California 3 Tier with Specialty Drug List

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The 3 Tier with Specialty Drug List (formulary) includes a list of drugs covered by Health Net. The drug list is updated at least monthly and is subject to change. All previous versions are no longer in effect. You can view the most current drug list by going to our website at www.healthnet.com. Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information.

California Small and Large Group members Go to Drug Lists - Use the “3 Tier with Specialty” Formulary.

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

Small Group If you have questions about your pharmacy coverage call Customer Service at 1-800-361-3366 Hours of Operation 8:00am – 6:00pm Monday through Friday

Large Group If you have questions about your pharmacy coverage call Customer Service at 1-800-522-0088 Hours of Operation 8:00am – 6:00pm Monday through Friday

Updated September 1, 2021

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

Table of Contents

What If I Have Questions Regarding My Pharmacy Benefit? …....……….….…. ii What is the Drug List? ...... ii How do I find a drug on the Drug List? ...... ii How are the drugs listed in the categorical list? ………………………………..…. ii How much will I pay for my drugs? ...... ….. iii Are there any limits on my drug coverage? ……………………………………… iv Abbreviations table How often does the Drug List change? …...... v How can I get prior authorization or an exception to the rules for drug coverage? v Are all contraceptives covered? ...... vi What blood glucose supplies are covered? ...... vi What drugs are covered under my medical benefit? ……………………………. vi Can I go to any pharmacy? ……………………………………………………. ... vii Can I use a mail order pharmacy?...... vii How can I save money on my prescription drugs? ……...... vii Definitions………………………………………………………………..….…. viii Categorical list of prescription drugs...... 1 Alphabetical index of prescription drugs …………………………...... …… Index 1

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

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

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

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

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

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

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

How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its therapeutic category and class. Example: Drug Tier Drug Limits Requirements/ Limits PA MAVYRET (glecaprevir-pibrentasvir) TABS 3 phentermine hcl caps 1 PA ii

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

Brand Drug Example: MAVYRET (glecaprevir-pibrentasvir) TABS

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

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

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

How much will I pay for my drugs? To see how much you will pay for a drug check the abbreviations in the Drug Tier column on the formulary. The copayment or coinsurance for each tier is defined in your Summary of Benefits or other plan documents.

Drug Class/Plan Benefit Phase Maximum Cost Share Days Supply Oral Cancer Drugs Before Deductible is Met $250 30 Days All other (non-oral After Deductible is Met $250 30 Days cancer) Drugs Bronze Plan Members After Deductible Met $500 30 Days

Below is a description for each tier. Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information. Tier Description 1 Drugs in this tier include generic drugs and low-cost preferred brand drugs. 2 Drugs in this tier are higher cost generic drugs and preferred brand drugs. Drugs in this tier are non-preferred brand drugs, brand drugs with generic equivalents on a lower tier, or drugs that have a preferred alternative at a lower 3 tier. Tier 4 Drugs include drugs that are made using biotechnology, drugs that must be distributed through a specialty pharmacy, drugs that require special training for self-administration, or drugs that require regular monitoring of care by a 4 pharmacy, and drugs that cost more than six hundred dollars for a one-month supply. Tier 5 includes preventive benefit drugs, including contraceptives, covered at no cost 5 to members under the Affordable Care Act. A deductible does not apply. iii

A Brand name is listed for reference only when a generic equivalent is available. 7 Generic drugs will be used whenever one is available. To get a brand drug that has a generic equivalent available, your doctor must request prior authorization to show medical necessity. If we approve the request, the drug may be covered at a higher copayment. Refer to your plan documents.

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

Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations. AC Anti-cancer These oral cancer drugs are have a maximum $250 copayment for a one-month supply, before any deductible has been met, per state law (or $750 maximum for a three-month supply through mail order, if applicable). LA Limited Access Some drugs may be subject to limited access or restricted access. This means that a drug may only be available at select pharmacies. Limited access may be due to the following reasons:  The FDA or the manufacturer has restricted distribution of a drug to certain facilities, pharmacies or prescribers, or  Certain drugs require special handling, coordination of care, or patient education that cannot be provided at a retail pharmacy. If the drug is approved, we will let you know how to get limited access drugs. PA Prior This drug requires prior authorization. This means that you or Authorization your prescriber must get approval from us before you fill your prescription. If you do not get approval, we may not cover the drug. PV Preventive Drugs Preventive Health Drugs are Affordable Care Act (ACA) preventive health drugs, including contraceptive drugs and devices, covered at no charge. Preventive health drugs are determined based on evidence-based recommendations by the United States Preventive Services Task Force. QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net. Health Net covers all self-administered hormonal contraceptives on the Formulary, up to a 12-month supply when dispensed at one time.

RX/OTC Prescription & Certain drugs are available both in a prescription form and in Over-the- an OTC form. Only prescription drugs are covered by your Counter (OTC) plan, with the exception of some insulin, insulin supplies and some covered preventive drugs. OTC drugs on the drug list, including OTC preventive drugs and contraceptives, require a prescription to be covered. ST Step Step therapy is when you are required to use one drug Therapy before another in a stepwise fashion. Unless an exception is made, one or more preferred drugs must be tried first before progressing to a drug that is subject to step therapy.

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

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

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

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

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

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

In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called step therapy. Step therapy is when you are required to use one drug before another in a stepwise fashion. The required first step drug or preferred drug is a proven cost-effective medication.

Unless an exception is made one or more preferred drugs must be tried before progressing to a drug that is subject to step therapy. You or your doctor can request an exception if your health may be harmed by waiting. Your doctor must submit a supporting statement to us explaining why you need the drug. You or your doctor may appeal the denial of an exception request. The denial documents provide more information on appeal rights and procedures if there is a medical need to use a second step drug without trying a first step drug. An exception to coverage may be requested by the prescriber.

A request for an exception to a step therapy requirement may be submitted in the same manner as a request for prior authorization. The request shall be treated in the same manner and shall be responded too in the same manner as a request for prior authorization. If you just enrolled in the health plan and have already tried and failed the preferred drug(s), or if you are already taking a drug that is subject to step therapy you will not have to undergo step therapy again. The drug will be approved for coverage when medically necessary.

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

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

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

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

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

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

Can I go to any pharmacy? Except in emergency and urgent situations, Health Net does not cover drugs dispensed by non-network pharmacies. Health Net contracts with most U.S. chain pharmacies and many independent pharmacies. These pharmacies are called in-network pharmacies. To find an in-network pharmacy near you visit our website at Find a pharmacy near you or call us at the telephone number on your Health Net ID card or listed on the front cover of this book.

Some injectable and high cost drugs are considered specialty drugs. These drugs must be filled at an in- network specialty pharmacy. Specialty drugs are noted on the drug list in the Requirements/Limits column with the abbreviation “LA” or a statement indicating the drug must be dispensed from a network specialty pharmacy. After your drug has been approved, we will arrange for the specialty pharmacy to contact you to set up delivery.

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

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

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

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

Prior Authorization: Is a decision by the plan that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in the drug list, your doctor must request approval from the plan to cover the drug before you fill your prescription. The plan must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy: Is a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in the drug list, you may have to try one or more other drugs before the plan will cover that drug for your medical condition. If your doctor submits a request for an exception to the step therapy requirement, the plan must grant the request when it is medically necessary for you to take the drug.

Subscriber: Means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- DEXEDRINE CP24 OBESITY/ANOREXIANTS - Drugs to Treat (dextroamphetamine 7 ADHD, Sleep and Eating Disorders sulfate) Amphetamines dextroamphetamine (Dextroamphetamine sulfate cp24 10 mg, 15 1 Sulfate) PROCENTRA 3 mg, 5 mg SOLN dextroamphetamine 3 (Dextroamphetamine sulfate soln 5 mg/5ml Sulfate) ZENZEDI TABS 10 1 MG, 5 MG dextroamphetamine ADDERALL TABS sulfate tabs 10 mg, 5 1 (amphetamine- 7 mg ) PA; ST; dextroamphetamine methamphetamine hcl 3 ADDERALL XR CP24 QL(2 ea tabs (amphetamine- 7 daily,90 day(s) VYVANSE CAPS 10 MG, QL(1 ea daily) dextroamphetamine) limit) 20 MG, 30 MG, 40 MG, 50 amphetamine- QL(2 ea MG, 60 MG, 70 MG 2 (lisdexamfetamine dextroamphetamine daily,90 day(s) dimesylate) cp24 1.25 mg-1.25 mg- limit) VYVANSE CHEW 10 MG, Limited to 1 per 1.25 mg-1.25 mg, 2.5 20 MG, 30 MG, 40 MG, 50 day;QL(1 ea mg-2.5 mg-2.5 mg-2.5 MG, 60 MG 2 daily) mg, 3.75 mg-3.75 mg- 1 (lisdexamfetamine 3.75 mg-3.75 mg, 5 dimesylate) mg-5 mg-5 mg-5 mg, 6.25 mg-6.25 mg-6.25 Analeptics mg-6.25 mg, 7.5 mg- caffeine citrate soln 1 7.5 mg-7.5 mg-7.5 mg amphetamine- Attention-Deficit/Hyperactivity Disorder (ADHD) dextroamphetamine atomoxetine hcl caps QL(2 ea daily) tabs 1.25 mg-1.25 mg- 10 mg, 18 mg, 25 mg, 1 1.25 mg-1.25 mg, 40 mg QL(1 ea daily) 1.875 mg-1.875 mg- atomoxetine hcl caps 1 1.875 mg-1.875 mg, 100 mg, 60 mg, 80 mg 2.5 mg-2.5 mg-2.5 mg- QL(1 ea daily) 1 guanfacine hcl (adhd) 1 2.5 mg, 3.125 mg- tb24 3.125 mg-3.125 mg- INTUNIV TB24 QL(1 ea daily) 7 3.125 mg, 3.75 mg- (guanfacine hcl (adhd)) 3.75 mg-3.75 mg-3.75 STRATTERA CAPS 10 QL(2 ea daily) mg, 5 mg-5 mg-5 mg-5 MG, 18 MG, 25 MG, 40 MG 7 mg, 7.5 mg-7.5 mg-7.5 (atomoxetine hcl) mg-7.5 mg STRATTERA CAPS 100 QL(1 ea daily) DESOXYN TABS PA; ST; MG, 60 MG, 80 MG 7 7 (methamphetamine hcl) (atomoxetine hcl)

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

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Stimulants - Misc. methylphenidate hcl QL(1 ea daily) APTENSIO XR CP24 PA; QL(1 ea cpcr 10 mg, 20 mg, 30 7 1 (methylphenidate hcl) daily) mg, 40 mg, 50 mg, 60 mg armodafinil tabs 1 PA; ST methylphenidate hcl CONCERTA TBCR 18 MG, QL(1 ea daily) soln 10 mg/5ml, 5 1 27 MG, 36 MG 7 mg/5ml (methylphenidate hcl) methylphenidate hcl CONCERTA TBCR 54 MG QL(2 ea daily) 1 7 tabs 10 mg, 5 mg (methylphenidate hcl) methylphenidate hcl QL(3 ea daily) DAYTRANA PTCH 1 3 tabs 20 mg (methylphenidate) methylphenidate hcl QL(1 ea dexmethylphenidate hcl QL(1 ea daily) tb24 18 mg, 27 mg, 54 1 daily,90 ea per cp24 10 mg, 15 mg, 20 3 mg fill retail) mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg methylphenidate hcl QL(2 ea 1 daily,180 ea dexmethylphenidate hcl QL(2 ea daily) tb24 36 mg per fill retail) tabs 10 mg, 2.5 mg, 5 1 methylphenidate hcl QL(1 ea mg 1 daily,90 ea per tbcr 10 mg FOCALIN TABS QL(2 ea daily) fill retail) (dexmethylphenidate 7 methylphenidate hcl QL(1 ea daily) hcl) tbcr 18 mg, 27 mg, 36 1 FOCALIN XR CP24 QL(1 ea daily) mg (dexmethylphenidate 7 methylphenidate hcl QL(1 ea hcl) 1 daily,90 day(s) tbcr 20 mg limit) METHYLIN SOLN 7 QL(2 ea daily) (methylphenidate hcl) methylphenidate hcl 1 methylphenidate hcl tbcr 54 mg chew 10 mg, 2.5 mg, 5 3 METHYLPHENIDATE QL(1 ea daily) mg HYDROCHLORIDE ER TBCR (methylphenidate 3 methylphenidate hcl PA; QL(1 ea hcl) cp24 10 mg, 15 mg, 20 daily) 3 3 ST; QL(1 ea mg, 30 mg, 40 mg, 50 modafinil tabs daily) mg, 60 mg NUVIGIL TABS PA; ST 7 methylphenidate hcl (armodafinil) cp24 10 mg, 20 mg, 30 3 PROVIGIL TABS ST; QL(1 ea 7 mg, 40 mg (modafinil) daily) QL(1 ea QUILLICHEW ER CHER PA methylphenidate hcl 3 3 daily,90 ea per (methylphenidate hcl) cp24 60 mg fill retail) QUILLIVANT XR SRER PA; ST;QL(12 3 (methylphenidate hcl) ml daily)

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELEXXII TBCR QL(1 ea daily) PA; ST; Must 3 (methylphenidate hcl) HUMIRA PEDIATRIC use CROHNS DISEASE RITALIN LA CP24 4 AcariaHealth 7 STARTER PACK PSKT Specialty Rx at (methylphenidate hcl) (adalimumab) 1-844-538- RITALIN TABS 10 MG, 5 4661 MG (methylphenidate 7 PA; ST; Must hcl) use RITALIN TABS 20 MG QL(3 ea daily) HUMIRA PEN PNKT AcariaHealth 7 4 ( ) (adalimumab) Specialty Rx at methylphenidate hcl 1-844-538- AMINOGLYCOSIDES - Drugs to Treat Bacterial 4661;LA Infections PA; ST; Must Aminoglycosides HUMIRA PEN-CD/UC/HS use STARTER PNKT 4 AcariaHealth ARIKAYCE SUSP PA Specialty Rx at (amikacin sulfate 4 (adalimumab) 1-844-538- liposome) 4661;LA BETHKIS NEBU PA PA; ST; Must 7 (tobramycin) HUMIRA PEN-PEDIATRIC use HUMATIN CAPS UC STARTER PACK 4 AcariaHealth 7 Specialty Rx at (paromomycin sulfate) PNKT (adalimumab) 1-844-538- KITABIS PAK NEBU PA 7 4661;LA (tobramycin) PA; ST; Must neomycin sulfate tabs 1 HUMIRA PEN-PS/UV use STARTER PNKT 4 AcariaHealth Specialty Rx at paromomycin sulfate 1 (adalimumab) caps 1-844-538- 4661;LA PA TOBI NEBU (tobramycin) 7 PA; ST; Must use TOBI PODHALER CAPS PA HUMIRA PSKT 4 4 AcariaHealth (tobramycin) (adalimumab) Specialty Rx at PA 1-844-538- tobramycin nebu 300 4 mg/4ml, 300 mg/5ml 4661 PA; Must use Antirheumatic - Enzyme Inhibitors tobramycin nebu 300 AcariaHealth PA; PA;ST; 4 Specialty Rx at Must use mg/5ml 1-844-538- RINVOQ TB24 4 AcariaHealth 4661 (upadacitinib) Specialty Rx at ANALGESICS - ANTI-INFLAMMATORY - Drugs 1-844-538- to Treat Pain, Swelling, Muscle and Joint 4661; Conditions PA; PA;ST; Must use Anti-TNF-alpha - Monoclonal Antibodies XELJANZ TABS 10 MG 4 AcariaHealth (tofacitinib citrate) Specialty Rx at 1-844-538- 4661;

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; PA;ST; PA; ST; Must Must use use ACTEMRA ACTPEN SOAJ XELJANZ TABS 5 MG AcariaHealth 4 AcariaHealth 4 Specialty Rx at (tocilizumab) Specialty Rx at (tofacitinib citrate) 1-844-538- 1-844-538- 4661;QL(2 ea 4661 daily); LA PA; ST; Must PA; PA;ST; use ACTEMRA SOSY Must use 4 AcariaHealth XELJANZ XR TB24 11 MG AcariaHealth (tocilizumab) Specialty Rx at 4 Specialty Rx at 1-844-538- (tofacitinib citrate) 1-844-538- 4661 4661;QL(1 ea PA; ST; Must daily); LA use KEVZARA SOAJ PA; PA;ST; 4 AcariaHealth Must use (sarilumab) Specialty Rx at XELJANZ XR TB24 22 MG AcariaHealth 1-844-538- 4 Specialty Rx at 4661 (tofacitinib citrate) 1-844-538- PA; ST; Must 4661;QL(1 ea use daily) KEVZARA SOSY 4 AcariaHealth Antirheumatic Antimetabolites (sarilumab) Specialty Rx at 1-844-538- METHOTREXATE TABS 4661 (methotrexate sodium 2 (antirheumatic)) Nonsteroidal Anti-inflammatory Agents (NSAIDs) OTREXUP SOAJ PA; ST (Diclofenac Potassium) 3 CATAFLAM TABS (methotrexate 4 (antirheumatic)) (Ibuprofen) IBU TABS 1 RASUVO SOAJ PA; ST (Nabumetone) RELAFEN 1 QL(4 ea daily) (methotrexate 4 TABS 500 MG (antirheumatic)) (Nabumetone) RELAFEN 1 QL(3 ea daily) Gold Compounds TABS 750 MG RIDAURA CAPS ARTHROTEC 50 TBEC 2 (auranofin) (diclofenac w/ 7 misoprostol) Interleukin-1 Blockers ARTHROTEC 75 TBEC PA; ST; Must use (diclofenac w/ 7 ARCALYST SOLR misoprostol) 4 AcariaHealth (rilonacept) Specialty Rx at ST; QL(1 ea 1-844-538- CELEBREX CAPS 100 MG 7 daily); AL(At 4661 (celecoxib) least 60 yrs Interleukin-6 Receptor Inhibitors old) ST; QL(2 ea CELEBREX CAPS 200 MG 7 daily); AL(At (celecoxib) least 60 yrs old)

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(1 ea FENOPROFEN CALCIUM CELEBREX CAPS 400 MG 7 daily); AL(At CAPS 200 MG 2 (celecoxib) least 60 yrs (fenoprofen calcium) old) fenoprofen calcium CELEBREX CAPS 50 MG PA; AL(At least 3 7 caps 400 mg (celecoxib) 60 yrs old) fenoprofen calcium 1 ST; QL(1 ea tabs 600 mg celecoxib caps 100 mg 1 daily); AL(At least 60 yrs flurbiprofen tabs 1 old) ST; QL(2 ea ibuprofen tabs 1 daily); AL(At celecoxib caps 200 mg 1 INDOCIN SUPP RE 50 MG least 60 yrs 3 old) (indomethacin) PA; QL(1 ea INDOCIN SUSP OR 25 2 1 daily); AL(At MG/5ML (indomethacin) celecoxib caps 400 mg least 60 yrs old) indomethacin caps 25 1 mg, 50 mg celecoxib caps 50 mg 1 PA; AL(At least 60 yrs old) indomethacin cpcr 75 1 DAYPRO TABS mg 7 (oxaprozin) ketoprofen caps 50 mg, 1 75 mg diclofenac potassium 3 tabs ketoprofen cp24 200 3 mg diclofenac sodium tb24 3 100 mg QL(20 ea per ketorolac tromethamine 1 tabs fill retail) diclofenac sodium tbec 1 25 mg, 50 mg, 75 mg LODINE TABS (etodolac) 7 diclofenac w/ 3 misoprostol tbec meclofenamate sodium 1 caps etodolac caps 200 mg, 1 300 mg mefenamic acid caps 3 etodolac tabs 400 mg, 1 meloxicam caps 10 mg 3 PA 500 mg QL(2 ea daily) 3 PA; ST etodolac tb24 400 mg, 1 meloxicam caps 5 mg 500 mg, 600 mg QL(1 ea daily) FELDENE CAPS 10 MG meloxicam tabs 15 mg 1 7 (piroxicam) meloxicam tabs 7.5 mg 1 QL(2 ea daily) FELDENE CAPS 20 MG QL(1 ea daily) 7 MOBIC TABS 15 MG QL(1 ea daily) (piroxicam) 7 fenoprofen calcium (meloxicam) 1 MOBIC TABS 7.5 MG QL(2 ea daily) caps 200 mg 7 (meloxicam)

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ea daily) ARAVA TABS 10 MG QL(2 ea daily) nabumetone tabs 500 1 7 mg (leflunomide) QL(3 ea daily) ARAVA TABS 20 MG QL(1 ea daily) nabumetone tabs 750 1 7 mg (leflunomide) NALFON TABS 600 MG QL(2 ea daily) 7 leflunomide tabs 10 mg 1 (fenoprofen calcium) QL(1 ea daily) NAPROSYN SUSP leflunomide tabs 20 mg 1 7 (naproxen) Soluble Tumor Necrosis Factor Receptor Agents NAPROSYN TABS 7 PA; PA;ST; (naproxen) Must use ENBREL MINI SOCT AcariaHealth naproxen sodium tabs 1 4 275 mg, 550 mg (etanercept) Specialty Rx at 1-844-538- naproxen susp 125 1 4661 mg/5ml PA; ST; Check plan naproxen tabs 250 mg, 1 375 mg, 500 mg documents for coverage-Must oxaprozin tabs 1 ENBREL SOLN 25 4 use MG/0.5ML (etanercept) AcariaHealth piroxicam caps 10 mg 1 Specialty Rx at 1-844-538- piroxicam caps 20 mg 1 QL(1 ea daily) 4661;QL(0.143 ml daily) QL(2 ea daily) sulindac tabs 150 mg 1 PA; ST; Check plan sulindac tabs 200 mg 1 documents for ENBREL SOLR 25 MG coverage-Must tolmetin sodium caps 1 4 use (etanercept) AcariaHealth tolmetin sodium tabs 1 Specialty Rx at 1-844-538- VIVLODEX CAPS 10 MG PA 7 4661 (meloxicam) PA; ST; Check VIVLODEX CAPS 5 MG PA; ST plan 7 (meloxicam) documents for ENBREL SOSY 25 coverage-Must Phosphodiesterase 4 (PDE4) Inhibitors MG/0.5ML, 50 MG/ML 4 use PA; ST; Must (etanercept) AcariaHealth OTEZLA TABS 4 use AcariaHlth Specialty Rx at (apremilast) Sp Rx 1-844- 1-844-538- 538-4661 4661 PA; ST; Must PA; PA;ST; OTEZLA TBPK use AcariaHlth Must use 4 ENBREL SURECLICK (apremilast) Sp Rx 1-844- 4 AcariaHealth 538-4661;LA SOAJ (etanercept) Specialty Rx at 1-844-538- Pyrimidine Synthesis Inhibitors 4661;LA

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANALGESICS - NonNarcotic - Drugs to Treat FIORINAL CAPS Pain, Muscle and Joint Conditions (butalbital-aspirin- 7 Analgesic Combinations caffeine) Salicylates (Butalbital-Acetaminophen) 3 BUPAP, TENCON TABS (Aspirin) ADULT ASPIRIN PV REGIMEN, ASPIR-LOW, (Butalbital-Acetaminophen- 1 Caffeine) BAC TABS ASPIRIN 81, ASPIRIN (Butalbital-Acetaminophen- ADULT LOW DOSE, ASPIRIN ADULT LOW Caffeine) ESGIC, 1 PHRENILIN FORTE, STRENGTH, ASPIRIN EC ZEBUTAL CAPS LOW DOSE, ASPIRIN ENTERIC COATED (Butalbital-Acetaminophen- ADULT LOW STRENGTH, Caffeine) ESGIC, 3 ASPIRIN LOW DOSE, PHRENILIN FORTE, BAYER ASPIRIN EC LOW ZEBUTAL CAPS DOSE, BAYER LOW butalbital- DOSE, CVS ASPIRIN acetaminophen tabs ADULT LOW STRENGTH, 300 mg-50 mg, 325 3 CVS ASPIRIN EC, CVS ASPIRIN LOW DOSE, CVS mg-50 mg, 50 mg-300 ASPIRIN LOW mg, 50 mg-325 mg STRENGTH, ECOTRIN butalbital- LOW STRENGTH, EQ acetaminophen- ASPIRIN ADULT LOW 3 DOSE, EQL ASPIRIN LOW 5 caffeine caps 300 mg- DOSE, GNP ASPIRIN 40 mg-50 mg, 40 mg- LOW DOSE, 50 mg-300 mg GOODSENSE ASPIRIN butalbital- LOW DOSE, H-E-B acetaminophen- ASPIRIN, HM ASPIRIN EC 1 LOW DOSE, KLS ASPIRIN caffeine caps 40 mg-50 LOW DOSE, KP ASPIRIN, mg-325 mg MINIPRIN LOW DOSE, QC butalbital- ASPIRIN LOW DOSE, RA acetaminophen- ASPIRIN EC ADULT LOW 1 STRENGTH, SB ASPIRIN, caffeine tabs 40 mg-50 SB ASPIRIN ADULT LOW mg-325 mg STRENGTH, SB LOW DOSE ASA EC, SM butalbital-aspirin- 1 caffeine caps ASPIRIN ADULT LOW STRENGTH, SM ASPIRIN ESGIC TABS (butalbital- EC LOW STRENGTH, ST acetaminophen- 7 JOSEPH ASPIRIN, TGT caffeine) ASPIRIN, TGT ASPIRIN FIORICET CAPS LOW DOSE TBEC (butalbital- acetaminophen- 7 caffeine)

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN 81 LOW PV (Aspirin) ASPIRIN ADULT, PV DOSE, ASPIRIN ADULT BAYER ADVANCED LOW STRENGTH, ASPIRIN REGULAR ASPIRIN CHILDRENS, STRENGTH, BAYER ASPIRIN LOW DOSE, ASPIRIN, CVS ASPIRIN, ASPIRIN LOW EQ ASPIRIN, EQL STRENGTH, BAYER ASPIRIN, GOODSENSE CHEWABLE LOW DOSE, ASPIRIN ADULTS, HM CHILDRENS ASPIRIN, ADULT ASPIRIN, 5 CHILDRENS ASPIRIN MEDIQUE ASPIRIN, LOW STRENGTH, CVS NORWICH ASPIRIN, PX ASPIRIN ADULT LOW ASPIRIN, QC ASPIRIN, RA DOSE, EQ ASPIRIN LOW ASPIRIN, RA PAIN DOSE, EQL ASPIRIN LOW RELIEF ASPIRIN, SB DOSE, GNP ADULT ASPIRIN, SM ADULT ASPIRIN LOW ASPIRIN, SM ASPIRIN, STRENGTH, TGT ASPIRIN TABS GOODSENSE ASPIRIN (Aspirin) GNP ASPIRIN, PV ADULT LOW STRENGTH, 5 GOODSENSE ASPIRIN, 5 PX ASPIRIN, QC ASPIRIN HM ASPIRIN TABS 325 LOW DOSE, QC MG CHEWABLE ASPIRIN LOW DOSE, QC (Aspirin) GNP ASPIRIN, PV CHILDRENS ASPIRIN, RA GOODSENSE ASPIRIN, 5 ASPIRIN ADULT LOW PX ENTERIC ASPIRIN, RA DOSE, RA ASPIRIN ASPIRIN EC TBEC 81 MG ADULT LOW STRENGTH, (Aspirin) GOODSENSE PV RA ASPIRIN CHILDRENS, ASPIRIN, HM ASPIRIN 5 SB CHILDRENS ASPIRIN, CHEW 81 MG SM ASPIRIN ADULT LOW 5 PV STRENGTH, SM ASPIRIN aspirin chew 81 mg LOW DOSE, SM PV CHILDRENS ASPIRIN, ST aspirin tabs 325 mg 5 JOSEPH LOW DOSE PV ASPIRIN, TGT ASPIRIN, aspirin tbec 81 mg 5 TGT CHILDRENS ASPIRIN CHEW diflunisal tabs 3 salsalate tabs 1 ANALGESICS - OPIOID - Drugs to Treat Pain, Muscle and Joint Conditions Opioid Agonists (Methadone Hcl) METHADONE 1 HYDROCHLORIDE INTENSOL CONC (Methadone Hcl) METHADOSE TBSO 40 1 MG

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTIQ LPOP 1200 MCG, PA; ST hydrocodone bitartrate PA 200 MCG, 400 MCG, 600 3 7 cp12 MCG, 800 MCG (fentanyl HYDROCODONE PA citrate) BITARTRATE ER CP12 ACTIQ LPOP 1600 MCG PA; ST;QL(4 3 7 (hydrocodone (fentanyl citrate) ea daily) bitartrate) ARYMO ER TBEA PA PA 3 hydrocodone bitartrate 3 (morphine sulfate) t24a codeine sulfate tabs 1 hydromorphone hcl liqd 1 1 mg/ml CONZIP CP24 ( tramadol 7 hcl) hydromorphone hcl 1 tabs 2 mg, 4 mg, 8 mg DILAUDID LIQD 7 (hydromorphone hcl) hydromorphone hcl QL(4 ea daily) DILAUDID TABS tb24 12 mg, 16 mg, 8 3 7 (hydromorphone hcl) mg DOLOPHINE TABS QL(12 ea daily) hydromorphone hcl QL(2 ea daily) 7 3 (methadone hcl) tb24 32 mg HYSINGLA ER T24A PA DURAGESIC PT72 Limit 15 per 7 month;QL(0.5 (hydrocodone 7 (fentanyl) ea daily) bitartrate) EMBEDA CPCR 0.8 MG- PA; ST KADIAN CP24 10 MG 7 20 MG (morphine- 3 (morphine sulfate) naltrexone) KADIAN CP24 100 MG, 20 QL(2 ea daily) MG, 30 MG, 40 MG, 50 EMBEDA CPCR 1.2 MG- PA 7 30 MG, 2 MG-50 MG, 2.4 MG, 60 MG, 80 MG MG-60 MG, 3.2 MG-80 3 (morphine sulfate) MG, 4 MG-100 MG KADIAN CP24 200 MG 3 (morphine-naltrexone) (morphine sulfate) fentanyl citrate lpop bu PA; ST PA; ST levorphanol tartrate 3 1200 mcg, 200 mcg, 1 tabs 400 mcg, 600 mcg, 800 mcg meperidine hcl soln 1 PA; ST;QL(4 fentanyl citrate lpop bu 1 meperidine hcl tabs 1 1600 mcg ea daily) fentanyl pt72 100 Limit 15 per methadone hcl conc 10 1 mcg/hr, 12 mcg/hr, 25 month;QL(0.5 mg/ml 1 ea daily) mcg/hr, 50 mcg/hr, 75 methadone hcl soln 10 1 mcg/hr mg/5ml, 5 mg/5ml PA; Limit 15 QL(12 ea daily) fentanyl pt72 37.5 methadone hcl tabs 10 1 3 patches per mg, 5 mg mcg/hr, 62.5 mcg/hr, month;QL(0.5 87.5 mcg/hr ea daily) methadone hcl tbso 40 1 mg

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHADOSE CONC 10 7 oxycodone hcl conc 1 MG/ML (methadone hcl) 100 mg/5ml METHADOSE SUGAR- oxycodone hcl soln 5 1 FREE CONC 7 mg/5ml (methadone hcl) oxycodone hcl tabs 10 QL(1 ea daily) morphine sulfate beads 1 mg, 15 mg, 20 mg, 5 1 cp24 mg morphine sulfate cp24 QL(4 ea daily) 1 oxycodone hcl tabs 30 1 or 10 mg mg morphine sulfate cp24 QL(2 ea daily) QL(8 ea daily) oxymorphone hcl tabs 3 or 100 mg, 20 mg, 30 1 10 mg mg, 50 mg, 60 mg, 80 oxymorphone hcl tabs mg 3 5 mg QL(2 ea daily) morphine sulfate cp24 3 or 40 mg oxymorphone hcl tb12 QL(2 ea daily) 10 mg, 15 mg, 20 mg, 1 morphine sulfate soln 30 mg, 40 mg, 5 mg, or 10 mg/5ml, 100 1 7.5 mg mg/5ml, 20 mg/5ml, 20 mg/ml ROXICODONE TABS 15 MG, 5 MG (oxycodone 7 morphine sulfate supp hcl) re 10 mg, 20 mg, 30 1 ROXICODONE TABS 30 QL(4 ea daily) 7 mg, 5 mg MG (oxycodone hcl) morphine sulfate tabs 1 PA or 15 mg, 30 mg SUBSYS LIQD (fentanyl) 4 morphine sulfate tbcr or QL(3 ea daily) tramadol hcl cp24 100 100 mg, 15 mg, 200 1 mg, 150 mg, 200 mg, 3 mg, 30 mg, 60 mg 300 mg MS CONTIN TBCR QL(3 ea daily) tramadol hcl tabs 50 QL(8 ea daily) 7 1 (morphine sulfate) mg NUCYNTA ER TB12 QL(2 ea daily) QL(3 ea daily) 2 tramadol hcl tb24 100 3 (tapentadol hcl) mg NUCYNTA TABS QL(6 ea daily) 2 tramadol hcl tb24 100 3 (tapentadol hcl) mg, 200 mg, 300 mg OPANA TABS 10 MG QL(8 ea daily) QL(1 ea daily) 7 tramadol hcl tb24 200 3 (oxymorphone hcl) mg OPANA TABS 5 MG 7 ULTRAM TABS (tramadol QL(8 ea daily) (oxymorphone hcl) 7 hcl) OXAYDO TABS 2 ZOHYDRO ER CP12 PA (oxycodone hcl) (hydrocodone 7 oxycodone hcl caps 5 1 bitartrate) mg Opioid Combinations

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Acetaminophen-Caff- 3 QL(12 ea daily) FIORICET/CODEINE Dihydrocod) TREZIX CAPS CAPS (butalbital- 7 (Butalbital-Aspirin-Caffeine acetaminophen- W/Cod) 3 caffeine w/ codeine) ASCOMP/CODEINE CAPS FIORINAL/CODEINE #3 (Hydrocodone- QL(240 ea per CAPS (butalbital-aspirin- 7 Acetaminophen) LORCET, 1 fill retail) LORCET HD, LORCET caffeine w/cod) PLUS TABS hydrocodone- acetaminophen soln (Hydrocodone-Ibuprofen) 1 IBUDONE TABS 2.5 mg/5ml-108 (Oxycodone W/ mg/5ml, 325 mg/15ml- 1 Acetaminophen) 3 7.5 mg/15ml, 5 ENDOCET TABS 2.5 MG- mg/10ml-217 mg/10ml, 325 MG 7.5 mg/15ml-325 (Oxycodone W/ QL(4 ea daily) mg/15ml Acetaminophen) 3 ENDOCET TABS 325 MG- hydrocodone- 10 MG, 7.5 MG-325 MG acetaminophen tabs 10 1 (Oxycodone W/ QL(6 ea daily) mg-300 mg, 300 mg-5 Acetaminophen) 1 mg, 5 mg-300 mg ENDOCET TABS 5 MG- hydrocodone- QL(240 ea per 325 MG acetaminophen tabs 10 fill retail) acetaminophen w/ mg-325 mg, 325 mg-10 1 codeine soln 12 1 mg, 325 mg-5 mg, 325 mg/5ml-120 mg/5ml, mg-7.5 mg, 5 mg-325 120 mg/5ml-12 mg/5ml mg, 7.5 mg-325 mg acetaminophen w/ hydrocodone- QL(6 ea daily) codeine tabs 15 mg- 1 acetaminophen tabs 1 300 mg, 30 mg-300 7.5 mg-300 mg mg, 300 mg-30 mg hydrocodone-ibuprofen Not available acetaminophen w/ QL(6 ea daily) 1 through mail codeine tabs 60 mg- 1 tabs 10 mg-200 mg order 300 mg hydrocodone-ibuprofen acetaminophen-caff- QL(12 ea daily) tabs 10 mg-200 mg, 7.5 1 dihydrocod caps 16 3 mg-200 mg mg-30 mg-320.5 mg LORTAB ELIX butalbital- (hydrocodone- 3 acetaminophen) acetaminophen- 3 caffeine w/ codeine NORCO TABS QL(240 ea per caps (hydrocodone- 7 fill retail) acetaminophen) butalbital-aspirin- 3 caffeine w/cod caps

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxycodone w/ QL(4 ea daily) TYLENOL/CODEINE #4 QL(6 ea daily) TABS (acetaminophen 7 acetaminophen tabs 10 3 mg-325 mg, 7.5 mg- w/ codeine) 325 mg ULTRACET TABS QL(8 ea daily) oxycodone w/ (tramadol- 7 acetaminophen) acetaminophen tabs 3 2.5 mg-325 mg, 325 Opioid Partial Agonists mg-2.5 mg QL(3 ea daily) buprenorphine hcl subl 1 oxycodone w/ QL(6 ea daily) 2 mg acetaminophen tabs QL(4 ea daily) 1 buprenorphine hcl subl 1 325 mg-5 mg, 5 mg- 8 mg 325 mg buprenorphine hcl- QL(3 ea daily) QL(4 ea daily) oxycodone-ibuprofen 3 naloxone hcl dihydrate tabs film 0.5 mg-2 mg, 1 mg- 1 OXYCODONE/ACETAMIN 4 mg, 2 mg-0.5 mg, 2 OPHEN TABS mg-8 mg (oxycodone w/ 3 buprenorphine hcl- QL(2 ea daily) acetaminophen) naloxone hcl dihydrate 1 PERCOCET TABS 10 MG- QL(4 ea daily) 325 MG, 7.5 MG-325 MG film 3 mg-12 mg (oxycodone w/ 7 buprenorphine hcl- QL(3 ea daily) acetaminophen) naloxone hcl dihydrate 1 PERCOCET TABS 325 subl 0.5 mg-2 mg, 2 MG-2.5 MG (oxycodone 7 mg-8 mg, 8 mg-2 mg w/ acetaminophen) buprenorphine ptwk td QL(4 ea per 28 days retail) PERCOCET TABS 5 MG- QL(6 ea daily) 10 mcg/hr, 15 mcg/hr, 3 325 MG (oxycodone w/ 7 20 mcg/hr, 5 mcg/hr, acetaminophen) 7.5 mcg/hr Limited to 4 PRIMLEV TABS buprenorphine ptwk td (oxycodone w/ 3 patches per 10 mcg/hr, 5 mcg/hr, 3 month;QL(4 ea acetaminophen) 7.5 mcg/hr per 28 days PROLATE TABS 10 MG- retail) 300 MG, 5 MG-300 MG, Limit 4 patches 7.5 MG-300 MG 3 buprenorphine ptwk td per 28 (oxycodone w/ 3 days;QL(4 ea acetaminophen) 15 mcg/hr per 28 days QL(8 ea daily) retail) tramadol- 3 acetaminophen tabs Limit 4 patches buprenorphine ptwk td 3 per month;QL(4 TYLENOL/CODEINE #3 20 mcg/hr ea per 28 days TABS (acetaminophen 7 retail) w/ codeine)

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 7.5mls STRIANT MISC QL(2 ea daily) 3 butorphanol tartrate 3 per (testosterone) soln month;QL(0.25 TESTIM GEL PA; QL(10 gm ml daily) 7 (testosterone) daily) pentazocine w/ 3 3 PA; QL(10 gm naloxone tabs testosterone gel 1 % daily) SUBOXONE FILM 1 MG-4 QL(3 ea daily) Limited to 300 MG, 2 MG-0.5 MG, 2 MG-8 testosterone gel 1 %, 1.62 %, 20.25 gms per MG (buprenorphine hcl- 7 mg/1.25gm, 25 1 month;QL(10 naloxone hcl dihydrate) gm daily) mg/2.5gm, 40.5 SUBOXONE FILM 3 MG- QL(2 ea daily) mg/2.5gm, 50 mg/5gm 12 MG (buprenorphine hcl-naloxone hcl 7 Limit 300gms testosterone gel 1 %, 1 per dihydrate) 50 mg/5gm month;QL(10 ANDROGENS-ANABOLIC - Drugs to Regulate gm daily) Hormones QL(4 gm daily) testosterone gel 10 1 Anabolic Steroids mg/act ANADROL-50 TABS testosterone gel 25 QL(10 gm 3 1 (oxymetholone) mg/2.5gm, 50 mg/5gm daily) QL(2 ea daily) VOGELXO GEL PA; QL(10 gm oxandrolone tabs 10 1 7 mg (testosterone) daily) ANORECTAL AND RELATED PRODUCTS - oxandrolone tabs 2.5 1 mg Rectal Drugs to Treat Pain, Swelling and Itching Androgens Intrarectal Steroids ST; QL(60 ea (Hydrocortisone QL(60 ml daily) ANDRODERM PT24 (Intrarectal)) COLOCORT 1 3 per fill (testosterone) retail,120 ea ENEM per fill mail) CORTENEMA ENEM QL(60 ml daily) ANDROGEL GEL 20.25 Limited to 300 (hydrocortisone 7 MG/1.25GM, 40.5 7 gms per (intrarectal)) month;QL(10 CORTIFOAM FOAM MG/2.5GM (testosterone) gm daily) (hydrocortisone acetate 2 Limited to 300 ) ANDROGEL PUMP GEL gms per (intrarectal) 7 QL(60 ml daily) (testosterone) month;QL(10 hydrocortisone 1 gm daily) (intrarectal) enem danazol caps 1 UCERIS FOAM RE 2 PA; ST MG/ACT (budesonide 3 FORTESTA GEL QL(4 gm daily) 7 (intrarectal)) (testosterone) Rectal Combinations METHITEST TABS 2 (methyltestosterone) ANALPRAM-HC LOTN (hydrocortisone acetate 3 methyltestosterone 1 w/ pramoxine) caps

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROCTOFOAM HC FOAM metronidazole caps 1 (hydrocortisone acetate 2 w/ pramoxine) metronidazole tabs 1 Rectal Steroids NEBUPENT SOLR (Hydrocortisone (Rectal)) (pentamidine 7 PROCTO-MED HC, 1 isethionate) PROCTOSOL HC, PROCTOZONE-HC CREA pentamidine isethionate 1 ANUSOL-HC CREA solr 7 PRIMSOL SOLN (hydrocortisone (rectal)) 3 (trimethoprim hcl) hydrocortisone (rectal) 1 crea tinidazole tabs 250 mg 3 PA; ST Vasodilating Agents tinidazole tabs 500 mg 3 ST RECTIV OINT (nitroglycerin (intra- 3 trimethoprim tabs 1 anal)) XIFAXAN TABS 200 MG PA; Limit 9 per ANTHELMINTICS - Drugs to Treat Worm 3 month;QL(0.3 Infections (rifaximin) ea daily) Anthelmintics XIFAXAN TABS 550 MG PA; QL(2 ea 3 (rifaximin) daily) albendazole tabs 3 QL(4 ea per fill retail) Anti-infective Misc. - Combinations ALBENZA TABS QL(4 ea per fill 7 (Sulfamethoxazole- (albendazole) retail) Trimethoprim) SULFATRIM 1 BENZNIDAZOLE TABS AL(At least 2 PEDIATRIC SUSP 2 yrs old - Up to (benznidazole) BACTRIM DS TABS 12 yrs old) (sulfamethoxazole- 7 BILTRICIDE TABS 7 trimethoprim) (praziquantel) BACTRIM TABS ivermectin tabs or 3 mg 3 (sulfamethoxazole- 7 trimethoprim) praziquantel tabs 1 sulfamethoxazole- 1 STROMECTOL TABS trimethoprim susp 7 (ivermectin) sulfamethoxazole- 1 ANTI-INFECTIVE AGENTS - MISC. - Drugs to trimethoprim tabs Treat Bacterial Infections Antiprotozoal Agents Anti-infective Agents - Misc. ALINIA SUSR 100 MG/5ML 3 FLAGYL CAPS (nitazoxanide) 7 (metronidazole) ALINIA TABS 500 MG 7 FLAGYL TABS (nitazoxanide) 7 (metronidazole) atovaquone susp 1 IMPAVIDO CAPS 4 (miltefosine) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEPRON SUSP 7 Urinary Anti-infectives (atovaquone) fosfomycin 3 nitazoxanide tabs or 3 tromethamine pack FURADANTIN SUSP 7 Glycopeptides (nitrofurantoin) FIRVANQ SOLR PA 3 HIPREX TABS (vancomycin hcl) (methenamine 7 VANCOCIN HCL CAPS PA 7 hippurate) ( ) vancomycin hcl MACROBID CAPS vancomycin hcl caps 1 PA (nitrofurantoin monohyd 7 macro) VANCOMYCIN PA HYDROCHLORIDE SOLR MACRODANTIN CAPS OR 250 MG/5ML 3 (nitrofurantoin 7 (vancomycin hcl) macrocrystal) Leprostatics methenamine hippurate 3 tabs dapsone tabs 100 mg 1 QL(4 ea daily) methenamine dapsone tabs 25 mg 1 mandelate tabs 0.5 gm, 1 1 gm Lincosamides MONUROL PACK CLEOCIN CAPS OR 150 (fosfomycin 7 MG, 300 MG, 75 MG 7 tromethamine) (clindamycin hcl) nitrofurantoin CLEOCIN PEDIATRIC 1 GRANULES SOLR macrocrystal caps 7 (clindamycin palmitate nitrofurantoin monohyd 1 hydrochloride) macro caps clindamycin hcl caps 1 nitrofurantoin susp 1 ANTIANGINAL AGENTS - Drugs to Treat Chest clindamycin palmitate 3 hydrochloride solr Pain Oxazolidinones Antianginals-Other QL(210 ml per RANEXA TB12 1000 MG linezolid susr 100 1 7 mg/5ml 90 days retail) (ranolazine) RANEXA TB12 500 MG QL(4 ea daily) 1 QL(20 ea per 7 linezolid tabs 600 mg 90 days retail) (ranolazine) SIVEXTRO TABS QL(6 ea per 90 ranolazine tb12 1000 2 3 (tedizolid phosphate) days retail) mg ZYVOX SUSR 100 QL(210 ml per QL(4 ea daily) 7 ranolazine tb12 500 mg 3 MG/5ML (linezolid) 90 days retail) ZYVOX TABS 600 MG QL(20 ea per Nitrates 7 90 days retail) (linezolid) (Nitroglycerin) MINITRAN 1 QL(1 ea daily) PT24 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DILATRATE SR CPCR 3 hydroxyzine pamoate 1 (isosorbide dinitrate) caps ISORDIL TITRADOSE VISTARIL CAPS 7 TABS (isosorbide 7 (hydroxyzine pamoate) ) dinitrate Benzodiazepines isosorbide dinitrate 1 (Alprazolam) 1 tabs ALPRAZOLAM XR TB24 isosorbide dinitrate tbcr 1 (Diazepam) DIAZEPAM 1 INTENSOL CONC isosorbide mononitrate 1 (Lorazepam) LORAZEPAM 1 tabs INTENSOL CONC ALPRAZOLAM INTENSOL isosorbide mononitrate 1 3 tb24 CONC (alprazolam) NITRO-BID OINT 2 alprazolam tabs 1 (nitroglycerin) NITRO-DUR PT24 0.1 QL(1 ea daily) alprazolam tb24 1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR 7 alprazolam tbdp 1 (nitroglycerin) ATIVAN TABS 7 NITRO-DUR PT24 0.3 QL(1 ea daily) (lorazepam) MG/HR, 0.8 MG/HR 2 (nitroglycerin) chlordiazepoxide hcl 1 caps nitroglycerin pt24 td 0.1 QL(1 ea daily) mg/hr, 0.2 mg/hr, 0.4 1 clorazepate 1 mg/hr, 0.6 mg/hr dipotassium tabs diazepam conc 5 mg/ml 1 nitroglycerin soln tl 0.4 1 mg/spray diazepam soln 5 1 nitroglycerin subl sl 0.3 1 mg/5ml mg, 0.4 mg, 0.6 mg 1 QL(4 ea daily) NITROLINGUAL diazepam tabs 10 mg PUMPSPRAY SOLN 7 diazepam tabs 2 mg, 5 1 (nitroglycerin) mg NITROSTAT SUBL 7 (nitroglycerin) lorazepam conc 1 ANTIANXIETY AGENTS - Drugs to Treat Anxiety lorazepam tabs 1

Antianxiety Agents - Misc. oxazepam caps 10 mg, 1 15 mg buspirone hcl tabs 1 oxazepam caps 30 mg 1 QL(2 ea daily) hydroxyzine hcl syrp 1 TRANXENE T TABS hydroxyzine hcl tabs 1 (clorazepate 7 dipotassium)

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VALIUM TABS 10 MG QL(4 ea daily) 7 amiodarone hcl tabs 1 (diazepam) VALIUM TABS 2 MG, 5 dofetilide caps 1 7 MG ( ) diazepam MULTAQ TABS XANAX TABS 2 7 (dronedarone hcl) ( ) alprazolam TIKOSYN CAPS XANAX XR TB24 7 7 (dofetilide) (alprazolam) ANTIASTHMATIC AND BRONCHODILATOR ANTIARRHYTHMICS - Drugs to treat abnormal AGENTS - Drugs to Treat Lung Conditions heart rhythms Anti-Inflammatory Agents Antiarrhythmics Type I-A cromolyn sodium nebu 1 disopyramide 1 phosphate caps Antiasthmatic - Monoclonal Antibodies NORPACE CAPS PA; PA;AC; (disopyramide 7 FASENRA PEN SOAJ Must use 4 Acaria phosphate) (benralizumab) NORPACE CR CP12 Specialty (844) 538-4661; (disopyramide 2 PA; PA; Must phosphate) NUCALA SOAJ 100 4 use Acaria quinidine gluconate 1 MG/ML (mepolizumab) Specialty (844) tbcr 538-4661; PA; PA; Must quinidine sulfate tabs 1 NUCALA SOLR 100 MG 4 use Acaria Antiarrhythmics Type I-B (mepolizumab) Specialty (844) 538-4661;SP mexiletine hcl caps 1 PA; PA; Must NUCALA SOSY 100 4 use Acaria Antiarrhythmics Type I-C MG/ML (mepolizumab) Specialty (844) flecainide acetate tabs 1 538-4661; PA; Must use propafenone hcl cp12 XOLAIR SOLR 150 MG 4 AcariaHlth Sp 225 mg, 325 mg, 425 1 (omalizumab) Rx 1-844-538- mg 4661 QL(6 ea daily) XOLAIR SOSY 150 PA propafenone hcl tabs 1 150 mg MG/ML, 75 MG/0.5ML 4 (omalizumab) QL(3 ea daily) propafenone hcl tabs 1 225 mg, 300 mg Bronchodilators - Anticholinergics Limit 2 inhalers RYTHMOL SR CP12 ATROVENT HFA AERS 7 ( 2 per (propafenone hcl) ipratropium bromide month;QL(0.86 hfa) Antiarrhythmics Type III gm daily) INCRUSE ELLIPTA AEPB QL(1 ea daily) (Amiodarone Hcl) 1 2 PACERONE TABS (umeclidinium bromide)

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ipratropium bromide FLOVENT DISKUS AEPB QL(20 ea daily) 1 100 MCG/BLIST soln 2 SPIRIVA HANDIHALER QL(1 ea daily) (fluticasone propionate CAPS (tiotropium 2 (inhalation)) bromide monohydrate) FLOVENT DISKUS AEPB QL(8 ea daily) 250 MCG/BLIST SPIRIVA RESPIMAT Limit 1 Inhaler 2 AERS 1.25 MCG/ACT per (fluticasone propionate (tiotropium bromide 2 month;QL(0.14 (inhalation)) monohydrate) 3 gm daily) FLOVENT DISKUS AEPB QL(40 ea daily) 50 MCG/BLIST SPIRIVA RESPIMAT Limit 1 inhaler 2 AERS 2.5 MCG/ACT per (fluticasone propionate (tiotropium bromide 2 month;QL(0.14 (inhalation)) monohydrate) gm daily) FLOVENT HFA AERO 110 Limit 2 inhalers MCG/ACT, 220 MCG/ACT per Leukotriene Modulators (fluticasone propionate 2 month;QL(0.8 QL(1 ea daily) gm daily) montelukast sodium 1 hfa) chew FLOVENT HFA AERO 44 Limit 1 inhaler QL(1 ea daily) per montelukast sodium 1 MCG/ACT (fluticasone 2 pack month;QL(0.36 propionate hfa) gm daily) QL(1 ea daily) montelukast sodium 1 PULMICORT FLEXHALER Limit 2 inhalers tabs AEPB 180 MCG/ACT per SINGULAIR CHEW QL(1 ea daily) 2 month;QL(0.07 7 (budesonide (montelukast sodium) (inhalation)) ea daily) SINGULAIR PACK QL(1 ea daily) 7 PULMICORT FLEXHALER Limit 2 inhalers (montelukast sodium) AEPB 90 MCG/ACT per 2 SINGULAIR TABS QL(1 ea daily) (budesonide month;QL(0.27 7 (montelukast sodium) (inhalation)) ea daily) PULMICORT SUSP 0.25 QL(8 ml daily) zileuton tb12 3 ST MG/2ML (budesonide 7 ZYFLO TABS (zileuton) 3 ST (inhalation)) PULMICORT SUSP 0.5 QL(4 ml daily) Steroid Inhalants MG/2ML (budesonide 7 ARNUITY ELLIPTA AEPB QL(1 ea daily) (inhalation)) (fluticasone furoate 2 PULMICORT SUSP 1 QL(2 ml daily) (inhalation)) MG/2ML (budesonide 7 QL(8 ml daily) budesonide (inhalation) 1 (inhalation)) susp 0.25 mg/2ml QVAR REDIHALER AERB QL(0.72 gm QL(4 ml daily) (beclomethasone 2 daily) budesonide (inhalation) 1 susp 0.5 mg/2ml dipropionate hfa) QL(2 ml daily) budesonide (inhalation) 1 Sympathomimetics susp 1 mg/2ml (Fluticasone-Salmeterol) 1 QL(2 ea daily) WIXELA INHUB AEPB

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADVAIR DISKUS AEPB QL(2 ea daily) QL(2 ea daily) 7 fluticasone-salmeterol (fluticasone-salmeterol) aepb 100 mcg/act-50 Limit 1 inhaler mcg/act, 50 mcg/act- ADVAIR HFA AERO 2 per 250 mcg/act, 50 (fluticasone-salmeterol) month;QL(0.4 mcg/dose-100 1 gm daily) mcg/dose, 50 QL(0.47 gm albuterol sulfate aers in 1 mcg/dose-250 108 mcg/act daily) mcg/dose, 50 QL(1.2 gm mcg/dose-500 albuterol sulfate aers in 1 108 mcg/act daily) mcg/dose QL(0.57 gm ipratropium-albuterol albuterol sulfate aers in 1 1 108 mcg/act daily) soln albuterol sulfate nebu levalbuterol hcl nebu 1 in 0.083 %, 0.5 %, 0.63 1 QL(0.5 gm mg/3ml, 1.25 mg/3ml, levalbuterol tartrate 1 2.5 mg/0.5ml aero daily) ALBUTEROL SULFATE Limit 2 inhalers PROAIR RESPICLICK NEBU IN 0.5 % (albuterol 2 3 per AEPB (albuterol sulfate) month;QL(0.07 sulfate) ea daily) albuterol sulfate syrp or 1 SEREVENT DISKUS QL(2 ea daily) 2 mg/5ml AEPB (salmeterol 2 xinafoate) albuterol sulfate tabs or 1 2 mg, 4 mg STIOLTO RESPIMAT QL(0.14 gm QL(2 ea daily) AERS (tiotropium 2 daily) albuterol sulfate tb12 or 1 4 mg, 8 mg bromide-olodaterol hcl) ANORO ELLIPTA AEPB QL(2 ea daily) Limit 1 inhaler STRIVERDI RESPIMAT (umeclidinium- 2 2 per vilanterol) AERS (olodaterol hcl) month;QL(0.14 gm daily) ARCAPTA NEOHALER QL(1 ea daily) CAPS (indacaterol 3 terbutaline sulfate tabs 1 maleate) TRELEGY ELLIPTA AEPB QL(2 ea daily) BREO ELLIPTA AEPB QL(2 ea daily) (fluticasone- 2 (fluticasone furoate- 2 umeclidinium-vilanterol) vilanterol) XOPENEX budesonide-formoterol Limit 1 inhaler CONCENTRATE NEBU 7 fumarate dihydrate 1 per (levalbuterol hcl) month;QL(0.34 XOPENEX NEBU aero gm daily) 7 (levalbuterol hcl) COMBIVENT RESPIMAT Limit 1 inhaler Xanthines AERS (ipratropium- 3 per month;QL(0.2 ELIXOPHYLLIN ELIX albuterol) 3 gm daily) (theophylline)

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THEO-24 CP24 ARIXTRA SOLN 5 QL(3 ml per 90 2 (theophylline) MG/0.4ML (fondaparinux 7 days retail) sodium) theophylline soln 80 3 QL(42 ml per 7 mg/15ml enoxaparin sodium 1 QL(2 ea daily) soln ij 300 mg/3ml days retail) theophylline tb12 300 1 mg enoxaparin sodium QL(14 ml per 7 QL(1 ea daily) soln sc 100 mg/ml, 150 1 days retail) theophylline tb12 450 1 mg mg/ml QL(1 ea daily) enoxaparin sodium QL(11.2 ml per theophylline tb24 400 1 mg, 600 mg soln sc 120 mg/0.8ml, 1 7 days retail) 80 mg/0.8ml ANTICOAGULANTS - Blood Thinners QL(4.2 ml per 7 enoxaparin sodium 1 Coumarin Anticoagulants soln sc 30 mg/0.3ml days retail) (Warfarin Sodium) QL(5.6 ml per 7 1 enoxaparin sodium 1 JANTOVEN TABS soln sc 40 mg/0.4ml days retail) COUMADIN TABS QL(8.4 ml per 7 7 enoxaparin sodium 1 (warfarin sodium) soln sc 60 mg/0.6ml days retail) warfarin sodium tabs 1 QL(6 ml per 90 fondaparinux sodium 4 soln 10 mg/0.8ml days retail) Direct Factor Xa Inhibitors QL(4 ml per 90 BEVYXXA CAPS QL(42 ea per fondaparinux sodium 3 4 days retail) (betrixaban maleate) 42 days retail) soln 2.5 mg/0.5ml, 7.5 mg/0.6ml ELIQUIS STARTER PACK 2 QL(3 ml per 90 TBPK ( ) fondaparinux sodium apixaban 4 days retail) ELIQUIS TABS 2.5 MG QL(2 ea daily) soln 5 mg/0.4ml 2 (apixaban) FRAGMIN SOLN 10000 QL(7 ml per 90 UNIT/ML ( 4 days retail) ELIQUIS TABS 5 MG dalteparin 2 sodium) (apixaban) FRAGMIN SOLN 12500 QL(4 ml per 90 XARELTO TABS 10 MG, UNIT/0.5ML, 15000 days retail) 15 MG, 2.5 MG 2 UNIT/0.6ML (dalteparin 4 (rivaroxaban) sodium) XARELTO TABS 20 MG QL(1 ea daily) 2 FRAGMIN SOLN 18000 QL(5 ml per 90 (rivaroxaban) UNT/0.72ML (dalteparin 4 days retail) Heparins And Heparinoid-Like Agents sodium) ARIXTRA SOLN 10 QL(6 ml per 90 FRAGMIN SOLN 2500 QL(1 ml per 90 MG/0.8ML (fondaparinux 7 days retail) UNIT/0.2ML, 5000 days retail) sodium) UNIT/0.2ML (dalteparin 4 ARIXTRA SOLN 2.5 QL(4 ml per 90 sodium) MG/0.5ML, 7.5 MG/0.6ML 7 days retail) FRAGMIN SOLN 7500 QL(2 ml per 90 (fondaparinux sodium) UNIT/0.3ML (dalteparin 4 days retail) sodium)

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FRAGMIN SOLN 95000 PA DIASTAT PEDIATRIC GEL Limit 4 per UNIT/3.8ML (dalteparin 4 (diazepam 7 month;QL(0.14 sodium) (anticonvulsant)) ea daily) LOVENOX SOLN IJ 300 QL(42 ml per 7 diazepam Limit 4 per days retail) 3 month;QL(0.14 MG/3ML (enoxaparin 7 (anticonvulsant) gel sodium) ea daily) KLONOPIN TABS LOVENOX SOLN SC 100 QL(14 ml per 7 7 MG/ML, 150 MG/ML 7 days retail) (clonazepam) (enoxaparin sodium) NAYZILAM SOLN PA; QL(10 ea LOVENOX SOLN SC 120 QL(11.2 ml per (midazolam 4 per 30 days MG/0.8ML, 80 MG/0.8ML 7 7 days retail) (anticonvulsant)) retail) (enoxaparin sodium) ONFI SUSP 2.5 MG/ML 7 LOVENOX SOLN SC 30 QL(4.2 ml per 7 (clobazam) MG/0.3ML (enoxaparin 7 days retail) ONFI TABS 10 MG QL(1 ea daily) 7 sodium) (clobazam) LOVENOX SOLN SC 40 QL(5.6 ml per 7 ONFI TABS 20 MG QL(2 ea daily) 7 MG/0.4ML (enoxaparin 7 days retail) (clobazam) ) sodium Anticonvulsants - Misc. LOVENOX SOLN SC 60 QL(8.4 ml per 7 (Carbamazepine) EPITOL 1 MG/0.6ML (enoxaparin 7 days retail) TABS sodium) (Lamotrigine) SUBVENITE ST ANTICONVULSANTS - Drugs to Treat Seizures STARTER KIT/BLUE, SUBVENITE STARTER 1 AMPA Glutamate Receptor Antagonists KIT/GREEN, SUBVENITE STARTER KIT/ORANGE FYCOMPA SUSP 3 KIT (perampanel) (Lamotrigine) SUBVENITE FYCOMPA TABS 1 3 TABS (perampanel) (Levetiracetam) QL(3 ea daily) Anticonvulsants - Benzodiazepines ROWEEPRA TABS 1000 1 MG clobazam susp 2.5 3 mg/ml (Levetiracetam) QL(6 ea daily) ROWEEPRA TABS 500 1 clobazam tabs 10 mg 3 QL(1 ea daily) MG, 750 MG (Levetiracetam) 1 QL(4 ea daily) clobazam tabs 20 mg 3 QL(2 ea daily) ROWEEPRA XR TB24 APTIOM TABS PA; QL(1 ea clonazepam tabs 1 (eslicarbazepine 3 daily) acetate) clonazepam tbdp 1 BANZEL SUSP 40 MG/ML 7 DIASTAT ACUDIAL GEL Limit 4 per (rufinamide) month;QL(0.14 (diazepam 7 BANZEL TABS 200 MG ea daily) 7 (anticonvulsant)) (rufinamide)

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BANZEL TABS 400 MG QL(8 ea daily) 7 gabapentin tabs 1 (rufinamide) BRIVIACT SOLN 10 PA; ST KEPPRA SOLN 100 3 7 MG/ML (brivaracetam) MG/ML (levetiracetam) BRIVIACT TABS 10 MG PA; ST KEPPRA TABS 1000 MG QL(3 ea daily) 3 7 (brivaracetam) (levetiracetam) BRIVIACT TABS 100 MG PA; ST;QL(2 KEPPRA TABS 250 MG, QL(6 ea daily) 3 500 MG, 750 MG (brivaracetam) ea daily) 7 (levetiracetam) BRIVIACT TABS 25 MG, PA KEPPRA XR TB24 QL(4 ea daily) 50 MG, 75 MG 3 7 (brivaracetam) (levetiracetam) carbamazepine chew LAMICTAL CHEWABLE 1 DISPERSIBLE CHEW 7 100 mg (lamotrigine) carbamazepine cp12 LAMICTAL ODT KIT PA; ST 3 100 mg, 200 mg, 300 1 (lamotrigine) mg LAMICTAL ODT KIT PA; ST 7 carbamazepine susp 1 (lamotrigine) 100 mg/5ml LAMICTAL ODT TBDP 100 PA MG, 200 MG, 25 MG, 50 carbamazepine tabs 1 7 200 mg MG (lamotrigine) LAMICTAL STARTER/NOT ST carbamazepine tb12 1 100 mg TAKING CARBAMAZEPINE KIT 7 QL(8 ea daily) carbamazepine tb12 1 (lamotrigine) 200 mg LAMICTAL ST QL(4 ea daily) carbamazepine tb12 1 STARTER/TAKING 400 mg CARBAMAZEPINE/NOT 7 CARBATROL CP12 TAKING VALPROATE KIT 7 (carbamazepine) (lamotrigine) DIACOMIT CAPS 250 MG PA; QL(12 ea LAMICTAL ST 4 daily) STARTER/TAKING (stiripentol) VALPROATE KIT 7 DIACOMIT CAPS 500 MG PA; QL(6 ea (lamotrigine) 4 daily) (stiripentol) LAMICTAL TABS 7 DIACOMIT PACK 250 MG PA; QL(12 ea (lamotrigine) 4 daily) (stiripentol) LAMICTAL XR KIT PA; ST 3 DIACOMIT PACK 500 MG PA; QL(6 ea (lamotrigine) 4 daily) (stiripentol) LAMICTAL XR TB24 100 PA; QL(1 ea EPIDIOLEX SOLN PA; ST 4 MG, 200 MG, 25 MG, 50 7 daily) (cannabidiol) MG (lamotrigine) LAMICTAL XR TB24 250 PA gabapentin caps 1 7 MG (lamotrigine) gabapentin soln 1

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL XR TB24 300 PA; QL(2 ea NEURONTIN SOLN 7 7 MG (lamotrigine) daily) (gabapentin) NEURONTIN TABS lamotrigine chew 25 1 7 mg, 5 mg (gabapentin) PA; ST QL(40 ml daily) lamotrigine kit 3 oxcarbazepine susp 1 300 mg/5ml, 60 mg/ml lamotrigine kit 25 mg, 1 ST oxcarbazepine tabs 1 lamotrigine tabs 100 150 mg QL(8 ea daily) mg, 150 mg, 200 mg, 1 oxcarbazepine tabs 1 25 mg 300 mg QL(4 ea daily) lamotrigine tb24 100 PA; QL(1 ea oxcarbazepine tabs 1 mg, 200 mg, 25 mg, 50 3 daily) 600 mg mg OXTELLAR XR TB24 150 ST PA MG, 300 MG 3 lamotrigine tb24 250 3 mg (oxcarbazepine) OXTELLAR XR TB24 600 ST; QL(4 ea PA; QL(2 ea 3 lamotrigine tb24 300 3 MG (oxcarbazepine) daily) mg daily) pregabalin caps 100 PA; ST;QL(3 PA lamotrigine tbdp 100 mg, 150 mg, 200 mg, 3 ea daily) mg, 200 mg, 25 mg, 50 3 25 mg, 50 mg, 75 mg mg PA; ST;QL(2 pregabalin caps 225 3 levetiracetam soln 100 1 mg, 300 mg ea daily) mg/ml, 500 mg/5ml pregabalin soln 20 PA; QL(30 ml QL(3 ea daily) 3 levetiracetam tabs 1 mg/ml daily) 1000 mg QL(6 ea daily) primidone tabs 1 levetiracetam tabs 250 1 mg, 500 mg, 750 mg QUDEXY XR CS24 100 PA; ST;QL(1 QL(4 ea daily) MG, 150 MG, 200 MG 7 ea daily) levetiracetam tb24 500 1 mg, 750 mg (topiramate) QUDEXY XR CS24 25 MG, PA; ST;QL(2 LYRICA CAPS 100 MG, PA; ST;QL(3 7 150 MG, 200 MG, 25 MG, ea daily) 50 MG (topiramate) ea daily) 50 MG, 75 MG 7 rufinamide susp 40 1 (pregabalin) mg/ml LYRICA CAPS 225 MG, PA; ST;QL(2 7 300 MG (pregabalin) ea daily) rufinamide tabs 200 mg 1 LYRICA SOLN 20 MG/ML PA; QL(30 ml QL(8 ea daily) 7 rufinamide tabs 400 mg 1 (pregabalin) daily) SPRITAM TB3D PA MYSOLINE TABS 7 3 (primidone) (levetiracetam) NEURONTIN CAPS TEGRETOL SUSP 7 7 (gabapentin) (carbamazepine) TEGRETOL TABS 7 (carbamazepine) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGRETOL-XR TB12 100 TROKENDI XR CP24 25 PA; ST 7 3 MG (carbamazepine) MG (topiramate) TEGRETOL-XR TB12 200 QL(8 ea daily) VIMPAT SOLN 10 MG/ML QL(40 ml daily) 7 2 MG (carbamazepine) (lacosamide) TEGRETOL-XR TB12 400 QL(4 ea daily) VIMPAT TABS 100 MG, 7 MG (carbamazepine) 150 MG, 200 MG, 50 MG 2 TOPAMAX SPRINKLE (lacosamide) 7 ZONEGRAN CAPS 100 QL(6 ea daily) CPSP (topiramate) 7 TOPAMAX TABS 100 MG QL(4 ea daily) MG (zonisamide) 7 ZONEGRAN CAPS 25 MG (topiramate) 7 TOPAMAX TABS 200 MG QL(2 ea daily) (zonisamide) 7 QL(6 ea daily) (topiramate) zonisamide caps 100 1 TOPAMAX TABS 25 MG mg 7 (topiramate) zonisamide caps 25 1 TOPAMAX TABS 50 MG QL(8 ea daily) mg, 50 mg 7 (topiramate) Carbamates topiramate cpsp 15 mg, 1 25 mg felbamate susp 1 PA; ST;QL(1 topiramate cs24 100 3 felbamate tabs 1 mg, 150 mg, 200 mg ea daily) FELBATOL SUSP 7 topiramate cs24 25 mg, PA; ST;QL(2 (felbamate) 3 ea daily) 50 mg FELBATOL TABS 7 topiramate tabs 100 mg 1 QL(4 ea daily) (felbamate) GABA Modulators topiramate tabs 200 mg 1 QL(2 ea daily) (Vigabatrin) VIGADRONE 4 QL(6 ea daily) topiramate tabs 25 mg 1 PACK GABITRIL TABS 7 topiramate tabs 50 mg 1 QL(8 ea daily) (tiagabine hcl) SABRIL PACK QL(6 ea daily) TRILEPTAL SUSP 300 QL(40 ml daily) 7 MG/5ML 7 (vigabatrin) SABRIL TABS (oxcarbazepine) 7 TRILEPTAL TABS 150 MG (vigabatrin) 7 (oxcarbazepine) tiagabine hcl tabs 3 TRILEPTAL TABS 300 MG QL(8 ea daily) 7 QL(6 ea daily) (oxcarbazepine) vigabatrin pack 4 TRILEPTAL TABS 600 MG QL(4 ea daily) 7 4 (oxcarbazepine) vigabatrin tabs TROKENDI XR CP24 100 PA Hydantoins 3 MG, 50 MG (topiramate) (Phenytoin) PHENYTOIN 1 TROKENDI XR CP24 200 PA; QL(2 ea INFATABS CHEW 3 MG (topiramate) daily)

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DILANTIN CAPS 100 MG divalproex sodium csdr 1 (phenytoin sodium 7 extended) divalproex sodium tb24 1 DILANTIN CAPS 30 MG (phenytoin sodium 2 divalproex sodium tbec 1 extended) valproate sodium soln 1 DILANTIN INFATABS 7 CHEW (phenytoin) valproic acid caps or 1 DILANTIN-125 SUSP 7 (phenytoin) ANTIDEPRESSANTS - Drugs to Treat Depression PEGANONE TABS 3 (ethotoin) Alpha-2 Receptor Antagonists (Tetracyclics) PHENYTEK CAPS mirtazapine tabs 1 (phenytoin sodium 7 extended) mirtazapine tbdp 1 REMERON SOLTAB TBDP phenytoin chew 1 7 (mirtazapine) phenytoin sodium 1 REMERON TABS extended caps 7 (mirtazapine) phenytoin susp 1 Antidepressants - Misc. Succinimides bupropion hcl tabs 100 1 CELONTIN CAPS mg, 75 mg 2 ( ) methsuximide bupropion hcl tb12 100 1 mg, 150 mg, 200 mg ethosuximide caps 1 QL(1 ea daily) bupropion hcl tb24 150 1 ethosuximide soln 1 mg, 300 mg ZARONTIN CAPS bupropion hcl tb24 450 ST; QL(1 ea 7 3 daily) (ethosuximide) mg ZARONTIN SOLN FORFIVO XL TB24 ST; QL(1 ea 7 7 (ethosuximide) (bupropion hcl) daily) Valproic Acid maprotiline hcl tabs 1 DEPAKENE CAPS WELLBUTRIN SR TB12 7 7 (valproic acid) (bupropion hcl) DEPAKOTE ER TB24 WELLBUTRIN XL TB24 QL(1 ea daily) 7 7 (divalproex sodium) (bupropion hcl) DEPAKOTE SPRINKLES Monoamine Oxidase Inhibitors (MAOIs) CSDR (divalproex 7 EMSAM PT24 QL(1 ea daily) sodium) 3 (selegiline) DEPAKOTE TBEC 7 MARPLAN TABS (divalproex sodium) 3 (isocarboxazid)

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NARDIL TABS FLUOXETINE QL(1 ea daily) 7 (phenelzine sulfate) HYDROCHLORIDE TABS 7 PARNATE TABS (fluoxetine hcl) QL(3 ea daily) (tranylcypromine 7 fluvoxamine maleate 1 sulfate) cp24 100 mg phenelzine sulfate tabs 1 fluvoxamine maleate 1 cp24 150 mg tranylcypromine sulfate QL(3 ea daily) 1 fluvoxamine maleate 1 tabs tabs 100 mg Selective Serotonin Reuptake Inhibitors (SSRIs) fluvoxamine maleate 1 CELEXA TABS QL(1 ea daily) tabs 25 mg, 50 mg (citalopram 7 LEXAPRO TABS 10 MG, QL(1 ea daily) hydrobromide) 20 MG (escitalopram 7 citalopram QL(20 ml daily) oxalate) hydrobromide soln 10 3 LEXAPRO TABS 5 MG QL(2 ea daily) 7 mg/5ml (escitalopram oxalate) citalopram QL(1 ea daily) paroxetine hcl tabs 1 hydrobromide tabs 10 1 mg, 20 mg, 40 mg paroxetine hcl tb24 1 escitalopram oxalate 1 PAXIL CR TB24 soln 5 mg/5ml 7 (paroxetine hcl) QL(1 ea daily) escitalopram oxalate PAXIL SUSP 10 MG/5ML 1 2 tabs 10 mg, 20 mg (paroxetine hcl) QL(2 ea daily) escitalopram oxalate 1 PAXIL TABS 10 MG, 20 tabs 5 mg MG, 30 MG, 40 MG 7 (paroxetine hcl) fluoxetine hcl caps 10 1 mg, 20 mg PROZAC CAPS 10 MG, 20 7 QL(1 ea daily) MG (fluoxetine hcl) fluoxetine hcl caps 40 1 PROZAC CAPS 40 MG QL(1 ea daily) mg 7 (fluoxetine hcl) fluoxetine hcl cpdr 90 3 mg sertraline hcl conc 20 1 fluoxetine hcl soln 20 QL(15 ml daily) mg/ml 1 QL(2 ea daily) mg/5ml sertraline hcl tabs 100 1 fluoxetine hcl tabs 10 mg, 25 mg, 50 mg 1 ZOLOFT CONC 20 MG/ML mg 7 QL(1 ea daily) (sertraline hcl) fluoxetine hcl tabs 20 1 mg ZOLOFT TABS 100 MG, QL(2 ea daily) 25 MG, 50 MG (sertraline 7 fluoxetine hcl tabs 60 QL(1 ea daily) 3 hcl) mg Serotonin Modulators nefazodone hcl tabs 3

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits trazodone hcl tabs 1 venlafaxine hcl tb24 QL(1 ea daily) 150 mg, 37.5 mg, 75 1 TRINTELLIX TABS ST; QL(1 ea 3 mg (vortioxetine hbr) daily) venlafaxine hcl tb24 VIIBRYD STARTER PACK 1 3 225 mg KIT (vilazodone hcl) VIIBRYD TABS 10 MG, 40 ST Tricyclic Agents 3 MG (vilazodone hcl) amitriptyline hcl tabs 1 VIIBRYD TABS 20 MG ST; QL(2 ea 3 (vilazodone hcl) daily) amoxapine tabs 1 ANAFRANIL CAPS Serotonin-Norepinephrine Reuptake Inhibitors 7 CYMBALTA CPEP QL(2 ea daily) (clomipramine hcl) 7 (duloxetine hcl) clomipramine hcl caps 1 QL(1 ea daily) desvenlafaxine 1 succinate tb24 desipramine hcl tabs 1 QL(2 ea daily) duloxetine hcl cpep 20 1 doxepin hcl caps 1 mg, 30 mg, 60 mg EFFEXOR XR CP24 150 QL(2 ea daily) doxepin hcl conc 1 7 MG (venlafaxine hcl) imipramine hcl tabs 10 1 EFFEXOR XR CP24 37.5 QL(1 ea daily) mg, 25 mg MG, 75 MG (venlafaxine 7 QL(4 ea daily) hcl) imipramine hcl tabs 50 1 mg FETZIMA CP24 120 MG, ST; QL(1 ea 40 MG, 80 MG 3 daily) imipramine pamoate 3 (levomilnacipran hcl) caps FETZIMA CP24 20 MG ST; QL(2 ea NORPRAMIN TABS 3 7 (levomilnacipran hcl) daily) (desipramine hcl) FETZIMA TITRATION ST nortriptyline hcl caps 10 PACK C4PK 3 mg, 25 mg, 50 mg, 75 1 (levomilnacipran hcl) mg PRISTIQ TB24 QL(1 ea daily) nortriptyline hcl soln 10 2 (desvenlafaxine 7 mg/5ml succinate) PAMELOR CAPS QL(2 ea daily) 7 venlafaxine hcl cp24 1 (nortriptyline hcl) 150 mg protriptyline hcl tabs 3 venlafaxine hcl cp24 QL(1 ea daily) 1 TOFRANIL TABS 10 MG, 37.5 mg, 75 mg 7 venlafaxine hcl tabs 25 MG (imipramine hcl) TOFRANIL TABS 50 MG QL(4 ea daily) 100 mg, 25 mg, 37.5 1 7 mg, 50 mg, 75 mg (imipramine hcl) trimipramine maleate 3 caps

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIDIABETICS - Drugs to Regulate Blood pioglitazone hcl- 1 Sugar metformin hcl tabs Alpha-Glucosidase Inhibitors repaglinide-metformin 3 hcl tabs acarbose tabs 1 SYNJARDY TABS GLYSET TABS (miglitol) 7 (empagliflozin- 2 metformin hcl) miglitol tabs 3 SYNJARDY XR TB24 PRECOSE TABS (empagliflozin- 2 7 (acarbose) metformin hcl) TRIJARDY XR TB24 Antidiabetic Combinations (empagliflozin- 2 ACTOPLUS MET TABS linagliptin-metformin) (pioglitazone hcl- 7 metformin hcl) XIGDUO XR TB24 10 MG- QL(1 ea daily) 1000 MG, 10 MG-500 MG DUETACT TABS (dapagliflozin- 2 (pioglitazone hcl- 7 metformin hcl) glimepiride) XIGDUO XR TB24 2.5 MG- QL(2 ea daily) glipizide-metformin hcl 1 1000 MG, 5 MG-1000 MG, tabs 5 MG-500 MG 2 (dapagliflozin- glyburide-metformin 1 tabs metformin hcl) GLYXAMBI TABS Biguanides (empagliflozin- 2 metformin hcl soln 500 3 linagliptin) mg/5ml JANUMET TABS 50 MG- metformin hcl tabs 1000 MG (sitagliptin- 2 1000 mg, 500 mg, 850 1 metformin hcl) mg JANUMET TABS 50 MG- QL(2 ea daily) metformin hcl tb24 500 1 500 MG, 500 MG-50 MG mg, 750 mg (sitagliptin-metformin 2 hcl) METFORMIN HYDROCHLORIDE SOLN 3 JANUMET XR TB24 100 QL(1 ea daily) (metformin hcl) MG-1000 MG ( 2 sitagliptin- RIOMET SOLN ) 3 metformin hcl (metformin hcl) JANUMET XR TB24 50 QL(2 ea daily) MG-1000 MG, 50 MG-500 Diabetic Other MG, 500 MG-50 MG 2 BAQSIMI ONE PACK PA; QL(2 ea 3 per 30 days (sitagliptin-metformin POWD (glucagon) hcl) retail) BAQSIMI TWO PACK PA; QL(2 ea pioglitazone hcl- 1 3 per 30 days glimepiride tabs POWD (glucagon) retail)

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVANDIA TABS diazoxide susp 3 2 (rosiglitazone maleate) PA; QL(1 ea pioglitazone hcl tabs 15 4 per fill retail,2 1 glucagon (rdna) kit ea per 30 days mg retail) QL(1 ea daily) pioglitazone hcl tabs 30 1 GLUCAGON PA; QL(1 ea mg, 45 mg EMERGENCY KIT KIT 7 per fill retail,2 ea per 30 days Insulin (glucagon (rdna)) retail) HUMALOG JUNIOR Limit 45mls per PROGLYCEM SUSP KWIKPEN SOPN (insulin 2 month;QL(1.5 7 ml daily) (diazoxide) lispro) HUMALOG KWIKPEN Limit 45mls per Dipeptidyl Peptidase-4 (DPP-4) Inhibitors SOPN 100 UNIT/ML 2 month;QL(1.5 alogliptin benzoate tabs 1 (insulin lispro) ml daily) 12.5 mg, 6.25 mg HUMALOG KWIKPEN Limit 24mls per QL(1 ea daily) SOPN 200 UNIT/ML month;QL(0.8 alogliptin benzoate tabs 1 2 25 mg (insulin lispro) ml daily) JANUVIA TABS 100 MG, QL(1 ea daily) HUMALOG MIX 50/50 Limit 45mls per 50 MG (sitagliptin 2 KWIKPEN SUPN (insulin month;QL(1.5 2 phosphate) lispro protamine & ml daily) JANUVIA TABS 25 MG lispro) 2 (sitagliptin phosphate) HUMALOG MIX 50/50 Limit 45mls per month;QL(1.5 Incretin Mimetic Agents (GLP-1 Receptor SUSP (insulin lispro 2 ) ml daily) PA; Not protamine & lispro OZEMPIC SOPN 2 HUMALOG MIX 75/25 Limit 45mls per 2 available MG/1.5ML (semaglutide) through Mail KWIKPEN SUPN (insulin month;QL(1.5 Order lispro protamine & 2 ml daily) PA; Not lispro) RYBELSUS TABS 4 available HUMALOG MIX 75/25 Limit 40mls per through Mail (semaglutide) SUSP ( 2 month;QL(1.34 Order insulin lispro protamine & lispro) ml daily) PA; Not TRULICITY SOPN available HUMALOG SOCT (insulin Limit 45mls per 2 2 month;QL(1.5 (dulaglutide) through mail lispro) order ml daily) PA; Not HUMALOG SOLN (insulin Limit 45mls per VICTOZA SOPN 2 month;QL(1.5 2 available lispro) (liraglutide) through mail ml daily) order HUMULIN 70/30 SUSP Limit 40mls per (insulin nph isophane & 2 month;QL(1.34 Insulin Sensitizing Agents ml daily) ACTOS TABS 15 MG reg (human)) 7 (pioglitazone hcl) HUMULIN N KWIKPEN Limit 45mls per month;QL(1.5 ACTOS TABS 30 MG, 45 QL(1 ea daily) SUPN (insulin nph 2 7 ml daily) MG (pioglitazone hcl) (human) (isophane))

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMULIN N SUSP Limit 40mls per Limited to 27 (insulin nph (human) 2 month;QL(1.34 TRESIBA FLEXTOUCH mls /month (isophane)) ml daily) SOPN 200 UNIT/ML 2 without prior HUMULIN R SOLN Limit 40mls per (insulin degludec) authorization;Q L(0.9 ml daily) (insulin regular 2 month;QL(1.34 TRESIBA SOLN ( (human)) ml daily) insulin 2 ) HUMULIN R SOLN Limit 45mls per degludec (insulin regular 2 month;QL(1.5 Meglitinide Analogues ml daily) (human)) nateglinide tabs 1 HUMULIN R U-500 QL(1.34 ml daily) PRANDIN TABS (CONCENTRATED) 2 7 SOLN (insulin regular (repaglinide) (human)) repaglinide tabs 1 HUMULIN R U-500 Limit 40mls per STARLIX TABS KWIKPEN SOPN (insulin 2 month;QL(1.34 7 regular (human)) ml daily) (nateglinide) INSULIN LISPRO Limit 45mls per Sodium-Glucose Co-Transporter 2 (SGLT2) PROTAMINE/INSULIN month;QL(1.5 FARXIGA TABS QL(1 ea daily) LISPRO KWIKPEN SUPN 2 ml daily) (dapagliflozin 2 (insulin lispro protamine propanediol) ) & lispro JARDIANCE TABS QL(1 ea daily) 2 LANTUS SOLN (insulin Limit 45mls per (empagliflozin) 2 month;QL(1.5 glargine) ml daily) Sulfonylureas (Glipizide) GLIPIZIDE XL LANTUS SOLOSTAR Limit 45mls per 1 2 month;QL(1.5 TB24 SOPN (insulin glargine) ml daily) AMARYL TABS 7 Limit 45mls per (glimepiride) LEVEMIR FLEXTOUCH 2 month;QL(1.5 SOPN (insulin detemir) ml daily,135 ml glimepiride tabs 1 per fill mail) Limit 45mls per glipizide tabs 1 LEVEMIR SOLN ( insulin 2 month;QL(1.5 detemir) ml daily,135 ml glipizide tb24 1 per fill mail) GLUCOTROL TABS 7 Limit 2 pens (glipizide) TOUJEO MAX SOLOSTAR per 2 GLUCOTROL XL TB24 SOPN (insulin glargine) month;QL(0.2 7 ml daily) (glipizide) Limit 3 pens glyburide micronized 1 TOUJEO SOLOSTAR 2 per tabs SOPN (insulin glargine) month;QL(0.15 ml daily) glyburide tabs 1 TRESIBA FLEXTOUCH Limit 45mls per GLYNASE TABS 7 SOPN 100 UNIT/ML 2 month;QL(1.5 (glyburide micronized) (insulin degludec) ml daily)

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tolbutamide tabs 1 deferiprone tabs 4 ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs FERRIPROX SOLN 100 Not available to Treat Diarrhea 4 through mail MG/ML (deferiprone) order Antidiarrheal - Chloride Channel Antagonists FERRIPROX TABS 500 MYTESI TBEC PA; QL(2 ea 7 3 MG (deferiprone) (crofelemer) daily) JADENU SPRINKLE PACK PA; LA 7 Antiperistaltic Agents (deferasirox) (Loperamide Hcl) ANTI- RX/OTC JADENU TABS PA 7 DIARRHEAL, CVS ANTI- (deferasirox) DIARRHEAL, EQ ANTI- DIARRHEAL, GNP ANTI- Antidotes and Specific Antagonists DIARRHEAL, HM ANTI- ANDEXXA SOLR PA DIARRHEAL, HM 3 (coagulation factor xa LOPERAMIDE HCL, QC 4 ANTI-DIARRHEAL, RA recomb inact-zhzo ANTI-DIARRHEAL, SM (andexanet alfa)) ANTI-DIARRHEAL, TGT VISTOGARD PACK LOPERAMIDE HCL CAPS (uridine triacetate 4 (emergency treatment)) diphenoxylate w/ 1 atropine liqd Opioid Antagonists diphenoxylate w/ 1 atropine tabs naloxone hcl sosy 1 IMODIUM A-D CAPS RX/OTC 7 naltrexone hcl tabs 1 (loperamide hcl) NARCAN LIQD QL(4 ea per 30 LOMOTIL TABS 2 (naloxone hcl) days retail) (diphenoxylate w/ 7 atropine) ANTIEMETICS - Drugs to Treat Nausea and Vomiting RX/OTC loperamide hcl caps 2 3 mg 5-HT3 Receptor Antagonists ANZEMET TABS PA; ST;QL(2 3 QL(2.4 ml 3 opium tincture tinc daily) (dolasetron mesylate) ea per fill retail) PA; ST; Limit 2 paregoric tinc 3 3 tablets per granisetron hcl tabs day;QL(2 ea ANTIDOTES AND SPECIFIC ANTAGONISTS daily) Antidotes - Chelating Agents ondansetron hcl soln 4 Limit 50mls per 1 month;QL(1.67 CHEMET CAPS 3 mg/5ml ml daily) (succimer) ondansetron hcl tabs 4 QL(20 ea per PA; LA 1 deferasirox pack 180 4 mg, 8 mg fill retail) mg, 360 mg, 90 mg QL(20 ea per PA ondansetron tbdp 1 deferasirox tabs 180 4 fill retail) mg, 360 mg, 90 mg

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SANCUSO PTCH PA; QL(1 ea aprepitant caps 125 QL(1 ea per fill 4 per 21 days 3 retail,1 ea per (granisetron) retail) mg, 80 mg 30 days retail) ZOFRAN TABS QL(20 ea per Limit 2 per 7 (ondansetron hcl) fill retail) aprepitant caps 40 mg 3 month;QL(0.07 ea daily) Antiemetics - Anticholinergic Limit 3 per ANTIVERT TABS 2 aprepitant misc 3 month;QL(0.1 (meclizine hcl) ea daily) MECLIZINE EMEND CAPS 125 MG, 80 QL(1 ea per fill HYDROCHLORIDE TABS 2 7 retail,1 ea per MG ( ) (meclizine hcl) aprepitant 30 days retail) EMEND CAPS 40 MG Limit 2 per scopolamine pt72 3 7 month;QL(0.07 (aprepitant) TIGAN CAPS ea daily) ( 7 EMEND SUSR 125 QL(1 ea per 30 trimethobenzamide 3 hcl) MG/5ML (aprepitant) days retail) TRANSDERM SCOP PT72 Limit 3 per 7 EMEND TRIPACK CAPS (scopolamine) 7 month;QL(0.1 (aprepitant) ea daily) TRANSDERM-SCOP PT72 7 VARUBI TBPK ( QL(4 ea per fill (scopolamine) rolapitant 3 hcl) retail) trimethobenzamide hcl 1 caps ANTIFUNGALS - Drugs to Treat Fungal Infections Antiemetics - Miscellaneous Antifungals AKYNZEO CAPS QL(2 ea per 28 ANCOBON CAPS 7 (netupitant- 3 days retail) (flucytosine) palonosetron) DICLEGIS TBEC QL(4 ea daily) flucytosine caps 3 (doxylamine- 7 griseofulvin microsize 1 pyridoxine) susp doxylamine-pyridoxine QL(4 ea daily) 3 griseofulvin microsize 1 tbec tabs dronabinol caps 10 mg, PA 3 griseofulvin 1 5 mg ultramicrosize tabs PA; ST dronabinol caps 2.5 mg 3 nystatin tabs 1 MARINOL CAPS 10 MG, 5 PA 7 QL(1 ea MG (dronabinol) terbinafine hcl tabs 1 daily,90 ea per MARINOL CAPS 2.5 MG PA; ST 365 days retail) 7 (dronabinol) Imidazole-Related Antifungals Substance P/Neurokinin 1 (NK1) Receptor CRESEMBA CAPS Not available Limit 3 per (isavuconazonium 3 through mail aprepitant caps 3 month;QL(0.1 sulfate) order ea daily) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIFLUCAN SUSR CARBINOXAMINE 7 ( ) MALEATE TABS 6 MG fluconazole 3 DIFLUCAN TABS (carbinoxamine 7 (fluconazole) maleate) CLEMASTINE FUMARATE fluconazole susr 1 SYRP 0.67 MG/5ML 2 (clemastine fumarate) fluconazole tabs 1 clemastine fumarate PA; ST 1 itraconazole caps 100 1 tabs 2.68 mg mg KARBINAL ER SUER PA itraconazole soln 10 1 (carbinoxamine 3 mg/ml maleate) ketoconazole tabs 1 RYVENT TABS (carbinoxamine 3 NOXAFIL SUSP 40 MG/ML 3 maleate) (posaconazole) Antihistamines - Non-Sedating NOXAFIL TBEC 100 MG 7 CLARINEX TABS PA; ST;QL(1 (posaconazole) 7 (desloratadine) ea daily) posaconazole tbec 3 PA; ST;QL(1 desloratadine tabs 5 3 SPORANOX CAPS 100 PA; ST mg ea daily) 7 MG (itraconazole) PA; ST desloratadine tbdp 2.5 3 SPORANOX PULSEPAK PA; ST mg 7 CAPS (itraconazole) PA desloratadine tbdp 5 3 SPORANOX SOLN 10 PA 7 mg MG/ML (itraconazole) Antihistamines - Phenothiazines TOLSURA CAPS PA 4 (Promethazine Hcl) 1 (itraconazole) PHENADOZ SUPP VFEND SUSR 40 MG/ML 7 (Promethazine Hcl) (voriconazole) PROMETHEGAN SUPP 1 VFEND TABS 200 MG, 50 QL(2 ea daily) 12.5 MG, 25 MG 7 MG (voriconazole) (Promethazine Hcl) QL(3 ea daily) PROMETHEGAN SUPP 50 1 voriconazole susr 40 1 MG mg/ml promethazine hcl soln QL(2 ea daily) 1 voriconazole tabs 200 1 or 6.25 mg/5ml mg, 50 mg promethazine hcl supp 1 ANTIHISTAMINES - Drugs to Treat Allergies re 12.5 mg, 25 mg QL(3 ea daily) Antihistamines - Ethanolamines promethazine hcl supp 1 re 50 mg carbinoxamine maleate 1 soln 4 mg/5ml promethazine hcl syrp 1 or 6.25 mg/5ml carbinoxamine maleate 3 tabs 4 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits promethazine hcl tabs 1 cholestyramine powd 1 or 12.5 mg QL(1 ea daily) QL(6 ea daily) colesevelam hcl pack 1 promethazine hcl tabs 1 or 25 mg 3.75 gm QL(7 ea daily) QL(3 ea daily) colesevelam hcl tabs 1 promethazine hcl tabs 1 or 50 mg 625 mg COLESTID FLAVORED 7 Antihistamines - Piperidines GRAN (colestipol hcl) cyproheptadine hcl COLESTID FLAVORED 1 7 syrp PACK (colestipol hcl) cyproheptadine hcl COLESTID GRAN 1 7 tabs (colestipol hcl) ANTIHYPERLIPIDEMICS - Drugs to Treat High COLESTID PACK 7 Cholesterol (colestipol hcl) Antihyperlipidemics - Combinations COLESTID TABS 7 QL(1 ea daily) (colestipol hcl) ezetimibe-simvastatin 1 tabs colestipol hcl gran 1 VYTORIN TABS QL(1 ea daily) 7 (ezetimibe-simvastatin) colestipol hcl pack 1 Antihyperlipidemics - Misc. colestipol hcl tabs 1 PA icosapent ethyl caps 3 QUESTRAN LIGHT POWD 7 LOVAZA CAPS ( QL(4 ea daily) (cholestyramine light) omega- 7 ) QUESTRAN PACK 3-acid ethyl esters 7 omega-3-acid ethyl QL(4 ea daily) (cholestyramine) 1 QUESTRAN POWD esters caps 7 VASCEPA CAPS 0.5 GM PA; ST (cholestyramine) 3 WELCHOL PACK 3.75 GM QL(1 ea daily) (icosapent ethyl) 7 VASCEPA CAPS 1 GM PA (colesevelam hcl) 3 WELCHOL TABS 625 MG QL(7 ea daily) (icosapent ethyl) 7 (colesevelam hcl) Bile Acid Sequestrants Fibric Acid Derivatives (Cholestyramine Light) 1 PREVALITE PACK ANTARA CAPS 3 (fenofibrate micronized) (Cholestyramine Light) 1 PREVALITE POWD QL(1 ea daily) choline fenofibrate cpdr 1 cholestyramine light 1 135 mg pack choline fenofibrate cpdr 1 cholestyramine light 1 45 mg powd fenofibrate caps 150 3 cholestyramine pack 1 mg, 50 mg

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) LESCOL XL TB24 QL(1 ea daily) fenofibrate micronized 1 7 caps 130 mg, 200 mg (fluvastatin sodium) LIPITOR TABS QL(1 ea daily) fenofibrate micronized 7 caps 134 mg, 43 mg, 1 (atorvastatin calcium) 67 mg $0 copay for QL(1 ea daily) Generic only, fenofibrate tabs 145 1 age 40 to mg, 160 mg lovastatin tabs 10 mg, 1 75;QL(1 ea FENOFIBRATE TABS 160 QL(1 ea daily) daily); AL(At 2 20 mg MG (fenofibrate) least 40 yrs old - Up to 75 yrs fenofibrate tabs 48 mg 1 old); PV QL(2 ea daily) $0 copay for fenofibrate tabs 54 mg 1 Generic only, FENOFIBRIC ACID TABS age 40 to 3 1 75;SL(2 ea 105 MG (fenofibric acid) lovastatin tabs 40 mg daily); AL(At FIBRICOR TABS 7 least 40 yrs old (fenofibric acid) - Up to 75 yrs old); PV 1 gemfibrozil tabs PRAVACHOL TABS 20 QL(1 ea daily) LIPOFEN CAPS MG, 80 MG (pravastatin 7 7 (fenofibrate) sodium) LOPID TABS PRAVACHOL TABS 40 QL(2 ea daily) 7 (gemfibrozil) MG (pravastatin 7 TRICOR TABS 145 MG QL(1 ea daily) sodium) 7 (fenofibrate) QL(1 ea daily) pravastatin sodium tabs 1 TRICOR TABS 48 MG 10 mg, 20 mg, 80 mg 7 (fenofibrate) QL(2 ea daily) pravastatin sodium tabs 1 TRIGLIDE TABS QL(1 ea daily) 2 40 mg (fenofibrate) rosuvastatin calcium QL(1 ea daily) TRILIPIX CPDR 135 MG QL(1 ea daily) 1 7 tabs (choline fenofibrate) simvastatin tabs 10 mg, QL(1 ea daily) TRILIPIX CPDR 45 MG 7 20 mg, 40 mg, 5 mg, 80 1 (choline fenofibrate) mg HMG CoA Reductase Inhibitors ZOCOR TABS QL(1 ea daily) 7 QL(1 ea daily) (simvastatin) atorvastatin calcium 1 tabs Intestinal Cholesterol Absorption Inhibitors CRESTOR TABS QL(1 ea daily) 7 1 (rosuvastatin calcium) ezetimibe tabs fluvastatin sodium caps 1 QL(1 ea daily) ZETIA TABS (ezetimibe) 7 fluvastatin sodium tb24 1 QL(1 ea daily) Microsomal Triglyceride Transfer Protein (MTP)

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JUXTAPID CAPS 10 MG, PA fosinopril sodium tabs 1 20 MG, 30 MG, 40 MG, 60 MG (lomitapide 4 lisinopril tabs 10 mg, mesylate) 2.5 mg, 20 mg, 30 mg, 1 JUXTAPID CAPS 5 MG PA; ST 5 mg 4 (lomitapide mesylate) lisinopril tabs 40 mg 1 QL(2 ea daily) Nicotinic Acid Derivatives LOTENSIN TABS 7 (Niacin ( ) (Antihyperlipidemic)) 3 benazepril hcl NIACOR TABS moexipril hcl tabs 1 niacin perindopril erbumine (antihyperlipidemic) 3 1 tabs 500 mg tabs niacin PRINIVIL TABS (lisinopril) 7 (antihyperlipidemic) QBRELIS SOLN QL(5 ml daily) 1 3 tbcr 1000 mg, 500 mg, (lisinopril) 750 mg quinapril hcl tabs 1 NIASPAN TBCR ( niacin 7 (antihyperlipidemic)) ramipril caps 1 QL(2 ea daily) Proprotein Convertase Subtilisin/Kexin Type 9 PRALUENT SOAJ PA trandolapril tabs 1 4 (alirocumab) VASOTEC TABS QL(2 ea daily) 7 REPATHA PUSHTRONEX PA; ST (enalapril maleate) SYSTEM SOCT 4 ZESTRIL TABS 10 MG, 2.5 (evolocumab) MG, 20 MG, 30 MG, 5 MG 7 REPATHA SOSY PA; ST (lisinopril) 4 (evolocumab) ZESTRIL TABS 40 MG QL(2 ea daily) 7 REPATHA SURECLICK PA; ST;LA (lisinopril) 4 SOAJ (evolocumab) Agents for Pheochromocytoma ANTIHYPERTENSIVES - Drugs to Treat High DEMSER CAPS 7 Blood Pressure (metyrosine) ACE Inhibitors DIBENZYLINE CAPS Not available ACCUPRIL TABS (phenoxybenzamine 7 through mail 7 (quinapril hcl) hcl) ALTACE CAPS (ramipril) 7 QL(2 ea daily) metyrosine caps 3 Not available benazepril hcl tabs 1 phenoxybenzamine hcl 1 caps through mail captopril tabs 1 Angiotensin II Receptor Antagonists enalapril maleate tabs QL(2 ea daily) ATACAND TABS 16 MG, 4 10 mg, 2.5 mg, 20 mg, 1 MG, 8 MG (candesartan 7 5 mg cilexetil)

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATACAND TABS 32 MG QL(1 ea daily) QL(2 ea daily) 7 valsartan tabs 160 mg 1 (candesartan cilexetil) AVAPRO TABS valsartan tabs 320 mg, 7 1 (irbesartan) 40 mg, 80 mg BENICAR TABS 20 MG, 5 Antiadrenergic Antihypertensives MG (olmesartan 7 CARDURA TABS 7 medoxomil) (doxazosin mesylate) BENICAR TABS 40 MG QL(1 ea daily) CATAPRES TABS 7 (olmesartan 7 (clonidine hcl) medoxomil) clonidine hcl tabs 1 candesartan cilexetil 1 tabs 16 mg, 4 mg, 8 mg doxazosin mesylate 1 QL(1 ea daily) tabs candesartan cilexetil 1 tabs 32 mg guanfacine hcl tabs 1 COZAAR TABS (losartan METHYLDOPA TABS 7 2 potassium) (methyldopa) DIOVAN TABS 160 MG QL(2 ea daily) MINIPRESS CAPS 7 7 (valsartan) (prazosin hcl) DIOVAN TABS 320 MG, 40 7 MG, 80 MG (valsartan) prazosin hcl caps 1 EDARBI TABS 40 MG 3 terazosin hcl caps 1 1 (azilsartan medoxomil) mg, 2 mg, 5 mg EDARBI TABS 80 MG QL(1 ea daily) QL(2 ea daily) 3 terazosin hcl caps 10 1 (azilsartan medoxomil) mg irbesartan tabs 1 Antihypertensive Combinations ACCURETIC TABS 10 losartan potassium MG-12.5 MG, 12.5 MG-20 1 tabs or 100 mg, 25 mg, MG (quinapril- 7 50 mg hydrochlorothiazide) MICARDIS TABS 20 MG, 7 ACCURETIC TABS 20 QL(1 ea daily) 40 MG ( ) telmisartan MG-25 MG (quinapril- 7 MICARDIS TABS 80 MG QL(1 ea daily) 7 hydrochlorothiazide) (telmisartan) amlodipine besylate- olmesartan medoxomil 1 benazepril hcl caps 10 1 tabs 20 mg, 5 mg mg-2.5 mg, 2.5 mg-10 QL(1 ea daily) olmesartan medoxomil 1 mg tabs 40 mg telmisartan tabs 20 mg, 1 40 mg telmisartan tabs 80 mg 1 QL(1 ea daily)

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amlodipine besylate- QL(1 ea daily) bisoprolol & benazepril hcl caps 10 hydrochlorothiazide 1 mg-20 mg, 10 mg-40 tabs mg, 10 mg-5 mg, 40 1 candesartan cilexetil- mg-10 mg, 40 mg-5 hydrochlorothiazide 1 mg, 5 mg-10 mg, 5 mg- tabs 20 mg, 5 mg-40 mg captopril & amlodipine besylate- QL(1 ea daily) hydrochlorothiazide 1 valsartan tabs 10 mg- 1 tabs 160 mg DIOVAN HCT TABS 12.5 amlodipine besylate- MG-160 MG, 12.5 MG-320 valsartan tabs 10 mg- MG, 12.5 MG-80 MG, 25 7 320 mg, 160 mg-5 mg, 1 MG-320 MG (valsartan- 5 mg-160 mg, 5 mg- hydrochlorothiazide) 320 mg DIOVAN HCT TABS 25 QL(1 ea daily) amlodipine-valsartan- MG-160 MG (valsartan- 7 hydrochlorothiazide 1 hydrochlorothiazide) tabs EDARBYCLOR TABS QL(1 ea daily) ATACAND HCT TABS (azilsartan medoxomil- 3 (candesartan cilexetil- 7 chlorthalidone) hydrochlorothiazide) enalapril maleate & hydrochlorothiazide 1 atenolol & 1 chlorthalidone tabs tabs AVALIDE TABS EXFORGE HCT TABS (irbesartan- 7 (amlodipine-valsartan- 2 hydrochlorothiazide) hydrochlorothiazide) benazepril & EXFORGE TABS 10 MG- QL(1 ea daily) hydrochlorothiazide 1 160 MG (amlodipine 7 tabs besylate-valsartan) BENAZEPRIL EXFORGE TABS 10 MG- 320 MG, 5 MG-160 MG, 5 HCL/HYDROCHLOROTHI 7 AZIDE TABS (benazepril 2 MG-320 MG (amlodipine & hydrochlorothiazide) besylate-valsartan) BENICAR HCT TABS 12.5 fosinopril sodium & MG-20 MG (olmesartan hydrochlorothiazide 1 medoxomil- 7 tabs hydrochlorothiazide) HYZAAR TABS (losartan BENICAR HCT TABS 12.5 QL(1 ea daily) potassium & 7 MG-40 MG, 25 MG-40 MG hydrochlorothiazide) (olmesartan 7 irbesartan- medoxomil- hydrochlorothiazide 1 hydrochlorothiazide) tabs

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lisinopril & propranolol & hydrochlorothiazide hydrochlorothiazide 1 tabs 10 mg-12.5 mg, 1 tabs 12.5 mg-10 mg, 12.5 quinapril- mg-20 mg hydrochlorothiazide lisinopril & QL(2 ea daily) tabs 10 mg-12.5 mg, 1 hydrochlorothiazide 1 12.5 mg-10 mg, 12.5 tabs 20 mg-25 mg mg-20 mg LOPRESSOR HCT TABS quinapril- QL(1 ea daily) (metoprolol & 7 hydrochlorothiazide 1 hydrochlorothiazide) tabs 20 mg-25 mg losartan potassium & TARKA TBCR hydrochlorothiazide 1 (trandolapril-verapamil 7 tabs hcl) LOTENSIN HCT TABS TEKTURNA HCT TABS ST (benazepril & 7 (aliskiren- 3 hydrochlorothiazide) hydrochlorothiazide) LOTREL CAPS QL(1 ea daily) telmisartan-amlodipine 1 (amlodipine besylate- 7 tabs benazepril hcl) telmisartan- methyldopa & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs TENORETIC 100 TABS metoprolol & (atenolol & 7 hydrochlorothiazide 1 chlorthalidone) tabs TENORETIC 50 TABS MICARDIS HCT TABS (atenolol & 7 (telmisartan- 7 chlorthalidone) hydrochlorothiazide) trandolapril-verapamil 3 olmesartan medoxomil- ST hcl tbcr amlodipine- 1 TRIBENZOR TABS ST hydrochlorothiazide (olmesartan tabs medoxomil-amlodipine- 7 olmesartan medoxomil- hydrochlorothiazide) TWYNSTA TABS hydrochlorothiazide 1 tabs 12.5 mg-20 mg, (telmisartan- 7 20 mg-12.5 mg amlodipine) olmesartan medoxomil- QL(1 ea daily) hydrochlorothiazide 1 tabs 12.5 mg-40 mg, 25 mg-40 mg

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits valsartan- Antimalarial Combinations hydrochlorothiazide atovaquone-proguanil 3 tabs 12.5 mg-160 mg, hcl tabs 1 12.5 mg-320 mg, 12.5 COARTEM TABS Limit 24 per mg-80 mg, 160 mg- (artemether- 2 month;QL(0.8 12.5 mg, 25 mg-320 lumefantrine) ea daily) mg, 80 mg-12.5 mg MALARONE TABS valsartan- QL(1 ea daily) (atovaquone-proguanil 7 hydrochlorothiazide 1 hcl) tabs 25 mg-160 mg Antimalarials VASERETIC TABS (enalapril maleate & 7 chloroquine phosphate 1 hydrochlorothiazide) tabs ZESTORETIC TABS 10 hydroxychloroquine 1 MG-12.5 MG, 12.5 MG-20 sulfate tabs 7 MG (lisinopril & KRINTAFEL TABS QL(2 ea per 30 2 hydrochlorothiazide) (tafenoquine succinate) days retail) ZESTORETIC TABS 20 QL(2 ea daily) mefloquine hcl tabs 1 QL(6 ea per fill MG-25 MG (lisinopril & 7 retail) hydrochlorothiazide) PLAQUENIL TABS ZIAC TABS ( (hydroxychloroquine 7 bisoprolol & 7 hydrochlorothiazide) sulfate) Antihypertensives - Misc. primaquine phosphate 1 VECAMYL TABS PA tabs 4 (mecamylamine hcl) PRIMAQUINE PHOSPHATE TABS 7 Direct Renin Inhibitors (primaquine phosphate) 3 QUALAQUIN CAPS PA; QL(2 ea aliskiren fumarate tabs 7 (quinine sulfate) daily) TEKTURNA TABS 7 (aliskiren fumarate) 3 PA; QL(2 ea quinine sulfate caps daily) Selective Aldosterone Receptor Antagonists ANTIMYASTHENIC/CHOLINERGIC AGENTS eplerenone tabs 1 Antimyasthenic/Cholinergic Agents INSPRA TABS 7 FIRDAPSE TABS PA; ST (eplerenone) (amifampridine 4 Vasodilators phosphate) GUANIDINE HCL TABS hydralazine hcl tabs 1 2 (guanidine hcl) minoxidil tabs 1 MESTINON SOLN 60 PA MG/5ML (pyridostigmine 7 ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections) bromide)

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MESTINON TABS 60 MG RIFADIN CAPS (rifampin) 7 (pyridostigmine 7 bromide) rifampin caps 1 MESTINON TIMESPAN TRECATOR TABS TBCR (pyridostigmine 7 2 (ethionamide) bromide) PA ANTINEOPLASTICS AND ADJUNCTIVE pyridostigmine bromide 4 THERAPIES - Drugs to Treat Cancer soln 60 mg/5ml pyridostigmine bromide Alkylating Agents 1 ALKERAN TABS AC tabs 60 mg 7 (melphalan) pyridostigmine bromide 1 cyclophosphamide AC tbcr 180 mg 1 caps 25 mg, 50 mg RUZURGI TABS PA; QL(10 ea 4 CYCLOPHOSPHAMIDE (amifampridine) daily) TABS 25 MG, 50 MG 2 ANTIMYCOBACTERIAL AGENTS - Drugs to (cyclophosphamide) Treat Tuberculosis (Bacterial Infections) GLEOSTINE CAPS AC 2 Anti TB Combinations (lomustine) RIFAMATE CAPS LEUKERAN TABS AC 2 2 (isoniazid & rifampin) (chlorambucil) RIFATER TABS melphalan tabs 1 AC (isoniazid-rifampin w/ 3 MYLERAN TABS AC pyrazinamide) 2 ( ) Antimycobacterial Agents busulfan TEMODAR CAPS AC 7 cycloserine caps 3 (temozolomide) ethambutol hcl tabs 1 temozolomide caps 1 AC isoniazid syrp 1 Antimetabolites capecitabine tabs 4 AC isoniazid tabs 1 AC MYAMBUTOL TABS mercaptopurine tabs 1 7 (ethambutol hcl) methotrexate sodium MYCOBUTIN CAPS 7 soln ij 1 gm/40ml, 250 4 (rifabutin) mg/10ml, 50 mg/2ml PASER PACK AC 3 methotrexate sodium 1 (aminosalicylic acid) tabs or 2.5 mg PRIFTIN TABS ONUREG TABS PA; AC 3 4 (rifapentine) (azacitidine) 1 PURIXAN SUSP AC pyrazinamide tabs 2 (mercaptopurine) rifabutin caps 1

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TABLOID TABS AC VENCLEXTA STARTING PA; PA; AC;AC 2 (thioguanine) PACK TBPK 4 TREXALL TABS AC (venetoclax) 3 (methotrexate sodium) VENCLEXTA TABS 10 MG PA; PA; 4 AC;QL(2 ea XATMEP SOLN PA; AC ( ) 4 venetoclax daily); AC (methotrexate) PA; PA; XELODA TABS AC VENCLEXTA TABS 100 7 4 AC;QL(4 ea (capecitabine) MG (venetoclax) daily); AC VENCLEXTA TABS 50 MG PA; PA; AC;AC Antineoplastic - Angiogenesis Inhibitors 4 PA; PA; AC; (venetoclax) Must use Antineoplastic - EGFR Inhibitors 4 AcariaHlth SP INLYTA TABS (axitinib) pharmacy 1- PA; PA; AC; 844-538- Must use 4665;AC 4 AcariaHlth SP erlotinib hcl tabs pharmacy 1- LENVIMA 10 MG DAILY PA; PA; AC;AC 844-538- DOSE CPPK (lenvatinib 4 4665;LA; AC mesylate) PA; PA; AC; LENVIMA 12MG DAILY PA; PA; AC;AC Must use GILOTRIF TABS ( DOSE CPPK (lenvatinib 4 afatinib 4 AcariaHlth SP mesylate) dimaleate) pharmacy 1- 844-538- LENVIMA 14 MG DAILY PA; PA; AC;AC 4664;AC DOSE CPPK (lenvatinib 4 AC;AC mesylate) IRESSA TABS (gefitinib) 4 LENVIMA 18 MG DAILY PA; PA; AC;AC TAGRISSO TABS PA; PA; AC;AC 4 DOSE CPPK (lenvatinib 4 (osimertinib mesylate) mesylate) PA; PA; AC; LENVIMA 20 MG DAILY PA; PA; AC;AC Must use TARCEVA TABS ( DOSE CPPK (lenvatinib 4 erlotinib 7 AcariaHlth SP ) hcl) pharmacy 1- mesylate 844-538- LENVIMA 24 MG DAILY PA; PA; AC;AC 4665;LA; AC DOSE CPPK (lenvatinib 4 VIZIMPRO TABS PA; PA; AC;AC 4 mesylate) (dacomitinib) LENVIMA 4 MG DAILY PA; PA; AC;AC Antineoplastic - Hedgehog Pathway Inhibitors DOSE CPPK (lenvatinib 4 DAURISMO TABS PA mesylate) 4 (glasdegib maleate) LENVIMA 8 MG DAILY PA; PA; AC;AC ERIVEDGE CAPS AC DOSE CPPK (lenvatinib 4 4 ( ) mesylate) vismodegib ODOMZO CAPS AC 4 Antineoplastic - Anti-HER2 Agents (sonidegib phosphate) TUKYSA TABS PA; PA; AC;AC 4 (tucatinib) Antineoplastic - Hormonal and Related Agents Antineoplastic - BCL-2 Inhibitors 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; PA; AC; megestrol acetate susp 1 AC Must use abiraterone acetate AcariaHlth SP 4 megestrol acetate tabs 1 AC tabs pharmacy 1- 844-538- NILANDRON TABS AC 7 4665;LA; AC (nilutamide) 1 QL(1 ea daily); AC anastrozole tabs PV; AC nilutamide tabs 1 ARIMIDEX TABS QL(1 ea daily); 7 PA; See plan (anastrozole) PV; AC documents for AROMASIN TABS PV; AC NUBEQA TABS specific 7 4 (exemestane) (darolutamide) Coverage; Not available thru 1 QL(1 ea daily); Mail;AC bicalutamide tabs AC SOLTAMOX SOLN PV; AC CASODEX TABS QL(1 ea daily); 5 7 (tamoxifen citrate) (bicalutamide) AC PV; AC ELIGARD KIT ( PA tamoxifen citrate tabs 5 leuprolide 3 acetate (3 month)) toremifene citrate tabs 1 AC ELIGARD KIT ( PA leuprolide 3 ) PA; AC: Must acetate (4 month) use ELIGARD KIT (leuprolide PA XTANDI CAPS 3 4 AcariaHealth acetate (6 month)) (enzalutamide) Specialty Rx at 1-844-538- ELIGARD KIT ( PA leuprolide 3 4661;AC acetate) PA; AC: Must EMCYT CAPS AC use (estramustine 2 XTANDI TABS 4 AcariaHealth phosphate sodium) (enzalutamide) Specialty Rx at ERLEADA TABS PA; AC 1-844-538- 4 4661;AC (apalutamide) YONSA TABS PA; PA; AC;AC PV; AC 4 exemestane tabs 1 (abiraterone acetate) FARESTON TABS AC PA; PA; AC; 7 (toremifene citrate) Must use ZYTIGA TABS AcariaHlth SP FEMARA TABS AC 7 7 (abiraterone acetate) pharmacy 1- (letrozole) 844-538- 4665;LA; AC flutamide caps 1 AC Antineoplastic - Immunomodulators AC letrozole tabs 1 PA; PA;AC Must use leuprolide acetate kit 3 PA POMALYST CAPS 4 Exactus ( ) Specialty Rx 1- LYSODREN TABS AC pomalidomide 2 866-458- (mitotane) 9246;LA; AC Antineoplastic - PDGFR-alpha Inhibitors 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AYVAKIT TABS 100 MG, PA; PA; PA; PA; AC; 200 MG, 300 MG 4 AC;QL(1 ea Must use AFINITOR DISPERZ TBSO (avapritinib) daily); SP 4 AcariaHlth SP AYVAKIT TABS 25 MG, 50 PA; QL(1 ea (everolimus) pharmacy 1- 4 daily); SP; AC 844-538- MG (avapritinib) 4661;AC Antineoplastic - XPO1 Inhibitors PA; PA; AC; XPOVIO 100 MG ONCE PA; PA; AC; Must use AFINITOR TABS 10 MG WEEKLY TBPK 4 4 AcariaHlth SP (selinexor) (everolimus) pharmacy 1- 844-538- XPOVIO 60 MG ONCE PA; PA; AC; 4661;AC WEEKLY TBPK 4 AFINITOR TABS 2.5 MG PA; AC (selinexor) 7 (everolimus) XPOVIO 80 MG ONCE PA; PA; AC; WEEKLY TBPK 4 PA; PA; AC; Must use (selinexor) AFINITOR TABS 5 MG, 7.5 7 AcariaHlth SP XPOVIO 80 MG TWICE PA; PA; AC; MG (everolimus) pharmacy 1- WEEKLY TBPK 4 844-538- (selinexor) 4661;AC XPOVIO TBPK PA; AC PA; PA; AC; 4 (selinexor) Must use ALECENSA CAPS 4 AcariaHlth SP Antineoplastic Combinations (alectinib hcl) pharmacy 1- INQOVI TABS PA 844-538- (decitabine- 4 4661;AC ) ALUNBRIG TABS PA; PA; AC;AC cedazuridine 4 PA; PA;AC; (brigatinib) KISQALI FEMARA 200 Must use ALUNBRIG TBPK PA; PA; AC;AC 4 DOSE TBPK (ribociclib 3 Acaria (brigatinib) succinate-letrozole) Specialty (844) 538-4661;AC PA; PA; AC; Must use PA; PA;AC; BALVERSA TABS AcariaHlth SP KISQALI FEMARA 400 4 Must use (erdafitinib) pharmacy 1- DOSE TBPK (ribociclib 3 Acaria 844-538- succinate-letrozole) Specialty (844) 4661;AC 538-4661;AC PA; PA; AC; PA; PA;AC; Must use KISQALI FEMARA 600 Must use BOSULIF TABS 100 MG, 4 AcariaHlth SP DOSE TBPK (ribociclib 3 Acaria 500 MG (bosutinib) pharmacy 1- succinate-letrozole) Specialty (844) 844-538- 538-4661;AC 4661;LA; AC LONSURF TABS PA; AC 4 PA; PA; AC; (trifluridine-tipiracil) Must use BOSULIF TABS 400 MG Antineoplastic Enzyme Inhibitors 4 AcariaHlth SP (bosutinib) pharmacy 1- 844-538- 4661;AC

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRAFTOVI CAPS PA; PA; AC;LA; PA; PA; AC; 4 (encorafenib) AC Must use BRUKINSA CAPS PA; PA; AC;AC everolimus tabs 5 mg, 4 AcariaHlth SP 4 7.5 mg pharmacy 1- (zanubrutinib) 844-538- PA; PA; AC; 4661;AC Must use PA; PA; AC; CABOMETYX TABS 4 AcariaHlth SP Must use (cabozantinib s-malate) pharmacy 1- FARYDAK CAPS 4 AcariaHlth SP 844-538- (panobinostat lactate) pharmacy 1- 4661;AC 844-538- CALQUENCE CAPS PA; PA; AC;AC 4664;AC 4 (acalabrutinib) GLEEVEC TABS ( PA; PA; AC;AC imatinib 7 PA; PA; AC; mesylate) Must use CAPRELSA TABS PA; Must use 4 AcariaHlth SP IBRANCE CAPS 100 MG, AcariaHealth (vandetanib) pharmacy 1- 125 MG, 75 MG 3 Specialty Rx at 844-538- (palbociclib) 1-844-538- 4661;AC 4661;LA; AC PA; PA; AC; PA; Must use Must use IBRANCE TABS 100 MG, COMETRIQ KIT AcariaHealth 4 AcariaHlth SP 125 MG, 75 MG 3 Specialty Rx at pharmacy 1- (cabozantinib s-malate) (palbociclib) 1-844-538- 844-538- 4661 ;AC 4662;AC PA; PA; AC; PA; PA; AC; Must use Must use ICLUSIG TABS 10 MG, 30 AcariaHlth SP COMETRIQ KIT AcariaHlth SP 4 4 MG (ponatinib hcl) pharmacy 1- (cabozantinib s-malate) pharmacy 1- 844-538- 844-538- 4664;LA; AC 4664;AC PA; PA; AC; PA; PA; AC; Must use Must use ICLUSIG TABS 15 MG AcariaHlth SP COMETRIQ KIT AcariaHlth SP 4 4 (ponatinib hcl) pharmacy 1- (cabozantinib s-malate) pharmacy 1- 844-538- 844-538- 4664;AC 4663;AC PA; PA; AC; COPIKTRA CAPS PA; PA; AC;AC 4 Must use (duvelisib) ICLUSIG TABS 45 MG 4 AcariaHlth SP PA; PA; AC; (ponatinib hcl) pharmacy 1- Must use 844-538- COTELLIC TABS 4665;AC 4 AcariaHlth SP (cobimetinib fumarate) pharmacy 1- IDHIFA TABS PA; PA; AC;LA; 4 844-538- (enasidenib mesylate) AC 4664;AC imatinib mesylate tabs 4 PA; PA; AC;AC everolimus tabs 2.5 mg 4 PA; AC IMBRUVICA CAPS 140 PA; PA; AC;AC 4 MG, 70 MG (ibrutinib)

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IMBRUVICA TABS 140 PA; PA; PA; PA; AC; MG, 280 MG, 420 MG, 560 4 AC;QL(1 ea Must use NEXAVAR TABS MG (ibrutinib) daily); AC 4 AcariaHlth SP INREBIC CAPS PA; PA; AC;AC (sorafenib tosylate) pharmacy 1- 4 844-538- (fedratinib hcl) 4668;LA; AC JAKAFI TABS ( PA; PA; AC;AC ruxolitinib 4 PA; PA;AC phosphate) Must use KISQALI TBPK (ribociclib PA; AC NINLARO CAPS Exactus 3 4 Specialty Rx 1- succinate) (ixazomib citrate) 866-458- KOSELUGO CAPS PA; PA; AC 4 9246;QL(0.1 ea (selumetinib sulfate) daily); AC PA; PA; AC; PA; PA; AC; Must use Must use PIQRAY 200MG DAILY AcariaHlth SP 4 AcariaHlth SP 4 lapatinib ditosylate tabs pharmacy 1- DOSE TBPK (alpelisib) pharmacy 1- 844-538- 844-538- 4665;AC 4665;AC PA; PA; AC; PA; PA; AC; Must use Must use LORBRENA TABS 100 MG PIQRAY 250MG DAILY AcariaHlth SP 4 AcariaHlth SP 4 (lorlatinib) pharmacy 1- DOSE TBPK (alpelisib) pharmacy 1- 844-538- 844-538- 4665;AC 4665;AC PA; PA; AC; PA; PA; AC; Must use Must use LORBRENA TABS 25 MG PIQRAY 300MG DAILY 4 AcariaHlth SP 4 AcariaHlth SP (lorlatinib) pharmacy 1- DOSE TBPK (alpelisib) pharmacy 1- 844-538-4665; 844-538- LYNPARZA TABS PA; PA; AC;AC 4665;AC 4 QINLOCK TABS PA; PA; AC;AC (olaparib) 3 PA; PA; AC; (ripretinib) Must use RETEVMO CAPS PA; AC MEKINIST TABS 4 ( 4 AcariaHlth SP (selpercatinib) trametinib dimethyl pharmacy 1- sulfoxide) PA; PA; AC; 844-538- Must use 4665;AC ROZLYTREK CAPS AcariaHlth SP MEKTOVI TABS PA; PA; AC;LA; 4 4 (entrectinib) pharmacy 1- (binimetinib) AC 844-538- PA; PA; AC; 4665;AC Must use RUBRACA TABS PA; PA; AC;AC NERLYNX TABS 4 4 AcariaHlth SP (rucaparib camsylate) (neratinib maleate) pharmacy 1- PA; PA; AC; 844-538- Must use 4667;LA; AC RYDAPT CAPS 4 AcariaHlth SP (midostaurin) pharmacy 1- 844-538- 4665;AC 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; PA; AC; TAZVERIK TABS PA; PA; AC; 4 Must use (tazemetostat hbr) SPRYCEL TABS 4 AcariaHlth SP TIBSOVO TABS PA; PA; AC;AC (dasatinib) pharmacy 1- 4 844-538- (ivosidenib) 4665;AC TURALIO CAPS PA; PA; AC;AC 4 PA; PA; AC; (pexidartinib hcl) Must use PA; PA; AC; STIVARGA TABS 4 AcariaHlth SP Must use (regorafenib) pharmacy 1- TYKERB TABS ( lapatinib 7 AcariaHlth SP 844-538- ditosylate) pharmacy 1- 4665;SP; AC 844-538- PA; PA; AC; 4665;AC Must use VERZENIO TABS PA; AC 4 4 AcariaHlth SP (abemaciclib) sunitinib malate caps pharmacy 1- 844-538- PA; PA; AC; 4665;LA; AC Must use VITRAKVI CAPS 100 MG 4 AcariaHlth SP PA; PA; AC; (larotrectinib sulfate) pharmacy 1- Must use 844-538- SUTENT CAPS ( sunitinib 7 AcariaHlth SP 4665;AC malate) pharmacy 1- 844-538- PA; PA; AC; 4665;LA; AC VITRAKVI CAPS 25 MG Must use 4 AcariaHlth SP PA; PA; AC; (larotrectinib sulfate) pharmacy 1- Must use 844-538-4665; TABRECTA TABS AcariaHlth SP 4 PA; PA; AC; (capmatinib hcl) pharmacy 1- VITRAKVI SOLN 20 844-538- Must use 4665;AC MG/ML (larotrectinib 4 AcariaHlth SP sulfate) pharmacy 1- PA; PA; AC; 844-538-4665; Must use TAFINLAR CAPS PA; PA; AC; 4 AcariaHlth SP pharmacy 1- Must use (dabrafenib mesylate) VOTRIENT TABS 844-538- 4 AcariaHlth SP 4665;AC (pazopanib hcl) pharmacy 1- 844-538- PA; PA; AC; 4665;AC Must use TALZENNA CAPS PA; PA; AC; 4 AcariaHlth SP pharmacy 1- Must use (talazoparib tosylate) XALKORI CAPS 844-538- 4 AcariaHlth SP 4665;AC (crizotinib) pharmacy 1- 844-538- PA; PA; AC; 4665;AC Must use TASIGNA CAPS ( XOSPATA TABS PA; PA; AC;AC nilotinib 4 AcariaHlth SP 4 hcl) pharmacy 1- (gilteritinib fumarate) 844-538- ZEJULA CAPS ( PA; PA; AC;AC niraparib 4 4665;AC tosylate)

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; PA; AC; TARGRETIN CAPS OR 75 AC 7 Must use MG (bexarotene) ZELBORAF TABS 4 AcariaHlth SP AC (vemurafenib) pharmacy 1- tretinoin 1 844-538- (chemotherapy) caps 4665;AC Chemotherapy Rescue/Antidote/Protective Agents PA; PA; AC; AC Must use leucovorin calcium tabs 1 ZOLINZA CAPS 4 AcariaHlth SP AC (vorinostat) pharmacy 1- MESNEX TABS (mesna) 3 844-538- 4665;AC Mitotic Inhibitors ZYDELIG TABS PA; PA; AC;AC PA; PA; AC; 3 (idelalisib) Must use 4 AcariaHlth SP PA; PA; AC; etoposide caps pharmacy 1- Must use 844-538- ZYKADIA CAPS 4 AcariaHlth SP 4664;AC (ceritinib) pharmacy 1- 844-538- Topoisomerase I Inhibitors 4665;AC AC; Must use PA; PA; AC; HYCAMTIN CAPS AcariaHlth SP 4 pharmacy 1- Must use (topotecan hcl) ZYKADIA TABS 844-538- 4 AcariaHlth SP (ceritinib) pharmacy 1- 4664;AC 844-538- ANTIPARKINSON AND RELATED THERAPY 4665;AC AGENTS - Drugs to Treat Parkinson's Disease Antineoplastics Misc. Antiparkinson Adjunctive Therapy ACTIMMUNE SOLN PA 4 3 (interferon gamma-1b) carbidopa tabs ALFERON N SOLN PA LODOSYN TABS 4 7 (interferon alfa-n3) (carbidopa) bexarotene caps 4 AC Antiparkinson Anticholinergics benztropine mesylate HYDREA CAPS AC 1 7 tabs (hydroxyurea) trihexyphenidyl hcl soln 1 hydroxyurea caps 1 AC INTRON A SOLN PA trihexyphenidyl hcl tabs 1 4 (interferon alfa-2b) Antiparkinson COMT Inhibitors INTRON A SOLR PA 4 COMTAN TABS ) 7 (interferon alfa-2b (entacapone) MATULANE CAPS AC 4 (procarbazine hcl) entacapone tabs 3 PA; Must use TASMAR TABS SYLATRON KIT 7 ( 4 AcariaHlth Sp (tolcapone) peginterferon alfa-2b Rx 1-844-538- (antineoplastic)) 4661;LA 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tolcapone tabs 3 MIRAPEX TABS 0.125 MG, 0.25 MG, 0.5 MG, 7 Antiparkinson Dopaminergics 0.75 MG (pramipexole dihydrochloride) amantadine hcl caps 1 MIRAPEX TABS 1 MG QL(4 ea daily) amantadine hcl syrp 1 (pramipexole 7 dihydrochloride) amantadine hcl tabs 1 MIRAPEX TABS 1.5 MG QL(3 ea daily) (pramipexole 7 bromocriptine mesylate 1 caps dihydrochloride) NEUPRO PT24 bromocriptine mesylate 3 1 (rotigotine) tabs PARLODEL CAPS carbidopa-levodopa (bromocriptine 7 tabs 10 mg-100 mg, 1 mesylate) 100 mg-25 mg, 25 mg- 100 mg, 25 mg-250 mg PARLODEL TABS (bromocriptine 7 QL(8 ea daily) carbidopa-levodopa 1 mesylate) tbcr 25 mg-100 mg pramipexole carbidopa-levodopa 1 dihydrochloride tabs 1 tbcr 50 mg-200 mg 0.125 mg, 0.25 mg, 0.5 carbidopa-levodopa mg, 0.75 mg tbdp 10 mg-100 mg, 25 3 pramipexole QL(4 ea daily) mg-100 mg, 25 mg-250 dihydrochloride tabs 1 1 mg mg carbidopa-levodopa- 1 pramipexole QL(3 ea daily) entacapone tabs dihydrochloride tabs 1 CARBIDOPA/LEVODOPA 1.5 mg ODT TBDP (carbidopa- 3 pramipexole levodopa) dihydrochloride tb24 DUOPA SUSP PA 3 0.375 mg, 0.75 mg, 1.5 3 (carbidopa-levodopa) mg, 2.25 mg, 3.75 mg, INBRIJA CAPS PA 3 4.5 mg (levodopa) pramipexole QL(1 ea daily) MIRAPEX ER TB24 0.375 dihydrochloride tb24 3 3 MG, 0.75 MG, 1.5 MG, mg 2.25 MG, 3.75 MG, 4.5 MG 7 (pramipexole REQUIP XL TB24 12 MG QL(2 ea daily) dihydrochloride) (ropinirole 7 hydrochloride) MIRAPEX ER TB24 3 MG QL(1 ea daily) (pramipexole 7 REQUIP XL TB24 4 MG, 6 dihydrochloride) MG, 8 MG (ropinirole 7 hydrochloride)

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ropinirole hydrochloride rasagiline mesylate 1 tabs 0.25 mg, 0.5 mg, 1 1 tabs mg, 2 mg, 3 mg, 4 mg, selegiline hcl caps 1 QL(2 ea daily) 5 mg QL(2 ea daily) 1 QL(2 ea daily) ropinirole hydrochloride 3 selegiline hcl tabs tb24 12 mg ZELAPAR TBDP 3 ropinirole hydrochloride (selegiline hcl) tb24 2 mg, 4 mg, 6 mg, 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS - 8 mg Drugs to Treat Mood Disorders RYTARY CPCR 23.75 MG- PA; ST;QL(10 95 MG (carbidopa- 3 ea daily) Antimanic Agents levodopa) lithium carbonate caps 1 RYTARY CPCR 36.25 MG- PA; QL(10 ea 150 mg, 600 mg 145 MG, 48.75 MG-195 daily) QL(6 ea daily) lithium carbonate caps 1 MG, 61.25 MG-245 MG 3 300 mg (carbidopa-levodopa) lithium carbonate tabs 1 SINEMET CR TBCR 25 QL(8 ea daily) 300 mg MG-100 MG (carbidopa- 7 lithium carbonate tbcr levodopa) 1 300 mg, 450 mg SINEMET CR TBCR 50 MG-200 MG (carbidopa- 7 LITHIUM SOLN (lithium) 2 levodopa) LITHOBID TBCR (lithium SINEMET TABS 7 7 carbonate) (carbidopa-levodopa) Antipsychotics - Misc. STALEVO 100 TABS EQUETRO CP12 (carbidopa-levodopa- 7 ( entacapone) carbamazepine 3 (antipsychotic)) STALEVO 125 TABS GEODON CAPS 20 MG, (carbidopa-levodopa- 7 7 40 MG ( ) entacapone) ziprasidone hcl GEODON CAPS 60 MG, QL(2 ea daily) STALEVO 150 TABS 7 80 MG ( ) (carbidopa-levodopa- 7 ziprasidone hcl LATUDA TABS entacapone) 3 ( ) STALEVO 50 TABS lurasidone hcl (carbidopa-levodopa- 7 NUPLAZID CAPS PA; QL(1 ea 4 daily) entacapone) (pimavanserin tartrate) STALEVO 75 TABS NUPLAZID TABS PA; QL(1 ea 4 daily) (carbidopa-levodopa- 7 (pimavanserin tartrate) VRAYLAR CAPS QL(1 ea daily) entacapone) 4 (cariprazine hcl) Antiparkinson Monoamine Oxidase Inhibitors VRAYLAR CPPK QL(1 ea daily) AZILECT TABS 4 7 (cariprazine hcl) (rasagiline mesylate)

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLOZARIL TABS ziprasidone hcl caps 20 1 7 mg, 40 mg (clozapine) QL(2 ea daily) FAZACLO TBDP ziprasidone hcl caps 60 1 7 mg, 80 mg (clozapine) Benzisoxazoles loxapine succinate 1 INVEGA TB24 caps 7 (paliperidone) olanzapine tabs 10 mg, 1 2.5 mg, 5 mg, 7.5 mg paliperidone tb24 3 olanzapine tabs 15 mg, QL(1 ea daily) RISPERDAL SOLN 1 1 7 20 mg MG/ML (risperidone) olanzapine tbdp 10 mg, 3 RISPERDAL TABS 0.25 15 mg, 20 mg, 5 mg MG, 0.5 MG, 1 MG, 2 MG, 7 4 MG (risperidone) quetiapine fumarate tabs 100 mg, 25 mg, 50 1 RISPERDAL TABS 3 MG QL(2 ea daily) 7 mg (risperidone) quetiapine fumarate QL(4 ea daily) risperidone soln 1 1 1 tabs 200 mg mg/ml quetiapine fumarate QL(2 ea daily) risperidone tabs 0.25 1 tabs 300 mg, 400 mg mg, 0.5 mg, 1 mg, 2 1 mg, 4 mg quetiapine fumarate PA 3 QL(2 ea daily) tb24 150 mg, 200 mg, risperidone tabs 3 mg 1 300 mg, 400 mg quetiapine fumarate PA; ST risperidone tbdp 0.25 3 3 mg tb24 50 mg risperidone tbdp 0.5 SAPHRIS SUBL 10 MG, mg, 1 mg, 2 mg, 3 mg, 1 2.5 MG, 5 MG (asenapine 7 4 mg maleate) SAPHRIS SUBL 5 MG Butyrophenones 3 (asenapine maleate) haloperidol lactate conc 1 SEROQUEL TABS 100 MG, 25 MG, 50 MG 7 haloperidol tabs 1 (quetiapine fumarate) SEROQUEL TABS 200 MG QL(4 ea daily) Dibenzapines 7 (quetiapine fumarate) asenapine maleate 3 subl SEROQUEL TABS 300 QL(2 ea daily) MG, 400 MG (quetiapine 7 clozapine tabs 100 mg, 1 200 mg, 25 mg, 50 mg fumarate) SEROQUEL XR TB24 150 PA clozapine tbdp 100 mg, MG, 200 MG, 300 MG, 400 12.5 mg, 150 mg, 200 3 MG (quetiapine 7 mg, 25 mg fumarate)

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SEROQUEL XR TB24 50 PA; ST ABILIFY TABS 20 MG QL(1 ea daily) 7 MG (quetiapine 7 (aripiprazole) fumarate) aripiprazole soln 1 1 VERSACLOZ SUSP QL(18 ml daily) 3 mg/ml (clozapine) aripiprazole tabs 10 1 ZYPREXA TABS 10 MG, mg, 2 mg, 30 mg, 5 mg 2.5 MG, 5 MG, 7.5 MG 7 QL(2 ea daily) (olanzapine) aripiprazole tabs 15 mg 1 ZYPREXA TABS 15 MG, QL(1 ea daily) 7 aripiprazole tabs 20 mg 1 QL(1 ea daily) 20 MG (olanzapine) ZYPREXA ZYDIS TBDP aripiprazole tbdp 10 PA 7 3 (olanzapine) mg, 15 mg REXULTI TABS Phenothiazines 3 (brexpiprazole) (Prochlorperazine) 1 QL(2 ea daily) COMPRO SUPP Thioxanthenes chlorpromazine hcl 1 thiothixene caps 1 tabs ANTIVIRALS - Drugs to Treat Viral Infections fluphenazine hcl conc 5 3 mg/ml Antiretrovirals fluphenazine hcl elix 1 2.5 mg/5ml abacavir sulfate soln 1 fluphenazine hcl tabs 1 abacavir sulfate tabs 1 mg, 10 mg, 2.5 mg, 5 1 mg abacavir sulfate- 1 lamivudine tabs perphenazine tabs 1 abacavir sulfate- 1 prochlorperazine 1 lamivudine-zidovudine maleate tabs tabs QL(2 ea daily) APTIVUS CAPS prochlorperazine supp 1 2 (tipranavir) thioridazine hcl tabs 10 APTIVUS SOLN 1 2 mg, 100 mg, 25 mg (tipranavir) QL(4 ea daily) thioridazine hcl tabs 50 1 mg atazanavir sulfate caps 1 ATRIPLA TABS QL(1 ea daily) trifluoperazine hcl tabs 1 (efavirenz- 7 Quinolinone Derivatives emtricitabine-tenofovir ABILIFY TABS 10 MG, 2 disoproxil fumarate) MG, 30 MG, 5 MG 7 BIKTARVY TABS (aripiprazole) (bictegravir- 2 ABILIFY TABS 15 MG QL(2 ea daily) emtricitabine-tenofovir 7 (aripiprazole) alafenamide fumarate)

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CIMDUO TABS EMTRIVA CAPS 200 MG 7 (lamivudine-tenofovir 2 (emtricitabine) disoproxil fumarate) EMTRIVA SOLN 10 2 COMBIVIR TABS MG/ML (emtricitabine) 7 (lamivudine-zidovudine) EPIVIR SOLN 7 COMPLERA TABS (lamivudine) (emtricitabine- EPIVIR TABS 2 7 rilpivirine-tenofovir (lamivudine) disoproxil fumarate) EPZICOM TABS CRIXIVAN CAPS 2 (abacavir sulfate- 7 (indinavir sulfate) lamivudine) DELSTRIGO TABS etravirine tabs 1 (doravirine-lamivudine- tenofovir disoproxil 2 EVOTAZ TABS fumarate) (atazanavir sulfate- 2 DESCOVY TABS PV cobicistat) (emtricitabine-tenofovir 5 fosamprenavir calcium 1 alafenamide fumarate) tabs FUZEON SOLR PA; ST didanosine cpdr 1 4 (enfuvirtide) DOVATO TABS GENVOYA TABS (dolutegravir sodium- 2 (elvitegravir-cobicistat- lamivudine) emtricitabine-tenofovir 2 EDURANT TABS 2 alafenamide) (rilpivirine hcl) INTELENCE TABS 100 7 efavirenz caps 1 MG, 200 MG (etravirine) INTELENCE TABS 25 MG 2 efavirenz tabs 1 (etravirine) INVIRASE TABS efavirenz-emtricitabine- QL(1 ea daily) 2 tenofovir disoproxil 1 (saquinavir mesylate) ISENTRESS CHEW fumarate tabs 2 (raltegravir potassium) emtricitabine caps 1 ISENTRESS HD TABS 2 emtricitabine-tenofovir (raltegravir potassium) disoproxil fumarate ISENTRESS TABS 2 tabs 100 mg-150 mg, 1 (raltegravir potassium) 133 mg-200 mg, 150 JULUCA TABS mg-100 mg, 167 mg- (dolutegravir sodium- 2 250 mg rilpivirine hcl) emtricitabine-tenofovir PV KALETRA SOLN 7 disoproxil fumarate 5 (lopinavir-ritonavir) tabs 200 mg-300 mg, 300 mg-200 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KALETRA TABS RESCRIPTOR TABS 7 2 (lopinavir-ritonavir) (delavirdine mesylate) RETROVIR CAPS lamivudine soln 1 7 (zidovudine) lamivudine tabs 1 RETROVIR SYRP 7 (zidovudine) lamivudine-zidovudine 1 tabs REYATAZ CAPS 150 MG, 200 MG, 300 MG 7 LEXIVA SUSP 50 MG/ML (atazanavir sulfate) (fosamprenavir 2 REYATAZ PACK 50 MG 2 calcium) (atazanavir sulfate) LEXIVA TABS 700 MG (fosamprenavir 7 ritonavir tabs 1 calcium) RUKOBIA TB12 lopinavir-ritonavir soln 1 (fostemsavir 4 tromethamine) lopinavir-ritonavir tabs 1 SELZENTRY SOLN 2 (maraviroc) nevirapine susp 1 SELZENTRY TABS 2 nevirapine tabs 1 (maraviroc) stavudine caps 15 mg, 1 nevirapine tb24 1 20 mg, 30 mg, 40 mg NORVIR PACK 100 MG STAVUDINE CAPS 15 MG, 2 (ritonavir) 20 MG, 30 MG, 40 MG 2 (stavudine) NORVIR SOLN 80 MG/ML 2 (ritonavir) STRIBILD TABS (elvitegravir-cobicistat- NORVIR TABS 100 MG 2 7 emtricitabine-tenofovir (ritonavir) df) ODEFSEY TABS SUSTIVA CAPS (emtricitabine- 7 2 (efavirenz) rilpivirine-tenofovir SUSTIVA TABS alafenamide fumarate) 7 (efavirenz) PIFELTRO TABS 2 (doravirine) SYMTUZA TABS (darunavir-cobicistat- PREZCOBIX TABS QL(1 ea daily) 2 2 emtricitabine-tenofovir (darunavir-cobicistat) alafenamide) PREZISTA SUSP 100 TEMIXYS TABS MG/ML (darunavir 3 (lamivudine-tenofovir 2 ethanolate) disoproxil fumarate) PREZISTA TABS 150 MG, 600 MG, 75 MG, 800 MG 2 tenofovir disoproxil 1 (darunavir ethanolate) fumarate tabs

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIVICAY TABS VIREAD TABS 300 MG 2 (dolutegravir sodium) (tenofovir disoproxil 7 TRIUMEQ TABS fumarate) (abacavir-dolutegravir- 2 ZIAGEN SOLN ( abacavir 7 lamivudine) sulfate) TRIZIVIR TABS (abacavir ZIAGEN TABS ( abacavir 7 sulfate-lamivudine- 7 sulfate) zidovudine) zidovudine caps 1 TRUVADA TABS 133 MG- 200 MG, 150 MG-100 MG, zidovudine syrp 1 167 MG-250 MG 7 (emtricitabine-tenofovir zidovudine tabs 1 disoproxil fumarate) TRUVADA TABS 200 MG- PV CMV Agents 300 MG (emtricitabine- VALCYTE SOLR 50 QL(21 ml daily) tenofovir disoproxil 7 MG/ML (valganciclovir 7 fumarate) hcl) TYBOST TABS VALCYTE TABS 450 MG 2 7 (cobicistat) (valganciclovir hcl) VIDEX EC CPDR 125 MG valganciclovir hcl solr QL(21 ml daily) 2 1 (didanosine) 50 mg/ml VIDEX EC CPDR 200 MG, valganciclovir hcl tabs 1 250 MG, 400 MG 7 450 mg (didanosine) Hepatitis Agents VIDEXPEDIATRIC SOLR 2 (didanosine) adefovir dipivoxil tabs 1 VIRACEPT TABS BARACLUDE SOLN 0.05 PA 2 4 (nelfinavir mesylate) MG/ML (entecavir) VIRAMUNE SUSP BARACLUDE TABS 0.5 7 7 (nevirapine) MG, 1 MG (entecavir) VIRAMUNE TABS 7 1 (nevirapine) entecavir tabs VIRAMUNE XR TB24 EPCLUSA TABS 400 MG- PA 7 (nevirapine) 100 MG (sofosbuvir- 3 VIREAD POWD 40 MG/GM velpatasvir) (tenofovir disoproxil 2 EPIVIR HBV SOLN 5 fumarate) MG/ML (lamivudine 3 VIREAD TABS 150 MG, (hbv)) 200 MG, 250 MG EPIVIR HBV TABS 100 2 7 (tenofovir disoproxil MG (lamivudine (hbv)) fumarate) HEPSERA TABS 7 (adefovir dipivoxil)

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOVIRAX CAPS OR 200 lamivudine (hbv) tabs 3 7 MG (acyclovir) PA; PA: Must ZOVIRAX SUSP OR 200 MAVYRET TABS use 7 AcariaHealth MG/5ML (acyclovir) (glecaprevir- 4 ZOVIRAX TABS OR 400 Specialty Rx at 7 pibrentasvir) 1-844-538- MG (acyclovir) 4661;;LA ZOVIRAX TABS OR 800 QL(5 ea daily) 7 PEGASYS PROCLICK PA MG (acyclovir) SOLN (peginterferon 4 Influenza Agents alfa-2a) FLUMADINE TABS PEGASYS SOLN PA 4 (rimantadine 7 (peginterferon alfa-2a) hydrochloride) PEGINTRON KIT PA 4 oseltamivir phosphate QL(10 ea per (peginterferon alfa-2b) 1 fill retail); AL(At VEMLIDY TABS ST; LA caps or 30 mg, 45 mg least 1 yrs old) (tenofovir alafenamide 4 oseltamivir phosphate 1 fumarate) caps or 75 mg PA; PA: Must QL(75 ml use VOSEVI TABS oseltamivir phosphate 1 daily,5 day(s) (sofosbuvir-velpatasvir- 3 AcariaHealth susr or 6 mg/ml limit); AL(At Specialty Rx at least 1 yrs old) voxilaprevir) 1-844-538- RELENZA DISKHALER QL(20 ea per 4661;;LA 3 AEPB (zanamivir) fill retail) Herpes Agents rimantadine 3 acyclovir caps 200 mg 1 hydrochloride tabs TAMIFLU CAPS 30 MG, 45 QL(10 ea per acyclovir susp 200 1 mg/5ml MG (oseltamivir 7 fill retail); AL(At phosphate) least 1 yrs old) acyclovir tabs 400 mg 1 TAMIFLU CAPS 75 MG 7 acyclovir tabs 800 mg 1 QL(5 ea daily) (oseltamivir phosphate) QL(75 ml TAMIFLU SUSR 6 MG/ML famciclovir tabs 1 7 daily,5 day(s) (oseltamivir phosphate) limit); AL(At SITAVIG TABS PA least 1 yrs old) 3 (acyclovir) BETA BLOCKERS - Drugs to Treat High Blood QL(4 ea daily) Pressure valacyclovir hcl tabs 1 1 gm, 1000 mg Alpha-Beta Blockers valacyclovir hcl tabs QL(8 ea daily) 1 carvedilol phosphate 3 500 mg cp24 VALTREX TABS 1 GM QL(4 ea daily) 7 carvedilol tabs 12.5 mg, 1 (valacyclovir hcl) 25 mg, 6.25 mg VALTREX TABS 500 MG QL(8 ea daily) QL(2 ea daily) 7 carvedilol tabs 3.125 1 (valacyclovir hcl) mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COREG CR CP24 INDERAL XL CP24 7 (carvedilol phosphate) (propranolol hcl 3 COREG TABS 12.5 MG, sustained-release 25 MG, 6.25 MG 7 beads) (carvedilol) INNOPRAN XL CP24 COREG TABS 3.125 MG QL(2 ea daily) (propranolol hcl 7 3 (carvedilol) sustained-release beads) labetalol hcl tabs 1 nadolol tabs 1 Beta Blockers Cardio-Selective acebutolol hcl caps 1 pindolol tabs 1 atenolol tabs 1 propranolol hcl cp24 1 betaxolol hcl tabs 1 propranolol hcl soln 1 QL(1 ea daily) 1 bisoprolol fumarate 1 propranolol hcl tabs tabs or 10 mg, 5 mg BYSTOLIC TABS sotalol hcl (afib/afl) tabs 1 2 (nebivolol hcl) sotalol hcl tabs 1 LOPRESSOR TABS 7 QL(6 ea daily) (metoprolol tartrate) timolol maleate tabs 10 1 metoprolol succinate mg 1 QL(2 ea daily) tb24 timolol maleate tabs 20 1 mg, 5 mg metoprolol tartrate tabs 1 CALCIUM CHANNEL BLOCKERS - Drugs to TENORMIN TABS 7 Treat High Blood Pressure ( ) atenolol Calcium Channel Blockers TOPROL XL TB24 7 (Diltiazem Hcl Coated 1 QL(1 ea daily) (metoprolol succinate) Beads) CARTIA XT CP24 Beta Blockers Non-Selective (Diltiazem Hcl Coated 1 Beads) MATZIM LA TB24 (Sotalol Hcl) SORINE 1 TABS (Diltiazem Hcl Extended BETAPACE AF TABS Release Beads) TAZTIA 1 7 (sotalol hcl (afib/afl)) XT, TIADYLT ER CP24 (Diltiazem Hcl) DILT-XR BETAPACE TABS ( 1 sotalol 7 CP24 hcl) ADALAT CC TB24 30 MG, CORGARD TABS 7 7 60 MG (nifedipine) (nadolol) ADALAT CC TB24 90 MG QL(1 ea daily) INDERAL LA CP24 7 7 (nifedipine) (propranolol hcl) QL(1 ea daily) amlodipine besylate 1 tabs 10 mg, 5 mg

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily) amlodipine besylate 1 isradipine caps 1 tabs 2.5 mg CALAN SR TBCR 120 MG nicardipine hcl caps 1 7 (verapamil hcl) nifedipine caps 10 mg, CALAN SR TBCR 180 MG, QL(2 ea daily) 1 7 20 mg 240 MG (verapamil hcl) nifedipine tb24 30 mg, CALAN TABS ( 1 verapamil 7 60 mg ) hcl QL(1 ea daily) nifedipine tb24 30 mg, 1 CARDIZEM CD CP24 QL(1 ea daily) 60 mg, 90 mg (diltiazem hcl coated 7 beads) nimodipine caps 1 CARDIZEM LA TB24 120 1 MG (diltiazem hcl 2 nisoldipine tb24 coated beads) NORVASC TABS 10 MG, 5 QL(1 ea daily) CARDIZEM LA TB24 180 MG (amlodipine 7 MG, 240 MG, 300 MG, 360 besylate) 7 MG, 420 MG (diltiazem NORVASC TABS 2.5 MG QL(2 ea daily) 7 hcl coated beads) (amlodipine besylate) CARDIZEM TABS 7 NYMALIZE SOLN 30 (diltiazem hcl) MG/10ML, 60 MG/20ML 3 diltiazem hcl coated QL(1 ea daily) (nimodipine) PROCARDIA CAPS beads cp24 120 mg, 1 7 180 mg, 240 mg, 300 (nifedipine) mg, 360 mg PROCARDIA XL TB24 QL(1 ea daily) 7 diltiazem hcl coated (nifedipine) SULAR TB24 beads tb24 180 mg, 1 7 240 mg, 300 mg, 360 (nisoldipine) mg, 420 mg TIAZAC CP24 (diltiazem hcl extended release 7 diltiazem hcl cp12 120 1 mg, 60 mg, 90 mg beads) verapamil hcl cp24 100 diltiazem hcl cp24 180 1 mg, 240 mg mg, 120 mg, 200 mg, 1 diltiazem hcl extended 240 mg, 300 mg 1 QL(2 ea daily) release beads cp24 verapamil hcl cp24 180 1 diltiazem hcl tabs 120 mg QL(1 ea daily) mg, 30 mg, 60 mg, 90 1 verapamil hcl cp24 360 1 mg mg QL(1 ea daily) felodipine tb24 10 mg 1 verapamil hcl tabs 120 1 mg, 40 mg, 80 mg felodipine tb24 2.5 mg, 1 verapamil hcl tbcr 120 1 5 mg mg

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily) PA; Check plan verapamil hcl tbcr 180 1 mg, 240 mg documents for coverage;QL(8 VERELAN CP24 120 MG, CIALIS TABS 10 MG, 20 7 7 ea per 30 days 240 MG (verapamil hcl) MG, 5 MG (tadalafil) retail); AL(At VERELAN CP24 180 MG QL(2 ea daily) least 21 yrs 7 (verapamil hcl) old) VERELAN CP24 360 MG QL(1 ea daily) PA; QL(1 ea 7 CIALIS TABS 2.5 MG (verapamil hcl) 7 daily,30 ea per (tadalafil) fill retail,90 ea VERELAN PM CP24 7 per fill mail) (verapamil hcl) PA; Check plan CARDIOTONICS - Drugs to Treat Heart Failure documents for and Abnormal Heart Rhythm coverage;QL(8 sildenafil citrate tabs 4 ea per 30 days Cardiac Glycosides retail); AL(At (Digoxin) DIGITEK, DIGOX 1 least 21 yrs TABS old) digoxin soln 0.05 mg/ml 1 PA; Check plan documents for coverage;QL(8 digoxin tabs 0.125 mg, 1 tadalafil tabs 10 mg, 20 125 mcg, 250 mcg 4 ea per 30 days mg, 5 mg retail); AL(At LANOXIN TABS 125 MCG, 7 least 21 yrs 250 MCG (digoxin) old) LANOXIN TABS 62.5 MCG 2 PA; QL(1 ea (digoxin) 4 daily,30 ea per tadalafil tabs 2.5 mg fill retail,90 ea CARDIOVASCULAR AGENTS - MISC. - Drugs to per fill mail) Treat Heart and Circulation Conditions PA; Check plan Cardiovascular Agents Misc. - Combinations documents for amlodipine besylate- PA VIAGRA TABS (sildenafil coverage;QL(8 atorvastatin calcium 3 7 ea per 30 days citrate) retail); AL(At tabs least 21 yrs BIDIL TABS (isosorbide old) dinitrate-hydralazine 3 Prostaglandin Vasodilators hcl) ORENITRAM TBCR PA 4 CADUET TABS PA (treprostinil diolamine) (amlodipine besylate- 7 TYVASO REFILL SOLN PA 4 atorvastatin calcium) (treprostinil) ENTRESTO TABS 24 MG- PA; QL(2 ea TYVASO SOLN PA 26 MG, 26 MG-24 MG 3 daily) 4 ( ) (sacubitril-valsartan) treprostinil TYVASO STARTER SOLN PA ENTRESTO TABS 49 MG- PA 4 51 MG, 97 MG-103 MG 3 (treprostinil) VENTAVIS SOLN PA (sacubitril-valsartan) 4 (iloprost) Impotence Agents

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

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Transthyretin Stabilizers cefditoren pivoxil tabs 3 VYNDAMAX CAPS PA; QL(1 ea 4 (tafamidis) daily) cefixime caps 400 mg 3 VYNDAQEL CAPS PA; QL(4 ea cefixime susr 100 1 (tafamidis meglumine 4 daily) mg/5ml, 200 mg/5ml (cardiac)) cefpodoxime proxetil 1 CEPHALOSPORINS - Drugs to Treat Bacterial susr Infections cefpodoxime proxetil 1 Cephalosporins - 1st Generation tabs 1 SUPRAX CAPS 400 MG cefadroxil caps 7 (cefixime) cefadroxil susr 1 SUPRAX CHEW 100 MG, 3 200 MG (cefixime) cefadroxil tabs 1 SUPRAX SUSR 100 MG/5ML, 200 MG/5ML 7 cephalexin caps 250 1 mg, 500 mg (cefixime) SUPRAX SUSR 500 cephalexin caps 750 3 3 mg MG/5ML (cefixime) cephalexin susr 125 1 CHEMICALS mg/5ml, 250 mg/5ml Bulk Chemicals - E's cephalexin tabs 250 3 mg, 500 mg ESTRADIOL CONCENTRATE CREA 3 KEFLEX CAPS 7 (estradiol (bulk)) (cephalexin) CONTRACEPTIVES - Drugs to Prevent Cephalosporins - 2nd Generation Pregnancy cefaclor caps 1 Combination Contraceptives - Oral CEFACLOR ER TB12 (Desogestrel & Ethinyl PV 3 Estradiol) APRI, CYRED, (cefaclor monohydrate) CYRED EQ, cefaclor susr 1 EMOQUETTE, ENSKYCE, 5 ISIBLOOM, JULEBER, cefprozil susr 1 KALLIGA, RECLIPSEN TABS cefprozil tabs 1 (Desogestrel-Ethinyl PV Estradiol (Biphasic)) cefuroxime axetil tabs 1 AZURETTE, BEKYREE, 5 KARIVA, PIMTREA, Cephalosporins - 3rd Generation SIMLIYA, VIORELE, VOLNEA TABS cefdinir caps 1 (Desogestrel-Ethinyl PV Estradiol (Triphasic)) 5 cefdinir susr 1 CAZIANT, VELIVET TABS

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Drospirenone-Ethinyl QL(1 ea daily); (Norethin Acet & Estrad- PV Estradiol) GIANVI, PV Fe) AUROVELA 24 FE, JASMIEL, LO- AUROVELA FE 1.5/30, ZUMANDIMINE, LORYNA, 5 AUROVELA FE 1/20, NIKKI, OCELLA, SYEDA, BLISOVI 24 FE, BLISOVI VESTURA, ZARAH, FE 1.5/30, BLISOVI FE ZUMANDIMINE TABS 1/20, HAILEY 24 FE, (Drospirenone-Ethinyl QL(1 ea daily); HAILEY FE 1.5/30, HAILEY Estradiol-Levomefolate 5 PV FE 1/20, JUNEL FE 1.5/30, Calcium) TYDEMY TABS JUNEL FE 1/20, JUNEL FE 5 24, LARIN 24 FE, LARIN (Ethynodiol Diacet & Eth PV FE 1.5/30, LARIN FE 1/20, Estrad) KELNOR 1/35, 5 LOESTRIN FE 1.5/30, KELNOR 1/50, ZOVIA LOESTRIN FE 1/20, 1/35, ZOVIA 1/35E TABS MICROGESTIN 24 FE, (Levonorgestrel & Eth PV MICROGESTIN FE 1.5/30, Estradiol) AFIRMELLE, MICROGESTIN FE 1/20, ALTAVERA, AUBRA, TARINA 24 FE, TARINA AUBRA EQ, AVIANE, FE 1/20, TARINA FE 1/20 AYUNA, CHATEAL, EQ TABS CHATEAL EQ, DELYLA, (Norethin Acet & Estrad- QL(365 ea per FALMINA, KURVELO, 5 Fe) CHARLOTTE 24 FE, 5 fill retail); PV LARISSIA, LESSINA, MELODETTA 24 FE, LEVORA 0.15/30-28, MIBELAS 24 FE CHEW LILLOW, LUTERA, MARLISSA, ORSYTHIA, (Norethin Acet & Estrad- PA; PV PORTIA-28, SRONYX, Fe) GEMMILY, MERZEE, 5 VIENVA TABS TAYSOFY CAPS (Levonorgestrel-Eth PV (Norethindrone & Eth PV Estradiol (Triphasic)) Estradiol) ALYACEN 1/35, ENPRESSE-28, 5 BALZIVA, BRIELLYN, LEVONEST, TRIVORA-28 CYCLAFEM 1/35, TABS DASETTA 1/35, NECON 5 0.5/35-28, NORTREL (Levonorgestrel-Ethinyl QL(1 ea 0.5/35 (28), NORTREL Estradiol (91-Day)) daily,91 day(s) 1/35, PHILITH, PIRMELLA AMETHIA, AMETHIA LO, limit); PV 1/35, VYFEMLA, WERA ASHLYNA, CAMRESE, TABS CAMRESE LO, DAYSEE, 5 FAYOSIM, ICLEVIA, (Norethindrone & Ethinyl QL(1 ea daily); INTROVALE, JAIMIESS, Estradiol-Fe) KAITLIB FE, 5 PV JOLESSA, LOJAIMIESS, LAYOLIS FE, WYMZYA FE RIVELSA, SETLAKIN, CHEW SIMPESSE TABS (Norethindrone & Ethinyl PV (Levonorgestrel-Ethinyl PV Estradiol-Fe) KAITLIB FE, 5 LAYOLIS FE, WYMZYA FE Estradiol (Continuous)) 5 AMETHYST, DOLISHALE CHEW TABS

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

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levonorgestrel-eth PV norethindrone & ethinyl QL(1 ea daily); 5 PV estradiol (triphasic) estradiol-fe chew 0.8 5 tabs mg-25 mcg-75 mg, 75 mg-0.8 mg-25 mcg levonorgestrel-ethinyl QL(1 ea 5 daily,91 day(s) PV estradiol (91-day) tabs norethindrone acet & 5 limit); PV eth estra tabs levonorgestrel-ethinyl PV norgestimate-ethinyl PV estradiol (continuous) 5 estradiol (triphasic) 5 tabs tabs LO LOESTRIN FE TABS QL(1 ea daily); norgestimate-ethinyl QL(1 ea daily); (norethindrone acetate- PV PV ethinyl estradiol-fe fum 5 estradiol (triphasic) 5 tabs (biphasic)) norgestimate-ethinyl QL(1 ea daily); LOSEASONIQUE TABS QL(1 ea 5 PV (levonorgestrel-ethinyl 7 daily,91 day(s) estradiol tabs estradiol (91-day)) limit); PV ORTHO TRI-CYCLEN LO PV TABS (norgestimate- MINASTRIN 24 FE CHEW QL(365 ea per 7 (norethin acet & estrad- 7 fill retail); PV ethinyl estradiol fe) (triphasic)) MIRCETTE TABS PV ORTHO-NOVUM 1/35 PV (desogestrel-ethinyl 7 TABS (norethindrone & 7 estradiol (biphasic)) eth estradiol) NATAZIA TABS QL(1 ea daily); ORTHO-NOVUM 7/7/7 QL(1 ea daily); PV (estradiol valerate- 5 PV TABS (norethindrone- 7 dienogest) eth estradiol (triphasic)) NEXTSTELLIS TABS PV QUARTETTE TABS QL(1 ea 5 daily,91 day(s) (drospirenone-estetrol) (levonorgestrel-ethinyl 7 estradiol (91-day)) limit); PV norethin acet & estrad- PA; PV fe caps 1 mg-20 mcg- SAFYRAL TABS QL(1 ea daily); 5 (drospirenone-ethinyl PV 75 mg, 75 mg-1 mg-20 7 mcg estradiol-levomefolate calcium) norethin acet & estrad- QL(365 ea per fill retail); PV SEASONIQUE TABS QL(1 ea fe chew 1 mg-20 mcg- (levonorgestrel-ethinyl 7 daily,91 day(s) 5 75 mg, 1 mg-75 mg-20 estradiol (91-day)) limit); PV mcg, 75 mg-1 mg-20 mcg TAYTULLA CAPS PA; PV (norethin acet & estrad- 7 norethin acet & estrad- PV fe) fe tabs 1 mg-20 mcg- 5 TYBLUME CHEW PV 75 mg, 75 mg-1.5 mg- (levonorgestrel & eth 5 30 mcg estradiol) norethindrone & ethinyl PV estradiol-fe chew 0.4 5 mg-35 mcg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits YASMIN 28 TABS QL(1 ea daily); (Norethindrone QL(1 ea daily); (drospirenone-ethinyl 7 PV (Contraceptive)) CAMILA, PV estradiol) DEBLITANE, ERRIN, HEATHER, INCASSIA, YAZ TABS QL(1 ea daily); JENCYCLA, LYLEQ, 5 (drospirenone-ethinyl 7 PV LYZA, NORA-BE, estradiol) NORLYDA, NORLYROC, SHAROBEL, TULANA Combination Contraceptives - Transdermal TABS (Norelgestromin-Ethinyl 365 rtl day(s) QL(1 ea daily); 5 norethindrone Estradiol) XULANE, supply,; PV 5 PV ZAFEMY PTWK (contraceptive) tabs TWIRLA PTWK QL(3 ea per 28 ORTHO MICRONOR QL(1 ea daily); (levonorgestrel-ethinyl 5 days retail); PV TABS (norethindrone 7 PV estradiol) (contraceptive)) SLYND TABS QL(1 ea daily); Combination Contraceptives - Vaginal 5 (drospirenone) PV (Etonogestrel-Ethinyl 1 PV Estradiol) ELURYNG RING CORTICOSTEROIDS - Steroid Hormone Drugs to PV Treat Systemic Swelling Conditions etonogestrel-ethinyl 1 estradiol ring Glucocorticosteroids NUVARING RING PV (Dexamethasone) 1 (etonogestrel-ethinyl 7 DECADRON ELIX estradiol) (Dexamethasone) 1 DECADRON TABS Emergency Contraceptives QL(3 ea daily) (Levonorgestrel AL(Up to 17 yrs budesonide cpep 3 mg 1 (Emergency Oc)) AFTERA, old ); PV PA AFTERPILL, ECONTRA budesonide tb24 9 mg 3 EZ, ECONTRA ONE- CORTEF TABS STEP, MY CHOICE, MY 5 7 WAY, NEW DAY, (hydrocortisone) OPCICON ONE-STEP, cortisone acetate tabs 1 OPTION 2, PREVENTEZA, REACT, TAKE ACTION dexamethasone elix 0.5 1 TABS mg/5ml ELLA TABS ( PV ulipristal 5 DEXAMETHASONE acetate) INTENSOL CONC 2 AL(Up to 17 yrs (dexamethasone) levonorgestrel 5 (emergency oc) tabs old ); PV dexamethasone soln 1 PLAN B ONE-STEP TABS AL(Up to 17 yrs 0.5 mg/5ml (levonorgestrel 7 old ); PV dexamethasone tabs (emergency oc)) 0.5 mg, 0.75 mg, 1 mg, 1 Progestin Contraceptives - Oral 1.5 mg, 2 mg, 4 mg, 6 mg EMFLAZA SUSP PA; LA 4 (deflazacort)

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMFLAZA TABS PA; LA 4 prednisone tbpk 10 mg, 1 (deflazacort) 5 mg ENTOCORT EC CPEP QL(3 ea daily) UCERIS TB24 OR 9 MG PA 7 7 (budesonide) (budesonide) hydrocortisone tabs 1 Mineralocorticoids MEDROL DOSEPAK TBPK fludrocortisone acetate 7 1 (methylprednisolone) tabs MEDROL TABS 16 MG, 32 COUGH/COLD/ALLERGY - Drugs to Treat MG, 4 MG, 8 MG 7 Cough, Cold and Allergy Symptoms (methylprednisolone) Antitussives MEDROL TABS 2 MG 2 (Hydrocodone W/ (methylprednisolone) Homatropine) HYDROMET 1 SYRP methylprednisolone 1 tabs benzonatate caps 100 1 mg, 200 mg methylprednisolone 1 tbpk benzonatate caps 150 3 ORAPRED ODT TBDP mg (prednisolone sodium 7 HYCODAN SYRP phosphate) (hydrocodone w/ 7 PEDIAPRED SOLN homatropine) (prednisolone sodium 7 hydrocodone w/ phosphate) homatropine syrp 1.5 1 prednisolone sodium mg/5ml-5 mg/5ml, 5 phosphate soln or 15 mg/5ml-1.5 mg/5ml 1 TESSALON PERLES mg/5ml, 5 mg/5ml, 6.7 7 mg/5ml CAPS (benzonatate) prednisolone sodium Cough/Cold/Allergy Combinations phosphate soln or 25 3 (Guaifenesin-Codeine) G mg/5ml TUSSIN AC, MAXI-TUSS 1 prednisolone sodium AC, VIRTUSSIN A/C SOLN phosphate tbdp or 10 3 (Guaifenesin-Codeine) GUAIATUSSIN AC, 1 mg, 15 mg, 30 mg GUAIFENESIN AC SYRP prednisolone soln 1 (Guaifenesin-Codeine) TRYMINE CG, VIRTUSSIN 3 PREDNISONE INTENSOL 2 AC/ALC LIQD CONC (prednisone) (Guaifenesin-Codeine) TRYMINE CG, VIRTUSSIN 1 prednisone soln 5 1 mg/5ml AC/ALC LIQD prednisone tabs 1 mg, 10 mg, 2.5 mg, 20 mg, 1 5 mg, 50 mg

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Phenylephrine- (Pseudoephedrine- Brompheniramine-Dm) Guaifenesin) MUCUS 3 GLENMAX PEB DM 3 RELIEF D TB12 120 MG- FORTE, PRESGEN B, 1200 MG TUSSI-PRES B LIQD (Pseudoephedrine- (Phenylephrine-Chlorphen- Guaifenesin) MUCUS 1 Dm) ED A-HIST DM, 3 RELIEF D TB12 60 MG- NOHIST-DM LIQD 600 MG, 600 MG-60 MG (Pseudoephedrine W/ ACTINEL PEDIATRIC Codeine-Gg) 1 LIQD (pseudoephedrine 3 GUAIFENESIN DAC SOLN w/ dm-gg) (Pseudoephedrine- BIO-DTUSS DMX LIQD Guaifenesin) AMBI 3 40PSE/400GFN TABS (pseudoephed- 3 bromphen-dm) (Pseudoephedrine- Guaifenesin) CVS MUCUS BIONEL PEDIATRIC LIQD D EXTENDED RELEASE, (pseudoephedrine w/ 3 CVS MUCUS D MAXIMUM dm-gg) STRENGTH ER, EQ BRONKIDS LIQD MUCUS-D, GNP MUCUS D 12 HR, HM MUCUS (phenylephrine- 3 RELIEF D, MUCUS D, 1 chlorphen-dm) MUCUS D MAXIMUM CAPCOF SYRP STRENGTH, MUCUS-D, (phenylephrine- RA MUCUS RELIEF D, RA chlorpheniramine w/ 3 MUCUS RELIEF D MAXIMUMSTRENGTH, codeine) CODITUSSIN AC LIQD SM MUCUS RELIEF D 3 TB12 (guaifenesin-codeine) (Pseudoephedrine- ED BRON GP LIQD Guaifenesin) CVS MUCUS (phenylephrine- 3 D EXTENDED RELEASE, guaifenesin) CVS MUCUS D MAXIMUM STRENGTH ER, EQ GILPHEX TR TABS RX/OTC MUCUS-D, GNP MUCUS (phenylephrine- 3 D 12 HR, HM MUCUS guaifenesin) RELIEF D, MUCUS D, 3 GILTUSS COUGH & COLD RX/OTC MUCUS D MAXIMUM TABS ( 3 STRENGTH, MUCUS-D, phenylephrine w/ RA MUCUS RELIEF D, RA dm-gg) MUCUS RELIEF D GILTUSS SINUS & RX/OTC MAXIMUMSTRENGTH, CONGESTION TABS SM MUCUS RELIEF D (phenylephrine- 3 TB12 guaifenesin) (Pseudoephedrine- GILTUSS TR TABS RX/OTC Guaifenesin) MUCUS 3 ( 3 RELIEF D TABS 40 MG- phenylephrine w/ dm- 400 MG, 400 MG-40 MG gg)

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLENMAX PEB LIQD QL(30 ml daily) promethazine & 1 (brompheniramine & 3 phenylephrine syrp phenyleph) QL(30 ml daily) promethazine 1 guaifenesin-codeine 1 w/codeine soln soln QL(30 ml daily) promethazine 1 hydrocodone polistirex- w/codeine syrp chlorpheniramine 1 QL(30 ml daily) promethazine-dm syrp 1 polistirex suer 6.25 mg/5ml-15 mg/5ml LOHIST-DM SYRP promethazine- (phenylephrine- 3 phenylephrine-codeine 1 brompheniramine-dm) syrp M-CLEAR WC SOLN 3 pseudoephed- (guaifenesin-codeine) 3 bromphen-dm syrp M-END PE LIQD (phenylephrine- pseudoephed-cpm w/ 3 brompheniramine w/ 3 hydrocod soln codeine) pseudoephedrine- MAR-COF BP LIQD guaifenesin tb12 120 3 (pseudoephedrine- mg-1200 mg brompheniramine- 3 pseudoephedrine- codeine) guaifenesin tb12 60 1 MAR-COF CG mg-600 mg, 600 mg-60 EXPECTORANT LIQD 7 mg (guaifenesin-codeine) RYDEX LIQD MAXI-TUSS PE MAX LIQD (pseudoephedrine- 3 (phenylephrine- 3 brompheniramine- guaifenesin) codeine) MUCINEX D MAXIMUM SORBUTUSS NR LIQD STRENGTH TB12 ( 3 7 dextromethorphan-gg- (pseudoephedrine- potassium citrate) guaifenesin) TUSNEL C SYRP MUCINEX D TB12 (pseudoephedrine w/ 3 (pseudoephedrine- 7 codeine-gg) guaifenesin) TUSNEL PEDIATRIC LIQD NEOTUSS PLUS LIQD (pseudoephedrine w/ 3 (phenylephrine- 3 dm-gg) chlorphen-dm) TUSNEL TABS NINJACOF-XG LIQD 3 (pseudoephedrine w/ 3 (guaifenesin-codeine) dm-gg) PRO-RED AC SYRP (phenylephrine- dexchlorpheniramine- 3 codeine)

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUSSICAPS CP12 HYPERSAL NEBU 7 % (hydrocodone (sodium chloride 7 polistirex- 3 (inhalant)) chlorpheniramine NEBUSAL NEBU polistirex) (sodium chloride 3 VANACOF LIQD (inhalant)) (pseudoephedrine- 3 sodium chloride 1 dexchlorpheniramine- (inhalant) nebu 0.9 % chlophedianol) sodium chloride 3 VIRTUSSIN DAC SOLN (inhalant) nebu 7 % (pseudoephedrine w/ 2 codeine-gg) Mucolytics Expectorants acetylcysteine soln 1 (Guaifenesin) BIDEX, DERMATOLOGICALS - Drugs to Treat Skin CHEST CONGESTION Conditions RELIEF, CVS CHEST CONGESTION RELIEF, Acne Products FENESIN IR, GNP MUCUS QL(45 gm per RELIEF, GNP TAB (Adapalene) ADAPALENE 1 TREATMENT GEL fill retail); TUSSIN, GOODSENSE RX/OTC MUCUS RELIEF, HM (Clindamycin Phosphate CHEST CONGESTION (Topical)) CLINDACIN ETZ 3 RELIEF, KLS MUCUS 3 PLEDGETS, CLINDACIN-P RELIEF CHEST, LIQUIBID, SWAB MUCOSA, MUCUS RELIEF, MUCUS RELIEF (Clindamycin Phosphate- CHEST CONGESTION, Benzoyl Peroxide 1 PHARBINEX, QC MEDIFIN (Refrigerate)) NEUAC GEL 400, REFENESEN 400, SB (Erythromycin (Acne Aid)) 3 MUCUS RELIEF, SM ERY PADS CHEST CONGESTION (Isotretinoin) ACCUTANE, QL(4 ea RELIEF, XPECT TABS AMNESTEEM, CLARAVIS, 1 daily,150 3 MYORISAN, ZENATANE day(s) limit) guaifenesin tabs CAPS 10 MG Misc. Respiratory Inhalants (Isotretinoin) ACCUTANE, QL(5 ea (Sodium Chloride AMNESTEEM, CLARAVIS, 1 daily,150 (Inhalant)) PULMOSAL 3 MYORISAN, ZENATANE day(s) limit) NEBU CAPS 20 MG HYPER-SAL NEBU (Isotretinoin) ACCUTANE, QL(2 ea AMNESTEEM, CLARAVIS, 1 daily,150 (sodium chloride 7 MYORISAN, ZENATANE day(s) limit) (inhalant)) CAPS 40 MG HYPERSAL NEBU 3.5 % (Isotretinoin) ACCUTANE, QL(3 ea (sodium chloride 3 CLARAVIS, MYORISAN, 1 daily,150 (inhalant)) ZENATANE CAPS 30 MG day(s) limit)

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Sulfacetamide Sodium W/ AZELEX CREA ( azelaic 3 Sulfur) BP 10-1, 3 acid (acne)) SULFAMEZ WASH EMUL BENZACLIN GEL (Sulfacetamide Sodium W/ 1 ( Sulfur) SSS 10-5 FOAM clindamycin phosphate-benzoyl 7 (Sulfacetamide Sodium- Sulfur In Urea Vehicle) BP 1 peroxide) CLEANSING WASH EMUL BENZACLIN WITH PUMP GEL (clindamycin (Tretinoin) AVITA CREA 1 phosphate-benzoyl 7 (Tretinoin) AVITA GEL 1 peroxide) BENZAMYCIN GEL QL(2 gm daily) ABSORICA CAPS 10 MG, QL(4 ea (benzoyl peroxide- 7 7 daily,150 25 MG (isotretinoin) day(s) limit) erythromycin) benzoyl peroxide- QL(2 gm daily) ABSORICA CAPS 20 MG QL(5 ea 1 7 daily,150 erythromycin gel (isotretinoin) day(s) limit) CLEOCIN-T GEL ABSORICA CAPS 30 MG QL(3 ea (clindamycin phosphate 7 7 daily,150 (topical)) (isotretinoin) day(s) limit) CLEOCIN-T LOTN ABSORICA CAPS 35 MG, QL(2 ea (clindamycin phosphate 7 7 daily,150 40 MG (isotretinoin) day(s) limit) (topical)) ACZONE GEL 5 % PA; ST CLINDAGEL GEL 7 (dapsone (topical)) (clindamycin phosphate 7 ACZONE GEL 7.5 % PA; ST;QL(2 (topical)) 7 (dapsone (topical)) gm daily) clindamycin phosphate 3 (topical) foam 1 QL(45 gm per adapalene crea 0.1 % fill retail) clindamycin phosphate 1 QL(45 gm per (topical) gel adapalene gel 0.1 % 1 fill retail); clindamycin phosphate 1 RX/OTC (topical) lotn QL(45 gm per adapalene gel 0.3 % 1 fill retail,135 gm clindamycin phosphate 1 per fill mail) (topical) soln Limit 59mls per clindamycin phosphate 3 adapalene lotn 0.1 % 3 month;QL(1.97 (topical) swab ml daily) clindamycin phosphate- Limit 45gms benzoyl peroxide 1 adapalene-benzoyl 1 per peroxide gel month;QL(1.5 (refrigerate) gel gm daily) clindamycin phosphate- Limit 45gms benzoyl peroxide gel 1 3 per ATRALIN GEL (tretinoin) 7 %-5 % month;QL(1.5 QL(1 gm daily) gm daily) clindamycin phosphate- 3 tretinoin gel 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; ST QL(5 ea dapsone (topical) gel 5 3 % isotretinoin caps 20 mg 1 daily,150 day(s) limit) dapsone (topical) gel PA; ST;QL(2 3 gm daily) QL(3 ea 7.5 % isotretinoin caps 30 mg 1 daily,150 DIFFERIN CREA 0.1 % QL(45 gm per day(s) limit) 7 (adapalene) fill retail) isotretinoin caps 35 mg, QL(2 ea 1 daily,150 DIFFERIN GEL 0.1 % QL(45 gm per 7 fill retail); 40 mg day(s) limit) (adapalene) RX/OTC KLARON LOTN DIFFERIN GEL 0.3 % QL(45 gm per (sulfacetamide sodium 7 7 fill retail,135 gm (acne)) (adapalene) per fill mail) PLEXION CLEANSER DIFFERIN LOTN 0.1 % Limit 59mls per LIQD (sulfacetamide 7 3 month;QL(1.97 (adapalene) ml daily) sodium w/ sulfur) PLEXION CREA DUAC GEL (clindamycin phosphate-benzoyl 7 (sulfacetamide sodium 7 ) peroxide (refrigerate)) w/ sulfur PLEXION LOTN PA; ST; Limited EPIDUO FORTE GEL (sulfacetamide sodium 7 ( 3 45gms per adapalene-benzoyl month;QL(1.5 w/ sulfur) peroxide) gm daily) RETIN-A CREA (tretinoin) 7 EPIDUO GEL Limit 45gms ( 7 per RETIN-A GEL (tretinoin) 7 adapalene-benzoyl month;QL(1.5 peroxide) gm daily) RETIN-A MICRO GEL 0.04 Limit 20gms ERYGEL GEL %, 0.1 % (tretinoin 7 per (erythromycin (acne 7 month;QL(0.67 microsphere) gm daily) aid)) Limit 20gms erythromycin (acne aid) RETIN-A MICRO PUMP 1 GEL 0.04 %, 0.1 % 7 per gel month;QL(0.67 (tretinoin microsphere) gm daily) erythromycin (acne aid) 3 pads RETIN-A MICRO PUMP PA; ST GEL 0.08 % (tretinoin 3 erythromycin (acne aid) 1 soln microsphere) EVOCLIN FOAM SODIUM SULFACETAMIDE/SULFU (clindamycin phosphate 7 R CLEANSER IN UREA (topical)) EMUL (sulfacetamide 3 Limit 50gms sodium-sulfur in urea FABIOR FOAM 3 per vehicle) (tazarotene (acne)) month;QL(1.67 gm daily) sulfacetamide sodium 1 (acne) lotn isotretinoin caps 10 QL(4 ea 1 daily,150 mg, 25 mg day(s) limit) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfacetamide sodium (Diclofenac Sodium RX/OTC w/ sulfur crea 4.8 %-9.8 3 (Topical)) ARTHRITIS % PAIN RELIEVER, ASPERCREME sulfacetamide sodium ARTHRITIS PAIN w/ sulfur liqd 4.8 %-9.8 3 RELIEVER, CVS 1 %, 9.8 %-4.8 % DICLOFENAC SODIIUM, GNP ARTHRITIS PAIN, sulfacetamide sodium GOODSENSE ARTHRITIS w/ sulfur lotn 4.8 %-9.8 3 PAIN, QC DICLOFENAC % SODIIUM GEL QL(30 gm per diclofenac sodium RX/OTC sulfacetamide sodium 1 1 w/ sulfur lotn 5 %-10 % fill retail) (topical) gel 1 % Limit 50gms diclofenac sodium QL(5 ml daily) TAZAROTENE FOAM 1 3 per (topical) soln 1.5 % (tazarotene (acne)) month;QL(1.67 gm daily) REXAPHENAC CREA (diclofenac sodium 3 tretinoin crea 0.025 %, 1 (topical)) 0.05 %, 0.1 % VOLTAREN GEL RX/OTC tretinoin gel 0.01 %, 1 (diclofenac sodium 7 0.025 % (topical)) Limit 45gms per Antibiotics - Topical tretinoin gel 0.05 % 3 ALTABAX OINT month;QL(1.5 3 gm daily) (retapamulin) Limit 20gms CENTANY OINT 2 tretinoin microsphere 1 per (mupirocin) gel month;QL(0.67 gm daily) gentamicin sulfate 1 VELTIN GEL QL(1 gm daily) (topical) crea (clindamycin 7 gentamicin sulfate 1 phosphate-tretinoin) (topical) oint ZIANA GEL ( QL(1 gm daily) clindamycin 7 mupirocin oint 1 phosphate-tretinoin) Antifungals - Topical Agents for External Genital and Perianal Warts (Ciclopirox) CICLODAN 3 VEREGEN OINT QL(30 gm per SOLN 3 fill retail) (sinecatechins) (Iodoquinol-Hydrocortisone Anti-inflammatory Agents - Topical In Aloe Vehicle) 3 IODOQUIMEZ-HC CREA (Ketoconazole (Topical)) 3 KETODAN FOAM (Nystatin (Topical)) NYAMYC, NYSTOP 1 POWD ciclopirox gel ex 0.77 % 1

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOPROX CREA ciclopirox olamine crea 1 7 (ciclopirox olamine) ciclopirox olamine susp 1 LOPROX SHAMPOO 7 SHAM (ciclopirox) ciclopirox sham ex 1 % 3 LOPROX SUSP 7 (ciclopirox olamine) ciclopirox soln ex 8 % 3 LOTRISONE CREA Limit 45gms Limit 45gms (clotrimazole w/ 7 per clotrimazole w/ 1 per month;QL(1.5 betamethasone crea month;QL(1.5 betamethasone) gm daily) gm daily) 3 PA QL(2 ml daily) luliconazole crea clotrimazole w/ 1 LUZU CREA PA betamethasone lotn 7 (luliconazole) econazole nitrate crea 1 naftifine hcl crea 1 %, 2 3 Limit 70gms % ECOZA FOAM per 3 NAFTIFINE (econazole nitrate) month;QL(2.34 gm daily) HYDROCHLORIDE CREA 7 (naftifine hcl) ERTACZO CREA PA 4 NAFTIN CREA 2 % (sertaconazole nitrate) 7 (naftifine hcl) EXELDERM CREA 7 NAFTIN GEL 2 % (sulconazole nitrate) 3 (naftifine hcl) EXELDERM SOLN 2 NIZORAL SHAM (sulconazole nitrate) 7 (ketoconazole (topical)) EXELDERM SOLN 7 (sulconazole nitrate) nystatin (topical) crea 1 EXODERM LOTN (sodium thiosulfate- 3 nystatin (topical) oint 1 salicylic acid) nystatin (topical) powd 1 EXTINA FOAM 7 (ketoconazole (topical)) nystatin-triamcinolone 1 iodoquinol- crea hydrocortisone in aloe 3 nystatin-triamcinolone 1 vehicle crea oint JUBLIA SOLN PA; ST 3 oxiconazole nitrate crea 3 (efinaconazole) OXISTAT CREA ketoconazole (topical) QL(2 gm daily) 7 1 (oxiconazole nitrate) crea OXISTAT LOTN 3 ketoconazole (topical) 3 (oxiconazole nitrate) foam PENLAC NAIL LACQUER 7 ketoconazole (topical) 1 SOLN (ciclopirox) sham

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 gm daily) sulconazole nitrate 3 calcipotriene foam 3 crea CALCIPOTRIENE FOAM QL(4 gm daily) 3 sulconazole nitrate soln 1 (calcipotriene) VYTONE CREA calcipotriene oint 1 QL(5 gm daily) (iodoquinol- 7 hydrocortisone in aloe calcipotriene soln 1 vehicle) Limit 100gms Antineoplastic or Premalignant Lesion Agents - calcitriol (topical) oint 1 per CARAC CREA QL(1 gm daily) month;QL(3.34 7 (fluorouracil (topical)) gm daily) PA COSENTYX PA; ST diclofenac sodium 3 SENSOREADY PEN SOAJ 4 (actinic keratoses) gel (secukinumab) EFUDEX CREA COSENTYX SOSY 150 PA; ST 7 4 (fluorouracil (topical)) MG/ML (secukinumab) FLUOROPLEX CREA 2 COSENTYX SOSY 75 PA (fluorouracil (topical)) MG/0.5ML 4 QL(1 gm daily) (secukinumab) fluorouracil (topical) 1 crea 0.5 % DOVONEX CREA QL(5 gm daily) 7 (calcipotriene) fluorouracil (topical) 1 crea 5 % ILUMYA SOSY PA; ST 4 (tildrakizumab-asmn) fluorouracil (topical) 1 soln 2 %, 5 % methoxsalen rapid caps 1 PANRETIN GEL PA 3 OXSORALEN ULTRA (alitretinoin) CAPS (methoxsalen 7 PICATO GEL ( ingenol 3 rapid) mebutate) PA; QL(1 ml TARGRETIN GEL EX 1 % SKYRIZI PEN SOAJ 2 4 per 84 days (bexarotene (topical)) (risankizumab-rzaa) retail) VALCHLOR GEL PA; ST SKYRIZI PSKT 75 PA (mechlorethamine hcl 4 MG/0.83ML 4 (topical)) (risankizumab-rzaa) Antipsoriatics SKYRIZI SOSY 150 PA; QL(1 ml MG/ML (risankizumab- 4 per 84 days (Calcipotriene) 1 QL(5 gm daily) retail) CALCITRENE OINT rzaa) SORIATANE CAPS 10 MG QL(1 ea daily) 3 QL(1 ea daily) 7 acitretin caps 10 mg (acitretin) SORIATANE CAPS 25 MG QL(2 ea daily) acitretin caps 17.5 mg 3 7 (acitretin) QL(2 ea daily) acitretin caps 25 mg 3 SORILUX FOAM QL(4 gm daily) 3 (calcipotriene) calcipotriene crea 1 QL(5 gm daily)

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use acyclovir topical oint 1 QL(1 gm daily) STELARA SOLN AcariaHealth 4 Specialty Rx at PA; Limit 5gms (ustekinumab) 1-844-538- ZOVIRAX CREA EX 5 % 7 per 4661;LA (acyclovir topical) month;QL(0.17 gm daily) tazarotene crea 1 QL(1 gm daily) ZOVIRAX OINT EX 5 % QL(1 gm daily) TAZORAC CREA 0.05 % QL(1 gm daily) 7 2 (acyclovir topical) (tazarotene) Burn Products TAZORAC CREA 0.1 % QL(1 gm daily) 7 (Silver Sulfadiazine) SSD 1 (tazarotene) CREA TAZORAC GEL 0.05 %, QL(1 gm daily) 2 0.1 % (tazarotene) mafenide acetate pack 3 PA; Must use SILVADENE CREA ( silver 7 TREMFYA SOPN AcariaHealth sulfadiazine) 4 Specialty Rx at (guselkumab) 1-844-538- silver sulfadiazine crea 1 4661;LA SULFAMYLON CREA 85 Limit 100gms VECTICAL OINT MG/GM (mafenide 3 7 per (calcitriol (topical)) month;QL(3.34 acetate) gm daily) SULFAMYLON PACK 5 % 7 Antiseborrheic Products (mafenide acetate) (Sulfacetamide Sodium) Corticosteroids - Topical SODIUM 1 (Clobetasol Propionate SULFACETAMIDE WASH Emollient Base) LIQD 10 % CLOBETASOL OVACE PLUS WASH LIQD PROPIONATE E, 1 7 (sulfacetamide sodium) CLOBETASOL PROPIONATE OVACE WASH LIQD 7 EMOLLIENT CREA (sulfacetamide sodium) (Clobetasol Propionate 3 selenium sulfide lotn 1 Emulsion) TOVET FOAM (Clobetasol Propionate) 1 SODIUM CLODAN SHAM SULFACETAMIDE WASH LIQD 0.5 %-10 % 3 (Desonide) DESRX GEL 3 (sulfacetamide sodium (Diflorasone Diacetate) 1 in bakuchiol vehicle) PSORCON CREA sulfacetamide sodium 1 (Flurandrenolide) NOLIX 3 liqd CREA Antivirals - Topical (Flurandrenolide) NOLIX 3 PA PA; Limit 5gms LOTN (Fluticasone Propionate) 3 per 3 acyclovir topical crea month;QL(0.17 BESER LOTN gm daily)

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Hydrocortisone (Topical)) betamethasone ALA SCALP, ALA-SCALP 3 dipropionate 1 LOTN augmented oint (Hydrocortisone (Topical)) 1 ALA-CORT CREA betamethasone 1 valerate crea 0.1 % (Triamcinolone Acetonide 1 (Topical)) TRIDERM CREA betamethasone 3 ALA-SCALP LOTN valerate foam 0.12 % (hydrocortisone 3 betamethasone 1 (topical)) valerate lotn 0.1 % alclometasone 1 betamethasone 1 dipropionate crea valerate oint 0.1 % ST; QL(2 gm alclometasone 1 calcipotriene- dipropionate oint betamethasone 3 daily) amcinonide crea 3 dipropionate oint calcipotriene- ST; QL(2 gm amcinonide lotn 3 betamethasone 3 daily) AMCINONIDE OINT dipropionate susp 3 CAPEX SHAM (amcinonide) 2 APEXICON E CREA (fluocinolone acetonide) (diflorasone diacetate 2 clobetasol propionate 1 emollient base) crea betamethasone clobetasol propionate 1 dipropionate (topical) 1 emollient base crea crea clobetasol propionate 3 betamethasone emulsion foam dipropionate (topical) 1 clobetasol propionate 3 lotn foam betamethasone clobetasol propionate 1 dipropionate (topical) 1 gel oint clobetasol propionate 3 betamethasone liqd dipropionate 1 clobetasol propionate 3 augmented crea lotn betamethasone clobetasol propionate 1 dipropionate 1 oint augmented gel clobetasol propionate 1 betamethasone sham dipropionate 1 clobetasol propionate augmented lotn 1 soln

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLOBEX LIQD ST 7 desoximetasone liqd 3 (clobetasol propionate) 0.25 % CLOBEX LOTN 7 desoximetasone oint 3 (clobetasol propionate) 0.05 % CLOBEX SHAM 7 desoximetasone oint 1 (clobetasol propionate) 0.25 % clocortolone pivalate 3 diflorasone diacetate 1 crea crea CLODERM CREA 7 diflorasone diacetate 1 (clocortolone pivalate) oint CORDRAN CREA 0.05 % 7 DIPROLENE AF CREA (flurandrenolide) (betamethasone CORDRAN LOTN 0.05 % PA 7 7 dipropionate (flurandrenolide) augmented) CORDRAN OINT 0.05 % PA 7 DIPROLENE OINT (flurandrenolide) (betamethasone CORDRAN TAPE 4 dipropionate 7 MCG/SQCM 3 augmented) ( ) flurandrenolide ELOCON CREA CUTIVATE LOTN 7 7 (mometasone furoate) ( ) fluticasone propionate EPIFOAM FOAM 3 DERMA-SMOOTHE/FS (pramoxine-hc) BODY OIL (fluocinolone 7 fluocinolone acetonide acetonide) 1 crea DERMA-SMOOTHE/FS SCALP OIL (fluocinolone 7 fluocinolone acetonide 1 acetonide) oil DESONATE GEL fluocinolone acetonide 7 1 (desonide) oint fluocinolone acetonide 1 desonide crea 1 soln desonide gel 3 fluocinonide crea 1 desonide lotn 1 fluocinonide emulsified 1 base crea desonide oint 1 fluocinonide gel 1 DESOWEN CREA 7 (desonide) fluocinonide oint 1 desoximetasone crea 1 0.05 %, 0.25 % fluocinonide soln 1 desoximetasone gel 1 flurandrenolide crea 3 0.05 %

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits flurandrenolide lotn 3 PA LOCOID LIPOCREAM CREA (hydrocortisone 7 flurandrenolide oint 3 PA butyrate hydrophilic lipo base) fluticasone propionate 1 LOCOID LOTN PA crea 0.05 % (hydrocortisone 7 fluticasone propionate 3 butyrate) lotn 0.05 % LOCOID SOLN fluticasone propionate 1 (hydrocortisone 7 oint 0.005 % butyrate) LUXIQ FOAM halobetasol propionate 1 crea (betamethasone 7 valerate) halobetasol propionate 1 oint mometasone furoate 1 crea hydrocortisone (topical) 1 crea mometasone furoate 1 oint hydrocortisone (topical) 1 lotn mometasone furoate 1 soln hydrocortisone (topical) 1 oint OLUX FOAM ( clobetasol 7 propionate) hydrocortisone butyrate 1 crea OLUX-E FOAM hydrocortisone butyrate (clobetasol propionate 7 hydrophilic lipo base 3 emulsion) crea PRAMOSONE LOTN 1 %- 1 %, 1 %-2.5 % hydrocortisone butyrate PA 3 3 (pramoxine-hc) lotn PRAMOSONE OINT 1 %-1 3 hydrocortisone butyrate 1 % (pramoxine-hc) oint PRAMOSONE OINT 1 %- 2 hydrocortisone butyrate 3 2.5 % (pramoxine-hc) soln prednicarbate crea 1 hydrocortisone valerate 3 crea prednicarbate oint 3 hydrocortisone valerate 3 SYNALAR CREA oint 7 (fluocinolone acetonide) KENALOG AERS SYNALAR OINT (triamcinolone 7 7 (fluocinolone acetonide) acetonide (topical)) SYNALAR SOLN LOCOID CREA 7 (fluocinolone acetonide) (hydrocortisone 7 butyrate)

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TACLONEX OINT ST; QL(2 gm VANOS CREA 7 (calcipotriene- daily) (fluocinonide) 7 betamethasone Eczema Agents dipropionate) DUPIXENT SOPN 300 PA 4 TACLONEX SUSP ST; QL(2 gm MG/2ML (dupilumab) daily) (calcipotriene- DUPIXENT SOSY 200 PA 7 4 betamethasone MG/1.14ML (dupilumab) dipropionate) PA; Must use TEMOVATE CREA 7 DUPIXENT SOSY 300 AcariaHealth (clobetasol propionate) 4 Specialty Rx at MG/2ML (dupilumab) TEMOVATE OINT 1-844-538- 7 (clobetasol propionate) 4661;;LA TEXACORT SOLN Enzymes - Topical (hydrocortisone 3 SANTYL OINT 3 (topical)) (collagenase) TOPICORT CREA 0.05 %, Immunomodulating Agents - Topical 0.25 % 7 ALDARA CREA 7 (desoximetasone) (imiquimod) TOPICORT GEL 0.05 % 7 (desoximetasone) imiquimod crea 5 % 1 TOPICORT LIQD 0.25 % ST 7 Immunosuppressive Agents - Topical (desoximetasone) ELIDEL CREA QL(60 gm per 7 TOPICORT OINT 0.05 %, (pimecrolimus) fill retail) 0.25 % 7 3 QL(60 gm per (desoximetasone) pimecrolimus crea fill retail) triamcinolone PROTOPIC OINT 0.03 % QL(2 gm daily); acetonide (topical) aers 1 7 AL(At least 2 0.147 mg/gm (tacrolimus (topical)) yrs old) triamcinolone PROTOPIC OINT 0.1 % QL(2 gm daily); 7 AL(At least 15 acetonide (topical) crea 1 (tacrolimus (topical)) 0.025 %, 0.1 %, 0.5 % yrs old) tacrolimus (topical) oint QL(2 gm daily); triamcinolone 1 AL(At least 2 acetonide (topical) lotn 1 0.03 % yrs old) 0.025 %, 0.1 % tacrolimus (topical) oint QL(2 gm daily); 1 AL(At least 15 triamcinolone 0.1 % acetonide (topical) oint 1 yrs old) 0.025 %, 0.1 %, 0.5 % Keratolytic/Antimitotic Agents TRIDESILON CREA (Salicylic Acid) KERALYT 7 1 (desonide) SHAM BENSAL HP OINT RX/OTC ULTRAVATE LOTN PA; ST 3 (halobetasol 3 (salicylic acid) CONDYLOX GEL propionate) 2 (podofilox) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MG217 PSORIASIS RX/OTC (Metronidazole (Topical)) 1 MULTI-SYMTOM OINT 3 ROSADAN CREA (salicylic acid) (Metronidazole (Topical)) 1 QL(45 gm per PODOCON 25 IN ROSADAN GEL fill retail) BENZOIN TINCTURE azelaic acid gel 1 SOLN (podophyllum 3 PA; ST;QL(1 resin) doxycycline (rosacea) 3 cpdr ea daily) podofilox soln 1 FINACEA FOAM (azelaic SALEX SHAM ( 3 salicylic 7 acid) acid) FINACEA GEL ( azelaic 7 salicylic acid crea 6 % 3 acid) PA; QL(1.5 gm ivermectin (rosacea) 3 salicylic acid sham 6 % 1 crea daily) salicylic acid soln 26 % 3 IVERMECTIN CREA EX 1 PA; QL(1.5 gm % (ivermectin 3 daily) PA salicylic acid soln 28.5 3 (rosacea)) % METROCREAM CREA SALIMEZ CREA ( salicylic 3 (metronidazole 7 acid) (topical)) ULTRASAL-ER SOLN PA METROGEL GEL 7 (salicylic acid) (metronidazole 7 Local Anesthetics - Topical (topical)) METROLOTION LOTN QL(60 ml per 3 QL(3 ea daily) lidocaine ptch ex 5 % (metronidazole 7 fill retail) (topical)) lidocaine-prilocaine 3 crea metronidazole (topical) 1 LIDODERM PTCH QL(3 ea daily) crea 0.75 % 7 (lidocaine) QL(45 gm per metronidazole (topical) 1 Misc. Topical gel 0.75 % fill retail) DRYSOL SOLN metronidazole (topical) 2 1 (aluminum chloride) gel 1 % XERAC AC SOLN QL(60 ml per metronidazole (topical) 1 (aluminum chloride in 3 lotn 0.75 % fill retail) alcohol) MIRVASO GEL PA; ST Phosphodiesterase 4 (PDE4) Inhibitors - Topical (brimonidine tartrate 3 PA; ST; Limited (topical)) EUCRISA OINT to 60 gm per ORACEA CPDR PA; ST;QL(1 3 7 (crisaborole) month;QL(2 gm (doxycycline (rosacea)) ea daily) daily) RHOFADE CREA PA; ST Rosacea Agents (oxymetazoline hcl 3 (topical))

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOOLANTRA CREA PA; QL(1.5 gm Limit 200 per 7 (ivermectin (rosacea)) daily) FREESTYLE LITE TEST month without STRIPS STRP (glucose 2 authorization;Q Scabicides & Pediculicides blood) L(6.7 ea daily); ELIMITE CREA QL(60 gm per RX/OTC 7 (permethrin) fill retail) Limit 200 per RX/OTC FREESTYLE TEST month without ivermectin 3 (pediculicide) lotn STRIPS STRP (glucose 2 authorization;Q blood) L(6.7 ea daily); IVERMECTIN LOTN EX RX/OTC RX/OTC 0.5 % (ivermectin 3 KETONE STRP ( QL(50 ea per acetone 2 (pediculicide)) (urine) test) fill retail) malathion lotn 3 KETOSTIX STRP QL(50 ea per 2 fill retail) NATROBA SUSP AL(At least 4 (acetone (urine) test) 7 (spinosad) yrs old) Limit 200 per ONETOUCH ULTRA STRP month without OVIDE LOTN (malathion) 7 2 authorization;Q (glucose blood) L(6.7 ea daily); 1 QL(60 gm per RX/OTC permethrin crea fill retail) Limit 200 per SKLICE LOTN RX/OTC ONETOUCH VERIO TEST month without (ivermectin 7 STRIPS STRP (glucose 2 authorization;Q (pediculicide)) blood) L(6.7 ea daily); RX/OTC 3 AL(At least 4 spinosad susp yrs old) Limit 200 per PRECISION XTRA BLOOD month without Wound Care Products GLUCOSE TEST STRIPS 2 authorization;Q REGRANEX GEL QL(15 gm per 3 STRP (glucose blood) L(6.7 ea daily); (becaplermin) fill retail) RX/OTC Limit 200 per DIAGNOSTIC PRODUCTS PRECISION XTRA STRP 2 month without Diagnostic Drugs VI (ketone blood test) authorization;Q L(6.7 ea daily) METOPIRONE CAPS 3 (metyrapone) DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes Diagnostic Tests Digestive Enzymes Limit 200 per FREESTYLE INSULINX CREON CPEP BLOODGLUCOSE TEST month without (pancrelipase (lipase- 2 STRIPS STRP (glucose 2 authorization;Q L(6.7 ea daily); protease-amylase)) blood) RX/OTC Limit 200 per FREESTYLE INSULINX month without BLOODGLUCOSE TEST 2 authorization;Q STRP (glucose blood) L(6.7 ea daily); RX/OTC

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PANCREAZE CPEP 10500 amiloride & UNIT-35500 UNIT-61500 hydrochlorothiazide 1 UNIT, 15200 UNIT-2600 tabs UNIT-8800 UNIT, 16800 UNIT-56800 UNIT-98400 DYAZIDE CAPS UNIT, 21000 UNIT-54700 3 (triamterene & 7 UNIT-83900 UNIT, 4200 hydrochlorothiazide) UNIT-14200 UNIT-24600 MAXZIDE TABS QL(1 ea daily) UNIT (pancrelipase (triamterene & 7 (lipase-protease- hydrochlorothiazide) amylase)) MAXZIDE-25 TABS QL(2 ea daily) PERTZYE CPEP (triamterene & 7 (pancrelipase (lipase- 3 hydrochlorothiazide) protease-amylase)) spironolactone & SUCRAID SOLN PA 4 hydrochlorothiazide 1 (sacrosidase) tabs VIOKACE TABS triamterene & (pancrelipase (lipase- 3 hydrochlorothiazide protease-amylase)) 1 caps 25 mg-37.5 mg, ZENPEP CPEP 37.5 mg-25 mg (pancrelipase (lipase- 2 QL(2 ea daily) protease-amylase)) triamterene & hydrochlorothiazide 1 DIURETICS - Drugs to Treat Heart, Circulation tabs 25 mg-37.5 mg, Conditions and Blood Pressure 37.5 mg-25 mg Carbonic Anhydrase Inhibitors triamterene & QL(1 ea daily) acetazolamide cp12 QL(2 ea daily) 1 hydrochlorothiazide 1 500 mg tabs 50 mg-75 mg, 75 mg-50 mg acetazolamide tabs 1 125 mg Loop Diuretics acetazolamide tabs QL(4 ea daily) 1 bumetanide tabs 0.5 1 250 mg mg, 1 mg methazolamide tabs 1 bumetanide tabs 2 mg 1 QL(5 ea daily) Diuretic Combinations BUMEX TABS 0.5 MG, 1 7 ALDACTAZIDE TABS 25 MG (bumetanide) MG-25 MG BUMEX TABS 2 MG QL(5 ea daily) 7 7 (spironolactone & (bumetanide) hydrochlorothiazide) EDECRIN TABS ST 7 ALDACTAZIDE TABS 50 (ethacrynic acid) MG-50 MG ST (spironolactone & 2 ethacrynic acid tabs 3 hydrochlorothiazide) furosemide soln 10 1 mg/ml

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 4 for 28 furosemide soln 8 3 ACTONEL TABS 35 MG mg/ml 7 days;QL(0.15 (risedronate sodium) ea daily) furosemide tabs 20 mg, 1 ACTONEL TABS 5 MG QL(1 ea daily) 40 mg, 80 mg 7 (risedronate sodium) LASIX TABS 7 (furosemide) alendronate sodium 3 soln 70 mg/75ml torsemide tabs 10 mg, 1 QL(1 ea daily) 20 mg, 5 mg alendronate sodium 1 tabs 10 mg, 5 mg torsemide tabs 100 mg 1 QL(2 ea daily) alendronate sodium Limit 4 per 28 1 days;QL(0.15 Potassium Sparing Diuretics tabs 35 mg, 70 mg ea daily) ALDACTONE TABS 7 alendronate sodium 1 (spironolactone) tabs 40 mg amiloride hcl tabs 1 BONIVA TABS Limit 1 per 7 month;QL(0.04 DYRENIUM CAPS (ibandronate sodium) 7 ea daily) ( ) triamterene PA calcitonin (salmon) soln 4 spironolactone tabs 1 ij 200 unit/ml calcitonin (salmon) soln 1 triamterene caps 3 na 200 unit/act Thiazides and Thiazide-Like Diuretics etidronate disodium 3 chlorothiazide tabs 3 tabs FOSAMAX TABS Limit 4 per 28 chlorthalidone tabs 1 7 days;QL(0.15 (alendronate sodium) ea daily) DIURIL SUSP 3 ibandronate sodium Limit 1 per (chlorothiazide) 1 month;QL(0.04 tabs ea daily) hydrochlorothiazide 1 MIACALCIN SOLN PA caps 7 (calcitonin (salmon)) hydrochlorothiazide 1 tabs NATPARA CART PA (parathyroid hormone 4 indapamide tabs 1 (recombinant)) PROLIA SOSY PA metolazone tabs 1 4 (denosumab) ENDOCRINE AND METABOLIC AGENTS - risedronate sodium Limit 1 per MISC. - Drugs to Treat Bone Disease and 3 month;QL(0.04 Regulate Hormones tabs 150 mg ea daily) Bone Density Regulators QL(1 ea daily) risedronate sodium 3 ACTONEL TABS 150 MG Limit 1 per tabs 30 mg, 5 mg 7 month;QL(0.04 (risedronate sodium) risedronate sodium Limit 4 for 28 ea daily) 3 days;QL(0.15 tabs 35 mg ea daily) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYMLOS SOPN PA EVISTA TABS ( PV 4 raloxifene 7 (abaloparatide) hcl) OSPHENA TABS Fertility Regulators 3 Check plan (ospemifene) documents for 5 PV coverage;QL(1 raloxifene hcl tabs 1 5 ea per fill Insulin-Like Growth Factors (Somatomedins) clomiphene citrate tabs retail,00 ea per INCRELEX SOLN PA fill mail,15 ea 4 per 30 days (mecasermin) retail) LHRH/GnRH Agonist Analog Pituitary Growth Hormone Receptor Antagonists FENSOLVI KIT PA SOMAVERT SOLR PA (leuprolide acetate 3 4 (pegvisomant) (cpp) (6 month)) SYNAREL SOLN Growth Hormone Releasing Hormones (GHRH) 2 EGRIFTA SOLR 2 MG PA; LA (nafarelin acetate) 4 (tesamorelin acetate) Metabolic Modifiers EGRIFTA SV SOLR PA; LA BUPHENYL POWD PA 4 (tesamorelin acetate) (sodium 7 Growth Hormones phenylbutyrate) PA; Please BUPHENYL TABS PA ( 7 HUMATROPE COMBO refer to your sodium PACK SOLR 4 plan phenylbutyrate) documents for (somatropin) specific calcitriol caps 0.25 mcg 1 coverage QL(4 ea daily) PA; Please calcitriol caps 0.5 mcg 1 refer to your HUMATROPE SOLR calcitriol soln 1 mcg/ml 1 4 plan (somatropin) documents for CARBAGLU TABS 4 specific ( ) coverage carglumic acid PA; Please CARNITOR SF SOLN refer to your (levocarnitine 7 NORDITROPIN FLEXPRO (metabolic modifiers)) 4 plan SOPN (somatropin) documents for CARNITOR SOLN specific (levocarnitine 7 coverage (metabolic modifiers)) SEROSTIM SOLR PA CARNITOR TABS (somatropin (non- 4 (levocarnitine 7 refrigerated)) (metabolic modifiers)) ZORBTIVE SOLR PA PA (somatropin (non- 4 cinacalcet hcl tabs 3 refrigerated)) CYSTADANE POWD PA 4 Hormone Receptor Modulators (betaine)

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxercalciferol caps 3 Specialty Drug sapropterin 4 refer to GALAFOLD CAPS PA; QL(0.5 ea dihydrochloride tabs Caremark SP 4 (migalastat hcl) daily) RX SENSIPAR TABS PA KUVAN PACK Specialty Drug 7 (cinacalcet hcl) (sapropterin 7 refer to Caremark SP PA dihydrochloride) sodium phenylbutyrate 4 RX powd Specialty Drug KUVAN TABS sodium phenylbutyrate PA ( 7 refer to 4 sapropterin Caremark SP tabs dihydrochloride) RX STRENSIQ SOLN PA 4 (asfotase alfa) levocarnitine (metabolic 3 modifiers) soln ZEMPLAR CAPS 7 (paricalcitol) levocarnitine (metabolic 3 modifiers) tabs Posterior Pituitary Hormones MYALEPT SOLR PA DDAVP SOLN NA 0.01 % 4 (metreleptin) (desmopressin acetate 2 nitisinone caps 4 PA refrigerated) DDAVP SOLN NA 0.01 % ORFADIN CAPS 10 MG, 2 PA 7 (desmopressin acetate 7 MG, 5 MG (nitisinone) spray) ORFADIN CAPS 20 MG PA DDAVP TABS OR 0.1 MG 4 7 (nitisinone) (desmopressin acetate) ORFADIN SUSP 4 MG/ML PA DDAVP TABS OR 0.2 MG QL(6 ea daily) 4 7 (nitisinone) (desmopressin acetate) PALYNZIQ SOSY PA 4 DESMOPRESSIN (pegvaliase-pqpz) ACETATE SOLN NA 1.5 3 paricalcitol caps 3 MG/ML (desmopressin acetate) RAVICTI LIQD (glycerol PA 4 desmopressin acetate 1 phenylbutyrate) spray refrigerated soln ROCALTROL CAPS 0.25 7 desmopressin acetate 1 MCG (calcitriol) spray soln ROCALTROL CAPS 0.5 QL(4 ea daily) 7 MCG (calcitriol) desmopressin acetate 1 tabs or 0.1 mg ROCALTROL SOLN 1 7 QL(6 ea daily) MCG/ML (calcitriol) desmopressin acetate 1 Specialty Drug tabs or 0.2 mg STIMATE SOLN sapropterin 4 refer to 3 dihydrochloride pack Caremark SP (desmopressin acetate) RX Prolactin Inhibitors cabergoline tabs 1

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Somatostatic Agents norethindrone acetate- 1 ethinyl estradiol tabs octreotide acetate soln 4 PA ORIAHNN CPPK PA SANDOSTATIN SOLN PA 7 (elagolix sodium- (octreotide acetate) estradiol-norethindrone 4 SIGNIFOR SOLN PA acetate) (pasireotide 4 PREFEST TABS 3 diaspartate) (estradiol-norgestimate) Vasopressin Receptor Antagonists PREMPHASE TABS JYNARQUE TBPK 15 MG PA; LA (conjugated estrogens- 4 2 (tolvaptan) medroxyprogesterone acetate) ESTROGENS - Hormone Replacement/Modifying Drugs PREMPRO TABS 0.45 MG-1.5 MG, 0.625 MG-2.5 Estrogen Combinations MG, 0.625 MG-5 MG (Estradiol & Norethindrone (conjugated estrogens- 2 Acetate) AMABELZ, 1 medroxyprogesterone LOPREEZA, MIMVEY, ) MIMVEY LO TABS acetate (Norethindrone Acetate- PREMPRO TABS 1.5 MG- QL(1 ea daily) Ethinyl Estradiol) 1 0.3 MG (conjugated FYAVOLV, JINTELI TABS estrogens- 2 ACTIVELLA TABS medroxyprogesterone (estradiol & 7 acetate) norethindrone acetate) Estrogens ANGELIQ TABS Limit 8 patches (drospirenone- 3 (Estradiol) DOTTI, 1 per estradiol) LYLLANA PTTW month;QL(0.29 ea daily) CLIMARA PRO PTWK Limit 4 per 28 (estradiol- 2 days;QL(0.15 Limit 8 patches ea daily) 2 per levonorgestrel) ALORA PTTW (estradiol) month;QL(0.29 COMBIPATCH PTTW ea daily) (estradiol & 3 CLIMARA PTWK Limit 4 per 28 norethindrone acetate) 7 days;QL(0.15 (estradiol) DUAVEE TABS ea daily) (conjugated estrogens- 3 DIVIGEL GEL 0.25 bazedoxifene) MG/0.25GM, 0.5 MG/0.5GM, 1 MG/GM, 1.25 3 estradiol & MG/1.25GM (estradiol) 1 norethindrone acetate ELESTRIN GEL tabs 3 (estradiol) FEMHRT TABS ESTRACE TABS (norethindrone acetate- 7 7 (estradiol) ethinyl estradiol)

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 8 patches CIPRO TABS 250 MG, 500 estradiol pttw td 0.025 7 mg/24hr, 0.0375 per MG (ciprofloxacin hcl) month;QL(0.29 mg/24hr, 0.05 mg/24hr, 1 ciprofloxacin hcl tabs 1 0.075 mg/24hr, 0.1 ea daily) mg/24hr ciprofloxacin susr 1 Limit 4 per 28 estradiol ptwk td 0.025 LEVAQUIN TABS QL(14 ea per days;QL(0.15 7 mg/24hr, 0.05 mg/24hr, (levofloxacin) fill retail) 0.06 mg/24hr, 0.075 1 ea daily) mg/24hr, 0.1 mg/24hr, levofloxacin soln 25 1 37.5 mcg/24hr mg/ml levofloxacin tabs 250 QL(14 ea per estradiol tabs or 0.5 1 1 fill retail) mg, 1 mg, 2 mg mg, 500 mg, 750 mg Limit 50gms moxifloxacin hcl tabs 1 ESTROGEL GEL 3 per (estradiol) month;QL(1.67 ofloxacin tabs 300 mg 1 gm daily) QL(28 ea per EVAMIST SOLN ofloxacin tabs 400 mg 3 3 90 days retail) (estradiol) GASTROINTESTINAL AGENTS - MISC. - MENEST TABS 2 Miscellaneous Gastrointestinal Drugs (esterified estrogens) Limit 4 per 28 Agents for Chronic Idiopathic Constipation (CIC) MENOSTAR PTWK TRULANCE TABS PA; ST 3 days;QL(0.15 3 (estradiol) ea daily) (plecanatide) Limit 8 patches Farnesoid X Receptor (FXR) Agonists MINIVELLE PTTW 7 per OCALIVA TABS 10 MG PA (estradiol) month;QL(0.29 4 ea daily) (obeticholic acid) OCALIVA TABS 5 MG PA; ST PREMARIN TABS OR 0.3 QL(1 ea daily) 4 MG, 0.45 MG, 0.625 MG, (obeticholic acid) 2 1.25 MG (estrogens, Gallstone Solubilizing Agents conjugated) ACTIGALL CAPS 7 PREMARIN TABS OR 0.9 (ursodiol) MG (estrogens, 2 CHENODAL TABS PA 4 conjugated) (chenodiol) Limit 8 patches URSO 250 TABS VIVELLE-DOT PTTW 7 7 per (ursodiol) (estradiol) month;QL(0.29 URSO FORTE TABS ea daily) 7 (ursodiol) FLUOROQUINOLONES - Drugs to Treat Bacterial Infections ursodiol caps 300 mg 1 Fluoroquinolones ursodiol tabs 250 mg, 1 CIPRO SUSR 5 500 mg GM/100ML, 500 MG/5ML 2 (ciprofloxacin) Gastrointestinal Chloride Channel Activators

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMITIZA CAPS QL(6 ea daily) 7 mesalamine cpdr or 1 (lubiprostone) 400 mg QL(60 ml daily) lubiprostone caps 1 mesalamine enem re 4 1 gm Gastrointestinal Stimulants QL(1 ea daily) mesalamine supp re 1 metoclopramide hcl 1000 mg soln 10 mg/10ml, 5 3 QL(4 ea daily) mesalamine tbec or 1.2 1 mg/5ml gm metoclopramide hcl 1 mesalamine tbec or 1 tabs 10 mg, 5 mg 800 mg metoclopramide hcl 3 PENTASA CPCR 250 MG PA 3 tbdp 5 mg (mesalamine) METOCLOPRAMIDE ODT PENTASA CPCR 500 MG PA; QL(8 ea 3 TBDP (metoclopramide 3 (mesalamine) daily) hcl) SFROWASA ENEM REGLAN TABS 2 7 (mesalamine) (metoclopramide hcl) 1 QL(8 ea daily) Inflammatory Bowel Agents sulfasalazine tabs APRISO CP24 QL(4 ea daily) QL(8 ea daily) 7 sulfasalazine tbec 1 (mesalamine) ASACOL HD TBEC Intestinal Acidifiers 7 (mesalamine) (Lactulose (Encephalopathy)) AZULFIDINE EN-TABS QL(8 ea daily) 1 7 ENULOSE, GENERLAC TBEC (sulfasalazine) SOLN AZULFIDINE TABS QL(8 ea daily) 7 lactulose 1 (sulfasalazine) (encephalopathy) soln balsalazide disodium QL(9 ea 1 daily,280 ea Irritable Bowel Syndrome (IBS) Agents caps per fill retail) alosetron hcl tabs 3 CANASA SUPP QL(1 ea daily) 7 LINZESS CAPS (mesalamine) 2 (linaclotide) QL(9 ea COLAZAL CAPS LOTRONEX TABS 7 daily,280 ea 7 (balsalazide disodium) per fill retail) (alosetron hcl) DELZICOL CPDR QL(6 ea daily) VIBERZI TABS 100 MG PA 7 3 (mesalamine) (eluxadoline) DIPENTUM CAPS VIBERZI TABS 75 MG PA; ST 3 3 (olsalazine sodium) (eluxadoline) LIALDA TBEC QL(4 ea daily) 7 Peripheral Opioid Receptor Antagonists (mesalamine) alvimopan caps 3 mesalamine cp24 or QL(4 ea daily) 1 ENTEREG CAPS 0.375 gm 7 (alvimopan) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOVANTIK TABS 12.5 MG PHOSLYRA SOLN 3 (naloxegol oxalate) (calcium acetate 3 MOVANTIK TABS 25 MG QL(1 ea daily) (phosphate binder)) 3 (naloxegol oxalate) RENAGEL TABS PA; ST;QL(16 7 RELISTOR SOLN SC 12 PA (sevelamer hcl) ea daily) MG/0.6ML, 8 MG/0.4ML RENVELA PACK 0.8 GM 4 7 (methylnaltrexone (sevelamer carbonate) bromide) RENVELA PACK 2.4 GM QL(5 ea daily) 7 RELISTOR TABS OR 150 PA; ST (sevelamer carbonate) MG (methylnaltrexone 4 RENVELA TABS 800 MG 7 bromide) (sevelamer carbonate) Phosphate Binder Agents sevelamer carbonate 1 (Calcium Acetate RX/OTC pack 0.8 gm (Phosphate Binder)) 1 QL(5 ea daily) CALPHRON TABS sevelamer carbonate 1 pack 2.4 gm AURYXIA TABS ( PA; ST ferric 3 citrate) sevelamer carbonate 1 tabs 800 mg calcium acetate PA; ST (phosphate binder) 1 sevelamer hcl tabs 400 3 caps mg RX/OTC sevelamer hcl tabs 800 PA; ST;QL(16 calcium acetate 3 ea daily) (phosphate binder) 1 mg tabs Short Bowel Syndrome (SBS) Agents GATTEX KIT PA; ST FOSRENOL CHEW 1000 QL(3 ea daily) 4 MG (lanthanum 7 (teduglutide (rdna)) carbonate) Tryptophan Hydroxylase Inhibitors FOSRENOL CHEW 500 XERMELO TABS PA; ST; Not MG (lanthanum 7 4 available (telotristat etiprate) carbonate) through mail FOSRENOL CHEW 750 QL(4 ea daily) GENITOURINARY AGENTS - MISCELLANEOUS MG (lanthanum 7 - Miscellaneous Drugs to Treat Reproductive carbonate) Organs and Urinary System FOSRENOL PACK 1000 Acidifiers MG, 750 MG (lanthanum 3 K-PHOS NO 2 TABS carbonate) (potassium & sodium 2 QL(3 ea daily) acid phosphates) lanthanum carbonate 1 chew 1000 mg Alkalinizers (Pot & Sod Citrates lanthanum carbonate 1 chew 500 mg W/Citric Ac) CYTRA-3 1 QL(4 ea daily) SYRP lanthanum carbonate 1 chew 750 mg

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Potassium Citrate-Citric dutasteride caps 1 AL(At least 40 Acid) CYTRA K 1 yrs old) CRYSTALS, TARON- dutasteride-tamsulosin 1 CRYSTALS PACK hcl caps (Potassium Citrate-Citric 1 RX/OTC Acid) CYTRA-K SOLN QL(1 ea daily); finasteride tabs 1 AL(At least 40 ORACIT SOLN ( sodium 3 yrs old) citrate & citric acid) FLOMAX CAPS QL(2 ea daily) 7 pot & sod citrates 3 (tamsulosin hcl) w/citric ac soln JALYN CAPS (dutasteride-tamsulosin 7 potassium citrate 1 (alkalinizer) tbcr hcl) RX/OTC QL(1 ea daily); potassium citrate-citric 1 PROSCAR TABS acid soln 7 AL(At least 40 (finasteride) yrs old) UROCIT-K 10 TBCR RAPAFLO CAPS 8 MG QL(1 ea daily) (potassium citrate 7 7 (silodosin) (alkalinizer)) UROCIT-K 15 TBCR silodosin caps 4 mg 1 (potassium citrate 7 QL(1 ea daily) (alkalinizer)) silodosin caps 8 mg 1 UROCIT-K 5 TBCR tamsulosin hcl caps 1 QL(2 ea daily) (potassium citrate 7 UROXATRAL TB24 QL(1 ea daily) (alkalinizer)) 7 (alfuzosin hcl) Cystinosis Agents CYSTAGON CAPS PA Urinary Stone Agents 4 LITHOSTAT TABS (cysteamine bitartrate) 3 PROCYSBI CPDR PA (acetohydroxamic acid) 4 THIOLA EC TBEC (cysteamine bitartrate) 3 PROCYSBI PACK PA (tiopronin) 4 (cysteamine bitartrate) THIOLA TABS (tiopronin) 7 Interstitial Cystitis Agents tiopronin tabs 3 ELMIRON CAPS QL(3 ea daily) (pentosan polysulfate 3 GOUT AGENTS - Drugs to Treat Gout sodium) Prostatic Hypertrophy Agents Gout Agent Combinations QL(1 ea daily) colchicine w/ 1 alfuzosin hcl tb24 1 probenecid tabs AVODART CAPS AL(At least 40 7 Gout Agents (dutasteride) yrs old) 1 QL(3 ea daily) CARDURA XL TB24 allopurinol tabs 100 mg (doxazosin mesylate 3 allopurinol tabs 300 mg 1 QL(2 ea daily) (bph))

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits colchicine caps 3 AFSTYLA KIT PA; LA (antihemophilic factor 4 colchicine tabs 1 (recombinant) single chain) COLCRYS TABS 7 ALPHANATE SOLR PA (colchicine) (antihemophilic febuxostat tabs 40 mg 1 QL(2 ea daily) factor/von willebrand 4 factor complex QL(1 ea daily) febuxostat tabs 80 mg 1 (human)) MITIGARE CAPS ALPHANATE/VON PA 7 (colchicine) WILLEBRANDFACTOR COMPLEX/HUMAN SOLR ULORIC TABS 40 MG QL(2 ea daily) 7 (antihemophilic 4 (febuxostat) factor/von willebrand ULORIC TABS 80 MG QL(1 ea daily) 7 factor complex (febuxostat) (human)) ZYLOPRIM TABS 100 MG QL(3 ea daily) ALPHANINE SD SOLR PA 7 4 (allopurinol) (coagulation factor ix) ZYLOPRIM TABS 300 MG QL(2 ea daily) 7 ALPROLIX SOLR 1000 PA (allopurinol) UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 Uricosurics 4 UNIT (coagulation factor probenecid tabs 1 ix (recomb) fc fusion protein (rfixfc)) HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders ALPROLIX SOLR 4000 PA; Must use AcariaHlth Sp UNIT (coagulation factor 4 Antihemophilic Products ix (recomb) fc fusion Rx 1-844-538- ADVATE SOLR PA protein (rfixfc)) 4661;LA (antihemophilic factor 4 BENEFIX KIT PA (rcmb) plasma/albumin (coagulation factor ix 4 free (rahf-pfm)) (recombinant)) ADYNOVATE SOLR 1000 PA COAGADEX SOLR PA UNIT, 2000 UNIT, 250 ( 4 UNIT, 500 UNIT 4 coagulation factor x (antihemophilic factor (human)) (recombinant) pegylated) CORIFACT KIT (factor PA ADYNOVATE SOLR 1500 PA; Must use xiii concentrate 4 UNIT, 750 UNIT AcariaHlth Sp (human)) 4 (antihemophilic factor Rx 1-844-538- ELOCTATE SOLR 1000 PA; LA (recombinant) pegylated) 4661 UNIT, 1500 UNIT, 2000 ADYNOVATE SOLR 3000 PA; LA UNIT, 250 UNIT, 3000 UNIT, 500 UNIT, 750 UNIT UNIT (antihemophilic 4 4 (antihemophilic factor factor (recombinant) pegylated) (rcmb) fc fusion protein(bdd-rfviiifc))

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELOCTATE SOLR 4000 PA; Must use IXINITY SOLR 1500 UNIT PA; LA UNIT, 5000 UNIT, 6000 AcariaHlth Sp (coagulation factor ix 4 UNIT (antihemophilic 4 Rx 1-844-538- (recombinant)) 4661;SP factor (rcmb) fc fusion JIVI SOLR (antihemophil PA protein(bdd-rfviiifc)) fact(rcmb) pegylated-aucl 4 FEIBA SOLR PA (bdd-rfviii peg-aucl)) (antiinhibitor coagulant 4 KCENTRA KIT PA complex) (prothrombin complex 4 FIBRYGA SOLR PA concentrate human) (fibrinogen concentrate 4 KOATE SOLR PA; LA (human)) (antihemophilic factor 3 HELIXATE FS KIT PA (human)) (antihemophilic factor 4 KOATE-DVI SOLR PA; LA (recombinant) (rfviii)) (antihemophilic factor 3 HEMOFIL M SOLR 1000 PA; LA (human)) UNIT, 250 UNIT, 500 UNIT KOGENATE FS KIT PA (antihemophilic factor 3 (antihemophilic factor 4 (human)) (recombinant) (rfviii)) HEMOFIL M SOLR 1501 - PA 2000 UNIT, 1700 UNIT KOVALTRY SOLR PA 4 (antihemophilic factor (antihemophilic factor 4 (human)) (rcmb) plasma/albumin free (rahf-pfm)) HUMATE-P SOLR PA MONONINE SOLR PA (antihemophilic 4 (coagulation factor ix) factor/von willebrand 4 factor complex NOVOEIGHT SOLR PA (human)) (antihemophilic factor 4 (rcmb) bd truncated (bd IDELVION SOLR 1000 PA; SP trunc-rfviii)) UNIT, 2000 UNIT, 250 UNIT, 500 UNIT NOVOSEVEN RT SOLR PA (coagulation factor ix 4 (coagulation factor viia 4 recomb albumin fusion (recombinant)) protein (rix-fp)) NUWIQ KIT 2500 UNIT, PA; Refer to 3000 UNIT, 4000 UNIT Accredo SP IDELVION SOLR 3500 PA ( 4 Rx;LA UNIT (coagulation factor antihemophilic factor 4 (rcmb) simoctocog ix recomb albumin alfa(bdd-rfviii,sim)) fusion protein (rix-fp)) NUWIQ SOLR 2500 UNIT, PA; SP- Acaria IXINITY SOLR 1000 UNIT, PA 3000 UNIT, 4000 UNIT Health;LA 2000 UNIT, 250 UNIT, (antihemophilic factor 4 3000 UNIT, 500 UNIT 4 (rcmb) simoctocog (coagulation factor ix alfa(bdd-rfviii,sim)) (recombinant))

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OBIZUR SOLR PA XYNTHA SOLOFUSE KIT PA; SP 3000 UNIT (antihemophilic factor 4 (recombinant porcine) (antihemophilic factor 4 (rpfviii)) (rcmb) moroctocog PROFILNINE SD SOLR PA alfa(bdd-rfviii,mor)) 4 (factor ix complex) Bradykinin B2 Receptor Antagonists PROFILNINE SOLR PA (Icatibant Acetate) PA; LA 4 4 (factor ix complex) SAJAZIR SOLN FIRAZYR SOLN ( PA; LA REBINYN SOLR PA icatibant 7 acetate) (coagulation factor ix 4 (recombinant) 4 PA; LA glycopegylated) icatibant acetate soln RECOMBINATE SOLR PA Complement Inhibitors (antihemophilic factor 4 PA; Must use (recombinant) (rfviii)) HAEGARDA SOLR (c1 AcariaHealth RIASTAP SOLR PA esterase inhibitor 4 Specialty Rx at (fibrinogen concentrate 4 (human)) 1-844-538- 4661;LA (human)) RIXUBIS SOLR PA Hemataologic - Tyrosine Kinase Inhibitors TAVALISSE TABS 100 MG PA; ST;LA (coagulation factor ix 4 4 (recombinant)) (fostamatinib disodium) TAVALISSE TABS 150 MG PA; LA TRETTEN SOLR PA 4 (coagulation factor xiii (fostamatinib disodium) 4 a-subunit Hematorheologic Agents (recombinant)) pentoxifylline tbcr 1 QL(3 ea daily) VONVENDI SOLR (von PA willebrand factor 4 Human Protein C (recombinant)) CEPROTIN SOLR PA WILATE KIT PA; SP (protein c concentrate 4 (antihemophilic (human)) factor/von willebrand 4 Platelet Aggregation Inhibitors factor complex AGGRENOX CP12 7 (human)) (aspirin-dipyridamole) XYNTHA KIT PA AGRYLIN CAPS 7 (antihemophilic factor 4 (anagrelide hcl) (rcmb) moroctocog alfa(bdd-rfviii,mor)) anagrelide hcl caps 1 XYNTHA SOLOFUSE KIT PA aspirin-dipyridamole 1000 UNIT, 2000 UNIT, 1 250 UNIT, 500 UNIT cp12 4 BRILINTA TABS 60 MG QL(2 ea daily) (antihemophilic factor 2 (rcmb) moroctocog (ticagrelor) alfa(bdd-rfviii,mor)) BRILINTA TABS 90 MG 2 (ticagrelor)

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cilostazol tabs 1 QL(2 ea daily) folic acid tabs 1 mg 1 RX/OTC QL(2 ea daily) PV clopidogrel bisulfate 1 folic acid tabs 400 mcg, 5 tabs 800 mcg dipyridamole tabs 1 Hematopoietic Growth Factors FULPHILA SOSY PA EFFIENT TABS 4 7 (pegfilgrastim-jmdb) (prasugrel hcl) GRANIX SOLN ( PA PLAVIX TABS QL(2 ea daily) tbo- 4 7 (clopidogrel bisulfate) filgrastim) LEUKINE SOLR PA 4 prasugrel hcl tabs 1 (sargramostim) MULPLETA TABS PA HEMATOPOIETIC AGENTS - Drugs to Treat 4 Blood Disorders (lusutrombopag) NIVESTYM SOLN 300 PA; ST Agents for Gaucher Disease 4 CERDELGA CAPS PA MCG/ML (filgrastim-aafi) 4 (eliglustat tartrate) NIVESTYM SOLN 480 PA PA; ST MCG/1.6ML (filgrastim- 4 miglustat caps 4 aafi) ZAVESCA CAPS PA; ST NIVESTYM SOSY 300 PA 7 (miglustat) MCG/0.5ML, 480 MCG/0.8ML (filgrastim- 4 Agents for Sickle Cell Disease aafi) DROXIA CAPS PROMACTA PACK 12.5 PA; QL(1 ea (hydroxyurea (sickle 2 MG (eltrombopag 4 daily) cell anemia)) olamine) SIKLOS TABS 100 MG PA; ST;AC PROMACTA PACK 25 MG PA (hydroxyurea (sickle 4 4 (eltrombopag olamine) cell anemia)) PROMACTA TABS 12.5 PA; QL(1 ea SIKLOS TABS 1000 MG PA; AC MG, 25 MG, 50 MG, 75 MG 4 daily) (hydroxyurea (sickle 4 (eltrombopag olamine) cell anemia)) RETACRIT SOLN 10000 PA Folic Acid/Folates UNIT/ML, 2000 UNIT/ML, 20000 UNIT/2ML, 3000 (Folic Acid) CVS FOLIC PV 4 ACID, FOLATE, GNP UNIT/ML, 4000 UNIT/ML, FOLIC ACID, HM FOLIC 40000 UNIT/ML (epoetin ACID, PX FOLIC ACID, QC 5 alfa-epbx) FOLIC ACID, RA FOLIC PA; ST; Must ACID, SM FOLIC ACID, YL use FOLIC ACID TABS UDENYCA SOSY 4 AcariaHealth (Folic Acid) KP FOLIC 1 RX/OTC (pegfilgrastim-cbqv) Specialty Rx at ACID TABS 1 MG 1-844-538- 4661 (Folic Acid) KP FOLIC 5 PV ACID TABS 800 MCG ZARXIO SOSY PA; LA 4 (filgrastim-sndz)

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZIEXTENZO SOSY PA; ST HALCION TABS QL(1 ea daily) 4 7 (pegfilgrastim-bmez) (triazolam) LUNESTA TABS QL(1 ea daily) HEMOSTATICS - Drugs to Stop Bleeding/Treat 7 Blood Disorders (eszopiclone) Hemostatics - Systemic midazolam hcl syrp 3 AMICAR SOLN 7 (aminocaproic acid) quazepam tabs 3 AMICAR TABS RESTORIL CAPS 15 MG QL(2 ea daily) 7 7 (aminocaproic acid) (temazepam) RESTORIL CAPS 22.5 QL(1 ea daily) aminocaproic acid soln 3 7 MG, 30 MG (temazepam) aminocaproic acid tabs 3 RESTORIL CAPS 7.5 MG 7 LYSTEDA TABS QL(6 ea daily,5 (temazepam) 7 day(s) limit) QL(2 ea daily) (tranexamic acid) temazepam caps 15 1 mg 1 QL(6 ea daily,5 tranexamic acid tabs day(s) limit) QL(1 ea daily) temazepam caps 22.5 3 HYPNOTICS/SEDATIVES/SLEEP DISORDER mg AGENTS QL(1 ea daily) temazepam caps 30 1 Barbiturate Hypnotics mg BUTISOL SODIUM TABS 3 temazepam caps 7.5 1 (butabarbital sodium) mg phenobarbital elix 1 triazolam tabs 0.125 1 mg phenobarbital soln 1 triazolam tabs 0.25 mg 1 QL(1 ea daily) phenobarbital tabs 1 zaleplon caps 1 QL(1 ea daily) Non-Barbiturate Hypnotics zolpidem tartrate tabs QL(1 ea daily) AMBIEN CR TBCR QL(1 ea daily) 1 7 or 10 mg, 5 mg (zolpidem tartrate) zolpidem tartrate tbcr or QL(1 ea daily) AMBIEN TABS ( QL(1 ea daily) 1 zolpidem 7 12.5 mg, 6.25 mg tartrate) Orexin Receptor Antagonists DORAL TABS 7 BELSOMRA TABS ST; QL(1 ea (quazepam) 2 (suvorexant) daily) 1 estazolam tabs Selective Melatonin Receptor Agonists QL(1 ea daily) HETLIOZ CAPS PA; ST eszopiclone tabs 1 4 (tasimelteon) flurazepam hcl caps 15 QL(2 ea daily) 1 3 ST; QL(1 ea mg ramelteon tabs daily) flurazepam hcl caps 30 QL(1 ea daily) ROZEREM TABS ST; QL(1 ea 1 7 mg (ramelteon) daily)

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PV LAXATIVES - Bowel Treatment Drugs peg 3350-kcl-nacl-na sulfate-na ascorbate- 5 Laxative Combinations ascorbic acid solr (Bisacodyl-Peg 3350-Pot QL(1 ea per fill peg 3350-kcl-sod QL(4000 ml per Chloride-Sod Bicarb-Sod 5 retail); PV bicarb-sod chloride-sod 5 fill retail); PV Chloride) PEG-PREP KIT sulfate solr (Peg 3350-Kcl-Nacl-Na PV Sulfate-Na Ascorbate- peg 3350-potassium PV Ascorbic Acid) PEG- 5 chloride-sod 5 3350/ELECTROLYTES/AS bicarbonate-sod CORBATE SOLR chloride solr (Peg 3350-Kcl-Sod Bicarb- QL(4000 ml per Laxatives - Miscellaneous Sod Chloride-Sod Sulfate) 5 fill retail); PV GAVILYTE-C, GAVILYTE- (Lactulose) CONSTULOSE 1 G SOLR SOLN (Peg 3350-Potassium PV (Polyethylene Glycol 3350) Limited to 510 Chloride-Sod Bicarbonate- CLEARLAX, CVS Gm per Sod Chloride) GAVILYTE- 5 PURELAX, EQ month;QL(17.6 N/FLAVOR PACK, CLEARLAX, EQL gm daily) TRILYTE SOLR CLEARLAX, GAVILAX, COLYTE-FLAVOR PACKS QL(4000 ml per GENTLELAX, GLYCOLAX, GNP CLEARLAX, SOLR (peg 3350-kcl- fill retail); PV 7 GOODSENSE CLEARLAX, 1 sod bicarb-sod HM CLEARLAX, KLS chloride-sod sulfate) LAXACLEAR, MM GOLYTELY SOLR 2.97 QL(4000 ml per CLEARLAX, QC NATURA- GM-5.86 GM-6.74 GM- fill retail); PV LAX, SB POLYETHYLENE 22.74 GM-236 GM (peg GLYCOL 3350, SM 7 CLEARLAX, SMOOTH 3350-kcl-sod bicarb- LAX, TGT POWDERLAX sod chloride-sod POWD sulfate) Limited to 510 GOLYTELY SOLR 21.5 PA; QL(4000 (Polyethylene Glycol 3350) 1 Gm per GM-2.82 GM-5.53 GM-6.36 ea per fill RA LAXATIVE POWD 17 month;QL(17.6 GM/SCOOP GM-227.1 GM (peg 3350- 5 retail); PV gm daily) kcl-sod bicarb-sod lactulose soln 10 1 chloride-sod sulfate) gm/15ml, 20 gm/30ml NULYTELY SOLR (peg PV MIRALAX POWD Limited to 510 3350-potassium ( 7 Gm per polyethylene glycol month;QL(17.6 chloride-sod 7 3350) bicarbonate-sod gm daily) chloride) Limited to 510 polyethylene glycol 1 Gm per NULYTELY/FLAVOR PV 3350 powd month;QL(17.6 PACKS SOLR (peg 3350- gm daily) potassium chloride-sod 7 Saline Laxatives bicarbonate-sod chloride)

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OSMOPREP TABS PA (Bisacodyl) BISACODYL Available for (sodium phosphate LAXATIVE, CVS members in monobasic-sodium 5 BISACODYL, CVS non- ) GENTLE LAXATIVE, grandfathered phosphate dibasic GENTLE LAXATIVE, GNP plans ages 50- Stimulant Laxatives GENTLE LAXATIVE, HM 1 74;AL(At least (Bisacodyl) ALOPHEN, Available for LAXATIVE, LAXATIVE, QC 50 yrs old - Up BISACODYL EC, members in GENTLE LAXATIVE, RA to 74 yrs old); CORRECT, CORRECTOL, non- FAST RELIEF LAXATIVE, PV CVS BISACODYL, CVS C- grandfathered SB LAXATIVE, SM LAX LAXATIVE, CVS plans ages 50- LAXATIVE, THE MAGIC GENTLE LAXATIVE, CVS 74;AL(At least BULLET SUPP GENTLE LAXATIVE 50 yrs old - Up Available for WOMENS, DUCODYL, EQ to 74 yrs old); members in GENTLE LAXATIVE, EQL PV non- GENTLE LAXATIVE, EQL (Bisacodyl) RA LAXATIVE grandfathered 1 plans ages 50- LAXATIVE, EQL WOMANS TBEC 5 MG LAXATIVE, EX-LAX 74;AL(At least ULTRA, FEENAMINT, 50 yrs old - Up GENTLE LAXATIVE, GNP to 74 yrs old); BISA-LAX, GNP GENTLE PV LAXATIVE, GNP Available for WOMENS GENTLE members in LAXATIVE, GOODSENSE 1 non- BISACODYL EC, grandfathered GOODSENSE WOMENS bisacodyl supp 1 plans ages 50- LAXATIVE, HM LAXATIVE, 74;AL(At least KP BISACODYL, 50 yrs old - Up LAXATIVE, PX LAXATIVE, to 74 yrs old); QC GENTLE LAXATIVE, PV RA WOMENS LAXATIVE, SB BISACODYL Available for LAXATIVE EC, SB members in GENTLE LAX-WOMEN, non- SM GENTLE LAXATIVE, DULCOLAX SUPP grandfathered 7 plans ages 50- SM WOMANS LAXATIVE, (bisacodyl) STIMULANT LAXATIVE, 74;AL(At least TGT GENTLE LAXATIVE, 50 yrs old - Up TGT WOMENS LAXATIVE, to 74 yrs old); VERACOLATE, WOMANS PV LAXATIVE, WOMENS Available for LAXATIVE TBEC members in non- DULCOLAX TBEC grandfathered 7 plans ages 50- (bisacodyl) 74;AL(At least 50 yrs old - Up to 74 yrs old); PV MACROLIDES - Drugs to Treat Bacterial Infections

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Azithromycin E.E.S. GRANULES SUSR (erythromycin 7 azithromycin pack 1 gm 1 ethylsuccinate) ERYPED 200 SUSR azithromycin susr 100 1 mg/5ml, 200 mg/5ml (erythromycin 7 QL(6 ea per fill ethylsuccinate) azithromycin tabs 250 1 mg retail) ERYPED 400 SUSR QL(3 ea daily) (erythromycin 7 azithromycin tabs 500 1 mg ethylsuccinate) QL(10 ea per erythromycin base azithromycin tabs 600 1 1 mg fill retail) cpep ZITHROMAX PACK 1 GM erythromycin base tabs 1 7 (azithromycin) ZITHROMAX SUSR 100 erythromycin base tbec 1 MG/5ML, 200 MG/5ML 7 erythromycin (azithromycin) ethylsuccinate susr 200 1 ZITHROMAX TABS 250 QL(6 ea per fill mg/5ml, 400 mg/5ml 7 retail) MG (azithromycin) erythromycin ZITHROMAX TABS 500 QL(3 ea daily) 7 ethylsuccinate tabs 400 1 MG (azithromycin) mg ZITHROMAX TABS 600 QL(10 ea per 7 Fidaxomicin MG (azithromycin) fill retail) DIFICID TABS 200 MG ZITHROMAX TRI-PAK QL(3 ea daily) 3 7 (fidaxomicin) TABS (azithromycin) ZITHROMAX Z-PAK TABS QL(6 ea per fill MEDICAL DEVICES AND SUPPLIES 7 (azithromycin) retail) Contraceptives Clarithromycin CAYA DPRH (diaphragm QL(1 ea per 5 365 days clarithromycin susr 125 1 arc-spring) mg/5ml, 250 mg/5ml retail); PV FC FEMALE CONDOM PV clarithromycin tabs 250 1 mg, 500 mg MISC (condoms - 5 female) QL(14 ea per clarithromycin tb24 500 1 mg fill retail) FC2 FEMALE CONDOM PV MISC (condoms - 5 Erythromycins female) (Erythromycin Base) ERY- 1 FEMCAP DEVI (cervical PV TAB TBEC 5 caps) (Erythromycin OMNIFLEX DIAPHRAGM PV Ethylsuccinate) E.E.S. 400 1 5 TABS DPRH (diaphragms) (Erythromycin Stearate) ERYTHROCIN STEARATE 1 TABS

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WIDE-SEAL SILICONE PV BD AUTOSHIELD DUO DIAPHRAGM KIT 60 30G X 5MM MISC ( 5 insulin 2 DPRH (diaphragm wide pen needle) seal) BD ECLIPSE NEEDLE WIDE-SEAL SILICONE PV 30G X1/2" MISC (needle 2 DIAPHRAGM KIT 65 5 (disp) 30 g) DPRH (diaphragm wide BD NEEDLE/30G X 1/2" seal) MISC (needle (disp) 30 2 WIDE-SEAL SILICONE PV g) DIAPHRAGM KIT 70 5 BD PEN DPRH (diaphragm wide NEEDLE/MICRO/ULTRA- seal) FINE/32G X 6MM MISC 2 WIDE-SEAL SILICONE PV (insulin pen needle) DIAPHRAGM KIT 75 Limit 200 per DPRH ( 5 BD PEN diaphragm wide NEEDLE/MINI/ULTRA- month without seal) FINE/31G X 5MM MISC 2 authorization;Q L(6.67 ea WIDE-SEAL SILICONE PV (insulin pen needle) DIAPHRAGM KIT 80 daily); RX/OTC DPRH (diaphragm wide 5 BD PEN seal) NEEDLE/ORIGINAL/ULTR A-FINE/29G X 12.7MM 2 WIDE-SEAL SILICONE PV MISC (insulin pen DIAPHRAGM KIT 85 needle) DPRH (diaphragm wide 5 seal) BD PEN Limited to 200 NEEDLE/SHORT/ULTRA- without prior WIDE-SEAL SILICONE PV 2 auth;QL(6.67 DIAPHRAGM KIT 90 FINE/31G X 8MM MISC 5 ea daily); DPRH (diaphragm wide (insulin pen needle) RX/OTC seal) BD SAFETYGLIDE RX/OTC WIDE-SEAL SILICONE PV INSULIN DIAPHRAGM KIT 95 SYRINGE/0.3ML/31G X 2 DPRH (diaphragm wide 5 15/64" MISC (insulin seal) syringe/needle u-100) Diabetic Supplies BD SAFETYGLIDE Limit 200 per INSULIN month;QL(6.67 ONETOUCH ULTRA 2 KIT QL(1 ea per SYRINGE/1ML/31G X 2 ea daily) (blood glucose 2 365 days retail); RX/OTC 15/64" MISC (insulin monitoring supplies) syringe/needle u-100) ONETOUCH VERIO FLEX QL(1 ea per BD VEO INSULIN RX/OTC BLOOD GLUCOSE 365 days SYRINGE ULTRA- MONITORING SYSTEM retail); RX/OTC 2 AFINE/0.3ML/31G X 6MM 2 KIT (blood glucose MISC (insulin monitoring supplies) syringe/needle u-100) Parenteral Therapy Supplies

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD VEO INSULIN RX/OTC EASY TOUCH SYRINGE ULTRA- HYPODERMIC NEEDLES FINE/0.3ML/31G X 6MM 2 30GX1/2" MISC (needle 2 MISC (insulin (disp) 30 g) syringe/needle u-100) GLOBAL EASY GLIDE RX/OTC BD VEO INSULIN RX/OTC INSULIN SYRINGE ULTRA- SYRINGE/0.3ML/31G X 2 FINE/1/2 UNIT/0.3ML/31G 2 15/64" MISC (insulin X 6MM MISC (insulin syringe/needle u-100) syringe/needle u-100) GLOBAL EASY GLIDE Limit 200 per BD VEO INSULIN Limit 200 per INSULIN month;QL(6.67 SYRINGE ULTRA- month;QL(6.67 SYRINGE/1ML/31G X 2 ea daily) FINE/1ML/31G X 6MM 2 ea daily) 15/64" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100) HYPODERMIC NEEDLE BD VEO INSULIN RX/OTC 30GX1/2" MISC (needle 2 SYRINGE ULTRA-FINE/U- (disp) 30 g) 100/0.3ML/31G X 15/64" 2 INSULIN SYRINGES AND 2 MISC (insulin PEN NEEDLES syringe/needle u-100) POLY HUB NEEDLE/30G BD VEO INSULIN Limit 200 per X 1/2" MISC (needle 2 SYRINGE ULTRA-FINE/U- month;QL(6.67 (disp) 30 g) 100/1ML/31G X 15/64" 2 ea daily) MISC (insulin RELION INSULIN Limit 200 per syringe/needle u-100) SYRINGE month;QL(6.67 1ML/31GX15/64" MISC 2 ea daily) DROPLET INSULIN RX/OTC (insulin syringe/needle SYRINGE U- u-100) 100/0.3ML/31G X 15/64" 2 MISC (insulin RELION INSULIN RX/OTC syringe/needle u-100) SYRINGE/U- 100/0.3ML/31G X 15/64" 2 DROPLET INSULIN Limit 200 per MISC (insulin SYRINGE U-100/1ML/31G month;QL(6.67 syringe/needle u-100) X 15/64" MISC (insulin 2 ea daily) syringe/needle u-100) RELION INSULIN Limit 200 per SYRINGE/U-100/1ML/31G month;QL(6.67 DROPLET INSULIN RX/OTC X 15/64" MISC (insulin 2 ea daily) SYRINGE/U- syringe/needle u-100) 100/0.3ML/31G X 15/64" 2 MISC (insulin TECHLITE INSULIN RX/OTC syringe/needle u-100) SYRINGEU- 100/0.3ML/31G X 15/64" 2 DROPLET INSULIN Limit 200 per MISC (insulin SYRINGE/U-100/1ML/31G month;QL(6.67 syringe/needle u-100) X 15/64" MISC (insulin 2 ea daily) syringe/needle u-100) TECHLITE INSULIN Limit 200 per SYRINGEU-100/1ML/31G month;QL(6.67 EASY TOUCH FLIPLOCK X 15/64" MISC (insulin 2 ea daily) NEEDLES 30GX1/2" MISC 2 syringe/needle u-100) (needle (disp) 30 g) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN RX/OTC AEROCHAMBER Z-STAT RX/OTC SYRINGE 31X6MM MISC PLUS VALVED HOLDING (insulin syringe/needle 2 CHAMBER W/FLOW VU 2 u-100) MISC (spacer/aerosol- holding chambers) Respiratory Therapy Supplies ADULT MASK DEVI RX/OTC AEROCHAMBER Z-STAT RX/OTC PLUS/FLOWSIGNAL MISC (respiratory therapy 2 (spacer/aerosol-holding 2 supplies) chambers) AEROBIKA DEVI RX/OTC AEROCHAMBER Z-STAT RX/OTC (respiratory therapy 2 PLUS/LARGE MASK MISC supplies) (spacer/aerosol-holding 2 AEROCHAMBER MINI RX/OTC chambers) AEROSOLCHAMBER 2 AEROCHAMBER Z-STAT RX/OTC DEVI (spacer/aerosol- PLUS/MEDIUM MASK holding chambers) MISC (spacer/aerosol- 2 AEROCHAMBER MV RX/OTC holding chambers) MISC (spacer/aerosol- 2 AEROCHAMBER Z-STAT RX/OTC holding chambers) PLUS/SMALL MASK MISC AEROCHAMBER PLUS RX/OTC (spacer/aerosol-holding 2 FLOW VU MISC 2 chambers) (spacer/aerosol-holding AEROCHAMBER/FLOWSI RX/OTC chambers) GNAL MISC AEROCHAMBER PLUS RX/OTC (spacer/aerosol-holding 2 FLOW-VU MISC 2 chambers) (spacer/aerosol-holding AEROVENT PLUS RX/OTC chambers) HOLDING AEROCHAMBER PLUS RX/OTC CHAMBER/COLLAPSIBLE 2 FLOW-VU/LARGE MASK DEVI (spacer/aerosol- 2 MISC (spacer/aerosol- holding chambers) holding chambers) ALL FLOW 1000 PFT RX/OTC AEROCHAMBER PLUS RX/OTC FILTER DEVI FLOW-VU/MASK MISC (respiratory therapy 2 2 (spacer/aerosol-holding supplies) chambers) ALL FLOW 2000 PFT RX/OTC AEROCHAMBER PLUS RX/OTC FILTER DEVI FLOW-VU/MEDIUM MASK (respiratory therapy 2 2 MISC (spacer/aerosol- supplies) holding chambers) ALL FLOW 3000 PFT RX/OTC AEROCHAMBER PLUS RX/OTC FILTER DEVI FLOW-VU/SMALL MASK (respiratory therapy 2 2 MISC (spacer/aerosol- supplies) holding chambers)

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALL FLOW 4000 PFT RX/OTC BREATHERITE RX/OTC FILTER DEVI COLLAPSIBLEINFANT (respiratory therapy 2 SPACER W/MASK MISC 2 supplies) (spacer/aerosol-holding ALL FLOW 5000 PFT RX/OTC chambers) FILTER DEVI BREATHERITE RX/OTC (respiratory therapy 2 COLLAPSIBLESMALL supplies) CHILD SPACER W/MASK 2 ALL FLOW 6000 PFT RX/OTC MISC (spacer/aerosol- FILTER DEVI holding chambers) (respiratory therapy 2 BREATHERITE RX/OTC supplies) COLLAPSIBLESPACER W/ NEONATE MASK MISC ALL FLOW 7000 PFT RX/OTC 2 FILTER DEVI (spacer/aerosol-holding (respiratory therapy 2 chambers) supplies) BREATHERITE MISC RX/OTC ARIAL CHAMBER DEVI RX/OTC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) BREATHERITE RIGID RX/OTC SPACERW/MASK MISC BREATHE EASE/LARGE RX/OTC 2 MASK DEVI (spacer/aerosol-holding (spacer/aerosol-holding 2 chambers) chambers) BREATHERITE VALVED RX/OTC MDI BREATHE EASE/MEDIUM RX/OTC CHAMBER/COLLAPSIBLE MASK DEVI 2 DEVI (respiratory (spacer/aerosol-holding 2 therapy supplies) chambers) BREATHERITE VALVED RX/OTC BREATHE EASE/SMALL RX/OTC MDI CHAMBER/RIGID MASK DEVI DEVI (respiratory 2 (spacer/aerosol-holding 2 therapy supplies) chambers) BREATHERITE W/LARGE RX/OTC BREATHERITE RX/OTC MASK MISC COLLAPSIBLEADULT (spacer/aerosol-holding 2 SPACER W/MASK MISC 2 (spacer/aerosol-holding chambers) chambers) BREATHERITE RX/OTC W/MEDIUM MASK MISC BREATHERITE RX/OTC 2 COLLAPSIBLECHILD (spacer/aerosol-holding SPACER W/MASK MISC 2 chambers) (spacer/aerosol-holding BREATHERITE W/SMALL RX/OTC chambers) MASK MISC (spacer/aerosol-holding 2 chambers)

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE ANTI- RX/OTC COMPACT SPACE RX/OTC STATICVALVED CHAMBER/ANTI- HOLDING STATIC/MEDIUM MASK 2 CHAMBER/ADULT LARGE 2 DEVI (spacer/aerosol- DEVI (spacer/aerosol- holding chambers) holding chambers) COMPACT SPACE RX/OTC CLEVER CHOICE ANTI- RX/OTC CHAMBER/ANTI- STATICVALVED STATIC/SMALL MASK 2 HOLDING DEVI ( 2 spacer/aerosol- CHAMBER/MEDIUM DEVI holding chambers) (spacer/aerosol-holding EASIVENT MISC RX/OTC chambers) (spacer/aerosol-holding 2 CLEVER CHOICE ANTI- RX/OTC chambers) STATICVALVED HOLDING EASIVENT/MASK-LARGE RX/OTC CHAMBER/MEDIUM/3 2 MISC (spacer/aerosol- 2 YEA DEVI holding chambers) (spacer/aerosol-holding EASIVENT/MASK- RX/OTC chambers) MEDIUM MISC 2 CLEVER CHOICE ANTI- RX/OTC (spacer/aerosol-holding STATICVALVED chambers) HOLDING 2 EASIVENT/MASK-SMALL RX/OTC CHAMBER/SMALL DEVI MISC (spacer/aerosol- 2 (spacer/aerosol-holding holding chambers) chambers) EASY FLOW BLACK/BLUE RX/OTC CLEVER CHOICE ANTI- RX/OTC DEVI (respiratory 2 STATICVALVED HOLDING therapy supplies) CHAMBER/SMALL 2 EASY FLOW RX/OTC INFANT DEVI BLACK/ORANGE DEVI 2 (spacer/aerosol-holding (respiratory therapy chambers) supplies) CO MONITOR DEVI RX/OTC EASY FLOW BLACK/RED RX/OTC (respiratory therapy 2 DEVI (respiratory 2 supplies) therapy supplies) COMPACT SPACE RX/OTC EASY FLOW RX/OTC CHAMBER/ANTI-STATIC BLACK/WHITE DEVI 2 DEVI (spacer/aerosol- 2 (respiratory therapy holding chambers) supplies) COMPACT SPACE RX/OTC EASY FLOW RX/OTC CHAMBER/ANTI- BLACK/YELLOW DEVI 2 STATIC/LARGE MASK 2 (respiratory therapy DEVI (spacer/aerosol- supplies) holding chambers) EASY FLOW WHITE/BLUE RX/OTC DEVI (respiratory 2 therapy supplies)

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY FLOW RX/OTC IN-CHECK INSPIRATORY RX/OTC WHITE/GREEN DEVI FLOWMETER/NASAL (respiratory therapy 2 WITH MASK DEVI 2 supplies) (respiratory therapy EASY FLOW WHITE/PINK RX/OTC supplies) DEVI (respiratory 2 IN-CHECK INSPIRATORY RX/OTC FLOWMETER/ORAL DEVI therapy supplies) 2 EASY FLOW RX/OTC (respiratory therapy WHITE/WHITE DEVI supplies) (respiratory therapy 2 INSPIRACHAMBER/ANTI- RX/OTC supplies) STATIC VALVED/MOUTHPIECE EASY FLOW RX/OTC 2 WHITE/YELLOW DEVI DEVI (spacer/aerosol- (respiratory therapy 2 holding chambers) supplies) INSPIRACHAMBER/LARG RX/OTC EQ SPACE CHAMBER RX/OTC E DEVI (spacer/aerosol- 2 ANTI-STATIC DEVI holding chambers) (spacer/aerosol-holding 2 INSPIRACHAMBER/SOOT RX/OTC chambers) HERMASK/INSPIRAMASK /MEDIUM DEVI EQ SPACE CHAMBER RX/OTC 2 ANTI-STATIC/LARGE (spacer/aerosol-holding MASK DEVI 2 chambers) (spacer/aerosol-holding INSPIRACHAMBER/SOOT RX/OTC chambers) HERMASK/INSPIRAMASK /SMALL DEVI EQ SPACE CHAMBER RX/OTC 2 ANTI-STATIC/MEDIUM (spacer/aerosol-holding MASK DEVI 2 chambers) (spacer/aerosol-holding INSPIREASE DRUG RX/OTC DELIVERYSYSTEM MISC chambers) 2 EQ SPACE CHAMBER RX/OTC (spacer/aerosol-holding ANTI-STATIC/SMALL chambers) MASK DEVI 2 LITEAIRE DEVI RX/OTC (spacer/aerosol-holding (spacer/aerosol-holding 2 chambers) chambers) FLEXICHAMBER DEVI RX/OTC MICROCHAMBER DEVI RX/OTC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) IN-CHECK DIAL RX/OTC MICROCHAMBER MISC RX/OTC INSPIRATORYFLOW (spacer/aerosol-holding 2 TRAINER DEVI 2 chambers) (respiratory therapy MICROSPACER MISC RX/OTC supplies) (spacer/aerosol-holding 2 chambers)

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MISTASSIST DEVI RX/OTC OPTICHAMBER RX/OTC (respiratory therapy 2 DIAMOND/SMALLFACE supplies) MASK MISC 2 NEBULIZER CUP/TUBING RX/OTC (spacer/aerosol-holding DEVI (respiratory 2 chambers) therapy supplies) OPTICHAMBER FACE RX/OTC MASK/LARGE MISC OMBRA TABLE TOP RX/OTC 2 COMPRESSOR DEVI (spacer/aerosol-holding (respiratory therapy 2 chambers) supplies) OPTICHAMBER FACE RX/OTC MASK/MEDIUM MISC ONE FLOW FVC RX/OTC 2 MONITORING (spacer/aerosol-holding SPIROMETER DEVI 2 chambers) (respiratory therapy OPTICHAMBER FACE RX/OTC MASK/SMALL MISC supplies) 2 OPTICHAMBER RX/OTC (spacer/aerosol-holding ADVANTAGE/LARGE chambers) MASK MISC 2 OPTIHALER MDI DRUG RX/OTC ( DELIVERY SYSTEM DEVI spacer/aerosol-holding 2 chambers) (spacer/aerosol-holding OPTICHAMBER RX/OTC chambers) ADVANTAGE/MEDIUM OPTIHALER MISC RX/OTC FACE MASK MISC 2 (spacer/aerosol-holding 2 (spacer/aerosol-holding chambers) chambers) PARI MANUAL RX/OTC OPTICHAMBER RX/OTC INTERRUPTER DEVI ADVANTAGE/SMALL (respiratory therapy 2 FACE MASK MISC 2 supplies) (spacer/aerosol-holding PARI TREK S COMBO RX/OTC chambers) PACK DEVI (respiratory 2 OPTICHAMBER RX/OTC therapy supplies) DIAMOND MISC POCKET CHAMBER DEVI RX/OTC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) OPTICHAMBER RX/OTC DIAMOND/LARGEFACE POCKET SPACER DEVI RX/OTC MASK DEVI 2 (spacer/aerosol-holding 2 (spacer/aerosol-holding chambers) chambers) PRIMEAIRE DUAL- RX/OTC OPTICHAMBER RX/OTC VALVED HOLDING DIAMOND/MEDIUM FACE CHAMBER DEVI 2 MASK MISC 2 (respiratory therapy (spacer/aerosol-holding supplies) chambers)

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INHALER RX/OTC VORTEX HOLDING RX/OTC SPACER CHAMBER CHAMBER/MASK/CHILDS ADULT MISC 2 /FROG DEVI (respiratory 2 (spacer/aerosol-holding therapy supplies) chambers) VORTEX HOLDING RX/OTC PRO COMFORT INHALER RX/OTC CHAMBER/MASK/TODDL SPACER CHAMBER ER DEVI (respiratory 2 CHILD MISC 2 therapy supplies) (spacer/aerosol-holding VORTEX HOLDING RX/OTC chambers) CHAMBER/MASK/TODDL PRO COMFORT INHALER RX/OTC ER/LADY BUG DEVI 2 SPACER CHAMBER (respiratory therapy INFANT DEVI 2 supplies) (spacer/aerosol-holding VORTEX VALVED RX/OTC chambers) HOLDING CHAMBER PROCARE SPACER RX/OTC DEVI (spacer/aerosol- 2 CHAMBER W/ADULT holding chambers) MASK DEVI 2 WATCHHALER DEVI RX/OTC (spacer/aerosol-holding (spacer/aerosol-holding 2 chambers) chambers) PROCARE SPACER RX/OTC CHAMBER W/CHILD MIGRAINE PRODUCTS - Drugs to Treat Migraine MASK DEVI 2 Headaches (spacer/aerosol-holding Calcitonin Gene-Related Peptide (CGRP) chambers) AIMOVIG SOAJ PA 2 QUAKE DEVI RX/OTC (erenumab-aooe) (respiratory therapy 2 EMGALITY SOAJ 120 PA; ST supplies) MG/ML (galcanezumab- 2 RITEFLO DEVI RX/OTC gnlm) (spacer/aerosol-holding 2 EMGALITY SOSY 120 PA; ST chambers) MG/ML (galcanezumab- 2 SPIRO PD DEVI RX/OTC gnlm) (respiratory therapy 2 Migraine Combinations supplies) (Ergotamine W/ Caffeine) 1 THRESHOLD PEP DEVI RX/OTC MIGERGOT SUPP (respiratory therapy 2 CAFERGOT TABS supplies) (ergotamine w/ 7 VALVED HOLDING RX/OTC caffeine) CHAMBER DEVI 2 (spacer/aerosol-holding ergotamine w/ caffeine 1 chambers) tabs VORTEX HOLDING RX/OTC Migraine Products CHAMBER/MASK/CHILDS D.H.E. 45 SOLN PA 2 DEVI (respiratory (dihydroergotamine 7 therapy supplies) mesylate) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dihydroergotamine PA IMITREX STATDOSE PA SYSTEM SOAJ 4 mesylate soln ij 1 4 7 mg/ml MG/0.5ML (sumatriptan dihydroergotamine QL(0.27 ml succinate) mesylate soln na 4 3 daily) IMITREX STATDOSE PA; Limit 2 per SYSTEM SOAJ 6 fill, 4 per mg/ml 7 month;QL(0.14 ERGOMAR SUBL MG/0.5ML (sumatriptan 2 ml daily,2 ml (ergotamine tartrate) succinate) per fill retail) MIGRANAL SOLN QL(0.27 ml IMITREX TABS OR 100 Limit 9 per (dihydroergotamine 7 daily) MG, 25 MG, 50 MG 7 month;QL(2 ea mesylate) (sumatriptan succinate) daily) Limit 18 tabs Serotonin Agonists MAXALT TABS 7 per Limit 6 per (rizatriptan benzoate) month;QL(0.6 almotriptan malate tabs 1 month;QL(0.2 ea daily) ea daily) MAXALT-MLT TBDP Limit 12 per AMERGE TABS Limit 9 per 7 month;QL(0.4 7 month;QL(0.3 (rizatriptan benzoate) ea daily) (naratriptan hcl) ea daily) Limit 9 per eletriptan hydrobromide Limit 6 per naratriptan hcl tabs 1 month;QL(0.3 3 month;QL(0.2 ea daily) tabs ea daily) RELPAX TABS (eletriptan Limit 6 per FROVA TABS Limit 9 per 7 month;QL(0.2 7 month;QL(0.3 hydrobromide) ea daily) (frovatriptan succinate) ea daily) Limit 18 tabs frovatriptan succinate Limit 9 per rizatriptan benzoate per 3 month;QL(0.3 1 tabs tabs 10 mg, 5 mg month;QL(0.6 ea daily) ea daily) Limit 6 Limit 12 per IMITREX SOLN NA 20 rizatriptan benzoate 7 sprayers per 1 month;QL(0.4 MG/ACT (sumatriptan) month;QL(2 ea tbdp 10 mg, 5 mg ea daily) daily) Limit 6 IMITREX SOLN NA 5 Limit 6 per sumatriptan soln 20 sprayers per 7 month;QL(0.2 1 MG/ACT (sumatriptan) mg/act month;QL(2 ea ea daily) daily) IMITREX SOLN SC 6 PA; ST;QL(2 ml sumatriptan soln 5 Limit 6 per MG/0.5ML (sumatriptan 7 per 30 days 1 month;QL(0.2 succinate) retail) mg/act ea daily) IMITREX STATDOSE PA; ST PA sumatriptan succinate 4 REFILL SOCT 4 MG/0.5ML 7 soaj sc 4 mg/0.5ml (sumatriptan succinate) PA; Limit 2 per IMITREX STATDOSE PA sumatriptan succinate fill, 4 per REFILL SOCT 6 MG/0.5ML 4 month;QL(0.14 7 soaj sc 6 mg/0.5ml (sumatriptan succinate) ml daily,2 ml per fill retail)

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; ST sumatriptan succinate 4 Fluoride soct sc 4 mg/0.5ml (Sodium Fluoride) AL(Up to 6 yrs PA FLUORITAB, FLURA- old ); PV sumatriptan succinate 4 1 soct sc 6 mg/0.5ml DROPS, NAFRINSE DROPS SOLN sumatriptan succinate PA; ST;QL(2 ml 4 per 30 days (Sodium Fluoride) 1 AL(Up to 6 yrs soln sc 6 mg/0.5ml retail) NAFRINSE CHEW old ); PV PA FLORIVA LIQD (sodium sumatriptan succinate 4 3 sosy sc 6 mg/0.5ml fluoride-vitamin d) Limit 9 per FLUORABON SOLN AL(Up to 6 yrs sumatriptan succinate 2 old ); PV tabs or 100 mg, 25 mg, 1 month;QL(2 ea (sodium fluoride) 50 mg daily) sodium fluoride chew AL(Up to 6 yrs old ); PV Limit 6 per 0.25 mg, 0.5 mg, 1 mg, 1 zolmitriptan soln 1 month;QL(0.2 2.2 mg ea daily) sodium fluoride soln 0.5 AL(Up to 6 yrs 1 old ); RX/OTC; Limit 6 per mg/ml zolmitriptan tabs 1 month;QL(0.2 PV ea daily) AL(Up to 6 yrs sodium fluoride tabs 1 Limit 6 per 0.5 mg, 1 mg old ); PV zolmitriptan tbdp 1 month;QL(0.2 ea daily) Iodine Products iodine strong (lugol's) ZOMIG SOLN Limit 6 per 3 7 month;QL(0.2 soln (zolmitriptan) ea daily) Phosphate ZOMIG TABS Limit 6 per (Pot Phosphate Monobasic 7 month;QL(0.2 (zolmitriptan) W/ Sod Phosphate Dibasic ea daily) & Monobasic) PHOSPHA ZOMIG ZMT TBDP Limit 6 per 250 NEUTRAL, 1 7 month;QL(0.2 (zolmitriptan) PHOSPHO-TRIN 250 ea daily) NEUTRAL, VIRT-PHOS 250 NEUTRAL TABS MINERALS & ELECTROLYTES K-PHOS NEUTRAL TABS Calcium (pot phosphate CALCIFOL WAFR monobasic w/ sod 7 (calcium carbonate-folic phosphate dibasic & acid-vit d-b6-b12- 3 monobasic) boron-magnesium) K-PHOS TABS CALCIUM-FOLIC ACID (potassium phosphate 2 PLUS D WAFR (calcium monobasic) carbonate-folic acid-vit 3 pot phosphate d-b6-b12-boron- monobasic w/ sod 1 magnesium) phosphate dibasic & MAGNEBIND 400 TABS monobasic tabs (calcium carbonate- 3 Potassium magnesium carbonate) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Potassium Bicarbonate) 1 EFFER-K TBEF 25 MEQ MISCELLANEOUS THERAPEUTIC CLASSES (Potassium Bicarbonate) K- Chelating Agents PRIME, KLOR-CON/EF 1 (Trientine Hcl) CLOVIQUE 4 PA TBEF CAPS (Potassium Chloride CUPRIMINE CAPS PA 7 Microencapsulated ( ) Crystals Er) KLOR-CON 1 penicillamine D-PENAMINE TABS M10, KLOR-CON M15, 2 KLOR-CON M20 TBCR (penicillamine) (Potassium Chloride) DEPEN TITRATABS TABS 7 KLOR-CON 10, KLOR- 1 (penicillamine) CON 8 TBCR penicillamine caps 4 PA (Potassium Chloride) 1 KLOR-CON PACK penicillamine tabs 1 (Potassium Chloride) KLOR-CON SPRINKLE 1 SYPRINE CAPS ( PA trientine 7 CPCR hcl) EFFER-K TBEF 0.84 GM-1 PA GM, 1.68 GM-2 GM trientine hcl caps 4 (potassium 3 Immunomodulators bicarbonate-citric acid) PA; Must use K-TAB TBCR (potassium 7 REVLIMID CAPS Exactus chloride) 4 Specialty Rx 1- (lenalidomide) 866-458- potassium chloride cpcr 1 10 meq, 8 meq 9246;AC Must use potassium chloride THALOMID CAPS Exactus microencapsulated 1 3 Specialty Rx 1- crystals er tbcr 10 meq, (thalidomide) 866-458- 20 meq 9246;LA; AC Immunosuppressive Agents potassium chloride 1 pack 20 meq (Cyclosporine Modified (For Microemulsion)) 1 potassium chloride soln 1 10 %, 20 % GENGRAF CAPS (Cyclosporine Modified (For potassium chloride tbcr 1 Microemulsion)) 1 10 meq, 8 meq GENGRAF SOLN ASTAGRAF XL CP24 PA potassium chloride tbcr 3 3 20 meq (tacrolimus) AZASAN TABS Zinc 3 (azathioprine) GALZIN CAPS ( zinc 3 acetate (oral)) azathioprine tabs 1 WILZIN CAPS ( zinc 3 acetate (oral))

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELLCEPT CAPS PROGRAF PACK 0.2 MG, PA 4 (mycophenolate 7 1 MG (tacrolimus) mofetil) RAPAMUNE SOLN 7 CELLCEPT SUSR (sirolimus) (mycophenolate 7 RAPAMUNE TABS 7 mofetil) (sirolimus) CELLCEPT TABS SANDIMMUNE CAPS 100 (mycophenolate 7 MG, 25 MG 7 mofetil) (cyclosporine) SANDIMMUNE SOLN 100 cyclosporine caps 1 2 MG/ML (cyclosporine) cyclosporine modified (for microemulsion) 1 sirolimus soln 3 caps sirolimus tabs 3 cyclosporine modified (for microemulsion) 1 tacrolimus caps 1 soln ZORTRESS TABS 0.25 everolimus MG, 0.5 MG, 0.75 MG (immunosuppressant) 1 (everolimus 7 tabs (immunosuppressant)) IMURAN TABS ZORTRESS TABS 1 MG 7 (azathioprine) (everolimus 2 (immunosuppressant)) mycophenolate mofetil 1 caps or 250 mg Potassium Removing Agents (Sodium Polystyrene mycophenolate mofetil 1 susr or 200 mg/ml Sulfonate) KIONEX, SPS 1 SUSP mycophenolate mofetil 1 tabs or 500 mg LOKELMA PACK ST (sodium zirconium 3 mycophenolate sodium 3 cyclosilicate) tbec sodium polystyrene 1 MYFORTIC TBEC sulfonate powd (mycophenolate 7 sodium) sodium polystyrene 1 sulfonate susp NEORAL CAPS (cyclosporine modified 7 Systemic Lupus Erythematosus Agents (for microemulsion)) PA; Must use NEORAL SOLN BENLYSTA SOAJ AcariaHealth 4 Specialty Rx at (cyclosporine modified 7 (belimumab) 1-844-538- (for microemulsion)) 4661;;LA PROGRAF CAPS 0.5 MG, 7 1 MG, 5 MG (tacrolimus)

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use QL(6 ea daily) pilocarpine hcl (oral) 1 BENLYSTA SOSY AcariaHealth tabs 5 mg 4 Specialty Rx at (belimumab) QL(4 ea daily) 1-844-538- pilocarpine hcl (oral) 1 4661;;LA tabs 7.5 mg SALAGEN TABS 5 MG QL(6 ea daily) MOUTH/THROAT/DENTAL AGENTS 7 (pilocarpine hcl (oral)) Anesthetics Topical Oral SALAGEN TABS 7.5 MG QL(4 ea daily) 7 FIRST-MOUTHWASH BLM (pilocarpine hcl (oral)) SUSP (diphenhydramine- MULTIVITAMINS 3 lidocaine-alum Multiple Vitamins w/ Minerals hydroxide-mg ONEVITE TABS (multiple hydroxide-simeth) vitamins w/ minerals & 3 lidocaine hcl (mouth- 1 folic acid) throat) soln THRIVITE 19 TABS Anti-infectives - Throat (multiple vitamins w/ 3 minerals & folic acid) clotrimazole troc 1 UDAMIN SP TABS nystatin (mouth-throat) 1 (multiple vitamins w/ 3 susp minerals & folic acid) ORAVIG TABS VENTRIXYL TABS (miconazole (mouth- 3 (multiple vitamins w/ 3 throat)) minerals & folic acid) Dental Products Ped MV w/ Fluoride PREVIDENT RINSE SOLN (Pediatric Multivitamins AL(Up to 6 yrs (sodium fluoride 7 W/Fl) MULTI- old ); RX/OTC (dental)) VITAMIN/FLUORIDE DROPS, MULTIVITAMIN 1 sodium fluoride (dental) 3 WITH FLUORIDE, soln MULTIVITAMIN/FLUORID Steroids - Mouth/Throat/Dental E SOLN (Triamcinolone Acetonide (Pediatric Multivitamins AL(Up to 6 yrs (Mouth)) ORALONE 1 W/Fl) old ); RX/OTC DENTAL PASTE PSTE MULTIVITAMIN/FLUORID 1 E, triamcinolone 1 MULTIVITAMINS/FLUORI acetonide (mouth) pste DE CHEW Throat Products - Misc. (Pediatric Vitamins Acd W/ AL(Up to 6 yrs QL(3 ea daily) Fluoride) MULTIVITAMIN old ); RX/OTC cevimeline hcl caps 3 SELECT/FLUORIDE, 1 EVOXAC CAPS QL(3 ea daily) VITAMINS 7 A/C/D/FLUORIDE SOLN (cevimeline hcl) MUCOTROL WAFR ( oral 3 wound care products)

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Vitamins Acd W/ AL(Up to 6 yrs Ped Multi Vitamins w/Fl & FE Fluoride) TRI- old ); RX/OTC (Ped Multivitamins W/Fl & RX/OTC VITE/FLUORIDE SOLN 1 0.25 MG/ML-35 MG/ML- Iron) MULTI- 400 UNIT/ML-1500 VIT/IRON/FLUORIDE, UNIT/ML MULTI- 1 VITAMIN/FLUORIDE/IRON (Pediatric Vitamins Acd W/ AL(Up to 6 yrs , Fluoride) TRI- old ) MULTIVITAMIN/FLUORID VITE/FLUORIDE SOLN 0.5 1 E/IRON SOLN MG/ML-35 MG/ML-400 UNIT/ML-1500 UNIT/ML ESCAVITE D CHEW (ped 3 FLORIVA PLUS SOLN AL(Up to 6 yrs multivitamins w/fl & (pediatric multivitamins 2 old ); RX/OTC iron) w/fl) POLY-VI-FLOR/IRON AL(Up to 6 yrs CHEW 0.5 MG-10 MG-15 old ) MULTIVITAMIN + AL(Up to 6 yrs UNIT-200 MCG-400 UNIT FLUORIDE CHEW old ); RX/OTC 3 (ped multivitamins w/fl ( 2 pediatric multivitamins & iron) w/fl) POLY-VI-FLOR/IRON pediatric vitamins acd AL(Up to 6 yrs SUSP 200 MCG/ML-0.25 1 old ) w/ fluoride soln MG/ML-7 MG/ML (ped 3 POLY-VI-FLOR CHEW AL(Up to 6 yrs multivitamins w/fl & 0.25 MG-15 UNIT-200 old ) iron) MCG-400 UNIT, 0.5 MG-15 QUFLORA FE PEDIATRIC AL(Up to 6 yrs UNIT-200 MCG-400 UNIT, 3 1 MG-15 UNIT-200 MCG- LIQD (ped multivitamins 2 old ) 400 UNIT (pediatric w/fl & iron) multivitamins w/fl) Pediatric Multiple Vitamins & Minerals w/ Fluoride POLY-VI-FLOR SUSP 0.25 FLORIVA CHEW MG/ML-200 MCG/ML 3 (pediatric multiple (pediatric multivitamins vitamins & minerals w/ 3 w/fl) fluoride) QUFLORA PEDIATRIC AL(Up to 6 yrs Prenatal Vitamins CHEW (pediatric 2 old ); RX/OTC (Prenatal Vit W/ Docusate- RX/OTC multivitamins w/fl) Fe Fumarate-Folic Acid) QUFLORA PEDIATRIC AL(Up to 6 yrs PRENATAL 19 TABS 1 old ); RX/OTC SOLN (pediatric 2 MG-3 MG-3 MG-7 MG-12 3 multivitamins w/fl) MCG-15 MG-20 MG-20 MG-25 MG-29 MG-30 TRI-VI-FLOR SUSP UNIT-100 MG-200 MG-400 (pediatric vitamins acd 3 UNIT-1000 UNIT & l-methylfolate w/ (Prenatal Vit W/ Docusate- fluoride) Iron Carbonyl-Folic Acid) 1 TRI-VI-FLORO SUSP INATAL GT TABS (pediatric vitamins acd & l-methylfolate w/ 3 fluoride)

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

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENBRACE HR CAPS NESTABS DHA MISC (prenatal vit w/ fe (prenatal vit without vit glycine cysteinate-fa- 3 a w/ fe bisglycinate-fa- 2 omega 3 fatty acids) omeg 3) FOLET DHA THPK NESTABS ONE CAPS (prenatal vit w/fe (prenatal w/o a w/fe carbonyl-fe bisglyc- 3 carbonyl-fe bisglyc-l 3 methylfol-dss & dha) methylfol-dha) FOLIVANE-OB CAPS NESTABS TABS (prenatal without a vit (prenatal vit without vit w/ fe fum-iron 2 a w/ fe bisglycinate-folic 3 polysacch complex -fa) acid) MARNATAL-F CAPS NEXA PLUS CAPS (prenatal without vit a (prenatal w/o vit a w/fe w/ iron polysaccharide 2 fumarate-docusate ca- 3 complex-fa) folic acid-dha) MYNATAL ADVANCE OB COMPLETE ONE TABS (prenatal vit w/ CAPS (prenatal w/o vit docusate-iron carbonyl- 2 a w/ fe carbonyl-fe 3 folic acid) aspart glyc-fa-fish oil) MYNATAL ULTRACAPLET OB COMPLETE PETITE TABS (prenatal vit w/ CAPS (prenatal w/o vit docusate-iron carbonyl- 2 a w/ fe carbonyl-fe 3 folic acid) aspart glyc-fa-omega 3) MYNATE 90 PLUS TBCR OB COMPLETE PREMIER (prenatal vit w/ TABS (prenatal vit w/ docusate-fe fumarate- 2 iron carbonyl-fe aspart 3 folic acid) glycinate-fa) NATACHEW CHEW OB COMPLETE/DHA (prenatal vit w/ fe fum- CAPS (prenat vit w/ iron fe bisglycinate chelate- 3 carbonyl-fe asp glyc-fa- 3 folic acid) omega fatty acid) NATELLE ONE CAPS OBSTETRIX DHA MISC RX/OTC (prenatal without vit a (prenatal w/fe carbonyl- w/ fe fum-fa-omega 3 fa-dss-omega 3 fatty 2 fatty acids) acids) NEEVO DHA CAPS OBTREX DHA MISC RX/OTC (prenatal without vit a (prenatal w/fe carbonyl- w/ fe fumarate-l 3 fa-dss-omega 3 fatty 2 methylfolate-omegas) acids) PNV TABS 29-1 TABS (prenatal vit w/ iron 2 carbonyl-folic acid)

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PNV-DHA+DOCUSATE PRENATAL + DHA THPK CAPS (prenatal w/o vit (prenatal w/o vit a w/ a w/ fe fumarate-dss- 3 ferrous fumarate-folic 3 fa-dha) acid-dha) PNV-OMEGA CAPS PRENATAL 19 CHEW 1 (prenatal without a w/ MG-3 MG-3 MG-7 MG-12 fe fumarate-l 3 MCG-15 MG-20 MG-20 MG-29 MG-30 UNIT-100 methylfolate-fa-omega MG-200 MG-400 UNIT- 2 ) 3 1000 UNIT (prenatal vit PR NATAL 400 EC MISC w/ ferrous fumarate- (prenatal mv & min w/fe 2 folic acid) bisglyc-fe prot succ-fa- PRENATAL 19 TABS 1 RX/OTC ca-omega 3) MG-3 MG-3 MG-7 MG-12 PR NATAL 430 EC MISC MCG-15 MG-20 MG-20 (prenatal mv & min w/fe MG-25 MG-29 MG-30 bisglyc-fe prot succ-fa- 2 UNIT-100 MG-200 MG-400 ca-omega 3) UNIT-1000 UNIT, 3 MG-12 MCG-1 MG-3 MG-7 MG-15 3 PR NATAL 430 MISC MG-20 MG-20 MG-25 MG- (prenatal mv & min w/fe 29 MG-30 UNIT-100 MG- bisglyc-fe prot succ-fa- 2 200 MG-400 UNIT-1000 ca-omega 3) UNIT (prenatal vit w/ PREMESISRX TABS docusate-fe fumarate- (prenatal w/ calcium-vit folic acid) b6-vit b12-folic acid- 3 PRENATAL ginger) MULTIVITAMIN PLUS PRENA 1 TRUE MISC DHA MISC (prenatal mv 3 (prenatal without a w/ & min w/fe fumarate-fa- fe amino acid chelate- 2 dha) fa-dha) PRENATAL PLUS IRON PRENA1 PEARL CPCR TABS (prenatal vit w/ 2 (prenatal without a w/ iron carbonyl-folic acid) fe fumarate-sod 3 PRENATAL+DHA MISC feredetate-fa-dha) (prenatal mv & min w/fe 3 PRENAISSANCE CAPS fumarate-fa-dha) (prenatal w/o vit a w/ fe 3 PRENATAL-U CAPS (prenatal without a vit fumarate-dss-fa-dha) 2 PRENAISSANCE PLUS w/ fe fumarate-folic CAPS (prenatal w/o vit acid) a w/ fe carbonyl-dss-fa- 3 PRENATE AM TABS dha) (prenatal w/ calcium-vit b6-vit b12-folic acid- 3 ginger)

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATE CHEW SE-NATAL 19 CHEW 15 (prenatal multivitamins MG-1 MG-7 MG-12 MCG-3 & minerals w/ l- 3 MG-3 MG-20 MG-20 MG- ) 29 MG-30 UNIT-100 MG- methylfolate-fa 200 MG-400 UNIT-1000 2 PRENATE DHA CAPS UNIT (prenatal vit w/ (prenatal w/o a w/ fe 3 ferrous fumarate-folic asparto glyc-l acid) ) methylfolate-fa-dha SE-NATAL 19 TABS 1 MG- RX/OTC PRENATE ENHANCE 3 MG-3 MG-7 MG-12 CAPS (prenatal without MCG-15 MG-20 MG-20 a w/ fe fumarate-l 3 MG-29 MG-30 UNIT-100 3 methylfolate-fa-dha) MG-200 MG-400 UNIT- PRENATE ESSENTIAL 1000 UNIT (prenatal vit CAPS (prenatal w/o a w/ docusate-fe w/ fe asparto glyc-l 3 fumarate-folic acid) methylfolate-fa-dha) SELECT-OB CHEW 0.4 MG-0.6 MG-1.6 MG-1.8 PRENATE MINI CAPS MG-2.5 MG-5 MCG-15 (prenatal w/o vit a w/ fe 3 MG-15 MG-25 MG-29 MG- carbonyl-fe asp glyc- 30 UNIT-60 MG-400 UNIT- 2 methfol-fa-dha) 1700 UNIT (prenatal vit PRENATE PIXIE CAPS w/ iron polysaccharide (prenatal w/o a w/ fe cmplx-l methylfolate-fa) 3 asparto glyc-l SELECT-OB CHEW 2.5 methylfolate-fa-dha) MG-1 MG-1.6 MG-1.8 MG- PRENATE RESTORE 5 MCG-15 MG-15 MG-25 MG-29 MG-30 UNIT-1700 CAPS (prenatal without 3 UNIT-400 UNIT-60 MG 3 a w/ fe fumarate-l (prenatal vit w/ iron methylfolate-fa-dha) polysaccharide PROVIDA OB CAPS complex-folic acid) (prenatal without a vit 2 SELECT-OB+DHA MISC w/ fe fum-iron (prenatal mv & min w/fe polysacch complex -fa) polysaccharide 3 R-NATAL OB CAPS complex-fa-dha) (prenatal w/o vit a w/ fe 3 TARON-C DHA CAPS carbonyl-folic acid-dha) (prenatal vit w/ fe fum- RELNATE DHA CAPS iron polysacch complex 2 (prenatal vit w/ ferrous 3 -fa-omega 3) fumarate-fa-omega 3 TARON-PREX CAPS fatty acids) (prenatal w/o vit a w/ fe 3 fumarate-dss-fa-dha) THRIVITE RX TABS (prenatal vit w/ iron 2 carbonyl-folic acid) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TL-CARE DHA CAPS VIRT-PN DHA CAPS (prenatal w/fe 3 (prenatal without a w/ 3 fumarate-fa-dss-fish oil) fe fumarate-l TL-SELECT CAPS methylfolate-fa-dha) (prenatal w/o vit a w/ fe 3 VIRT-PN PLUS CAPS fumarate-dss-fa-dha) (prenatal without a w/ TRI-TABS DHA MISC fe fumarate-l 3 (prenatal vit without vit methylfolate-fa-omega a w/ fe bisglycinate-fa- 2 3) omeg 3) VITAFOL FE+ CPPK 0.4 TRICARE PRENATAL MG-0.6 MG-1.6 MG-1.8 DHA ONE CAPS MG-2 MG-2.5 MG-15 MG- ( 3 20 MG-20 UNIT-25 MCG- prenatal w/fe 25 MG-50 MG-60 MG-90 fumarate-fa-dss-fish oil) MG-150 MCG-200 MG-415 3 TRINATAL RX 1 TABS MG-1000 UNIT-1100 UNIT (prenatal vit w/ ferrous 2 (prenatal vit w/ fe fumarate-folic acid) polysacch complex-l TRISTART DHA CAPS methylfol-fa-dha-dss) (prenatal without a w/ VITAFOL GUMMIES 3 fe carbonyl-l CHEW (prenatal vit w/ 3 methylfolate-fa-dha) ferric phosphate-fa- TRISTART ONE CAPS omega 3 fatty acids) (prenatal without a w/ VITAFOL-NANO TABS 3 fe carbonyl-l (prenatal w/o a vit w/ fe 3 methylfolate-fa-dha) fumarate-l methylfolate- VINATE DHA RF CAPS folic acid) (prenatal without vit a VITAFOL-ONE CAPS 3 w/ fe fumarate-l (prenatal mv & min w/fe 3 methylfolate-omegas) polysaccharide VINATE ONE TABS complex-fa-dha) (prenatal vit w/ ferrous 2 VITAMEDMD ONE fumarate-folic acid) RX/QUATREFOLIC CAPS VIRT-C DHA CAPS (prenatal without a w/ 3 (prenatal vit w/ fe fum- fe fumarate-l iron polysacch complex 2 methylfolate-fa-dha) -fa-omega 3) VITAPEARL CPCR (prenatal without a w/ VIRT-NATE DHA CAPS 3 (prenatal vit w/ ferrous fe fumarate-sod fumarate-fa-omega 3 3 feredetate-fa-dha) fatty acids) VITATRUE MISC (prenatal without a w/ fe amino acid chelate- 2 fa-dha)

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIVA DHA CAPS chlorzoxazone tabs 3 (prenatal vit w/ ferrous 500 mg fumarate-fa-omega 3 3 cyclobenzaprine hcl 1 fatty acids) tabs 10 mg, 5 mg VOL-TAB RX TABS QL(4 ea daily) (prenatal vit w/ iron 2 metaxalone tabs 3 carbonyl-folic acid) methocarbamol tabs 1 VP-PNV-DHA CAPS (prenatal vit w/ ferrous orphenadrine citrate 1 fumarate-fa-omega 3 3 tb12 fatty acids) ROBAXIN-750 TABS 7 WEGMANS COMPLETE (methocarbamol) PRENATAL+DHA MISC SKELAXIN TABS QL(4 ea daily) 3 7 (prenatal mv & min w/fe (metaxalone) fumarate-fa-dha) SOMA TABS 7 WESTGEL DHA CAPS (carisoprodol) (prenatal without a w/ 3 tizanidine hcl caps 2 1 fe carbonyl-l mg, 4 mg, 6 mg methylfolate-fa-dha) ZATEAN-PN DHA CAPS tizanidine hcl tabs 2 mg 1 (prenatal without a w/ QL(9 ea daily) fe fumarate-l 3 tizanidine hcl tabs 4 mg 1 ) ZANAFLEX CAPS 2 MG, 4 methylfolate-fa-dha 7 ZATEAN-PN PLUS CAPS MG, 6 MG (tizanidine hcl) ( ZANAFLEX TABS 4 MG QL(9 ea daily) prenatal without a w/ 7 fe fumarate-l 3 (tizanidine hcl) methylfolate-fa-omega Direct Muscle Relaxants 3) DANTRIUM CAPS 7 MUSCULOSKELETAL THERAPY AGENTS - (dantrolene sodium) Drugs to Treat Spasms dantrolene sodium 1 Central Muscle Relaxants caps (Carisoprodol) VANADOM 1 Muscle Relaxant Combinations TABS QL(6 ea daily) carisoprodol w/ aspirin 3 baclofen tabs 10 mg 1 & codeine tabs QL(4 ea daily) baclofen tabs 20 mg 1 carisoprodol w/ aspirin 1 tabs baclofen tabs 5 mg 1 orphenadrine w/ aspirin & caff tabs 25 mg-30 1 carisoprodol tabs 250 3 mg mg-385 mg NASAL AGENTS - SYSTEMIC AND TOPICAL - carisoprodol tabs 350 1 mg Drugs to treat the Nose or Sinus Nasal Agent Combinations 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azelastine hcl- Limit 1 bottle (Fluticasone Propionate Limit 2 inhalers 3 per (Nasal)) ALLERGY per fluticasone propionate month;QL(0.77 RELIEF, CLARISPRAY, month;QL(1.07 susp gm daily) CVS FLUTICASONE ml daily); Limit 1 bottle PROPRIONATE NASAL RX/OTC DYMISTA SUSP SPRAY, EQ ALLERGY ( 7 per azelastine hcl- month;QL(0.77 RELIEF, EQL fluticasone propionate) gm daily) FLUTICASONE PROPIONATE, EQL Nasal Antiallergy FLUTICASONE Limit 1 inhaler PROPIONATE CHILDRENS, GNP azelastine hcl soln 0.1 1 per %, 137 mcg/spray month;QL(1.2 FLUTICASONE 1 ml daily) PROPIONATE, GNP Limit 1 bottle FLUTICASONE PROPIONATE azelastine hcl soln 0.15 1 per % month;QL(1.2 CHILDRENS, HM ml daily) ALLERGY RELIEF NASAL SPRAY 24HR, KLS olopatadine hcl (nasal) 3 ALLER-FLO, QC soln ALLERGY RELIEF, QC PATANASE SOLN FLUTICASONE (olopatadine hcl 7 PROPIONATE, SM ALLERGY RELIEF NASAL (nasal)) SPRAY SUSP Nasal Anticholinergics (Triamcinolone Acetonide Limit 1 sprayer (Nasal)) ALLERGY NASAL per ipratropium bromide 1 1 (nasal) soln SPRAY 24 HOUR AERO month;QL(1.2 55 MCG/ACT ml daily) Nasal Steroids (Triamcinolone Acetonide Limit 1 sprayer (Fluticasone Propionate Limit 2 inhalers (Nasal)) CVS NASAL per (Nasal)) ALLERGY NASAL per ALLERGY SPRAY, EQ month;QL(1.2 1 month;QL(1.07 NASAL ALLERGY SPRAY, ml daily) SPRAY 24 HOUR SUSP ml daily); 50 MCG/ACT GNP 24 HOUR NASAL RX/OTC ALLERGY SPRAY, GOODSENSE NASAL ALLERGY SPRAY, HM 24 1 HOUR NASAL ALLERGYSPRAY, KLS ALLER-CORT, NASAL ALLERGY 24 HOUR, NASAL ALLERGY 24 HOUR MULTI-SYMPTOM, RA NASAL ALLERGY SPRAY AERO FLONASE ALLERGY Limit 2 inhalers RELIEF CHILDRENS per SUSP ( 7 month;QL(1.07 fluticasone ml daily); propionate (nasal)) RX/OTC

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLONASE ALLERGY Limit 2 inhalers Lipids per RELIEF SUSP DOJOLVI LIQD PA ( 7 month;QL(1.07 4 fluticasone propionate ml daily); (triheptanoin) (nasal)) RX/OTC OPHTHALMIC AGENTS - Drugs to Treat the Eye Limit 2 inhalers fluticasone propionate per Artificial Tears and Lubricants 1 month;QL(1.07 LACRISERT INST (nasal) susp 3 ml daily); (artificial tear insert) RX/OTC Limit 2 inhalers Beta-blockers - Ophthalmic (Timolol Maleate (Ophth)) mometasone furoate 1 per (nasal) susp month;QL(1.22 TIMOLOL MALEATE IN 3 gm daily) OCUDOSE SOLN NASACORT ALLERGY Limit 1 sprayer betaxolol hcl (ophth) 1 24HR AERO per soln (triamcinolone 2 month;QL(1.2 acetonide (nasal)) ml daily) BETIMOL SOLN (timolol) 2 NASACORT ALLERGY Limit 1 sprayer BETOPTIC-S SUSP 2 24HR AERO per (betaxolol hcl (ophth)) (triamcinolone 7 month;QL(1.2 ml daily) carteolol hcl (ophth) 3 acetonide (nasal)) soln NASACORT ALLERGY Limit 1 sprayer COMBIGAN SOLN 24HR CHILDRENS AERO per (brimonidine tartrate- 3 (triamcinolone 7 month;QL(1.2 timolol maleate) acetonide (nasal)) ml daily) COSOPT PF SOLN Limit 2 inhalers NASONEX SUSP (dorzolamide hcl-timolol 7 ( 7 per mometasone furoate month;QL(1.22 maleate) (nasal)) gm daily) COSOPT SOLN Limit 1 sprayer (dorzolamide hcl-timolol 7 triamcinolone 1 per maleate) acetonide (nasal) aero month;QL(1.2 ml daily) dorzolamide hcl-timolol 3 maleate soln 0.5 %-2 % NEUROMUSCULAR AGENTS - Drugs to Relax/Paralyze Muscles dorzolamide hcl-timolol maleate soln 0.5 %-2 ALS Agents %, 22.3 mg/ml-6.8 1 RILUTEK TABS (riluzole) 7 mg/ml, 5 mg/ml-20 mg/ml, 6.8 mg/ml-22.3 riluzole tabs 3 mg/ml ISTALOL SOLN ( Spinal Muscular Atrophy Agents (SMA) timolol 7 EVRYSDI SOLR PA maleate (ophth)) 4 (risdiplam) levobunolol hcl soln 1 NUTRIENTS

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MYDRIACYL SOLN timolol maleate (ophth) 1 7 solg 0.25 %, 0.5 % (tropicamide) phenylephrine hcl timolol maleate (ophth) 1 3 soln 0.25 %, 0.5 % (mydriatic) soln 10 % phenylephrine hcl timolol maleate (ophth) 3 1 soln 0.5 % (mydriatic) soln 2.5 % TIMOPTIC OCUDOSE tropicamide soln 3 SOLN 0.25 % (timolol 3 maleate (ophth)) Miotics ISOPTO CARPINE SOLN QL(0.5 ml TIMOPTIC OCUDOSE 7 SOLN 0.5 % (timolol 7 (pilocarpine hcl) daily) maleate (ophth)) PHOSPHOLINE IODIDE TIMOPTIC SOLN ( SOLR (echothiophate 2 timolol 7 maleate (ophth)) iodide) TIMOPTIC-XE SOLG pilocarpine hcl soln 1 QL(0.5 ml (timolol maleate 7 daily) (ophth)) Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % Cycloplegic Mydriatics 2 ( ) (Homatropine Hbr) brimonidine tartrate 1 ALPHAGAN P SOLN 0.15 HOMATROPAIRE SOLN 7 (Phenylephrine Hcl % (brimonidine tartrate) (Mydriatic)) ALTAFRIN 3 apraclonidine hcl soln 1 SOLN 10 % (Phenylephrine Hcl brimonidine tartrate 1 (Mydriatic)) ALTAFRIN 1 soln SOLN 2.5 % IOPIDINE SOLN 3 atropine sulfate 1 (apraclonidine hcl) (ophthalmic) oint SIMBRINZA SUSP ATROPINE SULFATE (brinzolamide- 3 SOLN OP 1 % (atropine 2 brimonidine tartrate) sulfate (ophthalmic)) Ophthalmic Anti-infectives CYCLOGYL SOLN 7 (Bacitracin-Polymyxin B (cyclopentolate hcl) (Ophth)) AK-POLY-BAC, 1 CYCLOMYDRIL SOLN POLYCIN OINT (cyclopentolate w/ 3 (Gentamicin Sulfate 1 phenylephrine) (Ophth)) GENTAK OINT 1 (Neomycin-Bacitracin Zn- cyclopentolate hcl soln Polymyxin) NEO-POLYCIN 1 OINT homatropine hbr soln 1 AZASITE SOLN Limit 5mls per ISOPTO ATROPINE SOLN 3 month;QL(0.17 (azithromycin (ophth)) (atropine sulfate 2 ml daily) (ophthalmic))

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bacitracin (ophthalmic) 1 neomycin-polymyxin- 1 oint gramicidin soln OCUFLOX SOLN QL(5 ml per fill bacitracin-polymyxin b 1 7 (ophth) oint (ofloxacin (ophth)) retail) BESIVANCE SUSP QL(5 ml per fill 3 ofloxacin (ophth) soln 1 (besifloxacin hcl) retail) BETADINE OPHTHALMIC polymyxin b- 1 PREP SOLN (povidone- 3 trimethoprim soln iodine (ophth)) POLYTRIM SOLN BLEPH-10 SOLN (polymyxin b- 7 (sulfacetamide sodium 7 trimethoprim) (ophth)) POVIDONE IODINE SOLN CILOXAN OINT (povidone-iodine 3 (ciprofloxacin hcl 2 (ophth)) (ophth)) sulfacetamide sodium 1 CILOXAN SOLN (ophth) oint (ciprofloxacin hcl 7 sulfacetamide sodium 1 (ophth)) (ophth) soln ciprofloxacin hcl 1 tobramycin (ophth) soln 1 (ophth) soln TOBREX OINT erythromycin (ophth) 1 2 oint (tobramycin (ophth)) TOBREX SOLN 7 gatifloxacin (ophth) 3 soln (tobramycin (ophth)) trifluridine soln 1 gentamicin sulfate 1 (ophth) soln VIGAMOX SOLN QL(3 ml per fill KLARITY-A SOLN Limit 5mls per (moxifloxacin hcl 7 retail) 3 month;QL(0.17 (ophth)) (azithromycin (ophth)) ml daily) ZIRGAN GEL 3 levofloxacin (ophth) 1 (ganciclovir ophthalmic) soln ZYMAXID SOLN 7 MOXEZA SOLN (gatifloxacin (ophth)) (moxifloxacin hcl 7 (ophth)) Ophthalmic Immunomodulators RESTASIS EMUL QL(2 ml moxifloxacin hcl (ophth) QL(3 ml per fill 2 daily,64 ml per 1 retail) soln (cyclosporine (ophth)) fill retail) moxifloxacin hcl (ophth) 1 RESTASIS MULTIDOSE QL(2 ml soln EMUL (cyclosporine 2 daily,64 ml per NATACYN SUSP (ophth)) fill retail) 2 (natamycin) Ophthalmic Local Anesthetics neomycin-bacitracin 1 zn-polymyxin oint 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tetracaine Hcl (Ophth)) FML FORTE SUSP ALTACAINE, TETCAINE, 3 (fluorometholone 2 TETRAVISC, TETRAVISC (ophth)) FORTE SOLN FML LIQUIFILM SUSP AKTEN GEL ( lidocaine 3 (fluorometholone 7 hcl (ophth)) (ophth)) ALCAINE SOLN 7 FML OINT (proparacaine hcl) (fluorometholone 2 proparacaine hcl soln 3 (ophth)) LOTEMAX GEL tetracaine hcl (ophth) 7 3 (loteprednol etabonate) soln LOTEMAX OINT 3 Ophthalmic Nerve Growth Factors (loteprednol etabonate) OXERVATE SOLN PA 4 LOTEMAX SUSP Limit 6 per (cenegermin-bkbj) 7 month;QL(0.2 (loteprednol etabonate) Ophthalmic Steroids ml daily) (Bacitracin-Poly-Neomycin- QL(4 gm per fill loteprednol etabonate 3 Hc) NEO-POLYCIN HC 1 retail) gel OINT loteprednol etabonate Limit 6 per (Prednisolone Acetate 3 month;QL(0.2 (Ophth)) PREDNISOLONE 1 susp ml daily) ACETATE P-F SUSP MAXIDEX SUSP ALREX SUSP 3 (dexamethasone 2 (loteprednol etabonate) (ophth)) QL(4 gm per fill MAXITROL OINT bacitracin-poly- 1 neomycin-hc oint retail) (neomycin-polymy- 7 BLEPHAMIDE S.O.P. dexameth) OINT (sulfacetamide 2 MAXITROL SUSP sod-prednisolone) (neomycin-polymy- 7 BLEPHAMIDE SUSP dexameth) (sulfacetamide sod- 2 neomycin-polymy- 1 prednisolone) dexameth oint dexamethasone neomycin-polymy- 1 sodium phosphate 1 dexameth susp (ophth) soln neomycin-polymyxin-hc DUREZOL EMUL 1 3 (ophth) susp (difluprednate) PRED MILD SUSP FLAREX SUSP (prednisolone acetate 2 (fluorometholone 2 (ophth)) acetate) PRED-G S.O.P. OINT fluorometholone 1 (gentamicin- 3 (ophth) susp prednisolone acetate)

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRED-G SUSP (Olopatadine Hcl) CVS Limit 10mls per (gentamicin- 3 OLOPATADINE month;QL(0.34 prednisolone acetate) HYDROCHLORIDE, EYE ml daily); ALLERGY ITCH RELIEF, RX/OTC prednisolone acetate 1 EYE ALLERGY 1 (ophth) susp ITCH/REDNESSRELIEF, PREDNISOLONE SODIUM HM EYE ALLERGY PHOSPHATE SOLN OP 1 ITCH/REDNESS RELIEF % (prednisolone sodium 2 SOLN phosphate (ophth)) (Olopatadine Hcl) GNP Limit 10mls per OLOPATADINE 1 month;QL(0.34 PREDNISOLONE SODIUM HYDROCHLORIDE SOLN ml daily); PHOSPHATE/MOXIFLOXA 0.1 % RX/OTC CIN SOLN 3 ( Limit 2.5mls prednisolone- (Olopatadine Hcl) GNP per moxifloxacin) OLOPATADINE 1 month;QL(0.08 HYDROCHLORIDE SOLN 4 ml daily); sulfacetamide sod- 1 0.2 % prednisolone soln RX/OTC TOBRADEX OINT ACULAR LS SOLN (tobramycin- 3 (ketorolac 7 dexamethasone) tromethamine (ophth)) TOBRADEX ST SUSP ACULAR SOLN (tobramycin- 3 (ketorolac 7 dexamethasone) tromethamine (ophth)) TOBRADEX SUSP QL(5 ml per fill ACUVAIL SOLN (tobramycin- 7 retail) (ketorolac 3 dexamethasone) tromethamine (ophth)) QL(5 ml per fill ALOCRIL SOLN tobramycin- 1 dexamethasone susp retail) (nedocromil sodium 3 (ophth)) ZYLET SUSP QL(5 ml per fill (loteprednol etabonate- 3 retail) ALOMIDE SOLN tobramycin) (lodoxamide 2 tromethamine) Ophthalmic Surgical Aids azelastine hcl (ophth) 1 GELFILM OP FILM soln (gelatin adsorbable 3 ) AZOPT SUSP Limit 10mls per (ophth) 7 month;QL(0.34 Ophthalmics - Misc. (brinzolamide) ml daily) (Olopatadine Hcl) CVS Limit 2.5mls ST; QL(0.34 ml bepotastine besilate 3 OLOPATADINE per soln daily) HYDROCHLORIDE, EYE month;QL(0.08 BEPREVE SOLN ST; QL(0.34 ml ALLERGY ITCH RELIEF, 4 ml daily); 7 EYE ALLERGY 1 RX/OTC (bepotastine besilate) daily) ITCH/REDNESSRELIEF, Limit 10mls per HM EYE ALLERGY brinzolamide susp 1 month;QL(0.34 ITCH/REDNESS RELIEF ml daily) SOLN 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; Limit 1 bromfenac sodium 1 (ophth) soln PATADAY EXTRA bottle per STRENGTH SOLN 3 month;QL(0.08 BROMSITE SOLN (olopatadine hcl) 4 ml daily); (bromfenac sodium 3 RX/OTC (ophth)) Limit 10mls per PATADAY SOLN 0.1 % month;QL(0.34 cromolyn sodium 1 7 (ophth) soln (olopatadine hcl) ml daily); RX/OTC PA; Limit 4 CYSTARAN SOLN Limit 2.5mls 4 bottles per (cysteamine hcl) month;QL(2.15 PATADAY SOLN 0.2 % per ml daily) 7 month;QL(0.08 (olopatadine hcl) 4 ml daily); diclofenac sodium 1 RX/OTC (ophth) soln Limit 10mls per QL(0.34 ml PATANOL SOLN dorzolamide hcl soln 1 7 month;QL(0.34 daily) (olopatadine hcl) ml daily); DORZOLAMIDE HCL QL(0.34 ml RX/OTC 2 SOLN (dorzolamide hcl) daily) ST; Limit 1 PAZEO SOLN bottle per epinastine hcl (ophth) 1 3 month;QL(0.08 soln (olopatadine hcl) 4 ml daily); RX/OTC flurbiprofen sodium 1 soln PROLENSA SOLN ILEVRO SUSP (bromfenac sodium 3 3 (nepafenac) (ophth)) TRUSOPT SOLN QL(0.34 ml ketorolac tromethamine 1 7 (ophth) soln (dorzolamide hcl) daily) LASTACAFT SOLN ST Prostaglandins - Ophthalmic 3 (alcaftadine) Limit 2.5mls NEVANAC SUSP per 3 bimatoprost soln 1 (nepafenac) month;QL(0.08 4 ml daily) Limit 10mls per QL(0.0949 ml olopatadine hcl soln 0.1 1 month;QL(0.34 latanoprost soln op 1 % ml daily); daily) RX/OTC Limit 2.5mls LUMIGAN SOLN Limit 2.5mls 2 per (bimatoprost) month;QL(0.08 olopatadine hcl soln 0.2 per 1 month;QL(0.08 4 ml daily) % 4 ml daily); Limit 2.5mls TRAVATAN Z SOLN RX/OTC 7 per PAREMYD SOLN (travoprost) month;QL(0.08 4 ml daily) (hydroxyamphetamine- 3 tropicamide) Limit 2.5mls 1 per travoprost soln month;QL(0.08 4 ml daily)

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XALATAN SOLN QL(0.0949 ml 7 neomycin-polymyxin-hc 1 (latanoprost) daily) (otic) susp ZIOPTAN SOLN QL(1 ea daily) 3 OTICIN HC NR SOLN (tafluprost) (pramoxine-hc- 7 chloroxylenol) OTIC AGENTS - Drugs to Treat the Ear OTOVEL SOLN Limit 15mls per Otic Agents - Miscellaneous (ciprofloxacin- 7 month;QL(0.5 ea daily) acetic acid (otic) soln 1 fluocinolone acetonide) Otic Steroids Otic Anti-infectives (Fluocinolone Acetonide CETRAXAL SOLN 3 7 (Otic)) FLAC OIL (ciprofloxacin hcl (otic)) DERMOTIC OIL ciprofloxacin hcl (otic) 1 (fluocinolone acetonide 7 soln (otic)) FLOXIN OTIC SOLN 7 fluocinolone acetonide 3 (ofloxacin (otic)) (otic) oil ofloxacin (otic) soln 1 hydrocortisone w/acetic QL(10 ml per 3 fill retail,30 ml Otic Combinations acid soln per fill mail) (Pramoxine-Hc- OXYTOCICS - Drugs to Prevent/Control Uterine Chloroxylenol) CORTIC- 1 Bleeding ND, EXOTIC-HC SOLN Abortifacients/Agents for Cervical Ripening CIPRO HC SUSP CERVIDIL INST (ciprofloxacin- 3 3 ) hydrocortisone) (dinoprostone PREPIDIL GEL CIPRODEX SUSP QL(8 ml per fill 3 ( ) (ciprofloxacin- 7 retail) dinoprostone dexamethasone) Oxytocics QL(8 ml per fill (Methylergonovine ciprofloxacin- 1 dexamethasone susp retail) Maleate) METHERGINE 1 TABS ciprofloxacin- Limit 15mls per month;QL(0.5 methylergonovine 1 fluocinolone acetonide 3 maleate tabs soln ea daily) COLY-MYCIN S SUSP PENICILLINS - Drugs to Treat Bacterial Infections ( 3 neomycin-colistin-hc- Aminopenicillins thonzonium) CORTISPORIN-TC SUSP amoxicillin caps 1 (neomycin-colistin-hc- 3 1 thonzonium) amoxicillin chew neomycin-polymyxin-hc 1 amoxicillin susr 1 (otic) soln amoxicillin tabs 1

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ampicillin caps 1 PROGESTINS - Hormone Replacement/Modifying Drugs Natural Penicillins Progestins penicillin v potassium AYGESTIN TABS 1 7 solr (norethindrone acetate) penicillin v potassium QL(1 ea daily) 1 medroxyprogesterone 1 tabs acetate tabs 10 mg Penicillin Combinations medroxyprogesterone acetate tabs 2.5 mg, 5 1 amoxicillin & pot 1 clavulanate chew mg MEGACE ES SUSP AC amoxicillin & pot 1 clavulanate susr (megestrol acetate 7 amoxicillin & pot (appetite)) 1 AC clavulanate tabs megestrol acetate 3 (appetite) susp amoxicillin & pot 1 clavulanate tb12 norethindrone acetate 1 AUGMENTIN ES-600 tabs SUSR (amoxicillin & pot 7 progesterone caps 1 QL(1 ea daily) clavulanate) PROMETRIUM CAPS QL(1 ea daily) AUGMENTIN SUSR 31.25 7 MG/5ML-125 MG/5ML (progesterone) (amoxicillin & pot 2 PROVERA TABS 10 MG QL(1 ea daily) clavulanate) (medroxyprogesterone 7 AUGMENTIN SUSR 62.5 acetate) MG/5ML-250 MG/5ML PROVERA TABS 2.5 MG, 7 5 MG (amoxicillin & pot 7 clavulanate) (medroxyprogesterone AUGMENTIN TABS 125 acetate) MG-500 MG (amoxicillin 7 PSYCHOTHERAPEUTIC AND NEUROLOGICAL & pot clavulanate) AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions Penicillinase-Resistant Penicillins Agents for Chemical Dependency dicloxacillin sodium 1 caps acamprosate calcium 1 tbec PHARMACEUTICAL ADJUVANTS ANTABUSE TABS 7 Liquid Vehicles (disulfiram) BASE GELATIN GUMMY disulfiram tabs 1 TROCHE GEL (gummy 3 LUCEMYRA TABS PA; QL(224 ea gel base) 4 per 14 days GUM BASE GELATIN GEL (lofexidine hcl) 3 retail) ( ) gummy gel base Anti-Cataplectic Agents

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XYREM SOLN ( PA; ST NAMENDA XR CP24 14 PA sodium 4 oxybate) MG, 21 MG, 28 MG 7 (memantine hcl) Antidementia Agents NAMENDA XR CP24 7 MG PA; ST ARICEPT TABS QL(1 ea daily) 7 (memantine hcl) (donepezil 7 hydrochloride) NAMENDA XR TITRATION PA; ST PACK CP24 (memantine 3 QL(1 ea daily) donepezil 1 hcl) hydrochloride tabs NAMZARIC C4PK 10 MG PA QL(1 ea daily) donepezil 1 (memantine hcl- 3 hydrochloride tbdp donepezil hcl) EXELON PT24 7 NAMZARIC CP24 10 MG- PA (rivastigmine) 14 MG, 10 MG-21 MG, 10 3 galantamine QL(1 ea daily) MG-28 MG (memantine hydrobromide cp24 16 1 hcl-donepezil hcl) mg, 24 mg, 8 mg NAMZARIC CP24 10 MG-7 PA; ST galantamine MG (memantine hcl- 3 hydrobromide soln 4 1 donepezil hcl) mg/ml RAZADYNE ER CP24 QL(1 ea daily) galantamine (galantamine 7 hydrobromide tabs 12 1 hydrobromide) mg, 4 mg, 8 mg RAZADYNE TABS PA (galantamine 7 memantine hcl cp24 14 3 mg, 21 mg, 28 mg hydrobromide) PA; ST rivastigmine pt24 1 memantine hcl cp24 7 3 mg rivastigmine tartrate 1 memantine hcl soln 10 1 caps mg/5ml, 2 mg/ml Combination Psychotherapeutics memantine hcl tabs 1 chlordiazepoxide- 3 QL(2 ea daily) amitriptyline tabs memantine hcl tabs 10 1 mg olanzapine-fluoxetine 3 QL(4 ea daily) hcl caps memantine hcl tabs 5 1 mg perphenazine- 3 NAMENDA TABS 10 MG QL(2 ea daily) amitriptyline tabs 7 (memantine hcl) SYMBYAX CAPS NAMENDA TABS 5 MG QL(4 ea daily) (olanzapine-fluoxetine 7 7 (memantine hcl) hcl) NAMENDA TITRATION Fibromyalgia Agents PAK TABS (memantine 7 SAVELLA TABS 100 MG, PA; QL(2 ea hcl) 25 MG, 50 MG 3 daily) (milnacipran hcl)

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAVELLA TABS 12.5 MG PA; ST;QL(2 PA; MUST 3 (milnacipran hcl) ea daily) USE ACARIA SAVELLA TITRATION PA; QL(2 ea dimethyl fumarate cpdr 3 SPECIALTY PACK MISC daily) RX 844-538- 3 4661;LA (milnacipran hcl) PA; MUST Movement Disorder Drug Therapy USE ACARIA AUSTEDO TABS 12 MG, 9 PA dimethyl fumarate misc 3 SPECIALTY 4 MG (deutetrabenazine) RX 844-538- 4661;LA AUSTEDO TABS 6 MG PA; ST 4 EXTAVIA KIT ( PA (deutetrabenazine) interferon 4 beta-1b) PA; Specialty INGREZZA CAPS 40 MG GILENYA CAPS PA; LA 4 drug-Health 3 (valbenazine tosylate) Net will refer to (fingolimod hcl) SP Pharmacy glatiramer acetate sosy 1 PA INGREZZA CAPS 60 MG PA 4 (valbenazine tosylate) MAVENCLAD TBPK PA INGREZZA CPPK PA (cladribine (multiple 4 4 (valbenazine tosylate) sclerosis)) MAYZENT TABS PA 3 tetrabenazine tabs 4 (siponimod fumarate) XENAZINE TABS 7 PA; Must use (tetrabenazine) PLEGRIDY SOPN SC AcariaHealth 4 Specialty Rx at Multiple Sclerosis Agents (peginterferon beta-1a) 1-844-538- (Glatiramer Acetate) 1 PA 4661;LA GLATOPA SOSY PLEGRIDY SOSY IM PA AMPYRA TB12 PA 4 7 (peginterferon beta-1a) (dalfampridine) PA; Must use AUBAGIO TABS PA PLEGRIDY SOSY SC 3 4 AcariaHlth Sp (teriflunomide) (peginterferon beta-1a) Rx 1-844-538- PA; Must use 4661;LA AVONEX PEN AJKT PA; Must use 4 AcariaHlth Sp (interferon beta-1a) Rx 1-844-538- PLEGRIDY STARTER AcariaHealth 4661;LA PACK SOPN 4 Specialty Rx at PA; Must use (peginterferon beta-1a) 1-844-538- AVONEX PSKT 4661;LA 4 AcariaHlth Sp (interferon beta-1a) Rx 1-844-538- PLEGRIDY STARTER PA; Must use 4661;LA PACK SOSY 4 AcariaHlth Sp BETASERON KIT PA Rx 1-844-538- 4 (peginterferon beta-1a) 4661;LA (interferon beta-1b) PA; Must use COPAXONE SOSY PA REBIF REBIDOSE SOAJ 7 4 AcariaHlth Sp (glatiramer acetate) (interferon beta-1a) Rx 1-844-538- dalfampridine tb12 1 PA 4661;LA

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REBIF REBIDOSE PA; Must use NUEDEXTA CAPS PA TITRATIONPACK SOAJ 4 AcariaHlth Sp (dextromethorphan hbr- 4 Rx 1-844-538- quinidine sulfate) (interferon beta-1a) 4661;LA PA; Must use Psychotherapeutic and Neurological Agents - REBIF SOSY ( interferon 4 AcariaHlth Sp ergoloid mesylates tabs 3 beta-1a) Rx 1-844-538- 4661;LA pimozide tabs 3 REBIF TITRATION PACK PA; Must use SOSY (interferon beta- 4 AcariaHlth Sp Restless Leg Syndrome (RLS) Agents Rx 1-844-538- HORIZANT TBCR 300 MG QL(1 ea daily) 1a) 3 4661;LA (gabapentin enacarbil) PA; MUST HORIZANT TBCR 600 MG QL(2 ea daily) TECFIDERA CPDR USE ACARIA 3 7 SPECIALTY (gabapentin enacarbil) (dimethyl fumarate) RX 844-538- Smoking Deterrents 4661;LA (Nicotine Polacrilex) CVS PV PA; MUST NICOTINE LOZENGE, TECFIDERA STARTER USE ACARIA CVS NICOTINE PACK MISC (dimethyl 7 SPECIALTY POLACRILEX, EQ fumarate) RX 844-538- NICOTINE LOZENGES, 4661;LA EQ NICOTINE Postherpetic Neuralgia (PHN)/Neuropathic Pain POLACRILEX, EQL NICOTINE POLACRILEX, GRALISE MISC PA GNP NICOTINE MINI (gabapentin (once- 3 LOZENGE, GNP daily)) NICOTINE POLACRILEX, GRALISE TABS 300 MG PA; ST GNP NICOTINE (gabapentin (once- 3 POLACRILEX MINI, GOODSENSE NICOTINE, 5 daily)) GOODSENSE NICOTINE GRALISE TABS 600 MG PA; ST;QL(3 POLACRILEX, HM (gabapentin (once- 3 ea daily) NICOTINE POLACRILEX, daily)) KLS QUIT2, KLS QUIT4, NICOTINE MINI Premenstrual Dysphoric Disorder (PMDD) Agents LOZENGE, NICOTINE POLACRILEX MINI, PX fluoxetine hcl (pmdd) 1 caps 10 mg STOP SMOKING AID, RA MINI NICOTINE, RA QL(1 ea daily) fluoxetine hcl (pmdd) 1 NICOTINE POLACRILEX, caps 20 mg SM NICOTINE, SM fluoxetine hcl (pmdd) NICOTINE POLACRILEX, 3 TGT NICOTINE tabs 10 mg, 20 mg POLACRILEX LOZG SARAFEM TABS 7 (fluoxetine hcl (pmdd)) Pseudobulbar Affect (PBA) Agents

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

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

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use doxycycline ESBRIET CAPS Exactus (monohydrate) susr 25 1 4 Specialty Rx 1- mg/5ml (pirfenidone) 866-458- 9246;LA doxycycline PA; Must use (monohydrate) tabs 1 ESBRIET TABS Exactus 100 mg 4 Specialty Rx 1- (pirfenidone) doxycycline ST 866-458- 3 9246;LA (monohydrate) tabs 150 mg OFEV CAPS ( PA; QL(1 ea nintedanib 4 esylate) daily) doxycycline (monohydrate) tabs 50 3 SULFONAMIDES - Drugs to Treat Bacterial mg, 75 mg Infections doxycycline hyclate 1 Sulfonamides caps 100 mg, 50 mg SULFADIAZINE TABS 3 doxycycline hyclate (sulfadiazine) 1 tabs 100 mg TETRACYCLINES - Drugs to Treat Bacterial Infections doxycycline hyclate tabs 150 mg, 20 mg, 75 3 Tetracyclines mg (Doxycycline MINOCIN CAPS (Monohydrate)) AVIDOXY 1 7 ) TABS (minocycline hcl (Doxycycline minocycline hcl caps 1 100 mg, 50 mg, 75 mg (Monohydrate)) 1 MONDOXYNE NL, OKEBO PA minocycline hcl tabs 1 CAPS 100 mg, 50 mg, 75 mg (Doxycycline Hyclate) MORGIDOX 1X100MG, tetracycline hcl caps 1 MORGIDOX 1X50MG, 1 MORGIDOX 2X100MG VIBRAMYCIN CAPS 100 CAPS MG (doxycycline 7 ACTICLATE TABS hyclate) 7 (doxycycline hyclate) VIBRAMYCIN SUSR 25 MG/5ML (doxycycline 7 demeclocycline hcl 1 tabs (monohydrate)) VIBRAMYCIN SYRP 50 doxycycline MG/5ML (doxycycline 2 (monohydrate) caps 1 calcium) 100 mg, 50 mg, 75 mg ST THYROID AGENTS - Drugs to Regulate Thyroid doxycycline Hormones (monohydrate) caps 3 150 mg Antithyroid Agents methimazole tabs 1

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits propylthiouracil tabs 1 QL(3 ea daily) levothyroxine sodium tabs or 100 mcg, 137 TAPAZOLE TABS 7 mcg, 150 mcg, 25 mcg, 1 (methimazole) 300 mcg, 50 mcg, 75 Thyroid Hormones mcg, 88 mcg (Levothyroxine Sodium) QL(1 ea daily) levothyroxine sodium QL(1 ea daily) EUTHYROX, LEVO-T, tabs or 112 mcg, 125 LEVOXYL, UNITHROID 1 1 TABS 112 MCG, 125 MCG, mcg, 175 mcg, 200 175 MCG, 200 MCG mcg QL(2 ea daily) (Levothyroxine Sodium) liothyronine sodium 1 EUTHYROX, LEVOXYL tabs 25 mcg, 50 mcg TABS 100 MCG, 137 MCG, 1 liothyronine sodium 150 MCG, 25 MCG, 50 1 MCG, 75 MCG, 88 MCG tabs 5 mcg NATURE-THROID NT-2.5 (Levothyroxine Sodium) 2 LEVO-T, UNITHROID TABS (thyroid) TABS 100 MCG, 137 MCG, NATURE-THROID TABS 1 2 150 MCG, 25 MCG, 300 (thyroid) MCG, 50 MCG, 75 MCG, 88 MCG SYNTHROID TABS 100 MCG, 137 MCG, 150 MCG, (Thyroid) NP THYROID 25 MCG, 300 MCG, 50 2 120, NP THYROID 15, NP MCG, 75 MCG, 88 MCG THYROID 30, NP 1 (levothyroxine sodium) THYROID 60, NP THYROID 90 TABS SYNTHROID TABS 112 QL(1 ea daily) MCG, 125 MCG, 175 MCG, ARMOUR THYROID TABS 2 120 MG, 15 MG, 30 MG, 2 200 MCG (levothyroxine 60 MG, 90 MG (thyroid) sodium) ARMOUR THYROID TABS thyroid tabs 1 180 MG, 240 MG, 300 MG 2 (thyroid) TIROSINT CAPS 100 MCG, 112 MCG, 13 MCG, CYTOMEL TABS 25 MCG, QL(2 ea daily) 137 MCG, 150 MCG, 175 50 MCG (liothyronine 2 MCG, 200 MCG, 25 MCG, 7 sodium) 50 MCG, 75 MCG, 88 MCG CYTOMEL TABS 5 MCG (levothyroxine sodium) 2 ( ) TIROSINT CAPS 125 MCG QL(1 ea daily) liothyronine sodium 7 levothyroxine sodium (levothyroxine sodium) TIROSINT CAPS 75 MCG caps or 100 mcg, 112 2 (levothyroxine sodium) mcg, 13 mcg, 137 mcg, 1 150 mcg, 175 mcg, 200 WESTHROID TABS 2 mcg, 25 mcg, 50 mcg, (thyroid) 75 mcg, 88 mcg WP THYROID TABS 2 QL(1 ea daily) (thyroid) levothyroxine sodium 1 caps or 125 mcg ULCER DRUGS - Drugs to Treat Bowel, Intestine and Stomach Conditions 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antispasmodics LIBRAX CAPS PA (Hyoscyamine Sulfate) ED- (chlordiazepoxide hcl- 7 SPAZ, NULEV, OSCIMIN 1 clidinium bromide) TBDP methscopolamine 1 (Hyoscyamine Sulfate) bromide tabs OSCIMIN SR, SYMAX-SR 1 TB12 propantheline bromide 1 tabs (Hyoscyamine Sulfate) 1 OSCIMIN TABS H-2 Antagonists ANASPAZ TBDP 7 cimetidine hcl soln 1 (hyoscyamine sulfate) BELLADONNA/OPIUM cimetidine tabs 300 mg, 1 SUPP (belladonna 3 800 mg alkaloids & opium) cimetidine tabs 400 mg 1 QL(4 ea daily) chlordiazepoxide hcl- PA 1 famotidine susr 40 clidinium bromide caps 3 mg/5ml CUVPOSA SOLN 2 QL(2 ea daily) (glycopyrrolate) famotidine tabs 40 mg 1 dicyclomine hcl caps 1 nizatidine caps 1 dicyclomine hcl soln 1 nizatidine soln 1 PEPCID TABS 40 MG QL(2 ea daily) dicyclomine hcl tabs 1 7 (famotidine) GLYCATE TABS 3 (glycopyrrolate) Misc. Anti-Ulcer CARAFATE SUSP 1 glycopyrrolate tabs or 1 1 7 mg, 2 mg GM/10ML (sucralfate) CARAFATE TABS 1 GM QL(4 ea daily) GLYCOPYRROLATE 7 TABS OR 1.5 MG 3 (sucralfate) ( ) glycopyrrolate sucralfate susp 1 1 gm/10ml hyoscyamine sulfate 1 tabs sucralfate tabs 1 gm 1 QL(4 ea daily) hyoscyamine sulfate 1 tb12 Proton Pump Inhibitors QL(2 ea daily); hyoscyamine sulfate (Lansoprazole) CVS 3 1 LANSOPRAZOLE TBDD AL(Up to 12 yrs tbdp old ); RX/OTC LEVBID TB12 7 (hyoscyamine sulfate) LEVSIN TABS 7 (hyoscyamine sulfate)

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lansoprazole) CVS QL(1 ea daily); PREVACID SOLUTAB QL(2 ea daily); LANSOPRAZOLE, EQ RX/OTC TBDD 15 MG 7 AL(Up to 12 yrs LANSOPRAZOLE, GNP (lansoprazole) old ); RX/OTC LANSOPRAZOLE, PREVACID SOLUTAB QL(1 ea daily); GOODSENSE TBDD 30 MG 7 AL(Up to 12 yrs LANSOPRAZOLE, old ) HEARTBURN 1 (lansoprazole) TREATMENT 24 HOUR, PRILOSEC PACK PA HM LANSOPRAZOLE, (omeprazole 3 KLS LANSOPRAZOLE, QC magnesium) LANSOPRAZOLE, RA PROTONIX PACK QL(1 ea daily) LANSOPRAZOLE, SM 7 LANSOPRAZOLE CPDR (pantoprazole sodium) PROTONIX TBEC QL(1 ea daily) ACIPHEX SPRINKLE PA 7 CPSP 10 MG 3 (pantoprazole sodium) (rabeprazole sodium) RABEPRAZOLE SODIUM PA ACIPHEX SPRINKLE PA; ST DR SPRINKLE CPSP 3 CPSP 5 MG (rabeprazole 3 (rabeprazole sodium) sodium) PA; ST;QL(1 rabeprazole sodium 3 ACIPHEX TBEC PA; ST;QL(1 tbec ea daily) 7 (rabeprazole sodium) ea daily) Ulcer Drugs - Prostaglandins lansoprazole cpdr 15 QL(1 ea daily); CYTOTEC TABS 1 7 mg RX/OTC (misoprostol) QL(1 ea daily) lansoprazole cpdr 30 1 misoprostol tabs 1 mg lansoprazole tbdd 15 QL(2 ea daily); Ulcer Therapy Combinations 3 AL(Up to 12 yrs mg HELIDAC THERAPY MISC old ); RX/OTC (metronidazole- 3 lansoprazole tbdd 30 QL(1 ea daily); tetracycline w/ bismuth 3 AL(Up to 12 yrs subsalicylate) mg old ) OMECLAMOX-PAK MISC 1 QL(1 ea daily); omeprazole cpdr 20 mg RX/OTC (amoxicillin- clarithromycin w/ 3 QL(1 ea daily) omeprazole cpdr 40 mg 1 omeprazole) QL(1 ea daily) PYLERA CAPS (bismuth PA pantoprazole sodium 3 pack 40 mg subcitrate potassium- 2 QL(1 ea daily) metronidazole- pantoprazole sodium 1 tbec 20 mg, 40 mg tetracycline) PREVACID 24HR CPDR QL(1 ea daily); URINARY ANTISPASMODICS - Drugs to Treat 7 (lansoprazole) RX/OTC Miscellaneous Bladder Spasms PREVACID CPDR 15 MG QL(1 ea daily); Urinary Antispasmodic - Antimuscarinics 7 (lansoprazole) RX/OTC darifenacin 3 PREVACID CPDR 30 MG QL(1 ea daily) hydrobromide tb24 7 (lansoprazole)

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DETROL LA CP24 QL(1 ea daily) 7 flavoxate hcl tabs 1 (tolterodine tartrate) DETROL TABS QL(2 ea daily) 7 VACCINES (tolterodine tartrate) Viral Vaccines DITROPAN XL TB24 7 (oxybutynin chloride) FLUMIST PV QUADRIVALENT SUSP ENABLEX TB24 (influenza virus vaccine 5 (darifenacin 7 live quadrivalent) hydrobromide) QL(15 ml daily) VAGINAL AND RELATED PRODUCTS oxybutynin chloride 1 syrp 5 mg/5ml Spermicides oxybutynin chloride QL(4 ea daily) ENCARE SUPP PV 1 5 tabs 5 mg (nonoxynol-9) oxybutynin chloride OPTIONS CONCEPTROL PV VAGINAL tb24 10 mg, 15 mg, 5 1 7 mg CONTRACEPTIVE GEL QL(1 ea daily) (nonoxynol-9) solifenacin succinate 1 tabs 10 mg OPTIONS GYNOL II PV VAGINALCONTRACEPTIV 5 solifenacin succinate 1 E GEL (nonoxynol-9) tabs 5 mg TODAY SPONGE MISC PV QL(1 ea daily) 5 tolterodine tartrate 1 (nonoxynol-9) cp24 2 mg, 4 mg VCF VAGINAL PV QL(2 ea daily) CONTRACEPTIVE FILM 5 tolterodine tartrate tabs 1 1 mg, 2 mg FILM (nonoxynol-9) TOVIAZ TB24 QL(1 ea daily) VCF VAGINAL PV 2 (fesoterodine fumarate) CONTRACEPTIVE FOAM 5 FOAM (nonoxynol-9) trospium chloride cp24 1 60 mg VCF VAGINAL PV CONTRACEPTIVEGEL 5 QL(2 ea daily) trospium chloride tabs 1 GEL (nonoxynol-9) 20 mg Vaginal Anti-infectives VESICARE TABS 10 MG QL(1 ea daily) 7 (Metronidazole Vaginal) 1 (solifenacin succinate) VANDAZOLE GEL VESICARE TABS 5 MG 7 (Miconazole Nitrate (solifenacin succinate) Vaginal) MICONAZOLE 3 3 Urinary Antispasmodics - Cholinergic Agonists SUPP AVC CREA bethanechol chloride 1 3 tabs (sulfanilamide vaginal) URECHOLINE TABS CLEOCIN CREA VA 2 % 7 (bethanechol chloride) (clindamycin phosphate 7 vaginal) Urinary Antispasmodics - Direct Muscle Relaxants

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEOCIN SUPP VA 100 PREMARIN CREA VA QL(2 gm daily) MG ( 0.625 MG/GM clindamycin 3 2 phosphate vaginal) (estrogens, conjugated clindamycin phosphate vaginal) 1 VAGIFEM TABS vaginal crea 7 CLINDESSE CREA (estradiol vaginal) (clindamycin phosphate 3 Vaginal Progestins (one dose)) CRINONE GEL PA GYNAZOLE-1 CREA (progesterone 3 (butoconazole nitrate 3 (vaginal)) (one dose)) ENDOMETRIN INST PA; ST METROGEL-VAGINAL (progesterone 3 GEL (metronidazole 7 (vaginal)) vaginal) VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions metronidazole vaginal 1 gel Anaphylaxis Therapy Agents NUVESSA GEL PA 3 Not available (metronidazole vaginal) epinephrine through terconazole vaginal 4 mail;QL(2 ea 1 (anaphylaxis) soaj 0.15 per fill retail,4 crea 0.4 %, 0.8 % mg/0.15ml ea per 30 days retail) terconazole vaginal 3 supp 80 mg epinephrine QL(2 ea per fill Vaginal Contraceptive - pH Modulators (anaphylaxis) soaj 0.15 4 retail,4 ea per 30 days retail) PHEXXI GEL (lactic PV mg/0.3ml acid-citric acid- 5 Limited to 2 potassium bitartrate) pens per fill; 4 epinephrine pens per Vaginal Estrogens (anaphylaxis) soaj 0.3 3 month;QL(2 ea per fill retail,4 (Estradiol Vaginal) 1 mg/0.3ml YUVAFEM TABS ea per 30 days retail) ESTRACE CREA 7 (estradiol vaginal) epinephrine QL(2 ea per fill (anaphylaxis) soaj 0.3 3 retail,4 ea per estradiol vaginal crea 1 mg/0.3ml 30 days retail) estradiol vaginal tabs 1 SYMJEPI SOSY 0.15 PA; QL(2 ea MG/0.3ML (epinephrine 3 per fill retail) ESTRING RING 3 (anaphylaxis)) (estradiol vaginal) SYMJEPI SOSY 0.3 PA; QL(2 ea FEMRING RING Limit 1 per MG/0.3ML (epinephrine 3 per fill retail,4 (estradiol acetate 3 month;QL(0.04 ea per 30 days (anaphylaxis)) vaginal) ea daily) retail) Neurogenic Orthostatic Hypotension (NOH) - droxidopa caps 4 PA 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

138 Drug Requirements/ Drug Name Tier Limits NORTHERA CAPS PA 7 (droxidopa) Vasopressors midodrine hcl tabs 1

VITAMINS Oil Soluble Vitamins DRISDOL CAPS PV 7 (ergocalciferol) ergocalciferol caps 1 PV MEPHYTON TABS 7 (phytonadione) phytonadione tabs 1 Water Soluble Vitamins POTABA CAPS (potassium 3 aminobenzoate)

139 Index abacavir sulfate 52 ADEMPAS 60 ALA-SCALP 76 abacavir sulfate-lamivudine 52 adult aspirin regimen 7 albendazole 14 abacavir sulfate-lamivudine- ADULT MASK 101 ALBENZA 14 zidovudine 52 ADVAIR DISKUS 19 albuterol sulfate 19 ABILIFY 52 ADVAIR HFA 19 ALBUTEROL SULFATE 19 abiraterone acetate 43 ADVATE 91 albuterol sulfate 19 ABSORICA 70 ADYNOVATE 91 ALCAINE 123 acamprosate calcium 127 AEROBIKA 101 alclometasone dipropionate 76 acarbose 28 AEROCHAMBER MINI ALDACTAZIDE 82 ACCUPRIL 36 AEROSOLCHAMBER 101 ALDACTONE 83 ACCURETIC 37 AEROCHAMBER MV 101 ALDARA 79 accutane 69 AEROCHAMBER PLUS FLOW ALECENSA 44 acebutolol hcl 57 VU 101 AEROCHAMBER PLUS alendronate sodium 83 acetaminophen w/ codeine 11 FLOW-VU 101 ALFERON N 48 acetaminophen-caff-dihydrocod AEROCHAMBER PLUS 11 FLOW-VU/LARGE MASK 101 alfuzosin hcl 90 acetazolamide 82 AEROCHAMBER PLUS ALINIA 14 acetic acid (otic) 126 FLOW-VU/MASK 101 aliskiren fumarate 40 AEROCHAMBER PLUS ALKERAN 41 acetylcysteine 69 FLOW-VU/MEDIUM ACIPHEX 136 MASK 101 ALL FLOW 1000 PFT AEROCHAMBER PLUS FILTER 101 ACIPHEX SPRINKLE 136 ALL FLOW 2000 PFT acitretin 74 FLOW-VU/SMALL MASK 101 AEROCHAMBER Z-STAT FILTER 101 ACTEMRA 4 PLUS VALVED HOLDING ALL FLOW 3000 PFT ACTEMRA ACTPEN 4 CHAMBER W/FLOW VU 101 FILTER 101 ALL FLOW 4000 PFT ACTICLATE 133 AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL 101 FILTER 102 ACTIGALL 87 AEROCHAMBER Z-STAT ALL FLOW 5000 PFT ACTIMMUNE 48 PLUS/LARGE MASK 101 FILTER 102 AEROCHAMBER Z-STAT ALL FLOW 6000 PFT ACTINEL PEDIATRIC 67 FILTER 102 ACTIQ 9 PLUS/MEDIUM MASK 101 AEROCHAMBER Z-STAT ALL FLOW 7000 PFT ACTIVELLA 86 PLUS/SMALL MASK 101 FILTER 102 ACTONEL 83 AEROCHAMBER/FLOWSIGNA allergy nasal spray 24 hour 119 ACTOPLUS MET 28 L 101 allopurinol 90 AEROVENT PLUS HOLDING almotriptan malate 107 ACTOS 29 CHAMBER/COLLAPSIBLE ACULAR 124 101 ALOCRIL 124 ACULAR LS 124 AFINITOR 44 alogliptin benzoate 29 ACUVAIL 124 AFINITOR DISPERZ 44 ALOMIDE 124 acyclovir 56 afirmelle 62 ALORA 86 acyclovir topical 75 AFSTYLA 91 alosetron hcl 88 ACZONE 70 aftera 65 ALPHAGAN P 121 ADALAT CC 57 AGGRENOX 93 ALPHANATE 91 adapalene 70 AGRYLIN 93 ALPHANATE/VON WILLEBRANDFACTOR adapalene treatment 69 AIMOVIG 106 COMPLEX/HUMAN 91 adapalene-benzoyl peroxide 70 ak-poly-bac 121 ALPHANINE SD 91 ADCIRCA 60 AKTEN 123 alprazolam 16 ADDERALL 1 AKYNZEO 32 ALPRAZOLAM INTENSOL 16 ADDERALL XR 1 ala scalp 76 alprazolam xr 16 adefovir dipivoxil 55 ala-cort 76 ALPROLIX 91

Index 1 ALREX 123 anagrelide hcl 93 asenapine maleate 51 ALTABAX 72 ANALPRAM-HC 13 aspirin 8 altacaine 123 ANASPAZ 135 aspirin 81 low dose 8 ALTACE 36 anastrozole 43 aspirin adult 8 altafrin 121 ANCOBON 32 aspirin-dipyridamole 93 ALUNBRIG 44 ANDEXXA 31 ASTAGRAF XL 109 alvimopan 88 ANDRODERM 13 ATABEX EC 113 alyacen 1/35 62 ANDROGEL 13 ATACAND 36,37 alyacen 7/7/7 63 ANDROGEL PUMP 13 ATACAND HCT 38 alyq 60 ANGELIQ 86 atazanavir sulfate 52 amabelz 86 ANORO ELLIPTA 19 atenolol 57 amantadine hcl 49 ANTABUSE 127 atenolol & chlorthalidone 38 AMARYL 30 ANTARA 34 ATIVAN 16 ambi 40pse/400gfn 67 anti-diarrheal 31 atomoxetine hcl 1 AMBIEN 95 ANTIVERT 32 atorvastatin calcium 35 AMBIEN CR 95 ANUSOL-HC 14 atovaquone 14 ambrisentan 60 ANZEMET 31 atovaquone-proguanil hcl 40 amcinonide 76 APEXICON E 76 ATRALIN 70 AMCINONIDE 76 APO-VARENICLINE 132 ATRIPLA 52 AMERGE 107 apraclonidine hcl 121 ATROPINE SULFATE 121 amethia 62 aprepitant 32 atropine sulfate amethyst 62 apri 61 (ophthalmic) 121 ATROVENT HFA 17 AMICAR 95 APRISO 88 AUBAGIO 129 amiloride & APTENSIO XR 2 AUGMENTIN 127 hydrochlorothiazide 82 APTIOM 21 amiloride hcl 83 AUGMENTIN ES-600 127 APTIVUS 52 aminocaproic acid 95 aurovela 1.5/30 63 aranelle 63 amiodarone hcl 17 aurovela 24 fe 62 ARAVA 6 AMITIZA 88 AURYXIA 89 ARCALYST 4 amitriptyline hcl 27 AUSTEDO 129 ARCAPTA NEOHALER 19 amlodipine besylate 57,58 AVALIDE 38 ARIAL CHAMBER 102 amlodipine besylate-atorvastatin AVANDIA 29 ARICEPT 128 calcium 59 AVAPRO 37 amlodipine besylate-benazepril ARIKAYCE 3 AVC 137 hcl 37,38 ARIMIDEX 43 amlodipine besylate- avidoxy 133 aripiprazole 52 valsartan 38 avita 70 amlodipine-valsartan- ARIXTRA 20 AVODART 90 hydrochlorothiazide 38 armodafinil 2 AVONEX 129 amoxapine 27 ARMOUR THYROID 134 AVONEX PEN 129 amoxicillin 126 ARNUITY ELLIPTA 18 AYGESTIN 127 amoxicillin & pot AROMASIN 43 clavulanate 127 AYVAKIT 44 arthritis pain reliever 72 amphetamine- AZASAN 109 dextroamphetamine 1 ARTHROTEC 50 4 AZASITE 121 ampicillin 127 ARTHROTEC 75 4 azathioprine 109 AMPYRA 129 ARYMO ER 9 azelaic acid 80 ANADROL-50 13 ASACOL HD 88 azelastine hcl 119 ANAFRANIL 27 ascomp/codeine 11

Index 2 azelastine hcl (ophth) 124 BD VEO INSULIN SYRINGE bethanechol chloride 137 azelastine hcl-fluticasone ULTRA-FINE/0.3ML/31G X BETHKIS 3 6MM 100 propionate 119 BETIMOL 120 AZELEX 70 BD VEO INSULIN SYRINGE ULTRA-FINE/1/2 BETOPTIC-S 120 AZILECT 50 UNIT/0.3ML/31G X 6MM 100 BEVYXXA 20 azithromycin 98 BD VEO INSULIN SYRINGE bexarotene 48 AZOPT 124 ULTRA-FINE/1ML/31G X BEYAZ 63 AZULFIDINE 88 6MM 100 BD VEO INSULIN SYRINGE bicalutamide 43 AZULFIDINE EN-TABS 88 ULTRA-FINE/U-100/0.3ML/31G bidex 69 azurette 61 X 15/64" 100 BIDIL 59 bac 7 BD VEO INSULIN SYRINGE ULTRA-FINE/U-100/1ML/31G BIKTARVY 52 bacitracin (ophthalmic) 122 X 15/64" 100 BILTRICIDE 14 bacitracin-poly-neomycin-hc BELLADONNA/OPIUM 135 123 bimatoprost 125 bacitracin-polymyxin b BELSOMRA 95 BIO-DTUSS DMX 67 (ophth) 122 benazepril & BIONEL PEDIATRIC 67 hydrochlorothiazide 38 baclofen 118 bisacodyl 97 BACTRIM 14 benazepril hcl 36 BENAZEPRIL bisoprolol & BACTRIM DS 14 HCL/HYDROCHLOROTHIAZID hydrochlorothiazide 38 balsalazide disodium 88 E 38 bisoprolol fumarate 57 BALVERSA 44 BENEFIX 91 BLEPH-10 122 BANZEL 21,22 BENICAR 37 BLEPHAMIDE 123 BAQSIMI ONE PACK 28 BENICAR HCT 38 BLEPHAMIDE S.O.P. 123 BAQSIMI TWO PACK 28 BENLYSTA 110 BONIVA 83 BARACLUDE 55 BENSAL HP 79 bosentan 60 BASE GELATIN GUMMY BENZACLIN 70 BOSULIF 44 TROCHE 127 BENZACLIN WITH PUMP 70 bp 10-1 70 BD AUTOSHIELD DUO 30G X 5MM 99 BENZAMYCIN 70 bp cleansing wash 70 BD ECLIPSE NEEDLE 30G BENZNIDAZOLE 14 BRAFTOVI 45 X1/2" 99 benzonatate 66 BREATHE EASE/LARGE BD NEEDLE/30G X 1/2" 99 benzoyl peroxide- MASK 102 BD PEN erythromycin 70 BREATHE EASE/MEDIUM MASK 102 NEEDLE/MICRO/ULTRA- benztropine mesylate 48 FINE/32G X 6MM 99 BREATHE EASE/SMALL BD PEN NEEDLE/MINI/ULTRA- bepotastine besilate 124 MASK 102 FINE/31G X 5MM 99 BEPREVE 124 BREATHERITE 102 BD PEN beser 75 BREATHERITE NEEDLE/ORIGINAL/ULTRA- BESIVANCE 122 COLLAPSIBLEADULT SPACER FINE/29G X 12.7MM 99 W/MASK 102 BD PEN BETADINE OPHTHALMIC BREATHERITE PREP 122 COLLAPSIBLECHILD SPACER NEEDLE/SHORT/ULTRA- betamethasone dipropionate FINE/31G X 8MM 99 W/MASK 102 (topical) 76 BREATHERITE BD SAFETYGLIDE INSULIN betamethasone dipropionate SYRINGE/0.3ML/31G X COLLAPSIBLEINFANT SPACER augmented 76 15/64" 99 W/MASK 102 BD SAFETYGLIDE INSULIN betamethasone valerate 76 BREATHERITE SYRINGE/1ML/31G X BETAPACE 57 COLLAPSIBLESMALL CHILD 15/64" 99 BETAPACE AF 57 SPACER W/MASK 102 BD VEO INSULIN SYRINGE BETASERON 129 BREATHERITE ULTRA-AFINE/0.3ML/31G X COLLAPSIBLESPACER W/ 6MM 99 betaxolol hcl 57 NEONATE MASK 102 betaxolol hcl (ophth) 120

Index 3 BREATHERITE RIGID CABOMETYX 45 CARDURA 37 SPACERW/MASK 102 CADUET 59 CARDURA XL 90 BREATHERITE VALVED MDI CHAMBER/COLLAPSIBLE 102 CAFERGOT 106 carisoprodol 118 BREATHERITE VALVED MDI caffeine citrate 1 carisoprodol w/ aspirin 118 CHAMBER/RIGID 102 CALAN 58 carisoprodol w/ aspirin & BREATHERITE W/LARGE CALAN SR 58 codeine 118 MASK 102 CARNITOR 84 BREATHERITE W/MEDIUM CALCIFOL 108 CARNITOR SF 84 MASK 102 calcipotriene 74 carteolol hcl (ophth) 120 BREATHERITE W/SMALL CALCIPOTRIENE 74 MASK 102 calcipotriene-betamethasone cartia xt 57 BREO ELLIPTA 19 dipropionate 76 carvedilol 56 BRILINTA 93 calcitonin (salmon) 83 carvedilol phosphate 56 brimonidine tartrate 121 calcitrene 74 CASODEX 43 brinzolamide 124 calcitriol 84 cataflam 4 BRIVIACT 22 calcitriol (topical) 74 CATAPRES 37 bromfenac sodium (ophth) 125 calcium acetate (phosphate CAYA 98 bromocriptine mesylate 49 binder) 89 caziant 61 BROMSITE 125 CALCIUM-FOLIC ACID PLUS D 108 cefaclor 61 BRONKIDS 67 calphron 89 CEFACLOR ER 61 BRUKINSA 45 CALQUENCE 45 cefadroxil 61 budesonide 65 camila 65 cefdinir 61 budesonide (inhalation) 18 CANASA 88 cefditoren pivoxil 61 budesonide-formoterol fumarate cefixime 61 dihydrate 19 candesartan cilexetil 37 bumetanide 82 candesartan cilexetil- cefpodoxime proxetil 61 hydrochlorothiazide 38 BUMEX 82 cefprozil 61 CAPCOF 67 cefuroxime axetil 61 bupap 7 capecitabine 41 BUPHENYL 84 CELEBREX 4,5 CAPEX 76 celecoxib 5 buprenorphine 12 CAPRELSA 45 buprenorphine hcl 12 CELEXA 26 captopril 36 CELLCEPT 110 buprenorphine hcl-naloxone hcl captopril & dihydrate 12 hydrochlorothiazide 38 CELONTIN 25 bupropion hcl 25 CARAC 74 CENTANY 72 bupropion hcl (smoking cephalexin 61 deterrent) 132 CARAFATE 135 CEPROTIN 93 buspirone hcl 16 CARBAGLU 84 CERDELGA 94 butalbital-acetaminophen 7 carbamazepine 22 butalbital-acetaminophen- CARBATROL 22 CERVIDIL 126 caffeine 7 carbidopa 48 CETRAXAL 126 butalbital-acetaminophen- carbidopa-levodopa 49 cevimeline hcl 111 caffeine w/ codeine 11 carbidopa-levodopa- CHANTIX 132 butalbital-aspirin-caffeine 7 entacapone 49 CHANTIX CONTINUING butalbital-aspirin-caffeine CARBIDOPA/LEVODOPA MONTHPAK 132 w/cod 11 ODT 49 CHANTIX STARTING MONTH BUTISOL SODIUM 95 carbinoxamine maleate 33 PAK 132 butorphanol tartrate 13 CARBINOXAMINE charlotte 24 fe 62 BYSTOLIC 57 MALEATE 33 CHEMET 31 C-NATE DHA 113 CARDIZEM 58 CHENODAL 87 cabergoline 85 CARDIZEM CD 58 chlordiazepoxide hcl 16 CARDIZEM LA 58

Index 4 chlordiazepoxide hcl-clidinium CLEMASTINE clomiphene citrate 84 bromide 135 FUMARATE 33 clomipramine hcl 27 chlordiazepoxide-amitriptyline clemastine fumarate 33 clonazepam 21 128 CLEOCIN 137,138 clonidine hcl 37 chloroquine phosphate 40 CLEOCIN PEDIATRIC chlorothiazide 83 GRANULES 15 clopidogrel bisulfate 94 chlorpromazine hcl 52 CLEOCIN-T 70 clorazepate dipotassium 16 chlorthalidone 83 CLEVER CHOICE ANTI- clotrimazole 111 chlorzoxazone 118 STATICVALVED HOLDING clotrimazole w/ CHAMBER/ADULT betamethasone 73 cholestyramine 34 LARGE 103 clovique 109 cholestyramine light 34 CLEVER CHOICE ANTI- clozapine 51 choline fenofibrate 34 STATICVALVED HOLDING CLOZARIL 51 CIALIS 59 CHAMBER/MEDIUM 103 CLEVER CHOICE ANTI- CO MONITOR 103 ciclodan 72 STATICVALVED HOLDING COAGADEX 91 ciclopirox 72,73 CHAMBER/MEDIUM/3 COARTEM 40 ciclopirox olamine 73 YEA 103 CLEVER CHOICE ANTI- codeine sulfate 9 cilostazol 94 STATICVALVED HOLDING CODITUSSIN AC 67 CILOXAN 122 CHAMBER/SMALL 103 COLAZAL 88 CIMDUO 53 CLEVER CHOICE ANTI- colchicine 91 cimetidine 135 STATICVALVED HOLDING CHAMBER/SMALL colchicine w/ probenecid 90 cimetidine hcl 135 INFANT 103 COLCRYS 91 cinacalcet hcl 84 CLIMARA 86 colesevelam hcl 34 CIPRO 87 CLIMARA PRO 86 COLESTID 34 CIPRO HC 126 clindacin etz pledgets 69 COLESTID FLAVORED 34 CIPRODEX 126 CLINDAGEL 70 colestipol hcl 34 ciprofloxacin 87 clindamycin hcl 15 colocort 13 ciprofloxacin hcl 87 clindamycin palmitate COLY-MYCIN S 126 ciprofloxacin hcl (ophth) 122 hydrochloride 15 clindamycin phosphate COLYTE-FLAVOR PACKS 96 ciprofloxacin hcl (otic) 126 (topical) 70 COMBIGAN 120 ciprofloxacin-dexamethasone clindamycin phosphate COMBIPATCH 86 126 vaginal 138 ciprofloxacin-fluocinolone clindamycin phosphate-benzoyl COMBIVENT RESPIMAT 19 acetonide 126 peroxide 70 COMBIVIR 53 citalopram hydrobromide 26 clindamycin phosphate-benzoyl COMETRIQ 45 CITRANATAL 90 DHA 113 peroxide (refrigerate) 70 COMPACT SPACE CITRANATAL ASSURE 113 clindamycin phosphate- CHAMBER/ANTI-STATIC 103 tretinoin 70 CITRANATAL B-CALM 113 COMPACT SPACE CLINDESSE 138 CHAMBER/ANTI- CITRANATAL BLOOM 113 clobazam 21 STATIC/LARGE MASK 103 CITRANATAL BLOOM clobetasol propionate 76 COMPACT SPACE DHA 113 CHAMBER/ANTI- CITRANATAL ESSENCE 113 clobetasol propionate e 75 STATIC/MEDIUM MASK 103 CITRANATAL HARMONY 113 clobetasol propionate emollient COMPACT SPACE base 76 CITRANATAL MEDLEY 113 CHAMBER/ANTI-STATIC/SMALL clobetasol propionate MASK 103 CITRANATAL RX 113 emulsion 76 COMPLERA 53 CLARINEX 33 CLOBEX 77 COMPLETENATE 113 clarispray 119 clocortolone pivalate 77 compro 52 clarithromycin 98 clodan 75 COMTAN 48 clearlax 96 CLODERM 77 CONCEPT DHA 113

Index 5 CONCEPT OB 113 cvs nicotine DEPAKOTE ER 25 CONCERTA 2 transdermalsystem 131 DEPAKOTE SPRINKLES 25 cvs olopatadine CONDYLOX 79 hydrochloride 124 DEPEN TITRATABS 109 constulose 96 CVS WOMENS DERMA-SMOOTHE/FS CONZIP 9 PRENATAL+DHA 113 BODY 77 cyclobenzaprine hcl 118 DERMA-SMOOTHE/FS COPAXONE 129 SCALP 77 CYCLOGYL 121 COPIKTRA 45 DERMOTIC 126 CYCLOMYDRIL 121 CORDRAN 77 DESCOVY 53 cyclopentolate hcl 121 COREG 57 desipramine hcl 27 cyclophosphamide 41 COREG CR 57 desloratadine 33 CORGARD 57 CYCLOPHOSPHAMIDE 41 DESMOPRESSIN CORIFACT 91 cycloserine 41 ACETATE 85 CORLANOR 60 cyclosporine 110 desmopressin acetate 85 cyclosporine modified (for CORTEF 65 desmopressin acetate spray 85 microemulsion) 110 desmopressin acetate spray CORTENEMA 13 CYMBALTA 27 refrigerated 85 cortic-nd 126 cyproheptadine hcl 34 desogestrel & ethinyl CORTIFOAM 13 CYSTADANE 84 estradiol 63 cortisone acetate 65 desogestrel-ethinyl estradiol CYSTAGON 90 (biphasic) 63 CORTISPORIN-TC 126 CYSTARAN 125 DESONATE 77 COSENTYX 74 CYTOMEL 134 desonide 77 COSENTYX SENSOREADY CYTOTEC 136 PEN 74 DESOWEN 77 COSOPT 120 cytra k crystals 90 desoximetasone 77 COSOPT PF 120 cytra-3 89 DESOXYN 1 COTELLIC 45 cytra-k 90 desrx 75 COUMADIN 20 D-PENAMINE 109 desvenlafaxine succinate 27 COZAAR 37 D.H.E. 45 106 DETROL 137 CREON 81 dalfampridine 129 DETROL LA 137 CRESEMBA 32 danazol 13 dexamethasone 65 CRESTOR 35 DANTRIUM 118 DEXAMETHASONE dantrolene sodium 118 INTENSOL 65 CRINONE 138 dexamethasone sodium CRIXIVAN 53 dapsone 15 phosphate (ophth) 123 cromolyn sodium 17 dapsone (topical) 71 DEXEDRINE 1 cromolyn sodium (ophth) 125 darifenacin hydrobromide 136 dexmethylphenidate hcl 2 cryselle-28 63 DAURISMO 42 dextroamphetamine sulfate 1 CUPRIMINE 109 DAYPRO 5 DIACOMIT 22 CUTIVATE 77 DAYTRANA 2 DIASTAT ACUDIAL 21 CUVPOSA 135 DDAVP 85 DIASTAT PEDIATRIC 21 cvs folic acid 94 decadron 65 diazepam 16 cvs lansoprazole 135 deferasirox 31 diazepam (anticonvulsant) 21 cvs mucus d extended deferiprone 31 diazepam intensol 16 release 67 DELSTRIGO 53 diazoxide 29 cvs mucus d maximum strength DELZICOL 88 er 67 DIBENZYLINE 36 demeclocycline hcl 133 cvs nasal allergy spray 119 DICLEGIS 32 DEMSER 36 cvs nicotine 131 diclofenac potassium 5 DEPAKENE 25 cvs nicotine lozenge 130 diclofenac sodium 5 DEPAKOTE 25

Index 6 diclofenac sodium (actinic DORZOLAMIDE HCL 125 e.e.s. 400 98 keratoses) 74 dorzolamide hcl-timolol E.E.S. GRANULES 98 diclofenac sodium (ophth) 125 maleate 120 EASIVENT 103 diclofenac sodium (topical) 72 dotti 86 EASIVENT/MASK-LARGE 103 diclofenac w/ misoprostol 5 DOVATO 53 EASIVENT/MASK-MEDIUM dicloxacillin sodium 127 DOVONEX 74 103 dicyclomine hcl 135 doxazosin mesylate 37 EASIVENT/MASK-SMALL 103 didanosine 53 doxepin hcl 27 EASY FLOW BLACK/BLUE103 DIFFERIN 71 doxercalciferol 85 EASY FLOW DIFICID 98 doxycycline BLACK/ORANGE 103 EASY FLOW BLACK/RED 103 diflorasone diacetate 77 (monohydrate) 133 doxycycline (rosacea) 80 EASY FLOW DIFLUCAN 33 doxycycline hyclate 133 BLACK/WHITE 103 diflunisal 8 EASY FLOW doxylamine-pyridoxine 32 digitek 59 BLACK/YELLOW 103 DRISDOL 139 digoxin 59 EASY FLOW WHITE/BLUE 103 dihydroergotamine dronabinol 32 EASY FLOW mesylate 107 DROPLET INSULIN SYRINGE WHITE/GREEN 104 DILANTIN 25 U-100/0.3ML/31G X EASY FLOW WHITE/PINK 104 15/64" 100 EASY FLOW DILANTIN INFATABS 25 DROPLET INSULIN SYRINGE WHITE/WHITE 104 DILANTIN-125 25 U-100/1ML/31G X 15/64" 100 EASY FLOW DILATRATE SR 16 DROPLET INSULIN WHITE/YELLOW 104 SYRINGE/U-100/0.3ML/31G X DILAUDID 9 EASY TOUCH FLIPLOCK 15/64" 100 NEEDLES 30GX1/2" 100 dilt-xr 57 DROPLET INSULIN EASY TOUCH HYPODERMIC diltiazem hcl 58 SYRINGE/U-100/1ML/31G X NEEDLES 30GX1/2" 100 diltiazem hcl coated beads 58 15/64" 100 econazole nitrate 73 drospirenone-ethinyl diltiazem hcl extended release ECOZA 73 estradiol 63 beads 58 drospirenone-ethinyl estradiol- ed a-hist dm 67 dimethyl fumarate 129 levomefolate calcium 63 ED BRON GP 67 DIOVAN 37 DROXIA 94 ed-spaz 135 DIOVAN HCT 38 droxidopa 138 EDARBI 37 DIPENTUM 88 DRYSOL 80 EDARBYCLOR 38 diphenoxylate w/ atropine 31 DUAC 71 EDECRIN 82 DIPROLENE 77 DUAVEE 86 EDURANT 53 DIPROLENE AF 77 DUET DHA 400 113 efavirenz 53 dipyridamole 94 DUET DHA BALANCED 113 efavirenz-emtricitabine-tenofovir disopyramide phosphate 17 DUETACT 28 disoproxil fumarate 53 disulfiram 127 DULCOLAX 97 effer-k 109 DITROPAN XL 137 duloxetine hcl 27 EFFER-K 109 DIURIL 83 DUOPA 49 EFFEXOR XR 27 divalproex sodium 25 DUPIXENT 79 EFFIENT 94 DIVIGEL 86 DURAGESIC 9 EFUDEX 74 dofetilide 17 DUREZOL 123 EGRIFTA 84 DOJOLVI 120 dutasteride 90 EGRIFTA SV 84 DOLOPHINE 9 dutasteride-tamsulosin hcl 90 ELESTRIN 86 donepezil hydrochloride 128 DYAZIDE 82 eletriptan hydrobromide 107 DORAL 95 DYMISTA 119 ELIDEL 79 dorzolamide hcl 125 DYRENIUM 83 ELIGARD 43

Index 7 ELIMITE 81 EPIVIR 53 eszopiclone 95 ELIQUIS 20 EPIVIR HBV 55 ethacrynic acid 82 ELIQUIS STARTER PACK 20 eplerenone 40 ethambutol hcl 41 ELIXOPHYLLIN 19 EPZICOM 53 ethosuximide 25 ELLA 65 EQ SPACE CHAMBER ANTI- ethynodiol diacet & eth ELMIRON 90 STATIC 104 estrad 63 EQ SPACE CHAMBER ANTI- etidronate disodium 83 ELOCON 77 STATIC/LARGE MASK 104 etodolac 5 ELOCTATE 91,92 EQ SPACE CHAMBER ANTI- etonogestrel-ethinyl estradiol65 eluryng 65 STATIC/MEDIUM MASK 104 EQ SPACE CHAMBER ANTI- etoposide 48 EMBEDA 9 STATIC/SMALL MASK 104 etravirine 53 EMCYT 43 EQUETRO 50 EUCRISA 80 EMEND 32 ergocalciferol 139 euthyrox 134 EMEND TRIPACK 32 ergoloid mesylates 130 EVAMIST 87 EMFLAZA 65 ERGOMAR 107 everolimus 45 EMGALITY 106 ergotamine w/ caffeine 106 everolimus EMSAM 25 ERIVEDGE 42 (immunosuppressant) 110 emtricitabine 53 ERLEADA 43 EVISTA 84 emtricitabine-tenofovir disoproxil erlotinib hcl 42 EVOCLIN 71 fumarate 53 EVOTAZ 53 EMTRIVA 53 ERTACZO 73 EVOXAC 111 ENABLEX 137 ery 69 EVRYSDI 120 enalapril maleate 36 ery-tab 98 enalapril maleate & ERYGEL 71 EXELDERM 73 hydrochlorothiazide 38 ERYPED 200 98 EXELON 128 ENBRACE HR 114 ERYPED 400 98 exemestane 43 ENBREL 6 erythrocin stearate 98 EXFORGE 38 ENBREL MINI 6 erythromycin (acne aid) 71 EXFORGE HCT 38 ENBREL SURECLICK 6 erythromycin (ophth) 122 EXODERM 73 ENCARE 137 erythromycin base 98 EXTAVIA 129 endocet 11 erythromycin EXTINA 73 ENDOMETRIN 138 ethylsuccinate 98 eye allergy enoxaparin sodium 20 ESBRIET 133 itch/rednessrelief 124 ezetimibe 35 enpresse-28 62 ESCAVITE D 112 ezetimibe-simvastatin 34 entacapone 48 escitalopram oxalate 26 FABIOR 71 entecavir 55 esgic 7 famciclovir 56 ENTEREG 88 ESGIC 7 famotidine 135 ENTOCORT EC 66 estarylla 63 FARESTON 43 ENTRESTO 59 estazolam 95 FARXIGA 30 enulose 88 ESTRACE 86 FARYDAK 45 EPCLUSA 55 estradiol 87 estradiol & norethindrone FASENRA PEN 17 EPIDIOLEX 22 acetate 86 FAZACLO 51 EPIDUO 71 ESTRADIOL FC FEMALE CONDOM 98 EPIDUO FORTE 71 CONCENTRATE 61 FC2 FEMALE CONDOM 98 EPIFOAM 77 estradiol vaginal 138 febuxostat 91 epinastine hcl (ophth) 125 ESTRING 138 FEIBA 92 epinephrine (anaphylaxis) 138 ESTROGEL 87 felbamate 24 epitol 21 ESTROSTEP FE 63

Index 8 FELBATOL 24 FLOVENT HFA 18 fosfomycin tromethamine 15 FELDENE 5 FLOXIN OTIC 126 fosinopril sodium 36 felodipine 58 fluconazole 33 fosinopril sodium & FEMARA 43 flucytosine 32 hydrochlorothiazide 38 FOSRENOL 89 FEMCAP 98 fludrocortisone acetate 66 FRAGMIN 20,21 FEMHRT 86 FLUMADINE 56 FREESTYLE INSULINX FEMRING 138 FLUMIST BLOODGLUCOSE TEST 81 fenofibrate 34,35 QUADRIVALENT 137 FREESTYLE INSULINX fluocinolone acetonide 77 FENOFIBRATE 35 BLOODGLUCOSE TEST fluocinolone acetonide STRIPS 81 fenofibrate 35 (otic) 126 FREESTYLE LITE TEST fenofibrate micronized 35 fluocinonide 77 STRIPS 81 FENOFIBRIC ACID 35 fluocinonide emulsified FREESTYLE TEST STRIPS 81 fenoprofen calcium 5 base 77 FROVA 107 FENOPROFEN CALCIUM 5 FLUORABON 108 frovatriptan succinate 107 fenoprofen calcium 5 fluoritab 108 FULPHILA 94 FENSOLVI 84 fluorometholone (ophth) 123 FURADANTIN 15 fentanyl 9 FLUOROPLEX 74 furosemide 82,83 fentanyl citrate 9 fluorouracil (topical) 74 FUZEON 53 FERRIPROX 31 fluoxetine hcl 26 fyavolv 86 FETZIMA 27 fluoxetine hcl (pmdd) 130 FYCOMPA 21 FLUOXETINE FETZIMA TITRATION PACK27 HYDROCHLORIDE 26 g tussin ac 66 FIBRICOR 35 fluphenazine hcl 52 gabapentin 22 FIBRYGA 92 flurandrenolide 77 GABITRIL 24 FINACEA 80 flurazepam hcl 95 GALAFOLD 85 finasteride 90 flurbiprofen 5 galantamine hydrobromide 128 FIORICET 7 flurbiprofen sodium 125 GALZIN 109 FIORICET/CODEINE 11 flutamide 43 gatifloxacin (ophth) 122 FIORINAL 7 fluticasone propionate 78 GATTEX 89 FIORINAL/CODEINE #3 11 fluticasone propionate gavilyte-c 96 FIRAZYR 93 (nasal) 120 gavilyte-n/flavor pack 96 FIRDAPSE 40 fluticasone-salmeterol 19 GELFILM OP 124 FIRST-MOUTHWASH BLM 111 fluvastatin sodium 35 gemfibrozil 35 FIRVANQ 15 fluvoxamine maleate 26 gemmily 62 flac 126 FML 123 GENERESS FE 63 FLAGYL 14 FML FORTE 123 gengraf 109 FLAREX 123 FML LIQUIFILM 123 gentak 121 flavoxate hcl 137 FOCALIN 2 gentamicin sulfate (ophth) 122 flecainide acetate 17 FOCALIN XR 2 gentamicin sulfate (topical) 72 FLEXICHAMBER 104 FOLET DHA 114 GENVOYA 53 FLOMAX 90 folic acid 94 GEODON 50 FLONASE ALLERGY FOLIVANE-OB 114 gianvi 62 RELIEF 120 fondaparinux sodium 20 GILENYA 129 FLONASE ALLERGY RELIEF FORFIVO XL 25 CHILDRENS 119 GILOTRIF 42 FLORIVA 108 FORTESTA 13 GILPHEX TR 67 FLORIVA PLUS 112 FOSAMAX 83 GILTUSS COUGH & COLD 67 FLOVENT DISKUS 18 fosamprenavir calcium 53

Index 9 GILTUSS SINUS & GUANIDINE HCL 40 HYCAMTIN 48 CONGESTION 67 GUM BASE GELATIN 127 HYCODAN 66 GILTUSS TR 67 GYNAZOLE-1 138 hydralazine hcl 40 glatiramer acetate 129 HAEGARDA 93 HYDREA 48 glatopa 129 HALCION 95 hydrochlorothiazide 83 GLEEVEC 45 halobetasol propionate 78 hydrocodone bitartrate 9 GLENMAX PEB 68 haloperidol 51 HYDROCODONE BITARTRATE glenmax peb dm forte 67 haloperidol lactate 51 ER 9 GLEOSTINE 41 hydrocodone polistirex- HELIDAC THERAPY 136 glimepiride 30 chlorpheniramine polistirex 68 HELIXATE FS 92 hydrocodone w/ glipizide 30 HEMOFIL M 92 homatropine 66 glipizide xl 30 hydrocodone- HEPSERA 55 glipizide-metformin hcl 28 acetaminophen 11 HETLIOZ 95 GLOBAL EASY GLIDE INSULIN hydrocodone-ibuprofen 11 SYRINGE/0.3ML/31G X HIPREX 15 hydrocortisone 66 15/64" 100 homatropaire 121 hydrocortisone (intrarectal) 13 GLOBAL EASY GLIDE INSULIN homatropine hbr 121 SYRINGE/1ML/31G X hydrocortisone (rectal) 14 15/64" 100 HORIZANT 130 hydrocortisone (topical) 78 glucagon (rdna) 29 HUMALOG 29 hydrocortisone butyrate 78 GLUCAGON EMERGENCY HUMALOG JUNIOR hydrocortisone butyrate KIT 29 KWIKPEN 29 hydrophilic lipo base 78 GLUCOTROL 30 HUMALOG KWIKPEN 29 hydrocortisone valerate 78 GLUCOTROL XL 30 HUMALOG MIX 50/50 29 hydrocortisone w/acetic glyburide 30 HUMALOG MIX 50/50 acid 126 KWIKPEN 29 hydromet 66 glyburide micronized 30 HUMALOG MIX 75/25 29 hydromorphone hcl 9 glyburide-metformin 28 HUMALOG MIX 75/25 hydroxychloroquine sulfate 40 GLYCATE 135 KWIKPEN 29 hydroxyurea 48 glycopyrrolate 135 HUMATE-P 92 hydroxyzine hcl 16 GLYCOPYRROLATE 135 HUMATIN 3 hydroxyzine pamoate 16 GLYNASE 30 HUMATROPE 84 hyoscyamine sulfate 135 GLYSET 28 HUMATROPE COMBO PACK 84 HYPER-SAL 69 GLYXAMBI 28 HUMIRA 3 HYPERSAL 69 gnp aspirin 8 HUMIRA PEDIATRIC CROHNS HYPODERMIC NEEDLE gnp olopatadine DISEASE STARTER PACK 3 30GX1/2" 100 hydrochloride 124 HUMIRA PEN 3 HYSINGLA ER 9 GOLYTELY 96 HUMIRA PEN-CD/UC/HS HYZAAR 38 goodsense aspirin 8 STARTER 3 ibandronate sodium 83 GRALISE 130 HUMIRA PEN-PEDIATRIC UC IBRANCE 45 granisetron hcl 31 STARTER PACK 3 HUMIRA PEN-PS/UV ibu 4 GRANIX 94 STARTER 3 ibudone 11 griseofulvin microsize 32 HUMULIN 70/30 29 ibuprofen 5 griseofulvin ultramicrosize 32 HUMULIN N 30 icatibant acetate 93 guaiatussin ac 66 HUMULIN N KWIKPEN 29 ICLUSIG 45 guaifenesin 69 HUMULIN R 30 icosapent ethyl 34 guaifenesin dac 67 HUMULIN R U-500 IDELVION 92 guaifenesin-codeine 68 (CONCENTRATED) 30 HUMULIN R U-500 IDHIFA 45 guanfacine hcl 37 KWIKPEN 30 ILEVRO 125 guanfacine hcl (adhd) 1

Index 10 ILUMYA 74 INSULIN LISPRO JARDIANCE 30 imatinib mesylate 45 PROTAMINE/INSULIN LISPRO JIVI 92 KWIKPEN 30 IMBRUVICA 45,46 INSULIN SYRINGES AND PEN JUBLIA 73 imipramine hcl 27 NEEDLES 100 JULUCA 53 imipramine pamoate 27 INTELENCE 53 JUXTAPID 36 imiquimod 79 INTRON A 48 JYNARQUE 86 IMITREX 107 INTUNIV 1 K-PHOS 108 IMITREX STATDOSE INVEGA 51 K-PHOS NEUTRAL 108 REFILL 107 INVIRASE 53 K-PHOS NO 2 89 IMITREX STATDOSE SYSTEM 107 iodine strong (lugol's) 108 k-prime 109 IMODIUM A-D 31 iodoquimez-hc 72 K-TAB 109 IMPAVIDO 14 iodoquinol-hydrocortisone in KADIAN 9 aloe vehicle 73 kaitlib fe 62 IMURAN 110 IOPIDINE 121 IN-CHECK DIAL KALETRA 53 ipratropium bromide 18 INSPIRATORYFLOW KALYDECO 132 TRAINER 104 ipratropium bromide IN-CHECK INSPIRATORY (nasal) 119 KARBINAL ER 33 FLOWMETER/NASAL WITH ipratropium-albuterol 19 KCENTRA 92 MASK 104 irbesartan 37 KEFLEX 61 IN-CHECK INSPIRATORY irbesartan-hydrochlorothiazide kelnor 1/35 62 FLOWMETER/ORAL 104 38 KENALOG 78 inatal gt 112 IRESSA 42 KEPPRA 22 INBRIJA 49 ISENTRESS 53 KEPPRA XR 22 INCRELEX 84 ISENTRESS HD 53 keralyt 79 INCRUSE ELLIPTA 17 isoniazid 41 ketoconazole 33 indapamide 83 ISOPTO ATROPINE 121 ketoconazole (topical) 73 INDERAL LA 57 ISOPTO CARPINE 121 ketodan 72 INDERAL XL 57 ISORDIL TITRADOSE 16 KETONE 81 INDOCIN 5 isosorbide dinitrate 16 ketoprofen 5 indomethacin 5 isosorbide mononitrate 16 INGREZZA 129 ketorolac tromethamine 5 isotretinoin 71 ketorolac tromethamine INLYTA 42 isradipine 58 (ophth) 125 INNOPRAN XL 57 ISTALOL 120 KETOSTIX 81 INQOVI 44 itraconazole 33 KEVZARA 4 INREBIC 46 ivermectin 14 kionex 110 INSPIRACHAMBER/ANTI- IVERMECTIN 80,81 KISQALI 46 STATIC KISQALI FEMARA 200 VALVED/MOUTHPIECE 104 ivermectin (pediculicide) 81 INSPIRACHAMBER/LARGE ivermectin (rosacea) 80 DOSE 44 KISQALI FEMARA 400 104 IXINITY 92 INSPIRACHAMBER/SOOTHER DOSE 44 JADENU 31 KISQALI FEMARA 600 MASK/INSPIRAMASK/MEDIUM DOSE 44 104 JADENU SPRINKLE 31 INSPIRACHAMBER/SOOTHER JAKAFI 46 KITABIS PAK 3 MASK/INSPIRAMASK/SMALL JALYN 90 KLARITY-A 122 104 jantoven 20 KLARON 71 INSPIREASE DRUG KLONOPIN 21 DELIVERYSYSTEM 104 JANUMET 28 INSPRA 40 JANUMET XR 28 klor-con 109 JANUVIA 29 klor-con 10 109 klor-con m10 109

Index 11 klor-con sprinkle 109 LENVIMA 24 MG DAILY liothyronine sodium 134 KOATE 92 DOSE 42 LIPITOR 35 LENVIMA 4 MG DAILY KOATE-DVI 92 DOSE 42 LIPOFEN 35 KOGENATE FS 92 LENVIMA 8 MG DAILY lisinopril 36 KOSELUGO 46 DOSE 42 lisinopril & KOVALTRY 92 LESCOL XL 35 hydrochlorothiazide 39 LITEAIRE 104 kp folic acid 94 LETAIRIS 60 LITHIUM 50 KRINTAFEL 40 letrozole 43 lithium carbonate 50 KUVAN 85 leucovorin calcium 48 LITHOBID 50 labetalol hcl 57 LEUKERAN 41 LITHOSTAT 90 LACRISERT 120 LEUKINE 94 LO LOESTRIN FE 64 lactulose 96 leuprolide acetate 43 LOCOID 78 lactulose (encephalopathy) 88 levalbuterol hcl 19 LOCOID LIPOCREAM 78 LAMICTAL 22 levalbuterol tartrate 19 LAMICTAL CHEWABLE LEVAQUIN 87 LODINE 5 DISPERSIBLE 22 LEVBID 135 LODOSYN 48 LAMICTAL ODT 22 LEVEMIR 30 LOHIST-DM 68 LAMICTAL STARTER/NOT LEVEMIR FLEXTOUCH 30 LOKELMA 110 TAKING CARBAMAZEPINE 22 LOMOTIL 31 LAMICTAL STARTER/TAKING levetiracetam 23 CARBAMAZEPINE/NOT TAKING levo-t 134 LONSURF 44 VALPROATE 22 levobunolol hcl 120 loperamide hcl 31 LAMICTAL STARTER/TAKING levocarnitine (metabolic LOPID 35 VALPROATE 22 modifiers) 85 lopinavir-ritonavir 54 LAMICTAL XR 22,23 levofloxacin 87 LOPRESSOR 57 lamivudine 54 levofloxacin (ophth) 122 LOPRESSOR HCT 39 lamivudine (hbv) 56 levonorgestrel & eth LOPROX 73 lamivudine-zidovudine 54 estradiol 63 LOPROX SHAMPOO 73 lamotrigine 23 levonorgestrel (emergency oc) 65 lorazepam 16 LANOXIN 59 levonorgestrel-eth estradiol lorazepam intensol 16 lansoprazole 136 (triphasic) 64 LORBRENA 46 lanthanum carbonate 89 levonorgestrel-ethinyl estradiol (91-day) 64 lorcet 11 LANTUS 30 levonorgestrel-ethinyl estradiol LORTAB 11 LANTUS SOLOSTAR 30 (continuous) 64 losartan potassium 37 lapatinib ditosylate 46 levorphanol tartrate 9 losartan potassium & LASIX 83 levothyroxine sodium 134 hydrochlorothiazide 39 LASTACAFT 125 LEVSIN 135 LOSEASONIQUE 64 latanoprost 125 LEXAPRO 26 LOTEMAX 123 LATUDA 50 LEXIVA 54 LOTENSIN 36 leflunomide 6 LIALDA 88 LOTENSIN HCT 39 LENVIMA 10 MG DAILY LIBRAX 135 loteprednol etabonate 123 DOSE 42 lidocaine 80 LENVIMA 12MG DAILY LOTREL 39 lidocaine hcl (mouth- DOSE 42 LOTRISONE 73 throat) 111 LENVIMA 14 MG DAILY LOTRONEX 88 lidocaine-prilocaine 80 DOSE 42 lovastatin 35 LENVIMA 18 MG DAILY LIDODERM 80 LOVAZA 34 DOSE 42 linezolid 15 LENVIMA 20 MG DAILY LOVENOX 21 LINZESS 88 DOSE 42 loxapine succinate 51

Index 12 lubiprostone 88 MEGACE ES 127 methylphenidate hcl 2 LUCEMYRA 127 megestrol acetate 43 METHYLPHENIDATE luliconazole 73 megestrol acetate HYDROCHLORIDE ER 2 methylprednisolone 66 LUMIGAN 125 (appetite) 127 MEKINIST 46 methyltestosterone 13 LUNESTA 95 MEKTOVI 46 metoclopramide hcl 88 LUXIQ 78 meloxicam 5 METOCLOPRAMIDE ODT 88 LUZU 73 melphalan 41 metolazone 83 LYNPARZA 46 memantine hcl 128 METOPIRONE 81 LYRICA 23 MENEST 87 metoprolol & LYSODREN 43 MENOSTAR 87 hydrochlorothiazide 39 LYSTEDA 95 metoprolol succinate 57 meperidine hcl 9 M-CLEAR WC 68 metoprolol tartrate 57 MEPHYTON 139 M-END PE 68 METROCREAM 80 MEPRON 15 MACROBID 15 METROGEL 80 mercaptopurine 41 MACRODANTIN 15 METROGEL-VAGINAL 138 mesalamine 88 mafenide acetate 75 METROLOTION 80 MESNEX 48 MAGNEBIND 400 108 metronidazole 14 MESTINON 40,41 MALARONE 40 metronidazole (topical) 80 MESTINON TIMESPAN 41 malathion 81 metronidazole vaginal 138 metaxalone 118 maprotiline hcl 25 metyrosine 36 metformin hcl 28 MAR-COF BP 68 METFORMIN mexiletine hcl 17 MAR-COF CG HYDROCHLORIDE 28 MG217 PSORIASIS MULTI- EXPECTORANT 68 methadone hcl 9 SYMTOM 80 MARINOL 32 methadone hydrochloride MIACALCIN 83 MARNATAL-F 114 intensol 8 MICARDIS 37 MARPLAN 25 methadose 8 MICARDIS HCT 39 MATULANE 48 METHADOSE 10 miconazole 3 137 matzim la 57 METHADOSE SUGAR- MICROCHAMBER 104 MAVENCLAD 129 FREE 10 MICROSPACER 104 methamphetamine hcl 1 MAVYRET 56 midazolam hcl 95 methazolamide 82 MAXALT 107 midodrine hcl 139 methenamine hippurate 15 MAXALT-MLT 107 migergot 106 methenamine mandelate 15 MAXI-TUSS PE MAX 68 miglitol 28 methergine 126 MAXIDEX 123 miglustat 94 methimazole 133 MAXITROL 123 MIGRANAL 107 METHITEST 13 MAXZIDE 82 MINASTRIN 24 FE 64 methocarbamol 118 MAXZIDE-25 82 MINIPRESS 37 METHOTREXATE 4 MAYZENT 129 minitran 15 methotrexate sodium 41 MECLIZINE MINIVELLE 87 HYDROCHLORIDE 32 methoxsalen rapid 74 MINOCIN 133 meclofenamate sodium 5 methscopolamine minocycline hcl 133 MEDROL 66 bromide 135 minoxidil 40 MEDROL DOSEPAK 66 METHYLDOPA 37 medroxyprogesterone methyldopa & MIRALAX 96 acetate 127 hydrochlorothiazide 39 MIRAPEX 49 methylergonovine mefenamic acid 5 maleate 126 MIRAPEX ER 49 mefloquine hcl 40 METHYLIN 2 MIRCETTE 64

Index 13 mirtazapine 25 MYNATE 90 PLUS 114 neo-polycin hc 123 MIRVASO 80 MYSOLINE 23 neomycin sulfate 3 misoprostol 136 MYTESI 31 neomycin-bacitracin zn- MISTASSIST 105 nabumetone 6 polymyxin 122 neomycin-polymy- MITIGARE 91 nadolol 57 dexameth 123 MOBIC 5 nafrinse 108 neomycin-polymyxin-gramicidin modafinil 2 naftifine hcl 73 122 neomycin-polymyxin-hc moexipril hcl 36 NAFTIFINE 73 (ophth) 123 mometasone furoate 78 HYDROCHLORIDE neomycin-polymyxin-hc mometasone furoate NAFTIN 73 (otic) 126 (nasal) 120 NALFON 6 NEORAL 110 mondoxyne nl 133 naloxone hcl 31 NEOTUSS PLUS 68 MONONINE 92 naltrexone hcl 31 NERLYNX 46 montelukast sodium 18 NAMENDA 128 NESTABS 114 MONUROL 15 NAMENDA TITRATION NESTABS DHA 114 morgidox 1x100mg 133 PAK 128 NAMENDA XR 128 NESTABS ONE 114 morphine sulfate 10 NAMENDA XR TITRATION neuac 69 morphine sulfate beads 10 PACK 128 NEUPRO 49 MOVANTIK 89 NAMZARIC 128 NEURONTIN 23 MOXEZA 122 NAPROSYN 6 NEVANAC 125 moxifloxacin hcl 87 naproxen 6 nevirapine 54 moxifloxacin hcl (ophth) 122 naproxen sodium 6 NEXA PLUS 114 MS CONTIN 10 naratriptan hcl 107 NEXAVAR 46 MUCINEX D 68 NARCAN 31 NEXTSTELLIS 64 MUCINEX D MAXIMUM NARDIL 26 niacin (antihyperlipidemic) 36 STRENGTH 68 NASACORT ALLERGY niacor 36 MUCOTROL 111 24HR 120 mucus relief d 67 NASACORT ALLERGY 24HR NIASPAN 36 MULPLETA 94 CHILDRENS 120 nicardipine hcl 58 MULTAQ 17 NASONEX 120 NICODERM CQ 132 multi-vit/iron/fluoride 112 NATACHEW 114 NICORETTE 132 multi-vitamin/fluoride drops 111 NATACYN 122 NICORETTE MINI 132 MULTIVITAMIN + NATAZIA 64 NICORETTE STARTER FLUORIDE 112 nateglinide 30 KIT 132 nicotine 132 multivitamin select/fluoride 111 NATELLE ONE 114 nicotine polacrilex 132 multivitamin/fluoride 111 NATPARA 83 NICOTINE TRANSDERMAL mupirocin 72 NATROBA 81 SYSTEM 132 MYALEPT 85 NATURE-THROID 134 NICOTROL INHALER 132 MYAMBUTOL 41 NATURE-THROID NT- NICOTROL NS 132 2.5 134 MYCOBUTIN 41 nifedipine 58 mycophenolate mofetil 110 NAYZILAM 21 NEBULIZER NILANDRON 43 mycophenolate sodium 110 CUP/TUBING 105 nilutamide 43 MYDRIACYL 121 NEBUPENT 14 nimodipine 58 MYFORTIC 110 NEBUSAL 69 NINJACOF-XG 68 MYLERAN 41 NEEVO DHA 114 NINLARO 46 MYNATAL ADVANCE 114 nefazodone hcl 26 nisoldipine 58 MYNATAL ULTRACAPLET 114 neo-polycin 121 nitazoxanide 15

Index 14 nitisinone 85 NUPLAZID 50 ONE FLOW FVC MONITORING NITRO-BID 16 NUVARING 65 SPIROMETER 105 ONETOUCH ULTRA 81 NITRO-DUR 16 NUVESSA 138 ONETOUCH ULTRA 2 99 nitrofurantoin 15 NUVIGIL 2 ONETOUCH VERIO FLEX nitrofurantoin macrocrystal 15 NUWIQ 92 BLOOD GLUCOSE nitrofurantoin monohyd nyamyc 72 MONITORING SYSTEM 99 macro 15 NYMALIZE 58 ONETOUCH VERIO TEST nitroglycerin 16 STRIPS 81 nystatin 32 NITROLINGUAL ONEVITE 111 nystatin (mouth-throat) 111 PUMPSPRAY 16 ONFI 21 nystatin (topical) 73 NITROSTAT 16 ONUREG 41 nystatin-triamcinolone 73 NIVESTYM 94 OPANA 10 OB COMPLETE ONE 114 nizatidine 135 opium tincture 31 OB COMPLETE PETITE 114 NIZORAL 73 OPSUMIT 60 nolix 75 OB COMPLETE PREMIER 114 OPTICHAMBER NORCO 11 ADVANTAGE/LARGE OB COMPLETE/DHA 114 NORDITROPIN FLEXPRO 84 MASK 105 OBIZUR 93 OPTICHAMBER norethin acet & estrad-fe 64 OBSTETRIX DHA 114 ADVANTAGE/MEDIUM FACE norethindrone & ethinyl estradiol- OBTREX DHA 114 MASK 105 fe 64 OPTICHAMBER norethindrone OCALIVA 87 ADVANTAGE/SMALL FACE (contraceptive) 65 octreotide acetate 86 MASK 105 norethindrone acet & eth estra 64 OCUFLOX 122 OPTICHAMBER DIAMOND105 norethindrone acetate 127 ODEFSEY 54 OPTICHAMBER ODOMZO 42 DIAMOND/LARGEFACE norethindrone acetate-ethinyl MASK 105 estradiol 86 OFEV 133 OPTICHAMBER norgestimate-ethinyl ofloxacin 87 DIAMOND/MEDIUM FACE estradiol 64 ofloxacin (ophth) 122 MASK 105 norgestimate-ethinyl estradiol OPTICHAMBER (triphasic) 64 ofloxacin (otic) 126 DIAMOND/SMALLFACE NORPACE 17 olanzapine 51 MASK 105 NORPACE CR 17 olanzapine-fluoxetine hcl 128 OPTICHAMBER FACE NORPRAMIN 27 olmesartan medoxomil 37 MASK/LARGE 105 OPTICHAMBER FACE NORTHERA 139 olmesartan medoxomil- MASK/MEDIUM 105 nortriptyline hcl 27 amlodipine-hydrochlorothiazide OPTICHAMBER FACE 39 MASK/SMALL 105 NORVASC 58 olmesartan medoxomil- NORVIR 54 hydrochlorothiazide 39 OPTIHALER 105 NOVOEIGHT 92 olopatadine hcl 125 OPTIHALER MDI DRUG DELIVERY SYSTEM 105 NOVOSEVEN RT 92 olopatadine hcl (nasal) 119 OPTIONS CONCEPTROL NOXAFIL 33 OLUX 78 VAGINAL np thyroid 120 134 OLUX-E 78 CONTRACEPTIVE 137 OPTIONS GYNOL II NUBEQA 43 OMBRA TABLE TOP COMPRESSOR 105 VAGINALCONTRACEPTIVE NUCALA 17 137 OMECLAMOX-PAK 136 NUCYNTA 10 ORACEA 80 omega-3-acid ethyl esters 34 NUCYNTA ER 10 ORACIT 90 omeprazole 136 NUEDEXTA 130 oralone dental paste 111 OMNIFLEX DIAPHRAGM 98 NULYTELY 96 ORAPRED ODT 66 ondansetron 31 NULYTELY/FLAVOR ORAVIG 111 ondansetron hcl 31 PACKS 96 ORENITRAM 59

Index 15 ORFADIN 85 pantoprazole sodium 136 perphenazine 52 ORIAHNN 86 paregoric 31 perphenazine-amitriptyline 128 ORKAMBI 132 PAREMYD 125 PERTZYE 82 orphenadrine citrate 118 PARI MANUAL phenadoz 33 orphenadrine w/ aspirin & INTERRUPTER 105 phenelzine sulfate 26 PARI TREK S COMBO caff 118 phenobarbital 95 ORTHO MICRONOR 65 PACK 105 paricalcitol 85 phenoxybenzamine hcl 36 ORTHO TRI-CYCLEN LO 64 PARLODEL 49 phenylephrine hcl ORTHO-NOVUM 1/35 64 (mydriatic) 121 PARNATE 26 ORTHO-NOVUM 7/7/7 64 PHENYTEK 25 paromomycin sulfate 3 oscimin 135 phenytoin 25 paroxetine hcl 26 oscimin sr 135 phenytoin infatabs 24 PASER 41 oseltamivir phosphate 56 phenytoin sodium extended 25 PATADAY 125 OSMOPREP 97 PHEXXI 138 PATADAY EXTRA OSPHENA 84 STRENGTH 125 PHOSLYRA 89 OTEZLA 6 PATANASE 119 phospha 250 neutral 108 OTICIN HC NR 126 PATANOL 125 PHOSPHOLINE IODIDE 121 OTOVEL 126 PAXIL 26 phrenilin forte 7 OTREXUP 4 PAXIL CR 26 phytonadione 139 OVACE PLUS WASH 75 PAZEO 125 PICATO 74 OVACE WASH 75 PEDIAPRED 66 PIFELTRO 54 OVIDE 81 pediatric vitamins acd w/ pilocarpine hcl 121 oxandrolone 13 fluoride 112 pilocarpine hcl (oral) 111 peg 3350-kcl-nacl-na sulfate-na oxaprozin 6 ascorbate-ascorbic acid 96 pimecrolimus 79 OXAYDO 10 peg 3350-kcl-sod bicarb-sod pimozide 130 oxazepam 16 chloride-sod sulfate 96 pindolol 57 oxcarbazepine 23 peg 3350-potassium chloride- pioglitazone hcl 29 sod bicarbonate-sod OXERVATE 123 chloride 96 pioglitazone hcl-glimepiride 28 oxiconazole nitrate 73 peg- pioglitazone hcl-metformin OXISTAT 73 3350/electrolytes/ascorbate hcl 28 96 PIQRAY 200MG DAILY OXSORALEN ULTRA 74 peg-prep 96 DOSE 46 OXTELLAR XR 23 PIQRAY 250MG DAILY PEGANONE 25 oxybutynin chloride 137 DOSE 46 PEGASYS 56 PIQRAY 300MG DAILY oxycodone hcl 10 PEGASYS PROCLICK 56 DOSE 46 oxycodone w/ piroxicam 6 acetaminophen 12 PEGINTRON 56 oxycodone-ibuprofen 12 penicillamine 109 PLAN B ONE-STEP 65 OXYCODONE/ACETAMINOPHE penicillin v potassium 127 PLAQUENIL 40 N 12 PENLAC NAIL LACQUER 73 PLAVIX 94 oxymorphone hcl 10 pentamidine isethionate 14 PLEGRIDY 129 OZEMPIC 29 PENTASA 88 PLEGRIDY STARTER PACK 129 pacerone 17 pentazocine w/ naloxone 13 paliperidone 51 PLEXION 71 pentoxifylline 93 PLEXION CLEANSER 71 PALYNZIQ 85 PEPCID 135 PAMELOR 27 PNV TABS 29-1 114 PERCOCET 12 pnv-dha 113 PANCREAZE 82 perindopril erbumine 36 PANRETIN 74 PNV-DHA+DOCUSATE 115 permethrin 81 PNV-OMEGA 115

Index 16 pnv-select 113 prednisolone acetate PRILOSEC 136 POCKET CHAMBER 105 (ophth) 124 primaquine phosphate 40 prednisolone acetate p-f 123 POCKET SPACER 105 PRIMAQUINE PHOSPHATE 40 prednisolone sodium PODOCON 25 IN BENZOIN phosphate 66 PRIMEAIRE DUAL-VALVED TINCTURE 80 PREDNISOLONE SODIUM HOLDING CHAMBER 105 podofilox 80 PHOSPHATE 124 primidone 23 POLY HUB NEEDLE/30G X PREDNISOLONE SODIUM PRIMLEV 12 1/2" 100 PHOSPHATE/MOXIFLOXACIN PRIMSOL 14 POLY-VI-FLOR 112 124 PRINIVIL 36 POLY-VI-FLOR/IRON 112 prednisone 66 PRISTIQ 27 PREDNISONE INTENSOL 66 polyethylene glycol 3350 96 PRO COMFORT INHALER polymyxin b-trimethoprim 122 PREFEST 86 SPACER CHAMBER POLYTRIM 122 pregabalin 23 ADULT 106 POMALYST 43 PREMARIN 87,138 PRO COMFORT INHALER SPACER CHAMBER posaconazole 33 PREMESISRX 115 CHILD 106 pot & sod citrates w/citric ac 90 PREMPHASE 86 PRO COMFORT INHALER pot phosphate monobasic w/ sod PREMPRO 86 SPACER CHAMBER phosphate dibasic & PRENA 1 TRUE 115 INFANT 106 monobasic 108 PRO-RED AC 68 PRENA1 PEARL 115 POTABA 139 PROAIR RESPICLICK 19 PRENAISSANCE 115 potassium chloride 109 probenecid 91 PRENAISSANCE PLUS 115 potassium chloride PROCARDIA 58 microencapsulated crystals prenatabs rx 113 PROCARDIA XL 58 er 109 PRENATAL + DHA 115 PROCARE SPACER CHAMBER potassium citrate prenatal 19 112,113 (alkalinizer) 90 W/ADULT MASK 106 potassium citrate-citric acid 90 PRENATAL 19 115 PROCARE SPACER CHAMBER PRENATAL MULTIVITAMIN W/CHILD MASK 106 POVIDONE IODINE 122 PLUS DHA 115 procentra 1 PR NATAL 400 EC 115 PRENATAL PLUS IRON 115 prochlorperazine 52 PR NATAL 430 115 PRENATAL+DHA 115 prochlorperazine maleate 52 PR NATAL 430 EC 115 PRENATAL-U 115 procto-med hc 14 PRALUENT 36 PRENATE 116 PROCTOFOAM HC 14 pramipexole dihydrochloride 49 PRENATE AM 115 PROCYSBI 90 PRAMOSONE 78 PRENATE DHA 116 PROFILNINE 93 PRANDIN 30 PRENATE ENHANCE 116 PROFILNINE SD 93 prasugrel hcl 94 PRENATE ESSENTIAL 116 progesterone 127 PRAVACHOL 35 PRENATE MINI 116 PROGLYCEM 29 pravastatin sodium 35 PRENATE PIXIE 116 PROGRAF 110 praziquantel 14 PRENATE RESTORE 116 PROLATE 12 prazosin hcl 37 PREPIDIL 126 PROLENSA 125 PRECISION XTRA 81 PREVACID 136 PROLIA 83 PRECISION XTRA BLOOD PREVACID 24HR 136 GLUCOSE TEST STRIPS 81 PROMACTA 94 PRECOSE 28 PREVACID SOLUTAB 136 promethazine & phenylephrine 68 PRED MILD 123 prevalite 34 PREVIDENT RINSE 111 promethazine hcl 33,34 PRED-G 124 promethazine w/codeine 68 PRED-G S.O.P. 123 PREZCOBIX 54 PREZISTA 54 promethazine-dm 68 prednicarbate 78 promethazine-phenylephrine- prednisolone 66 PRIFTIN 41 codeine 68

Index 17 promethegan 33 quinidine gluconate 17 repaglinide-metformin hcl 28 PROMETRIUM 127 quinidine sulfate 17 REPATHA 36 propafenone hcl 17 quinine sulfate 40 REPATHA PUSHTRONEX propantheline bromide 135 QVAR REDIHALER 18 SYSTEM 36 REPATHA SURECLICK 36 proparacaine hcl 123 R-NATAL OB 116 REQUIP XL 49 propranolol & ra laxative 96,97 RESCRIPTOR 54 hydrochlorothiazide 39 rabeprazole sodium 136 propranolol hcl 57 RABEPRAZOLE SODIUM DR RESTASIS 122 propylthiouracil 134 SPRINKLE 136 RESTASIS MULTIDOSE 122 PROSCAR 90 raloxifene hcl 84 RESTORIL 95 PROTONIX 136 ramelteon 95 RETACRIT 94 PROTOPIC 79 ramipril 36 RETEVMO 46 protriptyline hcl 27 RANEXA 15 RETIN-A 71 PROVERA 127 ranolazine 15 RETIN-A MICRO 71 PROVIDA OB 116 RAPAFLO 90 RETIN-A MICRO PUMP 71 PROVIGIL 2 RAPAMUNE 110 RETROVIR 54 PROZAC 26 rasagiline mesylate 50 REVATIO 60 pseudoephed-bromphen-dm 68 RASUVO 4 REVLIMID 109 pseudoephed-cpm w/ RAVICTI 85 REXAPHENAC 72 hydrocod 68 RAZADYNE 128 REXULTI 52 pseudoephedrine-guaifenesin 68 RAZADYNE ER 128 REYATAZ 54 psorcon 75 REBIF 130 RHOFADE 80 PULMICORT 18 REBIF REBIDOSE 129 RIASTAP 93 PULMICORT FLEXHALER 18 REBIF REBIDOSE RIDAURA 4 TITRATIONPACK 130 pulmosal 69 rifabutin 41 REBIF TITRATION PACK130 PULMOZYME 132 RIFADIN 41 REBINYN 93 PURIXAN 41 RIFAMATE 41 RECOMBINATE 93 PYLERA 136 rifampin 41 RECTIV 14 pyrazinamide 41 RIFATER 41 REGLAN 88 pyridostigmine bromide 41 RILUTEK 120 REGRANEX 81 QBRELIS 36 riluzole 120 relafen 4 QINLOCK 46 rimantadine hydrochloride 56 RELENZA DISKHALER 56 QUAKE 106 RINVOQ 3 RELEXXII 3 RIOMET 28 QUALAQUIN 40 RELION INSULIN SYRINGE QUARTETTE 64 1ML/31GX15/64" 100 risedronate sodium 83 quazepam 95 RELION INSULIN SYRINGE/U- RISPERDAL 51 QUDEXY XR 23 100/0.3ML/31G X 15/64" 100 risperidone 51 RELION INSULIN SYRINGE/U- QUESTRAN 34 100/1ML/31G X 15/64" 100 RITALIN 3 QUESTRAN LIGHT 34 RELISTOR 89 RITALIN LA 3 quetiapine fumarate 51 RELNATE DHA 116 RITEFLO 106 QUFLORA FE PEDIATRIC 112 RELPAX 107 ritonavir 54 QUFLORA PEDIATRIC 112 REMERON 25 rivastigmine 128 QUILLICHEW ER 2 REMERON SOLTAB 25 rivastigmine tartrate 128 QUILLIVANT XR 2 RENAGEL 89 RIXUBIS 93 quinapril hcl 36 RENVELA 89 rizatriptan benzoate 107 quinapril-hydrochlorothiazide repaglinide 30 ROBAXIN-750 118 39

Index 18 ROCALTROL 85 SEREVENT DISKUS 19 SOOLANTRA 81 ropinirole hydrochloride 50 SEROQUEL 51 SORBUTUSS NR 68 rosadan 80 SEROQUEL XR 51,52 SORIATANE 74 rosuvastatin calcium 35 SEROSTIM 84 SORILUX 74 roweepra 21 sertraline hcl 26 sorine 57 roweepra xr 21 sevelamer carbonate 89 sotalol hcl 57 ROXICODONE 10 sevelamer hcl 89 sotalol hcl (afib/afl) 57 ROZEREM 95 SFROWASA 88 spinosad 81 ROZLYTREK 46 SIGNIFOR 86 SPIRIVA HANDIHALER 18 RUBRACA 46 SIKLOS 94 SPIRIVA RESPIMAT 18 rufinamide 23 sildenafil citrate 59 SPIRO PD 106 RUKOBIA 54 sildenafil citrate (pulmonary spironolactone 83 RUZURGI 41 hypertension) 60 spironolactone & silodosin 90 RYBELSUS 29 hydrochlorothiazide 82 SILVADENE 75 SPORANOX 33 RYDAPT 46 silver sulfadiazine 75 SPORANOX PULSEPAK 33 RYDEX 68 SIMBRINZA 121 SPRITAM 23 RYTARY 50 simvastatin 35 SPRYCEL 47 RYTHMOL SR 17 SINEMET 50 ssd 75 RYVENT 33 SINEMET CR 50 sss 10-5 70 SABRIL 24 SINGULAIR 18 STALEVO 100 50 SAFYRAL 64 sirolimus 110 STALEVO 125 50 sajazir 93 SITAVIG 56 STALEVO 150 50 SALAGEN 111 SIVEXTRO 15 STALEVO 50 50 SALEX 80 SKELAXIN 118 STALEVO 75 50 salicylic acid 80 SKLICE 81 STARLIX 30 SALIMEZ 80 SKYRIZI 74 stavudine 54 salsalate 8 SKYRIZI PEN 74 STAVUDINE 54 SANCUSO 32 SLYND 65 STELARA 75 SANDIMMUNE 110 sm gentle laxative 97 STIMATE 85 SANDOSTATIN 86 sm laxative 97 STIOLTO RESPIMAT 19 SANTYL 79 sodium chloride (inhalant) 69 STIVARGA 47 SAPHRIS 51 sodium fluoride 108 STRATTERA 1 sapropterin dihydrochloride 85 sodium fluoride (dental) 111 STRENSIQ 85 SARAFEM 130 sodium phenylbutyrate 85 STRIANT 13 SAVELLA 128,129 sodium polystyrene SAVELLA TITRATION STRIBILD 54 sulfonate 110 STRIVERDI RESPIMAT 19 PACK 129 sodium sulfacetamide scopolamine 32 wash 75 STROMECTOL 14 SE-NATAL 19 116 SODIUM SULFACETAMIDE SUBOXONE 13 SEASONIQUE 64 WASH 75 SUBSYS 10 SODIUM SELECT-OB 116 SULFACETAMIDE/SULFUR subvenite 21 SELECT-OB+DHA 116 CLEANSER IN UREA 71 subvenite starter kit/blue 21 selegiline hcl 50 solifenacin succinate 137 SUCRAID 82 selenium sulfide 75 SOLTAMOX 43 sucralfate 135 SELZENTRY 54 SOMA 118 SULAR 58 SENSIPAR 85 SOMAVERT 84 sulconazole nitrate 74

Index 19 sulfacetamide sod- TARGRETIN 48,74 tetracaine hcl (ophth) 123 prednisolone 124 TARKA 39 tetracycline hcl 133 sulfacetamide sodium 75 TARON-C DHA 116 TEXACORT 79 sulfacetamide sodium (acne)71 TARON-PREX 116 THALOMID 109 sulfacetamide sodium (ophth) 122 TASIGNA 47 THEO-24 20 sulfacetamide sodium w/ TASMAR 48 theophylline 20 sulfur 72 TAVALISSE 93 THIOLA 90 SULFADIAZINE 133 TAYTULLA 64 THIOLA EC 90 sulfamethoxazole-trimethoprim 14 TAZAROTENE 72 thioridazine hcl 52 SULFAMYLON 75 tazarotene 75 thiothixene 52 sulfasalazine 88 TAZORAC 75 THRESHOLD PEP 106 sulfatrim pediatric 14 taztia xt 57 THRIVITE 19 111 sulindac 6 TAZVERIK 47 THRIVITE RX 116 sumatriptan 107 TECFIDERA 130 thyroid 134 sumatriptan succinate 107,108 TECFIDERA STARTER tiagabine hcl 24 PACK 130 TIAZAC 58 sunitinib malate 47 TECHLITE INSULIN SUPRAX 61 SYRINGEU-100/0.3ML/31G X TIBSOVO 47 SUSTIVA 54 15/64" 100 TIGAN 32 TECHLITE INSULIN TIKOSYN 17 SUTENT 47 SYRINGEU-100/1ML/31G X SYLATRON 48 15/64" 100 tilia fe 63 SYMBYAX 128 TEGRETOL 23 timolol maleate 57 SYMDEKO 132 TEGRETOL-XR 24 timolol maleate (ophth) 121 SYMJEPI 138 TEGSEDI 132 timolol maleate in ocudose 120 SYMTUZA 54 TEKTURNA 40 TIMOPTIC 121 SYNALAR 78 TEKTURNA HCT 39 TIMOPTIC OCUDOSE 121 SYNAREL 84 telmisartan 37 TIMOPTIC-XE 121 SYNJARDY 28 telmisartan-amlodipine 39 tinidazole 14 SYNJARDY XR 28 telmisartan-hydrochlorothiazide tiopronin 90 SYNTHROID 134 39 TIROSINT 134 temazepam 95 SYPRINE 109 TIVICAY 55 TEMIXYS 54 TABLOID 42 tizanidine hcl 118 TEMODAR 41 TABRECTA 47 TL-CARE DHA 117 TEMOVATE 79 TACLONEX 79 TL-SELECT 117 temozolomide 41 tacrolimus 110 TOBI 3 tenofovir disoproxil TOBI PODHALER 3 tacrolimus (topical) 79 fumarate 54 tadalafil 59 TENORETIC 100 39 TOBRADEX 124 tadalafil (pulmonary TENORETIC 50 39 TOBRADEX ST 124 hypertension) 60 TENORMIN 57 tobramycin 3 TAFINLAR 47 terazosin hcl 37 tobramycin (ophth) 122 TAGRISSO 42 tobramycin- terbinafine hcl 32 TALZENNA 47 dexamethasone 124 terbutaline sulfate 19 TAMIFLU 56 TOBREX 122 terconazole vaginal 138 tamoxifen citrate 43 TODAY SPONGE 137 TESSALON PERLES 66 tamsulosin hcl 90 TOFRANIL 27 TESTIM 13 TAPAZOLE 134 tolbutamide 31 testosterone 13 TARCEVA 42 tolcapone 49 tetrabenazine 129

Index 20 tolmetin sodium 6 triamcinolone acetonide TYBLUME 64 TOLSURA 33 (nasal) 120 TYBOST 55 triamcinolone acetonide tolterodine tartrate 137 (topical) 79 tydemy 62 TOPAMAX 24 triamterene 83 TYKERB 47 TOPAMAX SPRINKLE 24 triamterene & TYLENOL/CODEINE #3 12 TOPICORT 79 hydrochlorothiazide 82 TYLENOL/CODEINE #4 12 topiramate 24 triazolam 95 TYMLOS 84 TOPROL XL 57 TRIBENZOR 39 TYVASO 59 TRICARE PRENATAL DHA toremifene citrate 43 ONE 117 TYVASO REFILL 59 torsemide 83 TRICOR 35 TYVASO STARTER 59 TOUJEO MAX SOLOSTAR 30 triderm 76 UCERIS 13,66 TOUJEO SOLOSTAR 30 TRIDESILON 79 UDAMIN SP 111 tovet 75 trientine hcl 109 UDENYCA 94 TOVIAZ 137 trifluoperazine hcl 52 ULORIC 91 TRACLEER 60 trifluridine 122 ULTILET INSULIN SYRINGE tramadol hcl 10 31X6MM 101 TRIGLIDE 35 ULTRACET 12 tramadol-acetaminophen 12 trihexyphenidyl hcl 48 ULTRAM 10 trandolapril 36 TRIJARDY XR 28 ULTRASAL-ER 80 trandolapril-verapamil hcl 39 TRIKAFTA 132 ULTRAVATE 79 tranexamic acid 95 TRILEPTAL 24 UPTRAVI 60 TRANSDERM SCOP 32 TRILIPIX 35 URECHOLINE 137 TRANSDERM-SCOP 32 trimethobenzamide hcl 32 UROCIT-K 10 90 TRANXENE T 16 trimethoprim 14 UROCIT-K 15 90 tranylcypromine sulfate 26 trimipramine maleate 27 UROCIT-K 5 90 TRAVATAN Z 125 TRINATAL RX 1 117 UROXATRAL 90 travoprost 125 TRINTELLIX 27 URSO 250 87 trazodone hcl 27 TRISTART DHA 117 URSO FORTE 87 TRECATOR 41 TRISTART ONE 117 ursodiol 87 TRELEGY ELLIPTA 19 TRIUMEQ 55 VAGIFEM 138 TREMFYA 75 TRIZIVIR 55 valacyclovir hcl 56 TRESIBA 30 TROKENDI XR 24 VALCHLOR 74 TRESIBA FLEXTOUCH 30 tropicamide 121 VALCYTE 55 tretinoin 72 trospium chloride 137 valganciclovir hcl 55 tretinoin (chemotherapy) 48 TRULANCE 87 VALIUM 17 tretinoin microsphere 72 TRULICITY 29 valproate sodium 25 TRETTEN 93 TRUSOPT 125 valproic acid 25 TREXALL 42 TRUVADA 55 valsartan 37 trezix 11 trymine cg 66 valsartan-hydrochlorothiazide tri femynor 63 TUKYSA 42 40 tri-lo-estarylla 63 TURALIO 47 VALTREX 56 TRI-TABS DHA 117 TUSNEL 68 VALVED HOLDING CHAMBER 106 TRI-VI-FLOR 112 TUSNEL C 68 VANACOF 69 TRI-VI-FLORO 112 TUSNEL PEDIATRIC 68 vanadom 118 tri-vite/fluoride 112 TUSSICAPS 69 VANCOCIN HCL 15 triamcinolone acetonide TWIRLA 65 (mouth) 111 vancomycin hcl 15 TWYNSTA 39

Index 21 VANCOMYCIN VIRAMUNE 55 VYTONE 74 HYDROCHLORIDE 15 VIRAMUNE XR 55 VYTORIN 34 vandazole 137 VIREAD 55 VYVANSE 1 VANOS 79 VIRT-C DHA 117 warfarin sodium 20 VARUBI 32 VIRT-NATE DHA 117 WATCHHALER 106 VASCEPA 34 VIRT-PN DHA 117 WEGMANS COMPLETE VASERETIC 40 VIRT-PN PLUS 117 PRENATAL+DHA 118 VASOTEC 36 WELCHOL 34 virtussin ac/alc 66 VCF VAGINAL WELLBUTRIN SR 25 VIRTUSSIN DAC 69 CONTRACEPTIVE FILM 137 WELLBUTRIN XL 25 VCF VAGINAL VISTARIL 16 WESTGEL DHA 118 CONTRACEPTIVE FOAM 137 VISTOGARD 31 VCF VAGINAL WESTHROID 134 VITAFOL FE+ 117 CONTRACEPTIVEGEL 137 WIDE-SEAL SILICONE VECAMYL 40 VITAFOL GUMMIES 117 DIAPHRAGM KIT 60 99 VECTICAL 75 VITAFOL-NANO 117 WIDE-SEAL SILICONE VITAFOL-ONE 117 DIAPHRAGM KIT 65 99 VELTIN 72 WIDE-SEAL SILICONE VEMLIDY 56 VITAMEDMD ONE RX/QUATREFOLIC 117 DIAPHRAGM KIT 70 99 WIDE-SEAL SILICONE VENCLEXTA 42 VITAPEARL 117 VENCLEXTA STARTING DIAPHRAGM KIT 75 99 PACK 42 VITATRUE 117 WIDE-SEAL SILICONE venlafaxine hcl 27 VITRAKVI 47 DIAPHRAGM KIT 80 99 VIVA DHA 118 WIDE-SEAL SILICONE VENTAVIS 59 DIAPHRAGM KIT 85 99 VENTRIXYL 111 VIVELLE-DOT 87 WIDE-SEAL SILICONE verapamil hcl 58,59 VIVLODEX 6 DIAPHRAGM KIT 90 99 VIZIMPRO 42 WIDE-SEAL SILICONE VEREGEN 72 DIAPHRAGM KIT 95 99 VOGELXO 13 VERELAN 59 WILATE 93 VOL-TAB RX 118 VERELAN PM 59 WILZIN 109 VOLTAREN 72 VERSACLOZ 52 wixela inhub 18 VONVENDI 93 VERZENIO 47 WP THYROID 134 voriconazole 33 VESICARE 137 wymzya fe 62 VFEND 33 VORTEX HOLDING CHAMBER/MASK/CHILDS XALATAN 126 VIAGRA 59 106 XALKORI 47 VIBERZI 88 VORTEX HOLDING XANAX 17 VIBRAMYCIN 133 CHAMBER/MASK/CHILDS/FR XANAX XR 17 OG 106 VICTOZA 29 VORTEX HOLDING XARELTO 20 VIDEX EC 55 CHAMBER/MASK/TODDLER XATMEP 42 VIDEXPEDIATRIC 55 106 XELJANZ 3,4 vigabatrin 24 VORTEX HOLDING CHAMBER/MASK/TODDLER/L XELJANZ XR 4 vigadrone 24 ADY BUG 106 XELODA 42 VIGAMOX 122 VORTEX VALVED HOLDING XENAZINE 129 VIIBRYD 27 CHAMBER 106 XERAC AC 80 VOSEVI 56 VIIBRYD STARTER PACK 27 XERMELO 89 VOTRIENT 47 VIMPAT 24 XIFAXAN 14 VP-PNV-DHA 118 VINATE DHA RF 117 XIGDUO XR 28 VRAYLAR 50 VINATE ONE 117 XOLAIR 17 VYNDAMAX 61 VIOKACE 82 XOPENEX 19 VYNDAQEL 61 VIRACEPT 55 XOPENEX CONCENTRATE 19

Index 22 XOSPATA 47 ZOFRAN 32 XPOVIO 44 ZOHYDRO ER 10 XPOVIO 100 MG ONCE ZOLINZA 48 WEEKLY 44 zolmitriptan 108 XPOVIO 60 MG ONCE WEEKLY 44 ZOLOFT 26 XPOVIO 80 MG ONCE zolpidem tartrate 95 WEEKLY 44 ZOMIG 108 XPOVIO 80 MG TWICE WEEKLY 44 ZOMIG ZMT 108 XTANDI 43 ZONEGRAN 24 xulane 65 zonisamide 24 XYNTHA 93 ZORBTIVE 84 XYNTHA SOLOFUSE 93 ZORTRESS 110 XYREM 128 ZOVIRAX 56,75 YASMIN 28 65 ZYDELIG 48 YAZ 65 ZYFLO 18 YONSA 43 ZYKADIA 48 yuvafem 138 ZYLET 124 zaleplon 95 ZYLOPRIM 91 ZANAFLEX 118 ZYMAXID 122 ZARONTIN 25 ZYPREXA 52 ZARXIO 94 ZYPREXA ZYDIS 52 ZATEAN-PN DHA 118 ZYTIGA 43 ZATEAN-PN PLUS 118 ZYVOX 15 ZAVESCA 94 ZEJULA 47 ZELAPAR 50 ZELBORAF 48 ZEMPLAR 85 ZENPEP 82 zenzedi 1 ZESTORETIC 40 ZESTRIL 36 ZETIA 35 ZIAC 40 ZIAGEN 55 ZIANA 72 zidovudine 55 ZIEXTENZO 95 zileuton 18 ZIOPTAN 126 ziprasidone hcl 51 ZIRGAN 122 ZITHROMAX 98 ZITHROMAX TRI-PAK 98 ZITHROMAX Z-PAK 98 ZOCOR 35

Index 23