California Health and Wellness Plan Preferred Drug List

The California Health and Wellness Plan Preferred Drug List (PDL) includes drugs covered by California Health and Wellness. The drug list is updated each month and may change. To get the most up-to-date information or a printed copy, call Member Services at 1-877-658-0305 (TTY: 711).

The latest drug list can be found on our website at https://www.cahealthwellness.com/members/medicaid/benefits-services/pharmacy.html. It is also found on our web site in a machine readable format. Go to “Which drugs are covered?” Use the “Preferred Drug List” link to view the list of drugs covered by California Health & Wellness Plan.

PLEASE THROW AWAY ALL PREVIOUS VERSIONS OF THE DRUG LIST

CHW Drug List Front Matter_ENGLISH_2.5.20 Table of Contents

What is the California Health and Wellness Plan PDL?...... iii

How do I use the California Health and Wellness Plan PDL?...... iii

How do I find a drug in the Drug List?...... iii

How are the drugs listed in the categorical list?...... iv

What if my drug is not on the California Health and Wellness Plan PDL?...... iv

Can I go to any pharmacy?...... v

Are there any limits on my drug coverage?...... v

Are there limits on opioid pain drugs?...... v

What is Morphine Milligram Equivalent (MME) Dosing?...... v

How can I get an exception to the rules for the drug coverage?...... vi

What if I’m a new member?...... vi

What are over-the-counter drugs?...... vi

Are brand name drugs covered?...... vi

What is a generic drug?...... vi

Will the pharmacist give me a generic drug if one is available?...... vi

Are there any excluded or carve-out drugs?...... vi

What is California Children’s Services?...... vii

What about drugs I get from my doctor or in my doctor’s office?...... vii

Definitions………………………………………………………………………………...vii

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

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

ii Welcome to California Health and Wellness Plan

What is the California Health and Wellness Plan PDL? The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists meet regularly to decide which drugs should be on the drug list. The team reviews current and new drugs and choose drugs that work best and are safe. This drug list is updated each month. These changes may include the form a drug comes in (i.e. tablet or capsule) or if a drug has a limit on the amount that can be filled at one time. Changes may also include if a drug requires prior authorization, step therapy, or if a drug is no longer covered on the drug list.

How do I use the California Health and Wellness Plan PDL? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Brand name and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.

The table below has descriptions of the limits that may appear on the drug list: Abbreviation Term What it means AL Age Limit Some drugs are only covered for certain ages. These drugs are carved out by the Department of Health Care Services. This means these drugs are covered by the Medi- CO Carve Out Cal Fee-for-Service program and can be billed to the State by the pharmacy. F Formulary These drugs are covered on the Drug List. These drugs are not covered on the Drug List. If your doctor NF Non-Formulary feels you need a drug that is not covered, he or she can ask us to make an exception. Prior Your doctor must ask for approval from California Health PA Authorization and Wellness Plan before some drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. Prescription and These drugs are made in both prescription form and Over-the- RX/OTC OTC counter (OTC) form. In some cases, you must first try certain drugs before California Health and Wellness Plan covers another drug for your health condition. ST Step Therapy For example, if Drug A and Drug B both treat your medical condition, California Health and Wellness Plan may not cover Drug B unless you try Drug A first. Specialty These drugs are specialty drugs. You can only get these drugs SP Pharmacy from a specialty pharmacy. All prescriptions must be filled Program by the listed specialty pharmacy.

How do I find a drug in the Drug List? You can search for a drug by using the search tool. Drugs can be found in alphabetical order or by medical condition. There are three ways to find out if your drug is covered.

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

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

Therapeutic Category: The drugs are grouped into categories. The categories may also be grouped by the class to which the drug is in. If you know what category your drug is in, look on the list to find the category. You can then look for your drug in that category.

A drug will not be on the list if a generic equivalent for a brand name drug is not offered. A drug may not be found if it is not covered. Even though a drug is on the drug list, it does not mean that your doctor will prescribe the drug for your medical condition.

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

The generic drug name for a brand drug is included after the brand name in parentheses in bold lowercase and italicized letters. Brand Drug Example: EPOGEN (epoetin alfa)

If a generic equivalent for a brand name drug is on the list and covered, the generic drug will be on the list apart from the brand name drug. It will be in bold lowercase and italicized letters.

Generic Drug Example: esomeprazole magnesium cap delayed release

If a generic drug is marketed under a trademark protected brand name, the brand name will be on the list in all CAPITAL letters. It will appear after the generic name in parentheses. It will be in regular typeface with first letter of each word capitalized.

Generic Drug Marketed Under A Brand Name Example: (Levothyroxine Sodium) LEVOXYL

What if my drug is not on the California Health and Wellness Plan PDL? If your drug is not on the drug list, call Member Services at 1-877-658-0305 and ask if your drug is covered. If your drug is not on the list, you can ask your doctor if there is a drug on the list that will work the same way. If your doctor wants you to have a drug that is not on the list, your doctor can ask us to make an exception. See the section, “How can I get an exception to the rules for the drug coverage?” for more information. Can I go to any pharmacy?

iv Members must use a pharmacy in the retail network. These pharmacies have a contract with California Health and Wellness Plan. To find a pharmacy, call Member Services at 1-877-658-0305. You can also visit our website at www.cahealthwellness.com.

Some drugs are only covered when they come from a specialty pharmacy. Specialty drugs are used to treat ongoing or complex conditions. They also may need special handling or training to ensure safe use. The specialty pharmacy will mail drugs to your home, to your work, or to another address you choose. Specialty drugs may also be sent to your doctor’s office. Specialty drugs are listed in the Requirements/Limits column on the drug list. Drugs that do not have a specialty pharmacy listed in the Requirements/Limits column on the drug list can be filled at any pharmacy in the network.

You can ask for an exception to have a specialty drug filled at a retail network pharmacy if: • How you take your drug has changed and you need to fill the drug right now. • Your drug is going to arrive late or always arrives late. • You have an urgent need for a drug and did not understand how to get the drug from the specialty pharmacy. • You have an emergency and cannot wait for the drug to come from the specialty pharmacy.

If you cannot use a specialty pharmacy, you can ask for an exception to get all your drugs filled at a retail network pharmacy if: • You do not have a mailing address or a way to get your drugs by mail. • Your doctor’s office gives the drugs to you. • Using a specialty pharmacy is a hardship for you.

If you need an exception, you must ask us. Your doctor or your pharmacy may also ask for an exception. To ask us for an exception, please call California Health and Wellness at 1-877-658-0305 (TTY: 711). We are here 24 hours a day, seven days a week. .

Are there any limits on my drug coverage? Some drugs have limits on coverage. These limits are noted in the Requirements/Limits column on the drug list.

Are there limits on opioid pain drugs? Prior Authorization is not required for short term use of most opioid pain drugs. You can get a 7 day supply of these drugs when your doctor orders them for you the first time. There are quantity limits on all opioid pain drugs based on Morphine Milligram Equivalents (MME). You may need prior authorization if you need more than a 7 day supply. This limit does not apply if you are being treated for cancer or sickle cell.

What is Morphine Milligram Equivalent (MME) Dosing? MME dosing is a tool used to make sure you take a safe dose of opioid pain drugs. This tool helps measure the amount of opioid pain drugs you take each day. The recommended limit for most opioid pain drugs is 90 MME per day. The quantity limits on the drug list are less than or the same as 90 MME per day. Your doctor may ask for prior authorization if the dose you need is more than 90 MME per day. This limit does not apply if you are being treated for cancer or sickle cell.

How can I get an exception to the rules for the drug coverage?

v Your doctor can ask for an exception to our rules for drug coverage. • Your doctor can ask us to cover a drug if it is not on the drug list. • Your doctor can ask us to make an exception to limits on a drug. For example, if a drug has a limit of 1 tablet per day, your doctor can ask us to cover more.

To ask for an exception, your doctor can fax a prior authorization request to us at 1-866-399-0929. After we receive the request, we will make a decision and notify your doctor within 24 hours. If we deny the request, we will send you and your doctor a letter and tell you how to file an appeal. If we do not respond to a request within 24 hours, the request will be approved. If we approve a drug for you, you can continue to get the drug from California Health and Wellness Plan as long as the drug works for you and your doctor wants you to stay on the drug.

What if I’m a new member? If you are a new member in our plan, you may be taking drugs that are not on our drug list. You may also be taking a drug that is on our drug list, but the drug now has limits. You should talk to your doctor to see if you can change to a drug on the list. Your doctor may ask us for an exception to cover a drug you have been taking. See the section, “How can I get an exception to the rules for the drug coverage?” for more information.

What are over-the-counter drugs? Over-the-counter (OTC) drugs are drugs you can buy without a prescription. The California Health and Wellness Plan PDL covers OTC drugs just like those found on the State Medi-Cal List of Contract Drugs. If you want California Health and Wellness Plan to cover an OTC drug on the drug list, your doctor must write a prescription for that drug.

Are brand name drugs covered? Your pharmacy benefit does not cover brand name drugs when a generic drug is available. A brand name drug may be covered if a generic drug is not available. Your doctor may also ask us to cover a brand name drug if he/she thinks it will work the best for you.

What is a generic drug? A generic drug has the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective.

Will the pharmacist give me a generic drug if one is available? Yes. A pharmacy may give you a generic drug unless your doctor says that you must have the brand name drug.

Are there any excluded or carve-out drugs? Excluded drugs The California Health and Wellness Plan PDL is similar to the State Medi-Cal List of Contract Drugs. The following types of drugs are not a covered benefit and not on the PDL: • Multivitamins • Erectile or sexual dysfunction drugs • Drugs used for cosmetic reasons or hair growth • Drugs that are considered experimental

vi • Drugs used to treat infertility • OTC cough and cold drugs • OTC adult acetaminophen

Drug Efficacy Study and Implementation Drugs (DESI) DESI products and other related drugs are not covered by California Health and Wellness Plan. The Food and Drug Administration has defined them as less than effective. There is a lack of proof these drugs are safe and effective.

Carve-out drugs Some drugs are carved out by the Department of Health Care Services. This means that these drugs are covered by the Medi-Cal Fee-for-Service program. The following types of drugs are carved out: • Select psychiatric drugs • Select HIV AIDS treatment drugs • Select alcohol, heroin detoxification, and dependency treatment drugs • Select drugs to treat hemophilia

What is California Children’s Services? California Children’s Services (CCS) is a state program for children (up to 21 years old) with certain health problems. Some drugs for CCS covered health problems are not covered by California Health and Wellness Plan.

Only doctors approved by CCS can order drugs used to treat CCS covered health problems. These drugs are not covered by California Health and Wellness Plan. The Pharmacy must bill CCS for these drugs. If you are at the pharmacy and you are not in the CCS system, call Member Services at 1-877-658-0305. Member Services can help you enroll with CCS. They may also help you get an emergency supply of your drug.

What about drugs I get from my doctor or in my doctor’s office? Some drugs that are given to you by your doctor may be covered under your medical benefit. You may be able to get these drugs from a retail pharmacy. Your doctor may also give them to you in the office. We will work with your doctor to find the best way for you to get these drugs. If you have questions about these drugs, please call Member Services at 1-877-658-0305.

Definitions

Brand Name Drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drug is listed in this formulary in all CAPITAL letters.

Exception Request: Is a request for coverage of a prescription drug. If an enrollee, his or her designee, or prescribing health care provider submits an exception request for coverage of a prescription drug, the health plan must cover the prescription drug when the drug is determined to be medically necessary to treat the enrollee’s condition

Formulary: Is also referred to as the Preferred Drug List, is the complete list of prescription drugs preferred for use and eligible for coverage under a health plan, and includes all drugs covered under the outpatient prescription drug benefit of the health plan.

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Generic Drug: Is a drug that is the same as its brand name drug equivalent in dosage, safety, strength, how it is taken, quality, effect and intended use. A generic drug is listed in the drug list in bold and italicized lowercase letters.

Medically Necessary: Is health care benefits needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Plans usually do not cover health care benefits that are not medically necessary.

Member: Is a person enrolled in a health plan who is entitled to receive services from the plan.

Non-Formulary Drug: Is a prescription drug that is not listed on the Preferred Drug List.

Preferred Drug List: Is also referred to as the Formulary, is the complete list of prescription drugs preferred for use and eligible for coverage under a health plan, and includes all drugs covered under the outpatient prescription drug benefit of the health plan.

Prescribing Provider: Is a health care provider authorized to write a prescription to treat a medical condition for a health plan member.

Prescription: Is an oral, written, or electronic order by a prescribing provider for a specific member that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the member, the medical condition or purpose for which the drug is being prescribed.

Prescription Drug: Is a drug that is prescribed by the enrollee’s prescribing provider and requires a prescription under applicable law.

Prior Authorization: Is a health plan’s requirement that the member or the member's prescribing provider obtain the health plan’s authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the member to obtain the drug.

Quantity Limit: Is a restriction on the number of doses or any other limitations on the quantity of a prescription drug a health plan will cover during a specific time period.

Specialty Drugs: Specialty Drugs include drugs that are made using biotechnology, drugs that must be distributed through a specialty pharmacy, drugs that require special training for self- administration, or drugs that require regular monitoring of care by a pharmacy.

Step Therapy: Is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the member to try one or more drugs to treat the member's medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request. If the member's prescribing provider submits a request for step therapy exception, the health plans shall make exceptions to step therapy when the criteria is met.

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Need more information? For more information about your pharmacy benefits, please review your Member Handbook or call Member Services at 1-877-658-0305.

ix Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- VYVANSE CAPS 10 MG, PA; QL(1 ea OBESITY/ANOREXIANTS - Drugs to Treat 20 MG, 30 MG, 40 MG, 50 daily) ADHD, Sleep and Eating Disorders MG, 60 MG, 70 MG F (lisdexamfetamine Amphetamines dimesylate) (Dextroamphetamine QL(3 ea daily) Sulfate) ZENZEDI TABS 10 F Analeptics MG caffeine citrate soln F QL(45 ml per (Dextroamphetamine fill retail) Sulfate) ZENZEDI TABS 5 F Anorexiants Non-Amphetamine MG benzphetamine hcl tabs PA QL(1 ea daily) F amphetamine- 25 mg dextroamphetamine cp24 1.25 mg-1.25 mg- diethylpropion hcl tabs F PA 1.25 mg-1.25 mg, 2.5 PA mg-2.5 mg-2.5 mg-2.5 diethylpropion hcl tb24 F mg, 3.75 mg-3.75 mg- F LOMAIRA TABS PA F 3.75 mg-3.75 mg, 5 (phentermine hcl) mg-5 mg-5 mg-5 mg, PA 6.25 mg-6.25 mg-6.25 phentermine hcl caps F mg-6.25 mg, 7.5 mg- phentermine hcl tabs F PA 7.5 mg-7.5 mg-7.5 mg amphetamine- QSYMIA CP24 PA dextroamphetamine (phentermine hcl- F tabs 1.25 mg-1.25 mg- topiramate) 1.25 mg-1.25 mg, Anti-Obesity Agents 1.875 mg-1.875 mg- ALLI CAPS (orlistat) F PA 1.875 mg-1.875 mg, BELVIQ TABS PA 2.5 mg-2.5 mg-2.5 mg- F F 2.5 mg, 3.125 mg- (lorcaserin hcl) BELVIQ XR TB24 PA 3.125 mg-3.125 mg- F 3.125 mg, 3.75 mg- (lorcaserin hcl) 3.75 mg-3.75 mg-3.75 CONTRAVE TB12 PA mg, 5 mg-5 mg-5 mg-5 (naltrexone hcl- F mg, 7.5 mg-7.5 mg-7.5 bupropion hcl) mg-7.5 mg SAXENDA SOPN PA dextroamphetamine (liraglutide (weight F sulfate cp24 10 mg, 15 F management)) mg, 5 mg XENICAL CAPS (orlistat) F PA QL(3 ea daily) dextroamphetamine F sulfate tabs 10 mg Attention-Deficit/Hyperactivity Disorder (ADHD) F dextroamphetamine F atomoxetine hcl caps sulfate tabs 5 mg clonidine hcl (adhd) F tb12

CA Health & Wellness Preferred Drug List Updated September 1, 2021

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) QL(160 ea per guanfacine hcl (adhd) F tb24 paromomycin sulfate F fill retail)1 rtl caps MAX fill,30 rtl Stimulants - Misc. day(s) supply, PA TOBI PODHALER CAPS AL(At least 21 armodafinil tabs F F (tobramycin) yrs old); SP QL(2 ea daily); dexmethylphenidate hcl AL(At least 21 AL(At least 6 tobramycin nebu 300 F tabs 10 mg, 2.5 mg, 5 F mg/4ml yrs old) mg yrs old) PA; SP QL(1 ea daily); tobramycin nebu 300 F methylphenidate hcl mg/5ml cpcr 10 mg, 40 mg, 50 F AL(At least 6 mg, 60 mg yrs old) tobramycin sulfate soln F PA methylphenidate hcl QL(2 ea daily); PA F AL(At least 6 tobramycin sulfate solr F cpcr 20 mg, 30 mg yrs old) ANALGESICS - ANTI-INFLAMMATORY - Drugs methylphenidate hcl to Treat Pain, Swelling, Muscle and Joint tabs 10 mg, 20 mg, 5 F Conditions mg Anti-TNF-alpha - Monoclonal Antibodies QL(1 ea daily) methylphenidate hcl F HUMIRA PEDIATRIC PA; SP- tb24 18 mg, 27 mg CROHNS DISEASE AcariaHealth;S STARTER PACK PSKT F P methylphenidate hcl F tb24 36 mg, 54 mg (adalimumab) methylphenidate hcl HUMIRA PEN PNKT PA; SP- F F AcariaHealth;S tbcr 10 mg, 20 mg (adalimumab) P methylphenidate hcl QL(1 ea daily) HUMIRA PEN-CD/UC/HS PA; SP- tbcr 18 mg, 27 mg, 54 F STARTER PNKT F AcariaHealth;S mg (adalimumab) P QL(2 ea daily) HUMIRA PEN-PEDIATRIC PA; SP- methylphenidate hcl F tbcr 36 mg UC STARTER PACK F AcariaHealth;S PNKT (adalimumab) P F PA; QL(1 ea modafinil tabs daily) HUMIRA PEN-PS/UV PA; SP- STARTER PNKT F AcariaHealth;S AMINOGLYCOSIDES - Drugs to Treat Bacterial P Infections (adalimumab) HUMIRA PSKT PA; SP- Aminoglycosides F AcariaHealth;S ARIKAYCE SUSP PA (adalimumab) P (amikacin sulfate F SIMPONI ARIA SOLN PA; SP- liposome) F AcariaHealth;S (golimumab) PA P gentamicin in saline F soln Antirheumatic - Enzyme Inhibitors KITABIS PAK NEBU PA; SP XELJANZ TABS 10 MG, 5 PA; SP- Acaria F F (tobramycin) MG (tofacitinib citrate) Health;SP XELJANZ XR TB24 11 MG PA; SP- Acaria neomycin sulfate tabs F F (tofacitinib citrate) Health;SP CA Health & Wellness Preferred Drug List Updated September 1, 2021

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XELJANZ XR TB24 22 MG PA; SP- (Ibuprofen) ADDAPRIN, F AcariaHealth;S ADVIL JUNIOR (tofacitinib citrate) P STRENGTH, CVS IBUPROFEN, CVS Antirheumatic Antimetabolites IBUPROFEN IB, DYSPEL, METHOTREXATE TABS EQ IBUPROFEN, EQL (methotrexate sodium F IBUPROFEN, GNP (antirheumatic)) IBUPROFEN, GOODSENSE Gold Compounds IBUPROFEN, HM RIDAURA CAPS IBUPROFEN, HM F (auranofin) IBUPROFEN IB, IBU, IBU- 200, KLS IBUPROFEN, F Interleukin-1beta Blockers KLS IBUPROFEN IB, ILARIS SOLN PA; SP- MEDI-PROFEN, MEIJER F AcariaHealth;S (canakinumab) IBUPROFEN, MOTRIN IB, P PROVIL, PX IBUPROFEN, Interleukin-6 Receptor Inhibitors QC IBUPROFEN, QC IBUPROFEN IB, RA PAIN ACTEMRA SOLN IV 200 PA; SP- RELIEF IBUPROFEN, SB MG/10ML, 400 MG/20ML, F AcariaHealth;S IBUPROFEN, SM 80 MG/4ML (tocilizumab) P IBUPROFEN, SM KEVZARA SOAJ PA; SP- IBUPROFEN IB, SM F (sarilumab) AcariaHealth IBUPROFEN JR, TGT IBUPROFEN, WAL- KEVZARA SOSY PA; SP- F PROFEN TABS (sarilumab) AcariaHealth Nonsteroidal Anti-inflammatory Agents (NSAIDs) (Diclofenac Potassium) F CATAFLAM TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ibuprofen) ADVIL JUNIOR (Ibuprofen) CHILDRENS RX/OTC STRENGTH, CVS IBUPROFEN, CHILDRENS IBUPROFEN JUNIOR IBUPROFEN 100, STRENGTH, EQ CHILDRENS MEDI- IBUPROFEN JUNIOR PROFEN, CVS STRENGTH, EQL CHILDRENS IBUPROFEN, IBUPROFEN JUNIOR CVS IBUPROFEN STRENGTH, GNP CHILDRENS, CVS IBUPROFEN CHILDRENS, IBUPROFEN INFANTS, GNP IBUPROFEN JUNIOR EQ IBUPROFEN STRENGTH, CHILDRENS, EQ GOODSENSE IBUPROFEN INFANTS, IBUPROFEN JUNIOR EQL CHILDRENS STRENGTH, HM IBUPROFEN, EQL IBUPROFEN, HM F IBUPROFEN INFANTS, IBUPROFEN IB/JUNIOR GNP CHILDRENS STRENGTH, IBUPROFEN IBUPROFEN, GNP 100 JUNIOR STRENGTH, IBUPROFEN INFANTS, IBUPROFEN JUNIOR GOODSENSE STRENGTH, PX IBUPROFEN CHILDRENS, IBUPROFEN JUNIOR GOODSENSE STRENGTH, RA IBUPROFEN INFANTS, IBUPROFEN JUNIOR HM IBUPROFEN STRENGTH, SM CHILDRENS, HM IBUPROFEN IB, SM IBUPROFEN INFANTS, F IBUPROFEN IB HYVEE IBUPROFEN CHILDRENS, TGT CHILDRENS, IBUPROFEN IBUPROFEN JUNIOR CHILDRENS, IBUPROFEN STRENGTH CHEW INFANTS, IBUPROFEN (Ibuprofen) ADVIL LIQUI- INFANTS DROPS, GELS MINIS, CVS INFANTS IBUPROFEN, IBUPROFEN, CVS MEDI-PROFEN, PX IBUPROFEN LIQUID CHILDRENS PROFEN IB, FILLED, EQ IBUPROFEN, PX INFANTS PROFEN IB, EQL IBUPROFEN, GNP QC CHILDRENS IBUPROFEN, IBUPROFEN, QC IBUPROFEN INFANTS, GOODSENSE F IBUPROFEN, HM RA IBUPROFEN IBUPROFEN, KS CHILDRENS, RA IBUPROFEN, MEDI- IBUPROFEN INFANTS, SB PROFEN, MOTRIN IB, QC INFANTS IBUPROFEN, IBUPROFEN, SM SM CHILDRENS IBUPROFEN, TGT IBUPROFEN, SM IBUPROFEN, WAL- INFANTS IBUPROFEN, PROFEN CAPS TGT CHILDRENS IBUPROFEN, TGT IBUPROFEN CHILDRENS, TGT INFANTS IBUPROFEN SUSP

CA Health & Wellness Preferred Drug List Updated September 1, 2021

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ibuprofen) CHILDRENS (Ibuprofen) RA IBUPROFEN, CHILDRENS IBUPROFEN CAPS 200 F IBUPROFEN 100, MG CHILDRENS MEDI- (Ibuprofen) RA RX/OTC PROFEN, CVS IBUPROFEN SUSP 100 F CHILDRENS IBUPROFEN, MG/5ML CVS IBUPROFEN CHILDRENS, CVS (Ibuprofen) RA IBUPROFEN INFANTS, IBUPROFEN TABS 200 F EQ IBUPROFEN MG CHILDRENS, EQ (Nabumetone) RELAFEN F IBUPROFEN INFANTS, TABS EQL CHILDRENS (Naproxen Sodium) ALL IBUPROFEN, EQL DAY PAIN RELIEF, ALL IBUPROFEN INFANTS, DAY RELIEF, CVS ALL GNP CHILDRENS DAY PAIN RELIEF, CVS IBUPROFEN, GNP NAPROXEN SODIUM, EQ IBUPROFEN INFANTS, ALL DAY PAIN RELIEF, GOODSENSE EQ NAPROXEN SODIUM, IBUPROFEN CHILDRENS, EQL NAPROXEN GOODSENSE SODIUM, FLANAX PAIN IBUPROFEN INFANTS, RELIEF, GNP ALL DAY HM IBUPROFEN PAIN RELIEF, GNP CHILDRENS, HM NAPROXEN, GNP IBUPROFEN INFANTS, F NAPROXEN SODIUM, HYVEE IBUPROFEN GOODSENSE F CHILDRENS, IBUPROFEN NAPROXEN SODIUM, HM CHILDRENS, IBUPROFEN NAPROXEN SODIUM, HY- INFANTS, IBUPROFEN VEE ALL DAY RELIEF, INFANTS DROPS, KLS NAPROXEN INFANTS IBUPROFEN, SODIUM, MEDIPROXEN, MEDI-PROFEN, PX PAMPRIN ALL DAY CHILDRENS PROFEN IB, MAXIMUM STRENGTH, PX INFANTS PROFEN IB, PX ALL DAY RELIEF, QC QC CHILDRENS NAPROXEN SODIUM, RA IBUPROFEN, QC NAPROXEN SODIUM, SB IBUPROFEN INFANTS, NAPROXEN SODIUM, SM RA IBUPROFEN NAPROXEN SODIUM, CHILDRENS, RA TGT NAPROXEN SODIUM IBUPROFEN INFANTS, SB TABS INFANTS IBUPROFEN, (Naproxen Sodium) CVS SM CHILDRENS NAPROXEN SODIUM, EQ IBUPROFEN, SM NAPROXEN SODIUM, INFANTS IBUPROFEN, EQL NAPROXEN TGT CHILDRENS SODIUM, GNP F IBUPROFEN, TGT NAPROXEN SODIUM, HM IBUPROFEN CHILDRENS, NAPROXEN SODIUM, SM TGT INFANTS NAPROXEN SODIUM, IBUPROFEN SUSP TGT NAPROXEN SODIUM CAPS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Naproxen) EC- F meclofenamate sodium F NAPROXEN TBEC caps F PA celecoxib caps meloxicam tabs 15 mg, F 7.5 mg diclofenac potassium F tabs nabumetone tabs F F diclofenac sodium tb24 naproxen sodium caps F 220 mg diclofenac sodium tbec F naproxen sodium tabs etodolac caps F 220 mg, 275 mg, 550 F mg etodolac tabs F naproxen susp F etodolac tb24 F naproxen tabs F fenoprofen calcium F tabs 600 mg naproxen tbec F flurbiprofen tabs F oxaprozin tabs F ibuprofen caps 200 mg F piroxicam caps F RX/OTC ibuprofen susp 100 F sulindac tabs F mg/5ml ibuprofen tabs 200 mg, tolmetin sodium caps F 400 mg, 600 mg, 800 F mg tolmetin sodium tabs F INDOCIN SUPP Phosphodiesterase 4 (PDE4) Inhibitors F (indomethacin) OTEZLA TABS PA; SP F INDOCIN SUSP (apremilast) F (indomethacin) OTEZLA TBPK PA; SP F (apremilast) indomethacin caps 25 F mg, 50 mg Pyrimidine Synthesis Inhibitors indomethacin cpcr 75 F leflunomide tabs F mg Selective Costimulation Modulators ketoprofen caps or 50 F mg, 75 mg ORENCIA CLICKJECT PA; SP- F AcariaHealth;S ketoprofen cp24 or 200 F SOAJ (abatacept) P mg ORENCIA SOLR PA; SP- QL(20 ea per F AcariaHealth;S (abatacept) ketorolac tromethamine F 30 days retail); P tabs or 10 mg AL(At least 17 yrs old) ORENCIA SOSY PA; SP- F AcariaHealth;S (abatacept) P

CA Health & Wellness Preferred Drug List Updated September 1, 2021

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Soluble Tumor Necrosis Factor Receptor Agents (Acetaminophen) AL(Up to 21 yrs ACETAMINOPHEN old ) ENBREL MINI SOCT PA; SP- F AcariaHealth;S JUNIOR STRENGTH, ACETAMINOPHEN RAPID (etanercept) P TABSCHILDRENS, ENBREL SOLR 25 MG PA; SP- CHILDRENS PAIN F AcariaHealth;S (etanercept) RELIEVER, EQ P ACETAMINOPHEN ENBREL SOSY 25 PA; SP- CHILDRENS, EQL MG/0.5ML, 50 MG/ML F AcariaHealth;S ACETAMINOPHEN, EQL F (etanercept) P ACETAMINOPHEN RAPID TABS, GNP CHILDRENS ENBREL SURECLICK PA; SP- EASY-MELTS, QC NON- F AcariaHealth;S SOAJ (etanercept) ASPIRIN JR STRENGTH, P SB CHILDRENS NON- ANALGESICS - NonNarcotic - Drugs to Treat ASPIRIN, SB NON- Pain, Muscle and Joint Conditions ASPIRIN JR STRENGTH, SM RAPID MELTS Analgesic Combinations JUNIOR TBDP (Butalbital-Acetaminophen) F (Acetaminophen) APRA, TENCON TABS CHILDRENS ASPIRIN (Butalbital-Acetaminophen- F FREE, MEDI-TABS F Caffeine) BAC TABS CHILDRENS, PAIN (Butalbital-Acetaminophen- RELIEF CHILDRENS ELIX Caffeine) ESGIC, F ZEBUTAL CAPS butalbital- acetaminophen tabs F 325 mg-50 mg, 50 mg- 325 mg butalbital- acetaminophen- F caffeine caps 40 mg-50 mg-325 mg butalbital- acetaminophen- F caffeine tabs 40 mg-50 mg-325 mg butalbital-aspirin- F caffeine caps BUTALBITAL/ASPIRIN/CA FFEINE TABS (butalbital-aspirin- F caffeine) Analgesics Other

CA Health & Wellness Preferred Drug List Updated September 1, 2021

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Acetaminophen) RELIEVER, RA AUROPHEN CHILDRENS, CHILDRENS NON- BETATEMP CHILDRENS, ASPIRIN, RA FEVER CVS INFANTS PAIN REDUCER & PAIN RELIEF, CVS PAIN & RELIEVER INFANTS, RA FEVER CHILDRENS, CVS FEVER REDUCER/PAIN PAIN & FEVER INFANTS, RELIEVER CHILDRENS, EQ PAIN & FEVER RA FEVER INFANTS, EQL REDUCER/PAIN ACETAMINOPHEN RELIEVER INFANTS, SB CHILDRENS, EQL PAIN RELIEVER ACETAMINOPHEN CHILDRENS, SM PAIN & INFANTS, EQL FEVER CHILDRENS, SM CHILDRENS PAIN PAIN & FEVER INFANTS, RELIEF, GNP INFANTS SM PAIN RELIEVER PAIN RELIEF, GNP CHILDRENS, TGT INFANTS PAIN/FEVER, ACETAMINOPHEN GNP PAIN & FEVER CHILDRENS, TGT CHILDRENS, GNP PAIN & CHILDRENS FEVER INFANTS, ACETAMINOPHEN SUSP GOODSENSE PAIN & (Acetaminophen) AL(Up to 21 yrs FEVER CHILDRENS, CHILDRENS F old ) GOODSENSE PAIN & ACETAMINOPHEN TBDP FEVER INFANTS, HM 80 MG PAIN & FEVER (Acetaminophen) CHILDRENS, HM PAIN & F CHILDRENS FEVER INFANTS, HM ACETAMINOPHEN, PAIN RELIEVER CHILDRENS NON- CHILDRENS, HM PAIN ASPIRIN, CVS PAIN RELIEVER CHILDRENS RELIEF CHILDRENS, EQ F DYE-FREE, HM PAIN PAIN & FEVER RELIEVER INFANTS, CHILDRENS, PAIN & INFANTS PAIN & FEVER, FEVER CHILDRENS, QC NON-ASPIRIN NON-ASPIRIN CHILDRENS, NORTEMP, CHILDRENS SUSP 160 PAIN & FEVER MG/5ML CHILDRENS/DYE-FREE, PAIN & FEVER INFANTS, PAIN RELIEF CHILDRENS, PANADOL CHILDRENS, PANADOL INFANT, PEDIACARE CHILDREN, PEDIACARE FEVER REDUCER/PAIN RELIEVER/INFANT, PEDIACARE INFANTS, PX CHILDRENS PAIN RELIEF, QC PAIN RELIEF CHILDRENS, QC PAIN RELIEF INFANTS, RA CHILDRENS FEVER REDUCER & PAIN CA Health & Wellness Preferred Drug List Updated September 1, 2021

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Acetaminophen) AL(Up to 21 yrs (Acetaminophen) CVS AL(Up to 21 yrs CHILDRENS APAP, old ) PAIN RELIEF old ) CHILDRENS MEDI-TABS, CHILDRENS, EQ PAIN & CHILDRENS PAIN FEVER CHILDRENS, PAIN F RELIEVER, CHILDRENS & FEVER CHILDRENS, TACTINAL, CVS CHILDS QC NON-ASPIRIN NON-ASPIRIN, CVS NON- CHILDRENS CHEW 160 ASPIRIN CHILDRENS, MG GNP PAIN RELIEF, HM AL(Up to 21 yrs acetaminophen chew F ACETAMINOPHEN F old ) CHILDRENS, MAPAP or 160 mg CHILDRENS, MEDI-TABS acetaminophen elix or F JUNOR STRENGTH, 160 mg/5ml MEIJER JR STRENGTH ASPIRIN FREE, NON- acetaminophen liqd or F ASPIRIN JUNIOR 160 mg/5ml STRENGTH, RA acetaminophen soln or ACETAMINOPHEN 160 mg/5ml, 325 CHILDRENS, SB NON- F ASPIRIN CHEW mg/10.15ml, 650 mg/20.3ml (Acetaminophen) AL(Up to 21 yrs CHILDRENS NON- F old ) acetaminophen supp re F ASPIRIN CHEW 80 MG 120 mg (Acetaminophen) acetaminophen susp or CHILDRENS SILAPAP, 160 mg/5ml, 650 F ED-APAP, LIQUID ACETAMINOPHEN, mg/20.3ml FEVERALL INFANTS AL(Up to 21 yrs LIQUID PAIN RELIEF, F LITTLE REMEDIES SUPP (acetaminophen) old ) FEVER/PAIN RELIEVER NORTEMP INFANTS F F CHILDRENS, LITTLE SUSP (acetaminophen) REMEDIES FOR FEVERS FEVER/PAIN RELIEVER Salicylates CHILDRENS, LITTLE (Aspirin Buffered (Cal REMEDIES FOR FEVERS Carb-Mag Carb-Mag FEVER/PAIN RELIEVER Oxide)) CVS BUFFERED INFANT, M-PAP LIQD ASPIRIN, SM ASPIRIN F (Acetaminophen) CVS TRI-BUFFERED, TRI- FEVER REDUCING BUFFERED ASPIRIN CHILDRENS, FEVER TABS REDUCER CHILDRENS, F FEVERALL CHILDRENS, PAIN RELIEVER/FEVER REDUCER CHILDRENS SUPP

CA Health & Wellness Preferred Drug List Updated September 1, 2021

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ADULT ASPIRIN STRENGTH, SM ASPIRIN REGIMEN, ASPIR-LOW, ENTERIC COATED, ST ASPIRIN 81, ASPIRIN JOSEPH ASPIRIN, TGT ADULT LOW DOSE, ASPIRIN, TGT ASPIRIN ASPIRIN ADULT LOW LOW DOSE, TGT STRENGTH, ASPIRIN EC ENTERIC-COATED LOW DOSE, ASPIRIN ASPIRIN TBEC ENTERIC COATED (Aspirin) ASPIRIN 81 LOW ADULT LOW STRENGTH, DOSE, ASPIRIN ADULT ASPIRIN LOW DOSE, LOW STRENGTH, BAYER ASPIRIN, BAYER ASPIRIN CHILDRENS, ASPIRIN EC LOW DOSE, ASPIRIN LOW DOSE, BAYER ASPIRIN ASPIRIN LOW REGIMEN, BAYER LOW STRENGTH, BAYER DOSE, CVS ASPIRIN, CHEWABLE LOW DOSE, CVS ASPIRIN ADULT CHILDRENS ASPIRIN, LOW STRENGTH, CVS CHILDRENS ASPIRIN ASPIRIN EC, CVS LOW STRENGTH, CVS ASPIRIN LOW DOSE, CVS ASPIRIN ADULT LOW ASPIRIN LOW DOSE, EQ ASPIRIN LOW STRENGTH, ECOTRIN DOSE, EQL ASPIRIN LOW LOW STRENGTH, DOSE, GNP ADULT ECPIRIN, EQ ASPIRIN ASPIRIN LOW ADULT LOW DOSE, EQ STRENGTH, ASPIRIN EC, EQL GOODSENSE ASPIRIN, ASPIRIN EC, EQL F GOODSENSE ASPIRIN F ASPIRIN LOW DOSE, ADULT LOW STRENGTH, GNP ASPIRIN, GNP HM ASPIRIN, PX ASPIRIN, ASPIRIN LOW DOSE, QC ASPIRIN LOW DOSE, GOODSENSE ASPIRIN, QC CHEWABLE ASPIRIN GOODSENSE ASPIRIN LOW DOSE, QC LOW DOSE, H-E-B CHILDRENS ASPIRIN, RA ASPIRIN, HM ASPIRIN, ASPIRIN ADULT LOW HM ASPIRIN EC, HM DOSE, RA ASPIRIN ASPIRIN EC LOW DOSE, ADULT LOW STRENGTH, KLS ASPIRIN EC, KLS RA ASPIRIN CHILDRENS, ASPIRIN LOW DOSE, KP SB CHILDRENS ASPIRIN, ASPIRIN, MEIJER SM ASPIRIN ADULT LOW ASPIRIN EC, MINIPRIN STRENGTH, SM ASPIRIN LOW DOSE, PX ENTERIC LOW DOSE, SM ASPIRIN, QC ASPIRIN, CHILDRENS ASPIRIN, ST QC ASPIRIN LOW DOSE, JOSEPH LOW DOSE QC ENTERIC ASPIRIN, ASPIRIN, TGT ASPIRIN, RA ASPIRIN EC, RA TGT CHILDRENS ASPIRIN EC ADULT LOW ASPIRIN CHEW STRENGTH, SB ASPIRIN, SB ASPIRIN ADULT LOW STRENGTH, SB ASPIRIN EC, SB LOW DOSE ASA EC, SM ASPIRIN ADULT LOW STRENGTH, SM ASPIRIN EC LOW CA Health & Wellness Preferred Drug List Updated September 1, 2021

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN ADULT, (Methadone Hcl) PA; QL(1 ea BAYER ADVANCED METHADOSE TBSO 40 F daily) ASPIRIN REGULAR MG STRENGTH, BAYER (Morphine Sulfate) F PA; QL(10 ml ASPIRIN, CVS ASPIRIN, DURAMORPH SOLN daily) EQ ASPIRIN, EQL ASPIRIN, GNP ASPIRIN, CODEINE SULFATE TABS QL(6 ea daily) GOODSENSE ASPIRIN, 15 MG, 60 MG (codeine F GOODSENSE ASPIRIN sulfate) ADULTS, HM ADULT F QL(6 ea daily) codeine sulfate tabs 30 F ASPIRIN, HM ASPIRIN, mg MEDIQUE ASPIRIN, NORWICH ASPIRIN, PX fentanyl pt72 td 100 QL(0.34 ea ASPIRIN, QC ASPIRIN, RA daily) mcg/hr, 12 mcg/hr, 25 F ASPIRIN, RA PAIN mcg/hr, 50 mcg/hr, 75 RELIEF ASPIRIN, SB mcg/hr ASPIRIN, SM ADULT QL(20 ml daily) ASPIRIN, SM ASPIRIN, hydromorphone hcl liqd F TGT ASPIRIN TABS or 1 mg/ml aspirin buffered (cal HYDROMORPHONE HCL QL(4 ea daily) carb-mag carb-mag F SUPP RE 3 MG F oxide) tabs (hydromorphone hcl) hydromorphone hcl QL(6 ea daily) aspirin chew or 81 mg F F tabs or 2 mg, 4 mg ASPIRIN SUPP RE 300 QL(3 ea daily) F hydromorphone hcl F MG, 600 MG (aspirin) tabs or 8 mg aspirin tabs or 325 mg F hydromorphone hcl QL(1 ea daily) tb24 or 12 mg, 16 mg, F aspirin tbec or 325 mg, F 81 mg 8 mg KADIAN CP24 200 MG QL(1 ea daily) BUFFERIN EXTRA F STRENGTH TABS (morphine sulfate) QL(16 ml daily) (aspirin buffered (cal F meperidine hcl soln or F carb-mag carb-mag 50 mg/5ml oxide)) QL(6 ea daily) meperidine hcl tabs or F diflunisal tabs F 50 mg PA; QL(3 ml methadone hcl conc or F salsalate tabs F 10 mg/ml daily) PA; QL(15 ml ANALGESICS - OPIOID - Drugs to Treat Pain, methadone hcl soln or F daily) Muscle and Joint Conditions 10 mg/5ml Opioid Agonists methadone hcl soln or PA; QL(30 ml F daily) (Methadone Hcl) PA; QL(3 ml 5 mg/5ml METHADONE daily) PA; QL(3 ea F methadone hcl tabs or F HYDROCHLORIDE 10 mg daily) INTENSOL CONC PA; QL(6 ea methadone hcl tabs or F 5 mg daily) CA Health & Wellness Preferred Drug List Updated September 1, 2021

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea PA; QL(30 ml methadone hcl tbso or F morphine sulfate soln iv F 40 mg daily) 1 mg/ml daily) QL(1 ea daily) PA; QL(9 ml morphine sulfate beads F morphine sulfate soln iv F cp24 10 mg/ml daily) morphine sulfate cp24 QL(1 ea daily) MORPHINE SULFATE PA; QL(18 ml SOLN IV 150 MG/30ML F daily) or 10 mg, 100 mg, 20 F mg, 30 mg, 50 mg, 60 (morphine sulfate) PA; QL(22 ml mg, 80 mg morphine sulfate soln iv F MORPHINE SULFATE PA; QL(6 ml 4 mg/ml daily) DEVI IM 10 MG/0.7ML F daily) PA; QL(1 ml morphine sulfate soln iv F (morphine sulfate) 50 mg/ml daily) morphine sulfate soln ij PA; QL(10 ml PA; QL(11 ml F morphine sulfate soln iv F 0.5 mg/ml, 1 mg/ml daily) 8 mg/ml daily) MORPHINE SULFATE PA; QL(10 ml morphine sulfate soln QL(16 ml daily) SOLN IJ 1 MG/ML F daily) or 10 mg/5ml, 20 F (morphine sulfate) mg/5ml morphine sulfate soln ij PA; QL(9 ml F morphine sulfate soln QL(4 ml daily) 10 mg/ml daily) or 100 mg/5ml, 20 F MORPHINE SULFATE PA; QL(9 ml mg/ml SOLN IJ 10 MG/ML F daily) QL(6 ea daily) (morphine sulfate) morphine sulfate supp F MORPHINE SULFATE PA; QL(24 ml re 10 mg, 5 mg QL(4 ea daily) SOLN IJ 2 MG/ML F daily) morphine sulfate supp F (morphine sulfate) re 20 mg MORPHINE SULFATE PA; QL(25 ml QL(3 ea daily) morphine sulfate supp F SOLN IJ 2 MG/ML F daily) re 30 mg (morphine sulfate) QL(6 ea daily) morphine sulfate tabs F MORPHINE SULFATE PA; QL(22 ml or 15 mg SOLN IJ 4 MG/ML F daily) QL(3 ea daily) (morphine sulfate) morphine sulfate tabs F MORPHINE SULFATE PA; QL(18 ml or 30 mg QL(2 ea daily) SOLN IJ 5 MG/ML F daily) morphine sulfate tbcr or F (morphine sulfate) 100 mg, 200 mg, 60 mg PA; QL(11 ml morphine sulfate tbcr or QL(3 ea daily) morphine sulfate soln ij F F 8 mg/ml daily) 15 mg, 30 mg MORPHINE SULFATE PA; QL(11 ml NUCYNTA ER TB12 PA; QL(2 ea F SOLN IJ 8 MG/ML F daily) (tapentadol hcl) daily) (morphine sulfate) OXAYDO TABS 5 MG QL(6 ea daily) F MORPHINE SULFATE PA; QL(10 ml (oxycodone hcl) SOLN IV 0.5 MG/ML, 2 daily) QL(6 ea daily) F oxycodone hcl caps 5 F MG/ML (morphine mg sulfate) QL(3 ml daily) oxycodone hcl conc F 100 mg/5ml CA Health & Wellness Preferred Drug List Updated September 1, 2021

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 ml daily) QL(90 ml daily) oxycodone hcl soln 5 F hydrocodone- mg/5ml acetaminophen soln oxycodone hcl t12a 10 PA; QL(2 ea 2.5 mg/5ml-108 F daily) mg/5ml, 5 mg/10ml-217 mg, 15 mg, 20 mg, 30 F mg, 40 mg, 60 mg, 80 mg/10ml, 7.5 mg/15ml- mg 325 mg/15ml QL(6 ea daily) hydrocodone- QL(8 ea daily) oxycodone hcl tabs 10 F mg, 5 mg acetaminophen tabs 10 QL(4 ea daily) mg-300 mg, 10 mg-325 oxycodone hcl tabs 15 F mg mg, 325 mg-10 mg, 5 F mg-300 mg, 5 mg-325 QL(3 ea daily) oxycodone hcl tabs 20 F mg, 7.5 mg-300 mg, mg 7.5 mg-325 mg QL(2 ea daily) oxycodone hcl tabs 30 F oxycodone w/ QL(6 ea daily) mg acetaminophen tabs 10 QL(8 ea daily) F tramadol hcl tabs 50 F mg-325 mg, 5 mg-325 mg mg, 7.5 mg-325 mg Opioid Combinations oxycodone-aspirin tabs F QL(6 ea daily) (Butalbital-Aspirin-Caffeine QL(4 ea daily) W/Cod) F tramadol- QL(4 ea daily); ASCOMP/CODEINE CAPS F AL(At least 18 acetaminophen tabs yrs old) (Hydrocodone- QL(8 ea daily) Opioid Partial Agonists Acetaminophen) LORCET, F LORCET HD, LORCET BELBUCA FILM CO PLUS TABS (buprenorphine hcl) (Oxycodone W/ QL(6 ea daily) BUNAVAIL FILM Acetaminophen) ENDOCET TABS 10 MG- F (buprenorphine hcl- CO 325 MG, 5 MG-325 MG, naloxone hcl dihydrate) 7.5 MG-325 MG BUPRENEX SOLN CO acetaminophen w/ QL(30 ml daily) (buprenorphine hcl) codeine soln 12 F buprenorphine hcl film CO mg/5ml-120 mg/5ml, 120 mg/5ml-12 mg/5ml buprenorphine hcl soln CO acetaminophen w/ QL(6 ea daily) buprenorphine hcl subl CO codeine tabs 15 mg- F 300 mg, 30 mg-300 buprenorphine hcl- mg, 60 mg-300 mg naloxone hcl dihydrate CO butalbital- QL(4 ea daily) film acetaminophen- F buprenorphine hcl- caffeine w/ codeine naloxone hcl dihydrate CO caps subl butalbital-aspirin- QL(4 ea daily) F buprenorphine ptwk CO caffeine w/cod caps CA Health & Wellness Preferred Drug List Updated September 1, 2021

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUTRANS PTWK VOGELXO GEL CO F (buprenorphine) (testosterone) PROBUPHINE IMPLANT VOGELXO PUMP GEL F KIT IMPL CO (testosterone) (buprenorphine hcl) ANORECTAL AND RELATED PRODUCTS - SUBLOCADE SOSY CO Rectal Drugs to Treat Pain, Swelling and Itching (buprenorphine) Intrarectal Steroids SUBOXONE FILM (Hydrocortisone (buprenorphine hcl- CO (Intrarectal)) COLOCORT F naloxone hcl dihydrate) ENEM ZUBSOLV SUBL CORTIFOAM FOAM (buprenorphine hcl- CO (hydrocortisone acetate F naloxone hcl dihydrate) (intrarectal)) ANDROGENS-ANABOLIC - Drugs to Regulate hydrocortisone F Hormones (intrarectal) enem Anabolic Steroids Rectal Combinations oxandrolone tabs F (Lidocaine-Hydrocortisone Acetate (Rectal)) F Androgens LIDOCORT CREA ANDRODERM PT24 QL(1 ea daily) (Phenylephrine-Shark Liver F (testosterone) Oil-Cocoa Butter) HEMORRHOIDAL danazol caps F SUPPOSITORIES, PX F HEMORRHOIDAL, RA METHITEST TABS F HEMORRHOIDAL SUPP (methyltestosterone) 0.25 %-3 %-85.5 % methyltestosterone F (Phenylephrine-Shark Liver caps Oil-Cocoa Butter) testosterone cypionate QL(0.134 ml HEMORRHOIDAL F daily) SUPPOSITORIES, PX F soln ij 200 mg/ml HEMORRHOIDAL, RA TESTOSTERONE QL(0.134 ml HEMORRHOIDAL SUPP CYPIONATE SOLN IJ 200 daily) RE 0.25 %-3 %-85.5 % F MG/ML (testosterone (Phenylephrine-Shark Liver QL(60 gm per cypionate) Oil-Mineral Oil-Petrolatum) fill retail) PA PX HEMORRHOIDAL, RA F testosterone cypionate F HEMORRHOIDAL OINT soln im 100 mg/ml RE 0.25 %-3 %-14 %-71.9 QL(0.134 ml % testosterone cypionate F soln im 200 mg/ml daily) (Phenylephrine-Shark Liver QL(60 gm per testosterone gel 1 %, Oil-Mineral Oil-Petrolatum) F fill retail) SB HEMORRHOID OINT 1.62 %, 20.25 RE F mg/1.25gm, 25 ANALPRAM-HC LOTN 1 mg/2.5gm, 40.5 %-2.5 % (hydrocortisone F mg/2.5gm, 50 mg/5gm acetate w/ pramoxine)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Alum & Mag Hydrox- hydrocortisone acetate F w/ pramoxine crea Simethicone) ALMACONE, ALMACONE DOUBLE lidocaine- STRENGTH, hydrocortisone acetate F ALUMINA/MAGNESIA/SIM (rectal) crea ex 0.5 %-3 ETHICONE, ANTACID + % ANTI-GAS LIQUID lidocaine- QL(2 ea per fill MAXIMUM STRENGTH, retail) ANTACID ADVANCED, hydrocortisone acetate ANTACID ANTI-GAS, (rectal) kit re 0.5 %-3 F ANTACID ANTI-GAS %, 1 %-3 %, 2.5 %-3 MAXIMUMSTRENGTH, %, 3 %-0.5 % ANTACID ANTI-GAS REGULARSTRENGTH, PROCTOFOAM HC FOAM ANTACID EXTRA (hydrocortisone acetate F STRENGTH ANTI-GAS, w/ pramoxine) ANTACID FAST RELIEF, Rectal Local Anesthetics ANTACID I, ANTACID III, ANTACID LIQUID, pramoxine hcl (rectal) F ANTACID M, ANTACID foam MAXIMUM STRENGTH, ANTACID PLUS ANTI-GAS Rectal Steroids FAST ACTING, ANTACID (Hydrocortisone (Rectal)) PLUS ANTI-GAS RELIEF, PROCTO-MED HC, ANTACID PLUS ANTI-GAS PROCTO-PAK, F RELIEF MAXIMUM F PROCTOSOL HC, STRENGTH, ANTACID PROCTOZONE-HC CREA REGULAR STRENGTH, ANTACID/ANTI-GAS, hydrocortisone (rectal) F crea ANTACID/ANTIGAS LIQUID, Vasodilating Agents ANTACID/SIMETHICONE RECTIV OINT DOUBLE STRENGTH, (nitroglycerin (intra- F COMFORT GEL, anal)) COMFORT GEL ANTACID ANTI-GAS, COMFORT ANTACIDS GEL ANTACID ANTI-GAS MAXIMUM STRENGTH, Antacid Combinations COMFORT GEL ANTACID& ANTI-GAS, CVS ANTACID PLUS ANTIGAS, CVS ANTACID/ANTI-GAS, CVS ANTACID/ANTI-GAS LIQUID, EQ ANTACID, EQ ANTACID MAXIMUM STRENGTH, EQ ANTACID/ANTI-GAS, EQL ANTACID ADVANCED MAXIMUM STRENGTH, EQL ANTACID/ANTI-GAS, FAST ACTING ANTACID CA Health & Wellness Preferred Drug List Updated September 1, 2021

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLUSANTI-GAS ANTACID ADVANCED MAXIMUM STRENGTH, MAXIMUM STRENGTH, GERI-LANTA, GERI-MOX, SM ANTACID ANTI-GAS, GNP ANTACID & ANTI- SM ANTACID MAXIMUM GAS/REGULAR STRENGTH, SM STRENGTH, GNP ANTACID/ANTIGAS, TGT ANTACID AND ANTI- ANTACID ANTI-GAS GAS/MAXIMUM REGULAR STRENGTH STRENGTH, GNP SUSP ANTACID ANTI-GAS, GNP (Alum & Mag Hydrox- ANTACID ANTI- Simethicone) ANTACID GAS/MAXIMUM SUSP 0.2 %-40 MG/10ML- STRENGTH, GNP 400 MG/10ML-400 ANTACID/REGULAR MG/10ML, 20 MG/5ML-200 F STRENGTH, MG/5ML-200 MG/5ML, 40 GOODSENSE ANTACID & MG/10ML-400 MG/10ML- GAS RELIEF REGULAR 400 MG/10ML, 40 STRENGTH, HM MG/5ML-400 MG/5ML-400 ADVANCED ANTACID MG/5ML MAXIMUM STRENGTH, (Alum & Mag Hydrox- HM ANTACID, HM Simethicone) MAALOX ANTACID ANTI-GAS MAX, PX ANTACID F EXTRASTRENGTH, HM MAXIMUM STRENGTH ANTACID/ANTIGAS, SUSP 40 MG/5ML-400 MAALOX MULTI MG/5ML-400 MG/5ML SYMPTOM MAXIMUM STRENGTH, MEIJER (Alum & Mag Hydrox- ANTACID ANTI-GAS, Simethicone) MAG-AL F MEIJER ANTACID PLUS, MAG-AL PLUS XS MAXIMUM STRENGTH, LIQD MI-ACID, MI-ACID (Alum & Mag Hydrox- MAXIMUM STRENGTH, Simethicone) MINTOX F MILANTEX, MILANTEX PLUS CHEW EXTRA STRENGTH, alum & mag hydrox- MINTOX MAXIMUM F STRENGTH, MINTOX simethicone susp REGULAR STRENGTH, SM FOAMING ANTACID MYLANTA MAXIMUM CHEW (aluminum F STRENGTH, PX ANTACID hydroxide-mag trisil) REGULAR STRENGTH, QC ANTACID, QC Antacids - Aluminum Salts ANTACID/ANTI-GAS, QC ALUMINUM HYDROXIDE ANTACID/ANTI-GAS SUSP (aluminum F MAXIMUM STRENGTH, hydroxide gel) RA ANTACID/ANTI-GAS, RA ANTACID/ANTIGAS Antacids - Bicarbonate MAXIMUM STRENGTH, sodium bicarbonate F RA ANTACID/GAS RELIEF (antacid) tabs MAXIMUM STRENGTH, SB ANTACID ANTI-GAS, Antacids - Calcium Salts SM ANTACID, SM ANTACID ADVANCED, SM CA Health & Wellness Preferred Drug List Updated September 1, 2021

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Calcium Carbonate ANTACID, SB ANTACID (Antacid)) ANTACID EXTRA STRENGTH, SM CALCIUM EXTRA ANTACID, SM CALCIUM STRENGTH, ANTACID ANTACID, SM CALCIUM CALCIUM REGULAR ANTACID STRENGTH, ANTACID EXTRASTRENGTH, SM CALCIUM RICH, ANTACID SMOOTH ANTACID FLAVOR CHEWS, CAL- EXTRA STRENGTH, GEST ANTACID, TUMS SMOOTHIES CALCIUM ANTACID, CHEW CALCIUM ANTACID (Calcium Carbonate EXTRA STRENGTH, CVS (Antacid)) ANTACID F ANTACID EXTRA, CVS CHEW 500 MG, 750 MG ANTACID EXTRA (Calcium Carbonate STRENGTH, CVS (Antacid)) ANTACID ANTACID KIDS, CVS EXTRA STRENGTH, GNP CHEWY NOT CHALKY ANTACID EXTRA F FLAVOR CHEWS, CVS STRENGTH, TGT SMOOTH ANTACID ANTACID EXTRA EXTRASTRENGTH, EQ STRENGTH CHEW 750 ANTACID, EQ ANTACID MG EXTRA STRENGTH, EQL ANTACID, EQL ANTACID calcium carbonate F EXTRA STRENGTH, GNP (antacid) chew ANTACID, GOODSENSE calcium carbonate F ANTACID/EXTRA F STRENGTH, (antacid) susp GOODSENSE CALCIUM CARBONATE ANTACID/REGULAR TABS 648 MG (calcium F STRENGTH, HEALTHY carbonate (antacid)) MAMA TAME THE FLAME, HM ANTACID EXTRA MAALOX CHEW STRENGTH, HM ANTACID (calcium carbonate F REGULAR STRENGTH, (antacid)) HM CALCIUM ANTACID, Antacids - Magnesium Salts HM CALCIUM ANTACID EXTRASTRENGTH, HM (Magnesium Oxide) HM CALCIUM ANTACID MAGNESIUM TABS 400 F SMOOTHDISSOLVE, HM MG CALCIUM ANTACID magnesium oxide tabs F SMOOTHDISSOLVE 400 mg EXTRA STRENGTH, LONG LASTING ANTHELMINTICS - Drugs to Treat Worm ANTACID, PX ANTACID Infections EXTRA STRENGTH, PX Anthelmintics CALCIUM ANTACID REGULAR STRENGTH, (Pyrantel Pamoate) CVS QC ANTACID, QC PINWORM TREATMENT, ANTACID EXTRA PIN-AWAY, PINWORM F STRENGTH, RA MEDICINE, REESES ANTACID, RA ANTACID PINWORM MEDICINE EXTRA STRENGTH, SB SUSP CA Health & Wellness Preferred Drug List Updated September 1, 2021

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea per sulfamethoxazole- fill retail)1 rtl albendazole tabs F trimethoprim tabs or F MAX fill,30 rtl 160 mg-800 mg, 80 day(s) supply, mg-400 mg EMVERM CHEW QL(2 ea per fill F (mebendazole) retail) Antiprotozoal Agents QL(20 ea per atovaquone susp F QL(10 ml daily) F fill retail)1 rtl praziquantel tabs MAX fill,30 rtl Chloramphenicols day(s) supply, PA chloramphenicol F ANTI-INFECTIVE AGENTS - MISC. - Drugs to sodium succinate solr Treat Bacterial Infections Glycopeptides Anti-infective Agents - Misc. FIRVANQ SOLR QL(300 ml per IMPAVIDO CAPS F fill retail) F (vancomycin hcl) (miltefosine) QL(4 ea daily) vancomycin hcl caps or F metronidazole caps or F 125 mg 375 mg vancomycin hcl caps or QL(8 ea daily) PA F metronidazole in nacl F 250 mg soln vancomycin hcl solr iv 1 F METRONIDAZOLE SOLN PA gm, 1000 mg, 500 mg IV 5 MG/ML F PA (metronidazole) vancomycin hcl solr iv 1.5 gm, 10 gm, 100 gm, F metronidazole tabs or F 5 gm, 750 mg 250 mg, 500 mg VANCOMYCIN PA trimethoprim tabs F HYDROCHLORIDE SOLN IV 1000 MG/10ML, 1250 Anti-infective Misc. - Combinations MG/12.5ML, 1500 F (Methenamine-Hyosc- MG/15ML, 1750 Methylene Blue-Sod Phos- MG/17.5ML, 2000 MG/20ML, 750 MG/7.5ML Phenyl Sal) F PHOSPHASAL, URETRON (vancomycin hcl) D/S, URIN D/S, UTIRA-C VANCOMYCIN PA TABS HYDROCHLORIDE SOLR (Sulfamethoxazole- IV 1.5 GM, 250 MG F Trimethoprim) SULFATRIM F (vancomycin hcl) PEDIATRIC SUSP VANCOMYCIN QL(300 ml per sulfamethoxazole- PA HYDROCHLORIDE SOLR fill retail) trimethoprim soln iv 80 F OR 250 MG/5ML F mg/5ml-400 mg/5ml (vancomycin hcl) sulfamethoxazole- Leprostatics trimethoprim susp or 40 F dapsone tabs F mg/5ml-200 mg/5ml Lincosamides

CA Health & Wellness Preferred Drug List Updated September 1, 2021

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEOCIN PHOSPHATE PA NITRO-DUR PT24 0.3 SOLN IV 300 MG/2ML, 600 MG/HR, 0.8 MG/HR F MG/4ML, 900 MG/6ML F (nitroglycerin) (clindamycin nitroglycerin pt24 td 0.1 phosphate) mg/hr, 0.2 mg/hr, 0.4 F clindamycin hcl caps F mg/hr, 0.6 mg/hr nitroglycerin subl sl 0.3 clindamycin palmitate F F hydrochloride solr mg, 0.4 mg, 0.6 mg PA ANTIANXIETY AGENTS - Drugs to Treat Anxiety clindamycin phosphate F soln Antianxiety Agents - Misc. Oxazolidinones buspirone hcl tabs F SIVEXTRO TABS PA; QL(6 ea F (tedizolid phosphate) per fill retail) hydroxyzine hcl syrp F Urinary Anti-infectives hydroxyzine hcl tabs F methenamine F mandelate tabs hydroxyzine pamoate F caps nitrofurantoin F macrocrystal caps meprobamate tabs F nitrofurantoin monohyd F macro caps Benzodiazepines (Lorazepam) LORAZEPAM F nitrofurantoin susp F INTENSOL CONC ANTIANGINAL AGENTS - Drugs to Treat Chest alprazolam tabs 0.25 F Pain mg, 0.5 mg, 1 mg, 2 mg Nitrates chlordiazepoxide hcl F caps (Nitroglycerin) MINITRAN F PT24 clorazepate F (Nitroglycerin) NITRO- F dipotassium tabs TIME CPCR diazepam soln 5 DILATRATE SR CPCR F F mg/5ml (isosorbide dinitrate) diazepam tabs 10 mg, F isosorbide dinitrate F 2 mg, 5 mg tabs lorazepam conc F isosorbide dinitrate tbcr F lorazepam tabs F isosorbide mononitrate F tabs oxazepam caps 10 mg, F 15 mg, 30 mg isosorbide mononitrate F tb24 ANTIARRHYTHMICS - Drugs to treat abnormal NITRO-BID OINT heart rhythms F (nitroglycerin) Antiarrhythmics Type I-A

CA Health & Wellness Preferred Drug List Updated September 1, 2021

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP- disopyramide F FASENRA SOSY phosphate caps F AcariaHealth;S (benralizumab) P NORPACE CAPS PA; SP- ( F NUCALA SOLR 100 MG disopyramide F AcariaHealth;S phosphate) (mepolizumab) P NORPACE CR CP12 XOLAIR SOLR PA; SP- (disopyramide F F AcariaHealth;S phosphate) (omalizumab) P F PA XOLAIR SOSY PA; SP- procainamide hcl soln F AcariaHealth;S (omalizumab) P quinidine gluconate F tbcr Asthma and Bronchodilator Agent Combinations quinidine sulfate tabs F (Dyphylline-Guaifenesin) F DIFIL-G FORTE LIQD Antiarrhythmics Type I-B Bronchodilators - Anticholinergics mexiletine hcl caps 150 F ATROVENT HFA AERS mg, 200 mg, 250 mg (ipratropium bromide F Antiarrhythmics Type I-C hfa) INCRUSE ELLIPTA AEPB F F flecainide acetate tabs (umeclidinium bromide) propafenone hcl cp12 F ipratropium bromide F soln propafenone hcl tabs F SPIRIVA HANDIHALER QL(1 ea daily) CAPS ( Antiarrhythmics Type III tiotropium F bromide monohydrate) (Amiodarone Hcl) F PACERONE TABS SPIRIVA RESPIMAT QL(0.14 gm AERS (tiotropium F daily) amiodarone hcl tabs F bromide monohydrate) dofetilide caps F TUDORZA PRESSAIR AEPB (aclidinium F MULTAQ TABS F bromide) (dronedarone hcl) Leukotriene Modulators ANTIASTHMATIC AND BRONCHODILATOR montelukast sodium QL(1 ea daily) AGENTS - Drugs to Treat Lung Conditions F chew Anti-Inflammatory Agents QL(1 ea daily) montelukast sodium F cromolyn sodium nebu F pack QL(1 ea daily) Antiasthmatic - Monoclonal Antibodies montelukast sodium F tabs CINQAIR SOLN PA; SP- F AcariaHealth;S zafirlukast tabs F (reslizumab) P Steroid Inhalants

CA Health & Wellness Preferred Drug List Updated September 1, 2021

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARNUITY ELLIPTA AEPB Limit 1 inhaler FLOVENT HFA AERO 110 QL(12 gm per ( per month;QL(1 MCG/ACT, 220 MCG/ACT fill retail,12 gm fluticasone furoate F F (inhalation)) ea daily) (fluticasone propionate per 25 days retail) ASMANEX HFA AERO 100 Limit 1 inhaler hfa) MCG/ACT, 200 MCG/ACT per FLOVENT HFA AERO 44 (mometasone furoate F month;QL(0.44 MCG/ACT (fluticasone F (inhalation)) gm daily) propionate hfa) ASMANEX TWISTHALER Limit 1 Inhaler PULMICORT FLEXHALER 120 METERED DOSES per AEPB ( F budesonide F AEPB (mometasone month;QL(0.03 (inhalation)) 4 ea daily) furoate (inhalation)) QVAR REDIHALER AERB QL(0.36 gm ASMANEX TWISTHALER Limit 1 Inhaler 40 MCG/ACT daily) 14 METERED DOSES per ( F F beclomethasone AEPB (mometasone month;QL(0.03 dipropionate hfa) 4 ea daily) furoate (inhalation)) QVAR REDIHALER AERB QL(0.72 gm ASMANEX TWISTHALER Limit 1 Inhaler 80 MCG/ACT daily) 30 METERED DOSES per ( F F beclomethasone AEPB (mometasone month;QL(0.03 dipropionate hfa) furoate (inhalation)) 4 ea daily) Sympathomimetics ASMANEX TWISTHALER Limit 1 Inhaler 60 METERED DOSES per (Fluticasone-Salmeterol) F QL(2 ea daily) WIXELA INHUB AEPB AEPB (mometasone F month;QL(0.03 ADVAIR HFA AERO PA; QL(0.4 gm furoate (inhalation)) 4 ea daily) F (fluticasone-salmeterol) daily) ASMANEX TWISTHALER Limit 1 Inhaler 7 METERED DOSES per albuterol sulfate aers in QL(0.45 gm F daily) AEPB (mometasone F month;QL(0.03 108 mcg/act ) 4 ea daily) QL(1.2 gm furoate (inhalation) albuterol sulfate aers in F budesonide (inhalation) QL(8 ml daily) 108 mcg/act daily) F QL(0.57 gm susp 0.25 mg/2ml albuterol sulfate aers in F budesonide (inhalation) QL(4 ml daily) 108 mcg/act daily) susp 0.5 mg/2ml, 1 F albuterol sulfate nebu mg/2ml in 0.083 %, 0.5 %, 0.63 F FLOVENT DISKUS AEPB QL(2 ea daily) mg/3ml, 1.25 mg/3ml, 100 MCG/BLIST 2.5 mg/0.5ml F (fluticasone propionate ALBUTEROL SULFATE (inhalation)) NEBU IN 0.5 % (albuterol F FLOVENT DISKUS AEPB QL(8 ea daily) sulfate) 250 MCG/BLIST F albuterol sulfate syrp or F (fluticasone propionate 2 mg/5ml (inhalation)) albuterol sulfate tabs or FLOVENT DISKUS AEPB F 50 MCG/BLIST 2 mg, 4 mg F (fluticasone propionate albuterol sulfate tb12 or F (inhalation)) 4 mg, 8 mg

CA Health & Wellness Preferred Drug List Updated September 1, 2021

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANORO ELLIPTA AEPB QL(2 ea daily) SEREVENT DISKUS QL(2 ea daily) (umeclidinium- F AEPB (salmeterol F vilanterol) xinafoate) BEVESPI AEROSPHERE QL(0.36 gm STIOLTO RESPIMAT Limit 1 inhaler AERO (glycopyrrolate- F daily) AERS (tiotropium F per formoterol fumarate) month;QL(0.14 bromide-olodaterol hcl) gm daily) BREO ELLIPTA AEPB 25 PA; Limit 1 MCG/INH-100 MCG/INH inhaler per STRIVERDI RESPIMAT QL(0.14 gm F daily) (fluticasone furoate- F month;QL(2 ea AERS (olodaterol hcl) daily) vilanterol) terbutaline sulfate tabs F BREO ELLIPTA AEPB 25 PA MCG/INH-200 MCG/INH TRELEGY ELLIPTA AEPB QL(2 ea daily) (fluticasone furoate- F (fluticasone- F vilanterol) umeclidinium-vilanterol) budesonide-formoterol Xanthines fumarate dihydrate F aminophylline soln F PA aero ELIXOPHYLLIN ELIX COMBIVENT RESPIMAT F (theophylline) AERS (ipratropium- F THEO-24 CP24 albuterol) F (theophylline) DULERA AERO PA ( theophylline soln 80 QL(475 ml per mometasone furoate- F fill retail) formoterol fumarate F mg/15ml dihydrate) theophylline tb12 100 fluticasone-salmeterol QL(0.04 ea mg, 200 mg, 300 mg, F aepb 14 mcg/act-113 daily) 450 mg mcg/act, 14 mcg/act- F theophylline tb24 400 F 232 mcg/act, 14 mg, 600 mg mcg/act-55 mcg/act ANTICOAGULANTS - Blood Thinners fluticasone-salmeterol QL(2 ea daily) aepb 50 mcg/act-100 Coumarin Anticoagulants mcg/act, 50 mcg/act- (Warfarin Sodium) F 250 mcg/act, 50 JANTOVEN TABS COUMADIN TABS mcg/dose-100 F F mcg/dose, 50 (warfarin sodium) mcg/dose-250 warfarin sodium tabs F mcg/dose, 50 mcg/dose-500 Direct Factor Xa Inhibitors mcg/dose QL(42 ea per BEVYXXA CAPS ipratropium-albuterol F fill retail,42 ea F (betrixaban maleate) per 42 days soln retail) ELIQUIS STARTER PACK F TBPK (apixaban) CA Health & Wellness Preferred Drug List Updated September 1, 2021

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELIQUIS TABS F AMPA Glutamate Receptor Antagonists (apixaban) FYCOMPA SUSP F XARELTO STARTER (perampanel) PACK TBPK F FYCOMPA TABS ) F (rivaroxaban (perampanel) XARELTO TABS 10 MG QL(1 ea F daily,35 ea per Anticonvulsants - Benzodiazepines (rivaroxaban) 180 days retail) clonazepam tabs F XARELTO TABS 15 MG, F 20 MG (rivaroxaban) clonazepam tbdp F Heparins And Heparinoid-Like Agents diazepam F enoxaparin sodium QL(14 ml per 7 (anticonvulsant) gel F days retail)3 rtl soln sc 100 mg/ml, 150 MAX fill,180 rtl NAYZILAM SOLN PA; QL(10 ea mg/ml day(s) supply, (midazolam F per 30 days (anticonvulsant)) retail) enoxaparin sodium QL(12 ml per 7 F days retail)3 rtl Anticonvulsants - Misc. soln sc 120 mg/0.8ml, MAX fill,180 rtl 80 mg/0.8ml (Carbamazepine) EPITOL F day(s) supply, TABS QL(5 ml per 7 (Lamotrigine) SUBVENITE F enoxaparin sodium F days retail)3 rtl TABS soln sc 30 mg/0.3ml MAX fill,180 rtl day(s) supply, (Levetiracetam) F ROWEEPRA TABS QL(6 ml per 7 (Levetiracetam) ST enoxaparin sodium F days retail)3 rtl F soln sc 40 mg/0.4ml MAX fill,180 rtl ROWEEPRA XR TB24 day(s) supply, carbamazepine chew F QL(9 ml per 7 enoxaparin sodium F days retail)3 rtl carbamazepine cp12 F soln sc 60 mg/0.6ml MAX fill,180 rtl day(s) supply, carbamazepine susp F PA heparin sod (porcine) in F d5w soln carbamazepine tabs F heparin sodium F carbamazepine tb12 F (porcine) soln HEPARIN PA gabapentin caps F SODIUM/DEXTROSE SOLN (heparin sod F gabapentin soln F (porcine) in d5w) gabapentin tabs F Thrombin Inhibitors PRADAXA CAPS PA lamotrigine chew 25 F (dabigatran etexilate F mg, 5 mg mesylate) lamotrigine tabs 100 mg, 150 mg, 200 mg, F ANTICONVULSANTS - Drugs to Treat Seizures 25 mg

CA Health & Wellness Preferred Drug List Updated September 1, 2021

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lamotrigine tb24 100 ST (Vigabatrin) VIGADRONE F SP- mg, 200 mg, 25 mg, PACK Caremark;SP F GABITRIL TABS 4 MG 250 mg, 300 mg, 50 F mg (tiagabine hcl) levetiracetam soln 100 F tiagabine hcl tabs F mg/ml, 500 mg/5ml F SP- levetiracetam tabs vigabatrin pack Caremark;SP 1000 mg, 250 mg, 500 F SP-Accredo;SP mg, 750 mg vigabatrin tabs F ST Hydantoins levetiracetam tb24 500 F mg, 750 mg (Phenytoin) PHENYTOIN F INFATABS CHEW oxcarbazepine susp F DILANTIN CAPS 100 MG oxcarbazepine tabs F (phenytoin sodium F extended) primidone tabs F DILANTIN CAPS 30 MG SP (phenytoin sodium F rufinamide susp F extended) SP DILANTIN INFATABS rufinamide tabs F F CHEW (phenytoin) TEGRETOL SUSP DILANTIN-125 SUSP F F (carbamazepine) (phenytoin) TEGRETOL TABS F (carbamazepine) phenytoin chew F TEGRETOL-XR TB12 F phenytoin sodium F (carbamazepine) extended caps topiramate cpsp or 15 F phenytoin susp F mg, 25 mg topiramate tabs or 100 Succinimides CELONTIN CAPS mg, 200 mg, 25 mg, 50 F F mg (methsuximide) VIMPAT SOLN F ethosuximide caps F (lacosamide) VIMPAT TABS ethosuximide soln F F (lacosamide) ZARONTIN CAPS F zonisamide caps F (ethosuximide) ZARONTIN SOLN F Carbamates (ethosuximide) felbamate susp F Valproic Acid DEPAKENE CAPS felbamate tabs F F (valproic acid) GABA Modulators CA Health & Wellness Preferred Drug List Updated September 1, 2021

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits divalproex sodium csdr F Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram QL(20 ml daily) divalproex sodium tb24 F hydrobromide soln 10 F mg/5ml divalproex sodium tbec F citalopram QL(4 ea daily) valproate sodium soln F hydrobromide tabs 10 F mg valproic acid caps F citalopram QL(2 ea daily) ANTIDEPRESSANTS - Drugs to Treat hydrobromide tabs 20 F Depression mg Alpha-2 Receptor Antagonists (Tetracyclics) citalopram QL(1 ea daily) hydrobromide tabs 40 F mirtazapine tabs F mg mirtazapine tbdp F escitalopram oxalate F soln Antidepressants - Misc. escitalopram oxalate F bupropion hcl tabs 100 F tabs mg, 75 mg fluoxetine hcl caps 10 F bupropion hcl tb12 100 F mg, 20 mg, 40 mg mg, 150 mg fluoxetine hcl soln 20 QL(2 ea daily) F bupropion hcl tb12 200 F mg/5ml mg fluoxetine hcl tabs 10 QL(3 ea daily) F bupropion hcl tb24 150 F mg, 20 mg mg fluvoxamine maleate QL(1 ea daily) F bupropion hcl tb24 300 F cp24 mg fluvoxamine maleate F maprotiline hcl tabs F tabs Monoamine Oxidase Inhibitors (MAOIs) paroxetine hcl tabs F EMSAM PT24 CO paroxetine hcl tb24 F (selegiline) MARPLAN TABS PAXIL SUSP 10 MG/5ML CO F (isocarboxazid) (paroxetine hcl) NARDIL TABS CO sertraline hcl conc F (phenelzine sulfate) PARNATE TABS sertraline hcl tabs F ( CO tranylcypromine Serotonin Modulators sulfate) nefazodone hcl tabs F phenelzine sulfate tabs CO trazodone hcl tabs F tranylcypromine sulfate CO tabs CA Health & Wellness Preferred Drug List Updated September 1, 2021

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIIBRYD TABS PA F ANTIDIABETICS - Drugs to Regulate Blood (vilazodone hcl) Sugar Serotonin-Norepinephrine Reuptake Inhibitors Alpha-Glucosidase Inhibitors DESVENLAFAXINE ER ST F acarbose tabs F TB24 (desvenlafaxine) Antidiabetic - Amylin Analogs desvenlafaxine F SYMLINPEN 120 SOPN PA succinate tb24 F (pramlintide acetate) desvenlafaxine tb24 F ST SYMLINPEN 60 SOPN PA F QL(2 ea daily) (pramlintide acetate) duloxetine hcl cpep 20 F mg, 30 mg, 60 mg Antidiabetic Combinations KHEDEZLA TB24 ST F alogliptin-metformin hcl F (desvenlafaxine) tabs venlafaxine hcl cp24 alogliptin-pioglitazone F 150 mg, 37.5 mg, 75 F tabs mg glipizide-metformin hcl F venlafaxine hcl tabs tabs 100 mg, 25 mg, 37.5 F mg, 50 mg, 75 mg glyburide-metformin F tabs venlafaxine hcl tb24 INVOKAMET TABS PA 150 mg, 225 mg, 75 F mg (canagliflozin- F metformin hcl) QL(1 ea daily) venlafaxine hcl tb24 F INVOKAMET XR TB24 PA 37.5 mg (canagliflozin- F Tricyclic Agents metformin hcl) amitriptyline hcl tabs F JANUMET TABS PA (sitagliptin-metformin F amoxapine tabs F hcl) JANUMET XR TB24 PA clomipramine hcl caps F (sitagliptin-metformin F hcl) desipramine hcl tabs F JENTADUETO TABS PA; AL(At least doxepin hcl caps F (linagliptin-metformin F 18 yrs old) hcl) doxepin hcl conc F KOMBIGLYZE XR TB24 PA (saxagliptin-metformin F imipramine hcl tabs F hcl) QL(1 ea daily) nortriptyline hcl caps F pioglitazone hcl- F glimepiride tabs nortriptyline hcl soln F pioglitazone hcl- F metformin hcl tabs protriptyline hcl tabs F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SEGLUROMET TABS QL(2 ea daily) glucagon (rdna) kit F QL(1 ea per fill (ertugliflozin-metformin F retail) hcl) GLUCOSE CHEW 4 GM SOLIQUA 100/33 SOPN PA (dextrose (diabetic F (insulin glargine- F use)) lixisenatide) GNP GLUCOSE CHEW 4 SYNJARDY TABS PA GM (dextrose (diabetic F (empagliflozin- F use)) metformin hcl) GNP QUICK DISSOLVE GLUCOSE CHEW SYNJARDY XR TB24 PA F (empagliflozin- F (dextrose (diabetic metformin hcl) use)) XULTOPHY 100/3.6 SOPN PA GVOKE PFS SOSY QL(0.02 ml F daily) (insulin degludec- F (glucagon) liraglutide) KORLYM TABS PA; SP (mifepristone F Biguanides (hyperglycemia)) metformin hcl tabs LEADER QUICK 1000 mg, 500 mg, 850 F DISSOLVE GLUCOSE mg CHEW (dextrose F metformin hcl tb24 500 F (diabetic use)) mg, 750 mg SM GLUCOSE CHEW 4 Diabetic Other GM (dextrose (diabetic F BAQSIMI ONE PACK QL(0.069 ea use)) F POWD (glucagon) daily) WALGREENS GLUCOSE BAQSIMI TWO PACK QL(0.069 ea CHEW 4 GM (dextrose F F POWD (glucagon) daily) (diabetic use)) BD GLUCOSE CHEW Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (dextrose (diabetic F alogliptin benzoate tabs F use)) JANUVIA TABS PA CVS GLUCOSE CHEW 4 F GM (dextrose (diabetic F (sitagliptin phosphate) ONGLYZA TABS PA use)) F CVS SOFT GLUCOSE (saxagliptin hcl) TRADJENTA TABS PA CHEW (dextrose F F (diabetic use)) (linagliptin) DEX4 QUICK DISSOLVE Dopamine Receptor Agonists - Antidiabetic GLUCOSE CHEW F CYCLOSET TABS (dextrose (diabetic (bromocriptine F use)) mesylate (diabetes)) GLUCAGEN HYPOKIT Incretin Mimetic Agents (GLP-1 Receptor SOLR (glucagon hcl F ADLYXIN SOPN PA (rdna)) F (lixisenatide) CA Health & Wellness Preferred Drug List Updated September 1, 2021

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADLYXIN STARTER PACK PA HUMULIN 70/30 KWIKPEN F PNKT (lixisenatide) SUPN (insulin nph F BYDUREON BCISE AUIJ PA isophane & reg F (exenatide) (human)) BYDUREON PEN PEN PA HUMULIN 70/30 SUSP F (exenatide) (insulin nph isophane & F BYETTA SOPN PA reg (human)) F (exenatide) HUMULIN N KWIKPEN TRULICITY SOPN 0.75 PA SUPN (insulin nph F MG/0.5ML, 1.5 MG/0.5ML F (human) (isophane)) (dulaglutide) HUMULIN N SUSP VICTOZA SOPN PA (insulin nph (human) F F (liraglutide) (isophane)) HUMULIN R SOLN Insulin Sensitizing Agents (insulin regular F AVANDIA TABS F (human)) (rosiglitazone maleate) HUMULIN R U-500 Limit 20 per F month;QL(0.67 pioglitazone hcl tabs (CONCENTRATED) F SOLN (insulin regular ml daily) Insulin (human)) ADMELOG SOLN ( QL(1.67 ml insulin F HUMULIN R U-500 Limit 20 per lispro) daily) KWIKPEN SOPN (insulin F month;QL(0.67 ADMELOG SOLOSTAR QL(30 ml per regular (human)) ml daily) F SOPN (insulin lispro) 30 days retail) INSULIN ASPART QL(30 ml per PROTAMINE/INSULIN 30 days retail) BASAGLAR KWIKPEN Limit 50mls per F month;QL(1.67 ASPART FLEXPEN SUPN SOPN (insulin glargine) ml daily) (insulin aspart F HUMALOG MIX 50/50 protamine & aspart KWIKPEN SUPN (insulin (human)) F lispro protamine & INSULIN ASPART QL(40 ml per lispro) PROTAMINE/INSULIN 30 days retail) HUMALOG MIX 50/50 ASPART SUSP (insulin F SUSP (insulin lispro F aspart protamine & protamine & lispro) aspart (human)) HUMALOG MIX 75/25 INSULIN LISPRO PROTAMINE/INSULIN KWIKPEN SUPN (insulin F LISPRO KWIKPEN SUPN F lispro protamine & (insulin lispro protamine lispro) & lispro) HUMALOG MIX 75/25 NOVOLIN 70/30 FLEXPEN SUSP (insulin lispro F RELION SUPN (insulin protamine & lispro) nph isophane & reg F (human))

CA Health & Wellness Preferred Drug List Updated September 1, 2021

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOLIN 70/30 FLEXPEN NOVOLOG MIX 70/30 QL(40 ml per SUPN (insulin nph SUSP (insulin aspart 30 days retail) isophane & reg F protamine & aspart F (human)) (human)) NOVOLIN 70/30 RELION Meglitinide Analogues SUSP (insulin nph isophane & reg F nateglinide tabs F (human)) Sodium-Glucose Co-Transporter 2 (SGLT2) NOVOLIN 70/30 SUSP INVOKANA TABS PA F (insulin nph isophane & F (canagliflozin) reg (human)) JARDIANCE TABS PA F NOVOLIN N FLEXPEN (empagliflozin) RELION SUPN (insulin F STEGLATRO TABS QL(1 ea daily) nph (human) (isophane)) (ertugliflozin l- F NOVOLIN N FLEXPEN pyroglutamic acid) SUPN (insulin nph F (human) (isophane)) Sulfonylureas (Glipizide) GLIPIZIDE XL F NOVOLIN N RELION TB24 SUSP (insulin nph F (human) (isophane)) glimepiride tabs F NOVOLIN N SUSP glipizide tabs F (insulin nph (human) F (isophane)) glipizide tb24 F NOVOLIN R RELION SOLN (insulin regular F glyburide micronized F (human)) tabs NOVOLIN R SOLN glyburide tabs F (insulin regular F (human)) tolbutamide tabs F NOVOLOG MIX 70/30 QL(30 ml per PREFILLED FLEXPEN 30 days retail) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea RELION SUPN (insulin F aspart protamine & Antidiarrheal/Probiotic Agents - Misc. aspart (human)) NOVOLOG MIX 70/30 QL(30 ml per PREFILLED FLEXPEN 30 days retail) SUPN (insulin aspart F protamine & aspart (human)) NOVOLOG MIX 70/30 QL(40 ml per RELION SUSP (insulin 30 days retail) aspart protamine & F aspart (human))

CA Health & Wellness Preferred Drug List Updated September 1, 2021

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Bismuth Subsalicylate) RELIEF ULTRA SUSP BISMATROL, BISMATROL MAXIMUM STRENGTH, (Bismuth Subsalicylate) CVS STOMACH RELIEF, BISMATROL, CVS CVS STOMACH RELIEF BISMUTH, CVS MAXIMUM STRENGTH, STOMACH RELIEF, EQ DIARRHEA, DIOTAME PINK-BISMUTH, EQL INSTYDOSE, EQ STOMACH RELIEF, GNP STOMACH RELIEF, EQL PINK BISMUTH, STOMACH RELIEF, EQL GOODSENSE STOMACH F STOMACH RELIEF RELIEF, HM STOMACH MAXIMUM STRENGTH, RELIEF, MEDI-BISMUTH, GERI-PECTATE, GNP PEPTIC RELIEF, PX STOMACH RELIEF, GNP STOMACH RELIEF, QC STOMACH RELIEF PINK BISMUTH, RA PINK MAXIMUM STRENGTH, BISMUTH, SM STOMACH GNP ULTRA STOMACH RELIEF, STOMACH RELIEF, GOODSENSE RELIEF CHEW STOMACH RELIEF, (Bismuth Subsalicylate) GOODSENSE STOMACH CVS ANTI-DIARRHEAL F RELIEF/MAXIMUM SUSP 262 MG/15ML STRENGTH, HM STOMACH RELIEF, HM (Bismuth Subsalicylate) STOMACH RELIEF CVS BISMUTH, CVS MAXIMUMSTRENGTH, STOMACH RELIEF, EQL STOMACH RELIEF, GNP HM STOMACH RELIEF F ULTRA, KAOPECTATE, PINK BISMUTH, F KAOPECTATE EXTRA KAOPECTATE, QC PINK STRENGTH, PINK BISMUTH, SB BISMUTH, BISMUTH, PINK BISMUTH SM STOMACH RELIEF, MAXIMUM STRENGTH, TGT STOMACH RELIEF PX STOMACH RELIEF, PX TABS STOMACH RELIEF (Bismuth Subsalicylate) MAXIMUM STRENGTH, SOOTHE CHEW OR 262 F QC DIARRHEA RELIEF, MG QC PINK BISMUTH, RA (Bismuth Subsalicylate) STOMACH RELIEF, RA SOOTHE SUSP OR 262 F STOMACH RELIEF MG/15ML, 525 MG/30ML MAXIMUM STRENGTH, (Bismuth Subsalicylate) SM STOMACH RELIEF, SOOTHE TABS OR 262 F SM STOMACH RELIEF MG LIQUID, SM STOMACH RELIEF bismuth subsalicylate F MAXIMUMSTRENGTH, chew SOOTHE MAXIMUM bismuth subsalicylate STRENGTH, STOMACH F RELIEF, STOMACH susp RELIEF EXTRA Antiperistaltic Agents STRENGTH, STOMACH RELIEF MAXIMUM STRENGTH, STOMACH RELIEF PLUS, STOMACH CA Health & Wellness Preferred Drug List Updated September 1, 2021

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Loperamide Hcl) ANTI- QL(8 ea daily); Antidotes - Chelating Agents DIARRHEAL, CVS ANTI- RX/OTC CHEMET CAPS DIARRHEAL, HM ANTI- F DIARRHEAL, HM F (succimer) LOPERAMIDE HCL, SM deferasirox pack 180 PA; SP- ANTI-DIARRHEAL CAPS 2 F AcariaHealth;S MG mg, 360 mg, 90 mg P (Loperamide Hcl) ANTI- QL(8 ea daily) PA; SP deferasirox tabs 180 F DIARRHEAL, CVS ANTI- mg, 360 mg, 90 mg DIARRHEAL, HM ANTI- F DIARRHEAL, SM ANTI- Antidotes and Specific Antagonists DIARRHEAL TABS 2 MG VISTOGARD PACK (Loperamide Hcl) QL(8 ea daily) (uridine triacetate F DIAMODE, EQ ANTI- (emergency treatment)) DIARRHEAL, EQL ANTI- DIARRHEAL, GNP ANTI- Opioid Antagonists DIARRHEAL, KLS ANTI- EVZIO SOAJ ( naloxone CO DIARRHEAL, MEIJER hcl) ANTI-DIARRHEAL, MM F ANTI-DIARRHEAL, PX naloxone hcl soaj CO ANTI-DIARRHEAL, QC ANTI-DIARRHEAL, RA naloxone hcl soct CO ANTI-DIARRHEAL, SB ANTI-DIARRHEA, SR naloxone hcl soln CO ANTI-DIARRHEAL, TGT ANTI-DIARRHEAL TABS naloxone hcl sosy CO (Loperamide Hcl) EQ QL(8 ea daily); ANTI-DIARRHEAL, GNP RX/OTC naltrexone hcl tabs CO ANTI-DIARRHEAL, QC F ANTI-DIARRHEAL, RA NALTREXONE IMPL ANTI-DIARRHEAL, TGT (naltrexone- CO LOPERAMIDE HCL CAPS triamcinolone) ANTI-DIARRHEAL LIQD 1 QL(40 ml daily) NARCAN LIQD CO MG/5ML (loperamide F (naloxone hcl) hcl) VIVITROL SUSR CO (naltrexone) diphenoxylate w/ F atropine liqd ANTIEMETICS - Drugs to Treat Nausea and Vomiting diphenoxylate w/ F atropine tabs 5-HT3 Receptor Antagonists loperamide hcl caps 2 QL(8 ea daily); F granisetron hcl soln F PA mg RX/OTC QL(8 ea daily) F PA loperamide hcl tabs 2 F granisetron hcl tabs mg QL(50 ml per ondansetron hcl soln 4 F paregoric tinc F mg/5ml fill retail) QL(20 ea per ondansetron hcl tabs 4 F ANTIDOTES AND SPECIFIC ANTAGONISTS mg, 8 mg 30 days retail)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(20 ea per DRAMAMINE CHEW ondansetron tbdp F F 30 days retail) (dimenhydrinate) Antiemetics - Anticholinergic meclizine hcl chew F RX/OTC (Dimenhydrinate) CVS MOTION SICKNESS, meclizine hcl tabs F RX/OTC DRIMINATE, EQ MOTION SICKNESS RELIEF, trimethobenzamide hcl F GOODSENSE MOTION caps SICKNESS, HM MOTION F SICKNESS, QC MOTION Antiemetics - Miscellaneous SICKNESS RELIEF, SB Limit 2 fills per MOTION SICKNESS, SM BONJESTA TBCR year;QL(1 ea MOTION SICKNESS F daily)2 rtl MAX RELIEF, TRAV-TABS, (doxylamine-pyridoxine) fill,365 rtl WAL-DRAM TABS day(s) supply, (Dimenhydrinate) GNP Limit 2 fills per MOTION SICKNESS doxylamine-pyridoxine year;QL(2 ea RELIEF, HM MOTION F daily)2 rtl MAX SICKNESS RELIEF, tbec fill,365 rtl day(s) supply, MOTION SICKNESS F RELIEF, RA MOTION PA SICKNESS RELIEF, SM dronabinol caps F MOTION SICKNESS, TRAVEL SICKNESS TABS Substance P/Neurokinin 1 (NK1) Receptor 50 MG aprepitant caps F 1 rtl pack lmt (Meclizine Hcl) BONINE, RX/OTC per fill, QL(1 ea per fill CVS MOTION SICKNESS F aprepitant caps 125 mg F RELIEF, MOTION-TIME, retail) QC TRAVEL EASE CHEW aprepitant caps 40 mg F (Meclizine Hcl) CVS RX/OTC MOTION SICKNESS II, aprepitant caps 80 mg F QL(2 ea per fill CVS MOTION SICKNESS retail) LESSDROWSY aprepitant misc F 1 rtl pack lmt FORMULA, DRAMAMINE F per fill, LESS DROWSY, EQL MOTION SICKNESS ANTIFUNGALS - Drugs to Treat Fungal Infections RELIEF, HM MOTION RELIEF, TRAVEL-EASE, Antifungals WAL-DRAM II TABS griseofulvin microsize F (Meclizine Hcl) GNP RX/OTC susp MOTION SICKNESS griseofulvin microsize RELIEF, HM MOTION F F SICKNESS RELIEF, SM tabs MOTION SICKNESS TABS griseofulvin F 25 MG ultramicrosize tabs (Meclizine Hcl) MOTION RX/OTC SICKNESS RELIEF, RA nystatin tabs F MOTION SICKNESS F F QL(90 ea per RELIEF, TRAVEL terbinafine hcl tabs 365 days retail) SICKNESS CHEW 25 MG CA Health & Wellness Preferred Drug List Updated September 1, 2021

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Imidazole-Related Antifungals (Chlorpheniramine Maleate) DIABETIC F fluconazole susr F TUSSIN ALLERGY, ED CHLORPED JR SYRP fluconazole tabs F (Dexchlorpheniramine F PA Maleate) RYCLORA SOLN itraconazole caps 100 F mg chlorpheniramine F maleate tabs 4 mg ketoconazole tabs F dexchlorpheniramine F voriconazole susr F maleate soln Antihistamines - Ethanolamines voriconazole tabs F (Clemastine Fumarate) DAYHIST ALLERGY 12 ANTIHISTAMINES - Drugs to Treat Allergies HOUR RELIEF, GNP F DAYHIST ALLERGY, PX Antihistamines - Alkylamines DAYHIST ALLERGY, SM (Chlorpheniramine ALLERGY RELIEF TABS Maleate) ALLER-CHLOR, (Diphenhydramine Hcl) ALLERGY TABLETS, ALER-CAP, COMPLETE ALLERGY-TIME, ALLERGY MEDICINE, CHLORHIST, EQ CVS ALLERGY, CHLORTABS, EQL DIPHENHIST, EQL ALLERGY, GNP ALLERGY RELIEF, GNP ALLERGY, GNP ALLERGY ALLERGY, GNP ALLERGY RELIEF, GOODSENSE RELIEF, HM ALLERGY ALLERGY RELIEF, HM RELIEF, HM ALLGERY ALLERGY RELIEF, F MULTI SYMPTOM, KP PHARBECHLOR, QC DIPHENHYDRAMINE F ALLERGY RELIEF 4- HCL, MEDI-PHEDRYL, HOUR, QC CHLOR- MEIJER ANTIHISTAMINE PHENIRAMINE, RA ALLERGY, PHARBEDRYL, ALLERGY RELIEF, RA PX ALLERGY, RA CHLORPHENIRAMINE ALLERGY MEDICATION, MALEATE, SB RA ALLERGY RELIEF, SB CHLORPHENIRAMINE, ALLERGY, SM ALLERGY SM ALLERGY 4 HOUR, RELIEF, TGT ALLERGY WAL-FINATE TABS RELIEF, WAL-DRYL (Chlorpheniramine ALLERGY CAPS Maleate) ALLERGY, ALLERGY RELIEF, CVS F ALLERGY RELIEF TABS 4 MG (Chlorpheniramine Maleate) ALLERGY, ALLERGY RELIEF, CVS F ALLERGY RELIEF TABS OR 4 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl) (Diphenhydramine Hcl) ALERTAB, ALKA- ALLERGY CHILDRENS, SELTZER PLUS ALLERGY AURODRYL ALLERGY FAST RELIEF FORMULA, CHILDRENS, CVS ANTI-HIST ALLERGY, ALLERGY RELIEF COMPLETE ALLERGY ADULTMAXIMUM MEDICINE, COMPLETE STRENGTH, CVS ALLERGY RELIEF, CHILDRENS ALLERGY, DIPHEN, EQL ALLERGY, CVS CHILDRENS EQL ALLERGY RELIEF, ALLERGY RELIEF, DYE- GERI-DRYL ALLERGY FREE ALLERGY RELIEF RELIEF, GNP ALLERGY, CHILDRENS, EQL GNP ALLERGY RELIEF, CHILDRENS ALLERGY, HM ALLERGY, HM GERI-DRYL, GNP ALLERGY RELIEF, KLS F ALLERGY ALLERGY MEDICINE, PX ANTIHISTAMINE, GNP ALLERGY, QC ALLERGY COMPLETE ALLERGY ANTIHISTAMINECHILDRE MEDICINE, QLEARQUIL NS, GNP CHILDRENS NIGHTTIME ALLEGY ALLERGY, H-E-B RELIEF, RA ALLERGY, RA CHILDRENS ALLERGY, ALLERGY MEDICATION, HM ALLERGY RELIEF RA COMPLETE CHILDRENS, LIQUID ALLERGY, SB ALLERGY ALLERGY RELIEF, M- MEDICINE, SM ALLERGY DRYL, NARAMIN, F RELIEF, TGT ALLERGY PEDIACARE CHILDRENS RELIEF, TOTAL ALLERGY, PX ALLERGY, ALLERGY, WAL-DRYL QC ALLERGY ALLERGY TABS CHILDRENS, RA ALLERGY, RA ALLERGY MEDICATION CHILDRENS, RA DIPHEDRYL ALLERGY, SB ALLERGY MEDICINE, SILADRYL ALLERGY, SM ALLERGY RELIEF, SM ALLERGY RELIEF CHILDRENS, TGT ALLERGY RELIEF CHILDRENS, TGT ALLERGY RELIEF CHILDRENS DYE FREE, TOTAL ALLERGY MEDICINE, WAL-DRYL ALLERGY, WAL-DRYL ALLERGY CHILDRENS, WAL-DRYL ALLERGY DYE-FREECHILDRENS LIQD

CA Health & Wellness Preferred Drug List Updated September 1, 2021

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl) clemastine fumarate F ALLERGY RELIEF tabs CHILDRENS, CVS ALLERGY RELIEF diphenhydramine hcl F caps CHILDRENS, EQ F ALLERGY RELIEF diphenhydramine hcl CHILDRENS, RA F ALLERGY RELIEF chew CHILDRENS LIQD 12.5 diphenhydramine hcl F MG/5ML elix (Diphenhydramine Hcl) diphenhydramine hcl F ALLERGY, ALLERGY liqd RELIEF, BANOPHEN, CVS ALLERGY RELIEF, EQ F diphenhydramine hcl F ALLERGY RELIEF, QC tabs ALLERGY RELIEF TABS 25 MG Antihistamines - Non-Sedating (Diphenhydramine Hcl) (Cetirizine Hcl) ALL DAY QL(240 ml per ALLERGY, ALLERGY ALLERGY CHILDRENS, fill retail); RELIEF, BANOPHEN, CVS ALL-DAY ALLERGY RX/OTC ALLERGY RELIEF, EQ F CHILDRENS, CETIRIZINE ALLERGY RELIEF, QC HCL ALLERGY ALLERGY RELIEF TABS CHILDRENS, CETIRIZINE OR 25 MG HCL CHILDRENSALLERGY, (Diphenhydramine Hcl) CETIRIZINE ALLERGY, ALLERGY HYDROCHLORIDECHILD RELIEF, CVS ALLERGY F RENS ALLERGY, EQL ALL RELIEF, EQ ALLERGY DAY ALLERGY RELIEF CAPS 25 MG CHILDRENS, GNP ALL (Diphenhydramine Hcl) DAY ALLERGY ALLERGY, ALLERGY CHILDRENS, RELIEF, CVS ALLERGY F GOODSENSE ALL DAY RELIEF, EQ ALLERGY ALLERGYCHILDRENS, RELIEF CAPS OR 25 MG HM ALL DAY ALLERGY F (Diphenhydramine Hcl) CHILDRENS, HM BANOPHEN CAPS OR 25 F CETIRIZINE HCL MG, 50 MG CHILDRENS, KLS ALLER- TEC CHILDRENS, PX (Diphenhydramine Hcl) CHILDRENS ALLERGY, CVS ALLERGY RELIEF F QC CHILDRENS LIQD 25 MG/10ML ALLERGY, SB (Diphenhydramine Hcl) DI- F CETIRIZINE HCL PHEN, DIPHEN ELIX CHILDRENS, SM ALL DAY (Diphenhydramine Hcl) ALLERGY CHILDRENS, GNP ALLERGY RELIEF F TGT ALL DAY ALLERGY CHEW RELIEF CHILDRENS, ALER-DRYL TABS WAL-ZYR ALL DAY F ALLERGY CHILDRENS, (diphenhydramine hcl) WAL-ZYR ALL DAY ALLERGYCHILDRENS SOLN CA Health & Wellness Preferred Drug List Updated September 1, 2021

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cetirizine Hcl) ALL DAY (Cetirizine Hcl) QL(240 ml per ALLERGY, ALLERGY CETIRIZINE HCL fill retail); 24HOUR CHILDRENS, EQ F RX/OTC INDOOR/OUTDOOR, ALLERGY RELIEF SOLN ALLERGY OR 1 MG/ML RELIEF/INDOOR/OUTDO (Cetirizine Hcl) OR, CVS CETIRIZINE HCL INDOOR/OUTDOOR CHILDRENS, WAL-ZYR F ALLERGY RELIEF, EQL CHILDRENS CHEW 10 ALL DAY ALLERGY, GNP MG, 5 MG ALL DAY ALLERGY, GOODSENSE ALL DAY (Cetirizine Hcl) CVS QL(240 ml per ALLERGY RELIEF fill retail); ALLERGY, HM ALL DAY F ALLERGY, HM ALLERGY CHILDRENS, EQ F RX/OTC RELIEF, HM CETIRIZINE ALLERGY RELIEF HYDROCHLORIDE, KLS CHILDRENS, WAL-ZYR ALLER-TEC, KP SOLN 5 MG/5ML CETIRIZINE HCL, KP (Cetirizine Hcl) EQ CETIRIZINE CETIRIZINE F HYDROCHLORIDE, PX HYDROCHLORIDE ALLERGY RELIEF, QC CHILDRENS CHEW ALL DAY ALLERGY, RA (Cetirizine Hcl) QC QL(240 ml per ALLERGY RELIEF, SB ALLERGY RELIEF F fill retail); ALLERGY, SM ALL DAY CHILDRENS SYRP 1 RX/OTC ALLERGY, TGT ALL DAY MG/ML ALLERGY RELIEF TABS (Cetirizine Hcl) RA QL(240 ml per (Cetirizine Hcl) ALLERGY QL(240 ml per ALLERGY RELIEF F fill retail); RELIEF CHILDRENS, RA fill retail); CHILDRENS SYRP 5 RX/OTC ALLERGY RELIEF F RX/OTC MG/5ML CHILDRENS, WAL-ZYR CHILDRENS SOLN 1 MG/ML, 5 MG/5ML (Cetirizine Hcl) ALLERGY RELIEF, CVS ALLERGY RELIEF, EQ ALLERGY F RELIEF, QC ALLERGY RELIEF, WAL-ZYR TABS 10 MG (Cetirizine Hcl) ALLERGY RELIEF, CVS ALLERGY RELIEF, EQ ALLERGY F RELIEF, QC ALLERGY RELIEF, WAL-ZYR TABS OR 10 MG (Cetirizine Hcl) QL(240 ml per CETIRIZINE HCL fill retail); CHILDRENS, EQ F RX/OTC ALLERGY RELIEF SOLN 1 MG/ML

CA Health & Wellness Preferred Drug List Updated September 1, 2021

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Fexofenadine Hcl) 24HR (Levocetirizine RX/OTC ALLERGY RELIEF, Dihydrochloride) ALLERGY ALLER-EASE, ALLERGY RELIEF 24HR, CVS F 24-HR, ALLERGY RELIEF ALLERGY RELIEF TABS 5 24HR/INDOOR/OUTDOOR MG , EQL ALLER-EASE, GNP (Levocetirizine RX/OTC ALLERGY RELIEF, Dihydrochloride) GNP F GOODSENSE ALLER- ALLERGY RELIEF 24 EASE, HM ALLERGY HOUR TABS RELIEF, HM FEXOFENADINE (Loratadine) ALAVERT, EQ HYDROCHLORIDE, KLS LORATADINE, GNP ALLER-FEX, KP LORATADINE, HM FEXOFENADINE HCL, MM ALLERGY RELIEF, MEIJER ALLERGY FEXOFENADINE F HYDROCHLORIDE, PX RELIEF, PX ALLERGY ALLERGY RELIEF, QC RELIEF, SB ALLERGY FEXOFENADINE RELIEF, SM ALLERGY HYDROCHLORIDE, RA RELIEF, SM LORATADINE F ALLERGY RELIEF, RA ALLERGY RELIEF, TGT ALLERGY RELIEF 24 ALLERGY RELIEF, HOUR, SM TRIAMINIC FEXOFENADINE HCL, SM ALLERCHEWS, WAL-ITIN, FEXOFENADINE WAL-ITIN ALLER-MELTS, HYDROCHLORIDE, TGT WAL-ITIN ALLERGY ALLERGY RELIEF, WAL- RELIEF REDITABS, WAL- FEX, WAL-FEX 24 HOUR VERT TBDP ALLERGY, WAL-FEX (Loratadine) ALLERGY ALLERGY, WAL-FEX CHILDRENS, ALLERGY ALLERGY 12 HOUR TABS RELIEF CHILD, (Fexofenadine Hcl) CHILDRENS ALLERGY RELIEF 24HR, LORATADINE, CLARITIN EQ ALLERGY RELIEF, QC F ALLERGY CHILDRENS, ALLERGY RELIEF TABS EQ ALLERGY 180 MG CHILDRENS, GNP LORATADINE, HM (Fexofenadine Hcl) LORATADINE ALLERGY RELIEF 24HR, CHILDRENS, MEIJER F EQ ALLERGY RELIEF, QC F LORATADINE, RA ALLERGY RELIEF TABS LORATADINE, SB OR 180 MG LORATADINE, SM (Fexofenadine Hcl) ALLERGY CHILDRENS, ALLERGY RELIEF, CVS F SM CHILDRENS ALLERGY RELIEF TABS LORATADINE, SM 180 MG, 60 MG LORATADINE, TGT (Fexofenadine Hcl) LORATADINE CHILDRENS, WAL-ITIN ALLERGY RELIEF, CVS F ALLERGY RELIEF TABS SYRP OR 180 MG, 60 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Loratadine) ALLERGY (Loratadine) ALLERGY, RELIEF CHILDRENS, CVS ALLERGY RELIEF, CVS ALLERGY RELIEF ALLERGY RELIEF, EQ F CHILDRENS, EQ ALLERGY RELIEF TABS ALLERGY RELIEF 10 MG CHILDRENS, F (Loratadine) ALLERGY, LORATADINE ALLERGY RELIEF, CVS CHILDRENS, QC ALLERGY RELIEF, EQ F ALLERGY RELIEF ALLERGY RELIEF TABS CHILDRENS SYRP 5 OR 10 MG MG/5ML (Loratadine) CHILDRENS (Loratadine) ALLERGY LORATADINE, WAL-ITIN F RELIEF CHILDRENS, GNP CHILDRENS SOLN LORATADINE F CHILDRENS SOLN 5 cetirizine hcl chew 10 F MG/5ML mg, 5 mg (Loratadine) ALLERGY cetirizine hcl soln 1 QL(240 ml per RELIEF LORATADINE, EQ F fill retail); LORATADINE, EQL mg/ml, 5 mg/5ml RX/OTC ALLERGY RELIEF, GNP cetirizine hcl tabs 10 F LORATADINE, mg, 5 mg GOODSENSE ALLERGY CLARITIN REDITABS RELIEF, HM F LORATADINE, KLS TBDP 5 MG (loratadine) ALLERCLEAR, KP LORATADINE, fexofenadine hcl tabs F LORADAMED, MEIJER levocetirizine RX/OTC ALLERGY RELIEF, PX ALLERGY RELIEF, QC F dihydrochloride tabs 5 F LORATADINE ALLERGY mg RELIEF, QLEARQUIL ALL loratadine syrp 5 F DAY & ALLNIGHT 24 mg/5ml HOUR ALLERGY RELIEF, RA ALLERGY RELIEF 24 loratadine tabs 10 mg F HOUR, RA LORATADINE, SB LORATADINE, SB Antihistamines - Phenothiazines LORATADINE ALLERGY (Promethazine Hcl) RELIEF, SM PHENADOZ, F LORATADINE, TGT PROMETHEGAN SUPP ALLERGY RELIEF, WAL- ITIN TABS promethazine hcl soln F (Loratadine) ALLERGY or 6.25 mg/5ml promethazine hcl supp RELIEF, CVS ALLERGY F RELIEF, QC ALLERGY re 12.5 mg, 25 mg, 50 F RELIEF TBDP 10 MG mg (Loratadine) ALLERGY promethazine hcl syrp F RELIEF, CVS ALLERGY F RELIEF, QC ALLERGY or 6.25 mg/5ml RELIEF TBDP OR 10 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine hcl tabs fenofibrate tabs 54 mg F QL(3 ea daily) or 12.5 mg, 25 mg, 50 F mg gemfibrozil tabs F Antihistamines - Piperidines TRIGLIDE TABS QL(1 ea daily) F (fenofibrate) cyproheptadine hcl F syrp HMG CoA Reductase Inhibitors cyproheptadine hcl QL(1 ea daily) F atorvastatin calcium F tabs tabs ANTIHYPERLIPIDEMICS - Drugs to Treat High F QL(1 ea daily) Cholesterol fluvastatin sodium caps Antihyperlipidemics - Combinations fluvastatin sodium tb24 F QL(1 ea daily) ezetimibe-simvastatin ST; QL(1 ea QL(1.5 ea F daily) lovastatin tabs 10 mg, F tabs 20 mg daily) Bile Acid Sequestrants lovastatin tabs 40 mg F QL(2 ea daily) (Cholestyramine Light) F PREVALITE PACK pravastatin sodium tabs F QL(1 ea daily) (Cholestyramine Light) F ST; QL(1 ea PREVALITE POWD rosuvastatin calcium F cholestyramine light tabs daily) F QL(1 ea daily) pack simvastatin tabs 10 mg, F 20 mg, 40 mg, 5 mg cholestyramine light F powd simvastatin tabs 80 mg F PA cholestyramine pack F Intestinal Cholesterol Absorption Inhibitors cholestyramine powd F ezetimibe tabs F ST colestipol hcl gran 5 gm F Nicotinic Acid Derivatives (Niacin colestipol hcl tabs 1 gm F (Antihyperlipidemic)) F NIACOR TABS Fibric Acid Derivatives niacin fenofibrate micronized F (antihyperlipidemic) F caps 130 mg, 43 mg tabs QL(1 ea daily) fenofibrate micronized F niacin caps 134 mg, 200 mg (antihyperlipidemic) F QL(2 ea daily) fenofibrate micronized F tbcr caps 67 mg ANTIHYPERTENSIVES - Drugs to Treat High fenofibrate tabs 160 mg F QL(1 ea daily) Blood Pressure FENOFIBRATE TABS 160 QL(1 ea daily) ACE Inhibitors F MG (fenofibrate) benazepril hcl tabs F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits captopril tabs F guanfacine hcl tabs F enalapril maleate tabs methyldopa tabs F 10 mg, 2.5 mg, 20 mg, F 5 mg prazosin hcl caps F fosinopril sodium tabs F terazosin hcl caps F lisinopril tabs F Antihypertensive Combinations amlodipine besylate- QL(1 ea daily) moexipril hcl tabs F F benazepril hcl caps quinapril hcl tabs F amlodipine besylate- ST F QL(2 ea daily) olmesartan medoxomil ramipril caps F tabs QL(1 ea daily) amlodipine besylate- ST trandolapril tabs 1 mg, F F 2 mg valsartan tabs trandolapril tabs 4 mg F QL(2 ea daily) amlodipine-valsartan- ST hydrochlorothiazide F Agents for Pheochromocytoma tabs SP- atenolol & F metyrosine caps F AcariaHealth;S chlorthalidone tabs P benazepril & phenoxybenzamine hcl F caps hydrochlorothiazide F tabs Angiotensin II Receptor Antagonists BENAZEPRIL HCL/HYDROCHLOROTHI candesartan cilexetil F tabs AZIDE TABS (benazepril F & hydrochlorothiazide) irbesartan tabs F bisoprolol & losartan potassium hydrochlorothiazide F tabs or 100 mg, 25 mg, F tabs 50 mg candesartan cilexetil- ST olmesartan medoxomil F hydrochlorothiazide F tabs tabs telmisartan tabs F captopril & hydrochlorothiazide F valsartan tabs F QL(1 ea daily) tabs Antiadrenergic Antihypertensives DUTOPROL TB24 12.5 MG-50 MG (metoprolol & F clonidine hcl tabs F hydrochlorothiazide) doxazosin mesylate enalapril maleate & tabs or 1 mg, 2 mg, 4 F hydrochlorothiazide F mg, 8 mg tabs CA Health & Wellness Preferred Drug List Updated September 1, 2021

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXFORGE HCT TABS ST propranolol & (amlodipine-valsartan- F hydrochlorothiazide F hydrochlorothiazide) tabs fosinopril sodium & quinapril- hydrochlorothiazide F hydrochlorothiazide F tabs tabs irbesartan- telmisartan-amlodipine F hydrochlorothiazide F tabs tabs telmisartan- lisinopril & hydrochlorothiazide F hydrochlorothiazide F tabs tabs trandolapril-verapamil F losartan potassium & hcl tbcr hydrochlorothiazide F valsartan- QL(1 ea daily) tabs hydrochlorothiazide F methyldopa & tabs F hydrochlorothiazide Vasodilators tabs hydralazine hcl tabs or metoprolol & 10 mg, 100 mg, 25 mg, F hydrochlorothiazide F 50 mg tabs METOPROLOL QL(1 ea daily) minoxidil tabs F SUCCINATE ER/HYDROCHLOROTHIA ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) ZIDE TB24 12.5 MG-100 F MG, 12.5 MG-25 MG Antimalarial Combinations (metoprolol & QL(1 ea daily) atovaquone-proguanil F hydrochlorothiazide) hcl tabs METOPROLOL COARTEM TABS QL(24 ea per SUCCINATE fill retail) ER/HYDROCHLOROTHIA (artemether- F ZIDE TB24 12.5 MG-50 F lumefantrine) MG (metoprolol & Antimalarials hydrochlorothiazide) QL(2 ea daily) chloroquine phosphate F olmesartan medoxomil- ST tabs 250 mg amlodipine- QL(8 ea per 56 F chloroquine phosphate F hydrochlorothiazide tabs 500 mg days retail) tabs hydroxychloroquine F olmesartan medoxomil- ST sulfate tabs hydrochlorothiazide F KRINTAFEL TABS QL(2 ea per 30 F tabs (tafenoquine succinate) days retail) mefloquine hcl tabs F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits YONDELIS SOLR PA; SP- ANTIMYASTHENIC/CHOLINERGIC AGENTS F AcariaHealth;S (trabectedin) Antimyasthenic/Cholinergic Agents P Antimetabolites pyridostigmine bromide F tabs 60 mg SP- capecitabine tabs 150 F mg AcariaHealth pyridostigmine bromide F tbcr 180 mg capecitabine tabs 500 SP- F AcariaHealth;S ANTIMYCOBACTERIAL AGENTS - Drugs to mg P Treat Tuberculosis (Bacterial Infections) F PA; SP Antimycobacterial Agents decitabine solr ethambutol hcl tabs F mercaptopurine tabs or F methotrexate sodium isoniazid syrp or 50 F F mg/5ml soln methotrexate sodium isoniazid tabs or 100 F F mg, 300 mg tabs PRIFTIN TABS PURIXAN SUSP F F (rifapentine) (mercaptopurine) F TABLOID TABS SP- pyrazinamide tabs F AcariaHealth;S (thioguanine) P rifabutin caps F TREXALL TABS F rifampin caps F (methotrexate sodium) XATMEP SOLN PA; SP TRECATOR TABS F F (methotrexate) (ethionamide) Antineoplastic - Angiogenesis Inhibitors ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer AVASTIN SOLN PA; SP- F AcariaHealth;S Alkylating Agents (bevacizumab) P GLEOSTINE CAPS F CYRAMZA SOLN PA; SP- (lomustine) F AcariaHealth;S (ramucirumab) LEUKERAN TABS P F (chlorambucil) PA; SP- INLYTA TABS (axitinib) F AcariaHealth;S melphalan tabs F P MYLERAN TABS LENVIMA 10 MG DAILY PA; SP F (busulfan) DOSE CPPK (lenvatinib F temozolomide caps SP- mesylate) 100 mg, 20 mg, 250 F AcariaHealth;S LENVIMA 14 MG DAILY PA; SP mg, 5 mg P DOSE CPPK (lenvatinib F mesylate) SP- temozolomide caps F 140 mg, 180 mg AcariaHealth

CA Health & Wellness Preferred Drug List Updated September 1, 2021

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LENVIMA 18 MG DAILY PA; SP- VENCLEXTA STARTING PA DOSE CPPK (lenvatinib F Biologics;SP PACK TBPK F mesylate) (venetoclax) VENCLEXTA TABS PA LENVIMA 20 MG DAILY PA; SP F DOSE CPPK (lenvatinib F (venetoclax) mesylate) Antineoplastic - Cellular Immunotherapy LENVIMA 24 MG DAILY PA; SP KYMRIAH SUSP PA; SP F DOSE CPPK (lenvatinib F (tisagenlecleucel) mesylate) PROVENGE SUSP PA F LENVIMA 8 MG DAILY PA; SP- (sipuleucel-t) DOSE CPPK (lenvatinib F Biologics;SP Antineoplastic - EGFR Inhibitors mesylate) erlotinib hcl tabs 100 PA; SP- ZALTRAP SOLN (ziv- PA; SP- F AcariaHealth;S F AcariaHealth;S mg, 25 mg P aflibercept) P PA; SP erlotinib hcl tabs 150 F Antineoplastic - Anti-HER2 Agents mg PA; SP- HERCEPTIN SOLR GILOTRIF TABS ( PA; SP F AcariaHealth;S afatinib F (trastuzumab) P dimaleate) PA; SP PERJETA SOLN PA; SP- IRESSA TABS (gefitinib) F F AcariaHealth;S (pertuzumab) TAGRISSO TABS PA; SP P F ( ) Antineoplastic - Antibodies osimertinib mesylate Antineoplastic - Hedgehog Pathway Inhibitors DARZALEX SOLN 100 PA; SP- F AcariaHealth;S ERIVEDGE CAPS PA; SP MG/5ML (daratumumab) F P (vismodegib) DARZALEX SOLN 400 PA; SP- ODOMZO CAPS SP F MG/20ML F AcariaHealth (sonidegib phosphate) (daratumumab) Antineoplastic - Hormonal and Related Agents EMPLICITI SOLR PA; SP- F AcariaHealth;S abiraterone acetate PA; SP- (elotuzumab) P F AcariaHealth;S tabs P KADCYLA SOLR (ado- PA; SP- trastuzumab F AcariaHealth;S anastrozole tabs F emtansine) P bicalutamide tabs F OPDIVO SOLN PA; SP- F AcariaHealth;S (nivolumab) ELIGARD KIT (leuprolide PA; SP- P F AcariaHealth;S acetate (3 month)) P RITUXAN SOLN PA; SP- F AcariaHealth;S (rituximab) ELIGARD KIT (leuprolide PA; SP- P F AcariaHealth;S acetate (4 month)) Antineoplastic - BCL-2 Inhibitors P ELIGARD KIT (leuprolide PA; SP- F AcariaHealth;S acetate (6 month)) P CA Health & Wellness Preferred Drug List Updated September 1, 2021

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELIGARD KIT (leuprolide PA; SP- megestrol acetate susp F F AcariaHealth;S acetate) P megestrol acetate tabs F EMCYT CAPS SP- (estramustine F AcariaHealth;S tamoxifen citrate tabs F phosphate sodium) P PA ERLEADA TABS PA; SP-Acaria toremifene citrate tabs F F (apalutamide) Health;SP TRELSTAR MIXJECT PA; SP- exemestane tabs F SUSR (triptorelin F AcariaHealth;S pamoate) P FIRMAGON SOLR 120 PA; SP VANTAS KIT (histrelin PA; SP- MG/VIAL (degarelix F F AcariaHealth;S acetate) acetate) P PA; SP- XTANDI CAPS 40 MG PA; SP FIRMAGON SOLR 80 MG F F AcariaHealth;S (enzalutamide) (degarelix acetate) P YONSA TABS PA F flutamide caps F (abiraterone acetate) hydroxyprogesterone PA; SP ZOLADEX IMPL PA; SP- F AcariaHealth;S caproate F (goserelin acetate) P (antineoplastic) soln Antineoplastic - Immunomodulators letrozole tabs F POMALYST CAPS PA; SP F PA; SP- (pomalidomide) leuprolide acetate kit F AcariaHealth;S Antineoplastic - PDGFR-alpha Inhibitors P LARTRUVO SOLN PA; SP- PA; SP- F LUPRON DEPOT (1- (olaratumab) Accredo;SP MONTH) KIT 3.75 MG F AcariaHealth;S (leuprolide acetate) P Antineoplastic Antibiotics LUPRON DEPOT (1- PA; SP- (Doxorubicin Hcl) F PA ADRIAMYCIN SOLN MONTH) KIT 7.5 MG F AcariaHealth (leuprolide acetate) (Doxorubicin Hcl) PA ADRIAMYCIN, F LUPRON DEPOT (3- PA; SP- ADRIAMYCIN SOLR F AcariaHealth;S MONTH) KIT (leuprolide PA acetate (3 month)) P bleomycin sulfate solr F LUPRON DEPOT (4- PA; SP- PA doxorubicin hcl soln 2 F MONTH) KIT (leuprolide F AcariaHealth;S mg/ml, 200 mg/100ml acetate (4 month)) P PA; SP- LUPRON DEPOT (6- PA; SP- mitoxantrone hcl conc F AcariaHealth;S MONTH) KIT (leuprolide F AcariaHealth;S P acetate (6 month)) P Antineoplastic Combinations LYSODREN TABS SP- F AcariaHealth;S KISQALI FEMARA 200 PA; SP (mitotane) P DOSE TBPK (ribociclib F succinate-letrozole)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KISQALI FEMARA 400 PA; SP COTELLIC TABS PA; SP F DOSE TBPK (ribociclib F (cobimetinib fumarate) succinate-letrozole) PA; SP- KISQALI FEMARA 600 PA; SP everolimus tabs F AcariaHealth;S DOSE TBPK (ribociclib F P FARYDAK CAPS PA; SP succinate-letrozole) F LONSURF TABS PA; SP (panobinostat lactate) F (trifluridine-tipiracil) IBRANCE CAPS PA; SP-Acaria F Health;SP RITUXAN HYCELA SOLN PA; SP- (palbociclib) AcariaHealth;S IBRANCE TABS PA; SP-Acaria (rituximab- F F hyaluronidase human) P (palbociclib) Health;SP Antineoplastic Enzyme Inhibitors ICLUSIG TABS 10 MG, 15 PA; QL(1 ea MG, 30 MG, 45 MG F daily); SP AFINITOR DISPERZ TBSO PA; SP F (ponatinib hcl) (everolimus) IDHIFA TABS PA; SP- F AFINITOR TABS 10 MG PA; SP- (enasidenib mesylate) Accredo;SP F AcariaHealth;S (everolimus) P imatinib mesylate tabs F PA; SP ALECENSA CAPS PA; SP F IMBRUVICA CAPS 140 PA; SP (alectinib hcl) F MG (ibrutinib) ALUNBRIG TABS 180 MG, PA; SP- F IMBRUVICA CAPS 70 MG PA; SP- 90 MG (brigatinib) Caremark;SP F (ibrutinib) Biologics;SP ALUNBRIG TABS 30 MG PA; SP F IMBRUVICA TABS 140 PA; QL(1 ea (brigatinib) MG, 280 MG, 420 MG, 560 F daily) ALUNBRIG TBPK PA; SP- MG (ibrutinib) F Caremark;SP (brigatinib) JAKAFI TABS 10 MG, 15 SP BOSULIF TABS 100 MG, PA; SP- MG, 20 MG, 5 MG F F AcariaHealth;S (ruxolitinib phosphate) 500 MG (bosutinib) P JAKAFI TABS 25 MG BRAFTOVI CAPS PA F F (ruxolitinib phosphate) (encorafenib) KISQALI TBPK (ribociclib PA; SP CABOMETYX TABS PA; SP F F succinate) (cabozantinib s-malate) SP CALQUENCE CAPS PA lapatinib ditosylate tabs F F (acalabrutinib) LYNPARZA TABS PA; SP- CAPRELSA TABS 100 MG PA; SP- F Biologics;SP F (olaparib) (vandetanib) Biologics;SP MEKINIST TABS PA; SP CAPRELSA TABS 300 MG PA; SP F (trametinib dimethyl F (vandetanib) sulfoxide) COMETRIQ KIT PA; SP MEKTOVI TABS PA F F (cabozantinib s-malate) (binimetinib) COPIKTRA CAPS PA NERLYNX TABS PA; SP F F (duvelisib) (neratinib maleate)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEXAVAR TABS PA; SP MATULANE CAPS F F (sorafenib tosylate) (procarbazine hcl) NINLARO CAPS PA; SP SYLATRON KIT PA; SP- F (ixazomib citrate) (peginterferon alfa-2b F AcariaHealth RUBRACA TABS PA; SP (antineoplastic)) F (rucaparib camsylate) SP- tretinoin F RYDAPT CAPS PA; SP (chemotherapy) caps AcariaHealth F (midostaurin) Chemotherapy Rescue/Antidote/Protective Agents SPRYCEL TABS PA; SP F leucovorin calcium tabs (dasatinib) or 10 mg, 15 mg, 25 F STIVARGA TABS PA; SP- mg, 5 mg F AcariaHealth;S (regorafenib) P Mitotic Inhibitors PA; SP DOCETAXEL CONC 160 PA; SP- sunitinib malate caps F MG/8ML, 20 MG/ML, 200 AcariaHealth;S F TAFINLAR CAPS PA; SP MG/10ML, 80 MG/4ML P F (dabrafenib mesylate) (docetaxel) docetaxel conc 160 PA; SP- TASIGNA CAPS 150 MG, PA; SP- F AcariaHealth;S mg/8ml, 20 mg/ml, 80 F AcariaHealth;S 200 MG (nilotinib hcl) P mg/4ml P TIBSOVO TABS PA; SP F DOCETAXEL CONC 20 PA; SP- (ivosidenib) MG/ML, 80 MG/4ML F AcariaHealth;S VOTRIENT TABS PA; SP (docetaxel) P F (pazopanib hcl) docetaxel soln 160 PA; SP- AcariaHealth;S XALKORI CAPS PA; SP- mg/16ml, 20 mg/2ml, F F AcariaHealth;S 80 mg/8ml P (crizotinib) P DOCETAXEL SOLN 160 PA; SP- ZEJULA CAPS ( PA; SP niraparib F MG/16ML, 20 MG/2ML, 80 F AcariaHealth;S tosylate) MG/8ML (docetaxel) P ZELBORAF TABS PA; SP F etoposide caps or 50 SP- (vemurafenib) F AcariaHealth;S mg P ZOLINZA CAPS PA; SP- F AcariaHealth;S HALAVEN SOLN (eribulin PA; SP- (vorinostat) P F AcariaHealth;S mesylate) ZYDELIG TABS PA; SP P F (idelalisib) IXEMPRA KIT SOLR PA; SP- F AcariaHealth;S Antineoplastics Misc. (ixabepilone) P ACTIMMUNE SOLN PA; SP- F F PA (interferon gamma-1b) Caremark vincristine sulfate soln bexarotene caps F PA; SP Topoisomerase I Inhibitors HYCAMTIN CAPS OR 0.25 PA; SP- hydroxyurea caps F MG, 1 MG (topotecan F AcariaHealth hcl)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP- carbidopa-levodopa irinotecan hcl soln F AcariaHealth;S tabs 10 mg-100 mg, 25 F P mg-100 mg, 25 mg-250 topotecan hcl soln 4 PA; SP- mg F AcariaHealth mg/4ml carbidopa-levodopa TOPOTECAN HCL SOLN PA; SP- tbcr 100 mg-25 mg, 25 F 4 MG/4ML (topotecan F AcariaHealth mg-100 mg, 50 mg-200 hcl) mg F PA; SP- GOCOVRI CP24 topotecan hcl solr 4 mg AcariaHealth CO (amantadine hcl) ANTIPARKINSON AND RELATED THERAPY OSMOLEX ER T4PK CO AGENTS - Drugs to Treat Parkinson's Disease (amantadine hcl) Antiparkinson Adjunctive Therapy OSMOLEX ER TB24 CO carbidopa tabs F (amantadine hcl) pramipexole Antiparkinson Anticholinergics dihydrochloride tabs benztropine mesylate CO 0.125 mg, 0.25 mg, 0.5 F soln mg, 0.75 mg, 1 mg, 1.5 mg benztropine mesylate CO tabs ropinirole hydrochloride F COGENTIN SOLN CO tabs (benztropine mesylate) ropinirole hydrochloride F trihexyphenidyl hcl soln CO tb24 Antiparkinson Monoamine Oxidase Inhibitors trihexyphenidyl hcl tabs CO selegiline hcl caps F Antiparkinson COMT Inhibitors selegiline hcl tabs F entacapone tabs F ANTIPSYCHOTICS/ANTIMANIC AGENTS - Antiparkinson Dopaminergics Drugs to Treat Mood Disorders amantadine hcl caps CO Antimanic Agents amantadine hcl syrp CO lithium carbonate caps CO amantadine hcl tabs CO lithium carbonate tabs CO bromocriptine mesylate F lithium carbonate tbcr CO caps LITHIUM SOLN (lithium) CO bromocriptine mesylate F tabs LITHOBID TBCR ( lithium CO carbonate) Antipsychotics - Misc.

CA Health & Wellness Preferred Drug List Updated September 1, 2021

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAPLYTA CAPS RISPERDAL TABS CO CO (lumateperone tosylate) (risperidone) GEODON CAPS CO risperidone soln CO (ziprasidone hcl) GEODON SOLR risperidone tabs CO CO (ziprasidone mesylate) LATUDA TABS risperidone tbdp CO CO (lurasidone hcl) Butyrophenones NUPLAZID CAPS CO HALDOL DECANOATE (pimavanserin tartrate) 100 SOLN (haloperidol CO NUPLAZID TABS CO decanoate) (pimavanserin tartrate) HALDOL DECANOATE 50 VRAYLAR CAPS CO SOLN (haloperidol CO (cariprazine hcl) decanoate) VRAYLAR CPPK HALDOL SOLN CO CO (cariprazine hcl) (haloperidol lactate) ziprasidone hcl caps CO haloperidol decanoate CO soln ziprasidone mesylate CO solr haloperidol lactate conc CO Benzisoxazoles haloperidol lactate soln CO FANAPT TABS CO (iloperidone) haloperidol tabs or 0.5 FANAPT TITRATION mg, 1 mg, 10 mg, 2 mg, CO PACK TABS CO 20 mg, 5 mg (iloperidone) Dibenzapines INVEGA SUSTENNA ADASUVE AEPB CO SUSY (paliperidone CO (loxapine) palmitate) asenapine maleate INVEGA TB24 CO CO subl (paliperidone) CO INVEGA TRINZA SUSY clozapine tabs CO (paliperidone palmitate) clozapine tbdp CO paliperidone tb24 CO CLOZARIL TABS CO PERSERIS PRSY (clozapine) CO (risperidone) FAZACLO TBDP CO RISPERDAL CONSTA (clozapine) SRER (risperidone CO loxapine succinate CO microspheres) caps RISPERDAL SOLN CO olanzapine solr CO (risperidone)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olanzapine tabs CO fluphenazine CO decanoate soln CO olanzapine tbdp fluphenazine hcl conc CO quetiapine fumarate CO tabs fluphenazine hcl elix CO quetiapine fumarate CO fluphenazine hcl soln CO tb24 SAPHRIS SUBL 10 MG, fluphenazine hcl tabs CO 2.5 MG, 5 MG (asenapine CO maleate) perphenazine tabs CO SAPHRIS SUBL 5 MG CO prochlorperazine F (asenapine maleate) maleate tabs SECUADO PT24 CO prochlorperazine supp F (asenapine) SEROQUEL TABS CO thioridazine hcl tabs CO (quetiapine fumarate) SEROQUEL XR TB24 trifluoperazine hcl tabs CO CO ( ) quetiapine fumarate Quinolinone Derivatives VERSACLOZ SUSP ABILIFY MAINTENA PRSY CO CO (clozapine) (aripiprazole) ZYPREXA RELPREVV ABILIFY MAINTENA SRER CO SUSR (olanzapine CO (aripiprazole) pamoate) ABILIFY MYCITE TABS ZYPREXA SOLR CO CO (aripiprazole) (olanzapine) ABILIFY TABS ZYPREXA TABS CO CO (aripiprazole) (olanzapine) ZYPREXA ZYDIS TBDP aripiprazole soln CO CO (olanzapine) aripiprazole tabs CO Dihydroindolones CO molindone hcl tabs CO aripiprazole tbdp ARISTADA INITIO PRSY CO Phenothiazines (aripiprazole lauroxil) (Prochlorperazine) F ARISTADA PRSY COMPRO SUPP CO (aripiprazole lauroxil) chlorpromazine hcl soln CO REXULTI TABS ij 25 mg/ml, 50 mg/2ml CO (brexpiprazole) chlorpromazine hcl tabs or 10 mg, 100 mg, CO Thioxanthenes 200 mg, 25 mg, 50 mg thiothixene caps CO

CA Health & Wellness Preferred Drug List Updated September 1, 2021

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUTARALDEHYDE ANTISEPTICS & DISINFECTANTS F SOLN EX 25 % (glutaral) Antiseptic Combinations GNP HYDROGEN EXCEL AP SWAB PEROXIDE WIPES MISC F (povidone-iodine & F (hydrogen peroxide) isopropyl alcohol) hydrogen peroxide soln F IV PREP WIPES PADS ex 3 % (antiseptic products, F HYDROGEN PEROXIDE misc.) SOLN EX 3 % (hydrogen F MICROCLENS WIPES peroxide) PADS (antiseptic F hydrogen peroxide soln F products, misc.) xx 30 % UNI-SOLVE PADS HYLAMEND FIRST AID (antiseptic products, F ANTISEPTIC GEL F misc.) (hydrogen peroxide) KERR TRIPLE DYE SWAB Antiseptics & Disinfectants F (Hydrogen Peroxide) CVS (triple dye) HYDROGEN PEROXIDE, PHENOL EZ SWABS F EQ HYDROGEN SWAB (phenol) PEROXIDE, EQL PHENOL LIQD EX HYDROGEN PEROXIDE, F GNP HYDROGEN (phenol) PEROXIDE, GOODSENSE Chlorine Antiseptics HYDROGEN PEROXIDE, HM HYDROGEN (Benzalkonium Chloride) PEROXIDE, MEIJER F ANTISEPTIC SPRAY, CVS HYDROGEN PEROXIDE, MERTHIOLATE, EQL PX HYDROGEN ANTIBACTERIAL HAND F PEROXIDE, QC SOAP, EQL HAND SOAP, HYDROGEN PEROXIDE, HANDCLENS 2 IN 1 RA HYDROGEN FOAMINGSANITIZER/LOT PEROXIDE, SM ION, MERTHIOLATE LIQD HYDROGEN PEROXIDE, (Benzalkonium Chloride) TGT HYDROGEN BZK ANTISEPTIC PEROXIDE SOLN TOWELETTES, EQ F CETYLCIDE-G CONC ANTIBACTERIAL HANDS F &FACE WIPES MISC (glutaral) (Benzethonium Chloride) F DERMA CIDOL 2000 LIQD MICROKLENZ LIQD (chloroxylenol F (antiseptic)) QL(90 ml per formaldehyde soln 10 F % fill retail) FORMALDEHYDE SOLN RX/OTC F 37 % (formaldehyde)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Chlorhexidine Gluconate) BENZALKONIUM ANTISEPTIC SKIN CHLORIDE CONC 50 % F CLEANSER, CVS (benzalkonium chloride) ANTISEPTIC SKIN CLEANSER, CVS HAND benzalkonium chloride F WASH ADVANCED misc 0.13 % ANTIBACTERIAL, DYNA- BENZALKONIUM HEX 2, DYNA-HEX 4, GNP F CHLORIDE SOLN F ANTISEPTIC SKIN (benzalkonium chloride) CLEANSER, HM ANTISEPTIC SKIN BENZALKONIUM RX/OTC CLEANSER, RA CHLORIDE SOLN 50 % F ANTISEPTIC SKIN (benzalkonium chloride) CLEANSER, SM BIOPATCH ANTISEPTIC SKIN ANTIMICROBIAL CLEANSER SOLN DRESSING/1" DISK/4MM F (Chlorhexidine Gluconate) HOLE MISC BETASEPT SURGICAL F (chlorhexidine SCRUB LIQD gluconate) (Chlorhexidine Gluconate) BIOPATCH CHLORHEXIDINE F ANTIMICROBIAL GLUCONATE SOLN EX 2 DRESSING/1" DISK/7MM % HOLE MISC F (Sodium Hypochlorite) H- (chlorhexidine CHLOR 12, HYSEPT F gluconate) SOLN BIOPATCH (Triclosan) ANTIMICROBIAL ANTIBACTERIAL LIQUID DRESSING/3/4" SOAP, RA RENEWAL DISK/1.5MM HOLE MISC F ANTIBACTERIALHAND F (chlorhexidine SOAP REFILL, SM ANTIBACTERIAL LIQUID gluconate) SOAP LIQD BIOPATCH PROTECTIVE AMERIWASH LOTN DISKWITH F CHG/1"DISK/4MM HOLE (triclosan) F MISC (chlorhexidine ANASEPT gluconate) ANTIMICROBIAL SKIN & F CA-REZZ CREA 0.3 % WOUND GEL GEL F (sodium hypochlorite) (triclosan) ANASEPT LIQD ( CA-REZZ GENTLE LIQD sodium F F hypochlorite) (triclosan) ANTISEPTIC WOUND & CA-REZZ MOISTURE SKIN CLEANSER LIQD BARRIER CREA F (benzethonium F (triclosan) chloride) CA-REZZ NORISC CREAM CREA (benzethonium F chloride)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CA-REZZ NORISC LIQD EQL ANTIBACTERIAL F ( ) FOAMINGHAND WASH triclosan F CAVILON SKIN LIQD (benzalkonium CLEANSER LIQD chloride) (benzalkonium F GERMBLOC HEALTH chloride) FOAM (benzalkonium F CHLORHEXIDINE chloride) GLUCONATE CLOTH GERMBLOC HEALTH F PADS (chlorhexidine HAND SANITIZER LOTN F gluconate) (benzalkonium chloride) CHLORHEXIDINE GOLD BOND FIRST AID GLUCONATE LIQD EX 2 QUICK SPRAY LIQD % (chlorhexidine F (benzethonium F gluconate) chloride-menthol) GOLD BOND ULTIMATE chlorhexidine gluconate F liqd ex 4 % HAND SANITIZER SHEER MOISTURE LIQD CHLORHEXIDINE F GLUCONATE SOLN XX 20 (benzethonium % (chlorhexidine F chloride) gluconate) GOLD BOND ULTIMATE HAND CLORPACTIN WCS-90 SANITIZER/MOISTURIZE F POWD (oxychlorosene F R LIQD (benzethonium sodium) chloride) CURECHROME SOLN H-CHLOR 6 SOLN F (benzalkonium F (sodium hypochlorite) chloride) H-CHLOR WOUND GEL F CURX ANTIMICROBIAL (sodium hypochlorite) GEL (benzalkonium F MERTHIOLATE chloride) TINCTURE TINC DI-DAK-SOL SOLN F F (benzalkonium (sodium hypochlorite) chloride-alcohol) DIABET-X DAILY OXYZAL WET DRESSING PREVENTIONSKIN F SOLN (benzalkonium THERAPY CREA chloride w/ F (triclosan) oxyquinoline sulfate) DIABETIC BASICS HEALTHY FOOT LOTN REMEDY F ANTIMICROBIAL (benzalkonium CLEANSER LIQD F chloride) (benzalkonium chloride) EQL ANTIBACTERIAL TEGADERM CHG DEODORANT SOAP BAR F DRESSING/2-3/4"X3-3/8" (triclosan) MISC (chlorhexidine F gluconate)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGADERM CHG (Povidone-Iodine) DRESSING/3-1/2"X4-1/2" APLICARE POVIDONE- MISC (chlorhexidine F IODINESCRUB, gluconate) APLICARE POVIDONE/IODINE, CVS TEGADERM CHG POVIDONE-IODINE, EQ DRESSING/4"X4-3/4" F FIRST AID ANTISEPTIC, MISC (chlorhexidine EQ POVIDONE-IODINE, ) gluconate GNP POVIDONE-IODINE, F TEGADERM CHG HM POVIDONE-IODINE, DRESSING/4"X6-1/8" PVP PREP, PVP SCRUB, MISC (chlorhexidine F QC POVIDONE IODINE, RA ANTISEPTIC, SB gluconate) POVIDONE-IODINE, triclosan liqd F SCRUB CARE POVIDONE- WALTZ FREE HAND IODINE/PAINT, SM SANITIZER LOTN POVIDONE-IODINE SOLN F (benzalkonium (Povidone-Iodine) chloride) CLOROX NASAL F WALTZ FREE HAND ANTISEPTIC SWABS SANITZER FOAM SWAB (benzalkonium F APLICARE chloride) POVIDONE/IODINE GEL F (povidone-iodine) Disinfectants BETADINE SOLN 5 % F CETYLCIDE II CONC (povidone-iodine) (disinfectant products, F BETADINE SURGICAL misc.) SCRUB SOLN F CREOLIN LIQD (povidone-iodine) (disinfectant products, F CVS IODINE TINCTURE RX/OTC F misc.) TINC (iodine (topical)) Iodine Antiseptics DECOLORIZED IODINE RX/OTC F TINC (iodine (topical)) FIRST AID ANTISEPTIC OINTMENT OINT F (povidone-iodine) GNP IODIDES TINCTURE RX/OTC F TINC (iodine (topical)) GNP IODINE TINCTURE RX/OTC F TINC (iodine (topical)) GOODSENSE IODINE RX/OTC F TINC (iodine (topical)) HM IODIDES TINCTURE RX/OTC F TINC (iodine (topical))

CA Health & Wellness Preferred Drug List Updated September 1, 2021

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HM IODINE TINCTURE RX/OTC KENDALL WET SKIN F TINC (iodine (topical)) SCRUB PACK KIT F IODEX OINT ( (povidone-iodine) iodine F (topical)) LUGOLS STRONG IODEX/METHYL IODINE SOLN (iodine F SALICYLATE OINT (topical)) ( F iodine-methyl povidone-iodine oint 10 F salicylate) % IODINE TINCTURE MILD RX/OTC POVIDONE-IODINE PREP F TINC (iodine (topical)) PAD PADS (povidone- F IODINE TINCTURE iodine) STRONG DECOLORIZED F POVIDONE-IODINE PREP TINC (iodine (topical)) PADS PADS (povidone- F IODINE TINCTURE iodine) STRONG TINC (iodine F POVIDONE-IODINE (topical)) SCRUB LARGE WINGED F IODINE TINCTURE TINC RX/OTC SPONGE MISC F (iodine (topical)) (povidone-iodine) IODOFLEX PADS POVIDONE-IODINE F ( ) SCRUB SMALL WINGED cadexomer iodine SPONGE MISC F IODOSORB GEL F (povidone-iodine) ( ) cadexomer iodine POVIDONE-IODINE KENDALL GEL SKIN SCRUB SPONGE STICKS F SCRUB PACK/LARGE MISC (povidone-iodine) WINGED SPONGES KIT F (povidone-iodine) povidone-iodine soln F KENDALL GEL SKIN 10 % SCRUB PACK/SMALL povidone-iodine swab F WINGED SPONGES KIT F 10 % (povidone-iodine) POVIDONE-IODINE SWAB F KENDALL MINOR WET 7.5 % (povidone-iodine) SKIN SCRUB PACK KIT F QC IODIDES TINCTURE RX/OTC F (povidone-iodine) TINC (iodine (topical)) KENDALL SPONGE QC IODINE TINCTURE RX/OTC STICK/PVP MISC F F TINC (iodine (topical)) (povidone-iodine) RA FIRST AID IODINE RX/OTC KENDALL VAGINAL PREP F TINC (iodine (topical)) PACK KIT (povidone- F SM IODIDES TINCTURE RX/OTC iodine) F TINC (iodine (topical)) KENDALL VAGINAL PREP SM IODINE TINCTURE RX/OTC TRAY KIT (povidone- F F iodine) TINC (iodine (topical)) ANTIVIRALS - Drugs to Treat Viral Infections

CA Health & Wellness Preferred Drug List Updated September 1, 2021

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antiretrovirals didanosine cpdr F abacavir sulfate soln CO DOVATO TABS (dolutegravir sodium- CO abacavir sulfate tabs CO lamivudine) EDURANT TABS abacavir sulfate- CO CO lamivudine tabs (rilpivirine hcl) abacavir sulfate- efavirenz caps CO lamivudine-zidovudine CO tabs efavirenz tabs CO APTIVUS CAPS CO efavirenz-emtricitabine- (tipranavir) tenofovir disoproxil CO APTIVUS SOLN CO fumarate tabs (tipranavir) efavirenz-lamivudine- atazanavir sulfate caps CO tenofovir disoproxil CO ATRIPLA TABS fumarate tabs (efavirenz- emtricitabine caps CO emtricitabine-tenofovir CO disoproxil fumarate) emtricitabine-tenofovir disoproxil fumarate CO BIKTARVY TABS tabs (bictegravir- CO EMTRIVA CAPS 200 MG emtricitabine-tenofovir CO alafenamide fumarate) (emtricitabine) EMTRIVA SOLN 10 CIMDUO TABS CO (lamivudine-tenofovir CO MG/ML (emtricitabine) EPIVIR SOLN disoproxil fumarate) CO COMBIVIR TABS (lamivudine) CO EPIVIR TABS (lamivudine-zidovudine) CO COMPLERA TABS (lamivudine) (emtricitabine- EPZICOM TABS rilpivirine-tenofovir CO (abacavir sulfate- CO disoproxil fumarate) lamivudine) CRIXIVAN CAPS CO CO etravirine tabs (indinavir sulfate) EVOTAZ TABS DELSTRIGO TABS (atazanavir sulfate- CO (doravirine-lamivudine- cobicistat) tenofovir disoproxil CO fumarate) fosamprenavir calcium CO tabs DESCOVY TABS FUZEON SOLR (emtricitabine-tenofovir CO CO alafenamide fumarate) (enfuvirtide)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENVOYA TABS nevirapine tabs CO (elvitegravir-cobicistat- CO emtricitabine-tenofovir nevirapine tb24 CO alafenamide) NORVIR PACK 100 MG INTELENCE TABS 100 CO CO (ritonavir) MG, 200 MG (etravirine) NORVIR SOLN 80 MG/ML INTELENCE TABS 25 MG CO CO (ritonavir) (etravirine) NORVIR TABS 100 MG INVIRASE TABS CO CO (ritonavir) (saquinavir mesylate) ODEFSEY TABS ISENTRESS CHEW CO (emtricitabine- (raltegravir potassium) rilpivirine-tenofovir CO ISENTRESS HD TABS CO alafenamide fumarate) ( ) raltegravir potassium PIFELTRO TABS ISENTRESS PACK CO CO (doravirine) ( ) raltegravir potassium PREZCOBIX TABS ISENTRESS TABS CO CO (darunavir-cobicistat) ( ) raltegravir potassium PREZISTA SUSP CO JULUCA TABS (darunavir ethanolate) ( CO dolutegravir sodium- PREZISTA TABS rilpivirine hcl) CO (darunavir ethanolate) KALETRA SOLN CO RESCRIPTOR TABS (lopinavir-ritonavir) CO (delavirdine mesylate) KALETRA TABS CO REYATAZ CAPS 150 MG, (lopinavir-ritonavir) 200 MG, 300 MG CO lamivudine soln CO (atazanavir sulfate) REYATAZ PACK 50 MG CO lamivudine tabs CO (atazanavir sulfate) lamivudine-zidovudine CO ritonavir tabs CO tabs SELZENTRY SOLN CO LEXIVA SUSP 50 MG/ML (maraviroc) (fosamprenavir CO SELZENTRY TABS calcium) CO (maraviroc) LEXIVA TABS 700 MG (fosamprenavir CO stavudine caps 15 mg, CO calcium) 20 mg, 30 mg, 40 mg STAVUDINE CAPS 15 MG, lopinavir-ritonavir soln CO 20 MG, 30 MG, 40 MG CO (stavudine) lopinavir-ritonavir tabs CO nevirapine susp CO

CA Health & Wellness Preferred Drug List Updated September 1, 2021

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STRIBILD TABS VIDEX EC CPDR 125 MG F (elvitegravir-cobicistat- (didanosine) CO emtricitabine-tenofovir VIDEXPEDIATRIC SOLR F df) (didanosine) SUSTIVA CAPS VIRACEPT TABS CO CO (efavirenz) (nelfinavir mesylate) SUSTIVA TABS VIRAMUNE SUSP CO CO (efavirenz) (nevirapine) SYMFI LO TABS VIRAMUNE TABS (efavirenz-lamivudine- CO CO (nevirapine) tenofovir disoproxil VIRAMUNE XR TB24 CO fumarate) (nevirapine) SYMFI TABS (efavirenz- VIREAD POWD 40 MG/GM lamivudine-tenofovir CO (tenofovir disoproxil CO disoproxil fumarate) fumarate) SYMTUZA TABS VIREAD TABS 150 MG, (darunavir-cobicistat- 200 MG, 250 MG CO emtricitabine-tenofovir (tenofovir disoproxil CO alafenamide) fumarate) TEMIXYS TABS VIREAD TABS 300 MG (lamivudine-tenofovir CO (tenofovir disoproxil CO disoproxil fumarate) fumarate) ZIAGEN SOLN (abacavir tenofovir disoproxil CO CO fumarate tabs sulfate) TIVICAY PD TBSO ZIAGEN TABS ( CO abacavir CO (dolutegravir sodium) sulfate) TIVICAY TABS CO zidovudine caps F SP (dolutegravir sodium) TRIUMEQ TABS zidovudine syrp F SP (abacavir-dolutegravir- CO SP lamivudine) zidovudine tabs F TRIZIVIR TABS (abacavir CMV Agents CO sulfate-lamivudine- PA zidovudine) cidofovir soln F TROGARZO SOLN QL(21 ml CO (ibalizumab-uiyk) valganciclovir hcl solr F daily); AL(At TRUVADA TABS 50 mg/ml least 21 yrs old) (emtricitabine-tenofovir CO disoproxil fumarate) valganciclovir hcl tabs F TYBOST TABS 450 mg CO (cobicistat) Hepatitis Agents

CA Health & Wellness Preferred Drug List Updated September 1, 2021

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ribavirin (Hepatitis C)) PA; SP- VEMLIDY TABS RIBASPHERE CAPS 200 F AcariaHealth;S (tenofovir alafenamide CO MG P fumarate) (Ribavirin (Hepatitis C)) PA; SP- RIBASPHERE TABS 200 F AcariaHealth;S Herpes Agents MG, 600 MG P acyclovir caps F adefovir dipivoxil tabs F SP acyclovir susp F BARACLUDE SOLN 0.05 F MG/ML (entecavir) acyclovir tabs F SP entecavir tabs 0.5 mg F famciclovir tabs F entecavir tabs 1 mg F valacyclovir hcl tabs F EPIVIR HBV SOLN 5 Influenza Agents MG/ML (lamivudine CO QL(20 ea per (hbv)) oseltamivir phosphate F caps or 30 mg 30 days retail) EPIVIR HBV TABS 100 CO QL(10 ea per MG (lamivudine (hbv)) oseltamivir phosphate F caps or 45 mg, 75 mg 30 days retail) lamivudine (hbv) tabs CO QL(120 ml per oseltamivir phosphate F PEGASYS PROCLICK PA; SP- susr or 6 mg/ml 30 days retail) SOLN (peginterferon F AcariaHealth;S RELENZA DISKHALER AL(At least 5 P F alfa-2a) AEPB (zanamivir) yrs old) PEGASYS SOLN PA; SP- rimantadine F AcariaHealth;S F (peginterferon alfa-2a) P hydrochloride tabs TAMIFLU CAPS 30 MG QL(20 ea per PEGINTRON KIT PA; SP- F F AcariaHealth;S (oseltamivir phosphate) 30 days retail) (peginterferon alfa-2b) P TAMIFLU CAPS 45 MG, 75 QL(10 ea per RIBASPHERE RIBAPAK PA; SP- MG (oseltamivir F 30 days retail) TBPK (ribavirin F AcariaHealth;S phosphate) (hepatitis c)) P TAMIFLU SUSR 6 MG/ML QL(120 ml per F RIBASPHERE TABS 400 PA; SP- (oseltamivir phosphate) 30 days retail) MG (ribavirin (hepatitis F AcariaHealth;S BETA BLOCKERS - Drugs to Treat High Blood c)) P Pressure ribavirin (hepatitis c) PA; SP- Alpha-Beta Blockers F AcariaHealth;S caps QL(1 ea daily) P carvedilol phosphate F cp24 ribavirin (hepatitis c) PA; SP- F AcariaHealth;S carvedilol tabs F tabs P PA; SP- Acaria F sofosbuvir-velpatasvir F labetalol hcl tabs tabs Health;SP Beta Blockers Cardio-Selective

CA Health & Wellness Preferred Drug List Updated September 1, 2021

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acebutolol hcl caps F (Diltiazem Hcl Extended Release Beads) TAZTIA F atenolol tabs F XT, TIADYLT ER CP24 (Diltiazem Hcl) DILT-XR F CP24 bisoprolol fumarate F tabs or 10 mg, 5 mg amlodipine besylate QL(1 ea daily) tabs or 10 mg, 2.5 mg, F metoprolol succinate F tb24 5 mg diltiazem hcl coated metoprolol tartrate tabs F 100 mg, 25 mg, 50 mg beads cp24 120 mg, F Beta Blockers Non-Selective 180 mg, 240 mg, 300 mg, 360 mg (Sotalol Hcl) SORINE F TABS diltiazem hcl cp12 120 F HEMANGEOL SOLN PA mg, 60 mg, 90 mg F (propranolol hcl) diltiazem hcl cp24 180 F nadolol tabs F mg, 240 mg diltiazem hcl extended F pindolol tabs F release beads cp24 propranolol hcl cp24 or diltiazem hcl tabs 120 120 mg, 160 mg, 60 F mg, 30 mg, 60 mg, 90 F mg, 80 mg mg PA felodipine tb24 F propranolol hcl soln iv 1 F mg/ml nicardipine hcl caps F propranolol hcl soln or F 20 mg/5ml, 40 mg/5ml nifedipine caps 10 mg, F propranolol hcl tabs or 20 mg 10 mg, 20 mg, 40 mg, F QL(1 ea daily) nifedipine tb24 30 mg, F 60 mg, 80 mg 90 mg sotalol hcl (afib/afl) tabs F nifedipine tb24 60 mg F QL(2 ea daily) sotalol hcl tabs F QL(12 ea nimodipine caps F daily,252 ea SOTYLIZE SOLN ( per 21 days sotalol F hcl) retail) nisoldipine tb24 17 mg, F timolol maleate tabs F 25.5 mg, 34 mg, 8.5 mg CALCIUM CHANNEL BLOCKERS - Drugs to NYMALIZE SOLN 30 Treat High Blood Pressure MG/10ML, 60 MG/20ML F Calcium Channel Blockers (nimodipine) (Diltiazem Hcl Coated F Beads) CARTIA XT CP24

CA Health & Wellness Preferred Drug List Updated September 1, 2021

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits verapamil hcl cp24 or Pulmonary Hypertension - Phosphodiesterase 100 mg, 120 mg, 180 F (Tadalafil (Pulmonary PA; SP mg, 200 mg, 240 mg, Hypertension)) ALYQ F 300 mg, 360 mg TABS PA tadalafil (pulmonary PA; SP verapamil hcl soln iv F F 2.5 mg/ml hypertension) tabs CEPHALOSPORINS - Drugs to Treat Bacterial verapamil hcl tabs or F 120 mg, 40 mg, 80 mg Infections verapamil hcl tbcr or Cephalosporins - 1st Generation 120 mg, 180 mg, 240 F cefadroxil caps F mg VERELAN CP24 360 MG cefadroxil susr F F (verapamil hcl) VERELAN PM CP24 cefadroxil tabs F F (verapamil hcl) CEFAZOLIN PA CARDIOTONICS - Drugs to Treat Heart Failure SODIUM/SODIUM and Abnormal Heart Rhythm CHLORIDE SOLN F (cefazolin sodium in Cardiac Glycosides sodium chloride) (Digoxin) DIGITEK, DIGOX F CEFAZOLIN/SODIUM PA TABS CHLORIDE SOLN F digoxin soln or 0.05 F (cefazolin sodium in mg/ml sodium chloride) digoxin tabs or 0.125 F cephalexin caps 250 F mg, 125 mcg, 250 mcg mg, 500 mg LANOXIN TABS OR 125 F cephalexin susr 125 F MCG, 250 MCG (digoxin) mg/5ml, 250 mg/5ml CARDIOVASCULAR AGENTS - MISC. - Drugs to cephalexin tabs 250 F Treat Heart and Circulation Conditions mg, 500 mg Prostaglandin Vasodilators Cephalosporins - 2nd Generation F PA; SP- treprostinil soln Caremark cefaclor caps F VENTAVIS SOLN PA; SP- F F (iloprost) Caremark cefaclor susr Pulmonary Hypertension - Endothelin Receptor cefprozil susr F PA; SP ambrisentan tabs F cefprozil tabs F SP bosentan tabs 125 mg F cefuroxime axetil tabs F bosentan tabs 62.5 mg F Cephalosporins - 3rd Generation TRACLEER TBSO 32 MG F cefdinir caps F (bosentan)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cefdinir susr F (Drospirenone-Ethinyl 365 day supply Estradiol) GIANVI, allowed; JASMIEL, LO- cefpodoxime proxetil F susr ZUMANDIMINE, LORYNA, F NIKKI, OCELLA, SYEDA, cefpodoxime proxetil F VESTURA, ZARAH, tabs ZUMANDIMINE TABS ceftriaxone sodium solr (Ethynodiol Diacet & Eth 365 day supply ij 1 gm, 250 mg, 500 F Estrad) KELNOR 1/35, F allowed; mg KELNOR 1/50, ZOVIA 1/35, ZOVIA 1/35E TABS CEFTRIAXONE SODIUM PA SOLR IJ 100 GM (Levonorgestrel & Eth 365 day supply F Estradiol) AFIRMELLE, allowed; (ceftriaxone sodium) ALTAVERA, AUBRA, PA AUBRA EQ, AVIANE, ceftriaxone sodium solr F ij 2 gm AYUNA, CHATEAL, CHATEAL EQ, DELYLA, PA ceftriaxone sodium solr F FALMINA, KURVELO, F iv 1 gm, 10 gm, 2 gm LARISSIA, LESSINA, LEVORA 0.15/30-28, CHEMICALS LILLOW, LUTERA, Bulk Chemicals - H's MARLISSA, ORSYTHIA, PORTIA-28, SRONYX, HALOPERIDOL POWD XX CO VIENVA TABS (haloperidol (bulk)) (Levonorgestrel-Eth 365 day supply CONTRACEPTIVES - Drugs to Prevent Estradiol (Triphasic)) allowed; Pregnancy ENPRESSE-28, F LEVONEST, TRIVORA-28 Combination Contraceptives - Oral TABS (Desogestrel & Ethinyl 365 day supply (Levonorgestrel-Ethinyl 365 day supply Estradiol) APRI, CYRED, allowed; Estradiol (91-Day)) allowed; CYRED EQ, AMETHIA, AMETHIA LO, EMOQUETTE, ENSKYCE, F ASHLYNA, CAMRESE, ISIBLOOM, JULEBER, CAMRESE LO, DAYSEE, F KALLIGA, RECLIPSEN ICLEVIA, INTROVALE, TABS JAIMIESS, JOLESSA, (Desogestrel-Ethinyl 365 day supply LOJAIMIESS, SETLAKIN, Estradiol (Biphasic)) allowed; SIMPESSE TABS AZURETTE, BEKYREE, F (Levonorgestrel-Ethinyl 365 day supply KARIVA, PIMTREA, Estradiol (91-Day)) allowed;QL(1 SIMLIYA, VIORELE, AMETHIA, AMETHIA LO, ea daily) VOLNEA TABS ASHLYNA, CAMRESE, (Desogestrel-Ethinyl 365 day supply CAMRESE LO, DAYSEE, F Estradiol (Triphasic)) F allowed; ICLEVIA, INTROVALE, CAZIANT, VELIVET TABS JAIMIESS, JOLESSA, LOJAIMIESS, SETLAKIN, SIMPESSE TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethin Acet & Estrad- 365 day supply (Norethindrone Acet & Eth 365 day supply Fe) AUROVELA 24 FE, allowed; Estra) AUROVELA 1.5/30, allowed;QL(1 AUROVELA FE 1.5/30, AUROVELA 1/20, HAILEY ea daily) AUROVELA FE 1/20, 1.5/30, JUNEL 1.5/30, BLISOVI 24 FE, BLISOVI JUNEL 1/20, LARIN 1.5/30, F FE 1.5/30, BLISOVI FE LARIN 1/20, LOESTRIN 1/20, HAILEY 24 FE, 1.5/30-21, LOESTRIN HAILEY FE 1.5/30, HAILEY 1/20-21, MICROGESTIN FE 1/20, JUNEL FE 1.5/30, 1.5/30, MICROGESTIN JUNEL FE 1/20, JUNEL FE F 1/20 TABS 24, LARIN 24 FE, LARIN (Norethindrone Acetate- 365 day supply FE 1.5/30, LARIN FE 1/20, Ethinyl Estradiol-Fe) TILIA F allowed; LOESTRIN FE 1.5/30, FE, TRI-LEGEST FE TABS LOESTRIN FE 1/20, MICROGESTIN 24 FE, (Norethindrone-Eth 365 day supply MICROGESTIN FE 1.5/30, Estradiol (Triphasic)) allowed; MICROGESTIN FE 1/20, ALYACEN 7/7/7, TARINA 24 FE, TARINA ARANELLE, CYCLAFEM F FE 1/20, TARINA FE 1/20 7/7/7, DASETTA 7/7/7, EQ TABS LEENA, NORTREL 7/7/7, NYLIA 7/7/7, PIRMELLA (Norethindrone & Eth 365 day supply 7/7/7 TABS Estradiol) ALYACEN 1/35, allowed; BALZIVA, BRIELLYN, (Norgestimate-Ethinyl 365 day supply CYCLAFEM 1/35, Estradiol (Triphasic)) TRI allowed; FEMYNOR, TRI- DASETTA 1/35, NECON F 0.5/35-28, NORTREL ESTARYLLA, TRI-LINYAH, 0.5/35 (28), NORTREL TRI-LO-ESTARYLLA, TRI- 1/35, PHILITH, PIRMELLA LO-MARZIA, TRI-LO-MILI, F 1/35, VYFEMLA, WERA TRI-LO-SPRINTEC, TRI- TABS MILI, TRI-NYMYO, TRI- PREVIFEM, TRI- (Norethindrone & Ethinyl 365 day supply SPRINTEC, TRI-VYLIBRA, Estradiol-Fe) KAITLIB FE, F allowed; TRI-VYLIBRA LO TABS LAYOLIS FE, WYMZYA FE CHEW (Norgestimate-Ethinyl 365 day supply Estradiol) ESTARYLLA, allowed; (Norethindrone Acet & Eth 365 day supply FEMYNOR, MILI, MONO- F Estra) AUROVELA 1.5/30, allowed; LINYAH, NYMYO, AUROVELA 1/20, HAILEY PREVIFEM, SPRINTEC 1.5/30, JUNEL 1.5/30, 28, VYLIBRA TABS JUNEL 1/20, LARIN 1.5/30, F LARIN 1/20, LOESTRIN (Norgestrel & Ethinyl 365 day supply 1.5/30-21, LOESTRIN Estradiol) CRYSELLE-28, allowed; 1/20-21, MICROGESTIN ELINEST, LOW- F 1.5/30, MICROGESTIN OGESTREL, OGESTREL 1/20 TABS TABS 365 day supply desogestrel & ethinyl F estradiol tabs allowed; 365 day supply desogestrel-ethinyl F estradiol (biphasic) tabs allowed; 365 day supply drospirenone-ethinyl F estradiol tabs allowed; CA Health & Wellness Preferred Drug List Updated September 1, 2021

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 365 day supply (Levonorgestrel QL(6 ea per ethynodiol diacet & eth F estrad tabs allowed; (Emergency Oc)) AFTERA, 365 days retail) AFTERPILL, ECONTRA 365 day supply levonorgestrel & eth F EZ, ECONTRA ONE- estradiol tabs allowed; STEP, MY CHOICE, MY F levonorgestrel-eth 365 day supply WAY, NEW DAY, F allowed; OPCICON ONE-STEP, estradiol (triphasic) OPTION 2, PREVENTEZA, tabs REACT, TAKE ACTION 365 day supply TABS levonorgestrel-ethinyl F estradiol (91-day) tabs allowed; ELLA TABS (ulipristal QL(6 ea per F 365 days retail) levonorgestrel-ethinyl 365 day supply acetate) F allowed;QL(1 QL(6 ea per estradiol (91-day) tabs levonorgestrel F ea daily) (emergency oc) tabs 365 days retail) norethin acet & estrad- 365 day supply allowed; Progestin Contraceptives - Injectable fe tabs 1 mg-20 mcg- F 75 mg, 1.5 mg-30 mcg- DEPO-SUBQ PROVERA QL(1 ml per fill 75 mg 104 SUSY retail) (medroxyprogesterone F 365 day supply norethindrone & ethinyl F acetate (contraceptive)) estradiol-fe chew allowed; medroxyprogesterone QL(1 ml per fill norethindrone acet & 365 day supply F retail) allowed;QL(1 acetate (contraceptive) eth estra tabs 1 mg-20 F susp mcg ea daily) medroxyprogesterone QL(1 ml per fill norethindrone acet & 365 day supply F retail) allowed; acetate (contraceptive) eth estra tabs 1.5 mg- F susy 30 mcg norgestimate-ethinyl 365 day supply Progestin Contraceptives - Oral F allowed; (Norethindrone 365 day supply estradiol (triphasic) (Contraceptive)) CAMILA, allowed; tabs DEBLITANE, ERRIN, 365 day supply HEATHER, INCASSIA, norgestimate-ethinyl F estradiol tabs allowed; JENCYCLA, LYLEQ, F LYZA, NORA-BE, TYBLUME CHEW 365 day supply NORLYDA, NORLYROC, (levonorgestrel & eth F allowed; SHAROBEL, TULANA estradiol) TABS 365 day supply Combination Contraceptives - Transdermal norethindrone F (contraceptive) tabs allowed; (Norelgestromin-Ethinyl F 365 day supply Estradiol) XULANE PTWK allowed; CORTICOSTEROIDS - Steroid Hormone Drugs to Combination Contraceptives - Vaginal Treat Systemic Swelling Conditions (Etonogestrel-Ethinyl F 365 day supply Glucocorticosteroids Estradiol) ELURYNG RING allowed; (Dexamethasone) F 365 day supply DECADRON ELIX etonogestrel-ethinyl F estradiol ring allowed; (Dexamethasone) F Emergency Contraceptives DECADRON TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREDNISONE INTENSOL budesonide cpep 3 mg F F CONC (prednisone) cortisone acetate tabs F prednisone soln F dexamethasone elix F 0.5 mg/5ml prednisone tabs F DEXAMETHASONE prednisone tbpk F INTENSOL CONC F (dexamethasone) Mineralocorticoids QL(5 ml daily) dexamethasone fludrocortisone acetate F tabs sodium phosphate soln F 120 mg/30ml, 20 COUGH/COLD/ALLERGY - Drugs to Treat mg/5ml, 4 mg/ml Cough, Cold and Allergy Symptoms DEXAMETHASONE QL(5 ml daily) Antitussives SODIUM PHOSPHATE (Hydrocodone W/ SOLN 4 MG/ML F ( Homatropine) HYDROMET F dexamethasone SYRP sodium phosphate) benzonatate caps 100 F dexamethasone soln F mg, 200 mg 0.5 mg/5ml hydrocodone w/ F dexamethasone tabs homatropine syrp 0.5 mg, 0.75 mg, 1 mg, F 1.5 mg, 2 mg, 4 mg, 6 hydrocodone w/ F mg homatropine tabs Cough/Cold/Allergy Combinations hydrocortisone tabs F (Brompheniramine & MEDROL TABS 2 MG Phenyleph) CHILDRENS F (methylprednisolone) COLD & ALLERGY, COLD & ALLERGY, methylprednisolone F COLD/ALLERGY tabs CHILDRENS, DIMAPHEN CHILDRENS, GNP COLD methylprednisolone F tbpk & ALLERGY CHILDRENS, HM COLD & ALLERGY F MILLIPRED TABS F CHILDRENS, PX (prednisolone) DIBROMM prednisolone sodium COLD/ALLERGY phosphate soln or 15 CHILDRENS, RYNEX PE, F SB COLD & ALLERGY mg/5ml, 5 mg/5ml, 6.7 CHILDRENS, SM COLD & mg/5ml ALLERGY CHILDRENS prednisolone sodium QL(150 ml per ELIX phosphate soln or 20 F fill retail) mg/5ml prednisolone soln F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Brompheniramine & (Chlorpheniramine & Phenyleph) COLD & Phenylephrine) CVS ALLERGY CHILDRENS, F SINUS & ALLERGY CVS COLD & ALLERGY MAXIMUM STRENGTH, CHILDRENS ELIX 1 CVS SINUS PE & MG/5ML-2.5 MG/5ML ALLERGY MAXIMUM (Brompheniramine & STRENGTH, ED A-HIST, Pseudoeph) RYNEX PSE F EQ SUPHEDRINE PE LIQD SINUS &ALLERGY, EQL SINUS & ALLERGY PE, F (Brompheniramine & GNP SINUS & ALLERGY Pseudoeph) SM COLD & RELIEF PE, RA ALLERGY CHILDRENS, F SUPHEDRINE PE, SB WAL-TAP COLD & ALLERFED COLD & ALLERGY ELIX ALLERGY, SB SINUS & (Cetirizine- ALLERGY MAXIMUM Pseudoephedrine) 12 STRENGTH, SM COLD & HOUR ALLERGY-D, ALL ALLERGY PE, WAL-PHED DAY ALLERGY D, ALL PE SINUS/ALLERGY DAY ALLERGY D-12, ALL TABS DAY ALLERGY-D, ALLERGY D-12, ALLERGY RELIEF D, ALLERGY RELIEF NASAL DECONGESTANT, ALLERGY RELIEF-D, CVS ALLERGY RELIEF-D, EQ ALLERGY RELIEF NASAL F DECONGESTANT, EQL ALL DAY ALLERGY-D, GNP ALL DAY ALLERGY- D, GOODSENSE ALL DAY ALLERGY-D, HM ALLERGY COMPLETE-D, KLS ALLER-TEC D, PX ALLERGY RELIEF D, RA CETIRI-D, SHOPKO ALLERGY RELIEF-D, SM ALL DAY ALLERGY-D, SW ALLERGY RELIEF-D, WAL-ZYR D TB12 (Cetirizine- Pseudoephedrine) TGT ALLERGY+ CONGESTION F RELIEF-D TB12 5 MG-120 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Dextromethorphan- CONGESTION LIQD Guaifenesin) BIOCOTRON, CVS (Diphenhydramine- TUSSIN DM, DIABETIC Phenylephrine) SILTUSSIN-DM, DIABETIC BENADRYL ALLERGY TUSSIN DM, DIABETIC PLUS CONGESTION F TUSSIN FOR CHILDREN, ULTRATABS, WAL-DRYL GILTUSS COUGH & PE ALLERGY/SINUS CHEST CONGESTION, TABS GILTUSS COUGH & (Diphenhydramine- CHEST CONGESTION Phenylephrine) CVS F CHILDRENS, GILTUSS ALLERGY/CONGESTION DIABETIC COUGH CHILDRENS SOLN &COLD, GILTUSS HONEY COUGH & CHEST (Diphenhydramine- CONGESTION, GILTUSS Phenylephrine- HONEY COUGH & CHEST Acetaminophen) GNP CONGESTION ALLERGY PLUS SINUS CHILDRENS, GNP HEADACHE, MUCINEX TUSSIN DM, GNP TUSSIN FAST-MAX NIGHT TIME DM COUGH, GUAIASORB COLD & FLU MAXIMUM DM, HM TUSSIN ADULT STRENGTH, QC COUGH & CHEST ALLERGY/SINUS CONGESTION DM, MAXI- HEADACHE, SB F TUSS G, PX TUSSIN DM, ALLERGY & COLD PE, SB SEVERE COLD PE, QC TUSSIN DM COUGH & F CHEST THERAFLU CONGESTION/ADULT, RA EXPRESSMAX SEVERE TUSSIN COUGH, RA COLD & COUGH TUSSIN COUGH/CHEST NIGHTTIME, WAL-DRYL CONGESTION DM, RA ALLERGY/SINUS TUSSIN DM, ROBAFEN HEADACHE, WAL-PHED DM COUGH, ROBAFEN PE SEVERE COLD TABS DM COUGH/CHEST (Guaifenesin-Codeine) G CONGESTION, ROBAFEN TUSSIN AC, MAXI-TUSS F DM PEAK COLD AC, VIRTUSSIN A/C SOLN COUGH/CHEST (Guaifenesin-Codeine) CONGESTION, GUAIATUSSIN AC, F ROBITUSSIN PEAK COLD GUAIFENESIN AC SYRP COUGH+ CHEST (Guaifenesin-Codeine) F CONGESTION DM, SAFE VIRTUSSIN AC/ALC LIQD TUSSIN DM ADULT, SB COUGH CONTROL DM, SILTUSSIN DM DAS, SORBUGEN NR, TGT COUGH FORMULA DM, TUSNEL DIABETIC, TUSSIN DM, TUSSIN DM COUGH + CHEST CONGESTION, WAL- TUSSIN DM, WAL-TUSSIN DM COUGH & CHEST CA Health & Wellness Preferred Drug List Updated September 1, 2021

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Loratadine & (Loratadine & Pseudoephedrine) Pseudoephedrine) ALAVERT ALLERGY RELIEF D, ALLERGY/SINUS, ALLERGY RELIEF D-24, ALLERGY & ALLERGY RELIEF-D, CONGESTION RELIEF, ALLERGY RELIEF/NASAL ALLERGY RELIEF D-12, DECONGESTANT, ALLERGY RELIEF-D, CVS ALLERGY-RELIEF-D, CVS ALLERGY RELIEF-D12, ALLERGY RELIEF-D, EQL EQ ALLERGY & ALLERGY/CONGESTION CONGESTION RELIEF, RELIEF, GNP ALLERGY & GNP LORATADINE-D CONGESTIONRELIEF, 12HR, HM ALLERGY & F HM ALLERGY RELIEF & CONGESTION, KLS NASALDECONGESTANT, ALLERCLEAR D-12 HR, KLS ALLERCLEAR D- F KLS ALLERCLEAR D- 24HR, KLS ALLERCLEAR- 12HR, LORATADINE-D D 24HR, LORATADINE-D 12HR, MEIJER ALLERGY 24HR, PX ALLERGY RELIEF-D, PX ALLERGY RELIEF D, QC RELIEF D, RA LORATADINE-D, RA ALLERGY/CONGESTION ALLERGY RELIEF & RELIEF, SHOPKO NASALDECONGESTANT, ALLERGY RELIEF-D, SM RA LORATA-D, SB LORATADINE D 12HR, ALLERGY RELIEF/NASAL WAL-ITIN D TB12 DECONGESTANT, SM LORATA-DINE D, TGT ALLERGY & CONGESTIONRELIEF, WAL-ITIN D 24 HOUR TB24 (Pseudoephedrine- Ibuprofen) CVS COLD & SINUS RELIEF, HM COLD & SINUS RELIEF, IBUPROFEN COLD & SINUS, PX IBUPROFEN COLD & SINUS, QC F IBUPROFEN COLD/SINUS, RA IBU- PROFEN COLD/SINUS, SM COLD & SINUS RELIEF, WAL-PROFEN COLD & SINUS TABS (Triprolidine & Pseudoephedrine) APRODINE, ED A-HIST F PSE, EQL COLD & ALLERGY, WAL-ACT TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVIL ALLERGY & promethazine- CONGESTION TABS phenylephrine-codeine F (chlorpheniramine- F syrp phenylephrine- RYMED TABS ibuprofen) (dexchlorpheniramine- F ADVIL MULTI-SYMPTOM phenylephrine) COLD& FLU TABS (chlorpheniramine- F Misc. Respiratory Inhalants phenylephrine- (Sodium Chloride ibuprofen) (Inhalant)) NEBUSAL F NEBU 3 % cetirizine- F (Sodium Chloride pseudoephedrine tb12 (Inhalant)) SIMPLY F SALINE BABY AERS dextromethorphan- F guaifenesin liqd HYPERSAL NEBU 3.5 % DRIXORAL (sodium chloride F COLD/ALLERGY TB12 (inhalant)) (dexbrompheniramine F sodium chloride F & pseudoephedrine) (inhalant) aers 0.9 % ED CHLORPED D LIQD sodium chloride (chlorpheniramine & F (inhalant) nebu 0.9 %, F phenylephrine) 3 % guaifenesin-codeine F Mucolytics soln hydrocodone polistirex- AL(At least 6 acetylcysteine soln F yrs old) chlorpheniramine F DERMATOLOGICALS - Drugs to Treat Skin polistirex suer Conditions MAXI-TUSS PE LIQD Acne Products (brompheniramine & F Limit 45gms phenyleph) per (Adapalene) ADAPALENE F month;QL(1.5 NEXAFED SINUS TREATMENT GEL PRESSURE +PAIN TABS gm daily); (pseudoephedrine- F RX/OTC acetaminophen) promethazine & F phenylephrine syrp promethazine F w/codeine soln promethazine F w/codeine syrp promethazine-dm syrp F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Benzoyl Peroxide) ACNE RX/OTC (Benzoyl Peroxide) ACNE FOAMING WASH, TREATMENT BENZEPRO CREAMY CLEANSINGBAR F WASH, CERAVE ACNE MAXIMUM STRENGTH, FOAMING CVS ACNE CLEANSING CREAMCLEANSER, CVS BAR BAR ACNE FOAMING FACE (Benzoyl Peroxide) WASH, CVS ADVANCED BENZOYL PEROXIDE 3-IN-1 EXFOLIATING F WASH, KP BENZOYL F CLEANSER, CVS PEROXIDE WASH LIQD CREAMY ACNE FACE 10 % WASH, CVS FOAMING ACNE FACE WASH, (Benzoyl Peroxide) RX/OTC PANOXYL CREAMY BENZOYL PEROXIDE WASH, PANOXYL WASH, KP BENZOYL F FOAMING WASH, PR PEROXIDE WASH LIQD 5 BENZOYL PEROXIDE % WASH LIQD (Benzoyl Peroxide) BP F (Benzoyl Peroxide) ACNE WASH LIQD 10 %, 7 % FOAMING WASH, (Benzoyl Peroxide) BP F RX/OTC BENZEPRO CREAMY WASH LIQD 2.5 %, 5 % WASH, CERAVE ACNE (Erythromycin (Acne Aid)) F FOAMING ERY PADS CREAMCLEANSER, CVS (Isotretinoin) ACCUTANE, QL(4 ea daily) ACNE FOAMING FACE AMNESTEEM, CLARAVIS, F WASH, CVS ADVANCED MYORISAN, ZENATANE 3-IN-1 EXFOLIATING F CAPS 10 MG CLEANSER, CVS CREAMY ACNE FACE (Isotretinoin) ACCUTANE, QL(5 ea daily) WASH, CVS FOAMING AMNESTEEM, CLARAVIS, F ACNE FACE WASH, MYORISAN, ZENATANE PANOXYL CREAMY CAPS 20 MG WASH, PANOXYL (Isotretinoin) ACCUTANE, QL(2 ea daily) FOAMING WASH, PR AMNESTEEM, CLARAVIS, F BENZOYL PEROXIDE MYORISAN, ZENATANE WASH LIQD CAPS 40 MG (Benzoyl Peroxide) ACNE (Isotretinoin) ACCUTANE, QL(3 ea daily) MEDICATION 10, ACNE CLARAVIS, MYORISAN, F MEDICATION 2.5, ACNE ZENATANE CAPS 30 MG MEDICATION 5, ACNE TREATMENT GEL, ACNE- (Tretinoin) AVITA CREA F CLEAR, BP GEL, CLEAN & CLEAR PERSA-GEL F (Tretinoin) AVITA GEL F MAXIMUM STRENGTH, ACNE MEDICATION 10 CVS ACNE TREATMENT/MAXIMUM LOTN (benzoyl F STRENGTH, KP peroxide) BENZOYL PEROXIDE ACNE MEDICATION 5 GEL LOTN (benzoyl F peroxide)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 45gms sulfacetamide sodium F F per (acne) lotn adapalene crea 0.1 % month;QL(1.5 gm daily) sulfacetamide sodium F Limit 45gms w/ sulfur lotn 5 %-10 % per tretinoin crea 0.025 %, F adapalene gel 0.1 % F month;QL(1.5 0.05 %, 0.1 % gm daily); RX/OTC tretinoin gel 0.01 %, F Limit 45gms 0.025 % Limit 50gms adapalene gel 0.3 % F per month;QL(1.5 tretinoin microsphere F per month gm daily) gel ;QL(1.67 gm BENZOYL PEROXIDE daily) CLEANSER LIQD F Anti-inflammatory Agents - Topical (benzoyl peroxide) (Diclofenac Sodium QL(6.68 gm (Topical)) ARTHRITIS daily); RX/OTC benzoyl peroxide gel F 10 %, 2.5 %, 5 % PAIN RELIEVER, ASPERCREME benzoyl peroxide- F ARTHRITIS PAIN erythromycin gel RELIEVER, CVS F clindamycin phosphate DICLOFENAC SODIIUM, F GNP ARTHRITIS PAIN, (topical) gel GOODSENSE ARTHRITIS PAIN, QC DICLOFENAC clindamycin phosphate F (topical) lotn SODIIUM GEL diclofenac sodium QL(6.68 gm clindamycin phosphate F F (topical) soln (topical) gel 1 % daily); RX/OTC Antibiotics - Topical erythromycin (acne aid) F gel (Bacitracin (Topical)) erythromycin (acne aid) ANTIBIOTIC OINTMENT, F F QC BACITRACIN, SB pads BACITRACIN OINT erythromycin (acne aid) F (Bacitracin (Topical)) soln BACITRAYCIN PLUS OINT F 500 UNIT/GM isotretinoin caps 10 mg F QL(4 ea daily) (Bacitracin Zinc) CVS F QL(5 ea daily) BACITRACIN, EQ isotretinoin caps 20 mg BACITRACIN ZINC, EQL QL(3 ea daily) BACITRACIN ZINC, GNP isotretinoin caps 30 mg F BACITRACIN ZINC, HM QL(2 ea daily) BACITRACIN, KP F isotretinoin caps 40 mg F BACITRACIN ZINC, RA SODIUM QL(30 gm per BACITRACIN, RA SULFACETAMIDE/SULFU fill retail) BACITRACIN ZINC R SUSP 5 %-10 % F FIRSTAID, SM (sulfacetamide sodium ANTIBIOTIC OINT w/ sulfur)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Bacitracin-Polymyxin B) (Neomycin-Polymyxin W/ QL(30 gm per CVS POLY BACITRACIN, Pramoxine) CVS fill retail) DOUBLE ANTIBIOTIC, HM ANTIBIOTIC PLUS, CVS DOUBLE ANTIBIOTIC, KP ANTIBIOTIC/PAIN RELIEF, DOUBLE ANTIBIOTIC, F EQ ANTIBIOTIC + PAIN NEOSPORIN, POLY RELIEF MAXIMUM BACITRACIN, RA STRENGTH, EQL DOUBLE ANTIBIOTIC, SM ANTIBIOTIC + PAIN DOUBLE ANTIBIOTIC, RELIEF MAXIMUM WAL-SPORIN OINT STRENGTH, GNP (Neomycin-Bacitracin- QL(454 gm per ANTIBIOTIC + PAIN F Polymyxin) CURAD fill retail) RELIEF, GOODSENSE TRIPLE ANTIBIOTIC, CVS ANTIBIOTIC/PAIN RELIEF, ANTIBIOTIC, EQ TRIPLE MULTI ANTIBIOTIC PLUS, ANTIBIOTIC, EQL FIRST RA ANTIBIOTIC PLUS, SM AID ANTIBIOTIC, GNP ANTIBIOTIC PLUS PAIN TRIPLE ANTIBIOTIC, HM RELIEF MAXIMUM TRIPLE ANTIBIOTIC, STRENGTH, TGT FIRST LANABIOTIC, MEDI-FIRST AID ANTIBIOTICMAXIMUM TRIPLE ANTIBIOTIC, F MEIJER TRIPLE STRENGTH CREA ANTIBIOTIC, PX TRIPLE bacitracin (topical) oint F OINTMENT, RA TRIPLE ANTIBIOTIC, SM TRIPLE F ANTIBIOTIC, SM TRIPLE bacitracin zinc oint ANTIBIOTIC ORIGINAL gentamicin sulfate F STRENGTH, TRIPLE (topical) crea ANTIBIOTIC, TRIPLE ANTIBIOTIC FIRST AID gentamicin sulfate F OINT (topical) oint (Neomycin-Bacitracin- QL(454 gm per mupirocin calcium F Polymyxin) FIRST AID fill retail) (topical) crea ANTIBIOTIC OINT 3.5 MG- F 400 UNIT-5000 UNIT, 3.5 mupirocin oint F MG/GM-500 UNIT/GM- 10000 UNIT/GM Antifungals - Topical (Neomycin-Bacitracin- QL(454 gm per Polymyxin) SB TRIPLE fill retail) ANTIBIOTIC OINT 3.5 F MG/GM-400 UNIT/GM- 5000 UNIT/GM

CA Health & Wellness Preferred Drug List Updated September 1, 2021

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Clotrimazole (Topical)) RX/OTC (Miconazole Nitrate ANTI-FUNGAL, (Topical)) CARRINGTON CLOTRIMAZOLE AF, ANTIFUNGAL, CAVILON, CLOTRIMAZOLE ANTI- KP MICONAZOLE FUNGAL, NITRATE, MICADERM, CLOTRIMAZOLE MICONAZOLE ANTIFUNGAL, ANTIFUNGAL, REMEDY F CLOTRIMAZOLE ANTIFUNGAL, SM ATHLETES FOOT, ANTIFUNGAL CLOTRIMAZOLE GRX, MICONAZOLE, SOOTHE CVS CLOTRIMAZOLE, & COOL INZO CVS ITCH RELIEF ANTIFUNGAL CREAM, ANTIFUNGAL, CVS TINEACIDE CREA RINGWORM, EQ (Nystatin (Topical)) QL(60 gm per ANTIFUNGAL, EQ NYAMYC, NYSTOP F fill retail) ATHLETES FOOT, EQ POWD JOCK ITCH, EQL F ANTIFUNGAL, EQL (Terbinafine Hcl (Topical)) ATHLETES FOOT, GNP ATHLETES FOOT AF ATHLETES FOOT, JOCK CREAM, CVS ATHLETES ITCH, JOCK ITCH RELIEF, FOOT, CVS JOCK ITCH, KP CLOTRIMAZOLE, EQ ATHLETES FOOT, PRO-EX ANTIFUNGAL, EQL ATHLETES FOOT, PX ATHLETIC FOOT, QC GNP TERBINAFINE CLOTRIMAZOLE, RA HYDROCHLORIDE, KP F ATHLETES FOOT, RA TERBINAFINE CLOTRIMAZOLE, RA HYDROCHLORIDE, QC JOCK ITCH, SB ATHLETES FOOT, RA CLOTRIMAZOLE FOOT, ANTIFUNGAL FOOT SHOPKO ATHLETES CARE, RA FOOT CARE FOOT, SM ANTIFUNGAL ANTIFUNGAL, SM CLOTRIMAZOLE, TGT ATHLETES FOOT, TGT CLOTRIMAZOLE CREA ATHLETES FOOT CREA (Clotrimazole (Topical)) RX/OTC (Terbinafine Hcl (Topical)) ATHLETES FOOT CREA 1 F ANTIFUNGAL, ATHLETES F FOOT, DESENEX CREA 1 % % (Tolnaftate) ANTIFUNGAL F (Clotrimazole (Topical)) RX/OTC CREA 1 % CVS CLOTRIMAZOLE (Tolnaftate) BLIS-TO-SOL F MAXIMUMSTRENGTH, F LIQD FUNGICURE INTENSIVE WITHNAILGUARD SOLN (Ketoconazole (Topical)) F QL(200 ml per NIZORAL A-D SHAM fill retail) (Miconazole Nitrate (Topical)) ANTIFUNGAL F CREA 2 %

CA Health & Wellness Preferred Drug List Updated September 1, 2021

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tolnaftate) CVS ketoconazole (topical) F ANTIFUNGAL, CVS sham ATHLETES FOOT, EQ ATHLETES FOOT, EQL LAMISIL AT SPRAY SOLN ANTIFUNGAL, FUNGI- (terbinafine hcl F GUARD, FUNGOID-D, (topical)) GNP TOLNAFTATE, KP miconazole nitrate F TOLNAFTATE, QC F TOLNAFTATE, RA FOOT (topical) crea CARE ANTIFUNGAL, SB naftifine hcl crea F ANTI-FUNGAL, SM ANTIFUNGAL naftifine hcl gel F TOLNAFTATE, TGT ANTIFUNGAL, NAFTIN GEL 2 % F TOLNAFTATE (naftifine hcl) ANTIFUNGAL CREA NIZORAL A-D SHAM QL(200 ml per F (Tolnaftate) DR GS CLEAR (ketoconazole (topical)) fill retail) NAIL, FOOT REPAIR SERUM, FORMULA 3 THE nystatin (topical) crea F TREATMENT, FORMULA 7 THE SOLUTION, nystatin (topical) oint F FUNGAL NAIL ERASER, F MEDICATED ANTI- nystatin (topical) powd F QL(60 gm per FUNGAL, MYCOCIDE fill retail) CLINICAL NS nystatin-triamcinolone F ANTIFUNGAL crea TREATMENT, MYCOZYL AL, TINASPORE SOLN nystatin-triamcinolone F ALEVAZOL OINT oint F (clotrimazole (topical)) sulconazole nitrate soln F clotrimazole (topical) RX/OTC F terbinafine hcl (topical) crea F crea RX/OTC clotrimazole (topical) F soln tolnaftate crea F clotrimazole w/ F Antihistamines-Topical betamethasone crea ITCH RELIEF CREA QL(30 ml per clotrimazole w/ F (diphenhydramine hcl F betamethasone lotn fill retail) (topical)) econazole nitrate crea F Antineoplastic or Premalignant Lesion Agents - ex CARAC CREA EXELDERM SOLN F F (fluorouracil (topical)) (sulconazole nitrate) FLUOROPLEX CREA EXELDERM SOLN F F (fluorouracil (topical)) (sulconazole nitrate) fluorouracil (topical) F ketoconazole (topical) F crea 0.5 %, 5 % crea

CA Health & Wellness Preferred Drug List Updated September 1, 2021

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(10 ml per TAZORAC GEL 0.05 %, fluorouracil (topical) F F soln 2 %, 5 % fill retail) 0.1 % (tazarotene) PANRETIN GEL F Antiseborrheic Products (alitretinoin) (Selenium Sulfide) ANTI- PICATO GEL ( DANDRUFF SHAMPOO, F ingenol F mebutate) DANDREX SHAM (Selenium Sulfide) CVS Antipruritics - Topical ANTI-DANDRUFF, (Camphor & Menthol) QL(222 ml per DANDRUFF SHAMPOO, F ANTI-ITCH, GNP ANTI- F fill retail) EQL MEDICATED ITCH LOTN 0.5 %-0.5 % DANDRUFF LOTN (Camphor & Menthol) CVS QL(222 ml per (Sulfacetamide Sodium) QL(480 ml per ANTI-ITCH, MEN-PHOR F fill retail) SODIUM F fill retail) LOTN SULFACETAMIDE WASH Antipsoriatics LIQD 10 % selenium sulfide lotn (Calcipotriene) F F CALCITRENE OINT 2.5 % QL(480 ml per calcipotriene crea F sulfacetamide sodium F liqd fill retail) calcipotriene oint F Antivirals - Topical F QL(5 gm per fill calcipotriene soln F acyclovir topical crea retail) calcitriol (topical) oint F acyclovir topical oint F COSENTYX PA; SP Burn Products SENSOREADY PEN SOAJ F (Silver Sulfadiazine) SSD F (secukinumab) CREA COSENTYX SOSY PA; SP F (secukinumab) silver sulfadiazine crea F DRITHO-CREME HP SULFAMYLON CREA 85 F CREA (anthralin) MG/GM (mafenide F acetate) STELARA SOLN PA; SP- F AcariaHealth;S Corticosteroids - Topical (ustekinumab) P (Clobetasol Propionate STELARA SOSY PA; SP- Emollient Base) F AcariaHealth;S (ustekinumab) CLOBETASOL P PROPIONATE E, F TALTZ SOAJ PA CLOBETASOL F (ixekizumab) PROPIONATE TALTZ SOSY PA EMOLLIENT CREA F (ixekizumab) (Hydrocortisone (Topical)) F ALA-CORT CREA 2.5 % tazarotene crea F TAZORAC CREA 0.05 % F (tazarotene) CA Health & Wellness Preferred Drug List Updated September 1, 2021

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) RX/OTC (Hydrocortisone (Topical)) RX/OTC ALA-CORT, ANTI-ITCH AQUAPHOR ITCH RELIEF MAXIMUM STRENGTH, MAXIMUM STRENGTH, CVS HYDROCORTISONE F CORTIZONE-10, CVS ANTI-ITCH, CORTISONE MAXIMUM PREPARATION H, SM STRENGTH, EQL ANTI- HYDROCORTISONE ITCH MAXIMUM CREA 1 % STRENGTH, GNP (Hydrocortisone (Topical)) RX/OTC HYDROCORTISONE ALA-CORT, ANTI-ITCH MAXIMUM STRENGTH, MAXIMUM STRENGTH, GOODSENSE ANTI-ITCH MAXIMUM STRENGTH, CVS HYDROCORTISONE F ANTI-ITCH, HYDROCORTISONE IN F PREPARATION H, SM ABSORBASE, HYDROCORTISONE HYDROCORTISONE CREA EX 1 % MAXIMUM STRENGTH, KP HYDROCORTISONE (Hydrocortisone (Topical)) MAXIMUM STRENGTH, AQUANIL HC, BETA HC, RA ANTI-ITCH/MAXIMUM CORTIZONE-10 STRENGTH, SB DIABETICS SKIN, HYDROCORTISONE CORTIZONE-10 ECZEMA, MAXIMUM STRENGTH, CORTIZONE-10 SM HYDROCORTISONE HYDRATENSIVEHEALING F MAXIMUM STRENGTH , CORTIZONE-10 OINT HYDRATENSIVESOOTHI NG, CVS CORTISONE MAXIMUM STRENGTH, DERMAREST ECZEMA, SARNOL-HC LOTN

CA Health & Wellness Preferred Drug List Updated September 1, 2021

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) RX/OTC HYDROCORTISONE AVEENO ANTI-ITCH PLUS 12, SB MAXIMUMSTRENGTH, HYDROCORTISONE, TGT CORTAID MAXIMUM ANTI-ITCH PLUS STRENGTH, CURAD OATMEAL, TGT ANTI- HYDROCORTISONE, CVS ITCH/ALOE/VITAMIN E ANTI-ITCH MAXIMUM CREA STRENGTH, CVS CORTISONE INTENSE HEALING ANTI-ITCH, CVS CORTISONE MAXIMUM STRENGTH, CVS ECZEMA ANTI-ITCH MAXIMUM STRENGTH, CVS HYDROCORTISONE MAXIMUM STRENGTH, EQ 1% HYDROCORTISONE, EQ HYDROCORTISONE MAXIMUM STRENGTH, EQ HYDROCORTISONE PLUS, EQL ANTI-ITCH INTENSIVE HEALING FORMULA, EQL ANTI- ITCH MAXIMUM STRENGTH, EQL ANTI- F ITCH MAXIMUM STRENGTH PLUS 10 HEALING MOISTURIZERS, GNP HYDROCORTISONE, GNP HYDROCORTISONE PLUS, HYDROCORTISONE ANTI-ITCH, HYDROCORTISONE INTENSIVEHEALING, HYDROCORTISONE MAXIMUM STRENGTH, HYDROCORTISONE MAXIMUM STRENGTH PLUS 12 MOISTURIZERS, HYDROCORTISONE PLUS, INSTACORT 5, KERICORT 10, KP HYDROCORTISONE, MEIJER HYDROCORTISONE, NOBLE FORMULA HC, PX HYDROCREAM, RA ANTI- ITCH MAXIMUM STRENGTH, RA CA Health & Wellness Preferred Drug List Updated September 1, 2021

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) HYDROCORTISONE AVEENO ANTI-ITCH PLUS 12, SB MAXIMUMSTRENGTH, HYDROCORTISONE, TGT CORTAID MAXIMUM ANTI-ITCH PLUS STRENGTH, CURAD OATMEAL, TGT ANTI- HYDROCORTISONE, CVS ITCH/ALOE/VITAMIN E ANTI-ITCH MAXIMUM CREA STRENGTH, CVS (Hydrocortisone (Topical)) CORTISONE INTENSE CVS HYDROCORTISONE HEALING ANTI-ITCH, CVS ANTI-ITCH, SM F CORTISONE MAXIMUM HYDROCORTISONE STRENGTH, CVS CREA 0.5 % ECZEMA ANTI-ITCH (Hydrocortisone (Topical)) MAXIMUM STRENGTH, NOBLE FORMULA HC, CVS HYDROCORTISONE SCALP RELIEF MAXIMUM F MAXIMUM STRENGTH, STRENGTH, SCALPICIN EQ 1% MAXIMUM STRENGTH HYDROCORTISONE, EQ SOLN HYDROCORTISONE MAXIMUM STRENGTH, (Hydrocortisone (Topical)) EQ HYDROCORTISONE SM HYDROCORTISONE F PLUS, EQL ANTI-ITCH OINT 0.5 % INTENSIVE HEALING (Hydrocortisone Acetate FORMULA, EQL ANTI- (Topical)) GYNECORT 10, F ITCH MAXIMUM LANACORT 10 CREA STRENGTH, EQL ANTI- F (Hydrocortisone Acetate ITCH MAXIMUM (Topical)) VAGISIL CREA 1 F STRENGTH PLUS 10 % HEALING MOISTURIZERS, GNP HYDROCORTISONE, GNP HYDROCORTISONE PLUS, HYDROCORTISONE ANTI-ITCH, HYDROCORTISONE INTENSIVEHEALING, HYDROCORTISONE MAXIMUM STRENGTH, HYDROCORTISONE MAXIMUM STRENGTH PLUS 12 MOISTURIZERS, HYDROCORTISONE PLUS, INSTACORT 5, KERICORT 10, KP HYDROCORTISONE, MEIJER HYDROCORTISONE, NOBLE FORMULA HC, PX HYDROCREAM, RA ANTI- ITCH MAXIMUM STRENGTH, RA CA Health & Wellness Preferred Drug List Updated September 1, 2021

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone-Aloe Vera) betamethasone CORTIZONE-10 dipropionate F INTENSIVE HEALING, augmented lotn CORTIZONE-10 PLUS, CORTIZONE-10/ALOE, betamethasone GNP dipropionate F HYDROCORTISONE/ALO augmented oint E, HM HYDROCORTISONE betamethasone F PLUS, HM valerate crea 0.1 % HYDROCORTISONE/ALO betamethasone F E MAXIMUM STRENGTH, valerate lotn 0.1 % HYDROCORTISONE/ALO F E MAXIMUM STRENGTH, betamethasone F KLS HYDROCORTISONE valerate oint 0.1 % PLUS, KP CAPEX SHAM F HYDROCORTISONE/ALO ( ) E, RA fluocinolone acetonide HYDROCORTISONE clobetasol propionate F PLUS, SM crea HYDROCORTISONE PLUS, SM clobetasol propionate F HYDROCORTISONE/ALO emollient base crea E MAXIMUM STRENGTH clobetasol propionate F CREA foam (Triamcinolone Acetonide F clobetasol propionate F (Topical)) TRIDERM CREA gel APEXICON E CREA (diflorasone diacetate F clobetasol propionate F emollient base) oint betamethasone clobetasol propionate F dipropionate (topical) F soln crea desonide crea F QL(2 gm daily) betamethasone QL(2 gm daily) dipropionate (topical) F desonide oint F lotn desoximetasone crea F betamethasone 0.05 % dipropionate (topical) F QL(2 gm daily) desoximetasone crea F oint 0.25 % betamethasone QL(50 gm per QL(2 gm daily) desoximetasone gel F dipropionate F fill retail) 0.05 % augmented crea QL(2 gm daily) desoximetasone oint F betamethasone 0.25 % dipropionate F diflorasone diacetate F augmented gel crea

CA Health & Wellness Preferred Drug List Updated September 1, 2021

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(60 ml per diflorasone diacetate F hydrocortisone butyrate F oint soln fill retail) EPIFOAM FOAM F hydrocortisone valerate F (pramoxine-hc) crea fluocinolone acetonide F hydrocortisone valerate F crea oint fluocinolone acetonide F hydrocortisone-aloe F oil vera crea fluocinolone acetonide F mometasone furoate F oint crea fluocinolone acetonide F mometasone furoate F soln oint fluocinonide crea 0.05 QL(60 ml per F mometasone furoate F % soln fill retail) fluocinonide emulsified PRAMOSONE CREA F F base crea (pramoxine-hc) PRAMOSONE LOTN fluocinonide gel 0.05 % F F (pramoxine-hc) fluocinonide oint 0.05 F F QL(60 gm per % prednicarbate crea fill retail) QL(60 gm per fluocinonide soln 0.05 F prednicarbate oint F % fill retail) QL(60 gm per PSORCON CREA fluticasone propionate F F crea 0.05 % fill retail) (diflorasone diacetate) QL(60 gm per triamcinolone acetonide fluticasone propionate F oint 0.005 % fill retail) (topical) aers 0.147 F mg/gm halobetasol propionate F crea triamcinolone acetonide (topical) crea 0.025 %, F hydrocortisone (topical) F 0.1 %, 0.5 % crea 0.5 %, 2.5 % triamcinolone acetonide hydrocortisone (topical) RX/OTC F (topical) lotn 0.025 %, F crea 1 % 0.1 % hydrocortisone (topical) F triamcinolone acetonide lotn 1 %, 2.5 % (topical) oint 0.025 %, F hydrocortisone (topical) F 0.1 %, 0.5 % oint 0.5 %, 2.5 % Eczema Agents RX/OTC hydrocortisone (topical) F DUPIXENT SOSY 200 PA; SP-Acaria F oint 1 % MG/1.14ML (dupilumab) Health hydrocortisone acetate DUPIXENT SOSY 300 PA; SP-Acaria F F (topical) crea MG/2ML (dupilumab) Health;SP

CA Health & Wellness Preferred Drug List Updated September 1, 2021

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONDYLOX GEL Emollient/Keratolytic Agents F QL(200 gm per (podofilox) (Urea) GORDONS UREA, F UREMEZ-40 CREA fill retail); podofilox soln F RX/OTC QL(100 gm per (Urea) UREA-C40 LOTN F QL(325 ml per salicylic acid gel F fill retail) fill retail) QL(325 ml per Local Anesthetics - Topical CEROVEL LOTN (urea) F fill retail) (Capsaicin) CAPSAICIN QL(43 gm per QL(200 gm per HP, CAPZIX, CVS fill retail) urea crea ex 40 % F fill retail); CAPSAICIN HP, RX/OTC DERMACINRX PENETRAL, RA F QL(325 ml per urea lotn ex 40 % fill retail) ARTHRITIS PAIN RELIEF, F SURE RESULT SR Emollients RELIEF, ZOSTRIX HIGH (Lactic Acid (Ammonium RX/OTC POTENCY, ZOSTRIX Lactate)) AL12, HIGH POTENCY AMLACTIN, AMLACTIN FOOTPAIN RELIEF CREA DAILY, CVS HYDRATING (Capsaicin) CAPSAICIN QL(60 gm per SKIN TREATMENT, CVS F HP, CAPZIX, CVS fill retail) SKIN TREATMENT, CVS CAPSAICIN HP, SKIN TREATMENT BODY DERMACINRX LOTION, GERI- PENETRAL, RA HYDROLAC 12 LOTN ARTHRITIS PAIN RELIEF, F (Lactic Acid (Ammonium RX/OTC SURE RESULT SR Lactate)) GERI- F RELIEF, ZOSTRIX HIGH HYDROLAC 12 CREA POTENCY, ZOSTRIX RX/OTC HIGH POTENCY lactic acid (ammonium F lactate) crea FOOTPAIN RELIEF CREA (Capsaicin) CAPSAICIN RX/OTC lactic acid (ammonium F HP, CAPZIX, CVS lactate) lotn CAPSAICIN HP, LACTIC ACID E CREA DERMACINRX F (lactic acid w/ vitamin e) PENETRAL, RA ARTHRITIS PAIN RELIEF, F Enzymes - Topical SURE RESULT SR SANTYL OINT RELIEF, ZOSTRIX HIGH F (collagenase) POTENCY, ZOSTRIX HIGH POTENCY Immunomodulating Agents - Topical FOOTPAIN RELIEF CREA imiquimod crea 5 % F (Dibucaine) CVS QL(57 gm per HEMORRHOIDAL & F fill retail) Immunosuppressive Agents - Topical TOPICAL ANALGESIC, PA; QL(30 gm NUPERCAINAL OINT (Lidocaine Hcl) 7T LIDO RX/OTC F per fill retail); pimecrolimus crea AL(At least 2 GEL, REGENECARE HA F yrs old) GEL Keratolytic/Antimitotic Agents

CA Health & Wellness Preferred Drug List Updated September 1, 2021

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lidocaine Hcl) QL(2 ml daily) ETHYL ASPERCREME CHLORIDE/MEDIUM W/LIDOCAINE, STREAM AERO (ethyl F ASPERCREME/LIDOCAIN chloride) E, BENGAY LIDOCAINE, CVS LIDOCAINE lidocaine crea ex 3 % F QL(454 gm per MAXIMUM STRENGTH, fill retail) CVS PAIN lidocaine crea ex 4 % F RELIEF/MAXIMUM STRENGTH, EQ QL(454 gm per LIDOCAINE PAIN lidocaine hcl crea 3 % F fill retail); RELIEVING/MAX RX/OTC STRENGTH, GNP F QL(2 ml daily) LIDOCAINE PAIN lidocaine hcl crea 4 % F RELIEVING, GOLD BOND MULTI-SYMPTOM/ITCH & lidocaine hcl gel 2 % F PAIN RELIEF/MAXIMUM STRENGTH, LIDOCAINE lidocaine hcl prsy 2 % F PLUS, NEUROMED7, PAIN RELIEVING lidocaine hcl soln 4 % F MAXIMUM STRENGTH, PAIN lidocaine-prilocaine F RELIEVING/LIDOCAINE, crea RA PAIN RELIEF, XOLIDO REGENECARE HA LIQD F XP CREA (lidocaine hcl) (Lidocaine Hcl) GLYDO F PRSY Misc. Topical QL(454 gm per (Aluminum Sulfate & (Lidocaine Hcl) LIDOPIN F Calcium Acetate) BORO- CREA 3 % fill retail); RX/OTC PACKS, CVS ASTRINGENT SOLUTION F (Lidocaine) ANECREAM, SOOTHING RELIEF, BLUE TUBE PAIN F PEDI-BORO SOAK PAKS RELIEVING/ALOE CREA PACK ARTHRITIS PAIN QL(60 gm per (Lanolin (Topical)) AMEDA RELIEVING CREA F fill retail) TRIPLE ZERO LANOLIN, (capsaicin) HPA LANOLIN, LAN-O- SOOTHE, LANSINOH capsaicin crea 0.025 % F LANOLIN, LANSINOH F LANOLIN MINIS NIPPLE, F QL(43 gm per capsaicin crea 0.1 % fill retail) LANSINOH LANOLIN CAPZASIN-P CREA QL(43 gm per NIPPLE, MEDELA F fill retail) TENDER CARE LANOLIN (capsaicin) CREA dibucaine oint ex F QL(57 gm per (Zinc Oxide (Topical)) CVS QL(500 gm per fill retail) ZINC OXIDE, GNP ZINC fill retail) ethyl chloride aero F OXIDE, MEIJER ZINC F OXIDE, RA ZINC OXIDE ETHYL CHLORIDE/FINE OINT STREAM AERO (ethyl F chloride) CA Health & Wellness Preferred Drug List Updated September 1, 2021

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(500 gm per aluminum sulfate & F zinc oxide (topical) oint F calcium acetate pack 20 % fill retail) CALAMINE LOTN F Rosacea Agents (calamine-zinc oxide) (Metronidazole (Topical)) F CALAMINE PHENOLATED ROSADAN CREA LOTN (calamine F (Metronidazole (Topical)) F phenolated) ROSADAN GEL DRYSOL SOLN Limit 50gms F (aluminum chloride) F per azelaic acid gel month;QL(1.67 GNP CALAMINE LOTN F gm daily) (calamine-zinc oxide) metronidazole (topical) F GNP CALAMINE crea 0.75 % PHENOLATED LOTN F (calamine phenolated) metronidazole (topical) F HM CALAMINE LOTN gel 0.75 % F QL(2 gm daily) (calamine-zinc oxide) metronidazole (topical) F HYDRO-LAN CREA gel 1 % F (lanolin (topical)) metronidazole (topical) F lotn 0.75 % lanolin (topical) oint F Scabicides & Pediculicides LANOLOR CREA (lanolin F (Crotamiton) CROTAN F (topical)) LOTN MEIJER CALAMINE LOTN F (Permethrin) BEDDING (calamine-zinc oxide) SPRAY LICE TREATMENT OFF DEEP WOODS AERO QL(170 gm per STEP 3, CVS BEDDING (diethyltoluamide F fill retail) SPRAY LICE (deet)) TREATMENT, CVS LICE/BEDBUG/MITE, GNP F OFF DEEP WOODS DRY QL(113 gm per HOME AERO (diethyltoluamide F fill retail) LICE/BEDBUG/DUST (deet)) MITE SPRAY, SM PX CALAMINE LOTN BEDDING LICE F TREATMENT, STOP LICE, (calamine-zinc oxide) STOP LICE STEP 3 AERO QC CALAMINE LOTN F (Permethrin) CVS LICE (calamine) TREATMENT, GNP LICE SM CALAMINE LOTN TREATMENT, HM LICE F (calamine-zinc oxide) TREATMENT, LICE F TREATMENT, LICE SM CALAMINE TREATMENT CREME PHENOLATED LOTN F RINSE, SB LICE (calamine phenolated) TREATMENT LIQD ULTRATHON INSECT QL(170 gm per (Permethrin) LICE REPELLENT 8 AERO fill retail) F TREATMENT, RA LICE F (diethyltoluamide TREATMENT, SM LICE (deet)) TREATMENT LOTN

CA Health & Wellness Preferred Drug List Updated September 1, 2021

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pyrethrins-Piperonyl LICEMD GEL Butoxide) CVS LICE (pyrethrins-piperonyl F KILLING, EQ LICE butoxide) KILLING MAXIMUM STRENGTH, EQL LICE malathion lotn F KILLING MAXIMUMSTRENGTH, permethrin crea F GNP LICE TREATMENT, HM LICE KILLING RID ESSENTIAL LICE ELIMINATION KIT KIT MAXIMUM STRENGTH, F LICE KILLING MAXIMUM (pyrethrins-piperonyl STRENGTH, LICE F butoxide) KILLING SHAMPOO, RA SCHOOLTIME SHAMPOO LICE MAXIMUM F STRENGTH, RID LICE SHAM (nit remover) KILLING SHAMPOO, SB QL(120 ml per LICE KILLING MAXIMUM spinosad susp F fill retail,240 ml STRENGTH, SM LICE per 30 days KILLING, SM LICE retail) KILLING MAXIMUM Tar Products STRENGTH, STOP LICE MAXIMUM STRENGTH (Coal Tar Extract) CVS SHAM THERAPEUTIC, EQL THERAPEUTIC, SM ANTI- (Pyrethrins-Piperonyl DANDRUFF COAL Butoxide) SB LICE TARTHERAPEUTIC, F TREATMENT, STOP LICE F TERA-GEL TAR, MAXIMUM STRENGTH THERAPEUTIC LIQD SHAMPOO, (Pyrethrins-Piperonyl THERAPEUTIC T+PLUS Butoxide-Permethrin-Nit SHAM Remover) CVS LICE SOLUTION KIT, CVS LICE coal tar extract soln F SOLUTION KIT, LICIDE COMPLETE LICE F DIAGNOSTIC PRODUCTS TREATMENT, RA LICE SOLUTION KIT, SM LICE Diagnostic Tests SOLUTION KIT, STOP Available to LICE COMPLETE LICE ASSURE PLATINUM TEST members in TREATMENT KIT STRIPS STRP (glucose F LTC/SNF CVS LICE SOLUTION KIT blood) only;QL(10 ea 3-STEP KIT (pyrethrins- daily); RX/OTC piperonyl butoxide- F BD VERITOR SYSTEM permethrin-nit remover) FOR RAPID DETECTION OF SARS-COV-2 KIT CO EURAX CREA F (covid-19 antigen test) (crotamiton) BINAXNOW COVID-19 AG RX/OTC LICE B GONE SHAM F CARD HOME TEST KIT CO (vegetable extract) (covid-19 at home test)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BINAXNOW COVID-19 AG FREESTYLE TEST QL(10 ea CARD KIT (covid-19 CO STRIPS STRP (glucose F daily); RX/OTC antigen test) blood) CHEMSTRIP -10 WITH SG GOJJI BLOOD KETONE STRP (multiple urine F TEST STRIPS STRP F tests) (ketone blood test) CHEMSTRIP 10 MD STRP ID NOW COVID-19 F (multiple urine tests) CONTROL SWAB KIT KIT CO CHEMSTRIP 2 GP (covid-19 control test) ID NOW COVID-19 KIT STRIPS STRP (multiple F CO urine tests) (covid-19 test) CHEMSTRIP 5 OB STRP KETONE STRP (acetone F F (multiple urine tests) (urine) test) CHEMSTRIP 7 STRP KETONE TEST STRIPS F (multiple urine tests) STRP (acetone (urine) F test) CHEMSTRIP 9 STRIPS KETOSTIX STRP STRP (multiple urine F F tests) (acetone (urine) test) CHEMSTRIP-K STRP LUCIRA COVID-19 ALL-IN- F ONE TEST KIT KIT (acetone (urine) test) CO (covid-19 at home test) DIASTIX STRP (glucose LYRA DIRECT SARS- urine test-(glucose F COV-2 ASSAY KIT CO oxidase)) (covid-19 test) FORA GTEL BLOOD LYRA SARS-COV-2 KETONE TEST STRIPS F ASSAY KIT (covid-19 CO STRP (ketone blood test) test) NOVA MAX PLUS FREESTYLE INSULINX QL(10 ea KETONE TESTSTRIPS BLOODGLUCOSE TEST daily); RX/OTC F F STRP (ketone blood STRIPS STRP (glucose test) blood) PRECISION XTRA BLOOD QL(10 ea FREESTYLE INSULINX QL(10 ea GLUCOSE TEST STRIPS F daily); RX/OTC BLOODGLUCOSE TEST F daily); RX/OTC STRP (glucose blood) STRP (glucose blood) PRECISION XTRA STRP F FREESTYLE LITE TEST QL(10 ea VI (ketone blood test) STRIPS STRP (glucose F daily); RX/OTC PTS PANELS KETONE blood) TEST STRP (ketone F FREESTYLE PRECISION QL(10 ea blood test) NEO BLOOD GLUCOSE daily); RX/OTC TEST STRIPS STRP F QUICKVUE AT-HOME RX/OTC (glucose blood) COVID-19 TEST KIT CO (covid-19 at home test)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QUICKVUE SARS triamterene & ANTIGEN TEST KIT CO hydrochlorothiazide F (covid-19 antigen test) tabs RELION KETONE TEST Loop Diuretics STRIPS STRP (acetone F (urine) test) bumetanide tabs F SOFIA SARS ANTIGEN furosemide soln or 10 F FIA KIT (covid-19 CO mg/ml, 8 mg/ml antigen test) furosemide tabs or 20 F SOFIA2 SARS ANTIGEN mg, 40 mg, 80 mg FIA KIT (covid-19 CO QL(1 ea daily) antigen test) torsemide tabs 10 mg, F 100 mg, 5 mg XPERT XPRESS SARS- COV-2 KIT (covid-19 CO torsemide tabs 20 mg F test) Potassium Sparing Diuretics DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes amiloride hcl tabs F Digestive Enzymes spironolactone tabs F CREON CPEP (pancrelipase (lipase- F Thiazides and Thiazide-Like Diuretics protease-amylase)) QL(2 ea daily) chlorothiazide tabs 250 F PANCREAZE CPEP mg (pancrelipase (lipase- F QL(4 ea daily) chlorothiazide tabs 500 F protease-amylase)) mg DIURETICS - Drugs to Treat Heart, Circulation chlorthalidone tabs F Conditions and Blood Pressure Carbonic Anhydrase Inhibitors hydrochlorothiazide F caps acetazolamide cp12 F hydrochlorothiazide F acetazolamide tabs F tabs indapamide tabs F methazolamide tabs F F Diuretic Combinations metolazone tabs amiloride & QL(1 ea daily) ENDOCRINE AND METABOLIC AGENTS - hydrochlorothiazide F MISC. - Drugs to Treat Bone Disease and tabs Regulate Hormones spironolactone & Bone Density Regulators F QL(10.8 ml hydrochlorothiazide alendronate sodium F tabs soln 70 mg/75ml daily) triamterene & alendronate sodium QL(1 ea daily) hydrochlorothiazide F tabs 10 mg, 40 mg, 5 F caps mg CA Health & Wellness Preferred Drug List Updated September 1, 2021

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.15 ea PA; SP- alendronate sodium F NORDITROPIN FLEXPRO tabs 35 mg, 70 mg daily) F AcariaHealth;S SOPN (somatropin) P calcitonin (salmon) soln QL(2 ml per 30 F days retail) OMNITROPE SOCT 10 PA; SP- ij 200 unit/ml MG/1.5ML, 5 MG/1.5ML F AcariaHealth;S P calcitonin (salmon) soln F (somatropin) na 200 unit/act ZOMACTON SOLR 5 MG PA; SP- F AcariaHealth;S etidronate disodium F (somatropin) tabs P FOSAMAX PLUS D TABS Limit 4 per Hormone Receptor Modulators month;QL(0.15 (alendronate sodium- F raloxifene hcl tabs F cholecalciferol) ea daily) PA; QL(1 ea LHRH/GnRH Agonist Analog Pituitary risedronate sodium F tabs 30 mg, 5 mg daily) FENSOLVI KIT PA; SP- AcariaHealth;S PA; QL(0.15 ea (leuprolide acetate F risedronate sodium F P tabs 35 mg daily) (cpp) (6 month)) risedronate sodium LUPRON DEPOT-PED (1- PA; SP- F MONTH) KIT (leuprolide F AcariaHealth;S tbec 35 mg acetate (cpp)) P zoledronic acid conc 4 PA; SP- PA; SP- F AcariaHealth;S LUPRON DEPOT-PED (3- AcariaHealth;S mg/5ml P MONTH) KIT (leuprolide F acetate (cpp) (3 month)) P ZOLEDRONIC ACID SOLN PA; SP- 4 MG/100ML (zoledronic F AcariaHealth;S SUPPRELIN LA KIT PA; SP- P F AcariaHealth;S acid) (histrelin acetate (cpp)) P zoledronic acid soln 4 PA; SP- SP- F AcariaHealth;S SYNAREL SOLN mg/100ml, 5 mg/100ml F AcariaHealth;S P (nafarelin acetate) P ZOLEDRONIC ACID SOLR PA F Metabolic Modifiers 4 MG (zoledronic acid) ALDURAZYME SOLN PA; SP- Corticotropin F AcariaHealth;S ( ) ACTHAR GEL PA; SP- laronidase P F (corticotropin) Caremark;SP calcitriol caps or 0.25 F Growth Hormones mcg, 0.5 mcg GENOTROPIN SOLR 5 PA; SP- calcitriol soln or 1 F F AcariaHealth;S MG (somatropin) mcg/ml P CARBAGLU TABS SP-Accredo;SP F HUMATROPE COMBO PA; SP- (carglumic acid) PACK SOLR F AcariaHealth;S PA (somatropin) P cinacalcet hcl tabs 30 F mg PA; SP- HUMATROPE SOLR PA; SP F AcariaHealth;S cinacalcet hcl tabs 60 F (somatropin) P mg, 90 mg

CA Health & Wellness Preferred Drug List Updated September 1, 2021

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FABRAZYME SOLR PA; SP- Prolactin Inhibitors F AcariaHealth;S (agalsidase beta) P cabergoline tabs F levocarnitine (metabolic F Vasopressin Receptor Antagonists modifiers) soln JYNARQUE TABS 15 MG, QL(1 ea daily); F levocarnitine (metabolic F 30 MG (tolvaptan) SP modifiers) tabs JYNARQUE TBPK 15 MG, PA F LUMIZYME SOLR PA; SP- (tolvaptan) F AcariaHealth;S (alglucosidase alfa) P F QL(1 ea daily); tolvaptan tabs SP NAGLAZYME SOLN PA; SP- F (galsulfase) Accredo;SP ESTROGENS - Hormone Replacement/Modifying Drugs paricalcitol caps F Estrogen Combinations sapropterin (Estradiol & Norethindrone QL(1 ea daily) dihydrochloride pack F Acetate) AMABELZ, F 100 mg LOPREEZA, MIMVEY, MIMVEY LO TABS SP-Caremark sapropterin (Norethindrone Acetate- dihydrochloride pack F Ethinyl Estradiol) F 500 mg FYAVOLV, JINTELI TABS sapropterin SP-Caremark CLIMARA PRO PTWK Limit 4 per 28 dihydrochloride tabs F (estradiol- F days;QL(0.15 100 mg levonorgestrel) ea daily) XURIDEN PACK ( AL(At least 21 COMBIPATCH PTTW QL(0.29 ea uridine F triacetate) yrs old) (estradiol & F daily) norethindrone acetate) Posterior Pituitary Hormones QL(1 ea daily) DDAVP SOLN NA 0.01 % estradiol & (desmopressin acetate F norethindrone acetate F refrigerated) tabs DESMOPRESSIN PA; SP- norethindrone acetate- F ACETATE SOLN NA 1.5 AcariaHealth;S ethinyl estradiol tabs F MG/ML (desmopressin P PREMPHASE TABS acetate) (conjugated estrogens- medroxyprogesterone F desmopressin acetate F spray refrigerated soln acetate) PREMPRO TABS desmopressin acetate F spray soln (conjugated estrogens- medroxyprogesterone F desmopressin acetate F acetate) tabs or 0.1 mg, 0.2 mg Estrogens STIMATE SOLN PA; SP- F AcariaHealth;S (Estradiol) DOTTI, F QL(0.29 ea (desmopressin acetate) P LYLLANA PTTW daily)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F QL(0.29 ea (Simethicone) CVS GAS QL(30 ml per ALORA PTTW (estradiol) daily) RELIEF DROPS EXTRA fill retail) estradiol pttw td 0.025 QL(0.29 ea STRENGTH, GAS RELIEF daily) INFANTS, GAS-X INFANT F mg/24hr, 0.0375 DROPS, SIMETHICONE mg/24hr, 0.05 mg/24hr, F DROPS INFANTS, TGT 0.075 mg/24hr, 0.1 GAS RELIEF INFANTS mg/24hr DROPS LIQD estradiol ptwk td 0.025 QL(0.143 ea (Simethicone) CVS GAS QL(60 ml per mg/24hr, 0.05 mg/24hr, daily) RELIEF INFANTS, CVS fill retail) INFANTS GAS RELIEF, F 0.06 mg/24hr, 0.075 EQ INFANTS GAS mg/24hr, 0.1 mg/24hr, RELIEF, EQL INFANTS 37.5 mcg/24hr GAS RELIEF, GAS estradiol tabs or 0.5 RELIEF DROPS INFANTS, F GAS RELIEF INFANTS, mg, 1 mg, 2 mg GNP INFANT GAS MENEST TABS F RELIEF, GNP INFANTS (esterified estrogens) GAS RELIEF, HM GAS PREMARIN TABS OR 0.3 RELIEF INFANTS, MG, 0.45 MG, 0.625 MG, INFANTS GAS RELIEF, F 0.9 MG, 1.25 MG F INFANTS SIMETHICONE, (estrogens, conjugated) LITTLE REMEDIES FOR TUMMYS GAS RELIEF, FLUOROQUINOLONES - Drugs to Treat Bacterial LITTLE TUMMYS GAS Infections RELIEF, MOMMYS BLISS GAS RELIEF DROPS, Fluoroquinolones PEDIACARE GAS RELIEF CIPRO SUSR 5 DROPS INFANTS, PX GM/100ML, 500 MG/5ML F GAS RELIEF INFANTS, (ciprofloxacin) SIMEPED, SM GAS RELIEF DROPS INFANTS, ciprofloxacin hcl tabs F SM GAS RELIEF INFANTS DROPS SUSP ciprofloxacin susr F levofloxacin soln 25 F mg/ml QL(14 ea per levofloxacin tabs 250 F mg, 500 mg, 750 mg fill retail) ofloxacin tabs 300 mg F

F QL(56 ea per ofloxacin tabs 400 mg fill retail) GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs Antiflatulents

CA Health & Wellness Preferred Drug List Updated September 1, 2021

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Simethicone) CVS GAS (Simethicone) EQL GAS RELIEF, CVS GAS RELIEF RELIEF, GAS-X EXTRA F EXTRA STRENGTH, DRX STRENGTH CAPS 125 CHOICE GAS RELIEF, EQ MG GAS RELIEF EXTRA (Simethicone) GAS F STRENGTH, EQL GAS RELIEF CHEW 80 MG GONE EXTRA STRENGTH, GAS RELIEF (Simethicone) PHAZYME, EXTRA STRENGTH, GNP SB GAS RELIEF CHEW F GAS RELIEF, GNP GAS 125 MG RELIEF EXTRA (Simethicone) SB GAS QL(60 ml per STRENGTH, F RELIEF SUSP 40 F fill retail) GOODSENSE GAS MG/0.6ML RELIEF EXTRA (Simethicone) SM GAS STRENGTH, HM GAS RELIEF CHEW 125 MG, F RELIEF, MI-ACID GAS 80 MG RELIEF, QC GAS RELIEF, QC GAS RELIEF EXTRA simethicone caps 125 F STRENGTH, RA GAS mg RELIEF, RA GAS RELIEF simethicone chew 125 F EXTRA STRENGTH, TGT mg, 80 mg GAS RELIEF EXTRA STRENGTH CHEW simethicone susp 40 QL(60 ml per F fill retail) (Simethicone) CVS GAS mg/0.6ml RELIEF, CVS GAS RELIEF Bile Acid Synthesis Disorder Agents EXTRA STRENGTH, EQ CHOLBAM CAPS (cholic PA; QL(5 ea GAS RELIEF, EQL GAS F daily); SP RELIEF EXTRA acid) STRENGTH, GAS RELIEF Gallstone Solubilizing Agents EXTRA STRENGTH, GNP GAS RELIEF EXTRA ursodiol caps 300 mg F STRENGTH, HM GAS RELIEF EXTRA ursodiol tabs 250 mg F STRENGTH, PX GAS F RELIEF EXTRA Gastrointestinal Antiallergy Agents STRENGTH, QC GAS cromolyn sodium F RELIEF, QC GAS RELIEF (mastocytosis) conc EXTRA STRENGTH, RA GAS RELIEF, RA GAS Gastrointestinal Chloride Channel Activators RELIEF EXTRA PA STRENGTH, SM GAS lubiprostone caps F RELIEF EXTRA STRENGTH, TGT GAS Gastrointestinal Stimulants RELIEF EXTRA metoclopramide hcl STRENGTH CAPS soln 10 mg/10ml, 5 F (Simethicone) EQL GAS QL(60 ml per mg/5ml RELIEF, GAS RELIEF F fill retail) metoclopramide hcl F SUSP 20 MG/0.3ML tabs 10 mg, 5 mg Inflammatory Bowel Agents

CA Health & Wellness Preferred Drug List Updated September 1, 2021

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits balsalazide disodium F calcium acetate caps (phosphate binder) F caps ENTYVIO SOLR PA; SP- F AcariaHealth;S (vedolizumab) GENITOURINARY AGENTS - MISCELLANEOUS P - Miscellaneous Drugs to Treat Reproductive INFLECTRA SOLR PA; SP- Organs and Urinary System F AcariaHealth;S (infliximab-dyyb) P Alkalinizers mesalamine cp24 or (Potassium Citrate-Citric F Acid) CYTRA K F 0.375 gm CRYSTALS, TARON- QL(12 ea daily) CRYSTALS PACK mesalamine cpdr or F 400 mg ORACIT SOLN ( sodium F citrate & citric acid) mesalamine enem re 4 F gm potassium citrate (alkalinizer) tbcr 10 F mesalamine tbec or 1.2 F gm, 800 mg meq, 1080 mg, 540 mg QL(4 ea per 28 sodium citrate & citric RX/OTC mesalamine w/ F cleanser kit days retail) acid soln 334 mg/5ml- 334 mg/5ml-500 REMICADE SOLR PA; SP- F F AcariaHealth;S mg/5ml-500 mg/5ml, (infliximab) P 334 mg/5ml-500 RENFLEXIS SOLR PA; SP- mg/5ml F AcariaHealth;S (infliximab-abda) P Genitourinary Irrigants SFROWASA ENEM (Sodium Chloride (Gu F Irrigant)) ARGYLE F (mesalamine) STERILE SALINE, CURITY STELARA SOLN PA; SP- STERILE SALINE SOLN F AcariaHealth;S (ustekinumab (iv)) P acetic acid soln F sulfasalazine tabs F sodium chloride (gu F irrigant) soln sulfasalazine tbec F Interstitial Cystitis Agents Intestinal Acidifiers ELMIRON CAPS QL(3 ea daily) (Lactulose (pentosan polysulfate F sodium) (Encephalopathy)) F ENULOSE, GENERLAC Prostatic Hypertrophy Agents SOLN alfuzosin hcl tb24 F lactulose F (encephalopathy) soln dutasteride-tamsulosin F Peripheral Opioid Receptor Antagonists hcl caps MOVANTIK TABS PA F finasteride tabs F (naloxegol oxalate) Phosphate Binder Agents CA Health & Wellness Preferred Drug List Updated September 1, 2021

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tamsulosin hcl caps F ALPHANATE SOLR (antihemophilic Urinary Analgesics factor/von willebrand CO factor complex (Phenazopyridine Hcl) F PHENAZO TABS 200 MG (human)) ALPHANATE/VON phenazopyridine hcl F tabs WILLEBRANDFACTOR COMPLEX/HUMAN SOLR Urinary Stone Agents (antihemophilic CO tiopronin tabs F SP factor/von willebrand factor complex GOUT AGENTS - Drugs to Treat Gout (human)) ALPHANINE SD SOLR Gout Agent Combinations CO (coagulation factor ix) colchicine w/ F probenecid tabs ALPROLIX SOLR (coagulation factor ix CO Gout Agents (recomb) fc fusion protein allopurinol tabs F (rfixfc)) BENEFIX KIT colchicine tabs F (coagulation factor ix CO (recombinant)) KRYSTEXXA SOLN PA; SP- F AcariaHealth;S COAGADEX SOLR (pegloticase) P (coagulation factor x CO Uricosurics (human)) CORIFACT KIT (factor probenecid tabs F xiii concentrate CO HEMATOLOGICAL AGENTS - MISC. - Drugs to (human)) Treat Blood Disorders ELOCTATE SOLR Antihemophilic Products (antihemophilic factor CO ADVATE SOLR (rcmb) fc fusion protein(bdd-rfviiifc)) (antihemophilic factor CO (rcmb) plasma/albumin FEIBA SOLR free (rahf-pfm)) (antiinhibitor coagulant CO ADYNOVATE SOLR complex) (antihemophilic factor CO FIBRYGA SOLR (recombinant) pegylated) (fibrinogen concentrate CO AFSTYLA KIT (human)) HELIXATE FS KIT (antihemophilic factor CO (recombinant) single (antihemophilic factor CO chain) (recombinant) (rfviii)) HEMLIBRA SOLN CO (emicizumab-kxwh)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEMOFIL M SOLR NUWIQ KIT (antihemophilic factor CO (antihemophilic factor CO (human)) (rcmb) simoctocog HUMATE-P SOLR alfa(bdd-rfviii,sim)) (antihemophilic NUWIQ SOLR factor/von willebrand CO (antihemophilic factor CO factor complex (rcmb) simoctocog (human)) alfa(bdd-rfviii,sim)) IDELVION SOLR OBIZUR SOLR (coagulation factor ix (antihemophilic factor CO recomb albumin fusion CO (recombinant porcine) (rpfviii)) protein (rix-fp)) PROFILNINE SD SOLR IXINITY SOLR CO (factor ix complex) (coagulation factor ix CO PROFILNINE SOLR (recombinant)) CO (factor ix complex) JIVI SOLR (antihemophil SP REBINYN SOLR fact(rcmb) pegylated-aucl CO (bdd-rfviii peg-aucl)) (coagulation factor ix CO (recombinant) KCENTRA KIT glycopegylated) (prothrombin complex CO RECOMBINATE SOLR concentrate human) (antihemophilic factor CO KOATE SOLR (recombinant) (rfviii)) (antihemophilic factor CO RIASTAP SOLR (human)) (fibrinogen concentrate CO KOATE-DVI SOLR (human)) (antihemophilic factor CO RIXUBIS SOLR (human)) (coagulation factor ix CO KOGENATE FS KIT (recombinant)) (antihemophilic factor CO SEVENFACT SOLR (recombinant) (rfviii)) (coagulation factor viia CO KOVALTRY SOLR (recombinant)-jncw) (antihemophilic factor CO TRETTEN SOLR (rcmb) plasma/albumin free (rahf-pfm)) (coagulation factor xiii a-subunit CO MONONINE SOLR CO (recombinant)) (coagulation factor ix) NOVOEIGHT SOLR VONVENDI SOLR (von willebrand factor CO (antihemophilic factor CO (rcmb) bd truncated (bd (recombinant)) trunc-rfviii)) WILATE KIT NOVOSEVEN RT SOLR (antihemophilic (coagulation factor viia CO factor/von willebrand CO (recombinant)) factor complex (human)) CA Health & Wellness Preferred Drug List Updated September 1, 2021

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XYNTHA KIT DROXIA CAPS (antihemophilic factor CO (hydroxyurea (sickle F (rcmb) moroctocog cell anemia)) alfa(bdd-rfviii,mor)) Cobalamins XYNTHA SOLOFUSE KIT cyanocobalamin soln ij (antihemophilic factor CO F (rcmb) moroctocog 1000 mcg/ml alfa(bdd-rfviii,mor)) cyanocobalamin tabs or F Complement Inhibitors 250 mcg CINRYZE SOLR (c1 PA; SP- Folic Acid/Folates esterase inhibitor F Caremark;SP (Folic Acid) CVS FOLIC (human)) ACID, FOLATE, GNP FOLIC ACID, HM FOLIC SOLIRIS SOLN PA; SP- ACID, PX FOLIC ACID, QC F F AcariaHealth;S (eculizumab) FOLIC ACID, RA FOLIC P ACID, SM FOLIC ACID, YL Hematorheologic Agents FOLIC ACID TABS pentoxifylline tbcr F (Folic Acid) FA-8 CAPS F Platelet Aggregation Inhibitors (Folic Acid) KP FOLIC F RX/OTC ACID TABS 1 MG anagrelide hcl caps F (Folic Acid) KP FOLIC F BRILINTA TABS ACID TABS 800 MCG F FOLIC ACID CAPS OR 20 (ticagrelor) F MG, 5 MG (folic acid) cilostazol tabs F folic acid caps or 800 F mcg clopidogrel bisulfate F tabs 300 mg folic acid tabs or 1 mg F RX/OTC QL(1 ea daily) clopidogrel bisulfate F tabs 75 mg folic acid tabs or 400 F mcg, 800 mcg dipyridamole tabs F Hematopoietic Growth Factors prasugrel hcl tabs F QL(1 ea daily) ARANESP ALBUMIN PA; SP- FREE SOLN F AcariaHealth;S ZONTIVITY TABS F (darbepoetin alfa) P (vorapaxar sulfate) ARANESP ALBUMIN PA; SP- HEMATOPOIETIC AGENTS - Drugs to Treat FREE SOSY F AcariaHealth;S Blood Disorders (darbepoetin alfa) P NPLATE SOLR 250 MCG, PA; SP- Agents for Gaucher Disease F CEREZYME SOLR PA; SP- 500 MCG (romiplostim) AcariaHealth F (imiglucerase) AcariaHealth PROMACTA PACK 12.5 PA; SP- VPRIV SOLR PA; SP- MG (eltrombopag F AcariaHealth;A F AcariaHealth L(At least 21 (velaglucerase alfa) olamine) yrs old) Agents for Sickle Cell Disease

CA Health & Wellness Preferred Drug List Updated September 1, 2021

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP- Acaria (Ferrous Sulfate) PROMACTA PACK 25 MG F Health;AL(At BPROTECTED PEDIA (eltrombopag olamine) least 21 yrs IRON, FE-VITE IRON, old); SP IRON SUPPLEMENT F PA; SP- Acaria CHILDRENS, PC PROMACTA TABS 12.5 PEDIATRIC IRON DROPS MG, 25 MG, 50 MG, 75 MG F Health;AL(At least 21 yrs SOLN (eltrombopag olamine) old); SP (Ferrous Sulfate) CVS RETACRIT SOLN 10000 SP- IRON, EQL IRON UNIT/ML, 2000 UNIT/ML, AcariaHealth;S SUPPLEMENT THERAPY, 20000 UNIT/2ML, 3000 P FEROSUL, FERROUSUL, F UNIT/ML, 4000 UNIT/ML, GOODSENSE IRON, KP F 40000 UNIT/ML (epoetin FERROUS SULFATE, MEIJER FERROUS alfa-epbx) SULFATE, NAT-RUL RETACRIT SOLN 20000 SP- IRON, QC FERROUS UNIT/ML (epoetin alfa- F AcariaHealth SULFATE, SM IRON TABS ) ;SP epbx (Ferrous Sulfate) FE TABS F TBEC ZARXIO SOSY PA; SP- F AcariaHealth;S (Ferrous Sulfate) IRON F (filgrastim-sndz) P SUPPLEMENT ELIX Hematopoietic Mixtures (Ferrous Sulfate) RA IRON F TABS 325 MG (Ferrous Fumarate-Fa-B QL(1 ea daily) Complex-C-Zn-Mg-Mn-Cu) (Ferrous Sulfate) SLOW RELEASE IRON TBCR 50 F FERROCITE PLUS, F HEMATINIC PLUS MG VITAMINS/MINERALS, (Polysaccharide Iron HEMOCYTE-PLUS TABS Complex) FERREX 150, (Iron Combinations) RX/OTC FERRIC X-150, MYFERON F 150, NU-IRON 150, POLY- CHROMAGEN, F HEMATOGEN, IRON IRON 150 CAPS COMPLEX CAPS FERRETTS TABS F Iron (ferrous fumarate) ferrous fumarate tabs (Ferrous Fumarate) F F FERROCITE TABS 324 mg (Ferrous Gluconate) CVS ferrous gluconate tabs F IRON, FERATE, FERGON, F 240 mg, 27 mg FERROTABS, IRON 27 TABS FERROUS GLUCONATE (Ferrous Sulfate Dried) TABS 324 MG (ferrous F EQL SLOW RELEASE F gluconate) IRON, SLOW IRON TBCR ferrous sulfate elix 220 F (Ferrous Sulfate Dried) mg/5ml SLOW RELEASE IRON, F FERROUS SULFATE LIQD SM IRON SLOW RELEASE TBCR 160 MG 220 MG/5ML (ferrous F sulfate)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl ferrous sulfate soln 15 F mg/ml (Sleep)) COMPOZ, CVS SLEEP AID ferrous sulfate syrp 300 F NIGHTTIME/MAXIMUM mg/5ml STRENGTH, EQ ferrous sulfate tabs 28 NIGHTTIME SLEEP AID F MAXIMUM STRENGTH, mg, 325 mg, 65 mg EQL SLEEP AID ferrous sulfate tbcr 50 F MAXIMUM STRENGTH, mg GOODSENSE SLEEP AID, FERROUS SULFATE ORMIR, QC SLEEP AID F MAXIMUM STRENGTH, TBEC 324 MG (ferrous F QC SLEEP-AID MAXIMUM sulfate) STRENGTH, RA SLEEP AID MAXIMUM ferrous sulfate tbec 325 F mg STRENGTH, SM SLEEP AID MAXIMUM IRON CHEWS PEDIATRIC F STRENGTH, TGT SLEEP CHEW (carbonyl iron) AID MAXIMUM STRENGTH, WAL-SOM polysaccharide iron F complex caps MAXIMUM STRENGTH CAPS HEMOSTATICS - Drugs to Stop Bleeding/Treat (Diphenhydramine Hcl Blood Disorders (Sleep)) COMPOZ, CVS Hemostatics - Systemic SLEEP AID, CVS SLEEP AID NIGHTTIME, EQL aminocaproic acid soln SP- F AcariaHealth;S NIGHTTIME SLEEP AID, 0.25 gm/ml P GNP NIGHTTIME SLEEP AID, GNP SLEEP AID aminocaproic acid tabs SP- NIGHTTIME, HM F AcariaHealth;S 500 mg NIGHTTIME SLEEP AID, P NIGHT TIME SLEEP AID, tranexamic acid tabs F NIGHTTIME SLEEP AID, F NIGHTTIME SLEEP-AID, HYPNOTICS/SEDATIVES/SLEEP DISORDER NYTOL, QC REST AGENTS SIMPLY, RA NIGHTTIME SLEEP AID, RA SLEEP Antihistamine Hypnotics AID, SB SLEEP, SIMPLY SLEEP, SLEEP II, SLEEP TABS, SLEEP-TABS, SM NIGHTTIME SLEEP AID, SM SLEEP AID NIGHT TIME, TGT NIGHTTIME SLEEP AID TABS (Diphenhydramine Hcl (Sleep)) CVS SLEEP-AID F NIGHTTIME, SLEEP AID TABS 25 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl QL(1 ea daily) zolpidem tartrate tabs F (Sleep)) CVS SLEEP-AID F or 10 mg, 5 mg NIGHTTIME, SLEEP AID, SLEEP-AID CAPS 50 MG LAXATIVES - Bowel Treatment Drugs (Doxylamine Succinate Bulk Laxatives (Sleep)) CVS SLEEP-AID F NIGHTTIME, SLEEP AID, (Calcium Polycarbophil) SLEEP-AID TABS 25 MG CVS FIBER LAXATIVE, (Doxylamine Succinate EQL FIBER LAXATIVE, (Sleep)) CVS ULTRA FIBER LAXATIVE, FIBER- SLEEP, EQL NIGHTTIME LAX, GNP FIBER-CAPS, F SLEEP AID, GNP SLEEP KONSYL FIBER, PX AID, HM SLEEP AID, KLS F FIBER, RA FIBER SLEEP AID, RA NIGHT THERAPY, SB FIBER SLEEP AID, RA SLEEP LAXATIVE, TGT FIBER AID, SM SLEEP AID, WAL- LAXATIVE TABS SOM TABS (Calcium Polycarbophil) EQ FIBER THERAPY, SM F diphenhydramine hcl F FIBER TABS 625 MG (sleep) tabs (Methylcellulose (Laxative)) F Barbiturate Hypnotics SOLUBLE FIBER POWD phenobarbital elix F (Psyllium) CVS DAILY FIBER, EQ FIBER F phenobarbital soln F THERAPY, REGULOID CAPS 0.52 GM phenobarbital tabs F (Psyllium) CVS FIBER, FIBER LAXATIVE, GNP Non-Barbiturate Hypnotics NATURAL FIBER, MEDI- MUCIL, PX FIBER, QC estazolam tabs F FIBER LAXATIVE, RA F PA; QL(1 ea FIBER, RA FIBER eszopiclone tabs F daily); AL(Up to THERAPY, TGT 64 yrs old ) PSYLLIUM FIBER, WAL- MUCIL CAPS flurazepam hcl caps F midazolam hcl soln ij 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 F mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml temazepam caps F triazolam tabs F QL(1 ea daily); zaleplon caps F AL(At least 18 yrs old)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Psyllium) CVS NATURAL (Psyllium) KONSYL POWD F DAILY FIBER, EQL 30.9 % NATURAL FIBER, EQL (Psyllium) REGULOID SMOOTH TEXTURE POWD 25 %, 28.3 %, F FIBERSUPPLEMENT, 48.57 %, 51.7 %, 58.6 % GERI-MUCIL, GNP NATURAL FIBER, (Psyllium) SM FIBER GOODSENSE NATURAL POWD 28.3 %, 48.57 %, F FIBER, GOODSENSE 51.7 %, 58.6 % PSYLLIUM FIBER, HM calcium polycarbophil F FIBER POWDER, KLS tabs NATURAL PSYLLIUM CVS DAILY FIBER PACK FIBER, METAMUCIL F SMOOTH TEXTURE, 58.6 % (psyllium) METAMUCIL SMOOTH CVS NATURAL FIBER SUPPLEMENT PACK 58.6 F TEXTURESUGAR FREE, F NATURAL FIBER, % (psyllium) NATURAL FIBER DAILY FIBER PACK 51.7 LAXATIVE, NATURAL F FIBER THERAPY, % (psyllium) EQUALACTIN CHEW NATURAL PSYLLIUM F SEED INDIAN HUSKS, (calcium polycarbophil) NATURAL VEGETABLE HYDROCIL INSTANT F FIBER, PSYLDEX, QC PACK (psyllium) NATURAL VEGETABLE, RA MULTIHEALTH FIBER KONSYL DAILY FIBER SUPPLEMENT, SB FIB PACK 100 %, 28.3 %, 60.3 F LAX ORANGE, SB FIBER % (psyllium) LAXATIVE, SB NATURAL KONSYL DAILY FIBER F FIBER LAXATIVE, TGT POWD 60.3 % (psyllium) FIBER THERAPY, WAL- KONSYL ORIGINAL DAILY MUCIL POWD F (Psyllium) CVS NATURAL FIBER PACK (psyllium) FIBER SUPPLEMENT F KONSYL PACK 60.3 % F POWD 100 % (psyllium) (Psyllium) EQ DAILY KONSYL POWD 60.3 %, F F FIBER POWD 51.7 % 71.67 % (psyllium) (Psyllium) EQL FIBER KONSYL-D POWD F F THERAPY POWD 28.3 %, ( ) 48.57 % psyllium METAMUCIL CAPS 0.36 (Psyllium) FIBER F THERAPY, SM FIBER F GM (psyllium) POWDER POWD 25 % METAMUCIL FIBER PACK F (Psyllium) HM FIBER (psyllium) POWD 28.3 %, 30.9 %, F METAMUCIL PACK 28 % F 51.7 %, 58.6 % (psyllium) (Psyllium) KONSYL DAILY METAMUCIL WAFR FIBER, METAMUCIL F F POWD 28.3 % (psyllium)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits psyllium caps F (Sennosides-Docusate Sodium) COLACE 2-IN-1, psyllium powd F CVS SENNA PLUS, CVS STOOL SOFTENER PLUS SM FIBER POWDER STIMULANT LAXATIVE, F POWD 27 % (psyllium) DOCUZEN, DOK PLUS, EASY-LAX PLUS, EQ UNIFIBER POWD F SENNA-S, EQ STOOL (cellulose) SOFTENER/STIMULANT Laxative Combinations LAXATIVE, EQL SENNA- S, EQL STOOL (Peg 3350-Kcl-Sod Bicarb- SOFTENER/STIMULANT Sod Chloride-Sod Sulfate) F LAXATIVE, EQL STOOL GAVILYTE-C, GAVILYTE- SOFTENER/STIMULANT G SOLR LAXATIVE OVERNIGHT (Peg 3350-Potassium RELIEF, GNP SENNA Chloride-Sod Bicarbonate- PLUS, GNP STOOL Sod Chloride) GAVILYTE- F SOFTENER/STIMULANT N/FLAVOR PACK, LAXATIVE, GOODSENSE TRILYTE SOLR STIMULANT LAXATIVE PLUS, HM SENNA-S, HM STOOL SOFTENER/LAXATIVE, HM STOOL SOFTENER/STIMULANT LAXATIVE, LAXACIN, F MEDI-NATURAL PLUS, QC SENNA-S, QC STOOL SOFTENER PLUS LAXATIVE, QC STOOL SOFTENER PLUS STIMULANT LAXATIVE, RA 2-IN-1 LAXATIVE/STOOLSOFTE NER, RA LAXATIVE & STOOL SOFTENER, RA P COL-RITE, RA SENNA PLUS, SB DOCUSATE SODIUM/SENNA, SENEXON-S, SENNA PLUS, SENNA S, SENNA- PLUS, SENNA-S, SENNA- TIME S, SM NATURAL LAXATIVE PLUSSTOOL SOFTENER, SM SENNA- S, SM STOOL SOFTENER, SM STOOL SOFTENER PLUS LAXATIVE, SM STOOL SOFTENER/STIMULANT LAXATIVE, STIMULANT LAXATIVE, STOOL CA Health & Wellness Preferred Drug List Updated September 1, 2021

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOFTENER + STIMULANT (Polyethylene Glycol 3350) QL(34 gm LAXATIVE, STOOL CLEARLAX, EQ daily) SOFTENER LAXATIVE, CLEARLAX, EQL STOOL SOFTENER PLUS CLEARLAX, GAVILAX, LAXATIVE, STOOL GENTLELAX, GLYCOLAX, SOFTENER PLUS GOODSENSE CLEARLAX, F STIMULANT LAXATIVE, KLS LAXACLEAR, MM STOOL CLEARLAX, QC NATURA- SOFTENER/LAXATIVE, LAX, SB POLYETHYLENE TGT SENNA LAXATIVE, GLYCOL 3350, SM TGT SENNA CLEARLAX POWD LAXATIVE/STOOLSOFTE (Polyethylene Glycol 3350) QL(34 gm NER, TGT STOOL CVS PURELAX POWD 17 F daily) SOFTENER & GM/SCOOP, STIMULANT LAXATIVE, VEGETABLE (Polyethylene Glycol 3350) LAXATIVE+STOOLSOFTE CVS PURELAX, GNP NER TABS CLEARLAX, HM F CLEARLAX, SMOOTH GOLYTELY SOLR 2.82 LAX, TGT POWDERLAX GM-5.53 GM-6.36 GM-21.5 PACK 17 GM GM-227.1 GM (peg 3350- F (Polyethylene Glycol 3350) QL(34 gm kcl-sod bicarb-sod GNP CLEARLAX, HM daily) chloride-sod sulfate) CLEARLAX, RA F peg 3350-kcl-sod LAXATIVE, SMOOTH LAX, TGT POWDERLAX POWD F bicarb-sod chloride-sod 17 GM/SCOOP sulfate solr (Polyethylene Glycol 3350) F peg 3350-potassium HEALTHYLAX PACK chloride-sod F FLEET LIQUID GLYCERIN bicarbonate-sod SUPPOSITORIES ENEM F chloride solr (glycerin (laxative)) sennosides-docusate F glycerin (laxative) supp F sodium tabs 2 gm Laxatives - Miscellaneous lactulose soln 10 F (Glycerin (Laxative)) gm/15ml, 20 gm/30ml AVEDANA GLYCERIN F polyethylene glycol F (ADULT), GLYCERIN 3350 pack 17 gm ADULT SUPP polyethylene glycol QL(34 gm (Glycerin (Laxative)) CVS daily) GLYCERIN ADULT SUPP F 3350 powd 17 F 2 GM gm/scoop (Lactulose) CONSTULOSE SORBITOL SOLN OR 70 F F SOLN % (sorbitol (laxative)) Saline Laxatives

CA Health & Wellness Preferred Drug List Updated September 1, 2021

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Magnesium Citrate) (Sodium Phosphates) CVS CITROMA, CVS CITRATE ENEMA DISPOSABLE, OF MAGNESIA, CVS CVS ENEMA READY-TO- MAGNESIUM CITRATE, USE, ENEMA EQ MAGNESIUM DISPOSABLE, ENEMA CITRATE, EQL READY-TO-USE, EQ MAGNESIUM CITRATE, ENEMA, EQL READY-TO- GNP MAGNESIUM USE ENEMA, GNP CITRATE, GOODSENSE F ENEMA, GOODSENSE F MAGNESIUM CITRATE, READY TO USE ENEMA, HM MAGNESIUM HM ENEMA READY-TO- CITRATE, QC USE, HM ENEMA SALINE MAGNESIUM CITRATE, LAXATIVE, PEDIATRIC RA MAGNESIUM ENEMA, PURE & GENTLE CITRATE, SB ENEMA, QC ENEMA, RA MAGNESIUM CITRATE, ENEMA, RA SALINE SM MAGNESIUM ENEMA, SM ENEMA, TGT CITRATE SOLN SALINE LAXATIVE ENEM (Magnesium Hydroxide) magnesium citrate soln F CVS MILK OF MAGNESIA, 1.745 gm/30ml, DULCOLAX LIQUID, DULCOLAX MILK OF PHILLIPS MILK OF MAGNESIA CHEWABLE MAGNESIA, EQL MILK OF F MAGNESIA, GNP MILK OF CHEW (magnesium MAGNESIA, HM MILK OF hydroxide) MAGNESIA, MILK OF F PHILLIPS MILK OF MAGNESIA, MILK OF MAGNESIA MAGNESIA CONCENTRATED SUSP F CONCENTRATE, PX MILK (magnesium hydroxide) OF MAGNESIA, QC MILK OF MAGNESIA, RA MILK PHILLIPS MILK OF MAGNESIA SUSP 800 OF MAGNESIA, SB MILK F OF MAGNESIA, SM MILK MG/5ML (magnesium OF MAGNESIA SUSP hydroxide) (Magnesium Hydroxide) sodium phosphates F PHILLIPS MILK OF F enem MAGNESIA SUSP 1200 MG/15ML, 400 MG/5ML Stimulant Laxatives

CA Health & Wellness Preferred Drug List Updated September 1, 2021

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Bisacodyl) ALOPHEN, (Bisacodyl) LAXATIVE, RA F BISACODYL EC, LAXATIVE TBEC 5 MG CORRECT, CORRECTOL, (Bisacodyl) LAXATIVE, RA F CVS BISACODYL, CVS C- LAXATIVE TBEC OR 5 MG LAX LAXATIVE, CVS GENTLE LAXATIVE, CVS (Sennosides) CVS SENNA, GENTLE LAXATIVE DR EDWARDS OLIVE WOMENS, DUCODYL, EQ LAXATIVE, EQ NATURAL GENTLE LAXATIVE, EQL LAXATIVE, EQ NATURAL GENTLE LAXATIVE, EQL VEGETABLE LAXATIVE, LAXATIVE, EQL WOMANS EQL SENNA LAXATIVE, LAXATIVE, EX-LAX GERI-KOT, GNP SENNA ULTRA, FEENAMINT, LAX, GOODSENSE GENTLE LAXATIVE, GNP SENNA LAXATIVE, HM BISA-LAX, GNP GENTLE SENNA, KP SENNA, LAXATIVE, GNP LAXATIVE PILLS WOMENS GENTLE REGULAR STRENGTH, LAXATIVE REGULAR LAXATIVE, GOODSENSE F BISACODYL EC, STRENGTH, MEDI-LAX, GOODSENSE WOMENS MEDI-NATURAL, LAXATIVE, HM LAXATIVE, NATURAL SENNA F KP BISACODYL, PX LAXATIVE, PERDIEM, PX LAXATIVE, QC GENTLE VEGETABLE LAXATIVE, LAXATIVE, RA WOMENS QC NATURAL LAXATIVE, SB VEGETABLE LAXATIVE, BISACODYL LAXATIVE QC SENNA, RA SENNA, EC, SB GENTLE LAX- SB SENNA-LAX, SENNA WOMEN, SM GENTLE LAXATIVE, SENNA LAXATIVE, SM WOMANS REGULAR STRENGTH, LAXATIVE, STIMULANT SENNA SMOOTH, LAXATIVE, TGT GENTLE SENNA-LAX, SENNA- LAXATIVE, TGT WOMENS TABS, SENNA-TIME, LAXATIVE, SENNO, SM SENNA VERACOLATE, WOMANS LAXATIVE, TGT SENNA, LAXATIVE, WOMENS TGT SENNA LAXATIVE LAXATIVE TBEC TABS (Bisacodyl) BISACODYL (Sennosides) EVAC-U- F LAXATIVE, CVS GEN TABS 8.6 MG BISACODYL, CVS bisacodyl supp F GENTLE LAXATIVE, FLEET BISACODYL ENEM GENTLE LAXATIVE, GNP F GENTLE LAXATIVE, HM F (bisacodyl) LAXATIVE, QC GENTLE LAXATIVE, RA FAST sennosides tabs 8.6 mg F RELIEF LAXATIVE, SB LAXATIVE, SM LAXATIVE, Surfactant Laxatives THE MAGIC BULLET SUPP (Bisacodyl) LAXATIVE F SUPP RE 10 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Docusate Calcium) CVS (Docusate Sodium) CVS STOOL SOFTENER, GNP MINI ENEMA KIDS, DOCUSATE CALCIUM, DOCUSATE MINI, F GNP STOOL SOFTENER, DOCUSOL MINI, KAO-TIN, QC DOCUSATE ENEMEEZ MINI ENEM CALCIUM, SB STOOL F (Docusate Sodium) SOFTENER, SM DIOCTO, DOCU, DOCU, DOCUSATE CALCIUM, GNP STOOL SOFTENER, F SM STOOL SOFTENER, SILACE, STOOL STOOL SOFTENER, SOFTENER LIQD SURFAK CAPS (Docusate Sodium) (Docusate Sodium) DIOCTO, GNP STOOL F CORRECTOL EXTRA SOFTENER, SILACE GENTLE, CVS STOOL SYRP SOFTENER, DOCU SOFT, DOCUSIL, DOK, (Docusate Sodium) DOK, DULCOLAX PINK STOOL HEALTHY MAMA MOVE IT SOFTENER, DULCOLAX ALONG, HM STOOL STOOL SOFTENER, SOFTENER, F EASY-LAX, EQ STOOL PROMOLAXIN, SM SOFTENER, EQL STOOL STOOL SOFTENER, SOFTENER, GNP STOOL STOOL SOFTENER TABS SOFTENER, docusate calcium caps F GOODSENSE GENTLE STOOL SOFTENER, HM docusate sodium caps F STOOL SOFTENER, HM STOOL SOFTENER docusate sodium liqd F MAXIMUM STRENGTH, KLS STOOL SOFTENER, F KS STOOL SOFTENER, F docusate sodium syrp LAXA BASIC, MM STOOL SOFTENER LAXATIVE, docusate sodium tabs F PHILLIPS STOOL DOCUSOL PLUS MINI- SOFTENER, PX ENEMA ENEM DOCUSATE SODIUM, QC (benzocaine-docusate F STOOL SOFTENER, RA COL-RITE, RA STOOL sodium) SOFTENER, SB ENEMEEZ PLUS ENEM DOCUSATE SODIUM, SM (benzocaine-docusate F STOOL SOFTENER, sodium) STOOL SOFTENER, STOOL SOFTENER MACROLIDES - Drugs to Treat Bacterial EXTRA STRENGTH, Infections STOOL SOFTENER Azithromycin LAXATIVE, STOOL SOFTENER LAXATIVE azithromycin pack 1 gm F QL(2 ea per fill EXTRA STRENGTH, TGT retail) STOOL SOFTENER CAPS azithromycin susr 100 F mg/5ml, 200 mg/5ml azithromycin tabs 250 F mg, 500 mg, 600 mg CA Health & Wellness Preferred Drug List Updated September 1, 2021

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Clarithromycin BAND-AID ALL-IN-ONE ADHESIVE GAUZE clarithromycin susr F PAD/LARGE PADS F (adhesive bandages) clarithromycin tabs F BAND-AID ALL-IN-ONE ADHESIVE GAUZE clarithromycin tb24 F PAD/MEDIUM PADS F Erythromycins (adhesive bandages) (Erythromycin Base) ERY- BAND-AID GAUZE PADS RX/OTC F LARGE4" X 4" PADS TAB TBEC F (Erythromycin (gauze pads & Ethylsuccinate) E.E.S. 400 F dressings) TABS BAND-AID GAUZE PADS MEDIUM 3" X 3" PADS (Erythromycin Stearate) F ERYTHROCIN STEARATE F (gauze pads & TABS dressings) erythromycin base F BAND-AID GAUZE PADS RX/OTC cpep SMALL2" X 2" PADS (gauze pads & F erythromycin base tabs F dressings) erythromycin base tbec F BAND-AID HURT-FREE NON-STICK PADS LARGE erythromycin 3" X 4" PADS (adhesive F ethylsuccinate susr 200 F bandages) mg/5ml, 400 mg/5ml BAND-AID HURT-FREE NON-STICK PADS erythromycin F ethylsuccinate tabs 400 F MEDIUM 2" X 3" PADS mg (adhesive bandages) BAND-AID MIRASORB RX/OTC MEDICAL DEVICES AND SUPPLIES GAUZE SPONGES LARGE 4" X 4" PADS F Bandages-Dressings-Tape (gauze pads & ADHESIVE dressings) PADS/LARGE/3"X4" PADS F ( ) BAND-AID QUILTVENT adhesive bandages WATERPROOF PAD ADHESIVE LARGE 2.875" X 4" PADS F PADS/MEDIUM/2"X3" (adhesive bandages) PADS ( F adhesive BIOGUARD GAUZE RX/OTC bandages) SPONGE 2"X2" 8 PLY AMD FOAM DRESSING RX/OTC PADS (gauze pads & F 4"X4" PADS (gauze F dressings) pads & dressings) BIOGUARD GAUZE RX/OTC AMD FOAM RX/OTC SPONGES 4"X4" 12 PLY DRESSING/TOPSHEET F F PADS (gauze pads & 4"X4" PADS (gauze dressings) pads & dressings) CA Health & Wellness Preferred Drug List Updated September 1, 2021

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BORDERED GAUZE RX/OTC CURITY ALL PURPOSE PADS ( SPONGES 3"X3" 4PLY gauze pads & F F dressings) PADS (gauze pads & CARRASMART FOAM RX/OTC dressings) PADS (gauze pads & F CURITY ALL PURPOSE RX/OTC SPONGES 4 PLY PADS dressings) F CARRASMART PADS RX/OTC (gauze pads & (gauze pads & F dressings) dressings) CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" 4PLY COPA ISLAND RX/OTC F BORDERED FOAM PADS (gauze pads & DRESSING 4"X4" PADS F dressings) (gauze pads & CURITY ALL PURPOSE RX/OTC dressings) SPONGES 4"X4" 4PLY/SOFT POUCH PADS COPA PLUS RX/OTC F HYDROPHILIC FOAM (gauze pads & DRESSING 4"X4" PADS F dressings) (gauze pads & CURITY ALL PURPOSE RX/OTC SPONGES 4"X4" PADS dressings) F COVRSITE COVER RX/OTC (gauze pads & DRESSING PADS dressings) (gauze pads & F CURITY AMD RX/OTC dressings) ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY COVRSITE PLUS RX/OTC F COMPOSITE DRESSING PADS (gauze pads & PADS (gauze pads & F dressings) dressings) CURITY AMD RX/OTC ANTIMICROBIALGAUZE CRUAD GAUZE PADS 4" RX/OTC SPONGES 4"X4" 12 PLY F X 4" PADS (gauze pads F PADS (gauze pads & & dressings) dressings) CURAD NON-STICK CURITY COVER SPONGE RX/OTC PADS WITHADHESIVE TABS 3"X4" PADS F 4"X4" PADS (gauze F (adhesive bandages) pads & dressings) CURITY ALL PURPOSE RX/OTC CURITY COVER SPONGES 3"X3" PADS SPONGES 2"X2" 4PLY F PADS (gauze pads & F (gauze pads & dressings) dressings) CURITY ALL PURPOSE RX/OTC CURITY COVER RX/OTC SPONGES 4"X4" PADS SPONGES 2"X2" PADS F (gauze pads & F (gauze pads & dressings) dressings)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CURITY DRESSING RX/OTC CURITY GAUZE SPONGE RX/OTC SPONGES 4"X4" 6 PLY 4"X4"16 PLY PADS PADS (gauze pads & F (gauze pads & F dressings) dressings) CURITY GAUZE PADS RX/OTC CURITY GAUZE RX/OTC 2"X2" 12 PLY PADS SPONGES 4"X4" 12 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings) CURITY GAUZE PADS RX/OTC CURITY GAUZE RX/OTC 2"X2" PADS ( SPONGES 4"X4" 8 PLY gauze F F pads & dressings) PADS (gauze pads & CURITY GAUZE PADS dressings) 3"X3" PADS (gauze F CURITY NON-ADHERENT STRIPS 3"X3" PADS pads & dressings) F CURITY GAUZE PADS RX/OTC (gauze pads & 4"X4" 12 PLY PADS dressings) (gauze pads & F CURITY RX/OTC dressings) SPONGES/CELLULOSEFI LLED/2"X2" PADS CURITY GAUZE SPONGE RX/OTC F 2"X2" 8 PLY PADS (gauze pads & (gauze pads & F dressings) dressings) CURITY RX/OTC SPONGES/CELLULOSEFI CURITY GAUZE SPONGE RX/OTC LLED/4"X4" PADS 2"X2"12 PLY PADS F (gauze pads & (gauze pads & F dressings) dressings) CVS ADHESIVE PAD CURITY GAUZE SPONGE 3"X3" 12 PLY PADS 4"X4" PADS (adhesive F (gauze pads & F bandages) dressings) CVS ADHESIVE PAD CURITY GAUZE SPONGE RX/OTC 6"X6" PADS (adhesive F 4"X4" 12 PLY PADS bandages) (gauze pads & F CVS ADHESIVE PADS dressings) 2.25"X3" PADS F CURITY GAUZE SPONGE RX/OTC (adhesive bandages) 4"X4" 16 PLY PADS CVS GAUZE PAD 3"X3" (gauze pads & F PADS (gauze pads & F dressings) dressings) CURITY GAUZE SPONGE RX/OTC CVS GAUZE PADS 2"X2" RX/OTC 4"X4" 8 PLY PADS 12-PLY PADS (gauze F (gauze pads & F pads & dressings) dressings) CVS GAUZE PADS 4"X4" RX/OTC 12-PLY PADS (gauze F pads & dressings)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS GAUZE PADS RX/OTC DERMACEA I.V. RX/OTC STERILE 4"X4" 12-PLY SPONGES 2"X2" PADS PADS (gauze pads & F (gauze pads & F dressings) dressings) DERMACEA DRAIN RX/OTC DERMACEA NON-WOVEN RX/OTC SPONGES 4"X4" PADS SPONGES 2"X2" 4 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA NON-WOVEN SPONGE 2"X2" 12 PLY SPONGES 3"X3" 4 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA NON-WOVEN RX/OTC SPONGE 2"X2" 8 PLY SPONGES 4"X4" 4 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE DERMACEA NON-WOVEN RX/OTC SPONGE 3"X3" 12 PLY SPONGES 4"X4" 6 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE DERMACEA TYPE VII RX/OTC SPONGE 3"X3" 8 PLY GAUZE 2"X2" 12 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA TYPE VII RX/OTC SPONGE 4"X4" 12 PLY GAUZE 2"X2" 8 PLY PADS PADS (gauze pads & F (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA TYPE VII SPONGE 4"X4" 16 PLY GAUZE 3"X3" 12 PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA GAUZE RX/OTC DERMACEA TYPE VII SPONGE 4"X4" 8 PLY GAUZE 3"X3" 12PLY PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA I.V. DRAIN RX/OTC DERMACEA TYPE VII RX/OTC SPONGES 2"X2" PADS GAUZE 4"X4" 12 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings) DERMACEA I.V. DRAIN RX/OTC DERMACEA TYPE VII RX/OTC SPONGES 4"X4" PADS GAUZE 4"X4" 16 PLY (gauze pads & F PADS (gauze pads & F dressings) dressings)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DERMACEA TYPE VII RX/OTC EXCILON I.V. SPONGES RX/OTC GAUZE 4"X4" 8 PLY PADS 2"X2" 6 PLY PADS (gauze pads & F (gauze pads & F dressings) dressings) DERMACEA X-RAY RX/OTC GAUZE DRESSING 4"X4" RX/OTC SPONGES 4"X4" 16 PLY PADS ( F gauze pads & F PADS (gauze pads & dressings) dressings) GAUZE PADS 2"X2" PADS RX/OTC DERMALEVIN ADHESIVE RX/OTC (gauze pads & F FOAMDRESSING 4"X4" F dressings) PADS (gauze pads & GAUZE PADS 3"X3" PADS dressings) (gauze pads & F DRYMAX EXTRA PADS RX/OTC dressings) (gauze pads & F GAUZE PADS 4"X4" PADS RX/OTC dressings) (gauze pads & F EQL GAUZE PADS RX/OTC dressings) 2"X2"/SMALL PADS F GAUZE SPONGE TYPE RX/OTC (gauze pads & VII MEDI-PAK 2"X2" 8PLY dressings) PADS (gauze pads & F EQL GAUZE PADS RX/OTC dressings) 4"X4"/LARGE PADS GAUZE SPONGES 4"X4" RX/OTC (gauze pads & F 12 PLY PADS (gauze F dressings) pads & dressings) EQL GAUZE STERILE PADS 3"X3" PADS GNP STERILE GAUZE RX/OTC PADS 2"X2" PADS (gauze pads & F (gauze pads & F dressings) dressings) EXCILON AMD RX/OTC ANTIMICROBIALDRAIN GNP STERILE GAUZE PADS 3"X3" PADS SPONGES 4"X4" 6 PLY F F PADS (gauze pads & (gauze pads & dressings) dressings) EXCILON AMD RX/OTC HM ADHESIVE PADS ANTIBACTERIAL/SHEER ANTIMICROBIALNON- F WOVEN SPONGES 4"X4" F PADS (adhesive 6 PLY PADS (gauze bandages) pads & dressings) HM STERILE PADS 2"X2" RX/OTC EXCILON DRAIN RX/OTC PADS (gauze pads & F SPONGE 4"X4" PADS dressings) F (gauze pads & HM STERILE PADS PADS RX/OTC dressings) (gauze pads & F EXCILON DRAIN RX/OTC dressings) SPONGES 4"X4" 6 PLY PADS (gauze pads & F dressings)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HYDROCELL ADHESIVE RX/OTC KENDALL HYDROPHILIC RX/OTC DRESSING 4"X4" PADS FOAMDRESSING 4"X4" (gauze pads & F PADS (gauze pads & F dressings) dressings) HYDROCELL DRESSING RX/OTC KENDALL HYDROPHILIC RX/OTC 4"X4" PADS ( FOAMPLUS DRESSING gauze F F pads & dressings) 2"X2" PADS (gauze J & J ADHESIVE LARGE pads & dressings) PADS (adhesive F KENDALL HYDROPHILIC FOAMPLUS DRESSING bandages) F J & J GAUZE 2"X2" 8 PLY RX/OTC 3"X3" PADS (gauze PADS (gauze pads & F pads & dressings) dressings) KERLIX SPONGES 4" X 4" RX/OTC J & J GAUZE 4"X4" 12 PLY RX/OTC 12 PLY PADS (gauze F PADS (gauze pads & F pads & dressings) dressings) KERLIX SPONGES 4" X 4" RX/OTC J & J GAUZE 4"X4" 8 PLY RX/OTC 16 PLY PADS (gauze F PADS (gauze pads & F pads & dressings) dressings) MIRASORB SPONGES 2" RX/OTC J & J GAUZE SPONGES RX/OTC X 2" MISC (gauze pads F 12-PLY 4" X 4" MISC & dressings) (gauze pads & F MIRASORB SPONGES 4" RX/OTC dressings) X 4" MISC (gauze pads F J & J GAUZE SPONGES RX/OTC & dressings) 16-PLY 4" X 4" MISC MOLESKIN FOAM (gauze pads & F PADDING PADS F dressings) (adhesive bandages) J & J GAUZE SPONGES RX/OTC NEXCARE ABSOLUTE 8-PLY4" X 4" MISC WATERPROOF PAD F (gauze pads & F PADS (adhesive dressings) bandages) J & J NON-STICK PADS NU GAUZE 4PLY 4"X4" RX/OTC 100LARGE PADS F PADS (gauze pads & F (adhesive bandages) dressings) KENDALL HYDROPHILIC RX/OTC NU GAUZE GENERAL- RX/OTC FOAMDRESSING 2"X2" USE SPONGES 4"X4" 4 PADS (gauze pads & F PLY MISC (gauze pads F dressings) & dressings) KENDALL HYDROPHILIC OPTIFOAM PADS (gauze RX/OTC FOAMDRESSING 3"X3" F F pads & dressings) PADS (gauze pads & POLYMEM FILM DOT dressings) PADS (adhesive F bandages)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POLYMEM NON- RX/OTC RESTORE FOAM RX/OTC ADHESIVE PAD PADS DRESSING BORDERED (gauze pads & F 4"X4" PADS (gauze F dressings) pads & dressings) QC ALL PURPOSE RX/OTC RESTORE FOAM RX/OTC DRESSINGS4"X4" PADS DRESSING NON- (gauze pads & F BORDERED 4"X4" PADS F dressings) (gauze pads & QC BORDER ISLAND RX/OTC dressings) GAUZE PAD 2"X2" PADS RESTORE ODOR RX/OTC ( F ABSORBING DRESSING gauze pads & F dressings) 4"X4" PADS (gauze QC STERILE PADS PADS RX/OTC pads & dressings) (gauze pads & F RESTORE TRIO ABSORBENT DRESSING dressings) F QC STERILE PADS PADS 3"X3" PADS (gauze (gauze pads & F pads & dressings) dressings) SM ADHESIVE PADS RA FIRST AID NON-STICK 2"X3" PADS (adhesive F PADS PADS (adhesive F bandages) bandages) SM ADHESIVE PADS RA SHEER ADHESIVE 3"X4" PADS (adhesive F LARGE PADS (adhesive F bandages) bandages) SM GAUZE PADS 2"X2" RX/OTC RA STERILE PADS 2"X2" RX/OTC PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) SM GAUZE PADS 3"X3" RA STERILE PADS 3"X3" PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) SM GAUZE PADS 4"X4" RX/OTC RA STERILE PADS 4"X4" RX/OTC PADS (gauze pads & F PADS (gauze pads & F dressings) dressings) SM STERILE PADS 2"X2" RX/OTC RAY-TEC X-RAY RX/OTC PADS (gauze pads & F DETECTABLESPONGES dressings) 4" X 4" 16 PLY MISC F SM STERILE PADS PADS RX/OTC (gauze pads & (gauze pads & F dressings) dressings) RESTORE CONTACT RX/OTC SOF-SET ADHESIVE LAYER/NON-ADHERENT PATCH PADS ( F adhesive F 2"X2" PADS (gauze bandages) pads & dressings) SOF-WICK 4"X4" PADS RX/OTC (gauze pads & F dressings) CA Health & Wellness Preferred Drug List Updated September 1, 2021

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STERILE GAUZE PADS RX/OTC FANTASY LUBRICATED 2"X2" PADS (gauze F MISC (condoms latex F pads & dressings) lubricated - male) STERILE GAUZE PADS FANTASY 3"X3" PADS ( LUBRICATED/SPERMICID gauze F F pads & dressings) E MISC (condoms latex STERILE PADS 2"X2" RX/OTC lubricated - male) PADS (gauze pads & F FC FEMALE CONDOM dressings) MISC (condoms - F STERILE PADS 3"X3" female) PADS (gauze pads & F FC2 FEMALE CONDOM dressings) MISC (condoms - F STERILE PADS 4"X4" RX/OTC female) FEMCAP DEVI ( QL(1 ea per PADS (gauze pads & F cervical F dressings) caps) 365 days retail) SURGICAL GAUZE RX/OTC K-Y ME & YOU EXTRA LUBRICATED DEVI SPONGE PADS (gauze F F pads & dressings) (condoms latex TEGADERM FOAM RX/OTC lubricated - male) DRESSING 2"X2" PADS K-Y ME & YOU INTENSE (gauze pads & F DEVI (condoms latex F dressings) lubricated - male) TEGADERM FOAM RX/OTC KAMELEON LUBRICATED DRESSING 4"X4" PADS MISC (condoms latex F F (gauze pads & lubricated - male) dressings) KIMONO COLORS DEVI THERAGAUZE PADS RX/OTC (condoms latex F (gauze pads & F lubricated - male) dressings) KIMONO LUBRICATED TOPPER DRESSING RX/OTC MISC (condoms latex F SPONGES 4"X4" MISC F lubricated - male) (gauze pads & KIMONO MICRO THIN dressings) MISC (condoms latex F Contraceptives non-lubricated - male) AIMSCO LUBRICATED KIMONO MICRO THIN MISC (condoms latex F PLUS SPERMICIDE lubricated - male) LUBRICATED MISC F (condoms latex CAYA DPRH (diaphragm QL(1 ea per fill F retail,1 ea per lubricated - male) arc-spring) 365 days retail) KIMONO PLUS DUREX EXTRA SPERMICIDE SENSITIVE DEVI LUBRICATED MISC F (condoms latex F (condoms latex lubricated - male) lubricated - male) CA Health & Wellness Preferred Drug List Updated September 1, 2021

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO PLUS REALITY LATEX/ULTRA SPERMICIDE/LUBRICATE THIN DEVI ( F condoms F D MISC (condoms latex latex lubricated - male) lubricated - male) TRUSTEX COLOR KIMONO PS LUBRICATED CONDOMS + LUBE MISC MISC (condoms latex F (condoms latex F lubricated - male) lubricated - male) KIMONO PS PLUS TRUSTEX LUBRICATED SPERMICIDE/LUBRICATE EXTRALARGE MISC D MISC (condoms latex F (condoms latex F lubricated - male) lubricated - male) KIMONO SENSATION TRUSTEX LUBRICATED LUBRICATED MISC EXTRASTRENGTH MISC (condoms latex F (condoms latex F lubricated - male) lubricated - male) KIMONO SENSATION TRUSTEX LUBRICATED PLUS SPERMICIDE MISC (condoms latex F LUBRICATED MISC F lubricated - male) (condoms latex TRUSTEX lubricated - male) LUBRICATED/RIBBED/ST KIMONO SPECIAL DEVI UDDED MISC (condoms F (condoms latex F latex lubricated - male) lubricated - male) TRUSTEX MAXX LUBRICATED MISC LUBRICATED/SPERMICID (condoms latex F E EXTRA LARGE MISC F lubricated - male) (condoms latex MAXX PLUS SPERMICIDE lubricated - male) LUBRICATED MISC TRUSTEX (condoms latex F LUBRICATED/SPERMICID lubricated - male) E EXTRA STRENGTH F OMNIFLEX DIAPHRAGM QL(1 ea per MISC (condoms latex F DPRH (diaphragms) 365 days retail) lubricated - male) PREMIUM CONDOMS TRUSTEX LUBRICATED/SPERMICID LUBRICATED MISC F (condoms latex F E MISC (condoms latex lubricated - male) lubricated - male) REALITY LATEX TRUSTEX NATURAL CONDOMS/LUBRICATED CONDOMS +LUBE/LUBRICATED MISC (condoms latex F F MISC (condoms latex lubricated - male) lubricated - male) REALITY LATEX/ULTRA TEXTURED DEVI TRUSTEX NON- F LUBRICATED MISC (condoms latex F (condoms latex non- lubricated - male) lubricated - male)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX WITH ADVOCATE LANCING NONOXYNOL- DEVICE MISC (lancet F 9/RIBBED/STUDDED F devices) MISC (condoms latex ADVOCATE RAPID-SAFE lubricated - male) LANCING DEVICE MISC F TRUSTEX/RIA (lancet devices) LUBRICATED MISC F AGAMATRIX ULTRA-THIN (condoms latex LANCETS 33G MISC F lubricated - male) (lancets) TRUSTEX/RIA ALTERNATE SITE LUBRICATED LANCING DEVICE MISC F SPERMICIDE MISC F (lancet devices) (condoms latex AQUA LANCE lubricated - male) ADJUSTABLE LANCING TRUSTEX/RIA DEVICE DEVI (lancet F LUBRICATED/SPERMICID devices) E MISC (condoms latex F AQUALANCE LANCETS lubricated - male) ULTRA THIN 30G MISC F TRUSTEX/RIA NON- (lancets) LUBRICATED MISC ASSURE COMFORT (condoms latex non- F LANCETS ULTRA THIN F lubricated - male) 28G MISC (lancets) Diabetic Supplies ASSURE HAEMOLANCE 1ST TIER UNILET PLUS HIGH FLOW 18G F COMFORTOUCH F MISC (lancets) LANCETS 28G MISC ASSURE HAEMOLANCE (lancets) PLUS LOW FLOW 25G F 1ST TIER UNILET MISC (lancets) COMFORTOUCH ASSURE HAEMOLANCE LANCETS 30G MISC F PLUS MICRO FLOW 28G F (lancets) MISC (lancets) ACCU-CHEK FASTCLIX ASSURE HAEMOLANCE LANCETDEVICE KIT KIT F PLUS NORMAL FLOW F (lancets misc.) 21G MISC (lancets) ACCU-CHEK MULTICLIX ASSURE HAEMOLANCE LANCET DEVICE KIT KIT F PLUS PEDIATRIC BLADE F (lancets misc.) MISC (lancets) ACCU-CHEK SOFTCLIX ASSURE LANCE LANCETDEVICE KIT KIT F LANCETS 21G MISC F (lancets misc.) (lancets) ADJUSTABLE LANCING ASSURE LANCE F DEVICE MISC (lancet F LANCETS MISC (lancets) devices) ASSURE LANCE PLUS SAFETYLANCETS 25G F MISC (lancets) CA Health & Wellness Preferred Drug List Updated September 1, 2021

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASSURE LANCE PLUS CAREONE LANCET THIN F SAFETYLANCETS 30G F MISC (lancets) MISC (lancets) CARETOUCH LANCING AURORA LANCET SUPER DEVICEWITH EJECTOR F F THIN30G MISC (lancets) MISC (lancet devices) AURORA LANCET THIN CARETOUCH TWIST F 23G MISC (lancets) LANCETS 30G MISC F AUTO-LANCET MINI MISC (lancets) F CLEANLET LANCETS 28G (lancet devices) F AUTO-LANCET MISC MISC (lancets) F (lancet devices) COMFORT ASSURED AUTOLET II CLINISAFE LANCETS SUPER THIN F F KIT (lancets misc.) 28G MISC (lancets) COMFORT LANCETS AUTOLET IMPRESSION F LANCING DEVICE MISC F MISC (lancets) CVS LANCETS 21G MISC (lancet devices) F AUTOLET LANCING (lancets) CVS LANCETS MICRO DEVICE MISC (lancet F F devices) THIN 33G MISC (lancets) CVS LANCETS MICRO- AUTOLET LITE F CLINISAFE KIT (lancets F THIN 33G MISC (lancets) misc.) CVS LANCETS ORIGINAL F AUTOLET LITE STARTER MISC (lancets) PACK KIT (lancets F CVS LANCETS THIN 26G F misc.) MISC (lancets) AUTOLET MINI MISC CVS LANCETS ULTRA F F (lancet devices) THIN 30G MISC (lancets) AUTOLET PLATFORMS CVS LANCETS ULTRA- F F MISC (lancets misc.) THIN 30G MISC (lancets) AUTOLET PLUS MISC CVS LANCING DEVICE F F (lancet devices) MISC (lancet devices) BD LANCET ULTRAFINE CVS ULTRA THIN F F 30G MISC (lancets) LANCETS MISC (lancets) CARDIOCOM LANCING DIATHRIVE LANCETS F DEVICE MISC (lancet F MISC (lancets) devices) DIATHRIVE LANCETS CAREONE ADVANCED ULTRA THIN 30G MISC F LANCINGDEVICE MISC F (lancets) (lancet devices) DIATHRIVE LANCING CAREONE LANCET DEVICE MISC (lancet F SUPER THIN/30G MISC F devices) (lancets)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET GENTEEL EASY TOUCH LANCETS LANCING DEVICE MISC F 26G/PULL-TOP MISC F (lancet devices) (lancets) DROPLET LANCETS EASY TOUCH LANCETS ULTRA THIN 30G MISC F 28G/PULL-TOP MISC F (lancets) (lancets) DROPLET LANCING EASY TOUCH LANCETS DEVICE MISC (lancet F 28G/TWIST MISC F devices) (lancets) DRUG MART EASY TOUCH LANCETS ADJUSTABLE LANCING 30G/PULL-TOP MISC F DEVICE MISC (lancet F (lancets) devices) EASY TOUCH LANCETS DRUG MART LANCETS 30G/TWIST MISC F F THIN MISC (lancets) (lancets) DRUG MART UNILET EASY TOUCH LANCETS LANCETSSUPER THIN F 32G/PULL-TOP MISC F 30G MISC (lancets) (lancets) DRUG MART UNILET EASY TOUCH LANCETS LANCETSULTRA THIN F 32G/TWIST MISC F 28G MISC (lancets) (lancets) DRUG MART UNILET EASY TOUCH LANCETS MICRO THIN LANCETS F 33G/TWIST MISC F 33G MISC (lancets) (lancets) E-Z JECT LANCETS 21G EASY TOUCH LANCING F DEVICE/EJECTOR MISC MISC (lancets) F (lancet devices) E-Z JECT LANCETS F EMBRACE LANCING COLOR MISC (lancets) DEVICE WITH EJECTOR F E-Z JECT LANCETS MISC F MISC (lancet devices) ( ) lancets EQL COLOR LANCETS F E-Z JECT LANCETS 21G MISC (lancets) SUPER THIN 30G MISC F EQL COLOR LANCETS (lancets) MICRO THIN 33G MISC F E-Z JECT LANCETS THIN F (lancets) 26G MISC ( ) lancets EQL SUPER THIN E-ZJECT LANCETS LANCETS 30G MISC F MICRO-THIN 33G MISC F (lancets) ( ) lancets EQL THIN LANCETS 26G F EASY MINI EJECT MISC (lancets) LANCING DEVICE MISC F EZ-LETS LANCETS 26G (lancet devices) SUPER-SOFT MISC F EASY MINI LANCING (lancets) DEVICE MISC (lancet F devices)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EZ-LETS LANCETS 28G FREESTYLE PRECISION QL(1 ea per fill ULTRA-SOFT MISC F NEO BLOOD GLUCOSE retail,1 ea per (lancets) MONITORING SYSTEM F 365 days EZ-LETS LANCETS 30G KIT (blood glucose retail); RX/OTC F MISC (lancets) monitoring supplies) FORA LANCETS MISC FREESTYLE UNISTICK II F F (lancets) LANCETS MISC (lancets) FORA LANCING DEVICE GENTEEL CONTACT F MISC (lancet devices) TIPS/BLUE MISC F (lancets misc.) FORA LANCING DEVICE/CLEARCAP MISC F GENTEEL CONTACT (lancet devices) TIPS/CLEAR MISC F (lancets misc.) FREDS PHARMACY AUTOLET LANCING GENTEEL CONTACT DEVICE MISC (lancet F TIPS/GREEN MISC F devices) (lancets misc.) FREDS PHARMACY GENTEEL CONTACT TIPS/ORANGE MISC UNILET LANCETS SUPER F F THIN 30G MISC (lancets) (lancets misc.) FREDS PHARMACY GENTEEL CONTACT TIPS/RAINBOW MISC UNILET LANCETS ULTRA F F THIN 28G MISC (lancets) (lancets misc.) FREESTYLE CONTROL GENTEEL CONTACT SOLUTION HIGH/LOW TIPS/VIOLET MISC F LIQD (blood glucose F (lancets misc.) calibration) GENTEEL CONTACT TIPS/YELLOW MISC F FREESTYLE CONTROL (lancets misc.) SOLUTION LIQD (blood F ) GENTEEL LANCING glucose calibration DEVICE/GLORIOUS FREESTYLE FREEDOM QL(1 ea per fill GOLD MISC (lancet F LITE KIT ( F retail,1 ea per blood glucose 365 days devices) monitoring supplies) retail); RX/OTC GENTEEL LANCING DEVICE/PRECIOUS FREESTYLE INSULINX QL(1 ea per fill F BLOODGLUCOSE retail,1 ea per PLATINUM MISC (lancet MONITORING SYSTEM F 365 days devices) KIT (blood glucose retail); RX/OTC GENTEEL LANCING monitoring supplies) DEVICE/STATELY SILVER F FREESTYLE LANCETS MISC (lancet devices) F MISC (lancets) GENTEEL LANCING FREESTYLE LITE BLOOD QL(1 ea per fill KIT/BUTTERFLY BLUE F GLUCOSE MONITORING retail,1 ea per KIT (lancets misc.) 365 days retail) GENTEEL NOZZLES SYSTEM DEVI (blood F F glucose monitoring MISC (lancets misc.) supplies) CA Health & Wellness Preferred Drug List Updated September 1, 2021

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTEEL PLUS LANCING GNP LANCETS MICRO F DEVICE/BUFF BLACK F THIN 33G MISC (lancets) MISC (lancet devices) GNP LANCETS SUPER F GENTEEL PLUS LANCING THIN 30G MISC (lancets) DEVICE/BUTTERFLY GNP LANCETS THIN 26G F F BLUE MISC (lancet MISC (lancets) devices) GNP LANCETS THIN F GENTEEL PLUS LANCING MISC ( ) DEVICE/PLAYFUL lancets PURPLE MISC (lancet F GOJJI LANCING DEVICE/CLEAR CAP devices) F MISC (lancet devices) GENTEEL PLUS LANCING DEVICE/PRINCESS PINK F GOODSENSE COLOR LANCETS MICRO-THIN MISC (lancet devices) 33G UNIVERSAL MISC F GENTEEL PLUS LANCING (lancets) DEVICE/WILLOWY WHITE F GOODSENSE LANCETS MISC (lancet devices) MICRO-THIN 33G MISC F GENTLE-LET GP (lancets) LANCETS MISC F GOODSENSE LANCETS (lancets) MICRO-THIN 33G GENTLE-LET LANCETS UNIVERSAL MISC F GENERAL PURPOSE (lancets) STYLE/FINE POINT MISC F GOODSENSE LANCETS (lancets) ULTRA-THIN 26G GENTLE-LET LANCETS UNIVERSAL MISC F GENERAL PURPOSE (lancets) STYLE/MEDIUM POINT F GOODSENSE LANCETS MISC (lancets) ULTRA-THIN 30G MISC F GENTLE-LET LANCETS (lancets) SAFETY STYLE/FINE F GOODSENSE LANCETS POINT MISC (lancets) ULTRA-THIN 30G GENTLE-LET LANCETS UNIVERSAL MISC F SAFETY STYLE/MEDIUM F (lancets) POINT MISC (lancets) GOODSENSE LANCING GENTLE-LET DEVICE MISC (lancet F PLATFORMS 2.4MM MISC F devices) (lancets misc.) H-E-B INCONTROL GENTLE-LET ADVANCEDLANCING PLATFORMS 3.0MM MISC F DEVICE MISC (lancet F (lancets misc.) devices) GLOBAL LANCING H-E-B INCONTROL DEVICE MISC (lancet F LANCETS MICRO THIN F devices) 33G MISC (lancets) GNP LANCETS 21G MISC F (lancets) CA Health & Wellness Preferred Drug List Updated September 1, 2021

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B INCONTROL IN TOUCH LANCING LANCETS SUPER THIN F DEVICE MISC (lancet F 30G MISC (lancets) devices) H-E-B INCONTROL KINNEY LANCETS MISC F LANCETS ULTRA THIN F (lancets) 28G MISC (lancets) KINNEY THIN LANCETS F HAEMOLANCE LOW MISC (lancets) FLOW LANCETS MISC F KROGER AUTOLET (lancets) LANCING DEVICE MISC F HAEMOLANCE MISC F (lancet devices) (lancets) KROGER HEALTHPRO HAEMOLANCE PLUS TWIST LANCETS/26G F HIGH FLOW MISC F MISC (lancets) (lancets) KROGER LANCETS 21G F HAEMOLANCE PLUS MISC (lancets) LOW FLOW MISC F KROGER LANCETS (lancets) MICRO THIN33G MISC F HAEMOLANCE PLUS (lancets) MAX FLOW MISC F KROGER LANCETS MISC (lancets) F (lancets) HAEMOLANCE PLUS F KROGER LANCETS MISC (lancets) SUPER THIN MISC F HAEMOLANCE PLUS (lancets) PEDIATRIC FLOW MISC F KROGER LANCETS THIN (lancets) F 26G MISC (lancets) HEALTH CARE LANCING KROGER LANCETS THIN DEVICE MISC (lancet F F MISC (lancets) devices) KROGER LANCETS HEALTHY ACCENTS ULTRATHIN30G MISC AUTOLET IMPRESSION F LANCING DEVICE MISC F (lancets) (lancet devices) KROGER LANCING HEALTHY ACCENTS DEVICE MISC (lancet F UNILET LANCETS SUPER F devices) THIN 30G MISC (lancets) LANCET DEVICE HY-VEE LANCETS MISC ADJUSTABLE MISC F F (lancets) (lancet devices) HY-VEE THIN LANCETS LANCET DEVICE WITH F MISC (lancets) EJECTOR MISC (lancet F ) HYPOLANCE AST devices LANCING KIT KIT F LANCET TRANSPORTER (lancets misc.) CASE MISC (lancets F misc.)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCETS 26G TWIST LIVE BETTER LANCET F TOP MISC (lancets) ULTRATHIN 28G MISC F LANCETS 28G MISC (lancets) F (lancets) LONGS LANCETS LANCETS 30G MISC STANDARD MISC F F (lancets) (lancets) LANCETS MISC LONGS LANCETS THIN F F (lancets) MISC (lancets) LANCETS SAFETY SEAL MEDISENSE THIN F F 21G MISC (lancets) LANCETS MISC (lancets) LANCETS SAFETY SEAL MEIJER COLOR F LANCETS UNIVERSAL F 26G MISC (lancets) 33G MISC (lancets) LANCETS SAFETY SEAL F MEIJER LANCETS MISC 28G MISC (lancets) F (lancets) LANCETS SUPER THIN F MEIJER LANCETS THIN 28G MISC (lancets) F MISC (lancets) LANCETS THIN MISC F MEIJER LANCETS (lancets) UNIVERSAL21G MISC F LANCETS ULTRA THIN F (lancets) MISC (lancets) MEIJER LANCETS LANCING DEVICE UNIVERSAL30G MISC F ADJUSTABLE MISC F (lancets) (lancet devices) MEIJER LANCETS LANCING DEVICE MISC UNIVERSAL33G MISC F F (lancet devices) (lancets) LANZO MISC ( MEIJER SUPER THIN lancet F F devices) LANCETS MISC (lancets) LEADER ADVANCED MICROLET NEXT MISC F LANCING DEVICE MISC F (lancet devices) (lancet devices) MINI LANCING DEVICE F LIBERTY MINI LANCING MISC (lancet devices) DEVICE MISC (lancet F MM LANCING DEVICE F devices) MISC (lancet devices) LITE TOUCH LANCING MONOLET LANCETS F PEN MISC (lancet F MISC (lancets) devices) MONOLET OPD LANCETS F LIVE BETTER ADVANCED MISC (lancets) LANCING DEVICE MISC F MULTI-LANCET DEVICE 2 (lancet devices) F KIT (lancets misc.) LIVE BETTER LANCET MULTI-LANCET DEVICE SUPERTHIN 30G MISC F F (lancets) MISC (lancet devices)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVA SUREFLEX PENLET II LANCETS MISC F REPLACEMENT CAPS- (lancets) REGULAR MISC (lancets F NOVA SUREFLEX misc.) LANCING DEVICE MISC F PERFECT LANCETS 30G F (lancet devices) MISC (lancets) ON CALL LANCING PHARMACY COUNTER F DEVICE MISC (lancet F LANCETS MISC (lancets) devices) PRECISION GLUCOSE ON CALL PLUS LANCING CONTROL LIQD (blood F DEVICE MISC (lancet F glucose calibration) devices) PRECISION GLUCOSE ONETOUCH DELICA CONTROLSOLUTION LANCING DEVICE MISC F (TRI- F (lancet devices) LEVEL/HI/LO/NORMAL ONETOUCH DELICA ) SOLN (blood glucose PLUS LANCING DEVICE F calibration) MISC (lancet devices) PRECISION GLUCOSE ONETOUCH DELICA KETONECONTROL SAFETY LACING DEVICE F SOLUTION 1-LOW, 1- F MISC (lancet devices) HIGH LIQD (blood ONETOUCH SURESOFT glucose calibration) LANCING DEVICE/18G F PRECISION MISC (lancets misc.) GLUCOSE/KETONECONT ROL SOLUTIONS 1-HI 1- ONETOUCH SURESOFT F LO LIQD (blood glucose LANCING DEVICE/21G F MISC (lancets misc.) calibration) PRECISION THINS GP ONETOUCH SURESOFT F LANCING DEVICE/28G F LANCET MISC (lancets) MISC (lancets misc.) PRECISION XTRA DEVI QL(1 ea per fill PC LANCETS SUPER XX (blood glucose F retail,1 ea per F 365 days retail) THIN 30G MISC (lancets) monitoring supplies) PENLET II AUTOMATIC PRECISION XTRA KIT XX QL(1 ea per fill BLOODSAMPLER KIT F (blood glucose F retail,1 ea per (lancets misc.) monitoring supplies) 365 days retail) PENLET II PREFERRED PLUS REPLACEMENT CAPS F LANCETS COLORED 21G F MISC (lancets misc.) MISC (lancets) PENLET II PREFERRED PLUS REPLACEMENT CAPS- LANCETS SUPER THIN F DEEP MISC (lancets F 30G MISC (lancets) misc.) PREFERRED PLUS LANCETS THIN 26G MISC F (lancets)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRODIGY LANCING RA E-ZJECT LANCETS F DEVICE MISC (lancet F THIN 28G MISC (lancets) devices) RA E-ZJECT LANCETS PRODIGY TWIST TOP ULTRATHIN 30G MISC F LANCETS MISC F (lancets) (lancets) READYLANCE SAFETY PSS SELECT GP LANCETS/30G/1.6MM F LANCETS MISC F MISC (lancets) (lancets) REALITY LANCETS MISC F PSS SELECT (lancets) PLATFORMS MISC F RELION 2-IN-1 LANCET (lancets misc.) DEVICES 30G MISC F PSS SELECT SAFETY (lancet devices) LANCETS MISC F RELION 2-IN-1 LANCING (lancets) DEVICE 25G MISC F PX ADVANCED LANCING (lancet devices) DEVICE MISC (lancet F RELION 2-IN-1 LANCING devices) DEVICE 30G MISC F PX LANCET AUTO (lancet devices) INJECTOR MISC (lancet F RELION LANCETS devices) MICRO-THIN33G MISC F PX LANCETS ULTRA (lancets) F RELION LANCETS THIN THIN 28G MISC (lancets) F PX LANCETS ULTRA 26G MISC (lancets) F THIN MISC (lancets) RELION LANCETS ULTRA-THIN30G MISC QC ADVANCED LANCING F ( ) DEVICE MISC (lancet F lancets devices) RELION LANCING DEVICE KIT ( QC LANCETS SUPER lancets F F ) THIN MISC (lancets) misc. RELION LANCING QC LANCETS ULTRA F THIN MISC (lancets) DEVICE MISC (lancet F devices) QC UNILET LANCETS 28G/ULTRA THIN MISC F RELION ULTRA THIN LANCETS30G MISC (lancets) F (lancets) QC UNILET LANCETS 33G/MICRO THIN MISC F RELION ULTRA THIN PLUS LANCETS 32G (lancets) F MISC (lancets) RA E-ZJECT LANCETS F RELION ULTRA THIN 28G MISC (lancets) PLUS LANCETS 33G F RA E-ZJECT LANCETS F MISC (lancets) THIN 26G MISC ( ) lancets REXALL LANCETS ULTRA F THIN MISC (lancets)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RIGHTEST GD-L500 SM TRUEDRAW LANCING ALTERNATE SITE DEVICE MISC ( F lancet F ADAPTER MISC (lancets devices) misc.) SMART DIABETES RIGHTEST GD500 VANTAGE LANCING LANCING DEVICE MISC F DEVICE MISC (lancet F (lancet devices) devices) RIGHTEST GL300 SMART SENSE COLOR LANCETS MISC F LANCETS UNIVERSAL F (lancets) 33G MISC (lancets) SAFETY LANCETS 28G F SMART SENSE MISC (lancets) STANDARD LANCETS F SAFETY SEAL LANCETS UNIVERSAL 21G MISC F 28G MISC (lancets) (lancets) SAFETY SEAL LANCETS SMART SENSE SUPER F 30G MISC ( ) THIN LANCETS lancets UNIVERSAL 30G MISC F SAPS HEALTH TWIST (lancets) TOP LANCETS 30G MISC F (lancets) SMART SENSE THIN LANCETSUNIVERSAL F SB LANCETS THIN MISC F 26G MISC (lancets) ( ) lancets SOLUS V2 LANCING SB LANCETS ULTRA F DEVICE MISC (lancet F THIN MISC (lancets) devices) SELECT-LITE STERILANCE PA MISC DEVICE/LANCETS KIT F F (lancets misc.) (lancets misc.) STERILANCE TL MISC SELECT-LITE LANCING F (lancets) DEVICE MISC (lancet F SUPER THIN LANCETS devices) F MISC (lancets) SHOPKO AUTOLET LANCING DEVICE MISC F SURE COMFORT (lancet devices) LANCETS 18G MISC F (lancets) SHOPKO UNILET LANCETS SUPER THIN F SURE COMFORT 30G MISC (lancets) LANCETS 21G MISC F (lancets) SHOPKO UNILET LANCETS ULTRA THIN F SURE COMFORT 28G MISC (lancets) LANCETS 23G MISC F (lancets) SIMPLE DIAGNOSTICS LANCING DEVICE MISC F SURE COMFORT (lancet devices) LANCETS 30G MISC F (lancets) SM MICRO THIN LANCETS 33G MISC F (lancets)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT TRUE METRIX CONTROL QL(90 day(s) LANCING PEN MISC F SOLUTION LEVEL 2 limit) (lancet devices) SOLN (blood glucose F SURE-PEN MISC ( calibration) lancet F devices) TRUE METRIX CONTROL QL(90 day(s) SURELITE LANCETS SOLUTION LEVEL 3 limit) F F MISC (lancets) SOLN (blood glucose calibration) TECHLITE AST LANCETS F MISC (lancets) TRUECONTROL GLUCOSE CONTROL TECHLITE LANCETS 30G F F LEVEL 0 LIQD (blood MISC (lancets) glucose calibration) TECHLITE LANCETS F TRUECONTROL MISC (lancets) GLUCOSE CONTROL TGT LANCET MICRO F F LEVEL 1 LIQD (blood THIN 33G MISC (lancets) glucose calibration) TGT LANCET THIN 26G F TRUEDRAW LANCING MISC (lancets) DEVICE MISC (lancet F TGT LANCET ULTRA devices) F THIN 30G MISC (lancets) TRUEPLUS LANCETS F TGT LANCING DEVICE 26G MISC (lancets) F MISC (lancet devices) TRUEPLUS LANCETS F THINLETS GP LANCETS 28G MISC (lancets) F MISC (lancets) TRUEPLUS LANCETS TODAYS HEALTH 28G SUPER THIN MISC F ADVANCED LANCING (lancets) F DEVICE MISC (lancet TRUEPLUS LANCETS F devices) 30G MISC (lancets) TODAYS HEALTH SUPER TRUEPLUS LANCETS THINLANCETS 30G MISC F 30G ULTRA THIN MISC F (lancets) (lancets) TODAYS HEALTH ULTRA TRUEPLUS LANCETS F THINLANCETS 28G MISC F 33G MISC (lancets) (lancets) ULTI-LANCE AUTOMATIC/ TOPCARE LANCETS CLEAR TIP MISC (lancet F MICRO-THIN 33G MISC F devices) (lancets) ULTILET CLASSIC F TRUE METRIX CONTROL QL(90 day(s) LANCETS MISC (lancets) SOLUTION LEVEL 1 limit) F ULTRALANCE MISC SOLN (blood glucose F calibration) (lancets misc.) UNILET COMFORTOUCH F LANCET MISC (lancets)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNILET EXCELITE II MISC UNISTIK 3 EXTRA F SINGLE USE SAFETY (lancets) F UNILET EXCELITE MISC LANCETS/21G MISC F (lancets) (lancets misc.) UNILET G.P. LANCET UNISTIK 3 MISC (lancets F F MISC (lancets) misc.) UNILET G.P. SUPERLITE UNISTIK 3 NEONATAL F F LANCET MISC (lancets) MISC (lancets misc.) UNILET GP 28 ULTRA UNISTIK 3 NORMAL MISC F F THIN MISC (lancets) (lancets misc.) UNILET LANCET MISC UNISTIK CZT COMFORT F F (lancets) MISC (lancets misc.) UNISTIK CZT NORMAL UNILET LANCETS F MICRO-THIN33G MISC F MISC (lancets misc.) (lancets) UNISTIK NORMAL MISC F UNILET LANCETS (lancets misc.) SUPER-THIN30G MISC F UNIVERSAL 1 LANCETS F (lancets) THIN26G MISC (lancets) UNILET LANCETS UNIVERSAL 1 LANCETS ULTRA-THIN 28G MISC F ULTRA THIN 30G MISC F (lancets) (lancets) UNILET SUPERLITE F UNIVERSAL 1 LANCET MISC (lancets) LANCETS/33G/MICRO- F UNISTIK 1 MISC ( THIN MISC (lancets) lancets F misc.) VALUE PLUS LANCETS UNISTIK 2 COMFORT STANDARD 21G MISC F F MISC (lancets misc.) (lancets) UNISTIK 2 EXTRA MISC VALUE PLUS LANCETS F SUPERTHIN 30G MISC F (lancets misc.) (lancets) UNISTIK 2 MISC (lancets VALUE PLUS LANCETS F F misc.) THIN 26G MISC (lancets) UNISTIK 2 NEONATAL F VALUE PLUS LANCING MISC (lancets misc.) DEVICE MISC (lancet F UNISTIK 2 NORMAL MISC F devices) (lancets misc.) VALUMARK LANCET UNISTIK 2 SUPER MISC F SUPER THIN 30G MISC F (lancets misc.) (lancets) UNISTIK 3 COMFORT F VALUMARK LANCET MISC (lancets misc.) ULTRA THIN 28G MISC F UNISTIK 3 EXTRA MISC (lancets) F (lancets misc.) VIDA MIA AUTOLET LANCINGDEVICE MISC F (lancet devices) CA Health & Wellness Preferred Drug List Updated September 1, 2021

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNILET CURITY ALCOHOL RX/OTC LANCETS SUPER THIN F SWABS PADS (alcohol F 30G MISC (lancets) swabs) VIDA MIA UNILET CVS ALCOHOL PREP RX/OTC LANCETS ULTRA THIN F PADS PADS (alcohol F 28G MISC (lancets) swabs) VIVAGUARD LANCING CVS PREP PADS PADS RX/OTC F DEVICE MISC (lancet F (alcohol swabs) devices) EASY TOUCH ALCOHOL RX/OTC WALGREENS COMFORT PREP PADS/MEDIUM F ASSUREDLANCETS PADS (alcohol swabs) MICRO THIN/33G MISC F EQL ALCOHOL SWABS RX/OTC (lancets) F PADS (alcohol swabs) WALGREENS COMFORT ASSUREDLANCETS FIFTY50 ALCOHOL PREP RX/OTC SUPER THIN/28G MISC F PADS PADS (alcohol F (lancets) swabs) GNP ALCOHOL SWABS RX/OTC WALGREENS THIN F LANCETS MISC F PADS (alcohol swabs) (lancets) H-E-B INCONTROL RX/OTC Misc. Devices ALCOHOL PADS PADS F ( ) ALCOH-WIPE 12" X 12" alcohol swabs F SHEE (alcohol sheets) MEIJER ALCOHOL RX/OTC SWABS EXTRA-THICK F ALCOHOL PREP PADS RX/OTC F PADS (alcohol swabs) PADS (alcohol swabs) QC ALCOHOL SWABS RX/OTC ALCOHOL SWABS PADS RX/OTC F F PADS (alcohol swabs) (alcohol swabs) RA ALCOHOL SWABS RX/OTC ALCOHOL SWABSTICK RX/OTC F F PADS (alcohol swabs) PADS (alcohol swabs) REALITY SWABS PADS RX/OTC F APLICARE ALCOHOL RX/OTC (alcohol swabs) SWABSTICK PADS F (alcohol swabs) RELION ALCOHOL RX/OTC SWABS PADS ( F BD SWABS SINGLE USE RX/OTC alcohol BUTTERFLY PADS F swabs) (alcohol swabs) SB ALCOHOL PREP RX/OTC BD SWABS SINGLE USE RX/OTC PADS PADS (alcohol F F PADS (alcohol swabs) swabs) CARETOUCH ALCOHOL RX/OTC SHOPKO ALCOHOL RX/OTC PREP PADS PADS F SWABS PADS (alcohol F (alcohol swabs) swabs) CURITY ALCOHOL RX/OTC SM ALCOHOL PREP RX/OTC PREPS/MEDIUM 2 PLY F PADS PADS (alcohol F PADS (alcohol swabs) swabs)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TGT ALCOHOL SWABS RX/OTC 1ST TIER UNIFINE RX/OTC F PADS ( ) PENTIPSPLUS 32GX4MM alcohol swabs F ULTICARE ALCOHOL RX/OTC MISC (insulin pen SWABS PADS (alcohol F needle) swabs) 1ST TIER UNIFINE PENTIPSPLUS 33GX4MM WEBCOL ALCOHOL RX/OTC F PREP LARGE 1 PLY F MISC (insulin pen PADS (alcohol swabs) needle) WEBCOL ALCOHOL RX/OTC 1ST TIER UNIFINE RX/OTC PENTIPSPLUS/MINI/31GX PREP LARGE 2 PLY F F PADS (alcohol swabs) 5MM MISC (insulin pen WEBCOL ALCOHOL RX/OTC needle) PREP MEDIUM 2 PLY F 1ST TIER UNIFINE RX/OTC PADS (alcohol swabs) PENTIPSPLUS/ORIGINAL/ 29GX12MM MISC (insulin F Parenteral Therapy Supplies pen needle) 1ST TIER UNIFINE RX/OTC PENTIPS/MINI/31GX5MM 1ST TIER UNIFINE F PENTIPSPLUS/ULTRA MISC (insulin pen SHORT/31GX6MM MISC F needle) (insulin pen needle) 1ST TIER UNIFINE RX/OTC 3ML LUER LOCK SAFETY RX/OTC PENTIPS29GX12MM F SYRINGES 3ML/22G X 1 MISC (insulin pen 1/2" MISC F needle) (syringe/needle (disp) 3 1ST TIER UNIFINE ml) PENTIPS31GX6MM MISC F 3ML LUER LOCK SAFETY RX/OTC (insulin pen needle) SYRINGES/3ML/21G X 1 1ST TIER UNIFINE RX/OTC 1/2" MISC F PENTIPS31GX8MM MISC F (syringe/needle (disp) 3 (insulin pen needle) ml) 1ST TIER UNIFINE RX/OTC 3ML LUER LOCK SAFETY SYRINGES/3ML/22G X 1" PENTIPS32GX4MM MISC F F (insulin pen needle) MISC (syringe/needle ) 3 ml) 1ST TIER UNIFINE (disp PENTIPS32GX6MM MISC F 3ML LUER LOCK SAFETY RX/OTC (insulin pen needle) SYRINGES/3ML/23G X 1" MISC ( F 1ST TIER UNIFINE syringe/needle PENTIPS33GX4MM MISC F (disp) 3 ml) (insulin pen needle) 3ML LUER LOCK SAFETY RX/OTC SYRINGES/3ML/25G X 1" 1ST TIER UNIFINE RX/OTC F PENTIPSPLUS 31GX8MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3ML LUER LOCK SAFETY RX/OTC 3ML SYRINGE/21G X RX/OTC SYRINGES/3ML/25G X 1"/LUER LOCK TIP MISC F 5/8" MISC F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/21G X RX/OTC 3ML LUER-LOK SYRINGE RX/OTC 1"/LUER SLIP TIP MISC 22GX 1-1/2" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/21G X 1- RX/OTC 3ML LUER-LOK RX/OTC 1/2"/LUER LOCK TIP MISC SYRINGE21G X 1" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/21G X 1- 3ML LUER-LOK RX/OTC 1/4"/LUER LOCK TIP MISC F SYRINGE21G X 1-1/2" (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) 3ML SYRINGE/22G 1- RX/OTC 1/2"/LUER LOCK TIP MISC 3ML LUER-LOK F SYRINGE22G X 1" MISC (syringe/needle (disp) 3 F (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/22G X 1"/LUER LOCK TIP MISC 3ML LUER-LOK RX/OTC F SYRINGE25G X 5/8" MISC (syringe/needle (disp) 3 F (syringe/needle (disp) 3 ml) ml) 3ML SYRINGE/22G X 1- 1/4"/LUER LOCK TIP MISC 3ML LUER-LOK TIP F SYRINGE25G X 1-1/2" (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) 3ML SYRINGE/22G X 3/4"/LUER LOCK TIP MISC 3ML SYRINGE/18G X 1- RX/OTC F 1/2"/LUER LOCK TIP (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) 3ML SYRINGE/22G X 3/4"/LUER SLIP TIP MISC 3ML SYRINGE/20G X RX/OTC F 1"/LUER LOCK TIP MISC (syringe/needle (disp) 3 F ml) (syringe/needle (disp) 3 ml) 3ML SYRINGE/25G X RX/OTC 1"/LUER LOCK TIP MISC 3ML SYRINGE/20G X RX/OTC F 1"/LUER SLIP TIP MISC (syringe/needle (disp) 3 F ml) (syringe/needle (disp) 3 ml) 3ML SYRINGE/27G X 1- RX/OTC 1/4"/LUER LOCK TIP MISC 3ML SYRINGE/20G X 1- RX/OTC F 1/2"/LUER LOCK TIP (syringe/needle (disp) 3 ml) MISC (syringe/needle F (disp) 3 ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 3ML SYRINGE/LUER RX/OTC ADVOCATE INSULIN PEN RX/OTC LOCK TIP MISC NEEDLES 31GX8MM F (syringe/needle (disp) 3 MISC (insulin pen F ml) needle) 3ML SYRINGE/LUER RX/OTC ADVOCATE INSULIN PEN LOCK TIP23GX1" MISC F NEEDLES MISC (insulin F (syringe/needle (disp) 3 pen needle) ml) ADVOCATE INSULIN RX/OTC 3ML SYRINGE/LUER SYRINGE/U- LOCK TIP25G X 1-1/2" F 100/0.3ML/29GX1/2" MISC F MISC (syringe/needle (insulin syringe/needle (disp) 3 ml) u-100) 3ML SYRINGE/LUER SLIP RX/OTC ADVOCATE INSULIN RX/OTC TIP23GX1" MISC F SYRINGE/U- (syringe/needle (disp) 3 100/0.3ML/30GX5/16" F ml) MISC (insulin 3ML SYRINGE/NEEDLE RX/OTC syringe/needle u-100) REGULAR WALL LUER- LOK 25GX5/8" SUB-Q ADVOCATE INSULIN F SYRINGE/U- MISC (syringe/needle 100/0.3ML/31GX5/16" F (disp) 3 ml) MISC (insulin ABOUTTIME PEN RX/OTC syringe/needle u-100) NEEDLE 32GX 5/32" MISC F ADVOCATE INSULIN RX/OTC (insulin pen needle) SYRINGE/U- ABOUTTIME PEN RX/OTC 100/0.5ML/29GX1/2" MISC F NEEDLES 30GX 5/16" F (insulin syringe/needle MISC (insulin pen u-100) needle) ADVOCATE INSULIN RX/OTC ABOUTTIME PEN RX/OTC SYRINGE/U- NEEDLES 31G X 3/16" 100/0.5ML/30GX5/16" F F MISC (insulin pen MISC (insulin needle) syringe/needle u-100) ABOUTTIME PEN RX/OTC ADVOCATE INSULIN NEEDLES 31G X 5/16" SYRINGE/U- F MISC (insulin pen 100/0.5ML/31GX5/16" F needle) MISC (insulin ADVOCATE INSULIN PEN syringe/needle u-100) NEEDLES 29GX12.7MM ADVOCATE INSULIN RX/OTC MISC (insulin pen F SYRINGE/U- needle) 100/1ML/29GX1/2" MISC F ADVOCATE INSULIN PEN RX/OTC (insulin syringe/needle NEEDLES 31GX5MM u-100) MISC (insulin pen F needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVOCATE INSULIN RX/OTC AURORA UNIFINE RX/OTC SYRINGE/U- PENTIPS/MINI/31GX3/16" 100/1ML/30GX5/16" MISC F MISC (insulin pen F (insulin syringe/needle needle) u-100) B-D INSULIN SYRINGE ADVOCATE INSULIN ULTRAFINE II/0.3ML/31G SYRINGE/U- X 5/16" MISC (insulin F 100/1ML/31GX5/16" MISC F syringe/needle u-100) (insulin syringe/needle B-D INSULIN SYRINGE u-100) ULTRAFINE II/0.5ML/31G ASSURE ID INSULIN RX/OTC X 5/16" MISC (insulin F SAFETYSYRINGE/U- syringe/needle u-100) 100/0.5ML/29G X 1/2" F B-D INSULIN SYRINGE MISC (insulin ULTRAFINE II/1ML/31G X syringe/needle u-100) 5/16" MISC (insulin F ASSURE ID INSULIN RX/OTC syringe/needle u-100) SAFETYSYRINGE/U- 100/1ML/29G X 1/2" MISC B-D INSULIN SYRINGE F ULTRAFINE/0.3ML/30G X (insulin syringe/needle 1/2" MISC (insulin F u-100) syringe/needle u-100) ASSURE ID SAFETY PEN NEEDLES 30G X 3/16" B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X MISC (insulin pen F 1/2" MISC (insulin F needle) syringe/needle u-100) ASSURE ID SAFETY PEN RX/OTC NEEDLES 30G X 5/16" BD LO-DOSE INSULIN RX/OTC SYRINGE MICROFINE MISC (insulin pen F IV/0.5ML/28G X 1/2" MISC F needle) (insulin syringe/needle ASSURE ID SAFETY PEN RX/OTC u-100) NEEDLES 31G X 3/16" F BD 3ML LUER-LOCK RX/OTC MISC (insulin pen SYRINGE18G X 1 1/2" needle) MISC (syringe/needle F AURORA PEN NEEDLES RX/OTC (disp) 3 ml) 29GX12MM MISC F BD 3ML LUER-LOK RX/OTC (insulin pen needle) SYRINGE 18G X 1 1/2" AURORA PEN NEEDLES MISC (syringe/needle F 31G X6MM MISC (insulin F (disp) 3 ml) pen needle) BD 3ML LUER-LOK RX/OTC AURORA PEN NEEDLES RX/OTC SYRINGE 20G X 1-1/2" 31G X8MM MISC (insulin F MISC (syringe/needle F pen needle) (disp) 3 ml) AURORA UNIFINE RX/OTC BD 3ML LUER-LOK RX/OTC PENTIPS/32GX5/32" MISC F SYRINGE/20G X 1" MISC F (insulin pen needle) (syringe/needle (disp) 3 ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD 3ML LUER-LOK RX/OTC BD AUTOSHIELD 29G X SYRINGE/21G X 1" MISC F 5/16" MISC (insulin pen F (syringe/needle (disp) 3 needle) ml) BD AUTOSHIELD DUO BD 3ML LUER-LOK RX/OTC 30G X 5MM MISC (insulin F SYRINGE/21G X 1-1/2" pen needle) MISC (syringe/needle F ) 3 ml) BD ECLIPSE SYRINGE RX/OTC (disp 3ML/21G X 1" MISC F BD 3ML LUER-LOK RX/OTC (syringe/needle (disp) 3 SYRINGE/23G X 1" MISC F ml) (syringe/needle (disp) 3 BD ECLIPSE SYRINGE ml) LUER-LOK/3ML/22G X 1" BD 3ML LUER-LOK MISC (syringe/needle F SYRINGE/23G X 1-1/2" (disp) 3 ml) MISC (syringe/needle F ) 3 ml) BD ECLIPSE SYRINGE RX/OTC (disp LUER-LOK/3ML/25G X 1" BD 3ML LUER-LOK RX/OTC MISC (syringe/needle F SYRINGE/25G X 1" MISC F (disp) 3 ml) (syringe/needle (disp) 3 ml) BD ECLIPSE RX/OTC SYRINGE/3ML/23G X 1" BD 3ML LUER-LOK F SYRINGE/26G X 5/8" MISC (syringe/needle MISC (syringe/needle F (disp) 3 ml) (disp) 3 ml) BD ECLIPSE RX/OTC SYRINGE/3ML/25GX5/8" BD 3ML RX/OTC F SYRINGE/SAFETYGLIDE MISC (syringe/needle SHIELDING IM NEEDLE (disp) 3 ml) 22GX1-1/2" MISC F BD ECLIPSE RX/OTC (syringe/needle (disp) 3 SYRINGE/LUER- ml) LOK/3ML/22G X 1-1/2" F BD 3ML RX/OTC MISC (syringe/needle SYRINGE/SAFETYGLIDE (disp) 3 ml) SHIELDING IM NEEDLE F BD INSULIN SYRINGE RX/OTC 23GX1" MISC LUER-LOK/U-100/1ML (syringe/needle (disp) 3 MISC (insulin syringes F ml) (disposable)) BD 3ML RX/OTC BD INSULIN SYRINGE RX/OTC SYRINGE/SAFETYGLIDE MICROFINE IV/U- SHIELDING NEEDLE 100/0.5ML/28G X 1/2" 25GX5/8" MISC F F MISC (insulin (syringe/needle (disp) 3 ml) syringe/needle u-100) BD AUTOSHIELD 29G X BD INSULIN SYRINGE MICROFINE IV/U- 3/16" MISC ( insulin pen F 100/1ML/27G X 5/8" MISC ) F needle (insulin syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE RX/OTC BD INSULIN SYRINGE MICROFINE IV/U- ULTRA-FINE/1/2 100/1ML/28G X 1/2" MISC F UNIT/0.3ML/31G X 8MM F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) BD INSULIN SYRINGE RX/OTC BD INSULIN SYRINGE MICROFINE/U- ULTRA-FINE/1ML/30G X 100/0.5ML/28G X 1/2" F 12.7MM MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) BD INSULIN SYRINGE BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X MICROFINE/U- 8MM MISC (insulin F 100/1ML/27G X 5/8" MISC F syringe/needle u-100) (insulin syringe/needle BD INSULIN SYRINGE u-100) ULTRAFINE HALF- BD INSULIN SYRINGE RX/OTC UNIT/0.3ML/31G X 5/16" F MICROFINE/U- MISC (insulin 100/1ML/28G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle BD INSULIN SYRINGE u-100) ULTRAFINE/0.3ML/30G X BD INSULIN SYRINGE RX/OTC 1/2" MISC (insulin F SAFETYGLIDE/1ML/29G X F syringe/needle u-100) 1/2" MISC (insulin BD INSULIN SYRINGE syringe/needle u-100) ULTRAFINE/0.3ML/31G X BD INSULIN SYRINGE RX/OTC 5/16" MISC (insulin F SLIP TIP/U-100/1ML MISC F syringe/needle u-100) (insulin syringes BD INSULIN SYRINGE (disposable)) ULTRAFINE/0.5ML/30G X BD INSULIN SYRINGE 1/2" MISC (insulin F ULTRA-FINE/0.3ML/30G X F syringe/needle u-100) 12.7MM MISC (insulin BD INSULIN SYRINGE syringe/needle u-100) ULTRAFINE/0.5ML/31G X BD INSULIN SYRINGE 5/16" MISC (insulin F ULTRA-FINE/0.3ML/31G X F syringe/needle u-100) 8MM MISC (insulin BD INSULIN SYRINGE syringe/needle u-100) ULTRAFINE/1ML/30G X BD INSULIN SYRINGE 1/2" MISC (insulin F ULTRA-FINE/0.5ML/30G X F syringe/needle u-100) 12.7MM MISC (insulin BD INSULIN SYRINGE RX/OTC syringe/needle u-100) ULTRAFINE/U- BD INSULIN SYRINGE 100/0.3ML/29G X 1/2" F ULTRA-FINE/0.5ML/31G X MISC ( F insulin 8MM MISC (insulin syringe/needle u-100) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE RX/OTC BD INSULIN SYRINGE/U- RX/OTC ULTRAFINE/U- 100/1ML/27G X 1/2" MISC 100/0.5ML/29G X 1/2" F (insulin syringe/needle F MISC (insulin u-100) syringe/needle u-100) BD INSULIN SYRINGE/U- BD INSULIN SYRINGE RX/OTC 100/2ML/27.5G X 5/8" ULTRAFINE/U- MISC (insulin F 100/1ML/29G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle BD INSULIN SYRINGE/U- u-100) 500/0.5ML/31G X 6MM BD INSULIN SYRINGE MISC (insulin F ULTRAFINE/U- syringe/needle u-500) 100/1ML/31G X 5/16" F BD INTEGRA 3ML RX/OTC MISC (insulin SYRINGE syringe/needle u-100) W/RETRACTING BD INSULIN RX/OTC NEEDLE/21G X 1-1/2" F SYRINGE/0.3ML/29G X MISC ( F syringe/needle 12.7MM MISC (insulin (disp) 3 ml) syringe/needle u-100) BD INTEGRA 3ML RX/OTC BD INSULIN RX/OTC SYRINGE SYRINGE/0.5ML/29G X W/RETRACTING F 12.7MM MISC (insulin F NEEDLE/25G X 1" MISC syringe/needle u-100) (syringe/needle (disp) 3 BD INSULIN RX/OTC ml) SYRINGE/1ML/27G X BD INTEGRA RX/OTC F SYRINGE/3ML/21G X 1" 12.7MM MISC (insulin F syringe/needle u-100) MISC (syringe/needle ) 3 ml) BD INSULIN RX/OTC (disp SYRINGE/1ML/29G X BD INTEGRA RX/OTC F SYRINGE/3ML/22G X 1.5" 12.7MM MISC (insulin F syringe/needle u-100) MISC (syringe/needle ) 3 ml) BD INSULIN (disp SYRINGE/DETACHABLE BD INTEGRA RX/OTC SYRINGE/3ML/23G X 1" NEEDLE/U-100/1ML/25G F F X 1" MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) BD INSULIN BD INTEGRA RX/OTC SYRINGE/3ML/25G X 5/8 SYRINGE/DETACHABLE F NEEDLE/U-100/1ML/25G F MISC (syringe/needle X 5/8" MISC (insulin (disp) 3 ml) syringe/needle u-100) BD LUER-LOK SYRINGE/3ML/22G X 3/4" BD INSULIN F SYRINGE/DETACHABLE MISC (syringe/needle NEEDLE/U-100/1ML/26G F (disp) 3 ml) X 1/2" MISC (insulin syringe/needle u-100) CA Health & Wellness Preferred Drug List Updated September 1, 2021

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD PEN BD SAFETYGLIDE NEEDLE/MICRO/ULTRA- INSULIN F FINE/32G X 6MM MISC SYRINGE/0.3ML/31G X F (insulin pen needle) 5/16" MISC (insulin BD PEN RX/OTC syringe/needle u-100) NEEDLE/MINI/ULTRA- F BD SAFETYGLIDE FINE/31G X 5MM MISC INSULIN (insulin pen needle) SYRINGE/0.5ML/31G X F BD PEN NEEDLE/NANO RX/OTC 15/64" MISC (insulin 2ND GEN/32G X 5/32" syringe/needle u-100) F MISC (insulin pen BD SAFETYGLIDE needle) INSULIN BD PEN RX/OTC SYRINGE/1ML/31G X F NEEDLE/NANO/ULTRA- 15/64" MISC (insulin FINE/32G X 4MM MISC F syringe/needle u-100) (insulin pen needle) BD SAFETYGLIDE RX/OTC BD PEN INSULIN NEEDLE/ORIGINAL/ULTR SYSYRINGE/0.5ML/30G X F A-FINE/29G X 12.7MM F 5/16" MISC (insulin MISC (insulin pen syringe/needle u-100) needle) BD SAFETYGLIDE RX/OTC BD PEN RX/OTC SYRINGE 3ML/25GX1" NEEDLE/SHORT/ULTRA- MISC (syringe/needle F F FINE/31G X 8MM MISC (disp) 3 ml) (insulin pen needle) BD VEO INSULIN BD SAFETY-GLIDE RX/OTC SYRINGE ULTR-FINE/U- INSULIN 100/0.5ML/31G X 15/64" F SYRINGE/0.5ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) BD VEO INSULIN RX/OTC BD SAFETY-LOK INSULIN RX/OTC SYRINGE ULTRA- SYRINGE/PERM AFINE/0.3ML/31G X 6MM F NEEDLE/UF/1ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) BD VEO INSULIN RX/OTC BD SAFETYGLIDE RX/OTC SYRINGE ULTRA- INSULIN FINE/0.3ML/31G X 6MM F SYRINGE/0.3ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) BD VEO INSULIN BD SAFETYGLIDE RX/OTC SYRINGE ULTRA- INSULIN FINE/0.5ML/31G X 6MM F SYRINGE/0.3ML/31G X F MISC (insulin 15/64" MISC (insulin syringe/needle u-100) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD VEO INSULIN RX/OTC CAREFINE PEN SYRINGE ULTRA- NEEDLES 32GX6MM FINE/1/2 UNIT/0.3ML/31G F MISC (insulin pen F X 6MM MISC (insulin needle) syringe/needle u-100) CAREONE INSULIN BD VEO INSULIN SYRINGES/0.3ML/30G X SYRINGE ULTRA- 1/2" MISC (insulin F FINE/1ML/31G X 6MM F syringe/needle u-100) MISC (insulin CAREONE INSULIN syringe/needle u-100) SYRINGES/0.3ML/31G X BD VEO INSULIN RX/OTC 5/16" MISC (insulin F SYRINGE ULTRA-FINE/U- syringe/needle u-100) 100/0.3ML/31G X 15/64" F CAREONE INSULIN MISC (insulin SYRINGES/0.5ML/30G X syringe/needle u-100) 1/2" MISC (insulin F BD VEO INSULIN syringe/needle u-100) SYRINGE ULTRA-FINE/U- 100/1ML/31G X 15/64" CAREONE INSULIN F SYRINGES/0.5ML/31G X MISC (insulin 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) CAREFINE PEN NEEDLE RX/OTC CAREONE INSULIN 32GX4MM MISC (insulin F SYRINGES/1ML/30G X pen needle) 1/2" MISC (insulin F CAREFINE PEN RX/OTC syringe/needle u-100) NEEDLES 29GX1/2" MISC F CAREONE INSULIN (insulin pen needle) SYRINGES/1ML/31GX5/16 CAREFINE PEN RX/OTC " MISC (insulin F NEEDLES 30GX5/16" syringe/needle u-100) MISC (insulin pen F CAREONE UNIFINE RX/OTC needle) PENTIPS 29GX12MM CAREFINE PEN MISC (insulin pen F NEEDLES 31GX6MM needle) MISC (insulin pen F CAREONE UNIFINE RX/OTC needle) PENTIPS 31GX5MM MISC F CAREFINE PEN RX/OTC (insulin pen needle) NEEDLES 31GX8MM CAREONE UNIFINE MISC (insulin pen F PENTIPS 31GX6MM MISC F needle) (insulin pen needle) CAREFINE PEN RX/OTC CAREONE UNIFINE RX/OTC NEEDLES 32GX5MM F PENTIPS 31GX8MM MISC F MISC (insulin pen (insulin pen needle) needle) CAREONE UNIFINE RX/OTC PENTIPS PEN NEEDLES 32GX4MM MISC (insulin F pen needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREONE UNIFINE RX/OTC CARETOUCH INSULIN PENTIPS PLUS PEN SYRINGE/U-100/1ML/28G NEEDLES 29GX12MM F X 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) CARETOUCH INSULIN CAREONE UNIFINE RX/OTC SYRINGE/U-100/1ML/29G PENTIPS PLUS PEN X 5/16" MISC (insulin F NEEDLES 31GX5MM F syringe/needle u-100) MISC (insulin pen CARETOUCH PEN needle) NEEDLES 31G X 6 MM CAREONE UNIFINE MISC (insulin pen F PENTIPS PLUS PEN needle) NEEDLES 31GX6MM F CARETOUCH PEN RX/OTC MISC (insulin pen NEEDLES 31GX 5MM needle) MISC (insulin pen F CAREONE UNIFINE RX/OTC needle) PENTIPS PLUS PEN NEEDLES 31GX8MM CARETOUCH PEN RX/OTC F NEEDLES 31GX 8MM MISC (insulin pen MISC (insulin pen F needle) needle) CAREONE UNIFINE RX/OTC PENTIPS PLUS PEN CARETOUCH PEN RX/OTC NEEDLES 32GX 4MM NEEDLES 32GX4MM F F MISC (insulin pen MISC (insulin pen needle) needle) CAREONE UNIFINE CARETOUCH PEN RX/OTC NEEDLES 32GX 5MM PENTIPS PLUS PEN F NEEDLES/33G X 5/32" F MISC (insulin pen MISC (insulin pen needle) needle) CLEVER CHOICE RX/OTC CAREPOINT SAFETY 1ST RX/OTC COMFORT EZINSULIN SYRINGE/NEEDLE PEN NEEDLES 31GX8MM F 3ML/23G X 1" MISC F MISC (insulin pen (syringe/needle (disp) 3 needle) ml) CLEVER CHOICE CAREPOINT SAFETY 1ST RX/OTC COMFORT EZINSULIN SYRINGE/NEEDLE PEN NEEDLES 33GX4MM F 3ML/25G X 1" MISC F MISC (insulin pen (syringe/needle (disp) 3 needle) ml) CLEVER CHOICE RX/OTC CAREPOINT SAFETY 1ST RX/OTC COMFORT EZINSULIN SYRINGE/NEEDLE SYRINGE/0.3ML/29G X F 3ML/25G X 5/8" MISC F 1/2" MISC (insulin (syringe/needle (disp) 3 syringe/needle u-100) ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE CLEVER CHOICE RX/OTC COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.3ML/30G X F SYRINGE/1ML/28G X 1/2" F 1/2" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) CLEVER CHOICE RX/OTC CLEVER CHOICE RX/OTC COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.3ML/30G X F SYRINGE/1ML/29G X 1/2" F 5/16" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) CLEVER CHOICE CLEVER CHOICE RX/OTC COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.3ML/31G X F SYRINGE/1ML/30G X F 5/16" MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100) CLEVER CHOICE RX/OTC CLEVER CHOICE COMFORT EZINSULIN COMFORT EZINSULIN SYRINGE/0.5ML/28G X F SYRINGE/U- 1/2" MISC (insulin 100/1ML/31GX5/16" MISC F syringe/needle u-100) (insulin syringe/needle CLEVER CHOICE RX/OTC u-100) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/0.5ML/29G X F COMFORT EZPEN 1/2" MISC (insulin NEEDLES 29GX12MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE needle) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/0.5ML/30G X F COMFORT EZPEN 1/2" MISC (insulin NEEDLES 31GX5MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE RX/OTC needle) COMFORT EZINSULIN CLEVER CHOICE SYRINGE/0.5ML/30G X F COMFORT EZPEN 5/16" MISC (insulin NEEDLES 31GX6MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE needle) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/0.5ML/31G X F COMFORT EZPEN 5/16" MISC (insulin NEEDLES 31GX8MM F syringe/needle u-100) MISC (insulin pen CLEVER CHOICE needle) COMFORT EZINSULIN CLEVER CHOICE RX/OTC SYRINGE/1.0ML/30G X F COMFORT EZPEN 1/2" MISC (insulin NEEDLES 32GX4MM F syringe/needle u-100) MISC (insulin pen needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE RX/OTC CLICKFINE PEN COMFORT EZPEN NEEDLES 31G X 1/4" NEEDLES 32GX5MM F MISC (insulin pen F MISC (insulin pen needle) needle) CLICKFINE PEN RX/OTC CLEVER CHOICE NEEDLES 31G X 3/16" COMFORT EZPEN MISC (insulin pen F NEEDLES 32GX6MM F needle) MISC (insulin pen CLICKFINE PEN RX/OTC needle) NEEDLES 31G X 5/16" CLEVER CHOICE MISC (insulin pen F COMFORT EZPEN needle) NEEDLES 32GX8MM F CLICKFINE PEN RX/OTC MISC (insulin pen NEEDLES 31G X 8MM needle) MISC (insulin pen F CLEVER CHOICE needle) COMFORT EZPEN NEEDLES 33GX4MM CLICKFINE PEN RX/OTC F NEEDLES 32G X 5/32" MISC (insulin pen MISC (insulin pen F needle) needle) CLEVER CHOICE COMFORT EZPEN CLICKFINE PEN NEEDLES/31GX1/4" MISC NEEDLES 33GX5MM F F MISC (insulin pen (insulin pen needle) needle) CLICKFINE UNIVERSAL RX/OTC PEN NEEDLES 31GX5/16" CLEVER CHOICE F COMFORT EZPEN MISC (insulin pen NEEDLES 33GX6MM F needle) MISC (insulin pen COMFORT ASSIST RX/OTC needle) INSULIN SYRINGE 0.3ML/29G X 1/2" MISC CLEVER CHOICE F COMFORT EZPEN (insulin syringe/needle NEEDLES 33GX8MM F u-100) MISC (insulin pen COMFORT ASSIST RX/OTC needle) INSULIN SYRINGE/0.3ML/30G X CLICKFINE PEN NEEDLE RX/OTC F 5/16" MISC (insulin 32GX5/32" MISC (insulin F syringe/needle u-100) pen needle) COMFORT ASSIST CLICKFINE PEN NEEDLE INSULIN UNIVERSAL/31GX1/4" F SYRINGE/0.3ML/31G X F MISC (insulin pen 5/16" MISC (insulin needle) syringe/needle u-100) CLICKFINE PEN NEEDLE RX/OTC UNIVERSAL/31GX5/16" MISC (insulin pen F needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST RX/OTC COMFORT EZ/31G X 5MM RX/OTC INSULIN MISC (insulin pen F SYRINGE/0.5ML/29G X F needle) 1/2" MISC (insulin COMFORT EZ/31G X 6MM syringe/needle u-100) MISC (insulin pen F COMFORT ASSIST RX/OTC needle) INSULIN SYRINGE/0.5ML/30G X COMFORT TOUCH PEN F NEEDLES/31G X 4MM 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) COMFORT ASSIST INSULIN COMFORT TOUCH PEN RX/OTC NEEDLES/31G X 5MM SYRINGE/0.5ML/31G X F F 5/16" MISC (insulin MISC (insulin pen syringe/needle u-100) needle) COMFORT ASSIST RX/OTC COMFORT TOUCH PEN NEEDLES/31G X 6 MM INSULIN F SYRINGE/1ML/29G X 1/2" F MISC (insulin pen MISC (insulin needle) syringe/needle u-100) COMFORT TOUCH PEN RX/OTC NEEDLES/31G X 8 MM COMFORT ASSIST RX/OTC F INSULIN MISC (insulin pen SYRINGE/1ML/30G X F needle) 5/16" MISC (insulin COMFORT TOUCH PEN RX/OTC syringe/needle u-100) NEEDLES/32G X 4MM F COMFORT ASSIST MISC (insulin pen INSULIN needle) SYRINGE/1ML/31G X F COMFORT TOUCH PEN RX/OTC 5/16" MISC (insulin NEEDLES/32G X 5MM syringe/needle u-100) MISC (insulin pen F COMFORT EZ INSULIN needle) SYRINGE/U- COMFORT TOUCH PEN 100/0.5ML/31G X 5/16" F NEEDLES/32G X 6MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) COMFORT EZ INSULIN COMFORT TOUCH PEN SYRINGE/U-100/1ML/31G F NEEDLES/32G X 8MM X 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) COMFORT EZ RX/OTC COMFORT TOUCH PEN MICRO/32G X 4MM MISC F NEEDLES/33G X 5/32" (insulin pen needle) MISC (insulin pen F COMFORT EZ RX/OTC needle) SHORT/31G X 8MM MISC F (insulin pen needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT TOUCH PEN DROPLET INSULIN NEEDLES/33GX 3/16" SYRINGE U- MISC (insulin pen F 100/0.3ML/30G X 1/2" F needle) MISC (insulin COMFORT TOUCH PEN syringe/needle u-100) NEEDLES/33GX1/4" MISC F DROPLET INSULIN RX/OTC (insulin pen needle) SYRINGE U- DIALYSIS SAFETY RX/OTC 100/0.3ML/30G X 5/16" F SYRINGES/LOW DEAD MISC (insulin SPACE 3ML/22GX1-1/2" F syringe/needle u-100) MISC (syringe/needle DROPLET INSULIN RX/OTC (disp) 3 ml) SYRINGE U- DIATHRIVE PEN 100/0.3ML/31G X 15/64" F NEEDLE/31 G X 6MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) DROPLET INSULIN DIATHRIVE PEN RX/OTC SYRINGE U- NEEDLE/31 GX 8MM 100/0.5ML/30G X 1/2" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) DIATHRIVE PEN RX/OTC DROPLET INSULIN RX/OTC NEEDLE/31GX 5MM MISC SYRINGE U- F 100/0.5ML/30G X 5/16" (insulin pen needle) F MISC (insulin DIATHRIVE PEN RX/OTC syringe/needle u-100) NEEDLE/32GX 4MM MISC F ( ) DROPLET INSULIN insulin pen needle SYRINGE U- DROPLET INSULIN RX/OTC 100/0.5ML/31G X 5/16" F SYRINGE 0.3ML/29G X F MISC (insulin 1/2" MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN DROPLET INSULIN RX/OTC SYRINGE U-100/1ML/30G SYRINGE 0.5ML/29G X F F X 1/2" MISC (insulin 1/2" MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN RX/OTC DROPLET INSULIN RX/OTC SYRINGE U-100/1ML/30G SYRINGE 1ML/29G X 1/2" F F X 5/16" MISC (insulin MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN DROPLET INSULIN SYRINGE U-100/1ML/31G SYRINGE U-100/0.3/31G F F X 15/64" MISC (insulin X 5/16" MISC (insulin syringe/needle u-100) ) syringe/needle u-100 DROPLET INSULIN SYRINGE U-100/1ML/31G X 5/16" MISC (insulin F syringe/needle u-100) CA Health & Wellness Preferred Drug List Updated September 1, 2021

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET INSULIN RX/OTC DROPLET PEN NEEDLES RX/OTC SYRINGE/U- 29GX12MM MISC (insulin F 100/0.3ML/31G X 15/64" F pen needle) MISC (insulin DROPLET PEN NEEDLES RX/OTC syringe/needle u-100) 30G X 5/16" MISC F DROPLET INSULIN (insulin pen needle) SYRINGE/U- DROPLET PEN NEEDLES RX/OTC 100/0.3ML/31G X 5/16" F 31G X3/16" MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) DROPLET PEN NEEDLES RX/OTC DROPLET INSULIN SYRINGE/U- 31G X5/16" MISC (insulin F 100/0.5ML/30G X 1/2" F pen needle) MISC (insulin DROPLET PEN NEEDLES RX/OTC syringe/needle u-100) 31GX5MM MISC (insulin F DROPLET INSULIN pen needle) SYRINGE/U- DROPLET PEN NEEDLES 100/0.5ML/31G X 15/64" F 31GX6MM MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) DROPLET PEN NEEDLES RX/OTC DROPLET INSULIN 31GX8MM MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/31G X 5/16" F MISC (insulin DROPLET PEN NEEDLES syringe/needle u-100) 32G X 1/4" MISC (insulin F pen needle) DROPLET INSULIN SYRINGE/U-100/1ML/30G DROPLET PEN NEEDLES RX/OTC X 1/2" MISC (insulin F 32G X 3/16" MISC F syringe/needle u-100) (insulin pen needle) DROPLET INSULIN DROPLET PEN NEEDLES SYRINGE/U-100/1ML/31G 32G X 5/16" MISC F X 15/64" MISC (insulin F (insulin pen needle) syringe/needle u-100) DROPLET PEN NEEDLES RX/OTC 32G X 5/32" MISC DROPLET INSULIN F SYRINGE/U-100/1ML/31G (insulin pen needle) X 5/16" MISC (insulin F DROPLET PEN NEEDLES RX/OTC syringe/needle u-100) 32GX4MM MISC (insulin F DROPLET PEN NEEDLES RX/OTC pen needle) 29G X1/2" MISC (insulin F DROPLET PEN NEEDLES RX/OTC pen needle) 32GX5MM MISC (insulin F DROPLET PEN NEEDLES pen needle) 29GX10MM MISC F DROPLET PEN NEEDLES (insulin pen needle) 32GX6MM MISC (insulin F pen needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET PEN NEEDLES EASY COMFORT INSULIN 32GX8MM MISC ( SYRINGE/1ML/31G X insulin F F pen needle) 5/16" MISC (insulin DROPSAFE SAFETY PEN RX/OTC syringe/needle u-100) NEEDLES/31G X 5/16" EASY COMFORT INSULIN MISC (insulin pen F SYRINGE/U- needle) 100/0.5ML/30G X 1/2" F DROPSAFE SAFTEY PEN MISC (insulin NEEDLES/31G X 1/4" syringe/needle u-100) MISC (insulin pen F EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G needle) F DRUG MART UNIFINE RX/OTC X 1/2" MISC (insulin PENTIPS 31GX5MM MISC F syringe/needle u-100) (insulin pen needle) EASY COMFORT PEN DRUG MART UNIFINE RX/OTC NEEDLES31GX1/4" MISC F PENTIPS29G X 12MM (insulin pen needle) MISC (insulin pen F EASY COMFORT PEN RX/OTC needle) NEEDLES31GX3/16" MISC F DRUG MART UNIFINE (insulin pen needle) PENTIPS31GX6MM MISC F EASY COMFORT PEN RX/OTC (insulin pen needle) NEEDLES31GX5/16" MISC F DRUG MART UNIFINE RX/OTC (insulin pen needle) PENTIPS31GX8MM MISC F EASY COMFORT PEN RX/OTC (insulin pen needle) NEEDLES32GX5/32" MISC F DRUG MART UNIFINE RX/OTC (insulin pen needle) PENTIPS32GX4MM MISC F EASY COMFORT PEN NEEDLES33G X 4MM (insulin pen needle) F DRUG MART UNIFINE RX/OTC MISC (insulin pen PENTIPSPLUS 32GX4MM needle) MISC (insulin pen F EASY COMFORT PEN NEEDLES33G X 5MM needle) F EASY COMFORT INSULIN RX/OTC MISC (insulin pen SYRINGE/0.5ML/30G X needle) 5/16" MISC (insulin F EASY COMFORT PEN NEEDLES33G X 6MM syringe/needle u-100) F EASY COMFORT INSULIN MISC (insulin pen SYRINGE/0.5ML/31G X needle) 5/16" MISC (insulin F EASY GLIDE PEN NEEDLES 33G X 5/32" syringe/needle u-100) F EASY COMFORT INSULIN RX/OTC MISC (insulin pen SYRINGE/1ML/30G X needle) 5/16" MISC (insulin F EASY TOUCH 32GX5MM RX/OTC syringe/needle u-100) MISC (insulin pen F needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH 32GX6MM EASY TOUCH FLIPLOCK RX/OTC MISC (insulin pen F SAFETY SYRINGE needle) 3ML/23GX1" MISC F EASY TOUCH FLIPLOCK RX/OTC (syringe/needle (disp) 3 SAFETTY SYRINGES ml) 3ML/18GX1-1/2" MISC F EASY TOUCH FLIPLOCK (syringe/needle (disp) 3 SAFETY SYRINGE ml) 3ML/23GX1-1/2" MISC F EASY TOUCH FLIPLOCK RX/OTC (syringe/needle (disp) 3 SAFETY INSULIN ml) SYRINGE 1ML/29GX1/2" F EASY TOUCH FLIPLOCK RX/OTC MISC (insulin SAFETY SYRINGE 3ML/25GX1" MISC syringe/needle u-100) F (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK ml) SAFETY INSULIN SYRINGE 1ML/30GX1/2" EASY TOUCH FLIPLOCK RX/OTC F SAFETY SYRINGE MISC (insulin 3ML/25GX5/8" MISC F syringe/needle u-100) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK RX/OTC ml) SAFETY INSULIN EASY TOUCH FLIPLOCK RX/OTC SYRINGE 1ML/30GX5/16" F SAFETY SYRINGES MISC (insulin 3ML/18GX1" MISC F syringe/needle u-100) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK ml) SAFETY INSULIN EASY TOUCH FLIPLOCK RX/OTC SYRINGE 1ML/31GX5/16" F SAFETY SYRINGES MISC (insulin 3ML/20GX1" MISC F syringe/needle u-100) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK RX/OTC ml) SAFETY SYRINGE EASY TOUCH FLIPLOCK RX/OTC 3ML/21GX1" MISC F SAFETY SYRINGES (syringe/needle (disp) 3 3ML/20GX1-1/2" MISC F ml) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK ml) SAFETY SYRINGE EASY TOUCH FLIPLOCK RX/OTC 3ML/22GX1" MISC F SAFETY SYRINGES (syringe/needle (disp) 3 3ML/21GX1-1/2" MISC F ml) (syringe/needle (disp) 3 EASY TOUCH FLIPLOCK RX/OTC ml) SAFETY SYRINGE EASY TOUCH INSULIN RX/OTC 3ML/22GX1-1/2" MISC F SYRINGE/0.3ML/30G X F (syringe/needle (disp) 3 5/16" MISC (insulin ml) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH INSULIN EASY TOUCH INSULIN RX/OTC SYRINGE/0.3ML/31G X SYRINGE/U- 5/16" MISC (insulin F 100/0.5ML/28G X 1/2" F syringe/needle u-100) MISC (insulin EASY TOUCH INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.5ML/29G X EASY TOUCH INSULIN RX/OTC 1/2" MISC (insulin F SYRINGE/U- syringe/needle u-100) 100/0.5ML/29G X 1/2" F EASY TOUCH INSULIN RX/OTC MISC (insulin SYRINGE/0.5ML/30G X syringe/needle u-100) 5/16" MISC (insulin F EASY TOUCH INSULIN syringe/needle u-100) SYRINGE/U- 100/0.5ML/30G X 1/2" EASY TOUCH INSULIN RX/OTC F SYRINGE/1ML/30G X MISC (insulin 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) EASY TOUCH INSULIN SYRINGE/U- EASY TOUCH INSULIN RX/OTC 100/0.5ML/31G X 5/16" SYRINGE/SAFETY/U- F MISC (insulin 100/0.5ML/29G X 1/2" F MISC (insulin syringe/needle u-100) syringe/needle u-100) EASY TOUCH INSULIN RX/OTC SYRINGE/U-100/1ML/27G EASY TOUCH INSULIN RX/OTC F SYRINGE/SAFETY/U- X 1/2" MISC (insulin 100/0.5ML/30G X 5/16" F syringe/needle u-100) MISC (insulin EASY TOUCH INSULIN RX/OTC SYRINGE/U-100/1ML/28G syringe/needle u-100) F EASY TOUCH INSULIN RX/OTC X 1/2" MISC (insulin SYRINGE/SAFETY/U- syringe/needle u-100) 100/1ML/29G X 1/2" MISC F EASY TOUCH INSULIN RX/OTC ( SYRINGE/U-100/1ML/29G insulin syringe/needle F u-100) X 1/2" MISC (insulin EASY TOUCH INSULIN syringe/needle u-100) SYRINGE/SAFETY/U- EASY TOUCH INSULIN 100/1ML/30G X 1/2" MISC F SYRINGE/U-100/1ML/30G (insulin syringe/needle X 1/2" MISC (insulin F u-100) syringe/needle u-100) EASY TOUCH INSULIN EASY TOUCH INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 100/0.3ML/30G X 1/2" F X 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) EASY TOUCH PEN RX/OTC EASY TOUCH INSULIN NEEDLE 30G X 5/16" SYRINGE/U- MISC (insulin pen F 100/0.5ML/27G X 1/2" F needle) MISC (insulin syringe/needle u-100) CA Health & Wellness Preferred Drug List Updated September 1, 2021

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH PEN EASY TOUCH SAFETY RX/OTC NEEDLE/30G X 3/16" SYRINGE/3ML/21G X 1" MISC (insulin pen F MISC (syringe/needle F needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH SAFETY NEEDLES 29GX1/2" MISC F SYRINGE/3ML/22G X 1" (insulin pen needle) MISC (syringe/needle F EASY TOUCH PEN (disp) 3 ml) NEEDLES 31GX1/4" MISC F EASY TOUCH SAFETY RX/OTC (insulin pen needle) SYRINGE/3ML/22G X 1- EASY TOUCH PEN RX/OTC 1/2" MISC F NEEDLES 31GX5/16" (syringe/needle (disp) 3 MISC (insulin pen F ml) needle) EASY TOUCH SAFETY RX/OTC SYRINGE/3ML/23G X 1" EASY TOUCH PEN F NEEDLES 32GX1/4" MISC F MISC (syringe/needle (insulin pen needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH SAFETY RX/OTC SYRINGE/3ML/25G X 1" NEEDLES 32GX3/16" F MISC (insulin pen F MISC (syringe/needle needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH SAFETY RX/OTC SYRINGE/3ML/25G X 5/8" NEEDLES 32GX5/32" F MISC (insulin pen F MISC (syringe/needle needle) (disp) 3 ml) EASY TOUCH PEN RX/OTC EASY TOUCH RX/OTC NEEDLES/31G X 3/16" SHEATHLOCK SAFETY F INSULIN SYRINGE MISC (insulin pen 1ML/29GX1/2" MISC F needle) (insulin syringe/needle EASY TOUCH SAFETY u-100) PEN NEEDLES/29G X F EASY TOUCH RX/OTC 5MM MISC (insulin pen SHEATHLOCK SAFETY needle) INSULIN SYRINGE EASY TOUCH SAFETY 1ML/30GX5/16" MISC F PEN NEEDLES/29G X F (insulin syringe/needle 8MM MISC (insulin pen u-100) needle) EASY TOUCH EASY TOUCH SAFETY RX/OTC SHEATHLOCK SAFETY PEN NEEDLES/30G X INSULIN SYRINGE 5/16" MISC (insulin pen F 1ML/31GX5/16" MISC F needle) (insulin syringe/needle EASY TOUCH SAFETY RX/OTC u-100) SYRINGE/3ML/20G X 1" MISC (syringe/needle F (disp) 3 ml) CA Health & Wellness Preferred Drug List Updated September 1, 2021

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH EASYPOINT RX/OTC SHEATHLOCK SAFETY NEEDLE/SYRINGE SYRINGE 1ML/30GX1/2" F 3ML/18G X 1-1/2" MISC F MISC (insulin (syringe/needle (disp) 3 syringe/needle u-100) ml) EASY TOUCH RX/OTC EASYPOINT RX/OTC SHEATHLOCK SAFETY NEEDLE/SYRINGE SYRINGE 3ML/21GX1" F 3ML/23 G X 1" MISC F MISC (syringe/needle (syringe/needle (disp) 3 (disp) 3 ml) ml) EASY TOUCH RX/OTC EASYPOINT RX/OTC SHEATHLOCK SAFETY NEEDLE/SYRINGE 3ML/25G X 1" MISC F SYRINGE 3ML/21GX1-1/2" F MISC (syringe/needle (syringe/needle (disp) 3 ml) (disp) 3 ml) EASYPOINT RX/OTC EASY TOUCH NEEDLE/SYRINGE SHEATHLOCK SAFETY 3ML/25G X 5/8" MISC F SYRINGE 3ML/22GX1" F (syringe/needle (disp) 3 MISC (syringe/needle ml) (disp) 3 ml) ELITE-THIN INSULIN EASY TOUCH RX/OTC SYRINGE/0.3ML/31G X SHEATHLOCK SAFETY 5/16" MISC (insulin F SYRINGE 3ML/22GX1-1/2" F syringe/needle u-100) MISC (syringe/needle ELITE-THIN INSULIN RX/OTC (disp) 3 ml) SYRINGE/0.5ML/29G X EASY TOUCH RX/OTC 1/2" MISC (insulin F SHEATHLOCK SAFETY syringe/needle u-100) SYRINGE 3ML/23GX1" F MISC (syringe/needle ELITE-THIN INSULIN RX/OTC SYRINGE/0.5ML/30G X (disp) 3 ml) 5/16" MISC (insulin F EASY TOUCH RX/OTC SHEATHLOCK SAFETY syringe/needle u-100) SYRINGE 3ML/25GX1" F ELITE-THIN INSULIN SYRINGE/1ML/29G X MISC (syringe/needle F (disp) 3 ml) 5/16" MISC (insulin EASY TOUCH RX/OTC syringe/needle u-100) SHEATHLOCK SAFETY ELITE-THIN INSULIN RX/OTC SYRINGE/1ML/30G X SYRINGE 3ML/25GX5/8" F F MISC (syringe/needle 5/16" MISC (insulin (disp) 3 ml) syringe/needle u-100) EASYPOINT RX/OTC ELITE-THIN INSULIN RX/OTC NEEDLE/SYRINGE SYRINGE/U- 3ML/18G X 1" MISC F 100/0.5ML/28G X 1/2" F (syringe/needle (disp) 3 MISC (insulin ml) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN EQL INSULIN RX/OTC SYRINGE/U- SYRINGE/0.5ML/29G X 100/0.5ML/28G X 5/16" F 1/2" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) EQL INSULIN RX/OTC ELITE-THIN INSULIN SYRINGE/0.5ML/30G X SYRINGE/U- 5/16" MISC (insulin F 100/0.5ML/29G X 5/16" F syringe/needle u-100) MISC (insulin EQL INSULIN syringe/needle u-100) SYRINGE/0.5ML/31G X ELITE-THIN INSULIN 5/16" MISC (insulin F SYRINGE/U- syringe/needle u-100) 100/0.5ML/31G X 5/16" F EQL INSULIN RX/OTC MISC (insulin SYRINGE/1ML/29G X 1/2" syringe/needle u-100) MISC (insulin F ELITE-THIN INSULIN RX/OTC syringe/needle u-100) SYRINGE/U-100/1ML/28G F EQL INSULIN RX/OTC X 1/2" MISC (insulin SYRINGE/1ML/30G X syringe/needle u-100) 5/16" MISC (insulin F ELITE-THIN INSULIN syringe/needle u-100) SYRINGE/U-100/1ML/28G F EQL INSULIN X 5/16" MISC (insulin SYRINGE/1ML/31G X syringe/needle u-100) 5/16" MISC (insulin F ELITE-THIN INSULIN RX/OTC syringe/needle u-100) SYRINGE/U-100/1ML/29G F EXCEL COMFORT POINT X 1/2" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 31G X 4MM MISC (insulin F ELITE-THIN INSULIN pen needle) SYRINGE/U-100/1ML/31G F EXEL COMFORT POINT RX/OTC X 5/16" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 29G X 12MM MISC F EQL INSULIN RX/OTC (insulin pen needle) SYRINGE/0.3ML/29G X F EXEL COMFORT POINT 1/2" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 31G X 6MM MISC (insulin F EQL INSULIN RX/OTC pen needle) SYRINGE/0.3ML/30G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN PEN NEEDLES syringe/needle u-100) 31G X 8MM MISC (insulin F EQL INSULIN pen needle) SYRINGE/0.3ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/0.3ML/29G X F 1/2" MISC (insulin syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXEL COMFORT POINT RX/OTC FIFTY50 PEN RX/OTC INSULIN NEEDLES/31GX8MM SYRINGE/0.3ML/30G X F MISC (insulin pen F 5/16" MISC (insulin needle) syringe/needle u-100) FIFTY50 PEN RX/OTC EXEL COMFORT POINT RX/OTC NEEDLES/32GX4MM INSULIN MISC (insulin pen F SYRINGE/0.5ML/28G X F needle) 1/2" MISC (insulin FIFTY50 PEN syringe/needle u-100) NEEDLES/32GX6MM EXEL COMFORT POINT RX/OTC MISC (insulin pen F INSULIN needle) SYRINGE/0.5ML/29G X F FIFTY50 SUPERIOR 1/2" MISC (insulin COMFORTINSULIN syringe/needle u-100) SYRINGE/0.3ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/0.5ML/30G X F FIFTY50 SUPERIOR 5/16" MISC (insulin COMFORTINSULIN syringe/needle u-100) SYRINGE/0.5ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/1ML/28G X 1/2" F FIFTY50 SUPERIOR MISC (insulin COMFORTINSULIN syringe/needle u-100) SYRINGE/1ML/31G X F EXEL COMFORT POINT RX/OTC 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGE/1ML/29G X 1/2" F FREDS PHARMACY RX/OTC MISC (insulin UNIFINE PENTIPS PEN syringe/needle u-100) NEEDLES 32GX4MM F EXEL COMFORT POINT RX/OTC MISC (insulin pen INSULIN needle) SYRINGE/1ML/30G X F FREDS PHARMACY RX/OTC 5/16" MISC (insulin UNIFINE PENTIPS PLUS syringe/needle u-100) 31GX5MM MISC (insulin F FIFTY50 PEN NEEDLES RX/OTC pen needle) F 31G X3/16" (5MM) MISC FREDS PHARMACY RX/OTC (insulin pen needle) UNIFINE PENTIPS PLUS FIFTY50 PEN NEEDLES RX/OTC 31GX8MM MISC (insulin F 31G X5/16" (8MM) MISC F pen needle) (insulin pen needle) FREESTYLE PRECISION RX/OTC FIFTY50 PEN NEEDLES RX/OTC INSULIN SYRINGE/U- 31GX5MM MISC (insulin F 100/0.5ML/30G X 5/16" F pen needle) MISC (insulin syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE PRECISION GLOBAL EASY GLIDE INSULIN SYRINGE/U- INSULINSYRINGE/U- 100/0.5ML/31G X 5/16" F 100/0.3ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) FREESTYLE PRECISION GLOBAL EASY GLIDE RX/OTC INSULIN SYRINGE/U- PEN NEEDLES 32GX4MM 100/1ML/31G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC FREESTYLE PRECISION RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGES/U- 100/0.3ML/29G X 1/2" F 100/1ML/30G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE GLOBAL EASE INJECT RX/OTC INSULIN SYRINGE/U- PEN NEEDLES 100/0.3ML/30G X 1/2" F F 29GX12MM MISC MISC (insulin (insulin pen needle) syringe/needle u-100) GLOBAL EASE INJECT RX/OTC GLOBAL INJECT EASE RX/OTC PEN NEEDLES 31GX8MM INSULIN SYRINGE/U- F MISC (insulin pen 100/0.3ML/30G X 5/16" F needle) MISC (insulin GLOBAL EASE INJECT RX/OTC syringe/needle u-100) PEN NEEDLES 32GX4MM GLOBAL INJECT EASE MISC (insulin pen F INSULIN SYRINGE/U- needle) 100/0.3ML/31G X 5/16" F GLOBAL EASE INJECT RX/OTC MISC (insulin PEN NEEEDLES syringe/needle u-100) 31GX5MM MISC (insulin F GLOBAL INJECT EASE RX/OTC pen needle) INSULIN SYRINGE/U- GLOBAL EASY GLIDE RX/OTC 100/0.5ML/28G X 1/2" F INSULIN MISC (insulin SYRINGE/0.3ML/31G X F syringe/needle u-100) 15/64" MISC (insulin GLOBAL INJECT EASE RX/OTC syringe/needle u-100) INSULIN SYRINGE/U- GLOBAL EASY GLIDE 100/0.5ML/29G X 1/2" F INSULIN MISC (insulin SYRINGE/0.5ML/31G X F syringe/needle u-100) 15/64" MISC (insulin GLOBAL INJECT EASE syringe/needle u-100) INSULIN SYRINGE/U- GLOBAL EASY GLIDE 100/0.5ML/30G X 1/2" F INSULIN MISC (insulin SYRINGE/1ML/31G X F syringe/needle u-100) 15/64" MISC (insulin syringe/needle u-100) CA Health & Wellness Preferred Drug List Updated September 1, 2021

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/0.5ML/30G X 5/16" F 100/0.3ML/30G X 1/2" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE GLUCOPRO INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/0.5ML/31G X 5/16" F 100/0.3ML/30G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/28G X 1/2" MISC F 100/0.3ML/31G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/29G X 1/2" MISC F 100/0.5ML/30G X 1/2" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) GLOBAL INJECT EASE GLUCOPRO INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/30G X 1/2" MISC F 100/0.5ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) GLOBAL INJECT EASE RX/OTC GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/30G X 5/16" F 100/0.5ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL INJECT EASE GLUCOPRO INSULIN INSULIN SYRINGE/U- SYRINGE/U-100/1ML/30G 100/1ML/31G X 5/16" F X 1/2" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) GLUCOPRO INSULIN RX/OTC GLOBAL INSULIN SYRINGE/U-100/1ML/30G SYRINGE/U- X 5/16" MISC (insulin F 100/0.3ML/30G X 1/2" F syringe/needle u-100) MISC (insulin GLUCOPRO INSULIN syringe/needle u-100) SYRINGE/U-100/1ML/31G GLOBAL INSULIN RX/OTC X 5/16" MISC (insulin F SYRINGES/U- syringe/needle u-100) 100/0.3ML/30GX5/16" F GNP CLICKFINE MISC (insulin UNIVERSAL PEN syringe/needle u-100) NEEDLES 31GX1/4" MISC F (insulin pen needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP CLICKFINE RX/OTC GNP INSULIN UNIVERSAL PEN SYRINGE/1ML/31G X NEEDLES 31GX5/16" F 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) GNP ULTICARE PEN RX/OTC GNP INSULIN RX/OTC NEEDLES/31GX5/16" SYRINGE/0.3ML/29G X MISC ( F F insulin pen 1/2" MISC (insulin needle) syringe/needle u-100) GNP ULTICARE PEN RX/OTC GNP INSULIN RX/OTC NEEDLES/32GX 5/32" SYRINGE/0.3ML/30G X MISC ( F F insulin pen 5/16" MISC (insulin needle) syringe/needle u-100) GNP ULTICARE PEN GNP INSULIN NEEDLES/32GX1/4" MISC F SYRINGE/0.3ML/31G X ( ) F insulin pen needle 5/16" MISC (insulin GNP ULTICARE PEN RX/OTC syringe/needle u-100) NEEDLES31G X 5MM GNP INSULIN RX/OTC MISC (insulin pen F SYRINGE/0.5ML/28G X ) F needle 1/2" MISC (insulin GNP ULTRA COMFORT RX/OTC syringe/needle u-100) INSULIN GNP INSULIN RX/OTC SYRINGE/0.3ML/29G X F SYRINGE/0.5ML/29G X 1/2" MISC (insulin 1/2" MISC (insulin F syringe/needle u-100) syringe/needle u-100) GNP ULTRA COMFORT RX/OTC GNP INSULIN RX/OTC INSULIN SYRINGE/0.5ML/30G X SYRINGE/0.3ML/30G X F 5/16" MISC (insulin F 5/16" SHORT MISC syringe/needle u-100) (insulin syringe/needle GNP INSULIN u-100) SYRINGE/0.5ML/31G X GNP ULTRA COMFORT RX/OTC 5/16" MISC (insulin F INSULIN syringe/needle u-100) SYRINGE/0.5ML/28G X F 1/2" MISC (insulin GNP INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" syringe/needle u-100) MISC (insulin F GNP ULTRA COMFORT RX/OTC syringe/needle u-100) INSULIN SYRINGE/0.5ML/29G X F GNP INSULIN RX/OTC 1/2" MISC (insulin SYRINGE/1ML/29G X 1/2" syringe/needle u-100) MISC (insulin F ) GNP ULTRA COMFORT RX/OTC syringe/needle u-100 INSULIN GNP INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" F SYRINGE/1ML/30G X F MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ULTRA COMFORT RX/OTC H-E-B IN CONTROL PEN RX/OTC INSULIN NEEDLES/NANO/32GX4M SYRINGE/1ML/29G X 1/2" F M MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) H-E-B IN CONTROL GOODSENSE CLICKFINE RX/OTC UNIFINEPENTIPS PLUS SAFETY PEN 31GX1/4" MISC (insulin F NEEDLE/31G X 3/16" F pen needle) MISC (insulin pen H-E-B IN CONTROL RX/OTC needle) UNIFINEPENTIPS PLUS GOODSENSE PEN RX/OTC 31GX3/16" MISC (insulin F NEEDLE/PENFINE pen needle) CLASSIC/31G X 3/16" F H-E-B IN CONTROL RX/OTC MISC (insulin pen UNIFINEPENTIPS PLUS needle) 31GX5/16" MISC (insulin F GOODSENSE PEN RX/OTC pen needle) NEEDLE/PENFINE CLASSIC/31G X 5/16" H-E-B IN CONTROL RX/OTC F UNIFINEPENTIPS PLUS MISC (insulin pen 31GX5MM MISC (insulin F needle) pen needle) GOODSENSE PEN NEEDLE/PENFINE H-E-B IN CONTROL RX/OTC F UNIFINEPENTIPS PLUS CLASSIC/32G X 1/4" MISC F (insulin pen needle) 32GX4MM MISC (insulin ) GOODSENSE PEN RX/OTC pen needle NEEDLE/PENFINE H-E-B IN CONTROL RX/OTC UNIFINEPENTIPS PLUS CLASSIC/32G X 5/32" F F MISC (insulin pen 32GX5/32" MISC (insulin needle) pen needle) H-E-B IN CONTROL PEN RX/OTC H-E-B IN CONTROL UNIFINEPENTIPS PLUS NEEDLE 31GX3/16" MISC F F (insulin pen needle) 33GX5/32" MISC (insulin H-E-B IN CONTROL PEN RX/OTC pen needle) NEEDLES 31GX5MM H-E-B INCONTROL PEN RX/OTC F NEEDLES 29GX12MM MISC (insulin pen F needle) MISC (insulin pen H-E-B IN CONTROL PEN needle) NEEDLES 31GX6MM HEALTHWISE INSULIN RX/OTC MISC (insulin pen F SYRINGE/U- needle) 100/0.3ML/30G X 5/16" F MISC ( H-E-B IN CONTROL PEN RX/OTC insulin NEEDLES 31GX8MM syringe/needle u-100) MISC (insulin pen F needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHWISE INSULIN HEALTHWISE SHORT RX/OTC SYRINGE/U- PEN NEEDLES/31G X 100/0.3ML/31G X 5/16" F 5/16" MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) HEALTHWISE UNIFINE RX/OTC HEALTHWISE INSULIN RX/OTC PENTIPS PEN NEEDLES SYRINGE/U- 32GX4MM MISC (insulin F 100/0.5ML/30G X 5/16" F pen needle) MISC (insulin HEALTHY ACCENTS RX/OTC syringe/needle u-100) UNIFINE PENTIPS PEN HEALTHWISE INSULIN NEEDLES 29GX12MM F SYRINGE/U- MISC (insulin pen 100/0.5ML/31G X 5/16" F needle) MISC (insulin HEALTHY ACCENTS RX/OTC syringe/needle u-100) UNIFINE PENTIPS PEN HEALTHWISE INSULIN RX/OTC NEEDLES 31GX5MM F SYRINGE/U-100/1ML/30G MISC ( F insulin pen X 5/16" MISC (insulin needle) syringe/needle u-100) HEALTHY ACCENTS HEALTHWISE INSULIN UNIFINE PENTIPS PEN SYRINGE/U-100/1ML/31G NEEDLES 31GX6MM F X 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) HEALTHWISE MICRON RX/OTC HEALTHY ACCENTS RX/OTC PEN NEEDLES/32G X UNIFINE PENTIPS PEN 5/32" MISC (insulin pen F NEEDLES 31GX8MM F needle) MISC (insulin pen HEALTHWISE MINI PEN needle) NEEDLES 31GX6MM HEALTHY ACCENTS RX/OTC MISC (insulin pen F UNIFINE PENTIPS PEN needle) NEEDLES 32GX4MM F HEALTHWISE PEN RX/OTC MISC (insulin pen NEEDLES 29GX12MM needle) MISC (insulin pen F HM ULTICARE INSULIN SYRINGE/1ML/30G X 1/2" needle) F HEALTHWISE SHORT RX/OTC MISC (insulin PEN NEEDLES 31GX8MM syringe/needle u-100) MISC (insulin pen F HM ULTICARE INSULIN needle) SYRINGE/U- 100/0.3ML/31G X 5/16" HEALTHWISE SHORT RX/OTC F PEN NEEDLES/31G X MISC (insulin 3/16" MISC (insulin pen F syringe/needle u-100) needle) HM ULTICARE MINI PEN RX/OTC NEEDLES/31G X 5MM F (3/16") MISC (insulin pen needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HM ULTICARE SHORT RX/OTC INSULIN RX/OTC PEN NEEDLES 31GX8MM SYRINGE/1ML/28G X 1/2" MISC (insulin pen F MISC (insulin F needle) syringe/needle u-100) INSULIN SYRINGE INSULIN RX/OTC 1ML/31G X1/4" MISC SYRINGE/1ML/29G X 1/2" (insulin syringe/needle F MISC (insulin F u-100) syringe/needle u-100) INSULIN INSULIN RX/OTC SYRINGE/0.3ML/29G X 1" SYRINGE/1ML/30G X MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) INSULIN RX/OTC INSULIN RX/OTC SYRINGE/0.3ML/29G X SYRINGE/NEEDLE 1/2" MISC (insulin F 0.3ML/30G X 5/16" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN RX/OTC u-100) SYRINGE/0.3ML/30G X INSULIN 5/16" MISC (insulin F SYRINGE/NEEDLE syringe/needle u-100) 0.3ML/31G X 5/16" MISC F INSULIN (insulin syringe/needle SYRINGE/0.3ML/31G X u-100) 5/16" MISC (insulin F INSULIN RX/OTC syringe/needle u-100) SYRINGE/NEEDLE 0.5ML/29G X 1/2" MISC INSULIN F SYRINGE/0.5ML/27G X (insulin syringe/needle 1/2" MISC (insulin F u-100) syringe/needle u-100) INSULIN RX/OTC SYRINGE/NEEDLE INSULIN RX/OTC 0.5ML/30G X 5/16" MISC SYRINGE/0.5ML/28G X F (insulin syringe/needle 1/2" MISC (insulin F u-100) syringe/needle u-100) INSULIN INSULIN SYRINGE/NEEDLE SYRINGE/0.5ML/30G X F 0.5ML/31G X 5/16" MISC F 1/2" MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) INSULIN RX/OTC INSULIN RX/OTC SYRINGE/0.5ML/30G X F SYRINGE/NEEDLE 5/16" MISC (insulin 1ML/29G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN u-100) SYRINGE/0.5ML/31G X 5/16" MISC (insulin F syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN RX/OTC INSULIN SYRINGE/NEEDLE SYRINGES/0.5ML/27GX1/ 1ML/30G X 5/16" MISC F 2" MISC (insulin F (insulin syringe/needle syringe/needle u-100) u-100) INSULIN RX/OTC INSULIN SYRINGES/0.5ML/28GX1/ SYRINGE/NEEDLE 2" MISC (insulin F 1ML/31G X 5/16" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN RX/OTC u-100) SYRINGES/0.5ML/29GX1/ INSULIN SYRINGE/U- RX/OTC 2" MISC (insulin F 100/0.3ML/29G X 1/2" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/0.5ML/30GX5/ INSULIN SYRINGE/U- RX/OTC 16" MISC (insulin F 100/0.5ML/29G X 1/2" F syringe/needle u-100) MISC (insulin INSULIN syringe/needle u-100) SYRINGES/0.5ML/31GX INSULIN SYRINGE/U- RX/OTC 5/16" MISC (insulin F 100/1ML/29G X 1/2" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN u-100) SYRINGES/0.5ML/31GX5/ INSULIN SYRINGE/U- RX/OTC 16" MISC (insulin F 100/1ML/30G X 5/16" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/1ML/27GX/1/2" INSULIN SYRINGE/U- MISC (insulin F 100/1ML/30G X 5/16" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/1ML/27GX1/2" INSULIN SYRINGE/U- MISC (insulin F 100/1ML/31G X 5/16" F syringe/needle u-100) MISC (insulin INSULIN RX/OTC syringe/needle u-100) SYRINGES/1ML/28GX1/2" INSULIN SYRINGES MISC (insulin F 0.3ML/31G X 1/4" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN RX/OTC u-100) SYRINGES/1ML/29GX1/2" INSULIN SYRINGES MISC (insulin F 0.5ML/31G X 1/4" MISC F syringe/needle u-100) (insulin syringe/needle INSULIN u-100) SYRINGES/1ML/30GX1/2" MISC (insulin F syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN KINRAY INSULIN SYRINGES/1ML/31GX5/16 SYRINGE PREFERRED " MISC (insulin F PLUS/0.3ML/31G X 5/16" F syringe/needle u-100) MISC (insulin INSUPEN 29G X 12MM RX/OTC syringe/needle u-100) MISC (insulin pen F KINRAY INSULIN needle) SYRINGE PREFERRED PLUS/0.5ML/31G X 5/16" INSUPEN 31G X 5MM RX/OTC F MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) KINRAY INSULIN INSUPEN 31G X 8MM RX/OTC SYRINGE PREFERRED MISC (insulin pen F PLUS/1ML/31G X 5/16" F needle) MISC (insulin INSUPEN 32G X 4MM RX/OTC syringe/needle u-100) MISC (insulin pen F KINRAY INSULIN RX/OTC needle) SYRINGE/0.5ML/29G X F INSUPEN 33GX4MM MISC 1/2" MISC (insulin F (insulin pen needle) syringe/needle u-100) INSUPEN PEN NEEDLES RX/OTC KMART VALU PLUS 32G X4MM MISC (insulin F INSULIN pen needle) SYRINGE/0.3ML/30G F MISC (insulin syringes INSUPEN SENSITIVE (disposable)) 32GX6MM MISC (insulin F pen needle) KMART VALU PLUS INSULIN INSUPEN SENSITIVE SYRINGE/0.5ML/29G F 32GX8MM MISC (insulin F MISC (insulin syringes pen needle) (disposable)) INSUPEN ULTRAFIN RX/OTC KMART VALU PLUS 29GX12MM MISC F INSULIN (insulin pen needle) SYRINGE/0.5ML/30G F INSUPEN ULTRAFIN RX/OTC MISC (insulin syringes 30GX8MM MISC (insulin F (disposable)) pen needle) KMART VALU PLUS RX/OTC INSUPEN ULTRAFIN INSULIN 31GX6MM MISC (insulin F SYRINGE/1ML/29G MISC F pen needle) (insulin syringes (disposable)) INSUPEN ULTRAFIN RX/OTC 31GX8MM MISC (insulin F KMART VALU PLUS RX/OTC INSULIN pen needle) SYRINGE/1ML/30G MISC F (insulin syringes (disposable))

CA Health & Wellness Preferred Drug List Updated September 1, 2021

154 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KROGER INSULIN RX/OTC KROGER PEN NEEDLES SYRINGE/0.3ML/29G X 31GX1/4" MISC ( F insulin F 1/2" MISC (insulin pen needle) syringe/needle u-100) KROGER PEN KROGER INSULIN RX/OTC NEEDLES/31G X1/4" MISC F SYRINGE/0.3ML/30G X ( ) F insulin pen needle 5/16" MISC (insulin KROGER PEN RX/OTC syringe/needle u-100) NEEDLES/31G X3/16" KROGER INSULIN MISC (insulin pen F SYRINGE/0.3ML/31G X ) F needle 5/16" MISC (insulin KROGER PEN RX/OTC syringe/needle u-100) NEEDLES/31G X5/16" KROGER INSULIN RX/OTC MISC (insulin pen F SYRINGE/0.5ML/29G X ) F needle 1/2" MISC (insulin KROGER PEN RX/OTC syringe/needle u-100) NEEDLES/32G X5/32" KROGER INSULIN RX/OTC MISC (insulin pen F SYRINGE/0.5ML/30G X ) F needle 5/16" MISC (insulin KROGER PEN syringe/needle u-100) NEEDLES/33G X5/32" KROGER INSULIN MISC (insulin pen F SYRINGE/0.5ML/31G X ) F needle 5/16" MISC (insulin LEADER INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.3ML/29G X KROGER INSULIN RX/OTC 1/2" MISC (insulin F SYRINGE/1ML/29G X 1/2" ) F syringe/needle u-100 MISC (insulin LEADER INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.3ML/30G X KROGER INSULIN RX/OTC 5/16" MISC (insulin F SYRINGE/1ML/30G X ) F syringe/needle u-100 5/16" MISC (insulin LEADER INSULIN syringe/needle u-100) SYRINGE/0.3ML/31G X KROGER INSULIN 5/16" MISC (insulin F SYRINGE/1ML/31G X ) F syringe/needle u-100 5/16" MISC (insulin LEADER INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.5ML/28G X KROGER PEN NEEDLES RX/OTC 1/2" MISC (insulin F 29G X12MM MISC F syringe/needle u-100) (insulin pen needle) LEADER INSULIN RX/OTC KROGER PEN NEEDLES RX/OTC SYRINGE/0.5ML/29G X 31G X8MM MISC (insulin F 1/2" MISC (insulin F pen needle) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

155 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER INSULIN RX/OTC LEADER UNIFINE RX/OTC SYRINGE/0.5ML/30G X PENTIPS/PLUS/32GX5/32" 5/16" MISC (insulin F MISC (insulin pen F syringe/needle u-100) needle) LEADER INSULIN LITETOUCH INSULIN PEN RX/OTC SYRINGE/0.5ML/31G X NEEDLES/32G X 5/16" MISC (insulin F 4MM/MINI MISC (insulin F syringe/needle u-100) pen needle) LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" SYRINGE/0.3ML/29G X MISC (insulin F 1/2" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER INSULIN RX/OTC LITETOUCH INSULIN RX/OTC SYRINGE/1ML/29G X 1/2" SYRINGE/0.3ML/30G X MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER INSULIN RX/OTC LITETOUCH INSULIN SYRINGE/1ML/30G X SYRINGE/0.3ML/31G X 5/16" MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER INSULIN LITETOUCH INSULIN RX/OTC SYRINGE/1ML/31G X SYRINGE/0.5ML/30G X 5/16" MISC (insulin F 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) LEADER UNIFINE RX/OTC LITETOUCH INSULIN PENTIPS SYRINGE/0.5ML/31G X PLUS/MINI/31GX3/16" F 5/16" MISC (insulin F MISC (insulin pen syringe/needle u-100) needle) LITETOUCH INSULIN RX/OTC LEADER UNIFINE RX/OTC SYRINGE/1ML/30G X PENTIPS 5/16" MISC (insulin F PLUS/SHORT/31GX5/16" F syringe/needle u-100) MISC (insulin pen LITETOUCH INSULIN RX/OTC needle) SYRINGE/U- LEADER UNIFINE RX/OTC 100/0.3ML/30G X 5/16" F PENTIPS/MINI/31GX3/16" MISC ( F insulin MISC (insulin pen syringe/needle u-100) needle) LITETOUCH INSULIN LEADER UNIFINE RX/OTC SYRINGE/U- PENTIPS/NANO/32GX5/32 100/0.3ML/31G X 5/16" F " MISC (insulin pen F MISC (insulin needle) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

156 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITETOUCH INSULIN RX/OTC LITETOUCH PEN SYRINGE/U- NEEDLES 31G X 100/0.5ML/28G X 1/2" F 6MM/ULTRA SHORT F MISC (insulin MISC (insulin pen syringe/needle u-100) needle) LITETOUCH INSULIN RX/OTC LITETOUCH PEN RX/OTC SYRINGE/U- NEEDLES 31GX8MM 100/0.5ML/29G X 1/2" F SHORT MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) LITETOUCH PEN RX/OTC LITETOUCH INSULIN RX/OTC NEEDLES/31G X 3/16" SYRINGE/U- MISC (insulin pen F 100/0.5ML/30G X 5/16" F needle) MISC (insulin LITETOUCH PEN RX/OTC syringe/needle u-100) NEEDLES/31G X LITETOUCH INSULIN 5MM/MINI MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/31G X 5/16" F LITETOUCH PEN RX/OTC MISC (insulin NEEDLES/31G X syringe/needle u-100) 8MM/SHORT MISC F LITETOUCH INSULIN RX/OTC (insulin pen needle) SYRINGE/U-100/1ML/28G F LONGS INSULIN X 1/2" MISC (insulin SYRINGE/0.5ML/31G X syringe/needle u-100) 5/16" MISC (insulin F LITETOUCH INSULIN RX/OTC syringe/needle u-100) SYRINGE/U-100/1ML/29G F MAGELLAN INSULIN RX/OTC X 1/2" MISC (insulin SAFETY SYRINGE/U- syringe/needle u-100) 100/0.3ML/29G X 1/2" F LITETOUCH INSULIN RX/OTC MISC (insulin SYRINGE/U-100/1ML/30G ) F syringe/needle u-100 X 5/16" MISC (insulin MAGELLAN INSULIN RX/OTC syringe/needle u-100) SAFETY SYRINGE/U- LITETOUCH INSULIN 100/0.3ML/30G X 5/16" F SYRINGE/U-100/1ML/31G MISC (insulin X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) MAGELLAN INSULIN RX/OTC LITETOUCH PEN SAFETY SYRINGE/U- NEEDLES 29GX12.7MM 100/0.5ML/29G X 1/2" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) LITETOUCH PEN MAGELLAN INSULIN RX/OTC NEEDLES 31G X 6MM SAFETY SYRINGE/U- MISC (insulin pen F 100/0.5ML/30G X 5/16" F needle) MISC (insulin syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

157 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAGELLAN INSULIN RX/OTC MAXICOMFORT INSULIN RX/OTC SAFETY SYRINGE/U- SYRINGES 27G X 1/2" 100/1ML/29G X 1/2" MISC F MISC (insulin F (insulin syringe/needle syringe/needle u-100) u-100) MAXICOMFORT INSULIN MAGELLAN INSULIN RX/OTC SYRINGES 27G X 1/2" SAFETY SYRINGE/U- MISC (insulin F 100/1ML/30G X 5/16" F syringe/needle u-100) MISC (insulin MEDIC INSULIN RX/OTC syringe/needle u-100) SYRINGE/0.3ML/30G X MARATHON MEDICAL RX/OTC 5/16" MISC (insulin F PENTIPS29GX12MM F syringe/needle u-100) MISC (insulin pen MEDIC INSULIN RX/OTC needle) SYRINGE/0.5ML/30G X MARATHON MEDICAL RX/OTC 5/16" MISC (insulin F PENTIPS31GX5MM MISC F syringe/needle u-100) (insulin pen needle) MEDICINE SHOPPE PEN RX/OTC MARATHON MEDICAL RX/OTC NEEDLES 29G X 12MM PENTIPS31GX8MM MISC F MISC (insulin pen F (insulin pen needle) needle) MARATHON MEDICAL RX/OTC MEDICINE SHOPPE PEN PENTIPS32GX4MM MISC F NEEDLES 31G X 6MM (insulin pen needle) MISC (insulin pen F MAXI-COMFORT INSULIN RX/OTC needle) SYRINGE/U- MEDICINE SHOPPE PEN RX/OTC 100/0.5ML/28GX1/2" MISC F NEEDLES 31G X 8MM (insulin syringe/needle MISC (insulin pen F u-100) needle) MAXI-COMFORT INSULIN RX/OTC MEIJER PEN NEEDLES RX/OTC SYRINGE/U- 29G X12MM MISC 100/1ML/28GX1/2" MISC F F ) (insulin syringe/needle (insulin pen needle u-100) MEIJER PEN NEEDLES 31G X6MM MISC ( MAXI-COMFORT SAFETY insulin F PEN NEEDLE/29G X 3/16" pen needle) MISC (insulin pen F MEIJER PEN NEEDLES RX/OTC needle) 31G X8MM MISC (insulin F MAXI-COMFORT SAFETY pen needle) PEN NEEDLE/29G X 5/16" MICRODOT PEN F NEEDLE/31G X 6 MM MISC (insulin pen F needle) MISC (insulin pen MAXICOMFORT II PEN needle) NEEDLES/31G X 1/4" MISC (insulin pen F needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

158 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MICRODOT PEN RX/OTC MONOJECT 3ML RX/OTC NEEDLE/32G X 4 MM SYRINGE/STANDARD F HYPODERMIC MISC (insulin pen F needle) NEEDLE/21GX1-1/2" MISC MICRODOT PEN (syringe/needle (disp) 3 NEEDLE/33G X 4 MM ml) MISC (insulin pen F MONOJECT INSULIN RX/OTC SYRINGE/1ML MISC needle) (insulin syringes F MM INSULIN SYRINGE/U- RX/OTC ) 100/0.3ML/30G X 5/16" (disposable) MISC (insulin F MONOJECT INSULIN SYRINGE/1ML/31G X syringe/needle u-100) 5/16" MISC (insulin F MM INSULIN SYRINGE/U- ) 100/0.3ML/31G X 5/16" syringe/needle u-100 MISC (insulin F MONOJECT INSULIN SYRINGE/DETACH syringe/needle u-100) NEEDLE/1ML/25G X 5/8" F MM INSULIN SYRINGE/U- RX/OTC MISC (insulin 100/1/2ML/30G X 5/16" syringe/needle u-100) MISC (insulin F MONOJECT INSULIN RX/OTC syringe/needle u-100) SYRINGE/DETACH MM INSULIN SYRINGE/U- NEEDLE/1ML/27G X 1/2" F 100/1/2ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) MONOJECT INSULIN RX/OTC MM INSULIN SYRINGE/U- RX/OTC SYRINGE/PERM 100/1ML/30G X 5/16" NEEDLE/1ML/28G X 1/2" F F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) MM INSULIN SYRINGE/U- MONOJECT INSULIN RX/OTC 100/1ML/31G X 5/16" SYRINGE/PERM F MISC (insulin NEEDLE/U-100/0.5ML/28G F syringe/needle u-100) X 1/2" MISC (insulin MM PEN NEEDLES 31G X syringe/needle u-100) 1/4" MISC (insulin pen F MONOJECT INSULIN RX/OTC needle) SYRINGE/SAFETY/PERM MM PEN NEEDLES 31G X RX/OTC NEEDLE/0.3ML/29G X 1/2" F 3/16" MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) MM PEN NEEDLES 31G X RX/OTC MONOJECT INSULIN RX/OTC SYRINGE/SAFETY/PERM 5/16" MISC ( F insulin pen NEEDLE/0.3ML/29GX1/2" F needle) MISC (insulin MM PEN NEEDLES 32G X RX/OTC syringe/needle u-100) 5/32" MISC (insulin pen F needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

159 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT INSULIN RX/OTC MONOJECT LIFESHIELD RX/OTC SYRINGE/SAFETY/PERM BLUNTCANNULA/LUER NEEDLE/0.5ML/29G X 1/2" F LOCK SYR/3ML/18G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/SAFETY/PERM SYRINGE/SAFETY NEEDLE/1ML/29G X 1/2" F NEEDLE/3ML/20G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/SOFTPACK/1M SYRINGE/SAFETY L/27G X 1/2" MISC F NEEDLE/3ML/20G X 1-1/2" F (insulin syringe/needle MISC (syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/SOFTPACK/U- SYRINGE/SAFETY 100/0.5ML/28G X 1/2" F NEEDLE/3ML/21G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/U- SYRINGE/SAFETY 100/0.3ML/30G X 5/16" F NEEDLE/3ML/21G X 1-1/2" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN SYRINGE/U- SYRINGE/SAFETY 100/0.5ML/30G X 5/16" F NEEDLE/3ML/22G X 1" F MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT INSULIN RX/OTC MONOJECT MAGELLAN RX/OTC SYRINGE/U-100/1ML/28G SYRINGE/SAFETY X 1/2" MISC (insulin F NEEDLE/3ML/22G X 1-1/2" F syringe/needle u-100) MISC (syringe/needle MONOJECT INSULIN RX/OTC (disp) 3 ml) SYRINGE/U-100/1ML/30G MONOJECT MAGELLAN RX/OTC X 5/16" MISC (insulin F SYRINGE/SAFETY syringe/needle u-100) NEEDLE/3ML/23G X 1" F MONOJECT INSULIN RX/OTC MISC (syringe/needle SYRINGEREGULAR LUER (disp) 3 ml) TIP/SOFTPACK/1ML MISC F MONOJECT MAGELLAN RX/OTC (insulin syringes SYRINGE/SAFETY (disposable)) NEEDLE/3ML/25G X 1" F MISC (syringe/needle (disp) 3 ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

160 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT MAGELLAN RX/OTC MONOJECT RX/OTC SYRINGE/SAFETY SYRINGE/LUER NEEDLE/3ML/25G X 5/8" F LOCK/3ML/27G X 1-1/4" F MISC (syringe/needle MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER SYRINGE/LUER- LOCK/3ML/20G X 1" MISC F LOCK/3ML/21G X 1" MISC F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/LUER SYRINGE/LUER- LOCK/3ML/20G X 1-1/2" F LOCK/3ML/21G X 1-1/2" F MISC (syringe/needle MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) MONOJECT MONOJECT RX/OTC SYRINGE/LUER SYRINGE/STANDARDHY LOCK/3ML/20G X 3/4" F PODERMIC MISC (syringe/needle NEEDLE/3ML/20GX1" F (disp) 3 ml) MISC (syringe/needle MONOJECT (disp) 3 ml) SYRINGE/LUER MONOJECT RX/OTC LOCK/3ML/22G X 1" MISC F SYRINGE/STANDARDHY (syringe/needle (disp) 3 PODERMIC ml) NEEDLE/3ML/20GX1-1/2" F MONOJECT RX/OTC MISC (syringe/needle SYRINGE/LUER (disp) 3 ml) LOCK/3ML/22G X 1-1/2" F MONOJECT RX/OTC MISC (syringe/needle SYRINGE/STANDARDHY (disp) 3 ml) PODERMIC F MONOJECT RX/OTC NEEDLE/3ML/21GX1" SYRINGE/LUER MISC (syringe/needle LOCK/3ML/23G X 1" MISC F (disp) 3 ml) (syringe/needle (disp) 3 MONOJECT ml) SYRINGE/STANDARDHY PODERMIC MONOJECT RX/OTC F SYRINGE/LUER NEEDLE/3ML/22GX1" LOCK/3ML/25G X 1" MISC F MISC (syringe/needle (syringe/needle (disp) 3 (disp) 3 ml) ml) MONOJECT RX/OTC MONOJECT RX/OTC SYRINGE/STANDARDHY SYRINGE/LUER PODERMIC F LOCK/3ML/25G X 5/8" F NEEDLE/3ML/22GX1-1/2" MISC (syringe/needle MISC (syringe/needle (disp) 3 ml) (disp) 3 ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

161 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT RX/OTC MONOJECT ULTRA RX/OTC SYRINGE/STANDARDHY COMFORT INSULIN PODERMIC SYRINGE/0.5ML/28G X F NEEDLE/3ML/23GX1" F 1/2" MISC (insulin MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) MONOJECT ULTRA RX/OTC MONOJECT RX/OTC COMFORT INSULIN SYRINGE/STANDARDHY SYRINGE/0.5ML/29G X F PODERMIC 1/2" MISC ( F insulin NEEDLE/3ML/25GX1" syringe/needle u-100) MISC (syringe/needle MONOJECT ULTRA RX/OTC (disp) 3 ml) COMFORT INSULIN MONOJECT SYRINGE/0.5ML/30G X F SYRINGE/STANDARDHY 5/16" MISC (insulin PODERMIC syringe/needle u-100) NEEDLE/3ML/25GX1-1/4" F MONOJECT ULTRA MISC (syringe/needle COMFORT INSULIN (disp) 3 ml) SYRINGE/0.5ML/31G X F MONOJECT RX/OTC 5/16" MISC (insulin SYRINGE/STANDARDHY syringe/needle u-100) PODERMIC NEEDLE/3ML/25GX5/8" F MONOJECT ULTRA RX/OTC COMFORT INSULIN MISC (syringe/needle SYRINGE/1ML/28G X 1/2" F (disp) 3 ml) MISC (insulin MONOJECT RX/OTC syringe/needle u-100) SYRINGE/STANDARDHY PODERMIC MONOJECT ULTRA RX/OTC NEEDLE/3ML/27GX1-1/4" F COMFORT INSULIN SYRINGE/1ML/29G X 1/2" MISC (syringe/needle F MISC (insulin (disp) 3 ml) syringe/needle u-100) MONOJECT ULTRA RX/OTC COMFORT INSULIN MS INSULIN SYRINGE/0.3ML/31G X SYRINGE/0.3ML/29G X F F 1/2" MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100) MONOJECT ULTRA RX/OTC MS INSULIN SYRINGE/0.5ML/31G X COMFORT INSULIN F SYRINGE/0.3ML/30G X F 5/16" MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100) MS INSULIN SYRINGE/1ML/31G X MONOJECT ULTRA F COMFORT INSULIN 5/16" MISC (insulin SYRINGE/0.3ML/31G X F syringe/needle u-100) 5/16" MISC (insulin NOVOFINE AUTOCOVER RX/OTC syringe/needle u-100) PEN NEEDLE 30G X 8MM MISC (insulin pen F needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

162 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOFINE PEN NEEDLE PEN NEEDLES 31G X RX/OTC 32G X 4MM MISC F 3/16" MISC (insulin pen F (insulin pen needle) needle) NOVOFINE PLUS PEN RX/OTC PEN NEEDLES 31G X RX/OTC NEEDLE32G X 4MM MISC F 5MM MISC (insulin pen F (insulin pen needle) needle) NOVOTWIST PEN RX/OTC PEN NEEDLES 31G X NEEDLE 32GX 5MM MISC F 6MM MISC (insulin pen F (insulin pen needle) needle) PC UNIFINE PENTIPS RX/OTC PEN NEEDLES 31G X RX/OTC 29G X1/2" MISC ( insulin F 8MM MISC (insulin pen F pen needle) needle) PC UNIFINE PENTIPS RX/OTC PEN NEEDLES 31GX5/16" RX/OTC 31G X5MM MINI MISC F (insulin pen needle) MISC (insulin pen F needle) PC UNIFINE PENTIPS 31G X6MM ULTRA PEN NEEDLES 31GX6MM SHORT MISC (insulin F (1/4") MISC (insulin pen F pen needle) needle) PEN NEEDLES 31GX8MM RX/OTC PC UNIFINE PENTIPS RX/OTC F 31G X8MM SHORT MISC F (5/16") MISC (insulin pen needle) (insulin pen needle) PEN NEEDLES 31GX8MM RX/OTC PEN NEEDLES 29G X RX/OTC MISC (insulin pen F 12MM MISC (insulin pen F needle) needle) PEN NEEDLES 32G X RX/OTC PEN NEEDLES 29GX1/2" RX/OTC 4MM MISC (insulin pen F MISC (insulin pen F needle) needle) PEN NEEDLES 32G X RX/OTC PEN NEEDLES RX/OTC 5MM MISC ( 29GX12MM MISC F insulin pen F (insulin pen needle) needle) PEN NEEDLES 30GX5/16" RX/OTC PEN NEEDLES 32G X MISC (insulin pen F 6MM MISC (insulin pen F needle) needle) PEN NEEDLES 30GX5MM PEN NEEDLES 32GX4MM RX/OTC MISC (insulin pen F MISC (insulin pen F needle) needle) PEN NEEDLES 30GX8MM RX/OTC PEN NEEDLES 33G X MISC (insulin pen F 5/32" MISC (insulin pen F needle) needle) PEN NEEDLES 31G X 1/4" PEN NEEDLES/29G X 1/2" RX/OTC SHORT MISC (insulin F MISC (insulin pen F pen needle) needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

163 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEN NEEDLES/31G X 1/4" PRECISION SURE-DOSE RX/OTC MISC (insulin pen F INSULIN needle) SYRINGE/0.5ML/28G X F PEN NEEDLES/31G X RX/OTC 1/2" MISC (insulin 3/16" MISC (insulin pen F syringe/needle u-100) needle) PRECISION SURE-DOSE RX/OTC INSULIN PEN NEEDLES/31G X RX/OTC SYRINGE/0.5ML/29G X F 5/16" MISC (insulin pen F 1/2" MISC (insulin needle) syringe/needle u-100) PEN NEEDLES/31G X PRECISION SURE-DOSE 6MM MISC (insulin pen F INSULIN needle) SYRINGE/0.5ML/30G X F PEN NEEDLES/32G X RX/OTC 3/8" MISC (insulin 5/32" MISC (insulin pen F syringe/needle u-100) needle) PRECISION SURE-DOSE RX/OTC PENTIPS 29G X 12MM RX/OTC INSULIN MISC (insulin pen F SYRINGE/1ML/28G X 1/2" F needle) MISC (insulin syringe/needle u-100) PENTIPS 29GX12MM RX/OTC MISC (insulin pen F PRECISION SURE-DOSE RX/OTC PLUSINSULIN needle) SYRINGE/0.3ML/29G X F PENTIPS 31G X 5MM RX/OTC 1/2" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) PRECISION SURE-DOSE RX/OTC PENTIPS 31G X 8MM RX/OTC PLUSINSULIN MISC (insulin pen F SYRINGE/1ML/29G X 1/2" F needle) MISC (insulin PENTIPS 31GX5MM MISC RX/OTC syringe/needle u-100) F (insulin pen needle) PREFERRED PLUS RX/OTC PENTIPS 31GX6MM MISC INSULIN SYRINGE/U- F 100/0.3ML/29G X 1/2" (insulin pen needle) F MISC (insulin PENTIPS 31GX8MM MISC RX/OTC F syringe/needle u-100) (insulin pen needle) PREFERRED PLUS RX/OTC PENTIPS 32G X 4MM RX/OTC INSULIN SYRINGE/U- MISC (insulin pen F 100/0.3ML/30G X 5/16" F needle) MISC (insulin PENTIPS 32GX4MM MISC RX/OTC syringe/needle u-100) F (insulin pen needle) PREFERRED PLUS RX/OTC PRECISION SURE-DOSE RX/OTC INSULIN SYRINGE/U- INSULIN 100/0.5ML/28G X 1/2" F SYRINGE/0.3ML/30G X F MISC (insulin 5/16" MISC (insulin syringe/needle u-100) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

164 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREFERRED PLUS RX/OTC PREFERRED PLUS RX/OTC INSULIN SYRINGE/U- UNIFINE 100/0.5ML/29G X 1/2" F PENTIPS/MINI/31GX5MM F MISC (insulin MISC (insulin pen syringe/needle u-100) needle) PREFERRED PLUS RX/OTC PREVENT SAFETY PEN INSULIN SYRINGE/U- NEEDLES 31GX1/4" MISC F 100/0.5ML/30G X 5/16" F (insulin pen needle) MISC (insulin PREVENT SAFETY PEN RX/OTC syringe/needle u-100) NEEDLES 31GX5/16" PREFERRED PLUS RX/OTC MISC (insulin pen F INSULIN SYRINGE/U- needle) 100/1ML/28G X 1/2" MISC F PRO COMFORT INSULIN (insulin syringe/needle SYRINGES/0.5ML/30G X u-100) 1/2" MISC (insulin F PREFERRED PLUS RX/OTC syringe/needle u-100) INSULIN SYRINGE/U- PRO COMFORT INSULIN RX/OTC 100/1ML/29G X 1/2" MISC F SYRINGES/0.5ML/30G X (insulin syringe/needle 5/16" MISC (insulin F u-100) syringe/needle u-100) PREFERRED PLUS RX/OTC PRO COMFORT INSULIN INSULIN SYRINGE/U- SYRINGES/0.5ML/31G X 100/1ML/30G X 5/16" F 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) PRO COMFORT INSULIN PREFERRED PLUS RX/OTC SYRINGES/1ML/30G X UNIFINE PENTIPS 29G X F F 1/2" MISC (insulin 12MM MISC (insulin pen syringe/needle u-100) needle) PRO COMFORT INSULIN RX/OTC PREFERRED PLUS SYRINGES/1ML/30G X UNIFINE PENTIPS 31G X 5/16" MISC (insulin F 6MM ULTRA SHORT F MISC (insulin pen syringe/needle u-100) needle) PRO COMFORT INSULIN SYRINGES/1ML/31G X PREFERRED PLUS RX/OTC F UNIFINE PENTIPS 31G X 5/16" MISC (insulin 8MM SHORT MISC F syringe/needle u-100) (insulin pen needle) PRO COMFORT PEN RX/OTC NEEDLES/31G X 8MM PREFERRED PLUS RX/OTC F UNIFINE PENTIPS MISC (insulin pen 32GX4MM MISC (insulin F needle) pen needle) PRO COMFORT PEN RX/OTC NEEDLES/32G X 4MM MISC (insulin pen F needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

165 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT PEN RX/OTC PX PEN NEEDLE RX/OTC NEEDLES/32G X 5MM 29GX12MM MISC ( F insulin F MISC (insulin pen pen needle) needle) PX PEN NEEDLE RX/OTC PRO COMFORT PEN 31GX8MM MISC (insulin F NEEDLES/32G X 6MM F pen needle) MISC (insulin pen PX SHORTLENGTH PEN RX/OTC needle) NEEDLES/31GX8MM PRODIGY INSULIN MISC (insulin pen F SYRING/U-100/0.3ML/31G F needle) X 5/16" MISC (insulin QC PEN NEEDLES 29G X RX/OTC syringe/needle u-100) 12MM MISC (insulin pen F PRODIGY INSULIN needle) SYRINGE/1/2ML/31G X QC PEN NEEDLES 31G X 5/16" MISC (insulin F 6MM MISC (insulin pen F syringe/needle u-100) needle) PRODIGY INSULIN RX/OTC SYRINGE/1ML/28G X 1/2" QC PEN NEEDLES 31G X RX/OTC MISC (insulin F 8MM MISC (insulin pen F syringe/needle u-100) needle) PURE COMFORT PEN QC UNIFINE PENTIPS RX/OTC NEEDLE 32G X6MM MISC F 32GX4MM MISC (insulin F (insulin pen needle) pen needle) PURE COMFORT PEN RA INSULIN RX/OTC SYRINGE/0.5ML/29G X NEEDLE 32G X8MM MISC F F (insulin pen needle) 1/2" MISC (insulin PURE COMFORT PEN RX/OTC syringe/needle u-100) NEEDLE/32G X 5MM RA INSULIN RX/OTC F SYRINGE/1ML/29G X 1/2" MISC (insulin pen F needle) MISC (insulin PURE COMFORT PEN RX/OTC syringe/needle u-100) NEEDLE/32G X4MM MISC F RA INSULIN SYRINGE/U- RX/OTC 100/0.5ML/30G X 5/16" (insulin pen needle) F PX EXTRA SHORT PEN MISC (insulin NEEDLES 31GX6MM syringe/needle u-100) MISC (insulin pen F RA INSULIN SYRINGE/U- RX/OTC 100/1 ML/30G X 5/16" needle) F PX INSULIN SYRINGE/U- MISC (insulin 100/0.5ML/30G X 1/2" syringe/needle u-100) MISC (insulin F RA PEN NEEDLES 31G X RX/OTC syringe/needle u-100) 5MM3/16" MISC (insulin F PX MINI PEN NEEDLES RX/OTC pen needle) 31GX5MM MISC (insulin F RA PEN NEEDLES 31G X RX/OTC pen needle) 8MM5/16" MISC (insulin F pen needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

166 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REALITY INSULIN RX/OTC RELION INSULIN SYRINGE/U- SYRINGE/U- 100/0.5ML/28G X 1/2" F 100/0.5ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) REALITY INSULIN RX/OTC RELION INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 100/0.5ML/29G X 1/2" F X 15/64" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) RELION INSULIN REALITY INSULIN RX/OTC SYRINGE/U-100/1ML/31G SYRINGE/U-100/1ML/28G X 5/16" MISC ( F F insulin X 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) RELION MINI PEN REALITY INSULIN RX/OTC NEEDLES 31GX6MM SYRINGE/U-100/1ML/29G MISC ( F F insulin pen X 1/2" MISC (insulin needle) syringe/needle u-100) RELION PEN NEEDLES RX/OTC RELION INSULIN 29GX12MM MISC (insulin F SYRINGE 0.5ML/31G X F pen needle) 15/64" MISC (insulin RELION PEN NEEDLES syringe/needle u-100) 31G X6MM MISC (insulin F RELION INSULIN pen needle) SYRINGE RELION PEN NEEDLES RX/OTC 1ML/31GX15/64" MISC F (insulin syringe/needle 31G X8MM MISC (insulin F u-100) pen needle) RELION INSULIN RX/OTC RELION PEN NEEDLES RX/OTC SYRINGE/U- 31GX5/16" MISC (insulin F 100/0.3ML/31G X 15/64" F pen needle) MISC (insulin RELION PEN NEEDLES syringe/needle u-100) 31GX6MM MISC (insulin F RELION INSULIN pen needle) SYRINGE/U- RELION PEN NEEDLES RX/OTC 100/0.3ML/31G X 5/16" F 31GX8MM MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) RELION PEN NEEDLES RX/OTC RELION INSULIN RX/OTC 32G X4MM MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/29G X 1/2" F MISC (insulin RELION PEN NEEDLES RX/OTC syringe/needle u-100) 32G X5/32" MISC (insulin F pen needle) RELION PEN NEEDLES RX/OTC 32GX4MM MISC (insulin F pen needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

167 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELION PEN SAFESNAP RX/OTC NEEDLES/31G X1/4" SYRINGE/NEEDLE/3ML/2 MISC (insulin pen F 1G X 1-1/2" MISC F needle) (syringe/needle (disp) 3 RELION SHORT PEN RX/OTC ml) NEEDLES31GX8MM MISC F SAFESNAP (insulin pen needle) SYRINGE/NEEDLE/3ML/2 2G X 1" MISC F SAFESNAP INSULIN RX/OTC (syringe/needle (disp) 3 SYRINGE/0.3ML/30G X ml) 5/16" MISC (insulin F SAFESNAP RX/OTC syringe/needle u-100) SYRINGE/NEEDLE/3ML/2 SAFESNAP INSULIN RX/OTC 2G X 1-1/2" MISC F SYRINGE/0.5ML/29G X F (syringe/needle (disp) 3 1/2" MISC (insulin ml) syringe/needle u-100) SAFESNAP RX/OTC SAFESNAP INSULIN RX/OTC SYRINGE/NEEDLE/3ML/2 SYRINGE/0.5ML/30G X 3G X 1" MISC F 5/16" MISC (insulin F (syringe/needle (disp) 3 syringe/needle u-100) ml) SAFESNAP INSULIN RX/OTC SAFESNAP SYRINGE/1ML/28G X 1/2" SYRINGE/NEEDLE/3ML/2 MISC (insulin F 3G X 1-1/2" MISC F syringe/needle u-100) (syringe/needle (disp) 3 ml) SAFESNAP INSULIN RX/OTC SAFESNAP RX/OTC SYRINGE/1ML/29G X 1/2" F SYRINGE/NEEDLE/3ML/2 MISC (insulin 5G X 1" MISC F syringe/needle u-100) (syringe/needle (disp) 3 SAFESNAP RX/OTC ml) SYRINGE/NEEDLE/3ML/2 SAFESNAP RX/OTC 0G X 1" MISC F SYRINGE/NEEDLE/3ML/2 (syringe/needle (disp) 3 5G X 5/8" MISC F ml) (syringe/needle (disp) 3 SAFESNAP RX/OTC ml) SYRINGE/NEEDLE/3ML/2 SAFETY INSULIN RX/OTC 0G X 1-1/2" MISC F SYRINGES (syringe/needle (disp) 3 0.5ML/29GX1/2" MISC F ml) (insulin syringe/needle SAFESNAP RX/OTC u-100) SYRINGE/NEEDLE/3ML/2 SAFETY INSULIN RX/OTC 1G X 1" MISC F SYRINGES (syringe/needle (disp) 3 0.5ML/30GX5/16" MISC ml) F (insulin syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

168 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAFETY INSULIN RX/OTC SAFETY RX/OTC SYRINGES 1ML/27GX1/2" SYRINGES/NEEDLE MISC (insulin F 3ML/25GX5/8" MISC F syringe/needle u-100) (syringe/needle (disp) 3 SAFETY INSULIN RX/OTC ml) SYRINGES 1ML/29GX1/2" SAFETY-LOK RX/OTC MISC (insulin F SYRINGE/NEEDLE3ML LUER-LOK 21GX1-1/2" syringe/needle u-100) F MISC (syringe/needle SAFETY INSULIN ) 3 ml) SYRINGES 1ML/30GX1/2" (disp MISC (insulin F SAFETY-LOK SYRINGE/NEEDLE3ML syringe/needle u-100) LUER-LOK 22GX1" MISC F SAFETY RX/OTC (syringe/needle (disp) 3 SYRINGES/NEEDLE ml) 3ML/20GX1" MISC F SAFETY-LOK RX/OTC (syringe/needle (disp) 3 SYRINGE/NEEDLE3ML ml) LUER-LOK 22GX1-1/2" F SAFETY RX/OTC MISC (syringe/needle SYRINGES/NEEDLE (disp) 3 ml) 3ML/20GX1-1/2" MISC F (syringe/needle (disp) 3 SAFETY-LOK RX/OTC ml) SYRINGE/NEEDLE3ML LUER-LOK 23GX1" MISC F SAFETY RX/OTC SYRINGES/NEEDLE (syringe/needle (disp) 3 ml) 3ML/21GX1" MISC F (syringe/needle (disp) 3 SAFETY-LOK RX/OTC ml) SYRINGE/NEEDLE3ML LUER-LOK 25GX5/8" SAFETY RX/OTC F SYRINGES/NEEDLE MISC (syringe/needle 3ML/21GX1-1/2" MISC F (disp) 3 ml) (syringe/needle (disp) 3 SB INSULIN SYRINGE/U- RX/OTC ml) 100/0.5ML/29G X 1/2" F SAFETY MISC (insulin SYRINGES/NEEDLE syringe/needle u-100) 3ML/22GX1" MISC F SB INSULIN SYRINGE/U- RX/OTC (syringe/needle (disp) 3 100/0.5ML/30G X 5/16" ml) MISC (insulin F SAFETY RX/OTC syringe/needle u-100) SYRINGES/NEEDLE SB INSULIN SYRINGE/U- RX/OTC 3ML/22GX1-1/2" MISC F 100/1ML/29G X 1/2" MISC (syringe/needle (disp) 3 (insulin syringe/needle F ml) u-100) SAFETY RX/OTC SYRINGES/NEEDLE SB INSULIN SYRINGE/U- RX/OTC 100/1ML/30G X 5/16" 3ML/23GX1" MISC F F (syringe/needle (disp) 3 MISC (insulin ml) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

169 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SB INSULIN SYRINGE/U- SECURESAFE RX/OTC 100/1ML/31G X 5/16" SYRINGE/NEEDLE/3ML/2 MISC (insulin F 2G X 1-1/2" MISC F syringe/needle u-100) (syringe/needle (disp) 3 SECURESAFE SAFETY RX/OTC ml) INSULIN SYRINGES/U- SECURESAFE RX/OTC 100/0.5ML/29GX1/2" MISC F SYRINGE/NEEDLE/3ML/2 (insulin syringe/needle 3G X 1" MISC F u-100) (syringe/needle (disp) 3 ml) SECURESAFE SAFETY RX/OTC INSULIN SYRINGES/U- SECURESAFE RX/OTC 100/1ML/29GX1/2" MISC SYRINGE/NEEDLE/3ML/2 F 5G X 5/8" MISC F (insulin syringe/needle (syringe/needle (disp) 3 u-100) ml) SECURESAFE SAFETY RX/OTC SHOPKO UNIFINE RX/OTC PEN NEEDLES/30G X F PENTIPS PEN 5/16" MISC (insulin pen NEEDLES/MICRO/32GX4 F needle) MM MISC (insulin pen SECURESAFE RX/OTC needle) SYRINGE/NEEDLE/3ML/2 SHOPKO UNIFINE RX/OTC 0G X 1" MISC F PENTIPS PEN (syringe/needle (disp) 3 NEEDLES/MINI/31GX5MM F ml) MISC (insulin pen SECURESAFE RX/OTC needle) SYRINGE/NEEDLE/3ML/2 0G X 1-1/2" MISC F SHOPKO UNIFINE RX/OTC PENTIPS PEN (syringe/needle (disp) 3 NEEDLES/ORIGINAL/29G ml) F X12MM MISC (insulin SECURESAFE RX/OTC ) SYRINGE/NEEDLE/3ML/2 pen needle 1G X 1" MISC F SHOPKO UNIFINE RX/OTC (syringe/needle (disp) 3 PENTIPS PEN ml) NEEDLES/SHORT/31GX8 F SECURESAFE RX/OTC MM MISC (insulin pen SYRINGE/NEEDLE/3ML/2 needle) 1G X 1-1/2" MISC F SHOPKO UNIFINE RX/OTC (syringe/needle (disp) 3 PENTIPS PLUS PEN ml) NEEDLES/MICRO/REMOV F SECURESAFE R/32GX4MM MISC SYRINGE/NEEDLE/3ML/2 (insulin pen needle) 2G X 1" MISC F SHOPKO UNIFINE RX/OTC (syringe/needle (disp) 3 PENTIPS PLUS PEN ml) NEEDLES/MINI/REMOVE F R/31GX5MM MISC (insulin pen needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

170 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SHOPKO UNIFINE RX/OTC SURE COMFORT RX/OTC PENTIPS PLUS PEN INSULIN SYRINGE/U- NEEDLES/REMOVER/29G F 100/0.5ML/29G X 1/2" F X12MM MISC (insulin MISC (insulin pen needle) syringe/needle u-100) SHOPKO UNIFINE RX/OTC SURE COMFORT PENTIPS PLUS PEN INSULIN SYRINGE/U- NEEDLES/SHORT/REMO F 100/0.5ML/30G X 1/2" F VR/31GX8MM MISC MISC (insulin (insulin pen needle) syringe/needle u-100) SURE COMFORT RX/OTC SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/29G X 1/2" F 100/0.5ML/30G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) SURE COMFORT SURE COMFORT INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/30G X 1/2" F 100/0.5ML/31G X 5/16 F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) SURE COMFORT RX/OTC SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/30G X 5/16" F 100/1ML/28G X 1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) SURE COMFORT SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16 F 100/1ML/29G X 1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) SURE COMFORT SURE COMFORT INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" F 100/1ML/30G X 1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) SURE COMFORT SURE COMFORT RX/OTC INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.3ML/31GX1/4" MISC F 100/1ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) SURE COMFORT RX/OTC SURE COMFORT INSULIN SYRINGE/U- INSULIN SYRINGE/U- 100/0.5ML/28G X 1/2" F 100/1ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

171 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT SURE-JECT INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGES/0.5ML/31G X F 100/0.3ML/29G X 1/2" F 6MM MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) SURE COMFORT SURE-JECT INSULIN RX/OTC INSULIN SYRINGES/U- SYRINGE/U- 100/1ML/31GX6MM MISC F 100/0.3ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) SURE COMFORT PEN SURE-JECT INSULIN NEEDLES29GX1/2" SYRINGE/U- 12.7MM MISC (insulin F 100/0.3ML/31G X 5/16" F pen needle) MISC (insulin SURE COMFORT PEN RX/OTC syringe/needle u-100) NEEDLES30GX5/16" SURE-JECT INSULIN RX/OTC SHORT MISC (insulin F SYRINGE/U- pen needle) 100/0.5ML/28G X 1/2" F SURE COMFORT PEN RX/OTC MISC (insulin NEEDLES31GX3/16" syringe/needle u-100) F (5MM) MISC (insulin pen SURE-JECT INSULIN RX/OTC needle) SYRINGE/U- SURE COMFORT PEN RX/OTC 100/0.5ML/29G X 1/2" F NEEDLES31GX5/16" MISC (insulin F (8MM) MISC (insulin pen syringe/needle u-100) needle) SURE-JECT INSULIN RX/OTC SURE COMFORT PEN RX/OTC SYRINGE/U- NEEDLES32GX5/32" 100/0.5ML/30G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) SURE COMFORT PEN SURE-JECT INSULIN NEEDLES32GX6MM MISC F SYRINGE/U- (insulin pen needle) 100/0.5ML/31G X 5/16" F MISC (insulin SURE-FINE PEN NEEDLES 29GX1/2" syringe/needle u-100) 12.7MM MISC (insulin F SURE-JECT INSULIN RX/OTC pen needle) SYRINGE/U-100/1ML/28G X 1/2" MISC (insulin F SURE-FINE PEN RX/OTC NEEDLES 31GX3/16" syringe/needle u-100) 5MM MISC (insulin pen F SURE-JECT INSULIN RX/OTC needle) SYRINGE/U-100/1ML/29G X 1/2" MISC (insulin F SURE-FINE PEN RX/OTC NEEDLES 31GX5/16" syringe/needle u-100) 8MM MISC (insulin pen F needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

172 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE-JECT INSULIN RX/OTC SYRINGE/LUER SYRINGE/U-100/1ML/30G LOCK/3ML/22GX1" MISC F X 5/16" MISC (insulin F (syringe/needle (disp) 3 syringe/needle u-100) ml) SURE-JECT INSULIN SYRINGE/LUER RX/OTC LOCK/3ML/22GX1-1/2" SYRINGE/U-100/1ML/31G F X 5/16" MISC (insulin F MISC (syringe/needle syringe/needle u-100) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/20G X 1" MISC LOCK/3ML/23G X 1" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGE/LUER LOCK/3ML/23G X 1-1/2" LOCK/3ML/20G X 1-1/2" F MISC (syringe/needle F MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/23GX1" MISC LOCK/3ML/20GX1-1/2" F MISC (syringe/needle F (syringe/needle (disp) 3 (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/21G X 1" MISC LOCK/3ML/25G X 1" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGE/LUER LOCK/3ML/25G X 1-1/2" LOCK/3ML/21G X 1-1/2" F MISC (syringe/needle F MISC (syringe/needle (disp) 3 ml) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/21GX1" MISC LOCK/3ML/25G X 5/8" F F (syringe/needle (disp) 3 MISC (syringe/needle ml) (disp) 3 ml) SYRINGE/LUER RX/OTC SYRINGE/LUER RX/OTC LOCK/3ML/25GX1" MISC LOCK/3ML/21GX1-1/2" F MISC (syringe/needle F (syringe/needle (disp) 3 (disp) 3 ml) ml) SYRINGE/LUER SYRINGE/LUER RX/OTC LOCK/3ML/22G X 1" MISC LOCK/3ML/25GX5/8" MISC F F (syringe/needle (disp) 3 (syringe/needle (disp) 3 ml) ml) SYRINGE/LUER RX/OTC SYRINGES/LUER RX/OTC LOCK/1ML/20GX1" MISC LOCK/3ML/22G X 1-1/2" F MISC (syringe/needle F (syringe/needle (disp) 3 ml) (disp) 3 ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

173 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN RX/OTC TECHLITE INSULIN SYRINGEU- SYRINGEU- 100/0.3ML/29G X 1/2" F 100/0.5ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) TECHLITE INSULIN TECHLITE INSULIN RX/OTC SYRINGEU- SYRINGEU-100/1ML/29G 100/0.3ML/30G X 1/2" F X 1/2" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) TECHLITE INSULIN TECHLITE INSULIN RX/OTC SYRINGEU-100/1ML/30G SYRINGEU- X 1/2" MISC (insulin F 100/0.3ML/30G X 5/16" F syringe/needle u-100) MISC (insulin TECHLITE INSULIN RX/OTC syringe/needle u-100) SYRINGEU-100/1ML/30G TECHLITE INSULIN RX/OTC X 5/16" MISC (insulin F SYRINGEU- syringe/needle u-100) 100/0.3ML/31G X 15/64" F TECHLITE INSULIN MISC (insulin SYRINGEU-100/1ML/31G syringe/needle u-100) X 15/64" MISC (insulin F TECHLITE INSULIN syringe/needle u-100) SYRINGEU- 100/0.3ML/31G X 5/16" TECHLITE INSULIN F SYRINGEU-100/1ML/31G MISC (insulin X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) TECHLITE INSULIN RX/OTC SYRINGEU- TECHLITE PEN NEEDLES 29GX 10MM MISC 100/0.5ML/29G X 1/2" F F MISC (insulin (insulin pen needle) syringe/needle u-100) TECHLITE PEN NEEDLES RX/OTC 29GX 12 MM MISC TECHLITE INSULIN F SYRINGEU- (insulin pen needle) 100/0.5ML/30G X 1/2" F TECHLITE PEN NEEDLES RX/OTC MISC (insulin 31GX 5MM MISC (insulin F syringe/needle u-100) pen needle) TECHLITE INSULIN RX/OTC TECHLITE PEN RX/OTC SYRINGEU- NEEDLES/31GX 5MM F 100/0.5ML/30G X 5/16" F MISC (insulin pen MISC (insulin needle) syringe/needle u-100) TECHLITE PEN TECHLITE INSULIN NEEDLES/31GX 6 MM SYRINGEU- MISC (insulin pen F 100/0.5ML/31G X 15/64" F needle) MISC (insulin syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

174 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE PEN RX/OTC TOPCARE ULTRA NEEDLES/31GX 8MM COMFORT INSULIN MISC (insulin pen F SYRINGE/0.3ML/31G X F needle) 5/16" MISC (insulin TECHLITE PEN RX/OTC syringe/needle u-100) NEEDLES/32GX 4MM TOPCARE ULTRA RX/OTC MISC (insulin pen F COMFORT INSULIN needle) SYRINGE/0.5ML/30G X F TECHLITE PEN 5/16" MISC (insulin NEEDLES/32GX 6MM syringe/needle u-100) MISC (insulin pen F TOPCARE ULTRA needle) COMFORT INSULIN SYRINGE/0.5ML/31G X TECHLITE PEN F NEEDLES/32GX 8MM 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) TOPCARE ULTRA RX/OTC COMFORT INSULIN TODAYS HEALTH MINI SYRINGE/1ML/30G X PEN NEEDLES 31G X 1/4" F 5/16" MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) TOPCARE ULTRA TODAYS HEALTH RX/OTC COMFORT INSULIN ORIGINAL PEN NEEDLES F SYRINGE/1ML/31G X F 29G X 1/2" MISC (insulin 5/16" MISC (insulin pen needle) syringe/needle u-100) TODAYS HEALTH SHORT RX/OTC TOPCARE ULTRA RX/OTC PEN NEEDLES 31G X F COMFORT INSULIN 5/16" MISC (insulin pen SYRINGE/U- needle) 100/0.3ML/29G X 1/2" F TOPCARE CLICKFINE MISC (insulin UNIVERSAL PEN EEDLES syringe/needle u-100) F 31GX1/4" MISC (insulin TOPCARE ULTRA RX/OTC pen needle) COMFORT INSULIN SYRINGE/U- TOPCARE CLICKFINE RX/OTC F UNIVERSAL PEN EEDLES 100/0.5ML/29G X 1/2" 31GX5/16" MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) TOPCARE ULTRA RX/OTC TOPCARE ULTRA RX/OTC COMFORT INSULIN COMFORT INSULIN SYRINGE/0.3ML/30G X F SYRINGE/U-100/1ML/29G F 5/16" MISC (insulin X 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) TRUE COMFORT INSULIN SYRINGE/0.5ML/31G X 5/16" MISC (insulin F syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

175 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUE COMFORT INSULIN TRUE COMFORT PRO RX/OTC SYRINGE/1ML/31G X PEN NEEDLES 31G X 5/16" MISC (insulin F 5MM MISC (insulin pen F syringe/needle u-100) needle) TRUE COMFORT PEN RX/OTC TRUE COMFORT PRO NEEDLES31G X 5MM PEN NEEDLES 31G X MISC (insulin pen F 6MM MISC (insulin pen F needle) needle) TRUE COMFORT PEN TRUE COMFORT PRO RX/OTC NEEDLES31G X 6MM PEN NEEDLES 31G X MISC (insulin pen F 8MM MISC (insulin pen F needle) needle) TRUE COMFORT PEN RX/OTC TRUE COMFORT PRO RX/OTC NEEDLES32G X 4MM PEN NEEDLES 32G X MISC (insulin pen F 4MM MISC (insulin pen F needle) needle) TRUE COMFORT PRO RX/OTC TRUE COMFORT PRO RX/OTC INSULINSYRINGE/0.5ML/ PEN NEEDLES 32G X 30G X 5/16" MISC F 5MM MISC (insulin pen F (insulin syringe/needle needle) u-100) TRUE COMFORT PRO TRUE COMFORT PRO PEN NEEDLES 32G X INSULINSYRINGE/0.5ML/ 6MM MISC (insulin pen F 31G X 5/16" MISC F needle) (insulin syringe/needle TRUE COMFORT PRO u-100) PEN NEEDLES 33G X TRUE COMFORT PRO RX/OTC 4MM MISC (insulin pen F INSULINSYRINGE/1ML/30 F needle) G X 5/16" MISC (insulin TRUE COMFORT PRO syringe/needle u-100) PEN NEEDLES 33G X TRUE COMFORT PRO 5MM MISC (insulin pen F INSULINSYRINGE/1ML/31 F needle) G X 5/16" MISC (insulin TRUE COMFORT PRO syringe/needle u-100) PEN NEEDLES 33G X TRUE COMFORT PRO 6MM MISC (insulin pen F INSULINSYRINGE/U- needle) 100/0.5ML/30G X 1/2" F TRUEPLUS 5-BEVEL PEN MISC (insulin NEEDLES 29GX12.7MM syringe/needle u-100) MISC (insulin pen F TRUE COMFORT PRO needle) INSULINSYRINGE/U- 100/1ML/30G X 1/2" MISC TRUEPLUS 5-BEVEL PEN RX/OTC F NEEDLES 31GX5MM (insulin syringe/needle MISC (insulin pen F u-100) needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

176 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUEPLUS 5-BEVEL PEN TRUEPLUS INSULIN NEEDLES 31GX6MM SYRINGE/U- MISC (insulin pen F 100/0.5ML/31G X 5/16" F needle) MISC (insulin TRUEPLUS 5-BEVEL PEN RX/OTC syringe/needle u-100) NEEDLES 31GX8MM TRUEPLUS INSULIN RX/OTC MISC ( F SYRINGE/U-100/1ML/28G insulin pen F needle) X 1/2" MISC (insulin TRUEPLUS 5-BEVEL PEN RX/OTC syringe/needle u-100) NEEDLES 32GX4MM TRUEPLUS INSULIN RX/OTC MISC ( F SYRINGE/U-100/1ML/29G insulin pen F needle) X 1/2" MISC (insulin TRUEPLUS INSULIN RX/OTC syringe/needle u-100) SYRINGE/U- TRUEPLUS INSULIN RX/OTC 100/0.3ML/29G X 1/2" F SYRINGE/U-100/1ML/30G MISC (insulin X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) TRUEPLUS INSULIN RX/OTC TRUEPLUS INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 100/0.3ML/30G X 5/16" F X 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) TRUEPLUS PEN RX/OTC TRUEPLUS INSULIN NEEDLES 29GX12MM SYRINGE/U- MISC (insulin pen F 100/0.3ML/31G X 5/16" F needle) MISC (insulin TRUEPLUS PEN RX/OTC syringe/needle u-100) NEEDLES 31GX5MM TRUEPLUS INSULIN RX/OTC MISC (insulin pen F SYRINGE/U- needle) 100/0.5ML/28G X 1/2" F TRUEPLUS PEN MISC (insulin NEEDLES 31GX6MM syringe/needle u-100) MISC (insulin pen F TRUEPLUS INSULIN RX/OTC needle) SYRINGE/U- 100/0.5ML/29G X 1/2" TRUEPLUS PEN RX/OTC F NEEDLES 31GX8MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) TRUEPLUS INSULIN RX/OTC SYRINGE/U- TRUEPLUS PEN RX/OTC NEEDLES 32GX4MM 100/0.5ML/30G X 5/16" F F MISC (insulin MISC (insulin pen syringe/needle u-100) needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

177 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN RX/OTC ULTICARE INSULIN RX/OTC SAFETY SYRINGE/1ML/29G X 1/2" SYRINGE/0.5ML/29G X F MISC (insulin F 1/2" MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTICARE INSULIN ULTICARE INSULIN RX/OTC SYRINGE/1ML/30G X 1/2" SAFETY MISC (insulin F SYRINGE/1ML/29G X 1/2" F syringe/needle u-100) MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/1ML/30G X ULTICARE INSULIN RX/OTC 5/16" MISC (insulin F SYRINGE/0.3ML/29G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/SHORT/0.3ML/3 ULTICARE INSULIN 0G X 5/16" MISC (insulin F SYRINGE/0.3ML/30G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/SHORT/0.3ML/3 ULTICARE INSULIN RX/OTC 1G X 5/16" MISC (insulin F SYRINGE/0.3ML/30G X F syringe/needle u-100) 5/16" MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/SHORT/0.5ML/3 ULTICARE INSULIN RX/OTC 0G X 5/16" MISC (insulin F SYRINGE/0.5ML/28G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/SHORT/0.5ML/3 ULTICARE INSULIN RX/OTC 1G X 5/16" MISC (insulin F SYRINGE/0.5ML/29G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN RX/OTC syringe/needle u-100) SYRINGE/SHORT/1ML/30 ULTICARE INSULIN G X 5/16" MISC (insulin F SYRINGE/0.5ML/30G X F syringe/needle u-100) 1/2" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/SHORT/1ML/31 ULTICARE INSULIN RX/OTC G X 5/16" MISC (insulin F SYRINGE/0.5ML/30G X F syringe/needle u-100) 5/16" MISC (insulin ULTICARE INSULIN syringe/needle u-100) SYRINGE/U- ULTICARE INSULIN RX/OTC 100/0.3ML/30G X 1/2" F SYRINGE/1ML/28G X 1/2" MISC ( F insulin MISC (insulin syringe/needle u-100) syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

178 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN ULTICARE MICRO PEN SYRINGE/U- NEEDLES/31G X 1/4" 100/0.3ML/31G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) ULTICARE MICRO PEN RX/OTC ULTICARE INSULIN NEEDLES/31G X 5/16" SYRINGE/U- MISC (insulin pen F 100/0.5ML/30G X 1/2" F needle) MISC (insulin ULTICARE MICRO PEN RX/OTC syringe/needle u-100) NEEDLES/32G X 4MM ULTICARE INSULIN MISC (insulin pen F SYRINGE/U- needle) 100/0.5ML/31G X 5/16" F ULTICARE MICRO PEN RX/OTC MISC (insulin NEEDLES/32G X 5/32" syringe/needle u-100) MISC (insulin pen F ULTICARE INSULIN needle) SYRINGE/U-100/1ML/30G F ULTICARE MINI PEN X 1/2" MISC (insulin NEEDLES 31GX6MM syringe/needle u-100) MISC (insulin pen F ULTICARE INSULIN needle) SYRINGE/U-100/1ML/31G F ULTICARE MINI PEN X 5/16" MISC (insulin NEEDLES ULTI-FINE IV syringe/needle u-100) MISC (insulin pen F ULTICARE INSULIN needle) SYRINGEULTRAFINE U- 100/0.3ML/31G X 5/16" ULTICARE MINI PEN F NEEDLES/31G X 6MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) ULTICARE INSULIN SYRINGEULTRAFINE U- ULTICARE MINI PEN NEEDLES/32G X 1/4" 100/0.5ML/31G X 5/16" F F MISC (insulin MISC (insulin pen syringe/needle u-100) needle) ULTICARE INSULIN ULTICARE MINI PEN SYRINGEULTRAFINE U- NEEDLES31GX6MM MISC F 100/1ML/31G X 5/16" F (insulin pen needle) MISC (insulin ULTICARE MINI SAFETY PENNEEDLES 30G X syringe/needle u-100) F ULTICARE MICRO PEN RX/OTC 3/16" MISC (insulin pen NEEDLES 31G X 8MM needle) MISC (insulin pen F ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE needle) F ULTICARE MICRO PEN RX/OTC MISC (insulin pen NEEDLES 32G X 4MM needle) MISC (insulin pen F needle) CA Health & Wellness Preferred Drug List Updated September 1, 2021

179 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE PEN NEEDLES RX/OTC ULTIGUARD SAFEPACK 31GX 5MM/MINI MISC F INSULIN SYRINGE (insulin pen needle) 0.3ML/30G X 1/2"/SHARPS F ULTICARE PEN C MISC (insulin NEEDLES/29GX 12.7MM syringe/needle u-100) MISC (insulin pen F ULTIGUARD SAFEPACK needle) INSULIN SYRINGE 1/2ML ULTICARE SHORT PEN RX/OTC 30G X 1/2"/SHARPS C F NEEDLES 31GX8MM MISC (insulin MISC (insulin pen F syringe/needle u-100) needle) ULTIGUARD SAFEPACK ULTICARE SHORT PEN RX/OTC INSULIN SYRINGE 1ML NEEDLES ULTI-FINE IV 30G X 1/2"/SHARPS CON F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) ULTICARE SHORT PEN RX/OTC ULTIGUARD SAFEPACK NEEDLES/31G X 8MM INSULIN SYRINGE 1ML 31G X 5/16"/SHARPS CO MISC (insulin pen F F MISC (insulin needle) syringe/needle u-100) ULTICARE SHORT RX/OTC SAFETY PEN NEEDLES ULTIGUARD SAFEPACK 30G X 5/16" MISC F INSULIN SYRINGE/0.3ML/30G X (insulin pen needle) 1/2"/SHARPS C MISC F ULTICARE SYRINGE/LOW RX/OTC (insulin syringe/needle DEADSPACE/3ML/22G u-100) X1-1/2" MISC F (syringe/needle (disp) 3 ULTIGUARD SAFEPACK ml) INSULIN SYRINGE/0.3ML/31G X ULTICARE U-100 INSULIN 5/16"/SHARPS MISC F SYRINGES/0.3ML/31G X F (insulin syringe/needle 1/4" MISC (insulin u-100) syringe/needle u-100) ULTIGUARD SAFEPACK ULTICARE U-100 INSULIN INSULIN SYRINGES/0.3ML/31G F SYRINGE/0.5ML/30G X X1/4" MISC (insulin 1/2"/SHARPS C MISC F syringe/needle u-100) (insulin syringe/needle ULTICARE U-100 INSULIN u-100) SYRINGES/0.5ML/31G X F ULTIGUARD SAFEPACK RX/OTC 1/4" MISC (insulin MINI PEN NEEDLE/31G X syringe/needle u-100) 3/16"/SHARPS CONTAI F ULTICARE U-100 INSULIN MISC (insulin pen SYRINGES/1ML/31G X needle) 1/4" MISC (insulin F syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

180 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTIGUARD SAFEPACK ULTILET INSULIN RX/OTC PEN NEEDLE/29G X SYRINGE 31X6MM MISC 1/2"/SHARPS F (insulin syringe/needle F CONTAINER MISC u-100) (insulin pen needle) ULTILET INSULIN ULTIGUARD RX/OTC SYRINGE 31X6MM MISC SAFEPACK/MICROPEN (insulin syringe/needle F NEEDLE/32G X 5/32" F u-100) MISC (insulin pen ULTILET INSULIN RX/OTC needle) SYRINGE/0.3ML/30G X ULTIGUARD RX/OTC 8MM MISC (insulin F SAFEPACK/MICROPEN ) NEEDLE/32G X syringe/needle u-100 5/32"/SHARPS CONTA F ULTILET INSULIN SYRINGE/0.3ML/31G X MISC (insulin pen F needle) 8MM MISC (insulin ) ULTIGUARD syringe/needle u-100 SAFEPACK/MINI PEN ULTILET INSULIN RX/OTC SYRINGE/0.5ML/30G X NEEDLE/31G X F 1/4"/SHARPS CONTAIN F 8MM MISC (insulin MISC (insulin pen syringe/needle u-100) needle) ULTILET INSULIN RX/OTC SYRINGE/1ML/30G X ULTIGUARD RX/OTC F SAFEPACK/MINI PEN 8MM MISC (insulin NEEDLE/31G X syringe/needle u-100) F 3/16"/SHARPS CONTAI ULTILET INSULIN MISC (insulin pen SYRINGE/1ML/31G X needle) 8MM MISC (insulin F ULTIGUARD syringe/needle u-100) SAFEPACK/MINI PEN ULTILET INSULIN NEEDLE/32G X SYRINGE/SHORT/0.3ML/3 1/4"/SHARPS CONTAIN F 0G X 12.7MM MISC F MISC (insulin pen (insulin syringe/needle needle) u-100) ULTIGUARD RX/OTC ULTILET INSULIN RX/OTC SAFEPACK/SHORTPEN SYRINGE/SHORT/0.3ML/3 NEEDLE/31G X F 5/16"/SHARPS CONTA F 0G X 5/16" MISC (insulin MISC (insulin pen syringe/needle u-100) needle) ULTILET INSULIN SYRINGE/SHORT/0.3ML/3 ULTIGUARD F SAFEPACK/SYRINGE/NE 1G X 5/16" MISC (insulin EDLE/31G X syringe/needle u-100) 5/16"/SHARPS CONTAIN F ULTILET INSULIN RX/OTC MISC (insulin SYRINGE/SHORT/0.5ML/3 F syringe/needle u-100) 0G X 5/16" MISC (insulin syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

181 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN ULTILET SHORT PEN RX/OTC SYRINGE/SHORT/0.5ML/3 NEEDLES31GX3/16" MISC F 1G X 5/16" MISC (insulin F (insulin pen needle) syringe/needle u-100) ULTILET U-100 INSULIN ULTILET INSULIN RX/OTC SYRINGES/1ML/31G X SYRINGE/SHORT/1ML/30 6MM MISC (insulin F G X 5/16" MISC (insulin F syringe/needle u-100) syringe/needle u-100) ULTRA COMFORT RX/OTC ULTILET INSULIN INSULIN SYRINGE/U- SYRINGE/SHORT/1ML/31 100/0.3ML/30G X 5/16" F G X 5/16" MISC (insulin F MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTILET INSULIN ULTRA FLO INSULIN PEN RX/OTC SYRINGE/U- NEEDLE 31GX5MM MISC F 100/0.5ML/30G X 1/2" F (insulin pen needle) MISC (insulin ULTRA FLO INSULIN PEN RX/OTC syringe/needle u-100) NEEDLE 32GX4MM MISC F ULTILET INSULIN (insulin pen needle) SYRINGE/U- ULTRA FLO INSULIN PEN 100/0.5ML/31GX6MM F NEEDLE 33GX4MM MISC F MISC (insulin (insulin pen needle) syringe/needle u-100) ULTRA FLO INSULIN PEN RX/OTC ULTILET INSULIN NEEDLES MISC (insulin F SYRINGE/U-100/1ML/30G F pen needle) X 1/2" MISC (insulin ULTRA FLO INSULIN PEN RX/OTC syringe/needle u-100) NEELE 31GX8MM MISC F ULTILET PEN NEEDLE (insulin pen needle) 29GX12.7MM MISC F ULTRA FLO INSULIN RX/OTC (insulin pen needle) SYRINGE 0.3ML/29G X ULTILET PEN NEEDLE RX/OTC 1/2" MISC (insulin F 31GX5MM MISC (insulin F syringe/needle u-100) pen needle) ULTRA FLO INSULIN ULTILET PEN NEEDLE RX/OTC SYRINGE 0.3ML/30GX1/2" F 31GX8MM MISC (insulin F MISC (insulin pen needle) syringe/needle u-100) ULTILET PEN NEEDLE RX/OTC ULTRA FLO INSULIN RX/OTC 32GX4MM MISC (insulin F SYRINGE pen needle) 0.3ML/30GX5/16" MISC F ( ULTILET PEN NEEDLE RX/OTC insulin syringe/needle 32GX4MM/SHORT MISC F u-100) (insulin pen needle) ULTRA FLO INSULIN SYRINGE ULTILET SHORT PEN RX/OTC 0.3ML/31GX5/16" MISC NEEDLES 31GX5/16" F ( MISC (insulin pen F insulin syringe/needle needle) u-100) CA Health & Wellness Preferred Drug List Updated September 1, 2021

182 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA FLO INSULIN RX/OTC ULTRA FLO INSULIN SYRINGE 0.5ML/29GX1/2" SYRINGE 1ML/31GX5/16" MISC (insulin F MISC (insulin F syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA THIN PEN RX/OTC SYRINGE 0.5ML/30GX1/2" NEEDLES 32G X 4MM MISC (insulin F MISC (insulin pen F syringe/needle u-100) needle) ULTRA FLO INSULIN RX/OTC ULTRA-COMFORT RX/OTC SYRINGE INSULIN SYRINGE/U- 0.5ML/30GX5/16" MISC F 100/0.3ML/29G X 1/2" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA-COMFORT RX/OTC SYRINGE INSULIN SYRINGE/U- 0.5ML/31GX5/16" MISC F 100/0.3ML/30G X 5/16" F (insulin syringe/needle MISC (insulin u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA-COMFORT SYRINGE 1/2 INSULIN SYRINGE/U- UNIT/0.3ML/30GX1/2" F 100/0.3ML/31G X 5/16" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN RX/OTC ULTRA-COMFORT RX/OTC SYRINGE 1/2 INSULIN SYRINGE/U- UNIT/0.3ML/30GX5/16" F 100/0.5ML/28G X 1/2" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN ULTRA-COMFORT RX/OTC SYRINGE 1/2 INSULIN SYRINGE/U- UNIT/0.3ML/31GX5/16" F 100/0.5ML/29G X 1/2" F MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) ULTRA FLO INSULIN RX/OTC ULTRA-COMFORT RX/OTC SYRINGE 1M/29GX1/2" INSULIN SYRINGE/U- F MISC (insulin 100/0.5ML/30G X 5/16" F syringe/needle u-100) MISC (insulin ULTRA FLO INSULIN syringe/needle u-100) SYRINGE 1ML/30GX1/2" ULTRA-COMFORT MISC (insulin F INSULIN SYRINGE/U- syringe/needle u-100) 100/0.5ML/31G X 5/16" F ULTRA FLO INSULIN RX/OTC MISC (insulin SYRINGE 1ML/30GX5/16" syringe/needle u-100) MISC (insulin F syringe/needle u-100)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

183 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN INSULIN SYRINGE/U- SYRINGE SHORT/U- 100/1ML/28G X 1/2" MISC F 100/1ML/31GX5/16" MISC F (insulin syringe/needle (insulin syringe/needle u-100) u-100) ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/29G X 1/2" MISC F 100/0.5ML/29GX1/2" MISC F (insulin syringe/needle (insulin syringe/needle u-100) u-100) ULTRA-COMFORT RX/OTC ULTRA-THIN II INSULIN RX/OTC INSULIN SYRINGE/U- SYRINGE/U- 100/1ML/30G X 5/16" F 100/1ML/29GX1/2" MISC F MISC (insulin (insulin syringe/needle syringe/needle u-100) u-100) ULTRA-COMFORT ULTRA-THIN II MINI PEN RX/OTC INSULIN SYRINGE/U- NEEEDLES/31GX3/16" 100/1ML/31G X 5/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) ULTRA-THIN II PEN ULTRA-THIN II INSULIN RX/OTC NEEDLES 29GX1/2" MISC F SYRINGE SHORT/U- (insulin pen needle) 100/0.3ML/30GX5/16" F ULTRA-THIN II PEN RX/OTC MISC (insulin NEEDLES/SHORT/31GX5/ syringe/needle u-100) 16" MISC (insulin pen F ULTRA-THIN II INSULIN needle) SYRINGE SHORT/U- ULTRACARE INSULIN RX/OTC 100/0.3ML/31GX5/16" F SYRINGE/U- MISC (insulin 100/0.3ML/30G X 5/16" F syringe/needle u-100) MISC (insulin ULTRA-THIN II INSULIN RX/OTC syringe/needle u-100) SYRINGE SHORT/U- ULTRACARE INSULIN 100/0.5ML/30GX5/16" F SYRINGE/U- MISC (insulin 100/0.3ML/31G X 5/16" F syringe/needle u-100) MISC (insulin ULTRA-THIN II INSULIN syringe/needle u-100) SYRINGE SHORT/U- ULTRACARE INSULIN 100/0.5ML/31GX5/16" F SYRINGE/U- MISC (insulin 100/0.5ML/30G X 1/2" F syringe/needle u-100) MISC (insulin ULTRA-THIN II INSULIN RX/OTC syringe/needle u-100) SYRINGE SHORT/U- ULTRACARE INSULIN RX/OTC 100/1ML/30GX5/16" MISC F SYRINGE/U- (insulin syringe/needle 100/0.5ML/30G X 5/16" F u-100) MISC (insulin syringe/needle u-100) CA Health & Wellness Preferred Drug List Updated September 1, 2021

184 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRACARE INSULIN UNIFINE PEN RX/OTC SYRINGE/U- NEEDLE/32G X4MM MISC F 100/0.5ML/31G X 5/16" F (insulin pen needle) MISC (insulin UNIFINE PENTIPS RX/OTC syringe/needle u-100) 29GX12MM MISC (insulin F ULTRACARE INSULIN pen needle) SYRINGE/U-100/1ML/30G F UNIFINE PENTIPS 31G X RX/OTC X 1/2" MISC (insulin 3/16" MISC (insulin pen F syringe/needle u-100) needle) ULTRACARE INSULIN RX/OTC UNIFINE PENTIPS RX/OTC SYRINGE/U-100/1ML/30G F 31GX5MM MISC (insulin F X 5/16" MISC (insulin pen needle) syringe/needle u-100) UNIFINE PENTIPS ULTRACARE INSULIN SYRINGE/U-100/1ML/31G 31GX6MM MISC (insulin F X 5/16" MISC (insulin F pen needle) syringe/needle u-100) UNIFINE PENTIPS RX/OTC ULTRACARE PEN 31GX8MM MISC (insulin F NEEDLES/31G X 1/4" pen needle) MISC (insulin pen F UNIFINE PENTIPS RX/OTC needle) 32GX4MM MISC (insulin F ULTRACARE PEN RX/OTC pen needle) NEEDLES/31G X 3/16" UNIFINE PENTIPS F MISC (insulin pen 32GX6MM MISC (insulin F needle) pen needle) ULTRACARE PEN RX/OTC UNIFINE PENTIPS NEEDLES/31G X 5/16" F 33GX4MM MISC (insulin F MISC (insulin pen pen needle) needle) UNIFINE PENTIPS PLUS RX/OTC ULTRACARE PEN 29GX12MM MISC (insulin F NEEDLES/32G X 1/14" pen needle) MISC (insulin pen F UNIFINE PENTIPS PLUS RX/OTC needle) 31GX5MM MISC (insulin F ULTRACARE PEN RX/OTC pen needle) NEEDLES/32G X 3/16" MISC (insulin pen F UNIFINE PENTIPS PLUS needle) 31GX6MM MISC (insulin F pen needle) ULTRACARE PEN RX/OTC NEEDLES/32G X 5/32" UNIFINE PENTIPS PLUS RX/OTC MISC (insulin pen F 31GX8MM MISC (insulin F needle) pen needle) ULTRACARE PEN UNIFINE PENTIPS PLUS RX/OTC NEEDLES/33G X 5/32" 32GX4MM MISC (insulin F MISC (insulin pen F pen needle) needle)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

185 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIFINE PENTIPS PLUS VANISHPOINT INSULIN 33GX 5/32" MISC ( SYRINGE/0.5ML/30G X insulin F F pen needle) 1/2" MISC (insulin UNIFINE PENTIPS PLUS syringe/needle u-100) 33GX4MM MISC (insulin F VANISHPOINT INSULIN SYRINGE/0.5ML/30G X pen needle) F UNIFINE PENTIPS 3/16" MISC (insulin PLUS/30GX 3/16" MISC F syringe/needle u-100) (insulin pen needle) VANISHPOINT INSULIN RX/OTC SYRINGE/0.5ML/30G X UNIFINE PENTIPS/30G X F 3/16" MISC (insulin pen F 5/16" MISC (insulin needle) syringe/needle u-100) UNIFINE SAFECONTROL VANISHPOINT INSULIN RX/OTC SYRINGE/1ML/29G X 1/2" PEN NEEDLE/30G X 3/16" F MISC (insulin pen F MISC (insulin needle) syringe/needle u-100) UNIFINE SAFECONTROL RX/OTC VANISHPOINT INSULIN SYRINGE/1ML/29G X PEN NEEDLE/30G X 5/16" F MISC (insulin pen F 5/16" MISC (insulin needle) syringe/needle u-100) VALUE HEALTH INSULIN RX/OTC VANISHPOINT INSULIN SYRINGE/1ML/30G X SYRINGE/U- F 100/0.5ML/29G X 1/2" F 3/16" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) VANISHPOINT INSULIN RX/OTC SYRINGE/1ML/30G X VALUE HEALTH INSULIN RX/OTC F SYRINGE/U-100/1ML/29G 5/16" MISC (insulin X 1/2" MISC (insulin F syringe/needle u-100) syringe/needle u-100) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/20GX1" VALUMARK PEN RX/OTC F NEEDLES 29GX12MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/20GX1-1/2" VALUMARK PEN F NEEDLES 31GX 6MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/21GX1" VALUMARK PEN RX/OTC F NEEDLES 31GX 8MM MISC (syringe/needle MISC (insulin pen F (disp) 3 ml) needle) VANISHPOINT SAFETY RX/OTC SYRINGE/3ML/21GX1-1/2" MISC (syringe/needle F (disp) 3 ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

186 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANISHPOINT SAFETY VANISHPOINT RX/OTC SYRINGE/3ML/22GX1" SYRINGE/3ML/21G X 1- MISC (syringe/needle F 1/2" MISC F (disp) 3 ml) (syringe/needle (disp) 3 VANISHPOINT SAFETY RX/OTC ml) SYRINGE/3ML/22GX1-1/2" VANISHPOINT F SYRINGE/3ML/22G X 1" MISC (syringe/needle F (disp) 3 ml) MISC (syringe/needle ) 3 ml) VANISHPOINT SAFETY RX/OTC (disp SYRINGE/3ML/23GX1" VANISHPOINT RX/OTC MISC (syringe/needle F SYRINGE/3ML/22G X 1- 1/2" MISC (disp) 3 ml) F (syringe/needle (disp) 3 VANISHPOINT SAFETY ml) SYRINGE/3ML/23GX1-1/2" F VANISHPOINT RX/OTC MISC (syringe/needle SYRINGE/3ML/23G X 1" (disp) 3 ml) MISC (syringe/needle F VANISHPOINT SAFETY RX/OTC (disp) 3 ml) SYRINGE/3ML/25GX1" F VANISHPOINT MISC (syringe/needle SYRINGE/3ML/23G X 1- (disp) 3 ml) 1/2" MISC F VANISHPOINT SAFETY (syringe/needle (disp) 3 SYRINGE/3ML/25GX1-1/2" ml) F MISC (syringe/needle VANISHPOINT RX/OTC (disp) 3 ml) SYRINGE/3ML/25G X 1" F VANISHPOINT SAFETY RX/OTC MISC (syringe/needle SYRINGE/3ML/25GX5/8" (disp) 3 ml) F MISC (syringe/needle VANISHPOINT (disp) 3 ml) SYRINGE/3ML/25G X 1- VANISHPOINT SAFETY 1/2" MISC F SYRINGE/3ML/27GX1-1/2" (syringe/needle (disp) 3 MISC (syringe/needle F ml) (disp) 3 ml) VANISHPOINT RX/OTC SYRINGE/3ML/25G X 5/8" VANISHPOINT RX/OTC F SYRINGE/3ML/20G X 1" MISC (syringe/needle MISC (syringe/needle F (disp) 3 ml) (disp) 3 ml) VIDA MIA UNIFINE RX/OTC VANISHPOINT RX/OTC PENTIPS32GX4MM MISC F SYRINGE/3ML/20G X 1- (insulin pen needle) 1/2" MISC F VIDA MIA UNIFINE (syringe/needle (disp) 3 PENTIPSMINI 31GX6MM ml) MISC (insulin pen F VANISHPOINT RX/OTC needle) SYRINGE/3ML/21G X 1" MISC (syringe/needle F (disp) 3 ml)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

187 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNIFINE RX/OTC ZEVRX INSULIN RX/OTC PENTIPSORIGINAL SYRINGE/1ML/30G X F 29GX12MM MISC 5/16" MISC (insulin F (insulin pen needle) syringe/needle u-100) VIDA MIA UNIPFINE RX/OTC ZEVRX PEN NEEDLES RX/OTC PENTIPSSHORT F 31G X 5MM MISC (insulin F 31GX8MM MISC (insulin pen needle) pen needle) ZEVRX PEN NEEDLES VP INSULIN SYRINGE/U- RX/OTC 31G X 6MM MISC (insulin F 100/0.3ML/29G X 1/2" pen needle) MISC (insulin F ZEVRX PEN NEEDLES RX/OTC syringe/needle u-100) 31G X 8MM MISC (insulin F WEGMANS UNIFINE RX/OTC ) PENTIPS PLUS 32GX4MM pen needle MISC (insulin pen F ZEVRX PEN NEEDLES RX/OTC needle) 32G X 4MM MISC (insulin F ) WEGMANS UNIFINE RX/OTC pen needle PENTIPS Respiratory Therapy Supplies PLUS/MINI/31GX5MM F ACE AEROSOL CLOUD QL(1 ml per MISC (insulin pen ENHANCER MISC 360 days needle) (respiratory therapy F retail); RX/OTC WEGMANS UNIFINE RX/OTC supplies) PENTIPS ACTIVITY POUCH MISC QL(1 ml per PLUS/SHORT/31GX8MM F (respiratory therapy F 360 days MISC (insulin pen supplies) retail); RX/OTC needle) ADULT AEROSOL MASK QL(1 ml per WEGMANS UNIFINE MISC (respiratory F 360 days PENTIPS PLUS/ULTRA retail); RX/OTC SHORT/31GX6MM MISC F therapy supplies) (insulin pen needle) ADULT MASK LARGE QL(1 ml per MISC (respiratory F 360 days ZEVRX INSULIN retail); RX/OTC SYRINGE/0.5ML/30G X therapy supplies) 1/2" MISC (insulin F ADULT MASK MISC QL(1 ml per syringe/needle u-100) (respiratory therapy F 360 days retail); RX/OTC ZEVRX INSULIN RX/OTC supplies) SYRINGE/0.5ML/30G X AEROCHAMBER MINI RX/OTC 5/16" MISC (insulin F AEROSOLCHAMBER F syringe/needle u-100) DEVI (spacer/aerosol- ZEVRX INSULIN holding chambers) SYRINGE/1ML/30G X 1/2" AEROCHAMBER MV RX/OTC F MISC (insulin MISC (spacer/aerosol- F syringe/needle u-100) holding chambers)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

188 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AEROCHAMBER PLUS RX/OTC AEROCHAMBER/FLOWSI RX/OTC FLOW VU MISC GNAL MISC (spacer/aerosol-holding F (spacer/aerosol-holding F chambers) chambers) AEROCHAMBER PLUS RX/OTC AEROTRACH PLUS MISC QL(1 ml per FLOW-VU MISC ( 360 days F respiratory therapy F (spacer/aerosol-holding supplies) retail); RX/OTC chambers) AEROVENT PLUS RX/OTC AEROCHAMBER PLUS RX/OTC HOLDING FLOW-VU/LARGE MASK CHAMBER/COLLAPSIBLE F MISC (spacer/aerosol- F DEVI (spacer/aerosol- holding chambers) holding chambers) AEROCHAMBER PLUS RX/OTC AIRS PEDIATRIC QL(1 ml per FLOW-VU/MASK MISC AEROSOL MASK MISC 360 days (spacer/aerosol-holding F (respiratory therapy F retail); RX/OTC chambers) supplies) AEROCHAMBER PLUS RX/OTC AIRZONE PEAK FLOW QL(2 ea per FLOW-VU/MEDIUM MASK METER DEVI ( 365 days F peak flow F MISC (spacer/aerosol- meter) retail); RX/OTC holding chambers) ALL FLOW 1000 QL(1 ml per AEROCHAMBER PLUS RX/OTC PULMONARY FUNCTION 360 days FLOW-VU/SMALL MASK FILTER MISC F retail); RX/OTC MISC (spacer/aerosol- F (respiratory therapy holding chambers) supplies) AEROCHAMBER Z-STAT RX/OTC ARIAL CHAMBER DEVI RX/OTC PLUS VALVED HOLDING (spacer/aerosol-holding F CHAMBER W/FLOW VU F chambers) MISC (spacer/aerosol- ASSESS FULL RANGE QL(2 ea per holding chambers) PEAK FLOW METER DEVI F 365 days AEROCHAMBER Z-STAT RX/OTC (peak flow meter) retail); RX/OTC PLUS/FLOWSIGNAL MISC F ASSESS LOW RANGE QL(2 ea per (spacer/aerosol-holding PEAK FLOW METER DEVI F 365 days chambers) (peak flow meter) retail); RX/OTC AEROCHAMBER Z-STAT RX/OTC ASSESS PEAK FLOW QL(2 ea per PLUS/LARGE MASK MISC F METER FULL RANGE F 365 days (spacer/aerosol-holding DEVI (peak flow meter) retail); RX/OTC chambers) ASSESS PEAK FLOW QL(2 ea per AEROCHAMBER Z-STAT RX/OTC METER LOW RANGE F 365 days PLUS/MEDIUM MASK retail); RX/OTC F DEVI (peak flow meter) MISC (spacer/aerosol- ASTHMA CHECK METER- QL(2 ea per holding chambers) ZONE SYSTEM DEVI F 365 days AEROCHAMBER Z-STAT RX/OTC (peak flow meter) retail); RX/OTC PLUS/SMALL MASK MISC F ASTHMAMENTOR DEVI QL(2 ea per (spacer/aerosol-holding F 365 days chambers) (peak flow meter) retail); RX/OTC CA Health & Wellness Preferred Drug List Updated September 1, 2021

189 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREATHE EASE QL(1 ml per BREATHERITE RX/OTC NEBULIZER MASK/CHILD 360 days COLLAPSIBLESPACER MISC (respiratory F retail); RX/OTC W/ NEONATE MASK MISC F therapy supplies) (spacer/aerosol-holding BREATHE EASE QL(1 ml per chambers) NEBULIZER 360 days BREATHERITE MISC RX/OTC MASK/INFANT MISC F retail); RX/OTC (spacer/aerosol-holding F (respiratory therapy chambers) supplies) BREATHERITE RIGID RX/OTC BREATHE EASE PEAK QL(2 ea per SPACERW/MASK MISC FLOW METER DEVI F 365 days (spacer/aerosol-holding F (peak flow meter) retail); RX/OTC chambers) BREATHE EASE/LARGE RX/OTC BREATHERITE W/LARGE RX/OTC MASK DEVI MASK MISC F (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) BREATHE EASE/MEDIUM RX/OTC BREATHERITE RX/OTC MASK DEVI W/MEDIUM MASK MISC F (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) BREATHE EASE/SMALL RX/OTC BREATHERITE W/SMALL RX/OTC MASK DEVI MASK MISC F (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) BREATHERITE RX/OTC BUBBLES THE FISH II QL(1 ml per COLLAPSIBLEADULT PEDIATRIC MASK/PVC 360 days SPACER W/MASK MISC F MISC (respiratory F retail); RX/OTC (spacer/aerosol-holding therapy supplies) chambers) CARETOUCH 2 CPAP QL(1 ml per BREATHERITE RX/OTC HOSE HANGER MISC 360 days COLLAPSIBLECHILD (respiratory therapy F retail); RX/OTC SPACER W/MASK MISC F supplies) (spacer/aerosol-holding CARETOUCH CPAP & QL(1 ml per chambers) BIPAP HOSE/6FT MISC 360 days BREATHERITE RX/OTC (respiratory therapy F retail); RX/OTC COLLAPSIBLEINFANT supplies) SPACER W/MASK MISC F (spacer/aerosol-holding CARETOUCH CPAP QL(1 ml per MASK WIPES MISC 360 days chambers) (respiratory therapy F retail); RX/OTC BREATHERITE RX/OTC ) COLLAPSIBLESMALL supplies CHILD SPACER W/MASK F CARETOUCH CPAP QL(1 ml per MISC (spacer/aerosol- NEUTRALIZING PRE- 360 days F retail); RX/OTC holding chambers) WASH MISC (respiratory therapy supplies)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

190 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARETOUCH CPAP TUBE QL(1 ml per CO MONITOR QL(1 ml per CLEANING BRUSH MISC 360 days REPLACEMENT TPIECES 360 days (respiratory therapy F retail); RX/OTC MISC (respiratory F retail); RX/OTC supplies) therapy supplies) CARETOUCH UNIVERSAL QL(1 ml per COMPACT SPACE RX/OTC CPAPFILTERS MISC 360 days CHAMBER/ANTI-STATIC (respiratory therapy F retail); RX/OTC DEVI (spacer/aerosol- F supplies) holding chambers) CLEVER CHOICE ANTI- RX/OTC COMPACT SPACE RX/OTC STATICVALVED CHAMBER/ANTI- HOLDING STATIC/LARGE MASK F CHAMBER/ADULT LARGE F DEVI (spacer/aerosol- DEVI (spacer/aerosol- holding chambers) holding chambers) COMPACT SPACE RX/OTC CLEVER CHOICE ANTI- RX/OTC CHAMBER/ANTI- STATICVALVED STATIC/MEDIUM MASK F HOLDING DEVI ( F spacer/aerosol- CHAMBER/MEDIUM DEVI holding chambers) (spacer/aerosol-holding COMPACT SPACE RX/OTC chambers) CHAMBER/ANTI- CLEVER CHOICE ANTI- RX/OTC STATIC/SMALL MASK F STATICVALVED DEVI (spacer/aerosol- HOLDING holding chambers) CHAMBER/MEDIUM/3 F YEA DEVI EASIVENT MISC RX/OTC (spacer/aerosol-holding (spacer/aerosol-holding F chambers) chambers) CLEVER CHOICE ANTI- RX/OTC EASIVENT/MASK-LARGE RX/OTC STATICVALVED MISC (spacer/aerosol- F HOLDING holding chambers) F CHAMBER/SMALL DEVI EASIVENT/MASK- RX/OTC (spacer/aerosol-holding MEDIUM MISC chambers) (spacer/aerosol-holding F CLEVER CHOICE ANTI- RX/OTC chambers) STATICVALVED EASIVENT/MASK-SMALL RX/OTC HOLDING MISC (spacer/aerosol- F CHAMBER/SMALL F INFANT DEVI holding chambers) (spacer/aerosol-holding EASY FLOW 300 MM QL(1 ml per chambers) HOSE MISC (respiratory F 360 days retail); RX/OTC CLEVER CHOICE PEAK QL(2 ea per therapy supplies) FLOW METER DEVI F 365 days EASY FLOW 400 MM QL(1 ml per (peak flow meter) retail); RX/OTC HOSE MISC (respiratory F 360 days therapy supplies) retail); RX/OTC

CA Health & Wellness Preferred Drug List Updated September 1, 2021

191 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY FLOW AIR NOZZLE QL(1 ml per FLYP HYPERSONIQ QL(1 ml per MISC ( 360 days CARTRIDGE MISC 360 days respiratory F F therapy supplies) retail); RX/OTC (respiratory therapy retail); RX/OTC EASY FLOW HEPA QL(1 ml per supplies) FILTER MISC 360 days FULL KIT NEBULIZER QL(1 ml per (respiratory therapy F retail); RX/OTC SET MISC (respiratory F 360 days supplies) therapy supplies) retail); RX/OTC EBASE CONTROLLER KIT QL(1 ml per HUDSON RCI SEE-THRU QL(1 ml per MISC (respiratory F 360 days AEROSOL MASK 360 days therapy supplies) retail); RX/OTC ELONGATED/ADULT F retail); RX/OTC EFLOW SCF AEROSOL QL(1 ml per MISC (respiratory HEAD MISC (respiratory F 360 days therapy supplies) therapy supplies) retail); RX/OTC INNOSPIRE QL(1 ml per REPLACEMENT FILTER 360 days ELITE DC AUTO QL(1 ml per F retail); RX/OTC ADAPTER MISC 360 days MISC (respiratory (respiratory therapy F retail); RX/OTC therapy supplies) supplies) INSPIRACHAMBER/ANTI- RX/OTC STATIC EQ SPACE CHAMBER RX/OTC VALVED/MOUTHPIECE ANTI-STATIC DEVI F DEVI (spacer/aerosol- (spacer/aerosol-holding F holding chambers) chambers) INSPIRACHAMBER/LARG RX/OTC EQ SPACE CHAMBER RX/OTC ANTI-STATIC/LARGE E DEVI (spacer/aerosol- F MASK DEVI F holding chambers) (spacer/aerosol-holding INSPIRACHAMBER/SOOT RX/OTC chambers) HERMASK/INSPIRAMASK /MEDIUM DEVI EQ SPACE CHAMBER RX/OTC F ANTI-STATIC/MEDIUM (spacer/aerosol-holding MASK DEVI F chambers) (spacer/aerosol-holding INSPIRACHAMBER/SOOT RX/OTC chambers) HERMASK/INSPIRAMASK /SMALL DEVI EQ SPACE CHAMBER RX/OTC F ANTI-STATIC/SMALL (spacer/aerosol-holding MASK DEVI F chambers) (spacer/aerosol-holding INSPIREASE DRUG RX/OTC DELIVERYSYSTEM MISC chambers) F FILTER AIR PP MISC QL(1 ml per (spacer/aerosol-holding (respiratory therapy F 360 days chambers) supplies) retail); RX/OTC INSPIREASE RESERVOIR QL(3 ea per BAGS MISC 180 days retail) FLEXICHAMBER DEVI RX/OTC (spacer/aerosol-holding F (spacer/aerosol-holding F chamber supplies - chambers) bags)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

192 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITEAIRE DEVI RX/OTC MINI WRIGHT PEAK QL(2 ea per (spacer/aerosol-holding F FLOW METER DEVI F 365 days chambers) (peak flow meter) retail); RX/OTC LITETOUCH MASK QL(1 ml per MINI WRIGHT PEAK QL(2 ea per FLOW METER 365 days LARGE MISC 360 days F (respiratory therapy F retail); RX/OTC STANDARD RANGE DEVI retail); RX/OTC supplies) (peak flow meter) LITETOUCH MASK QL(1 ml per MINIELITE FILTER QL(1 ml per MEDIUM MISC 360 days REPLACEMENTS MISC 360 days F retail); RX/OTC (respiratory therapy F retail); RX/OTC (respiratory therapy supplies) supplies) LITETOUCH MASK QL(1 ml per MINIELITE QL(1 ml per SMALL MISC 360 days RECHARGEABLE 360 days BATTERY MISC retail); RX/OTC (respiratory therapy F retail); RX/OTC F supplies) (respiratory therapy supplies) LUNG PERFORMANCE QL(2 ea per PEAK FLOW METER DEVI F 365 days NEBULIZER AIR QL(1 ml per TUBE/PLUGS MISC 360 days (peak flow meter) retail); RX/OTC (respiratory therapy F retail); RX/OTC MICROCHAMBER DEVI RX/OTC supplies) (spacer/aerosol-holding F chambers) NEBULIZER PEDIATRIC QL(1 ml per MASK MISC (respiratory F 360 days MICROCHAMBER MISC RX/OTC therapy supplies) retail); RX/OTC (spacer/aerosol-holding F chambers) NOSE CLIP MISC QL(1 ml per (respiratory therapy F 360 days MICROELITE FILTER QL(1 ml per retail); RX/OTC REPLACEMENTS MISC 360 days supplies) (respiratory therapy F retail); RX/OTC OPTICHAMBER RX/OTC supplies) ADVANTAGE/LARGE MASK MISC F MICROELITE QL(1 ml per (spacer/aerosol-holding RECHARGEABLE 360 days chambers) BATTERY MISC F retail); RX/OTC (respiratory therapy OPTICHAMBER RX/OTC supplies) ADVANTAGE/MEDIUM FACE MASK MISC F MICROLIFE DIGITAL QL(2 ea per (spacer/aerosol-holding PEAK FLOW METER DEVI 365 days F chambers) (peak flow meter) retail); RX/OTC OPTICHAMBER RX/OTC MICROSPACER MISC RX/OTC ADVANTAGE/SMALL (spacer/aerosol-holding F FACE MASK MISC F chambers) (spacer/aerosol-holding MINI WRIGHT AFS PEAK QL(2 ea per chambers) FLOWMETER LOW 365 days F OPTICHAMBER RX/OTC RANGE DEVI (peak flow retail); RX/OTC DIAMOND MISC meter) (spacer/aerosol-holding F chambers)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

193 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTICHAMBER RX/OTC PARI BABY CONVERSION QL(1 ml per DIAMOND/LARGEFACE KITSIZE 2 MISC 360 days MASK DEVI F (respiratory therapy F retail); RX/OTC (spacer/aerosol-holding supplies) chambers) PARI BABY CONVERSION QL(1 ml per OPTICHAMBER RX/OTC KITSIZE 3 MISC 360 days DIAMOND/MEDIUM FACE (respiratory therapy F retail); RX/OTC MASK MISC F supplies) (spacer/aerosol-holding PARI ERAPID NEBULIZER QL(1 ml per chambers) HANDSET MISC 360 days OPTICHAMBER RX/OTC (respiratory therapy F retail); RX/OTC DIAMOND/SMALLFACE supplies) MASK MISC F PARI EXPIRATORY QL(1 ml per (spacer/aerosol-holding FILTER VALVE SET DEVI 360 days chambers) (respiratory therapy F retail); RX/OTC OPTICHAMBER FACE RX/OTC supplies) MASK/LARGE MISC PARI MASK SET MISC QL(1 ml per (spacer/aerosol-holding F (respiratory therapy F 360 days chambers) supplies) retail); RX/OTC OPTICHAMBER FACE RX/OTC MASK/MEDIUM MISC PARI SOFT PLASTIC QL(1 ml per ADULT MASK MISC 360 days (spacer/aerosol-holding F (respiratory therapy F retail); RX/OTC chambers) supplies) OPTICHAMBER FACE RX/OTC MASK/SMALL MISC PARI SOFT PLASTIC QL(1 ml per PEDIATRIC MASK MISC 360 days (spacer/aerosol-holding F (respiratory therapy F retail); RX/OTC chambers) supplies) OPTIHALER MDI DRUG RX/OTC DELIVERY SYSTEM DEVI PARI VORTEX ADULT QL(1 ml per F MASK MISC (respiratory F 360 days (spacer/aerosol-holding retail); RX/OTC chambers) therapy supplies) OPTIHALER MISC RX/OTC PEAK A-I-R FLOW METER QL(2 ea per F 365 days (spacer/aerosol-holding F DEVI (peak flow meter) retail); RX/OTC chambers) PEAK AIR PEAK FLOW QL(2 ea per PARI ALTERA QL(1 ml per METERADULT/PEDIATRI 365 days NEBULIZER HANDSET 360 days C DEVI (peak flow F retail); RX/OTC F retail); RX/OTC MISC (respiratory meter) therapy supplies) PEDIATRIC QL(1 ml per PARI BABY CONVERSION QL(1 ml per MOUTHPIECE/DISPOSAB 360 days KITSIZE 1 MISC 360 days LE MISC (respiratory F retail); RX/OTC F retail); RX/OTC (respiratory therapy therapy supplies) supplies) PERSONAL BEST FULL QL(2 ea per RANGE DEVI (peak flow F 365 days meter) retail); RX/OTC

CA Health & Wellness Preferred Drug List Updated September 1, 2021

194 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PERSONAL BEST LOW QL(2 ea per PRO COMFORT INHALER RX/OTC RANGE DEVI (peak flow F 365 days SPACER CHAMBER meter) retail); RX/OTC ADULT MISC F PFLEX MISC QL(1 ml per (spacer/aerosol-holding (respiratory therapy F 360 days chambers) supplies) retail); RX/OTC PRO COMFORT INHALER RX/OTC SPACER CHAMBER PHARMACIST CHOICE QL(1 ml per CHILD MISC NEBULIZER/CPAP/INHAL 360 days F ER CHAMBER MASK retail); RX/OTC (spacer/aerosol-holding WIPES MISC F chambers) (respiratory therapy PRO COMFORT INHALER RX/OTC supplies) SPACER CHAMBER INFANT DEVI F PIKO 1 ELECTRONIC QL(2 ea per F 365 days (spacer/aerosol-holding DEVI (peak flow meter) retail); RX/OTC chambers) PILLOW MASK/ADULT QL(1 ml per PROCARE SPACER RX/OTC MISC (respiratory F 360 days CHAMBER W/ADULT MASK DEVI therapy supplies) retail); RX/OTC F (spacer/aerosol-holding PILLOW MASK/CHILD QL(1 ml per chambers) MISC (respiratory F 360 days retail); RX/OTC PROCARE SPACER RX/OTC therapy supplies) CHAMBER W/CHILD PILLOW QL(1 ml per MASK DEVI F MASK/PEDIATRIC MISC 360 days F (spacer/aerosol-holding (respiratory therapy retail); RX/OTC chambers) supplies) PRONEB ULTRA FILTER QL(1 ml per POCKET CHAMBER DEVI RX/OTC SET MISC (respiratory F 360 days (spacer/aerosol-holding F therapy supplies) retail); RX/OTC chambers) PURE COMFORT PEAK QL(2 ea per POCKET PEAK FLOW QL(2 ea per FLOW METER ADULT F 365 days METER DEVI (peak flow F 365 days DEVI (peak flow meter) retail); RX/OTC retail); RX/OTC meter) PURE COMFORT PEAK QL(2 ea per POCKET SPACER DEVI RX/OTC FLOW METER CHILD F 365 days (spacer/aerosol-holding F DEVI (peak flow meter) retail); RX/OTC chambers) REPLACEMENT AIR QL(1 ml per FILTER MISC 360 days POCKETPEAK PEAK QL(2 ea per F FLOW METER LOW 365 days (respiratory therapy retail); RX/OTC RANGE DEVI (peak flow F retail); RX/OTC supplies) meter) REPLACEMENT FILTERS QL(1 ml per POCKETPEAK PEAK QL(2 ea per MISC (respiratory F 360 days FLOW 365 days therapy supplies) retail); RX/OTC METER/UNIVERSAL F retail); RX/OTC RITEFLO DEVI RX/OTC RANGE 50-720 LPM DEVI (spacer/aerosol-holding F (peak flow meter) chambers)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

195 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAMI THE SEAL QL(1 ml per SOOTHENEB NBL 100 QL(1 ml per REPLACEMENTFILTERS 360 days CHILD MASK MISC 360 days MISC (respiratory F retail); RX/OTC (respiratory therapy F retail); RX/OTC therapy supplies) supplies) SIDESTREAM ADULT QL(1 ml per SOOTHENEB NBL 100 QL(1 ml per FACE MASK MISC 360 days MEDICATION CUP MISC 360 days (respiratory therapy F retail); RX/OTC (respiratory therapy F retail); RX/OTC supplies) supplies) SIDESTREAM PEDIATRIC QL(1 ml per SOOTHENEB NBL 100 QL(1 ml per FACEMASK MISC 360 days MESH CAP MISC 360 days (respiratory therapy F retail); RX/OTC (respiratory therapy F retail); RX/OTC supplies) supplies) SIDESTREAM PEDIATRIC QL(1 ml per SOOTHENEB NBL100 QL(1 ml per FACEMASK/SAMI THE 360 days ADULT MASK MISC 360 days SEAL MISC (respiratory F retail); RX/OTC (respiratory therapy F retail); RX/OTC therapy supplies) supplies) SIDESTREAM PEDIATRIC QL(1 ml per THRESHOLD IMT MISC QL(1 ml per FACEMASK/TUCKER THE 360 days (respiratory therapy F 360 days TURTLE MISC F retail); RX/OTC supplies) retail); RX/OTC (respiratory therapy TRUZONE PEAK FLOW QL(2 ea per supplies) METER DEVI (peak flow F 365 days SIDESTREAM PLUS QL(1 ml per meter) retail); RX/OTC ADULT FACE MASK MISC 360 days TUBING/WING TIP MISC QL(1 ml per (respiratory therapy F retail); RX/OTC (respiratory therapy F 360 days supplies) supplies) retail); RX/OTC SILICONE MASK FOR QL(1 ml per BREATHERITE 360 days VALVED HOLDING RX/OTC CHAMBER DEVI CHAMBER/ADULT MISC F retail); RX/OTC F (respiratory therapy (spacer/aerosol-holding supplies) chambers) SILICONE MASK FOR QL(1 ml per VORTEX VALVED RX/OTC HOLDING CHAMBER BREATHERITE 360 days F CHAMBER/INFANT MISC F retail); RX/OTC DEVI (spacer/aerosol- (respiratory therapy holding chambers) supplies) WATCHHALER DEVI RX/OTC SILICONE MASK FOR QL(1 ml per (spacer/aerosol-holding F BREATHERITE 360 days chambers) CHAMBER/PEDIATRIC F retail); RX/OTC WINDMILL TRAINER QL(1 ml per MISC (respiratory MISC (respiratory F 360 days therapy supplies) therapy supplies) retail); RX/OTC SILICONE MASK FOR QL(1 ml per BREATHRITE 360 days MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches CHAMBER/ADULT MISC F retail); RX/OTC (respiratory therapy Calcitonin Gene-Related Peptide (CGRP) supplies)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

196 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AIMOVIG SOAJ PA; SP- Limit 2 per 7 F (erenumab-aooe) AcariaHealth sumatriptan succinate days;QL(0.29 F ml daily); AL(At Migraine Combinations soaj sc 4 mg/0.5ml least 12 yrs (Ergotamine W/ Caffeine) F old) MIGERGOT SUPP QL(2 ml per 7 sumatriptan succinate days retail); ergotamine w/ caffeine F F tabs soaj sc 6 mg/0.5ml AL(At least 12 yrs old) Migraine Products Limit 2 per 7 AL(At least 18 dihydroergotamine sumatriptan succinate days;QL(0.29 yrs old) F ml daily); AL(At mesylate soln ij 1 F soct sc 4 mg/0.5ml mg/ml least 12 yrs old) dihydroergotamine AL(At least 18 QL(2 ml per 7 mesylate soln na 4 F yrs old) sumatriptan succinate F days retail); mg/ml soct sc 6 mg/0.5ml AL(At least 12 ERGOMAR SUBL yrs old) F (ergotamine tartrate) QL(2.5 ml per MIGRANAL SOLN AL(At least 18 sumatriptan succinate F 30 days retail); (dihydroergotamine F yrs old) soln sc 6 mg/0.5ml AL(At least 12 yrs old) mesylate) QL(2 ml per 7 Serotonin Agonists sumatriptan succinate F days retail); QL(6 ea per 30 sosy sc 6 mg/0.5ml AL(At least 12 yrs old) almotriptan malate tabs F days retail); AL(At least 12 QL(9 ea per 30 yrs old) sumatriptan succinate tabs or 100 mg, 25 mg, F days retail); QL(6 ea per 30 AL(At least 12 50 mg yrs old) eletriptan hydrobromide F days retail); tabs AL(At least 18 QL(12 ea per yrs old) zolmitriptan soln na 5 F 30 days retail); QL(9 ea per 30 mg AL(At least 12 yrs old) naratriptan hcl tabs F days retail); AL(At least 18 QL(12 ea per yrs old) zolmitriptan tabs or 2.5 F 30 days retail); QL(12 ea per mg AL(At least 18 yrs old) rizatriptan benzoate F 30 days retail); tabs 10 mg, 5 mg AL(At least 6 QL(6 ea per 30 yrs old) zolmitriptan tabs or 5 F days retail); rizatriptan benzoate QL(0.4 ea mg AL(At least 18 F daily); AL(At yrs old) tbdp 10 mg, 5 mg least 6 yrs old) QL(12 ea per zolmitriptan tbdp or 2.5 30 days retail); F QL(6 ea per 30 F sumatriptan soln days retail) mg AL(At least 18 yrs old)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

197 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6 ea per 30 (Calcium Carbonate- zolmitriptan tbdp or 5 F days retail); Cholecalciferol) F mg AL(At least 18 CALCIUM+D3 TABS 15 yrs old) MCG-500 MG (Calcium Carbonate- MINERALS & ELECTROLYTES Cholecalciferol) Calcium CALCIUM/VITAMIN D-3, F OYSTER SHELL (Calcium Carbonate) CALCIUM 500+D CHEW CALCIUM 600 HIGH (Calcium Carbonate- POTENCY, CVS CALCIUM F CARBONATE, HIGH Cholecalciferol) KP F POTENCY CALCIUM CALCIUM 600+D3, LIQUID TABS CALCIUM/D3 CAPS (Calcium Carbonate) (Calcium Carbonate- CALCIUM 600 TABS 600 F Vitamin D) CALCIUM 500 + MG D, CALCIUM 500/D, CALCIUM 500/VITAMIN D, (Calcium Carbonate- CALCIUM 600+D HIGH Cholecalciferol) CALCIUM POTENCY, CALCIUM 500 + D, CALCIUM 500 HIGH POTENCY + +D3, CALCIUM EXTRA VITAMIN D, OYSTER D3, EQ CALCIUM 500+D, SHELL CALCIUM 500+ D, GNP CALCIUM 500 +D3, PX CALCIUM&D, RA F OS-CAL CALCIUM + D3, CALCIUM PLUS VITAMIN OS-CAL EXTRA D3, F D, RA HI CAL, SB OYSCO 500+D, OYSTER CALCIUM + D, SM CALCIUM/D3, OYSTER CALCIUM 600/VITAMIN D, SHELL CALCIUM SUPER CALCIUM 600 + PLUSVITAMIN D, D3, SUPER CALCIUM OYSTER SHELL 600+D 400, SUPER CALCIUM+D, SM CALCIUM 600+D3 400 CALCIUM /VITAMIN D TABS TABS (Calcium Carbonate- (Calcium Carbonate- Vitamin D) CALCIUM F Cholecalciferol) CALCIUM 500+D TABS 200 UNIT- 500+D, HM F 500 MG, 500 MG-200 UNIT CALCIUM/VITAMIN D, SM CALCIUM/VITAMIN D (Calcium Carbonate- TABS 200 UNIT-500 MG Vitamin D) CALCIUM 600 + F D, CALCIUM 600+D3 (Calcium Carbonate- TABS 400 UNIT-600 MG Cholecalciferol) CALCIUM F PLUS VITAMIN D TABS 5 (Calcium Carbonate- MCG-500 MG Vitamin D) CALCIUM F 600+D TABS 200 UNIT- (Calcium Carbonate- 600 MG, 400 UNIT-600 MG Cholecalciferol) CALCIUM PLUS VITAMIN D3, KP F (Calcium Citrate) F CALCIUM 600+D CAPS CALCITRATE TABS 500 UNIT-600 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

198 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Calcium Citrate-Vitamin D) calcium carbonate- CALCITRATE PLUS D, vitamin d tabs 125 unit- CALCIUM CITRATE + D, 250 mg, 125 unit-500 CALCIUM CITRATE+ D, F RA CALCIUM CITRATE mg, 200 unit-500 mg, F PLUS VITAMIN D, SM 200 unit-600 mg, 400 CALCIUM CITRATE + D unit-600 mg, 500 mg- TABS 200 unit, 600 mg-200 (Calcium Citrate-Vitamin D) unit CALCIUM CITRATE + D3 F CALCIUM CHEW 100 TABS 200 UNIT-250 MG UNIT-500 MG (calcium (Calcium Citrate-Vitamin D) carbonate- F CALCIUM CITRATE + F TABS 200 UNIT-315 MG cholecalciferol) CALCIUM CHEW 500 MG (Calcium Citrate-Vitamin D) F CALCIUM CITRATE/D3 F (calcium carbonate) TABS 5 MCG-315 MG CALCIUM CITRATE MALATE/VITAMIN D TABS (Oyster Shell) OYSCO 500, F OYSTERCAL, RA (calcium citrate malate- OYSTER SHELL F cholecalciferol) CALCIUM, SB OYSTER SHELL CALCIUM TABS calcium citrate tabs 200 F mg CALCIUM CARBONATE CHEW 500 MG (calcium F calcium citrate-vitamin carbonate) d tabs 200 unit-315 mg, F calcium carbonate tabs 5 mcg-315 mg 1250 mg, 500 mg, 600 F CALCIUM LACTATE TABS mg 648 MG, 750 MG (calcium F lactate) calcium carbonate- cholecalciferol caps F CALCIUM TABS 200 UNIT- 500 unit-600 mg 600 MG (calcium w/ F vitamin d) calcium carbonate- CALCIUM/VITAMIN D cholecalciferol chew 10 F CAPS (calcium mcg-500 mg, 100 unit- carbonate- F 500 mg cholecalciferol) calcium carbonate- CHEWABLE CALCIUM/D3 cholecalciferol tabs 200 F WAFR (calcium unit-500 mg, 5 mcg- carbonate- F 500 mg cholecalciferol) EQL CALCIUM/VITAMIN D CAPS 100 UNIT-600 MG (calcium carbonate- F cholecalciferol) oyster shell tabs F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

199 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PARVA-CAL TABS (Oral Electrolytes) F (calcium-ergocalciferol) ADVANTAGE CARE ORAL QC CALCIUM 500MG/D3 ELECTROLYTE PEDIATRIC, CERALYTE TABS (calcium- F 70, CVS ELECTROLYTE cholecalciferol) SOLUTION, CVS RA OYSTER SHELL PEDIATRIC CALCIUM/VITAMIN D ELECTROLYTE, CVS TABS (calcium F PEDIATRIC carbonate- ELECTROLYTE FREEZER POPS, GNP PEDIATRIC ergocalciferol) ELECTROLYTE, H-E-B RISACAL-D TABS ORAL ELECTROLYTE (calcium & phosphorus F SOLUTION, HM w/ vitamin d) PEDIATRIC ELECTROLYTE, ORAL Electrolyte Mixtures ELECTROLYTE SOLUTIONFREEZER POPS PEDIATRIC, F ORALYTE, ORALYTE FREEZER POPS, PEDIA VANCE, PEDIATRIC ELECTROLYTE, PEDIATRIC ELECTROLYTE FREEZE POPS, PEDIATRIC ELECTROLYTE FREEZER POPS, PEDIATRIC ELECTROLYTE/WITH ZINC, PEDIATRIC ELECTROLYTE/ZINC, RA PEDIATRIC ELECTROLYTE, REHYDRALYTE, SB PEDIATRIC ELECTROLYTE, SM PEDIATRIC ELECTROLYTE SOLN BIOLYTE SOLN ( oral F electrolytes) CERALYTE 70 SOLN F (oral electrolytes) CERASPORT EX1 SOLN F (oral electrolytes) CERASPORT SOLN 4 MEQ/L-6 MEQ/L-18 MEQ/L-20 MEQ/L (oral F electrolytes)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

200 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEXTROSE PA ISOLYTE-S PH 7.4 SOLN PA F 5%/ELECTROLYTE #48 (electrolyte-s (ph 7.4)) VIAFLEX SOLN F ISOLYTE-S SOLN PA F (electrolyte-48 in (electrolyte-s) dextrose) KCL 0.15%/D5W/NACL PA DEXTROSE 10%/NACL PA 0.225% SOLN 0.2% SOLN (dextrose w/ F (potassium chloride in F sodium chloride) dextrose & sodium DEXTROSE 5%/NACL PA chloride) 0.3% SOLN (dextrose w/ F KCL 0.3%/D5W/NACL PA sodium chloride) 0.9% SOLN (potassium dextrose w/ sodium PA chloride in dextrose & F chloride soln 0.2 %-5 sodium chloride) %, 0.225 %-5 %, 0.33 KINDERLYTE PREMAX F F %-5 %, 0.45 %-10 %, SOLN (oral electrolytes) 0.45 %-2.5 %, 0.45 %- KINDERLYTE SOLN ( oral F 5 %, 0.9 %-5 % electrolytes) DEXTROSE/SODIUM PA PA CHLORIDE SOLN lactated ringer's soln 20 (dextrose w/ sodium F mg/100ml-30 chloride) mg/100ml-310 mg/100ml-600 ENFAMIL ENFALYTE F mg/100ml, 3 meq/l-130 F SOLN (oral electrolytes) meq/l-4 meq/l-28 meq/l- HYDRALYTE FREEZER 109 meq/l, 3 meq/l-4 POPS SOLN (oral F meq/l-28 meq/l-109 electrolytes) meq/l-130 meq/l HYDRALYTE SOLN 16 NORMOSOL -R SOLN PA GM/L-20 MEQ/L-45 F MEQ/L-45 MEQ/L-90 (electrolyte-r) MEQ/L, 210 MG/250ML- F NORMOSOL-M IN D5W PA 270 MG/250ML (oral SOLN (electrolyte-m in F electrolytes) dextrose) IONOSOL-MB/DEXTROSE PA NORMOSOL-M/D5W PA 5% SOLN 3 MEQ/L-3 SOLN (electrolyte-m in F MEQ/L-5 %-20 MEQ/L-22 dextrose) MEQ/L-23 MEQ/L-25 NORMOSOL-R SOLN PA MEQ/L, 3 MEQ/L-3 F F MMOLE/L-5 %-20 MEQ/L- (electrolyte-r (ph 7.4)) 22 MEQ/L-23 MEQ/L-25 oral electrolytes soln F MEQ/L (electrolyte-mb PLASMA-LYTE A SOLN PA in dextrose) F ISOLYTE-P/DEXTROSE PA (electrolyte-a) PLASMA-LYTE-148 SOLN PA 5% SOLN (electrolyte-p F F in dextrose) (electrolyte-148)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

201 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride in PA MONOCAL TABS F (sodium dextrose & sodium F chloride soln monofluorophosphate- PA calcium carbonate) potassium chloride in F dextrose soln sodium fluoride chew potassium chloride in PA 0.25 mg, 0.5 mg, 1 mg, F nacl soln 0.15 %-0.9 %, 2.2 mg RX/OTC 0.45 %-20 meq/l, 0.9 F sodium fluoride soln 0.5 F %-20 meq/l, 0.9 %-40 mg/ml meq/l sodium fluoride tabs F POTASSIUM PA 0.5 mg, 1 mg CHLORIDE/DEXTROSE Magnesium SOLN (potassium F (Magnesium Chloride) F chloride in dextrose) MAGDELAY TBEC POTASSIUM PA MAGNESIUM CAPS 400 CHLORIDE/DEXTROSE/L ACTATED RINGERS MG (magnesium oxide F SOLN (potassium F (mg supplement)) chloride in d5w lactated magnesium chloride F ringers) tbec or 64 mg POTASSIUM PA MAGNESIUM EXTRA CHLORIDE/LIDOCAINE STRENGTH CAPS HYDROCHLORIDE/SODIU (magnesium oxide (mg F M CHLORIDE SOLN F supplement)) (potassium chloride- magnesium oxide (mg lidocaine-sodium supplement) tabs 400 F chloride) mg POTASSIUM PA MAGNESIUM OXIDE CHLORIDE/SODIUM CAPS 400 MG CHLORIDE SOLN F (magnesium oxide (mg F (potassium chloride in supplement)) nacl) POTASSIUM PA Phosphate CHLORIDE/SODIUMCHLO (Pot Phosphate Monobasic RIDE SOLN (potassium F W/ Sod Phosphate Dibasic chloride in nacl) & Monobasic) PHOSPHA 250 NEUTRAL, F ringer's soln F PA PHOSPHO-TRIN 250 NEUTRAL, VIRT-PHOS Fluoride 250 NEUTRAL TABS (Sodium Fluoride) K-PHOS TABS FLUORITAB, FLURA- F (potassium phosphate F DROPS, NAFRINSE monobasic) DROPS SOLN (Sodium Fluoride) F NAFRINSE CHEW CA Health & Wellness Preferred Drug List Updated September 1, 2021

202 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pot phosphate POTASSIUM CHLORIDE PA SOLN IV 0.4 MEQ/ML, 10 monobasic w/ sod F phosphate dibasic & MEQ/100ML, 10 MEQ/50ML, 20 monobasic tabs MEQ/100ML, 20 F Potassium MEQ/50ML, 40 MEQ/100ML (potassium (Potassium Bicarbonate) F EFFER-K TBEF 25 MEQ chloride) (Potassium Bicarbonate) K- potassium chloride soln PA PRIME, KLOR-CON/EF F iv 10 meq/50ml, 2 F TBEF meq/ml, 20 meq/50ml, (Potassium Chloride 40 meq/100ml Microencapsulated Crystals Er) KLOR-CON F potassium chloride soln F M10, KLOR-CON M15, or 10 %, 20 % KLOR-CON M20 TBCR potassium chloride tbcr F (Potassium Chloride) or 10 meq, 8 meq KLOR-CON 10, KLOR- F CON 8 TBCR Sodium LIQUIVIDA HYDRATION PA (Potassium Chloride) F KLOR-CON PACK KIT KIT (sodium F (Potassium Chloride) chloride) KLOR-CON SPRINKLE F PA sodium chloride soln ij F CPCR 10 MEQ 0.9 %, 2.5 meq/ml (Potassium Chloride) QL(1 ea daily) PA KLOR-CON SPRINKLE F sodium chloride soln iv CPCR 8 MEQ 0.45 %, 0.9 %, 3 %, 4 F K-TAB TBCR 8 MEQ meq/ml, 5 % F (potassium chloride) Zinc (Zinc Sulfate) ORAZINC, potassium chloride cpcr F F or 10 meq ZINC-220 CAPS QL(1 ea daily) zinc sulfate caps or 220 potassium chloride cpcr F F or 8 meq mg potassium chloride MISCELLANEOUS THERAPEUTIC CLASSES microencapsulated F crystals er tbcr 10 meq, Chelating Agents 20 meq penicillamine tabs F potassium chloride F Enzymes pack or 20 meq XIAFLEX SOLR PA; SP (collagenase clostridium F histolyticum) Immunomodulators

CA Health & Wellness Preferred Drug List Updated September 1, 2021

203 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REVLIMID CAPS PA; SP- F tacrolimus caps F (lenalidomide) Caremark;SP Immunosuppressive Agents Potassium Removing Agents (Cyclosporine Modified (Sodium Polystyrene (For Microemulsion)) F Sulfonate) KIONEX, SPS F GENGRAF CAPS SUSP (Cyclosporine Modified sodium polystyrene F (For Microemulsion)) F sulfonate powd GENGRAF SOLN sodium polystyrene AZASAN TABS F F sulfonate susp (azathioprine) Systemic Lupus Erythematosus Agents azathioprine tabs or 50 F BENLYSTA SOLR IV 120 PA; SP- mg MG, 400 MG F AcariaHealth;S cyclosporine caps F (belimumab) P cyclosporine modified MOUTH/THROAT/DENTAL AGENTS (for microemulsion) F Anesthetics Topical Oral caps FIRST-MOUTHWASH BLM cyclosporine modified SUSP (for microemulsion) F (diphenhydramine- soln lidocaine-alum F everolimus AL(At least 21 hydroxide-mg (immunosuppressant) F yrs old) hydroxide-simeth) tabs lidocaine hcl (mouth- F throat) soln 2 % mycophenolate mofetil F caps or 250 mg Anti-infectives - Throat mycophenolate mofetil F clotrimazole troc F susr or 200 mg/ml nystatin (mouth-throat) mycophenolate mofetil F F tabs or 500 mg susp Antiseptics - Mouth/Throat mycophenolate sodium F tbec (Chlorhexidine Gluconate PROGRAF PACK 0.2 MG, PA (Mouth-Throat)) PAROEX, F F PERIOGARD SOLN 1 MG (tacrolimus) chlorhexidine gluconate SANDIMMUNE CAPS 100 F MG, 25 MG F (mouth-throat) soln (cyclosporine) Dental Products SANDIMMUNE SOLN 100 (Sodium Fluoride (Dental)) QL(112 ml per F MG/ML (cyclosporine) CAVAREST, DENTAGEL, F fill retail) SF GEL sirolimus soln F sirolimus tabs F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

204 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Sodium Fluoride (Dental)) QL(102 gm per MOUTH KOTE SOLN QL(900 ml per DENTA 5000 PLUS, SF fill retail) F fill retail); (artificial saliva) 5000 PLUS, SODIUM F RX/OTC FLUORIDE 5000 PLUS, NUMOISYN LIQD QL(900 ml per SODIUM FLUORIDE 5000 F fill retail); PPM CREA (artificial saliva) RX/OTC (Stannous Fluoride) RX/OTC ORAL RELIEF SPRAY QL(900 ml per FLUORIDEX DAILY F FOR DRYMOUTH & fill retail); RENEWAL, PERIOMED DISCOMFORT SOLN F RX/OTC CONC (artificial saliva) sodium fluoride (dental) QL(102 gm per F fill retail) pilocarpine hcl (oral) F crea dt 1.1 % tabs sodium fluoride (dental) QL(112 ml per F RA DRY MOUTH SOLN QL(900 ml per gel dt 1.1 % fill retail) F fill retail); (artificial saliva) RX/OTC sodium fluoride (dental) F soln mt 0.2 % XEROSTOMIA RELIEF QL(900 ml per SPRAY SOLN (artificial F fill retail); Steroids - Mouth/Throat/Dental saliva) RX/OTC (Triamcinolone Acetonide (Mouth)) ORALONE F MULTIVITAMINS DENTAL PASTE PSTE B-Complex Vitamins triamcinolone F acetonide (mouth) pste (B-Complex Vitamins) RA B-COMPLEX, RA B- F Throat Products - Misc. COMPLEX WITH B-12 AQUORAL SOLN QL(900 ml per TABS F fill retail); (artificial saliva) b-complex vitamins F RX/OTC caps BIOTENE DRY MOUTH QL(900 ml per MOISTURIZING SPRAY F fill retail); b-complex vitamins F SOLN (artificial saliva) RX/OTC tabs B-Complex w/ C CAPHOSOL SOLN QL(900 ml per F fill retail); (artificial saliva) (B Complex W/ C) SUPER RX/OTC B WITH C, VITAMIN B F COMPLEX-C CAPS CVS DRY MOUTH SPRAY QL(900 ml per F fill retail); SOLN (artificial saliva) RX/OTC b complex w/ c caps F EQL DRY MOUTH ORAL QL(900 ml per B-Complex w/ Folic Acid RINSE SOLN (artificial F fill retail); (B-Complex W/ C & Folic QL(1 ea daily); saliva) RX/OTC Acid) ACTIVITE, DAVITE, RX/OTC DIALYVITE, FOLIKA-NC, MOI-STIR SOLN QL(900 ml per F fill retail); FOLIKA-T, GENICIN VITA- (artificial saliva) RX/OTC S, LORID, NEPHRONEX, F RENA-VITE RX, MOUTH KOTE REMINT QL(900 ml per F fill retail); TRONVITE, VITASURE, SOLN (artificial saliva) RX/OTC VOL-CARE RX, VP-VITE RX, XVITE TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

205 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (B-Complex W/ C & Folic RX/OTC multiple vitamins w/ F Acid) MYNEPHROCAPS, iron tabs MYNEPHRON, RENAL F CAPS, RENO CAPS, TAB-A-VITE TRIPHROCAPS, VIRT- MULTIVITAMIN/IRON AND CAPS CAPS BETA-CAROTENE TABS F (multiple vitamins w/ Multiple Vitamins w/ Iron iron) (Multiple Vitamins W/ Iron) DAILY MULTIPLE Multiple Vitamins w/ Minerals VITAMINS W/IRON, DAILY VITAMIN FORMULA+IRON, DAILY VITE MULTIVITAMIN/IRON, DAILY-VITAMIN/IRON, DAILY-VITE/IRON/BETA- CAROTENE, GNP ONE DAILY PLUS IRON, HM ONE DAILY/IRON, MULTI VITAMIN WITH IRON, MULTI-DAYPLUS IRON, MULTI-VITAMINS/IRON, MULTIVITAMIN PLUS IRON ADULT, NAT-RUL F DAILY-VITE + IRON, ONCE DAILY/IRON, ONE DAILY MULTIVITAMIN/IRON, ONE DAILY MULTIVITAMIN/IRON ADULT, ONE-DAILY MULTI-VITAMIN/IRON, ONE-DAILY/IRON, QC DAILY MULTIVITAMINS/IRON, SM MULTIPLE VITAMINS/IRON, STRESS B COMPLEX/IRON, TAB- A-VITE MULTIVITAMIN/IRON, TAB-A-VITE/IRON TABS (Multiple Vitamins W/ Iron) STRESS FORMULA/IRON TABS 5 MG-10 MG-10 MG-12 MCG-18 MG-20 MG-30 UNIT-45 MCG-100 F MG-400 MCG-500 MG, 5 MG-10 MG-12 MCG-15 MG-20 MG-27 MG-30 UNIT-45 MCG-100 MG- 400 MCG-500 MG CA Health & Wellness Preferred Drug List Updated September 1, 2021

206 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamins W/ QL(1 ea daily); SPECTRAVITE Minerals) A THRU Z RX/OTC ADVANCEDFORMULA, ADVANCED, A THRU Z CVS SPECTRAVITE MEN, ADVANCED ADULT CVS SPECTRAVITE MEN FORMULA, A THRU Z 50+, CVS SPECTRAVITE HIGH POTENCY, A THRU SENIOR, CVS Z SELECT, A THRU Z SPECTRAVITE ULTRA SELECT 50+ ADVANCED HEALTH MENS, CVS FORMULA, A THRU Z SPECTRAVITE ULTRA SELECT 50+ MENS, A WOMENS HEALTH THRU Z SELECT SENIOR, CVS ADVANCED, A THRU Z SPECTRAVITE WOMEN SELECT 50+, CVS WOMENS ULTIMATEWOMENS, A ACTIVE DAILY, DAILY THRU Z ULTIMATE BETIC, DAILY COMBO MENS, ABC PLUS, ABC MULTI VITAMIN, DAILY PLUS SENIOR, ABC PLUS MENS HEALTH SENIOR ADULTS 50+, FORMULA, DAILY MULTI, ANTIOXIDANT DAILY MULTI 50+, DAILY PROTECTION FORMULA, MULTIPLE ANTIOXIDANT VITAMINS, VITAMINS/MINERALS, B-PLEX PLUS, BIOCEL, DAILY VITAMIN BIOTIN FORMULA+MINERALS, PLUS/CALCIUM/VIT D3, DAILY WOMENS HEALTH CARRAVITE, CENTAVITE FORMULA, DAILY- A-Z COMPLETE F VITAMIN MAXIMUM MULTIVITAMIN/MINERAL FORMULA, DIABETES S, CENTRAVITES, HEALTH FORMULA, CENTURY, CENTURY DIALYVITE 800/ULTRA D, MATURE, CEROVITE DOCTORS CHOICE ADVANCED FORMULA, MULTIVITAMINS MEN, EQ CEROVITE SENIOR, COMPLETE CERTA PLUS, MULTIVITAMINADULTS COMPANION, COMPETE, 50+, EQ ONE DAILY COMPLETE, COMPLETE WOMENS PRO-ACTIVE, DAILY WITH LUTEIN, EQL CENTURY, EQL COMPLETE ENERGY, CENTURY MATURE, EQL COMPLETE SENIOR, CENTURY MATURE MEN COMPLETE WOMENS, 50+, EQL CENTURY CORVITE FREE, CVS MATURE WOMEN50+, DAILY MULTIPLE FOR EQL ONE DAILY MENS MEN, CVS DAILY 50+ ADVANCED, EQL MULTIPLE FOR WOMEN, ONE DAILY MENS CVS DAILY MULTIPLE HEALTH FORMULA, EQL FOR WOMEN 50+, CVS ONE DAILY WOMENS EYE HEALTH & LUTEIN, 50+ADVANCED, EQL CVS ONE DAILY VISION FORMULA, ESSENTIAL, CVS ONE ESSENTIA, ESSENTIAL DAILY MENS HEALTH BALANCE, EYE-VITES, FORMULA, CVS ONE EYEPROTECT, GERIVITE DAILY WOMENS COMPLETE, GNP FORMULA, CVS CENTURY, GNP CA Health & Wellness Preferred Drug List Updated September 1, 2021

207 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTURY ADULT DAILY, I-VITE, I-VITE FORMULA, GNP PROTECT, ICAPS MV, KP CENTURY ADULTS 50+ ADULTS 50+ DAILY SENIOR, GNP CENTURY FORMULA, KP ADULTS CARDIO DAILY FORMULA, KP HEALTHFORMULA, GNP MENS 50+ DAILY CENTURY MATURE FORMULA, KP MENS FORMULA/WOMEN'S 50+, DAILY FORMULA, KP GNP CENTURY VISION FORMULA, KP ULTIMATE MENS VISION FORMULA COMPLETE, GNP W/LUTEIN, KP WOMENS CENTURY ULTIMATE 50+ DAILY FORMULA, KP MENS SENIOR WOMENS DAILY FORMULA, GNP FORMULA, LYSIPLEX CENTURY ULTIMATE PLUS, MACUVITE, WOMENS COMPLETE, MACUVITE EYE CARE, GNP CENTURY MACUVITE/LUTEIN, ULTIMATE WOMENS MAXIMUM DAILY SENIOR FORMULA, GNP GREEN, MEDIPLEX HAIR/SKIN/NAILS, GNP PLUS, MEGA VM-80, HEALTHY EYES, GNP MEIJER ADVANCED MEGA MULTI FOR MEN, FORMULA, MEIJER GNP MEGA MULTI FOR ADVANCED FORMULA WOMEN, GNP ONE DAILY FOR ADULTS 50+, MENS MAXIMUM, GNP ONE HAIR FORMULA ULTRA DAILY MENS HEALTH MAN, MENS LIFE PACK, 50+, GNP ONE DAILY MILLTRIUM ADVANCED MENS FORMULA WITH BETA HEALTH/LYCOPENE, CAROTENE, MILLTRIUM GNP ONE DAILY CARDIO, MILLTRIUM WOMENS HEALTH 50+, SENIOR, MULTI GNP ONE DAILY COMPLETE/IRON, MULTI WOMENS METABOLISM FOR HER, MULTI FOR SUPPORT, GNP HER 50+, MULTI FOR THERAPEUTIC-M, HAIR HIM, MULTI FOR HIM 50+, FORMULA EXTRA MULTI-DAY WEIGHT STRENGTH, HAIR SKIN TRIM, MULTI-DAYPLUS AND NAILS FORMULA, MINERALS, MULTI-LEAN, HAIR VITAMINS, MULTI- HAIR/SKIN/NAILS, VITAMIN/MENOPAUSALF HEALTHY EYES, ORMULA, MULTI- HEALTHY EYES/LUTEIN, VITAMIN/MINERALS, HI-KOVITE 2-PART MULTIPLE FORMULA, HI-POTENCY VITAMIN/MINERALS/NO MULTI-VITAMIN/MINERAL IRON, MULTIPLE SUPPLEMENT, HM VITAMINS/WOMENS, ANTIOXIDANT VITAMINS, MULTIVITAMIN ADULTS HM COMPLETE 50+, HM 50+, MULTIVITAMIN MEN COMPLETE WOMEN, HM 50+, MULTIVITAMIN MENS 50+ ADVANCED WOMEN 50+, ONEDAILY, HM WOMENS MULTIVITAMIN WOMEN 50+ ADVANCED ONE 50+ ADVANCED, CA Health & Wellness Preferred Drug List Updated September 1, 2021

208 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MULTIVITAMIN WOMENS, OPTIMUM PMS, MYAMULTI, NUTRIFAC OSTEOPRIME ULTRA, ZX, NUTRITIONAL PROSIGHT, PX SUPPORT FOR YOUR ADVANCED FORMULA SKIN/HAIR/NAILS, MULTIVITAMINS/LYCOPE OCUTABS, OCUTABS NE, PX COMPLETE VISION FORMULA, SENIOR MULTIVITAMINS, OCUTABS/LUTEIN, PX MENS OCUVITE EXTRA, MULTIVITAMINS, QC OCUVITE EYE + MULTI, HAIR SKIN & NAILS, QC OCUVITE/LUTEIN, ONE MAXIMUM DAILY DAILY 50 PLUS, ONE MULTIVITAMIN/MULTIMIN DAILY ADULTS 50+, ONE ERAL, QC MENS DAILY DAILY COMPLETE, ONE MULTIVITAMIN, QC DAILY COMPLETE FOR MULTI-VITE 50 & OVER, MEN, ONE DAILY FOR QC THERIN-M, QC MEN 50+ ADVANCED, WOMENS DAILY ONE DAILY FOR MULTIVITAMIN, RA MEN/LYCOPENE, ONE CENTRAL-VITE MENS DAILY FOR WOMEN, ONE MATURE, RA CENTRAL- DAILY FOR WOMEN VITE WOMENS MATURE, 50+ADVANCED, ONE RA ONE DAILY ENERGY DAILY HEALTHY FORMULA, RA ONE WEIGHT, ONE DAILY DAILY MAXIMUM, RA HEALTHY ONE DAILY MENS 50+ WEIGHTADVANCED, ONE WITH VITAMIN D-3, RA DAILY MAXIMUM, ONE ONE DAILY MENS MULTI, DAILY MENS, ONE DAILY RA ONE DAILY MENS 50+ MENS/VITAMIND-3, RA MULTIVITAMIN, ONE ONE DAILY DAILY MENS WOMENS/VITAMIN D-3, HEALTH/LYCOPENE, RENAPLEX, SAVISION, ONE DAILY SENIOR TABS, SENTRY MULTIVITAMIN MEN, ONE ADULTS UNDER 50, SM DAILY MULTIVITAMIN ANTIOXIDANT VITAMINS, MENS 50+/LYCOPENE, SM COMPLETE, SM ONE DAILY COMPLETE 50+, SM MULTIVITAMIN WOMEN, COMPLETE 50+ ONE DAILY ULTIMATEMENS, SM MULTIVITAMIN/IRON- COMPLETE 50+ FREE, ONE DAILY PLUS ULTIMATEWOMENS, SM IRON, ONE DAILY PLUS COMPLETE ADVANCED MINERALS, ONE DAILY FORMULA, SM WOMENS 50 PLUS, ONE COMPLETE SENIOR DAILY WOMENS 50+, FORMULA, SM DAILY ONE DIET SUPPORT, SM DAILY/IRON/CALCIUM, HAIR/SKIN/NAILS, SM ONE DAILY/MINERALS, OPTI-VITAMINS, STRESS ONE-A-DAY TEEN B-COMPLEX/C/ZINC, ADVANTAGEFOR HER, STRESS FORMULA/ZINC, OPTIC-VITES, OPTIC- STRESSTABS VITES WITH LUTEIN, ADVANCED, SUNVITE CA Health & Wellness Preferred Drug List Updated September 1, 2021

209 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTIVE ADULT 50+, SENIOR, WOMENS DAILY SUNVITE ADVANCED, FORMULA, WOMENS SUPER DAILY FORMULA/FOLIC ANTIOXIDANT/A/C/E/SEL ACID/CALCIUM/IRON, ENIUM, SUPER AYTINAL WOMENS LIFE PACK, 50 PLUS, SUPER WOMENS MULTIVITAMIN, AYTINAL FOR WOMENS ONE DAILY, ACTIVEADULTS, SUPER YOUR LIFE MULTI MENS MULTIPLE, SUPER NU- 50+, YOUR LIFE MULTI THERA, SUPER THERA WOMENS 50+ TABS VITE M, SUPER VITA- (Multiple Vitamins W/ QL(1 ea daily); MINS, TGT Minerals) ANTIOXIDANT RX/OTC MULTIVITAMIN/MULTIMIN FORMULA TABS 17 MCG- F ERAL 53 MG-133 UNIT-167 MG- ADULTS/LYCOPENE, TGT 8333 UNIT MULTIVITAMIN/MULTIMIN (Multiple Vitamins W/ QL(1 ea daily); ERAL/ADULT, THERA Minerals) CENTRAVITES RX/OTC VITAL M, THERA VITAL- 50 PLUS TABS 1.5 MG-1.7 M, THERA-MILL M, MG-2 MG-2 MG-3 MG-3.5 THERABASIC-M, MG-4 MG-5 MCG-10 MCG- THERADEX "M", 10 MCG-10 MG-15 MG-20 THERADEX "M"/BETA MCG-20 MG-25 MCG-30 F CAROTENE, MCG-45 UNIT-48 MG-60 THERAPEUTIC MG-72 MG-80 MG-100 FORMULA/HEMATINICS, MG-130 MCG-150 MCG- THERAPEUTIC M, 150 MCG-160 MCG-200 THERAPEUTIC-M, MG-400 MCG-400 UNIT- THERAPEUTIC- 5000 UNIT M/LUTEIN, THERATRUM COMPLETE, THERATRUM COMPLETE 50 PLUS, THERAVIM-M, THRIVE FOR LIFE WOMENS, ULTRA ANTIOXIDANT FORMULA, ULTRA FREEDA, ULTRA FREEDA/IRON, ULTRA VITA-TIME, ULTRACHOICE ADVANCED FORMULA, ULTRACHOICE ADVANCED FORMULA MATURE, VISION FORMULA/LUTEIN, VISION VITAMINS, VISIVITES, VISIVITES/LUTEIN, VITA HAIR, VITA S FORTE, VITABASIC COMPLETE, VITABASIC SENIOR, VITACEL, VITATRUM COMPLETE, VITRUM CA Health & Wellness Preferred Drug List Updated September 1, 2021

210 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) RX/OTC Minerals) MULTIVITAMIN RX/OTC CERTAVITE/ANTIOXIDAN ADULTS TABS 0.5 MG-1.5 TS TABS 0.5 MG-1.5 MG- MG-1.7 MG-2 MG-2 MG- 1.7 MG-2 MG-2 MG-2.3 2.3 MG-5 MCG-6 MCG-10 MG-5 MCG-6 MCG-10 MCG-10 MCG-10 MCG-10 MCG-10 MCG-10 MG-11 MG-11 MG-13.5 MG-18 MG-18 MG-20 MG-20 MG- MG-20 MG-20 MG-25 25 MCG-30 MCG-30 UNIT- MCG-30 MCG-35 MCG-45 35 MCG-45 MCG-50 MG- MCG-50 MG-55 MCG-60 55 MCG-60 MG-72 MG-75 MG-72 MG-75 MCG-80 MCG-80 MG-150 MCG- F MG-150 MCG-200 MG-400 200 MG-400 MCG-400 MCG-1050 MCG, 0.5 MG- UNIT-3500 UNIT, 0.5 MG- 1.5 MG-1.7 MG-2 MG-2 1.7 MG-2 MG-2 MG-2.3 MG-2.3 MG-6 MCG-10 MG-5 MCG-6 MCG-10 MCG-10 MCG-10 MG-11 MCG-10 MG-18 MG-20 MG-13.5 MG-18 MG-20 F MG-20 MG-25 MCG-30 MG-20 MG-25 MCG-25 MCG-30 UNIT-1.5 MG-10 MCG-30 MCG-35 MCG-45 MCG-11 MG-35 MCG-45 MCG-50 MG-55 MCG-60 MCG-50 MG-55 MCG-60 MG-72 MG-80 MG-150 MG-72 MG-75 MCG-80 MCG-200 MG-400 MCG- MG-150 MCG-200 MG-400 1050 MCG, 0.5 MG-2 MG- MCG-400 UNIT-3500 UNIT 1.5 MG-1.7 MG-2 MG-2.3 (Multiple Vitamins W/ QL(1 ea daily); MG-5 MCG-6 MCG-10 Minerals) EQ ONE DAILY RX/OTC MCG-10 MCG-10 MG-11 WOMENS HEALTH TABS MG-18 MG-20 MG-20 MG- 1.5 MG-1.7 MG-2 MG-2 25 MCG-30 MCG-30 UNIT- 35 MCG-45 MCG-50 MG- MG-2 MG-6 MCG-10 MG- F 15 MG-18 MG-20 MCG-20 55 MCG-60 MG-72 MG-75 MG-22.5 UNIT-25 MCG-60 MCG-80 MG-150 MCG-200 MG-120 MCG-150 MCG- MG-400 MCG-400 UNIT- 300 MCG-400 MCG-500 3500 UNIT MG-1000 UNIT-2500 UNIT (Multiple Vitamins W/ QL(1 ea daily); Minerals) MULTILEX TABS RX/OTC 0.15 MG-1 MG-1 MG-1.5 MG-1.7 MG-3 MCG-5 MG- F 5 MG-5.5 UNIT-10 MG-10 MG-15 MG-30 MG-100 MG-400 UNIT-10000 UNIT

CA Health & Wellness Preferred Drug List Updated September 1, 2021

211 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) MULTIVITAMIN RX/OTC Minerals) QC MULTI-VITE RX/OTC WOMEN TABS 0.5 MG-1.1 TABS 0.9 MG-1.5 MG-1.7 MG-1.1 MG-1.8 MG-2 MG- MG-2 MG-2 MG-2.3 MG-5 6 MCG-8 MG-14 MG-15 MCG-6 MCG-10 MCG-10 MG-18 MCG-18 MG-20 MCG-10 MG-11 MG-18 MG-32 MCG-35 UNIT-40 MG-20 MG-20 MG-25 F MCG-50 MCG-50 MCG-72 MCG-30 MCG-30 UNIT-35 MG-75 MG-80 MG-100 MCG-45 MCG-50 MG-55 MG-150 MCG-200 MG-400 MCG-60 MG-72 MG-75 MCG-800 UNIT-3500 F MCG-80 MG-150 MCG-200 UNIT, 0.9 MG-1.1 MG-1.1 MG-400 MCG-400 UNIT- MG-1.8 MG-2 MG-2 MG-5 3500 UNIT MCG-6 MCG-8 MG-10 (Multiple Vitamins W/ QL(1 ea daily); MCG-10 MCG-14 MG-15 Minerals) QUINTABS-M RX/OTC MG-18 MG-20 MG-25 TABS 0.2 MG-2 MG-7.5 MCG-35 UNIT-40 MCG-50 MG-10 MG-15 MG-30 MCG-50 MCG-55 MCG-72 MCG-30 MCG-30 MG-30 F MG-75 MG-80 MG-100 MG-30 MG-30 MG-30 MG- MG-150 MCG-150 MCG- 35 MCG-50 UNIT-100 MG- 400 MCG-500 MG-800 150 MCG-300 MG-400 UNIT-3500 UNIT MCG-400 UNIT-5000 UNIT (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) ONE DAILY RX/OTC Minerals) SENTRY RX/OTC MULTIVITAMIN ADULT SENIOR TABS 0.5 MG-1.5 TABS 0.4 MG-1.5 MG-1.7 F MG-1.7 MG-2 MG-2.3 MG- MG-2 MG-6 MCG-10 3 MG-5 MCG-10 MCG-10 MCG-20 MG-30 UNIT-45 MG-11 MG-20 MG-20 MG- MG-60 MG-400 UNIT-3000 25 MCG-30 MCG-30 MCG- UNIT 45 MCG-45 MCG-50 MG- (Multiple Vitamins W/ QL(1 ea daily); 50 UNIT-55 MCG-60 MG- Minerals) ONE DAILY RX/OTC 72 MG-80 MG-150 MCG- WOMENS TABS 1.5 MG- 150 MCG-220 MG-250 1.7 MG-2 MG-2 MG-2 MG- MCG-300 MCG-400 MCG- F 6 MCG-10 MG-15 MG-18 500 UNIT-2500 UNIT, 0.9 MG-20 MCG-20 MG-22.5 MG-1.5 MG-1.7 MG-2 MG- UNIT-25 MCG-60 MG-120 2.3 MG-3 MG-5 MCG-10 MCG-150 MCG-300 MCG- F MCG-10 MG-11 MG-20 400 MCG-500 MG-1000 MG-25 MCG-30 MCG-30 UNIT-2500 UNIT, 1.5 MG- MCG-45 MCG-45 MCG-50 1.7 MG-2 MG-5 MG-6 MG-50 UNIT-55 MCG-72 MCG-10 MG-15 MG-18 MG-80 MG-90 MG-110 MG-30 UNIT-50 MG-60 MG-150 MCG-150 MCG- MG-400 MCG-400 UNIT- 220 MG-250 MCG-300 450 MG-2500 UNIT MCG-500 MCG-500 UNIT- 2500 UNIT

CA Health & Wellness Preferred Drug List Updated September 1, 2021

212 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamins W/ QL(1 ea daily); (Multiple Vitamins W/ QL(1 ea daily); Minerals) SENTRY TABS RX/OTC Minerals) THERA-M TABS RX/OTC 0.9 MG-1.5 MG-1.7 MG-2 2 MG-2 MG-3 MG-3 MG- MG-2 MG-2.3 MG-5 MCG- 3.4 MG-3.5 MG-5 MCG-7.5 6 MCG-10 MCG-10 MCG- MG-7.5 MG-9 MCG-10 10 MG-11 MG-18 MG-20 MCG-10 MCG-10 MG-15 MG-25 MCG-30 MCG-30 F MG-18 MG-20 MG-21 UNIT-35 MCG-45 MCG-55 MCG-26 MCG-28 MCG-30 MCG-72 MG-80 MG-90 MCG-30 UNIT-31 MG-32 MG-100 MG-109 MG-150 MCG-40 MG-90 MG-100 MCG-150 MCG-200 MG- MG-150 MCG-150 MCG- F 250 MCG-300 MCG-400 400 MCG-400 UNIT-5000 UNIT-500 MCG-3500 UNIT UNIT, 2 MG-3 MG-3 MG- (Multiple Vitamins W/ QL(1 ea daily); 3.4 MG-5 MG-7.5 MG-7.5 Minerals) STRESS RX/OTC MG-9 MCG-10 MCG-10 FORMULA TABS 3 MG-12 MG-15 MCG-15 MCG-15 MCG-20 MG-24 MG-30 MCG-15 MG-18 MG-30 UNIT-45 MCG-77 MG-100 MG-30 UNIT-31 MG-44 MG-5 MG-10 MG-10 MG- F MG-100 MG-120 MG-150 400 MCG-500 MG, 5 MG- MCG-400 MCG-400 UNIT- 10 MG-10 MG-12 MCG-20 5500 UNIT MG-30 UNIT-45 MCG-69 ABC COMPLETE SENIOR QL(1 ea daily); MG-100 MG-400 MCG-500 WOMENS 50+ TABS RX/OTC MG (multiple vitamins w/ F (Multiple Vitamins W/ QL(1 ea daily); minerals) Minerals) STRESS RX/OTC ADVANCED DIABETIC QL(1 ea daily); FORMULA/IRON TABS 5 MULTIVITAMIN FORMULA RX/OTC MG-10 MG-10 MG-12 F F MCG-18 MG-20 MG-30 TABS (multiple vitamins UNIT-45 MCG-100 MG- w/ minerals) 400 MCG-500 MG ALGAE BASED CALCIUM QL(1 ea daily); TABS (multiple vitamins F RX/OTC w/ minerals) ALIVE ENERGY 50+ TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC minerals) ALIVE MENS ENERGY QL(1 ea daily); TABS (multiple vitamins F RX/OTC w/ minerals) ALIVE ONCE DAILY QL(1 ea daily); WOMENS 50+ ULTRA RX/OTC POTENCY TABS F (multiple vitamins w/ minerals)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

213 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALIVE ONCE DAILY QL(1 ea daily); CENTRAVITES 50 PLUS QL(1 ea daily); WOMENS ULTRA RX/OTC TABS 0.5 MG-1.5 MG-1.7 RX/OTC POTENCY TABS F MG-2 MG-2.3 MG-3 MG-5 (multiple vitamins w/ MCG-10 MCG-10 MG-11 minerals) MG-19 MCG-20 MG-20 MG-25 MCG-30 MCG-30 ALIVE WOMENS 50+ QL(1 ea daily); MCG-45 MCG-50 MCG-50 TABS (multiple vitamins F RX/OTC MG-50 UNIT-60 MG-80 w/ minerals) MG-150 MCG-220 MG-250 ALIVE WOMENS ENERGY QL(1 ea daily); MCG-300 MCG-400 MCG- TABS (multiple vitamins F RX/OTC 1000 UNIT-2500 UNIT, 0.5 MG-1.7 MG-2 MG-2.3 MG- F w/ minerals) 3 MG-5 MCG-10 MG-19 ANTIOXIDANT FORMULA QL(1 ea daily); MCG-1.5 MG-10 MCG-11 TABS 17 MCG-53 MG-61 RX/OTC MG-20 MG-20 MG-25 MG-167 MG-2492 MCG F MCG-30 MCG-30 MCG-45 (multiple vitamins w/ MCG-50 MCG-50 MG-50 minerals) UNIT-60 MG-80 MG-150 MCG-220 MG-250 MCG- AZO HORMONAL QL(1 ea daily); 300 MCG-400 MCG-1000 HEALTH CYCLE CARE & RX/OTC UNIT-2500 UNIT (multiple COMFORT TABS F (multiple vitamins w/ vitamins w/ minerals) minerals) CENTRAVITES ADULTS QL(1 ea daily); RX/OTC AZO HORMONAL QL(1 ea daily); TABS (multiple vitamins F HEALTH HAPPY CYCLE RX/OTC w/ minerals) TABS (multiple vitamins F CENTRUM CARDIO TABS QL(1 ea daily); w/ minerals) (multiple vitamins w/ F RX/OTC BACMIN TABS ( QL(1 ea daily); minerals) multiple F vitamins w/ minerals) RX/OTC CENTRUM MEN TABS 2 QL(1 ea daily); MG-0.9 MG-1.2 MG-1.3 RX/OTC BASIC AM TABS QL(1 ea daily); MG-2 MG-2.3 MG-5 MCG- (multiple vitamins w/ F RX/OTC 6 MCG-8 MG-10 MCG-10 minerals) MCG-11 MG-16 MG-20 BASIC PM TABS QL(1 ea daily); MG-35 MCG-45 UNIT-50 (multiple vitamins w/ F RX/OTC MCG-60 MCG-72 MG-80 F ) MG-100 MCG-100 MG-150 minerals MCG-200 MCG-210 MG-15 CAL-DAY 1000 TABS QL(1 ea daily); MG-40 MCG-90 MG-600 (multiple vitamins w/ F RX/OTC MCG-1000 UNIT-3500 minerals) UNIT (multiple vitamins w/ minerals) CENTRUM SILVER QL(1 ea daily); ULTRA WOMENS TABS RX/OTC (multiple vitamins w/ F minerals) CENTRUM SPECIALIST QL(1 ea daily); HEART TABS (multiple F RX/OTC vitamins w/ minerals)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

214 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CENTRUM SPECIALIST QL(1 ea daily); CLINICAL NUTRIENTS QL(1 ea daily); IMMUNE SUPPORT TABS RX/OTC FOR MALE TEENS TABS RX/OTC (multiple vitamins w/ F (multiple vitamins w/ F minerals) minerals) CENTRUM SPECIALIST QL(1 ea daily); CLINICAL NUTRIENTS QL(1 ea daily); VISION TABS ( RX/OTC FOR MEN TABS RX/OTC multiple F F vitamins w/ minerals) (multiple vitamins w/ CENTRUM ULTRA QL(1 ea daily); minerals) WOMENS TABS RX/OTC CLINICAL NUTRIENTS QL(1 ea daily); ( F FOR WOMEN TABS RX/OTC multiple vitamins w/ F minerals) (multiple vitamins w/ CERTAVITE SENIOR QL(1 ea daily); minerals) TABS (multiple vitamins F RX/OTC CVS ONE DAILY MENS QL(1 ea daily); 50+ ADVANCED TABS RX/OTC w/ minerals) F CERTAVITE QL(1 ea daily); (multiple vitamins w/ SENIOR/ANTIOXIDANT RX/OTC minerals) NUTRIENTS TABS F CVS ONE DAILY QL(1 ea daily); ( WOMENS 50+ADVANCED RX/OTC multiple vitamins w/ F minerals) TABS (multiple vitamins CERTAVITE/ANTIOXIDAN QL(1 ea daily); w/ minerals) TS TABS 0.5 MG-1.5 MG- RX/OTC CVS SPECTRAVITE QL(1 ea daily); 1.7 MG-2 MG-2 MG-2.3 ADULT 50+ TABS RX/OTC MG-5 MCG-6 MCG-10 (multiple vitamins w/ F MCG-10 MCG-10 MCG-10 minerals) MG-11 MG-13.5 MG-18 CVS SPECTRAVITE QL(1 ea daily); MG-20 MG-20 MG-25 F MCG-30 MCG-35 MCG-45 ADULTS TABS (multiple F RX/OTC MCG-50 MG-55 MCG-60 vitamins w/ minerals) MG-72 MG-75 MCG-80 CVS SPECTRAVITE QL(1 ea daily); MG-150 MCG-200 MG-400 ULTRA MEN50+ TABS RX/OTC MCG-1050 MCG (multiple (multiple vitamins w/ F vitamins w/ minerals) minerals) CLINICAL NUTRIENTS 45- QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); PLUS WOMEN TABS RX/OTC F ULTRA MENS HEALTH RX/OTC (multiple vitamins w/ SENIOR TABS (multiple F minerals) vitamins w/ minerals) CLINICAL NUTRIENTS 50- QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); PLUS MEN TABS RX/OTC F ULTRA MENS HEALTH RX/OTC (multiple vitamins w/ TABS (multiple vitamins F minerals) w/ minerals) CLINICAL NUTRIENTS QL(1 ea daily); CVS SPECTRAVITE QL(1 ea daily); FOR FEMALE TEENS RX/OTC F ULTRA WOMEN TABS RX/OTC TABS (multiple vitamins (multiple vitamins w/ F w/ minerals) minerals)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

215 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS SPECTRAVITE QL(1 ea daily); EQ ONE DAILY WOMENS QL(1 ea daily); ULTRA WOMENS RX/OTC HEALTH TABS 1.5 MG-1.7 RX/OTC HEALTH SENIOR TABS F MG-2 MG-2 MG-2 MG-5 (multiple vitamins w/ MG-6 MCG-10 MG-15 MG- minerals) 18 MG-20 MCG-22.5 UNIT- 25 MCG-30 MCG-50 MG- F CVS SPECTRAVITE QL(1 ea daily); 60 MG-120 MCG-400 ULTRA WOMENS RX/OTC F MCG-500 MG-1000 UNIT- HEALTH TABS (multiple 2500 UNIT (multiple vitamins w/ minerals) vitamins w/ minerals) DAYAVITE TABS QL(1 ea daily); EQL CENTURY MATURE QL(1 ea daily); (multiple vitamins w/ F RX/OTC ADULTS50+ TABS RX/OTC minerals) (multiple vitamins w/ F DERMACINRX RIBOTIN-E QL(1 ea daily); minerals) TABS (multiple vitamins F RX/OTC EQL CENTURY MENS QL(1 ea daily); w/ minerals) TABS (multiple vitamins F RX/OTC DERMACINRX QL(1 ea daily); w/ minerals) ZINTREXYL-C TABS RX/OTC F EQL CENTURY WOMENS QL(1 ea daily); (multiple vitamins w/ TABS (multiple vitamins F RX/OTC minerals) w/ minerals) DERMAVITE TABS QL(1 ea daily); EQL ONE DAILY MENS QL(1 ea daily); RX/OTC (multiple vitamins w/ F TABS (multiple vitamins F RX/OTC minerals) w/ minerals) EQ COMPLETE QL(1 ea daily); ESTROVEN MENOPAUSE QL(1 ea daily); MULTIVITAMINADULTS RX/OTC SUPPLEMENT TABS RX/OTC UNDER 50 TABS F (multiple vitamins w/ F (multiple vitamins w/ minerals) minerals) EYE HEALTH/LUTEIN QL(1 ea daily); EQ ONE DAILY MENS 50+ QL(1 ea daily); TABS (multiple vitamins F RX/OTC TABS (multiple vitamins F RX/OTC w/ minerals) w/ minerals) EYE QL(1 ea daily); EQ ONE DAILY MENS QL(1 ea daily); MULTIVITAMIN/LUTEIN RX/OTC RX/OTC HEALTH TABS (multiple F TABS (multiple vitamins F vitamins w/ minerals) w/ minerals) EQ ONE DAILY WOMENS QL(1 ea daily); EYE QL(1 ea daily); 50+ TABS (multiple F RX/OTC MULTIVITAMIN/SODIUM RX/OTC vitamins w/ minerals) TABS (multiple vitamins F w/ minerals) FITNESS TABS FOR MEN QL(1 ea daily); AM/PM/LYCOPENE TABS RX/OTC (multiple vitamins w/ F minerals)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

216 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FITNESS TABS FOR QL(1 ea daily); HM COMPLETE MEN QL(1 ea daily); WOMEN RX/OTC TABS (multiple vitamins F RX/OTC AM/PM/LYCOPENE TABS F w/ minerals) (multiple vitamins w/ HM COMPLETE TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC FOLIKA-CI TABS QL(1 ea daily); minerals) RX/OTC (multiple vitamins w/ F HM HAIR/SKIN/NAILS QL(1 ea daily); minerals) TABS (multiple vitamins F RX/OTC FOLIKA-MG TABS QL(1 ea daily); w/ minerals) RX/OTC (multiple vitamins w/ F HM ONE DAILY MENS QL(1 ea daily); minerals) TABS (multiple vitamins F RX/OTC FOLITIN-Z TABS QL(1 ea daily); w/ minerals) RX/OTC (multiple vitamins w/ F HM ONE DAILY WOMENS QL(1 ea daily); minerals) TABS (multiple vitamins F RX/OTC FREEDAVITE TABS QL(1 ea daily); w/ minerals) RX/OTC (multiple vitamins w/ F HYLAZINC TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC GERI-FREEDA SENIOR QL(1 ea daily); minerals) FORMULA TABS RX/OTC ICAPS AREDS FORMULA QL(1 ea daily); (multiple vitamins w/ F TABS (multiple vitamins F RX/OTC minerals) w/ minerals) HAIR SKIN & NAILS QL(1 ea daily); ADVANCED FORMULA RX/OTC K-PAX IMMUNE QL(1 ea daily); F SUPPORT FORMULA RX/OTC TABS (multiple vitamins PROFESSIONAL w/ minerals) STRENGTH TABS F HIGH POTENCY QL(1 ea daily); (multiple vitamins w/ MULTIVITAMIN/BETA- RX/OTC minerals) CAROTENE TABS F LUTEIN QL(1 ea daily); (multiple vitamins w/ PLUS/ZEAXANTHIN TABS RX/OTC minerals) (multiple vitamins w/ F HIGH POTENCY QL(1 ea daily); minerals) MULTIVITAMIN/FOLIC RX/OTC MACULAR VITAMIN QL(1 ea daily); ACID TABS (multiple F BENEFIT TABS (multiple F RX/OTC vitamins w/ minerals) vitamins w/ minerals) HM COMPLETE 50+ QL(1 ea daily); MENS ULTIMATE TABS RX/OTC MEGA MULTI FOR MEN QL(1 ea daily); RX/OTC (multiple vitamins w/ F TABS (multiple vitamins F minerals) w/ minerals) HM COMPLETE 50+ QL(1 ea daily); MEGA MULTI FOR QL(1 ea daily); WOMENS ULTIMATE RX/OTC WOMEN TABS (multiple F RX/OTC TABS (multiple vitamins F vitamins w/ minerals) w/ minerals) MEGA MULTIVITAMIN QL(1 ea daily); FOR MEN TABS RX/OTC (multiple vitamins w/ F minerals) CA Health & Wellness Preferred Drug List Updated September 1, 2021

217 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEGA MULTIVITAMIN QL(1 ea daily); MULTIVITAMIN ADULTS QL(1 ea daily); FOR WOMEN TABS RX/OTC TABS 0.5 MG-1.5 MG-1.7 RX/OTC (multiple vitamins w/ F MG-2 MG-2 MG-2.3 MG-5 minerals) MCG-6 MCG-10 MCG-10 MCG-10 MG-11 MG-18 MEGAVITE FRUITS & QL(1 ea daily); MG-20 MG-20 MG-25 VEGGIES TABS RX/OTC F MCG-30 MCG-30 UNIT-35 (multiple vitamins w/ MCG-45 MCG-50 MG-55 minerals) MCG-60 MG-72 MG-75 MEGAVITE GOLDEN QL(1 ea daily); MCG-80 MG-150 MCG-200 YEARS 55+ TABS RX/OTC MG-400 MCG-400 UNIT- (multiple vitamins w/ F 3500 UNIT, 2 MG-0.5 MG- F 1.5 MG-1.7 MG-2 MG-2.3 minerals) MG-5 MCG-6 MCG-10 MENS 50+ MULTI QL(1 ea daily); MCG-10 MCG-10 MG-11 VITAMIN &MINERAL RX/OTC MG-18 MG-20 MG-20 MG- FORMULA TABS F 25 MCG-30 MCG-30 UNIT- (multiple vitamins w/ 35 MCG-45 MCG-50 MG- minerals) 55 MCG-60 MG-72 MG-75 MCG-80 MG-150 MCG-200 MENS MULTI VITAMIN & QL(1 ea daily); MG-400 MCG-400 UNIT- MINERAL FORMULA RX/OTC 3500 UNIT (multiple TABS (multiple vitamins F vitamins w/ minerals) w/ minerals) MULTIVITAMIN MEN QL(1 ea daily); MENS MULTIVITAMIN QL(1 ea daily); TABS (multiple vitamins F RX/OTC TABS (multiple vitamins F RX/OTC w/ minerals) w/ minerals) MULTIVITAMIN TABS 1 QL(1 ea daily); MULTI-BETIC DIABETES QL(1 ea daily); MG-1 MG-1.5 MG-2 MG- RX/OTC TABS (multiple vitamins F RX/OTC 2.5 MG-5 MG-7.5 MCG-10 w/ minerals) MCG-10 MG-10 MG-15 F MULTI-VITAMIN QL(1 ea daily); MG-15 MG-100 MG-150 MONOCAPS TABS RX/OTC MCG-150 MG-3000 MCG (multiple vitamins w/ F (multiple vitamins w/ minerals) minerals) MULTILEX T&M TABS QL(1 ea daily); MULTIVITAMIN WOMEN QL(1 ea daily); (multiple vitamins w/ F RX/OTC TABS 0.5 MG-1.8 MG-2 RX/OTC MG-1.1 MG-1.1 MG-2 MG- minerals) 6 MCG-8 MG-10 MCG-10 MULTILEX TABS 1 MG-1 QL(1 ea daily); MCG-14 MG-15 MG-15.7 MG-1.5 MG-1.7 MG-3 RX/OTC MG-18 MCG-18 MG-20 MCG-5 MG-5 MG-5.5 MG-25 MCG-32 MCG-40 F UNIT-10 MG-10 MG-15 MCG-50 MCG-50 MCG-72 MG-30 MG-100 MG-150 F MG-75 MG-80 MG-100 MCG-400 UNIT-10000 MG-150 MCG-200 MG-400 UNIT (multiple vitamins MCG-1050 MCG (multiple w/ minerals) vitamins w/ minerals) QL(1 ea daily); multiple vitamins w/ F minerals tabs RX/OTC

CA Health & Wellness Preferred Drug List Updated September 1, 2021

218 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MULTIVITAMIN/ZINC QL(1 ea daily); ONE DAILY WOMENS QL(1 ea daily); STRESSFORMULA TABS RX/OTC TABS 1.5 MG-1.7 MG-2 RX/OTC (multiple vitamins w/ F MG-2 MG-2 MG-6 MCG-10 minerals) MG-15 MG-18 MG-20 MCG-20 MG-22.5 UNIT-25 NAT-RUL THERAVITE- QL(1 ea daily); MCG-60 MG-120 MCG-150 F M/HIGHPOTENCY TABS RX/OTC F MCG-300 MCG-400 MCG- (multiple vitamins w/ 500 MG-1000 UNIT-2500 minerals) UNIT (multiple vitamins NATRUL-VITES TABS QL(1 ea daily); w/ minerals) (multiple vitamins w/ F RX/OTC ONE-A-DAY ENERGY QL(1 ea daily); minerals) TABS (multiple vitamins F RX/OTC NEOVITE TABS ( QL(1 ea daily); w/ minerals) multiple F vitamins w/ minerals) RX/OTC ONE-A-DAY MENOPAUSE QL(1 ea daily); FORMULA TABS RX/OTC NICADAN TABS QL(1 ea daily); F (multiple vitamins w/ F RX/OTC (multiple vitamins w/ minerals) minerals) NICADAN ZX TABS QL(1 ea daily); ONE-A-DAY MENS 50+ QL(1 ea daily); ADVANTAGE TABS RX/OTC (multiple vitamins w/ F RX/OTC F minerals) (multiple vitamins w/ minerals) NICAZEL FORTE TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC ONE-A-DAY MENS 50+ QL(1 ea daily); RX/OTC minerals) TABS (multiple vitamins F w/ minerals) NICAZEL TABS (multiple QL(1 ea daily); F RX/OTC ONE-A-DAY MENS QL(1 ea daily); vitamins w/ minerals) HEALTH FORMULA TABS RX/OTC NO IRON MULTIPLE QL(1 ea daily); (multiple vitamins w/ F VITAMIN/MINERALS RX/OTC minerals) TABS (multiple vitamins F ONE-A-DAY MENS PRO QL(1 ea daily); w/ minerals) EDGE TABS (multiple F RX/OTC NUTRICAP TABS QL(1 ea daily); vitamins w/ minerals) (multiple vitamins w/ F RX/OTC ONE-A-DAY MENS TABS QL(1 ea daily); minerals) 0.9 MG-1.32 MG-1.43 MG- RX/OTC OCULAR VITAMINS TABS QL(1 ea daily); 2.17 MG-2.3 MG-6.24 (multiple vitamins w/ F RX/OTC MCG-11 MG-15 MG-15.5 minerals) MG-17.6 MG-25 MCG-30 ONCOVITE TABS QL(1 ea daily); MCG-35 MCG-43 MCG-55 F RX/OTC MCG-99 MG-120 MG-150 (multiple vitamins w/ F MCG-210 MG-240 MCG- minerals) 300 MCG-900 MCG ONE DAILY MENS QL(1 ea daily); (multiple vitamins w/ FORMULA W/O IRON RX/OTC F minerals) TABS (multiple vitamins ONE-A-DAY PROACTIVE QL(1 ea daily); w/ minerals) 65+ TABS (multiple F RX/OTC vitamins w/ minerals)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

219 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONE-A-DAY TEEN QL(1 ea daily); QC MULTI-VITE TABS 0.5 QL(1 ea daily); ADVANTAGEFOR HIM RX/OTC MG-1.5 MG-1.7 MG-2 MG- RX/OTC TABS (multiple vitamins F 2 MG-2.3 MG-5 MCG-6 w/ minerals) MCG-10 MCG-10 MCG-10 MG-11 MG-18 MG-20 MG- ONE-A-DAY WOMENS QL(1 ea daily); 20 MG-25 MCG-30 MCG- RX/OTC TABS (multiple vitamins F 30 UNIT-35 MCG-45 MCG- F w/ minerals) 50 MG-55 MCG-60 MG-72 ONEVITE TABS (multiple MG-75 MCG-80 MG-150 MCG-200 MG-400 MCG- vitamins w/ minerals & F 400 UNIT-3500 UNIT folic acid) (multiple vitamins w/ OPURITY TABS (multiple QL(1 ea daily); minerals) F RX/OTC vitamins w/ minerals) QUIN B STRONG TABS QL(1 ea daily); OSTEOPRIME QL(1 ea daily); (multiple vitamins w/ F RX/OTC PLUS/CALCIUM & RX/OTC minerals) MAGNESIUM TABS F QUINTABS-M TABS 0.2 QL(1 ea daily); (multiple vitamins w/ MG-2 MG-7.5 MG-15 MG- RX/OTC minerals) 30 MCG-30 MCG-30 MG- PARVLEX TABS QL(1 ea daily); 30 MG-30 MG-30 MG-30 (multiple vitamins w/ F RX/OTC MG-35 MCG-50 UNIT-100 minerals) MG-150 MCG-300 MG-400 MCG-400 UNIT-5000 PHYTOMULTI TABS QL(1 ea daily); UNIT, 0.2 MG-30 MCG-30 F (multiple vitamins w/ F RX/OTC MCG-30 MG-30 MG-30 minerals) MG-2 MG-7.5 MG-15 MG- PRESERVISION AREDS QL(1 ea daily); 30 MG-30 MG-35 MCG-50 TABS (multiple vitamins F RX/OTC UNIT-100 MG-150 MCG- 300 MG-400 MCG-400 w/ minerals) UNIT-5000 UNIT (multiple PRO-CAL TABS 7.5 MG- QL(1 ea daily); vitamins w/ minerals) 40 MG-100 UNIT-145 MG- RX/OTC 187.5 MG (multiple F RA CENTRAL-VITE TABS QL(1 ea daily); RX/OTC vitamins w/ minerals) (multiple vitamins w/ F minerals) PROCERV HP TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC RENAPLEX-D TABS QL(1 ea daily); RX/OTC minerals) (multiple vitamins w/ F minerals) PRORENAL+D TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC REQ 49+ TABS (multiple QL(1 ea daily); F RX/OTC minerals) vitamins w/ minerals) PROVIT TABS ( QL(1 ea daily); multiple F vitamins w/ minerals) RX/OTC

CA Health & Wellness Preferred Drug List Updated September 1, 2021

220 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SENTRY SENIOR TABS QL(1 ea daily); SYSTANE ICAPS AREDS2 QL(1 ea daily); 0.5 MG-1.5 MG-1.7 MG-2 RX/OTC TABS (multiple vitamins F RX/OTC MG-2.3 MG-3 MG-5 MCG- w/ minerals) 10 MCG-10 MG-11 MG-20 T-VITES TABS ( QL(1 ea daily); MG-20 MG-25 MCG-30 multiple F MCG-30 MCG-45 MCG-45 vitamins w/ minerals) RX/OTC MCG-50 MG-50 UNIT-55 F THERA M PLUS TABS QL(1 ea daily); MCG-60 MG-72 MG-80 (multiple vitamins w/ F RX/OTC MG-150 MCG-150 MCG- 220 MG-250 MCG-300 minerals) MCG-400 MCG-500 UNIT- THERA-M TABS 2 MG-2 QL(1 ea daily); 2500 UNIT (multiple MG-3 MG-3.4 MG-5 MCG- RX/OTC vitamins w/ minerals) 6 MG-6 MG-7 MG-7.5 MG- 9 MG-10 MCG-10 MCG-10 SENTRY SENIOR/LUTEIN QL(1 ea daily); MG-12 MCG-15 MG-20 TABS (multiple vitamins F RX/OTC MG-23 MG-28 MCG-30 w/ minerals) MCG-30 MG-50 MCG-60 SENTRY TABS 0.5 MG-1.5 QL(1 ea daily); UNIT-70 MCG-75 MCG-90 MG-1.7 MG-2 MG-2 MG- RX/OTC MG-100 MG-150 MCG-150 2.3 MG-5 MCG-6 MCG-10 MCG-400 MCG-400 UNIT- 5000 UNIT, 2 MG-5 MCG-2 MCG-10 MCG-10 MG-11 F MG-18 MG-20 MG-20 MG- MG-3 MG-3.4 MG-6 MG-6 25 MCG-30 MCG-30 UNIT- MG-7 MG-7.5 MG-9 MG-10 35 MCG-45 MCG-50 MG- F MCG-10 MCG-10 MG-12 55 MCG-60 MG-72 MG-75 MCG-20 MG-23 MG-28 MCG-80 MG-150 MCG- MCG-30 MCG-30 MG-50 200 MG-400 MCG-400 MCG-70 MCG-75 MCG-90 MG-100 MG-150 MCG-150 UNIT-3500 UNIT (multiple MCG-400 MCG-400 UNIT- vitamins w/ minerals) 5000 UNIT-60 UNIT-15 MG SIDEROL TABS ( QL(1 ea daily); ( multiple F multiple vitamins w/ vitamins w/ minerals) RX/OTC minerals) SM ONE DAILY MENS QL(1 ea daily); THERA-TABS M TABS QL(1 ea daily); TABS (multiple vitamins F RX/OTC (multiple vitamins w/ F RX/OTC w/ minerals) minerals) SM ONE DAILY WOMENS QL(1 ea daily); THERABETIC MULTI- QL(1 ea daily); TABS (multiple vitamins F RX/OTC VITAMIN TABS (multiple F RX/OTC w/ minerals) vitamins w/ minerals) SOLO TABS (multiple QL(1 ea daily); THERAGRAN-M QL(1 ea daily); F RX/OTC ADVANCED 50 PLUS RX/OTC vitamins w/ minerals) F SPECTRAVITE TABS QL(1 ea daily); TABS (multiple vitamins (multiple vitamins w/ F RX/OTC w/ minerals) minerals) THERAGRAN-M QL(1 ea daily); ADVANCED TABS RX/OTC STROVITE ONE TABS QL(1 ea daily); (multiple vitamins w/ F (multiple vitamins w/ F RX/OTC minerals) minerals)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

221 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THERAGRAN-M PREMIER QL(1 ea daily); VITAMIN D3 COMPLETE QL(1 ea daily); 50 PLUS TABS (multiple F RX/OTC TABS (multiple vitamins F RX/OTC vitamins w/ minerals) w/ minerals) THERAGRAN-M PREMIER QL(1 ea daily); VITASANA TABS QL(1 ea daily); TABS (multiple vitamins F RX/OTC (multiple vitamins w/ F RX/OTC w/ minerals) minerals) THERAGRAN-M TABS QL(1 ea daily); VITATRUM TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC (multiple vitamins w/ F RX/OTC minerals) minerals) THEREMS-H TABS QL(1 ea daily); VITEYES CLASSIC QL(1 ea daily); ( RX/OTC MULTIIVITAMIN TABS RX/OTC multiple vitamins w/ F F minerals) (multiple vitamins w/ THEREMS-M TABS QL(1 ea daily); minerals) (multiple vitamins w/ F RX/OTC VITEYES CLASSIC QL(1 ea daily); MULTIVITAMIN TABS RX/OTC minerals) F THRIVITE 19 TABS (multiple vitamins w/ (multiple vitamins w/ F minerals) minerals & folic acid) VITEYES OPTIC NERVE QL(1 ea daily); SUPPORT TABS RX/OTC UDAMIN SP TABS (multiple vitamins w/ F (multiple vitamins w/ F minerals) minerals & folic acid) VITRANOL FE TABS QL(1 ea daily); UNICOMPLEX-M TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC (multiple vitamins w/ F RX/OTC minerals) minerals) VITRANOL TABS QL(1 ea daily); VENEXA FE TABS QL(1 ea daily); (multiple vitamins w/ F RX/OTC (multiple vitamins w/ F RX/OTC minerals) minerals) VITREXATE FE TABS QL(1 ea daily); VENEXA TABS (multiple QL(1 ea daily); RX/OTC F RX/OTC (multiple vitamins w/ F vitamins w/ minerals) minerals) VENTRIXYL FE TABS QL(1 ea daily); VITREXATE TABS QL(1 ea daily); RX/OTC (multiple vitamins w/ F (multiple vitamins w/ F RX/OTC minerals) minerals) VENTRIXYL TABS VITREXYL TABS QL(1 ea daily); (multiple vitamins w/ F (multiple vitamins w/ F RX/OTC minerals & folic acid) minerals) VITALINE TOTAL QL(1 ea daily); VITREXYL/IRON TABS QL(1 ea daily); FORMULA 2 TABS RX/OTC (multiple vitamins w/ F RX/OTC (multiple vitamins w/ F minerals) minerals) VITRUM 50+ ADULT- QL(1 ea daily); VITALINE TOTAL QL(1 ea daily); MULTI IRON FREE TABS RX/OTC FORMULA 3 TABS RX/OTC (multiple vitamins w/ F (multiple vitamins w/ F minerals) minerals)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

222 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITRUM 50+ SENIOR QL(1 ea daily); (Multiple Vitamin) ANTI- MULTI TABS (multiple F RX/OTC OXIDANT, DAILY vitamins w/ minerals) MULTIPLE VITAMINS, DAILY VALUE WHOLE FOOD QL(1 ea daily); MULTIVITAMIN, DAILY MULTIVITAMIN TABS RX/OTC F VITAMIN, DAILY (multiple vitamins w/ VITAMINS, DAILY VITE, minerals) DAILY-VITAMIN, DAILY- WOMENS 50+ MULTI QL(1 ea daily); VITE, DAILY-VITE VITAMIN& MINERAL RX/OTC MULTIVITAMIN, GNP FORMULA TABS F ESSENTIAL ONE DAILY, (multiple vitamins w/ HEALTHY HAIR SKIN & NAILS, MULTI VITAMIN minerals) DAILY, MULTI-DAY, WOMENS BIOMULTIPLE QL(1 ea daily); MULTI-VITAMIN, MULTI- TABS (multiple vitamins F RX/OTC VITAMIN DAILY, MULTI- w/ minerals) VITAMINS, MULTIPLE VITAMINS ESSENTIAL, F WOMENS MULTI VITAMIN QL(1 ea daily); MULTIVITAMIN ADULT & MINERAL FORMULA RX/OTC F ONE DAILY, TABS (multiple vitamins MULTIVITAMIN IRON- w/ minerals) FREE, ONCE DAILY, ONE YELETS TEENAGE QL(1 ea daily); DAILY, ONE-DAILY MULTI FORMULA TABS RX/OTC VITAMINS, ONE-DAILY (multiple vitamins w/ F MULTI-VITAMIN, QC ESSENTIALS, RA ONE minerals) DAILY ESSENTIAL, Multivitamins SIGTAB, SM MULTIPLE VITAMINS ESSENTIAL, STRESSTABS ENERGY, TAB-A-VITE, TAB-A-VITE W/BETA CAROTENE, THERA-MILL, THERA- TABS, THEREMS, VITALEE TABS (Multiple Vitamin) ONE DAILY ESSENTIAL TABS 1.5 MG-1.7 MG-2 MG-6 F MCG-7.5 UNIT-10 MG-20 MG-45 MG-60 MG-500 MCG-800 UNIT-3000 UNIT (Multiple Vitamin) ONE DAILY MULTIVITAMIN ADULT TABS 0.4 MG-1.5 F MG-1.7 MG-2 MG-6 MCG- 20 MG-60 MG-400 UNIT- 5000 UNIT

CA Health & Wellness Preferred Drug List Updated September 1, 2021

223 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Multiple Vitamin) STRESS OMNICAP TABS F FORMULA TABS 0.4 MG- (multiple vitamin) 12 MCG-15 MG-20 MG-30 ONE DAILY ESSENTIAL UNIT-45 MCG-100 MG- TABS 1.5 MG-1.7 MG-2 600 MG, 10 MG-12 MCG-3 MG-3.3 MG-6 MCG-10 MG-10 MG-20 MG-30 MG-20 MCG-20 MG-45 F UNIT-45 MCG-100 MG- MG-60 MG-500 MCG-900 400 MCG-500 MG, 30 MCG (multiple vitamin) UNIT-5 MG-12 MCG-20 F MG-10 MG-10 MG-45 QUINTABS TABS F MCG-100 MG-400 MCG- (multiple vitamin) 500 MG, 5 MG-10 MG-10 THERA TABS 3 MG-3 MG- MG-12 MCG-20 MG-30 3.4 MG-9 MCG-10 MG-20 UNIT-45 MCG-100 MG- MG-30 MCG-30 UNIT-35 400 MCG-500 MG, 5 MG- MG-45 MG-90 MG-400 10 MG-12 MCG-15 MG-20 MCG-400 UNIT-5000 MG-30 UNIT-45 MCG-100 UNIT, 3 MG-3 MG-3.4 MG- F MG-400 MCG-500 MG 9 MCG-10 MG-20 MG-30 (Multiple Vitamin) THERA MCG-30 UNIT-45 MG-90 TABS 3 MG-3 MG-3.4 MG- MG-400 MCG-400 UNIT- 9 MCG-10 MG-20 MG-30 5000 UNIT (multiple MCG-30 UNIT-90 MG-400 ) MCG-400 UNIT-5000 vitamin F THEREMS MULTIVITAMIN UNIT, 3 MG-9 MCG-10 F MG-20 MG-30 MCG-90 TABS (multiple vitamin) MG-400 MCG-400 UNIT-3 MG-3.4 MG-30 UNIT-5000 Ped MV w/ Fluoride UNIT (Pediatric Multivitamins AL(Up to 13 yrs W/Fl) MULTI- old ); RX/OTC ESTROFACTORS TABS F VITAMIN/FLUORIDE (multiple vitamin) DROPS, MULTIVITAMIN F HIGH POTENCY WITH FLUORIDE, MULTIVITAMIN TABS F MULTIVITAMIN/FLUORID (multiple vitamin) E SOLN MULTI VITAMIN TABS (Pediatric Multivitamins AL(Up to 13 yrs F (multiple vitamin) W/Fl) old ); RX/OTC MULTIVITAMIN/FLUORID MULTI VITAMIN/D-3 TABS F F E, (multiple vitamin) MULTIVITAMINS/FLUORI DE CHEW multiple vitamin tabs F (Pediatric Vitamins Acd W/ AL(Up to 13 yrs MULTIVITAMIN ADULT Fluoride) MULTIVITAMIN old ); RX/OTC F TABS (multiple vitamin) SELECT/FLUORIDE, F MULTIVITAMIN TABS 0.1 VITAMINS MG-1 MG-1.5 MG-2 MG-10 A/C/D/FLUORIDE SOLN MCG-20 MG-28.5 MG-37.5 F (Pediatric Vitamins Acd W/ AL(Up to 13 yrs MG-1500 MCG (multiple Fluoride) TRI- old ); RX/OTC ) VITE/FLUORIDE SOLN F vitamin 0.25 MG/ML-35 MG/ML- NEOMULTIVITE TABS F 400 UNIT/ML-1500 (multiple vitamin) UNIT/ML CA Health & Wellness Preferred Drug List Updated September 1, 2021

224 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Vitamins Acd W/ AL(Up to 13 yrs POLY-VI-FLOR/IRON AL(Up to 5 yrs Fluoride) TRI- old ) CHEW 0.5 MG-10 MG-15 old ) VITE/FLUORIDE SOLN 0.5 F UNIT-200 MCG-400 UNIT F MG/ML-35 MG/ML-400 (ped multivitamins w/fl UNIT/ML-1500 UNIT/ML & iron) FLORIVA PLUS SOLN AL(Up to 13 yrs Pediatric Multiple Vitamins (pediatric multivitamins F old ); RX/OTC ) (Pediatric Multiple Vitamin w/fl W/ C & Fa) ANIMAL AL(Up to 13 yrs pediatric vitamins acd F CHEWS, ANIMAL w/ fluoride soln old ) SHAPES, BITE-A-MINS, POLY-VI-FLOR CHEW AL(Up to 5 yrs BOUNTY BEARS/C, 0.25 MG-15 UNIT-200 old ) CHEWABLE VITAMINS MCG-400 UNIT, 0.5 MG-15 CHILDRENS, CHEWABLE VITE CHILDRENS, UNIT-200 MCG-400 UNIT, F 1 MG-15 UNIT-200 MCG- CHILDRENS CHEWABLE MULTIVITAMIN, 400 UNIT (pediatric CHILDRENS CHEWABLE multivitamins w/fl) VITAMIN, CHILDRENS QUFLORA PEDIATRIC AL(Up to 13 yrs CHEWABLE VITAMINS, CHEW (pediatric F old ); RX/OTC CHILDRENS multivitamins w/fl) MULTIVITAMIN, DINO- F LIFE, FLINTSTONES QUFLORA PEDIATRIC AL(Up to 13 yrs GUMMIES PLUSOMEGA-3 SOLN (pediatric F old ); RX/OTC DHA, FLINTSTONES multivitamins w/fl) PLUS CALCIUM, FLINTSTONES/MY FIRST, Ped MV w/ Iron FRUITY CHEWS, BPROTECTED PEDIA GERBER GROW MIGHTY, POLY-VITE/IRON SOLN F GNP LITTLE ONES (pediatric multiple CHILDRENS, LITTLE vitamins w/ iron) ANIMALS, MULTIVITAMIN PC PEDIATRIC POLY- CHILDRENS, POLY VITAMIN DROPS/IRON VITAMIN, SM ANIMAL SHAPES KIDS FIRST, SOLN (pediatric F ZOO FRIENDS GUMMIES multiple vitamins w/ CHEW iron) Pediatric Vitamins POLY-VITA/IRON SOLN (Pediatric Vitamins Adc) AL(Up to 5 yrs (pediatric multiple F BPROTECTED PEDIA old ) vitamins w/ iron) TRI-VITE, PC PEDIATRIC F Ped Multi Vitamins w/Fl & FE TRI-VITAMIN DROPS, TRI-VITE PEDIATRIC (Ped Multivitamins W/Fl & AL(Up to 13 yrs SOLN Iron) MULTI- old ); RX/OTC VIT/IRON/FLUORIDE, Prenatal Vitamins MULTI- F VITAMIN/FLUORIDE/IRON , MULTIVITAMIN/FLUORID E/IRON SOLN

CA Health & Wellness Preferred Drug List Updated September 1, 2021

225 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Prenatal Vit W/ Docusate- RX/OTC CALNA TABS ( prenatal F Fe Fumarate-Folic Acid) vitamin) PRENATAL 19 TABS 1 MG-3 MG-3 MG-7 MG-12 CENTRUM SPECIALIST F PRENATAL MISC MCG-15 MG-20 MG-20 F MG-25 MG-29 MG-30 (prenatal mv & min w/fe UNIT-100 MG-200 MG-400 fumarate-fa-dha) UNIT-1000 UNIT CLASSIC PRENATAL (Prenatal Vit W/ Docusate- TABS (prenatal vit w/ Iron Carbonyl-Folic Acid) F ferrous fumarate-folic F INATAL GT TABS acid) (Prenatal Vit W/ Ferrous CLINICAL NUTRIENTS Fumarate-Folic Acid) PRENATAL FORMULA PRENATAL 19 CHEW 1 TABS (prenatal vitamins F MG-3 MG-3 MG-6 MG-7 F MG-12 MCG-20 MG-20 w/ ferrous succinate- MG-25 MG-29 MG-30 folic acid) UNIT-100 MG-200 MG-400 CO-NATAL FA TABS RX/OTC UNIT-1000 UNIT (prenatal vit w/ ferrous F (Prenatal Vit W/ Ferrous fumarate-folic acid) Fumarate-Folic Acid) F TRINATE TABS COMPLETE NATAL DHA MISC (prenatal mv & (Prenatal Vit W/ Iron F Carbonyl-Folic Acid) F min w/fe bisglyc-fe prot PRENATABS RX TABS succ-fa-ca-omega 3) ALIVE PRENATAL MULTI- COMPLETENATE CHEW VITAMIN/PLANT DHA (prenatal vit w/ ferrous F CHEW (prenatal F fumarate-folic acid) multivitamins & CVS PRENATAL minerals w/fa-dha) GUMMIES CHEW F ATABEX EC TBEC (prenatal multivitamins (prenatal vit w/ & minerals w/fa-dha) F docusate-iron carbonyl- CVS PRENATAL folic acid) GUMMY/DHA/FOLIC ACID CHEW (prenatal ATABEX OB TABS F (prenatal vit w/ fe multivitamins & bisglycinate chelate- F minerals w/ folic acid- folic acid) fish oil) ATABEX PRENATAL CVS PRENATAL MULTI+DHA CAPS CHEW (prenatal without F a vit w/ iron carbonyl- F (prenatal mv & min w/fe folic acid) fumarate-fa-dha) BRAINSTRONG CVS PRENATAL TABS PRENATAL MISC (prenatal vit w/ ferrous F (prenatal mv & min w/fe F fumarate-folic acid) carbonyl-fa-dha)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

226 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS WOMENS M-NATAL PLUS TABS RX/OTC PRENATAL+DHA MISC ( F prenatal vit w/ ferrous F (prenatal mv & min w/fe fumarate-folic acid) fumarate-fa-dha) MARNATAL-F CAPS ENFAMIL EXPECTA MISC (prenatal without vit a (prenatal mv & min w/fe F w/ iron polysaccharide F fumarate-fa-dha) complex-fa) EQL PRENATAL MULTI PRENATAL TABS FORMULA TABS F (prenatal vit w/ ferrous F (prenatal vit w/ ferrous fumarate-folic acid) fumarate-folic acid) MYNATAL ADVANCE GNP PRENATAL TABS TABS (prenatal vit w/ (prenatal vit w/ ferrous F docusate-iron carbonyl- F fumarate-folic acid) folic acid) GOODSENSE PRENATAL MYNATAL CAPS VITAMINS TABS F (prenatal multivit-min F (prenatal vit w/ ferrous w/fe-fa) fumarate-folic acid) MYNATAL PLUS TABS HEALTHY MAMA BE ( WELL ROUNDED THPK prenatal vit w/ ferrous F fumarate-folic acid) (prenatal vit w/ fe F bisglycinate-folic acid- MYNATAL ULTRACAPLET TABS (prenatal vit w/ omega 3 fatty acd) F HM ONE DAILY docusate-iron carbonyl- PRENATAL COMBO MISC folic acid) (prenatal vit w/ ferrous F MYNATAL-Z TABS fumarate-fa-omega 3 (prenatal vit w/ ferrous F fatty acids) fumarate-folic acid) HM PRENATAL TABS MYNATE 90 PLUS TBCR (prenatal vit w/ (prenatal vit w/ ferrous F F fumarate-folic acid) docusate-fe fumarate- JENLIVA folic acid) PRENATAL/POSTNATAL NATALVIT TABS CAPS (prenatal multivit- F (prenatal vit w/ ferrous F min w/fe-fa) fumarate-folic acid) KP PRENATAL NEONATAL COMPLETE RX/OTC MULTIVITAMINS TABS TABS (prenatal vit w/ F (prenatal vit w/ ferrous ferrous fumarate-folic F fumarate-folic acid) acid) KPN PRENATAL TABS NEONATAL PLUS TABS RX/OTC (prenatal multivit-min F (prenatal vit w/ ferrous F w/fe-fa) fumarate-folic acid)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

227 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEONATAL VITAMIN ONE-A-DAY WOMENS TABS (prenatal vit w/ PRENATAL MISC ferrous fumarate-folic F (prenatal vit w/ ferrous F acid) fumarate-fa-omega 3 NIVA-PLUS TABS RX/OTC fatty acids) (prenatal vit w/ ferrous F PERRY PRENATAL CAPS fumarate-folic acid) (prenatal vit w/ ferrous F O-CAL FA TABS RX/OTC fumarate-folic acid) (prenatal vit w/ ferrous F PNV TABS 29-1 TABS fumarate-folic acid) (prenatal vit w/ iron F O-CAL PRENATAL TABS carbonyl-folic acid) (prenatal vit w/ ferrous F PRE-NATAL FORMULA RX/OTC fumarate-folic acid) TABS (prenatal multivit- F OBSTETRIX EC TABS RX/OTC min w/fe-fa) (prenatal vit w/ PRENATABS FA TABS RX/OTC docusate-iron carbonyl- F (prenatal vit w/ ferrous F folic acid) fumarate-folic acid) OBTREX TABS (prenatal RX/OTC PRENATAL 19 CHEW 1 vit w/ docusate-iron F MG-3 MG-3 MG-7 MG-12 MCG-15 MG-20 MG-20 carbonyl-folic acid) MG-29 MG-30 UNIT-100 ONE A DAY PRENATAL MG-200 MG-400 UNIT- F CHEW (prenatal 1000 UNIT ( F prenatal vit multivitamins & w/ ferrous fumarate- minerals w/fa-dha) folic acid) ONE A DAY WOMENS PRENATAL 19 TABS 1 RX/OTC PRENATAL/DHA MISC MG-3 MG-3 MG-12 MCG- (prenatal vit w/ ferrous F 15 MG-20 MG-20 MG-25 fumarate-fa-omega 3 MG-29 MG-30 UNIT-400 fatty acids) UNIT-7 MG-100 MG-200 MG-1000 UNIT, 1 MG-3 ONE A DAY WOMENS MG-3 MG-7 MG-12 MCG- F PRENATAL1 CAPS 15 MG-20 MG-20 MG-25 (prenatal vitamins w/ F MG-29 MG-30 UNIT-100 iron carbonyl-folic acid- MG-200 MG-400 UNIT- omega 3) 1000 UNIT (prenatal vit ONE VITE WOMENS RX/OTC w/ docusate-fe PRENATALVITAMIN PLUS fumarate-folic acid) TABS (prenatal vit w/ F PRENATAL ADULT ferrous fumarate-folic GUMMY/DHA/FOLIC ACID acid) CHEW (prenatal F ONE VITE WOMENS multivitamins & PRENATALVITAMIN TABS minerals w/fa-dha) F (prenatal vit w/ ferrous PRENATAL AND IRON RX/OTC fumarate-folic acid) TABS (prenatal multivit- F min w/fe-fa) CA Health & Wellness Preferred Drug List Updated September 1, 2021

228 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL COMPLETE PRENATAL TABS (prenatal vit w/ MULTIVITAMIN PLUS ferrous fumarate-folic F DHA MISC (prenatal mv F acid) & min w/fe fumarate-fa- PRENATAL FORMULA A- dha) FREE TABS (prenatal PRENATAL F MULTIVITAMIN TABS without a vit w/ fe F fumarate-folic acid) (prenatal vit w/ ferrous PRENATAL FORMULA fumarate-folic acid) CAPS (prenatal vit w/ PRENATAL ONE DAILY F TABS (prenatal vit w/ ferrous fumarate-fa- F omega 3 fatty acids) ferrous fumarate-folic PRENATAL FORTE TABS RX/OTC acid) (prenatal multivit-min F PRENATAL PLUS IRON w/fe-fa) TABS (prenatal vit w/ F PRENATAL iron carbonyl-folic acid) GUMMIES/DHA & FOLIC PRENATAL TABS 0.5 MG- ACID CHEW (prenatal 0.5 MG-0.5 MG-0.75 MG- F 0.75 MG-2.5 MCG-2.5 MG- multivitamins & 3.75 MG-3.75 UNIT-5 MG- minerals w/fa-omega-3 6.75 MG-15 MG-25 MCG- fatty acids) 25 MG-50 MG-100 UNIT- PRENATAL LOW IRON 200 MCG-500 UNIT, 0.8 TABS (prenatal vit w/ MG-1.5 MG-1.7 MG-2.6 F MG-4 MCG-11 UNIT-18 ferrous fumarate-folic MG-25 MG-27 MG-100 acid) MG-263 MG-400 UNIT- PRENATAL MULTI + DHA 4000 UNIT, 0.8 MG-1.7 CAPS (prenatal mv & MG-1.8 MG-2.6 MG-8 min w/fe fumarate-fa- F MCG-20 MG-25 MG-28 dha) MG-30 UNIT-120 MG-200 MG-400 UNIT-4000 UNIT, PRENATAL MULTI +DHA 1.5 MG-1.7 MG-2.6 MG-4 F CAPS (prenatal vit w/ MCG-5 MG-10 MCG-18 ferrous fumarate-fa- F MG-25 MG-27 MG-100 omega 3 fatty acids) MG-200 MG-800 MCG- 1200 MCG, 1.7 MG-1.8 PRENATAL MG-2.6 MG-8 MCG-20 MULTIVITAMIN + DHA MG-25 MG-28 MG-30 MISC (prenatal mv & F UNIT-120 MG-200 MG-400 min w/fe fumarate-fa- UNIT-800 MCG-4000 dha) UNIT, 1.7 MG-1.84 MG-2.6 PRENATAL MG-4 MCG-11 UNIT-18 MULTIVITAMIN PLUS MG-25 MG-27 MG-100 MG-160 MG-200 MG-400 DHA CAPS (prenatal mv F UNIT-800 MCG-4000 UNIT & min w/fe fumarate-fa- (prenatal vit w/ ferrous dha) fumarate-folic acid)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

229 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL TABS 0.8 MG- RX/OTC PRENATAL/OMEGA- 1.7 MG-1.84 MG-2.6 MG-4 3/FOLIC ACID/IRON CAPS MCG-11 UNIT-18 MG-25 (prenatal vit w/ ferrous F MG-27 MG-100 MG-200 F fumarate-fa-fish oil) MG-400 UNIT-4000 UNIT PRENATRIX TABS RX/OTC (prenatal multivit-min (prenatal vit w/ ferrous F w/fe-fa) fumarate-folic acid) PRENATAL TABS 1 MG- RX/OTC 1.84 MG-2 MG-3 MG-10 PRENATRYL TABS RX/OTC MCG-10 MG-10 MG-12 (prenatal vit w/ ferrous F MCG-20 MG-25 MG-27 fumarate-folic acid) F MG-120 MG-200 MG-1200 PRENATVITE RX TABS RX/OTC MCG (prenatal vit w/ (prenatal multivit-min F ferrous fumarate-folic w/fe-fa) acid) PREPLUS TABS RX/OTC PRENATAL VITAMIN & (prenatal vit w/ ferrous F MINERAL TABS fumarate-folic acid) (prenatal vit w/ ferrous F RX/OTC fumarate-folic acid) PRETAB TABS (prenatal vit w/ ferrous fumarate- F PRENATAL VITAMIN folic acid) TABS (prenatal vit w/ ferrous fumarate-folic F PX PRENATAL MULTIVITAMINS TABS acid) (prenatal vit w/ ferrous F PRENATAL fumarate-folic acid) VITAMIN/IRON TABS (prenatal vit w/ ferrous F QC PRENATAL TABS fumarate-folic acid) (prenatal vit w/ ferrous F fumarate-folic acid) PRENATAL VITAMINS RX/OTC PLUS LOW IRON TABS RA PRENATAL (prenatal vit w/ ferrous F FORMULA/FOLICACID fumarate-folic acid) TABS (prenatal vit w/ F ferrous fumarate-folic PRENATAL VITAMINS acid) TABS (prenatal vit w/ ferrous fumarate-folic F RA PRENATAL TABS acid) (prenatal vit w/ ferrous F fumarate-folic acid) PRENATAL+DHA MISC (prenatal mv & min w/fe F RIGHT STEP PRENATAL fumarate-fa-dha) TABS (prenatal vit w/ ferrous fumarate-folic F PRENATAL-U CAPS acid) (prenatal without a vit w/ fe fumarate-folic F SE-NATAL 19 CHEW acid) (prenatal vit w/ ferrous F fumarate-folic acid)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

230 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SE-NATAL 19 TABS RX/OTC TRINATAL RX 1 TABS (prenatal vit w/ (prenatal vit w/ ferrous F F docusate-fe fumarate- fumarate-folic acid) folic acid) VINATE II TABS SIMILAC PRENATAL (prenatal vit w/ fe EARLY SHIELD MISC F F bisglycinate chelate- (prenatal mv & min w/fe folic acid) fumarate-fa-dha) VINATE ONE TABS SM ONE DAILY (prenatal vit w/ ferrous F PRENATAL MISC fumarate-folic acid) (prenatal vit w/ ferrous F VITAFOL-OB TABS fumarate-fa-omega 3 (prenatal vit w/ ferrous F fatty acids) fumarate-folic acid) SM PRENATAL VITAMINS VITATHELY/GINGER RX/OTC TABS (prenatal vit w/ F TABS (prenatal vit w/ ferrous fumarate-folic ferrous fumarate-folic F acid) acid) STUART ONE CAPS VOL-NATE TABS (prenatal mv & min w/fe F (prenatal vit w/ ferrous F carbonyl-fa-dha) fumarate-folic acid) TARON-BC MISC VOL-PLUS TABS RX/OTC (prenatal without vit a F (prenatal vit w/ ferrous F w/ iron carbonyl-folic fumarate-folic acid) acid & vit b6) VOL-TAB RX TABS THERANATAL ( F COMPLETE MISC prenatal vit w/ iron carbonyl-folic acid) (prenatal mv & min w/fe F fumarate-fa-dha) WEGMANS COMPLETE PRENATAL+DHA MISC THERANATAL CORE RX/OTC ( F NUTRITION TABS prenatal mv & min w/fe fumarate-fa-dha) (prenatal vit w/ ferrous F fumarate-folic acid) WESTAB PLUS TABS RX/OTC ( F THRIVITE RX TABS prenatal vit w/ ferrous fumarate-folic acid) (prenatal vit w/ iron F carbonyl-folic acid) YOUR LIFE MULTI PRENATAL CAPS TL FOLATE TABS (prenatal vit w/ ferrous F (prenatal vit w/ ferrous fumarate-fa-fish oil) fumarate-l methylfolate- F folic acid) Vitamins w/ Lipotropics TRICARE TABS RX/OTC (Vitamins W/ Lipotropics) B-STRESS, BALANCED B- (prenatal vit w/ ferrous F 50 COMPLEX, F fumarate-folic acid) METHACHOLINE/LIVER, MULTI-VITAMIN HP/MINERALS CAPS CA Health & Wellness Preferred Drug List Updated September 1, 2021

231 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MUSCULOSKELETAL THERAPY AGENTS - (Saline) AFRIN SALINE Drugs to Treat Spasms NASAL MIST, ALTAMIST, AYR, BABY AYR SALINE, Central Muscle Relaxants CVS SALINE NASAL SPRAY, DEEP SEA (Carisoprodol) VANADOM F TABS NASAL SPRAY, EQ baclofen tabs or 10 mg, SALINE NASAL SPRAY, F EQL SALINE NASAL 20 mg SPRAY, GNP NASAL MOISTURIZING, HM carisoprodol tabs 350 F mg SALINE NASAL SPRAY, LITTLE NOSES SALINE, chlorzoxazone tabs F LITTLE NOSES STUFFY 500 mg NOSEKIT, MEIJER F cyclobenzaprine hcl SALINE NASAL SPRAY, tabs 10 mg, 5 mg, 7.5 F NASAL MOIST, NASAL MOISTURIZING SPRAY, mg OCEAN FOR KIDS, PX methocarbamol tabs or F SALINE NASAL SPRAY, 500 mg, 750 mg QC SALINE NASAL RELIEF, RA SALINE orphenadrine citrate F NASAL SPRAY, SALINE tb12 or 100 mg MIST, SB SALINE NOSE, SM NASAL SPRAY tizanidine hcl tabs 2 F mg, 4 mg SALINE, TGT NASAL SPRAY, TGT SALINE Direct Muscle Relaxants NASAL SPRAY SOLN dantrolene sodium F saline soln F caps NASAL AGENTS - SYSTEMIC AND TOPICAL - Nasal Antiallergy Drugs to treat the Nose or Sinus azelastine hcl soln F Nasal Agents - Misc. cromolyn sodium F (nasal) aers Nasal Anticholinergics ipratropium bromide F (nasal) soln Nasal Steroids (Budesonide (Nasal)) CVS BUDESONIDE NASAL SPRAY, EQ BUDESONIDE NASAL SPRAY, GNP BUDESONIDE NASAL F SPRAY, RA BUDESONIDE NASAL SPRAY, RHINOCORT ALLERGY SUSP

CA Health & Wellness Preferred Drug List Updated September 1, 2021

232 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Fluticasone Propionate RX/OTC (Triamcinolone Acetonide (Nasal)) ALLERGY NASAL (Nasal)) CVS NASAL SPRAY 24 HOUR, ALLERGY SPRAY, EQ ALLERGY RELIEF, EQ F NASAL ALLERGY SPRAY, ALLERGY RELIEF, QC GNP 24 HOUR NASAL ALLERGY RELIEF SUSP ALLERGY SPRAY, 50 MCG/ACT GOODSENSE NASAL F (Fluticasone Propionate RX/OTC ALLERGY SPRAY, NASAL (Nasal)) ALLERGY NASAL ALLERGY 24 HOUR, SPRAY 24 HOUR, NASAL ALLERGY 24 ALLERGY RELIEF, EQ F HOUR MULTI-SYMPTOM, ALLERGY RELIEF, QC RA NASAL ALLERGY ALLERGY RELIEF SUSP SPRAY AERO NA 50 MCG/ACT budesonide (nasal) F (Fluticasone Propionate RX/OTC susp (Nasal)) CLARISPRAY, CVS FLUTICASONE flunisolide (nasal) soln F PROPRIONATE NASAL RX/OTC SPRAY, EQL fluticasone propionate F FLUTICASONE (nasal) susp PROPIONATE, EQL triamcinolone acetonide F FLUTICASONE (nasal) aero PROPIONATE CHILDRENS, GNP Sympathomimetic Decongestants FLUTICASONE F PROPIONATE, GNP FLUTICASONE PROPIONATE CHILDRENS, HM ALLERGY RELIEF NASAL SPRAY 24HR, KLS ALLER-FLO, QC FLUTICASONE PROPIONATE, SM ALLERGY RELIEF NASAL SPRAY SUSP (Triamcinolone Acetonide (Nasal)) ALLERGY NASAL F SPRAY 24 HOUR AERO 55 MCG/ACT

CA Health & Wellness Preferred Drug List Updated September 1, 2021

233 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Phenylephrine Hcl (Oral)) (Pseudoephedrine Hcl) 12 CVS NASAL HOUR DECONGESTANT, DECONGESTANT PE, 12 HOUR NASAL CVS SINUS PE DECONGESTANT, CVS DECONGESTANT, EQL 12 HOUR NASAL NASAL DECONGESTANT DECONGESTANT, GNP PE MAXIMUM PSEUDOEPHEDRINE STRENGTH, GNP NASAL HCL ER, GNP DECONGESTANT PE PSEUDOEPHEDRINE MAXIMUM STRENGTH, HCL12 HOUR, HM NASAL HM NASAL DECONGESTANT DECONGESTANT PE, 12HOUR, NASAL KLS SUPHEDRINE PE, DECONGESTANT 12 NASAL DECONGESTANT HOUR SINUS, PX NASAL PE, NASAL F DECONGESTANT, QC DECONGESTANT PE SUPHEDRINE MAXIMUM F MAXIMUM STRENGTH, STRENGTH, RA NON-PSEUDO SINUS SUPHEDRINE, SHOPKO DECONGESTANT, PX NASAL DECONGESTANT, NASAL DECONGESTANT SINUS 12 HOUR, SM 12 PE, QC NASAL HOUR SINUS DECONGESTANT PE, RA DECONGESTANT, NASAL DECONGESTANT SUDAFED 12 HOUR, PE, RA SINUS SUDAFED SINUS PRESSURE/CONGESTIO CONGESTION12 HOUR, N RELIEF PE, SM NASAL SUDOGEST 12 HOUR, DECONGESTANT PE, SUPHEDRINE 12HOUR SUDOGEST PE, WAL- MAXIMUM STRENGTH, PHED PE TABS TGT SINUS 12 HOUR, WAL-PHED 12 HOUR, WAL-PHED D TB12

CA Health & Wellness Preferred Drug List Updated September 1, 2021

234 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pseudoephedrine Hcl) pseudoephedrine hcl F CVS NASAL tb12 DECONGESTANT, DECONGESTANT, EQL SUDAFED CHILDRENS NASAL DECONGESTANT, LIQD (pseudoephedrine F EQL NASAL hcl) DECONGESTANT SUDAFED PE MAXIMUM STRENGTH, CHILDRENS NASAL GENAPHED, GNP NASAL DECONGESTANT SOLN F DECONGESTANT, GNP (phenylephrine hcl NASAL DECONGESTANT/MAXIM (oral)) UM STRENGTH, HM NEUROMUSCULAR AGENTS - Drugs to NASAL DECONGESTANT, Relax/Paralyze Muscles KP PSEUDOEPHEDRINE HCL, MEIJER NASAL ALS Agents RADICAVA SOLN PA; SP- DECONGESTANT, NASAL F F DECONGESTANT (edaravone) Caremark;SP MAXIMUM STRENGTH, PX NASAL riluzole tabs F DECONGESTANT, QC SUPHEDRINE, RA Muscular Dystrophy Agents SUPHEDRINE, SHOPKO EXONDYS 51 SOLN PA; SP F NASAL (eteplirsen) DECONGESTANTMAXIM UM STRENGTH, SINUS Neuromuscular Blocking Agent - Neurotoxins CONGESTION BOTOX SOLR PA; SP- F AcariaHealth;S MAXIMUMSTRENGTH, ( ) SM NASAL onabotulinumtoxina P DECONGESTANT DYSPORT SOLR PA; SP- MAXIMUM STRENGTH, F AcariaHealth;S SUDOGEST, SUDOGEST (abobotulinumtoxina) P MAXIMUM STRENGTH, MYOBLOC SOLN PA; SP- WAL-PHED TABS F AcariaHealth;S (rimabotulinumtoxinb) (Pseudoephedrine Hcl) F P GNP SUPHEDRIN LIQD XEOMIN SOLR PA; SP- (Pseudoephedrine Hcl) F AcariaHealth;S NASAL DECONGESTANT F (incobotulinumtoxina) P TABS OR 30 MG Spinal Muscular Atrophy Agents (SMA) ADRENALIN SOLN SPINRAZA SOLN PA (epinephrine hcl F F (nasal)) (nusinersen) NUTRIENTS epinephrine hcl (nasal) F soln Carbohydrates phenylephrine hcl (oral) DEXTROSE 20% SOLN PA F F tabs (dextrose) pseudoephedrine hcl F tabs

CA Health & Wellness Preferred Drug List Updated September 1, 2021

235 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dextrose soln 10 %, PA (Omega-3 Fatty Acids) 250 mg/ml, 5 %, 50 %, F CVS NATURAL FISH OIL, 70 % EQL FISH OIL, EQL OMEGA 3 FISH OIL, DEXTROSE SOLN 20 %, PA F ESKIMO PUREFA, FISH 40 % (dextrose) OIL DOUBLE STRENGTH, POLYCOSE LIQD QL(124 ml per FISH OIL OMEGA-3, FISH F (glucose polymer) fill retail) OIL/SUPER POTENT/NOBURP, KP POLYCOSE POWD QL(350 gm per F FISH OIL, MAXEPA, (glucose polymer) fill retail) MAXIMUM EPA, Lipids NORWEGIAN SALMON OIL, OMEGA III EPA+DHA, CLINOLIPID EMUL ( PA fat F OMEGA-3 CF, OMEGA-3 F emulsion plant based) PLUS, OMERA, PX FISH INTRALIPID EMUL (fat PA OIL, QC FISH OIL, SB F OMEGA-3 FISH OIL, SEA- emulsion plant based) OMEGA, SEA-OMEGA 30, NUTRILIPID EMUL ( PA SM OMEGA-3 FISH OIL, fat F emulsion plant based) SUPER DHA GEMS, SUPER OMEGA 3 Misc. Nutritional Substances EPA/DHA FORMULA, (Docosahexaenoic Acid) SUPER OMEGA-3, ALGAL OMEGA-3 DHA, THERAGRAN-M FISH OIL ATABEX DHA 200, DHA F CONCENTRATE, COMPLETE, DHA THEROMEGA, ULTRA NATURAL OMEGA-3, OMEGA-3 CAPS PRENATAL DHA CAPS (Omega-3 Fatty Acids) (Omega-3 Fatty Acids) EQL OMEGA-3 FISH OIL CVS FISH OIL CAPS 300 CAPS 120 MG-180 MG- F MG-1000 MG, 360 MG- F 300 MG-1000 MG, 144 1200 MG, 360 MG-455 MG-216 MG-360 MG-1200 MG-900 MG-1000 MG MG (Omega-3 Fatty Acids) FISH OIL BURP-LESS CAPS 300 MG-1000 MG, F 60 MG-120 MG-180 MG- 1200 MG, 60 MG-300 MG- 360 MG-1200 MG (Omega-3 Fatty Acids) FISH OIL CONCENTRATE F CAPS 120 MG-180 MG- 300 MG, 300 MG-1000 MG (Omega-3 Fatty Acids) FISH OIL EXTRA F STRENGTH CAPS 360 MG-1200 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

236 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Omega-3 Fatty Acids) omega-3 fatty acids FISH OIL MAXIMUM F caps 1 unit-120 mg-180 STRENGTH CAPS 1200 mg-1000 mg, 1 unit- MG 120 mg-180 mg-340 (Omega-3 Fatty Acids) GNP FISH OIL CAPS 300 F mg-1000 mg, 1 unit- MG-1000 MG 300 mg-1000 mg, 1 (Omega-3 Fatty Acids) HM unit-300 mg-1000 mg- 1000 mg, 100 mg-150 FISH OIL CAPS 300 MG- F 1000 MG, 360 MG-1200 mg-300 mg-1000 mg, MG 1000 mg, 108 mg-180 (Omega-3 Fatty Acids) KP mg-360 mg-1200 mg, OMEGA-3 FISH OIL CAPS F 12 mg-360 mg-360 mg- 600 MG-1200 MG 1200 mg, 120 mg-1000 (Omega-3 Fatty Acids) RA mg-180 mg, 120 mg- FISH OIL CAPS 100 MG- F 180 mg, 120 mg-180 160 MG-1000 MG, 120 MG-180 MG mg-1000 mg, 120 mg- 180 mg-300 mg, 120 (Omega-3 Fatty Acids) SM FISH OIL CAPS 120 MG- mg-180 mg-300 mg- F 180 MG-1000 MG, 300 F 1000 mg, 1200 mg, 144 MG-1000 MG, 360 MG- mg-180 mg-1200 mg, 1200 MG 144 mg-216 mg-1200 mg, 144 mg-216 mg- docosahexaenoic acid F caps 360 mg-1200 mg, 15 unit-144 mg-216 mg- 1200 mg, 180 mg-270 mg-1000 mg, 3 mg-108 mg-162 mg-1000 mg, 300 mg-1000 mg, 350 mg-1000 mg, 360 mg- 1200 mg, 5 unit-120 mg-180 mg, 60 mg-120 mg-180 mg-1200 mg, 60 mg-300 mg-360 mg- 1200 mg, 600 mg-1000 mg, 600 mg-1200 mg Protein-Carbohydrate-Lipid Combinations KABIVEN EMUL (amino PA acids-dextrose-lipids F with electrolytes) PERIKABIVEN EMUL PA (amino acids-dextrose- F lipids with electrolytes) Proteins

CA Health & Wellness Preferred Drug List Updated September 1, 2021

237 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Amino Acid Infusion) PA CLINIMIX PA CLINISOL SF 15%, F 4.25%/DEXTROSE 25% HEPATAMINE, SOLN (amino acid F PLENAMINE SOLN infusion in d25w) AMINOSYN II SOLN 172 PA CLINIMIX PA MG/100ML-200 4.25%/DEXTROSE 5% MG/100ML-270 F MG/100ML-298 SOLN (amino acid MG/100ML-300 infusion in d5w) MG/100ML-400 CLINIMIX 5%/DEXTROSE PA MG/100ML-500 15% SOLN (amino acid F MG/100ML-500 infusion in d15w) MG/100ML-530 MG/100ML-660 CLINIMIX 5%/DEXTROSE PA MG/100ML-700 20% SOLN (amino acid F MG/100ML-722 infusion in d20w) MG/100ML-738 CLINIMIX 5%/DEXTROSE PA MG/100ML-993 25% SOLN (amino acid F MG/100ML-1000 MG/100ML-1018 infusion in d25w) MG/100ML-1050 CLINIMIX E PA MG/100ML, 38 MEQ/L- 2.75%/DEXTROSE 10% 71.8 MEQ/L-172 F SOLN (amino acid F MG/100ML-200 electrolyte w/ calcium MG/100ML-270 infusion in d10w) MG/100ML-298 MG/100ML-300 CLINIMIX E PA MG/100ML-400 2.75%/DEXTROSE 5% MG/100ML-500 SOLN (amino acid F MG/100ML-500 electrolyte w/ calcium MG/100ML-530 infusion in d5w) MG/100ML-660 MG/100ML-700 CLINIMIX E PA MG/100ML-722 4.25%/DEXTROSE 10% MG/100ML-738 SOLN (amino acid F MG/100ML-993 electrolyte w/ calcium MG/100ML-1000 infusion in d10w) MG/100ML-1018 CLINIMIX E PA MG/100ML-1050 4.25%/DEXTROSE 5% MG/100ML (amino acid SOLN (amino acid F infusion) electrolyte w/ calcium AMINOSYN-PF 7% SOLN PA F infusion in d5w) (amino acid infusion) CLINIMIX N9G20E SOLN PA AMINOSYN-PF SOLN PA F (amino acid electrolyte (amino acid infusion) w/ calcium infusion in F CLINIMIX PA d10w) 4.25%/DEXTROSE 10% F FREAMINE HBC 6.9% PA SOLN (amino acid SOLN (amino acid F infusion in d10w) infusion)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

238 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREAMINE III SOLN PA (White Petrolatum-Mineral QL(42 gm per F (amino acid infusion) Oil) ALTALUBE, fill retail) NEPHRAMINE SOLN PA ARTIFICAL EYE, CVS F DRY-EYE RELIEF (amino acid infusion) NIGHTTIME, CVS EYE PREMASOL SOLN PA LUBRICANT, CVS F (amino acid infusion) LUBRICATING EYE OINTMENT/OVERNIGHT, PROSOL SOLN ( PA amino F CVS NIGHTTIME DRY- acid infusion) EYE RELIEF, EQ SYNTHAMIN 17 SOLN PA RESTORE PM, EYE F (amino acid infusion) LUBRICANT, FOR STY TRAVASOL SOLN PA RELIEF, GENTEAL F TEARS NIGHT-TIME, GNP (amino acid infusion) LUBRICANT PM, TROPHAMINE SOLN PA HYPOTEARS, F F (amino acid infusion) LUBRICANT EYE, LUBRICANT EYE FAST OPHTHALMIC AGENTS - Drugs to Treat the Eye ACTING, LUBRICANT EYE NIGHTTIME, LUBRICANT Artificial Tears and Lubricants EYE PM, LUBRICANT PM, (Polyvinyl Alcohol) LUBRIFRESH P.M., ARTIFICIAL TEARS SOLN F PURALUBE, REFRESH 1.4 % LACRI-LUBE, REFRESH P.M., RETAINE PM, (Polyvinyl Alcohol) TEARS F AGAIN SOLN SOOTHE NIGHTTIME DRY EYETHERAPY, STYE, SYSTANE NIGHTTIME, TEARS AGAIN, TGT LUBRICANT EYE NIGHTTIME, ULTRA FRESH PM OINT (White Petrolatum-Mineral QL(42 gm per Oil) ARTIFICIAL TEARS F fill retail) OINT 15 %-83 %-83 % NUTRATEAR SOLN F (polyvinyl alcohol) polyvinyl alcohol soln F Beta-blockers - Ophthalmic (Timolol Maleate (Ophth)) QL(60 ea per TIMOLOL MALEATE IN F fill retail) OCUDOSE SOLN betaxolol hcl (ophth) F soln BETOPTIC-S SUSP F (betaxolol hcl (ophth))

CA Health & Wellness Preferred Drug List Updated September 1, 2021

239 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carteolol hcl (ophth) F phenylephrine hcl F soln (mydriatic) soln 2.5 % dorzolamide hcl-timolol tropicamide soln F maleate soln 0.5 %-2 Miotics %, 22.3 mg/ml-6.8 F mg/ml, 5 mg/ml-20 PHOSPHOLINE IODIDE mg/ml, 6.8 mg/ml-22.3 SOLR (echothiophate F mg/ml iodide) levobunolol hcl soln F pilocarpine hcl soln F timolol maleate (ophth) F Ophthalmic - Angiogenesis Inhibitors solg 0.25 %, 0.5 % LUCENTIS SOLN 0.3 PA; SP- MG/0.05ML, 0.5 AcariaHealth;S timolol maleate (ophth) F F soln 0.25 %, 0.5 % MG/0.05ML P (ranibizumab) QL(60 ea per timolol maleate (ophth) F soln 0.5 % fill retail) LUCENTIS SOSY 0.5 PA; SP- MG/0.05ML F AcariaHealth;S TIMOPTIC OCUDOSE (ranibizumab) P SOLN 0.25 % (timolol F maleate (ophth)) Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % TIMOPTIC-XE SOLG F (brimonidine tartrate) (timolol maleate F (ophth)) apraclonidine hcl soln F Cycloplegic Mydriatics brimonidine tartrate F (Homatropine Hbr) F soln HOMATROPAIRE SOLN IOPIDINE SOLN F (Phenylephrine Hcl (apraclonidine hcl) (Mydriatic)) ALTAFRIN F SOLN 2.5 % Ophthalmic Anti-infectives (Bacitracin-Polymyxin B atropine sulfate F (ophthalmic) oint (Ophth)) AK-POLY-BAC, F POLYCIN OINT ATROPINE SULFATE (Gentamicin Sulfate F SOLN OP 1 % (atropine F (Ophth)) GENTAK OINT sulfate (ophthalmic)) (Neomycin-Bacitracin Zn- CYCLOMYDRIL SOLN Polymyxin) NEO-POLYCIN F (cyclopentolate w/ F OINT phenylephrine) bacitracin (ophthalmic) F cyclopentolate hcl soln F oint bacitracin-polymyxin b F homatropine hbr soln F (ophth) oint ISOPTO ATROPINE SOLN CILOXAN OINT (atropine sulfate F (ciprofloxacin hcl F (ophthalmic)) (ophth))

CA Health & Wellness Preferred Drug List Updated September 1, 2021

240 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tetrahydrozoline Hcl QL(30 ml per ciprofloxacin hcl F (ophth) soln (Ophth)) CVS EYE DROPS fill retail) ORIGINAL, EQ EYE erythromycin (ophth) F DROPS, EQL EYE oint DROPS, EYE DROPS, HM F gatifloxacin (ophth) EYE DROPS, PX STERILE F EYE DROPS, QC EYE soln DROPS, REDNESS gentamicin sulfate F RELIEVER EYE DROPS, (ophth) soln SM EYE DROPS SOLN QL(3 ml per fill (Tetrahydrozoline Hcl QL(30 ml per moxifloxacin hcl (ophth) F soln retail) (Ophth)) GNP EYE F fill retail) DROPS, GOODSENSE NATACYN SUSP F EYE DROPS SOLN 0.05 % (natamycin) Ophthalmic Immunomodulators neomycin-bacitracin F RESTASIS EMUL PA F zn-polymyxin oint (cyclosporine (ophth)) neomycin-polymyxin- F RESTASIS MULTIDOSE PA gramicidin soln EMUL (cyclosporine F ofloxacin (ophth) soln F (ophth)) polymyxin b- Ophthalmic Kinase Inhibitors F RHOPRESSA SOLN PA trimethoprim soln F (netarsudil dimesylate) sulfacetamide sodium F (ophth) oint Ophthalmic Local Anesthetics (Tetracaine Hcl (Ophth)) sulfacetamide sodium F ALTACAINE, TETCAINE, F (ophth) soln TETRAVISC, TETRAVISC tobramycin (ophth) soln F FORTE SOLN PA TOBREX OINT proparacaine hcl soln F F (tobramycin (ophth)) tetracaine hcl (ophth) F trifluridine soln F soln Ophthalmic Steroids Ophthalmic Decongestants (Bacitracin-Poly-Neomycin- (Naphazoline W/ Hc) NEO-POLYCIN HC F Pheniramine) ALLERGY OINT EYE DROPS, CVS EYE ALLERGY RELIEF, EQ bacitracin-poly- F EYE ALLERGY RELIEF, F neomycin-hc oint EYE ALLERGY RELIEF, BLEPHAMIDE S.O.P. RA EYE ALLERGY OINT (sulfacetamide F RELIEF, TGT EYE ALLERGY RELIEF SOLN sod-prednisolone) (Naphazoline W/ BLEPHAMIDE SUSP Pheniramine) VISINE F (sulfacetamide sod- F SOLN 0.025 %-0.3 % prednisolone)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

241 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dexamethasone TOBRADEX OINT QL(4 gm per fill sodium phosphate F (tobramycin- F retail) (ophth) soln dexamethasone) tobramycin- fluorometholone F F (ophth) susp dexamethasone susp FML FORTE SUSP Ophthalmics - Misc. (fluorometholone F (Ketotifen Fumarate (ophth)) (Ophth)) ALAWAY, FML OINT ALAWAY CHILDRENS (fluorometholone F ALLERGYEYE ITCH RELIEF, ALLERGY EYE (ophth)) DROPS, CLARITIN EYE, MAXIDEX SUSP CVS ALLERGY EYE (dexamethasone F DROPS, CVS EYE ITCH (ophth)) RELIEF, EYE ITCH F RELIEF, GNP EYE ITCH neomycin-polymy- F RELIEF, GNP ITCHY EYE, dexameth oint HM EYE ITCH RELIEF, KP KETOTIFEN FUMARATE, neomycin-polymy- F dexameth susp RA EYE ITCH RELIEF, SM EYE ITCH RELIEF, neomycin-polymyxin-hc F THERATEARS ALLERGY (ophth) susp EYE ITCH RELIEF SOLN PRED MILD SUSP (Sodium Chloride (prednisolone acetate F Hypertonic) (ophth)) ALTACHLORE, CVS F SODIUM CHLORIDE, CVS PRED-G S.O.P. OINT SODIUM CHLORIDE (gentamicin- F HYPERTONICITY OINT prednisolone acetate) (Sodium Chloride PRED-G SUSP Hypertonic) (gentamicin- F ALTACHLORE, CVS F prednisolone acetate) SODIUM CHLORIDE, SOCHLOR SOLN prednisolone acetate F ALOCRIL SOLN QL(5 ml per fill (ophth) susp (nedocromil sodium F retail) PREDNISOLONE (ophth)) ACETATE P-F SUSP ALOMIDE SOLN QL(10 ml per (prednisolone acetate F (lodoxamide F fill retail) (ophth)) tromethamine) PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 azelastine hcl (ophth) F % (prednisolone sodium F soln phosphate (ophth)) F QL(15 ml per brinzolamide susp fill retail) sulfacetamide sod- F prednisolone soln bromfenac sodium F (ophth) soln

CA Health & Wellness Preferred Drug List Updated September 1, 2021

242 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(10 ml per (Carbamide Peroxide cromolyn sodium F (ophth) soln fill retail) (Otic)) CLEARCANAL EARWAX SOFTENER, Limit 4 bottles CVS EAR DROPS, CVS CYSTARAN SOLN F per EARWAX REMOVAL KIT, (cysteamine hcl) month;QL(2.15 CVS EARWAX REMOVAL ml daily) SYSTEM, EAR DROPS, QL(5 ml per fill EAR DROPS EARWAX diclofenac sodium F (ophth) soln retail) REMOVALAID, EAR WAX REMOVAL DROPS, EAR dorzolamide hcl soln F WAX REMOVAL KIT, EAR WAX REMOVAL SYSTEM, DORZOLAMIDE HCL F EARWAX REMOVAL, SOLN (dorzolamide hcl) EARWAX REMOVAL KIT, EQ EAR DROPS, EQ EAR flurbiprofen sodium F soln WAX REMOVAL AID, GNP EAR DROPS, GNP EAR F ketorolac tromethamine F SYSTEMS, GNP EARWAX (ophth) soln REMOVAL DROPS, GNP ketotifen fumarate EARWAX REMOVAL KIT, F GOODSENSE EAR WAX (ophth) soln REMOVAL DROPS, MURO 128 SOLN 2 % GOODSENSE EAR WAX (sodium chloride F REMOVAL KIT, MURINE hypertonic) EAR, MURINE FOR EAR WAX REMOVAL SYSTEM, sodium chloride F OTIX, QC EAR WAX hypertonic oint REMOVAL DROPS, QC EARWAX REMOVAL, QC sodium chloride F hypertonic soln EARWAX REMOVAL KIT, RA EAR DROPS, RA Prostaglandins - Ophthalmic EARWAX REMOVAL KIT, Limit 2.5mls SM EAR DROPS SOLN F per bimatoprost soln month;QL(0.09 acetic acid (otic) soln F ml daily) Otic Anti-infectives latanoprost soln F ciprofloxacin hcl (otic) F Limit 2.5mls soln LUMIGAN SOLN F per ofloxacin (otic) soln F (bimatoprost) month;QL(0.09 ml daily) Otic Combinations OTIC AGENTS - Drugs to Treat the Ear (Pramoxine-Hc- QL(15 ml per Chloroxylenol) CORTIC- F fill retail) Otic Agents - Miscellaneous ND, EXOTIC-HC SOLN QL(7.5 ml per ciprofloxacin- F dexamethasone susp 30 days retail) neomycin-polymyxin-hc F (otic) soln

CA Health & Wellness Preferred Drug List Updated September 1, 2021

243 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits neomycin-polymyxin-hc F ampicillin caps F (otic) susp Natural Penicillins Otic Steroids penicillin v potassium (Fluocinolone Acetonide F QL(20 ml per F (Otic)) FLAC OIL fill retail) solr QL(20 ml per penicillin v potassium fluocinolone acetonide F F (otic) oil fill retail) tabs QL(10 ml per Penicillin Combinations hydrocortisone w/acetic F acid soln fill retail) amoxicillin & pot F OXYTOCICS - Drugs to Prevent/Control Uterine clavulanate chew Bleeding amoxicillin & pot F Oxytocics clavulanate susr (Methylergonovine amoxicillin & pot F Maleate) METHERGINE F clavulanate tabs TABS amoxicillin & pot F methylergonovine F clavulanate tb12 maleate tabs or 0.2 mg AUGMENTIN SUSR 31.25 PASSIVE IMMUNIZING AND TREATMENT MG/5ML-125 MG/5ML AGENTS - Antibody Drugs to Treat Low Immune (amoxicillin & pot F System clavulanate) Immune Serums Penicillinase-Resistant Penicillins HYPERRHO S/D SOSY SP- dicloxacillin sodium F (rho d immune globulin F AcariaHealth;S caps (human)) P nafcillin sodium solr ij 1 PA RHOGAM ULTRA- SP- F FILTERED PLUS SOSY AcariaHealth;S gm, 2 gm F P PA (rho d immune globulin nafcillin sodium solr iv 1 F (human)) gm, 10 gm, 2 gm Monoclonal Antibodies NAFCILLIN SODIUM PA SOLR IV 10 GM (nafcillin F SYNAGIS SOLN PA; SP- F AcariaHealth;S sodium) (palivizumab) P PHARMACEUTICAL ADJUVANTS PENICILLINS - Drugs to Treat Bacterial Infections Internal Vehicle Ingredients/Agents Aminopenicillins SIMPLYTHICK EASY MIX GEL (xanthan gum F amoxicillin caps F (thickening)) amoxicillin chew F SIMPLYTHICK EASYMIX GEL (xanthan gum F amoxicillin susr F (thickening)) amoxicillin tabs F

CA Health & Wellness Preferred Drug List Updated September 1, 2021

244 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIMPLYTHICK GEL galantamine F (xanthan gum F hydrobromide cp24 (thickening)) galantamine F Semi Solid Vehicles hydrobromide soln (Lanolin) HPA LANOLIN RX/OTC F galantamine F OINT hydrobromide tabs lanolin oint F RX/OTC memantine hcl cp24 14 PA mg, 21 mg, 28 mg, 7 F PROGESTINS - Hormone Replacement/Modifying Drugs mg memantine hcl soln 10 F Progestins mg/5ml, 2 mg/ml hydroxyprogesterone PA; SP- F memantine hcl tabs 10 caproate oil AcariaHealth F mg, 5 mg, MAKENA SOAJ SC 275 PA; SP- MG/1.1ML AcariaHealth NAMENDA XR TITRATION PA (hydroxyprogesterone F PACK CP24 (memantine F caproate) hcl) rivastigmine pt24 F PA medroxyprogesterone F acetate tabs PA rivastigmine tartrate F norethindrone acetate F caps tabs Combination Psychotherapeutics progesterone caps 100 QL(1 ea daily) F chlordiazepoxide- mg F amitriptyline tabs progesterone caps 200 F olanzapine-fluoxetine mg CO hcl caps PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental and perphenazine- F Emotional Conditions amitriptyline tabs SYMBYAX CAPS Agents for Chemical Dependency (olanzapine-fluoxetine CO acamprosate calcium CO hcl) tbec Fibromyalgia Agents ANTABUSE TABS CO SAVELLA TABS PA (disulfiram) F (milnacipran hcl) disulfiram tabs CO SAVELLA TITRATION PA; QL(55 ea LUCEMYRA TABS PACK MISC F per 365 days CO retail) (lofexidine hcl) (milnacipran hcl) Antidementia Agents Movement Disorder Drug Therapy tetrabenazine tabs 12.5 AL(At least 21 donepezil F F yrs old) hydrochloride tabs mg tetrabenazine tabs 25 AL(At least 21 donepezil F F yrs old); SP hydrochloride tbdp mg CA Health & Wellness Preferred Drug List Updated September 1, 2021

245 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Multiple Sclerosis Agents REBIF REBIDOSE SOAJ PA; SP- F AcariaHealth;S PA; SP- (interferon beta-1a) (Glatiramer Acetate) F P GLATOPA SOSY AcariaHealth;S P REBIF REBIDOSE PA; SP- PA; SP- TITRATIONPACK SOAJ F AcariaHealth;S AUBAGIO TABS P F AcariaHealth;S (interferon beta-1a) (teriflunomide) P REBIF SOSY (interferon PA; SP- F AcariaHealth;S AVONEX PEN AJKT PA; SP- beta-1a) F AcariaHealth;S P (interferon beta-1a) P REBIF TITRATION PACK PA; SP- SOSY (interferon beta- F AcariaHealth;S AVONEX PSKT PA; SP- F AcariaHealth;S 1a) P (interferon beta-1a) P TYSABRI CONC PA; SP- BETASERON KIT PA; SP- F AcariaHealth;S F AcariaHealth;S (natalizumab) P (interferon beta-1b) P Premenstrual Dysphoric Disorder (PMDD) Agents PA; SP dalfampridine tb12 F QL(1 ea fluoxetine hcl (pmdd) F daily,270 ea dimethyl fumarate cpdr F PA; SP caps 10 mg per 9999 days retail) PA; SP dimethyl fumarate misc F QL(2 ea daily) fluoxetine hcl (pmdd) F caps 20 mg EXTAVIA KIT (interferon PA; SP- F AcariaHealth;S Psychotherapeutic and Neurological Agents - beta-1b) P ergoloid mesylates tabs F GILENYA CAPS 0.5 MG PA; SP- F AcariaHealth;S (fingolimod hcl) P pimozide tabs CO PA; SP- glatiramer acetate sosy F AcariaHealth;S Smoking Deterrents P LEMTRADA SOLN PA; SP- F (alemtuzumab (ms)) Caremark;SP OCREVUS SOLN PA; SP- F AcariaHealth;S (ocrelizumab) P PLEGRIDY SOPN SC PA; SP F (peginterferon beta-1a) PLEGRIDY SOSY SC PA; SP F (peginterferon beta-1a) PLEGRIDY STARTER PA; SP PACK SOPN F (peginterferon beta-1a) PLEGRIDY STARTER PA; SP PACK SOSY F (peginterferon beta-1a)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

246 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS (Nicotine Polacrilex) CVS NICOTINE LOZENGE, NICOTINE, CVS CVS NICOTINE NICOTINE POLACRILEX, POLACRILEX, EQ CVS NICOTINE NICOTINE LOZENGES, POLACRILEX STARTER, EQ NICOTINE EQ NICOTINE POLACRILEX, EQL POLACRILEX, EQL NICOTINE POLACRILEX, NICOTINE POLACRILEX, GNP NICOTINE MINI EQL NICOTINE LOZENGE, GNP POLACRILEX REFILL, NICOTINE POLACRILEX, EQL NICOTINE GNP NICOTINE POLACRILEX STARTER, POLACRILEX MINI, GNP NICOTINE GUM, GOODSENSE NICOTINE, F GNP NICOTINE F GOODSENSE NICOTINE POLACRILEX, POLACRILEX, HM GOODSENSE NICOTINE NICOTINE POLACRILEX, GUM, GOODSENSE KLS QUIT2, KLS QUIT4, NICOTINE POLACRILEX NICOTINE MINI GUM, HM NICOTINE LOZENGE, NICOTINE POLACRILEX, KLS QUIT2, POLACRILEX MINI, PX KLS QUIT4, PX STOP STOP SMOKING AID, RA SMOKING AID, RA MINI NICOTINE, RA NICOTINE, RA NICOTINE NICOTINE POLACRILEX, GUM, SM NICOTINE, SM SM NICOTINE, SM NICOTINE POLACRILEX, NICOTINE POLACRILEX, TGT NICOTINE GUM, TGT TGT NICOTINE NICOTINE POLACRILEX, POLACRILEX LOZG THRIVE GUM

CA Health & Wellness Preferred Drug List Updated September 1, 2021

247 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine) CVS NICOTINE SM NICOTINE TRANSDERMALSYSTEM, TRANSDERMAL CVS NICOTINE SYSTEM/STEP 1/CLEAR, TRANSDERMALSYSTEM SM NICOTINE STEP 1, CVS NICOTINE TRANSDERMAL TRANSDERMALSYSTEM SYSTEM/STEP 2/CLEAR, STEP 2, CVS NICOTINE SM NICOTINE TRANSDERMALSYSTEM/ TRANSDERMAL STEP 3, EQ NICOTINE, SYSTEM/STEP 3/CLEAR, EQ NICOTINE STEP 3, TGT NICOTINE STEP GNP NICOTINE ONE, TGT NICOTINE TRANSDERMALSYSTEM, STEP THREE, TGT GNP NICOTINE NICOTINE STEP TWO TRANSDERMALSYSTEM PT24 STEP 2, HABITROL, HM APO-VARENICLINE TABS QL(2 ea daily) F NICOTINE (varenicline tartrate) TRANSDERMAL SYSTEM, QL(2 ea daily) HM NICOTINE bupropion hcl (smoking F TRANSDERMAL SYSTEM deterrent) tb12 STEP 1, HM NICOTINE CHANTIX CONTINUING QL(2 ea daily) TRANSDERMAL SYSTEM MONTHPAK TABS F STEP 2, HM NICOTINE (varenicline tartrate) TRANSDERMAL SYSTEM STEP 3, HM NICOTINE CHANTIX STARTING TRANSDERMALSYSTEM, MONTH PAK TABS F (varenicline tartrate) NICOTINE STEP 1, F NICOTINE STEP 3, CHANTIX TABS QL(2 ea daily) F NICOTINE (varenicline tartrate) TRANSDERMAL SYSTEM STEP 1, NICOTINE nicotine polacrilex gum F TRANSDERMAL SYSTEM STEP 1/CLEAR, nicotine polacrilex lozg F NICOTINE TRANSDERMAL SYSTEM nicotine pt24 F STEP 2, NICOTINE TRANSDERMAL SYSTEM NICOTINE STEP 2/CLEAR, TRANSDERMAL SYSTEM F NICOTINE KIT (nicotine) TRANSDERMAL SYSTEM QL(16.8 ea STEP 3, NICOTINE NICOTROL INHALER F daily,1512 ea TRANSDERMAL INHA (nicotine) per 90 days SYSTSTEM STEP retail) 3/CLEAR, QC NICOTINE NICOTROL NS SOLN QL(360 ml per TRANSDERMAL F SYSTEM/STEP 1, QC (nicotine) 90 days retail) NICOTINE RESPIRATORY AGENTS - MISC. - Drugs to TRANSDERMAL Treat Lung Conditions SYSTEM/STEP 2, RA NICOTINE, RA NICOTINE Alpha-Proteinase Inhibitor (Human) TRANSDERMAL SYSTEM, SM NICOTINE TRANSDERMAL SYSTEM, CA Health & Wellness Preferred Drug List Updated September 1, 2021

248 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARALAST NP SOLR 1000 PA; SP (Doxycycline MG (alpha1-proteinase F (Monohydrate)) AVIDOXY F inhibitor (human)) TABS ARALAST NP SOLR 500 PA; SP- (Doxycycline Caremark;SP (Monohydrate)) F MG (alpha1-proteinase F MONDOXYNE NL CAPS inhibitor (human)) 100 MG GLASSIA SOLN (alpha1- PA; SP- (Doxycycline Hyclate) proteinase inhibitor F Caremark;SP MORGIDOX 1X100MG, (human)) MORGIDOX 1X50MG, F MORGIDOX 2X100MG PROLASTIN-C SOLN PA; SP CAPS (alpha1-proteinase F inhibitor (human)) doxycycline (monohydrate) caps F PROLASTIN-C SOLR PA; SP 100 mg, 50 mg (alpha1-proteinase F inhibitor (human)) doxycycline (monohydrate) susr 25 F ZEMAIRA SOLR (alpha1- PA; SP mg/5ml proteinase inhibitor F (human)) doxycycline (monohydrate) tabs F Cystic Fibrosis Agents 100 mg, 50 mg KALYDECO PACK PA; SP F doxycycline hyclate (ivacaftor) F caps 100 mg, 50 mg KALYDECO TABS PA; SP F (ivacaftor) doxycycline hyclate F tabs 100 mg, 20 mg ORKAMBI PACK PA; SP- Acaria F (lumacaftor-ivacaftor) Health;SP minocycline hcl caps F ORKAMBI TABS PA; SP- Acaria 100 mg, 50 mg, 75 mg F (lumacaftor-ivacaftor) Health;SP tetracycline hcl caps F PULMOZYME SOLN SP- VIBRAMYCIN SYRP 50 F AcariaHealth;S (dornase alfa) P MG/5ML (doxycycline F SYMDEKO TBPK PA calcium) F (tezacaftor-ivacaftor) THYROID AGENTS - Drugs to Regulate Thyroid Hormones SULFONAMIDES - Drugs to Treat Bacterial Infections Antithyroid Agents Sulfonamides methimazole tabs F SULFADIAZINE TABS F (sulfadiazine) propylthiouracil tabs F TETRACYCLINES - Drugs to Treat Bacterial Thyroid Hormones Infections (Levothyroxine Sodium) Tetracyclines EUTHYROX, LEVO-T, F LEVOXYL, UNITHROID TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

249 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Thyroid) NP THYROID Limit 1 dose 120, NP THYROID 15, NP ADACEL SUSP (tetanus per 10 years;1 THYROID 30, NP F toxoid-diphtheria- rtl MAX fill,999 THYROID 60, NP F rtl day(s) THYROID 90 TABS acellular pertussis supply,; AL(At ARMOUR THYROID TABS adsorb (tdap)) least 19 yrs 120 MG, 15 MG, 30 MG, F old) 60 MG, 90 MG (thyroid) Limit 1 dose ARMOUR THYROID TABS BOOSTRIX SUSP per 10 years;1 180 MG, 240 MG, 300 MG (tetanus toxoid- rtl MAX fill,999 F F rtl day(s) (thyroid) diphtheria-acellular supply,; AL(At CYTOMEL TABS 5 MCG pertussis adsorb (tdap)) least 19 yrs F (liothyronine sodium) old) levothyroxine sodium Limit 1 dose tabs or 100 mcg, 112 per 10 years;1 TDVAX SUSP (tetanus- rtl MAX fill,999 mcg, 125 mcg, 137 F rtl day(s) mcg, 150 mcg, 175 F diphtheria toxoids (td)) supply,; AL(At mcg, 200 mcg, 25 mcg, least 19 yrs 300 mcg, 50 mcg, 75 old) mcg, 88 mcg Limit 1 dose liothyronine sodium per 10 years;1 F TENIVAC INJ (tetanus- rtl MAX fill,999 tabs F rtl day(s) NATURE-THROID NT-2.5 diphtheria toxoids (td)) F supply,; AL(At TABS (thyroid) least 19 yrs NATURE-THROID TABS old) 130 MG, 16.25 MG, 195 Limit 1 dose F MG, 32.5 MG, 65 MG TETANUS/DIPHTHERIA per 10 years;1 (thyroid) TOXOIDS-ADSORBED rtl MAX fill,999 F rtl day(s) SYNTHROID TABS ADULT SUSP (tetanus- F supply,; AL(At (levothyroxine sodium) diphtheria toxoids (td)) least 19 yrs thyroid tabs F old) ULCER DRUGS - Drugs to Treat Bowel, Intestine WESTHROID TABS 130 and Stomach Conditions MG, 195 MG, 32.5 MG, 65 F MG (thyroid) Antispasmodics WP THYROID TABS 130 (Hyoscyamine Sulfate) ED- MG, 16.25 MG, 32.5 MG, F SPAZ, NULEV, OSCIMIN F 65 MG (thyroid) TBDP (Hyoscyamine Sulfate) TOXOIDS OSCIMIN SR, SYMAX-SR F TB12 Toxoid Combinations (Hyoscyamine Sulfate) F OSCIMIN SUBL (Hyoscyamine Sulfate) F OSCIMIN TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

250 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CUVPOSA SOLN (Famotidine) ACID RX/OTC F (glycopyrrolate) CONTROL MAXIMUM STRENGTH, ACID dicyclomine hcl caps F CONTROLLER, ACID CONTROLLER MAXIMUM dicyclomine hcl soln F STRENGTH, ACID REDUCER MAXIMUM dicyclomine hcl tabs F STRENGTH, ACID REDUCER ORIGINAL glycopyrrolate tabs or 1 F STRENGTH, CVS ACID mg, 2 mg CONTROLLER, CVS ACID hyoscyamine sulfate CONTROLLER MAXIMUM F STRENGTH, EQ elix or 0.125 mg/5ml FAMOTIDINE MAXIMUM STRENGTH, EQL hyoscyamine sulfate F soln or 0.125 mg/ml HEARTBURN PREVENTION, EQL hyoscyamine sulfate F HEARTBURN subl sl 0.125 mg PREVENTION/MAXIMUM STRENGTH, FAMOTIDINE hyoscyamine sulfate F tabs or 0.125 mg MAXIMUM STRENGTH, FAMOTIDINE ORIGINAL hyoscyamine sulfate F STRENGTH, GNP ACID tb12 or 0.375 mg REDUCER, GNP ACID F hyoscyamine sulfate REDUCER F MAXIMUMSTRENGTH, tbdp or 0.125 mg HEARTBURN RELIEF MAXIMUMSTRENGTH, propantheline bromide F tabs KLS ACID CONTROLLER SYMAX DUOTAB TBCR MAXIMUM STRENGTH, F MM ACID-PEP MAXIMUM (hyoscyamine sulfate) STRENGTH, MM H-2 Antagonists FAMOTIDINE, PX ACID (Cimetidine) CIMETIDINE RX/OTC REDUCER MAXIMUM 200, CIMETIDINE ACID STRENGTH, QC ACID REDUCER, EQ CONTROLLER, QC ACID CIMETIDINE ACID F CONTROLLER MAXIMUM REDUCER, GNP STRENGTH, RA ACID HEARTBURN RELIEF, SB REDUCER, RA ACID CIMETIDINE TABS REDUCER MAXIMUM STRENGTH, SB ACID (Cimetidine) CVS RX/OTC CONTROLLER, SB ACID HEARTBURN RELIEF, EQ CONTROLLER MAXIMUM ACID REDUCER, STRENGTH, SM ACID HEARTBURN RELIEF, PX F REDUCER MAXIMUM ACID REDUCER, SM STRENGTH, ZANTAC 360, ACID REDUCER TABS ZANTAC 360 MAXIMUM 200 MG STRENGTH TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

251 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID (Famotidine) ACID CONTROL MAXIMUM REDUCER, EQ ACID STRENGTH, ACID REDUCER, HEARTBURN CONTROLLER, ACID RELIEF, HM F CONTROLLER MAXIMUM FAMOTIDINE, PX ACID STRENGTH, ACID REDUCER, SB ACID REDUCER MAXIMUM REDUCER, SM ACID STRENGTH, ACID REDUCER TABS 10 MG REDUCER ORIGINAL (Famotidine) HM RX/OTC STRENGTH, CVS ACID FAMOTIDINE TABS 20 F CONTROLLER, CVS ACID MG CONTROLLER MAXIMUM STRENGTH, EQ FAMOTIDINE MAXIMUM STRENGTH, EQL HEARTBURN PREVENTION, EQL HEARTBURN PREVENTION/MAXIMUM STRENGTH, FAMOTIDINE MAXIMUM STRENGTH, FAMOTIDINE ORIGINAL STRENGTH, GNP ACID REDUCER, GNP ACID F REDUCER MAXIMUMSTRENGTH, HEARTBURN RELIEF MAXIMUMSTRENGTH, KLS ACID CONTROLLER MAXIMUM STRENGTH, MM ACID-PEP MAXIMUM STRENGTH, MM FAMOTIDINE, PX ACID REDUCER MAXIMUM STRENGTH, QC ACID CONTROLLER, QC ACID CONTROLLER MAXIMUM STRENGTH, RA ACID REDUCER, RA ACID REDUCER MAXIMUM STRENGTH, SB ACID CONTROLLER, SB ACID CONTROLLER MAXIMUM STRENGTH, SM ACID REDUCER MAXIMUM STRENGTH, ZANTAC 360, ZANTAC 360 MAXIMUM STRENGTH TABS

CA Health & Wellness Preferred Drug List Updated September 1, 2021

252 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ranitidine Hcl) ACID RX/OTC (Ranitidine Hcl) ACID CONTROL MAXIMUM CONTROL MAXIMUM STRENGTH, ACID STRENGTH, ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, CVS ACID STRENGTH, CVS ACID REDUCER, CVS ACID REDUCER, CVS ACID REDUCER REDUCER MAXIMUMSTRENGTH, MAXIMUMSTRENGTH, CVS RANITIDINE, EQ CVS RANITIDINE, EQ RANITIDINE, EQL ACID RANITIDINE, EQL ACID REDUCER, EQL ACID REDUCER, EQL ACID REDUCER REDUCER MAXIMUMSTRENGTH, MAXIMUMSTRENGTH, EQL HEARTBURN RELIEF EQL HEARTBURN RELIEF MAXIMUM STRENGTH, MAXIMUM STRENGTH, GNP ACID CONTROL 150 GNP ACID CONTROL 150 MAXIMUM STRENGTH, MAXIMUM STRENGTH, GNP ACID REDUCER, GNP ACID REDUCER, HEARTBURN RELIEF 150 HEARTBURN RELIEF 150 MAXIMUM STRENGTH, MAXIMUM STRENGTH, HM ACID REDUCER F HM ACID REDUCER F MAXIMUM STRENGTH, MAXIMUM STRENGTH, KLS ACID REDUCER, KLS KLS ACID REDUCER, KLS ACID REDUCER ACID REDUCER MAXIMUMSTRENGTH, PX MAXIMUMSTRENGTH, PX ACID REDUCER ACID REDUCER MAXIMUM STRENGTH, MAXIMUM STRENGTH, PX RANITIDINE, RA ACID PX RANITIDINE, RA ACID REDUCER, RA ACID REDUCER, RA ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, RANITIDINE STRENGTH, RANITIDINE 150 MAXIMUM 150 MAXIMUM STRENGTH, RANITIDINE STRENGTH, RANITIDINE ACID REDUCER, SB ACID ACID REDUCER, SB ACID REDUCER RANITIDINE REDUCER RANITIDINE 75, SM ACID REDUCER 75, SM ACID REDUCER MAXIMUM STRENGTH, MAXIMUM STRENGTH, TGT ACID REDUCER, TGT ACID REDUCER, WAL-ZAN 150 MAXIMUM WAL-ZAN 150 MAXIMUM STRENGTH, WAL-ZAN 75 STRENGTH, WAL-ZAN 75 TABS TABS (Ranitidine Hcl) ACID REDUCER, EQ ACID REDUCER, GOODSENSE ACID REDUCER, HM F ACID REDUCER, PX ACID REDUCER, SM ACID REDUCER TABS 75 MG

CA Health & Wellness Preferred Drug List Updated September 1, 2021

253 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ranitidine Hcl) ACID RX/OTC (Esomeprazole QL(2 ea daily); REDUCER, EQ ACID Magnesium) CVS RX/OTC REDUCER, GOODSENSE F ESOMEPRAZOLE ACID REDUCER, HM MAGNESIUM, GNP ACID REDUCER, SB ACID ESOMEPRAZOLE REDUCER TABS 150 MG MAGNESIUM, GOODSENSE cimetidine hcl soln 300 F ESOMEPRAZOLE F mg/5ml MAGNESIUM, HM cimetidine tabs 200 mg F RX/OTC ESOMEPRAZOLE MAGNESIUM DELAYED RELEASE, KLS cimetidine tabs 300 F mg, 400 mg, 800 mg ESOMEPRAZOLE MAGNESIUM, SM famotidine susr 40 F ESOMEPRAZOLE mg/5ml MAGNESIUM CPDR (Lansoprazole) CVS QL(1 ea daily); famotidine tabs 10 mg, F F 40 mg LANSOPRAZOLE TBDD RX/OTC RX/OTC (Lansoprazole) CVS QL(2 ea daily); famotidine tabs 20 mg F LANSOPRAZOLE, EQ RX/OTC GNP ACID CONTROL 150 RX/OTC LANSOPRAZOLE, GNP MAXIMUM STRENGTH F LANSOPRAZOLE, TABS (ranitidine hcl) GOODSENSE LANSOPRAZOLE, QL(2 ea daily) ranitidine hcl caps or F HEARTBURN F 150 mg, 300 mg TREATMENT 24 HOUR, ranitidine hcl syrp or 15 HM LANSOPRAZOLE, KLS LANSOPRAZOLE, QC mg/ml, 150 mg/10ml, F LANSOPRAZOLE, RA 75 mg/5ml LANSOPRAZOLE, SM RX/OTC LANSOPRAZOLE CPDR ranitidine hcl tabs or F 150 mg (Omeprazole Magnesium) QL(1 ea daily) ACID REDUCER TBEC 20 F ranitidine hcl tabs or F MG 300 mg, 75 mg (Omeprazole) CVS QL(1 ea daily) Misc. Anti-Ulcer OMEPRAZOLE TBEC 20 F MG sucralfate susp F (Omeprazole) EQ QL(1 ea daily) F OMEPRAZOLE, EQL sucralfate tabs OMEPRAZOLE, GNP Proton Pump Inhibitors OMEPRAZOLE, HM OMEPRAZOLE, KLS OMEPRAZOLE, PX F OMEPRAZOLE, RA OMEPRAZOLE, SB OMEPRAZOLE, SM OMEPRAZOLE, TGT OMEPRAZOLE TBEC QL(2 ea daily); esomeprazole F magnesium cpdr 20 mg RX/OTC CA Health & Wellness Preferred Drug List Updated September 1, 2021

254 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); lansoprazole cpdr 15 F trospium chloride cp24 F mg RX/OTC QL(2 ea daily) trospium chloride tabs F lansoprazole cpdr 30 F mg Urinary Antispasmodics - Cholinergic Agonists lansoprazole tbdd 15 QL(1 ea daily); F RX/OTC bethanechol chloride F mg tabs QL(1 ea daily) lansoprazole tbdd 30 F mg Urinary Antispasmodics - Direct Muscle Relaxants QL(2 ea daily) flavoxate hcl tabs F omeprazole cpdr 10 F mg, 40 mg VACCINES omeprazole cpdr 20 mg F QL(2 ea daily); RX/OTC Bacterial Vaccines QL(1 ea daily) omeprazole F ACTHIB SOLR AL(At least 19 magnesium tbec 20 mg (haemophilus b polysac F yrs old) omeprazole tbec 20 mg F QL(1 ea daily) conj vac) Limit 2 fills per pantoprazole sodium QL(1 ea daily) BEXSERO SUSY Lifetime;2 rtl F (meningococcal vac tbec 20 mg F MAX fill,999 rtl pantoprazole sodium QL(2 ea daily) group b (recombant day(s) supply,; F omv adjuvanted)) AL(At least 19 tbec 40 mg yrs old) Ulcer Drugs - Prostaglandins HIBERIX SOLR AL(At least 19 (haemophilus b polysac F yrs old) misoprostol tabs F conj vac) Ulcer Therapy Combinations MENACTRA INJ AL(At least 19 amoxicillin- QL(112 ea per (meningococcal yrs old) clarithromycin w/ F fill retail) (a,c,y&w-135) F lansoprazole misc polysaccharide conjugate vaccine) URINARY ANTISPASMODICS - Drugs to Treat MENQUADFI INJ AL(At least 19 Miscellaneous Bladder Spasms (meningococcal yrs old) Urinary Antispasmodic - Antimuscarinics (a,c,y&w-135) F polysaccharide conjugate oxybutynin chloride F syrp vaccine) MENVEO SOLR AL(At least 19 oxybutynin chloride F yrs old) tabs (meningococcal (a,c,y&w-135) F oxybutynin chloride F oligosaccharide conjugate tb24 vac) QL(1 ea daily) Limit 5 per tolterodine tartrate F cp24 2 mg, 4 mg PNEUMOVAX 23 INJ lifetime;5 rtl (pneumococcal vac F MAX fill,999 rtl tolterodine tartrate tabs F day(s) supply,; 1 mg, 2 mg polyvalent) AL(At least 19 yrs old)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

255 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 5 per AFLURIA QUADRIVALENT Limit 1 fill per lifetime;5 rtl 2021-2022 SUSP 180 days;AL(At PNEUMOVAX 23/1 DOSE F INJ (pneumococcal vac F MAX fill,999 rtl (influenza virus vaccine least 19 yrs day(s) supply,; split quadrivalent) old) polyvalent) AL(At least 19 yrs old) AFLURIA QUADRIVALENT Limit 1 fill per 2021-2022 SUSY 180 days;AL(At Limit 1 dose F PREVNAR 13 SUSP (influenza virus vaccine least 19 yrs per lifetime;1 rtl old) (pneumococcal 13- split quadrivalent) F MAX fill,999 rtl valent conjugate day(s) supply,; ASTRAZENECA COVID-19 AL(At least 19 vaccine) VACCINE SUSP (covid- CO yrs old) 19 (sars-cov-2) Limit 3 doses adenovirus vaccine) TRUMENBA SUSY per lifetime;3 rtl Limit 3 per (meningococcal group F MAX fill,999 rtl lifetime;3 rtl b vaccine day(s) supply,; ENGERIX-B INJ ( F MAX fill,999 rtl (recombinant)) AL(At least 19 hepatitis b vaccine day(s) supply,; yrs old) (recomb)) AL(At least 19 TYPHIM VI SOLN PA yrs old) (typhoid vi F Limit 3 per polysaccharide ENGERIX-B SUSP lifetime;3 rtl vaccine) (hepatitis b vaccine F MAX fill,999 rtl VAXCHORA SUSR PA day(s) supply,; (recomb)) AL(At least 19 (cholera vaccine live F yrs old) attenuated) FLUAD 2019-2020 SUSY Limit 1 fill per VIVOTIF CPDR ( PA typhoid F (influenza virus vaccine 180 days;AL(At vaccine) types a & b surface F least 19 yrs old) Viral Vaccines antigen adjuvant) AFLURIA QUADRIVALENT Limit 1 fill per FLUAD 2020-2021 SUSY Limit 1 fill per 2019-2020 SUSP 180 days;AL(At (influenza virus vaccine 180 days;AL(At F (influenza virus vaccine F least 19 yrs types a & b surface least 19 yrs split quadrivalent) old) antigen adjuvant) old) AFLURIA QUADRIVALENT Limit 1 fill per FLUAD QUADRIVALENT Limit 1 fill every 2019-2020 SUSY 180 days;AL(At 2021-2022 PRSY 180 days;AL(At F (influenza virus vaccine least 19 yrs (influenza virus vacc F least 19 yrs split quadrivalent) old) types a & b surf antigen old) AFLURIA QUADRIVALENT Limit 1 fill per adjuvant quad) 2020-2021 SUSP 180 days;AL(At F FLUAD QUADRIVALENT Limit 1 fill every (influenza virus vaccine least 19 yrs INFLUENZA VACCINE 180 days;AL(At split quadrivalent) old) FOR ADULTS PRSY least 19 yrs F AFLURIA QUADRIVALENT Limit 1 fill per (influenza virus vacc old) 2020-2021 SUSY 180 days;AL(At types a & b surf antigen (influenza virus vaccine F least 19 yrs adjuvant quad) split quadrivalent) old)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

256 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUARIX QUADRIVALENT Limit 1 fill per FLUCELVAX Limit 1 fill per 2019-2020 SUSY 180 days;AL(At QUADRIVALENT 2020- 180 days;AL(At (influenza virus vaccine F least 19 yrs 2021 SUSP (influenza least 19 yrs split quadrivalent) old) virus vaccine tissue- F old) FLUARIX QUADRIVALENT Limit 1 fill per cultured subunit 2020-2021 SUSY 180 days;AL(At quadrivalent) F (influenza virus vaccine least 19 yrs FLUCELVAX Limit 1 fill per split quadrivalent) old) QUADRIVALENT 2020- 180 days;AL(At FLUARIX QUADRIVALENT Limit 1 fill per 2021 SUSY (influenza least 19 yrs 2021-2022 SUSY 180 days;AL(At virus vaccine tissue- F old) (influenza virus vaccine F least 19 yrs cultured subunit split quadrivalent) old) quadrivalent) FLUBLOK Limit 1 fill per FLUCELVAX Limit 1 fill per QUADRIVALENT 2019- 180 days;AL(At QUADRIVALENT 2021- 180 days;AL(At 2020 SOSY (influenza least 19 yrs 2022 SUSP (influenza least 19 yrs virus vac recomb F old) virus vaccine tissue- F old) hemagglutinin (ha) cultured subunit quadrivalent) quadrivalent) FLUBLOK Limit 1 fill per FLUCELVAX Limit 1 fill per QUADRIVALENT 2020- 180 days;AL(At QUADRIVALENT 2021- 180 days;AL(At 2021 SOSY (influenza least 19 yrs least 19 yrs F 2022 SUSY (influenza virus vac recomb old) virus vaccine tissue- F old) hemagglutinin (ha) cultured subunit quadrivalent) quadrivalent) FLUBLOK Limit 1 fill per FLULAVAL Limit 1 fill per QUADRIVALENT 2021- 180 days;AL(At QUADRIVALENT 2019- 180 days;AL(At 2022 SOSY (influenza least 19 yrs least 19 yrs F old) 2020 SUSP (influenza F virus vac recomb virus vaccine split old) hemagglutinin (ha) quadrivalent) quadrivalent) FLULAVAL Limit 1 fill per FLUCELVAX Limit 1 fill per QUADRIVALENT 2019- 180 days;AL(At QUADRIVALENT 2019- 180 days;AL(At 2020 SUSY (influenza F least 19 yrs 2020 SUSP (influenza least 19 yrs old) virus vaccine tissue- F old) virus vaccine split cultured subunit quadrivalent) quadrivalent) FLULAVAL Limit 1 fill per QUADRIVALENT 2020- 180 days;AL(At FLUCELVAX Limit 1 fill per 2021 SUSY ( least 19 yrs QUADRIVALENT 2019- 180 days;AL(At influenza F virus vaccine split old) 2020 SUSY (influenza least 19 yrs virus vaccine tissue- F old) quadrivalent) cultured subunit FLULAVAL Limit 1 fill per QUADRIVALENT 2021- 180 days;AL(At quadrivalent) 2022 SUSY (influenza F least 19 yrs virus vaccine split old) quadrivalent)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

257 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUMIST Limit 1 fill per FLUZONE Limit 1 fill per QUADRIVALENT SUSP 180 days;AL(At QUADRIVALENT 2021- 180 days;AL(At F (influenza virus vaccine least 19 yrs 2022 SUSY (influenza F least 19 yrs live quadrivalent) old) virus vaccine split old) FLUZONE HIGH-DOSE PF Limit 1 fill per quadrivalent) 2019-2020 SUSY 180 days;AL(At Limit 3 per (influenza virus vaccine F least 19 yrs GARDASIL 9 SUSP lifetime;3 rtl old) split high-dose (human papillomavirus F MAX fill,999 rtl preservative free) (hpv) 9-valent recombinant day(s) supply,; vaccine) AL(At least 19 FLUZONE HIGH-DOSE PF Limit 1 fill every yrs old) 2020-2021 SUSY 180 days;AL(At least 19 yrs Limit 3 per (influenza virus vac F GARDASIL 9 SUSY lifetime;3 rtl split high-dose quad old) (human papillomavirus F MAX fill,999 rtl preservative free) (hpv) 9-valent recombinant day(s) supply,; FLUZONE HIGH-DOSE PF Limit 1 fill every vaccine) AL(At least 19 2021-2022 SUSY 180 days;AL(At yrs old) (influenza virus vac F least 19 yrs Limit 2 fills per split high-dose quad old) Lifetime;2 rtl HAVRIX SUSP ( preservative free) hepatitis F MAX fill,999 rtl a vaccine) day(s) supply,; FLUZONE Limit 1 fill per AL(At least 19 QUADRIVALENT 2019- 180 days;AL(At yrs old) 2020 SUSP (influenza F least 19 yrs old) Limit 2 fills per virus vaccine split HEPLISAV-B SOLN Lifetime;2 rtl quadrivalent) (hepatitis b vaccine F MAX fill,999 rtl FLUZONE Limit 1 fill per recombinant day(s) supply,; QUADRIVALENT 2019- 180 days;AL(At adjuvanted) AL(At least 19 yrs old) 2020 SUSY (influenza F least 19 yrs virus vaccine split old) Limit 2 fills per HEPLISAV-B SOSY Lifetime;2 rtl quadrivalent) (hepatitis b vaccine F MAX fill,999 rtl FLUZONE Limit 1 fill per recombinant day(s) supply,; QUADRIVALENT 2020- 180 days;AL(At adjuvanted) AL(At least 19 2021 SUSP (influenza F least 19 yrs yrs old) virus vaccine split old) IMOVAX RABIES quadrivalent) (H.D.C.V.) INJ (rabies F FLUZONE Limit 1 fill per virus vaccine, hdc) QUADRIVALENT 2020- 180 days;AL(At IXIARO SUSP (japanese PA 2021 SUSY (influenza F least 19 yrs encephalitis vaccine F old) virus vaccine split inactivated adsorbed) quadrivalent) JANSSEN COVID-19 FLUZONE Limit 1 fill per VACCINE SUSP (covid- CO QUADRIVALENT 2021- 180 days;AL(At 19 (sars-cov-2) 2022 SUSP (influenza F least 19 yrs adenovirus vaccine) virus vaccine split old) quadrivalent)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

258 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 fills per Limit 2 fills per M-M-R II SOLR Lifetime;2 rtl Lifetime;2 rtl MAX fill,999 rtl VARIVAX INJ (varicella MAX fill,999 rtl (measles, mumps & F F day(s) supply,; virus vaccine live) day(s) supply,; rubella virus vaccines) AL(At least 19 AL(At least 19 yrs old) yrs old) MODERNA COVID-19 YF-VAX INJ ( PA yellow F VACCINE SUSP (covid- CO fever vaccine) 19 (sars-cov-2) mrna Limit 1 dose virus vaccine) per lifetime;1 rtl ZOSTAVAX SUSR NOVAVAX COVID-19 F MAX fill,999 rtl VACCINE SUSP (covid- (zoster vaccine live) day(s) supply,; 19 (sars-cov-2) subunit CO AL(At least 50 (spike) protein virus yrs old) vaccine) VAGINAL AND RELATED PRODUCTS PFIZER-BIONTECH COVID-19VACCINE SUSP Spermicides CO (covid-19 (sars-cov-2) ENCARE SUPP F mrna virus vaccine) (nonoxynol-9) RABAVERT SUSR F OPTIONS GYNOL II (rabies vaccine, pcec) VAGINALCONTRACEPTIV F Limit 3 per E GEL (nonoxynol-9) RECOMBIVAX HB SUSP lifetime;3 rtl SHUR-SEAL GEL F ( F MAX fill,999 rtl (nonoxynol-9) hepatitis b vaccine day(s) supply,; (recomb)) TODAY SPONGE MISC AL(At least 19 F yrs old) (nonoxynol-9) Limit 2 doses VCF VAGINAL SHINGRIX SUSR (zoster per lifetime;2 rtl CONTRACEPTIVE FILM F F MAX fill,999 rtl FILM (nonoxynol-9) vaccine recombinant day(s) supply,; adjuvanted) VCF VAGINAL AL(At least 50 CONTRACEPTIVE FOAM yrs old) F FOAM (nonoxynol-9) STAMARIL SUSR ( PA yellow F VCF VAGINAL fever vaccine) CONTRACEPTIVEGEL F Limit 5 per GEL (nonoxynol-9) TWINRIX SUSY lifetime;5 rtl Vaginal Anti-infectives (hepatitis a F MAX fill,999 rtl (inactivated)-hepatitis b day(s) supply,; (Clotrimazole Vaginal) 3 QL(21 gm per (recombinant) vaccines) AL(At least 19 DAY VAGINAL, fill retail) yrs old) CLOTRIMAZOLE 3, Limit 2 fills per CLOTRIMAZOLE-7, CVS Lifetime;2 rtl CLOTRIMAZOLE 3, GNP F VAQTA SUSP ( CLOTRIMAZOLE 3, RA hepatitis F MAX fill,999 rtl a vaccine) day(s) supply,; CLOTRIMAZOLE 7, SM 3- AL(At least 19 DAY VAGINAL, SM yrs old) CLOTRIMAZOLE VAGINAL CREA

CA Health & Wellness Preferred Drug List Updated September 1, 2021

259 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Clotrimazole Vaginal) 3 (Miconazole Nitrate DAY VAGINAL, Vaginal) MICONAZOLE 7, F CLOTRIMAZOLE 3, SM MICONAZOLE 7 SUPP CLOTRIMAZOLE-7, CVS (Tioconazole Vaginal) CVS CLOTRIMAZOLE 3, GNP F TIOCONAZOLE 1, EQ CLOTRIMAZOLE 3, RA TIOCONAZOLE 1, EQL CLOTRIMAZOLE 7, SM 3- TIOCONAZOLE-1, GNP DAY VAGINAL, SM TIOCONAZOLE 1, CLOTRIMAZOLE MONISTAT 1-DAY, RA F VAGINAL CREA TIOCONAZOLE 1, SM (Metronidazole Vaginal) F TIOCONAZOLE-1, TGT VANDAZOLE GEL TIOCONAZOLE 1, TGT (Miconazole Nitrate TIOCONAZOLE 1DAY, Vaginal) CVS TIOCONAZOLE 1, MICONAZOLE 3 TIOCONAZOLE-1 OINT COMBINATION PACK, AVC CREA F EQL MICONAZOLE 3, (sulfanilamide vaginal) GNP MICONAZOLE 3, MICONAZOLE 3 clindamycin phosphate F COMBINATIONPACK, vaginal crea MICONAZOLE 3 COMBO F CLINDESSE CREA PACK, PX MICONAZOLE (clindamycin phosphate F 3-DAY COMBO PACK, RA (one dose)) MICONAZOLE 3 COMBINATION PACK, SM clotrimazole vaginal F MICONAZOLE 3, TGT crea MICONAZOLE 3 GYNAZOLE-1 CREA COMBINATION PACK, (butoconazole nitrate F VAGISTAT-3 KIT (one dose)) (Miconazole Nitrate Vaginal) CVS metronidazole vaginal F MICONAZOLE 7, EQ gel MICONAZOLE 7 DAY miconazole nitrate TREATMENT, EQL F MICONAZOLE 7, GNP vaginal crea MICONAZOLE 7, F QL(45 gm per terconazole vaginal F MICONAZOLE 7, QC 3 crea 0.4 % fill retail) DAY VAGINAL CREAM, terconazole vaginal QL(20 gm per QC MICONAZOLE 7, RA F fill retail) MICONAZOLE 7, SM crea 0.8 % MICONAZOLE 7, TGT QL(3 ea per fill terconazole vaginal F MICONAZOLE 7 CREA supp 80 mg retail) (Miconazole Nitrate Vaginal) MICONAZOLE 3 F Vaginal Estrogens CREA 4 % estradiol vaginal crea F (Miconazole Nitrate QL(3 ea per fill 0.1 mg/gm Vaginal) MICONAZOLE 3 F retail) PREMARIN CREA VA SUPP 200 MG 0.625 MG/GM (estrogens, conjugated F vaginal) CA Health & Wellness Preferred Drug List Updated September 1, 2021

260 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VASOPRESSORS - Drugs to Treat Heart and (Cholecalciferol) D 1000, D Circulation Conditions 400, D 5000, D-1000, D- 1000 EXTRA STRENGTH, Anaphylaxis Therapy Agents D-400, D-5000, D3, D3 epinephrine QL(2 ea per fill HIGH POTENCY, D3-1000, (anaphylaxis) soaj 0.15 retail) DELTA D3, GNP VITAMIN F D MAXIMUM STRENGTH, mg/0.15ml, 0.15 GNP VITAMIN D SUPER mg/0.3ml, 0.3 mg/0.3ml STRENGTH, GNP Vasopressors VITAMIN D-400, GNP VITAMIN D3 EXTRA midodrine hcl tabs F STRENGTH, HM VITAMIN F D, NAT-RUL VITAMIN D, VITAMINS NATURAL VITAMIN D-3, QC VITAMIN D3, RA Oil Soluble Vitamins VITAMIN D-3, RADIANCE (Cholecalciferol) PLATINUM VITAMIN D3, AQUEOUS VITAMIN D SM VITAMIN D, SM INFANTS, BABY SUPER VITAMIN D3, THERA-D DAILY D3, BABY VITAMIN 2000, THERA-D RAPID D3 DROPS, REPLETION, VITAMIN D- BPROTECTED PEDIA D- 1000 MAXIMUM VITE, D-VITE PEDIATRIC, F STRENGTH, VITAMIN D- D3 MAXIMUM 400 TABS STRENGTH, JUST D, (Cholecalciferol) D 1000, D PHARMACIST CHOICE D- 5000, D-3-5, D2000 VITAMIN PEDIATRIC ULTRA STRENGTH, D3 DROPS, VITAMIN D HIGH POTENCY, D3 INFANT LIQD MAXIMUM STRENGTH, (Cholecalciferol) CVS D3, D3 SUPER STRENGTH, D3-1000, D3-50, EQL VITAMIN D3 CAPS F 1000 UNIT, 2000 UNIT, DIALYVITE VITAMIN D 5000 UNIT 5000, GNP D 1000, KLS D3, KP VITAMIN D3, F OPTIMAL-D, OPTIMAL-D PACK, PRONUTRIENTS VITAMIN D3, QC VITAMIN D3, RA VITAMIN D-3, SM VITAMIN D3, VITAMIN D HIGH POTENCY, VITAMIN D3 HIGH POTENCY, VITAMIN D3 MAXIMUM STRENGTH, WEEKLY-D CAPS (Cholecalciferol) DECARA F CAPS 50000 UNIT (Cholecalciferol) GNP VITAMIN D TABS 1000 F UNIT

CA Health & Wellness Preferred Drug List Updated September 1, 2021

261 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cholecalciferol) HM cholecalciferol caps VITAMIN D3 CAPS 2000 F 1.25 mg, 1000 unit, 125 UNIT mcg, 2000 unit, 25 F (Cholecalciferol) HM mcg, 50 mcg, 5000 VITAMIN D3 TABS 25 F MCG unit, 50000 unit (Cholecalciferol) KP cholecalciferol liqd 400 F VITAMIN D CAPS 1000 F unit/ml, 5000 unit/ml UNIT, 2000 UNIT cholecalciferol tabs (Cholecalciferol) SM 1000 unit, 125 mcg, F VITAMIN D3 MAXIMUM F 2000 unit, 25 mcg, 400 STRENGTH CAPS 5000 UNIT unit, 50 mcg, 5000 unit F (Cholecalciferol) VITAMIN F ergocalciferol caps D3 TABS OR 2000 UNIT (Ergocalciferol) ergocalciferol soln F CALCIDOL, CALCIFEROL F SOLN KEY-E CHEW (vitamin e) F (Phytonadione) K 100 F phytonadione tabs or F TABS 100 mcg, 5 mg (Vitamin E) ALPH-E, ALPH-E-MIXED, CVS E, E- vitamin e caps or 100 200, E-400, E-400-CLEAR, unit, 180 mg, 200 unit, F E200, E400, EQL VITAMIN 400 unit, 45 mg, 90 mg E, GNP VITAMIN E VITAMIN E CHEW OR 400 F WATER DISPERSIBLE, UNIT ( ) HM E VITAMIN, KP vitamin e VITAMIN E, PX VITAMIN F Water Soluble Vitamins E, QC VITAMIN E, RA NATURAL VITAMIN E, RA VITAMIN E, VITAMIN E BLEND, VITAMIN E HIGH POTENCY, VITAMIN E- 200, VITAMIN E/D-ALPHA NATURAL CAPS (Vitamin E) CVS VITAMIN E CAPS OR 180 MG, 400 F UNIT (Vitamin E) GNP VITAMIN E, HM VITAMIN E, SM F VITAMIN E CAPS 200 UNIT, 400 UNIT (Vitamin E) NATURAL VITAMIN E CAPS 100 F UNIT, 400 UNIT BABY DDROPS LIQD 400 UNT/0.03ML F (cholecalciferol)

CA Health & Wellness Preferred Drug List Updated September 1, 2021

262 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ascorbic Acid) ASCO- (Pyridoxine Hcl) B6 TABS-1000, C 1000, C NATURAL, CVS B6, EQL 250, C 500, C 500/ROSE B-6, GNP VITAMIN B-6, HIPS, C-1000, C- KP VITAMIN B-6, NEURO- F 1000/ROSE HIPS, C-250, K-50, QC VITAMIN B6, RA C-500, C-500/ROSE HIPS, VITAMIN B-6, SM VITAMIN CVS VITAMIN C, CVS B-6, SM VITAMIN B6, YL VITAMIN C/ROSE HIPS, VITAMIN B-6 TABS EQL VITAMIN C, EQL (Riboflavin) CVS VITAMIN F VITAMIN C/ROSE HIPS, B-2 TABS GNP VITAMIN C W/ROSE HIPS, GNP VITAMIN (Thiamine Hcl) B1 HIGH C/ROSE HIPS, MEIJER C, POTENCY, CVS B-1, CVS F B1, GNP VITAMIN B-1, QC NATURAL C/ROSE HIPS, F PUREWAY-C, PX VITAMIN B1 TABS VITAMIN C, QC C WITH (Thiamine Mononitrate) HM ROSE HIPS, RA VITAMIN VITAMIN B1, RA VITAMIN F C/ROSE HIPS, SB B-1, SM VITAMIN B1 VITAMIN C, SM VIT TABS C/ROSE HIPS, SM ascorbic acid tabs or 10 VITAMIN C/ROSE HIPS, mg-500 mg, 1000 mg, VITAMIN C PLUS F BIOFLAVONOIDS/WILD 250 mg, 500 mg, 500 ROSE HIPS, VITAMIN mg-10 mg C/NATURAL ROSE HIPS, B-1 TABS (thiamine hcl) F YL VITAMIN C, YL VITAMIN C/ROSE HIPS niacin cpcr 250 mg, F TABS 500 mg (Ascorbic Acid) GNP niacin tabs 100 mg, 50 VITAMIN C, SM VITAMIN F F C TABS 1000 MG, 250 mg, 500 mg MG, 500 MG niacin tbcr 250 mg, 500 F (Ascorbic Acid) HM mg, 750 mg VITAMIN C, QC VITAMIN F C TABS 1000 MG, 500 MG NIACIN TR TBCR (niacin) F (Ascorbic Acid) RA pyridoxine hcl tabs or F VITAMIN C TABS 250 MG, F 100 mg, 25 mg, 50 mg 500 MG (Niacin) ENDUR-ACIN, HM riboflavin tabs 100 mg, F NIACIN, HM NIACIN TR, F 25 mg, 50 mg SM NIACIN CR TBCR thiamine hcl soln F (Niacin) KP NIACIN, NIACIN-50, PX NIACIN, F thiamine hcl tabs F RA NIACIN, RA NO FLUSH NIACIN 500 TABS thiamine mononitrate F tabs

CA Health & Wellness Preferred Drug List Updated September 1, 2021

263 Index 12 hour allergy-d 65 3ML LUER-LOK SYRINGE21G ABILIFY MAINTENA 49 12 hour decongestant 234 X 1-1/2" 126 ABILIFY MYCITE 49 3ML LUER-LOK SYRINGE22G 1ST TIER UNIFINE X 1" 126 abiraterone acetate 43 PENTIPS/MINI/31GX5MM 125 3ML LUER-LOK SYRINGE25G ABOUTTIME PEN NEEDLE 1ST TIER UNIFINE X 5/8" 126 32GX 5/32" 127 PENTIPS29GX12MM 125 3ML LUER-LOK TIP ABOUTTIME PEN NEEDLES 1ST TIER UNIFINE SYRINGE25G X 1-1/2" 126 30GX 5/16" 127 PENTIPS31GX6MM 125 3ML SYRINGE/18G X 1- ABOUTTIME PEN NEEDLES 1ST TIER UNIFINE 1/2"/LUER LOCK TIP 126 31G X 3/16" 127 PENTIPS31GX8MM 125 3ML SYRINGE/20G X 1"/LUER ABOUTTIME PEN NEEDLES 1ST TIER UNIFINE LOCK TIP 126 31G X 5/16" 127 PENTIPS32GX4MM 125 3ML SYRINGE/20G X 1"/LUER acamprosate calcium 245 1ST TIER UNIFINE SLIP TIP 126 acarbose 26 PENTIPS32GX6MM 125 3ML SYRINGE/20G X 1- 1ST TIER UNIFINE ACCU-CHEK FASTCLIX 1/2"/LUER LOCK TIP 126 LANCETDEVICE KIT 112 PENTIPS33GX4MM 125 3ML SYRINGE/21G X 1"/LUER 1ST TIER UNIFINE ACCU-CHEK MULTICLIX LOCK TIP 126 LANCET DEVICE KIT 112 PENTIPSPLUS 31GX8MM 125 3ML SYRINGE/21G X 1"/LUER 1ST TIER UNIFINE ACCU-CHEK SOFTCLIX SLIP TIP 126 LANCETDEVICE KIT 112 PENTIPSPLUS 32GX4MM 125 3ML SYRINGE/21G X 1- 1ST TIER UNIFINE ACE AEROSOL CLOUD 1/2"/LUER LOCK TIP 126 ENHANCER 188 PENTIPSPLUS 33GX4MM 125 3ML SYRINGE/21G X 1- 1ST TIER UNIFINE 1/4"/LUER LOCK TIP 126 acebutolol hcl 59 PENTIPSPLUS/MINI/31GX5MM 3ML SYRINGE/22G 1- acetaminophen 9 125 1/2"/LUER LOCK TIP 126 acetaminophen junior 1ST TIER UNIFINE 3ML SYRINGE/22G X 1"/LUER strength 7 PENTIPSPLUS/ORIGINAL/29GX LOCK TIP 126 12MM 125 acetaminophen w/ codeine 13 3ML SYRINGE/22G X 1- acetazolamide 85 1ST TIER UNIFINE 1/4"/LUER LOCK TIP 126 PENTIPSPLUS/ULTRA 3ML SYRINGE/22G X acetic acid 90 SHORT/31GX6MM 125 3/4"/LUER LOCK TIP 126 acetic acid (otic) 243 1ST TIER UNILET 3ML SYRINGE/22G X acetylcysteine 68 COMFORTOUCH LANCETS 3/4"/LUER SLIP TIP 126 28G 112 acid control maximum 3ML SYRINGE/25G X 1"/LUER strength 251 1ST TIER UNILET LOCK TIP 126 COMFORTOUCH LANCETS 3ML SYRINGE/27G X 1- acid controller 252 30G 112 1/4"/LUER LOCK TIP 126 acid reducer 253,254 24hr allergy relief 37 3ML SYRINGE/LUER LOCK acne foaming wash 69 3 day vaginal 259 TIP 127 3ML SYRINGE/LUER LOCK acne medication 10 69 3ML LUER LOCK SAFETY ACNE MEDICATION 10 69 SYRINGES 3ML/22G X 1 1/2" TIP23GX1" 127 125 3ML SYRINGE/LUER LOCK ACNE MEDICATION 5 69 3ML LUER LOCK SAFETY TIP25G X 1-1/2" 127 acne treatment cleansingbar SYRINGES/3ML/21G X 1 1/2" 3ML SYRINGE/LUER SLIP maximum strength 69 125 TIP23GX1" 127 ACTEMRA 3 3ML SYRINGE/NEEDLE 3ML LUER LOCK SAFETY ACTHAR 86 SYRINGES/3ML/22G X 1" 125 REGULAR WALL LUER-LOK 3ML LUER LOCK SAFETY 25GX5/8" SUB-Q 127 ACTHIB 255 SYRINGES/3ML/23G X 1" 125 7t lido gel 80 ACTIMMUNE 46 3ML LUER LOCK SAFETY abacavir sulfate 55 activite 205 SYRINGES/3ML/25G X 1" 125 abacavir sulfate- ACTIVITY POUCH 188 3ML LUER LOCK SAFETY lamivudine 55 SYRINGES/3ML/25G X 5/8" abacavir sulfate-lamivudine- acyclovir 58 126 zidovudine 55 acyclovir topical 74 3ML LUER-LOK SYRINGE 22GX ABC COMPLETE SENIOR ADACEL 250 1-1/2" 126 WOMENS 50+ 213 adapalene 70 3ML LUER-LOK SYRINGE21G X ABILIFY 49 1" 126 adapalene treatment 68

Index 1 ADASUVE 48 ADVOCATE INSULIN AFLURIA QUADRIVALENT adefovir dipivoxil 58 SYRINGE/U- 2021-2022 256 100/0.5ML/31GX5/16" 127 afrin saline nasal mist 232 ADHESIVE ADVOCATE INSULIN PADS/LARGE/3"X4" 103 AFSTYLA 91 ADHESIVE SYRINGE/U- 100/1ML/29GX1/2" 127 aftera 63 PADS/MEDIUM/2"X3" 103 ADVOCATE INSULIN AGAMATRIX ULTRA-THIN ADJUSTABLE LANCING LANCETS 33G 112 DEVICE 112 SYRINGE/U- 100/1ML/30GX5/16" 128 AIMOVIG 197 ADLYXIN 27 ADVOCATE INSULIN AIMSCO LUBRICATED 110 ADLYXIN STARTER PACK 28 SYRINGE/U- AIRS PEDIATRIC AEROSOL ADMELOG 28 100/1ML/31GX5/16" 128 MASK 189 ADMELOG SOLOSTAR 28 ADVOCATE LANCING AIRZONE PEAK FLOW DEVICE 112 ADRENALIN 235 METER 189 ADVOCATE RAPID-SAFE ak-poly-bac 240 adriamycin 44 LANCING DEVICE 112 al12 80 ADULT AEROSOL MASK 188 ADYNOVATE 91 ala-cort 74,75 adult aspirin regimen 10 AEROCHAMBER MINI AEROSOLCHAMBER 188 alavert 37 ADULT MASK 188 AEROCHAMBER MV 188 alavert allergy/sinus 67 ADULT MASK LARGE 188 AEROCHAMBER PLUS FLOW alaway 242 ADVAIR HFA 21 VU 189 ADVANCED DIABETIC AEROCHAMBER PLUS albendazole 18 MULTIVITAMIN FORMULA 213 FLOW-VU 189 albuterol sulfate 21 advantage care oral electrolyte AEROCHAMBER PLUS ALBUTEROL SULFATE 21 pediatric 200 FLOW-VU/LARGE MASK 189 albuterol sulfate 21 ADVATE 91 AEROCHAMBER PLUS ALCOH-WIPE 12" X 12" 124 ADVIL ALLERGY & FLOW-VU/MASK 189 CONGESTION 68 AEROCHAMBER PLUS ALCOHOL PREP PADS 124 advil junior strength 4 FLOW-VU/MEDIUM ALCOHOL SWABS 124 MASK 189 advil liqui-gels minis 4 AEROCHAMBER PLUS ALCOHOL SWABSTICK 124 ADVIL MULTI-SYMPTOM FLOW-VU/SMALL MASK 189 ALDURAZYME 86 COLD& FLU 68 AEROCHAMBER Z-STAT ALECENSA 45 ADVOCATE INSULIN PEN PLUS VALVED HOLDING alendronate sodium 85,86 NEEDLES 127 CHAMBER W/FLOW VU 189 ADVOCATE INSULIN PEN AEROCHAMBER Z-STAT aler-cap 33 NEEDLES 29GX12.7MM 127 PLUS/FLOWSIGNAL 189 ALER-DRYL 35 ADVOCATE INSULIN PEN AEROCHAMBER Z-STAT alertab 34 NEEDLES 31GX5MM 127 PLUS/LARGE MASK 189 ADVOCATE INSULIN PEN AEROCHAMBER Z-STAT ALEVAZOL 73 NEEDLES 31GX8MM 127 PLUS/MEDIUM MASK 189 alfuzosin hcl 90 ADVOCATE INSULIN AEROCHAMBER Z-STAT ALGAE BASED CALCIUM 213 SYRINGE/U- PLUS/SMALL MASK 189 100/0.3ML/29GX1/2" 127 AEROCHAMBER/FLOWSIGNA algal omega-3 dha 236 ADVOCATE INSULIN L 189 ALIVE ENERGY 50+ 213 SYRINGE/U- AEROTRACH PLUS 189 ALIVE MENS ENERGY 213 100/0.3ML/30GX5/16" 127 AEROVENT PLUS HOLDING ALIVE ONCE DAILY WOMENS ADVOCATE INSULIN CHAMBER/COLLAPSIBLE 50+ ULTRA POTENCY 213 SYRINGE/U- 189 ALIVE ONCE DAILY WOMENS 100/0.3ML/31GX5/16" 127 AFINITOR 45 ULTRA POTENCY 214 ADVOCATE INSULIN ALIVE PRENATAL MULTI- SYRINGE/U- AFINITOR DISPERZ 45 VITAMIN/PLANT DHA 226 100/0.5ML/29GX1/2" 127 afirmelle 61 ALIVE WOMENS 50+ 214 ADVOCATE INSULIN AFLURIA QUADRIVALENT ALIVE WOMENS ENERGY 214 SYRINGE/U- 2019-2020 256 100/0.5ML/30GX5/16" 127 AFLURIA QUADRIVALENT all day allergy 36 2020-2021 256 all day allergy childrens 35

Index 2 all day pain relief 5 amantadine hcl 47 antacid calcium extra ALL FLOW 1000 PULMONARY ambrisentan 60 strength 17 FUNCTION FILTER 189 AMD FOAM DRESSING antacid extra strength 17 allergy 35,38 4"X4" 103 anti-dandruff shampoo 74 allergy childrens 34 AMD FOAM anti-diarrheal 31 allergy eye drops 241 DRESSING/TOPSHEET ANTI-DIARRHEAL 31 4"X4" 103 allergy nasal spray 24 hour 233 ameda triple zero lanolin 81 anti-fungal 72 allergy relief 37,233 AMERIWASH 51 anti-itch 74 allergy relief 24hr 37 amethia 61 antibacterial liquid soap 51 allergy relief childrens 36,38 amiloride & antibiotic ointment 70 allergy relief d 67 hydrochlorothiazide 85 antifungal 72 allergy relief loratadine 38 amiloride hcl 85 antioxidant formula 210 ALLI 1 aminocaproic acid 95 ANTIOXIDANT FORMULA 214 allopurinol 91 aminophylline 22 antiseptic spray 50 almacone 15 AMINOSYN II 238 ANTISEPTIC WOUND & SKIN almotriptan malate 197 AMINOSYN-PF 238 CLEANSER 51 APEXICON E 78 ALOCRIL 242 AMINOSYN-PF 7% 238 APLICARE ALCOHOL alogliptin benzoate 27 amiodarone hcl 20 SWABSTICK 124 alogliptin-metformin hcl 26 amitriptyline hcl 26 aplicare povidone- alogliptin-pioglitazone 26 amlodipine besylate 59 iodinescrub 53 APLICARE ALOMIDE 242 amlodipine besylate-benazepril hcl 40 POVIDONE/IODINE 53 alophen 101 amlodipine besylate-olmesartan APO-VARENICLINE 248 ALORA 88 medoxomil 40 apra 7 alph-e 262 amlodipine besylate- apraclonidine hcl 240 ALPHAGAN P 240 valsartan 40 amlodipine-valsartan- aprepitant 32 ALPHANATE 91 hydrochlorothiazide 40 apri 61 ALPHANATE/VON amnesteem 69 aprodine 67 WILLEBRANDFACTOR COMPLEX/HUMAN 91 amoxapine 26 APTIVUS 55 ALPHANINE SD 91 amoxicillin 244 AQUA LANCE ADJUSTABLE LANCING DEVICE 112 alprazolam 19 amoxicillin & pot clavulanate 244 AQUALANCE LANCETS ULTRA ALPROLIX 91 amoxicillin-clarithromycin w/ THIN 30G 112 altacaine 241 lansoprazole 255 aquanil hc 75 altachlore 242 amphetamine- aquaphor itch relief maximum dextroamphetamine 1 altafrin 240 strength 75 ampicillin 244 aqueous vitamin d infants 261 altalube 239 anagrelide hcl 93 ALTERNATE SITE LANCING AQUORAL 205 DEVICE 112 ANALPRAM-HC 14 ARALAST NP 249 alum & mag hydrox- ANASEPT 51 ARANESP ALBUMIN FREE 93 simethicone 16 ANASEPT ANTIMICROBIAL argyle sterile saline 90 ALUMINUM HYDROXIDE 16 SKIN & WOUND GEL 51 ARIAL CHAMBER 189 aluminum sulfate & calcium anastrozole 43 ARIKAYCE 2 acetate 82 ANDRODERM 14 aripiprazole 49 ALUNBRIG 45 anecream 81 ARISTADA 49 alyacen 1/35 62 animal chews 225 ARISTADA INITIO 49 alyacen 7/7/7 62 ANORO ELLIPTA 22 armodafinil 2 alyq 60 ANTABUSE 245 ARMOUR THYROID 250 amabelz 87 antacid 16,17 ARNUITY ELLIPTA 21

Index 3 arthritis pain reliever 70 ASSURE ID SAFETY PEN aurovela 1.5/30 62 ARTHRITIS PAIN NEEDLES 30G X 5/16" 128 aurovela 1/20 62 ASSURE ID SAFETY PEN RELIEVING 81 aurovela 24 fe 62 artificial tears 239 NEEDLES 31G X 3/16" 128 ASSURE LANCE AUTO-LANCET 113 asco-tabs-1000 263 LANCETS 112 AUTO-LANCET MINI 113 ascomp/codeine 13 ASSURE LANCE LANCETS AUTOLET II CLINISAFE 113 ascorbic acid 263 21G 112 ASSURE LANCE PLUS AUTOLET IMPRESSION asenapine maleate 48 SAFETYLANCETS 25G 112 LANCING DEVICE 113 ASMANEX HFA 21 ASSURE LANCE PLUS AUTOLET LANCING ASMANEX TWISTHALER 120 SAFETYLANCETS 30G 113 DEVICE 113 METERED DOSES 21 ASSURE PLATINUM TEST AUTOLET LITE ASMANEX TWISTHALER 14 STRIPS 83 CLINISAFE 113 METERED DOSES 21 ASTHMA CHECK METER- AUTOLET LITE STARTER ASMANEX TWISTHALER 30 ZONE SYSTEM 189 PACK 113 METERED DOSES 21 ASTHMAMENTOR 189 AUTOLET MINI 113 ASMANEX TWISTHALER 60 ASTRAZENECA COVID-19 AUTOLET PLATFORMS 113 METERED DOSES 21 VACCINE 256 AUTOLET PLUS 113 ASMANEX TWISTHALER 7 ATABEX EC 226 METERED DOSES 21 AVANDIA 28 aspercreme w/lidocaine 81 ATABEX OB 226 AVASTIN 42 aspirin 11 ATABEX PRENATAL 226 AVC 260 ASPIRIN 11 atazanavir sulfate 55 avedana glycerin (adult) 99 aspirin 11 atenolol 59 aveeno anti-itch maximumstrength 76 aspirin 81 low dose 10 atenolol & chlorthalidone 40 avidoxy 249 aspirin adult 11 athletes foot 72 avita 69 aspirin buffered (cal carb-mag athletes foot af cream 72 carb-mag oxide) 11 atomoxetine hcl 1 AVONEX 246 ASSESS FULL RANGE PEAK atorvastatin calcium 39 AVONEX PEN 246 FLOW METER 189 AZASAN 204 ASSESS LOW RANGE PEAK atovaquone 18 FLOW METER 189 atovaquone-proguanil hcl 41 azathioprine 204 ASSESS PEAK FLOW METER ATRIPLA 55 azelaic acid 82 FULL RANGE 189 ATROPINE SULFATE 240 azelastine hcl 232 ASSESS PEAK FLOW METER azelastine hcl (ophth) 242 LOW RANGE 189 atropine sulfate ASSURE COMFORT LANCETS (ophthalmic) 240 azithromycin 102 ULTRA THIN 28G 112 ATROVENT HFA 20 AZO HORMONAL HEALTH ASSURE HAEMOLANCE PLUS AUBAGIO 246 CYCLE CARE & HIGH FLOW 18G 112 AUGMENTIN 244 COMFORT 214 ASSURE HAEMOLANCE PLUS AZO HORMONAL HEALTH LOW FLOW 25G 112 aurophen childrens 8 HAPPY CYCLE 214 ASSURE HAEMOLANCE PLUS AURORA LANCET SUPER azurette 61 THIN30G 113 MICRO FLOW 28G 112 b complex w/ c 205 ASSURE HAEMOLANCE PLUS AURORA LANCET THIN NORMAL FLOW 21G 112 23G 113 B-1 263 ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES b-complex vitamins 205 PEDIATRIC BLADE 112 29GX12MM 128 B-D INSULIN SYRINGE ASSURE ID INSULIN AURORA PEN NEEDLES 31G ULTRAFINE II/0.3ML/31G X SAFETYSYRINGE/U- X6MM 128 5/16" 128 100/0.5ML/29G X 1/2" 128 AURORA PEN NEEDLES 31G B-D INSULIN SYRINGE ASSURE ID INSULIN X8MM 128 ULTRAFINE II/0.5ML/31G X SAFETYSYRINGE/U- AURORA UNIFINE 5/16" 128 100/1ML/29G X 1/2" 128 PENTIPS/32GX5/32" 128 B-D INSULIN SYRINGE ASSURE ID SAFETY PEN AURORA UNIFINE ULTRAFINE II/1ML/31G X NEEDLES 30G X 3/16" 128 PENTIPS/MINI/31GX3/16" 5/16" 128 128

Index 4 B-D INSULIN SYRINGE BD 3ML LUER-LOCK BD INSULIN SYRINGE ULTRAFINE/0.3ML/30G X SYRINGE18G X 1 1/2" 128 MICROFINE IV/U-100/1ML/27G 1/2" 128 BD 3ML LUER-LOK SYRINGE X 5/8" 129 B-D INSULIN SYRINGE 18G X 1 1/2" 128 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X BD 3ML LUER-LOK SYRINGE MICROFINE IV/U-100/1ML/28G 1/2" 128 20G X 1-1/2" 128 X 1/2" 130 b-stress 231 BD 3ML LUER-LOK BD INSULIN SYRINGE b1 high potency 263 SYRINGE/20G X 1" 128 MICROFINE/U-100/0.5ML/28G X BD 3ML LUER-LOK 1/2" 130 BABY DDROPS 262 SYRINGE/21G X 1" 129 BD INSULIN SYRINGE bac 7 BD 3ML LUER-LOK MICROFINE/U-100/1ML/27G X bacitracin (ophthalmic) 240 SYRINGE/21G X 1-1/2" 129 5/8" 130 BD 3ML LUER-LOK BD INSULIN SYRINGE bacitracin (topical) 71 SYRINGE/23G X 1" 129 MICROFINE/U-100/1ML/28G X bacitracin zinc 71 BD 3ML LUER-LOK 1/2" 130 bacitracin-poly-neomycin-hc SYRINGE/23G X 1-1/2" 129 BD INSULIN SYRINGE 241 BD 3ML LUER-LOK SAFETYGLIDE/1ML/29G X bacitracin-polymyxin b SYRINGE/25G X 1" 129 1/2" 130 (ophth) 240 BD 3ML LUER-LOK BD INSULIN SYRINGE SLIP bacitraycin plus 70 SYRINGE/26G X 5/8" 129 TIP/U-100/1ML 130 BD 3ML baclofen 232 BD INSULIN SYRINGE ULTRA- SYRINGE/SAFETYGLIDE FINE/0.3ML/30G X 12.7MM130 BACMIN 214 SHIELDING IM NEEDLE BD INSULIN SYRINGE ULTRA- balsalazide disodium 90 22GX1-1/2" 129 FINE/0.3ML/31G X 8MM 130 BAND-AID ALL-IN-ONE BD 3ML BD INSULIN SYRINGE ULTRA- ADHESIVE GAUZE SYRINGE/SAFETYGLIDE FINE/0.5ML/30G X 12.7MM130 PAD/LARGE 103 SHIELDING IM NEEDLE BD INSULIN SYRINGE ULTRA- BAND-AID ALL-IN-ONE 23GX1" 129 FINE/0.5ML/31G X 8MM 130 ADHESIVE GAUZE BD 3ML BD INSULIN SYRINGE ULTRA- PAD/MEDIUM 103 SYRINGE/SAFETYGLIDE FINE/1/2 UNIT/0.3ML/31G X BAND-AID GAUZE PADS SHIELDING NEEDLE 8MM 130 LARGE4" X 4" 103 25GX5/8" 129 BD INSULIN SYRINGE ULTRA- BAND-AID GAUZE PADS BD AUTOSHIELD 29G X FINE/1ML/30G X 12.7MM 130 MEDIUM 3" X 3" 103 3/16" 129 BD INSULIN SYRINGE ULTRA- BAND-AID GAUZE PADS BD AUTOSHIELD 29G X FINE/1ML/31G X 8MM 130 SMALL2" X 2" 103 5/16" 129 BD INSULIN SYRINGE BAND-AID HURT-FREE NON- BD AUTOSHIELD DUO 30G X ULTRAFINE HALF- STICK PADS LARGE 3" X 5MM 129 UNIT/0.3ML/31G X 5/16" 130 4" 103 BD ECLIPSE SYRINGE BD INSULIN SYRINGE BAND-AID HURT-FREE NON- 3ML/21G X 1" 129 ULTRAFINE/0.3ML/30G X STICK PADS MEDIUM 2" X BD ECLIPSE SYRINGE LUER- 1/2" 130 3" 103 LOK/3ML/22G X 1" 129 BD INSULIN SYRINGE BAND-AID MIRASORB GAUZE BD ECLIPSE SYRINGE LUER- ULTRAFINE/0.3ML/31G X SPONGES LARGE 4" X 4" 103 LOK/3ML/25G X 1" 129 5/16" 130 BAND-AID QUILTVENT BD ECLIPSE BD INSULIN SYRINGE WATERPROOF PAD LARGE SYRINGE/3ML/23G X 1" 129 ULTRAFINE/0.5ML/30G X 2.875" X 4" 103 BD ECLIPSE 1/2" 130 banophen 35 SYRINGE/3ML/25GX5/8" BD INSULIN SYRINGE 129 BAQSIMI ONE PACK 27 ULTRAFINE/0.5ML/31G X BD ECLIPSE SYRINGE/LUER- 5/16" 130 BAQSIMI TWO PACK 27 LOK/3ML/22G X 1-1/2" 129 BD INSULIN SYRINGE BARACLUDE 58 BD GLUCOSE 27 ULTRAFINE/1ML/30G X BASAGLAR KWIKPEN 28 BD INSULIN SYRINGE LUER- 1/2" 130 LOK/U-100/1ML 129 BD INSULIN SYRINGE BASIC AM 214 BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G X BASIC PM 214 MICROFINE IV/U- 1/2" 130 BD LO-DOSE INSULIN 100/0.5ML/28G X 1/2" 129 BD INSULIN SYRINGE SYRINGE MICROFINE ULTRAFINE/U-100/0.5ML/29G X IV/0.5ML/28G X 1/2" 128 1/2" 131

Index 5 BD INSULIN SYRINGE BD PEN BD VEO INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X NEEDLE/NANO/ULTRA- ULTRA-FINE/U-100/0.3ML/31G 1/2" 131 FINE/32G X 4MM 132 X 15/64" 133 BD INSULIN SYRINGE BD PEN BD VEO INSULIN SYRINGE ULTRAFINE/U-100/1ML/31G X NEEDLE/ORIGINAL/ULTRA- ULTRA-FINE/U-100/1ML/31G X 5/16" 131 FINE/29G X 12.7MM 132 15/64" 133 BD INSULIN BD PEN BD VERITOR SYSTEM FOR SYRINGE/0.3ML/29G X NEEDLE/SHORT/ULTRA- RAPID DETECTION OF SARS- 12.7MM 131 FINE/31G X 8MM 132 COV-2 83 BD INSULIN BD SAFETY-GLIDE INSULIN bedding spray lice treatment step SYRINGE/0.5ML/29G X SYRINGE/0.5ML/29G X 3 82 12.7MM 131 1/2" 132 BELBUCA 13 BD INSULIN SYRINGE/1ML/27G BD SAFETY-LOK INSULIN BELVIQ 1 X 12.7MM 131 SYRINGE/PERM BD INSULIN SYRINGE/1ML/29G NEEDLE/UF/1ML/29G X BELVIQ XR 1 X 12.7MM 131 1/2" 132 benadryl allergy plus congestion BD INSULIN BD SAFETYGLIDE INSULIN ultratabs 66 SYRINGE/DETACHABLE SYRINGE/0.3ML/29G X benazepril & NEEDLE/U-100/1ML/25G X 1/2" 132 hydrochlorothiazide 40 1" 131 BD SAFETYGLIDE INSULIN benazepril hcl 39 BD INSULIN SYRINGE/0.3ML/31G X BENAZEPRIL SYRINGE/DETACHABLE 15/64" 132 HCL/HYDROCHLOROTHIAZIDE NEEDLE/U-100/1ML/25G X BD SAFETYGLIDE INSULIN 40 5/8" 131 SYRINGE/0.3ML/31G X BENEFIX 91 BD INSULIN 5/16" 132 BENLYSTA 204 SYRINGE/DETACHABLE BD SAFETYGLIDE INSULIN NEEDLE/U-100/1ML/26G X SYRINGE/0.5ML/31G X BENZALKONIUM 1/2" 131 15/64" 132 CHLORIDE 51 BD INSULIN SYRINGE/U- BD SAFETYGLIDE INSULIN benzalkonium chloride 51 100/1ML/27G X 1/2" 131 SYRINGE/1ML/31G X BENZALKONIUM BD INSULIN SYRINGE/U- 15/64" 132 CHLORIDE 51 100/2ML/27.5G X 5/8" 131 BD SAFETYGLIDE INSULIN benzonatate 64 BD INSULIN SYRINGE/U- SYSYRINGE/0.5ML/30G X benzoyl peroxide 70 500/0.5ML/31G X 6MM 131 5/16" 132 BENZOYL PEROXIDE BD INTEGRA 3ML SYRINGE BD SAFETYGLIDE SYRINGE CLEANSER 70 W/RETRACTING NEEDLE/21G 3ML/25GX1" 132 X 1-1/2" 131 BD SWABS SINGLE benzoyl peroxide wash 69 BD INTEGRA 3ML SYRINGE USE 124 benzoyl peroxide- W/RETRACTING NEEDLE/25G BD SWABS SINGLE USE erythromycin 70 X 1" 131 BUTTERFLY 124 benzphetamine hcl 1 BD INTEGRA BD VEO INSULIN SYRINGE benztropine mesylate 47 SYRINGE/3ML/21G X 1" 131 ULTR-FINE/U-100/0.5ML/31G BETADINE 53 BD INTEGRA X 15/64" 132 BETADINE SURGICAL SYRINGE/3ML/22G X 1.5" 131 BD VEO INSULIN SYRINGE SCRUB 53 BD INTEGRA ULTRA-AFINE/0.3ML/31G X betamethasone dipropionate SYRINGE/3ML/23G X 1" 131 6MM 132 (topical) 78 BD INTEGRA BD VEO INSULIN SYRINGE betamethasone dipropionate SYRINGE/3ML/25G X 5/8 131 ULTRA-FINE/0.3ML/31G X augmented 78 BD LANCET ULTRAFINE 6MM 132 30G 113 BD VEO INSULIN SYRINGE betamethasone valerate 78 BD LUER-LOK ULTRA-FINE/0.5ML/31G X betasept surgical scrub 51 SYRINGE/3ML/22G X 3/4" 131 6MM 132 BETASERON 246 BD PEN BD VEO INSULIN SYRINGE betaxolol hcl (ophth) 239 NEEDLE/MICRO/ULTRA- ULTRA-FINE/1/2 FINE/32G X 6MM 132 UNIT/0.3ML/31G X 6MM 133 bethanechol chloride 255 BD PEN NEEDLE/MINI/ULTRA- BD VEO INSULIN SYRINGE BETOPTIC-S 239 FINE/31G X 5MM 132 ULTRA-FINE/1ML/31G X BEVESPI AEROSPHERE 22 BD PEN NEEDLE/NANO 2ND 6MM 133 GEN/32G X 5/32" 132 BEVYXXA 22

Index 6 bexarotene 46 bprotected pedia tri-vite 225 bumetanide 85 BEXSERO 255 BRAFTOVI 45 BUNAVAIL 13 bicalutamide 43 BRAINSTRONG BUPRENEX 13 BIKTARVY 55 PRENATAL 226 buprenorphine 13 BREATHE EASE NEBULIZER bimatoprost 243 MASK/CHILD 190 buprenorphine hcl 13 BINAXNOW COVID-19 AG BREATHE EASE NEBULIZER buprenorphine hcl-naloxone hcl CARD 84 MASK/INFANT 190 dihydrate 13 BINAXNOW COVID-19 AG BREATHE EASE PEAK FLOW bupropion hcl 25 CARD HOME TEST 83 METER 190 bupropion hcl (smoking biocotron 66 BREATHE EASE/LARGE deterrent) 248 BIOGUARD GAUZE SPONGE MASK 190 buspirone hcl 19 BREATHE EASE/MEDIUM 2"X2" 8 PLY 103 butalbital-acetaminophen 7 BIOGUARD GAUZE SPONGES MASK 190 4"X4" 12 PLY 103 BREATHE EASE/SMALL butalbital-acetaminophen- caffeine 7 BIOLYTE 200 MASK 190 BREATHERITE 190 butalbital-acetaminophen- BIOPATCH ANTIMICROBIAL caffeine w/ codeine 13 BREATHERITE DRESSING/1" DISK/4MM butalbital-aspirin-caffeine 7 HOLE 51 COLLAPSIBLEADULT BIOPATCH ANTIMICROBIAL SPACER W/MASK 190 butalbital-aspirin-caffeine BREATHERITE w/cod 13 DRESSING/1" DISK/7MM BUTALBITAL/ASPIRIN/CAFFEIN HOLE 51 COLLAPSIBLECHILD SPACER BIOPATCH ANTIMICROBIAL W/MASK 190 E 7 DRESSING/3/4" DISK/1.5MM BREATHERITE BUTRANS 14 HOLE 51 COLLAPSIBLEINFANT BYDUREON BCISE 28 BIOPATCH PROTECTIVE SPACER W/MASK 190 BYDUREON PEN 28 BREATHERITE DISKWITH CHG/1"DISK/4MM BYETTA 28 HOLE 51 COLLAPSIBLESMALL CHILD BIOTENE DRY MOUTH SPACER W/MASK 190 bzk antiseptic towelettes 50 MOISTURIZING SPRAY 205 BREATHERITE CA-REZZ 51 bisacodyl 101 COLLAPSIBLESPACER W/ CA-REZZ GENTLE 51 NEONATE MASK 190 bisacodyl laxative 101 BREATHERITE RIGID CA-REZZ MOISTURE bismatrol 30 SPACERW/MASK 190 BARRIER 51 bismuth subsalicylate 30 BREATHERITE W/LARGE CA-REZZ NORISC 52 bisoprolol & MASK 190 CA-REZZ NORISC CREAM 51 hydrochlorothiazide 40 BREATHERITE W/MEDIUM cabergoline 87 bisoprolol fumarate 59 MASK 190 BREATHERITE W/SMALL CABOMETYX 45 bleomycin sulfate 44 MASK 190 caffeine citrate 1 BLEPHAMIDE 241 BREO ELLIPTA 22 CAL-DAY 1000 214 BLEPHAMIDE S.O.P. 241 BRILINTA 93 CALAMINE 82 blis-to-sol 72 brimonidine tartrate 240 CALAMINE PHENOLATED 82 bonine 32 brinzolamide 242 calcidol 262 BONJESTA 32 bromfenac sodium calcipotriene 74 BOOSTRIX 250 (ophth) 242 calcitonin (salmon) 86 BORDERED GAUZE 104 bromocriptine mesylate 47 BUBBLES THE FISH II calcitrate 198 boro-packs 81 PEDIATRIC MASK/PVC 190 calcitrate plus d 199 bosentan 60 budesonide 64 calcitrene 74 BOSULIF 45 budesonide (inhalation) 21 calcitriol 86 BOTOX 235 budesonide (nasal) 233 calcitriol (topical) 74 bp wash 69 budesonide-formoterol CALCIUM 199 bprotected pedia iron 94 fumarate dihydrate 22 calcium 500 + d 198 BUFFERIN EXTRA BPROTECTED PEDIA POLY- calcium 500+d 198 VITE/IRON 225 STRENGTH 11

Index 7 calcium 600 198 carbidopa-levodopa 47 CAREONE UNIFINE PENTIPS calcium 600 + d 198 CARDIOCOM LANCING PLUS PEN NEEDLES 31GX6MM 134 calcium 600 high potency 198 DEVICE 113 CAREFINE PEN NEEDLE CAREONE UNIFINE PENTIPS calcium 600+d 198 32GX4MM 133 PLUS PEN NEEDLES calcium acetate (phosphate CAREFINE PEN NEEDLES 31GX8MM 134 binder) 90 29GX1/2" 133 CAREONE UNIFINE PENTIPS CALCIUM CAREFINE PEN NEEDLES PLUS PEN NEEDLES CARBONATE 17,199 30GX5/16" 133 32GX4MM 134 calcium carbonate 199 CAREFINE PEN NEEDLES CAREONE UNIFINE PENTIPS calcium carbonate (antacid) 17 31GX6MM 133 PLUS PEN NEEDLES/33G X CAREFINE PEN NEEDLES 5/32" 134 calcium carbonate- CAREPOINT SAFETY 1ST cholecalciferol 199 31GX8MM 133 CAREFINE PEN NEEDLES SYRINGE/NEEDLE 3ML/23G X calcium carbonate-vitamin 1" 134 d 199 32GX5MM 133 CAREFINE PEN NEEDLES CAREPOINT SAFETY 1ST calcium citrate 199 32GX6MM 133 SYRINGE/NEEDLE 3ML/25G X calcium citrate + 199 CAREONE ADVANCED 1" 134 calcium citrate + d3 199 LANCINGDEVICE 113 CAREPOINT SAFETY 1ST CALCIUM CITRATE CAREONE INSULIN SYRINGE/NEEDLE 3ML/25G X MALATE/VITAMIN D 199 SYRINGES/0.3ML/30G X 5/8" 134 CARETOUCH 2 CPAP HOSE calcium citrate-vitamin d 199 1/2" 133 CAREONE INSULIN HANGER 190 calcium citrate/d3 199 SYRINGES/0.3ML/31G X CARETOUCH ALCOHOL PREP CALCIUM LACTATE 199 5/16" 133 PADS 124 calcium plus vitamin d 198 CAREONE INSULIN CARETOUCH CPAP & BIPAP SYRINGES/0.5ML/30G X HOSE/6FT 190 calcium plus vitamin d3 198 1/2" 133 CARETOUCH CPAP MASK calcium polycarbophil 97 CAREONE INSULIN WIPES 190 calcium+d3 198 SYRINGES/0.5ML/31G X CARETOUCH CPAP NEUTRALIZING PRE- CALCIUM/VITAMIN D 199 5/16" 133 CAREONE INSULIN WASH 190 calcium/vitamin d-3 198 SYRINGES/1ML/30G X CARETOUCH CPAP TUBE CALNA 226 1/2" 133 CLEANING BRUSH 191 CALQUENCE 45 CAREONE INSULIN CARETOUCH INSULIN SYRINGE/U-100/1ML/28G X camila 63 SYRINGES/1ML/31GX5/16" 133 5/16" 134 candesartan cilexetil 40 CAREONE LANCET SUPER CARETOUCH INSULIN candesartan cilexetil- THIN/30G 113 SYRINGE/U-100/1ML/29G X hydrochlorothiazide 40 CAREONE LANCET 5/16" 134 capecitabine 42 THIN 113 CARETOUCH LANCING CAPEX 78 CAREONE UNIFINE PENTIPS DEVICEWITH EJECTOR 113 29GX12MM 133 CARETOUCH PEN NEEDLES CAPHOSOL 205 CAREONE UNIFINE PENTIPS 31G X 6 MM 134 CAPLYTA 48 31GX5MM 133 CARETOUCH PEN NEEDLES CAPRELSA 45 CAREONE UNIFINE PENTIPS 31GX 5MM 134 31GX6MM 133 CARETOUCH PEN NEEDLES capsaicin 81 CAREONE UNIFINE PENTIPS 31GX 8MM 134 capsaicin hp 80 31GX8MM 133 CARETOUCH PEN NEEDLES captopril 40 CAREONE UNIFINE PENTIPS 32GX 4MM 134 captopril & PEN NEEDLES CARETOUCH PEN NEEDLES hydrochlorothiazide 40 32GX4MM 133 32GX 5MM 134 CARETOUCH TWIST LANCETS CAPZASIN-P 81 CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 30G 113 CARAC 73 29GX12MM 134 CARETOUCH UNIVERSAL CARBAGLU 86 CAREONE UNIFINE PENTIPS CPAPFILTERS 191 carbamazepine 23 PLUS PEN NEEDLES carisoprodol 232 carbidopa 47 31GX5MM 134 CARRASMART 104

Index 8 CARRASMART FOAM 104 CERTAVITE chlorothiazide 85 carrington antifungal 72 SENIOR/ANTIOXIDANT chlorpheniramine maleate 33 NUTRIENTS 215 carteolol hcl (ophth) 240 certavite/antioxidants 211 chlorpromazine hcl 49 cartia xt 59 CERTAVITE/ANTIOXIDANTS chlorthalidone 85 carvedilol 58 215 chlorzoxazone 232 carvedilol phosphate 58 cetirizine hcl 38 CHOLBAM 89 cataflam 3 cetirizine hcl childrens 36 cholecalciferol 262 cavarest 204 cetirizine-pseudoephedrine cholestyramine 39 68 CAVILON SKIN CLEANSER 52 cholestyramine light 39 CETYLCIDE II 53 CAYA 110 chromagen 94 CETYLCIDE-G 50 caziant 61 cidofovir 57 CHANTIX 248 cefaclor 60 CHANTIX CONTINUING cilostazol 93 cefadroxil 60 MONTHPAK 248 CILOXAN 240 CEFAZOLIN SODIUM/SODIUM CHANTIX STARTING MONTH CIMDUO 55 CHLORIDE 60 PAK 248 cimetidine 254 CEFAZOLIN/SODIUM CHEMET 31 cimetidine 200 251 CHLORIDE 60 CHEMSTRIP -10 WITH cefdinir 60 SG 84 cimetidine hcl 254 cefpodoxime proxetil 61 CHEMSTRIP 10 MD 84 cinacalcet hcl 86 cefprozil 60 CHEMSTRIP 2 GP CINQAIR 20 ceftriaxone sodium 61 STRIPS 84 CINRYZE 93 CHEMSTRIP 5 OB 84 CEFTRIAXONE SODIUM 61 CIPRO 88 CHEMSTRIP 7 84 ceftriaxone sodium 61 ciprofloxacin 88 CHEMSTRIP 9 STRIPS 84 cefuroxime axetil 60 ciprofloxacin hcl 88 CHEMSTRIP-K 84 celecoxib 6 ciprofloxacin hcl (ophth) 241 CHEWABLE CELONTIN 24 CALCIUM/D3 199 ciprofloxacin hcl (otic) 243 centravites 50 plus 210 childrens acetaminophen 8 ciprofloxacin-dexamethasone 243 CENTRAVITES 50 PLUS 214 childrens apap 9 citalopram hydrobromide 25 CENTRAVITES ADULTS 214 childrens cold & allergy 64 citroma 100 CENTRUM CARDIO 214 childrens ibuprofen 4 claravis 69 CENTRUM MEN 214 childrens loratadine 38 clarispray 233 CENTRUM SILVER ULTRA childrens non-aspirin 9 WOMENS 214 clarithromycin 103 CENTRUM SPECIALIST childrens silapap 9 CLARITIN REDITABS 38 chloramphenicol sodium HEART 214 CLASSIC PRENATAL 226 CENTRUM SPECIALIST succinate 18 IMMUNE SUPPORT 215 chlordiazepoxide hcl 19 CLEANLET LANCETS 28G 113 CENTRUM SPECIALIST chlordiazepoxide-amitriptyline clearcanal earwax softener 243 PRENATAL 226 245 clearlax 99 CENTRUM SPECIALIST chlorhexidine gluconate 51 clemastine fumarate 35 VISION 215 CHLORHEXIDINE CLEOCIN PHOSPHATE 19 CENTRUM ULTRA GLUCONATE 52 CLEVER CHOICE ANTI- WOMENS 215 chlorhexidine gluconate 52 cephalexin 60 STATICVALVED HOLDING CHLORHEXIDINE CHAMBER/ADULT LARGE 191 CERALYTE 70 200 GLUCONATE 52 CLEVER CHOICE ANTI- CERASPORT 200 chlorhexidine gluconate STATICVALVED HOLDING CERASPORT EX1 200 (mouth-throat) 204 CHAMBER/MEDIUM 191 CHLORHEXIDINE CEREZYME 93 CLEVER CHOICE ANTI- GLUCONATE CLOTH 52 STATICVALVED HOLDING CEROVEL 80 chloroquine phosphate 41 CHAMBER/MEDIUM/3 CERTAVITE SENIOR 215 YEA 191

Index 9 CLEVER CHOICE ANTI- CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 32G STATICVALVED HOLDING EZINSULIN X 5/32" 136 CHAMBER/SMALL 191 SYRINGE/1ML/30G X CLICKFINE PEN CLEVER CHOICE ANTI- 5/16" 135 NEEDLES/31GX1/4" 136 STATICVALVED HOLDING CLEVER CHOICE COMFORT CLICKFINE UNIVERSAL PEN CHAMBER/SMALL EZINSULIN SYRINGE/U- NEEDLES 31GX5/16" 136 INFANT 191 100/1ML/31GX5/16" 135 CLIMARA PRO 87 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT clindamycin hcl 19 EZINSULIN PEN NEEDLES EZPEN NEEDLES clindamycin palmitate 31GX8MM 134 29GX12MM 135 hydrochloride 19 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES EZPEN NEEDLES clindamycin phosphate 19 33GX4MM 134 31GX5MM 135 clindamycin phosphate CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT (topical) 70 EZINSULIN EZPEN NEEDLES clindamycin phosphate SYRINGE/0.3ML/29G X 31GX6MM 135 vaginal 260 1/2" 134 CLEVER CHOICE COMFORT CLINDESSE 260 CLEVER CHOICE COMFORT EZPEN NEEDLES CLINICAL NUTRIENTS 45-PLUS EZINSULIN 31GX8MM 135 WOMEN 215 SYRINGE/0.3ML/30G X CLEVER CHOICE COMFORT CLINICAL NUTRIENTS 50-PLUS 1/2" 135 EZPEN NEEDLES MEN 215 CLEVER CHOICE COMFORT 32GX4MM 135 CLINICAL NUTRIENTS FOR EZINSULIN CLEVER CHOICE COMFORT FEMALE TEENS 215 SYRINGE/0.3ML/30G X EZPEN NEEDLES CLINICAL NUTRIENTS FOR 5/16" 135 32GX5MM 136 MALE TEENS 215 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT CLINICAL NUTRIENTS FOR EZINSULIN EZPEN NEEDLES MEN 215 SYRINGE/0.3ML/31G X 32GX6MM 136 CLINICAL NUTRIENTS FOR 5/16" 135 CLEVER CHOICE COMFORT WOMEN 215 CLEVER CHOICE COMFORT EZPEN NEEDLES CLINICAL NUTRIENTS EZINSULIN 32GX8MM 136 PRENATAL FORMULA 226 SYRINGE/0.5ML/28G X CLEVER CHOICE COMFORT CLINIMIX 4.25%/DEXTROSE 1/2" 135 EZPEN NEEDLES 10% 238 CLEVER CHOICE COMFORT 33GX4MM 136 CLINIMIX 4.25%/DEXTROSE EZINSULIN CLEVER CHOICE COMFORT 25% 238 SYRINGE/0.5ML/29G X EZPEN NEEDLES CLINIMIX 4.25%/DEXTROSE 1/2" 135 33GX5MM 136 5% 238 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT CLINIMIX 5%/DEXTROSE EZINSULIN EZPEN NEEDLES 15% 238 SYRINGE/0.5ML/30G X 33GX6MM 136 CLINIMIX 5%/DEXTROSE 1/2" 135 CLEVER CHOICE COMFORT 20% 238 CLEVER CHOICE COMFORT EZPEN NEEDLES CLINIMIX 5%/DEXTROSE EZINSULIN 33GX8MM 136 25% 238 CLEVER CHOICE PEAK CLINIMIX E 2.75%/DEXTROSE SYRINGE/0.5ML/30G X 10% 238 5/16" 135 FLOW METER 191 CLICKFINE PEN NEEDLE CLINIMIX E 2.75%/DEXTROSE CLEVER CHOICE COMFORT 5% 238 EZINSULIN 32GX5/32" 136 CLICKFINE PEN NEEDLE CLINIMIX E 4.25%/DEXTROSE SYRINGE/0.5ML/31G X 10% 238 5/16" 135 UNIVERSAL/31GX1/4" 136 CLICKFINE PEN NEEDLE CLINIMIX E 4.25%/DEXTROSE CLEVER CHOICE COMFORT 5% 238 EZINSULIN UNIVERSAL/31GX5/16" 136 SYRINGE/1.0ML/30G X CLICKFINE PEN NEEDLES CLINIMIX N9G20E 238 1/2" 135 31G X 1/4" 136 CLINOLIPID 236 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES clobetasol propionate 78 31G X 3/16" 136 EZINSULIN SYRINGE/1ML/28G clobetasol propionate e 74 X 1/2" 135 CLICKFINE PEN NEEDLES 31G X 5/16" 136 clobetasol propionate emollient CLEVER CHOICE COMFORT base 78 EZINSULIN SYRINGE/1ML/29G CLICKFINE PEN NEEDLES X 1/2" 135 31G X 8MM 136 clomipramine hcl 26

Index 10 clonazepam 23 COMFORT ASSIST INSULIN COMPACT SPACE clonidine hcl 40 SYRINGE/0.5ML/31G X CHAMBER/ANTI- 5/16" 137 STATIC/MEDIUM MASK 191 clonidine hcl (adhd) 1 COMFORT ASSIST INSULIN COMPACT SPACE clopidogrel bisulfate 93 SYRINGE/1ML/29G X CHAMBER/ANTI-STATIC/SMALL clorazepate dipotassium 19 1/2" 137 MASK 191 clorox nasal antiseptic COMFORT ASSIST INSULIN COMPLERA 55 swabs 53 SYRINGE/1ML/30G X COMPLETE NATAL DHA 226 5/16" 137 CLORPACTIN WCS-90 52 COMFORT ASSIST INSULIN COMPLETENATE 226 clotrimazole 204 SYRINGE/1ML/31G X compoz 95 clotrimazole (topical) 73 5/16" 137 compro 49 clotrimazole vaginal 260 COMFORT ASSURED LANCETS SUPER THIN CONDYLOX 80 clotrimazole w/ constulose 99 betamethasone 73 28G 113 COMFORT EZ INSULIN CONTRAVE 1 clotrimazole-7 260 SYRINGE/U-100/0.5ML/31G X COPA ISLAND BORDERED clozapine 48 5/16" 137 FOAM DRESSING 4"X4" 104 CLOZARIL 48 COMFORT EZ INSULIN COPA PLUS HYDROPHILIC CO MONITOR REPLACEMENT SYRINGE/U-100/1ML/31G X FOAM DRESSING 4"X4" 104 TPIECES 191 5/16" 137 COPIKTRA 45 CO-NATAL FA 226 COMFORT EZ MICRO/32G X 4MM 137 CORIFACT 91 COAGADEX 91 COMFORT EZ SHORT/31G X correctol extra gentle 102 coal tar extract 83 8MM 137 cortic-nd 243 COARTEM 41 COMFORT EZ/31G X CORTIFOAM 14 5MM 137 CODEINE SULFATE 11 COMFORT EZ/31G X cortisone acetate 64 codeine sulfate 11 6MM 137 cortizone-10 intensive COGENTIN 47 COMFORT LANCETS 113 healing 78 colace 2-in-1 98 COMFORT TOUCH PEN COSENTYX 74 COSENTYX SENSOREADY colchicine 91 NEEDLES/31G X 4MM 137 COMFORT TOUCH PEN PEN 74 colchicine w/ probenecid 91 NEEDLES/31G X 5MM 137 COTELLIC 45 cold & allergy childrens 65 COMFORT TOUCH PEN COUMADIN 22 colestipol hcl 39 NEEDLES/31G X 6 MM 137 COVRSITE COVER COMFORT TOUCH PEN DRESSING 104 colocort 14 NEEDLES/31G X 8 MM 137 COMBIPATCH 87 COVRSITE PLUS COMPOSITE COMFORT TOUCH PEN DRESSING 104 NEEDLES/32G X 4MM 137 COMBIVENT RESPIMAT 22 CREOLIN 53 COMBIVIR 55 COMFORT TOUCH PEN NEEDLES/32G X 5MM 137 CREON 85 COMETRIQ 45 COMFORT TOUCH PEN CRIXIVAN 55 COMFORT ASSIST INSULIN NEEDLES/32G X 6MM 137 SYRINGE 0.3ML/29G X COMFORT TOUCH PEN cromolyn sodium 20 1/2" 136 NEEDLES/32G X 8MM 137 cromolyn sodium COMFORT ASSIST INSULIN COMFORT TOUCH PEN (mastocytosis) 89 SYRINGE/0.3ML/30G X NEEDLES/33G X 5/32" 137 cromolyn sodium (nasal) 232 5/16" 136 COMFORT TOUCH PEN cromolyn sodium (ophth) 243 COMFORT ASSIST INSULIN NEEDLES/33GX 3/16" 138 crotan 82 SYRINGE/0.3ML/31G X COMFORT TOUCH PEN CRUAD GAUZE PADS 4" X 5/16" 136 NEEDLES/33GX1/4" 138 COMFORT ASSIST INSULIN COMPACT SPACE 4" 104 SYRINGE/0.5ML/29G X CHAMBER/ANTI-STATIC cryselle-28 62 1/2" 137 191 CURAD NON-STICK PADS COMFORT ASSIST INSULIN COMPACT SPACE WITHADHESIVE TABS SYRINGE/0.5ML/30G X CHAMBER/ANTI- 3"X4" 104 5/16" 137 STATIC/LARGE MASK 191 curad triple antibiotic 71 CURECHROME 52

Index 11 CURITY ALCOHOL CURITY NON-ADHERENT cvs gas relief 89 PREPS/MEDIUM 2 PLY 124 STRIPS 3"X3" 105 cvs gas relief drops extra CURITY ALCOHOL CURITY strength 88 SWABS 124 SPONGES/CELLULOSEFILLE cvs gas relief infants 88 CURITY ALL PURPOSE D/2"X2" 105 SPONGES 2"X2" 104 CURITY CVS GAUZE PAD 3"X3" 105 CURITY ALL PURPOSE SPONGES/CELLULOSEFILLE CVS GAUZE PADS 2"X2" 12- SPONGES 2"X2" 4PLY 104 D/4"X4" 105 PLY 105 CURITY ALL PURPOSE CURX ANTIMICROBIAL 52 CVS GAUZE PADS 4"X4" 12- SPONGES 3"X3" 4PLY 104 PLY 105 CURITY ALL PURPOSE CUVPOSA 251 CVS GAUZE PADS STERILE SPONGES 4 PLY 104 cvs acid reducer 253 4"X4" 12-PLY 106 CURITY ALL PURPOSE CVS ADHESIVE PAD CVS GLUCOSE 27 SPONGES 4"X4" 104 4"X4" 105 cvs glycerin adult 99 CURITY ALL PURPOSE CVS ADHESIVE PAD SPONGES 4"X4" 4PLY 104 6"X6" 105 cvs heartburn relief 251 CURITY ALL PURPOSE CVS ADHESIVE PADS cvs hemorrhoidal & topical SPONGES 4"X4" 4PLY/SOFT 2.25"X3" 105 analgesic 80 POUCH 104 cvs advanced 3-in-1 exfoliating cvs hydrocortisone anti-itch 77 CURITY AMD cleanser 69 cvs hydrogen peroxide 50 CVS ALCOHOL PREP ANTIMICROBIALGAUZE cvs ibuprofen infants 5 SPONGES 2"X2" 8 PLY 104 PADS 124 CURITY AMD cvs allergy relief 36,37 CVS IODINE TINCTURE 53 ANTIMICROBIALGAUZE cvs allergy relief childrens 36 cvs iron 94 SPONGES 4"X4" 12 PLY 104 cvs allergy/congestion CVS LANCETS 21G 113 CURITY COVER SPONGE childrens 66 CVS LANCETS MICRO THIN 4"X4" 104 33G 113 CURITY COVER SPONGES cvs anti-dandruff 74 cvs anti-diarrheal 30 CVS LANCETS MICRO-THIN 3"X3" 104 33G 113 CURITY COVER SPONGES cvs anti-itch 74 CVS LANCETS ORIGINAL 113 4"X4" 104 cvs antibiotic plus 71 CURITY DRESSING SPONGES CVS LANCETS THIN 26G 113 4"X4" 6 PLY 105 cvs antifungal 73 CVS LANCETS ULTRA THIN CURITY GAUZE PADS cvs antiseptic skin 30G 113 2"X2" 105 cleanser 51 CVS LANCETS ULTRA-THIN CURITY GAUZE PADS 2"X2" 12 cvs bacitracin 70 30G 113 PLY 105 cvs bismuth 30 CVS LANCING DEVICE 113 CURITY GAUZE PADS cvs budesonide nasal cvs lansoprazole 254 3"X3" 105 spray 232 CURITY GAUZE PADS 4"X4" 12 cvs lice killing 83 PLY 105 cvs buffered aspirin 9 cvs lice solution kit 83 CURITY GAUZE SPONGE 2"X2" cvs clotrimazole CVS LICE SOLUTION KIT 3- 8 PLY 105 maximumstrength 72 STEP 83 CURITY GAUZE SPONGE cvs cold & sinus relief 67 cvs lice treatment 82 2"X2"12 PLY 105 cvs d3 261 cvs miconazole 3 combination CURITY GAUZE SPONGE 3"X3" cvs daily fiber 96 pack 260 12 PLY 105 CURITY GAUZE SPONGE 4"X4" CVS DAILY FIBER 97 cvs miconazole 7 260 12 PLY 105 CVS DRY MOUTH cvs milk of magnesia 100 CURITY GAUZE SPONGE 4"X4" SPRAY 205 cvs mini enema kids 102 cvs esomeprazole 16 PLY 105 cvs motion sickness 32 CURITY GAUZE SPONGE 4"X4" magnesium 254 8 PLY 105 cvs eye drops original 241 cvs motion sickness ii 32 CURITY GAUZE SPONGE cvs fever reducing childrens 9 cvs naproxen sodium 5 4"X4"16 PLY 105 cvs nasal allergy spray 233 CURITY GAUZE SPONGES cvs fiber 96 4"X4" 12 PLY 105 cvs fiber laxative 96 cvs nasal decongestant 235 CURITY GAUZE SPONGES cvs fish oil 236 cvs nasal decongestant pe 234 4"X4" 8 PLY 105 cvs folic acid 93 cvs natural daily fiber 97

Index 12 cvs natural fiber supplement 97 cvs zinc oxide 81 DERMACEA GAUZE SPONGE CVS NATURAL FIBER cyanocobalamin 93 4"X4" 16 PLY 106 DERMACEA GAUZE SPONGE SUPPLEMENT 97 cyclobenzaprine hcl 232 cvs natural fish oil 236 4"X4" 8 PLY 106 CYCLOMYDRIL 240 DERMACEA I.V. DRAIN cvs nicotine 247 cyclopentolate hcl 240 SPONGES 2"X2" 106 cvs nicotine lozenge 247 DERMACEA I.V. DRAIN CYCLOSET 27 cvs omeprazole 254 SPONGES 4"X4" 106 cyclosporine 204 CVS ONE DAILY MENS 50+ DERMACEA I.V. SPONGES ADVANCED 215 cyclosporine modified (for 2"X2" 106 CVS ONE DAILY WOMENS microemulsion) 204 DERMACEA NON-WOVEN 50+ADVANCED 215 cyproheptadine hcl 39 SPONGES 2"X2" 4 PLY 106 CYRAMZA 42 DERMACEA NON-WOVEN cvs pain relief childrens 9 SPONGES 3"X3" 4 PLY 106 cvs pinworm treatment 17 CYSTARAN 243 DERMACEA NON-WOVEN cvs poly bacitracin 71 CYTOMEL 250 SPONGES 4"X4" 4 PLY 106 CVS PRENATAL 226 cytra k crystals 90 DERMACEA NON-WOVEN SPONGES 4"X4" 6 PLY 106 CVS PRENATAL d 1000 261 DERMACEA TYPE VII GAUZE GUMMIES 226 DAILY FIBER 97 2"X2" 12 PLY 106 CVS PRENATAL daily multiple vitamins DERMACEA TYPE VII GAUZE GUMMY/DHA/FOLIC ACID 226 w/iron 206 2"X2" 8 PLY 106 CVS PRENATAL dalfampridine 246 DERMACEA TYPE VII GAUZE MULTI+DHA 226 3"X3" 12 PLY 106 CVS PREP PADS 124 danazol 14 DERMACEA TYPE VII GAUZE cvs purelax 99 dantrolene sodium 232 3"X3" 12PLY 106 cvs senna 101 dapsone 18 DERMACEA TYPE VII GAUZE cvs sinus & allergy maximum DARZALEX 43 4"X4" 12 PLY 106 strength 65 DERMACEA TYPE VII GAUZE DAYAVITE 216 4"X4" 16 PLY 106 cvs sleep-aid nighttime 95,96 dayhist allergy 12 hour DERMACEA TYPE VII GAUZE CVS SOFT GLUCOSE 27 relief 33 4"X4" 8 PLY 107 CVS SPECTRAVITE ADULT DDAVP 87 DERMACEA X-RAY SPONGES 50+ 215 decadron 63 4"X4" 16 PLY 107 CVS SPECTRAVITE decara 261 dermacinrx penetral 80 ADULTS 215 DERMACINRX RIBOTIN-E 216 CVS SPECTRAVITE ULTRA decitabine 42 MEN50+ 215 DERMACINRX ZINTREXYL- DECOLORIZED IODINE 53 C 216 CVS SPECTRAVITE ULTRA deferasirox 31 MENS HEALTH 215 DERMALEVIN ADHESIVE CVS SPECTRAVITE ULTRA DELSTRIGO 55 FOAMDRESSING 4"X4" 107 MENS HEALTH SENIOR 215 denta 5000 plus 205 DERMAVITE 216 CVS SPECTRAVITE ULTRA DEPAKENE 24 DESCOVY 55 WOMEN 215 DEPO-SUBQ PROVERA desipramine hcl 26 CVS SPECTRAVITE ULTRA 104 63 DESMOPRESSIN WOMENS HEALTH 216 ACETATE 87 CVS SPECTRAVITE ULTRA DERMA CIDOL 2000 50 WOMENS HEALTH DERMACEA DRAIN desmopressin acetate 87 SENIOR 216 SPONGES 4"X4" 106 desmopressin acetate spray 87 DERMACEA GAUZE SPONGE cvs stool softener 102 desmopressin acetate spray 2"X2" 12 PLY 106 refrigerated 87 cvs therapeutic 83 DERMACEA GAUZE SPONGE desogestrel & ethinyl cvs tioconazole 1 260 2"X2" 8 PLY 106 estradiol 62 CVS ULTRA THIN DERMACEA GAUZE SPONGE desogestrel-ethinyl estradiol LANCETS 113 3"X3" 12 PLY 106 (biphasic) 62 cvs vitamin b-2 263 DERMACEA GAUZE SPONGE desonide 78 3"X3" 8 PLY 106 cvs vitamin e 262 DERMACEA GAUZE SPONGE desoximetasone 78 CVS WOMENS 4"X4" 12 PLY 106 desvenlafaxine 26 PRENATAL+DHA 227

Index 13 DESVENLAFAXINE ER 26 DIATHRIVE PEN docusate sodium 102 desvenlafaxine succinate 26 NEEDLE/31GX 5MM 138 DOCUSOL PLUS MINI- DIATHRIVE PEN ENEMA 102 DEX4 QUICK DISSOLVE NEEDLE/32GX 4MM 138 GLUCOSE 27 dofetilide 20 diazepam 19 dexamethasone 64 dok 102 diazepam (anticonvulsant) 23 DEXAMETHASONE donepezil hydrochloride 245 dibucaine 81 INTENSOL 64 dorzolamide hcl 243 dexamethasone sodium diclofenac potassium 6 DORZOLAMIDE HCL 243 phosphate 64 diclofenac sodium 6 DEXAMETHASONE SODIUM dorzolamide hcl-timolol PHOSPHATE 64 diclofenac sodium (ophth)243 maleate 240 dexamethasone sodium diclofenac sodium (topical) 70 dotti 87 phosphate (ophth) 242 dicloxacillin sodium 244 DOVATO 55 dexchlorpheniramine maleate 33 dicyclomine hcl 251 doxazosin mesylate 40 dexmethylphenidate hcl 2 didanosine 55 doxepin hcl 26 dextroamphetamine sulfate 1 diethylpropion hcl 1 doxorubicin hcl 44 dextromethorphan-guaifenesin difil-g forte 20 doxycycline (monohydrate) 249 68 diflorasone diacetate 78 doxycycline hyclate 249 dextrose 236 diflunisal 11 doxylamine-pyridoxine 32 DEXTROSE 236 digitek 60 dr gs clear nail 73 DEXTROSE 5%/ELECTROLYTE digoxin 60 DRAMAMINE 32 #48 VIAFLEX 201 DEXTROSE 10%/NACL dihydroergotamine DRITHO-CREME HP 74 0.2% 201 mesylate 197 DRIXORAL DEXTROSE 20% 235 DILANTIN 24 COLD/ALLERGY 68 DEXTROSE 5%/NACL DILANTIN INFATABS 24 dronabinol 32 0.3% 201 DILANTIN-125 24 DROPLET GENTEEL LANCING dextrose w/ sodium DILATRATE SR 19 DEVICE 114 chloride 201 DROPLET INSULIN SYRINGE DEXTROSE/SODIUM dilt-xr 59 0.3ML/29G X 1/2" 138 CHLORIDE 201 diltiazem hcl 59 DROPLET INSULIN SYRINGE DI-DAK-SOL 52 diltiazem hcl coated beads 59 0.5ML/29G X 1/2" 138 DROPLET INSULIN SYRINGE di-phen 35 diltiazem hcl extended release beads 59 1ML/29G X 1/2" 138 DIABET-X DAILY DROPLET INSULIN SYRINGE PREVENTIONSKIN dimethyl fumarate 246 U-100/0.3/31G X 5/16" 138 THERAPY 52 diocto 102 DROPLET INSULIN SYRINGE DIABETIC BASICS HEALTHY diphenhydramine hcl 35 U-100/0.3ML/30G X 1/2" 138 FOOT 52 diphenhydramine hcl DROPLET INSULIN SYRINGE diabetic tussin allergy 33 (sleep) 96 U-100/0.3ML/30G X 5/16" 138 DIALYSIS SAFETY diphenoxylate w/ atropine 31 DROPLET INSULIN SYRINGE SYRINGES/LOW DEAD SPACE U-100/0.3ML/31G X 15/64" 138 3ML/22GX1-1/2" 138 dipyridamole 93 DROPLET INSULIN SYRINGE diamode 31 disopyramide phosphate 20 U-100/0.5ML/30G X 1/2" 138 DIASTIX 84 disulfiram 245 DROPLET INSULIN SYRINGE U-100/0.5ML/30G X 5/16" 138 DIATHRIVE LANCETS 113 divalproex sodium 25 DROPLET INSULIN SYRINGE DIATHRIVE LANCETS ULTRA DOCETAXEL 46 U-100/0.5ML/31G X 5/16" 138 THIN 30G 113 docetaxel 46 DROPLET INSULIN SYRINGE DIATHRIVE LANCING U-100/1ML/30G X 1/2" 138 DEVICE 113 DOCETAXEL 46 DROPLET INSULIN SYRINGE DIATHRIVE PEN NEEDLE/31 G docetaxel 46 U-100/1ML/30G X 5/16" 138 X 6MM 138 DOCETAXEL 46 DROPLET INSULIN SYRINGE DIATHRIVE PEN NEEDLE/31 docosahexaenoic acid 237 U-100/1ML/31G X 15/64" 138 GX 8MM 138 DROPLET INSULIN SYRINGE docusate calcium 102 U-100/1ML/31G X 5/16" 138

Index 14 DROPLET INSULIN DROPLET PEN NEEDLES E-ZJECT LANCETS MICRO- SYRINGE/U-100/0.3ML/31G X 32GX6MM 139 THIN 33G 114 15/64" 139 DROPLET PEN NEEDLES e.e.s. 400 103 DROPLET INSULIN 32GX8MM 140 EASIVENT 191 SYRINGE/U-100/0.3ML/31G X DROPSAFE SAFETY PEN 5/16" 139 NEEDLES/31G X 5/16" 140 EASIVENT/MASK-LARGE 191 DROPLET INSULIN DROPSAFE SAFTEY PEN EASIVENT/MASK-MEDIUM SYRINGE/U-100/0.5ML/30G X NEEDLES/31G X 1/4" 140 191 1/2" 139 drospirenone-ethinyl EASIVENT/MASK-SMALL 191 DROPLET INSULIN estradiol 62 EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X DROXIA 93 SYRINGE/0.5ML/30G X 15/64" 139 DRUG MART ADJUSTABLE 5/16" 140 DROPLET INSULIN LANCING DEVICE 114 EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X DRUG MART LANCETS SYRINGE/0.5ML/31G X 5/16" 139 THIN 114 5/16" 140 DROPLET INSULIN DRUG MART UNIFINE EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G X PENTIPS 31GX5MM 140 SYRINGE/1ML/30G X 1/2" 139 DRUG MART UNIFINE 5/16" 140 DROPLET INSULIN PENTIPS29G X 12MM 140 EASY COMFORT INSULIN SYRINGE/U-100/1ML/31G X DRUG MART UNIFINE SYRINGE/1ML/31G X 15/64" 139 PENTIPS31GX6MM 140 5/16" 140 DROPLET INSULIN DRUG MART UNIFINE EASY COMFORT INSULIN SYRINGE/U-100/1ML/31G X PENTIPS31GX8MM 140 SYRINGE/U-100/0.5ML/30G X 5/16" 139 DRUG MART UNIFINE 1/2" 140 DROPLET LANCETS ULTRA PENTIPS32GX4MM 140 EASY COMFORT INSULIN THIN 30G 114 DRUG MART UNIFINE SYRINGE/U-100/1ML/30G X DROPLET LANCING PENTIPSPLUS 1/2" 140 DEVICE 114 32GX4MM 140 EASY COMFORT PEN DROPLET PEN NEEDLES 29G DRUG MART UNILET NEEDLES31GX1/4" 140 X1/2" 139 LANCETSSUPER THIN EASY COMFORT PEN DROPLET PEN NEEDLES 30G 114 NEEDLES31GX3/16" 140 29GX10MM 139 DRUG MART UNILET EASY COMFORT PEN DROPLET PEN NEEDLES LANCETSULTRA THIN NEEDLES31GX5/16" 140 29GX12MM 139 28G 114 EASY COMFORT PEN DROPLET PEN NEEDLES 30G DRUG MART UNILET MICRO NEEDLES32GX5/32" 140 X 5/16" 139 THIN LANCETS 33G 114 EASY COMFORT PEN DROPLET PEN NEEDLES 31G DRYMAX EXTRA 107 NEEDLES33G X 4MM 140 X3/16" 139 DRYSOL 82 EASY COMFORT PEN DROPLET PEN NEEDLES 31G NEEDLES33G X 5MM 140 X5/16" 139 DULERA 22 EASY COMFORT PEN DROPLET PEN NEEDLES duloxetine hcl 26 NEEDLES33G X 6MM 140 31GX5MM 139 DUPIXENT 79 EASY FLOW 300 MM DROPLET PEN NEEDLES HOSE 191 31GX6MM 139 duramorph 11 EASY FLOW 400 MM DROPLET PEN NEEDLES DUREX EXTRA HOSE 191 31GX8MM 139 SENSITIVE 110 EASY FLOW AIR NOZZLE 192 DROPLET PEN NEEDLES 32G dutasteride-tamsulosin hcl 90 EASY FLOW HEPA X 1/4" 139 DUTOPROL 40 FILTER 192 DROPLET PEN NEEDLES 32G DYSPORT 235 EASY GLIDE PEN NEEDLES X 3/16" 139 33G X 5/32" 140 DROPLET PEN NEEDLES 32G E-Z JECT LANCETS 114 EASY MINI EJECT LANCING X 5/16" 139 E-Z JECT LANCETS 21G114 DEVICE 114 DROPLET PEN NEEDLES 32G E-Z JECT LANCETS EASY MINI LANCING X 5/32" 139 COLOR 114 DEVICE 114 DROPLET PEN NEEDLES E-Z JECT LANCETS SUPER EASY TOUCH 32GX5MM 140 32GX4MM 139 THIN 30G 114 DROPLET PEN NEEDLES E-Z JECT LANCETS THIN EASY TOUCH 32GX6MM 141 32GX5MM 139 26G 114 EASY TOUCH ALCOHOL PREP PADS/MEDIUM 124

Index 15 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH LANCETS SAFETTY SYRINGES SYRINGE/0.5ML/30G X 30G/TWIST 114 3ML/18GX1-1/2" 141 5/16" 142 EASY TOUCH LANCETS EASY TOUCH FLIPLOCK EASY TOUCH INSULIN 32G/PULL-TOP 114 SAFETY INSULIN SYRINGE SYRINGE/1ML/30G X EASY TOUCH LANCETS 1ML/29GX1/2" 141 5/16" 142 32G/TWIST 114 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH LANCETS SAFETY INSULIN SYRINGE SYRINGE/SAFETY/U- 33G/TWIST 114 1ML/30GX1/2" 141 100/0.5ML/29G X 1/2" 142 EASY TOUCH LANCING EASY TOUCH FLIPLOCK EASY TOUCH INSULIN DEVICE/EJECTOR 114 SAFETY INSULIN SYRINGE SYRINGE/SAFETY/U- EASY TOUCH PEN NEEDLE 1ML/30GX5/16" 141 100/0.5ML/30G X 5/16" 142 30G X 5/16" 142 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH PEN SAFETY INSULIN SYRINGE SYRINGE/SAFETY/U- NEEDLE/30G X 3/16" 143 1ML/31GX5/16" 141 100/1ML/29G X 1/2" 142 EASY TOUCH PEN NEEDLES EASY TOUCH FLIPLOCK EASY TOUCH INSULIN 29GX1/2" 143 SAFETY SYRINGE SYRINGE/SAFETY/U- EASY TOUCH PEN NEEDLES 3ML/21GX1" 141 100/1ML/30G X 1/2" 142 31GX1/4" 143 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES SAFETY SYRINGE SYRINGE/U-100/0.3ML/30G X 31GX5/16" 143 3ML/22GX1" 141 1/2" 142 EASY TOUCH PEN NEEDLES EASY TOUCH FLIPLOCK EASY TOUCH INSULIN 32GX1/4" 143 SAFETY SYRINGE 3ML/22GX1- SYRINGE/U-100/0.5ML/27G X EASY TOUCH PEN NEEDLES 1/2" 141 1/2" 142 32GX3/16" 143 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES SAFETY SYRINGE SYRINGE/U-100/0.5ML/28G X 32GX5/32" 143 3ML/23GX1" 141 1/2" 142 EASY TOUCH PEN EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLES/31G X 3/16" 143 SAFETY SYRINGE 3ML/23GX1- SYRINGE/U-100/0.5ML/29G X EASY TOUCH SAFETY PEN 1/2" 141 1/2" 142 NEEDLES/29G X 5MM 143 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH SAFETY PEN SAFETY SYRINGE SYRINGE/U-100/0.5ML/30G X NEEDLES/29G X 8MM 143 3ML/25GX1" 141 1/2" 142 EASY TOUCH SAFETY PEN EASY TOUCH FLIPLOCK EASY TOUCH INSULIN NEEDLES/30G X 5/16" 143 SAFETY SYRINGE SYRINGE/U-100/0.5ML/31G X EASY TOUCH SAFETY 3ML/25GX5/8" 141 5/16" 142 SYRINGE/3ML/20G X 1" 143 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH SAFETY SAFETY SYRINGES SYRINGE/U-100/1ML/27G X SYRINGE/3ML/21G X 1" 143 3ML/18GX1" 141 1/2" 142 EASY TOUCH SAFETY EASY TOUCH FLIPLOCK EASY TOUCH INSULIN SYRINGE/3ML/22G X 1" 143 SAFETY SYRINGES SYRINGE/U-100/1ML/28G X EASY TOUCH SAFETY 3ML/20GX1" 141 1/2" 142 SYRINGE/3ML/22G X 1- EASY TOUCH FLIPLOCK EASY TOUCH INSULIN 1/2" 143 SAFETY SYRINGES SYRINGE/U-100/1ML/29G X EASY TOUCH SAFETY 3ML/20GX1-1/2" 141 1/2" 142 SYRINGE/3ML/23G X 1" 143 EASY TOUCH FLIPLOCK EASY TOUCH INSULIN EASY TOUCH SAFETY SAFETY SYRINGES SYRINGE/U-100/1ML/30G X SYRINGE/3ML/25G X 1" 143 EASY TOUCH SAFETY 3ML/21GX1-1/2" 141 1/2" 142 EASY TOUCH INSULIN SYRINGE/3ML/25G X 5/8" 143 EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/31G X SAFETY INSULIN SYRINGE 5/16" 141 5/16" 142 EASY TOUCH LANCETS 1ML/29GX1/2" 143 EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK SYRINGE/0.3ML/31G X 26G/PULL-TOP 114 SAFETY INSULIN SYRINGE 5/16" 142 EASY TOUCH LANCETS 28G/PULL-TOP 114 1ML/30GX5/16" 143 EASY TOUCH INSULIN EASY TOUCH SHEATHLOCK SYRINGE/0.5ML/29G X EASY TOUCH LANCETS SAFETY INSULIN SYRINGE 1/2" 142 28G/TWIST 114 EASY TOUCH LANCETS 1ML/31GX5/16" 143 30G/PULL-TOP 114

Index 16 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN enalapril maleate & SAFETY SYRINGE SYRINGE/0.3ML/31G X hydrochlorothiazide 40 1ML/30GX1/2" 144 5/16" 144 ENBREL 7 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN ENBREL MINI 7 SAFETY SYRINGE SYRINGE/0.5ML/29G X 3ML/21GX1" 144 1/2" 144 ENBREL SURECLICK 7 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN ENCARE 259 SAFETY SYRINGE 3ML/21GX1- SYRINGE/0.5ML/30G X endocet 13 1/2" 144 5/16" 144 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN endur-acin 263 SAFETY SYRINGE SYRINGE/1ML/29G X ENEMEEZ PLUS 102 3ML/22GX1" 144 5/16" 144 ENFAMIL ENFALYTE 201 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN ENFAMIL EXPECTA 227 SAFETY SYRINGE 3ML/22GX1- SYRINGE/1ML/30G X 1/2" 144 5/16" 144 ENGERIX-B 256 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN enoxaparin sodium 23 SAFETY SYRINGE SYRINGE/U-100/0.5ML/28G X enpresse-28 61 3ML/23GX1" 144 1/2" 144 entacapone 47 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN SAFETY SYRINGE SYRINGE/U-100/0.5ML/28G X entecavir 58 3ML/25GX1" 144 5/16" 145 ENTYVIO 90 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN enulose 90 SAFETY SYRINGE SYRINGE/U-100/0.5ML/29G X 3ML/25GX5/8" 144 5/16" 145 EPIFOAM 79 EASYPOINT NEEDLE/SYRINGE ELITE-THIN INSULIN epinephrine (anaphylaxis) 261 3ML/18G X 1" 144 SYRINGE/U-100/0.5ML/31G X epinephrine hcl (nasal) 235 EASYPOINT NEEDLE/SYRINGE 5/16" 145 epitol 23 3ML/18G X 1-1/2" 144 ELITE-THIN INSULIN EASYPOINT NEEDLE/SYRINGE SYRINGE/U-100/1ML/28G X EPIVIR 55 3ML/23 G X 1" 144 1/2" 145 EPIVIR HBV 58 EASYPOINT NEEDLE/SYRINGE ELITE-THIN INSULIN EPZICOM 55 3ML/25G X 1" 144 SYRINGE/U-100/1ML/28G X eq allergy relief 36,37 EASYPOINT NEEDLE/SYRINGE 5/16" 145 3ML/25G X 5/8" 144 ELITE-THIN INSULIN eq anti-diarrheal 31 EBASE CONTROLLER KIT192 SYRINGE/U-100/1ML/29G X eq cetirizine hydrochloride ec-naproxen 6 1/2" 145 childrens 36 ELITE-THIN INSULIN EQ COMPLETE econazole nitrate 73 SYRINGE/U-100/1ML/31G X MULTIVITAMINADULTS UNDER ED CHLORPED D 68 5/16" 145 50 216 ed-spaz 250 ELIXOPHYLLIN 22 eq daily fiber 97 EDURANT 55 ELLA 63 eq fiber therapy 96 efavirenz 55 ELMIRON 90 eq omeprazole 254 efavirenz-emtricitabine-tenofovir ELOCTATE 91 EQ ONE DAILY MENS 50+ 216 disoproxil fumarate 55 eluryng 63 EQ ONE DAILY MENS efavirenz-lamivudine-tenofovir HEALTH 216 disoproxil fumarate 55 EMBRACE LANCING DEVICE WITH EJECTOR 114 EQ ONE DAILY WOMENS effer-k 203 50+ 216 EMCYT 44 EFLOW SCF AEROSOL eq one daily womens HEAD 192 EMPLICITI 43 health 211 eletriptan hydrobromide 197 EMSAM 25 EQ ONE DAILY WOMENS emtricitabine 55 HEALTH 216 ELIGARD 43 EQ SPACE CHAMBER ANTI- ELIQUIS 23 emtricitabine-tenofovir STATIC 192 disoproxil fumarate 55 ELIQUIS STARTER PACK 22 EQ SPACE CHAMBER ANTI- EMTRIVA 55 ELITE DC AUTO STATIC/LARGE MASK 192 ADAPTER 192 EMVERM 18 EQ SPACE CHAMBER ANTI- enalapril maleate 40 STATIC/MEDIUM MASK 192

Index 17 EQ SPACE CHAMBER ANTI- EQL SUPER THIN LANCETS euthyrox 249 STATIC/SMALL MASK 192 30G 114 evac-u-gen 101 EQL ALCOHOL SWABS 124 EQL THIN LANCETS everolimus 45 EQL ANTIBACTERIAL 26G 114 DEODORANT SOAP 52 EQUALACTIN 97 everolimus (immunosuppressant) 204 EQL ANTIBACTERIAL ergocalciferol 262 EVOTAZ 55 FOAMINGHAND WASH 52 ergoloid mesylates 246 EQL CALCIUM/VITAMIN D 199 EVZIO 31 ERGOMAR 197 EQL CENTURY MATURE EXCEL AP 50 ADULTS50+ 216 ergotamine w/ caffeine 197 EXCEL COMFORT POINT EQL CENTURY MENS 216 ERIVEDGE 43 INSULIN PEN NEEDLES 31G X EQL CENTURY WOMENS 216 ERLEADA 44 4MM 145 EQL COLOR LANCETS erlotinib hcl 43 EXCILON AMD ANTIMICROBIALDRAIN 21G 114 ery 69 EQL COLOR LANCETS MICRO SPONGES 4"X4" 6 PLY 107 THIN 33G 114 ery-tab 103 EXCILON AMD EQL DRY MOUTH ORAL erythrocin stearate 103 ANTIMICROBIALNON-WOVEN RINSE 205 erythromycin (acne aid) 70 SPONGES 4"X4" 6 PLY 107 eql fiber therapy 97 EXCILON DRAIN SPONGE erythromycin (ophth) 241 4"X4" 107 eql gas relief 89 erythromycin base 103 EXCILON DRAIN SPONGES EQL GAUZE PADS erythromycin 4"X4" 6 PLY 107 2"X2"/SMALL 107 ethylsuccinate 103 EXCILON I.V. SPONGES 2"X2" 6 EQL GAUZE PADS escitalopram oxalate 25 PLY 107 4"X4"/LARGE 107 EXEL COMFORT POINT EQL GAUZE STERILE PADS esgic 7 INSULIN PEN NEEDLES 29G X 3"X3" 107 esomeprazole 12MM 145 EQL INSULIN magnesium 254 EXEL COMFORT POINT SYRINGE/0.3ML/29G X estarylla 62 INSULIN PEN NEEDLES 31G X 1/2" 145 estazolam 96 6MM 145 EQL INSULIN estradiol 88 EXEL COMFORT POINT SYRINGE/0.3ML/30G X INSULIN PEN NEEDLES 31G X 5/16" 145 estradiol & norethindrone 8MM 145 EQL INSULIN acetate 87 EXEL COMFORT POINT SYRINGE/0.3ML/31G X estradiol vaginal 260 INSULIN SYRINGE/0.3ML/29G X 5/16" 145 ESTROFACTORS 224 1/2" 145 EQL INSULIN ESTROVEN MENOPAUSE EXEL COMFORT POINT SYRINGE/0.5ML/29G X SUPPLEMENT 216 INSULIN SYRINGE/0.3ML/30G X 1/2" 145 eszopiclone 96 5/16" 146 EQL INSULIN EXEL COMFORT POINT SYRINGE/0.5ML/30G X ethambutol hcl 42 INSULIN SYRINGE/0.5ML/28G X 5/16" 145 ethosuximide 24 1/2" 146 EQL INSULIN ethyl chloride 81 EXEL COMFORT POINT SYRINGE/0.5ML/31G X ETHYL CHLORIDE/FINE INSULIN SYRINGE/0.5ML/29G X 5/16" 145 STREAM 81 1/2" 146 EQL INSULIN ETHYL CHLORIDE/MEDIUM EXEL COMFORT POINT SYRINGE/1ML/29G X 1/2" 145 STREAM 81 INSULIN SYRINGE/0.5ML/30G X EQL INSULIN ethynodiol diacet & eth 5/16" 146 SYRINGE/1ML/30G X estrad 63 EXEL COMFORT POINT 5/16" 145 etidronate disodium 86 INSULIN SYRINGE/1ML/28G X EQL INSULIN 1/2" 146 SYRINGE/1ML/31G X etodolac 6 EXEL COMFORT POINT 5/16" 145 etonogestrel-ethinyl INSULIN SYRINGE/1ML/29G X eql omega-3 fish oil 236 estradiol 63 1/2" 146 EQL ONE DAILY MENS 216 etoposide 46 EXEL COMFORT POINT EQL PRENATAL etravirine 55 INSULIN SYRINGE/1ML/30G X FORMULA 227 EURAX 83 5/16" 146 eql slow release iron 94 EXELDERM 73

Index 18 exemestane 44 ferrous gluconate 94 FITNESS TABS FOR WOMEN EXFORGE HCT 41 FERROUS GLUCONATE 94 AM/PM/LYCOPENE 217 flac 244 EXONDYS 51 235 ferrous sulfate 94 flavoxate hcl 255 EXTAVIA 246 FERROUS SULFATE 94 flecainide acetate 20 EYE HEALTH/LUTEIN 216 ferrous sulfate 95 FLEET BISACODYL 101 EYE MULTIVITAMIN/LUTEIN FERROUS SULFATE 95 FLEET LIQUID GLYCERIN 216 ferrous sulfate 95 EYE MULTIVITAMIN/SODIUM SUPPOSITORIES 99 216 FEVERALL INFANTS 9 FLEXICHAMBER 192 EZ-LETS LANCETS 26G fexofenadine hcl 38 FLORIVA PLUS 225 SUPER-SOFT 114 fiber therapy 97 FLOVENT DISKUS 21 EZ-LETS LANCETS 28G ULTRA-SOFT 115 FIBRYGA 91 FLOVENT HFA 21 EZ-LETS LANCETS 30G 115 FIFTY50 ALCOHOL PREP FLUAD 2019-2020 256 PADS 124 ezetimibe 39 FIFTY50 PEN NEEDLES 31G FLUAD 2020-2021 256 ezetimibe-simvastatin 39 X3/16" (5MM) 146 FLUAD QUADRIVALENT 2021- 2022 256 fa-8 93 FIFTY50 PEN NEEDLES 31G X5/16" (8MM) 146 FLUAD QUADRIVALENT FABRAZYME 87 FIFTY50 PEN NEEDLES INFLUENZA VACCINE FOR famciclovir 58 31GX5MM 146 ADULTS 256 famotidine 254 FIFTY50 PEN FLUARIX QUADRIVALENT 2019-2020 257 FANAPT 48 NEEDLES/31GX8MM 146 FIFTY50 PEN FLUARIX QUADRIVALENT FANAPT TITRATION PACK 48 NEEDLES/32GX4MM 146 2020-2021 257 FANTASY LUBRICATED 110 FIFTY50 PEN FLUARIX QUADRIVALENT FANTASY NEEDLES/32GX6MM 146 2021-2022 257 LUBRICATED/SPERMICIDE FIFTY50 SUPERIOR FLUBLOK QUADRIVALENT 110 COMFORTINSULIN 2019-2020 257 FLUBLOK QUADRIVALENT FARYDAK 45 SYRINGE/0.3ML/31G X 5/16" 146 2020-2021 257 FASENRA 20 FIFTY50 SUPERIOR FLUBLOK QUADRIVALENT FAZACLO 48 COMFORTINSULIN 2021-2022 257 FC FEMALE CONDOM 110 SYRINGE/0.5ML/31G X FLUCELVAX QUADRIVALENT 2019-2020 257 FC2 FEMALE CONDOM 110 5/16" 146 FIFTY50 SUPERIOR FLUCELVAX QUADRIVALENT fe tabs 94 COMFORTINSULIN 2020-2021 257 FEIBA 91 SYRINGE/1ML/31G X FLUCELVAX QUADRIVALENT 2021-2022 257 felbamate 24 5/16" 146 fluconazole 33 felodipine 59 FILTER AIR PP 192 finasteride 90 fludrocortisone acetate 64 FEMCAP 110 FLULAVAL QUADRIVALENT fenofibrate 39 FIRMAGON 44 2019-2020 257 FENOFIBRATE 39 first aid antibiotic 71 FLULAVAL QUADRIVALENT fenofibrate 39 FIRST AID ANTISEPTIC 2020-2021 257 OINTMENT 53 FLULAVAL QUADRIVALENT fenofibrate micronized 39 FIRST-MOUTHWASH 2021-2022 257 fenoprofen calcium 6 BLM 204 FLUMIST QUADRIVALENT258 FENSOLVI 86 FIRVANQ 18 flunisolide (nasal) 233 fentanyl 11 fish oil burp-less 236 fluocinolone acetonide 79 FERRETTS 94 fish oil concentrate 236 fluocinolone acetonide ferrex 150 94 fish oil extra strength 236 (otic) 244 ferrocite 94 fish oil maximum strength 237 fluocinonide 79 ferrocite plus 94 FITNESS TABS FOR MEN fluocinonide emulsified base 79 AM/PM/LYCOPENE 216 ferrous fumarate 94 fluoridex daily renewal 205 fluoritab 202

Index 19 fluorometholone (ophth) 242 FREAMINE HBC 6.9% 238 FREESTYLE PRECISION NEO FLUOROPLEX 73 FREAMINE III 239 BLOOD GLUCOSE TEST STRIPS 84 FREDS PHARMACY fluorouracil (topical) 73,74 FREESTYLE TEST STRIPS 84 fluoxetine hcl 25 AUTOLET LANCING DEVICE 115 FREESTYLE UNISTICK II fluoxetine hcl (pmdd) 246 FREDS PHARMACY UNIFINE LANCETS 115 fluphenazine decanoate 49 PENTIPS PEN NEEDLES FULL KIT NEBULIZER SET 192 fluphenazine hcl 49 32GX4MM 146 FREDS PHARMACY UNIFINE furosemide 85 flurazepam hcl 96 PENTIPS PLUS FUZEON 55 flurbiprofen 6 31GX5MM 146 fyavolv 87 flurbiprofen sodium 243 FREDS PHARMACY UNIFINE FYCOMPA 23 flutamide 44 PENTIPS PLUS 31GX8MM 146 g tussin ac 66 fluticasone propionate 79 FREDS PHARMACY UNILET gabapentin 23 fluticasone propionate LANCETS SUPER THIN GABITRIL 24 (nasal) 233 30G 115 fluticasone-salmeterol 22 FREDS PHARMACY UNILET galantamine hydrobromide 245 fluvastatin sodium 39 LANCETS ULTRA THIN GARDASIL 9 258 fluvoxamine maleate 25 28G 115 gas relief 89 FLUZONE HIGH-DOSE PF 2019- FREEDAVITE 217 gatifloxacin (ophth) 241 FREESTYLE CONTROL 2020 258 GAUZE DRESSING 4"X4" 107 FLUZONE HIGH-DOSE PF 2020- SOLUTION 115 2021 258 FREESTYLE CONTROL GAUZE PADS 2"X2" 107 FLUZONE HIGH-DOSE PF 2021- SOLUTION HIGH/LOW 115 GAUZE PADS 3"X3" 107 2022 258 FREESTYLE FREEDOM GAUZE PADS 4"X4" 107 LITE 115 FLUZONE QUADRIVALENT GAUZE SPONGE TYPE VII 2019-2020 258 FREESTYLE INSULINX BLOODGLUCOSE MEDI-PAK 2"X2" 8PLY 107 FLUZONE QUADRIVALENT GAUZE SPONGES 4"X4" 12 2020-2021 258 MONITORING SYSTEM 115 FREESTYLE INSULINX PLY 107 FLUZONE QUADRIVALENT gavilyte-c 98 2021-2022 258 BLOODGLUCOSE TEST 84 FLYP HYPERSONIQ FREESTYLE INSULINX gavilyte-n/flavor pack 98 CARTRIDGE 192 BLOODGLUCOSE TEST gemfibrozil 39 STRIPS 84 FML 242 gengraf 204 FREESTYLE LANCETS 115 FML FORTE 242 FREESTYLE LITE BLOOD GENOTROPIN 86 FOLIC ACID 93 GLUCOSE MONITORING gentak 240 folic acid 93 SYSTEM 115 gentamicin in saline 2 FOLIKA-CI 217 FREESTYLE LITE TEST gentamicin sulfate (ophth) 241 STRIPS 84 FOLIKA-MG 217 FREESTYLE PRECISION gentamicin sulfate (topical) 71 FOLITIN-Z 217 INSULIN SYRINGE/U- GENTEEL CONTACT FORA GTEL BLOOD KETONE 100/0.5ML/30G X 5/16" 146 TIPS/BLUE 115 TEST STRIPS 84 FREESTYLE PRECISION GENTEEL CONTACT FORA LANCETS 115 INSULIN SYRINGE/U- TIPS/CLEAR 115 GENTEEL CONTACT FORA LANCING DEVICE 115 100/0.5ML/31G X 5/16" 147 FREESTYLE PRECISION TIPS/GREEN 115 FORA LANCING GENTEEL CONTACT DEVICE/CLEARCAP 115 INSULIN SYRINGE/U- 100/1ML/31G X 5/16" 147 TIPS/ORANGE 115 formaldehyde 50 FREESTYLE PRECISION GENTEEL CONTACT FORMALDEHYDE 50 INSULIN SYRINGES/U- TIPS/RAINBOW 115 FOSAMAX PLUS D 86 100/1ML/30G X 5/16" 147 GENTEEL CONTACT TIPS/VIOLET 115 fosamprenavir calcium 55 FREESTYLE PRECISION NEO BLOOD GLUCOSE GENTEEL CONTACT fosinopril sodium 40 MONITORING SYSTEM 115 TIPS/YELLOW 115 fosinopril sodium & hydrochlorothiazide 41

Index 20 GENTEEL LANCING glimepiride 29 GLOBAL INJECT EASE INSULIN DEVICE/GLORIOUS glipizide 29 SYRINGE/U-100/1ML/29G X GOLD 115 1/2" 148 GENTEEL LANCING glipizide xl 29 GLOBAL INJECT EASE INSULIN DEVICE/PRECIOUS glipizide-metformin hcl 26 SYRINGE/U-100/1ML/30G X PLATINUM 115 GLOBAL EASE INJECT PEN 1/2" 148 GENTEEL LANCING NEEDLES 29GX12MM 147 GLOBAL INJECT EASE INSULIN DEVICE/STATELY SILVER115 GLOBAL EASE INJECT PEN SYRINGE/U-100/1ML/30G X GENTEEL LANCING NEEDLES 31GX8MM 147 5/16" 148 KIT/BUTTERFLY BLUE 115 GLOBAL EASE INJECT PEN GLOBAL INJECT EASE INSULIN GENTEEL NOZZLES 115 NEEDLES 32GX4MM 147 SYRINGE/U-100/1ML/31G X GENTEEL PLUS LANCING GLOBAL EASE INJECT PEN 5/16" 148 DEVICE/BUFF BLACK 116 NEEEDLES 31GX5MM 147 GLOBAL INSULIN SYRINGE/U- GENTEEL PLUS LANCING GLOBAL EASY GLIDE 100/0.3ML/30G X 1/2" 148 DEVICE/BUTTERFLY INSULIN SYRINGE/0.3ML/31G GLOBAL INSULIN SYRINGES/U- BLUE 116 X 15/64" 147 100/0.3ML/30GX5/16" 148 GENTEEL PLUS LANCING GLOBAL EASY GLIDE GLOBAL LANCING DEVICE/PLAYFUL INSULIN SYRINGE/0.5ML/31G DEVICE 116 PURPLE 116 X 15/64" 147 GLUCAGEN HYPOKIT 27 GENTEEL PLUS LANCING GLOBAL EASY GLIDE glucagon (rdna) 27 DEVICE/PRINCESS PINK 116 INSULIN SYRINGE/1ML/31G X GLUCOPRO INSULIN GENTEEL PLUS LANCING 15/64" 147 GLOBAL EASY GLIDE SYRINGE/U-100/0.3ML/30G X DEVICE/WILLOWY WHITE 116 1/2" 148 GENTLE-LET GP INSULINSYRINGE/U- GLUCOPRO INSULIN LANCETS 116 100/0.3ML/31G X 5/16" 147 GLOBAL EASY GLIDE PEN SYRINGE/U-100/0.3ML/30G X GENTLE-LET LANCETS 5/16" 148 GENERAL PURPOSE NEEDLES 32GX4MM 147 GLUCOPRO INSULIN STYLE/FINE POINT 116 GLOBAL INJECT EASE INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/31G X GENTLE-LET LANCETS 5/16" 148 GENERAL PURPOSE 100/0.3ML/29G X 1/2" 147 GLUCOPRO INSULIN STYLE/MEDIUM POINT 116 GLOBAL INJECT EASE INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X GENTLE-LET LANCETS 1/2" 148 SAFETY STYLE/FINE 100/0.3ML/30G X 1/2" 147 GLUCOPRO INSULIN POINT 116 GLOBAL INJECT EASE INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X GENTLE-LET LANCETS 5/16" 148 SAFETY STYLE/MEDIUM 100/0.3ML/30G X 5/16" 147 GLUCOPRO INSULIN POINT 116 GLOBAL INJECT EASE INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/31G X GENTLE-LET PLATFORMS 5/16" 148 2.4MM 116 100/0.3ML/31G X 5/16" 147 GLUCOPRO INSULIN GENTLE-LET PLATFORMS GLOBAL INJECT EASE INSULIN SYRINGE/U- SYRINGE/U-100/1ML/30G X 3.0MM 116 1/2" 148 GENVOYA 56 100/0.5ML/28G X 1/2" 147 GLUCOPRO INSULIN GLOBAL INJECT EASE GEODON 48 INSULIN SYRINGE/U- SYRINGE/U-100/1ML/30G X GERI-FREEDA SENIOR 5/16" 148 100/0.5ML/29G X 1/2" 147 GLUCOPRO INSULIN FORMULA 217 GLOBAL INJECT EASE geri-hydrolac 12 80 INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G X 5/16" 148 GERMBLOC HEALTH 52 100/0.5ML/30G X 1/2" 147 GLUCOSE 27 GERMBLOC HEALTH HAND GLOBAL INJECT EASE SANITIZER 52 INSULIN SYRINGE/U- GLUTARALDEHYDE 50 gianvi 61 100/0.5ML/30G X 5/16" 148 glyburide 29 GLOBAL INJECT EASE glyburide micronized 29 GILENYA 246 INSULIN SYRINGE/U- GILOTRIF 43 100/0.5ML/31G X 5/16" 148 glyburide-metformin 26 GLASSIA 249 GLOBAL INJECT EASE glycerin (laxative) 99 glatiramer acetate 246 INSULIN SYRINGE/U- glycopyrrolate 251 100/1ML/28G X 1/2" 148 glatopa 246 glydo 81 GLEOSTINE 42

Index 21 GNP ACID CONTROL 150 GNP LANCETS MICRO THIN GOLD BOND ULTIMATE HAND MAXIMUM STRENGTH 254 33G 116 SANITIZER/MOISTURIZER 52 GNP ALCOHOL SWABS 124 GNP LANCETS SUPER THIN GOLYTELY 99 gnp allergy plus sinus 30G 116 GOODSENSE CLICKFINE headache 66 GNP LANCETS THIN 116 SAFETY PEN NEEDLE/31G X gnp allergy relief 35 GNP LANCETS THIN 3/16" 150 gnp allergy relief 24 hour 37 26G 116 GOODSENSE COLOR gnp motion sickness relief 32 LANCETS MICRO-THIN 33G GNP CALAMINE 82 UNIVERSAL 116 GNP CALAMINE GNP PRENATAL 227 GNP QUICK DISSOLVE GOODSENSE IODINE 53 PHENOLATED 82 GOODSENSE LANCETS gnp clearlax 99 GLUCOSE 27 gnp sleep aid 96 MICRO-THIN 33G 116 GNP CLICKFINE UNIVERSAL GOODSENSE LANCETS PEN NEEDLES 31GX1/4" 148 GNP STERILE GAUZE PADS 2"X2" 107 MICRO-THIN 33G GNP CLICKFINE UNIVERSAL UNIVERSAL 116 PEN NEEDLES 31GX5/16" 149 GNP STERILE GAUZE PADS 3"X3" 107 GOODSENSE LANCETS gnp eye drops 241 ULTRA-THIN 26G gnp suphedrin 235 gnp fish oil 237 UNIVERSAL 116 GNP ULTICARE PEN GNP GLUCOSE 27 GOODSENSE LANCETS NEEDLES/31GX5/16" 149 ULTRA-THIN 30G 116 gnp hydrocortisone 77 GNP ULTICARE PEN GOODSENSE LANCETS GNP HYDROGEN PEROXIDE NEEDLES/32GX 5/32" 149 ULTRA-THIN 30G WIPES 50 GNP ULTICARE PEN UNIVERSAL 116 GNP INSULIN NEEDLES/32GX1/4" 149 GOODSENSE LANCING SYRINGE/0.3ML/29G X GNP ULTICARE PEN DEVICE 116 1/2" 149 NEEDLES31G X 5MM 149 GOODSENSE PEN GNP INSULIN GNP ULTRA COMFORT NEEDLE/PENFINE SYRINGE/0.3ML/30G X INSULIN SYRINGE/0.3ML/29G CLASSIC/31G X 3/16" 150 5/16" 149 X 1/2" 149 GOODSENSE PEN GNP INSULIN GNP ULTRA COMFORT NEEDLE/PENFINE SYRINGE/0.3ML/31G X INSULIN SYRINGE/0.3ML/30G CLASSIC/31G X 5/16" 150 5/16" 149 X 5/16" SHORT 149 GOODSENSE PEN GNP INSULIN GNP ULTRA COMFORT NEEDLE/PENFINE SYRINGE/0.5ML/28G X INSULIN SYRINGE/0.5ML/28G CLASSIC/32G X 1/4" 150 1/2" 149 X 1/2" 149 GOODSENSE PEN GNP INSULIN GNP ULTRA COMFORT NEEDLE/PENFINE SYRINGE/0.5ML/29G X INSULIN SYRINGE/0.5ML/29G CLASSIC/32G X 5/32" 150 1/2" 149 X 1/2" 149 GOODSENSE PRENATAL GNP INSULIN GNP ULTRA COMFORT VITAMINS 227 SYRINGE/0.5ML/30G X INSULIN SYRINGE/1ML/28G X gordons urea 80 5/16" 149 1/2" 149 GNP INSULIN GNP ULTRA COMFORT granisetron hcl 31 SYRINGE/0.5ML/31G X INSULIN SYRINGE/1ML/29G X griseofulvin microsize 32 5/16" 149 1/2" 150 griseofulvin ultramicrosize 32 GNP INSULIN gnp vitamin c 263 guaiatussin ac 66 SYRINGE/1ML/28G X 1/2" 149 gnp vitamin d 261 GNP INSULIN guaifenesin-codeine 68 SYRINGE/1ML/29G X 1/2" 149 gnp vitamin e 262 guanfacine hcl 40 GNP INSULIN GOCOVRI 47 guanfacine hcl (adhd) 2 GOJJI BLOOD KETONE TEST SYRINGE/1ML/30G X GVOKE PFS 27 5/16" 149 STRIPS 84 GNP INSULIN GOJJI LANCING GYNAZOLE-1 260 SYRINGE/1ML/31G X DEVICE/CLEAR CAP 116 gynecort 10 77 5/16" 149 GOLD BOND FIRST AID h-chlor 12 51 GNP IODIDES TINCTURE 53 QUICK SPRAY 52 GOLD BOND ULTIMATE H-CHLOR 6 52 GNP IODINE TINCTURE 53 HAND SANITIZER SHEER H-CHLOR WOUND 52 GNP LANCETS 21G 116 MOISTURE 52 H-E-B IN CONTROL PEN NEEDLE 31GX3/16" 150

Index 22 H-E-B IN CONTROL PEN HALDOL 48 HEALTHY ACCENTS UNIFINE NEEDLES 31GX5MM 150 HALDOL DECANOATE PENTIPS PEN NEEDLES H-E-B IN CONTROL PEN 100 48 31GX8MM 151 NEEDLES 31GX6MM 150 HALDOL DECANOATE 50 48 HEALTHY ACCENTS UNIFINE H-E-B IN CONTROL PEN PENTIPS PEN NEEDLES NEEDLES 31GX8MM 150 halobetasol propionate 79 32GX4MM 151 H-E-B IN CONTROL PEN haloperidol 48 HEALTHY ACCENTS UNILET NEEDLES/NANO/32GX4MM HALOPERIDOL 61 LANCETS SUPER THIN 150 30G 117 H-E-B IN CONTROL haloperidol decanoate 48 HEALTHY MAMA BE WELL UNIFINEPENTIPS PLUS haloperidol lactate 48 ROUNDED 227 31GX1/4" 150 HAVRIX 258 healthylax 99 H-E-B IN CONTROL HEALTH CARE LANCING HELIXATE FS 91 UNIFINEPENTIPS PLUS DEVICE 117 31GX3/16" 150 HEALTHWISE INSULIN HEMANGEOL 59 H-E-B IN CONTROL SYRINGE/U-100/0.3ML/30G X HEMLIBRA 91 UNIFINEPENTIPS PLUS 5/16" 150 HEMOFIL M 92 31GX5/16" 150 HEALTHWISE INSULIN hemorrhoidal suppositories 14 H-E-B IN CONTROL SYRINGE/U-100/0.3ML/31G X UNIFINEPENTIPS PLUS 5/16" 151 heparin sod (porcine) in d5w 23 31GX5MM 150 HEALTHWISE INSULIN heparin sodium (porcine) 23 H-E-B IN CONTROL SYRINGE/U-100/0.5ML/30G X HEPARIN UNIFINEPENTIPS PLUS 5/16" 151 SODIUM/DEXTROSE 23 32GX4MM 150 HEALTHWISE INSULIN HEPLISAV-B 258 H-E-B IN CONTROL SYRINGE/U-100/0.5ML/31G X HERCEPTIN 43 UNIFINEPENTIPS PLUS 5/16" 151 32GX5/32" 150 HEALTHWISE INSULIN HIBERIX 255 H-E-B IN CONTROL SYRINGE/U-100/1ML/30G X HIGH POTENCY UNIFINEPENTIPS PLUS 5/16" 151 MULTIVITAMIN 224 33GX5/32" 150 HEALTHWISE INSULIN HIGH POTENCY H-E-B INCONTROL SYRINGE/U-100/1ML/31G X MULTIVITAMIN/BETA- ADVANCEDLANCING 5/16" 151 CAROTENE 217 DEVICE 116 HEALTHWISE MICRON PEN HIGH POTENCY H-E-B INCONTROL ALCOHOL NEEDLES/32G X 5/32" 151 MULTIVITAMIN/FOLIC PADS 124 HEALTHWISE MINI PEN ACID 217 H-E-B INCONTROL LANCETS NEEDLES 31GX6MM 151 HM ADHESIVE PADS MICRO THIN 33G 116 HEALTHWISE PEN NEEDLES ANTIBACTERIAL/SHEER 107 H-E-B INCONTROL LANCETS 29GX12MM 151 HM CALAMINE 82 SUPER THIN 30G 117 HEALTHWISE SHORT PEN HM COMPLETE 217 H-E-B INCONTROL LANCETS NEEDLES 31GX8MM 151 ULTRA THIN 28G 117 HM COMPLETE 50+ MENS HEALTHWISE SHORT PEN ULTIMATE 217 H-E-B INCONTROL PEN NEEDLES/31G X 3/16" 151 NEEDLES 29GX12MM 150 HM COMPLETE 50+ WOMENS HEALTHWISE SHORT PEN ULTIMATE 217 HAEMOLANCE 117 NEEDLES/31G X 5/16" 151 HAEMOLANCE LOW FLOW HEALTHWISE UNIFINE HM COMPLETE MEN 217 LANCETS 117 PENTIPS PEN NEEDLES hm famotidine 252 HAEMOLANCE PLUS 117 32GX4MM 151 hm fiber 97 HAEMOLANCE PLUS HIGH HEALTHY ACCENTS hm fish oil 237 AUTOLET IMPRESSION FLOW 117 HM HAIR/SKIN/NAILS 217 HAEMOLANCE PLUS LOW LANCING DEVICE 117 FLOW 117 HEALTHY ACCENTS UNIFINE HM IODIDES TINCTURE 53 HAEMOLANCE PLUS MAX PENTIPS PEN NEEDLES HM IODINE TINCTURE 54 FLOW 117 29GX12MM 151 hm magnesium 17 HAEMOLANCE PLUS HEALTHY ACCENTS UNIFINE PEDIATRIC FLOW 117 PENTIPS PEN NEEDLES HM ONE DAILY MENS 217 HAIR SKIN & NAILS ADVANCED 31GX5MM 151 HM ONE DAILY PRENATAL FORMULA 217 HEALTHY ACCENTS UNIFINE COMBO 227 HALAVEN 46 PENTIPS PEN NEEDLES HM ONE DAILY WOMENS 217 31GX6MM 151

Index 23 HM PRENATAL 227 HYCAMTIN 46 HYPERSAL 68 HM STERILE PADS 107 hydralazine hcl 41 HYPOLANCE AST LANCING HM STERILE PADS 2"X2" 107 HYDRALYTE 201 KIT 117 HM ULTICARE INSULIN HYDRALYTE FREEZER IBRANCE 45 SYRINGE/1ML/30G X 1/2" 151 POPS 201 ibuprofen 6 HM ULTICARE INSULIN HYDRO-LAN 82 ICAPS AREDS FORMULA 217 SYRINGE/U-100/0.3ML/31G X HYDROCELL ADHESIVE iclevia 61 5/16" 151 DRESSING 4"X4" 108 ICLUSIG 45 HM ULTICARE MINI PEN HYDROCELL DRESSING NEEDLES/31G X 5MM 4"X4" 108 ID NOW COVID-19 84 (3/16") 151 hydrochlorothiazide 85 ID NOW COVID-19 CONTROL HM ULTICARE SHORT PEN SWAB KIT 84 HYDROCIL INSTANT 97 NEEDLES 31GX8MM 152 IDELVION 92 hm vitamin b1 263 hydrocodone polistirex- chlorpheniramine polistirex 68 IDHIFA 45 hm vitamin c 263 hydrocodone w/ ILARIS 3 hm vitamin d3 262 homatropine 64 imatinib mesylate 45 hydrocodone- homatropaire 240 IMBRUVICA 45 homatropine hbr 240 acetaminophen 13 hydrocortisone 64 imipramine hcl 26 hpa lanolin 245 imiquimod 80 HUDSON RCI SEE-THRU hydrocortisone (intrarectal) 14 hydrocortisone (rectal) 15 IMOVAX RABIES AEROSOL MASK (H.D.C.V.) 258 ELONGATED/ADULT 192 hydrocortisone (topical) 79 IMPAVIDO 18 HUMALOG MIX 50/50 28 hydrocortisone acetate IN TOUCH LANCING HUMALOG MIX 50/50 (topical) 79 DEVICE 117 hydrocortisone acetate w/ KWIKPEN 28 inatal gt 226 HUMALOG MIX 75/25 28 pramoxine 15 HUMALOG MIX 75/25 hydrocortisone butyrate 79 INCRUSE ELLIPTA 20 KWIKPEN 28 hydrocortisone valerate 79 indapamide 85 HUMATE-P 92 hydrocortisone w/acetic INDOCIN 6 HUMATROPE 86 acid 244 indomethacin 6 HUMATROPE COMBO hydrocortisone-aloe vera 79 INFLECTRA 90 PACK 86 hydrogen peroxide 50 INLYTA 42 HUMIRA 2 HYDROGEN PEROXIDE 50 INNOSPIRE REPLACEMENT HUMIRA PEDIATRIC CROHNS hydrogen peroxide 50 FILTER 192 DISEASE STARTER PACK 2 hydromet 64 INSPIRACHAMBER/ANTI- HUMIRA PEN 2 STATIC HUMIRA PEN-CD/UC/HS hydromorphone hcl 11 VALVED/MOUTHPIECE 192 STARTER 2 HYDROMORPHONE HCL 11 INSPIRACHAMBER/LARGE HUMIRA PEN-PEDIATRIC UC hydromorphone hcl 11 192 STARTER PACK 2 INSPIRACHAMBER/SOOTHER HUMIRA PEN-PS/UV hydroxychloroquine sulfate 41 MASK/INSPIRAMASK/MEDIUM STARTER 2 hydroxyprogesterone 192 caproate 245 INSPIRACHAMBER/SOOTHER HUMULIN 70/30 28 hydroxyprogesterone caproate HUMULIN 70/30 KWIKPEN 28 MASK/INSPIRAMASK/SMALL (antineoplastic) 44 192 HUMULIN N 28 hydroxyurea 46 INSPIREASE DRUG HUMULIN N KWIKPEN 28 hydroxyzine hcl 19 DELIVERYSYSTEM 192 HUMULIN R 28 hydroxyzine pamoate 19 INSPIREASE RESERVOIR HUMULIN R U-500 HYLAMEND FIRST AID BAGS 192 (CONCENTRATED) 28 50 INSULIN ASPART ANTISEPTIC PROTAMINE/INSULIN HUMULIN R U-500 HYLAZINC 217 KWIKPEN 28 ASPART 28 hyoscyamine sulfate 251 INSULIN ASPART HY-VEE LANCETS 117 HYPERRHO S/D 244 PROTAMINE/INSULIN ASPART HY-VEE THIN LANCETS 117 FLEXPEN 28

Index 24 INSULIN LISPRO INSULIN INVEGA 48 PROTAMINE/INSULIN LISPRO SYRINGES/0.5ML/27GX1/2" INVEGA SUSTENNA 48 KWIKPEN 28 153 INSULIN SYRINGE 1ML/31G INSULIN INVEGA TRINZA 48 X1/4" 152 SYRINGES/0.5ML/28GX1/2" INVIRASE 56 INSULIN SYRINGE/0.3ML/29G X 153 INVOKAMET 26 1" 152 INSULIN INSULIN SYRINGE/0.3ML/29G X SYRINGES/0.5ML/29GX1/2" INVOKAMET XR 26 1/2" 152 153 INVOKANA 29 INSULIN SYRINGE/0.3ML/30G X INSULIN IODEX 54 5/16" 152 SYRINGES/0.5ML/30GX5/16" IODEX/METHYL INSULIN SYRINGE/0.3ML/31G X 153 SALICYLATE 54 5/16" 152 INSULIN IODINE TINCTURE 54 INSULIN SYRINGE/0.5ML/27G X SYRINGES/0.5ML/31GX 1/2" 152 5/16" 153 IODINE TINCTURE MILD 54 INSULIN SYRINGE/0.5ML/28G X INSULIN IODINE TINCTURE 1/2" 152 SYRINGES/0.5ML/31GX5/16" STRONG 54 INSULIN SYRINGE/0.5ML/30G X 153 IODINE TINCTURE STRONG 1/2" 152 INSULIN DECOLORIZED 54 INSULIN SYRINGE/0.5ML/30G X SYRINGES/1ML/27GX/1/2" IODOFLEX 54 5/16" 152 153 IODOSORB 54 INSULIN SYRINGE/0.5ML/31G X INSULIN IONOSOL-MB/DEXTROSE 5/16" 152 SYRINGES/1ML/27GX1/2" 5% 201 INSULIN SYRINGE/1ML/28G X 153 IOPIDINE 240 1/2" 152 INSULIN INSULIN SYRINGE/1ML/29G X SYRINGES/1ML/28GX1/2" ipratropium bromide 20 1/2" 152 153 ipratropium bromide (nasal)232 INSULIN SYRINGE/1ML/30G X INSULIN ipratropium-albuterol 22 5/16" 152 SYRINGES/1ML/29GX1/2" irbesartan 40 INSULIN SYRINGE/NEEDLE 153 0.3ML/30G X 5/16" 152 INSULIN irbesartan-hydrochlorothiazide INSULIN SYRINGE/NEEDLE SYRINGES/1ML/30GX1/2" 41 0.3ML/31G X 5/16" 152 153 IRESSA 43 INSULIN SYRINGE/NEEDLE INSULIN irinotecan hcl 47 0.5ML/29G X 1/2" 152 SYRINGES/1ML/31GX5/16" IRON CHEWS PEDIATRIC 95 INSULIN SYRINGE/NEEDLE 154 iron supplement 94 0.5ML/30G X 5/16" 152 INSUPEN 29G X 12MM 154 INSULIN SYRINGE/NEEDLE ISENTRESS 56 INSUPEN 31G X 5MM 154 0.5ML/31G X 5/16" 152 ISENTRESS HD 56 INSULIN SYRINGE/NEEDLE INSUPEN 31G X 8MM 154 ISOLYTE-P/DEXTROSE 1ML/29G X 1/2" 152 INSUPEN 32G X 4MM 154 INSULIN SYRINGE/NEEDLE 5% 201 1ML/30G X 5/16" 153 INSUPEN 33GX4MM 154 ISOLYTE-S 201 INSULIN SYRINGE/NEEDLE INSUPEN PEN NEEDLES 32G ISOLYTE-S PH 7.4 201 X4MM 154 1ML/31G X 5/16" 153 isoniazid 42 INSULIN SYRINGE/U- INSUPEN SENSITIVE 100/0.3ML/29G X 1/2" 153 32GX6MM 154 ISOPTO ATROPINE 240 INSULIN SYRINGE/U- INSUPEN SENSITIVE isosorbide dinitrate 19 100/0.5ML/29G X 1/2" 153 32GX8MM 154 isosorbide mononitrate 19 INSULIN SYRINGE/U- INSUPEN ULTRAFIN 100/1ML/29G X 1/2" 153 29GX12MM 154 isotretinoin 70 INSULIN SYRINGE/U- INSUPEN ULTRAFIN ITCH RELIEF 73 100/1ML/30G X 5/16" 153 30GX8MM 154 itraconazole 33 INSUPEN ULTRAFIN INSULIN SYRINGE/U- IV PREP WIPES 50 100/1ML/31G X 5/16" 153 31GX6MM 154 INSULIN SYRINGES 0.3ML/31G INSUPEN ULTRAFIN IXEMPRA KIT 46 X 1/4" 153 31GX8MM 154 IXIARO 258 INSULIN SYRINGES 0.5ML/31G INTELENCE 56 IXINITY 92 X 1/4" 153 INTRALIPID 236 J & J ADHESIVE LARGE 108

Index 25 J & J GAUZE 2"X2" 8 PLY 108 KENDALL GEL SKIN SCRUB KIMONO PS LUBRICATED111 J & J GAUZE 4"X4" 12 PLY108 PACK/SMALL WINGED KIMONO PS PLUS SPONGES 54 J & J GAUZE 4"X4" 8 PLY 108 SPERMICIDE/LUBRICATED KENDALL HYDROPHILIC 111 J & J GAUZE SPONGES 12-PLY FOAMDRESSING 2"X2" 108 KIMONO SENSATION 4" X 4" 108 KENDALL HYDROPHILIC LUBRICATED 111 J & J GAUZE SPONGES 16-PLY FOAMDRESSING 3"X3" 108 KIMONO SENSATION PLUS 4" X 4" 108 KENDALL HYDROPHILIC SPERMICIDE J & J GAUZE SPONGES 8- FOAMDRESSING 4"X4" 108 LUBRICATED 111 PLY4" X 4" 108 KENDALL HYDROPHILIC KIMONO SPECIAL 111 J & J NON-STICK PADS FOAMPLUS DRESSING 100LARGE 108 2"X2" 108 KINDERLYTE 201 JAKAFI 45 KENDALL HYDROPHILIC KINDERLYTE PREMAX 201 JANSSEN COVID-19 FOAMPLUS DRESSING KINNEY LANCETS 117 3"X3" 108 VACCINE 258 KINNEY THIN LANCETS 117 jantoven 22 KENDALL MINOR WET SKIN SCRUB PACK 54 KINRAY INSULIN SYRINGE JANUMET 26 KENDALL SPONGE PREFERRED PLUS/0.3ML/31G JANUMET XR 26 STICK/PVP 54 X 5/16" 154 JANUVIA 27 KENDALL VAGINAL PREP KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31G JARDIANCE 29 PACK 54 KENDALL VAGINAL PREP X 5/16" 154 JENLIVA TRAY 54 KINRAY INSULIN SYRINGE PRENATAL/POSTNATAL 227 KENDALL WET SKIN SCRUB PREFERRED PLUS/1ML/31G X JENTADUETO 26 PACK 54 5/16" 154 JIVI 92 KERLIX SPONGES 4" X 4" 12 KINRAY INSULIN JULUCA 56 PLY 108 SYRINGE/0.5ML/29G X KERLIX SPONGES 4" X 4" 16 1/2" 154 JYNARQUE 87 PLY 108 kionex 204 k 100 262 KERR TRIPLE DYE 50 KISQALI 45 K-PAX IMMUNE SUPPORT ketoconazole 33 KISQALI FEMARA 200 FORMULA PROFESSIONAL ketoconazole (topical) 73 DOSE 44 STRENGTH 217 KISQALI FEMARA 400 K-PHOS 202 KETONE 84 DOSE 45 k-prime 203 KETONE TEST STRIPS 84 KISQALI FEMARA 600 K-TAB 203 ketoprofen 6 DOSE 45 K-Y ME & YOU EXTRA ketorolac tromethamine 6 KITABIS PAK 2 LUBRICATED 110 ketorolac tromethamine klor-con 203 K-Y ME & YOU INTENSE 110 (ophth) 243 klor-con 10 203 KABIVEN 237 KETOSTIX 84 klor-con m10 203 KADCYLA 43 ketotifen fumarate (ophth)243 klor-con sprinkle 203 KADIAN 11 KEVZARA 3 KMART VALU PLUS INSULIN kaitlib fe 62 KEY-E 262 SYRINGE/0.3ML/30G 154 KHEDEZLA 26 KMART VALU PLUS INSULIN KALETRA 56 SYRINGE/0.5ML/29G 154 KALYDECO 249 KIMONO COLORS 110 KMART VALU PLUS INSULIN KAMELEON LUBRICATED 110 KIMONO LUBRICATED 110 SYRINGE/0.5ML/30G 154 KCENTRA 92 KIMONO MICRO THIN 110 KMART VALU PLUS INSULIN SYRINGE/1ML/29G 154 KCL 0.15%/D5W/NACL KIMONO MICRO THIN PLUS KMART VALU PLUS INSULIN SPERMICIDE 0.225% 201 SYRINGE/1ML/30G 154 KCL 0.3%/D5W/NACL LUBRICATED 110 0.9% 201 KIMONO PLUS SPERMICIDE KOATE 92 kelnor 1/35 61 LUBRICATED 110 KOATE-DVI 92 KENDALL GEL SKIN SCRUB KIMONO PLUS KOGENATE FS 92 PACK/LARGE WINGED SPERMICIDE/LUBRICATED KOMBIGLYZE XR 26 111 SPONGES 54 konsyl 97

Index 26 KONSYL 97 KROGER LANCETS THIN LANCETS THIN 118 konsyl daily fiber 97 26G 117 LANCETS ULTRA THIN 118 KROGER LANCETS KONSYL DAILY FIBER 97 ULTRATHIN30G 117 LANCING DEVICE 118 KONSYL ORIGINAL DAILY KROGER LANCING LANCING DEVICE FIBER 97 DEVICE 117 ADJUSTABLE 118 KONSYL-D 97 KROGER PEN NEEDLES 29G lanolin 245 KORLYM 27 X12MM 155 lanolin (topical) 82 KROGER PEN NEEDLES 31G KOVALTRY 92 X8MM 155 LANOLOR 82 kp calcium 600+d3 198 KROGER PEN NEEDLES LANOXIN 60 kp folic acid 93 31GX1/4" 155 lansoprazole 255 kp niacin 263 KROGER PEN NEEDLES/31G LANZO 118 X1/4" 155 kp omega-3 fish oil 237 KROGER PEN NEEDLES/31G lapatinib ditosylate 45 KP PRENATAL X3/16" 155 LARTRUVO 44 MULTIVITAMINS 227 KROGER PEN NEEDLES/31G latanoprost 243 kp vitamin d 262 X5/16" 155 LATUDA 48 KPN PRENATAL 227 KROGER PEN NEEDLES/32G X5/32" 155 laxative 101 KRINTAFEL 41 KROGER PEN NEEDLES/33G LEADER ADVANCED LANCING KROGER AUTOLET LANCING X5/32" 155 DEVICE 118 DEVICE 117 KRYSTEXXA 91 LEADER INSULIN KROGER HEALTHPRO TWIST KYMRIAH 43 SYRINGE/0.3ML/29G X LANCETS/26G 117 1/2" 155 KROGER INSULIN labetalol hcl 58 LEADER INSULIN SYRINGE/0.3ML/29G X lactated ringer's 201 SYRINGE/0.3ML/30G X 1/2" 155 lactic acid (ammonium 5/16" 155 KROGER INSULIN lactate) 80 LEADER INSULIN SYRINGE/0.3ML/30G X LACTIC ACID E 80 SYRINGE/0.3ML/31G X 5/16" 155 lactulose 99 5/16" 155 KROGER INSULIN LEADER INSULIN SYRINGE/0.3ML/31G X lactulose (encephalopathy)90 SYRINGE/0.5ML/28G X 5/16" 155 LAMISIL AT SPRAY 73 1/2" 155 KROGER INSULIN lamivudine 56 LEADER INSULIN SYRINGE/0.5ML/29G X SYRINGE/0.5ML/29G X 1/2" 155 lamivudine (hbv) 58 1/2" 155 KROGER INSULIN lamivudine-zidovudine 56 LEADER INSULIN SYRINGE/0.5ML/30G X lamotrigine 23,24 SYRINGE/0.5ML/30G X 5/16" 155 LANCET DEVICE 5/16" 156 KROGER INSULIN LEADER INSULIN SYRINGE/0.5ML/31G X ADJUSTABLE 117 LANCET DEVICE WITH SYRINGE/0.5ML/31G X 5/16" 155 5/16" 156 KROGER INSULIN EJECTOR 117 LANCET TRANSPORTER LEADER INSULIN SYRINGE/1ML/29G X 1/2" 155 SYRINGE/1ML/28G X 1/2" 156 KROGER INSULIN CASE 117 LANCETS 118 LEADER INSULIN SYRINGE/1ML/30G X SYRINGE/1ML/29G X 1/2" 156 5/16" 155 LANCETS 26G TWIST LEADER INSULIN KROGER INSULIN TOP 118 SYRINGE/1ML/30G X SYRINGE/1ML/31G X LANCETS 28G 118 5/16" 156 5/16" 155 LANCETS 30G 118 LEADER INSULIN KROGER LANCETS 117 LANCETS SAFETY SEAL SYRINGE/1ML/31G X KROGER LANCETS 21G 117 21G 118 5/16" 156 KROGER LANCETS MICRO LANCETS SAFETY SEAL LEADER QUICK DISSOLVE THIN33G 117 26G 118 GLUCOSE 27 KROGER LANCETS SUPER LANCETS SAFETY SEAL LEADER UNIFINE PENTIPS THIN 117 28G 118 PLUS/MINI/31GX3/16" 156 KROGER LANCETS THIN 117 LANCETS SUPER THIN LEADER UNIFINE PENTIPS 28G 118 PLUS/SHORT/31GX5/16" 156

Index 27 LEADER UNIFINE lidopin 81 LITETOUCH INSULIN PENTIPS/MINI/31GX3/16" 156 liothyronine sodium 250 SYRINGE/U-100/1ML/31G X LEADER UNIFINE 5/16" 157 PENTIPS/NANO/32GX5/32" LIQUIVIDA HYDRATION LITETOUCH MASK 156 KIT 203 LARGE 193 LEADER UNIFINE lisinopril 40 LITETOUCH MASK PENTIPS/PLUS/32GX5/32" lisinopril & MEDIUM 193 156 hydrochlorothiazide 41 LITETOUCH MASK SMALL193 leflunomide 6 LITE TOUCH LANCING LITETOUCH PEN NEEDLES PEN 118 LEMTRADA 246 29GX12.7MM 157 LITEAIRE 193 LENVIMA 10 MG DAILY LITETOUCH PEN NEEDLES LITETOUCH INSULIN PEN DOSE 42 31G X 6MM 157 LENVIMA 14 MG DAILY NEEDLES/32G X LITETOUCH PEN NEEDLES DOSE 42 4MM/MINI 156 31G X 6MM/ULTRA LENVIMA 18 MG DAILY LITETOUCH INSULIN SHORT 157 DOSE 43 SYRINGE/0.3ML/29G X LITETOUCH PEN NEEDLES LENVIMA 20 MG DAILY 1/2" 156 31GX8MM SHORT 157 DOSE 43 LITETOUCH INSULIN LITETOUCH PEN LENVIMA 24 MG DAILY SYRINGE/0.3ML/30G X NEEDLES/31G X 3/16" 157 DOSE 43 5/16" 156 LITETOUCH PEN LENVIMA 8 MG DAILY LITETOUCH INSULIN NEEDLES/31G X DOSE 43 SYRINGE/0.3ML/31G X 5MM/MINI 157 letrozole 44 5/16" 156 LITETOUCH PEN LITETOUCH INSULIN NEEDLES/31G X leucovorin calcium 46 SYRINGE/0.5ML/30G X 8MM/SHORT 157 LEUKERAN 42 5/16" 156 LITHIUM 47 leuprolide acetate 44 LITETOUCH INSULIN SYRINGE/0.5ML/31G X lithium carbonate 47 levetiracetam 24 5/16" 156 LITHOBID 47 levobunolol hcl 240 LITETOUCH INSULIN LIVE BETTER ADVANCED levocarnitine (metabolic SYRINGE/1ML/30G X LANCING DEVICE 118 modifiers) 87 5/16" 156 LIVE BETTER LANCET levocetirizine dihydrochloride38 LITETOUCH INSULIN SUPERTHIN 30G 118 LIVE BETTER LANCET levofloxacin 88 SYRINGE/U-100/0.3ML/30G X 5/16" 156 ULTRATHIN 28G 118 levonorgestrel & eth LITETOUCH INSULIN LOMAIRA 1 estradiol 63 SYRINGE/U-100/0.3ML/31G X levonorgestrel (emergency LONGS INSULIN 5/16" 156 oc) 63 SYRINGE/0.5ML/31G X LITETOUCH INSULIN 5/16" 157 levonorgestrel-eth estradiol SYRINGE/U-100/0.5ML/28G X (triphasic) 63 LONGS LANCETS levonorgestrel-ethinyl estradiol 1/2" 157 STANDARD 118 63 LITETOUCH INSULIN LONGS LANCETS THIN 118 (91-day) SYRINGE/U-100/0.5ML/29G X levothyroxine sodium 250 1/2" 157 LONSURF 45 LEXIVA 56 LITETOUCH INSULIN loperamide hcl 31 LIBERTY MINI LANCING SYRINGE/U-100/0.5ML/30G X lopinavir-ritonavir 56 DEVICE 118 5/16" 157 loratadine 38 LICE B GONE 83 LITETOUCH INSULIN lorazepam 19 lice treatment 82 SYRINGE/U-100/0.5ML/31G X 5/16" 157 lorazepam intensol 19 LICEMD 83 LITETOUCH INSULIN lorcet 13 lidocaine 81 SYRINGE/U-100/1ML/28G X losartan potassium 40 lidocaine hcl 81 1/2" 157 LITETOUCH INSULIN losartan potassium & lidocaine hcl (mouth-throat) 204 SYRINGE/U-100/1ML/29G X hydrochlorothiazide 41 lidocaine-hydrocortisone acetate 1/2" 157 lovastatin 39 (rectal) 15 LITETOUCH INSULIN loxapine succinate 48 lidocaine-prilocaine 81 SYRINGE/U-100/1ML/30G X lubiprostone 89 lidocort 14 5/16" 157

Index 28 LUCEMYRA 245 magnesium chloride 202 MEDICINE SHOPPE PEN LUCENTIS 240 magnesium citrate 100 NEEDLES 31G X 8MM 158 MEDISENSE THIN LUCIRA COVID-19 ALL-IN-ONE MAGNESIUM EXTRA LANCETS 118 TEST KIT 84 STRENGTH 202 MEDROL 64 LUGOLS STRONG IODINE 54 magnesium oxide 17 medroxyprogesterone LUMIGAN 243 MAGNESIUM OXIDE 202 acetate 245 LUMIZYME 87 magnesium oxide (mg medroxyprogesterone acetate LUNG PERFORMANCE PEAK supplement) 202 (contraceptive) 63 FLOW METER 193 MAKENA 245 mefloquine hcl 41 LUPRON DEPOT (1- malathion 83 MEGA MULTI FOR MEN 217 MONTH) 44 maprotiline hcl 25 MEGA MULTI FOR LUPRON DEPOT (3- WOMEN 217 MONTH) 44 MARATHON MEDICAL PENTIPS29GX12MM 158 MEGA MULTIVITAMIN FOR LUPRON DEPOT (4- MEN 217 MONTH) 44 MARATHON MEDICAL PENTIPS31GX5MM 158 MEGA MULTIVITAMIN FOR LUPRON DEPOT (6- WOMEN 218 MONTH) 44 MARATHON MEDICAL PENTIPS31GX8MM 158 MEGAVITE FRUITS & LUPRON DEPOT-PED (1- VEGGIES 218 MONTH) 86 MARATHON MEDICAL PENTIPS32GX4MM 158 MEGAVITE GOLDEN YEARS LUPRON DEPOT-PED (3- 55+ 218 MONTH) 86 MARNATAL-F 227 LUTEIN MARPLAN 25 megestrol acetate 44 MEIJER ALCOHOL SWABS PLUS/ZEAXANTHIN 217 MATULANE 46 LYNPARZA 45 EXTRA-THICK 124 MAXI-COMFORT INSULIN MEIJER CALAMINE 82 LYRA DIRECT SARS-COV-2 SYRINGE/U- MEIJER COLOR LANCETS ASSAY 84 100/0.5ML/28GX1/2" 158 LYRA SARS-COV-2 ASSAY 84 MAXI-COMFORT INSULIN UNIVERSAL 33G 118 MEIJER LANCETS 118 LYSODREN 44 SYRINGE/U- MEIJER LANCETS THIN 118 M-M-R II 259 100/1ML/28GX1/2" 158 MAXI-COMFORT SAFETY MEIJER LANCETS M-NATAL PLUS 227 PEN NEEDLE/29G X UNIVERSAL21G 118 MAALOX 17 3/16" 158 MEIJER LANCETS maalox max 16 MAXI-COMFORT SAFETY UNIVERSAL30G 118 MACULAR VITAMIN PEN NEEDLE/29G X MEIJER LANCETS BENEFIT 217 5/16" 158 UNIVERSAL33G 118 MEIJER PEN NEEDLES 29G mag-al plus 16 MAXI-TUSS PE 68 MAXICOMFORT II PEN X12MM 158 magdelay 202 NEEDLES/31G X 1/4" 158 MEIJER PEN NEEDLES 31G MAGELLAN INSULIN SAFETY MAXICOMFORT INSULIN X6MM 158 SYRINGE/U-100/0.3ML/29G X SYRINGES 27G X 1/2" 158 MEIJER PEN NEEDLES 31G 1/2" 157 MAXIDEX 242 X8MM 158 MAGELLAN INSULIN SAFETY MEIJER SUPER THIN SYRINGE/U-100/0.3ML/30G X MAXX LUBRICATED 111 LANCETS 118 5/16" 157 MAXX PLUS SPERMICIDE MEKINIST 45 LUBRICATED 111 MAGELLAN INSULIN SAFETY MEKTOVI 45 SYRINGE/U-100/0.5ML/29G X meclizine hcl 32 meloxicam 6 1/2" 157 meclofenamate sodium 6 MAGELLAN INSULIN SAFETY MEDIC INSULIN melphalan 42 SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/30G X memantine hcl 245 5/16" 157 5/16" 158 MENACTRA 255 MAGELLAN INSULIN SAFETY MEDIC INSULIN MENEST 88 SYRINGE/U-100/1ML/29G X SYRINGE/0.5ML/30G X 1/2" 158 5/16" 158 MENQUADFI 255 MAGELLAN INSULIN SAFETY MEDICINE SHOPPE PEN MENS 50+ MULTI VITAMIN SYRINGE/U-100/1ML/30G X NEEDLES 29G X 12MM 158 &MINERAL FORMULA 218 5/16" 158 MEDICINE SHOPPE PEN MENS MULTI VITAMIN & MAGNESIUM 202 NEEDLES 31G X 6MM 158 MINERAL FORMULA 218

Index 29 MENS MULTIVITAMIN 218 miconazole 7 260 MM INSULIN SYRINGE/U- MENVEO 255 miconazole nitrate (topical)73 100/0.3ML/31G X 5/16" 159 MM INSULIN SYRINGE/U- meperidine hcl 11 miconazole nitrate 100/1/2ML/30G X 5/16" 159 meprobamate 19 vaginal 260 MM INSULIN SYRINGE/U- MICROCHAMBER 193 mercaptopurine 42 100/1/2ML/31G X 5/16" 159 MICROCLENS WIPES 50 MM INSULIN SYRINGE/U- MERTHIOLATE TINCTURE 52 MICRODOT PEN 100/1ML/30G X 5/16" 159 mesalamine 90 NEEDLE/31G X 6 MM 158 MM INSULIN SYRINGE/U- mesalamine w/ cleanser 90 MICRODOT PEN 100/1ML/31G X 5/16" 159 METAMUCIL 97 NEEDLE/32G X 4 MM 159 MM LANCING DEVICE 118 MICRODOT PEN METAMUCIL FIBER 97 MM PEN NEEDLES 31G X NEEDLE/33G X 4 MM 159 1/4" 159 metformin hcl 27 MICROELITE FILTER MM PEN NEEDLES 31G X methadone hcl 11,12 REPLACEMENTS 193 3/16" 159 methadone hydrochloride MICROELITE MM PEN NEEDLES 31G X intensol 11 RECHARGEABLE 5/16" 159 methadose 11 BATTERY 193 MM PEN NEEDLES 32G X microklenz 50 5/32" 159 methazolamide 85 MICROLET NEXT 118 modafinil 2 methenamine mandelate 19 MICROLIFE DIGITAL PEAK MODERNA COVID-19 methergine 244 FLOW METER 193 VACCINE 259 methimazole 249 MICROSPACER 193 moexipril hcl 40 METHITEST 14 midazolam hcl 96 MOI-STIR 205 methocarbamol 232 midodrine hcl 261 MOLESKIN FOAM PADDING 108 METHOTREXATE 3 migergot 197 molindone hcl 49 methotrexate sodium 42 MIGRANAL 197 mometasone furoate 79 methyldopa 40 MILLIPRED 64 mondoxyne nl 249 methyldopa & MINI LANCING DEVICE 118 MONOCAL 202 hydrochlorothiazide 41 MINI WRIGHT AFS PEAK MONOJECT 3ML methylergonovine maleate 244 FLOWMETER LOW methylphenidate hcl 2 RANGE 193 SYRINGE/STANDARD HYPODERMIC NEEDLE/21GX1- methylprednisolone 64 MINI WRIGHT PEAK FLOW METER 193 1/2" 159 methyltestosterone 14 MINI WRIGHT PEAK FLOW MONOJECT INSULIN metoclopramide hcl 89 METER STANDARD SYRINGE/1ML 159 RANGE 193 MONOJECT INSULIN metolazone 85 SYRINGE/1ML/31G X metoprolol & MINIELITE FILTER REPLACEMENTS 193 5/16" 159 hydrochlorothiazide 41 MONOJECT INSULIN metoprolol succinate 59 MINIELITE RECHARGEABLE BATTERY 193 SYRINGE/DETACH METOPROLOL SUCCINATE NEEDLE/1ML/25G X 5/8" 159 ER/HYDROCHLOROTHIAZIDE minitran 19 MONOJECT INSULIN 41 minocycline hcl 249 SYRINGE/DETACH metoprolol tartrate 59 minoxidil 41 NEEDLE/1ML/27G X 1/2" 159 metronidazole 18 mintox plus 16 MONOJECT INSULIN SYRINGE/PERM MIRASORB SPONGES 2" X METRONIDAZOLE 18 NEEDLE/1ML/28G X 1/2" 159 metronidazole 18 2" 108 MIRASORB SPONGES 4" X MONOJECT INSULIN SYRINGE/PERM NEEDLE/U- metronidazole (topical) 82 4" 108 100/0.5ML/28G X 1/2" 159 metronidazole in nacl 18 mirtazapine 25 MONOJECT INSULIN metronidazole vaginal 260 misoprostol 255 SYRINGE/SAFETY/PERM metyrosine 40 mitoxantrone hcl 44 NEEDLE/0.3ML/29G X 1/2" 159 mexiletine hcl 20 MM INSULIN SYRINGE/U- MONOJECT INSULIN 100/0.3ML/30G X 5/16" 159 SYRINGE/SAFETY/PERM miconazole 3 260 NEEDLE/0.3ML/29GX1/2" 159

Index 30 MONOJECT INSULIN MONOJECT SYRINGE/LUER MONOJECT SYRINGE/SAFETY/PERM LOCK/3ML/20G X 1-1/2" 161 SYRINGE/STANDARDHYPODE NEEDLE/0.5ML/29G X 1/2" 160 MONOJECT SYRINGE/LUER RMIC NEEDLE/3ML/27GX1-1/4" MONOJECT INSULIN LOCK/3ML/20G X 3/4" 161 162 SYRINGE/SAFETY/PERM MONOJECT SYRINGE/LUER MONOJECT ULTRA COMFORT NEEDLE/1ML/29G X 1/2" 160 LOCK/3ML/22G X 1" 161 INSULIN SYRINGE/0.3ML/29G X MONOJECT INSULIN MONOJECT SYRINGE/LUER 1/2" 162 SYRINGE/SOFTPACK/1ML/27G LOCK/3ML/22G X 1-1/2" 161 MONOJECT ULTRA COMFORT X 1/2" 160 MONOJECT SYRINGE/LUER INSULIN SYRINGE/0.3ML/30G X MONOJECT INSULIN LOCK/3ML/23G X 1" 161 5/16" 162 SYRINGE/SOFTPACK/U- MONOJECT SYRINGE/LUER MONOJECT ULTRA COMFORT 100/0.5ML/28G X 1/2" 160 LOCK/3ML/25G X 1" 161 INSULIN SYRINGE/0.3ML/31G X MONOJECT INSULIN MONOJECT SYRINGE/LUER 5/16" 162 SYRINGE/U-100/0.3ML/30G X LOCK/3ML/25G X 5/8" 161 MONOJECT ULTRA COMFORT 5/16" 160 MONOJECT SYRINGE/LUER INSULIN SYRINGE/0.5ML/28G X MONOJECT INSULIN LOCK/3ML/27G X 1-1/4" 161 1/2" 162 SYRINGE/U-100/0.5ML/30G X MONOJECT SYRINGE/LUER- MONOJECT ULTRA COMFORT 5/16" 160 LOCK/3ML/21G X 1" 161 INSULIN SYRINGE/0.5ML/29G X MONOJECT INSULIN MONOJECT SYRINGE/LUER- 1/2" 162 SYRINGE/U-100/1ML/28G X LOCK/3ML/21G X 1-1/2" 161 MONOJECT ULTRA COMFORT 1/2" 160 MONOJECT INSULIN SYRINGE/0.5ML/30G X MONOJECT INSULIN SYRINGE/STANDARDHYPOD 5/16" 162 SYRINGE/U-100/1ML/30G X ERMIC MONOJECT ULTRA COMFORT 5/16" 160 NEEDLE/3ML/20GX1" 161 INSULIN SYRINGE/0.5ML/31G X MONOJECT INSULIN MONOJECT 5/16" 162 SYRINGEREGULAR LUER SYRINGE/STANDARDHYPOD MONOJECT ULTRA COMFORT TIP/SOFTPACK/1ML 160 ERMIC NEEDLE/3ML/20GX1- INSULIN SYRINGE/1ML/28G X MONOJECT LIFESHIELD 1/2" 161 1/2" 162 BLUNTCANNULA/LUER LOCK MONOJECT MONOJECT ULTRA COMFORT SYR/3ML/18G X 1" 160 SYRINGE/STANDARDHYPOD INSULIN SYRINGE/1ML/29G X MONOJECT MAGELLAN ERMIC 1/2" 162 SYRINGE/SAFETY NEEDLE/3ML/21GX1" 161 MONOLET LANCETS 118 MONOJECT NEEDLE/3ML/20G X 1" 160 MONOLET OPD LANCETS118 MONOJECT MAGELLAN SYRINGE/STANDARDHYPOD SYRINGE/SAFETY ERMIC MONONINE 92 NEEDLE/3ML/20G X 1-1/2"160 NEEDLE/3ML/22GX1" 161 montelukast sodium 20 MONOJECT MAGELLAN MONOJECT morgidox 1x100mg 249 SYRINGE/SAFETY SYRINGE/STANDARDHYPOD NEEDLE/3ML/21G X 1" 160 ERMIC NEEDLE/3ML/22GX1- morphine sulfate 12 MONOJECT MAGELLAN 1/2" 161 MORPHINE SULFATE 12 SYRINGE/SAFETY MONOJECT morphine sulfate 12 NEEDLE/3ML/21G X 1-1/2"160 SYRINGE/STANDARDHYPOD MORPHINE SULFATE 12 MONOJECT MAGELLAN ERMIC SYRINGE/SAFETY NEEDLE/3ML/23GX1" 162 morphine sulfate 12 NEEDLE/3ML/22G X 1" 160 MONOJECT MORPHINE SULFATE 12 MONOJECT MAGELLAN SYRINGE/STANDARDHYPOD morphine sulfate 12 ERMIC SYRINGE/SAFETY MORPHINE SULFATE 12 NEEDLE/3ML/22G X 1-1/2"160 NEEDLE/3ML/25GX1" 162 MONOJECT MAGELLAN MONOJECT morphine sulfate 12 SYRINGE/SAFETY SYRINGE/STANDARDHYPOD MORPHINE SULFATE 12 NEEDLE/3ML/23G X 1" 160 ERMIC NEEDLE/3ML/25GX1- morphine sulfate 12 MONOJECT MAGELLAN 1/4" 162 SYRINGE/SAFETY MONOJECT morphine sulfate beads 12 NEEDLE/3ML/25G X 1" 160 SYRINGE/STANDARDHYPOD motion sickness relief 32 MONOJECT MAGELLAN ERMIC MOUTH KOTE 205 SYRINGE/SAFETY NEEDLE/3ML/25GX5/8" 162 MOUTH KOTE REMINT 205 NEEDLE/3ML/25G X 5/8" 161 MONOJECT SYRINGE/LUER MOVANTIK 90 LOCK/3ML/20G X 1" 161 moxifloxacin hcl (ophth) 241

Index 31 MS INSULIN mynephrocaps 206 neomycin-polymyxin-hc SYRINGE/0.3ML/31G X MYOBLOC 235 (otic) 243 5/16" 162 NEONATAL COMPLETE 227 nabumetone 6 MS INSULIN NEONATAL PLUS 227 SYRINGE/0.5ML/31G X nadolol 59 NEONATAL VITAMIN 228 5/16" 162 nafcillin sodium 244 MS INSULIN SYRINGE/1ML/31G NEOVITE 219 NAFCILLIN SODIUM 244 X 5/16" 162 NEPHRAMINE 239 nafrinse 202 MULTAQ 20 NERLYNX 45 naftifine hcl 73 MULTI PRENATAL 227 nevirapine 56 NAFTIN 73 MULTI VITAMIN 224 NEXAFED SINUS PRESSURE MULTI VITAMIN/D-3 224 NAGLAZYME 87 +PAIN 68 MULTI-BETIC DIABETES 218 naloxone hcl 31 NEXAVAR 46 MULTI-LANCET DEVICE 118 NALTREXONE 31 NEXCARE ABSOLUTE WATERPROOF PAD 108 MULTI-LANCET DEVICE 2 118 naltrexone hcl 31 niacin 263 multi-vit/iron/fluoride 225 NAMENDA XR TITRATION PACK 245 niacin (antihyperlipidemic) 39 MULTI-VITAMIN MONOCAPS 218 naproxen 6 NIACIN TR 263 multi-vitamin/fluoride drops 224 naproxen sodium 6 niacor 39 multilex 211 naratriptan hcl 197 NICADAN 219 MULTILEX 218 NARCAN 31 NICADAN ZX 219 MULTILEX T&M 218 NARDIL 25 nicardipine hcl 59 multiple vitamin 224 nasal decongestant 235 NICAZEL 219 multiple vitamins w/ iron 206 NAT-RUL THERAVITE- NICAZEL FORTE 219 M/HIGHPOTENCY 219 multiple vitamins w/ nicotine 248 NATACYN 241 minerals 218 nicotine polacrilex 248 NATALVIT 227 MULTIVITAMIN 218,224 NICOTINE TRANSDERMAL MULTIVITAMIN ADULT 224 nateglinide 29 SYSTEM 248 multivitamin adults 211 NATRUL-VITES 219 NICOTROL INHALER 248 MULTIVITAMIN ADULTS 218 natural vitamin e 262 NICOTROL NS 248 MULTIVITAMIN MEN 218 NATURE-THROID 250 nifedipine 59 multivitamin select/fluoride 224 NATURE-THROID NT- nimodipine 59 2.5 250 NINLARO 46 multivitamin women 212 NAYZILAM 23 MULTIVITAMIN WOMEN 218 NEBULIZER AIR nisoldipine 59 multivitamin/fluoride 224 TUBE/PLUGS 193 NITRO-BID 19 MULTIVITAMIN/ZINC NEBULIZER PEDIATRIC NITRO-DUR 19 STRESSFORMULA 219 MASK 193 nitro-time 19 nebusal 68 mupirocin 71 nitrofurantoin 19 nefazodone hcl 25 mupirocin calcium (topical) 71 nitrofurantoin macrocrystal 19 MURO 128 243 neo-polycin 240 nitrofurantoin monohyd mycophenolate mofetil 204 neo-polycin hc 241 macro 19 mycophenolate sodium 204 NEOMULTIVITE 224 nitroglycerin 19 MYLERAN 42 neomycin sulfate 2 NIVA-PLUS 228 MYNATAL 227 neomycin-bacitracin zn- nizoral a-d 72 polymyxin 241 NIZORAL A-D 73 MYNATAL ADVANCE 227 neomycin-polymy- MYNATAL PLUS 227 dexameth 242 NO IRON MULTIPLE VITAMIN/MINERALS 219 MYNATAL ULTRACAPLET 227 neomycin-polymyxin-gramicidin noble formula hc 77 MYNATAL-Z 227 241 neomycin-polymyxin-hc NORDITROPIN FLEXPRO 86 MYNATE 90 PLUS 227 (ophth) 242 norethin acet & estrad-fe 63

Index 32 norethindrone & ethinyl estradiol- NOVOLOG MIX 70/30 omega-3 fatty acids 237 fe 63 PREFILLED FLEXPEN omeprazole 255 norethindrone RELION 29 (contraceptive) 63 NOVOLOG MIX 70/30 omeprazole magnesium 255 norethindrone acet & eth RELION 29 OMNICAP 224 estra 63 NOVOSEVEN RT 92 OMNIFLEX DIAPHRAGM 111 norethindrone acetate 245 NOVOTWIST PEN NEEDLE OMNITROPE 86 norethindrone acetate-ethinyl 32GX 5MM 163 ON CALL LANCING estradiol 87 np thyroid 120 250 DEVICE 119 norgestimate-ethinyl NPLATE 93 ON CALL PLUS LANCING estradiol 63 DEVICE 119 norgestimate-ethinyl estradiol NU GAUZE 4PLY 4"X4" 108 (triphasic) 63 NU GAUZE GENERAL-USE ONCOVITE 219 NORMOSOL -R 201 SPONGES 4"X4" 4 PLY 108 ondansetron 32 NORMOSOL-M IN D5W 201 NUCALA 20 ondansetron hcl 31 NORMOSOL-M/D5W 201 NUCYNTA ER 12 ONE A DAY PRENATAL 228 NORMOSOL-R 201 NUMOISYN 205 ONE A DAY WOMENS NUPLAZID 48 PRENATAL/DHA 228 NORPACE 20 ONE A DAY WOMENS NORPACE CR 20 NUTRATEAR 239 PRENATAL1 228 NORTEMP INFANTS 9 NUTRICAP 219 one daily essential 223 nortriptyline hcl 26 NUTRILIPID 236 ONE DAILY ESSENTIAL 224 NORVIR 56 NUWIQ 92 ONE DAILY MENS FORMULA W/O IRON 219 NOSE CLIP 193 nyamyc 72 NYMALIZE 59 one daily multivitamin NOVA MAX PLUS KETONE adult 212,223 TESTSTRIPS 84 nystatin 32 one daily womens 212 NOVA SUREFLEX nystatin (mouth-throat) 204 LANCETS 119 ONE DAILY WOMENS 219 NOVA SUREFLEX LANCING nystatin (topical) 73 one daily womens 50 plus 207 DEVICE 119 nystatin-triamcinolone 73 ONE VITE WOMENS NOVAVAX COVID-19 O-CAL FA 228 PRENATALVITAMIN 228 VACCINE 259 O-CAL PRENATAL 228 ONE VITE WOMENS NOVOEIGHT 92 PRENATALVITAMIN PLUS 228 OBIZUR 92 NOVOFINE AUTOCOVER PEN ONE-A-DAY ENERGY 219 NEEDLE 30G X 8MM 162 OBSTETRIX EC 228 ONE-A-DAY MENOPAUSE NOVOFINE PEN NEEDLE 32G X OBTREX 228 FORMULA 219 4MM 163 OCREVUS 246 ONE-A-DAY MENS 219 NOVOFINE PLUS PEN NEEDLE32G X 4MM 163 OCULAR VITAMINS 219 ONE-A-DAY MENS 50+ 219 NOVOLIN 70/30 29 ODEFSEY 56 ONE-A-DAY MENS 50+ ADVANTAGE 219 NOVOLIN 70/30 FLEXPEN 29 ODOMZO 43 ONE-A-DAY MENS HEALTH NOVOLIN 70/30 FLEXPEN OFF DEEP WOODS 82 FORMULA 219 RELION 28 OFF DEEP WOODS DRY 82 ONE-A-DAY MENS PRO NOVOLIN 70/30 RELION 29 ofloxacin 88 EDGE 219 NOVOLIN N 29 ONE-A-DAY PROACTIVE ofloxacin (ophth) 241 65+ 219 NOVOLIN N FLEXPEN 29 ofloxacin (otic) 243 ONE-A-DAY TEEN NOVOLIN N FLEXPEN ADVANTAGEFOR HIM 220 RELION 29 olanzapine 48 olanzapine-fluoxetine hcl 245 ONE-A-DAY WOMENS 220 NOVOLIN N RELION 29 ONE-A-DAY WOMENS NOVOLIN R 29 olmesartan medoxomil 40 PRENATAL 228 NOVOLIN R RELION 29 olmesartan medoxomil- ONETOUCH DELICA LANCING amlodipine-hydrochlorothiazide NOVOLOG MIX 70/30 29 DEVICE 119 41 ONETOUCH DELICA PLUS NOVOLOG MIX 70/30 olmesartan medoxomil- LANCING DEVICE 119 PREFILLED FLEXPEN 29 hydrochlorothiazide 41

Index 33 ONETOUCH DELICA SAFETY oscimin 250 PARVA-CAL 200 LACING DEVICE 119 oscimin sr 250 PARVLEX 220 ONETOUCH SURESOFT LANCING DEVICE/18G 119 oseltamivir phosphate 58 PAXIL 25 ONETOUCH SURESOFT OSMOLEX ER 47 PC LANCETS SUPER THIN LANCING DEVICE/21G 119 OSTEOPRIME 30G 119 ONETOUCH SURESOFT PLUS/CALCIUM & PC PEDIATRIC POLY-VITAMIN LANCING DEVICE/28G 119 MAGNESIUM 220 DROPS/IRON 225 ONEVITE 220 OTEZLA 6 PC UNIFINE PENTIPS 29G X1/2" 163 ONGLYZA 27 oxandrolone 14 PC UNIFINE PENTIPS 31G OPDIVO 43 oxaprozin 6 X5MM MINI 163 OPTICHAMBER OXAYDO 12 PC UNIFINE PENTIPS 31G ADVANTAGE/LARGE X6MM ULTRA SHORT 163 MASK 193 oxazepam 19 PC UNIFINE PENTIPS 31G OPTICHAMBER oxcarbazepine 24 X8MM SHORT 163 ADVANTAGE/MEDIUM FACE oxybutynin chloride 255 PEAK A-I-R FLOW METER 194 MASK 193 oxycodone hcl 12,13 PEAK AIR PEAK FLOW OPTICHAMBER oxycodone w/ METERADULT/PEDIATRIC ADVANTAGE/SMALL FACE 194 MASK 193 acetaminophen 13 oxycodone-aspirin 13 PEDIATRIC OPTICHAMBER DIAMOND193 MOUTHPIECE/DISPOSABLE OPTICHAMBER OXYZAL WET DRESSING 52 194 DIAMOND/LARGEFACE oysco 500 199 pediatric vitamins acd w/ MASK 194 oyster shell 199 fluoride 225 OPTICHAMBER peg 3350-kcl-sod bicarb-sod DIAMOND/MEDIUM FACE pacerone 20 chloride-sod sulfate 99 MASK 194 paliperidone 48 peg 3350-potassium chloride-sod OPTICHAMBER PANCREAZE 85 bicarbonate-sod chloride 99 DIAMOND/SMALLFACE PANRETIN 74 PEGASYS 58 MASK 194 PEGASYS PROCLICK 58 OPTICHAMBER FACE pantoprazole sodium 255 MASK/LARGE 194 paregoric 31 PEGINTRON 58 OPTICHAMBER FACE PARI ALTERA NEBULIZER PEN NEEDLES 29G X MASK/MEDIUM 194 HANDSET 194 12MM 163 OPTICHAMBER FACE PARI BABY CONVERSION PEN NEEDLES 29GX1/2" 163 MASK/SMALL 194 KITSIZE 1 194 PEN NEEDLES OPTIFOAM 108 PARI BABY CONVERSION 29GX12MM 163 OPTIHALER 194 KITSIZE 2 194 PEN NEEDLES 30GX5/16" 163 PARI BABY CONVERSION PEN NEEDLES 30GX5MM 163 OPTIHALER MDI DRUG KITSIZE 3 194 DELIVERY SYSTEM 194 PARI ERAPID NEBULIZER PEN NEEDLES 30GX8MM 163 OPTIONS GYNOL II HANDSET 194 PEN NEEDLES 31G X 1/4" VAGINALCONTRACEPTIVE PARI EXPIRATORY FILTER SHORT 163 259 VALVE SET 194 PEN NEEDLES 31G X OPURITY 220 PARI MASK SET 194 3/16" 163 ORACIT 90 PARI SOFT PLASTIC ADULT PEN NEEDLES 31G X oral electrolytes 201 MASK 194 5MM 163 PARI SOFT PLASTIC PEN NEEDLES 31G X ORAL RELIEF SPRAY FOR 6MM 163 DRYMOUTH & PEDIATRIC MASK 194 PARI VORTEX ADULT PEN NEEDLES 31G X DISCOMFORT 205 8MM 163 oralone dental paste 205 MASK 194 paricalcitol 87 PEN NEEDLES 31GX5/16" 163 orazinc 203 PEN NEEDLES 31GX6MM ORENCIA 6 PARNATE 25 (1/4") 163 ORENCIA CLICKJECT 6 paroex 204 PEN NEEDLES 31GX8MM 163 ORKAMBI 249 paromomycin sulfate 2 PEN NEEDLES 31GX8MM (5/16") 163 orphenadrine citrate 232 paroxetine hcl 25

Index 34 PEN NEEDLES 32G X PFLEX 195 pioglitazone hcl-glimepiride 26 4MM 163 PHARMACIST CHOICE pioglitazone hcl-metformin PEN NEEDLES 32G X NEBULIZER/CPAP/INHALER hcl 26 5MM 163 CHAMBER MASK piroxicam 6 PEN NEEDLES 32G X WIPES 195 PLASMA-LYTE A 201 6MM 163 PHARMACY COUNTER PEN NEEDLES 32GX4MM 163 LANCETS 119 PLASMA-LYTE-148 201 PEN NEEDLES 33G X phazyme 89 PLEGRIDY 246 5/32" 163 phenadoz 38 PLEGRIDY STARTER PEN NEEDLES/29G X 1/2" 163 PACK 246 phenazo 91 PEN NEEDLES/31G X 1/4" 164 plenamine 238 phenazopyridine hcl 91 PEN NEEDLES/31G X PNEUMOVAX 23 255 phenelzine sulfate 25 3/16" 164 PNEUMOVAX 23/1 DOSE 256 PEN NEEDLES/31G X phenobarbital 96 PNV TABS 29-1 228 5/16" 164 PHENOL 50 PEN NEEDLES/31G X POCKET CHAMBER 195 6MM 164 PHENOL EZ SWABS 50 POCKET PEAK FLOW PEN NEEDLES/32G X phenoxybenzamine hcl 40 METER 195 5/32" 164 phentermine hcl 1 POCKET SPACER 195 penicillamine 203 phenylephrine hcl POCKETPEAK PEAK FLOW penicillin v potassium 244 (mydriatic) 240 METER LOW RANGE 195 PENLET II AUTOMATIC phenylephrine hcl (oral) 235 POCKETPEAK PEAK FLOW BLOODSAMPLER 119 phenytoin 24 METER/UNIVERSAL RANGE 50- PENLET II REPLACEMENT 720 LPM 195 CAPS 119 phenytoin infatabs 24 podofilox 80 phenytoin sodium PENLET II REPLACEMENT POLY-VI-FLOR 225 CAPS-DEEP 119 extended 24 PENLET II REPLACEMENT phillips milk of magnesia 100 POLY-VI-FLOR/IRON 225 CAPS-REGULAR 119 PHILLIPS MILK OF POLY-VITA/IRON 225 PENTIPS 29G X 12MM 164 MAGNESIA 100 POLYCOSE 236 PENTIPS 29GX12MM 164 PHILLIPS MILK OF polyethylene glycol 3350 99 MAGNESIA CHEWABLE 100 PENTIPS 31G X 5MM 164 PHILLIPS MILK OF POLYMEM FILM DOT 108 PENTIPS 31G X 8MM 164 MAGNESIA POLYMEM NON-ADHESIVE PENTIPS 31GX5MM 164 CONCENTRATED 100 PAD 109 polymyxin b-trimethoprim 241 PENTIPS 31GX6MM 164 phospha 250 neutral 202 polysaccharide iron complex 95 PENTIPS 31GX8MM 164 phosphasal 18 polyvinyl alcohol 239 PENTIPS 32G X 4MM 164 PHOSPHOLINE IODIDE 240 POMALYST 44 PENTIPS 32GX4MM 164 PHYTOMULTI 220 phytonadione 262 pot phosphate monobasic w/ sod pentoxifylline 93 phosphate dibasic & PERFECT LANCETS 30G 119 PICATO 74 monobasic 203 PERIKABIVEN 237 PIFELTRO 56 potassium chloride 203 PERJETA 43 PIKO 1 ELECTRONIC 195 POTASSIUM CHLORIDE 203 permethrin 83 PILLOW MASK/ADULT 195 potassium chloride 203 perphenazine 49 PILLOW MASK/CHILD 195 potassium chloride in PILLOW dextrose 202 perphenazine-amitriptyline 245 MASK/PEDIATRIC 195 potassium chloride in dextrose & PERRY PRENATAL 228 pilocarpine hcl 240 sodium chloride 202 PERSERIS 48 pilocarpine hcl (oral) 205 potassium chloride in nacl 202 PERSONAL BEST FULL pimecrolimus 80 potassium chloride RANGE 194 microencapsulated crystals PERSONAL BEST LOW pimozide 246 er 203 RANGE 195 pindolol 59 POTASSIUM PFIZER-BIONTECH COVID- pioglitazone hcl 28 CHLORIDE/DEXTROSE 202 19VACCINE 259

Index 35 POTASSIUM PRECISION SURE-DOSE PREFERRED PLUS INSULIN CHLORIDE/DEXTROSE/LACTA INSULIN SYRINGE/0.5ML/30G SYRINGE/U-100/1ML/30G X TED RINGERS 202 X 3/8" 164 5/16" 165 POTASSIUM PRECISION SURE-DOSE PREFERRED PLUS LANCETS CHLORIDE/LIDOCAINE INSULIN SYRINGE/1ML/28G X COLORED 21G 119 HYDROCHLORIDE/SODIUM 1/2" 164 PREFERRED PLUS LANCETS CHLORIDE 202 PRECISION SURE-DOSE SUPER THIN 30G 119 POTASSIUM PLUSINSULIN PREFERRED PLUS LANCETS CHLORIDE/SODIUM SYRINGE/0.3ML/29G X THIN 26G 119 CHLORIDE 202 1/2" 164 PREFERRED PLUS UNIFINE POTASSIUM PRECISION SURE-DOSE PENTIPS 29G X 12MM 165 CHLORIDE/SODIUMCHLORIDE PLUSINSULIN PREFERRED PLUS UNIFINE 202 SYRINGE/1ML/29G X PENTIPS 31G X 6MM ULTRA potassium citrate 1/2" 164 SHORT 165 (alkalinizer) 90 PRECISION THINS GP PREFERRED PLUS UNIFINE povidone-iodine 54 LANCET 119 PENTIPS 31G X 8MM PRECISION XTRA 84 SHORT 165 POVIDONE-IODINE 54 PREFERRED PLUS UNIFINE POVIDONE-IODINE PREP PRECISION XTRA BLOOD GLUCOSE TEST STRIPS 84 PENTIPS 32GX4MM 165 PAD 54 PREFERRED PLUS UNIFINE POVIDONE-IODINE PREP PRED MILD 242 PENTIPS/MINI/31GX5MM 165 PADS 54 PRED-G 242 PREMARIN 88,260 POVIDONE-IODINE SCRUB PRED-G S.O.P. 242 LARGE WINGED SPONGE 54 PREMASOL 239 POVIDONE-IODINE SCRUB prednicarbate 79 PREMIUM CONDOMS SMALL WINGED SPONGE 54 prednisolone 64 LUBRICATED 111 POVIDONE-IODINE SCRUB prednisolone acetate PREMPHASE 87 SPONGE STICKS 54 (ophth) 242 PREMPRO 87 PRADAXA 23 PREDNISOLONE ACETATE P- PRENATABS FA 228 pramipexole dihydrochloride 47 F 242 prednisolone sodium prenatabs rx 226 PRAMOSONE 79 phosphate 64 PRENATAL 229,230 pramoxine hcl (rectal) 15 PREDNISOLONE SODIUM prenatal 19 226 PHOSPHATE 242 prasugrel hcl 93 PRENATAL 19 228 prednisone 64 pravastatin sodium 39 PRENATAL ADULT praziquantel 18 PREDNISONE INTENSOL 64 GUMMY/DHA/FOLIC ACID 228 prazosin hcl 40 PREFERRED PLUS INSULIN PRENATAL AND IRON 228 SYRINGE/U-100/0.3ML/29G X PRE-NATAL FORMULA 228 1/2" 164 PRENATAL COMPLETE 229 PRECISION GLUCOSE PREFERRED PLUS INSULIN PRENATAL FORMULA 229 CONTROL 119 SYRINGE/U-100/0.3ML/30G X PRENATAL FORMULA A- PRECISION GLUCOSE 5/16" 164 FREE 229 CONTROLSOLUTION (TRI- PREFERRED PLUS INSULIN PRENATAL FORTE 229 LEVEL/HI/LO/NORMAL) 119 SYRINGE/U-100/0.5ML/28G X PRENATAL GUMMIES/DHA & PRECISION GLUCOSE 1/2" 164 FOLIC ACID 229 KETONECONTROL SOLUTION PREFERRED PLUS INSULIN PRENATAL LOW IRON 229 1-LOW, 1-HIGH 119 SYRINGE/U-100/0.5ML/29G X PRECISION 1/2" 165 PRENATAL MULTI + DHA 229 GLUCOSE/KETONECONTROL PREFERRED PLUS INSULIN PRENATAL MULTI +DHA 229 SOLUTIONS 1-HI 1-LO 119 SYRINGE/U-100/0.5ML/30G X PRENATAL PRECISION SURE-DOSE 5/16" 165 MULTIVITAMIN 229 INSULIN SYRINGE/0.3ML/30G X PREFERRED PLUS INSULIN PRENATAL MULTIVITAMIN + 5/16" 164 SYRINGE/U-100/1ML/28G X DHA 229 PRECISION SURE-DOSE 1/2" 165 PRENATAL MULTIVITAMIN INSULIN SYRINGE/0.5ML/28G X PREFERRED PLUS INSULIN PLUS DHA 229 1/2" 164 SYRINGE/U-100/1ML/29G X PRENATAL ONE DAILY 229 PRECISION SURE-DOSE 1/2" 165 INSULIN SYRINGE/0.5ML/29G X PRENATAL PLUS IRON 229 1/2" 164 PRENATAL VITAMIN 230

Index 36 PRENATAL VITAMIN & PRO COMFORT PEN proparacaine hcl 241 MINERAL 230 NEEDLES/31G X 8MM 165 propranolol & PRENATAL PRO COMFORT PEN hydrochlorothiazide 41 VITAMIN/IRON 230 NEEDLES/32G X 4MM 165 propranolol hcl 59 PRENATAL VITAMINS 230 PRO COMFORT PEN propylthiouracil 249 PRENATAL VITAMINS PLUS NEEDLES/32G X 5MM 166 LOW IRON 230 PRO COMFORT PEN PRORENAL+D 220 PRENATAL+DHA 230 NEEDLES/32G X 6MM 166 PROSOL 239 PRO-CAL 220 PRENATAL-U 230 protriptyline hcl 26 PRENATAL/OMEGA-3/FOLIC probenecid 91 PROVENGE 43 PROBUPHINE IMPLANT ACID/IRON 230 PROVIT 220 PRENATRIX 230 KIT 14 procainamide hcl 20 pseudoephedrine hcl 235 PRENATRYL 230 PROCARE SPACER PSORCON 79 PRENATVITE RX 230 CHAMBER W/ADULT PSS SELECT GP preparation h 75 MASK 195 LANCETS 120 PREPLUS 230 PROCARE SPACER PSS SELECT CHAMBER W/CHILD PLATFORMS 120 PRESERVISION AREDS 220 MASK 195 PSS SELECT SAFETY PRETAB 230 PROCERV HP 220 LANCETS 120 prevalite 39 prochlorperazine 49 psyllium 98 PREVENT SAFETY PEN prochlorperazine maleate 49 PTS PANELS KETONE NEEDLES 31GX1/4" 165 TEST 84 PREVENT SAFETY PEN procto-med hc 15 PULMICORT FLEXHALER 21 NEEDLES 31GX5/16" 165 PROCTOFOAM HC 15 PULMOZYME 249 PREVNAR 13 256 PRODIGY INSULIN PURE COMFORT PEAK FLOW PREZCOBIX 56 SYRING/U-100/0.3ML/31G X METER ADULT 195 5/16" 166 PURE COMFORT PEAK FLOW PREZISTA 56 PRODIGY INSULIN PRIFTIN 42 METER CHILD 195 SYRINGE/1/2ML/31G X PURE COMFORT PEN NEEDLE primidone 24 5/16" 166 32G X6MM 166 PRO COMFORT INHALER PRODIGY INSULIN PURE COMFORT PEN NEEDLE SPACER CHAMBER SYRINGE/1ML/28G X 32G X8MM 166 ADULT 195 1/2" 166 PURE COMFORT PEN PRO COMFORT INHALER PRODIGY LANCING NEEDLE/32G X 5MM 166 SPACER CHAMBER DEVICE 120 PURE COMFORT PEN CHILD 195 PRODIGY TWIST TOP NEEDLE/32G X4MM 166 PRO COMFORT INHALER LANCETS 120 PURIXAN 42 SPACER CHAMBER PROFILNINE 92 PX ADVANCED LANCING INFANT 195 PROFILNINE SD 92 DEVICE 120 PRO COMFORT INSULIN progesterone 245 PX CALAMINE 82 SYRINGES/0.5ML/30G X 1/2" 165 PROGRAF 204 PX EXTRA SHORT PEN PRO COMFORT INSULIN PROLASTIN-C 249 NEEDLES 31GX6MM 166 px hemorrhoidal 14 SYRINGES/0.5ML/30G X PROMACTA 93,94 5/16" 165 PX INSULIN SYRINGE/U- promethazine & 100/0.5ML/30G X 1/2" 166 PRO COMFORT INSULIN phenylephrine 68 SYRINGES/0.5ML/31G X PX LANCET AUTO 5/16" 165 promethazine hcl 38 INJECTOR 120 PRO COMFORT INSULIN promethazine w/codeine 68 PX LANCETS ULTRA SYRINGES/1ML/30G X promethazine-dm 68 THIN 120 1/2" 165 promethazine-phenylephrine- PX LANCETS ULTRA THIN PRO COMFORT INSULIN codeine 68 28G 120 SYRINGES/1ML/30G X PRONEB ULTRA FILTER PX MINI PEN NEEDLES 5/16" 165 SET 195 31GX5MM 166 PX PEN NEEDLE PRO COMFORT INSULIN propafenone hcl 20 SYRINGES/1ML/31G X 29GX12MM 166 5/16" 165 propantheline bromide 251

Index 37 PX PEN NEEDLE quinapril-hydrochlorothiazide RA STERILE PADS 3"X3" 109 31GX8MM 166 41 RA STERILE PADS 4"X4" 109 PX PRENATAL quinidine gluconate 20 ra vitamin c 263 MULTIVITAMINS 230 quinidine sulfate 20 PX SHORTLENGTH PEN RABAVERT 259 QUINTABS 224 NEEDLES/31GX8MM 166 RADICAVA 235 quintabs-m 212 pyrazinamide 42 raloxifene hcl 86 QUINTABS-M 220 pyridostigmine bromide 42 ramipril 40 QVAR REDIHALER 21 pyridoxine hcl 263 ranitidine hcl 254 QC ADVANCED LANCING RA ALCOHOL SWABS 124 RAY-TEC X-RAY DEVICE 120 ra allergy relief 33 DETECTABLESPONGES 4" X 4" QC ALCOHOL SWABS 124 ra allergy relief childrens 36 16 PLY 109 QC ALL PURPOSE ra arthritis pain relief 80 READYLANCE SAFETY DRESSINGS4"X4" 109 LANCETS/30G/1.6MM 120 qc allergy relief childrens 36 ra b-complex 205 REALITY INSULIN SYRINGE/U- QC BORDER ISLAND GAUZE RA CENTRAL-VITE 220 100/0.5ML/28G X 1/2" 167 PAD 2"X2" 109 RA DRY MOUTH 205 REALITY INSULIN SYRINGE/U- QC CALAMINE 82 RA E-ZJECT LANCETS 100/0.5ML/29G X 1/2" 167 28G 120 REALITY INSULIN SYRINGE/U- QC CALCIUM 500MG/D3 200 100/1ML/28G X 1/2" 167 QC IODIDES TINCTURE 54 RA E-ZJECT LANCETS THIN 26G 120 REALITY INSULIN SYRINGE/U- QC IODINE TINCTURE 54 RA E-ZJECT LANCETS THIN 100/1ML/29G X 1/2" 167 QC LANCETS SUPER 28G 120 REALITY LANCETS 120 THIN 120 RA E-ZJECT LANCETS REALITY LATEX QC LANCETS ULTRA ULTRATHIN 30G 120 CONDOMS/LUBRICATED 111 THIN 120 ra enema 100 REALITY LATEX/ULTRA TEXTURED 111 qc multi-vite 212 RA FIRST AID IODINE 54 QC MULTI-VITE 220 REALITY LATEX/ULTRA RA FIRST AID NON-STICK 111 qc nicotine transdermal THIN PADS 109 REALITY SWABS 124 system/step 1 248 ra fish oil 237 QC PEN NEEDLES 29G X REBIF 246 ra ibuprofen 5 12MM 166 REBIF REBIDOSE 246 RA INSULIN QC PEN NEEDLES 31G X REBIF REBIDOSE 6MM 166 SYRINGE/0.5ML/29G X 1/2" 166 TITRATIONPACK 246 QC PEN NEEDLES 31G X REBIF TITRATION PACK 246 8MM 166 RA INSULIN QC PRENATAL 230 SYRINGE/1ML/29G X REBINYN 92 1/2" 166 RECOMBINATE 92 QC STERILE PADS 109 RA INSULIN SYRINGE/U- QC UNIFINE PENTIPS 100/0.5ML/30G X 5/16" 166 RECOMBIVAX HB 259 32GX4MM 166 RA INSULIN SYRINGE/U- RECTIV 15 QC UNILET LANCETS 100/1 ML/30G X 5/16" 166 REGENECARE HA 81 28G/ULTRA THIN 120 ra iron 94 QC UNILET LANCETS reguloid 97 33G/MICRO THIN 120 ra laxative 101 relafen 5 qc vitamin b6 263 RA OYSTER SHELL RELENZA DISKHALER 58 CALCIUM/VITAMIN D 200 QSYMIA 1 RA PEN NEEDLES 31G X RELION 2-IN-1 LANCET quetiapine fumarate 49 5MM3/16" 166 DEVICES 30G 120 RELION 2-IN-1 LANCING QUFLORA PEDIATRIC 225 RA PEN NEEDLES 31G X 8MM5/16" 166 DEVICE 25G 120 QUICKVUE AT-HOME COVID-19 RELION 2-IN-1 LANCING TEST 84 RA PRENATAL 230 DEVICE 30G 120 QUICKVUE SARS ANTIGEN RA PRENATAL RELION ALCOHOL TEST 85 FORMULA/FOLICACID 230 SWABS 124 QUIN B STRONG 220 RA SHEER ADHESIVE RELION INSULIN SYRINGE LARGE 109 0.5ML/31G X 15/64" 167 quinapril hcl 40 RA STERILE PADS 2"X2" 109

Index 38 RELION INSULIN SYRINGE REPLACEMENT AIR risedronate sodium 86 1ML/31GX15/64" 167 FILTER 195 RISPERDAL 48 RELION INSULIN SYRINGE/U- REPLACEMENT 100/0.3ML/31G X 15/64" 167 FILTERS 195 RISPERDAL CONSTA 48 RELION INSULIN SYRINGE/U- REQ 49+ 220 risperidone 48 100/0.3ML/31G X 5/16" 167 RESCRIPTOR 56 RITEFLO 195 RELION INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 167 RESTASIS 241 ritonavir 56 RELION INSULIN SYRINGE/U- RESTASIS MULTIDOSE 241 RITUXAN 43 100/0.5ML/31G X 5/16" 167 RESTORE CONTACT RITUXAN HYCELA 45 RELION INSULIN SYRINGE/U- LAYER/NON-ADHERENT rivastigmine 245 100/1ML/31G X 15/64" 167 2"X2" 109 RELION INSULIN SYRINGE/U- RESTORE FOAM DRESSING rivastigmine tartrate 245 100/1ML/31G X 5/16" 167 BORDERED 4"X4" 109 RIXUBIS 92 RELION KETONE TEST RESTORE FOAM DRESSING rizatriptan benzoate 197 STRIPS 85 NON-BORDERED 4"X4" 109 ropinirole hydrochloride 47 RELION LANCETS MICRO- RESTORE ODOR THIN33G 120 ABSORBING DRESSING rosadan 82 RELION LANCETS THIN 4"X4" 109 rosuvastatin calcium 39 26G 120 RESTORE TRIO ABSORBENT roweepra 23 RELION LANCETS ULTRA- DRESSING 3"X3" 109 roweepra xr 23 THIN30G 120 RETACRIT 94 RELION LANCING RUBRACA 46 REVLIMID 204 DEVICE 120 rufinamide 24 RELION MINI PEN NEEDLES REXALL LANCETS ULTRA 31GX6MM 167 THIN 120 ryclora 33 RELION PEN NEEDLES REXULTI 49 RYDAPT 46 29GX12MM 167 REYATAZ 56 RYMED 68 RELION PEN NEEDLES 31G RHOGAM ULTRA-FILTERED rynex pse 65 X6MM 167 PLUS 244 RELION PEN NEEDLES 31G SAFESNAP INSULIN X8MM 167 RHOPRESSA 241 SYRINGE/0.3ML/30G X RELION PEN NEEDLES RIASTAP 92 5/16" 168 31GX5/16" 167 ribasphere 58 SAFESNAP INSULIN SYRINGE/0.5ML/29G X RELION PEN NEEDLES RIBASPHERE 58 31GX6MM 167 1/2" 168 RELION PEN NEEDLES RIBASPHERE RIBAPAK 58 SAFESNAP INSULIN 31GX8MM 167 ribavirin (hepatitis c) 58 SYRINGE/0.5ML/30G X RELION PEN NEEDLES 32G riboflavin 263 5/16" 168 X4MM 167 SAFESNAP INSULIN RID ESSENTIAL LICE SYRINGE/1ML/28G X 1/2" 168 RELION PEN NEEDLES 32G ELIMINATION KIT 83 X5/32" 167 SAFESNAP INSULIN RELION PEN NEEDLES RIDAURA 3 SYRINGE/1ML/29G X 1/2" 168 32GX4MM 167 rifabutin 42 SAFESNAP RELION PEN NEEDLES/31G rifampin 42 SYRINGE/NEEDLE/3ML/20G X X1/4" 168 RIGHT STEP 1" 168 SAFESNAP RELION SHORT PEN PRENATAL 230 NEEDLES31GX8MM 168 RIGHTEST GD-L500 SYRINGE/NEEDLE/3ML/20G X RELION ULTRA THIN ALTERNATE SITE 1-1/2" 168 SAFESNAP LANCETS30G 120 ADAPTER 121 RELION ULTRA THIN PLUS RIGHTEST GD500 LANCING SYRINGE/NEEDLE/3ML/21G X LANCETS 32G 120 DEVICE 121 1" 168 RELION ULTRA THIN PLUS RIGHTEST GL300 SAFESNAP LANCETS 33G 120 LANCETS 121 SYRINGE/NEEDLE/3ML/21G X 1-1/2" 168 REMEDY ANTIMICROBIAL riluzole 235 CLEANSER 52 SAFESNAP REMICADE 90 rimantadine hydrochloride 58 SYRINGE/NEEDLE/3ML/22G X RENAPLEX-D 220 ringer's 202 1" 168 RENFLEXIS 90 RISACAL-D 200

Index 39 SAFESNAP SAFETY-LOK SECURESAFE SYRINGE/NEEDLE/3ML/22G X SYRINGE/NEEDLE3ML LUER- SYRINGE/NEEDLE/3ML/20G X 1-1/2" 168 LOK 25GX5/8" 169 1-1/2" 170 SAFESNAP salicylic acid 80 SECURESAFE SYRINGE/NEEDLE/3ML/23G X saline 232 SYRINGE/NEEDLE/3ML/21G X 1" 168 1" 170 SAFESNAP salsalate 11 SECURESAFE SYRINGE/NEEDLE/3ML/23G X SAMI THE SEAL SYRINGE/NEEDLE/3ML/21G X 1-1/2" 168 REPLACEMENTFILTERS 19 1-1/2" 170 SAFESNAP 6 SECURESAFE SYRINGE/NEEDLE/3ML/25G X SANDIMMUNE 204 SYRINGE/NEEDLE/3ML/22G X 1" 168 SANTYL 80 1" 170 SAFESNAP SECURESAFE SYRINGE/NEEDLE/3ML/25G X SAPHRIS 49 SYRINGE/NEEDLE/3ML/22G X 5/8" 168 sapropterin 1-1/2" 170 SAFETY INSULIN SYRINGES dihydrochloride 87 SECURESAFE 0.5ML/29GX1/2" 168 SAPS HEALTH TWIST TOP SYRINGE/NEEDLE/3ML/23G X SAFETY INSULIN SYRINGES LANCETS 30G 121 1" 170 0.5ML/30GX5/16" 168 SAVELLA 245 SECURESAFE SAFETY INSULIN SYRINGES SAVELLA TITRATION SYRINGE/NEEDLE/3ML/25G X 1ML/27GX1/2" 169 PACK 245 5/8" 170 SAFETY INSULIN SYRINGES SAXENDA 1 SEGLUROMET 27 1ML/29GX1/2" 169 SB ALCOHOL PREP SELECT-LITE SAFETY INSULIN SYRINGES PADS 124 DEVICE/LANCETS 121 1ML/30GX1/2" 169 sb gas relief 89 SELECT-LITE LANCING 121 SAFETY LANCETS 28G sb hemorrhoid 14 DEVICE 121 SAFETY SEAL LANCETS SB INSULIN SYRINGE/U- selegiline hcl 47 121 28G 100/0.5ML/29G X 1/2" 169 selenium sulfide 74 SAFETY SEAL LANCETS SB INSULIN SYRINGE/U- 121 SELZENTRY 56 30G 100/0.5ML/30G X 5/16" 169 SAFETY SYRINGES/NEEDLE SB INSULIN SYRINGE/U- sennosides 101 169 3ML/20GX1" 100/1ML/29G X 1/2" 169 sennosides-docusate SAFETY SYRINGES/NEEDLE SB INSULIN SYRINGE/U- sodium 99 169 3ML/20GX1-1/2" 100/1ML/30G X 5/16" 169 sentry 213 SAFETY SYRINGES/NEEDLE SB INSULIN SYRINGE/U- 3ML/21GX1" 169 SENTRY 221 SAFETY SYRINGES/NEEDLE 100/1ML/31G X 5/16" 170 sentry senior 212 SB LANCETS THIN 121 3ML/21GX1-1/2" 169 SENTRY SENIOR 221 SAFETY SYRINGES/NEEDLE SB LANCETS ULTRA 3ML/22GX1" 169 THIN 121 SENTRY SENIOR/LUTEIN 221 SAFETY SYRINGES/NEEDLE sb lice treatment 83 SEREVENT DISKUS 22 3ML/22GX1-1/2" 169 sb triple antibiotic 71 SEROQUEL 49 SAFETY SYRINGES/NEEDLE SEROQUEL XR 49 3ML/23GX1" 169 SCHOOLTIME SHAMPOO83 SAFETY SYRINGES/NEEDLE SE-NATAL 19 230 sertraline hcl 25 3ML/25GX5/8" 169 SECUADO 49 SEVENFACT 92 SAFETY-LOK SECURESAFE SAFETY SFROWASA 90 SYRINGE/NEEDLE3ML LUER- INSULIN SYRINGES/U- SHINGRIX 259 LOK 21GX1-1/2" 169 100/0.5ML/29GX1/2" 170 SAFETY-LOK SHOPKO ALCOHOL SECURESAFE SAFETY SWABS 124 SYRINGE/NEEDLE3ML LUER- INSULIN SYRINGES/U- LOK 22GX1" 169 SHOPKO AUTOLET LANCING 100/1ML/29GX1/2" 170 DEVICE 121 SAFETY-LOK SECURESAFE SAFETY PEN SYRINGE/NEEDLE3ML LUER- SHOPKO UNIFINE PENTIPS NEEDLES/30G X 5/16" 170 PEN LOK 22GX1-1/2" 169 SECURESAFE SAFETY-LOK NEEDLES/MICRO/32GX4MM SYRINGE/NEEDLE/3ML/20G X 170 SYRINGE/NEEDLE3ML LUER- 1" 170 LOK 23GX1" 169

Index 40 SHOPKO UNIFINE PENTIPS simethicone 89 sm vitamin d3 maximum PEN NEEDLES/MINI/31GX5MM SIMILAC PRENATAL EARLY strength 262 170 SHIELD 231 SMART DIABETES VANTAGE SHOPKO UNIFINE PENTIPS SIMPLE DIAGNOSTICS LANCING DEVICE 121 PEN LANCING DEVICE 121 SMART SENSE COLOR NEEDLES/ORIGINAL/29GX12M simply saline baby 68 LANCETS UNIVERSAL M 170 33G 121 SHOPKO UNIFINE PENTIPS SIMPLYTHICK 245 SMART SENSE STANDARD PEN SIMPLYTHICK EASY LANCETS UNIVERSAL NEEDLES/SHORT/31GX8MM MIX 244 21G 121 170 SIMPLYTHICK EASYMIX 244 SMART SENSE SUPER THIN SHOPKO UNIFINE PENTIPS SIMPONI ARIA 2 LANCETS UNIVERSAL PLUS PEN simvastatin 39 30G 121 NEEDLES/MICRO/REMOVR/32 SMART SENSE THIN GX4MM 170 sirolimus 204 LANCETSUNIVERSAL SHOPKO UNIFINE PENTIPS SIVEXTRO 19 26G 121 PLUS PEN slow release iron 94 sodium bicarbonate NEEDLES/MINI/REMOVER/31G SM ADHESIVE PADS (antacid) 16 X5MM 170 2"X3" 109 sodium chloride 203 SHOPKO UNIFINE PENTIPS SM ADHESIVE PADS sodium chloride (gu irrigant) 90 PLUS PEN 3"X4" 109 sodium chloride (inhalant) 68 NEEDLES/REMOVER/29GX12M SM ALCOHOL PREP M 171 PADS 124 sodium chloride hypertonic 243 SHOPKO UNIFINE PENTIPS SM CALAMINE 82 sodium citrate & citric acid 90 PLUS PEN SM CALAMINE sodium fluoride 202 NEEDLES/SHORT/REMOVR/31 PHENOLATED 82 GX8MM 171 sodium fluoride (dental) 205 SHOPKO UNILET LANCETS sm cold & allergy childrens 65 sodium phosphates 100 SUPER THIN 30G 121 sm fiber 97 sodium polystyrene SHOPKO UNILET LANCETS SM FIBER POWDER 98 sulfonate 204 ULTRA THIN 28G 121 sm fish oil 237 sodium sulfacetamide wash 74 SHUR-SEAL 259 SM FOAMING ANTACID 16 SODIUM SIDEROL 221 SULFACETAMIDE/SULFUR SIDESTREAM ADULT FACE sm gas relief 89 70 MASK 196 SM GAUZE PADS 2"X2" 109 SOF-SET ADHESIVE SIDESTREAM PEDIATRIC SM GAUZE PADS 3"X3" 109 PATCH 109 FACEMASK 196 SM GAUZE PADS 4"X4" 109 SOF-WICK 4"X4" 109 SIDESTREAM PEDIATRIC SM GLUCOSE 27 SOFIA SARS ANTIGEN FIA 85 FACEMASK/SAMI THE SOFIA2 SARS ANTIGEN SEAL 196 sm hydrocortisone 77 FIA 85 SIDESTREAM PEDIATRIC SM IODIDES TINCTURE 54 sofosbuvir-velpatasvir 58 FACEMASK/TUCKER THE SM IODINE TINCTURE 54 TURTLE 196 SOLIQUA 100/33 27 SIDESTREAM PLUS ADULT SM MICRO THIN LANCETS SOLIRIS 93 33G 121 FACE MASK 196 SOLO 221 SILICONE MASK FOR SM ONE DAILY MENS 221 BREATHERITE SM ONE DAILY soluble fiber 96 CHAMBER/ADULT 196 PRENATAL 231 SOLUS V2 LANCING SILICONE MASK FOR SM ONE DAILY DEVICE 121 BREATHERITE WOMENS 221 soothe 30 CHAMBER/INFANT 196 SM PRENATAL SOOTHENEB NBL 100 CHILD SILICONE MASK FOR VITAMINS 231 MASK 196 BREATHERITE SM STERILE PADS 109 SOOTHENEB NBL 100 CHAMBER/PEDIATRIC 196 SM STERILE PADS MEDICATION CUP 196 SILICONE MASK FOR 2"X2" 109 SOOTHENEB NBL 100 MESH BREATHRITE SM TRUEDRAW LANCING CAP 196 CHAMBER/ADULT 196 DEVICE 121 SOOTHENEB NBL100 ADULT silver sulfadiazine 74 MASK 196

Index 41 SORBITOL 99 sulfacetamide sod- SURE COMFORT INSULIN sorine 59 prednisolone 242 SYRINGE/U-100/1ML/28G X sulfacetamide sodium 74 1/2" 171 sotalol hcl 59 sulfacetamide sodium SURE COMFORT INSULIN sotalol hcl (afib/afl) 59 (acne) 70 SYRINGE/U-100/1ML/29G X SOTYLIZE 59 sulfacetamide sodium 1/2" 171 SURE COMFORT INSULIN SPECTRAVITE 221 (ophth) 241 sulfacetamide sodium w/ SYRINGE/U-100/1ML/30G X spinosad 83 sulfur 70 1/2" 171 SPINRAZA 235 SULFADIAZINE 249 SURE COMFORT INSULIN SPIRIVA HANDIHALER 20 sulfamethoxazole-trimethoprim SYRINGE/U-100/1ML/30G X 18 5/16" 171 SPIRIVA RESPIMAT 20 SURE COMFORT INSULIN spironolactone 85 SULFAMYLON 74 SYRINGE/U-100/1ML/31G X spironolactone & sulfasalazine 90 5/16" 171 hydrochlorothiazide 85 sulfatrim pediatric 18 SURE COMFORT INSULIN SPRYCEL 46 sulindac 6 SYRINGES/0.5ML/31G X ssd 74 6MM 172 sumatriptan 197 SURE COMFORT INSULIN STAMARIL 259 sumatriptan succinate 197 SYRINGES/U- stavudine 56 sunitinib malate 46 100/1ML/31GX6MM 172 STAVUDINE 56 SURE COMFORT LANCETS super b with c 205 18G 121 STEGLATRO 29 SUPER THIN LANCETS 121 SURE COMFORT LANCETS STELARA 74 SUPPRELIN LA 86 21G 121 STERILANCE PA 121 SURE COMFORT INSULIN SURE COMFORT LANCETS STERILANCE TL 121 SYRINGE/U-100/0.3ML/29G X 23G 121 SURE COMFORT LANCETS STERILE GAUZE PADS 1/2" 171 SURE COMFORT INSULIN 30G 121 2"X2" 110 SURE COMFORT LANCING STERILE GAUZE PADS SYRINGE/U-100/0.3ML/30G X 1/2" 171 PEN 122 3"X3" 110 SURE COMFORT PEN STERILE PADS 2"X2" 110 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X NEEDLES29GX1/2" STERILE PADS 3"X3" 110 5/16" 171 12.7MM 172 STERILE PADS 4"X4" 110 SURE COMFORT INSULIN SURE COMFORT PEN NEEDLES30GX5/16" STIMATE 87 SYRINGE/U-100/0.3ML/31G X 5/16 171 SHORT 172 STIOLTO RESPIMAT 22 SURE COMFORT INSULIN SURE COMFORT PEN STIVARGA 46 SYRINGE/U-100/0.3ML/31G X NEEDLES31GX3/16" stress formula 213,224 5/16" 171 (5MM) 172 SURE COMFORT PEN stress formula/iron 206,213 SURE COMFORT INSULIN SYRINGE/U- NEEDLES31GX5/16" stresstabs energy 223 100/0.3ML/31GX1/4" 171 (8MM) 172 STRIBILD 57 SURE COMFORT INSULIN SURE COMFORT PEN SYRINGE/U-100/0.5ML/28G X NEEDLES32GX5/32" 172 STRIVERDI RESPIMAT 22 SURE COMFORT PEN STROVITE ONE 221 1/2" 171 SURE COMFORT INSULIN NEEDLES32GX6MM 172 STUART ONE 231 SYRINGE/U-100/0.5ML/29G X SURE-FINE PEN NEEDLES SUBLOCADE 14 1/2" 171 29GX1/2" 12.7MM 172 SURE-FINE PEN NEEDLES SUBOXONE 14 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 31GX3/16" 5MM 172 subvenite 23 1/2" 171 SURE-FINE PEN NEEDLES sucralfate 254 SURE COMFORT INSULIN 31GX5/16" 8MM 172 SYRINGE/U-100/0.5ML/30G X SURE-JECT INSULIN SUDAFED CHILDRENS 235 SYRINGE/U-100/0.3ML/29G X SUDAFED PE CHILDRENS 5/16" 171 SURE COMFORT INSULIN 1/2" 172 NASAL DECONGESTANT 235 SURE-JECT INSULIN sulconazole nitrate 73 SYRINGE/U-100/0.5ML/31G X 5/16 171 SYRINGE/U-100/0.3ML/30G X 5/16" 172

Index 42 SURE-JECT INSULIN SYRINGE/LUER TDVAX 250 SYRINGE/U-100/0.3ML/31G X LOCK/3ML/21G X 1" 173 tears again 239 5/16" 172 SYRINGE/LUER SURE-JECT INSULIN LOCK/3ML/21G X 1-1/2" 173 TECHLITE AST LANCETS 122 SYRINGE/U-100/0.5ML/28G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 1/2" 172 LOCK/3ML/21GX1" 173 100/0.3ML/29G X 1/2" 174 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/29G X LOCK/3ML/21GX1-1/2" 173 100/0.3ML/30G X 1/2" 174 1/2" 172 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN LOCK/3ML/22G X 1" 173 100/0.3ML/30G X 5/16" 174 SYRINGE/U-100/0.5ML/30G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 5/16" 172 LOCK/3ML/22G X 1-1/2" 173 100/0.3ML/31G X 15/64" 174 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/31G X LOCK/3ML/22GX1" 173 100/0.3ML/31G X 5/16" 174 5/16" 172 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN LOCK/3ML/22GX1-1/2" 173 100/0.5ML/29G X 1/2" 174 SYRINGE/U-100/1ML/28G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 1/2" 172 LOCK/3ML/23G X 1" 173 100/0.5ML/30G X 1/2" 174 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/29G X LOCK/3ML/23G X 1-1/2" 173 100/0.5ML/30G X 5/16" 174 1/2" 172 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN LOCK/3ML/23GX1" 173 100/0.5ML/31G X 15/64" 174 SYRINGE/U-100/1ML/30G X SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 5/16" 173 LOCK/3ML/25G X 1" 173 100/0.5ML/31G X 5/16" 174 SURE-JECT INSULIN SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/1ML/31G X LOCK/3ML/25G X 1-1/2" 173 100/1ML/29G X 1/2" 174 5/16" 173 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- 100/1ML/30G X 1/2" 174 SURE-PEN 122 LOCK/3ML/25G X 5/8" 173 SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SURELITE LANCETS 122 LOCK/3ML/25GX1" 173 100/1ML/30G X 5/16" 174 SURGICAL GAUZE SYRINGE/LUER TECHLITE INSULIN SYRINGEU- SPONGE 110 LOCK/3ML/25GX5/8" 173 100/1ML/31G X 15/64" 174 SUSTIVA 57 SYRINGES/LUER TECHLITE INSULIN SYRINGEU- SYLATRON 46 LOCK/1ML/20GX1" 173 100/1ML/31G X 5/16" 174 SYSTANE ICAPS TECHLITE LANCETS 122 SYMAX DUOTAB 251 AREDS2 221 TECHLITE LANCETS 30G 122 SYMBYAX 245 T-VITES 221 TECHLITE PEN NEEDLES 29GX SYMDEKO 249 TAB-A-VITE 10MM 174 SYMFI 57 MULTIVITAMIN/IRON AND TECHLITE PEN NEEDLES 29GX SYMFI LO 57 BETA-CAROTENE 206 12 MM 174 TABLOID 42 TECHLITE PEN NEEDLES 31GX SYMLINPEN 120 26 tacrolimus 204 5MM 174 SYMLINPEN 60 26 tadalafil (pulmonary TECHLITE PEN NEEDLES/31GX SYMTUZA 57 hypertension) 60 5MM 174 SYNAGIS 244 TECHLITE PEN NEEDLES/31GX TAFINLAR 46 6 MM 174 SYNAREL 86 TAGRISSO 43 TECHLITE PEN NEEDLES/31GX SYNJARDY 27 TALTZ 74 8MM 175 SYNJARDY XR 27 TAMIFLU 58 TECHLITE PEN NEEDLES/32GX 4MM 175 SYNTHAMIN 17 239 tamoxifen citrate 44 TECHLITE PEN NEEDLES/32GX SYNTHROID 250 tamsulosin hcl 91 6MM 175 SYRINGE/LUER LOCK/3ML/20G TARON-BC 231 TECHLITE PEN NEEDLES/32GX X 1" 173 8MM 175 SYRINGE/LUER LOCK/3ML/20G TASIGNA 46 TEGADERM CHG DRESSING/2- X 1-1/2" 173 tazarotene 74 3/4"X3-3/8" 52 SYRINGE/LUER TAZORAC 74 TEGADERM CHG DRESSING/3- LOCK/3ML/20GX1-1/2" 173 taztia xt 59 1/2"X4-1/2" 53

Index 43 TEGADERM CHG THERA-M 221 tobramycin- DRESSING/4"X4-3/4" 53 THERA-TABS M 221 dexamethasone 242 TEGADERM CHG THERABETIC MULTI- TOBREX 241 DRESSING/4"X6-1/8" 53 TODAY SPONGE 259 TEGADERM FOAM DRESSING VITAMIN 221 2"X2" 110 THERAGAUZE 110 TODAYS HEALTH ADVANCED TEGADERM FOAM DRESSING THERAGRAN-M 222 LANCING DEVICE 122 4"X4" 110 TODAYS HEALTH MINI PEN THERAGRAN-M NEEDLES 31G X 1/4" 175 TEGRETOL 24 ADVANCED 221 TODAYS HEALTH ORIGINAL TEGRETOL-XR 24 THERAGRAN-M ADVANCED PEN NEEDLES 29G X 1/2" 175 50 PLUS 221 TODAYS HEALTH SHORT PEN telmisartan 40 THERAGRAN-M telmisartan-amlodipine 41 NEEDLES 31G X 5/16" 175 PREMIER 222 TODAYS HEALTH SUPER telmisartan-hydrochlorothiazide THERAGRAN-M PREMIER 50 THINLANCETS 30G 122 41 PLUS 222 TODAYS HEALTH ULTRA temazepam 96 THERANATAL THINLANCETS 28G 122 TEMIXYS 57 COMPLETE 231 THERANATAL CORE tolbutamide 29 temozolomide 42 NUTRITION 231 tolmetin sodium 6 tencon 7 THEREMS tolnaftate 73 TENIVAC 250 MULTIVITAMIN 224 tolterodine tartrate 255 THEREMS-H 222 tenofovir disoproxil fumarate 57 tolvaptan 87 terazosin hcl 40 THEREMS-M 222 TOPCARE CLICKFINE terbinafine hcl 32 thiamine hcl 263 UNIVERSAL PEN EEDLES 31GX1/4" 175 terbinafine hcl (topical) 73 thiamine mononitrate 263 THINLETS GP LANCETS122 TOPCARE CLICKFINE terbutaline sulfate 22 UNIVERSAL PEN EEDLES terconazole vaginal 260 thioridazine hcl 49 31GX5/16" 175 testosterone 14 thiothixene 49 TOPCARE LANCETS MICRO- THRESHOLD IMT 196 THIN 33G 122 testosterone cypionate 14 TOPCARE ULTRA COMFORT TESTOSTERONE THRIVITE 19 222 INSULIN SYRINGE/0.3ML/30G X CYPIONATE 14 THRIVITE RX 231 5/16" 175 testosterone cypionate 14 thyroid 250 TOPCARE ULTRA COMFORT TETANUS/DIPHTHERIA tiagabine hcl 24 INSULIN SYRINGE/0.3ML/31G X TOXOIDS-ADSORBED 5/16" 175 ADULT 250 TIBSOVO 46 TOPCARE ULTRA COMFORT tetrabenazine 245 tilia fe 62 INSULIN SYRINGE/0.5ML/30G X tetracaine hcl (ophth) 241 timolol maleate 59 5/16" 175 timolol maleate (ophth) 240 TOPCARE ULTRA COMFORT tetracycline hcl 249 INSULIN SYRINGE/0.5ML/31G X TGT ALCOHOL SWABS 125 timolol maleate in 5/16" 175 ocudose 239 tgt allergy+ congestion relief- TOPCARE ULTRA COMFORT d 65 TIMOPTIC OCUDOSE 240 INSULIN SYRINGE/1ML/30G X TGT LANCET MICRO THIN TIMOPTIC-XE 240 5/16" 175 33G 122 tiopronin 91 TOPCARE ULTRA COMFORT TGT LANCET THIN 26G 122 INSULIN SYRINGE/1ML/31G X TIVICAY 57 5/16" 175 TGT LANCET ULTRA THIN TIVICAY PD 57 30G 122 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U- TGT LANCING DEVICE 122 tizanidine hcl 232 TL FOLATE 231 100/0.3ML/29G X 1/2" 175 THEO-24 22 TOPCARE ULTRA COMFORT theophylline 22 TOBI PODHALER 2 INSULIN SYRINGE/U- thera 224 TOBRADEX 242 100/0.5ML/29G X 1/2" 175 TOPCARE ULTRA COMFORT THERA 224 tobramycin 2 tobramycin (ophth) 241 INSULIN SYRINGE/U- THERA M PLUS 221 100/1ML/29G X 1/2" 175 thera-m 213 tobramycin sulfate 2 topiramate 24

Index 44 topotecan hcl 47 TRIUMEQ 57 TRUE METRIX CONTROL TOPOTECAN HCL 47 TRIZIVIR 57 SOLUTION LEVEL 2 122 TRUE METRIX CONTROL topotecan hcl 47 TROGARZO 57 SOLUTION LEVEL 3 122 TOPPER DRESSING SPONGES TROPHAMINE 239 TRUECONTROL GLUCOSE 4"X4" 110 tropicamide 240 CONTROL LEVEL 0 122 toremifene citrate 44 TRUECONTROL GLUCOSE trospium chloride 255 torsemide 85 CONTROL LEVEL 1 122 TRUE COMFORT INSULIN TRUEDRAW LANCING TRACLEER 60 SYRINGE/0.5ML/31G X DEVICE 122 TRADJENTA 27 5/16" 175 TRUEPLUS 5-BEVEL PEN tramadol hcl 13 TRUE COMFORT INSULIN NEEDLES 29GX12.7MM 176 SYRINGE/1ML/31G X tramadol-acetaminophen 13 TRUEPLUS 5-BEVEL PEN 5/16" 176 NEEDLES 31GX5MM 176 trandolapril 40 TRUE COMFORT PEN TRUEPLUS 5-BEVEL PEN trandolapril-verapamil hcl 41 NEEDLES31G X 5MM 176 NEEDLES 31GX6MM 177 TRUE COMFORT PEN tranexamic acid 95 TRUEPLUS 5-BEVEL PEN NEEDLES31G X 6MM 176 NEEDLES 31GX8MM 177 tranylcypromine sulfate 25 TRUE COMFORT PEN TRUEPLUS 5-BEVEL PEN TRAVASOL 239 NEEDLES32G X 4MM 176 NEEDLES 32GX4MM 177 trazodone hcl 25 TRUE COMFORT PRO TRUEPLUS INSULIN INSULINSYRINGE/0.5ML/30G TRECATOR 42 SYRINGE/U-100/0.3ML/29G X X 5/16" 176 1/2" 177 TRELEGY ELLIPTA 22 TRUE COMFORT PRO TRUEPLUS INSULIN TRELSTAR MIXJECT 44 INSULINSYRINGE/0.5ML/31G SYRINGE/U-100/0.3ML/30G X treprostinil 60 X 5/16" 176 5/16" 177 TRUE COMFORT PRO TRUEPLUS INSULIN tretinoin 70 INSULINSYRINGE/1ML/30G X SYRINGE/U-100/0.3ML/31G X tretinoin (chemotherapy) 46 5/16" 176 5/16" 177 tretinoin microsphere 70 TRUE COMFORT PRO TRUEPLUS INSULIN INSULINSYRINGE/1ML/31G X TRETTEN 92 SYRINGE/U-100/0.5ML/28G X 5/16" 176 1/2" 177 TREXALL 42 TRUE COMFORT PRO TRUEPLUS INSULIN tri femynor 62 INSULINSYRINGE/U- SYRINGE/U-100/0.5ML/29G X tri-vite/fluoride 224,225 100/0.5ML/30G X 1/2" 176 1/2" 177 TRUE COMFORT PRO triamcinolone acetonide TRUEPLUS INSULIN INSULINSYRINGE/U- SYRINGE/U-100/0.5ML/30G X (mouth) 205 100/1ML/30G X 1/2" 176 triamcinolone acetonide 5/16" 177 TRUE COMFORT PRO PEN TRUEPLUS INSULIN (nasal) 233 NEEDLES 31G X 5MM 176 triamcinolone acetonide SYRINGE/U-100/0.5ML/31G X TRUE COMFORT PRO PEN 5/16" 177 (topical) 79 NEEDLES 31G X 6MM 176 triamterene & TRUEPLUS INSULIN TRUE COMFORT PRO PEN SYRINGE/U-100/1ML/28G X hydrochlorothiazide 85 NEEDLES 31G X 8MM 176 triazolam 96 1/2" 177 TRUE COMFORT PRO PEN TRUEPLUS INSULIN TRICARE 231 NEEDLES 32G X 4MM 176 SYRINGE/U-100/1ML/29G X triclosan 53 TRUE COMFORT PRO PEN 1/2" 177 NEEDLES 32G X 5MM 176 triderm 78 TRUEPLUS INSULIN TRUE COMFORT PRO PEN SYRINGE/U-100/1ML/30G X trifluoperazine hcl 49 NEEDLES 32G X 6MM 176 5/16" 177 trifluridine 241 TRUE COMFORT PRO PEN TRUEPLUS INSULIN TRIGLIDE 39 NEEDLES 33G X 4MM 176 SYRINGE/U-100/1ML/31G X TRUE COMFORT PRO PEN trihexyphenidyl hcl 47 5/16" 177 NEEDLES 33G X 5MM 176 TRUEPLUS LANCETS trimethobenzamide hcl 32 TRUE COMFORT PRO PEN 26G 122 trimethoprim 18 NEEDLES 33G X 6MM 176 TRUEPLUS LANCETS TRUE METRIX CONTROL TRINATAL RX 1 231 28G 122 SOLUTION LEVEL 1 122 TRUEPLUS LANCETS 28G trinate 226 SUPER THIN 122

Index 45 TRUEPLUS LANCETS TUDORZA PRESSAIR 20 ULTICARE INSULIN 30G 122 TWINRIX 259 SYRINGE/SHORT/0.5ML/30G X TRUEPLUS LANCETS 30G 5/16" 178 ULTRA THIN 122 TYBLUME 63 ULTICARE INSULIN TRUEPLUS LANCETS TYBOST 57 SYRINGE/SHORT/0.5ML/31G X 33G 122 TYPHIM VI 256 5/16" 178 TRUEPLUS PEN NEEDLES ULTICARE INSULIN 29GX12MM 177 TYSABRI 246 SYRINGE/SHORT/1ML/30G X TRUEPLUS PEN NEEDLES UDAMIN SP 222 5/16" 178 31GX5MM 177 ULTI-LANCE AUTOMATIC/ ULTICARE INSULIN TRUEPLUS PEN NEEDLES CLEAR TIP 122 SYRINGE/SHORT/1ML/31G X 31GX6MM 177 ULTICARE ALCOHOL 5/16" 178 TRUEPLUS PEN NEEDLES SWABS 125 ULTICARE INSULIN 31GX8MM 177 ULTICARE INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X TRUEPLUS PEN NEEDLES SYRINGE/0.5ML/29G X 1/2" 178 32GX4MM 177 1/2" 178 ULTICARE INSULIN TRULICITY 28 ULTICARE INSULIN SAFETY SYRINGE/U-100/0.3ML/31G X TRUMENBA 256 SYRINGE/1ML/29G X 5/16" 179 TRUSTEX COLOR CONDOMS + 1/2" 178 ULTICARE INSULIN ULTICARE INSULIN LUBE 111 SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/29G X 1/2" 179 TRUSTEX LUBRICATED 111 1/2" 178 ULTICARE INSULIN TRUSTEX LUBRICATED ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X EXTRALARGE 111 SYRINGE/0.3ML/30G X 5/16" 179 TRUSTEX LUBRICATED 1/2" 178 ULTICARE INSULIN EXTRASTRENGTH 111 ULTICARE INSULIN SYRINGE/U-100/1ML/30G X TRUSTEX SYRINGE/0.3ML/30G X 1/2" 179 LUBRICATED/RIBBED/STUDDE 5/16" 178 ULTICARE INSULIN D 111 ULTICARE INSULIN SYRINGE/U-100/1ML/31G X TRUSTEX SYRINGE/0.5ML/28G X 5/16" 179 LUBRICATED/SPERMICIDE 1/2" 178 ULTICARE INSULIN 111 ULTICARE INSULIN SYRINGEULTRAFINE U- TRUSTEX SYRINGE/0.5ML/29G X 100/0.3ML/31G X 5/16" 179 LUBRICATED/SPERMICIDE 1/2" 178 ULTICARE INSULIN EXTRA LARGE 111 ULTICARE INSULIN SYRINGEULTRAFINE U- TRUSTEX SYRINGE/0.5ML/30G X 100/0.5ML/31G X 5/16" 179 LUBRICATED/SPERMICIDE 1/2" 178 ULTICARE INSULIN EXTRA STRENGTH 111 ULTICARE INSULIN SYRINGEULTRAFINE U- TRUSTEX NATURAL SYRINGE/0.5ML/30G X 100/1ML/31G X 5/16" 179 CONDOMS 5/16" 178 ULTICARE MICRO PEN +LUBE/LUBRICATED 111 ULTICARE INSULIN NEEDLES 31G X 8MM 179 TRUSTEX NON- SYRINGE/1ML/28G X ULTICARE MICRO PEN LUBRICATED 111 1/2" 178 NEEDLES 32G X 4MM 179 TRUSTEX WITH NONOXYNOL- ULTICARE INSULIN ULTICARE MICRO PEN 9/RIBBED/STUDDED 112 SYRINGE/1ML/29G X NEEDLES/31G X 1/4" 179 TRUSTEX/RIA 1/2" 178 ULTICARE MICRO PEN LUBRICATED 112 ULTICARE INSULIN NEEDLES/31G X 5/16" 179 TRUSTEX/RIA LUBRICATED SYRINGE/1ML/30G X ULTICARE MICRO PEN SPERMICIDE 112 1/2" 178 NEEDLES/32G X 4MM 179 TRUSTEX/RIA ULTICARE INSULIN ULTICARE MICRO PEN LUBRICATED/SPERMICIDE SYRINGE/1ML/30G X NEEDLES/32G X 5/32" 179 112 5/16" 178 ULTICARE MINI PEN NEEDLES TRUSTEX/RIA NON- ULTICARE INSULIN 31GX6MM 179 LUBRICATED 112 SYRINGE/SHORT/0.3ML/30G ULTICARE MINI PEN NEEDLES TRUVADA 57 X 5/16" 178 ULTI-FINE IV 179 TRUZONE PEAK FLOW ULTICARE INSULIN ULTICARE MINI PEN METER 196 SYRINGE/SHORT/0.3ML/31G NEEDLES/31G X 6MM 179 TUBING/WING TIP 196 X 5/16" 178 ULTICARE MINI PEN NEEDLES/32G X 1/4" 179

Index 46 ULTICARE MINI PEN ULTIGUARD SAFEPACK PEN ULTILET INSULIN NEEDLES31GX6MM 179 NEEDLE/29G X 1/2"/SHARPS SYRINGE/SHORT/0.5ML/31G X ULTICARE MINI SAFETY CONTAINER 181 5/16" 182 PENNEEDLES 30G X ULTIGUARD ULTILET INSULIN 3/16" 179 SAFEPACK/MICROPEN SYRINGE/SHORT/1ML/30G X ULTICARE ORIGINAL PEN NEEDLE/32G X 5/32" 181 5/16" 182 NEEDLES ULTI-FINE 179 ULTIGUARD ULTILET INSULIN ULTICARE PEN NEEDLES SAFEPACK/MICROPEN SYRINGE/SHORT/1ML/31G X 31GX 5MM/MINI 180 NEEDLE/32G X 5/32"/SHARPS 5/16" 182 ULTICARE PEN CONTA 181 ULTILET INSULIN SYRINGE/U- NEEDLES/29GX 12.7MM 180 ULTIGUARD SAFEPACK/MINI 100/0.5ML/30G X 1/2" 182 ULTICARE SHORT PEN PEN NEEDLE/31G X ULTILET INSULIN SYRINGE/U- NEEDLES 31GX8MM 180 1/4"/SHARPS CONTAIN 181 100/0.5ML/31GX6MM 182 ULTICARE SHORT PEN ULTIGUARD SAFEPACK/MINI ULTILET INSULIN SYRINGE/U- NEEDLES ULTI-FINE IV 180 PEN NEEDLE/31G X 100/1ML/30G X 1/2" 182 ULTICARE SHORT PEN 3/16"/SHARPS CONTAI 181 ULTILET PEN NEEDLE NEEDLES/31G X 8MM 180 ULTIGUARD SAFEPACK/MINI 29GX12.7MM 182 ULTICARE SHORT SAFETY PEN NEEDLE/32G X ULTILET PEN NEEDLE PEN NEEDLES 30G X 1/4"/SHARPS CONTAIN 181 31GX5MM 182 5/16" 180 ULTIGUARD ULTILET PEN NEEDLE ULTICARE SYRINGE/LOW SAFEPACK/SHORTPEN 31GX8MM 182 DEADSPACE/3ML/22G X1- NEEDLE/31G X 5/16"/SHARPS ULTILET PEN NEEDLE 1/2" 180 CONTA 181 32GX4MM 182 ULTICARE U-100 INSULIN ULTIGUARD ULTILET PEN NEEDLE SYRINGES/0.3ML/31G X SAFEPACK/SYRINGE/NEEDL 32GX4MM/SHORT 182 1/4" 180 E/31G X 5/16"/SHARPS ULTILET SHORT PEN ULTICARE U-100 INSULIN CONTAIN 181 NEEDLES 31GX5/16" 182 SYRINGES/0.3ML/31G ULTILET CLASSIC ULTILET SHORT PEN X1/4" 180 LANCETS 122 NEEDLES31GX3/16" 182 ULTICARE U-100 INSULIN ULTILET INSULIN SYRINGE ULTILET U-100 INSULIN SYRINGES/0.5ML/31G X 31X6MM 181 SYRINGES/1ML/31G X 1/4" 180 ULTILET INSULIN 6MM 182 ULTICARE U-100 INSULIN SYRINGE/0.3ML/30G X ULTRA COMFORT INSULIN SYRINGES/1ML/31G X 8MM 181 SYRINGE/U-100/0.3ML/30G X 1/4" 180 ULTILET INSULIN 5/16" 182 ULTIGUARD SAFEPACK SYRINGE/0.3ML/31G X ULTRA FLO INSULIN PEN INSULIN SYRINGE 0.3ML/30G X 8MM 181 NEEDLE 31GX5MM 182 1/2"/SHARPS C 180 ULTILET INSULIN ULTRA FLO INSULIN PEN ULTIGUARD SAFEPACK SYRINGE/0.5ML/30G X NEEDLE 32GX4MM 182 INSULIN SYRINGE 1/2ML 30G X 8MM 181 ULTRA FLO INSULIN PEN 1/2"/SHARPS C 180 ULTILET INSULIN NEEDLE 33GX4MM 182 ULTIGUARD SAFEPACK SYRINGE/1ML/30G X ULTRA FLO INSULIN PEN INSULIN SYRINGE 1ML 30G X 8MM 181 NEEDLES 182 1/2"/SHARPS CON 180 ULTILET INSULIN ULTRA FLO INSULIN PEN ULTIGUARD SAFEPACK SYRINGE/1ML/31G X NEELE 31GX8MM 182 INSULIN SYRINGE 1ML 31G X 8MM 181 ULTRA FLO INSULIN SYRINGE 5/16"/SHARPS CO 180 ULTILET INSULIN 0.3ML/29G X 1/2" 182 ULTIGUARD SAFEPACK SYRINGE/SHORT/0.3ML/30G ULTRA FLO INSULIN SYRINGE INSULIN SYRINGE/0.3ML/30G X X 12.7MM 181 0.3ML/30GX1/2" 182 1/2"/SHARPS C 180 ULTILET INSULIN ULTRA FLO INSULIN SYRINGE ULTIGUARD SAFEPACK SYRINGE/SHORT/0.3ML/30G 0.3ML/30GX5/16" 182 INSULIN SYRINGE/0.3ML/31G X X 5/16" 181 ULTRA FLO INSULIN SYRINGE 5/16"/SHARPS 180 ULTILET INSULIN 0.3ML/31GX5/16" 182 ULTIGUARD SAFEPACK SYRINGE/SHORT/0.3ML/31G ULTRA FLO INSULIN SYRINGE INSULIN SYRINGE/0.5ML/30G X X 5/16" 181 0.5ML/29GX1/2" 183 1/2"/SHARPS C 180 ULTILET INSULIN ULTRA FLO INSULIN SYRINGE ULTIGUARD SAFEPACK MINI SYRINGE/SHORT/0.5ML/30G 0.5ML/30GX1/2" 183 PEN NEEDLE/31G X X 5/16" 181 ULTRA FLO INSULIN SYRINGE 3/16"/SHARPS CONTAI 180 0.5ML/30GX5/16" 183

Index 47 ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN ULTRACARE PEN 0.5ML/31GX5/16" 183 SYRINGE SHORT/U- NEEDLES/32G X 5/32" 185 ULTRA FLO INSULIN SYRINGE 100/0.5ML/30GX5/16" 184 ULTRACARE PEN 1/2 UNIT/0.3ML/30GX1/2" 183 ULTRA-THIN II INSULIN NEEDLES/33G X 5/32" 185 ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- ULTRALANCE 122 1/2 UNIT/0.3ML/30GX5/16" 100/0.5ML/31GX5/16" 184 ULTRATHON INSECT 183 ULTRA-THIN II INSULIN REPELLENT 8 82 ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- UNI-SOLVE 50 1/2 UNIT/0.3ML/31GX5/16" 100/1ML/30GX5/16" 184 183 ULTRA-THIN II INSULIN UNICOMPLEX-M 222 ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- UNIFIBER 98 1M/29GX1/2" 183 100/1ML/31GX5/16" 184 UNIFINE PEN NEEDLE/32G ULTRA FLO INSULIN SYRINGE ULTRA-THIN II INSULIN X4MM 185 1ML/30GX1/2" 183 SYRINGE/U- UNIFINE PENTIPS ULTRA FLO INSULIN SYRINGE 100/0.5ML/29GX1/2" 184 29GX12MM 185 1ML/30GX5/16" 183 ULTRA-THIN II INSULIN UNIFINE PENTIPS 31G X ULTRA FLO INSULIN SYRINGE SYRINGE/U- 3/16" 185 1ML/31GX5/16" 183 100/1ML/29GX1/2" 184 UNIFINE PENTIPS ULTRA THIN PEN NEEDLES ULTRA-THIN II MINI PEN 31GX5MM 185 32G X 4MM 183 NEEEDLES/31GX3/16" 184 UNIFINE PENTIPS ULTRA-COMFORT INSULIN ULTRA-THIN II PEN NEEDLES 31GX6MM 185 SYRINGE/U-100/0.3ML/29G X 29GX1/2" 184 UNIFINE PENTIPS 1/2" 183 ULTRA-THIN II PEN 31GX8MM 185 ULTRA-COMFORT INSULIN NEEDLES/SHORT/31GX5/16" UNIFINE PENTIPS SYRINGE/U-100/0.3ML/30G X 184 32GX4MM 185 5/16" 183 ULTRACARE INSULIN UNIFINE PENTIPS ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 32GX6MM 185 SYRINGE/U-100/0.3ML/31G X 5/16" 184 UNIFINE PENTIPS 5/16" 183 ULTRACARE INSULIN 33GX4MM 185 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/28G X 5/16" 184 29GX12MM 185 1/2" 183 ULTRACARE INSULIN UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 31GX5MM 185 SYRINGE/U-100/0.5ML/29G X 1/2" 184 UNIFINE PENTIPS PLUS 1/2" 183 ULTRACARE INSULIN 31GX6MM 185 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/30G X 5/16" 184 31GX8MM 185 5/16" 183 ULTRACARE INSULIN UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 32GX4MM 185 SYRINGE/U-100/0.5ML/31G X 5/16" 185 UNIFINE PENTIPS PLUS 33GX 5/16" 183 ULTRACARE INSULIN 5/32" 186 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X UNIFINE PENTIPS PLUS SYRINGE/U-100/1ML/28G X 1/2" 185 33GX4MM 186 1/2" 184 ULTRACARE INSULIN UNIFINE PENTIPS PLUS/30GX ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X 3/16" 186 SYRINGE/U-100/1ML/29G X 5/16" 185 UNIFINE PENTIPS/30G X 1/2" 184 ULTRACARE INSULIN 3/16" 186 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X UNIFINE SAFECONTROL PEN SYRINGE/U-100/1ML/30G X 5/16" 185 NEEDLE/30G X 3/16" 186 5/16" 184 ULTRACARE PEN UNIFINE SAFECONTROL PEN ULTRA-COMFORT INSULIN NEEDLES/31G X 1/4" 185 NEEDLE/30G X 5/16" 186 SYRINGE/U-100/1ML/31G X ULTRACARE PEN UNILET COMFORTOUCH 5/16" 184 NEEDLES/31G X 3/16" 185 LANCET 122 ULTRA-THIN II INSULIN ULTRACARE PEN UNILET EXCELITE 123 SYRINGE SHORT/U- NEEDLES/31G X 5/16" 185 UNILET EXCELITE II 123 100/0.3ML/30GX5/16" 184 ULTRACARE PEN UNILET G.P. LANCET 123 ULTRA-THIN II INSULIN NEEDLES/32G X 1/14" 185 SYRINGE SHORT/U- ULTRACARE PEN UNILET G.P. SUPERLITE 100/0.3ML/31GX5/16" 184 NEEDLES/32G X 3/16" 185 LANCET 123

Index 48 UNILET GP 28 ULTRA VALUE PLUS LANCETS VANISHPOINT SAFETY THIN 123 STANDARD 21G 123 SYRINGE/3ML/22GX1-1/2" UNILET LANCET 123 VALUE PLUS LANCETS 187 UNILET LANCETS MICRO- SUPERTHIN 30G 123 VANISHPOINT SAFETY THIN33G 123 VALUE PLUS LANCETS THIN SYRINGE/3ML/23GX1" 187 UNILET LANCETS SUPER- 26G 123 VANISHPOINT SAFETY THIN30G 123 VALUE PLUS LANCING SYRINGE/3ML/23GX1-1/2" UNILET LANCETS ULTRA-THIN DEVICE 123 187 28G 123 VALUMARK LANCET SUPER VANISHPOINT SAFETY UNILET SUPERLITE THIN 30G 123 SYRINGE/3ML/25GX1" 187 LANCET 123 VALUMARK LANCET ULTRA VANISHPOINT SAFETY UNISTIK 1 123 THIN 28G 123 SYRINGE/3ML/25GX1-1/2" VALUMARK PEN NEEDLES 187 UNISTIK 2 123 29GX12MM 186 VANISHPOINT SAFETY UNISTIK 2 COMFORT 123 VALUMARK PEN NEEDLES SYRINGE/3ML/25GX5/8" 187 UNISTIK 2 EXTRA 123 31GX 6MM 186 VANISHPOINT SAFETY VALUMARK PEN NEEDLES UNISTIK 2 NEONATAL 123 SYRINGE/3ML/27GX1-1/2" 31GX 8MM 186 187 UNISTIK 2 NORMAL 123 VALVED HOLDING VANISHPOINT UNISTIK 2 SUPER 123 CHAMBER 196 SYRINGE/3ML/20G X 1" 187 UNISTIK 3 123 vanadom 232 VANISHPOINT vancomycin hcl 18 SYRINGE/3ML/20G X 1- UNISTIK 3 COMFORT 123 1/2" 187 UNISTIK 3 EXTRA 123 VANCOMYCIN HYDROCHLORIDE 18 VANISHPOINT UNISTIK 3 EXTRA SINGLE USE SYRINGE/3ML/21G X 1" 187 SAFETY LANCETS/21G 123 vandazole 260 VANISHPOINT UNISTIK 3 NEONATAL 123 VANISHPOINT INSULIN SYRINGE/3ML/21G X 1- SYRINGE/0.5ML/30G X UNISTIK 3 NORMAL 123 1/2" 187 1/2" 186 VANISHPOINT UNISTIK CZT COMFORT 123 VANISHPOINT INSULIN SYRINGE/3ML/22G X 1" 187 UNISTIK CZT NORMAL 123 SYRINGE/0.5ML/30G X VANISHPOINT 3/16" 186 SYRINGE/3ML/22G X 1- UNISTIK NORMAL 123 VANISHPOINT INSULIN UNIVERSAL 1 LANCETS 1/2" 187 SYRINGE/0.5ML/30G X VANISHPOINT THIN26G 123 5/16" 186 UNIVERSAL 1 LANCETS ULTRA SYRINGE/3ML/23G X 1" 187 VANISHPOINT INSULIN VANISHPOINT THIN 30G 123 SYRINGE/1ML/29G X UNIVERSAL 1 SYRINGE/3ML/23G X 1- 1/2" 186 1/2" 187 LANCETS/33G/MICRO-THIN VANISHPOINT INSULIN 123 VANISHPOINT SYRINGE/1ML/29G X SYRINGE/3ML/25G X 1" 187 urea 80 5/16" 186 VANISHPOINT urea-c40 80 VANISHPOINT INSULIN SYRINGE/3ML/25G X 1- ursodiol 89 SYRINGE/1ML/30G X 1/2" 187 3/16" 186 vagisil 77 VANISHPOINT VANISHPOINT INSULIN SYRINGE/3ML/25G X 5/8" 187 valacyclovir hcl 58 SYRINGE/1ML/30G X VANTAS 44 5/16" 186 valganciclovir hcl 57 VAQTA 259 valproate sodium 25 VANISHPOINT SAFETY SYRINGE/3ML/20GX1" 186 VARIVAX 259 valproic acid 25 VANISHPOINT SAFETY VAXCHORA 256 valsartan 40 SYRINGE/3ML/20GX1-1/2" VCF VAGINAL valsartan-hydrochlorothiazide 186 CONTRACEPTIVE FILM 259 41 VANISHPOINT SAFETY VCF VAGINAL VALUE HEALTH INSULIN SYRINGE/3ML/21GX1" 186 CONTRACEPTIVE FOAM 259 SYRINGE/U-100/0.5ML/29G X VANISHPOINT SAFETY VCF VAGINAL 1/2" 186 SYRINGE/3ML/21GX1-1/2" CONTRACEPTIVEGEL 259 VALUE HEALTH INSULIN 186 VEMLIDY 58 SYRINGE/U-100/1ML/29G X VANISHPOINT SAFETY 1/2" 186 SYRINGE/3ML/22GX1" 187 VENCLEXTA 43

Index 49 VENCLEXTA STARTING vitamin d3 262 WALGREENS THIN PACK 43 VITAMIN D3 COMPLETE 222 LANCETS 124 VENEXA 222 WALTZ FREE HAND vitamin e 262 VENEXA FE 222 SANITIZER 53 VITAMIN E 262 WALTZ FREE HAND venlafaxine hcl 26 VITASANA 222 SANITZER 53 VENTAVIS 60 VITATHELY/GINGER 231 warfarin sodium 22 VENTRIXYL 222 VITATRUM 222 WATCHHALER 196 VENTRIXYL FE 222 VITEYES CLASSIC WEBCOL ALCOHOL PREP verapamil hcl 60 MULTIIVITAMIN 222 LARGE 1 PLY 125 VITEYES CLASSIC WEBCOL ALCOHOL PREP VERELAN 60 LARGE 2 PLY 125 VERELAN PM 60 MULTIVITAMIN 222 VITEYES OPTIC NERVE WEBCOL ALCOHOL PREP VERSACLOZ 49 SUPPORT 222 MEDIUM 2 PLY 125 VIBRAMYCIN 249 WEGMANS COMPLETE VITRANOL 222 PRENATAL+DHA 231 VICTOZA 28 VITRANOL FE 222 WEGMANS UNIFINE PENTIPS VIDA MIA AUTOLET VITREXATE 222 PLUS 32GX4MM 188 LANCINGDEVICE 123 VITREXATE FE 222 WEGMANS UNIFINE PENTIPS VIDA MIA UNIFINE PLUS/MINI/31GX5MM 188 PENTIPS32GX4MM 187 VITREXYL 222 WEGMANS UNIFINE PENTIPS VIDA MIA UNIFINE VITREXYL/IRON 222 PLUS/SHORT/31GX8MM 188 PENTIPSMINI 31GX6MM 187 VITRUM 50+ ADULT-MULTI WEGMANS UNIFINE PENTIPS VIDA MIA UNIFINE IRON FREE 222 PLUS/ULTRA PENTIPSORIGINAL VITRUM 50+ SENIOR SHORT/31GX6MM 188 29GX12MM 188 MULTI 223 WESTAB PLUS 231 VIDA MIA UNILET LANCETS VIVAGUARD LANCING SUPER THIN 30G 124 WESTHROID 250 DEVICE 124 WHOLE FOOD VIDA MIA UNILET LANCETS VIVITROL 31 ULTRA THIN 28G 124 MULTIVITAMIN 223 VIDA MIA UNIPFINE VIVOTIF 256 WILATE 92 PENTIPSSHORT VOGELXO 14 WINDMILL TRAINER 196 31GX8MM 188 VOGELXO PUMP 14 wixela inhub 21 VIDEX EC 57 VOL-NATE 231 WOMENS 50+ MULTI VITAMIN& VIDEXPEDIATRIC 57 VOL-PLUS 231 MINERAL FORMULA 223 vigabatrin 24 VOL-TAB RX 231 WOMENS BIOMULTIPLE 223 WOMENS MULTI VITAMIN & vigadrone 24 VONVENDI 92 VIIBRYD 26 MINERAL FORMULA 223 voriconazole 33 WP THYROID 250 VIMPAT 24 VORTEX VALVED HOLDING XALKORI 46 VINATE II 231 CHAMBER 196 XARELTO 23 VINATE ONE 231 VOTRIENT 46 XARELTO STARTER PACK 23 vincristine sulfate 46 VP INSULIN SYRINGE/U- 100/0.3ML/29G X 1/2" 188 XATMEP 42 VIRACEPT 57 VPRIV 93 XELJANZ 2 VIRAMUNE 57 VRAYLAR 48 XELJANZ XR 2,3 VIRAMUNE XR 57 VYVANSE 1 XENICAL 1 VIREAD 57 wal-profen 3 XEOMIN 235 virtussin ac/alc 66 WALGREENS COMFORT XEROSTOMIA RELIEF visine 241 ASSUREDLANCETS MICRO SPRAY 205 VISTOGARD 31 THIN/33G 124 XIAFLEX 203 VITAFOL-OB 231 WALGREENS COMFORT ASSUREDLANCETS SUPER XOLAIR 20 VITALINE TOTAL FORMULA THIN/28G 124 XPERT XPRESS SARS-COV- 2 222 WALGREENS GLUCOSE 27 2 85 VITALINE TOTAL FORMULA XTANDI 44 3 222

Index 50 xulane 63 ZOLINZA 46 XULTOPHY 100/3.6 27 zolmitriptan 197 XURIDEN 87 zolpidem tartrate 96 XYNTHA 93 ZOMACTON 86 XYNTHA SOLOFUSE 93 zonisamide 24 YELETS TEENAGE ZONTIVITY 93 FORMULA 223 ZOSTAVAX 259 YF-VAX 259 ZUBSOLV 14 YONDELIS 42 ZYDELIG 46 YONSA 44 ZYPREXA 49 YOUR LIFE MULTI PRENATAL 231 ZYPREXA RELPREVV 49 zafirlukast 20 ZYPREXA ZYDIS 49 zaleplon 96 ZALTRAP 43 ZARONTIN 24 ZARXIO 94 ZEJULA 46 ZELBORAF 46 ZEMAIRA 249 zenzedi 1 ZEVRX INSULIN SYRINGE/0.5ML/30G X 1/2" 188 ZEVRX INSULIN SYRINGE/0.5ML/30G X 5/16" 188 ZEVRX INSULIN SYRINGE/1ML/30G X 1/2" 188 ZEVRX INSULIN SYRINGE/1ML/30G X 5/16" 188 ZEVRX PEN NEEDLES 31G X 5MM 188 ZEVRX PEN NEEDLES 31G X 6MM 188 ZEVRX PEN NEEDLES 31G X 8MM 188 ZEVRX PEN NEEDLES 32G X 4MM 188 ZIAGEN 57 zidovudine 57 zinc oxide (topical) 82 zinc sulfate 203 ziprasidone hcl 48 ziprasidone mesylate 48 ZOLADEX 44 zoledronic acid 86 ZOLEDRONIC ACID 86 zoledronic acid 86 ZOLEDRONIC ACID 86

Index 51