOVE FROM Non-Formulary women disposable FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 146 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/19/2020 airborne natural multivitamin- REMOVE FROM Non-Formulary energy minerals/ascorbic FORMULARY acid/herbal no.124 06/19/2020 invigoflex d glucosamine sulfate REMOVE FROM Non-Formulary FORMULARY 06/19/2020 airborne gummy multivitamin-minerals/vit REMOVE FROM Non-Formulary c/herbal no.124 FORMULARY 06/19/2020 airborne multivitamin- REMOVE FROM Non-Formulary minerals/ascorbic FORMULARY acid/herbal no.124 06/19/2020 airborne kids multivitamin-minerals/vit REMOVE FROM Non-Formulary c/herbal no.124 FORMULARY 06/19/2020 ultra lubricant eye propylene REMOVE FROM Non-Formulary glycol/polyethylene glycol FORMULARY 400 06/19/2020 b-12 mecobalamin REMOVE FROM Non-Formulary FORMULARY 06/19/2020 INVIGOFLEX D glucosamine sulfate REMOVE FROM Non-Formulary FORMULARY 06/19/2020 GERBER LIL vit c/vit d3/vit e acet/choline REMOVE FROM Non-Formulary BRAINIES bit/omega 3,6,9 combo no.7 FORMULARY 06/19/2020 NAN PRO pediatric nut,milk REMOVE FROM Non-Formulary TODDLER based,iron/lactobacillus FORMULARY reuteri 06/19/2020 IS-ZC 50 zinc oxide-zinc citrate REMOVE FROM Non-Formulary FORMULARY 06/19/2020 DIGESTIVE bacillus coagulans REMOVE FROM Non-Formulary ADVANTAGE FORMULARY PROBIO-PRE 06/19/2020 DIGEST ADV bacillus coagulans/digestive REMOVE FROM Non-Formulary PROBIO PLUS enzymes combo no.10 FORMULARY GAS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 147 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/19/2020 AQUANAZ PSE guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr/pseudoephedrine hcl FORMULARY 06/19/2020 sodium sodium bicarbonate ADD TO FORMULARY Injectables bicarbonate 06/19/2020 dextrose 5%- dextrose 5 % and 0.2 % ADD TO FORMULARY Injectables 0.225% nacl sodium chloride 06/19/2020 desonide REMOVE FROM Non-Formulary FORMULARY 06/24/2020 clovique trientine hcl ADD TO FORMULARY Non-Formulary Non-Preferred Specialty 06/24/2020 PROCARDIA nifedipine ADD TO FORMULARY Non-Preferred Brands 06/24/2020 ARTHROTEC 75 diclofenac ADD TO FORMULARY Non-Formulary Non-Preferred sodium/misoprostol Brands 06/24/2020 CINRYZE c1 esterase inhibitor ADD UM: SPECIALTY Specialty Drug 06/24/2020 DELESTROGEN estradiol valerate REMOVE FROM Injectables Non-Formulary FORMULARY 06/24/2020 ATACAND HCT candesartan ADD TO FORMULARY Non-Formulary Non-Preferred cilexetil/hydrochlorothiazide Brands 06/24/2020 glatopa glatiramer acetate ADD UM: SPECIALTY Specialty Drug 06/24/2020 CLOZARIL clozapine ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/24/2020 BENICAR HCT olmesartan ADD TO FORMULARY Non-Formulary Non-Preferred medoxomil/hydrochlorothiazi Brands de 06/24/2020 BENICAR HCT olmesartan ADD TO FORMULARY Non-Formulary Non-Preferred medoxomil/hydrochlorothiazi Brands de 06/24/2020 BENICAR HCT olmesartan ADD TO FORMULARY Non-Formulary Non-Preferred medoxomil/hydrochlorothiazi Brands de

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 148 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2020 ATACAND HCT candesartan ADD TO FORMULARY Non-Formulary Non-Preferred cilexetil/hydrochlorothiazide Brands 06/25/2020 ATACAND HCT candesartan ADD TO FORMULARY Non-Formulary Non-Preferred cilexetil/hydrochlorothiazide Brands 06/25/2020 VENTAVIS iloprost tromethamine ADD UM: SPECIALTY Specialty Drug 06/25/2020 EXFORGE HCT amlodipine ADD TO FORMULARY Non-Formulary Non-Preferred besylate/valsartan/hydrochlo Brands rothiazide 06/25/2020 EXFORGE HCT amlodipine ADD TO FORMULARY Non-Formulary Non-Preferred besylate/valsartan/hydrochlo Brands rothiazide 06/25/2020 EXFORGE HCT amlodipine ADD TO FORMULARY Non-Formulary Non-Preferred besylate/valsartan/hydrochlo Brands rothiazide 06/25/2020 EXFORGE HCT amlodipine ADD TO FORMULARY Non-Preferred besylate/valsartan/hydrochlo Brands rothiazide 06/25/2020 EXFORGE HCT amlodipine ADD TO FORMULARY Non-Formulary Non-Preferred besylate/valsartan/hydrochlo Brands rothiazide 06/25/2020 subvenite (blue) lamotrigine ADD TO FORMULARY Non-Formulary Preferred Generics 06/25/2020 VANOS fluocinonide ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/25/2020 JYNARQUE tolvaptan ADD TO FORMULARY Non-Formulary Non-Preferred Specialty 06/25/2020 JYNARQUE tolvaptan ADD TO FORMULARY Non-Formulary Non-Preferred Specialty 06/25/2020 SYNAGIS palivizumab ADD UM: SPECIALTY Specialty Drug 06/25/2020 SYNAGIS palivizumab ADD UM: SPECIALTY Specialty Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 149 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2020 COLESTID colestipol hcl CHANGE TIER Non-Preferred Non-Preferred Generics Brands 06/25/2020 COLESTID colestipol hcl CHANGE TIER Non-Preferred Non-Preferred Generics Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 EUTHYROX levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/25/2020 euthyrox levothyroxine sodium ADD TO FORMULARY Non-Preferred Brands 06/26/2020 VENTAVIS iloprost ADD UM: SPECIALTY Specialty Drug tromethamine,iloprost 06/26/2020 TYVASO REFILL treprostinil/nebulizer REMOVE UM: SPECIALTY Specialty Drug KIT accessories

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 150 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2020 TYVASO treprostinil/nebulizer and REMOVE UM: SPECIALTY Specialty Drug STARTER accessories KIT,TYVASO INSTITUTIONAL START KIT 06/26/2020 TYVASO treprostinil REMOVE UM: SPECIALTY Specialty Drug 06/26/2020 PROLIA denosumab ADD UM: SPECIALTY Specialty Drug 06/26/2020 XGEVA denosumab ADD UM: SPECIALTY Specialty Drug 06/26/2020 CLOZARIL clozapine ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/26/2020 ISOPTO atropine sulfate ADD TO FORMULARY Non-Formulary Non-Preferred ATROPINE Brands 06/26/2020 ONMEL itraconazole ADD UM: SPECIALTY Specialty Drug 06/26/2020 ORENITRAM ER treprostinil diolamine ADD UM: SPECIALTY Specialty Drug 06/26/2020 ORENITRAM ER treprostinil diolamine ADD UM: SPECIALTY Specialty Drug 06/26/2020 ORENITRAM ER treprostinil diolamine ADD UM: SPECIALTY Specialty Drug 06/26/2020 ORENITRAM ER treprostinil diolamine ADD UM: SPECIALTY Specialty Drug 06/26/2020 ORENITRAM ER treprostinil diolamine ADD UM: SPECIALTY Specialty Drug 06/26/2020 glatopa glatiramer acetate ADD UM: SPECIALTY Specialty Drug 06/26/2020 MITIGARE colchicine ADD TO FORMULARY Non-Preferred Brands 06/26/2020 VIBRAMYCIN doxycycline monohydrate ADD TO FORMULARY Non-Preferred Brands 06/26/2020 AIRDUO fluticasone ADD TO FORMULARY Non-Preferred RESPICLICK propionate/salmeterol Brands xinafoate 06/26/2020 AIRDUO fluticasone ADD TO FORMULARY Non-Preferred RESPICLICK propionate/salmeterol Brands xinafoate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 151 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2020 AIRDUO fluticasone ADD TO FORMULARY Non-Preferred RESPICLICK propionate/salmeterol Brands xinafoate 06/26/2020 ILARIS canakinumab/pf ADD UM: SPECIALTY Specialty Drug 06/26/2020 METROLOTION metronidazole ADD TO FORMULARY Non-Formulary Non-Preferred Brands 06/26/2020 GAMMAPLEX immune globulin,gamma ADD UM: SPECIALTY Specialty Drug (igg)/glycine/iga 0 to 50 mcg/ml 06/26/2020 GAMASTAN S- immune ADD UM: SPECIALTY Specialty Drug D,GAMASTAN globulin,gamma(igg)/glycine 06/26/2020 ENDARI glutamine ADD UM: SPECIALTY Specialty Drug 06/26/2020 PANZYGA immune ADD UM: SPECIALTY Specialty Drug globulin,gamma(igg)-ifas human/glycine 06/26/2020 RYCLORA dexchlorpheniramine CHANGE TIER Non-Preferred Non-Preferred maleate Generics Brands 06/26/2020 ARTHROTEC 50 diclofenac ADD TO FORMULARY Non-Preferred sodium/misoprostol Brands 06/26/2020 AZOR amlodipine ADD TO FORMULARY Non-Preferred besylate/olmesartan Brands medoxomil 06/26/2020 AZOR amlodipine ADD TO FORMULARY Non-Preferred besylate/olmesartan Brands medoxomil 06/26/2020 AZOR amlodipine ADD TO FORMULARY Non-Preferred besylate/olmesartan Brands medoxomil 06/26/2020 RANEXA ranolazine CHANGE TIER Non-Preferred Preferred Brands Generics

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 152 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/27/2020 helidac bismuth REMOVE FROM Non-Formulary subsalicylate/metronidazole/ FORMULARY tetracycline hcl 06/27/2020 oyster shell calcium carbonate REMOVE FROM Non-Formulary calcium FORMULARY 06/27/2020 loratadine loratadine REMOVE FROM Non-Formulary FORMULARY 06/27/2020 glucosamine- glucosamine hcl/chondroitin REMOVE FROM Non-Formulary chondroitin sulfate a FORMULARY 06/27/2020 paroxetine cr paroxetine hcl REMOVE FROM Non-Formulary FORMULARY 06/27/2020 PAXIL CR paroxetine hcl REMOVE FROM Non-Formulary FORMULARY 06/27/2020 antacid extra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY 06/27/2020 artificial tears polyvinyl alcohol/povidone REMOVE FROM Non-Formulary FORMULARY 06/27/2020 antacid calcium carbonate REMOVE FROM Non-Formulary FORMULARY 06/27/2020 bacitracin zinc bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 06/27/2020 bacitracin zinc bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 06/27/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 06/27/2020 MOVE FREE cartilage/collagen type REMOVE FROM Non-Formulary ULTRA TRIPLE ii/boron FORMULARY ACTION glycinate/hyaluronate sod 06/27/2020 MOVE FREE glucosamine/chondroitin/hya REMOVE FROM Non-Formulary JOINT HEALTH luronic acid/calcium FORMULARY fructoborate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 153 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/27/2020 ENFAMIL A.R. infant formula with REMOVE FROM Non-Formulary iron/docosahexaenoic FORMULARY acid/arachidonic ac 06/27/2020 hand sanitizer ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 06/27/2020 white petrolatum petrolatum,white REMOVE FROM Non-Formulary FORMULARY 06/27/2020 vitamin a and d vitamins a and d/white REMOVE FROM Non-Formulary petrolatum/lanolin FORMULARY 06/27/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 06/27/2020 ketamine hcl-nacl ketamine hcl in sodium REMOVE FROM Non-Formulary chloride, iso-osmotic FORMULARY 06/27/2020 airborne multivitamin- REMOVE FROM Non-Formulary minerals/ascorbic FORMULARY acid/herbal no.124 06/27/2020 airborne gummy multivitamin-minerals/vit REMOVE FROM Non-Formulary c/herbal no.124 FORMULARY 06/27/2020 airborne natural multivitamin- REMOVE FROM Non-Formulary energy minerals/ascorbic FORMULARY acid/herbal no.124 06/27/2020 miclara lq triprolidine hcl REMOVE FROM Non-Formulary FORMULARY 06/27/2020 airborne plus multivit-min/vitamin REMOVE FROM Non-Formulary probiotic c/bacillus coagulans/herbal FORMULARY no.124 06/27/2020 airborne kids multivitamin-minerals/vit REMOVE FROM Non-Formulary c/herbal no.124 FORMULARY 06/27/2020 yogurt plus calcium phosphate, REMOVE FROM Non-Formulary calcium tribasic/cholecalciferol FORMULARY (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 154 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/27/2020 hemorrhoidal witch hazel REMOVE FROM Non-Formulary hygiene FORMULARY 06/27/2020 GERBER GROW pediatric multivitamin no.191 REMOVE FROM Non-Formulary MIGHTY FORMULARY 06/27/2020 DIGESTIVE l.acidoph,paracasei, b.lactis REMOVE FROM Non-Formulary ADVANTAGE FORMULARY ADVANCED 06/27/2020 SOPORDREN melatonin/gaba/5- REMOVE FROM Non-Formulary htp/theanine/magnesium FORMULARY citrate,oxide/herbs 06/27/2020 DIGESTIVE bacillus coagulans/bacillus REMOVE FROM Non-Formulary ADVANTAG subtilis FORMULARY MULTISTRAIN 06/27/2020 DIGESTIVE bacillus coagulans/bacillus REMOVE FROM Non-Formulary ADVANTAG subtilis FORMULARY MULTISTRAIN 06/27/2020 PKU SPHERE20 nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria (pku) no.67 FORMULARY 06/27/2020 ALKA-SELTZER calcium phosphate, REMOVE FROM Non-Formulary PM tribasic/melatonin FORMULARY 06/27/2020 PROMELLA lactobacillus REMOVE FROM Non-Formulary acidophilus/bifidobacterium FORMULARY animalis 06/27/2020 GLYTACTIN nutritional therapy for REMOVE FROM Non-Formulary BURST 10-10 phenylketonuria (pku) no.75 FORMULARY 06/27/2020 GLYTACTIN nutritional therapy for REMOVE FROM Non-Formulary BURST 10-10 phenylketonuria (pku) no.75 FORMULARY 06/27/2020 GLYTACTIN nutritional therapy for REMOVE FROM Non-Formulary BURST 10-10 phenylketonuria (pku) no.75 FORMULARY 06/27/2020 GLYTACTIN nutritional therapy for REMOVE FROM Non-Formulary BURST 20-20 phenylketonuria (pku) no.75 FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 155 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/27/2020 GLYTACTIN nutritional therapy for REMOVE FROM Non-Formulary BURST 20-20 phenylketonuria (pku) no.75 FORMULARY 06/27/2020 GLYTACTIN nutritional therapy for REMOVE FROM Non-Formulary BURST 20-20 phenylketonuria (pku) no.75 FORMULARY 06/27/2020 ethacrynic acid ethacrynic acid ADD TO FORMULARY Non-Preferred Generics 06/27/2020 covid19 covid-19 test specimen REMOVE FROM Non-Formulary specimen collect collection FORMULARY ncpdp 06/27/2020 covid19 test adm covid-19 test administered REMOVE FROM Non-Formulary by pharmacist by pharmacist FORMULARY 06/27/2020 XPOVIO selinexor ADD TO FORMULARY Non-Preferred Specialty 06/27/2020 XPOVIO selinexor ADD TO FORMULARY Non-Preferred Specialty 06/27/2020 LIDOTIN gabapentin/lidocaine REMOVE FROM Non-Formulary hcl/silicone adhesive FORMULARY 06/27/2020 NOPIOID-TC KIT cyclobenzaprine REMOVE FROM Non-Formulary hcl/lidocaine/menthol FORMULARY 06/27/2020 ECONASIL econazole nitrate/gauze REMOVE FROM Non-Formulary bandage/silicone, adhesive FORMULARY 06/27/2020 FLUOPAR fluocinonide/dimethicone REMOVE FROM Non-Formulary FORMULARY 06/27/2020 XPOVIO selinexor ADD TO FORMULARY Non-Preferred Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 156 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

July, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/01/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Preferred Non-Formulary er FORMULARY Generics 07/01/2020 relexxii methylphenidate hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY Generics 07/01/2020 ZIEXTENZO pegfilgrastim-bmez ADD UM: MED Medical Drug 07/01/2020 ZIRABEV bevacizumab-bvzr ADD UM: MED Medical Drug 07/01/2020 TRAZIMERA trastuzumab-qyyp ADD UM: MED Medical Drug 07/01/2020 HERZUMA trastuzumab-pkrb ADD UM: MED Medical Drug 07/01/2020 HERZUMA trastuzumab-pkrb ADD UM: MED Medical Drug 07/01/2020 ONTRUZANT trastuzumab-dttb ADD UM: MED Medical Drug 07/01/2020 ONTRUZANT trastuzumab-dttb ADD UM: MED Medical Drug 07/01/2020 dalfampridine er dalfampridine CHANGE TIER Non-Preferred Non-Preferred Specialty Generics 07/01/2020 AMPYRA dalfampridine CHANGE TIER Non-Preferred Non-Preferred Specialty Brands 07/03/2020 LIPRITIN II gabapentin/lidocaine/prilocai REMOVE FROM Non-Formulary ne/transparent dressing FORMULARY 07/03/2020 hylaguard emollient combination no.53 REMOVE FROM Non-Formulary FORMULARY 07/03/2020 potassium potassium chloride REMOVE FROM Non-Formulary chloride FORMULARY 07/03/2020 cocaine hcl cocaine hcl REMOVE FROM Non-Formulary FORMULARY 07/03/2020 cocaine hcl cocaine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 157 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/03/2020 brompheniramine brompheniramine REMOVE FROM Non-Formulary -pseudoephed- maleate/pseudoephedrine FORMULARY dm hcl/dextromethorphan 07/03/2020 brompheniramine brompheniramine REMOVE FROM Non-Formulary -pseudoephed- maleate/pseudoephedrine FORMULARY dm hcl/dextromethorphan 07/03/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 07/03/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 07/03/2020 butalbital- butalbital/acetaminophen/caf REMOVE FROM Non-Formulary acetaminophen- feine FORMULARY caffe 07/03/2020 guaiasorb dm guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 07/03/2020 therems multivitamin with folic acid REMOVE FROM Non-Formulary multivitamin FORMULARY 07/03/2020 airborne plus multivit-min/vitamin REMOVE FROM Non-Formulary probiotic c/bacillus coagulans/herbal FORMULARY no.124 07/03/2020 easy touch safety pen needle, diabetic, safety REMOVE FROM Non-Formulary pen needle FORMULARY 07/03/2020 freestyle libre 2 flash glucose scanning REMOVE FROM Non-Formulary reader reader FORMULARY 07/03/2020 freestyle libre 2 flash glucose sensor REMOVE FROM Non-Formulary sensor FORMULARY 07/03/2020 blue tube lidocaine REMOVE FROM Non-Formulary FORMULARY 07/03/2020 acne medication benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 158 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/03/2020 airborne multivitamin-minerals/vit REMOVE FROM Non-Formulary c/herbal no.124 FORMULARY 07/03/2020 CENTRUM multivitamin with REMOVE FROM Non-Formulary ADULT 50 minerals/folic acid FORMULARY FRESH-FRUITY 07/03/2020 FISH OIL omega-3 fatty REMOVE FROM Non-Formulary acids/dha/epa/other omega- FORMULARY 3s/fish oil 07/03/2020 dextrose in water dextrose 5 % in water ADD TO FORMULARY Injectables 07/11/2020 FERRIPROX (2 deferiprone ADD TO FORMULARY Non-Preferred TIMES A DAY) Specialty 07/11/2020 CYCLOPHOSPH cyclophosphamide ADD TO FORMULARY Non-Preferred AMIDE Brands 07/11/2020 CYCLOPHOSPH cyclophosphamide ADD TO FORMULARY Non-Preferred AMIDE Brands 07/11/2020 hydrocortisone hydrocortisone acetate REMOVE FROM Non-Formulary acetate FORMULARY 07/11/2020 hydrocortisone hydrocortisone acetate REMOVE FROM Non-Formulary acetate FORMULARY 07/11/2020 metronidazole metronidazole benzoate REMOVE FROM Non-Formulary benzoate FORMULARY 07/11/2020 metronidazole metronidazole benzoate REMOVE FROM Non-Formulary benzoate FORMULARY 07/11/2020 isosorbide isosorbide dinitrate REMOVE FROM Non-Formulary dinitrate FORMULARY 07/11/2020 neo-synephrine phenylephrine hcl REMOVE FROM Non-Formulary FORMULARY 07/11/2020 hydroxyurea hydroxyurea REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 159 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/11/2020 LORTUSS LQ doxylamine REMOVE FROM Non-Formulary succinate/pseudoephedrine FORMULARY hcl 07/11/2020 creatinine creatinine REMOVE FROM Non-Formulary FORMULARY 07/11/2020 creatinine creatinine REMOVE FROM Non-Formulary FORMULARY 07/11/2020 creatinine creatinine REMOVE FROM Non-Formulary FORMULARY 07/11/2020 creatinine creatinine REMOVE FROM Non-Formulary FORMULARY 07/11/2020 creatinine creatinine REMOVE FROM Non-Formulary FORMULARY 07/11/2020 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM Non-Formulary FORMULARY 07/11/2020 testosterone testosterone REMOVE FROM Non-Formulary FORMULARY 07/11/2020 cupric sulfate cupric sulfate pentahydrate REMOVE FROM Non-Formulary FORMULARY 07/11/2020 BOOST nutritional tx. glucose REMOVE FROM Non-Formulary GLUCOSE intolerance,lactose- FORMULARY CONTROL free,soy/fiber 07/11/2020 nutriarx triamcinolone REMOVE FROM Non-Formulary acetonide/dimethicone/silico FORMULARY ne, adhesive 07/11/2020 heparin sodium heparin sodium,porcine/pf REMOVE FROM Non-Formulary FORMULARY 07/11/2020 nusurgepak mupirocin/chlorhexidine REMOVE FROM Non-Formulary glucon/dimethicone/silicone FORMULARY adhesive

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 160 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/11/2020 REGULOID psyllium husk (with sugar) REMOVE FROM Non-Formulary FORMULARY 07/11/2020 NUDERMRXPAK calcipotriene/dimethicone REMOVE FROM Non-Formulary FORMULARY 07/11/2020 NUDERMRXPAK calcipotriene/dimethicone REMOVE FROM Non-Formulary FORMULARY 07/11/2020 unifine pentips pen needle, diabetic REMOVE FROM Non-Formulary maxflow FORMULARY 07/11/2020 unifine pentips pen needle, diabetic REMOVE FROM Non-Formulary plus maxflow FORMULARY 07/11/2020 cerave itch relief pramoxine hcl REMOVE FROM Non-Formulary FORMULARY 07/11/2020 airborne multivitamin- REMOVE FROM Non-Formulary elderberry minerals/ascorbic FORMULARY acid/elderberry/herb no.124 07/11/2020 airborne ascorbic acid/elderberry fruit REMOVE FROM Non-Formulary FORMULARY 07/11/2020 airborne ascorbic acid/vitamin REMOVE FROM Non-Formulary elderberry d3/vitamin e/zinc FORMULARY gummy gluconate/elderberry 07/11/2020 calcium citrate- calcium REMOVE FROM Non-Formulary vitamin d3 citrate/cholecalciferol FORMULARY (vitamin d3) 07/11/2020 MOVE FREE /hyaluronic REMOVE FROM Non-Formulary ULTRA OMEGA acid/astaxanthin FORMULARY JNT PLUS 07/11/2020 MOVE FREE glucosamine/chondroitin/ms REMOVE FROM Non-Formulary PLUS MSM m/hyaluronic ac/calc FORMULARY fructoborate 07/11/2020 MEGARED omega-3 fatty REMOVE FROM Non-Formulary ADVANCED 4- acids/dha/epa/fish oil/krill oil FORMULARY IN-1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 161 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/11/2020 MEGARED omega-3 fatty REMOVE FROM Non-Formulary ADVANCED 4- acids/dha/epa/fish oil/krill oil FORMULARY IN-1 07/11/2020 move free ultra tamarindus indica REMOVE FROM Non-Formulary turmeric-tamar seed/turmeric root extract FORMULARY 07/11/2020 germphobic ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 07/11/2020 germphobic ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 07/11/2020 germphobic ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 07/11/2020 minimed infusion set for insulin pump REMOVE FROM Non-Formulary silhouette FORMULARY 07/11/2020 dextrose 5%- dextrose 5 % and 0.9 % ADD TO FORMULARY Injectables 0.9% nacl sodium chloride 07/11/2020 dextrose 5%- potassium chloride in ADD TO FORMULARY Injectables 0.225% nacl-kcl dextrose 5 %-0.2 % sodium chloride 07/11/2020 paclitaxel paclitaxel ADD TO FORMULARY Injectables 07/11/2020 paclitaxel paclitaxel ADD TO FORMULARY Injectables 07/11/2020 FLUAD QUAD influenza vaccine REMOVE FROM Non-Formulary 2020-2021 quadrivalent 2020-21 (65 yr FORMULARY up)/mf59c.1/pf 07/11/2020 FLUARIX QUAD influenza virus vaccine REMOVE FROM Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 07/11/2020 FLULAVAL influenza virus vaccine REMOVE FROM Non-Formulary QUAD 2020- quadrival 2020-2021(6 mos FORMULARY 2021 and up)/pf

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 162 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/11/2020 FLUBLOK QUAD influenza virus vaccine qv REMOVE FROM Non-Formulary 2020-2021 2020-21(18 yrs and FORMULARY older)rcmb/pf 07/11/2020 FLUBLOK QUAD influenza virus vaccine qv REMOVE FROM Non-Formulary 2020-2021 2020-21(18 yrs and FORMULARY older)rcmb/pf 07/11/2020 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 07/11/2020 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 07/11/2020 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 07/11/2020 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non-Formulary 2020-2021 quadrival 2020-2021(6 mos FORMULARY and up)/pf 07/11/2020 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non-Formulary 2020-2021 quadrivalent 2020-21 (6 mos FORMULARY and up) 07/11/2020 FLUZONE QUAD influenza virus vaccine REMOVE FROM Non-Formulary 2020-2021 quadrivalent 2020-21 (6 mos FORMULARY and up) 07/11/2020 FLUZONE HIGH- influenza virus vaccine REMOVE FROM Non-Formulary DOSE QUAD quadrival split 2020-21(65 yr FORMULARY 2020-21 up)/pf 07/11/2020 FLUZONE HIGH- influenza virus vaccine REMOVE FROM Non-Formulary DOSE QUAD quadrival split 2020-21(65 yr FORMULARY 2020-21 up)/pf 07/11/2020 atropine sulfate atropine sulfate in 0.9 % REMOVE FROM Non-Formulary sodium chloride FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 163 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/11/2020 topotecan hcl topotecan hcl REMOVE FROM Non-Formulary FORMULARY 07/11/2020 GABAPAL gabapentin/lidocaine REMOVE FROM Non-Formulary hcl/gauze bandage/silicone FORMULARY adhesive 07/11/2020 PENTICAN gabapentin/lidocaine REMOVE FROM Non-Formulary FORMULARY 07/11/2020 TISSUEBLUE c.i. acid blue 90 REMOVE FROM Non-Formulary FORMULARY 07/11/2020 TISSUEBLUE c.i. acid blue 90 REMOVE FROM Non-Formulary FORMULARY 07/11/2020 DUPIXENT PEN dupilumab ADD TO FORMULARY Preferred Specialty 07/13/2020 LARTRUVO olaratumab REMOVE UM: Limited Access LIMITEDACCESS 07/13/2020 ACTHAR corticotropin REMOVE UM: Limited Access LIMITEDACCESS 07/13/2020 ADAKVEO crizanlizumab-tmca ADD UM: LIMITEDACCESS Limited Access 07/13/2020 ASCENIV immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)-slra human 07/13/2020 ASPARLAS calaspargase pegol-mknl ADD UM: LIMITEDACCESS Limited Access 07/13/2020 AUVI-Q epinephrine ADD UM: LIMITEDACCESS Limited Access 07/13/2020 AUVI-Q epinephrine ADD UM: LIMITEDACCESS Limited Access 07/13/2020 AYVAKIT avapritinib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 AYVAKIT avapritinib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 AYVAKIT avapritinib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 BRUKINSA zanubrutinib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 ENDARI glutamine ADD UM: LIMITEDACCESS Limited Access

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 164 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/13/2020 ENHERTU fam-trastuzumab ADD UM: LIMITEDACCESS Limited Access deruxtecan-nxki 07/13/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: LIMITEDACCESS Limited Access rec, b-dom truncated peg- exei 07/13/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: LIMITEDACCESS Limited Access rec, b-dom truncated peg- exei 07/13/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: LIMITEDACCESS Limited Access rec, b-dom truncated peg- exei 07/13/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: LIMITEDACCESS Limited Access rec, b-dom truncated peg- exei 07/13/2020 ESPEROCT antihemophilic factor (fviii) ADD UM: LIMITEDACCESS Limited Access rec, b-dom truncated peg- exei 07/13/2020 EYLEA aflibercept ADD UM: LIMITEDACCESS Limited Access 07/13/2020 FASENRA PEN benralizumab ADD UM: LIMITEDACCESS Limited Access 07/13/2020 FERRIPROX (2 deferiprone ADD UM: LIMITEDACCESS Limited Access TIMES A DAY) 07/13/2020 GIVLAARI givosiran sodium ADD UM: LIMITEDACCESS Limited Access 07/13/2020 HUMATE-P antihemophilic factor, ADD UM: LIMITEDACCESS Limited Access human/von willebrand factor,human 07/13/2020 HUMATE-P antihemophilic factor, ADD UM: LIMITEDACCESS Limited Access human/von willebrand factor,human 07/13/2020 HUMATE-P antihemophilic factor, ADD UM: LIMITEDACCESS Limited Access human/von willebrand factor,human

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 165 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/13/2020 ILUMYA tildrakizumab-asmn ADD UM: LIMITEDACCESS Limited Access 07/13/2020 INREBIC fedratinib dihydrochloride ADD UM: LIMITEDACCESS Limited Access 07/13/2020 JYNARQUE tolvaptan ADD UM: LIMITEDACCESS Limited Access 07/13/2020 JYNARQUE tolvaptan ADD UM: LIMITEDACCESS Limited Access 07/13/2020 KANJINTI trastuzumab-anns ADD UM: LIMITEDACCESS Limited Access 07/13/2020 KANJINTI trastuzumab-anns ADD UM: LIMITEDACCESS Limited Access 07/13/2020 KOSELUGO selumetinib sulfate/vitamin e ADD UM: LIMITEDACCESS Limited Access tpgs 07/13/2020 KOSELUGO selumetinib sulfate/vitamin e ADD UM: LIMITEDACCESS Limited Access tpgs 07/13/2020 MAYZENT siponimod ADD UM: LIMITEDACCESS Limited Access 07/13/2020 MAYZENT siponimod ADD UM: LIMITEDACCESS Limited Access 07/13/2020 MAYZENT siponimod ADD UM: LIMITEDACCESS Limited Access 07/13/2020 NUBEQA darolutamide ADD UM: LIMITEDACCESS Limited Access 07/13/2020 OSMOLEX ER amantadine hcl ADD UM: LIMITEDACCESS Limited Access 07/13/2020 OSMOLEX ER amantadine hcl ADD UM: LIMITEDACCESS Limited Access 07/13/2020 OXBRYTA voxelotor ADD UM: LIMITEDACCESS Limited Access 07/13/2020 PADCEV enfortumab vedotin-ejfv ADD UM: LIMITEDACCESS Limited Access 07/13/2020 PADCEV enfortumab vedotin-ejfv ADD UM: LIMITEDACCESS Limited Access 07/13/2020 POLIVY polatuzumab vedotin-piiq ADD UM: LIMITEDACCESS Limited Access 07/13/2020 PREVYMIS letermovir ADD UM: LIMITEDACCESS Limited Access 07/13/2020 PREVYMIS letermovir ADD UM: LIMITEDACCESS Limited Access 07/13/2020 PREVYMIS letermovir ADD UM: LIMITEDACCESS Limited Access 07/13/2020 PREVYMIS letermovir ADD UM: LIMITEDACCESS Limited Access 07/13/2020 REBLOZYL luspatercept-aamt ADD UM: LIMITEDACCESS Limited Access

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 166 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/13/2020 REBLOZYL luspatercept-aamt ADD UM: LIMITEDACCESS Limited Access 07/13/2020 RINVOQ upadacitinib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 ROZLYTREK entrectinib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 ROZLYTREK entrectinib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 TIBSOVO ivosidenib ADD UM: LIMITEDACCESS Limited Access 07/13/2020 TRIKAFTA elexacaftor/tezacaftor/ivacaft ADD UM: LIMITEDACCESS Limited Access or 07/13/2020 TURALIO pexidartinib hydrochloride ADD UM: LIMITEDACCESS Limited Access 07/13/2020 UDENYCA pegfilgrastim-cbqv ADD UM: LIMITEDACCESS Limited Access 07/13/2020 VUMERITY diroximel fumarate ADD UM: LIMITEDACCESS Limited Access 07/13/2020 VYNDAMAX tafamidis ADD UM: LIMITEDACCESS Limited Access 07/13/2020 VYONDYS-53 golodirsen ADD UM: LIMITEDACCESS Limited Access 07/13/2020 WAKIX pitolisant hcl ADD UM: LIMITEDACCESS Limited Access 07/13/2020 WAKIX pitolisant hcl ADD UM: LIMITEDACCESS Limited Access 07/13/2020 XEMBIFY immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)-klhw human 07/13/2020 XEMBIFY immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)-klhw human 07/13/2020 XEMBIFY immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)-klhw human 07/13/2020 XEMBIFY immune globulin,gamma ADD UM: LIMITEDACCESS Limited Access (igg)-klhw human 07/13/2020 XPOVIO selinexor ADD UM: LIMITEDACCESS Limited Access 07/13/2020 XPOVIO selinexor ADD UM: LIMITEDACCESS Limited Access 07/13/2020 ZULRESSO brexanolone ADD UM: LIMITEDACCESS Limited Access 07/15/2020 pristiq,desvenlafa desvenlafaxine succinate CHANGE UM: QUANTITY 1 / 1 days xine succinate er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 167 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/15/2020 cialis,tadalafil tadalafil CHANGE UM: QUANTITY 30 / 30 days 1 / 1 days 07/17/2020 hydrogen hydrogen peroxide REMOVE FROM Non-Formulary peroxide FORMULARY 07/17/2020 dextrose dextrose REMOVE FROM Non-Formulary FORMULARY 07/17/2020 dextrose dextrose REMOVE FROM Non-Formulary FORMULARY 07/17/2020 dextrose dextrose REMOVE FROM Non-Formulary FORMULARY 07/17/2020 orphengesic forte orphenadrine REMOVE FROM Non-Formulary citrate/aspirin/caffeine FORMULARY 07/17/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 07/17/2020 clomipramine hcl clomipramine hcl REMOVE FROM Non-Formulary FORMULARY 07/17/2020 clomipramine hcl clomipramine hcl REMOVE FROM Non-Formulary FORMULARY 07/17/2020 clomipramine hcl clomipramine hcl REMOVE FROM Non-Formulary FORMULARY 07/17/2020 TRIPLE neomycin sulfate/bacitracin REMOVE FROM Non-Formulary ANTIBIOTIC zinc/polymyxin b FORMULARY 07/17/2020 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 07/17/2020 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 07/17/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 07/17/2020 amphetamine amphetamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 168 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2020 phenylephrine phenylephrine hcl in 0.9 % REMOVE FROM Non-Formulary hcl-0.9% nacl sodium chloride FORMULARY 07/17/2020 reguloid psyllium husk REMOVE FROM Non-Formulary FORMULARY 07/17/2020 cold-flu m- chlorpheniram/phenyleph/de REMOVE FROM Non-Formulary symptom day- xtromethorphn/acetaminoph FORMULARY night en/guaifn 07/17/2020 NATESTO testosterone REMOVE FROM Non-Formulary FORMULARY 07/17/2020 flavorx grape grape flavor REMOVE FROM Non-Formulary flavor FORMULARY 07/17/2020 peg troche base troche base no.183 REMOVE FROM Non-Formulary FORMULARY 07/17/2020 assure id insulin syringe with needle, insulin, REMOVE FROM Non-Formulary safety safety, 1 ml FORMULARY 07/17/2020 assure id insulin syringe with needle, insulin, REMOVE FROM Non-Formulary safety safety, 0.5 ml FORMULARY 07/17/2020 assure id duo- pen needle, diabetic REMOVE FROM Non-Formulary shield disposable, safety FORMULARY 07/17/2020 assure id duo- pen needle, diabetic REMOVE FROM Non-Formulary shield disposable, safety FORMULARY 07/17/2020 MOVE FREE calcium fructoborate REMOVE FROM Non-Formulary ULTRA FASTER FORMULARY COMFORT 07/17/2020 all day allergy-d cetirizine REMOVE FROM Non-Formulary hcl/pseudoephedrine hcl FORMULARY 07/17/2020 cerave psoriasis salicylic acid REMOVE FROM Non-Formulary FORMULARY 07/17/2020 effaclar adapalene REMOVE FROM Non-Formulary adapalene FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 169 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/17/2020 vecuronium vecuronium bromide ADD TO FORMULARY Injectables bromide 07/17/2020 dacarbazine dacarbazine ADD TO FORMULARY Injectables 07/17/2020 midazolam hcl- midazolam in sodium ADD TO FORMULARY Injectables 0.8% nacl chloride, iso-osmotic/pf 07/17/2020 FLUAD 2020- influenza vaccine tvs 2020- REMOVE FROM Non-Formulary 2021 21 (65 yr up)/adjuvant FORMULARY mf59c.1/pf 07/17/2020 FLUMIST QUAD influenza vaccine REMOVE FROM Non-Formulary 2020-2021 quadrivalent live 2020-2021 FORMULARY (2 yrs-49 yrs) 07/17/2020 charlotte 24 fe norethindrone acetate- ADD TO FORMULARY Preventative ethinyl estradiol/ferrous fumarate 07/17/2020 SIRTURO bedaquiline fumarate ADD TO FORMULARY Non-Preferred Specialty 07/20/2020 tramadol hcl- tramadol hcl/acetaminophen CHANGE UM: QUANTITY 10 / 1 days acetaminophen,ul tracet 07/20/2020 MEDROL methylprednisolone REMOVE UM: MED Medical Drug 07/22/2020 METFORMIN metformin hcl CHANGE TIER Non-Preferred HCL Brands 07/22/2020 XPOVIO selinexor ADD UM: LIMITEDACCESS Limited Access 07/22/2020 MEDROL methylprednisolone CHANGE TIER Injectables Non-Preferred Brands 07/24/2020 prizopak ii lidocaine/prilocaine REMOVE FROM Non-Formulary FORMULARY 07/24/2020 aprizio pak ii lidocaine/prilocaine REMOVE FROM Non-Formulary FORMULARY 07/24/2020 magnesium oxide magnesium oxide REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 170 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2020 sodium sulfacetamide sodium/sulfur REMOVE FROM Non-Formulary sulfacetamide- FORMULARY sulfur 07/24/2020 sodium sulfacetamide sodium/sulfur REMOVE FROM Non-Formulary sulfacetamide- FORMULARY sulfur 07/24/2020 sumatriptan sumatriptan REMOVE FROM Non-Formulary FORMULARY 07/24/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 07/24/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 07/24/2020 orphenadrine- orphenadrine REMOVE FROM Non-Formulary aspirin-caffeine citrate/aspirin/caffeine FORMULARY 07/24/2020 GAS RELIEF simethicone REMOVE FROM Non-Formulary FORMULARY 07/24/2020 ALA-SCALP hydrocortisone REMOVE FROM Non-Formulary FORMULARY 07/24/2020 tranexamic acid tranexamic acid REMOVE FROM Non-Formulary FORMULARY 07/24/2020 tranexamic acid tranexamic acid REMOVE FROM Non-Formulary FORMULARY 07/24/2020 tranexamic acid tranexamic acid REMOVE FROM Non-Formulary FORMULARY 07/24/2020 sheer adhesive adhesive bandage REMOVE FROM Non-Formulary bandages FORMULARY 07/24/2020 allergy relief loratadine REMOVE FROM Non-Formulary FORMULARY 07/24/2020 all day allergy-d cetirizine REMOVE FROM Non-Formulary hcl/pseudoephedrine hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 171 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2020 diclofenac diclofenac sodium REMOVE FROM Non-Formulary sodium FORMULARY 07/24/2020 mometasone mometasone furoate REMOVE FROM Non-Formulary furoate FORMULARY 07/24/2020 calcipotriene calcipotriene REMOVE FROM Non-Formulary FORMULARY 07/24/2020 sodium sulfacetamide sodium/sulfur REMOVE FROM Non-Formulary sulfacetamide- FORMULARY sulfur 07/24/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 07/24/2020 water water for injection,sterile REMOVE FROM Non-Formulary FORMULARY 07/24/2020 thallous chloride thallous chloride tl-201 REMOVE FROM Non-Formulary tl-201 FORMULARY 07/24/2020 thallous chloride thallous chloride tl-201 REMOVE FROM Non-Formulary tl-201 FORMULARY 07/24/2020 effaclar (salicylic salicylic acid REMOVE FROM Non-Formulary acid) FORMULARY 07/24/2020 cerave itch relief pramoxine hcl REMOVE FROM Non-Formulary FORMULARY 07/24/2020 maxi-tuss tr triprolidine REMOVE FROM Non-Formulary hcl/pseudoephedrine hcl FORMULARY 07/24/2020 LIPIKAR colloidal oatmeal REMOVE FROM Non-Formulary ECZEMA FORMULARY 07/24/2020 CERAVE ACNE benzoyl peroxide REMOVE FROM Non-Formulary FORMULARY 07/24/2020 PREDIA magnesium oxide/chromium REMOVE FROM Non-Formulary picolinate/grape seed FORMULARY extract

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 172 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/24/2020 CERAVE petrolatum,white REMOVE FROM Non-Formulary HEALING FORMULARY 07/24/2020 CERAVE petrolatum,white REMOVE FROM Non-Formulary HEALING FORMULARY 07/24/2020 sumatriptan sumatriptan ADD TO FORMULARY Non-Formulary Non-Preferred Generics 07/24/2020 oxaliplatin oxaliplatin ADD TO FORMULARY Injectables 07/24/2020 oxaliplatin oxaliplatin ADD TO FORMULARY Injectables 07/24/2020 TASOPROL propionate/gauze REMOVE FROM Non-Formulary bandage/silicone, adhesive FORMULARY 07/24/2020 BACICAP lactobacillus REMOVE FROM Non-Formulary acidophilus,paracasei,planta FORMULARY rum/b.animalis 07/24/2020 ZOLPAK econazole REMOVE FROM Non-Formulary nitrate/transparent dressing FORMULARY 07/28/2020 OSMOLEX ER amantadine hcl ADD UM: QUANTITY 1 / 1 days 07/30/2020 ROMIDEPSIN romidepsin ADD TO FORMULARY Non-Formulary Injectables 07/30/2020 ROMIDEPSIN romidepsin ADD UM: MED Medical Drug 07/30/2020 SARCLISA isatuximab-irfc ADD TO FORMULARY Injectables 07/30/2020 SARCLISA isatuximab-irfc ADD UM: MED Medical Drug 07/31/2020 atopavo emollient combination no.10 REMOVE FROM Non-Formulary FORMULARY 07/31/2020 polyethylene polyethylene glycol 3350 REMOVE FROM Non-Formulary glycol 3350 FORMULARY 07/31/2020 hydrocortisone hydrocortisone acetate REMOVE FROM Non-Formulary acetate FORMULARY 07/31/2020 hydrogen hydrogen peroxide REMOVE FROM Non-Formulary peroxide FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 173 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 folic acid folic acid REMOVE FROM Non-Formulary FORMULARY 07/31/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 07/31/2020 chlordiazepoxide- chlordiazepoxide/clidinium REMOVE FROM Non-Formulary clidinium bromide FORMULARY 07/31/2020 cyanocobalamin cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 07/31/2020 cyanocobalamin cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 07/31/2020 cantharidin cantharidin REMOVE FROM Non-Formulary FORMULARY 07/31/2020 cantharidin cantharidin REMOVE FROM Non-Formulary FORMULARY 07/31/2020 clotrimazole clotrimazole REMOVE FROM Non-Formulary FORMULARY 07/31/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 07/31/2020 acid reducer famotidine REMOVE FROM Non-Formulary FORMULARY 07/31/2020 adapalene adapalene REMOVE FROM Non-Formulary FORMULARY 07/31/2020 adapalene adapalene REMOVE FROM Non-Formulary FORMULARY 07/31/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 07/31/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 07/31/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 174 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 07/31/2020 vitamin b b-complex with vitamin c REMOVE FROM Non-Formulary complex-vitamin FORMULARY c 07/31/2020 arthritis pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY 07/31/2020 all day allergy cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 07/31/2020 caldyphen clear pramoxine hcl/zinc acetate REMOVE FROM Non-Formulary FORMULARY 07/31/2020 selenium sulfide selenium sulfide REMOVE FROM Non-Formulary FORMULARY 07/31/2020 compact space inhaler,assist device with REMOVE FROM Non-Formulary chamber small mask FORMULARY 07/31/2020 compact space inhaler,assist device with REMOVE FROM Non-Formulary chamber large mask FORMULARY 07/31/2020 compact space inhaler,assist device with REMOVE FROM Non-Formulary chamber medium mask FORMULARY 07/31/2020 minimed infusion set for insulin pump REMOVE FROM Non-Formulary silhouette FORMULARY 07/31/2020 minimed infusion set for insulin pump REMOVE FROM Non-Formulary silhouette FORMULARY 07/31/2020 hemorrhoidal lidocaine REMOVE FROM Non-Formulary relief FORMULARY 07/31/2020 maxi-tuss gmx guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 07/31/2020 maxi-tuss g guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 07/31/2020 maxi-tuss ac codeine REMOVE FROM Non-Formulary phosphate/guaifenesin FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 175 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 maxi-tuss jr dextromethorphan REMOVE FROM Non-Formulary hbr/phenylephrine hcl FORMULARY 07/31/2020 maxi-tuss pe jr guaifenesin/phenylephrine REMOVE FROM Non-Formulary hcl FORMULARY 07/31/2020 maxi-tuss pe max guaifenesin/phenylephrine REMOVE FROM Non-Formulary hcl FORMULARY 07/31/2020 maxi-tuss pe brompheniramine REMOVE FROM Non-Formulary maleate/phenylephrine hcl FORMULARY 07/31/2020 therapeutic salicylic acid REMOVE FROM Non-Formulary dandruff FORMULARY shampoo 07/31/2020 MEGARED omega-3 fatty REMOVE FROM Non-Formulary ADVANCED acids/dha/epa/schizochytriu FORMULARY OMEGA-3 m algal oil ALGAE 07/31/2020 MEGARED krill oil/omega-3 fatty REMOVE FROM Non-Formulary OMEGA-3 KRILL acids/dha/epa/phospholipids FORMULARY OIL /astaxan 07/31/2020 MEGARED omega-3 fatty REMOVE FROM Non-Formulary ADVANCED 4- acids/docosahexaenoic FORMULARY IN-1 GUMMY acid/epa/fish oil 07/31/2020 MEGARED krill oil/hyaluronic REMOVE FROM Non-Formulary JOINT CARE acid/astaxanthin FORMULARY 07/31/2020 MEGARED KIDS omega-3 fatty REMOVE FROM Non-Formulary acids/docosahexaenoic FORMULARY acid/epa/fish oil 07/31/2020 DERMACINRX capsicum oleoresin REMOVE FROM Non-Formulary PENETRAL FORMULARY 07/31/2020 MUCINEX guaifenesin/phenylephrine REMOVE FROM Non-Formulary SINUS-MAX hcl/acetaminophen FORMULARY CONGEST-PAIN

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 176 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 pixel covid19 covid-19 test specimen REMOVE FROM Non-Formulary home collect kit collection FORMULARY 07/31/2020 sodium sodium bicarbonate ADD TO FORMULARY Injectables bicarbonate 07/31/2020 sodium sodium bicarbonate ADD TO FORMULARY Injectables bicarbonate 07/31/2020 sodium sodium bicarbonate ADD TO FORMULARY Injectables bicarbonate 07/31/2020 sodium sodium bicarbonate ADD TO FORMULARY Injectables bicarbonate 07/31/2020 dicyclomine hcl dicyclomine hcl ADD TO FORMULARY Injectables 07/31/2020 milrinone lactate milrinone lactate ADD TO FORMULARY Injectables 07/31/2020 milrinone lactate milrinone lactate ADD TO FORMULARY Injectables 07/31/2020 milrinone lactate milrinone lactate ADD TO FORMULARY Injectables 07/31/2020 levoleucovorin levoleucovorin calcium ADD TO FORMULARY Injectables calcium 07/31/2020 tranexamic acid tranexamic acid ADD TO FORMULARY Injectables 07/31/2020 tranexamic acid tranexamic acid ADD TO FORMULARY Injectables 07/31/2020 PENICILLIUM allergenic extract-penicillium REMOVE FROM Non-Formulary NOTATUM notatum FORMULARY 07/31/2020 PENICILLIUM allergenic extract-penicillium REMOVE FROM Non-Formulary NOTATUM notatum FORMULARY 07/31/2020 PENICILLIUM allergenic extract-penicillium REMOVE FROM Non-Formulary NOTATUM notatum FORMULARY 07/31/2020 PENICILLIUM allergenic extract-penicillium REMOVE FROM Non-Formulary NOTATUM notatum FORMULARY 07/31/2020 PENICILLIUM allergenic extract-penicillium REMOVE FROM Non-Formulary NOTATUM notatum FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 177 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 07/31/2020 ASPERGILLUS allergenic extract-aspergillus REMOVE FROM Non-Formulary FUMIGATUS fumigatus FORMULARY 07/31/2020 ASPERGILLUS allergenic extract-aspergillus REMOVE FROM Non-Formulary FUMIGATUS fumigatus FORMULARY 07/31/2020 ASPERGILLUS allergenic extract-aspergillus REMOVE FROM Non-Formulary FUMIGATUS fumigatus FORMULARY 07/31/2020 AUREOBASIDIU allergenic extract- REMOVE FROM Non-Formulary M PULLULANS aureobasidium pullulans FORMULARY 07/31/2020 AUREOBASIDIU allergenic extract- REMOVE FROM Non-Formulary M PULLULANS aureobasidium pullulans FORMULARY 07/31/2020 AUREOBASIDIU allergenic extract- REMOVE FROM Non-Formulary M PULLULANS aureobasidium pullulans FORMULARY 07/31/2020 metyrosine metyrosine REMOVE FROM Non-Formulary FORMULARY 07/31/2020 AZADROX silver/urea REMOVE FROM Non-Formulary FORMULARY 07/31/2020 ENBREL etanercept ADD TO FORMULARY Preferred Specialty 07/31/2020 ENBREL etanercept ADD TO FORMULARY Preferred Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 178 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

August, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2020 SCENESSE afamelanotide acetate ADD UM: MED Medical Drug 08/01/2020 toradol,ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 10 / 28 days tromethamine 08/01/2020 ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 10 / 28 days tromethamine 08/01/2020 toradol,ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 20 / 28 days tromethamine 08/01/2020 toradol,ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 10 / 28 days tromethamine 08/01/2020 ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 20 / 28 days tromethamine 08/01/2020 ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 20 / 28 days tromethamine 08/01/2020 toradol,ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 20 / 28 days tromethamine 08/01/2020 toradol,ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 20 / 28 days tromethamine 08/01/2020 toradol,ketorolac ketorolac tromethamine CHANGE UM: QUANTITY 4 / 28 days 20 / 28 days tromethamine 08/01/2020 thiotepa thiotepa ADD UM: MED Medical Drug 08/01/2020 tc99m mertiatide kit for prep tc-99m/mertiatide ADD UM: MED Medical Drug prep (betiatide) 08/01/2020 ziprasidone ziprasidone mesylate ADD UM: MED Medical Drug mesylate 08/01/2020 ZIRABEV bevacizumab-bvzr ADD UM: MED Medical Drug 08/01/2020 ANJESO meloxicam ADD UM: MED Medical Drug 08/01/2020 TEPEZZA teprotumumab-trbw ADD UM: MED Medical Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 179 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2020 TRAZIMERA trastuzumab-qyyp ADD UM: MED Medical Drug 08/01/2020 ONTRUZANT trastuzumab-dttb ADD UM: MED Medical Drug 08/01/2020 RUXIENCE rituximab-pvvr ADD UM: MED Medical Drug 08/01/2020 ONTRUZANT trastuzumab-dttb ADD UM: MED Medical Drug 08/01/2020 ROMIDEPSIN romidepsin ADD UM: MED Medical Drug 08/01/2020 TEPEZZA teprotumumab-trbw ADD UM: MED Medical Drug 08/01/2020 geodon,ziprasido ziprasidone mesylate CHANGE UM: MED Medical Drug ne mesylate 08/01/2020 TRIKAFTA elexacaftor/tezacaftor/ivacaft CHANGE TIER Non-Preferred Preferred or Specialty Specialty 08/01/2020 TRIKAFTA elexacaftor/tezacaftor/ivacaft ADD UM: QUANTITY 3 / 1 days or 08/01/2020 ADAKVEO crizanlizumab-tmca ADD UM: MED Medical Drug 08/01/2020 RYDAPT midostaurin REMOVE UM: QUANTITY 1 / 1 DAY 08/01/2020 SARCLISA isatuximab-irfc ADD UM: MED Medical Drug 08/01/2020 SYMTUZA darunavir ADD TO FORMULARY Non-Preferred eth/cobicistat/emtricitabine/t Specialty enofovir alafenamide 08/01/2020 VUMERITY diroximel fumarate ADD TO FORMULARY Preferred Specialty 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 180 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 XCOPRI cenobamate ADD TO FORMULARY Non-Preferred Brands 08/01/2020 KOSELUGO selumetinib sulfate/vitamin e ADD TO FORMULARY Preferred tpgs Specialty 08/01/2020 TRIKAFTA elexacaftor/tezacaftor/ivacaft ADD UM: LIMITEDACCESS Limited Access or 08/01/2020 TERIPARATIDE teriparatide ADD TO FORMULARY Non-Preferred Specialty 08/01/2020 FASENRA PEN benralizumab ADD UM: LIMITEDACCESS Limited Access 08/01/2020 KOSELUGO selumetinib sulfate/vitamin e ADD TO FORMULARY Preferred tpgs Specialty 08/01/2020 oxycontin,oxycod oxycodone hcl CHANGE UM: QUANTITY 2 / 1 days one hcl er 08/01/2020 OXYCONTIN,OX oxycodone hcl CHANGE UM: QUANTITY 2 / 1 days YCODONE HCL ER 08/01/2020 TAZVERIK tazemetostat hydrobromide ADD TO FORMULARY Non-Preferred Specialty 08/01/2020 VYEPTI eptinezumab-jjmr ADD UM: MED Medical Drug 08/01/2020 vecuronium vecuronium bromide CHANGE TIER Injectables bromide

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 181 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2020 testosterone testosterone cypionate CHANGE TIER Non-Preferred cypionate Brands 08/01/2020 carisoprodol carisoprodol CHANGE TIER Preferred Generics 08/01/2020 oxycodone hcl oxycodone hcl ADD TO FORMULARY Non-Preferred Generics 08/01/2020 baby's super cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Preventative daily d3 08/01/2020 kids first vitamin cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Preventative d3 08/01/2020 VENOFER iron sucrose complex REMOVE FROM Non-Formulary FORMULARY 08/01/2020 charlotte 24 fe norethindrone acetate- ADD TO FORMULARY Preventative ethinyl estradiol/ferrous fumarate 08/01/2020 KITABIS PAK tobramycin/nebulizer REMOVE FROM Injectables Non-Formulary FORMULARY 08/01/2020 water water for injection,sterile REMOVE FROM Injectables Non-Formulary FORMULARY 08/01/2020 acetic acid acetic acid REMOVE FROM Non-Formulary FORMULARY 08/01/2020 weekly-d cholecalciferol (vitamin d3) ADD TO FORMULARY Non-Formulary Preventative 08/01/2020 venlafaxine hcl er venlafaxine hcl CHANGE UM: QUANTITY 1 / 1 days 08/01/2020 oxycodone oxycodone hcl CHANGE UM: QUANTITY 10 / 1 days hcl,oxyir 08/01/2020 levo- levorphanol tartrate CHANGE UM: QUANTITY 8 / 1 days dromoran,levorph anol tartrate 08/01/2020 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 2 / 1 days er,kadian

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 182 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2020 ZOLPIMIST zolpidem tartrate CHANGE UM: QUANTITY 8 / 30 days 08/01/2020 fentanyl fentanyl CHANGE UM: QUANTITY 10 / 30 days 08/01/2020 fentanyl fentanyl CHANGE UM: QUANTITY 15 / 30 days 08/01/2020 treximet,sumatrip sumatriptan CHANGE UM: QUANTITY 9 / 30 days tan succ- succinate/naproxen sodium naproxen sod 08/01/2020 dolophine methadone hcl CHANGE UM: QUANTITY 8 / 1 days hcl,methadone hcl,methadose

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 183 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2020 answer,contour blood sugar diagnostic CHANGE UM: QUANTITY 5 / 1 days test strip,contour next test strip,relion confirm-micro,bg- star,advance test strips,assure pro,assure platinum,assure 4,glucocard expression,pocke tchem ez,relion prime test strips,micro,gluco card 01 sensor plus,glucocard x- sensor,glucocard vital,glucocard vital sensor,evencare g2,evencare,eve ncare g3,blood glucose test strip,easygluco test strips,easy gluco g2,control ast test strip,control,g- 4,maxima,infinity test strips,acura test strips,easygluco plus,easy pro plus,prodigy,prodi gy eject,prodigy no coding,prodigy autocode,prodigy voice,easy touch test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 184 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strip,eclipse,envis ion,evolution test strips,element test strips,smartdiabet es xpres,element plus,element compact,glucolab ,smartest test,glucocom glucose,rightest gs300 test strips,rightest gs100 test strips,rightest gs550 test strips,ge100 blood glucose test strip,nova max glucose test strips,keynote,wa vesense jazz,wavesense presto,agamatrix amp,liberty test strips,ultratrak,ult ratrak ultimate,solus v2 test strips,caresens n,smart caresens n,reveal test strip,glucose test strip,truetest test strips,truetrack test strip,premium blood glucose test,foracare

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 185 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value gd20,fora v10,choicedm g20,fora g20,fora test strip,fora g71a,foracare gd40,premium v10,test n'go,fora v12,refuah plus,surechek test strips,sure edge test strips,vocal point,ultratrak pro,truetrack smart system,easymax, easymax 15,easyplus,td gold test strip,myglucoheal th,accu-chek comfort curve,accu-chek active,microdot,m icrodot xtra,ez smart,ez smart plus,one touch verio,fast take,surestep,on e touch test strips,onetouch ultra blue test strp,onetouch verio test strip,onetouch ultra test strips,surestep pro,glucostix,test strips,test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 186 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strip,prestige test strips,prestige smart system,precision pcx plus,precision point of care,optium ez,precision q-i- d,precision pcx,optium,precis ion xtra,neutek 2tek test strips,telcare,sure -test easyplus mini,accu-chek aviva,accutrend glucose,accu- chek aviva plus,accu-chek smartview,ultima, on call plus test strip,optumrx,on call vivid test strip,gmate test strips,gluco navii,choicedm clarus test strips,quintet,quin tet ac,easy step,easy plus,easy trak,easy talk,easy plus ii,easy check test strip,diatrue plus,fifty50 test strip,embrace,vict ory,advocate test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 187 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strip,advocate redi- code,advocate redi-code+,clever choice test strips,clever choice voice+ tst strip,clever choice pro,pharmacist choice,clever choice micro test strip,clever choice talk,fora v10-v12-d10- d20,fora d15c,fora d15z,fora v20,fora v22,fora g30-premium v10 test strp,fora d15g,fora d20,fora g90,fora v30a,freestyle test strips,freestyle lite test strip,freestyle lite strips,freestyle insulinx test strips,freestyle insulinx,rightest gs260 test strips,glucometer elite,ascensia elite,pts panels,bioscanne r glucose test,at- last test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 188 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strips,assure ii,quicktek,assure 3,supreme test strips,smart sense test strips,nexgen,eas ypro,duo- care,accu-chek instant plus,accu- chek instant,one touch ultra test strips,accu-chek advantage,life medical test strip,diabetic.com test strip,sentry test strip,precision sof- tact,exactech,exa ctech rsg,rightest gs250s test strips,glucometer encore,glucofilm, glucostix reagent,visidex ii,seralyzer glucose,dextrosti x reagent,glucomet er dex,glucose test strips,duet,expres s view glucose test strp,glucoprotein, quick-check one,quick-check ii,quick-check

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 189 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value film,excel ge,excel g,uni- check,bd test strips,checkmate, checkmate plus,select gt,assure,senova, glucoleader,valus trip test strips,kyodex reagent,longs blood glucose strip,biotel hi- value v,biotel hi- value 3,truetrack,diasca n,diascan test strips,diascan dual pad test strips,diascan dual pad strips,ultra standard strips,ultra +,ultra,swiftcheck ,blood glucose test,tt strips,accu- chek,accu-chek simplicity,chemstr ip bg,tracer bg,blood glucose 3 test,reagent,gluc oscan test strips,glucoscan/ gm test strips,one touch,trendstrips, diascan first choice,trackease,

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 190 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value relief plus,companion 2,medisense 2 test strips,sof- tact,supreme confidence strips,ga test strips,one touch ii test strips,first choice,glucose alert,genstrip,unis trip1,onetouch verio,embrace evo,embrace pro test strip,on call express test strip,healthpro glucose test strips,advanced glucose test strips,true metrix glucose test strip,fora gd50 test strips,fora test n'go test strips,fortiscare glucose test strips,assure prism multi,glucocard shine,genultimate test strip,evencare mini glucose test str,fora tn'g voice test strips,freestyle precision neo,fora d40-g31

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 191 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value test strips,cool glucose test strip,accu-chek guide test strip,dario blood glucose test strip,iglucose test strip,infinity voice test strip,premier test strip,caretouch test strip,verasens test strip,goodlife ac-302 test strip,true metrix pro test strip,harmony glucose test strip,evencare proview test strip,pro voice v8- v9 test strip,fora 6 connect glucose strip,advanced glucose test strip,embrace talk test strip,fora gtel glucose test strip,vivaguard ino test strip,assure platinum test strip,gojji blood glucose test strip,agamatrix presto

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 192 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/01/2020 sodium sodium phenylbutyrate CHANGE UM: Limited Access phenylbutyrate LIMITEDACCESS 08/01/2020 dexamethasone dexamethasone sodium REMOVE FROM Non-Formulary sodium phosphate,dexamethasone FORMULARY phosphate sod phosphate 08/01/2020 hydroxychloroqui hydroxychloroquine sulfate REMOVE FROM Non-Formulary ne sulfate FORMULARY 08/01/2020 diltiazem hcl diltiazem hcl REMOVE FROM Non-Formulary FORMULARY 08/01/2020 vitamin d3 cholecalciferol (vitamin d3) CHANGE TIER Preventative 08/01/2020 emend,fosaprepit fosaprepitant dimeglumine CHANGE TIER Injectables ant dimeglumine 08/01/2020 cocaine cocaine hcl CHANGE TIER Injectables hcl,goprelto,num brino 08/01/2020 cocaine cocaine hcl CHANGE UM: MED Medical Drug hcl,goprelto,num brino 08/01/2020 ZIEXTENZO pegfilgrastim-bmez ADD TO FORMULARY Injectables 08/01/2020 TEPEZZA teprotumumab-trbw ADD TO FORMULARY Injectables 08/01/2020 VYEPTI eptinezumab-jjmr ADD TO FORMULARY Injectables 08/01/2020 SCENESSE afamelanotide acetate ADD TO FORMULARY Injectables 08/01/2020 ANJESO meloxicam ADD TO FORMULARY Non-Formulary Injectables 08/03/2020 midazolam hcl- midazolam in sodium ADD UM: MED Medical Drug 0.8% nacl chloride, iso-osmotic/pf 08/05/2020 AVSOLA infliximab-axxq ADD UM: MED Medical Drug 08/07/2020 CLOZAPINE clozapine ADD TO FORMULARY Non-Preferred ODT Brands

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 193 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 CLOZAPINE clozapine ADD TO FORMULARY Non-Preferred ODT Brands 08/07/2020 CLOZAPINE clozapine ADD TO FORMULARY Non-Preferred ODT Brands 08/07/2020 imiquimod imiquimod ADD TO FORMULARY Non-Preferred Brands 08/07/2020 prosilk gel protectives combination no.6 REMOVE FROM Non-Formulary FORMULARY 08/07/2020 vitamin c ascorbic acid REMOVE FROM Non-Formulary FORMULARY 08/07/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 08/07/2020 choline bitartrate choline bitartrate REMOVE FROM Non-Formulary FORMULARY 08/07/2020 bacitracin zinc bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 08/07/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 08/07/2020 bacitracin bacitracin REMOVE FROM Non-Formulary FORMULARY 08/07/2020 lidocaine lidocaine REMOVE FROM Non-Formulary FORMULARY 08/07/2020 beta carotene beta-carotene REMOVE FROM Non-Formulary FORMULARY 08/07/2020 cetirizine hcl cetirizine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 194 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 cetirizine hcl cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 cetirizine hcl cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 sulfacetamide sulfacetamide sodium REMOVE FROM Non-Formulary sodium FORMULARY 08/07/2020 NEO- phenylephrine hcl REMOVE FROM Non-Formulary SYNEPHRINE FORMULARY 08/07/2020 brompheniramine brompheniramine REMOVE FROM Non-Formulary -pseudoephed- maleate/pseudoephedrine FORMULARY dm hcl/dextromethorphan 08/07/2020 brompheniramine brompheniramine REMOVE FROM Non-Formulary -pseudoephed- maleate/pseudoephedrine FORMULARY dm hcl/dextromethorphan 08/07/2020 clotrimazole clotrimazole REMOVE FROM Non-Formulary FORMULARY 08/07/2020 VIBRAMYCIN doxycycline calcium REMOVE FROM Non-Formulary FORMULARY 08/07/2020 loratadine loratadine REMOVE FROM Non-Formulary FORMULARY 08/07/2020 loratadine loratadine REMOVE FROM Non-Formulary FORMULARY 08/07/2020 loratadine loratadine REMOVE FROM Non-Formulary FORMULARY 08/07/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 08/07/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 195 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 senna plus sennosides/docusate REMOVE FROM Non-Formulary sodium FORMULARY 08/07/2020 allergy relief d-12 loratadine/pseudoephedrine REMOVE FROM Non-Formulary sulfate FORMULARY 08/07/2020 capsaicin capsaicin REMOVE FROM Non-Formulary FORMULARY 08/07/2020 allergy relief diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 tizanidine hcl tizanidine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 tizanidine hcl tizanidine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 tizanidine hcl tizanidine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/07/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/07/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/07/2020 hrt base botanical cream base no.91 REMOVE FROM Non-Formulary FORMULARY 08/07/2020 niacin niacin REMOVE FROM Non-Formulary FORMULARY 08/07/2020 testosterone testosterone cypionate, REMOVE FROM Non-Formulary cypionate micro micronized FORMULARY 08/07/2020 STENDRA avanafil REMOVE FROM Non-Formulary FORMULARY 08/07/2020 baby buddha breast pump REMOVE FROM Non-Formulary breast pump FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 196 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 vivaguard ino test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 08/07/2020 diclofenac diclofenac sodium, REMOVE FROM Non-Formulary sodium micronized FORMULARY micronized 08/07/2020 diclofenac diclofenac sodium, REMOVE FROM Non-Formulary sodium micronized FORMULARY micronized 08/07/2020 diclofenac diclofenac sodium, REMOVE FROM Non-Formulary sodium micronized FORMULARY micronized 08/07/2020 TETRIX protectives combination no.2 REMOVE FROM Non-Formulary FORMULARY 08/07/2020 diclofenac diclofenac sodium, REMOVE FROM Non-Formulary sodium micronized FORMULARY micronized 08/07/2020 diclofenac diclofenac sodium, REMOVE FROM Non-Formulary sodium micronized FORMULARY micronized 08/07/2020 diclofenac diclofenac sodium, REMOVE FROM Non-Formulary sodium micronized FORMULARY micronized 08/07/2020 uristat ultra phenazopyridine hcl REMOVE FROM Non-Formulary FORMULARY 08/07/2020 anti-itch vaginal benzocaine//aloe REMOVE FROM Non-Formulary max strength vera/vitamin e acetate/vit a,d FORMULARY 08/07/2020 airborne plus multivit with minerals/vitamin REMOVE FROM Non-Formulary good rest c/theanine/herb no.310 FORMULARY 08/07/2020 airborne multivit with REMOVE FROM Non-Formulary everyday stress minerals/ascorbic FORMULARY away acid/theanine/herb no.310

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 197 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 anti-itch vaginal benzocaine/resorcinol REMOVE FROM Non-Formulary FORMULARY 08/07/2020 child mucus- guaifenesin/dextromethorph REMOVE FROM Non-Formulary cough relief an hbr FORMULARY 08/07/2020 oyster shell calcium REMOVE FROM Non-Formulary calcium-vit d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 08/07/2020 EFFACLAR salicylic acid/benzoyl REMOVE FROM Non-Formulary ACNE SYSTEM peroxide FORMULARY (3 STEP) 08/07/2020 INVIGOFLEX GS glucosamine sulfate REMOVE FROM Non-Formulary dipotassium chlor/boswellia FORMULARY serrata ext 08/07/2020 MOVE FREE cholecalciferol (vit REMOVE FROM Non-Formulary ULTRA- d3)/vitamin k2/calcium FORMULARY BORATE-K2-D3 fructoborate 08/07/2020 MOVE FREE glucosamine/chondroitin/ms REMOVE FROM Non-Formulary PLUS MSM-VIT m/d3/hyaluronic acid/cal FORMULARY D3 borate 08/07/2020 MAXIFED TR triprolidine REMOVE FROM Non-Formulary hcl/pseudoephedrine hcl FORMULARY 08/07/2020 CERTAVITE- multivitamin/ferrous REMOVE FROM Non-Formulary ANTIOXIDANT fumarate/folic acid FORMULARY 08/07/2020 prosilk gel-matrix pad dressing, REMOVE FROM Non-Formulary silicone FORMULARY 08/07/2020 pediatric comp- nebulizer and compressor REMOVE FROM Non-Formulary air compres neb FORMULARY 08/07/2020 vivaguard ino blood-glucose meter REMOVE FROM Non-Formulary smart gluc meter FORMULARY 08/07/2020 NORMOSOL-R electrolyte-r ADD TO FORMULARY Injectables AND DEXTROSE solution/dextrose 5 % in water

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 198 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/07/2020 neostigmine neostigmine methylsulfate ADD TO FORMULARY Injectables methylsulfate 08/07/2020 neostigmine neostigmine methylsulfate ADD TO FORMULARY Injectables methylsulfate 08/07/2020 CYCLOPHOSPH cyclophosphamide ADD TO FORMULARY Injectables AMIDE 08/07/2020 CYCLOPHOSPH cyclophosphamide ADD TO FORMULARY Injectables AMIDE 08/07/2020 methacholine methacholine chloride ADD TO FORMULARY Injectables chloride 08/07/2020 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 08/07/2020 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 08/07/2020 deferasirox deferasirox ADD TO FORMULARY Non-Preferred Specialty 08/07/2020 sofia sars antigen covid-19 antigen REMOVE FROM Non-Formulary fia immunoassay test FORMULARY 08/07/2020 TRICHOPHYTO allergenic extract- REMOVE FROM Non-Formulary N trichophyton FORMULARY MENTAGROPHY mentagrophytes TES 08/07/2020 TRICHOPHYTO allergenic extract- REMOVE FROM Non-Formulary N trichophyton FORMULARY MENTAGROPHY mentagrophytes TES 08/07/2020 TRICHOPHYTO allergenic extract- REMOVE FROM Non-Formulary N trichophyton FORMULARY MENTAGROPHY mentagrophytes TES 08/14/2020 WAKIX pitolisant hcl ADD UM: SPECIALTY Specialty Drug

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 199 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 WAKIX pitolisant hcl ADD UM: SPECIALTY Specialty Drug 08/14/2020 DERMACINRX cholecalciferol (vit d3)/folic REMOVE FROM Non-Formulary FOLIXAPURE acid FORMULARY 08/14/2020 sesame oil sesame oil REMOVE FROM Non-Formulary FORMULARY 08/14/2020 polyethylene polyethylene glycol 3350 REMOVE FROM Non-Formulary glycol 3350 FORMULARY 08/14/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/14/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/14/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY 08/14/2020 mifepristone REMOVE FROM Non-Formulary FORMULARY 08/14/2020 loratadine loratadine REMOVE FROM Non-Formulary FORMULARY 08/14/2020 NEO- phenylephrine hcl REMOVE FROM Non-Formulary SYNEPHRINE FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 200 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 omeprazole omeprazole REMOVE FROM Non-Formulary FORMULARY 08/14/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 08/14/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 08/14/2020 calcium calcium REMOVE FROM Non-Formulary carbonate/cholecalciferol FORMULARY (vitamin d3) 08/14/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 08/14/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 201 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 08/14/2020 dimenhydrinate dimenhydrinate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 dimenhydrinate dimenhydrinate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 dimenhydrinate dimenhydrinate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 dimenhydrinate dimenhydrinate REMOVE FROM Non-Formulary FORMULARY 08/14/2020 anti-itch menthol/camphor REMOVE FROM Non-Formulary FORMULARY 08/14/2020 children's pediatric multivitamin no.17 REMOVE FROM Non-Formulary multivitamin FORMULARY 08/14/2020 trochibase s troche base no.131 REMOVE FROM Non-Formulary FORMULARY 08/14/2020 lubricant eye mineral oil/petrolatum,white REMOVE FROM Non-Formulary FORMULARY 08/14/2020 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 08/14/2020 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 08/14/2020 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 08/14/2020 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 08/14/2020 ASPERCREME lidocaine hcl REMOVE FROM Non-Formulary LIDOCAINE FORMULARY 08/14/2020 airborne multivitamin- REMOVE FROM Non-Formulary minerals/ascorbic FORMULARY acid/herbal no.124

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 202 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 TAB-A-VITE multivitamin with folic acid REMOVE FROM Non-Formulary FORMULARY 08/14/2020 HIGH POTENCY multivitamin with folic acid REMOVE FROM Non-Formulary MULTIVITAMIN FORMULARY 08/14/2020 vivaguard ino blood glucose calibration REMOVE FROM Non-Formulary control solution control high and low FORMULARY 08/14/2020 vivaguard ino blood glucose calibration REMOVE FROM Non-Formulary control solution control solution, normal FORMULARY 08/14/2020 vitamin b6 pyridoxine hcl (vitamin b6) REMOVE FROM Non-Formulary FORMULARY 08/14/2020 folika probiotic lactobacillus REMOVE FROM Non-Formulary acidophilus/bifidobacterium FORMULARY animalis 08/14/2020 dulcolax magnesium hydroxide REMOVE FROM Non-Formulary FORMULARY 08/14/2020 mcl lidocaine/methyl REMOVE FROM Non-Formulary salicylate/camphor FORMULARY 08/14/2020 folika-nc vitamin b complex/folic REMOVE FROM Non-Formulary acid/ascorbic acid/biotin FORMULARY 08/14/2020 fosaprepitant fosaprepitant dimeglumine ADD TO FORMULARY Injectables dimeglumine 08/14/2020 VASOSTRICT vasopressin ADD TO FORMULARY Injectables 08/14/2020 moxifloxacin moxifloxacin hcl in sodium ADD TO FORMULARY Injectables chloride,iso-osmotic/pf 08/14/2020 moxifloxacin moxifloxacin hcl in sodium ADD TO FORMULARY Injectables chloride,iso-osmotic/pf 08/14/2020 ciprofloxacin- ciprofloxacin ADD TO FORMULARY Non-Preferred dexamethasone hcl/dexamethasone Generics 08/14/2020 ciprofloxacin- ciprofloxacin ADD TO FORMULARY Non-Preferred dexamethasone hcl/dexamethasone Generics

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 203 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/14/2020 pantoprazole pantoprazole sodium ADD TO FORMULARY Non-Preferred sodium Generics 08/19/2020 moxifloxacin moxifloxacin hcl in sodium ADD UM: MED Medical Drug chloride,iso-osmotic/pf 08/19/2020 moxifloxacin moxifloxacin hcl in sodium ADD UM: MED Medical Drug chloride,iso-osmotic/pf 08/19/2020 DUPIXENT PEN dupilumab ADD UM: QUANTITY 4 / 28 days 08/19/2020 SIRTURO bedaquiline fumarate ADD UM: LIMITEDACCESS Limited Access 08/21/2020 BACIGUENT bacitracin ADD TO FORMULARY Non-Preferred Brands 08/21/2020 fluoxetine hcl fluoxetine hcl REMOVE FROM Non-Formulary FORMULARY 08/21/2020 fluoxetine hcl fluoxetine hcl REMOVE FROM Non-Formulary FORMULARY 08/21/2020 aminophylline aminophylline REMOVE FROM Non-Formulary FORMULARY 08/21/2020 aminophylline aminophylline REMOVE FROM Non-Formulary FORMULARY 08/21/2020 fluoxetine hcl fluoxetine hcl REMOVE FROM Non-Formulary FORMULARY 08/21/2020 fluoxetine hcl fluoxetine hcl REMOVE FROM Non-Formulary FORMULARY 08/21/2020 TYLENOL acetaminophen REMOVE FROM Non-Formulary FORMULARY 08/21/2020 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 08/21/2020 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY 08/21/2020 esomeprazole esomeprazole magnesium REMOVE FROM Non-Formulary magnesium FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 204 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2020 ZELNORM tegaserod hydrogen maleate REMOVE FROM Non-Formulary FORMULARY 08/21/2020 ketotifen ketotifen fumarate REMOVE FROM Non-Formulary fumarate FORMULARY 08/21/2020 ALEVE-D SINUS naproxen REMOVE FROM Non-Formulary AND COLD sodium/pseudoephedrine FORMULARY hcl 08/21/2020 fora gtel ketone blood ketone test, strips REMOVE FROM Non-Formulary test strip FORMULARY 08/21/2020 vancomycin hcl vancomycin hcl in water for REMOVE FROM Non-Formulary injection (peg-400, nada) FORMULARY 08/21/2020 quick temp thermometer, infrared, non- REMOVE FROM Non-Formulary infrared thermom contact FORMULARY 08/21/2020 pro temp thermometer, electronic,oral REMOVE FROM Non-Formulary thermometer FORMULARY 08/21/2020 lifestylecomfort compression socks, large REMOVE FROM Non-Formulary socks FORMULARY 08/21/2020 minimed quick infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 08/21/2020 minimed quick infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 08/21/2020 minimed quick infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 08/21/2020 minimed quick infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 08/21/2020 minimed quick infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 08/21/2020 minimed quick infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY 08/21/2020 minimed quick infusion set for insulin pump REMOVE FROM Non-Formulary set FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 205 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2020 easy trak ii blood glucose calibration REMOVE FROM Non-Formulary control solution control solution, normal FORMULARY 08/21/2020 easy trak ii test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 08/21/2020 BENADRYL phenylephrine REMOVE FROM Non-Formulary ALLERGY PLUS hcl/diphenhydramine hcl FORMULARY CONGEST 08/21/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 08/21/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 08/21/2020 BOTRYTIS allergenic extract-botrytis REMOVE FROM Non-Formulary CINEREA cinerea FORMULARY 08/21/2020 BOTRYTIS allergenic extract-botrytis REMOVE FROM Non-Formulary CINEREA cinerea FORMULARY 08/21/2020 BOTRYTIS allergenic extract-botrytis REMOVE FROM Non-Formulary CINEREA cinerea FORMULARY 08/21/2020 ASPERGILLUS allergenic extract-aspergillus REMOVE FROM Non-Formulary FUMIGATUS fumigatus FORMULARY 08/21/2020 ASPERGILLUS allergenic extract-aspergillus REMOVE FROM Non-Formulary FUMIGATUS fumigatus FORMULARY 08/21/2020 EPICOCCUM allergenic extract-epicoccum REMOVE FROM Non-Formulary NIGRUM nigrum FORMULARY 08/21/2020 EPICOCCUM allergenic extract-epicoccum REMOVE FROM Non-Formulary NIGRUM nigrum FORMULARY 08/21/2020 vancomycin hcl vancomycin hcl in water for REMOVE FROM Non-Formulary injection (peg-400, nada) FORMULARY 08/21/2020 vancomycin hcl vancomycin hcl in water for REMOVE FROM Non-Formulary injection (peg-400, nada) FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 206 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/21/2020 XYZMUNE vitamin c/d3/folic REMOVE FROM Non-Formulary acid/zinc/lysine/herbal FORMULARY complex no.312 08/21/2020 FORTAZ ceftazidime ADD TO FORMULARY Injectables 08/21/2020 FORTAZ ceftazidime ADD TO FORMULARY Injectables 08/21/2020 FORTAZ ceftazidime ADD TO FORMULARY Injectables 08/21/2020 dimethyl dimethyl fumarate REMOVE FROM Non-Formulary fumarate FORMULARY 08/21/2020 dimethyl dimethyl fumarate REMOVE FROM Non-Formulary fumarate FORMULARY 08/21/2020 inavix diclofenac sodium/capsaicin REMOVE FROM Non-Formulary FORMULARY 08/21/2020 ZCORT dexamethasone REMOVE FROM Non-Formulary FORMULARY 08/26/2020 sterile water for water for injection,sterile ADD TO FORMULARY Non-Formulary Injectables ic-green 08/26/2020 sterile water for water for injection,sterile ADD UM: MED Medical Drug ic-green 08/26/2020 water water for injection,sterile CHANGE TIER Injectables 08/26/2020 vanadom carisoprodol CHANGE TIER Non-Preferred Preferred Generics Generics 08/26/2020 levonorgestrel levonorgestrel CHANGE TIER Preventative 08/26/2020 maxi-tuss ac codeine ADD TO FORMULARY Non-Formulary Preferred phosphate/guaifenesin Generics 08/26/2020 folic acid,hm folic folic acid CHANGE TIER Preventative acid 08/26/2020 thallous chloride thallous chloride tl-201 CHANGE TIER Injectables tl-201

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 207 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/26/2020 prothelial sucralfate malate, REMOVE UM: Limited Access polymerized LIMITEDACCESS 08/26/2020 KITABIS PAK tobramycin/nebulizer REMOVE UM: Limited Access LIMITEDACCESS 08/26/2020 viagra,sildenafil sildenafil citrate CHANGE UM: QUANTITY 8 / 30 days citrate 08/26/2020 viagra,sildenafil sildenafil citrate CHANGE UM: QUANTITY 8 / 30 days citrate 08/26/2020 viagra,sildenafil sildenafil citrate CHANGE UM: QUANTITY 8 / 30 days citrate 08/26/2020 varithena transfer set/syringe, REMOVE UM: Limited Access administration disposable/bandages,compr LIMITEDACCESS pack ession/tubing 08/28/2020 AZALGIA glucosamine/methylsulf/vit REMOVE FROM Non-Formulary c/folic ac/manganese/diet 29 FORMULARY 08/28/2020 glostrips fluorescein sodium REMOVE FROM Non-Formulary FORMULARY 08/28/2020 glostrips fluorescein sodium REMOVE FROM Non-Formulary FORMULARY 08/28/2020 all day pain relief naproxen sodium REMOVE FROM Non-Formulary FORMULARY 08/28/2020 all day pain relief naproxen sodium REMOVE FROM Non-Formulary FORMULARY 08/28/2020 all day pain relief naproxen sodium REMOVE FROM Non-Formulary FORMULARY 08/28/2020 PHENEX-2 nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria (pku) with FORMULARY iron no.1 08/28/2020 PHENEX-2 nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria (pku) with FORMULARY iron no.1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 208 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 08/28/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 08/28/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 08/28/2020 I-VALEX-2 nutritional therapy for REMOVE FROM Non-Formulary isovaleric acidemia with iron FORMULARY 08/28/2020 HOMINEX-2 nutritional therapy, REMOVE FROM Non-Formulary metabolic disorder, FORMULARY methionine-free 08/28/2020 KETONEX-2 nutritional therapy for msud REMOVE FROM Non-Formulary with iron FORMULARY 08/28/2020 GLUTAREX-2 nutritional therapy, glutaric REMOVE FROM Non-Formulary aciduria type 1 FORMULARY 08/28/2020 lansoprazole lansoprazole REMOVE FROM Non-Formulary FORMULARY 08/28/2020 lansoprazole lansoprazole REMOVE FROM Non-Formulary FORMULARY 08/28/2020 CYCLINEX-2 nutritional therapy, urea REMOVE FROM Non-Formulary cycle disorder FORMULARY 08/28/2020 PROPIMEX-2 nutritional therapy for REMOVE FROM Non-Formulary propionic acidemia with iron FORMULARY 08/28/2020 TYREX-2 nutritional therapy for REMOVE FROM Non-Formulary tyrosinemia with iron FORMULARY 08/28/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 08/28/2020 potassium REMOVE FROM Non-Formulary FORMULARY 08/28/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 209 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2020 SIMILAC infant formula with REMOVE FROM Non-Formulary SPECIAL CARE iron/docosahexaenoic FORMULARY 24 acid/arachidonic ac 08/28/2020 SIMILAC infant formula with REMOVE FROM Non-Formulary SPECIAL CARE iron/docosahexaenoic FORMULARY 24 acid/arachidonic ac 08/28/2020 pro-comfort vinyl gloves REMOVE FROM Non-Formulary gloves FORMULARY 08/28/2020 CERAVE ceramides 1,3,6- REMOVE FROM Non-Formulary FOAMING ii/niacinamide FORMULARY FACIAL 08/28/2020 cerave daily ceramides 1,3,6-ii REMOVE FROM Non-Formulary moisturizing FORMULARY 08/28/2020 spectravite multivitamin/ferrous REMOVE FROM Non-Formulary women fumarate/folic acid FORMULARY 08/28/2020 elderberry ascorbic acid/elderberry fruit REMOVE FROM Non-Formulary extract-vitamin c FORMULARY 08/28/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 08/28/2020 MEGARED omega-3 fatty REMOVE FROM Non-Formulary ADVANCED acids/dha/epa/fish FORMULARY TOTAL BODY oil/krill/lutein/zeaxanth 08/28/2020 REFRESH carboxymethylcellulose REMOVE FROM Non-Formulary DIGITAL PF sodium/glycerin/polysorbate FORMULARY 80/pf 08/28/2020 REFRESH carboxymethylcellulose REMOVE FROM Non-Formulary DIGITAL sodium/glycerin/polysorbate FORMULARY 80 08/28/2020 BRONKAID MAX ephedrine sulfate REMOVE FROM Non-Formulary FORMULARY 08/28/2020 BRONKAID MAX ephedrine sulfate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 210 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2020 HYLATOPICPLU emollient combination no.53 REMOVE FROM Non-Formulary S FORMULARY 08/28/2020 HYLATOPICPLU emollient combination no.53 REMOVE FROM Non-Formulary S FORMULARY 08/28/2020 NORMOSOL-R electrolyte-r (ph 7.4) REMOVE FROM Non-Formulary PH 7.4 FORMULARY 08/28/2020 penicillamine penicillamine REMOVE FROM Non-Formulary FORMULARY 08/28/2020 dihydroergotamin dihydroergotamine mesylate REMOVE FROM Non-Formulary e mesylate FORMULARY 08/28/2020 doxycycline doxycycline hyclate REMOVE FROM Non-Formulary hyclate FORMULARY 08/28/2020 erythromycin erythromycin ethylsuccinate REMOVE FROM Non-Formulary ethylsuccinate FORMULARY 08/28/2020 PLIAGLIS lidocaine/tetracaine REMOVE FROM Non-Formulary FORMULARY 08/28/2020 PLIAGLIS lidocaine/tetracaine REMOVE FROM Non-Formulary FORMULARY 08/28/2020 space chamber inhaler, assist devices REMOVE FROM Non-Formulary FORMULARY 08/28/2020 space chamber- inhaler,assist device with REMOVE FROM Non-Formulary large mask large mask FORMULARY 08/28/2020 space chamber- inhaler,assist device with REMOVE FROM Non-Formulary medium mask medium mask FORMULARY 08/28/2020 space chamber- inhaler,assist device with REMOVE FROM Non-Formulary small mask small mask FORMULARY 08/28/2020 SACCHAROMYC allergenic extract- REMOVE FROM Non-Formulary ES CEREVISIAE saccharomyces cerevisiae FORMULARY 08/28/2020 SACCHAROMYC allergenic extract- REMOVE FROM Non-Formulary ES CEREVISIAE saccharomyces cerevisiae FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 211 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 08/28/2020 SACCHAROMYC allergenic extract- REMOVE FROM Non-Formulary ES CEREVISIAE saccharomyces cerevisiae FORMULARY 08/28/2020 DORYX doxycycline hyclate REMOVE FROM Non-Formulary FORMULARY 08/28/2020 sodium chloride sodium chloride 0.45 % ADD TO FORMULARY Injectables 08/28/2020 cisatracurium cisatracurium besylate ADD TO FORMULARY Injectables besylate 08/28/2020 TOTECT dexrazoxane hcl ADD TO FORMULARY Injectables 08/28/2020 DICLOTREX diclofenac REMOVE FROM Non-Formulary sodium/menthol/camphor FORMULARY 08/28/2020 VISTASEAL thrombin(human plasma REMOVE FROM Non-Formulary FIBRIN derived)/fibrinogen/calcium FORMULARY SEALANT chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 212 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

September, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 BAQSIMI glucagon ADD TO FORMULARY Non-Formulary Preferred Brands 09/01/2020 fentanyl,duragesi fentanyl ADD UM: Total cumulative c QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 fentanyl,duragesi fentanyl CHANGE UM: QUANTITY 15 / 30 days c 09/01/2020 fentanyl,duragesi fentanyl ADD UM: Total cumulative c QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 fentanyl,duragesi fentanyl CHANGE UM: QUANTITY 15 / 30 days c 09/01/2020 fentanyl,duragesi fentanyl ADD UM: Total cumulative c QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 fentanyl,duragesi fentanyl CHANGE UM: QUANTITY 15 / 30 days c

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 213 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 fentanyl,duragesi fentanyl ADD UM: Total cumulative c QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 fentanyl,duragesi fentanyl ADD UM: Total cumulative c QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 butrans,buprenor buprenorphine ADD UM: Total cumulative phine QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 butrans,buprenor buprenorphine ADD UM: Total cumulative phine QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 butrans,buprenor buprenorphine ADD UM: Total cumulative phine QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 214 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 2 / 1 days 3 / 1 days er,kadian 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,kadian QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 kadian,morphine morphine sulfate CHANGE UM: QUANTITY 2 / 1 DAY 3 / 1 days sulfate er 09/01/2020 kadian,morphine morphine sulfate ADD UM: Total cumulative sulfate er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 3 / 1 days er,kadian 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,kadian QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 1 / 1 DAY 3 / 1 days er,kadian

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 215 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,kadian QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 kadian,morphine morphine sulfate CHANGE UM: QUANTITY 2 / 1 DAY 3 / 1 days sulfate er 09/01/2020 kadian,morphine morphine sulfate ADD UM: Total cumulative sulfate er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 butrans,buprenor buprenorphine ADD UM: Total cumulative phine QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 butrans,buprenor buprenorphine ADD UM: Total cumulative phine QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 oxycontin,oxycod oxycodone hcl CHANGE UM: QUANTITY 3 / 1 days one hcl er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 216 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 oxycontin,oxycod oxycodone hcl ADD UM: Total cumulative one hcl er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 oxycontin,oxycod oxycodone hcl CHANGE UM: QUANTITY 3 / 1 days one hcl er 09/01/2020 oxycontin,oxycod oxycodone hcl ADD UM: Total cumulative one hcl er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 OXYCONTIN,OX oxycodone hcl CHANGE UM: QUANTITY 3 / 1 days YCODONE HCL ER 09/01/2020 OXYCONTIN,OX oxycodone hcl ADD UM: Total cumulative YCODONE HCL QUANTITYCUSTOM opioid dose ER limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 oxycontin,oxycod oxycodone hcl CHANGE UM: QUANTITY 2 / 1 days 3 / 1 days one hcl er 09/01/2020 oxycontin,oxycod oxycodone hcl ADD UM: Total cumulative one hcl er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 217 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 OXYCONTIN,OX oxycodone hcl CHANGE UM: QUANTITY 2 / 1 days 3 / 1 days YCODONE HCL ER 09/01/2020 OXYCONTIN,OX oxycodone hcl ADD UM: Total cumulative YCODONE HCL QUANTITYCUSTOM opioid dose ER limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 zohydro hydrocodone bitartrate ADD UM: Total cumulative er,hydrocodone QUANTITYCUSTOM opioid dose bitartrate er limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 zohydro hydrocodone bitartrate ADD UM: Total cumulative er,hydrocodone QUANTITYCUSTOM opioid dose bitartrate er limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 zohydro hydrocodone bitartrate ADD UM: Total cumulative er,hydrocodone QUANTITYCUSTOM opioid dose bitartrate er limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 218 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 zohydro hydrocodone bitartrate ADD UM: Total cumulative er,hydrocodone QUANTITYCUSTOM opioid dose bitartrate er limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 zohydro hydrocodone bitartrate ADD UM: Total cumulative er,hydrocodone QUANTITYCUSTOM opioid dose bitartrate er limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 zohydro hydrocodone bitartrate ADD UM: Total cumulative er,hydrocodone QUANTITYCUSTOM opioid dose bitartrate er limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 MORPHABOND morphine sulfate CHANGE UM: QUANTITY 2 / 1 DAY 3 / 1 days ER 09/01/2020 MORPHABOND morphine sulfate ADD UM: Total cumulative ER QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 MORPHABOND morphine sulfate CHANGE UM: QUANTITY 2 / 1 DAY 3 / 1 days ER

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 219 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 MORPHABOND morphine sulfate ADD UM: Total cumulative ER QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 MORPHABOND morphine sulfate CHANGE UM: QUANTITY 1 / 1 DAY 3 / 1 days ER 09/01/2020 MORPHABOND morphine sulfate ADD UM: Total cumulative ER QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 MORPHABOND morphine sulfate CHANGE UM: QUANTITY 2 / 1 DAY 3 / 1 days ER 09/01/2020 MORPHABOND morphine sulfate ADD UM: Total cumulative ER QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 BELBUCA buprenorphine hcl ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 220 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 BELBUCA buprenorphine hcl ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 BELBUCA buprenorphine hcl ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 BELBUCA buprenorphine hcl ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 BELBUCA buprenorphine hcl ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 BELBUCA buprenorphine hcl ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 KADIAN morphine sulfate CHANGE UM: QUANTITY 1 / 1 DAY 3 / 1 days

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 221 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 KADIAN morphine sulfate ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 kadian,morphine morphine sulfate CHANGE UM: QUANTITY 3 / 1 days sulfate er 09/01/2020 kadian,morphine morphine sulfate ADD UM: Total cumulative sulfate er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 2 / 1 DAY 3 / 1 days er,kadian 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,kadian QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate CHANGE UM: QUANTITY 1 / 1 DAY 3 / 1 days er,kadian 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,kadian QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 222 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,morphine QUANTITYCUSTOM opioid dose sulfate,ms limited to 90 contin,oramorph morphine sr,morphine milligram sulfate cr equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate REMOVE UM: QUANTITY er,morphine sulfate,ms contin,oramorph sr,morphine sulfate cr 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,morphine QUANTITYCUSTOM opioid dose sulfate,morphine limited to 90 sulfate cr,ms morphine contin,oramorph milligram sr equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate REMOVE UM: QUANTITY er,morphine sulfate,morphine sulfate cr,ms contin,oramorph sr 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,morphine QUANTITYCUSTOM opioid dose sulfate,morphine limited to 90 sulfate cr,ms morphine contin,oramorph milligram sr,roxanol equivalent (MME) sr,roxanol per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 223 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 morphine sulfate morphine sulfate REMOVE UM: QUANTITY er,morphine sulfate,morphine sulfate cr,ms contin,oramorph sr,roxanol sr,roxanol 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,morphine QUANTITYCUSTOM opioid dose sulfate,ms limited to 90 contin,oramorph morphine sr,morphine milligram sulfate cr equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate REMOVE UM: QUANTITY er,morphine sulfate,ms contin,oramorph sr,morphine sulfate cr 09/01/2020 oxymorphone hcl oxymorphone hcl ADD UM: Total cumulative er,opana er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 oxymorphone hcl oxymorphone hcl ADD UM: Total cumulative er,opana er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 224 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 oxymorphone hcl oxymorphone hcl ADD UM: Total cumulative er,opana er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 oxymorphone hcl oxymorphone hcl ADD UM: Total cumulative er,opana er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 oxymorphone hcl oxymorphone hcl CHANGE UM: QUANTITY 1 / 1 DAY 2 / 1 days er,opana er 09/01/2020 oxymorphone hcl oxymorphone hcl ADD UM: Total cumulative er,opana er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 oxymorphone hcl oxymorphone hcl ADD UM: Total cumulative er,opana er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 225 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 oxymorphone hcl oxymorphone hcl ADD UM: Total cumulative er,opana er QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 XTAMPZA ER oxycodone myristate ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 XTAMPZA ER oxycodone myristate ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 XTAMPZA ER oxycodone myristate ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 XTAMPZA ER oxycodone myristate ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 226 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 XTAMPZA ER oxycodone myristate ADD UM: Total cumulative QUANTITYCUSTOM opioid dose limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 ARYMO ER morphine sulfate CHANGE UM: QUANTITY 2 / 1 DAY 3 / 1 days 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY Brands 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE UM: QUANTITY 1 / 1 DAY hcl 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY Brands 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE UM: QUANTITY 2 / 1 DAY hcl 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY Brands 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE UM: QUANTITY 1 / 1 DAY hcl 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY Brands 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE UM: QUANTITY 2 / 1 DAY hcl 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY Brands 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE UM: QUANTITY 2 / 1 DAY hcl 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE FROM Non-Preferred Non-Formulary hcl FORMULARY Brands

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 227 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 EMBEDA morphine sulfate/naltrexone REMOVE UM: QUANTITY 3 / 1 DAY hcl 09/01/2020 morphine sulfate morphine sulfate ADD UM: Total cumulative er,morphine QUANTITYCUSTOM opioid dose sulfate,ms contin limited to 90 morphine milligram equivalent (MME) per day 09/01/2020 morphine sulfate morphine sulfate REMOVE UM: QUANTITY er,morphine sulfate,ms contin

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 228 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/01/2020 levo- levorphanol ADD UM: Total cumulative dromoran,tramad tartrate,tramadol QUANTITYCUSTOM opioid dose ol hcl hcl,meperidine hcl,fentanyl limited to 90 er,demerol,onsoli citrate,morphine morphine s,morphine sulfate,codeine milligram sulfate,codeine sulfate,hydromorphone equivalent (MME) sulfate,hydromor hcl,oxymorphone per day phone hcl,methadone hcl,oxymorphone hcl,oxycodone hcl,methadone hcl,oxycodone hcl,levorphanol hcl/acetaminophen,butorpha tartrate,oxycodon nol tartrate,acetaminophen e hcl,oxycodone- with codeine acetaminophen,b phosphate,codeine utorphanol phosphate,hydrocodone tartrate,meperidin bitartrate/acetaminophen,hy e hcl,methadone drocodone/ibuprofen,propox intensol,roxicet,d yphene olophine napsylate/acetaminophen,pr hcl,diskets,tylenol opoxyphene -codeine hcl,fentanyl,butalbital/aceta no.3,tylenol- minophen/caffeine/codeine codeine phosphate,tramadol no.4,codeine hcl/acetaminophen,carisopr phosphate,vicodi odol/aspirin/codeine n,vicodin phosphate,ibuprofen/oxycod es,vicodin one hcl,propoxyphene hp,vicoprofen,tra hcl/acetaminophen,oxycodo madol ne hcl/aspirin,meperidine hcl,propoxyphene hcl/pf,fentanyl nap- citrate/pf,nalbuphine acetaminophen,p hcl,pentazocine ropoxyphene lactate,buprenorphine hcl,fentanyl hcl,morphine citrate,fentanyl,zo sulfate/pf,hydromorphone lvit,lortab,hydroco hcl/pf,alfentanil done- hcl,sufentanil ibuprofen,acetam citrate,morphine inophen- sulfate/dextrose 5%-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 229 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value codeine,oxymorp water/pf,dihydrocodeine hone hcl bitartrate/acetaminophen/caf er,hydrocodone- feine,codeine acetaminophen,c phosphate/butalbital/aspirin/ o-gesic,butalb- caffeine,opium/belladonna caff- alkaloids,pentazocine acetaminoph- hcl/naloxone codein,tramadol hcl,pentazocine hcl- hcl/acetaminophen,oxycodo acetaminophen,c ne hcl/oxycodone arisoprodol terephthalate/aspirin,hydroc compound- odone codeine,morphin bit/acetaminophen,tapentad e sulfate ol er,oxycodone hcl- hcl,acetaminophen/caffeine/ ibuprofen,capital dihydrocodeine w- bitartrate,morphine sulfate in codeine,propoxyp 0.9 % sodium hene hcl- chloride/pf,fentanyl citrate in acetaminophen,o 0.9 % sodium xycodone hcl- chloride/pf,methadone aspirin,methados hydrochloride in 0.9 % e,nalbuphine sodium hcl,talwin,bupren chloride,hydromorphone orphine hcl/bupivacaine hcl in 0.9% hcl,alfentanil sodium hcl,sufentanil chloride/pf,hydromorphone citrate,morphine hcl in 0.9 % sodium sulfate in chloride/pf,meperidine hcl in dextrose,hydroge 0.9 % sodium sic,panlor chloride,fentanyl ss,butalbital citrate/bupivacaine hcl in 0.9 compound- % sodium codeine,belladon chloride/pf,fentanyl na- citrate/ropivacaine opium,pentazocin hcl/sodium chloride e-naloxone 0.9%/pf,sufentanil hcl,pentazocine- citrate/pf,morphine sulfate acetaminophen,o liposomal/pf,morphine

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 230 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value xycodone- sulfate/naltrexone aspirin,butalb- hcl,buprenorphine,tramadol acetaminoph- hcl/glucosamine caff- sulfate,hydromorphone hcl codein,duramorp in 0.9 % sodium h,infumorph,marg chloride,morphine sulfate in esic h,lorcet 0.9 % sodium plus,lorcet 10- chloride,aspirin/caffeine/dihy 650,balacet drocodeine 325,oxycodone bitartrate,morphine sulfate in hcl- sodium chloride, iso- acetaminophen,s osmotic/pf,codeine ublimaze,sufenta, phosphate/carisoprodol/aspi alfenta,buprenex, rin,morphine hycet,ryzolt,nucy sulfate/dextrose 5 % in nta,avinza,aceta water,remifentanil hcl in 0.9 minoph-caff- % sodium dihydrocodein,ka chloride/pf,sufentanil dian,morphine citrate/bupivacaine hcl/0.9 % sulfate cr,opana sodium er,oxycontin,perc chloride/pf,propoxyphene ocet,meperitab,d napsylate,fentanyl citrate in uragesic,darvocet dextrose 5% in -n water/pf,hydromorphone hcl 100,opana,dilaudi in dextrose 5 %- d,xodol 10- water/pf,remifentanil 300,magnacet,da hcl,tramadol hcl/dietary rvon,fentora,endo supplement,misc. cet,exalgo,endod cb.11,hydrocodone an,zerlor,subsys, bitartrate/acetaminophen/die ultracet,ultram tary supplement er,xodol 5- #11,dihydrocodeine 300,xodol 7.5- bitartrate/aspirin/caffeine,fen 300,trezix,xolox,r tanyl oxicodone,primle citrate/droperidol,aspirin/cod v,morphine eine phosphate,meperidine sulfate-0.9% hcl/promethazine nacl,fentanyl hcl,hydrocodone citrate-0.9% bitartrate,fentanyl

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 231 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value nacl,methadone hcl,meperidine hcl in 0.9 % hcl-0.9% sodium nacl,hydromorph chloride/pf,hydromorphone one-bupivacaine- hcl/ropivacaine in 0.9 % ns,hydromorphon sodium e hcl-0.9% chloride/pf,oxycodone nacl,morphine myristate,hydromorphone sulfate- hcl in sterile d5w,meperidine water/pf,benzhydrocodone hcl-0.9% hcl/acetaminophen nacl,fentanyl- bupivacaine- ns,fentanyl- ropivacaine- ns,fentanyl citrate- ns,reprexain,dep odur,ms contin,oramorph sr,norco,actiq,em beda,butrans,nuc ynta er,abstral,synapr yn,hydromorphon e- bupivacaine,mep eridine hcl- ns,synalgos- dc,ultram,tylox,ib udone,cocet plus,cocet,lazand a,ascomp with codeine,morphin e sulfate-nacl,iso- osm,maxidone,fio ricet with codeine,fiorinal with codeine #3,zydone,conzip

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 232 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value ,darvocet a500,hydrocodon e bit- ibuprofen,aspirin- caffeine- dihydrocodein,sta gesic,dilaudid- hp,rybix odt,oxecta,fentan yl-bupivacaine- 0.9% nacl,fentanyl- ropivacaine-0.9% nacl,remifentanil hcl- ns,hydromorph- bupivac-0.9% nacl,sufentanil- bupivac-0.9% nacl,astramorph- pf,percodan,asa- butalb-caffeine- codeine,zamicet, oxycodone concentrate,caris oprodol-aspirin- codeine,propoxac et-n 100,darvon- n,darvocet-n 50,roxicodone intensol,fentanyl citrate- d5w,hydromorph one hcl- d5w,ultiva,theratr amadol- 60,theratramadol- 90,theracodophe n-

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 233 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 325,theracodoph en- 650,theracodoph en-low- 90,talacen,talwin nx,combunox,pan lor dc,polygesic,roxa nol,eth- oxydose,anexsia, primalev,soma compound with codeine,fentanyl with droperidol,dilaudi d- 5,hydrocet,phreni lin-caffeine- codeine,aspirin with codeine,meprozin e,dolorex forte,meperidine- promethazine,oxy codone hcl er,oxyir,stadol,hy dromorphone hcl- ns,numorphan,da zidox,alcet,lynox, vopac,zohydro er,xartemis xr,lorcet,lorcet hd,hydromorphon e er,verdrocet,xylo n 10,hysingla er,ionsys,acetami n-caff- dihydrocodeine,o

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 234 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value xaydo,belbuca,hy dromorph-ropiva- 0.9% nacl,xtampza er,arymo er,morphabond er,buprenorphine, fentanyl citrate- sterile water,remifentanil hcl,fentanyl citrate- water,panlor,nalo cet,roxybond,miti go,hydromorphon e hcl- water,dvorah,dsu via,apadaz,benzh ydrocodone- acetaminophen,h ydrocodone bitartrate er,prolate 09/01/2020 HUMIRA adalimumab REMOVE UM: Limited Access PEDIATRIC LIMITEDACCESS CROHN'S 09/01/2020 omeprazole omeprazole CHANGE TIER Non-Preferred Brands 09/03/2020 BIDIL isosorbide REMOVE FROM Non-Formulary dinitrate/hydralazine hcl FORMULARY 09/03/2020 levorphanol levorphanol tartrate REMOVE FROM Non-Formulary tartrate FORMULARY 09/03/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 235 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/03/2020 CLARITIN loratadine REMOVE FROM Non-Formulary FORMULARY 09/03/2020 iron ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 09/03/2020 RELAFEN nabumetone ADD TO FORMULARY Non-Preferred Brands 09/03/2020 RELAFEN nabumetone ADD TO FORMULARY Non-Preferred Brands 09/03/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 09/03/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 09/03/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 09/03/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 09/03/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 09/03/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 09/03/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 09/03/2020 red yeast rice REMOVE FROM Non-Formulary FORMULARY 09/03/2020 adapalene adapalene REMOVE FROM Non-Formulary FORMULARY 09/03/2020 ALKA-SELTZER chlorpheniramine REMOVE FROM Non-Formulary PLUS COLD maleate/phenylephrine FORMULARY bitartrate/aspirin 09/03/2020 HYLATOPICPLU emollient combination no.53 REMOVE FROM Non-Formulary S FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 236 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/03/2020 HYLATOPICPLU emollient combination no.53 REMOVE FROM Non-Formulary S FORMULARY 09/03/2020 adapalene adapalene REMOVE FROM Non-Formulary FORMULARY 09/03/2020 TOLSURA itraconazole REMOVE FROM Non-Formulary FORMULARY 09/03/2020 ashwagandha ashwagandha root extract REMOVE FROM Non-Formulary root extract FORMULARY 09/03/2020 dl-phenylalanine phenylalanine,dl- REMOVE FROM Non-Formulary FORMULARY 09/03/2020 dl-phenylalanine phenylalanine,dl- REMOVE FROM Non-Formulary FORMULARY 09/03/2020 dl-phenylalanine phenylalanine,dl- REMOVE FROM Non-Formulary FORMULARY 09/03/2020 purecomfort peak peak flow meter REMOVE FROM Non-Formulary flow meter FORMULARY 09/03/2020 purecomfort peak peak flow meter REMOVE FROM Non-Formulary flow meter FORMULARY 09/03/2020 bismuth bismuth subsalicylate REMOVE FROM Non-Formulary subsalicylate FORMULARY 09/03/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 09/03/2020 glucosamine- glucosamine REMOVE FROM Non-Formulary msm-hyaluronic hcl/methylsulfonylmethane/h FORMULARY yaluronic acid 09/03/2020 hematex iron polysaccharide complex REMOVE FROM Non-Formulary FORMULARY 09/03/2020 TRALEMENT zinc sulfate/cupric REMOVE FROM Non-Formulary sulfate/manganese FORMULARY sulfate/selenium

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 237 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/03/2020 MONOFERRIC ferric derisomaltose REMOVE FROM Non-Formulary FORMULARY 09/03/2020 AKYNZEO fosnetupitant chloride REMOVE FROM Non-Formulary hcl/palonosetron hcl FORMULARY 09/03/2020 emtricitabine emtricitabine ADD TO FORMULARY Non-Preferred Generics 09/03/2020 peg3350-sod sul- peg 3350/sodium ADD TO FORMULARY Non-Preferred nacl-kcl-asb-c sulfate/sod Generics chloride/kcl/ascorbate sod/vit c 09/04/2020 LIQUIVIDA 0.9 % sodium chloride REMOVE FROM Injectables Non-Formulary HYDRATION KIT FORMULARY 09/04/2020 LIQUIVIDA 0.9 % sodium chloride REMOVE UM: MED Medical Drug HYDRATION KIT 09/04/2020 MIXED VESPID allergenic extract-venom- REMOVE FROM Injectables Non-Formulary VENOM mixed vespid protein FORMULARY PROTEIN 09/04/2020 MIXED VESPID allergenic extract-venom- REMOVE UM: MED Medical Drug VENOM mixed vespid protein PROTEIN 09/04/2020 CANDIN candida albicans skin test REMOVE FROM Injectables Non-Formulary FORMULARY 09/04/2020 CANDIN candida albicans skin test REMOVE UM: MED Medical Drug 09/11/2020 chlorpromazine chlorpromazine hcl ADD TO FORMULARY Injectables hcl 09/11/2020 chlorpromazine chlorpromazine hcl ADD TO FORMULARY Injectables hcl 09/11/2020 paraplatin carboplatin ADD TO FORMULARY Injectables 09/11/2020 sanizen ethyl alcohol REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 238 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2020 CERAVE AM homosalate/meradimate/octi REMOVE FROM Non-Formulary noxate/octocrylene/zinc FORMULARY oxide 09/11/2020 GENADEK STEP multivit with minerals REMOVE FROM Non-Formulary 1 no.81/folic acid/vit FORMULARY k1/ubidecarenone 09/11/2020 GENADEK STEP multivit with minerals REMOVE FROM Non-Formulary 2 no.82/folic acid/vit FORMULARY k1/ubidecarenone 09/11/2020 ENTERADE sodium chloride/sodium REMOVE FROM Non-Formulary ADVANCED cit/potassium/magnes/calc/a FORMULARY ONCOLOGY mino acid 09/11/2020 ENTERADE sodium chloride/sodium REMOVE FROM Non-Formulary ADVANCED cit/potassium/magnes/calc/a FORMULARY ONCOLOGY mino acid 09/11/2020 EYE vit a, c, e/zinc oxide/sodium REMOVE FROM Non-Formulary MULTIVITAMIN selenate/cupric oxide/lutein FORMULARY WITH LUTEIN 09/11/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 09/11/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 09/11/2020 dermacinrx skin dimethicone REMOVE FROM Non-Formulary repair complex FORMULARY 09/11/2020 coconut oil coconut oil REMOVE FROM Non-Formulary FORMULARY 09/11/2020 sapropterin sapropterin dihydrochloride ADD TO FORMULARY Non-Preferred dihydrochloride Specialty 09/11/2020 sapropterin sapropterin dihydrochloride ADD TO FORMULARY Non-Preferred dihydrochloride Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 239 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/11/2020 sapropterin sapropterin dihydrochloride ADD TO FORMULARY Non-Preferred dihydrochloride Specialty 09/11/2020 MENQUADFI meningococcal vaccine a,c,y REMOVE FROM Non-Formulary and w-135,conj tetanus FORMULARY toxoid/pf 09/11/2020 MENQUADFI meningococcal vaccine a,c,y REMOVE FROM Non-Formulary and w-135,conj tetanus FORMULARY toxoid/pf 09/16/2020 moxeza,moxiflox moxifloxacin hcl REMOVE FROM Non-Formulary acin FORMULARY 09/18/2020 ENBREL etanercept ADD UM: QUANTITY 2 / 28 days 09/18/2020 CIPRODEX ciprofloxacin CHANGE TIER Preferred Brands Non-Preferred hcl/dexamethasone Brands 09/18/2020 oxaliplatin oxaliplatin REMOVE FROM Non-Formulary FORMULARY 09/18/2020 capsinac diclofenac sodium/capsicum REMOVE FROM Non-Formulary oleoresin FORMULARY 09/18/2020 estradiol estradiol cypionate REMOVE FROM Non-Formulary cypionate FORMULARY 09/18/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY 09/18/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 meclizine hcl meclizine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 vitamin b-1 thiamine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 docusate calcium docusate calcium REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 240 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2020 docusate calcium docusate calcium REMOVE FROM Non-Formulary FORMULARY 09/18/2020 aspirin aspirin REMOVE FROM Non-Formulary FORMULARY 09/18/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 docusate sodium docusate sodium REMOVE FROM Non-Formulary FORMULARY 09/18/2020 chromium chromium picolinate REMOVE FROM Non-Formulary picolinate FORMULARY 09/18/2020 thermometer thermometer probe covers REMOVE FROM Non-Formulary probe covers FORMULARY 09/18/2020 prilocaine hcl prilocaine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 prilocaine hcl prilocaine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 prilocaine hcl prilocaine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 dextrose in water dextrose 5 % in water ADD TO FORMULARY Injectables 09/18/2020 azithromycin azithromycin REMOVE FROM Non-Formulary FORMULARY 09/18/2020 bacitracin zinc bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 09/18/2020 phenylephrine hcl phenylephrine hcl REMOVE FROM Non-Formulary FORMULARY 09/18/2020 instant cold pack cold-hot pack REMOVE FROM Non-Formulary FORMULARY 09/18/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 241 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2020 anastrozole anastrozole REMOVE FROM Non-Formulary FORMULARY 09/18/2020 anastrozole anastrozole REMOVE FROM Non-Formulary FORMULARY 09/18/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 diclofenac diclofenac sodium REMOVE FROM Non-Formulary sodium FORMULARY 09/18/2020 eye itch relief ketotifen fumarate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 vitamin b-1 thiamine mononitrate (vit b1) REMOVE FROM Non-Formulary FORMULARY 09/18/2020 butalbital- butalbital/acetaminophen/caf REMOVE FROM Non-Formulary acetaminophen- feine FORMULARY caffe 09/18/2020 paper tape with adhesive tape REMOVE FROM Non-Formulary dispenser FORMULARY 09/18/2020 sinus wash neti sodium chloride,sod bicarb REMOVE FROM Non-Formulary pot with neti pot nasal rinse FORMULARY device 09/18/2020 SIGNIFOR LAR pasireotide pamoate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 SIGNIFOR LAR pasireotide pamoate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 SIGNIFOR LAR pasireotide pamoate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 zonisamide zonisamide REMOVE FROM Non-Formulary FORMULARY 09/18/2020 zonisamide zonisamide REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 242 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2020 TRULANCE plecanatide REMOVE FROM Non-Formulary FORMULARY 09/18/2020 SIGNIFOR LAR pasireotide pamoate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 SIGNIFOR LAR pasireotide pamoate REMOVE FROM Non-Formulary FORMULARY 09/18/2020 tropicamide- phenylephrine REMOVE FROM Non-Formulary phenylephrine hcl/tropicamide in sterile FORMULARY water 09/18/2020 magnesium , REMOVE FROM Non-Formulary glycinate magnesium oxide FORMULARY 09/18/2020 acidophilus lactobacillus acidophilus REMOVE FROM Non-Formulary probiotic FORMULARY 09/18/2020 KONSYL DAILY psyllium husk/sweetleaf REMOVE FROM Non-Formulary FIBER FORMULARY 09/18/2020 ENSURE RAPID sodium/potassium/chloride/d REMOVE FROM Non-Formulary HYDRATION extrose FORMULARY 09/18/2020 ONE-A-DAY prenatal vitamins REMOVE FROM Non-Formulary PRENATAL-1 no.168/iron/folic FORMULARY acid/omega-3/dha/epa 09/18/2020 SIMILAC infant formula with REMOVE FROM Non-Formulary ORGANIC A2 iron/docosahexaenoic FORMULARY MILK NO-GMO acid/arachidonic ac 09/18/2020 SIMILAC infant formula with REMOVE FROM Non-Formulary ORGANIC A2 iron/docosahexaenoic FORMULARY MILK NO-GMO acid/arachidonic ac 09/18/2020 nicotinamide nicotinamide riboside REMOVE FROM Non-Formulary riboside chloride chloride FORMULARY 09/18/2020 PRECEDEX dexmedetomidine hcl in 0.9 ADD TO FORMULARY Injectables % sodium chloride 09/18/2020 DETECTNET copper cu-64 dotatate ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 243 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/18/2020 tetracaine hcl tetracaine hcl/pf REMOVE FROM Non-Formulary FORMULARY 09/18/2020 vitamin d3 cholecalciferol (vitamin d3) ADD TO FORMULARY Preventative 09/18/2020 tobramycin tobramycin ADD TO FORMULARY Injectables 09/18/2020 tobramycin tobramycin ADD TO FORMULARY Injectables 09/18/2020 tobramycin tobramycin ADD TO FORMULARY Injectables 09/18/2020 diclofenac diclofenac submicronized REMOVE FROM Non-Formulary FORMULARY 09/18/2020 efavirenz-lamivu- efavirenz/lamivudine/tenofov ADD TO FORMULARY Non-Preferred tenofov disop ir disoproxil fumarate Generics 09/18/2020 efavirenz-lamivu- efavirenz/lamivudine/tenofov ADD TO FORMULARY Non-Preferred tenofov disop ir disoproxil fumarate Generics 09/18/2020 LIDOMARK 2-5 lidocaine hcl/preservative REMOVE FROM Non-Formulary free/adhesive bandage FORMULARY 09/18/2020 ARMONAIR fluticasone propionate REMOVE FROM Non-Formulary DIGIHALER FORMULARY 09/18/2020 ARMONAIR fluticasone propionate REMOVE FROM Non-Formulary DIGIHALER FORMULARY 09/18/2020 ARMONAIR fluticasone propionate REMOVE FROM Non-Formulary DIGIHALER FORMULARY 09/18/2020 SEVENFACT coagulation factor viia REMOVE FROM Non-Formulary recombinant-jncw FORMULARY 09/18/2020 SEVENFACT coagulation factor viia REMOVE FROM Non-Formulary recombinant-jncw FORMULARY 09/22/2020 COPIKTRA duvelisib ADD UM: LIMITEDACCESS Limited Access 09/22/2020 COPIKTRA duvelisib ADD UM: LIMITEDACCESS Limited Access 09/24/2020 decitabine decitabine REMOVE UM: Limited Access LIMITEDACCESS

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 244 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2020 folic d3 cholecalciferol (vit d3)/folic REMOVE FROM Non-Formulary acid FORMULARY 09/25/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY 09/25/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY 09/25/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY 09/25/2020 diphenhydramine diphenhydramine hcl REMOVE FROM Non-Formulary hcl FORMULARY 09/25/2020 cyclosporine cyclosporine REMOVE FROM Non-Formulary FORMULARY 09/25/2020 cyclosporine cyclosporine REMOVE FROM Non-Formulary FORMULARY 09/25/2020 heparin sodium heparin sodium,porcine ADD TO FORMULARY Injectables 09/25/2020 levorphanol levorphanol tartrate REMOVE FROM Non-Formulary tartrate FORMULARY 09/25/2020 allergy relief chlorpheniramine maleate REMOVE FROM Non-Formulary FORMULARY 09/25/2020 prednisolone prednisolone sodium REMOVE FROM Non-Formulary sodium phosphate FORMULARY phosphate 09/25/2020 prednisolone prednisolone sodium REMOVE FROM Non-Formulary sodium phosphate FORMULARY phosphate 09/25/2020 prednisolone prednisolone sodium REMOVE FROM Non-Formulary sodium phosphate FORMULARY phosphate 09/25/2020 prednisolone prednisolone sodium REMOVE FROM Non-Formulary sodium phosphate FORMULARY phosphate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 245 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 09/25/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 09/25/2020 CHILDREN'S acetaminophen REMOVE FROM Non-Formulary TYLENOL FORMULARY 09/25/2020 children's allergy diphenhydramine hcl REMOVE FROM Non-Formulary relief FORMULARY 09/25/2020 children's allergy diphenhydramine hcl REMOVE FROM Non-Formulary relief FORMULARY 09/25/2020 children's allergy diphenhydramine hcl REMOVE FROM Non-Formulary relief FORMULARY 09/25/2020 tizanidine hcl tizanidine hcl REMOVE FROM Non-Formulary FORMULARY 09/25/2020 tizanidine hcl tizanidine hcl REMOVE FROM Non-Formulary FORMULARY 09/25/2020 tizanidine hcl tizanidine hcl REMOVE FROM Non-Formulary FORMULARY 09/25/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 09/25/2020 hemorrhoidal witch hazel REMOVE FROM Non-Formulary hygiene FORMULARY 09/25/2020 super b complex- folic acid/vitamin b complex REMOVE FROM Non-Formulary vitamin c and vitamin c FORMULARY 09/25/2020 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 09/25/2020 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 246 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2020 men 50 plus multivitamin with REMOVE FROM Non-Formulary multivitamin minerals/folic FORMULARY acid/lycopene/lutein 09/25/2020 contour next test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 09/25/2020 guardian sensor blood-glucose sensor REMOVE FROM Non-Formulary 3 FORMULARY 09/25/2020 guardian sensor blood-glucose sensor REMOVE FROM Non-Formulary 3 FORMULARY 09/25/2020 guardian link 3 blood-glucose transmitter REMOVE FROM Non-Formulary FORMULARY 09/25/2020 guardian link 3 blood-glucose transmitter REMOVE FROM Non-Formulary FORMULARY 09/25/2020 PEDIASURE nutritional REMOVE FROM Non-Formulary HARVEST supplement,special FORMULARY formula,lactose free,iron/soy 09/25/2020 adults multivitamin with REMOVE FROM Non-Formulary multivitamin minerals/ferrous FORMULARY fumarate/folic acid/vit k 09/25/2020 PURE BLISS infant formula with REMOVE FROM Non-Formulary NON-GMO iron/docosahexaenoic FORMULARY acid/arachidonic ac 09/25/2020 water water for injection,sterile REMOVE FROM Non-Formulary FORMULARY 09/25/2020 men's 50 plus multivitamin with REMOVE FROM Non-Formulary multivitamin minerals/folic acid/vitamin FORMULARY k1/lycopene 09/25/2020 multivitamin multivitamin- REMOVE FROM Non-Formulary women 50 plus minerals/ferrous FORMULARY fumarate/folic acid/lutein

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 247 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2020 multivitamin multivitamin- REMOVE FROM Non-Formulary women 50 plus minerals/ferrous FORMULARY fumarate/folic acid/lutein 09/25/2020 bimatoprost bimatoprost REMOVE FROM Non-Formulary FORMULARY 09/25/2020 reusable hot-cold cold-hot pack REMOVE FROM Non-Formulary wrap FORMULARY 09/25/2020 GEN7T lidocaine REMOVE FROM Non-Formulary FORMULARY 09/25/2020 GEN7T PLUS lidocaine/menthol REMOVE FROM Non-Formulary FORMULARY 09/25/2020 tropicamide- phenylephrine REMOVE FROM Non-Formulary phenylephrine hcl/tropicamide in sterile FORMULARY water 09/25/2020 giltuss severe oxymetazoline hcl REMOVE FROM Non-Formulary sinus FORMULARY 09/25/2020 daily fiber psyllium husk/aspartame REMOVE FROM Non-Formulary FORMULARY 09/25/2020 calcium- calcium/magnesium REMOVE FROM Non-Formulary magnesium- oxide/cholecalciferol (vit FORMULARY vitamin d3 d3)/boron 09/25/2020 women 50 plus multivit with minerals/folic REMOVE FROM Non-Formulary multivit advance acid/calcium carbonate/vit FORMULARY k1 09/25/2020 lidocaine-menthol lidocaine/menthol REMOVE FROM Non-Formulary FORMULARY 09/25/2020 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY 09/25/2020 vitamin e vitamin e (dl-alpha REMOVE FROM Non-Formulary tocopheryl acetate) FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 248 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 09/25/2020 TUSNEL guaifenesin/phenylephrine REMOVE FROM Non-Formulary PEDIATRIC hcl FORMULARY 09/25/2020 BREEZA sorbitol/mannitol/xanthan REMOVE FROM Non-Formulary NEUTRAL AB- gum FORMULARY PELVIC IMAGE 09/25/2020 ALAHIST PE dexbrompheniramine REMOVE FROM Non-Formulary maleate/phenylephrine hcl FORMULARY 09/25/2020 nootropic coffee- coffee extract/phosphatidyl REMOVE FROM Non-Formulary ps serine FORMULARY 09/25/2020 magic3 catheter REMOVE FROM Non-Formulary intermittent FORMULARY catheter 09/25/2020 dihydroergotamin dihydroergotamine mesylate ADD TO FORMULARY Non-Preferred e mesylate Generics 09/25/2020 zoledronic acid zoledronic acid ADD TO FORMULARY Injectables 09/25/2020 FOLIKA-MG multivit with min no.83/iron REMOVE FROM Non-Formulary bis-glycinate/ no.10 FORMULARY 09/25/2020 deferiprone deferiprone ADD TO FORMULARY Non-Preferred Specialty 09/25/2020 POLIVY polatuzumab vedotin-piiq REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 249 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

October, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 TUKYSA tucatinib ADD TO FORMULARY Non-Preferred Specialty 10/01/2020 TUKYSA tucatinib ADD TO FORMULARY Non-Preferred Specialty 10/01/2020 FETROJA cefiderocol sulfate tosylate ADD UM: MED Medical Drug 10/01/2020 ursodiol ursodiol ADD TO FORMULARY Non-Formulary Non-Preferred Generics 10/01/2020 ACTIGALL ursodiol ADD TO FORMULARY Non-Preferred Brands 10/01/2020 xenazine,tetrabe tetrabenazine ADD UM: QUANTITY 4 / 1 days nazine 10/01/2020 DARAPRIM pyrimethamine REMOVE UM: Limited Access LIMITEDACCESS 10/01/2020 KYNAMRO mipomersen sodium REMOVE FROM Non-Preferred Non-Formulary FORMULARY Specialty 10/01/2020 BOTRYTIS allergenic extract-botrytis ADD UM: MED Medical Drug CINEREA cinerea 10/01/2020 DEFLUX dextranomer ADD UM: MED Medical Drug microspheres/hyaluronate sodium in 0.9 % nacl 10/01/2020 DILAUDID hydromorphone hcl/pf ADD UM: MED Medical Drug 10/01/2020 JELMYTO mitomycin ADD UM: MED Medical Drug 10/01/2020 DOVATO dolutegravir ADD TO FORMULARY Preferred Brands sodium/lamivudine 10/01/2020 CLADOSPORIU allergenic extract- ADD UM: MED Medical Drug M cladosporium CLADOSPORIOI cladosporioides DES

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 250 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 sucralfate sucralfate ADD TO FORMULARY Non-Preferred Generics 10/01/2020 ZEPOSIA ozanimod hydrochloride ADD TO FORMULARY Preferred Specialty 10/01/2020 ZEPOSIA ozanimod hydrochloride ADD TO FORMULARY Preferred Specialty 10/01/2020 ZEPOSIA ozanimod hydrochloride ADD TO FORMULARY Preferred Specialty 10/01/2020 xenazine,tetrabe tetrabenazine ADD UM: QUANTITY 4 / 1 days nazine 10/01/2020 TIVICAY PD dolutegravir sodium ADD TO FORMULARY Non-Preferred Brands 10/01/2020 TIVICAY PD dolutegravir sodium ADD UM: QUANTITY 6 / 1 days 10/01/2020 CETROTIDE cetrorelix acetate ADD UM: MED Medical Drug 10/01/2020 PREVNAR 13 pneumococcal 13-valent ADD UM: QUANTITY 1 / lifetime conjugate vaccine (diphtheria crm)/pf 10/01/2020 PREVNAR 13 pneumococcal 13-valent ADD UM: MED Medical Drug conjugate vaccine (diphtheria crm)/pf 10/01/2020 REPATHA evolocumab CHANGE TIER Preferred Preferred Brands SURECLICK Specialty 10/01/2020 REPATHA evolocumab CHANGE TIER Preferred Preferred Brands SYRINGE Specialty 10/01/2020 NARCAN naloxone hcl REMOVE UM: QUANTITY 2 / 30 days 10/01/2020 NARCAN naloxone hcl CHANGE TIER Non-Preferred Non-Preferred Brands Generics 10/01/2020 REPATHA evolocumab CHANGE TIER Preferred Preferred Brands PUSHTRONEX Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 251 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 EXONDYS-51 eteplirsen REMOVE UM: Limited Access LIMITEDACCESS 10/01/2020 naloxone hcl naloxone hcl ADD TO FORMULARY Preferred Brands 10/01/2020 evzio,naloxone naloxone hcl REMOVE UM: QUANTITY 0.8 / 365 days hcl 10/01/2020 SPRAVATO esketamine hcl ADD UM: SPECIALTY Specialty Drug 10/01/2020 SPRAVATO esketamine hcl ADD UM: SPECIALTY Specialty Drug 10/01/2020 DARZALEX daratumumab- ADD UM: MED Medical Drug FASPRO hyaluronidase-fihj 10/01/2020 FENSOLVI leuprolide acetate ADD UM: MED Medical Drug 10/01/2020 OSMOLEX ER amantadine hcl CHANGE UM: QUANTITY 1 / 1 days 2 / 1 days 10/01/2020 KYNMOBI apomorphine hcl ADD TO FORMULARY Preferred Specialty 10/01/2020 KYNMOBI apomorphine hcl ADD UM: QUANTITY 5 / 1 days 10/01/2020 KYNMOBI apomorphine hcl ADD UM: QUANTITY 5 / 1 days 10/01/2020 KYNMOBI apomorphine hcl ADD UM: QUANTITY 5 / 1 days 10/01/2020 KYNMOBI apomorphine hcl ADD TO FORMULARY Preferred Specialty 10/01/2020 KYNMOBI apomorphine hcl ADD TO FORMULARY Preferred Specialty 10/01/2020 KYNMOBI apomorphine hcl ADD TO FORMULARY Preferred Specialty 10/01/2020 KYNMOBI apomorphine hcl ADD TO FORMULARY Preferred Specialty 10/01/2020 KYNMOBI apomorphine hcl ADD UM: QUANTITY 5 / 1 days 10/01/2020 KYNMOBI apomorphine hcl ADD UM: QUANTITY 5 / 1 days 10/01/2020 PEMAZYRE pemigatinib ADD TO FORMULARY Non-Preferred Specialty

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 252 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/01/2020 PEMAZYRE pemigatinib ADD TO FORMULARY Non-Preferred Specialty 10/01/2020 PEMAZYRE pemigatinib ADD TO FORMULARY Non-Preferred Specialty 10/01/2020 levo- levorphanol tartrate CHANGE UM: QUANTITY 8 / 1 days dromoran,levorph anol tartrate 10/01/2020 levo- levorphanol tartrate CHANGE UM: Total cumulative dromoran,levorph QUANTITYCUSTOM opioid dose anol tartrate limited to 90 morphine milligram equivalent (MME) per day 10/01/2020 NORMOSOL-R electrolyte-r (ph 7.4) CHANGE TIER Injectables PH 7.4 10/02/2020 tropic- tropicamide/proparacaine/ph REMOVE FROM Non-Formulary proparacaine-pe- enylephrine/ketorolac in FORMULARY ketorlc water 10/02/2020 lidocaine lidocaine REMOVE FROM Non-Formulary FORMULARY 10/02/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 10/02/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 10/02/2020 capsaicin capsaicin REMOVE FROM Non-Formulary FORMULARY 10/02/2020 ferrous sulfate ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 10/02/2020 tranexamic acid tranexamic acid REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 253 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/02/2020 tranexamic acid tranexamic acid REMOVE FROM Non-Formulary FORMULARY 10/02/2020 indomethacin indomethacin REMOVE FROM Non-Formulary FORMULARY 10/02/2020 indomethacin indomethacin REMOVE FROM Non-Formulary FORMULARY 10/02/2020 capsaicin capsaicin REMOVE FROM Non-Formulary FORMULARY 10/02/2020 CERAVE ceramides 1,3,6-ii REMOVE FROM Non-Formulary MOISTURIZING FORMULARY 10/02/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 10/02/2020 contour next test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 10/02/2020 contour next test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 10/02/2020 CERAVE PM ceramides 1,3,6- REMOVE FROM Non-Formulary ii/niacinamide/hyaluronic FORMULARY acid 10/02/2020 cidofovir cidofovir REMOVE FROM Non-Formulary FORMULARY 10/02/2020 cidofovir cidofovir REMOVE FROM Non-Formulary FORMULARY 10/02/2020 ACZONE dapsone REMOVE FROM Non-Formulary FORMULARY 10/02/2020 XIMINO minocycline hcl REMOVE FROM Non-Formulary FORMULARY 10/02/2020 XIMINO minocycline hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 254 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/02/2020 XIMINO minocycline hcl REMOVE FROM Non-Formulary FORMULARY 10/02/2020 baclofen baclofen REMOVE FROM Non-Formulary FORMULARY 10/02/2020 REGULOID psyllium husk (with sugar) REMOVE FROM Non-Formulary FORMULARY 10/02/2020 reguloid psyllium husk/aspartame REMOVE FROM Non-Formulary FORMULARY 10/02/2020 pyridostigmine pyridostigmine bromide REMOVE FROM Non-Formulary bromide FORMULARY 10/02/2020 FINTEPLA fenfluramine hcl REMOVE FROM Non-Formulary FORMULARY 10/02/2020 ubiquinol ubiquinol REMOVE FROM Non-Formulary FORMULARY 10/02/2020 RHEUMATE levomefolate REMOVE FROM Non-Formulary calcium/mecobalamin/herbal FORMULARY complex no.236 10/02/2020 CERAVE ceramides 1,3,6-ii REMOVE FROM Non-Formulary HYDRATING FORMULARY FACIAL 10/02/2020 MEGARED ADV omega-3 fatty REMOVE FROM Non-Formulary TOTAL BODY acids/dha/epa/fish FORMULARY REFRESH oil/krill/lutein/zeaxanth 10/02/2020 TUSNEL-DM guaifenesin/dextromethorph REMOVE FROM Non-Formulary PEDIATRIC an hbr/phenylephrine FORMULARY 10/02/2020 ENSURE nutritional REMOVE FROM Non-Formulary HARVEST supplement,special FORMULARY formula,lactose free,iron/soy 10/02/2020 alocane lidocaine hcl REMOVE FROM Non-Formulary emergency burn FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 255 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/02/2020 cognitive health REMOVE FROM Non-Formulary FORMULARY 10/02/2020 XERAVA eravacycline di- ADD TO FORMULARY Injectables hydrochloride 10/02/2020 VISTASEAL thrombin(human plasma REMOVE FROM Non-Formulary FIBRIN derived)/fibrinogen/calcium FORMULARY SEALANT chloride 10/02/2020 FOLIKA-CI multivitamin with mineral REMOVE FROM Non-Formulary no.84/ferrous gluconate/folic FORMULARY acid 10/02/2020 irinotecan hcl irinotecan hcl ADD TO FORMULARY Injectables 10/02/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 10/02/2020 sildenafil citrate sildenafil citrate REMOVE FROM Non-Formulary FORMULARY 10/02/2020 sapropterin sapropterin dihydrochloride ADD TO FORMULARY Non-Preferred dihydrochloride Specialty 10/02/2020 lapatinib lapatinib ditosylate ADD TO FORMULARY Non-Preferred Specialty 10/05/2020 BELRAPZO bendamustine hcl REMOVE UM: Limited Access LIMITEDACCESS 10/05/2020 bendamustine hcl bendamustine hcl REMOVE UM: Limited Access LIMITEDACCESS 10/05/2020 dimethyl dimethyl fumarate ADD TO FORMULARY Preferred fumarate Specialty 10/05/2020 dimethyl dimethyl fumarate ADD UM: SPECIALTY Specialty Drug fumarate 10/05/2020 dimethyl dimethyl fumarate ADD TO FORMULARY Preferred fumarate Specialty 10/05/2020 dimethyl dimethyl fumarate ADD UM: SPECIALTY Specialty Drug fumarate

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 256 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/05/2020 dimethyl dimethyl fumarate ADD TO FORMULARY Preferred fumarate Specialty 10/05/2020 dimethyl dimethyl fumarate ADD UM: SPECIALTY Specialty Drug fumarate 10/05/2020 dexmedetomidine dexmedetomidine hcl in 0.9 ADD UM: MED Medical Drug -0.9% nacl % sodium chloride 10/05/2020 PRECEDEX dexmedetomidine hcl in 0.9 ADD UM: MED Medical Drug % sodium chloride 10/05/2020 DETECTNET copper cu-64 dotatate ADD UM: MED Medical Drug 10/05/2020 tecfidera,dimethyl dimethyl fumarate CHANGE UM: QUANTITY 2 / 1 days fumarate 10/05/2020 tecfidera,dimethyl dimethyl fumarate CHANGE UM: QUANTITY 2 / 1 days fumarate 10/05/2020 tecfidera,dimethyl dimethyl fumarate CHANGE UM: QUANTITY 2 / 1 days fumarate 10/07/2020 irinotecan hcl irinotecan hcl CHANGE UM: MED Medical Drug 10/07/2020 XERAVA eravacycline di- ADD UM: MED Medical Drug hydrochloride 10/09/2020 DIPHEN diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 10/09/2020 surgiflo gelatin sponge,absorbable REMOVE FROM Non-Formulary FORMULARY 10/09/2020 docusate sodium docusate sodium REMOVE FROM Non-Formulary FORMULARY 10/09/2020 senna sennosides REMOVE FROM Non-Formulary FORMULARY 10/09/2020 ear thermometer thermometer for the ear, REMOVE FROM Non-Formulary electronic FORMULARY 10/09/2020 phenazopyridine phenazopyridine hcl REMOVE FROM Non-Formulary hcl FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 257 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 10/09/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 10/09/2020 bacitracin zinc bacitracin zinc REMOVE FROM Non-Formulary FORMULARY 10/09/2020 senna sennosides REMOVE FROM Non-Formulary FORMULARY 10/09/2020 phenazopyridine phenazopyridine hcl REMOVE FROM Non-Formulary hcl FORMULARY 10/09/2020 sleep aid diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 10/09/2020 clotrimazole clotrimazole REMOVE FROM Non-Formulary FORMULARY 10/09/2020 infants' gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 10/09/2020 bisacodyl bisacodyl REMOVE FROM Non-Formulary FORMULARY 10/09/2020 phenobarbital- phenobarbital/hyoscyamine REMOVE FROM Non-Formulary hyosc-atrop-scop sulf/atropine FORMULARY sulf/scopolamine hb 10/09/2020 guaifenesin guaifenesin REMOVE FROM Non-Formulary FORMULARY 10/09/2020 co q-10 ubidecarenone REMOVE FROM Non-Formulary FORMULARY 10/09/2020 senna-s sennosides/docusate REMOVE FROM Non-Formulary sodium FORMULARY 10/09/2020 glucosamine- glucosamine hcl/chondroitin REMOVE FROM Non-Formulary chondroitin sulfate a FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 258 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 acid controller famotidine REMOVE FROM Non-Formulary FORMULARY 10/09/2020 fish oil omega-3 omega-3 fatty acids/fish oil REMOVE FROM Non-Formulary FORMULARY 10/09/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 10/09/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 10/09/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 10/09/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 10/09/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 10/09/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 10/09/2020 methylphenidate methylphenidate hcl REMOVE FROM Non-Formulary er FORMULARY 10/09/2020 men's underwear diaper,brief,adult, REMOVE FROM Non-Formulary disposable FORMULARY 10/09/2020 mucus er guaifenesin REMOVE FROM Non-Formulary FORMULARY 10/09/2020 mucus er guaifenesin REMOVE FROM Non-Formulary FORMULARY 10/09/2020 one daily multivitamin with folic acid REMOVE FROM Non-Formulary multivitamin FORMULARY 10/09/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 10/09/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 259 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 children's pain- acetaminophen REMOVE FROM Non-Formulary fever FORMULARY 10/09/2020 prenatal prenatal vits with calcium REMOVE FROM Non-Formulary multivitamin 95/ferrous fumarate/folic FORMULARY acid 10/09/2020 fish oil omega-3 fatty REMOVE FROM Non-Formulary acids/docosahexaenoic FORMULARY acid/epa/fish oil 10/09/2020 hemorrhoidal phenylephrine hcl/mineral REMOVE FROM Non-Formulary ointment oil/petrolatum,white FORMULARY 10/09/2020 reguloid psyllium husk (with sugar) REMOVE FROM Non-Formulary FORMULARY 10/09/2020 glucosamine glucosamine sulfate REMOVE FROM Non-Formulary sulfate FORMULARY 10/09/2020 testosterone testosterone REMOVE FROM Non-Formulary FORMULARY 10/09/2020 clear tape adhesive tape REMOVE FROM Non-Formulary FORMULARY 10/09/2020 clear tape adhesive tape REMOVE FROM Non-Formulary FORMULARY 10/09/2020 valerian root- valerian root extract/hops REMOVE FROM Non-Formulary hops FORMULARY 10/09/2020 minimed 770g subcutaneous insulin pump REMOVE FROM Non-Formulary FORMULARY 10/09/2020 minimed 770g subcutaneous insulin pump REMOVE FROM Non-Formulary FORMULARY 10/09/2020 magic3 go catheter REMOVE FROM Non-Formulary intermit catheter FORMULARY 10/09/2020 total care incontinence pad,liner,disp REMOVE FROM Non-Formulary underpads FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 260 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 germ-x ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 10/09/2020 elbow arm brace REMOVE FROM Non-Formulary compression FORMULARY 10/09/2020 pureair mini nebulizer and compressor REMOVE FROM Non-Formulary nebulizer FORMULARY 10/09/2020 CHEST guaifenesin REMOVE FROM Non-Formulary CONGESTION FORMULARY RELIEF 10/09/2020 CERAVE SA ceramides (1,3,6-ii)/salicylic REMOVE FROM Non-Formulary acid/niacinamide FORMULARY 10/09/2020 sodium chloride sodium chloride REMOVE FROM Non-Formulary FORMULARY 10/09/2020 lansoprazole lansoprazole REMOVE FROM Non-Formulary FORMULARY 10/09/2020 antacid extra calcium carbonate REMOVE FROM Non-Formulary strength FORMULARY 10/09/2020 alocane lidocaine hcl REMOVE FROM Non-Formulary emergency burn FORMULARY 10/09/2020 giltuss ex guaifenesin REMOVE FROM Non-Formulary FORMULARY 10/09/2020 giltuss cough- guaifenesin/dextromethorph REMOVE FROM Non-Formulary congestion an hbr FORMULARY 10/09/2020 INVIGOFLEX glucosamine dipot REMOVE FROM Non-Formulary AMPM chl/chondroitin sul a FORMULARY na/boswell/turmeric 10/09/2020 MULTI PRO multivit-mins no.85/iron/folic REMOVE FROM Non-Formulary acid/dha/ FORMULARY 10/09/2020 REGIOCIT (EUA) sodium chloride/sodium REMOVE FROM Non-Formulary citrate FORMULARY 10/09/2020 verapamil hcl verapamil hcl ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 261 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/09/2020 sodium nitroprusside sodium ADD TO FORMULARY Injectables nitroprusside 10/09/2020 fosfomycin fosfomycin tromethamine ADD TO FORMULARY Non-Preferred tromethamine Generics 10/09/2020 emtricitabine- emtricitabine/tenofovir ADD TO FORMULARY Non-Preferred tenofovir disop disoproxil fumarate Generics 10/09/2020 efavirenz-emtric- efavirenz/emtricitabine/tenof ADD TO FORMULARY Non-Preferred tenofov disop ovir disoproxil fumarate Generics 10/16/2020 dimethyl dimethyl fumarate REMOVE UM: SPECIALTY Specialty Drug fumarate 10/16/2020 dimethyl dimethyl fumarate REMOVE UM: SPECIALTY Specialty Drug fumarate 10/16/2020 dimethyl dimethyl fumarate REMOVE UM: SPECIALTY Specialty Drug fumarate 10/16/2020 epinephrine epinephrine hcl REMOVE FROM Non-Formulary chloride FORMULARY 10/16/2020 erythromycin erythromycin base REMOVE FROM Non-Formulary FORMULARY 10/16/2020 aminocaproic aminocaproic acid REMOVE FROM Non-Formulary acid FORMULARY 10/16/2020 erythromycin erythromycin base REMOVE FROM Non-Formulary FORMULARY 10/16/2020 alum-mag magnesium REMOVE FROM Non-Formulary hydroxide- hydroxide/aluminum FORMULARY simethicone hydroxide/simethicone 10/16/2020 DAILY-VITE multivitamin REMOVE FROM Non-Formulary FORMULARY 10/16/2020 sinus wash sodium chloride/sodium REMOVE FROM Non-Formulary bicarbonate FORMULARY 10/16/2020 TRIPLE neomycin sulfate/bacitracin REMOVE FROM Non-Formulary ANTIBIOTIC zinc/polymyxin b FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 262 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2020 adults 50 plus multivitamin with REMOVE FROM Non-Formulary multivitamin minerals/folic FORMULARY acid/lycopene/lutein 10/16/2020 children's pediatric multivitamin no.17 REMOVE FROM Non-Formulary multivitamin FORMULARY 10/16/2020 children's pediatric multivitamin no.17 REMOVE FROM Non-Formulary multivitamin FORMULARY 10/16/2020 lubricant pm mineral oil/petrolatum,white REMOVE FROM Non-Formulary FORMULARY 10/16/2020 giltuss cough- guaifenesin/dextromethorph REMOVE FROM Non-Formulary congestion an hbr FORMULARY 10/16/2020 women's diaper,brief,adult, REMOVE FROM Non-Formulary underwear disposable FORMULARY 10/16/2020 lofric primo catheter REMOVE FROM Non-Formulary nelaton FORMULARY 10/16/2020 supposi-pure c10-18 triglycerides REMOVE FROM Non-Formulary FORMULARY 10/16/2020 supposi-pure c10-18 triglycerides REMOVE FROM Non-Formulary FORMULARY 10/16/2020 ONE-A-DAY multivit with calcium- REMOVE FROM Non-Formulary WOMEN'S mins/iron fumarate/folic FORMULARY COMPLETE acid/vit k 10/16/2020 CERAVE SA ceramides (1,3,6-ii)/salicylic REMOVE FROM Non-Formulary acid/niacinamide FORMULARY 10/16/2020 CERAVE SA salicylic acid/ceramides REMOVE FROM Non-Formulary 1,3,6-ii FORMULARY 10/16/2020 acetaminophen acetaminophen REMOVE FROM Non-Formulary FORMULARY 10/16/2020 ibuprofen ibuprofen REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 263 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/16/2020 glycerin glycerin REMOVE FROM Non-Formulary FORMULARY 10/16/2020 alum-mag magnesium REMOVE FROM Non-Formulary hydroxide- hydroxide/aluminum FORMULARY simethicone hydroxide/simethicone 10/16/2020 chocolated sennosides REMOVE FROM Non-Formulary laxative FORMULARY 10/16/2020 lutein-zeaxanthin lutein/zeaxanthin REMOVE FROM Non-Formulary FORMULARY 10/16/2020 nighttime sleep diphenhydramine hcl REMOVE FROM Non-Formulary aid FORMULARY 10/16/2020 lutrish dietary supplement REMOVE FROM Non-Formulary FORMULARY 10/16/2020 magnesium REMOVE FROM Non-Formulary FORMULARY 10/16/2020 athlete's foot miconazole nitrate REMOVE FROM Non-Formulary FORMULARY 10/16/2020 arthritis pain diclofenac sodium REMOVE FROM Non-Formulary FORMULARY 10/16/2020 arthritis pain diclofenac sodium REMOVE FROM Non-Formulary FORMULARY 10/16/2020 cml lidocaine/methyl REMOVE FROM Non-Formulary salicylate/camphor FORMULARY 10/16/2020 testosterone testosterone REMOVE FROM Non-Formulary FORMULARY 10/16/2020 testosterone testosterone REMOVE FROM Non-Formulary FORMULARY 10/16/2020 CLOBETAVIX clobetasol REMOVE FROM Non-Formulary propionate/hydrocolloid FORMULARY dressing

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 264 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/20/2020 dimethyl dimethyl fumarate ADD UM: LIMITEDACCESS Limited Access fumarate 10/20/2020 dimethyl dimethyl fumarate ADD UM: LIMITEDACCESS Limited Access fumarate 10/20/2020 dimethyl dimethyl fumarate ADD UM: LIMITEDACCESS Limited Access fumarate 10/20/2020 abiraterone abiraterone acetate CHANGE TIER Non-Preferred Preferred acetate Specialty Specialty 10/22/2020 irinotecan hcl irinotecan hcl REMOVE FROM Non-Formulary FORMULARY 10/22/2020 olopatadine hcl olopatadine hcl ADD TO FORMULARY Non-Formulary Non-Preferred Generics 10/22/2020 PATANOL olopatadine hcl ADD TO FORMULARY Non-Formulary Non-Preferred Brands 10/22/2020 levo- levorphanol tartrate CHANGE UM: QUANTITY 8 / 1 days dromoran,levorph anol tartrate 10/22/2020 levo- levorphanol tartrate CHANGE UM: Total cumulative dromoran,levorph QUANTITYCUSTOM opioid dose anol tartrate limited to 90 morphine milligram equivalent (MME) per day 10/22/2020 viagra,sildenafil sildenafil citrate CHANGE UM: QUANTITY 8 / 30 days citrate 10/22/2020 viagra,sildenafil sildenafil citrate CHANGE UM: QUANTITY 8 / 30 days citrate 10/22/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 days xr,methylphenidat e er

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 265 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/22/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 days xr,methylphenidat e er 10/22/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 days xr,methylphenidat e er 10/22/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 days xr,methylphenidat e er 10/22/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 days xr,methylphenidat e er 10/22/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 days xr,methylphenidat e er 10/22/2020 aptensio methylphenidate hcl CHANGE UM: QUANTITY 1 / 1 days xr,methylphenidat e er 10/23/2020 BSP 0820 betamethasone ADD TO FORMULARY Injectables acetate/betamethasone sodium phosphate 10/23/2020 tavaborole tavaborole REMOVE FROM Non-Formulary FORMULARY 10/23/2020 westab mini cyanocobalamin/folic REMOVE FROM Non-Formulary acid/pyridoxine FORMULARY 10/23/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 10/23/2020 olopatadine hcl olopatadine hcl REMOVE FROM Non-Formulary FORMULARY 10/23/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 266 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2020 children's ibuprofen REMOVE FROM Non-Formulary ibuprofen FORMULARY 10/23/2020 senna plus sennosides/docusate REMOVE FROM Non-Formulary sodium FORMULARY 10/23/2020 stool softener- sennosides/docusate REMOVE FROM Non-Formulary laxative sodium FORMULARY 10/23/2020 hydroxyurea hydroxyurea REMOVE FROM Non-Formulary FORMULARY 10/23/2020 hydroxyurea hydroxyurea REMOVE FROM Non-Formulary FORMULARY 10/23/2020 olopatadine hcl olopatadine hcl REMOVE FROM Non-Formulary FORMULARY 10/23/2020 mitotane mitotane REMOVE FROM Non-Formulary FORMULARY 10/23/2020 clever choice bp blood pressure test kit-large REMOVE FROM Non-Formulary monitor FORMULARY 10/23/2020 nighttime dry-eye mineral oil/petrolatum,white REMOVE FROM Non-Formulary relief FORMULARY 10/23/2020 PKU EASY nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria(pku) no.56 FORMULARY 10/23/2020 pentylene glycol 1,2-pentanediol REMOVE FROM Non-Formulary FORMULARY 10/23/2020 pentylene glycol 1,2-pentanediol REMOVE FROM Non-Formulary FORMULARY 10/23/2020 pentylene glycol 1,2-pentanediol REMOVE FROM Non-Formulary FORMULARY 10/23/2020 CERTAVITE- multivitamin/ferrous REMOVE FROM Non-Formulary ANTIOXIDANT fumarate/folic acid FORMULARY 10/23/2020 lactobacillus lactobacillus REMOVE FROM Non-Formulary acidophilus/lactobacillus FORMULARY bulgaricus

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 267 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2020 new image skin ostomy supply REMOVE FROM Non-Formulary barrier-flange FORMULARY 10/23/2020 eye allergy relief naphazoline hcl/pheniramine REMOVE FROM Non-Formulary maleate FORMULARY 10/23/2020 dexamethasone dexamethasone sodium REMOVE FROM Non-Formulary sodium phosphate/pf FORMULARY phosphate 10/23/2020 lutrish dietary supplement REMOVE FROM Non-Formulary FORMULARY 10/23/2020 poly-vita pediatric multivitamin no.171 REMOVE FROM Non-Formulary FORMULARY 10/23/2020 poly-vita with iron pediatric multivitamin REMOVE FROM Non-Formulary no.160/ferrous sulfate FORMULARY 10/23/2020 quick temp pro thermometer, infrared, non- REMOVE FROM Non-Formulary thermometer contact FORMULARY 10/23/2020 atrantil tannic acid/horse chestnut REMOVE FROM Non-Formulary seed xt/peppermint leaf xt FORMULARY 10/23/2020 atrantil tannic acid/horse chestnut REMOVE FROM Non-Formulary seed xt/peppermint leaf xt FORMULARY 10/23/2020 SIMILAC bifidobacterium REMOVE FROM Non-Formulary PROBIOTIC TRI- animlis/bifidobacterium FORMULARY BLEND infantis/s. thermoph 10/23/2020 ENVIVE l.acidoph,paracasei, b.lactis REMOVE FROM Non-Formulary FORMULARY 10/23/2020 children's pain acetaminophen REMOVE FROM Non-Formulary relief FORMULARY 10/23/2020 children's pain acetaminophen REMOVE FROM Non-Formulary relief FORMULARY 10/23/2020 children's pain acetaminophen REMOVE FROM Non-Formulary relief FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 268 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/23/2020 anti-diarrheal- loperamide hcl/simethicone REMOVE FROM Non-Formulary anti-gas FORMULARY 10/23/2020 anti-diarrheal- loperamide hcl/simethicone REMOVE FROM Non-Formulary anti-gas FORMULARY 10/23/2020 anti-diarrheal- loperamide hcl/simethicone REMOVE FROM Non-Formulary anti-gas FORMULARY 10/23/2020 menthol- capsaicin/menthol REMOVE FROM Non-Formulary capsaicin FORMULARY 10/23/2020 sweet cheeks dextrose REMOVE FROM Non-Formulary FORMULARY 10/23/2020 5-htp cr 5-hydroxytryptophan (5-htp) REMOVE FROM Non-Formulary FORMULARY 10/23/2020 dr manzanilla phenylephrine REMOVE FROM Non-Formulary cough-cold hcl/diphenhydramine hcl FORMULARY 10/23/2020 dextrose in water dextrose 10 % in water ADD TO FORMULARY Injectables 10/26/2020 TRULICITY dulaglutide ADD UM: QUANTITY 2 / 28 days 10/26/2020 TRULICITY dulaglutide ADD UM: QUANTITY 2 / 28 days 10/26/2020 TRULICITY dulaglutide ADD TO FORMULARY Preferred Brands 10/26/2020 TRULICITY dulaglutide ADD TO FORMULARY Preferred Brands 10/27/2020 tolvaptan tolvaptan ADD UM: LIMITEDACCESS Limited Access 10/27/2020 tolvaptan tolvaptan ADD TO FORMULARY Non-Preferred Specialty 10/27/2020 tolvaptan tolvaptan ADD UM: LIMITEDACCESS Limited Access 10/27/2020 TRELEGY fluticasone ADD TO FORMULARY Preferred Brands ELLIPTA furoate/umeclidinium bromide/vilanterol trifenat 10/28/2020 SANTYL,BIOZY collagenase clostridium CHANGE UM: QUANTITY 1 / 1 DAY 30 / 30 days ME-C histolyticum

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 269 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/28/2020 sapropterin sapropterin dihydrochloride ADD UM: LIMITEDACCESS Limited Access dihydrochloride 10/28/2020 sapropterin sapropterin dihydrochloride ADD UM: LIMITEDACCESS Limited Access dihydrochloride 10/28/2020 sapropterin sapropterin dihydrochloride ADD UM: LIMITEDACCESS Limited Access dihydrochloride 10/28/2020 tobramycin tobramycin ADD UM: LIMITEDACCESS Limited Access 10/28/2020 tobramycin tobramycin ADD UM: MED Medical Drug 10/28/2020 SEVENFACT coagulation factor viia ADD UM: MED Medical Drug recombinant-jncw 10/29/2020 deferiprone deferiprone ADD UM: LIMITEDACCESS Limited Access 10/29/2020 POLIVY polatuzumab vedotin-piiq ADD UM: LIMITEDACCESS Limited Access 10/29/2020 POLIVY polatuzumab vedotin-piiq ADD UM: MED Medical Drug 10/29/2020 POLIVY polatuzumab vedotin-piiq ADD TO FORMULARY Non-Formulary Injectables 10/29/2020 lapatinib lapatinib ditosylate ADD UM: LIMITEDACCESS Limited Access 10/29/2020 emtricitabine- emtricitabine/tenofovir ADD UM: CUSTOM ACA Eligible for tenofovir disop disoproxil fumarate members not infected with HIV and are at higher risk of HIV infection 10/30/2020 TYBLUME levonorgestrel/ethinyl ADD TO FORMULARY Preventative estradiol 10/30/2020 microgestin 24 fe norethindrone acetate- ADD TO FORMULARY Preventative ethinyl estradiol/ferrous fumarate 10/30/2020 erythromycin erythromycin base REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 270 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 guaifenesin- guaifenesin/dextromethorph REMOVE FROM Non-Formulary dextromethorpha an hbr FORMULARY n 10/30/2020 guaifenesin- guaifenesin/dextromethorph REMOVE FROM Non-Formulary dextromethorpha an hbr FORMULARY n 10/30/2020 erythromycin erythromycin base REMOVE FROM Non-Formulary FORMULARY 10/30/2020 rifampin rifampin REMOVE FROM Non-Formulary FORMULARY 10/30/2020 rifampin rifampin REMOVE FROM Non-Formulary FORMULARY 10/30/2020 rifampin rifampin REMOVE FROM Non-Formulary FORMULARY 10/30/2020 hematogen forte ferrous fumarate/ascorbic REMOVE FROM Non-Formulary acid/cyanocobalamin/folic FORMULARY acid 10/30/2020 b-complex with b-complex with vitamin c REMOVE FROM Non-Formulary vitamin c FORMULARY 10/30/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 10/30/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 10/30/2020 MUCINEX DM guaifenesin/dextromethorph REMOVE FROM Non-Formulary an hbr FORMULARY 10/30/2020 ACTIDOSE- activated charcoal REMOVE FROM Non-Formulary AQUA FORMULARY 10/30/2020 calcium citrate- calcium REMOVE FROM Non-Formulary vitamin d3 citrate/cholecalciferol FORMULARY (vitamin d3)

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 271 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 10/30/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 10/30/2020 finasteride finasteride REMOVE FROM Non-Formulary FORMULARY 10/30/2020 mucus dm max guaifenesin/dextromethorph REMOVE FROM Non-Formulary er an hbr FORMULARY 10/30/2020 ALKA-SELTZER doxylamine REMOVE FROM Non-Formulary PLUS NIGHT succinate/phenylephrine/dex FORMULARY tromethorphan hbr/asa 10/30/2020 antacid-antigas magnesium REMOVE FROM Non-Formulary hydroxide/aluminum FORMULARY hydroxide/simethicone 10/30/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE FROM Non-Formulary -0.9% nacl % sodium chloride FORMULARY 10/30/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE FROM Non-Formulary -0.9% nacl % sodium chloride FORMULARY 10/30/2020 boost breeze lactose-reduced food REMOVE FROM Non-Formulary FORMULARY 10/30/2020 tavaborole tavaborole REMOVE FROM Non-Formulary FORMULARY 10/30/2020 tavaborole tavaborole REMOVE FROM Non-Formulary FORMULARY 10/30/2020 ENTTY palm oil/hyaluronate sodium REMOVE FROM Non-Formulary FORMULARY 10/30/2020 MEGARED omega-3 fatty REMOVE FROM Non-Formulary ADVANCED 4- acids/dha/epa/fish oil/krill oil FORMULARY IN-1

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 272 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 MEGARED krill oil/omega-3 fatty REMOVE FROM Non-Formulary OMEGA-3 KRILL acids/dha/epa/phospholipids FORMULARY OIL /astaxan 10/30/2020 ENTERADE sodium chloride/sodium REMOVE FROM Non-Formulary ADVANCED cit/potassium/magnes/calc/a FORMULARY ONCOLOGY mino acid 10/30/2020 ENTERADE sodium chloride/sodium REMOVE FROM Non-Formulary ADVANCED cit/potassium/magnes/calc/a FORMULARY ONCOLOGY mino acid 10/30/2020 pcca custom rdt tablet rapid dissolve REMOVE FROM Non-Formulary compounding base no.242 FORMULARY 10/30/2020 sofia2 flu-sars covid-19, influenza a, REMOVE FROM Non-Formulary antigen fia influenza b antigen FORMULARY immunoassay test 10/30/2020 stratagrt gel dressing REMOVE FROM Non-Formulary FORMULARY 10/30/2020 ciclopirox ciclopirox REMOVE FROM Non-Formulary FORMULARY 10/30/2020 ciclopirox ciclopirox REMOVE FROM Non-Formulary FORMULARY 10/30/2020 CHILD DELSYM diphenhydramine REMOVE FROM Non-Formulary COUGH-COLD hcl/phenylephrine FORMULARY hcl/acetaminophen 10/30/2020 ONE-A-DAY multivitamin,calcium,mineral REMOVE FROM Non-Formulary MEN'S s/folic acid/vitamin FORMULARY COMPLETE k1/lycopene 10/30/2020 BENZEPRO benzoyl peroxide micronized REMOVE FROM Non-Formulary FORMULARY 10/30/2020 BENZEPRO benzoyl peroxide micronized REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 273 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 CHILD MUCINEX triprolidine/phenylephrine/de REMOVE FROM Non-Formulary FREEFROM MS xtromethorph/acetamin/guaif FORMULARY D-N enes 10/30/2020 ADRENAMAX tyrosine/acetylcysteine REMOVE FROM Non-Formulary FORMULARY 10/30/2020 CHILD MUCINEX diphenhydramine REMOVE FROM Non-Formulary M-S COLD hcl/phenylephrine FORMULARY hcl/acetaminophen 10/30/2020 kinderlyte electrolytes/dextrose REMOVE FROM Non-Formulary FORMULARY 10/30/2020 kinderlyte electrolytes/dextrose REMOVE FROM Non-Formulary FORMULARY 10/30/2020 kinderlyte electrolytes/dextrose REMOVE FROM Non-Formulary FORMULARY 10/30/2020 kinderlyte electrolytes/dextrose REMOVE FROM Non-Formulary FORMULARY 10/30/2020 kinderlyte electrolytes/dextrose REMOVE FROM Non-Formulary FORMULARY 10/30/2020 kinderlyte electrolytes/dextrose REMOVE FROM Non-Formulary FORMULARY 10/30/2020 glucosamine- glucosamine hcl/hyaluronic REMOVE FROM Non-Formulary hyaluronic acid acid FORMULARY 10/30/2020 vitamin d3- calcium phosphate, REMOVE FROM Non-Formulary calcium- dibasic/cholecalciferol FORMULARY (vitamin d3) 10/30/2020 chest congestion guaifenesin/dextromethorph REMOVE FROM Non-Formulary relief dm an hbr FORMULARY 10/30/2020 isoproterenol hcl isoproterenol hcl ADD TO FORMULARY Injectables 10/30/2020 rocuronium rocuronium bromide ADD TO FORMULARY Injectables bromide

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 274 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 10/30/2020 rocuronium rocuronium bromide ADD TO FORMULARY Injectables bromide 10/30/2020 propofol propofol ADD TO FORMULARY Injectables 10/30/2020 propofol propofol ADD TO FORMULARY Injectables 10/30/2020 propofol propofol ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 275 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

November, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2020 ranexa,ranolazin ranolazine REMOVE UM: QUANTITY 2 / 1 DAY e er 11/01/2020 ranolazine ranolazine REMOVE UM: QUANTITY 2 / 1 DAY er,ranexa 11/01/2020 ezetimibe- ezetimibe/simvastatin CHANGE TIER Non-Preferred Preferred Brands simvastatin Generics 11/01/2020 ezetimibe- ezetimibe/simvastatin CHANGE TIER Non-Preferred Preferred Brands simvastatin Generics 11/01/2020 ezetimibe- ezetimibe/simvastatin CHANGE TIER Non-Preferred Preferred Brands simvastatin Generics 11/01/2020 ezetimibe- ezetimibe/simvastatin CHANGE TIER Non-Preferred Preferred Brands simvastatin Generics 11/01/2020 colesevelam hcl colesevelam hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY Generics 11/01/2020 WELCHOL colesevelam hcl REMOVE FROM Non-Preferred Non-Formulary FORMULARY Brands 11/01/2020 tolvaptan tolvaptan ADD TO FORMULARY Non-Preferred Specialty 11/01/2020 samsca,jynarque, tolvaptan CHANGE UM: Limited Access tolvaptan LIMITEDACCESS 11/01/2020 samsca,jynarque, tolvaptan CHANGE UM: Limited Access tolvaptan LIMITEDACCESS 11/01/2020 bethkis,tobramyci tobramycin CHANGE UM: MED Medical Drug n 11/01/2020 SEVENFACT coagulation factor viia ADD UM: MED Medical Drug recombinant-jncw

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 276 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/01/2020 MENQUADFI meningococcal vaccine a,c,y ADD UM: MED Medical Drug and w-135,conj tetanus toxoid/pf 11/01/2020 POLIVY polatuzumab vedotin-piiq ADD UM: MED Medical Drug 11/02/2020 beta betamethasone CHANGE UM: MED Medical Drug 1,readysharp acetate/betamethasone betamethasone,p sodium phosphate od-care 100c,bsp 0820 11/03/2020 RENACIDIN citric REMOVE UM: MED Medical Drug acid/gluconolactone/magnes ium carbonate 11/06/2020 CYSTARAN cysteamine hcl CHANGE UM: QUANTITY 60 / 30 days 2 / 1 days 11/06/2020 NOPIOID-LMC cyclobenzaprine REMOVE FROM Non-Formulary KIT hcl/lidocaine/menthol FORMULARY 11/06/2020 docosanol docosanol REMOVE FROM Non-Formulary FORMULARY 11/06/2020 estrone estrone REMOVE FROM Non-Formulary FORMULARY 11/06/2020 estrone estrone REMOVE FROM Non-Formulary FORMULARY 11/06/2020 acid reducer famotidine REMOVE FROM Non-Formulary FORMULARY 11/06/2020 brompheniramine brompheniramine REMOVE FROM Non-Formulary -pseudoephed- maleate/pseudoephedrine FORMULARY dm hcl/dextromethorphan 11/06/2020 brompheniramine brompheniramine REMOVE FROM Non-Formulary -pseudoephed- maleate/pseudoephedrine FORMULARY dm hcl/dextromethorphan 11/06/2020 brompheniramine brompheniramine REMOVE FROM Non-Formulary -pseudoephed- maleate/pseudoephedrine FORMULARY dm hcl/dextromethorphan

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 277 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2020 ergocalciferol ergocalciferol (vitamin d2) REMOVE FROM Non-Formulary FORMULARY 11/06/2020 ziprasidone ziprasidone mesylate REMOVE FROM Non-Formulary mesylate FORMULARY 11/06/2020 ORAMAGICRX potassium REMOVE FROM Non-Formulary sorbate/maltodextrin/aloe FORMULARY vera/mann ps 11/06/2020 ACTIDOSE- activated charcoal REMOVE FROM Non-Formulary AQUA FORMULARY 11/06/2020 cyproheptadine cyproheptadine hcl REMOVE FROM Non-Formulary hcl FORMULARY 11/06/2020 cyproheptadine cyproheptadine hcl REMOVE FROM Non-Formulary hcl FORMULARY 11/06/2020 acid reducer famotidine REMOVE FROM Non-Formulary FORMULARY 11/06/2020 lubricant eye carboxymethylcellulose REMOVE FROM Non-Formulary drops sodium FORMULARY 11/06/2020 all day allergy cetirizine hcl REMOVE FROM Non-Formulary FORMULARY 11/06/2020 allergy relief fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 11/06/2020 AZO URINARY phenazopyridine hcl REMOVE FROM Non-Formulary PAIN RELIEF FORMULARY 11/06/2020 BAYER aspirin REMOVE FROM Non-Formulary CHEWABLE FORMULARY ASPIRIN 11/06/2020 ulticare pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 11/06/2020 ulticare pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 278 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/06/2020 ulticare pen pen needle, diabetic REMOVE FROM Non-Formulary needle FORMULARY 11/06/2020 turmeric-tamarind tamarindus indica REMOVE FROM Non-Formulary blend seed/turmeric root extract FORMULARY 11/06/2020 valerian root- valerian/passion REMOVE FROM Non-Formulary herbal blend flower/hops/lemon balm FORMULARY 11/06/2020 tofacitinib citrate tofacitinib citrate REMOVE FROM Non-Formulary FORMULARY 11/06/2020 ACTIDOSE- activated charcoal REMOVE FROM Non-Formulary AQUA FORMULARY 11/06/2020 DIGESTIVE bacillus coagulans REMOVE FROM Non-Formulary ADVANTAGE FORMULARY KID PROBIO 11/06/2020 fish oil omega-3 fatty REMOVE FROM Non-Formulary acids/dha/epa/other omega- FORMULARY 3s/fish oil 11/06/2020 athlete's foot tolnaftate REMOVE FROM Non-Formulary FORMULARY 11/06/2020 k2-45 vitamin k2 REMOVE FROM Non-Formulary FORMULARY 11/06/2020 type ii collagen- cartilage/collagen type REMOVE FROM Non-Formulary ha-boron ii/boron FORMULARY glycinate/hyaluronate sod 11/06/2020 iron glycinate ferrous bis-glycinate chelate REMOVE FROM Non-Formulary FORMULARY 11/06/2020 miclara dm triprolidine hcl/phenylephrine REMOVE FROM Non-Formulary hcl/dextromethorphan hbr FORMULARY 11/06/2020 TRELSTAR triptorelin pamoate ADD TO FORMULARY Injectables 11/13/2020 lidocort lidocaine hcl/hydrocortisone REMOVE FROM Non-Formulary acetate FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 279 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 stratamark dimethicone REMOVE FROM Non-Formulary FORMULARY 11/13/2020 stratatriz dimethicone REMOVE FROM Non-Formulary FORMULARY 11/13/2020 clearshield sodium chloride 0.9 % REMOVE FROM Non-Formulary sodium chlor (flush) FORMULARY flush 11/13/2020 ibuprofen ibuprofen REMOVE FROM Non-Formulary FORMULARY 11/13/2020 aspirin aspirin REMOVE FROM Non-Formulary FORMULARY 11/13/2020 aspirin aspirin REMOVE FROM Non-Formulary FORMULARY 11/13/2020 stool softener docusate sodium REMOVE FROM Non-Formulary FORMULARY 11/13/2020 fexofenadine hcl fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 sore throat spray phenol REMOVE FROM Non-Formulary FORMULARY 11/13/2020 zinc sulfate zinc sulfate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 motion sickness dimenhydrinate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 stay awake caffeine REMOVE FROM Non-Formulary FORMULARY 11/13/2020 allergy relief chlorpheniramine maleate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 allergy relief chlorpheniramine maleate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 famotidine famotidine REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 280 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 vitamin b-12 cyanocobalamin (vitamin b- REMOVE FROM Non-Formulary 12) FORMULARY 11/13/2020 magnesium oxide magnesium oxide REMOVE FROM Non-Formulary FORMULARY 11/13/2020 sucralfate sucralfate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 sucralfate sucralfate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 sucralfate sucralfate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 triple antibiotic neomycin sulfate/bacitracin REMOVE FROM Non-Formulary zinc/polymyxin b FORMULARY 11/13/2020 stool softener docusate sodium REMOVE FROM Non-Formulary FORMULARY 11/13/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 11/13/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 11/13/2020 magnesium REMOVE FROM Non-Formulary citrate FORMULARY 11/13/2020 magnesium magnesium citrate REMOVE FROM Non-Formulary citrate FORMULARY 11/13/2020 chlordiazepoxide- chlordiazepoxide/clidinium REMOVE FROM Non-Formulary clidinium bromide FORMULARY 11/13/2020 purified water water REMOVE FROM Non-Formulary FORMULARY 11/13/2020 pain reliever pm acetaminophen/diphenhydra REMOVE FROM Non-Formulary mine hcl FORMULARY 11/13/2020 nighttime sleep diphenhydramine hcl REMOVE FROM Non-Formulary aid FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 281 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 ibuprofen ib ibuprofen REMOVE FROM Non-Formulary FORMULARY 11/13/2020 sleep aid doxylamine succinate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 allergy relief diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 clotrimazole REMOVE FROM Non-Formulary FORMULARY 11/13/2020 day time dextromethorphan REMOVE FROM Non-Formulary hbr/phenylephrine FORMULARY hcl/acetaminophen 11/13/2020 day time dextromethorphan REMOVE FROM Non-Formulary hbr/phenylephrine FORMULARY hcl/acetaminophen 11/13/2020 nasal phenylephrine hcl REMOVE FROM Non-Formulary decongestant pe FORMULARY 11/13/2020 pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY 11/13/2020 pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY 11/13/2020 pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY 11/13/2020 microcrystalline cellulose REMOVE FROM Non-Formulary cellulose FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 282 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 microcrystalline cellulose REMOVE FROM Non-Formulary cellulose FORMULARY 11/13/2020 microcrystalline cellulose REMOVE FROM Non-Formulary cellulose FORMULARY 11/13/2020 microcrystalline cellulose REMOVE FROM Non-Formulary cellulose FORMULARY 11/13/2020 eye itch relief ketotifen fumarate REMOVE FROM Non-Formulary FORMULARY 11/13/2020 daytime cold-flu dextromethorphan REMOVE FROM Non-Formulary hbr/phenylephrine FORMULARY hcl/acetaminophen 11/13/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 11/13/2020 calcium 600-vit calcium REMOVE FROM Non-Formulary d3 carbonate/cholecalciferol FORMULARY (vitamin d3) 11/13/2020 azo cranberry cranberry fruit REMOVE FROM Non-Formulary extract/ascorbic acid FORMULARY 11/13/2020 potassium potassium phosphate, REMOVE FROM Non-Formulary phosphate dibasic FORMULARY 11/13/2020 calcipotriene calcipotriene REMOVE FROM Non-Formulary FORMULARY 11/13/2020 calcipotriene calcipotriene REMOVE FROM Non-Formulary FORMULARY 11/13/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE FROM Non-Formulary -0.9% nacl % sodium chloride FORMULARY 11/13/2020 dexmedetomidine dexmedetomidine hcl in 0.9 REMOVE FROM Non-Formulary -0.9% nacl % sodium chloride FORMULARY 11/13/2020 sirolimus sirolimus REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 283 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 sirolimus sirolimus REMOVE FROM Non-Formulary FORMULARY 11/13/2020 norethin-eth norethindrone acetate- REMOVE FROM Non-Formulary estra-ferrous fum ethinyl estradiol/ferrous FORMULARY fumarate 11/13/2020 l-lysine lysine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 turmeric turmeric/turmeric root REMOVE FROM Non-Formulary extract FORMULARY 11/13/2020 l-histidine histidine REMOVE FROM Non-Formulary FORMULARY 11/13/2020 liquid c ascorbic acid REMOVE FROM Non-Formulary FORMULARY 11/13/2020 vivaguard ino test blood sugar diagnostic REMOVE FROM Non-Formulary strip FORMULARY 11/13/2020 succinylcholine succinylcholine chloride in REMOVE FROM Non-Formulary chloride-nacl sodium chloride,iso- FORMULARY osmotic/pf 11/13/2020 ethyl alcohol ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 11/13/2020 vivaguard thermometer, infrared, non- REMOVE FROM Non-Formulary infrared contact FORMULARY thermometer 11/13/2020 KONSYL psyllium husk REMOVE FROM Non-Formulary FORMULARY 11/13/2020 MG217 COAL REMOVE FROM Non-Formulary TAR FORMULARY 11/13/2020 ADRENAL multivitamin with REMOVE FROM Non-Formulary MANAGER minerals/herbal complex FORMULARY no.315

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 284 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 docosanol docosanol REMOVE FROM Non-Formulary FORMULARY 11/13/2020 pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY 11/13/2020 nighttime sleep diphenhydramine hcl REMOVE FROM Non-Formulary aid FORMULARY 11/13/2020 anti-diarrheal loperamide hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 urinary pain relief phenazopyridine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 11/13/2020 dual action famotidine/calcium REMOVE FROM Non-Formulary complete carbonate/magnesium FORMULARY hydroxide 11/13/2020 dual action famotidine/calcium REMOVE FROM Non-Formulary complete carbonate/magnesium FORMULARY hydroxide 11/13/2020 ibuprofen pm ibuprofen/diphenhydramine REMOVE FROM Non-Formulary citrate FORMULARY 11/13/2020 pain relief acetaminophen REMOVE FROM Non-Formulary FORMULARY 11/13/2020 mucus relief er guaifenesin REMOVE FROM Non-Formulary FORMULARY 11/13/2020 allergy relief fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 allergy relief fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 allergy relief fexofenadine hcl REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 285 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 mucus relief dm guaifenesin/dextromethorph REMOVE FROM Non-Formulary er an hbr FORMULARY 11/13/2020 z-sleep diphenhydramine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 mucus relief dm guaifenesin/dextromethorph REMOVE FROM Non-Formulary max er an hbr FORMULARY 11/13/2020 vitamin k2 vitamin k2 REMOVE FROM Non-Formulary FORMULARY 11/13/2020 l-theanine theanine REMOVE FROM Non-Formulary FORMULARY 11/13/2020 magnesium magnesium citrate REMOVE FROM Non-Formulary citrate FORMULARY 11/13/2020 mucus relief er guaifenesin REMOVE FROM Non-Formulary FORMULARY 11/13/2020 24 hour nasal triamcinolone acetonide REMOVE FROM Non-Formulary allergy FORMULARY 11/13/2020 children's allergy loratadine REMOVE FROM Non-Formulary relief FORMULARY 11/13/2020 urinary pain relief phenazopyridine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 krill-fish oil blend omega-3 fatty REMOVE FROM Non-Formulary acids/dha/epa/fish oil/krill oil FORMULARY 11/13/2020 k-mg citrate magnesium REMOVE FROM Non-Formulary citrate/ FORMULARY 11/13/2020 melatonin melatonin REMOVE FROM Non-Formulary FORMULARY 11/13/2020 k2-d3 10,000 cholecalciferol (vit REMOVE FROM Non-Formulary d3)/vitamin k2 FORMULARY 11/13/2020 glucosamine- glucosamine REMOVE FROM Non-Formulary vitamin d3-ha hcl/cholecalciferol (vit FORMULARY d3)/hyaluronic acid

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 286 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/13/2020 meclizine hcl meclizine hcl REMOVE FROM Non-Formulary FORMULARY 11/13/2020 micafungin micafungin sodium ADD TO FORMULARY Injectables 11/13/2020 micafungin micafungin sodium ADD TO FORMULARY Injectables 11/13/2020 VISTASEAL thrombin(human plasma REMOVE FROM Non-Formulary FIBRIN derived)/fibrinogen/calcium FORMULARY SEALANT chloride 11/20/2020 aminocaproic aminocaproic acid REMOVE FROM Non-Formulary acid FORMULARY 11/20/2020 lice killing piperonyl REMOVE FROM Non-Formulary butoxide/pyrethrins FORMULARY 11/20/2020 lidocaine lidocaine REMOVE FROM Non-Formulary FORMULARY 11/20/2020 hydrocortisone- hydrocortisone/aloe vera REMOVE FROM Non-Formulary aloe FORMULARY 11/20/2020 senna laxative sennosides REMOVE FROM Non-Formulary FORMULARY 11/20/2020 epsom salt magnesium sulfate REMOVE FROM Non-Formulary FORMULARY 11/20/2020 stomach relief bismuth subsalicylate REMOVE FROM Non-Formulary FORMULARY 11/20/2020 gas relief simethicone REMOVE FROM Non-Formulary FORMULARY 11/20/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 11/20/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 11/20/2020 sleep aid doxylamine succinate REMOVE FROM Non-Formulary FORMULARY

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 287 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2020 metformin er metformin hcl REMOVE FROM Non-Formulary osmotic FORMULARY 11/20/2020 metformin er metformin hcl REMOVE FROM Non-Formulary osmotic FORMULARY 11/20/2020 MIMYX emollient combination no.35 REMOVE FROM Non-Formulary FORMULARY 11/20/2020 tadalafil tadalafil REMOVE FROM Non-Formulary FORMULARY 11/20/2020 droplet lancets lancets REMOVE FROM Non-Formulary FORMULARY 11/20/2020 chlorzoxazone chlorzoxazone REMOVE FROM Non-Formulary FORMULARY 11/20/2020 CULTURELLE gg REMOVE FROM Non-Formulary HEALTH- FORMULARY WELLNESS 11/20/2020 CULTURELLE lactobacillus rhamnosus gg REMOVE FROM Non-Formulary HEALTH- FORMULARY WELLNESS 11/20/2020 PKU GO nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria(pku) with FORMULARY iron no.60 11/20/2020 CULTURELLE lactobacillus rhamnosus REMOVE FROM Non-Formulary DIGESTIVE gg/inulin FORMULARY 11/20/2020 CULTURELLE lactobacillus rhamnosus REMOVE FROM Non-Formulary DIGESTIVE gg/inulin FORMULARY 11/20/2020 TYR EASY nutritional therapy for REMOVE FROM Non-Formulary tyrosinemia without iron FORMULARY 11/20/2020 HCU EASY nutritional therapy, REMOVE FROM Non-Formulary metabolic disorder, FORMULARY methionine-free

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 288 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2020 PKU EASY nutritional therapy for REMOVE FROM Non-Formulary phenylketonuria(pku) no.56 FORMULARY 11/20/2020 fiber psyllium husk (with sugar) REMOVE FROM Non-Formulary FORMULARY 11/20/2020 MSUD EASY nutritional ther.msud(maple REMOVE FROM Non-Formulary syrup urine disease)without FORMULARY iron 11/20/2020 AZO COMPLETE lactobacillus crispatus/l. REMOVE FROM Non-Formulary FEMININE gasseri/l. jensenii/l. FORMULARY BALANCE rhamnosus 11/20/2020 DIGESTIVE bacillus coagulans REMOVE FROM Non-Formulary ADVANTAGE FORMULARY IMMUNE 11/20/2020 move free ultra tamarindus indica REMOVE FROM Non-Formulary turmeric-tamar seed/turmeric root extract FORMULARY 11/20/2020 ethyl alcohol ethyl alcohol REMOVE FROM Non-Formulary FORMULARY 11/20/2020 MOVE FREE cholecalciferol (vit REMOVE FROM Non-Formulary ULTRA- d3)/vitamin k2/calcium FORMULARY BORATE-K2-D3 fructoborate 11/20/2020 TAB-A-VITE multivitamin/ferrous REMOVE FROM Non-Formulary MULTIVIT WITH sulfate/folic acid FORMULARY IRON 11/20/2020 curad stretch gauze bandage REMOVE FROM Non-Formulary gauze bandage FORMULARY 11/20/2020 bremelanotide acetate REMOVE FROM Non-Formulary acetate FORMULARY 11/20/2020 bremelanotide bremelanotide acetate REMOVE FROM Non-Formulary acetate FORMULARY 11/20/2020 CULTURELLE lactobacillus rhamnosus gg REMOVE FROM Non-Formulary KIDS PURELY FORMULARY PROB

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 289 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2020 ANTARCTIC krill oil/omega-3 fatty REMOVE FROM Non-Formulary KRILL OIL acids/dha/epa/phospholipids FORMULARY /astaxan 11/20/2020 CEPACOL benzocaine/menthol REMOVE FROM Non-Formulary INSTAMAX FORMULARY SORE THROAT 11/20/2020 LIPOTROPIX inositol/choline/methionine/t REMOVE FROM Non-Formulary aurine/herbal no.317 FORMULARY 11/20/2020 ADRENAL vit b5/vit b6/paba/cordyceps REMOVE FROM Non-Formulary ESSENCE xt/rhodiola xt/panax FORMULARY xt 11/20/2020 MEGARED krill oil/omega-3 fatty REMOVE FROM Non-Formulary OMEGA-3 KRILL acids/dha/epa/phospholipids FORMULARY OIL /astaxan 11/20/2020 MAGNESIUM magnesium REMOVE FROM Non-Formulary COMPLEX carb,citrate,oxide FORMULARY 11/20/2020 LIVER acetylcysteine/alpha REMOVE FROM Non-Formulary PROTECT lipoic/milk FORMULARY thistle/selenomethionine 11/20/2020 ADRENALIV ascorbic acid/calcium REMOVE FROM Non-Formulary pant/pyridoxal FORMULARY phosphate/herbal no.316 11/20/2020 AZO vit REMOVE FROM Non-Formulary HORMONAL b1/b6/calcium/magnesium FORMULARY HLTH HAPPY oxide/chaste CYCLE tree/ashwagandha 11/20/2020 dexmedetomidine dexmedetomidine hcl in 0.9 ADD TO FORMULARY Injectables -0.9% nacl % sodium chloride 11/20/2020 sodium- sodium REMOVE FROM Non-Formulary potassium- phosphate/potassium FORMULARY phosphorus phosphates, monobasic and bibasic

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 290 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 11/20/2020 pediatric iron ferrous sulfate REMOVE FROM Non-Formulary FORMULARY 11/20/2020 pediatric tri- vitamin a palmitate/ascorbic REMOVE FROM Non-Formulary vitamin acid/cholecalciferol (vit d3) FORMULARY 11/20/2020 pediatric poly- pediatric multivitamin no.171 REMOVE FROM Non-Formulary vitamin FORMULARY 11/20/2020 arthritis pain diclofenac sodium REMOVE FROM Non-Formulary reliever FORMULARY 11/20/2020 biotin-vitamin c vitamin a/ascorbic REMOVE FROM Non-Formulary acid/biotin/zinc/selenomethi FORMULARY onine 11/20/2020 TRELSTAR triptorelin pamoate ADD TO FORMULARY Injectables 11/20/2020 TRELSTAR triptorelin pamoate ADD TO FORMULARY Injectables 11/20/2020 cyclophosphamid cyclophosphamide ADD TO FORMULARY Injectables e 11/20/2020 cyclophosphamid cyclophosphamide ADD TO FORMULARY Injectables e 11/20/2020 dextrose 5%- potassium chloride in ADD TO FORMULARY Injectables 0.45% nacl-kcl dextrose 5 %-0.45 % sodium chloride 11/20/2020 TRELSTAR triptorelin pamoate ADD TO FORMULARY Injectables 11/20/2020 TRELSTAR triptorelin pamoate ADD TO FORMULARY Injectables 11/20/2020 VENOFER iron sucrose complex ADD TO FORMULARY Injectables

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 291 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

December, 2020

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 freestyle libre 2 flash glucose scanning ADD UM: MED Medical Drug reader reader 12/01/2020 freestyle libre 2 flash glucose sensor ADD UM: MED Medical Drug sensor

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 292 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 answer,contour blood sugar diagnostic CHANGE UM: QUANTITY 5 / 1 days test strip,contour next test strip,relion confirm-micro,bg- star,advance test strips,assure pro,assure platinum,assure 4,glucocard expression,pocke tchem ez,relion prime test strips,micro,gluco card 01 sensor plus,glucocard x- sensor,glucocard vital,glucocard vital sensor,evencare g2,evencare,eve ncare g3,blood glucose test strip,easygluco test strips,easy gluco g2,control ast test strip,control,g- 4,maxima,infinity test strips,acura test strips,easygluco plus,easy pro plus,prodigy,prodi gy eject,prodigy no coding,prodigy autocode,prodigy voice,easy touch test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 293 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strip,eclipse,envis ion,evolution test strips,element test strips,smartdiabet es xpres,element plus,element compact,glucolab ,smartest test,glucocom glucose,rightest gs300 test strips,rightest gs100 test strips,rightest gs550 test strips,ge100 blood glucose test strip,nova max glucose test strips,keynote,wa vesense jazz,wavesense presto,agamatrix amp,liberty test strips,ultratrak,ult ratrak ultimate,solus v2 test strips,caresens n,smart caresens n,reveal test strip,glucose test strip,truetest test strips,truetrack test strip,premium blood glucose test,foracare

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 294 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value gd20,fora v10,choicedm g20,fora g20,fora test strip,fora g71a,foracare gd40,premium v10,test n'go,fora v12,refuah plus,surechek test strips,sure edge test strips,vocal point,ultratrak pro,truetrack smart system,easymax, easymax 15,easyplus,td gold test strip,myglucoheal th,accu-chek comfort curve,accu-chek active,microdot,m icrodot xtra,ez smart,ez smart plus,one touch verio,fast take,surestep,on e touch test strips,onetouch ultra blue test strp,onetouch verio test strip,onetouch ultra test strips,surestep pro,glucostix,test strips,test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 295 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strip,prestige test strips,prestige smart system,precision pcx plus,precision point of care,optium ez,precision q-i- d,precision pcx,optium,precis ion xtra,neutek 2tek test strips,telcare,sure -test easyplus mini,accu-chek aviva,accutrend glucose,accu- chek aviva plus,accu-chek smartview,ultima, on call plus test strip,optumrx,on call vivid test strip,gmate test strips,gluco navii,choicedm clarus test strips,quintet,quin tet ac,easy step,easy plus,easy trak,easy talk,easy plus ii,easy check test strip,diatrue plus,fifty50 test strip,embrace,vict ory,advocate test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 296 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strip,advocate redi- code,advocate redi-code+,clever choice test strips,clever choice voice+ tst strip,clever choice pro,pharmacist choice,clever choice micro test strip,clever choice talk,fora v10-v12-d10- d20,fora d15c,fora d15z,fora v20,fora v22,fora g30-premium v10 test strp,fora d15g,fora d20,fora g90,fora v30a,freestyle test strips,freestyle lite test strip,freestyle lite strips,freestyle insulinx test strips,freestyle insulinx,rightest gs260 test strips,glucometer elite,ascensia elite,pts panels,bioscanne r glucose test,at- last test

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 297 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value strips,assure ii,quicktek,assure 3,supreme test strips,smart sense test strips,nexgen,eas ypro,duo- care,accu-chek instant plus,accu- chek instant,one touch ultra test strips,accu-chek advantage,life medical test strip,diabetic.com test strip,sentry test strip,precision sof- tact,exactech,exa ctech rsg,rightest gs250s test strips,glucometer encore,glucofilm, glucostix reagent,visidex ii,seralyzer glucose,dextrosti x reagent,glucomet er dex,glucose test strips,duet,expres s view glucose test strp,glucoprotein, quick-check one,quick-check ii,quick-check

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 298 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value film,excel ge,excel g,uni- check,bd test strips,checkmate, checkmate plus,select gt,assure,senova, glucoleader,valus trip test strips,kyodex reagent,longs blood glucose strip,biotel hi- value v,biotel hi- value 3,truetrack,diasca n,diascan test strips,diascan dual pad test strips,diascan dual pad strips,ultra standard strips,ultra +,ultra,swiftcheck ,blood glucose test,tt strips,accu- chek,accu-chek simplicity,chemstr ip bg,tracer bg,blood glucose 3 test,reagent,gluc oscan test strips,glucoscan/ gm test strips,one touch,trendstrips, diascan first choice,trackease,

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 299 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value relief plus,companion 2,medisense 2 test strips,sof- tact,supreme confidence strips,ga test strips,one touch ii test strips,first choice,glucose alert,genstrip,unis trip1,onetouch verio,embrace evo,embrace pro test strip,on call express test strip,healthpro glucose test strips,advanced glucose test strips,true metrix glucose test strip,fora gd50 test strips,fora test n'go test strips,fortiscare glucose test strips,assure prism multi,glucocard shine,genultimate test strip,evencare mini glucose test str,fora tn'g voice test strips,freestyle precision neo,fora d40-g31

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 300 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value test strips,cool glucose test strip,accu-chek guide test strip,dario blood glucose test strip,iglucose test strip,infinity voice test strip,premier test strip,caretouch test strip,verasens test strip,goodlife ac-302 test strip,true metrix pro test strip,harmony glucose test strip,evencare proview test strip,pro voice v8- v9 test strip,fora 6 connect glucose strip,advanced glucose test strip,embrace talk test strip,fora gtel glucose test strip,vivaguard ino test strip,assure platinum test strip,gojji blood glucose test strip,agamatrix presto,easy trak ii test strip

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 301 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 12/01/2020 dexcom g5 blood-glucose ADD UM: MED Medical Drug meter,continuous 12/01/2020 clearshield sodium chloride 0.9 % ADD TO FORMULARY Non-Formulary Injectables sodium chlor (flush) flush 12/01/2020 clearshield sodium chloride 0.9 % ADD UM: MED Medical Drug sodium chlor (flush) flush 12/01/2020 levonorgestrel- levonorgestrel/ethinyl CHANGE TIER Preventative eth estradiol estradiol 12/01/2020 dexmedetomidine dexmedetomidine hcl in 0.9 CHANGE TIER Injectables -0.9% nacl % sodium chloride 12/01/2020 dexmedetomidine dexmedetomidine hcl in 0.9 CHANGE TIER Injectables -0.9% nacl % sodium chloride

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 302 UPDATED 12/2020 2020 PROVIDENCE FORMULARY A Updates

January, 2021

Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2021 NURTEC ODT rimegepant sulfate ADD UM: QUANTITY 8 / 30 days 01/01/2021 TREXALL methotrexate sodium REMOVE FROM Injectables Non-Formulary FORMULARY 01/01/2021 TREXALL methotrexate sodium REMOVE FROM Injectables Non-Formulary FORMULARY 01/01/2021 TREXALL methotrexate sodium REMOVE FROM Injectables Non-Formulary FORMULARY 01/01/2021 TREXALL methotrexate sodium REMOVE UM: MED Medical Drug 01/01/2021 TREXALL methotrexate sodium REMOVE FROM Injectables Non-Formulary FORMULARY 01/01/2021 cyclophosphamid cyclophosphamide REMOVE FROM Non-Preferred Non-Formulary e FORMULARY Generics 01/01/2021 LUMIGAN bimatoprost ADD TO FORMULARY Non-Preferred Brands

BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 303 UPDATED 12/2020